Nursing ManualPolicy Name Policy Number Date this Version Effective Responsible for Content Normal Newborn Infant Care NURS 0147 Feb 2016 Nursing I. Description Outlines the care of the newborn immediately following birth and during hospitalization, including thermoregulation, oxygen therapy in emergent situations, hypoglycemia, phototherapy, and circumcision. Table of Contents I. Description ....................................................................................................................................... 1 II. Rationale.......................................................................................................................................... 1 III. Policy/Procedure .............................................................................................................................. 1 A. Policy ......................................................................................................................................... 1 B. Procedure .................................................................................................................................. 2 Newborn Care Immediately Following Birth in Labor & Delivery ................................................. 2 Thermoregulation in the Newborn Immediately after Birth .......................................................... 5 Emergency Oxygen Therapy for Newborns in Newborn Nursery ................................................ 7 C. Protocol ...................................................................................................................................... 8 Newborn Care ............................................................................................................................ 8 Hypoglycemia in the Newborn .................................................................................................. 15 Phototherapy ............................................................................................................................ 22 Newborn Circumcision Care ..................................................................................................... 26 Safe Sleep……………………………………………………………………………………………….26 IV. References ......................................................................................................................... 32 V. Reviewed/Approved by .................................................................................................................. 33 VI. Original Policy Date and Revisions ................................................................................................ 33 Figure / Table List Figure 1. UNC algorithm for infants at risk for hypoglycemia ................................................................ 21 Figure 2. UNC Standing order sheet for transcutaneous bilirubin testing…………………………………25 Figure 3 UNC Safe sleep teaching plan for Newborn Nursery/NCCC…………………………………….29 II. Rationale After birth, a neonate must quickly adapt to extrauterine life, even though many of the neonate’s body systems are still developing. During this time of adaptation, the nurse must be aware of normal neonatal physiologic characteristics and assessment findings in order to detect possible problems and initiate appropriate interventions. III. Policy/Procedure A. Policy Describes practice utilizing current evidence and clinical guidelines for nursing care as it relates to managing the normal newborn infant after birth and during hospitalization NURS 0147 Date this Version Effective: Dec 2015 Page 1 of 33 Normal Newborn Infant Care B. Procedure Newborn Care Immediately Following Birth in Labor & Delivery Note: Performed by the RN. NA may perform certain aspects as delegated by the RN. 1. Gather Infant Resuscitation Equipment: Neopuff® set Laryngoscope #0 and #1 Laryngoscope blades (check bulb before using) Infant endotracheal tubes (2.5, 3.0, 3.5, 4.0) Stylettes Neonatal Code Cart (carts located outside triage 1 and between ORs 2 & 3) Radiant infant warmer Baby pack (blanket and towel) identification bands Complimentary Foot Print sheet Disposable gloves Warm blanket Infant hat Thermometer Erythromycin ophthalmic ointment Vitamin K 2. Perform hand hygiene. 3. Put on gloves. 4. Provide mother/infant skin-to-skin contact immediately after birth by placing the naked newborn baby prone on the mother’s bare chest for thermoregulation of the infant. If this is not possible place infant under radiant warmer. (See Newborn Care protocol below). . If the mother is unable to provide skin-to-skin contact with the infant the other parent should be considered as an alternative choice. Key Point: This practice based on intimate contact within the first hours of life may facilitate maternal-infant behavior and interactions through sensory stimuli such as touch, warmth, and odor. Moreover, skin-to-skin contact and rooming-in are considered critical components for successful breastfeeding initiation and continuation, but are recommended for all couplets regardless of feeding method. If skin-to-skin is interrupted for contraindication, it should be re-introduced as soon as possible. 5. Dry infant, initiate mother/infant skin-to-skin, cover head with hat and cover baby with warm blankets. Infants loose excessive heat via convection. 6. Assess immediately after birth: Patency of airway NURS 0147 Date this Version Effective: Feb 2016 Page 2 of 33 Normal Newborn Infant Care Respiratory effort Need for suctioning Need for stimulation and resuscitation measures. 7. Assess and assign Apgar Scores at 1 and 5 minutes. The Apgar score consists of the following parameters: - respiratory effort - heart rate - skin color - muscle tone - reflexes A score of 0 is give if the parameter is not present. A score of 1 is given if the parameter is somewhat present. A score of 2 is given if the parameter is fully present. 8. Assess infant continuously for signs of respiratory distress such as grunting, nasal flaring, chest retractions and cyanosis. Document vital signs every 30 minutes or more frequent as indicated in the electronic medical record. 9. Take axillary temperature of infant and assess infant for signs of cold stress. Infant temperature should be ≥ 36.4°C. If cold stress was not prevented using skin-to-skin, and infant exhibits signs of cold stress, transport to the NBN is necessary. Hypoxia, acidosis, hypoglycemia, lethargy and pulmonary vasoconstriction indicate cold stress. For serious complications contact NCCC immediately. 10. Evaluate thermoregulatory environment. (See the Thermoregulation in the Newborn Immediately after Birth procedure below). 11. Assess infant for signs of hypoglycemia such as jitteriness and lethargy. (See the Hypoglycemia in the Newborn protocol below). Symptomatic neonates need to be evaluated by NCCC. 12. Identify infant: Place identification bands on infant per unit protocol. Explain the procedure for checking identification bands with mother and or support person. Place security band on infant per Women’s hospital protocol. Educate mother and or support person on the security band (HUGS). Place infant’s footprints on complimentary certificate. 13. Verify cord clamp 2.5cm from umbilicus and cut cord above the clamp. The cord clamp is usually placed by the delivering LIP. 14. Assess the proximity of the cord clamp in relation to the skin around the umbilicus to prevent injury of the infant. 15. Offer support person the opportunity to cut the cord if the infant’s condition warrants. 16. Weigh infant after 90 mins of life (unless medically necessary) 17. Encourage mother/infant contact and point out infant feeding cues. NURS 0147 Date this Version Effective: Feb 2016 Page 3 of 33 Normal Newborn Infant Care 18. Encourage mother to initiate breastfeeding at the earliest signs of hunger. (See the protocol in the UNC Hospitals Nursing Breastfeeding and Human Milk Storage and Handling policy). Key Point: Mother-baby couplets are likely to initiate breastfeeding within the first hour of life if left skin-to-skin, uninterrupted. This is the time for encouragement and more rudimentary guidance including feeding cues and general expectations for feeding. 19. Transport infant to the Maternity Care Center within 2 hours of birth or immediately if signs of any of the following occur: Hypothermia (<36.4°) Respiratory distress Hypoglycemia (follow hypoglycemic protocol) If infant is not transferred to Maternity Care Center within 2 hours, document a complete head to toe assessment in the electronic medical record. Key Point: The mother-baby dyad should remain together, throughout transition from labor and delivery to the Maternity Care Center unless there is a specific contraindication. 20. Verify Vitamin K and ophthalmic suspension administration per protocol. Key Point: Both vitamin K and ophthalmic suspension should be administered without interrupting mother-infant skin-to-skin. 21. Keep bulb syringe with infant at all times. 22. Instruct mother not to give infant to anyone other than an individual with two appropriate forms of identification. 23. Report to mother-baby/nursery nurse: Name and Sex Time of birth Method of feeding Type of delivery High risk factors/prenatal history Anomalies Mother’s blood type Confirmation of cord blood being sent to lab if mother is Rh- or O+ Confirmation of ID band number Complications Abnormal findings on review of systems Infant’s follow-up care LIP Key Point: Transfer must be done by RN or LPN who is prepared in emergency measures. . NURS 0147 Date this Version Effective: Feb 2016 Page 4 of 33 Normal Newborn Infant Care 24. a complete delivery summary form in the electronic medical record and infant MAR. In patient’s electronic medical record o review of systems within two hours of birth Vital Signs Note: This task is to be performed by the RN or LPN. Per Unit Protocol is defined as Assess temperature, heart rate and respirations at 30 mins of life and every 30 mins x4. If stable infant may have vital signs obtained once per shift unless Late Preterm Infants (34 to 36 6/7 weeks gestation) receive vital signs every 4 hours. CODE SEPSIS- Infants with a blood culture pending receive vital signs every 4 hours until culture is documented as negative after 48hrs. Note: If axillary temp greater than 37.5C or less than 36.4C, obtain rectal temperature; If rectal temperature is less than 36.4C then warm baby using radiant warmer or skin-to-skin with mom and repeat rectal temp within 30 minutes;. Thermoregulation in the Newborn Immediately after Birth Note: Performed by the RN. NA may perform certain aspects as delegated by the RN. Thermoregulation is the ability of the newborn to balance heat production and heat loss in order to stabilize internal body temperature. Thermoregulation is essential in the neonate for optimal growth and normal physiological function. The newborn has special requirements for temperature maintenance due to: Larger body surface area in relation to body weight. Blood vessels relatively close to the skin surface. Less adipose tissue and subcutaneous fat Underdeveloped sweating and shivering mechanisms. Increased metabolic processes (non-shivering thermogenesis) produce heat beyond basal production. Heat production consumes a large number of calories. All infants are at risk including: Term newborns, especially during the first 12 hours of life Late pre-term infants (34 to 366/7 weeks gestation) Preterm infants Small for gestational age infants Environmental causes (e.g. overheating) Infection Dehydration NURS 0147 Date this Version Effective: Feb 2016 Page 5 of 33 Normal Newborn Infant Care Medication effects and drug withdrawal Infants with disorders of the endocrine, neurologic or cardiorespiratory problems Infants with congenital anomalies Hypoglycemic infants Infants with asphyxia Maternal fever during labor Congenital hypothyroidism Fetal stress manifested as decelerations, meconium-stained fluid, or low Apgar scores may indicate infant is at risk for impairment of thermoregulatory response. 1. Gather equipment: Radiant warmer Skin probe Warm blankets/towels Thermometer Hat 2. Prior to delivery, increase temperature in labor room/recovery room to 75ºF. This prevents heat loss due to convection. 3. Pre-warm radiant warmer. This prevents heat loss due to conduction. 4. Place warm blankets/towels under radiant warmer element. This prevents conductive heat loss in the case that the mother or other support person is not available for skin-to-skin contact. 5. Place infant skin-to-skin with mother and warm blankets over mother and baby. Skin-to-skin contact is the best heat source, but both will provide a heat giving environment. 6. Dry infant with warm absorbent blankets and/or towels, and immediately replace used blankets and/or towels with new warm ones. This prevents evaporative heat loss. 7. Warm hands and stethoscopes before coming in contact with infant. This prevents heat loss due to conduction. 8. Keep infant away from air conditioning ducts and other drafts. This prevents heat loss from convection and evaporation. 9. Keep oxygen (if used) directly over infant’s nose and mouth. This prevents heat loss from convection and evaporation. 10. Place a hat on the infant’s head and change when wet or soiled. This prevents heat loss from evaporation. 11. Maintain the infant’s temperature ≥ 36.4 ºC to ≤ 37.5 C while with mother in Labor & Delivery. Key Point: Place infant next to mother’s skin with warm blankets covering them. If cold stress ensues, use a portable radiant warmer and set skin temperature probe for 36.7 ºC to slowly warm infant. NURS 0147 Date this Version Effective: Feb 2016 Page 6 of 33 Normal Newborn Infant Care 12. Assess infant for signs of hyperthermia. Usually hyperthermic infants are warm to touch and exhibit red skin due to vasodilation related to releasing excess heat. Sweating is generally not present in infants Key Point: Infants who attempt to decrease their temperature may be irritable, lethargic, hypotonic, apneic, feed poorly, tachycardic, tachypneic or present with a weak or absent cry. 13. Assess infant’s temperature, per axilla, with electronic thermometer every 30 minutes for the first 2 hours after birth for a total of 4 times. 14. Transfer infant to nursery and report to care provider on thermoregulatory status if it is not possible to maintain infant’s temperature at 36.4 º C. Consider obtaining a blood glucose level if thermoregulation is compromised. a. Instructions noted in order set: Place under radiant warmer until temperature is >36.7 C. Remove infant from warmer. Double swaddle or place skin to skin again. Recheck temperature in 30 mins. If temperature drops again below 36.4 place under warmer for 2nd time and notify LIP. Obtain blood glucose if radiant warmer needed second time. 15. Document infant’s temperature and nursing actions on appropriate electronic medical record. Emergency Oxygen Therapy for Newborns in Newborn Nursery Note: Performed by the RN or LPN. Respiratory distress accompanied by central cyanosis, or cyanosis alone, is an indication for administering O2 per Neopuff set or facemask. Administration of O2, in an emergency situation, does not require a provider order. Neopuff setups are available in the Newborn Nursery, Labor and Delivery and 3 Women’s. 1. Gather Equipment: O2 flow meter Tubing Neopuff set 2. Assure that the infant is not choking, which is the primary cause of cyanosis. 3. Clear the airway with a bulb syringe if obstructed by mucous in the infant’s mouth. Stroke baby’s back. For excessive mucous in the throat, wall suction may be used. 4. Position the infant on back with the head of crib elevated and neck slightly extended. A rolled pillowcase may be placed under the back of shoulders to accommodate the extension. 5. Place the infant on continuous pulse oximetry. (This is a rapid and non-invasive assessment of the infant’s oxygenation) 6. Place the facemask securely over the infant’s nose and mouth and turn O2 source to 8L/min. and provide blow by oxygen. No longer than 15 minutes. 7. If the mask is held to tightly, pressure will build up in the Neopuff device and be transmitted to the infant’s lungs in the form on CPAP or PEEP. NURS 0147 Date this Version Effective: Feb 2016 Page 7 of 33 Normal Newborn Infant Care 8. Notify the LIP immediately on call if cyanosis or respiratory distress persists. 9. Initiate Neonatal Code Blue for respiratory/cardiac arrest by pushing the code blue button located in the NBN. 10. Initiate neonatal resuscitation (NRP) 11. Arrange a transfer to NCCC, if after 15 minutes, cyanosis persists. 12. Document the following on the Newborn electronic medical record: the time the O2 was initiated and discontinued the time of LIP’s arrival the time respiratory distress occurred the time of infant’s transfer to the NCCC patient teaching for the mother/caregiver, their level of understanding and responses to teaching C. Protocol Newborn Care Term newborn infants (37-42 weeks gestation) progress through predictable stages of adjustment to extrauterine life. Key elements of concern are: airway patency oxygenation ventilation thermoregulation adequacy of intake and output any abnormalities family attachment Late pre-term infants (34 to 36 6/7 weeks gestation) The healthy late pre-term infant may be physiologically stable and able to be admitted directly to the Maternity Care Center. The primary issues include, but are not limited to: feeding maintaining temperature control stabilizing blood glucose excreting bilirubin. Providing family-centered care, with minimal separation of mother and infant, fosters motherinfant attachment and early assumption of the parent role, as well as the parents’ understanding of their baby’s unique needs. Early feeding of this patient population is mutually beneficial to the mother and infant. It stabilizes blood glucose and stimulates stooling of the infant and promotes maternal infant bonding. Breastfeeding enhances these benefits by providing nutrition, which is rich in infection-fighting properties, including immunoglobulins. Breastfeeding also NURS 0147 Date this Version Effective: Feb 2016 Page 8 of 33 Normal Newborn Infant Care promotes skin-to-skin contact with the mother that facilitates temperature regulation of the infant. 1. Resources Licensed Independent Practitioners (LIP) NCCC nurses Lactation Consultants 2. Assessment Assess within 30 minutes of admission: airway patency, breath sounds cry skin and mucous membrane color vital signs (TPR) weight activity, muscle tone condition of scalp, skin, cord, eyes Moro reflex fontanels presence/absence of edema, physical abnormalities, birth trauma antepartum/intrapartum maternal risk factors (e.g. diabetes, maternal serology including HEPB status, HIV, GBS, chorioamnionitis, substance abuse, difficult delivery, maternal fever, heart disease and previous complications) Assess every shift: skin and mucous membrane color airway patency, cry, breath sounds vital signs (TPR) pain score (FLACC scale) activity, muscle tone signs of adequate milk transfer and or mL fed from bottle output review of systems cord, eye condition integrity of electronic security tag circumcision site, if applicable Assess infant’s activities/interaction every 2 hours when with mother/caregiver. NURS 0147 Date this Version Effective: Feb 2016 Page 9 of 33 Normal Newborn Infant Care Assess pulse oximetry if indicated by infant’s respiratory status. (Refer to the protocol in the UNC Hospitals Pediatric Cardiorespiratory and Pulse Oximetry Monitoring policy) Assess Bilirubin: Please check a transcutaneous bilirubin (TCB) on all babies after 24 hours of life with batched screening using the handheld bilimeter. Use Bilitool.org to evaluate risk zone for infant. If “HIGH RISK ZONE” RN to draw neobili STAT (may be drawn with newborn screen if lab available.) Notify LIP with results. Otherwise-if TCB>7mg/dL RN to order neobili with newborn screen www.bilitool.org Obtain TCB daily on any infant <37 weeks gestation draw and send neonatal bilirubin if TCB > 12mg/dL after 4 AM on day of discharge draw and send neonatal bilirubin if TCB > 12mg/dL Day of Discharge- Obtain TCB. RN to order serum if TCB >12mg/dL Note: Refer to Bhutani curve to identify “light level” for phototherapy treatment based on results of neobili and risk level. Risk factors include: <37 weeks gestation, hemolytic disease, asphyxia, lethargy, temperature instability, sepsis, acidosis, albumin <3.0g/dL 3. Notify LIP signs of respiratory distress o abnormal breath sounds o pale or cyanotic mucous membranes glucose < 45 mg/dl x 2 readings taken 30-60 minutes apart abnormal vital signs o Rectal temperature < 36.4 °C or > 37.5C o heart rate sustained < 100 or > 180 o respiratory rate < 30 or > 60 transcutaneous bilirubin ≥ 12 mg/dL positive direct Coombs or VDRL (Venereal Disease Research Laboratory) abnormal skin color, rash, or blisters abnormal or changed cry, e.g. high pitched weight loss/gain >10 % of birth weight. abnormal activity or muscle tone, e.g. jitteriness, lethargy abnormal neurological findings bulging or sunken fontanels NURS 0147 Date this Version Effective: Feb 2016 Page 10 of 33 Normal Newborn Infant Care edema, physical abnormalities or birth trauma, e.g. palsy, bone crepitations, facial palsy maternal risk factors requiring immediate follow-up (e.g. increased maternal temperature at delivery) inability to feed, rhinitis, excessive drooling or spitting, projectile vomiting no urine or stool within 24 hours of birth diarrhea and/or the presence of bright-red blood in stools, urine or mucus inflammation of cord, circumcision site, or eyes problems with parent’s caregiver bonding or providing routine care to the infant WBC < 9,000 or > 30,000/mm3 4. Administration Verify administration on Vitamin K (phytonadione) 1 mg I.M. within 1 hour of birth (usually in Labor and Delivery). Verify Erythromycin Ophthalmic Ointment given within 1 hour of birth (usually in Labor and Delivery). Obtain an order to administer Hepatitis B vaccine. Note: Consent for Hepatitis B vaccine must be obtained verbally from the mother. 5. Nursing Care Weigh daily Maintain a temperature range of ≥ 36.4° C. to ≤ 37.5° C. axillary. Note: If initial temperature is < 36.4 C, place infant skin-to-skin with care giver, covering both with a warmed blanket, or place infant under radiant warmer with temperature probe on and skin temperature set at 36.7° C. Refer to the Thermoregulation in the Newborn Immediately after Birth procedure above Wear gloves during all contact with infant prior to initial bath and all mother’s body fluids are removed. Take infant’s temperature before and after bath. Offer Bath and scalp care only when temperature ≥36.7°C after 24 hours i. Exception- Infants born to mothers with active HSV lesions or are HIV positive should be bathed shortly after birth. Delay bath/scalp care until the infant’s temperature has been stabilized at 36.7°C (term infants) 36.7° or higher for > 4 hours (near term infants) and after 24 hours of life. Bathe infants at mother’s request when at least 6 hours old if temperature stable at 36.7° C. Place infant skin-to-skin or under warmer if temperature < 36.4°C after bath until temperature reaches at least 36.7°C. Dress infant in shirt and diaper and swaddle in 2 blankets with cap when temperature stabilizes at 36.7 °C. Recheck temperature in 30 mins to ensure thermoregulation has been accomplished. NURS 0147 Date this Version Effective: Feb 2016 Page 11 of 33 Normal Newborn Infant Care Support optimal mother/caregiver interaction with infant: a. adjust the mother’s room temperature to ≥ 74° F b. encourage skin-to-skin contact c. encourage frequent breastfeeding d. encourage non separation to foster maternal infant attachment Begin feedings as follows: (1) Breastfed infants: Do not disrupt skin-to-skin contact. If contact is interrupted, offer breast within 2 hours of birth. Breastfed infants do not receive water feedings unless ordered by the LIP. (2) Non-breastfed infants: Allow parents to formula feed 5-10 mL by 4 hours of age unless infant is at risk for hypoglycemia per protocol requiring feeding by one hour of life, feeding according to infant hunger and satiety cues. Offer assistance to family regarding safe bottle feeding practices. (Refer to Baby Feeding and Diaper Count Chart Formula - Green Sheet.) If infant has no respiratory distress or GI incompetence, follow with formula not to exceed 30mLs. (3) Babies at risk for hypoglycemia must be fed within one hour of life prior to the first blood glucose level at 90 mins of life. Assist mother with breastfeeding (or provide non-breastfed infants with formula) every 24 hours after the initial feeding. Note: Breastfed infants are not to receive supplemental formula feedings unless requested by the mother or ordered by the LIP. Before supplementation is given, provide mother with supplementation information sheet which should be reviewed verbally with patient to ensure adequate understanding of risks of formula supplementation and attend to mothers’ desire for supplementation. As with all patient information, qualified interpreters must be utilized to ensure informed understanding. Review safe Baby Feeding and Diaper Count Chart Supplementation (Mixed Feeding) - Yellow Sheet Observe for signs of milk transfer during a minimum of two feedings prior to discharge. Signs of milk transfer include suck-swallow-breath cycle and satisfaction at the end of feeding. Assist mother/caregiver with physical care. Check diaper before and after feedings and when infant cries. Replace cord clamp if oozing occurs or end of cord is not clearly visible past outer edge of clamp. May remove cord clamp after 24 hours of life if cord is dry. Suction with bulb syringe for excessive fluid/mucus in nose, mouth, or throat. Provide support for family when abnormalities found or if infant transferred to NCCC. Activate order for serum bilirubin if TCB >12mg/dL (as described in this protocol under the transcutaneous bilirubin screening guidelines) by ordering a NEW Serum Neobili Do not use the nursing order for prn neobili as it does NOT communicate with the lab computer system. NURS 0147 Date this Version Effective: Feb 2016 Page 12 of 33 Normal Newborn Infant Care Obtain an order for newborn metabolic screening & newborn hearing screen prior to hospital discharge. Obtain an order for a Rh incompatibility work up and send cord blood or capillary blood specimen for: blood type and direct Coombs Note: Send only for neonates whose mother was Rh negative with a significant antibody or mother has type O blood or unknown blood type. Obtain an order for urine and meconium for toxicology on all infants admitted in the first 48 hrs. of life who have any of the following risk factors: Maternal Risk Factors history of substance abuse a) poor prenatal care (prenatal care starting after 16 weeks gestation or less than 4 prenatal visits) b) history of child abuse, neglect or court ordered placement of children outside of the home c) history of domestic violence d) history of hepatitis, HIV, syphilis or prostitution e) unexplained placental abruption f) acute alcohol intoxication around the time of delivery Infant Risk Factors g) infants with unexplained intrauterine growth restriction or small for gestational age h) infants with evidence of drug withdrawal (hypertonia, irritability or tremulousness Obtain an order for blood culture and CBC w/differential if mother is: GBS+, not treated and < 37weeks OR ROM > 18 hrs. has chorioamnionitis per obstetrician is GBS unknown and rupture of membranes occurred > 18 hours prior to delivery was febrile (>38C) during labor and delivery delivers at < 37 weeks and: GBS status unknown or > 5 weeks since last culture infant born with signs of sepsis has a history of GBS sepsis with a previous delivery 6. Safety Check identification of infant on admission, prior to visit to mother, before any procedure, and at discharge. NURS 0147 Date this Version Effective: Feb 2016 Page 13 of 33 Normal Newborn Infant Care The identification bands are to remain intact on the mother and infant. These bands are left in place to signify that the couplet belong together and not as a patient identifier. For mother/baby couplets: At time of discharge assure both patients’ ID bands are removed to de-identify them as patients. Give the patient/family a discharge pass (preferably the mother). Inform the person providing transportation to wait to get the car until the patient is in the lobby. The discharge pass identifies the patient as discharged and can be obtained from the nurses’ station. Pediatric patients do not require a discharge pass as they should be accompanied by a responsible adult. The HUGS tag must be removed with the patient ID band. Explain mother-baby security procedure. Teach infant safety by instructing mother/caregiver to: a) never leave infant unattended in room. b) never leave infant unsecured on flat surface. Support infant’s head, neck, and back at all times. Position infant on back to sleep. Provide infant car seat safety screening prior to discharge of infants born <37 weeks gestation, < 5 LBS (2.23 kg) or with any congenital issue that may compromise airway. Refer to the procedure in the UNC Hospitals Nursing Car Seat: Screening and ordering policy. 7. Emergency Measures Choking: i) use bulb syringe or wall suction to clear airway. j) administer oxygen if cyanotic. k) call NCCC for LIP assistance. l) Arrange transfer to NCCC if infant requires IV or oxygen for >15 minutes. m) Transport with portable oxygen. 8. Patient/Caregiver Teaching Teach parent/caregiver information for the first time visit including: car seat safety (pamphlet and video) bulb syringe suctioning and infant positioning in bassinette period of purple crying safe sleep protocols safe infant transport in bassinette swaddling/hat for thermoregulation comparison of indent-a-bands feeding NURS 0147 Date this Version Effective: Feb 2016 Page 14 of 33 Normal Newborn Infant Care diapering contacting the nurse and/or the nursery Complete Newborn Nursery Patient/Family instruction sheet prior to discharge. 9. Documentation Document in patients’ electronic medical record: o assessment findings o interventions and patient responses/outcomes o reported conditions o patient/caregiver teaching and level of understanding o active nursing protocols in chart o Newborn screenings completed and documented in the electronic medical record prior to discharge include Newborn Metabolic Screen Critical Congenital Heart Disease Screen Newborn Hearing Screen Hypoglycemia in the Newborn Transient hypoglycemia in the immediate newborn period is common. In most healthy neonates, low blood glucose may simply reflect normal metabolic transition to extrauterine life. This phenomenon is usually self-limited, and glucose levels begin to spontaneously rise within two to three hours of birth. This shift occurs even if oral feedings are withheld, due to a physiologic response of glucose release by the liver. However, this process may be disrupted by several factors, including: antepartum metabolic or nutritional events, intrapartum clinical management of the mother, congenital disorders, postnatal complications, prematurity and unnecessary supplementation. Concern arises when low blood glucose levels are prolonged or recurrent, as they may result in both acute and chronic sequelae. Therefore, monitoring of blood glucose level is warranted in situations where the infant is at-risk for and/or symptomatic of hypoglycemia. Conversely, the routine monitoring of blood glucose in healthy term newborns is not only unnecessary, but potentially harmful to the establishment of a healthy mother-infant relationship and successful breastfeeding patterns. In all neonates, thermoregulation is an important preventative measure against hypoglycemia. Early and prolonged skin-to-skin contact is optimal for adaptation in the first days after birth, facilitating the maintenance of body temperature and safe blood glucose (BG) levels in the healthy term infant. Early and exclusive breastfeeding best meets the nutritional needs of healthy term neonates and is protective against hypoglycemia. Healthy, term newborns that are breastfed on-demand need neither supplementation nor routine monitoring of blood glucose levels. Exclusively breastfed healthy neonates, in general, tend to have and safely tolerate lower blood glucose concentrations, but higher concentration of ketones, than formula-fed infants. This is thought to be a protective physiologic mechanism since exclusively breastfed newborns also have the most effective counter-regulatory release of glucose by the liver. Healthy, term newborns do not develop symptomatic NURS 0147 Date this Version Effective: Feb 2016 Page 15 of 33 Normal Newborn Infant Care hypoglycemia simply due to underfeeding any symptom that presents suggests an underlying condition that warrants attention. Obtain a heel stick glucose level with a blood glucose meter according to the Hypoglycemia in the Newborn protocol below. 1. Resources Immediate referral to a lactation consultant for breastfeeding difficulties. Immediate consult from NCCC team for all symptomatic infants or at risk infants not responding to feedings 2. Assess for: WARNING: Notify the Licensed Independent Practitioner (LIP) if infant is symptomatic a. symptomatic newborns, for whom immediate monitoring of heel stick glucose is indicated, by observing all newborns for clinical signs of hypoglycemia, including General findings: a) abnormal or high-pitched cry b) persistent hypothermia c) temperature instability d) diaphoresis e) weak or no suck f) poor feeding ability Neurological: a) irritability b) tremors or jitteriness not resolved by suckling on gloved finger c) exaggerated Moro reflex d) lethargy e) hypotonia f) seizures g) abnormal eye movements Cardiorespiratory: a) tachypnea b) apnea c) cyanosis d) respiratory distress e) tachycardia b. at-risk newborns for which routine monitoring of heel stick glucose is always indicated, even if asymptomatic. Neonatal-dependent factors: Small for gestational age(<10th percentile for weight/2500 grams) NURS 0147 Date this Version Effective: Feb 2016 Page 16 of 33 Normal Newborn Infant Care Large for gestational age(>10th percentile for weight/4000 grams) Late pre-term infant (34-366/7 weeks) Maternal-dependent factors: IDM (infant of diabetic mother) c. at risk newborns for which monitoring of heel stick glucose may be indicated based upon assessment findings, the presence of multiple risk factors simultaneously, or LIP order, even if asymptomatic. Neonatal-dependent factors: Discordant twin (≥10% difference in weight) Perinatal stress (5 min Apgar ≤7 or cord pH< 7.2) Hypoxia-ischemia Polycythemia (venous Hct>70%) Hypothermia or cold stress (temperature of ≤ 36.4 º C despite interventions) Hemolytic disease of the newborn Sepsis Respiratory distress Known or suspected metabolic or endocrine disorder Maternal-dependent factors: Medications (terbutaline, ritodrine, propanolol, oral hypoglycemics) 3. Notify LIP For all newborns where notification of the LIP is indicated on the hypoglycemia algorithm Feeding intolerance: inability to suck, swallow, or meet the minimal requirements of supplementation that is medically indicated Total supplementation of 3-5 mL/kg without stabilization of heel stick glucose concentration Note: Measureable feed includes: 3-5mg/kg of expressed colostrum or breast milk, donor milk, or formula. 4. Nursing Care Reduce cold stress by drying and placing all healthy term newborns skin-to-skin immediately following birth and throughout hospital stay for physiologic thermoregulation. Begin/continue breastfeeding as described in the algorithm, assisting the mother with latch and positioning. Page lactation services for immediate assistance for consultation, if warranted. If first screening heel stick glucose concentration is below threshold level: Supplement with 3-5 mL/kg/feeding of expressed colostrum or breast milk, donor human milk, or substitute formula. Cup or spoon-feeding is preferred over bottle feeding. D5W and D10W are not acceptable supplements. o Newborn should remain skin-to-skin with mother whenever possible, even if being supplemented. If separation is unavoidable, place infant under radiant warmer. NURS 0147 Date this Version Effective: Feb 2016 Page 17 of 33 Normal Newborn Infant Care Algorithm for Infants at Risk for Hypoglycemia The target heel stick glucose is ≥ 41 mg/dL prior to routine feedings in the first 4 hours of life and ≥ 46 mg/dL after 4 hours of life. The goal is 3 consecutive blood glucose readings within normal limits prior to discontinuing the screenings UNLESS ordered differently by the LIP. These 3 consecutive readings may include blood glucose readings ≥ 41 md/dL during the birth to 4 hour timeframe as part of the normal values. Note: Cleanse heel stick sites every shift with chlorhexidine and water if irritation develops. Note: Use a heel warmer prior to EVERY glucose assessment via heel stick. Cool extremities may cause extracellular use of glucose resulting in falsely low blood glucose results. Symptomatic Newborns: Obtain heel stick glucose on all symptomatic newborns and notify the LIP Stat for infants whose heel stick glucose levels are ≤ 40 mg/dL. Note: The recommended treatment in this situation is IV glucose. Oral feedings and skin-to-skin contact typically may continue during IV glucose therapy and mothers should be encouraged to breastfeed their babies. Mothers should begin expressing their milk as soon as possible if not directly nursing infant or if infant is not latching well. Obtain lactation consultation for all breastfeeding newborns transferred to NCCC. At-Risk Asymptomatic Newborns Birth to 4 hours of life: Initiate feeding within one hour of life and obtain heel stick glucose at 90 minutes of life regardless of if the infant has fed. Warm the heel with a heel warmer prior to obtaining blood specimen. o If Initial heel stick blood glucose is < 25 mg/dL, continue skin to skin, feed infant measurable amount and notify NBN LIP Note: Measurable amount of supplementation is 3-5 mL/kg and can be expressed breast milk, donor milk, or formula. May feed infant by cup, syringe, spoon, or bottle. Note: If after 2nd feeding the blood glucose is < 25mg/dL, notify NBN LIP for disposition of infant and continue skin to skin o If initial heel stick glucose is 25-40 mg/dL, continue skin to skin, feed measurable amount and recheck heel stick blood glucose one hour after initiation of feed. a. feed with a measurable amount of supplementation b. check the blood glucose 1 hour after initiation of feeding c. keep skin to skin Initial heel stick glucose is ≥ 41 mg/dL may feed the infant every 2-3 hours and check BG prior to each feed. NURS 0147 Page 18 of 33 Date this Version Effective: Feb 2016 o Normal Newborn Infant Care After 4 hours of life: Feed all at-risk asymptomatic newborns every 2-3 hours. Obtain heel stick glucose prior to each feeding. o If the heel stick blood glucose is < 35 mg/dL feed infant measurable amount and notify NBN LIP o If the heel stick blood glucose is 35-45 mg/dL a. feed with a measurable amount of supplementation b. check the blood glucose 1 hour after initiation of feeding c. notify NBN LIP if no improvement o If the heel stick blood glucose is > 46 mg/dL may feed the infant every 2-3 hours and check BG prior to each feed Evaluate all infants carefully who demonstrate any of the following signs and/or symptoms: o Inability to suck or swallow o Intolerance of feedings o Heel stick glucose concentration that does not increase after a feeding o Total supplementation exceeding 10 mL/kg Evaluate heel stick sites every shift for skin breakdown and/or signs of infection and provide wound care when appropriate. 5. Safety Any infant that becomes symptomatic at any point during the implementation of the algorithm needs to be evaluated by a LIP in the NBN or NCCC immediately. Notify NBN LIP if infant has not passed protocol by 12 hours of life. Per algorithm except for LIP or RN requested spot checks based on clinical judgment once monitoring of the heel stick glucose is initiated, three consecutive screenings ≥46 mg/dL must be obtained prior to discontinuing BG checks. If BG values during birth-4hrs of life are ≥41 they may be included in the 3 consecutive passing values. Heel stick values are a screening tool, and may be confirmed by a formal laboratory plasma glucose value for formal diagnosis. 6. Patient/Caregiver Teaching Discuss causes and symptoms of hypoglycemia. Instruct parents to notify nursing staff if newborn does not actively suck during feedings or demonstrates other symptoms of hypoglycemia. Emphasize importance of skin-to-skin contact and frequent feedings for achieving and maintaining stable blood glucose levels of hypoglycemic newborns. Note: Inform parents that oral feedings and skin-to-skin contact usually may continue during IV glucose therapy if infant is transferred to NCCC. Reassure breastfeeding mothers that hypoglycemia is not usually a consequence of underfeeding or inadequate milk supply and that if supplementation is required, it is only temporary. Instruct mother on use of hand expression and breast pump as soon as NURS 0147 Date this Version Effective: Feb 2016 Page 19 of 33 Normal Newborn Infant Care possible if infant is not latching well or is transferred to NCCC. Provide lactation contact information. Encourage verbalization of questions or concerns. 7. Documentation Document in patient’s electronic medical record: o Assessment findings o Interventions and patient responses/outcomes o Reported conditions o Feeding attempts o Amount, type and method of supplement, if given o Patient/caregiver teaching and level of understanding o Accepting Neonatal team’s (NCCC) discussion of transfer/pending transfer of the infant with the family NURS 0147 Date this Version Effective: Feb 2016 Page 20 of 33 Figure 1. UNC algorithm for infants at risk for hypoglycemia NURS 0147 Date this Version Effective: Dec 2015 Page 21 of 33 Phototherapy Altered metabolism of bilirubin is a common problem during the first week after birth. Excessive bilirubin production or altered hepatic clearance of bilirubin can lead to hyperbilirubinemia, a condition associated with kernicterus, especially in preterm and sick newborns. Common causes of hyperbilirubinemia include: fetomaternal blood group incompatibilities; congenital enzyme deficiencies; extensive bruising or cephalohematoma; sepsis; polycythemia; delayed passage of meconium; and altered hepatic function. Hyperbilirubinemia should be suspected in the following situations: onset of jaundice within 24 hours after birth; persistent jaundice (greater than one week in the term infant, greater than two weeks in the preterm infant); or a rise in total bilirubin of greater than 5 mg/dl per day. Phototherapy oxidizes bilirubin into water-soluble components for excretion and can be given via, Bili-lights (neoBLUE ™ LED Phototherapy light), traditional bank lights, BiliBed™, or Bili-blanket . Note: Severe neonatal hyperbilirubinemia (> 30mg/dL) is considered a sentinel event and should be reported to Risk Management. 1. Assessment Assess every 4 hours: skin, sclera, and mucous membrane color, i.e. bronzing and jaundice eyes, noting presence of edema, irritation and drainage axillary temperature (normal: 36.4°C- 37.5 C) Obtain rectal temperature if outside these parameters intake and output (feeds, voids, and stools) level of consciousness and activity, e.g. irritability, jitteriness, lethargy, seizure activity 2. Notify LIP abnormal temperature feeding problems, i.e. weak suck, inability to ingest and retain adequate fluids dehydration (urine output <1 ml/kg/hr.) delayed passage of meconium absence of stools for 24 hours lethargy signs of hypoglycemia, e.g. tremors/jitteriness seizure activity respiratory distress drainage from eyes abnormal lab results 3. Nursing Care a. Obtain an order to monitor results of: initial blood typing (mother and newborn) and direct and indirect Coombs serum total/direct bilirubin NURS 0147 Date this Version Effective: Dec 2015 Page 22 of 33 Normal Newborn Infant Care Hct/Hgb and/or CBC with differential if ABO incompatible with positive COOMBS b. If phototherapy is ordered via Bili-lights (neoBLUE™ or traditional bank lights) follow the steps/notes below: Note: For neoBLUE ™ LED Phototherapy, a setting of ‘high’ corresponds with intensive phototherapy traditionally known as double or triple phototherapy. A setting of ‘low’ corresponds to conventional phototherapy traditionally known as single phototherapy. o Phototherapy can be provided in the mother's room. This is optimal to promote nonseparation of mother and infant. Undress infant completely (except for diaper) while maintaining a neutral thermal environment with a radiant heat source. Cover eyes with a bili mask. Position infant comfortably but for maximum exposure. Turn Bili-lights on. Position neoBLUE ™ LED Phototherapy light 12 inches (30.5cm) from infant. Maintain distance of traditional bank Bili-lights 15 to 18 inches from patient (over bassinette side panels). Hold infant for feedings: Use bili blanket during feedings if possible. remove mask o place infant skin-to-skin or dress/cover infant o resume phototherapy immediately after feedings Note: Infants may be held and fed only for feedings of less than 45 minutes. Change mask when loose or soiled. Encourage parents to care for infant during feedings (30-45 minutes when formulafeeding or up to one hour when breastfeeding) unless contraindicated. c. If phototherapy is ordered via BiliBed™ follow the steps/notes below: Place BiliBed™ in the bassinette after removing mattress. Place the infant in the Bili-Combi™. Secure the Bili-Combi™ (and the infant) to the bed with the Velcro® strips. Turn the bed on. Note: The BiliBed™ can remain on while giving care, but bed should be off while holding and feeding. d. If phototherapy is ordered via Bili-blanket follow the steps/notes below: Place Bili-blanket under infant's clothing. Position infant comfortably. Transport babies with Bili-blankets to mother's rooms, if appropriate. Change Bili-blanket cover when loose or soiled. NURS 0147 Date this Version Effective: Feb 2016 Page 23 of 33 Normal Newborn Infant Care May leave eyes uncovered when Bili-blanket is used alone unless infant is premature or undressed, eyes must be covered. Turn Bili-blanket off while giving care (Bili-blanket may remain on when holding /feeding infant). e. Maintain patient temperature between 36.4 and 37.5C. f. Change position every four hours. g. Obtain an order to administer glycerin chip per rectum if no stool for 24 hours. 4. Safety a. Cover eyes continuously when infant is under Bili-lights. b. Do not apply lotions, creams, or oils to infants receiving phototherapy in order to prevent burns. c. Use principles of each light source for combined therapy. 5. Parent/Caregiver Teaching a. Depending on the situation, the nurse may instruct caregivers and/or reinforce the importance of treatment, length of treatment, lab tests, and sufficient fluid. b. Instruct parents to keep infant's eyes covered during phototherapy unless using a Biliblanket only. c. Emphasize length of time infant may be out from under Bili-lights (no longer than 45 minutes). d. Instruct parents/caregiver to inform nurse of intake and output. e. Instruct parents/caregiver to notify infant's nurse if infant refuses feeding or displays change in activity level, e.g. twitching, tremors, lethargy. 6. Documentation Document in patient’s electronic medical record: o additional interventions o assessment findings o interventions and patient responses/outcomes o reported conditions o parent/caregiver teaching and level of understanding NURS 0147 Date this Version Effective: Feb 2016 Page 24 of 33 Normal Newborn Infant Care Bilirubin: Figure 2 Please check a transcutaneous bilirubin (TCB) on all babies after 24 hours of life with batched screening. If TCB >7, RN to order neobili with newborn screen. Use Bilitool.org to evaluate risk zone for infant. If “HIGH RISK ZONE” RN to draw neobili STAT (may be drawn with newborn screen if lab available.) Notify LIP with results. www.bilitool.org Late preterm infants will continue to have serum bili done at 24 hours with newborn screen. Obtain TCB daily on any infant <37 weeks gestation. After first 24 hours of age, draw and send neonatal bilirubin if subsequent TCB > 12. Day of Discharge- Obtain TCB. RN to order serum if TCB >12. Note: Refer to bilitool.org to assess “light level” for phototherapy treatment based on results of neobili and risk level per AAP guideline. Risk factors include: <37 weeks gestation, hemolytic disease, asphyxia, lethargy, temperature instability, sepsis, acidosis, albumin <3.0g/dL Nursing Care Activate order for serum bilirubin if TCB is as described in this protocol under the transcutaneous bilirubin screening guidelines by ordering a NEW Serum Neobili Order- nursing cannot use the nursing order for prn neobili as it does NOT communicate with the lab computer system. Risk Zone Light Level NURS 0147 Date this Version Effective: Feb 2016 Page 25 of 33 Normal Newborn Infant Care Newborn Circumcision Care LIP discusses advantages and disadvantages of circumcision with parent (s)/caregiver. If circumcision is chosen, the LIP will explain the procedure and pain management to the parent (s)/caregiver. The American Academy of Pediatrics (AAP) states that there may be some reduction in STD’s (sexually transmitted disease) transference in circumcised males. The AAP states that procedural analgesia should be provided, endorsing the dorsal penile block or ring block, and physiological positioning. 1. Assessment a. Observe infant during procedure for: signs and symptoms of pain spitting up/choking respiratory distress b. Observe circumcision site after procedure for bleeding, if still in hospital: q 15 minutes x 2 or q 15 minutes until bleeding stops c. Assess effective pain relief, if still in hospital: q 30 minutes x 3 then q 4 hours x 24 hours d. Assess for signs of infection q shift or with every Vaseline gauze dressing change or diaper change. e. Monitor occurrence of voids. 2. Notify LIP continued oozing from circumcision site bleeding from site which cannot be controlled by direct pressure NURS 0147 Date this Version Effective: Feb 2016 Page 26 of 33 Normal Newborn Infant Care signs of infection, purulent drainage or excessive irritation of site failure to void within 8 hours after procedure 3. Nursing Care a. Withhold feedings a minimum of one hour prior to procedure. b. Maintain thermo-neutral environment to prevent cold stress. c. Obtain an order to apply topical anesthetic cream to the foreskin in the area of the incision and to the penile block site one hour prior to the procedure. d. Offer infant pacifier dipped in 24% sucrose 2 minutes prior to and during procedure. Note: 24% sucrose may be administered via syringe (0.1-0.2mL) to breastfed baby e. Obtain an order to maintain thermo-neutral environment to prevent cold stress. f. Ensure that all required equipment is at the bedside for the penile block and circumcision. g. Place infant on padded Circumstraint board immediately prior to procedure. h. Secure restraint on lower extremities. i. Secure upper extremities or swaddle upper body with a blanket. j. Set timer for 5 minutes to designate wait period between administration of penile block and procedure. k. Remove infant from board immediately after procedure, rewrap, and return to crib/isolette for 15 minutes of nursing observation in the newborn nursery. l. Cleanse circumcision site during the first 24 hours only when gauze is soiled by stool: do not rub area, may cause bleeding. gently squeeze water and non-alkaline soap over site rinse with water and pat dry m. Cleanse site after 24 hours with non-alkaline soap and water with each diaper change until site is healed. n. Change the Vaseline gauze within the first 24 hours if the dressing becomes soiled with stool. o. Obtain an order to apply Gelfoam to site for bleeding. 4. Safety Check immediately prior to procedure that: a signed consent form is in chart Note: Use a hospital interpreter for the explanation of consent with non-Englishspeaking parent/caregiver. infant's identification band is on and correctly matched to mother (Newborn Nursery only) Obtain an order to discharge after circumcision if circumcision site has not bled for one hour breastfeeding infant breastfed well at least once before circumcision NURS 0147 Date this Version Effective: Feb 2016 Page 27 of 33 Normal Newborn Infant Care 5. Patient/Caregiver Teaching a. Instruct the mother/caregiver that infant discomfort and anesthetic may interrupt breastfeeding. b. Give mother/caregiver UNC Healthcare teaching booklet “Caring for Yourself and Your Baby” and one-page patient education guide “Circumcision: A Choice” (available in Spanish and English). c. Instruct mother/caregiver to observe site every 15 minutes for bleeding during first hour post-procedure or more often if excessive bleeding has occurred. d. Instruct mother/caregiver to report any of the following: infant’s first void post-procedure, if still in the hospital bleeding from site signs and symptoms of infection (e.g., drainage with a foul odor) e. Demonstrate to parent(s)/caregiver: genital care/circumcision site care application of Vaseline gauze 6. Documentation Document in patient’s electronic medical record o time of medication/sucrose administration o time block administered and the time procedure begins and ends o LIP performing procedure o use of Vaseline gauze o assessment findings o interventions and patient responses/outcomes o reported conditions o parents’/caregivers’ level of understanding Care of the Newborn using Safe Sleep Guidelines for Newborn Nursery 1. Assessment Place infants on their backs to sleep for every sleep in the infant’s bassinet Observe infants sleeping position each hour during rounding. 2. Notify Licensed Independent Practitioner (LIP) Vital signs outside normal/ordered parameters. 3. Nursing Care Place infants on their backs to sleep for every sleep in the infant’s bassinet Place Infant on a firm sleep surface such as a crib mattress covered with a fitted sheet. Advise Room-sharing without bed-sharing is recommended NURS 0147 Date this Version Effective: Feb 2016 Page 28 of 33 Normal Newborn Infant Care a) The infant’s crib or other sleeping device should be placed in the parent’s bedroom close to the parent’s bed. b) Infants may be brought into the bed for feeding or comforting but should be returned to their own crib when the parent is ready to return to sleep. c) Infants should not be fed on a couch or armchair when there is a high risk that the parent might fall asleep. Avoid soft objects and loose bedding in the crib 4. Patient/caregiver teaching All Health care professionals, caring for Newborn infants should endorse safe sleep recommendations from birth. 5. Caregiver Education a. See Figure 3 6. Documentation Complete documentation on infant’s sleep position in the patient’s electronic medical record. Document completed safe sleep teaching in the infant’s electronic medical record. Figure 3 Teaching points for parents of Newborn infants Teaching Point Rationale Comments Sleeping Position: Place infants on their backs to sleep a. for every sleep. Have parents communicate this “back to sleep” message with everyone who cares for their infant. The risk of SIDS is 7 to 8 times higher among infants who normally sleep on their backs when placed on their stomachs to sleep. Side positioning is not recommended.b. Side lying is an unstable sleeping position because the If swaddling is needed for comfort or infant can more easily roll to the thermoregulation, swaddle below the prone position axilla. Once an infant can roll from supine to prone and from prone to supine, the infant can be allowed to remain in the sleep position that he or she assumes. Avoid overheating. Do not cover the infant’s face or head. Infants should be dressed in no more than 1 layer more than an adult would wear to be comfortable in that environment. Supervised, awake tummy time is recommended to facilitate development and to minimize development of positional plagiocephaly. NURS 0147 Date this Version Effective: Feb 2016 Evaluate infants for signs of overheating, such as sweating or the chest feeling hot to touch. There is insufficient evidence to recommend use of a fan. Tummy time is recommended on a daily basis, beginning as early as possible. Page 29 of 33 Normal Newborn Infant Care Sleeping Surface and Area Pillows or cushions should not be substituted for mattresses or in addition to a mattress. Couches, adult mattresses, futons, etc. are not considered a firm sleeping surface. Appropriately sized sleep sacks/blanket sleepers are optimal; avoid blankets and other loose bedding. Sitting devices, such as car safety seats, strollers, swings, infant carriers and infant slings are not recommended for routine sleep in the hospital or at home. Bed sharing with anyone, including parents, other children and particularly multiples is not safe. Pets also pose a threat to sleeping infants. No bumper pads, stuffed toys or any other objects in the crib. Avoid commercial devices marketed to reduce the risk of SIDS, plagiocephaly and acid reflux (products include wedges, positioning aids, rolled blankets). Avoid plagiocephaly by: limiting time in car seats, carriers, bouncers, and other devices; encourage “cuddle time” (bonding) by holding Infant’s orientation in crib should be changed regularly. Monitors are only machines and are not substitutes for direct observation. There is no evidence that these devices reduce the risk of SIDS or suffocation, or that they are safe Do not use home cardiorespiratory monitors as a strategy to reduce the risk of SIDS. Smoking/Smoke Clothing exposed to secondhand smoke should be changed, or a cover gown provided, prior to handling infants. Wash hands after smoking and before touching infant. Encourage families to set strict rules for smoke-free homes and cars to eliminate secondhand smoke. Feeding and Positioning Breast feeding is recommended Infants may be brought into bed for feeding or comforting but should be returned to their own bed when the NURS 0147 Date this Version Effective: Feb 2016 Infants should receive only breast milk for the first 6 months of life. For breastfed infants, avoid Page 30 of 33 Normal Newborn Infant Care parent is ready to return to sleep. The infant’s crib, portable crib, play yard or bassinet should be placed in the parent’s room, close to their bed, making it more convenient for feeding and contact. .Infants should not be fed/held on a couch, armchair or in bed when there is a high risk that the parent might fall asleep. pacifier use until breastfeeding is firmly established (approx. 1 month). Do not force an infant to take a pacifier. Educate parents that pacifiers should not be coated in any sweet solution, hung around the infant’s neck or attached to clothing while sleeping. The pacifier does not need to be reinserted once the infant falls asleep. Pacifiers should not be placed around the infant’s neck or attached to clothing during sleep. Stuff toys should not be attached to the pacifier. Consider offering a pacifier at nap time and bedtime. Skin-to-skin is another method of thermoregulation but should be used only when mother is awake. The protective effect of breastfeeding increases with exclusivity. However, any breast milk feeding has been shown to be more protective against SIDS than formula feeding. Prevention of SIDS Pregnant women should receive regular prenatal care There is no evidence that there is a casual relationship between immunizations and SIDS. Recent evidence suggests that immunizations might have a protective effect against SIDS. Avoid smoke exposure during pregnancy and after birth. Infants should be immunized in accordance with the recommendations of the AAP and Center for Disease Control (CDC) The protective effect persists throughout the sleep period even if the pacifier falls out of the infant’s mouth. Avoid alcohol and illicit drugs during pregnancy and after birth. Avoid commercial devices marketed to reduce the risk of SIDS. NURS 0147 Date this Version Effective: Feb 2016 Page 31 of 33 Normal Newborn Infant Care IV. References Alden, K. (2011). Physiologic and behavioral adaptations of the newborn. In Lowdermilk, D. & Perry, S.(Editors) Maternity & Women’s Health Care (10th ed.) (pp. 639-641). St. Louis: Mosby/Elsevier. American Academy of Pediatrics (2012). Male Circumcision. Pediatrics, 130(3). P. 756-785. American Academy of Pediatrics (2011). Postnatal glucose homeostasis in late-preterm and term infants. 127(3). p. 575-579 American Academy of Pediatrics Policy Statement: SIDS and other Sleep- Related Infant Deaths: Expansion of Recommendations for a Safe Infant Sleeping Environment. Pediatrics 2011;128;1030 American Academy of Pediatrics, Task Force of Sudden Infant Death Syndrome. (2011). SIDS and Other Sleep-Related Infant Deaths: Expansion of Recommendations for a Safe Infant Sleeping Environment. Pediatrics, 128(5), 1030-1039. American Academy of Pediatrics Technical Report: SIDS and other Sleep-Related Infant Deaths: Expansion of Recommendations for a Safe Infant Sleeping Environment. Pediatrics 2011; 128; e1341 Baddock SA, Galland BC, Bolton DP, Williams SM and Taylor BJ. (2012). Hypoxic and Hypercapnic Events in Young Infants During Bed-Sharing. Pediatrics, 130, 237-244 Becher, Bhushan & Lyon: “Unexpected Collapse in Apparently Health Newborns-a Prospective National Study of a Missing Cohort of Neonatal Deaths and Near-Death Events”, ADC Fetal and Neonatal Edition(2012). 97; F30-F34. Helsley L, McDonald JV and Stewart VT. (2010) Addressing In-Hospital Falls of Newborn Infants. The Joint Commission Journal on Quality and Patient Safety, 36(7), 327-333 Lowdermilk, D.L., & Perry, S.E. (2011). Maternity & Women’s Health Care. (10th ed.). St Louis: Mosby. Merenstein G and Gardner S(2011) Handbook of Neonatal Intensive Care (7th ed). Maryland Heights MO: CV Mosby/Elsevier Moon RY, Oden RP, Joyner BL and Ajao TI.(2010) Qualitative Analysis of Beliefs and Perceptions about Sudden Infant Death Syndrome in African American Mothers: Implications for Safe Sleep Recommendations. Journal of Pediatrics, 157, 92-7 National Association of Neonatal Nurses position statement on co-bedding of twins and higherorder multiples. Retrieved 2/3/13 from http://www.nann.org/uploads/files/Cobedding_of_Twins_or_Higher-Order_Multiples_2011.PDF neoBLUE LED Phototherapy. Hospital Inservice. http://www.natus.com/documents/051693E.pdf Schnitzer PG, Covington TM and Dykstra HK.(2012) Sudden Unexpected Infant Deaths: Sleep Environment and Circumstances. American Journal of Obstetrics, Gynecologic and Neonatal Nursing, 39, 618-626 Trachtenberg FL, Haas EA, Kinney HC, Stanley C and Krous HF.(2012) Risk Factor Changes for Sudden Infant Death Syndrome After Initiation of Back-to-Sleep Campaign Pediatrics, 129,630-638 Vennemann MM, Hense HW, Bajanowski T, Blair PS, Complojer C, Moon RY, and KiechlKohlendorfer U.(2012) Bed Sharing and the Risk of Sudden Infant Death Syndrome: Can We Resolve the Debate? Journal of Pediatrics, 160,44-48 NURS 0147 Date this Version Effective: Feb 2016 Page 32 of 33 Normal Newborn Infant Care Verklan MT and Walden M (2010). Core Curriculum of Neonatal Intensive Care Nursing (4th ed). Philadelphia PA:Saunders. V. Reviewed/Approved by Nursing Policy Committee, Women’s CPG, UNC Pediatrics VI. Original Policy Date and Revisions Oct 1990, Jan 1992, Sep 1992, Dec 1992, Dec 1993, Feb 1994, Apr 1994, Dec 1996, Feb 1997, Apr 1997, Jan 1999, Oct 1999, Mar 2000, Nov 2007, Aug 2008, May 2010-i, July 2010-i, Aug 2010-i, Jan 2011-i, April 2011-i, Aug 2011, Oct 2011-i, August 2013-i, Sept 2013-i, Oct 2014, Apr 2015-I, Dec 2015-i NURS 0147 Date this Version Effective: Feb 2016 Page 33 of 33
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