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Guideline

Women and Babies: Neonatal Early Assessment Program (NEAP)

Document No: RPAH_GL2016_xxx

Functional Sub-Group: Clinical Governance

Corporate Governance

Summary: The Neonatal Early Assessment Program (NEAP)

consists of a risk factor assessment and four sets of

measurements within the first 6 hours after birth:

1. The first physical examination.

2. The first lower limb oxygen saturation.

3. Anthropometry

4. Body fat (percentage) by air displacement

plethysmography

National Standard: National Standard 1

Policy Author: Original policy – Prof Heather Jeffery

Updated policy – Dr Tracey Lutz (Neonatologist)

Approved by: RPA Women and Babies Service Improvement Committee

Publication (Issue) Date: July 2016

Next Review Date: July 2019

Replaces Existing Policy: N/A

Previous Review Dates: N/A

Note: Sydney Local Health District (LHD) and South Western Sydney LHD were established

on 1 July 2011, with the dissolution of the former Sydney South West Area Health Service

(SSWAHS) in January 2011. The former SSWAHS was established on 1 January 2005 with

the amalgamation of the former Central Sydney Area Health Service (CSAHS) and the former

South Western Sydney Area Health Service (SWSAHS).

In the interim period between 1 January 2011 and the release of specific LHN policies (dated

after 1 January 2011) and SLHD (dated after July 2011), the former SSWAHS, CSAHS and

SWSAHS policies are applicable to the LHDs as follows:

Where there is a relevant SSWAHS policy, that policy will apply

Where there is no relevant SSWAHS policy, relevant CSAHS policies will apply to Sydney

LHD; and relevant SWSAHS policies will apply to South Western Sydney LHD.


Neonatal Early Assessment Program (NEAP)

Contents

1. Introduction 3

2. Policy Statement 3

3. Guidelines

3.1 Early Risk Factor assessment and clinical examination 3

3.2 Oxygen saturation screening 4

3.3 Anthropometry 4

3.4 Body composition - Fat measurement (fat mass, fat free mass and body fat %)

4. Figures

Figure 1: Overview on how to perform NEAP 7

Figure 2: Early physical examination of the newborn baby 8

Figure 3: Physical examination referral pathway 9

Figure 4: PeaPod quick reference guide 10

Figure 5: Anthropometric referral pathway 11

Figure 6: Oxygen saturation referral pathway 12

Figure 7: Body Fat percentage referral pathway 12

5. Key points 13

6. References 14

Sydney Local Health District Guideline No: RPAH_GL2013_019 Royal Prince Alfred Hospital September 2016


Neonatal Early Assessment Program (NEAP)

1. Introduction

The risks addressed by this policy:

Clinical risk of neurological damage or death of babies as a result of physical

abnormalities, cardiac defects, or neonatal hypoglycaemia going undetected and

untreated.

The aims / expected outcome of this policy

Babies with physical abnormalities, cardiac defects, or increased risk of hypoglycaemia

will be identified and appropriately managed.

2. Policy Statement

The goal of this guideline is to familiarise medical staff with the evidence, indications and

practical management of a neonate undergoing the NEAP (neonatal early assessment

program).

3. Guidelines

3.1 Early Risk Factor Assessment and Physical Examination

The overall goal of the early assessment is to identify risk factors for early neonatal problems

that will require regular postnatal observations, as well as identifying congenital and acquired

abnormalities which may have an immediate impact on the baby’s care and/or wellbeing.

Early Risk Factor Assessment

All babies should be reviewed for risk factors for the five main problem areas as identified on

the ‘Women and Babies Newborn Care Plan and Observations Chart (NCPOC – MR504) and

‘The Standard Newborn Observation Chart (SNOC – SMR 110.014)’. These include

Risk of hypoglycaemia

Respiratory distress

Risk of subgaleal haemorrhage - trauma from instrumental delivery

Risk of sepsis

Risk of jaundice

Assessment of risk of hypoglycaemia will include the anthropometric measurements and

percentage body fat as outlined below. Babies identified with risk factors will need

observations as outlined in the relevant RPAH guideline and on the NCPOC.

Early physical examination

The goal of this examination is to identify obvious external anomalies, as well as other

congenital and acquired problems that may have an immediate impact on the baby’s care or

well-being. This would include (but not be confined to) problems such as respiratory distress,

consequences of birth trauma (e.g bruising, sub-galeal haemorrhage, nerve palsy), cleft palate,

imperforate anus, abnormal genitalia and other dysmorphology. The examination should



include a complete ‘head to toe to back’ inspection of the baby as detailed below in Figure 2.

The findings should be documented in the relevant section of the NCPOC.

3.2 Oxygen saturation screening:

In the first minutes of life, there is a transition from the placenta being the main organ of gas

exchange to the newborn lungs. Toth1 et al demonstrated in 50 healthy newborns that it takes

between 12 and 14 minutes to achieve saturations > 95%. Routine oxygenation saturation

screening of well newborns has been shown to improve early diagnosis of congenital heart

disease (CHD)2 with a low false positive rate and minimal impact on resources. About half of

the babies with a low saturation screen (<95%) will have either congenital heart disease

(~1/3rd

) or other significant pathologies which include respiratory disease, delayed transition

to extra-uterine life (persistent pulmonary hypertension of the newborn), sepsis or metabolic

conditions (~2/3rd

)3. Saturation measurement within the first 4 to 6 hours of birth has a lower

accuracy for detection of CHD but greater sensitivity for non-cardiac pathology while

screening after 24 hours (late screen) has greater sensitivity for detection of CHD, especially

left heart ductal dependent lesions. At RPAH, both early and late oxygen saturation screening

will be performed in accordance with the existing guideline.

3.2.1 How to perform oxygen saturation screening:

Early oxygen saturation screening will be performed in accordance with the existing

guideline

Perform screening when the infant is quiet.

Place the probe around one foot with light source and receiver on each side of foot.

Secure with Coban® tape. To ensure good blood flow to the foot, do not secure too

tightly and do not hold the probe around the foot.

Switch on oximeter and allow signal to stabilise. Read when stabilised and there is a

good plethysmographic light pulse.

3.3 Anthropometry

Newborn measurement of weight, length, and head circumference reflects fetal nutrition and

forms the basis on which future growth measurements. 4,5,7,8

3.3.1 How to measure weight:

The scales on the Pea Pod are used for accurate measurement of weight to the nearest

gram.

The newborn is bare weighed.

The weight percentile is calculated using the Beeby electronic calculator on the

computer in the NEAP room, or if unavailable the weight is plotted on New South

Wales population-based birthweight percentile charts (less accurate)9.

3.3.2 How to measure length:

The length-board measurement, infantometer, has been shown to be the most reliable

and accurate measurement of neonatal length 6,10,11

and more recent designs have

improved ease of use such as the Easy-Glide Bearing Infantometer (Perspective

Enterprises, Portage, MI, USA).

The neonate is placed supine and unclothed on the board and held gently with his or

her body aligned and head in a neutral position. One person stands at the top of the

length board and holds the baby’s head in contact with the headboard while another



extends the left leg by placing the hand over the left knee, depressing the knee,

straightening the leg and moving the footboard to touch the plantar surface of the foot

at a right angle to the leg. Recheck that the head has not moved from the headboard

before taking the measurement. The actual reading is marked by an arrow as there is an

offset for greater ease of reading and accuracy.

The length percentile is calculated using the Beeby electronic calculator on the

computer in the NEAP room or plotted on New South Wales population-based birth

length percentile charts9

(less accurate).

.

3.3.3 How to measure head circumference:

Head circumference is measured using disposable paper circumference tapes at the

maximum fronto-occipital circumference.

Two reproducible measurements are required.

The head circumference percentile is calculated using the Beeby electronic calculator

on the computer in the NEAP room or plotted on New South Wales population-based

birth head circumference percentile charts9 (less accurate).

3.4 Body composition - Fat measurement (fat mass, fat free mass and body fat %)

Accurately determining the nutritional status of newborns is a major public health problem.

Furthermore undernourished neonates that survive are at risk of long term health outcomes,

including hypertension, stroke, type 2 diabetes, obesity and cardiovascular disease. 12,13

Neonatal undernutrition or ‘wasting’ is a clinical diagnosis often characterised by diminished

subcutaneous tissues and underlying muscles with loose wrinkled skin of the arms, thighs,

elbows and knees. However this clinical sign is, in our experience at RPAH, not well

recognised by a range of health providers.

Thus defining who is undernourished is problematic. Conventional approaches include the use

of population based percentiles (< 3rd

, 5th

or 10th

percentiles) or customised growth charts.

Population based charts rely on a large cross section of neonates and use weight for gestational

age by sex. Customised charts account for more maternal variables, however there is not

strong evidence to support their use at present. 14,15

An alternative to birth weight is the use of

body composition or body fat % (BF%).

The wasted, undernourished newborn is characterised by loss of the normal fat accretion in the

last 4-6 weeks of pregnancy. As fat is used by the newborn as an alternative substrate to

glucose for brain metabolism, BF% is a potentially very useful measure indicating degree of

undernutrition and directly related to neonatal metabolic outcomes. The additional advantage

is that it can distinguish the normal fat SGA (weight less than 10th

percentile) from the low fat,

undernourished SGA newborn and define the low fat AGA newborn at high risk of

hypoglycaemia, currently not possible with any other methods.

Recently a new technology using air displacement plethysmography (ADP) has become

available to non-invasively, accurately and quickly measure BF% in infants from birth to 6

months of age. ADP has been validated against the four-compartment model and biological

and physical phantoms16,17

and is considered the criterion method for determining BF% in

neonates. 18-22

Several studies have investigated the BF% as an indicator of neonatal nutritional status using

ADP. 20-25

Body fat is a better measure than customised charts for assessing neonatal

morbidity and as good as population based charts.26

The advantage of this method is it is



accurate, easy, reliable, non-invasive and acceptable to parents. The cut offs for low and high

fat are shown in the flow chart. These were determined by significantly better Receiver

Operator Curves (ROCs) for combined morbidity assessed by 3 pre-specified outcomes (temp

<36.5C, prolonged hospital stay, poor feeding (2 of 3 objective criteria). The cut off was

determined by the highest sensitivity balanced by the best specificity. 26

3.4.1 How to measure body composition:

This is performed in the NEAP room just after the measurement of length and weight

using the PeaPod (CosMed, USA).



Figure 1 - Overview on performing the NEAP



Figure 2 - Early Physical Examination of the Newborn Baby

The routine newborn assessment should include all aspects of the checklist on page 1 of the

NCPOC. The schema below moves from head to toe, front to back (adapted from Queensland

Maternity and Newborn Clinical Guidelines Program 61)27

. This examination does not replace

the discharge check which will include the red reflex, the heart and the hips.

Head

Palpate:

Sutures

Fontanelle

Trauma (check sub-galeal haemorrhage)

Face Inspect:

Morphology

Eyes, Ears

Nose, Jaw

Mouth Visualise and feel palate

(hard and soft)

Chest

Check:

Respiratory rate

No recession

Palpate neck

Abdomen

Check:

No distension

Palpate for masses

Umbilicus

Umbilical vessels (x3)

Anogenital

Check normal:

External genitalia

Anus patency, appearance and position

Limbs

Check normal:

Hands and Feet

Digits

Movements

Back

Check in ventral suspension:

Straight spine

No skin markings over spine

General

Check:

Skin & Colour

Symmetrical

Proportioned



Figure 3 - Physical examination referral pathway



Figure 4 - Pea Pod Quick Reference User Guide



Figure 5 - Anthropometry referral pathway



Figure 6 - Oxygen Saturation referral pathway



Figure 7 – Body fat percentage referral pathway



4. Key Points

Key point Level of Evidence &

Recommendation (NHMRC)25

Air displacement plethysmography (ADP) non-

invasively, accurately and quickly measures

BF% in infants from birth to 6 months of age.

Level of evidence: 3

Strength of recommendation: A

Body fat is a better measure than customised

charts for assessing neonatal morbidity

Level of evidence: 3

Strength of recommendation: A

5. References

1. Toth B, Becker A, Seelbach-Gobel B. Oxygen saturation in healthy newborn infants

immediately after birth measured by pulse oximetry. Arch Gynecol Obstet 2002 April:

266 (2)105-107

2. A. Meberg, A. Andreassen, L. Brunvand, T. Markestad, D. Moster, L. Nietsch, I. E.

Silberg, and J. E. Skålevik, 'Pulse Oximetry Screening as a Complementary Strategy to

Detect Critical Congenital Heart Defects', Acta Pædiatrica, 98 (2009), 682-86.

3. A. Meberg, S. Brugmann-Pieper, R. Due, Jr., L. Eskedal, I. Fagerli, T. Farstad, D. H.

Froisland, C. H. Sannes, O. J. Johansen, J. Keljalic, T. Markestad, E. A. Nygaard, A.

Rosvik, and I. E. Silberg, 'First Day of Life Pulse Oximetry Screening to Detect

Congenital Heart Defects', J Pediatr, 152 (2008), 761-5.

4. T. S. Johnson, J. L. Engstrom, and D. K. Gelhar, 'Intra- and Interexaminer Reliability

of Anthropometric Measurements of Term Infants', J Pediatr Gastroenterol Nutr, 24

(1997), 497-505.

5. T. S. Johnson, J. L. Engstrom, J. A. Warda, M. Kabat, and B. Peters, 'Reliability of

Length Measurements in Full-Term Neonates', J Obstet Gynecol Neonatal Nurs, 27

(1998), 270-6.

6. A. J. Wood, C. H. Raynes-Greenow, A. E. Carberry, and H. E. Jeffery, 'Neonatal

Length Inaccuracies in Clinical Practice and Related Percentile Discrepancies Detected

by a Simple Length-Board', J Paediatr Child Health, 49 (2013), 199-203.

7. T. H. Lipman, K. D. Hench, T. Benyi, J. Delaune, K. A. Gilluly, L. Johnson, M. G.

Johnson, H. McKnight-Menci, D. Shorkey, J. Shults, F. L. Waite, and C. Weber, 'A

Multicentre Randomised Controlled Trial of an Intervention to Improve the Accuracy

of Linear Growth Measurement', Arch Dis Child, 89 (2004), 342-6.

8. T. H. Lipman, K. D. Hench, J. D. Logan, D. A. DiFazio, P. M. Hale, and C. Singer-

Granick, 'Assessment of Growth by Primary Health Care Providers', Journal of

Pediatric Health Care, 14 (2000), 166-71.



9. P. J. Beeby, T. Bhutap, and L. K. Taylor, 'New South Wales Population-Based

Birthweight Percentile Charts', J Paediatr Child Health, 32 (1996), 512-8.

10. D. P. Davies, and R. E. Holding, 'Neonatometer: A New Infant Length Measurer', Arch

Dis Child, 47 (1972), 938-40.

11. A. F. Roche T. G. Lohman, & R. Martorell (eds.), Anthropometric Standardization

Reference Manual (Champaign, IL: Human Kinetics Books, 1988).

12. D. J. Barker, J. G. Eriksson, T. Forsen, and C. Osmond, 'Fetal Origins of Adult

Disease: Strength of Effects and Biological Basis', Int J Epidemiol, 31 (2002), 1235-9.

13. J. C. Wells, S. Chomtho, and M. S. Fewtrell, 'Programming of Body Composition by

Early Growth and Nutrition', Proc Nutr Soc, 66 (2007), 423-34.

14. A. E. Carberry, A. Gordon, D. M. Bond, J. Hyett, C. H. Raynes-Greenow, and H. E.

Jeffery, 'Customised Versus Population-Based Growth Charts as a Screening Tool for

Detecting Small for Gestational Age Infants in Low-Risk Pregnant Women', in

Cochrane Database of Systematic Reviews John Wiley & Sons, Ltd 2011 ).

15. A. E. Carberry, C. H. Raynes-Greenow, R. M. Turner, and H. E. Jeffery, 'Customized

Versus Population-Based Birth Weight Charts for the Detection of Neonatal Growth

and Perinatal Morbidity in a Cross-Sectional Study of Term Neonates', American

Journal of Epidemiology, August 21 (2013)..

16. A. Frondas-Chauty, I. Louveau, I. Le Huerou-Luron, J. C. Roze, and D. Darmaun, 'Air-

Displacement Plethysmography for Determining Body Composition in Neonates:

Validation Using Live Piglets', Pediatric research, 72 (2012), 26-31.

17. K. J. Ellis, M. Yao, R. J. Shypailo, A. Urlando, W. W. Wong, and W. C. Heird, 'Body-

Composition Assessment in Infancy: Air-Displacement Plethysmography Compared

with a Reference 4-Compartment Model', Am J Clin Nutr, 85 (2007), 90-5.

18. G. Ma, M. Yao, Y. Liu, A. Lin, H. Zou, A. Urlando, W. W. Wong, L. Nommsen-

Rivers, and K. G. Dewey, 'Validation of a New Pediatric Air-Displacement

Plethysmograph for Assessing Body Composition in Infants', Am J Clin Nutr, 79

(2004), 653-60.

19. A. Urlando, P. Dempster, and S. Aitkens, 'A New Air Displacement Plethysmograph

for the Measurement of Body Composition in Infants', Pediatr Res, 53 (2003), 486-92.

20. M. Yao, L. Nommsen-Rivers, K. Dewey, and A. Urlando, 'Preliminary Evaluation of a

New Pediatric Air Displacement Plethysmograph for Body Composition Assessment in

Infants', Acta Diabetol, 40 Suppl 1 (2003), S55-8.

21. G.S. Andersen, T. Girma, J.C.K. Wells, P. Kæstel, K.F. Michaelsen, and H. Friis, 'Fat

and Fat-Free Mass at Birth: Air Displacement Plethysmography Measurements on 350

Ethiopian Newborns', Pediatr Res, 70 (2011), 501-06.

22. D.A. Fields, J.M. Gilchrist, P.M. Catalano, M.L. Giannì, P.M. Roggero, and F. Mosca,

'Longitudinal Body Composition Data in Exclusively Breast-Fed Infants: A

Multicenter Study', Obesity, 19 (2011), 1887-91.

23. B. E. Lingwood, A. M. Storm van Leeuwen, A. E. Carberry, E. C. Fitzgerald, L. K.

Callaway, P. B. Colditz, and L. C. Ward, 'Prediction of Fat-Free Mass and Percentage

of Body Fat in Neonates Using Bioelectrical Impedance Analysis and Anthropometric

Measures: Validation against the Pea Pod', Br J Nutr, 107 (2012), 1545-52.



24. P. Roggero, M. L. Gianni, O. Amato, P. Piemontese, D. Morniroli, W. W. Wong, and

F. Mosca, 'Evaluation of Air-Displacement Plethysmography for Body Composition

Assessment in Preterm Infants', Pediatric research, 72 (2012), 316-20.

25. A. Fields, P. B. Higgins, and D. Radley, 'Air-Displacement Plethysmography: Here to

Stay', Curr Opin Clin Nutr Metab Care, 8 (2005), 624-9.

26. A. E. Carberry, C. H. Raynes-Greenow, R. M. Turner, L. M. Askie, and H. E. Jeffery,

'Is Body Fat Percentage a Better Measure of Undernutrition in Newborns Than Birth

Weight Percentiles', Pediatric Research, Advance online publication 02 October

(2013).

27. Queensland Maternity and Neonatal Clinical Guidelines Program, 'Examination of the

Newborn Baby', ed. by Queensland Health (Queensland Queensland Health, 2009).

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