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General: NICU Handbook

Provider Education
May 18, 2022

Edward F. Bell, MD
Peer Review Status: Internally Peer Reviewed

Edward F. Bell, MD
    Peer Review Status: Internally Peer Reviewed*

The following are indications for hearing screening prior to discharge:

  • Family history of childhood hearing loss
  • Congenital defects of the ear, nose, or throat
  • Birth weight <1500 grams
  • Meningitis
  • Congenital infection
  • Hyperbilirubinemia requiring an exchange transfusion
  • Pulmonary hypertension (persistent fetal circulation)
  • Maternal rubella infection
  • Birth asphyxia (5-minute Apgar score below 7)
  • Fetal Alcohol Syndrome
  • Other anomalies or relevant diagnoses that the physician believes warrants a hearing screen. A consult can be requested at the physician 's discretion.

Infants who satisfy any of these criteria (A-J) will normally be identified by an audiologist from the Department of Otolaryngology. The audiologist will place an E-1 consultation form on the baby's chart with the indicators for hearing test marked. The baby's resident physician should verify that the indication is met and sign the form as requesting physician.

Administration of aminoglycoside antibiotics is not an indication unless one of the above criteria is also met or if serum levels were in the toxic range. IV. Please schedule the hearing screening test at least one week prior to discharge.

*Note: It is anticipated that universal hearing screening may be implemented in the Special Care Nurseries within the lifetime of this edition.

Diane L. Eastman, RN, ARNP, C.P.N.P.
Peer Review Status: Internally Peer Reviewed

Background

Follow-up for children who have required special care as neonates is an integral part of the continuum of their care. There are several reasons why follow-up services are important.

  • To identify developmental and special health needs in children born at risk
  • To determine how new treatments offered by the perinatal care system influence long-term outcome

In response to these needs, the Iowa High-Risk Infant Follow-up Program was developed in 1978. Its goal is to provide developmental testing for certain categories of high-risk infants. At this time follow-up services are available nearly statewide. Currently, enrollment and evaluation centers are located at University of Iowa Health Care. Child Health Specialty Clinics have regional sites across the state that offer follow-up as does Cedar Rapids. Des Moines has follow-up programs at Blank and Mercy similar to this and accepts transfers for follow-up services

The follow-up program provides developmental testing by a pediatric nurse practitioner. This program supplements the role of the local physician who provides primary health care for the child.

Entry criteria

Certain categories of infants have been defined as being at risk and who therefore should receive follow-up. The criteria for the program include:

  1. Birth weight less than 1500 grams and/or gestational age of 32 weeks or less.
  2. Respiratory distress syndrome (RDS) requiring mechanical ventilation for two hours or more.
  3. Other forms of respiratory distress requiring ventilatory assistance for more than two hours.
  4. Clinical evidence of CNS infection.
  5. Asphyxia neonatorum as indicated by a five-minute Apgar score below 7.
  6. Hypoglycemia as proven by two consecutive blood glucose levels below 30 mg/dl.
  7. Neonatal seizures, as documented by physician observation with concurrence of staff neonatologist in Iowa City, or attending pediatrician in Level II Centers.
  8. Hypotonia on discharge examination.
  9. Polycythemia: Venous hematocrit of 65 or higher or 60-64 with signs and partial exchange transfusion.
  10. Maternal substance abuse during pregnancy.
  11. Other: Infants not included in criteria 1 through 10 but felt to be at risk by the attending physician. Examples include:
    1. Sepsis by positive culture
    2. SGA
    3. Hyperbilirubinemia with Total Bilirubin of 20 or greater
    4. Intraventricular hemorrhage
    5. Sibling meets criteria
    6. Intrauterine transfusion
    7. Chorioamnionitis
    8. Those who will be entering living environments which present serious psychosocial concerns.

Infants moving into Iowa from other states are accepted if one or more of the above criteria occurred within the neonatal period.

Process

Developmental screening is done by pediatric nurse practitioners supervised by a pediatrician. In Iowa City, patients are seen in the Pediatric Specialty Clinic. Appointments are scheduled at chronological ages 4, 9, 18 and 30 months. At each appointment physical and neurological examinations and the Denver II developmental test are performed.  The ASQ-3 is also completed at each visit.  Behavioral and autism screening are also completed.

Infants who are discharged with ongoing medical issues are scheduled in the Neonatology Clinic staffed by a neonatologist. Examples of children who are seen in the Neonatology Clinic are as follows: infants with bronchopulmonary dysplasia discharged on oxygen, monitors, or respiratory stimulant drug. In Neonatology Clinic, the same neonatologist and nurse practitioner follow an infant, in cooperation with his local physician, until the infant’s care can be fully transferred to the local physician.

Appointments for screening examinations and for Neonatology Clinic may be made by calling 1-319-353-6880.

Infants eligible for follow-up should be identified by the follow-up pediatric nurse practitioners relatively early in the hospital course. The parents are then be contacted and informed of follow-up services prior to discharge.

Edward F. Bell, MD
Peer Review Status: Internally Peer Reviewed

  1. The first dose of hepatitis B vaccine is recommended before discharge from the hospital or at the chronological age of 2 months, whichever comes first.
  2. At two, four and six months after birth (chronological not corrected age), the immunizations recommended by the American Academy of Pediatrics and the Centers for Disease Control and Prevention (https://www.cdc.gov/vaccines/schedules/) should be given, with the proviso that live virus vaccines should not be given to infants who are still hospitalized. 
  3. Infants with chronic lung disease who are 6 months or older should be given influenza virus vaccine when available each season (as should their immediate family members and hospital caregivers).
  4. Passive immunization against respiratory syncytial virus should be given according to unit policy.
  5. A signed informed consent is required prior to administration of immunizations.
  6. Please record the immunizations given in the appropriate place in the patient’s medical record and give the parents an immunization card with the dates and vaccines marked. Remind the parents when the next immunizations will be due.
  7. Please include the immunization history in the interim, transfer, and discharge summaries.

References

Centers for Disease Control and Prevention. Birth-18 years and “catch-up” immunization schedules. https://www.cdc.gov/vaccines-children/schedules/index.html.

Edward F. Bell, MD
Peer Review Status: Internally Peer Reviewed

  1. Every newborn infant should have his weight, length, and head circumference plotted against gestational age on the Lubchenco curves or other standard curves (Fenton). Those infants whose weights fall below the 10th percentile for gestational age may have experienced intrauterine growth restriction. The following is suggested management of these infants.
  2. Hematocrit should be monitored in the first hour of life and repeated at six hours. If the value is greater than 65% on a venous or arterial sample, the possibility of a dilutional phlebotomy (“partial exchange transfusion”) should be considered and discussed with the fellow or staff neonatologist. This procedure, which is sometimes undertaken in an effort to prevent complications of hyperviscosity syndrome, is done by removing whole blood and replacing it with an equal volume of normal saline
  3. Plasma or blood glucose determinations should be monitored during the first 24 hours. If the glucose is less than 40 mg/dl, an infusion of D10W, 2 ml/kg, should be given IV over one minute, followed by an infusion of D10W or D10/0.2 NS at a rate of 100 ml/kg/day (7 mg/kg/minute). If the true glucose is between 40 and 50 mg/dl and the infant's condition allows, enteral feedings should be given. Refer to guidelines for management of hypoglycemia.
  4. The maternal history should be reviewed for possible etiologies of the growth restriction. If possible, a description of the placenta should be obtained. The two most common causes of intrauterine growth restriction are placental insufficiency and intrauterine viral infection (the TORCH complex: toxoplasmosis, rubella, cytomegalovirus and herpes).

Reference:
Luchenco LO, Hansman C, Boyd E. Intrauterine growth in length and head circumference as estimated from live births at gestational ages from 26 to 42 weeks. Pediatrics 1966;37:403-408.

Fenton TR. A new growth chart for preterm babies: Babson and Benda's chart updated with recent data and a new format. BMC Pediatr. 2003 Dec 16;3:13.

Edward F. Bell, MD
Peer Review Status: Internally Peer Reviewed

New Ballard Scord Card

Reference

Ballard JL, Khoury JC, Wedig K, Wang L, Eilers-Walsman BL, Lipp R. New Ballard score, expanded to include extremely premature infants. J Pediatr 1991;119:417-423.

Edward F. Bell, MD
Peer Review Status: Internally Peer Reviewed

Newborn screen

In Iowa, all newborns are screened by the Iowa Birth Defects Institute for hypothyroidism, phenylketonuria, galactosemia, maple syrup urine disease, hemoglobinopathies, and adrenal hyperplasia. In Iowa and many other states, extended screening for many additional metabolic disorders is now done routinely using tandem mass spectrometry. Practical questions regarding newborn screening are addressed in an article in the Iowa Perinatal Letter in April 2008.

Criteria for screening include:

  1. A disorder that is sufficiently common to justify screening.
  2. A relatively simple, accurate and inexpensive screening test should be available, that has a high sensitivity with a high negative predictive value.
  3. Treatment should be available for the disorder, and there should be a demonstrable benefit to starting treatment before clinical symptoms appear and the diagnosis is made on clinical grounds.
  4. The test should be possible from the spot of blood obtained on the NNS card.

Sampling

Screening is mandated by Iowa State Law [Code of Iowa, Chapter 4:641 (136A)]. The ultimate responsibility for screening newborns rests with the attending physician. Should a parent refuse the test, they must sign a waiver form which is available in the Nursery. This waiver shall become a part of the medical record and a copy sent to the Birth Defects Institute of the Department of Public Health.

The information portion of the screening form will be filled out by the ward clerk. The circles on the filter paper should be filled almost to the black lines. At present, one additional drop of blood should be added. Each circle should be filled with a single large drop of blood obtained by heelstick or from an indwelling catheter. Multiple small drops will result in layering, which will give inaccurate results. Blood obtained through an umbilical catheter is not acceptable for testing if medications or parenteral nutrition solutions have recently been administered.

Screening should be done prior to discharge, ideally no sooner than 48 hours after birth (to allow phenylalanine levels to rise) and before 5 days.

Repeat screen immediately if:

  1. specimen rejected because of poor quality, insufficient blood, slip is incomplete or give incorrect demographic data.
  2. a presumptive positive on previous screen.

Repeat by 14 days if first NNS:

  1. done at < 48 hr. age - test for PKU and MSUD may be false-negative as blood levels for the amino acids may be normal at birth.
  2. Infant on antibiotics - must wait 24 hours after last dose to repeat NNS. If the infant is to go home before twenty-four hours, the repeat test should be performed at the time of discharge, and an additional repeat screening should be performed by the infant’s physician by 14 days age.

Multiple births may affect test results. Be sure to indicate - especially if twin-twin transfusion involved.

Transfusions

  • can potentially affect all tests
  • re-test 6 weeks after last transfusion to be certain of test results

If positive results

  • the patient’s UIHC physician will be notified by the University Hygienic Laboratory
  • confirmatory diagnostic tests and treatment should follow

Hemoglobinopathies

A very complicated group of diseases that involve defects in the kind or the amount of hemoglobin in red blood cells. Early detection identifies families at risk for having future affected children and allows early treatment of affected infants. The major disorders of clinical significance in the US are sickle cell disease and hemoglobin C disease.

Iowa detects abnormalities in the a and b chains including:

  • Hemoglobin-S, C, E, O, G, and D
  • Also detects Bart’s hemoglobin in a-thalassemia

Because of the high levels of hemoglobin F at birth, it may be difficult to accurately quantitate the hemoglobins. However, identification of hemoglobin S, C etc., defines a group of infants who should have a quantitative electrophoresis repeated at 3 - 6 mo. age. The test is done by isoelectric focusing and confirmed by high pressure liquid chromatography (HPLC). The test is affected by red blood cell transfusions and should not be performed within 6 weeks following a transfusion.

Phenylketonuria (PKU)

Incidence:

1 in 10-15,000 births. Autosomal recessive. Deficiency of liver enzyme phenylalanine hydroxylase (PH) that metabolizes phenylalanine to tyrosine. Gene for PH is on chromosome 12q, with > 20 different mutations identified.

Screening:

Currently, all 50 states screen newborns for this disease. Phenylalanine levels are normal in the cord blood of neonates and only rise after milk feedings have been initiated, hence screens obtained prior to 48 hours may give false negative results. In cases of infants discharged before 24 hours, most states recommend that a sample be obtained at discharge and subsequently repeated. In the case of sick newborns, who are not being fed, the initial newborn screen should not be withheld indefinitely but should be submitted at the recommended time, because screening for some other disorders, such as hypothyroidism is not affected by the feeding history. After feedings are started, a repeat screen should be submitted for PKU. Since a bacterial inhibition assay is used for screening, antibiotics given to the infant can interfere as well, hence screens should be repeated 24 - 48 hr. after stopping antibiotics.

Spectrum:

Severe deficiency - classical form; Milder deficiency - variant forms

Pathophysiology:

Leads to accumulation of phenylalanine and its metabolic byproducts in the blood and urine of affected individual. The urine of affected individuals has a peculiar musty odor. Brain myelination is abnormal. PKU should be considered in an infant who loses developmental milestones in the first 6 to 12 months of life.

Treatment:

Dietary restriction of phenylalanine is highly successful in preventing mental retardation, but the diet is unpalatable. A special formula (Lofenalac) low in phenylalanine is utilized in order to provide other necessary nutrients. However, Lofenalac alone is not an adequate diet for any infant, including infants with PKU, and caution should be exercised in placing children on low phenylalanine diets unless the diagnosis has been clearly established, and only after consultation with a center experienced in the management of PKU. Dietary restriction was once maintained for 5 to 6 years of age and then discontinued. However, some patients exhibited neurologic deterioration and loss of IQ points after discontinuation of the diet. In addition, this leads to potential adverse effects of maternal metabolic derangementis on fetal growth and development. Treatment is now maintained indefinitely in most cases.

Maternal PKU:

In the past, patients with PKU were severely retarded and did not reproduce. This changed completely with the initiation of newborn screening and early dietary management. It is especially important that affected women resume a strict dietary avoidance of phenylalanine prior to, during, and after pregnancy (esp. for those wishing to breast feed their infants), so that the fetus/infant does not see abnormally high levels of phenylalanine. For anyone who has been on a normal diet, the phenylalanine-restricted diet is a onerous diet, and is a very difficult goal to achieve. The maternal metabolic environment in this condition has extremely harmful effects on fetal development. Over 90% of infants of these mothers (most of whom do not themselves have PKU) are affected. These infants exhibit mental retardation (>90%), microcephaly (72%), growth retardation (40%), congenital heart disease (12%). The risk of these abnormalities is correlated with the mother’s blood phenylalanine level.

Galactosemia

Incidence:

1 in 50-75,000 births, or 2 infants in Iowa per year. Autosomal recessive.

Pathophysiology:

Deficiency of either

  1. galactose-1-phosphate uridyl transferase (GPUT) or
  2. galactokinase (GK) or
  3. uridine diphosphate galactose-4-epimerase

Galactose ----GK^ Gal-1-P + UDPG ----GPUT^ glucose-1-P + UDP-galactose

Classical galactosemia generally presents in the newborn period with failure to thrive, jaundice, hepatomegaly and renal failure. If unrecognized, death may result by 4 to 10 days of age, or a chronic course of cirrhosis, cataracts (w/ galactokinase deficiency), brain damage, seizures, and mental retardation may ensue. Liver biopsy shows marked fatty accumulation in hepatocytes and fibrosis that may be quite extensive even in the first weeks of life. Newborns have a greater risk of infection (esp. E-coli sepsis) if treatment is delayed.

The screening test is done by Beutler immunofluorescence and is affected by transfusions, as the RBCs contain the enzyme necessary for glycolysis. Dried blood disks are mixed with Gal-1-P and UDPG, and if the reaction is completed by GPUT from the infant’s blood, NADPH is made and detected by fluorescence. Note, this test does not detect galactokinase or epimerase deficiency, but will detect transferase deficiency regardless of prior dietary intake of galactose.

Treatment:

A positive test should be treated as a medical emergency. Immediately institute a strict diet low in lactose, galactose and milk solids (e.g. soy formula). Confirm diagnosis quickly by direct enzyme and galactose-1-phosphate measurement in red cells, and test for presence of urine reducing substances. It is very difficult to maintain strict dietary restriction because of the ubiquitous use of lactose as a food additive. Dietary treatment should be continued throughout the persons life.

Hypothyroidism

Incidence:

1 in 5000 births, or 9 infants/yr. in Iowa;
In North America, Female : male is 2 : 1.

Pathophysiology:

A variety of disturbances of morphogenesis involving the hypothalamic-pituitary axis and the thyroid gland may result in congenital deficiency of thyroxine. If undetected, the deficiency results in severe mental and growth retardation. Initial signs appearing over the first few weeks of life include lethargy, hypothermia, hypoactivity, hypotonia, large anterior and posterior fontanels, poor feeding, respiratory distress (myxedema of the airway), perioral cyanosis, pallor, poor or hoarse cry, mottled skin, constipation, and prolonged physiologic jaundice. The classic features of cretinism usually appear after 6 weeks of life, including the typical facies (depressed nasal bridge, narrow forehead, puffy eyelids, thick dry cold skin, coarse hair), abdominal distention, umbilical hernia, and large cranial fontanels.

Test done by radioimmunoassay - T4 assayed as initial screen; each day bottom 5 -10% are assayed for TSH. False positives occur frequently in LBW and premature infants.

Indications for re-testing: (normal level of T4 7 -10 mcg/dl in infants)

  • T4 5-7 mcg/dl with normal TSH (<20) - repeat q month until T4 > 7
  • T4 3-5 mcg/dl with normal TSH - repeat q 14 d until > 5, then every month until > 7
  • T4 < 3 mcg/dl - obtain serum T4, free T4 and TSH

Treatment:

The prognosis and outcome are greatly improved by early diagnosis and treatment with thyroid hormone replacement begun prior to 3 months of age. Confirmatory testing for primary hypothyroidism should be done prior to 3 weeks of age.

Maple syrup urine disease (MSUD)

Incidence:

1 in 150,000 - 206,000 births, or 1 infant in Iowa every 1 to 4 years.

Pathophysiology:

Branched chain ketoacidemia due to congenital deficiency of branched-chain ketoacid dehydrogenase (BCKD) that initiates degradation of branched-chain amino acids (BCAA) leucine, isoleucine, and valine. Urine has a sweet syrupy odor. If untreated the severe neonatal form leads to poor feeding, vomiting, tachypnea or irregular respirations, ketoacidosis, hypoglycemia and progressive neurologic dysfunction - rigidity alternating with periods of lethargy, or seizures, and often death. If the patient survives the initial episode, the disorder leads to severe mental and motor retardation, growth failure, hypertonia and seizures. The disorder is fatal if not appropriately treated. Death can occur by 4 to 7 days age due to acidosis and hypoglycemia.

Test done by bacterial inhibition assay; test can be affected by antibiotic use. Confirm diagnosis by specific blood and urinary testing looking for the characteristic large amounts of these three amino acids in the blood, and the urinary a ketoacids and organic acid patterns.

Treatment:

Given the rapid onset of this disease, immediately institute a special diet with reduced BCAA intake (amino-acid mix free of leucine, isoleucine, and valine) with added oil and dextromaltose. Since a minority of patients have thiamine-responsive defects some cases, supplementation with pharmacological doses of thiamine, a co-factor for the first component of the enzyme BCKD, is recommended. In practice, these patients require complex treatment and should immediately be referred to a center experienced in the management of patients with MSUD.

Congenital adrenal hyperplasia (CAH)

Incidence:

1 in 12,000-14,000 births

Pathophysiology:

Deficiency or abnormal form of one of five enzymes involved in adrenal steroid synthesis - leads to inability to synthesize the stress hormone cortisol, causing a secondary increase in ACTH. ACTH in turn stimulates adrenocortical hyperplasia and increases adrenocortical steroidogenic activity in an attempt to normalize cortisol production. The 21- and 11b-hydroxylase deficiencies, and to a lesser extent deficiency of 3b-hydroxysteroid dehydrogenase) result in excess formation of precursors steroids, which leads to excess androgen production that induces masculinization of affected female fetuses in utero. Affected females (pseudohermaphroditism) should be identifiable at birth. Affected males with 21- or 11b-hydroxylase deficiency will develop penile enlargement or other virilization postnatally if untreated. Affected males with 3b-hydrosteroid dehydrogenase deficiency will have ambiguous genitalia because of testosterone deficiency. Except for 17b-hydroxylase, the five enzymes involved in the synthesis of cortisol from cholesterol are also necessary for mineralocorticoid (aldosterone) biosynthesis. 21-hydroxylase deficiency is the most common cause of CAH accounting for 90% of cases. Three forms are recognized. Two forms are seen in neonates - a simple virilizing form (partial deficiency), and a salt losing form (a more complete deficiency) that may present at 1 - 2 weeks age with adrenal crisis, history of poor feeding and vomiting, and have profound hyponatremic dehydration, acidosis, hypoglycemia, and hyperkalemia. There is also a late-onset very mild enzyme deficiency that does not have clinical manifestations in the fetus, neonate, or infant.

Test is done by radioactive immunoassay - quite accurate
False positives seen in premature infants - Re-test them as soon as possible

Treatment:

Provide physiological replacement of end products (cortisol, aldosterone, gonadol sex steroid), i.e. cortisone, hydrocortisone, florinef, sodium supplementation etc.

Edward F. Bell, MD and Lou Ann Montgomery, PhD, RN, CCNS, CCRN
Peer Review Status: Internally Peer Reviewed

The neonatologist will page the primary call transport nurse on beeper 3210 and notify the nursing unit of the admission.

The primary call transport nurse will:

  • Take report from the physician
  • Consult with the neonatologist regarding the preferred mode of transport
  • Contact the Air Care dispatcher (353-6440), inform dispatcher of preferred mode of transport, and request dispatcher assistance in assembling team
  • Inform the pediatric nursing supervisor of the transport, admission unit, and expected time of arrival at UI Health Care

The Air Care dispatcher will call:

  • Second call transport nurse (beeper #4645 7:00 AM - 3:00 PM or beeper #3210 3:00 PM - 7:00 AM).
  • Respiratory therapist (for ground transport).
  • Driver or pilot as requested.

NOTE: The call schedules for respiratory therapy and the second call nurse will be in the dispatcher's office. Any changes in the schedule will be communicated to the Air Care dispatcher.

The transport team will assemble at the Air Care dispatcher's office within 20 minutes.

The primary call transport nurse will contact the referring hospital and obtain nursing report and patient registration information by completing the Neonatal Pre-Transport Information Sheet. An ETA will be given to the referring hospital.

Upon admission to the NICU or Intermediate Care Nursery, a referring physician call-back card will be stapled to the front of the baby's chart by the unit clerk (or physician if no unit clerk is available). This card shows the referring physician's name and phone number and is used to document telephone reports by our staff to the referring physician. Calls to referring physicians are the responsibility of the staff physician (unless delegated to the fellow or resident). The frequency of such calls depends on the patient's condition and may vary from daily (for the newly admitted critically-ill infant) to monthly (for a long-term chronically-ill infant).

Edward F. Bell, MD and Lou Ann Montgomery, PhD, RN, CCNS, CCRN
Peer Review Status: Internally Peer Reviewed

The neonatologist will page the primary call transport nurse on beeper 3210 and notify the nursing unit of the admission.

The primary call transport nurse will:

  • Take report from the physician.
  • Consult with the neonatologist regarding the preferred mode of transport.
  • Contact the Air Care dispatcher (353-6440), inform dispatcher of preferred mode of transport, and request dispatcher assistance in assembling team.
  • Inform the pediatric nursing supervisor of the transport, admission unit, and expected time of arrival at UI Health Care.

The Air Care dispatcher will call:

  • Second call transport nurse (beeper #4645 7:00 AM - 3:00 PM or beeper #3210 3:00 PM - 7:00 AM).
  • Respiratory therapist (for ground transport).
  • Driver or pilot as requested.

NOTE: The call schedules for respiratory therapy and the second call nurse will be in the dispatcher's office. Any changes in the schedule will be communicated to the Air Care dispatcher.

The transport team will assemble at the Air Care dispatcher's office within 20 minutes.

The primary call transport nurse will contact the referring hospital and obtain nursing report and patient registration information by completing the Neonatal Pre-Transport Information Sheet. An ETA will be given to the referring hospital.

Upon admission to the NICU or Intermediate Care Nursery, a referring physician call-back card will be stapled to the front of the baby's chart by the unit clerk (or physician if no unit clerk is available). This card shows the referring physician's name and phone number and is used to document telephone reports by our staff to the referring physician. Calls to referring physicians are the responsibility of the staff physician (unless delegated to the fellow or resident). The frequency of such calls depends on the patient's condition and may vary from daily (for the newly admitted critically-ill infant) to monthly (for a long-term chronically-ill infant).

Edward F. Bell, MD
Peer Review Status: Internally Peer Reviewed

The following protocol will be followed by NICU and Ob-Gyn/Labor & Delivery:

  • An infant of 20 weeks gestation or more with an Apgar score of one or more at any time after delivery is considered liveborn, regardless of whether the patient dies in the Delivery Room or NICU and regardless of whether the pediatric team was in attendance.
  • An infant with an Apgar score of zero at all times after delivery is considered stillborn and will be entered into Labor & Delivery statistics, but not admitted to the NICU.

For liveborn but nonviable infants:

If the infant is physically admitted to the NICU:

  • The NICU unit clerk will:
    1. Notify UI Health Care Registration of the infant's birth and obtain a hospital number
    2. Admit the patient to the NICU by entering the hospital number and patient data into the UI Health Care computer system and the census book Discharge the infant as a death on the computer and census book
    3. Enter the appropriate data into the Neonatal Registry field on the UI Health Care computer system (using gestational age by dates)
    4. Assemble a chart which will include a record of labor and delivery, white identification card, doctor's notes, including Delivery Room resuscitation if required, and other pertinent information 
  • Nursing personnel will:
    1. Complete the admission assessment form
    2. Notify Central Nursing Office and the pediatric nursing supervisor of the infant's death
  • The pediatricians will complete the physician's note

If the infant is not physically admitted to the NICU (regardless of whether pediatrics physicians or nurses ever attended the infant):

  • The nursing unit clerk from Labor & Delivery will:
    1. Notify U Health Care Registration of the infant's birth and attain a hospital number
    2. Admit the infant to Labor & Delivery on the UI Health Care computer system and discharge by computer when infant dies
    3. Enter the appropriate data into the Neonatal Registry field on the UI Health Care computer system (using gestational age by dates)
    4. Assemble a chart for the infant
    5. Notify Central Nursing Office of the infant’s death.   
  • If a pediatric physician provides any assessment or treatment, a note will be written for inclusion in the infant’s medical chart
  • The physician in attendance at the time of death, regardless of department, will be responsible for completing the chart
  • Labor & Delivery personnel will be responsible for notifying Central Nursing Office of the infant's death

Edward F. Bell, MD
Peer Review Status:  Internally Peer Reviewed
Maria Lofgren, ARNP, NNP-BC
Denise Holiday, ARNP, NNP-BC

Personnel in attendance

A pediatric team should be present at ALL high-risk deliveries.  All deliveries that are high-risk will be listed on the board in Labor and Delivery.  In addition, the pediatric team will attend any other deliveries when requested to do so by the obstetric staff.

The pediatric team will be notified of a high-risk delivery ahead of time so that they may familiarize themselves with the mother and any complications of the pregnancy in order to prepare for any type of neonatal emergency care that might be required.  The pediatric team and the NICU should be given an approximate expected time of delivery.

The pediatric resident and/or neonatal nurse practitioner will attend all high-risk deliveries (PL-2/NNP assigned to the NICU during the day and PL-3/NNP assigned to the NICU during the night).  The attending neonatologist (or fellow) in the NICU will decide on a case-by-case basis which members of the pediatric team should attend each high-risk delivery.  At least twice daily, the cases on the high-risk board in the NICU will be reviewed with the NICU medical team:  in the morning with the PL-2 and NNP, and in the evening with the PL-3/NNP.  The attending neonatologist will determine whether fellow or faculty attendance at the delivery is advisable.  A neonatal intensive care nurse will accompany the team.

The delivery of an infant equal to or less than 1500 grams is a special situation.  The infant who is less than 1500 grams should be resuscitated by the most skilled person available.  Time and communication are critical.  Therefore, intubation will generally be performed by the NNP, PL-2, fellow, or PL-3.  There are many other opportunities for the intern, either pediatric or obstetric, or the family practice resident to gain skills in intubation.  Clear communication should take place prior to the delivery so that each person understands his role.  The resuscitation team will decide on the timing of transfer to the NICU.

Pediatric personnel should be present in the delivery room to assist with effective resuscitation even in certain borderline situations when the obstetric staff has decided against fetal intervention.  If the estimated gestational age on a “22-23 week infant” is wrong, for example, and a depressed “26 week infant” is delivered, an immediate and full resuscitation effort is required.

ALL pediatric personnel who attend resuscitation should be listed on the Labor and Delivery Record and placed in the infant’s electronic medical record.  A procedure note entitled “Delivery Room Resuscitation” will be completed by LIP running the resuscitation (“the head of bed”) and signed by the neonatologist.

Equipment

A resuscitation bag will be kept stocked and available in the NICU at all times.  It will be the responsibility of the NICU nurse who is attending the delivery of a high-risk infant to take this bag with her.  Items in the resuscitation bag should include:

  • two each ET tubes: 2.5, 3.0, 3.5, 4.0
  • one MEC ET tube pack
  • two stylets
  • 250 cc anesthesia bag and masks (one preemie; one newborn)
  • one oxygen connecting tubing
  • one roll adhesive tape
  • one roll ¼” yellow tape
  • one can adhesive spray
  • two laryngoscope handles
  • two Miller 0 blades
  • one Miller 1 blade
  • two scissors (sterile)
  • one steri-drape
  • one hemostat (sterile)
  • Suction equipment
    • one bulb syringe
    • two 8 fr suction catheters
    • one 8 fr suction catheter with glove
    • one 6 fr suction catheter with glove
    • two sterile gloves
    • four sterile sims connectors
    • four RT saline (5 ml)
  • NG tubes
    • two 8 fr
    • two 5 fr
  • Needles and syringes
    • two 25 gauge short butterflies
    • two 23 gauge long butterflies
    • two 25 gauge needles
    • two 22 gauge needles
    • two 20 gauge needles
    • two 18 gauge needles
    • two 20 gauge IV catheters
    • two 22 gauge IV catheters
    • two 24 gauge IV catheters
    • one 20 cc syringe
    • one 10 cc syringe
    • two 3 cc syringes
    • two 1 cc syringes
  • Medications
    • two NaHCO3
    • one atropine sulfate
    • one epinephrine 1:10,000
    • normal saline 500 ml
    • one calcium gluconate 10%
    • two Narcan (naloxone hydrochloride) (0.4 mg/ml OR 1.0 mg/ml solution)
  • Other
    • one razor
    • four #11 blades
    • two 4x4’s
    • one needle aspiration pack
    • two stopcocks
    • twenty alcohol preps

Each of the radiant heater beds is equipped with a portable oxygen tank.  Following resuscitation and stabilization, the infant should be transferred to the NICU on the warmer bed.

Edward F. Bell, MD and Jonathan M. Klein, MD
Peer Review Status: Internally Peer Reviewed

 In the newborn period, an infant may require an increased ambient oxygen concentration in order to maintain a normal arterial blood oxygen tension. There appears to be a relationship between a higher than normal oxygen tension in the retinal arteries and retinopathy of prematurity (ROP). Susceptibility to ROP is increased in the preterm infant. An FiO2 of 0.4 or lower may be sufficient to raise the retinal artery oxygen tension to a dangerous level in many infants. Therefore, when an infant's clinical condition requires an oxygen enriched environment, frequent measurements of arterial blood gases and pH are mandatory.

  1. The normal PaO2 in utero is 30 mm Hg, while a normal infant breathing room air will have a PaO2 of 60-100 mm Hg. 
  2. The PaO2 of a premature infant in oxygen enriched environment should not exceed 80 mm Hg and should be maintained between 50-70 mm Hg. An arterial oxygen tension of 40-50 mm Hg may be adequate, providing cardiac output and peripheral perfusion are normal. A term infant may require a PaO2 of 55-70 mm Hg to be adequately oxygenated. 
  3. An infant requires the measurement of arterial blood gases and pH as frequently as demanded by the clinical status. When the condition is rapidly changing, measurements must be performed more frequently. 
  4. When an infant is placed in an oxygen enriched environment, the FiO2 delivered to the infant must be measured by an oxygen analyzer at least once an hour. 
  5. Mixtures of oxygen and air delivered to an infant by endotracheal tube, nasal CPAP, hood, or incubator should be warmed and humidified. 
  6. An infant recovering from Respiratory Distress Syndrome should have the FiO2 lowered in steps of no more than 0.10 at intervals of not less than 15-20 minutes, or with the use of continuous pulse oximetry, the FiO2 can be decreased at a faster rate as long as the O2 saturation remains within acceptable limits. An infant with chronic lung disease, especially those requiring oxygen therapy for more than 5-6 days, may require lowering of the FiO2 in steps of 0.02 - 0.05. 
  7. Exposure of the infant's eyes to bright light should be minimized. 

Ronald V. Keech, MD and Edward F. Bell, MD
Peer Review Status: Internally Peer Reviewed

Because of the continuing incidence of ROP, certain infants must have their fundi examined by an ophthalmologist prior to discharge from the hospital. The PL1 resident or PNP should fill out a blue consultation sheet on the following patients at the appropriate time (see below).

Physician Guidelines for the Evaluation of Infants at Risk for Retinopathy of Prematurity

Any one of the following criteria qualifies the patient for ROP screening

  • Infants with a birth weight of <1500 grams
  • Infants with an estimated gestational age at birth of < 32 weeks
  • Infants who do not meet the first two criteria but are deemed at risk due to other medical conditions

Method for Determining the Timing of the first ROP examination

  • For infants born at < 27 weeks gestation: first eye exam at 32 weeks postnatal age (gestation age at birth + chronologic age).
  • For infants born at > 27 weeks gestation: first eye exam at five weeks chronological age.

If the infant qualifies for an ROP screening but is to be discharged or transferred before the normal time for the first examination, then use the following guidelines:

If the scheduled discharge or transfer date is within two weeks of the designated time for the first ROP examination (see above), arrange for the ROP examination to be performed before discharge.

If the scheduled discharge or transfer date is more than two weeks before the designated time for the first ROP examination, then recommend a date for the first examination based on the standard criteria and include it on the ROP discharge form (Form #__).