Current Scope of Practice for Newborn Care in Non-Intensive Hospital Settings

The scope of practice for newborn care in nonintensive hospital settings is ever changing, with obstetric care advances, shorter length of stay (LOS), and increased family-centered care.1 In response to the US Surgeon General’s call to support breastfeeding and Baby Friendly USA, more infants receive care in their mothers’ rooms.2,3 Newborn clinicians require skills including diagnostic expertise and critical thinking, adaptability and sensitivity, and an understanding of this critical period of infant bonding. They also require leadership skills to manage hospital policies and link families with targeted community resources.This overview is based on the experience and research of a working group of the Academic Pediatric Association Newborn Nursery Special Interest Group (NN SIG), which consists of medical directors and physicians with expertise in newborn care from across the United States. The workgroup consisted of 17 newborn physicians ranging from young faculty to full professors at urban and rural academic and community hospitals in 17 cities and 12 states. Led by the immediate-past NN SIG co-chair, the group determined the article outline and content over 7 monthly, hour-long teleconferences. Over the subsequent 6 months, group content experts drafted each section on the basis of published guidelines and evidence. All sections were reviewed and vetted by the group and compiled into this Special Article, which is meant to fill gaps in the literature by addressing the current scope of practice for newborn clinicians, including 7 common clinical topics, newborn screening, anticipatory guidance, and provider tools. This overview is meant for novice and seasoned physician and nonphysician clinicians interested in newborn care in Level 1 nurseries (ie, well-newborn nurseries)4 in academic and community settings. It provides useful information for those interested in a career involving newborn care, in general pediatrics, and/or pediatric hospital medicine as a subspecialty.5Practitioners with varied educational backgrounds and expertise care for newborns during birth hospitalization. Depending on state law, nurse practitioners and physician assistants provide newborn care, with or without licensed physician supervision.6 Medical directors have responsibilities beyond direct patient care, which are summarized in Table 1.All newborn clinicians should be well versed in taking a newborn’s history and performing an examination to identify common findings and rare anomalies. Examinations conducted in the presence of families provide reassurance that their newborns are healthy, facilitate family involvement, and allow questions to be addressed. Expertise accrued after caring for a high volume of newborns may prevent unnecessary or invasive testing or imaging. Newborn clinicians need to work as part of a multidisciplinary team that includes those mentioned above, obstetricians, nurses, nurse midwives, lactation specialists, social workers, case managers, and/or persons in training across the health professions. The clinical team shares the responsibility of educating families about routine care, providing anticipatory guidance, and considering birthing plans on the basis of varying beliefs, traditions, and values.Newborn nursery medical directors should address care quality, expand knowledge through research and teaching, and stay current with changing guidelines by using resources such as the Academic Pediatric Association Better Outcomes through Research for Newborns (BORN) network,7 the NN SIG, and the American Academy of Pediatrics (AAP) Section on Hospital Medicine.Newborn clinicians should be familiar with routine care, including recommendations for vitamin K administration to prevent hemorrhagic disease of the newborn, hepatitis B vaccination (HBV), and erythromycin ointment to prevent gonococcal ophthalmia neonatorum.8–10 In this section, 7 common topics are discussed in the context of current evidence and practices. Table 2 provides Web-based tools and resources.The AAP, the Academy of Breastfeeding Medicine (ABM), and the US Surgeon General’s Call to Action emphasize the central role of clinicians in promoting and supporting breastfeeding.2,11,12 Approximately 80% of US mothers initiate breastfeeding, but <20% exclusively breastfeed for the recommended 6 months.2,13 In 2014, the Joint Commission added a core measure to track exclusive-breastfeeding rates for hospitals delivering ≥1100 infants annually.14 Hospitals should routinely promote exclusive breastfeeding and incorporate the World Health Organization and United Nations International Children’s Fund (WHO/UNICEF) “Ten Steps to Successful Breastfeeding.”2,11,12Policies that promote skin-to-skin (STS) immediately after delivery, breastfeeding within the first hour, and rooming-in with the mother are associated with increased breastfeeding initiation, duration, and exclusivity.11,15 The clinical team should offer families access to lactation specialists and community resources. Most pediatric training programs provide limited breastfeeding education, and attitudes and practices vary among pediatricians.16,17 Clinicians can obtain additional training by participating in the AAP Section on Breastfeeding, International Board Certified Lactation Consultant (IBCLC) certification, and the ABM.11,18,19Early, frequent feeding is critical for breastfeeding success,15,20 but it may be difficult for some mother-newborn dyads. Early hand expression (demonstrated by a trained lactation consultant or nurse), when compared with pumping in the first few postpartum days, is associated with longer breastfeeding duration and larger expressed breast milk volume.21,22 To prevent excess weight loss and dehydration, breastfed newborns should be monitored with daily weights, understanding that weight loss may be more pronounced in those born via cesarean delivery.23 The Newborn Weight Tool (Newt; Table 1), according to data from >160 000 newborns, allows clinicians to assess an infant’s weight in comparison with that of other newborns while taking into account his or her delivery mode and feeding method.24When determining the safety of maternal medications, it is important to consider the drug indication, impact on lactation, solubility and transfer into breast milk, absorption by infant mucosa, and the potential effect on the infant.25 Most medications are compatible with breastfeeding, and evidence-based resources like LactMed (Table 2) can help clinicians. Maternal use of illicit substances, rising opioid-use disorder rates, and marijuana legalization present added challenges. Mothers in a stable treatment program and on opioid-maintenance therapy with methadone or buprenorphine should be encouraged to breastfeed on the basis of associated reductions in neonatal abstinence syndrome (NAS) duration and severity, and LOS (see the Maternal Substance Use and NAS section).11,26 The AAP and ABM do not support marijuana use among breastfeeding mothers because of the lipid-soluble properties of the psychoactive substance in marijuana, δ-9-tetrahydrocannabinol, and potential adverse effects on the developing brain.11,26All newborns should have outpatient follow-up within 2 to 3 days of discharge27 to support breastfeeding, assess weight loss, and monitor jaundice. Further studies are needed to understand the impact of donor milk and human-milk fortifier on late-preterm and term infants and the impact of pacifier and formula use on breastfeeding duration and exclusivity.Up to 60% of term newborns develop jaundice in their first week.28 AAP guidelines provide strategies for addressing jaundice in infants born at ≥35 weeks’ gestation.29 Clinicians should examine all newborns for jaundice with the understanding that bilirubin prediction based solely on examination is unreliable. Therefore, hospitals may employ targeted or universal predischarge measurement of total serum bilirubin (TSB) and/or transcutaneous bilirubin (TcB).29 The risk of developing severe hyperbilirubinemia can be estimated by plotting TSB levels on the Bhutani nomogram29,30 or by using an online assessment tool such as BiliTool (Table 2). Although the Bhutani nomogram identifies infants of ≥35 weeks’ gestation who are at risk for significant hyperbilirubinemia,31 this tool should be used to inform, not dictate, clinical care. TcB measurements are best used when TSB levels are estimated to be <15 mg/dL and are relatively easy and painless29,32; however, result discrepancies may occur in neonates of African descent, and levels may vary on the basis of the type of TcB meter being used.32Phototherapy, which is effective in treating unconjugated hyperbilirubinemia, has reduced the need for exchange transfusion. Current guidelines recommend that phototherapy be applied to the maximal body surface area with appropriate irradiance.33 In many hospitals, newer technology lights with higher irradiance and lower heat output have replaced the “double” and “triple” phototherapy of the past.33 Effective phototherapy can be delivered while avoiding mother-infant separation,34 and clinicians should be selective in its use. In addition to the well-known risks of insensible water loss and retinal damage, a concern for an increased risk of infantile cancer35 and a lower likelihood of exclusive breastfeeding at 4 months have been found among those with a history of phototherapy.36Discharge timing for jaundiced newborns should be based on the availability of outpatient office, laboratory, and home care services; and follow-up should be guided by gestational age (GA) and other clinical risk factors. Home phototherapy and nursing visitation, including the ability to assess TSB levels, are options for outpatient management.Research reveals a complex genetic pattern that influences neonatal jaundice, including genetic mutations in glucose-6-phosphate dehydrogenase coding and polymorphisms related to enzymes involved in hepatic bilirubin uptake and conjugation.37,38 Further genetic research may influence future algorithms for hyperbilirubinemia risk assessment.Group B streptococcus (GBS) remains the leading cause of neonatal sepsis and meningitis in the United States despite an 80% decline in early-onset GBS disease after routine use of intrapartum antibiotic prophylaxis.39 In 2010, the Centers for Disease Control and Prevention (CDC) updated guidelines for perinatal GBS disease prevention.40 In 2011, Puopolo et al41 described a predictive model based on maternal information to establish a probability guide for sepsis management; the resultant “Neonatal Sepsis Calculator” (Table 2) takes into account a newborn’s clinical status.42 Evaluation and management of neonates at risk for sepsis varies, with some hospitals following the CDC guidelines and others using the “Neonatal Sepsis Calculator” or different combinations of laboratory tests, including complete blood counts with differentials, C-reactive protein levels, and blood cultures.43Neonates born to mothers with chorioamnionitis are at increased risk for sepsis. Recently, the American College of Obstetricians and Gynecologists held a workshop on chorioamnionitis, which by definition is inflammation of the chorion and amnion, but in clinical practice refers to a “heterogeneous array of conditions.”44 The American College of Obstetricians and Gynecologists’ chorioamnionitis workshop panel suggested that use of intrapartum “chorioamnionitis” be discontinued and replaced with “Triple I”: intrauterine inflammation, infection, or both.44 Efforts to build a consensus on evaluation and management of chorioamnionitis and newborn sepsis are ongoing.43,44 Integrative use of rapidly resulting serum tests and biomarkers may augment future decision-making.45,46Clinicians should consider logistical and medical consequences of treating newborns for presumed infection. For example, limited NICU space may require initial evaluation in a monitored nursery room. In certain circumstances, antibiotics may be administered to well-appearing, low-risk newborns in nonintensive settings. However, there are concerns about antibiotic overuse and the negative impact on the newborn microbiome.47Newborn clinicians should be familiar with the rationale for routine screening of pregnant women for syphilis, gonorrhea, chlamydia, and herpes simplex, hepatitis B, and human immunodeficiency viruses. The 2015 AAP Red Book provides detailed information on managing newborns who are exposed to these and other infections.48 Clinicians also should be familiar with their departments of public health and infectious disease reporting requirements. Prevention of hepatitis B virus infection is critical, and clinicians should be able to explain the reasons for universal newborn vaccination, particularly to families that refuse HBV.49 Hepatitis B immunoglobulin and HBV, when given in the first 12 hours of life to infants born to hepatitis B surface antigen-positive mothers, are highly effective in preventing neonatal infection.48 The AAP recommends that all pregnant women be tested for HIV to reduce pediatric infection.50 Newborn clinicians should be familiar with current guidelines for antiretroviral therapy51 and consult pediatric HIV specialists for proper management.Rising rates of NAS are well documented, with the majority of cases attributable to chronic opioid use during pregnancy.52,53 Determining which mothers should undergo toxicology testing remains controversial. Prenatally and at delivery, all mothers should be screened by their histories. Many obstetric groups use risk-based testing, whereas others conduct universal testing because of high opioid-use rates.54 Studies show the highest NAS risk with long-acting opioid exposure in late gestation, especially when combined with benzodiazepines, serotonin-specific reuptake inhibitors, or nicotine.53 Hospitals need policies to address all care aspects for substance-exposed neonates.52,53 Using a standard NAS-treatment protocol shortens LOS and pharmacological treatment duration and amount.3,53,55 Policies that use a multidisciplinary approach should address staff training, targeted versus universal drug testing, indications for abstinence scoring, supportive care, feeding plans, pharmacologic treatment, and designated care areas.52,55,56 Current recommendations are to monitor infants who are exposed to short-acting substances for at least 3 days and up to 4 to 7 days for long-acting substances such as methadone or buprenorphine.52 Designated care areas vary; some hospitals use high-cost NICUs, nonintensive settings, or both.3 Extended stays for mothers can be accomplished by converting the room charge from mother to infant on the mother-infant unit or by transferring the couplet to an inpatient pediatric service. When ongoing couplet care is not possible, some hospitals use low-acuity nursery space to monitor affected newborns.52,55–58In symptomatic infants, conditions mimicking NAS such as sepsis, hypoglycemia, and hypocalcemia should be considered.52 Supportive measures include a low-stimulation environment, swaddling, gentle handling, strategic positioning, kangaroo care, and soothing techniques. Thresholds for initiating medication depend on the NAS tool being used.56 The Finnegan Neonatal Abstinence Scoring Tool is the most commonly used.52 Morphine and methadone solutions are used when maximized environmental measures have failed to sufficiently control withdrawal symptoms, and patients typically are discharged when treatment is no longer necessary.52,56,59 Standardized treatment thresholds for newborns who are at high risk for NAS, breastfeeding promotion, and rooming-in with a combined inpatient-outpatient–weaning model have been effective.60,61 Hospitalized infants who require medication should be monitored with pulse oximetry and/or cardiorespiratory monitoring to detect apnea, bradycardia, seizures, and cardiac arrhythmias that may occur with NAS or oversedation from pharmacotherapy.57 Once symptoms are stable for at least 48 hours, weaning the medication dose by 10% to 20% every 24 to 72 hours is recommended.52,56,57 Outpatient weaning is acceptable when local resources allow for safe and effective care.55 After discharge, all infants with a history of substance exposure and/or NAS should be monitored for developmental, behavioral, and social concerns within the medical home context. When possible, drug-dependent mothers should be screened for depression, given their increased risk.62The management of NAS continues to challenge newborn clinicians. Mothers with substance use disorders often have mental health comorbidities and high rates of child protective and law enforcement involvement.63 The effects of NAS, perinatal substance exposure, and the home environment on brain development have not clearly been delineated.52,63,64 Researchers need to define additional NAS risks related to exposure and explore safe, effective, and cost-efficient models of care.3,53,56,65The newborn clinician should be skilled in the recognition and management of neonatal hypoglycemia (NH) and familiar with various management guidelines from the ABM, the AAP, and the Pediatric Endocrine Society.66–70 Preventative measures for at-risk infants include use of STS immediately after birth and feeding initiation within 30 to 60 minutes followed by on-demand feedings. Clinicians must carefully monitor newborns given the potential for adverse effects of NH on neurodevelopment.70 At-risk infants include those who were born to mothers with diabetes, are large or small for GA, are preterm, those who were exposed to antenatal betamethasone or are experiencing perinatal stress, and those with a family history of genetic forms of hypoglycemia or syndromes associated with hypoglycemia, such as Beckwith Wiedemann.66–69,71Initial glucose screening for asymptomatic, at-risk infants is recommended 30 minutes after the first feeding or within 2 hours of birth,66,67 but the ideal timing and frequency of screening has not been determined. Some experts advocate delaying screening in asymptomatic infants until after the physiologic nadir and “physiologic glucose homeostasis,” which occurs between 1 and 2 hours of life.69 The brain preferentially uses glucose for energy, but alternative fuel sources include plasma ketones and lactate.69 The availability of such alternative fuel sources may be however, levels may be in in the first 24 hours, levels typically by 2 to 3 in breastfed infants, but not in infants, or those with asymptomatic newborns, the of serum glucose NH has been acceptable definition of NH a but experts recommend levels to The Pediatric Endocrine the nadir to be to 60 mg/dL by 1 to 2 hours and rising to mg/dL by 2 to measurement its challenges. of care are for their at levels, with of as high as to for newborn are often the for require and often to critical levels of in can reduce by up to 6 mg/dL it is to to need for in asymptomatic newborns is limited to the that to glucose levels with breast milk or 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