Mother Baby Unit Basics

Monday Tuesday Wednesday Thursday FridayMorning Report

8-9 Peds

Tully

8-9 Peds

Tully11 a.m. Education

Interns

MBU

Attending

MBU

ICN-3 Resident

MBU

ICN-3 Resident

MBU

Students

MBU

Resident School

12-5 Family Medicine

12-5 Pediatrics

1. Daily Schedulea. Interns & medical students gather info on weight, bilis, labs prior to 8 am reportb. 8 a.m. Run list with charge nurse, lactation, SWc. 8:15 a.m. OB-Gyn runs their list briefly with NBN teamd. Walk or sit down rounds with attending and team (prioritize discharges, etc.)e. 11 a.m. Education as abovef. 2 p.m. Cutoff for admitting patients on weekendsg. 3 p.m. Cutoff for admitting patients on weekdays

2. Educationa. Peds intern does 2 short talks/rotationb. FM intern does 1 talk because only on 2 weeksc. If not already done, do 2 breastfeeding modules on Learning Central:

i. Expanding Clinicians’ Roles in Breastfeeding Support, Module 1ii. Expanding Clinicians’ Roles in Breastfeeding Support, Module 2

3. Pre-roundinga. Weight loss, Labs & Bili’s, Vitals, Ins & Outs, LATCH score. Please look these up

on all your patients before 8 a.m. rounds. This will help you to prioritize discharges, order phototherapy or repeat bilirubins, etc. in a timely fashion.

b. Weight loss i. Always calculate weight loss compared to BW (not prior day’s weight

unless that was date of birth). ii. If L&D weighed baby, do not use that as the birth weight, use first MBU

“Measured daily weight” as BWc. Bilirubins

i. Serum bilirubin is done at 24 hours and is in “lab results.”

ii. Transcutaneous bilirubin (TCB) is done daily in the morning (unless 24 hr serum bilirubin done after midnight the night before). TCB is found under “Interactive View/I&O” then “Newborn”

1. To get “Newborn” view on your Powerchart:a. Go to “View” b. Then “Layout”c. Then “Navigator Bands” where you will find “newborn” on

column on left which you then move to column on rightd. Need to get out of Powerchart and log back in after that

before you can access2. Computer calculates hours of life so you don’t have to

iii. Please plug most recent bilirubin result (serum or TCB) in Bilitool and report hour of life, light level, and recommended time to follow up.

iv. If baby has to go home that day and TCB is “high risk” (i.e., needs follow up in 4-24 hours), go ahead and order STAT serum bilirubin.

1. Always order serum bilirubins as newborn total and direct, STAT, nurse draw (even if ordering for later in the day or next morning—just be sure to put comment about when bilirubin is to be drawn and change date and time as needed).

d. Vital Signsi. Look at past 24 hour vital signs.ii. If normal, just say normal. If something abnormal, look to see if abnormal

vital sign (e.g., fever) was reported to anyone and what was done.iii. Temperatures are axillary so temperatures as low as 37.4 will be flagged

as abnormal on Powerchart. We generally aren’t going to worry unless temperature is 37.7 or higher.

e. Labs. Self-explanatory. f. Ins & Outs.

i. Report previous 24 hours’ worth of ins and outs.ii. If baby exclusively breastfed, you can just say baby breastfed x 8 or x 8 for

5-20 minutes each. You don’t have to report the time for every single breastfeeding episode though you should say how many were for 0 minutes if applicable.

iii. If baby getting EBM (expressed breast milk) or formula, say the number of times they got it and total volume in ml.

g. LATCH score. i. Give the most recent LATCH scoreii. <7 is concerning and we should get lactation involved

h. On days you have morning report, please look up weights, etc. as above and leave a note on the board or table for your attending with the info (e.g., BB Garcia 7% weight loss, TCB 10 with LL 11 for 37 week baby, blood culture no growth to date, VSS, breastfed x 8, no formula, LATCH 8, void x 3, stool x1).

i. If you know baby has to leave that day, let attending know when you think they should follow up and feel free to go ahead and put order in for follow up in Newborn Clinic before attending arrives.

4. Newborn Exam a. Must do complete exam on day of admission.

i. See Up To Date for great review of newborn exam, Assessment of the Newborn, http://www.uptodate.com/contents/assessment-of-the-newborn-infant?source=search_result&search=newborn&selectedTitle=2%7E150

ii. Stanford also has a wonderful website with pictures of newborn physical findings at http://newborns.stanford.edu/.

iii. The Newborn Book. Awesome book should be on shelf in team room (if not, look in nursery) by Janelle Aby who also is responsible for Stanford Newborn Gallery.

b. On subsequent and discharge days, must examine things that can change or are so critical you can’t afford to miss something, including:

i. General ii. Anterior fontanelle

iii. Eyes for red reflexiv. Lungsv. Heart (pay special attention for new murmurs not heard on first day)

vi. Pulses (pay special attention to femoral pulses, decreased or absent concerning for coarctation)

vii. Umbilicus (note presence or absence of erythema or anything else unusual)

viii. Hipsix. Tone

5. Breastfeeding a. Please always ask about previous breastfeeding experience on admission

i. Breastfed previous childrenii. How long

iii. Any problemsb. You must complete the 2 breastfeeding modules on Learning Central:

i. Expanding Clinicians’ Roles in Breastfeeding Support, Module 1

ii. Expanding Clinicians’ Roles in Breastfeeding Support, Module 2c. If Mom needs help with breastfeeding, typically start with her nurse (who has

received 20+ hours breastfeeding support training).d. Ask lactation specialist to see mom if having excessive difficulty, tongue-tie, or

experienced breastfeeding problems with previous children, especially if did not breastfeed previous children or only breastfed them for very short time.

e. Lactation specialists available 6 days a week inpatient, many night and Monday-Saturday outpatient

f. See also AAP 2012 (yes, this is most current policy) policy statement on Breastfeeding and the Use of Human Milk at http://pediatrics.aappublications.org/content/129/3/e827.full#content-block

6. Home Visitation a. All families should be counseled about the benefits of home visitation (improved

development, someone to answer questions and provide guidance between well child checks, breastfeeding help, etc.) and referred unless they actively say they do not want to be referred

b. Universal home visitation referral forms are located on wall in team roomi. You don’t have to try to figure out which program is best for familyii. Family can opt out either in MBU or when they receive the call after

initial referral madec. Put completed home visitation referral form in baby’s paper chart located

behind front desk7. Routine Screening

a. Hyperbilirubinemia (see attached Bilirubin Screening Protocol)i. Coombs done for all babies from cord bloodii. Blood type done if

1. Mom was AST+ or2. Mom blood type is O or3. Mom is Rh negative

iii. Serum bilirubin done1. At 24 hours on all babies2. Immediately if Coombs comes back positive3. If Tcb >13

iv. Transcutaneous bilirubin (Tcb) done1. Daily in morning unless serum bilirubin done after midnight (i.e.,

<5-6 hours ago)2. if Mom blood type comes back O before baby has had 24 hour

serum bilirubin.

b. Sepsis risk (see attached Evaluation of Neonatal Sepsis Risk)i. Use Kaiser Neonatal Sepsis Calculator for all babies:

https://neonatalsepsiscalculator.kaiserpermanente.orgii. For incidence of neonatal sepsis choose 0.5/1000 (CDC national

incidence)iii. Highest maternal temperature is found on cardex (in baby’s file behind

front desk or in nursery)iv. Need to include in assessment for all babies

c. Metabolic Screen (aka PKU)i. At 24 hours of lifeii. At 10-14 day visit

d. Critical Congenital Heart Disease (CCHD) (see attached CCHD Flowsheet)i. Done at 24 hours of life or shortly thereafterii. Tech does initial pre (right hand) and post (either foot) ductal sats.

iii. Pass if at least one sat is >/= 95% and difference between foot and hand is </= 3%.

iv. Fail if 1. either hand or foot is <90%, 2. if both pre and post ductal sats are between 90-95%, or3. if difference between foot and hand is >3%.

v. If 1 (<90%) tech notifies provider to evaluate and call NBICU if needed. vi. If 2 or 3, nurse repeats pre and post ductal sats up to 2 more times

before notifying provider.vii. For “fails”,

1. Examine baby a. to evaluate for other potential causes, e.g., respiratory

distress or sepsisb. pay special attention to femoral pulses

2. Get 4-point BP’s3. Call Cardiology for evaluation/echocardiogram separately).

e. Hearing i. Should be done automatically ii. If planning to send baby home after 1 midnight, make sure done

iii. If baby “refers” (i.e., fails) in either ear, Audiology will schedule FU outpatient

f. Glucose (see attached Hypoglycemia Protocol)i. Only checked in babies who

1. Are SGA (<10%) or LBW (<2500 grams)

2. Are LGA (>90%) or >4000 grams3. Infants of diabetic mothers (IDM)4. Late preterm (<37 weeks)5. are symptomatic, or6. have gone >5 hours without eating

ii. In first 24 hours of life, we want glucose to be >/= 45iii. Between 24-48 hours of life, we want glucose to be >/= 50iv. After 48 hours of life, we want glucose to be >/= 60v. For low glucose, first intervention is feed baby, preferably breastfeed or

EBMvi. Glucose gel is coming soon (as of 3/19) and will be in addition to feedvii. If baby has a low glucose, we must have 2 pre-feed (ac) glucoses after

the low glucose that are WNL. It is not enough to have a good post-feed glucose.

8. Circumcisions a. AAP now says medical benefits outweigh risks but are not great enough to

recommend circumcision outright for all baby boys. See http://pediatrics.aappublications.org/content/130/3/585.full.pdf+html (policy statement) and http://pediatrics.aappublications.org/content/130/3/e756.full.pdf+html (technical report).

b. Circumcision manual available in procedure room in Newborn Nurseryc. Information for parents about circumcision and consent forms available in

hanging files in team room.d. For note use template found on Powerchart at =pedcircumcision

i. As of March 2019, we are using lidocaine 1% preservative free instead of bupivacaine as stated in circumcision note.

ii. Request to change note to reflect this change submitted but until then1. you will need to change Bupivacaine 0.25% to Lidocaine 1%

throughout note & change amount wasted from 9.1 ml to 1.1 ml since Lidocaine comes in 2 ml bottle or

2. Use template I will provide with these changes already made9. Discharge and Follow Up

a. See 2015 AAP Hospital Stay for Healthy Newborns http://pediatrics.aappublications.org/content/early/2015/04/21/peds.2015-0699.full.pdf+html

b. AAP considers discharge <48 hours “early discharge.”c. Insurance companies go by midnights so 2 midnights ~= 48 hours

d. Insurance has to pay for at leasti. 2 midnights if vaginal deliveryii. 4 midnights if C-section

e. Mom’s with severe pre-eclampsia requiring magnesium sulfate typically stay at least 3 days

f. The following are not usually good candidates for “early discharge” (i.e., 1 midnight):

i. First time momsii. Teen moms

iii. GBS+ mom (unless adequately treated AND other discharge criteria met AND mom can monitor baby at home and FU in 24-48 hours).

iv. Babies who required CBC with diff/blood culture for ROSv. Late preterm (<37 weeks) babies

vi. Coombs+ babiesvii. Bilirubin in High Risk category (i.e., bilirubin needs to be rechecked in 4-

24 hours)viii. Excessive weight loss (usually >7%)

ix. LATCH score <7x. Mom with substance use issues

g. AAP recommends all babies follow up within 24-72 hours if discharged before 48 hours.

h. Even if discharged after 48 hours, probably need FU in 24-72 hours unless experienced breastfeeding mother or formula feeding with low risk bili, minimal weight loss, and no other concerns.

i. Primary factors to consider when deciding on timing of follow up includei. baby’s gestational ageii. bilirubin

iii. weight lossiv. feeding

j. Newborn Clinici. When ordering (“schedule”) put

1. reason for FU, e.g., 1st time mom, bilirubin, weight check and2. when you want scheduled, e.g., in 2 days

ii. Open 7 days a week except holidays iii. Advanced practitioners cover if available; otherwise resident/attendingsiv. Residents are welcome to see their babies in Clinic for follow up if you

have time (just let Newborn Clinic nurse know you want to be called on baby, can put in order for follow up along with your pager number).

k. Lactation Clinici. May need FU with Lactation Clinic in addition to or in lieu of FU in NBN

Clinic if having difficulty with breastfeeding.ii. Please do not order for every first time breastfeeding mother

iii. When ordering (“schedule”) put 1. Reason for FU, e.g., Mom having difficulty breastfeeding and using

nipple shield2. Timeframe for follow up, typically “first available”

iv. open Monday-Saturdayl. All babies must be seen at 10-14 days for WCC and 2nd metabolic screen whether

seen at 24-72 hours or not. Ask parents where they plan to go and either have them schedule 10-14 day visit prior to discharge or you or front staff can schedule.

i. UNM. If family wants to be seen at UNM but does not have a specific provider identified, ask them where they live and try to find clinic closest to their house (see attached map, sorry not very good). Clinics include:

1. Carrie Tingley -central2. Southwest Mesa - southwest3. Westside - west4. Eubank - northeast5. Young Children’s Health Center (YCHC) -southeast6. General Pediatric Clinic only if

a. Identified attending already sees siblings or has accepted patient

b. 10-14 days falls during Christmas or mid-summer weeks when residents do not have clinics

ii. First Choice clinics1. Our front staff can usually schedule2. First Choice has access to Powerchart records

iii. Non-UNM or First Choice providers1. Family usually has to schedule themselves or you can help2. Please print out H&P and Discharge Summary and give to family

and/or have faxed to clinic10. Neonatal Opioid Withdrawal Syndrome (NOWS)

a. If Mom used heroin, methadone, buprenorphine (Subutex, Suboxone), or other opiate on regular basis, baby must be watched for signs of withdrawal for a minimum of 96 hours.

b. If Mom was in an opiate replacement therapy program (e.g., Milagro, ASAP) and had negative UDM’s in 90 days before delivery, and had good prenatal care, she can probably breastfeed (see Substance Abuse and Breastfeeding Guideline for details).

c. If census allows, we can do 96 hour observation on MBU even if Mom has to be “discharged” earlier. Priority for staying on MBU goes to Moms who are breastfeeding and/or are staying with their babies consistently.

d. Finnegan scoring system for NAS being replaced by Eat, Sleep, Console (ESC) in late summer/fall 2019

e. See attached medication guidelines for methadone and morphine as treatment for withdrawal.

f. See attached Breastfeeding, Substance Abuse, and Infectious Diseases Guideline for information about breastfeeding and substance use.

11. Night Call and Coverage a. NICU takes calls on new babies, urgent (baby needs to be seen), lab results and

other clinical issues.i. BUT if we order a lab, we should follow. E.g., if you order a repeat serum

bilirubin to be done after 5pm, you need to check –best to include in order note for them to contact you with result, not NICU and you should plan to check Powerchart at appropriate time

ii. Don’t order any lab after 5pm that you don’t intend to follow.b. NICU generally doesn’t want sign out anymore. If you feel they need to know

about a baby, ask your attending to call their attending.c. Babies sent to CTH or GPU for hyperbili or opiate withdrawal, NBN covers as for

NBN with addition of taking calls about labs , etc. as NICU not involved unless baby needs to be evaluated

d. Babies transferred to ICN-3, ICN-3 covers

12. ICN-3 Transition Babiesa. If transitioned during night (i.e., 5 pm-8 am) and transferred to MBU before 8

am, MBU does H&P b. If transitioned during work day, ICN-3 does H&Pc. Beware: Transition note done by NICU in night may look like full H&P but is not

with regards to attending documentation & billing13. Protocol Book & Other Useful Info

a. Big white Protocol book in work roomb. The Newborn Book (mentioned above) in work room is great resource

(sometimes migrates to nursery)

c. If you haven’t gotten your Tdap booster, you can get it on the MBUd. Important People and Numbers

i. Nursery: 272-2512ii. MBU: 272-2370

iii. Emilie Sebesta (MBU medical director): 380-1147 (pager) & 505-385-5694 (cell)

iv. Sherry Weitzen (MBU medical director): 380-1782 ( pager) & 505-500-5538 (cell)

v. Samantha Schmaltz (unit director): 272-9171vi. Connie Peceny (PA): 380-2112 (pager) & 249-2080 (cell)vii. Rochelle Hedin (NP): 380-0107 (pager)

viii. ICN-3: 272-0830ix. Nicole Urrea (ICN-3 medical director): 380- (pager) & 505-803-6143 (cell)x. CTH Inpatient: 272-5355

xi. Newborn Clinic: 272-5964xii. Social Worker Cat weekends and evenings 380-9980

EDUCATIONAL GUIDELINEBilirubin Screening in the Healthy or Late Preterm Newborn

BRIEF STATEMENT OF THE EVIDENCE

The American Academy of Pediatrics recommends that a serum or transcutaneous bilirubin

(TcB) be checked in all newborns prior to discharge from the hospital and if a newborn is

jaundiced within the first 24 hours of life (AAP 2004 and Maisels, et al., 2009). In the 2009

update, they provided a structured algorithm for follow up based on risk factors and the zone in

which the bilirubin falls at the time of discharge (based on Bhutani’s nomogram). The AAP is

currently considering universal screening for biliary atresia.

BACKGROUND

Newborns cared for in the University of New Mexico Newborn Nursery, Mother Baby Unit, and

Women’s Special Care Unit have routinely had cord blood sent for DAT (direct antibody testing)

but blood type has only been checked in those newborns whose mothers are Rh-negative or

whose DAT is positive. Until now bilirubin screening with a serum bilirubin has been reserved

for those newborns who are Coombs positive or whose transcutaneous jaundice meter reading is

>13 or near light level. This guideline expands blood type screening, introduces universal serum

bilirubin screening, and provides additional guidance regarding evaluation of Coombs negative

newborns with evidence of hemolysis and newborns with elevated direct bilirubin.

**A table with hourly light levels for low risk, medium risk, and high risk newborns based on

the Bhutani Nomogram (4-11 hours) and Bilitool is provided for convenience.

PROCEDURE

Cord Blood Screening

1. All newborns will have a DAT (Coombs) sent from cord blood at birth.

2. A newborn’s cord blood will also be sent for blood type if his or her mother:

a. Is Rh-negative,

b. Has a positive AST (antibody screening test), or

c. Has Blood Type O

3. Newborns with a positive DAT (Coombs+) will have their cord blood tested for blood

type (if not already done).

Bilirubin Screening

1. Newborns with a positive DAT (Coombs+) will have a TSB (total and direct serum

bilirubin) and Hemoglobin (Hemacue) sent.

2. Newborns discovered to be at risk for ABO incompatibility (Mom Type O and

newborn with Type A or B) prior to 24 hours of life will have a TcB checked.

3. All newborns who have not already had a serum bilirubin sent will have a serum

bilirubin (total and direct) sent with their metabolic screen at about 24 hours of life.

4. After 24 hours of life all newborns will have a TCB (transcutaneous bilirubin)

checked prior to 8 am nursing rounds if the newborn

a. has not had a serum bilirubin drawn since midnight the night before,

b. has not received phototherapy within the past 48 hours, and

c. is not >96 hours old

5. A visual assessment for jaundice will be performed at least once per nursing shift (12

hours).

6. A nurse may check a TcB at his or her discretion if

a. a newborn <24 hours old appears jaundiced or

b. a newborn >24 hours old appears jaundiced and

i. has a cephalohematoma or bruising,

ii. was born at <38 weeks gestation,

iii. is not feeding well, or

iv. the jaundice appears to have developed rapidly.

7. A serum bilirubin will be sent if

a. the TcB is at or above light level, or

b. the TcB is ≥ 13 (regardless of the day of life or inpatient/outpatient status)

Notification of Providers

Nurses are to notify a newborn’s medical provider (or NBICU after hours) with results of TSB as follows:

a. If TSB is above light levelb. If provider has asked to be notified

Phototherapy

1. Except as described below, when phototherapy is ordered, the newborn’s

nurse should discuss family- centered phototherapy with the family and

proceed with family-centered phototherapy if the family desires. No

physician order is needed.

2. Whenever a newborn who has phototherapy ordered is not feeding or

undergoing family-centered phototherapy, he or she should be in his or her

bassinet with phototherapy lights and/or bed as ordered.

3. Family-centered phototherapy will not be done if mother is on methadone

unless newborn’s provider determines it is safe and writes an order for it.

4. If a nurse or physician does not believe family-centered phototherapy would

be safe because of a mother’s medical condition, behavior, or medications the

mother is taking, he or she can choose to proceed with standard phototherapy.

Guidance for Providers

1. Providers may order a TcB or TSB at any time and should consider other risk

factors (e.g., Native American or Asian descent, excessive weight loss, h/o

siblings requiring phototherapy, cephalohematoma or other significant bruising,

<38 weeks gestation) when deciding when and what to order.

2. Providers should consider further evaluation or transfer to a higher level of care if

a. TSB is significantly above light level, especially if newborn is <24 hours,

b. TSB continues to rise despite phototherapy, or

c. TSB is rising much more rapidly than expected (>0.2 mg/dL/hr).

3. Other causes of significant, rapidly rising, or phototherapy unresponsive bilirubin

to consider include G6PD deficiency, other red blood cell deformities, maternal

autoimmune hemolytic anemia, and maternal medications.

4. Suggested evaluation includes a CBC with differential, reticulocyte count, and

peripheral blood smear.

5. All newborns with a direct bilirubin ≥0.8 should have their total and direct

bilirubin repeated within 1-2 weeks, and, if rising, should be evaluated for biliary

atresia or other causes of elevated direct (~conjugated) bilirubin.

If a newborn’s direct bilirubin is ≥ 1.0 in the first week of life, the provider should

consider consulting a pediatric GI specialist for guidance regarding further

evaluation and monitoring regardless of the ratio of direct bilirubin to total

bilirubin.

REFERENCES

1. AAP, The Section on Surgery, The Committee on Fetus and Newborn, and the Childhood

Liver Disease Research Network, “Newborn Screening for Biliary Atresia,” Pediatrics.

2015;136(6):e1663-e1669.

2. AAP, Subcommittee on Hyperbilirubinemia, “Management of hyperbilirubinemia in the

newborn infant 35 or more weeks of gestation,” Pediatrics. 2004;114(1):297-316.

3. Harpavat, S., Finegold, M.J., & Karpen, S.J., “Patients with Biliary Atresia Have

Elevated Direct/Conjugated Bilirubin Levels Shortly After Birth,” Pediatrics.

2011;128(6):e1428-e1433.

4. Maisels, M.J., “Managing the jaundiced newborn: a persistent challenge,” CMAJ.

2015;187(5):335-343.

5. Maisels, M.J., et al., “Hyperbilirubinemia in the Newborn Infant ≥ 35 Weeks’ Gestation:

An Update with Clarifications,” Pediatrics. 2009;124: 1193-1198.

6. Shahid, R. & Graba, S., “Outcome and cost analysis of implementing selective Coombs

testing in the newborn nursery,” J. of Perinatology. 2012;32:966-969.

7. Valsami, S., “Importance of Direct Antiglobulin Test (DAT) in Cord Blood: Causes of

DAT (+) in a Cohort Study,” Pediatrics and Neonatology. 2015;56:256-260

Light Level Table (from Bilitool & Bhutani Nomogram)

Hour of Life 38+ weeks/Coombs- <38 weeks or Coombs+ <38 weeks AND Coombs+

4 ~7 ~6 ~4

5 ~7.6 ~6.2 ~4.6

6 ~7.8 ~6.3 ~4.7

7 ~7.9 ~6.6 ~4.9

8 ~8 ~6.8 ~5

9 ~8.4 ~7 ~5

10 ~8.6 ~7 ~5.1

11 ~8.8 ~7.2 ~5.5

12 9.1 7.7 6

13 9.3 7.9 6.2

14 9.5 8.1 6.3

15 9.8 8.3 6.5

16 10 8.4 6.7

17 10.2 8.6 6.8

18 10.4 8.8 7

19 10.6 9 7.2

20 10.8 9.2 7.3

21 11.1 9.4 7.5

22 11.3 9.5 7.7

23 11.5 9.7 7.8

24 11.7 9.9 8

25 11.9 10.1 8.1

26 12 10.2 8.3

27 12.2 10.4 8.4

28 12.3 10.5 8.5

29 12.5 10.7 8.7

30 12.7 10.8 8.8

31 12.8 11 8.9

32 13 11.1 9.1

33 13.1 11.3 9.2

34 13.3 11.4 9.3

35 13.4 11.6 9.5

36 13.6 11.7 9.6

37 13.7 11.8 9.8

38 13.9 11.9 9.9

39 14 12.1 10.1

40 14.2 12.2 10.2

Title: Evaluation of Neonatal Sepsis Risk GuidelinePatient Age Group: ( ) N/A ( ) All Ages (X) Newborns ( ) Pediatric ( ) Adult

DESCRIPTION/OVERVIEW

Newborn infants on Labor & Delivery (L&D), Newborn Nursery (NBN), Mother Baby Unit (MBU), Women’s Special Care Unit (WSCU), and Intermediate Care Nursery (ICN) will be evaluated for sepsis risk using the neonatal sepsis calculator found at: https://neonatalsepsiscalculator.kaiserpermanente.org/. Use of the neonatal sepsis calculator, which also factors in the infant’s clinical exam, will identify newborns that need follow-up and close observation while reducing antibiotic use in those who do not meet specific criteria. Providers should use clinical judgment when using the calculator to evaluate sepsis risk. Exceptions to this guideline can be made by the Licensed Independent Practitioner (LIP) in order to meet the needs of each individual patient toward the goal of optimal outcomes.

REFERENCES

Escobar, G.J., Puopolo, K.M, Wi, S., Turk, B.J., Kuzniewicz, M.W., Walsh, E.M, et al. (2014). Stratification of risk of early-onset sepsis in newborns ≥ 34 weeks’ gestation. Pediatrics, 133: 30-36.

Higgins, R.D., Saade, G., Polin, R.A., Grobman, W.A., Buhimschi, I.A., Watterberg, K., et al. (2016). Evaluation and management of women and newborns with a maternal diagnosis of chorioamnionitis. Obstetrics & Gynecology, 127 (3): 426-436.

Kuzniewicz MW, Puopolo KM, Fischer A, Walsh EM, Li S, Newman TB, et al. (2017). A quantitative, risk-based approach to the management of neonatal early-onset sepsis. JAMA Pediatrics, 171(4): 365-371.

AREAS OF RESPONSIBILITY

Newborn Nursery (NBN), Mother Baby Unit (MBU)

GUIDELINE PROCEDURES

1. Any infant’s (≥35 week’s gestation) sepsis risk can be calculated with the neonatal sepsis calculator.

Applies To: MBU/NBN/WSCU/L&D/ICNResponsible Department: NBN & MBU

2. Infants with the following conditions will be evaluated by using the neonatal sepsis calculator to guide clinical care and vital signs will be taken every 4 hours for the first 12 hours of life (regardless of sepsis calculator recommendations).

a. Mothers who have/are:i. GBS+ or GBS unknown

ii. Suspected Triple I (formerly referred to as chorioamnionitis)iii. Prolonged rupture of membranes (ROM) greater than 24 hoursiv. Isolated maternal fever within 2 hours after delivery (maternal temperature ≥

39.0°C on one occasion OR ≥38.0°C but <39.0°C on two occasions 30 minutes apart without a clear source).

v. No prenatal care or infant born outside of hospitalb. Infants who are born at 35 to 36 6/7 weeks gestation

3. Go to: https://neonatalsepsiscalculator.kaiserpermanente.org/a. Set incidence of Early-Onset Sepsis (first drop down tab) to CDC national incidence of

0.5/1,000 birthsb. Other values in calculator filled out by LIP or nurse according to history

i. Note : if ROM length unknown, use 24 hours as the valuec. Intrapartum Antibiotics defined as:

i. GBS-specific antibiotic prophylaxis*: Penicillin, ampicillin, erythromycin, cefazolin

ii. Broad spectrum: Other cephalosporins (other than cefazolin), fluoroquinolones, extended spectrum beta-lactam, any intra-partum antibiotic prophylaxis + an aminoglycoside

iii. *Note: Infants of GBS+ mothers who received vancomycin or clindamycin should be considered to have had NO antibiotics for use in the sepsis calculator.

4. After all values are filled in, click Calculate to obtain Early-Onset Sepsis Risk at Birth and after Clinical Exam

5. Clinical Recommendations depend on infant’s Clinical Exam6. Definitions for Clinical Exam (links also provided on sepsis calculator webpage)

a. Well Appearing- No persistent physiologic abnormalitiesb. Equivocal-

i. Persistent physiologic abnormality > 4 hrs 1. Tachycardia (HR > 160)2. Tachypnea (RR > 60)3. Temperature instability (> 100.4˚F or < 97.5˚F) (>38°C or <36.4°C)4. Respiratory distress (grunting, flaring, or retracting) not requiring

supplemental O2

ii. Two or more physiologic abnormalities lasting for > 2 hrs 1. Tachycardia (HR > 160)2. Tachypnea (RR > 60)3. Temperature instability (> 100.4˚F or < 97.5˚F) (>38°C or <36.4°C)4. Respiratory distress (grunting, flaring, or retracting) not requiring

supplemental O2

c. Clinical Illnessi. Persistent need for Nasal Continuous Positive Airway Pressure (NCPAP) / High

Flow Nasal Cannula (HFNC) / mechanical ventilation (outside of the delivery room)

ii. Hemodynamic instability requiring vasoactive drugs

iii. Neonatal encephalopathy /Perinatal depression 1. Seizure2. Apgar Score at 5 minutes < 5

iv. Need for supplemental O2 > 2 hours to maintain oxygen saturations > 90% (outside of the delivery room)

7. Abnormal vital signs or any of the above symptoms of equivocal exam or clinical illness will be reported to LIP ASAP.

8. When the sepsis calculator recommends Blood Culture or Antibiotics, both a Blood Culture and a Complete Blood Count with Differential (CBC with diff) will be drawn prior to antibiotic administration.

9. Antibiotic Dosing a. Ampicillin

i. 50 mg/kg/dose IM Q 8 hours (MBU/WSCU/NBN)ii. 100mg/k/dose IV Q 12 hours (ICN-3)

b. Gentamicin i. 4 mg/kg/dose IM Q 24 hours (MBU/WSCU/NBN, ≥ to 35 weeks gestational age)

ii. 4 mg/kg/dose IV Q 24 hours (ICN-3, ≥ to 35 weeks gestational age)10. Observation for 48 hours is required for infants whose mothers are/have:

a. GBS+ with inadequate treatmentb. Suspected or confirmed Triple Ic. GBS unknown AND either one of the following additional risk factors:

i. <37 weeks gestationii. >18 hours ROM

11. Observation for 48 hours is recommended for infants whose mothers are/have:a. GBS+ with adequate treatmentb. Isolated maternal temperature as defined above

12. This neonatal sepsis calculator should be used for ongoing evaluation of any newborn infant (≥35 week’s gestation) with an equivocal exam or clinical illness. (i.e. A well-appearing infant may become equivocal when vitals are repeated in 4 hours. At this time, the sepsis calculator should be used again to determine recommendations for treatment).

DEFINITIONS

Suspected Triple I is defined as fever (maternal temperature ≥ 39.0° C on one occasion OR ≥38.0 °C but <39.0 °C on two occasions 30 minutes apart without a clear source) AND one of the following:

o Fetal tachycardia >160 for ≥ 10 minutes (excluding accelerations, decelerations, or periods of marked variability)

o Maternal white cell count >15,000 in the absence of corticosteroids Note that admission or most recent WBC count may be used for diagnostic criteria If admission or most recent WBC count is below criteria threshold, recommend stat CBC to

determine WBC at time of fevero Purulent-appearing fluid coming from the cervical os

SUMMARY OF CHANGES

Previous practices for evaluating neonatal sepsis risk by using algorithms for different types of risk factors are being replaced by using a single neonatal sepsis risk calculator which considers significant risk factors. Guidelines being replaced: Evaluation of the healthy appearing term/near term infant born to a mother with a fever in labor, Newborn Admission Algorithm, Management of Asymptomatic infants born to GBS+ mothers or unknown GBS with risk factors.

Resource/Dept Contact InformationMother Baby Unit/Newborn Nursery & Intermediate Care Nursery

MBU/NBN UD 505-272-2191; MBU/NBN UBE 505-272-6458ICN UD 505-272-2458; ICN UBE 505-272-7482

DOCUMENT APPROVAL & TRACKINGItem Contact Date Approval

Owner NBN, MBU

Consultant(s)NBN Medical Directors, ICN Medical Directors, NBN Unit Director, NBN UBE, ICN Unit Director, ICN UBE, Maternal Sepsis Workgroup

Committee(s) Neonatal Sepsis Workgroup (Maternal Child Health Committee) [Y or N/A]

Nursing Officer Sheena Ferguson, Chief Nursing Officer [Y or N/A]

Medical Director/OfficerLarry Leeman MD, Emilie Sebesta MD (co-directors NBN), Larry Leeman MD, Nicole Urrea MD (co-directors ICN-3) [Y or N/A]

Human Resources [Name], HR Administrator, [UNMH or UNM] [Y or N/A]

Finance [Name, Title], [UNMH or HSC] [Y or N/A]

Official Approver [Name, Title, Area] Y

Official Signature Date:

Effective Date[Day/Mo/Year]

Origination Date[Month/Year]

Issue Date Clinical Operations Policy Coordinator

ATTACHMENTShttps://neonatalsepsiscalculator.kaiserpermanente.org/

UNMH Critical Congenital Heart Disease Screening Protocol

Short Acting Morphine for Neonatal Abstinence Syndrome:

Dose given q 3 - 4 hrs with feeds; do not exceed 4 hrs between dosesMorphine (0.04mg/0.1ml)

Score Dose For Initiation0-8 0 None9-12 0.04 mg/dose13-16 0.08 mg/dose17-20 0.12 mg/dose21-24 0.16 mg/dose25 or above 0.20mg/dose

Score Morphine Initiation:• If neonate scores 9-12 re-score after feeding or within the hour and if re-score is 9-12 start treatment based on highest score. If re-score is 0-8, do not initiate treatment.• If initial score is 13 or greater, start treatment immediately without reassessment.

Morphine Maintenance/Escalation• Maintain dose if score 0-8• Increase dose by 0.02 if score is 9-12 (rescore before dosing )• Increase dose by 0.04 if score 13-16• Increase score by 0.06 if score 17-20

Weaning Instructions:• Maintain on dose 48 hrs before starting weaning• Wean 0.02 mg morphine every day for a score is 0-8• Defer wean for score 9-12

Re-escalation• If neonate scores 9-12 re-score as described for initiation ,• If second score is in 9-12 increase morphine 0.01 mg q3-4 hrs• If 2 consecutive scores 13-16, increase 0.02 mg q3-4 hrs• If 2 consecutive scores in 17-20, increase 0.04 mg q3-4 hrs etc

Timing of Scoring: Hospitalized infants scored every 3-4 hrs before feeds. Reassessment Occurs immediately after feeds or within 1 hour.

Oxygen saturation and respiratory rate assessed 30-60 minutes after first two doses and after any dose escalation

Adapted from MOTHER TRIAL: Jones HE, Kaltenbach K, Heil SH, et al. Neonatal abstinence syndrome after methadone orbuprenorphine exposure. N Engl J Med 2010;363:2320-31.

UNMH Breastfeeding, Substance Abuse, & Infectious Diseases Guideline

Introduction:

Breast milk provides optimal nutrition and opportunity for mother-infant bonding that may lead to better parenting skills. Breast milk provides benefits, including protection from infection and some forms of cancer, that cannot be provided by artificial milk (formula). Some drugs of abuse may be passed to the newborn via breast milk and be dangerous for the baby. These guidelines are intended to encourage a consistent approach between providers; however, each case should be managed on an individual basis after considering the mother’s history of substance use, prenatal care, and treatment for substance abuse. When mother and baby have different providers, communication between teams is critical.

Guideline

1. Breastfeeding Supported

1.1. Breastfeeding should be supported/encouraged in mothers who have a history of occasional use of alcohol or marijuana and who:

1.1.1.quit when they discovered they were pregnant in the first or second trimester or

1.1.2.continued to use occasionally in pregnancy , i.e.., small amounts and not every day, and

1.1.3.plan not to drink alcohol or smoke marijuana while they are breastfeeding or plan only to use small amounts and not every day (i.e., occasional use vs. abuse).

1.2. A maternal or infant urine toxicology screen positive for THC at the time of delivery should not alone preclude breastfeeding if the provider has reason to believe the mother’s use is occasional, as described above, and documents his or her reasons for believing the mother’s use is occasional and therefore the benefits of breastfeeding outweigh the potential risks of the infant’s exposure to marijuana in the breast milk.1

1.3. In a mother with a known history of substance abuse during the current pregnancy, breastfeeding should be supported/encouraged under the following circumstances:

1.3.1.Mother’s urine toxicology screen is negative for illicit drugs and opiates at delivery (excepting opiates given during labor), and

1 There is little evidence regarding the effect of maternal marijuana use and breastfeeding. What evidence there is suggests that the risk would only be significant when the mother is a “heavy user” of marijuana. See Djulus, et al., Nice & Luo, LactMed, ABM, and AAP Committee on Drugs.

1.3.2.she has had no positive urine toxicology screens in the 90 days prior to delivery (unless mom was hospitalized or in jail during entire 90 days prior to delivery; see below), and

1.3.3.she indicates she does not intend to use illicit drugs or non-prescribed opiates while breastfeeding her baby, and

1.3.4.she has received consistent prenatal care starting prior to 26 weeks estimated gestational age

1.4. Mothers using methadone or buprenorphine may breastfeed if they are not using other drugs of abuse, are enrolled in a substance abuse program, and have a note in their chart indicating support of breastfeeding or there is an order indicating support of breastfeeding from the newborn’s provider.

2. Breastfeeding Generally Discouraged

2.1. In a mother with a known history of substance abuse (except isolated use of marijuana) during the current pregnancy, breastfeeding should usually be discouraged under the following circumstances:

2.1.1.Mother’s urine toxicology screen is positive for, or she admits to use of, any illicit substance or opiate at the time of delivery (excepting opiates given during labor) or during the 30 days prior to delivery. Or

2.1.2.Mother did not receive prenatal care during this pregnancy.

2.2. Exceptions to this recommendation are permitted based on the evaluation of a licensed independent practitioner, chart documentation of the rationale for the exception, and a written order. In these situations it may be appropriate to “pump and dump” until the drugs are cleared and to check weekly maternal UDMs over the first month or longer.

3. Breastfeeding Dependent on Healthcare Provider Discretion

3.1. In a mother with a known history of substance abuse during the current pregnancy, breastfeeding may be supported/encouraged or discouraged on a case by case basis with a written order from the baby’s provider in the following circumstances:

3.1.1.In the 30-90 day period prior to delivery (but not within 30 days of delivery) mother either admits to use of, or has a positive urine toxicology screen for, an illicit substance or non-prescription opiate. In this case, it is critical to talk with the mother’s prenatal providers or substance abuse counselors to obtain their opinion as to whether or not this was a limited relapse and whether or not they believe mom is likely to resume use upon discharge from the hospital.

3.1.2. Mother only obtained sobriety in an inpatient setting, including incarceration. Again, provider should talk with mother’s prenatal providers and/or substance abuse counselors.

3.2. If there is a question regarding whether or not it is okay for a mother to breastfeed (i.e., mother does not fall into the category where breastfeeding is generally discouraged or generally encouraged), the nurse should support a mother who wishes to breastfeed, let the mother know the plan might change, and document this, as well as the final decision by mother’s and/or baby’s providers, in the baby’s chart.

4. Provider Considerations

4.1. When deciding whether to encourage/support a mother’s decision to breastfeed in the hospital, providers may consider:

4.1.1.mother’s history of drug use (e.g., serious history of abuse vs. history of occasional recreational use).

4.1.2.mother’s participation in a substance abuse treatment program.

4.1.3.mother’s behavior on Mother-Baby Unit or Women’s Special Care Unit (e.g., frequent absences from unit or evidence of intoxication on unit).

4.2. In all instances where a mother’s prenatal provider knows of a mother’s current or past substance use or abuse, he or she should put recommendations regarding breastfeeding in the mother’s chart and, when possible, communicate with the baby’s provider.

5. Provider Counseling

Whether a provider is encouraging or discouraging breastfeeding in a woman with a history of substance use or abuse, he or she must counsel the mother on the possible harm to her baby if she breastfeeds and continues to use illicit substances or non-prescription opiates or is a heavy user of alcohol or marijuana, including but not necessarily limited to:

5.1.1.mother being impaired in her ability to care for her infant,

5.1.2.baby becoming sleepy or agitated or having difficulty sleeping depending on the drug,

5.1.3.the possibility of long-term effects on her baby’s neurobehavioral development, and

5.1.4.the possibility of legal repercussions if baby is found to be positive for an illicit substance or non-prescribed opiate.

6. Infectious Diseases

6.1. Mothers who are Hepatitis C or Hepatitis B positive and would otherwise be encouraged to breastfeed, may breastfeed unless

6.1.1.they have cracked and bleeding nipples or

6.1.2.have another contraindication to breastfeeding.

6.2. Mothers who are HIV (Human Immunodeficiency Virus) or HTLV (Human T-cell Lymphotropic Virus Type I or Type II) positive should not breastfeed.

6.3. Mothers who have active, untreated tuberculosis should not breastfeed and should be separated from their babies until

6.3.1.the mother has received 2 weeks of treatment and

6.3.2.it is documented that mother is no longer infectious.

6.3.3.Babies may receive mother’s expressed breast milk as tuberculosis is not transmitted via breast milk.

6.4. Mothers with active HSV (herpes simplex virus) lesions on their breasts should not breastfeed. Babies may receive mother’s expressed breast milk as HSV is not transmitted via breast milk.

6.5. Mothers who have contracted varicella within 5 days of delivery or 2 days postpartum should be separated from their infants but their babies may receive expressed breast milk as varicella is not transmitted via breast milk.

References

1. AAP Section on Breastfeeding, “Breastfeeding and the Use of Human Milk”, Pediatrics, 129:3 (2012).

2. The Academy of Breastfeeding Medicine Protocol Committee, “ABM Clinical Protocol #21: Guidelines for Breastfeeding and the Drug-Dependent Woman,” Breastfeeding Medicine, 4:4 (2009).

3. Nice, FJ, Luo, AC, “Medications and Breast-feeding: 4. Current Concepts,” JAPhA, 52:1, 86-94 (2012).5. Garry, A, et al., “Cannabis and Breastfeeding,” J. Toxicol. 2009; 2009:596149.6. Djulus, J, Moretti, M, Koren, G, “Marijuana Use and Breastfeeding,” Canadian Family Physician,

51:349-350 (2005).7. AAP Committee on Drugs, “The Transfer of Drugs and Other Chemicals Into Human Milk”

Pediatrics 2001; 108; 776.8. Sharma, P, Murthy, P, Bharath, MMS, “Chemistry, Metabolism, and Toxicology of Cannabis:

Clinical Implications,” Iran J Psychiatry. 2012 Fall; 7(4): 149–156. 9. CDC, Breastfeeding: Diseases and Conditions.

http://www.cdc.gov/breastfeeding/disease/index.htm10. CDC, Tuberculosis and Pregnancy.

http://www.cdc.gov/tb/publications/factsheets/specpop/pregnancy.htm

Approved UNM Maternal and Child Health Committee December 2013