1. Common calls from the Well Newborn Nursery

2. “Infant A has a temperature of 95 F. What would you like me to do?” What temperature is “normal” in a newborn? - above 97 degrees F

3. Clarification questions How old is the baby? What is the context of the low temperature? i.e right after delivery, after a bath, unswaddled/undressed infant? Where was the temperature taken? Is the prenatal/delivery/maternal history concerning? How does the baby look? What are the rest of the vital signs?

4. Next steps If exam is normal, ok to observe Warmer Obtain a repeat temperature in another hour

5. “Infant B on routine vital signs has a HR of 98. What would you like me to do?” What is normal HR in a newborn? – Average is 120 (range 80-160)

6. Clarification questions Was the baby awake or asleep? Is the HR “Reactive” How does the baby look? What are the other vital signs? Is the baby cold? Is the prenatal/delivery/maternal history significant? E.g maternal SLE Was mother taking any medications? Magnesium, Digoxin, CCBs, beta blockers Is there a family history of cardiac problems?

7. What could you do? Examine the baby Repeat HR in 30 mins Observe for recurrence Do an EKG

8. “Infant C has a HR of 170. What would you like me to do?” Normal HR?

9. Clarification questions What are the other vital signs? Is baby febrile? Was baby under the radiant warmer and overheated? How does the baby look? Is the prenatal/delivery/maternal history significant? E.g maternal temp, hyperthyroidism, smoking, caffeine How is the baby feeding? Evaluate for dehydration Family history of heart problems?

10. What could you do? Examine the baby EKG Sepsis evaluation

11. “Infant D just came up from delivery and is breathing in the 80s” What is normal RR in a newborn? – 40-50

12. Clarification questions What are the rest of the vital signs including oxygen saturation? What kind of delivery was this? What was the resuscitation? Any known cardiac problems? How does the baby look? Are breath sounds equal bilaterally?

13. What could you do? Observe and allow transition (think about the severity of respiratory symptoms and comfort of nursing staff) Examine the infant Sepsis evaluation CXR

14. “Infant E has a head circumference of 28 cm” What’s normal head circumference?

15. Clarification questions How does the baby look? Is there obvious microcephaly? Any known prenatal history? Any significant maternal history? What are the other growth parameters?

16. What should you do next? Re-measure the HC

17. Its 3am “Infant F has not stooled in 24 hrs” When should a newborn have stooled by? – 92% will have passed meconium by 24hrs of life

18. Clarification questions How does the baby look? What are the vital signs? How is feeding going? Did the baby stool at delivery? Did Dad or another family member toss out a poopy diaper? Is the prenatal history or prenatal ultrasounds significant?

19. What could you do? Observe till am Examine the infant – Look for anal disorders, spina bifida Confirm that the stooling is delayed or not Consider sepsis evaluation AXR Barium enema Gentle stimulation of the rectum

20. Its 4am “Infant G has not urinated in my shift” What’s normal expectation for urine in a newborn? – 92% will urinate in the 1 st 24 hrs

21. Clarification questions How old is the infant? Could the diaper have been missed? Was it mixed with stool? What is the infant’s intake for the day? Prenatal history or ultrasound significant? Does the infant have an dysmorphic facies? Assess infant’s hydration status

22. What could you do? Increase fluid intake if poor Increase frequency of feeds Observe for a few more hours Consider renal U/S Examine the infant Could catheterize the infant Suprapubic pressure

23. It’s 1 am “Baby’s TCB was elevated so we checked a serum bilirubin and it was 15” Infant is 36 hrs old, ex 36 week gestation, Mother is O+, baby is B+, coombs neg, breastfeeding with some supplementation. Weight loss is 8%

24. Clarification questions How old is the baby? How is feeding going? Is infant voiding and stooling? Any pertinent family history? What are this infant’s jaundice risk factors? What risk curve would you select for this baby?

25. Next steps What your next steps in management? Any additional lab work to consider? When would you check the next bili?

28. “Infant H is 20 hrs old and mother would like to go home.” When do babies generally go home?

29. What are the AAPs minimum criteria for discharge at <48hrs 1.The antepartum, intrapartum, and postpartum for both mother and neonate are uncomplicated. 2.Delivery was vaginal. 3.Single AGA birth at 38–42 wk of gestation 4.At discharge, the baby has just had 12 hr of stable vital signs, including a respiratory rate below 60/min, a heart rate of 100 to 160 beats per min, and the ability to maintain a body temperature in an open crib with typical newborn clothing of 36.1–37.0°C. 5.The baby has urinated and passed at least one stool. 6.The baby has finished at least two successful feedings, and it is documented that it can suck, swallow, and breathe while feeding. If breast-feeding, an actual feeding should be observed by a knowledgeable caregiver. 7.Physical examination shows no abnormalities that require continued hospitalization. 8.If circumcised, there was no evidence of excessive bleeding at the site for at least 2 hr. 9.There is no visible jaundice in the first 24 hr of life (the editor strongly believes that all children should have a percutaneous or serum bilirubin measurement prior to discharge). 10.The mother's (or preferably both parents') knowledge, ability, and confidence to provide adequate care for the neonate are documented by the fact that the following training and information have been received. – Condition of the neonate – The breast-feeding mother–neonate dyad should be assisted by trained staff regarding nursing position, latch on, and adequacy of swallowing – Knowledge of appropriate urine and stool frequency – Umbilical cord, skin, and infant genital care – Temperature assessment and use of thermometer – Recognition of illness, particularly jaundice – Instruction in proper newborn safety, including use of a car seat and BACK TO SLEEP

30. 11.Support people such as family members or health care providers are available to the mother to discuss newborn's care, lactation, jaundice, and dehydration in the first few days after discharge. 12.Parents know what instructions to follow in the event of a complication or emergency. 13.Laboratory data are available and reviewed, including maternal syphilis, hepatitis B virus surface antigen, HIV status, cord or infant blood type, and direct Coombs' test if indicated. 14.Screening tests are performed in accordance with state regulations 15.Initial hepatitis B vaccine is administered or a scheduled appointment for its administration has been made within the first week of life. 16.A source of continuing medical care for the mother and baby is identified. 17.A definite appointment is made for the baby to be examined within 48 hr. The follow-up visit can be made in the home or office, as long as the person evaluating the newborn is knowledgeable and competent about newborns, and reports the results of the visit to the family doctor or designee. 18.Family, environmental, and social risk factors have been discussed as well as assets. When risk factors are present, the discharge should be delayed until they are resolved or a plan to safeguard the newborn is in place. Factors include but are not limited to – Untreated parental substance abuse or positive urine toxicology test in mother – Past history of child abuse or neglect – Mental illness in a parent – Lack of social support – Lack of fixed home – History of untreated domestic violence – Adolescent mother