Newborn Nursery Basics



Newborn Nursery Basics (Substance)MondayTuesdayWednesdayThursdayFridayMorning Report8-9 PedsTully8-9 Peds Tully11 a.m. EducationInternsAttending on switch weeks; ICN-3 Resident otherwiseMBU ICN-3 ResidentMBUICN-3 ResidentMBUStudents MBUResident School12-5 Family Medicine12-5 PediatricsCircsNBNNBNNBNNBNNBNNewborn ExamMust do complete exam on day of admission (see Up To Date for great review of newborn exam, Assessment of the Newborn, . Also, Stanford has a wonderful website with pictures of newborn physical findings at . On subsequent and discharge days, must examineGeneral Anterior fontanelleEyes for red reflexLungsHeart (pay special attention for new murmurs not heard on first day)Pulses (pay special attention to femoral pulses, decreased or absent concerning for coarctation)Umbilicus (note presence or absence of erythema or anything else unusual)HipsToneDischarge and Follow UpSee 2015 AAP Hospital Stay for Healthy Newborns Anything before 48 hours is considered “early discharge”Early discharge discouraged if:gestational age less than 38 weeks (though late preterm technically only up to 36 6/7 weeks)Teen momFirst time momGBS+ mom (unless adequately treated AND other discharge criteria met AND mom can monitor baby at home and FU in 24-48 hours). See UNM GBS Guidelines attached.Bilirubin in High Risk category (or close to light level in baby with risk factors for hyperbilirubinemia, e.g., <38 weeks, Coombs+)Excessive weight loss (usually >7%)Mother with chorio (absolute bar to early discharge). See UNM Chorio guidelines attached.AAP recommends all babies follow up within 24-72 hours if discharged before 48 hours.Even if discharged after 48 hours, probably need FU in 24-72 hours unless experienced breastfeeding mother or bottle feeding with low risk bili, minimal weight loss, and no other concerns.Primary factors to consider when deciding on timing of follow up includebaby’s gestational agebilirubinweight lossfeedingMay need FU with Lactation Clinic in addition to or in lieu of FU in NBN Clinic or PCP visit if having difficulty with breastfeeding.All babies must be seen at 10-14 days for WCC and 2nd metabolic screen whether seen at 24-72 hours or not. CircumcisionsAAP now says medical benefits outweigh risks but are not great enough to recommend circumcision outright for all baby boys. See (policy statement) and HYPERLINK "" (technical report).Circumcision manual available in procedure room in Newborn NurseryConsent forms available in procedure room drawers.Tech usually available to help set up and assist with pacifier/sweetiesBreastfeedingPlease always ask about previous breastfeeding experience on admissionBreastfed previous childrenHow longAny problemsLactation specialists available 6 days a week inpatient, many night and Monday-Saturday outpatientLactation lectures 11 am every Monday, 4th Floor L&D Conference RoomMust complete Wellstart Breastfeeding Education Module and exam by completion of rotation. See . Turn in certificate of completion to Dr. Sebesta or Unit Director, Andrea Petitto (office across from Rooms 22 & 23), or Unit Educator, Bekki Brown (office next to Andrea’s, closer to Room 24).See also AAP 2012 policy statement on Breastfeeding and the Use of Human Milk at . Critical Congenital Heart Disease ScreeningFully implemented July 1, 2012Tech does initial pre (right hand) and post (either foot) ductal sats. Fail if (1) either hand or foot is <90%, (2) if both pre and postductal sats are between 90-95%, or (3) if difference between foot and hand is >3%. Pass if at least one sat is >/= 95% and difference between foot and hand is </= 3%. If (1), tech notifies provider to evaluate and call NBICU if needed. If (2) or (3) nurse repeats pre and post ductal sats up to 2 more times before notifying provider.See Protocol below and Powerpoint on CCHD Screening (sent separately).Recommended Learning TopicsHyperbilirubinemia (protocol attached below)Serum bilirubin done on all babies at 24 hrs w/ metabolic screenSerum bilirubin <24 hrs if Coombs+TcB <24 hrs if potential ABO incompatabilityTcB every morning unless Serum bilirubin done since midnightPhototherapy within 48 hoursBaby>5 days oldScreening for biliary atresia/disorders with high direct biliIf direct bili 0.8-0.9, recheck direct and total bili in 1-2 weeksIf direct bili 1.0 or higher, call Peds GI See AAP’s Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation, and Bhutani nomogram I also really like the two part series on hyperbilirubinemia by Maisels which you can find if you search “Jaundice in a Newborn” in Contemporary Pediatrics (free to view & save if you set up free account)Group B Strep & Maternal ChorioSee UNM Guidelines (attached to this document).See also AAP’s Recommendations for the Prevention of Perinatal Group B Streptococcal (GBS) Disease, Newborn Nursery Guidelines in draft. Screening now done for risk factorsPretermSGAIDMLGAOr if symptomaticSee also AAP’s 2011 Clinical Report on Neonatal Hypoglycemia, AAP’s 1993 Routine Evaluation of Blood Pressure, Hematocrit, and Glucose in Newborns, andMarvin Cornblath’s Controversies Regarding Definition of Neonatal Hypoglycemia : Suggested Operational Thresholds, prevention. Biggest risk factors Maternal smoking (even if only during pregnancy)Sleeping prone or on sideSoft beddingOverheatingBed sharing (though still controversial)Protective factorsBreastfeedingPacifiers, possiblySeeAAP Technical Report on SIDS (October, 2011), AAP Policy Statement on SIDS (October,2011), Risk Factor Changes for SIDS after Back to Sleep Campaign, (March, 2012), HYPERLINK "" . Hip Dysplasia Check for with each exam (Ortolani & Barlow)Begin with Ortolani (putting femur back in socket) then Barlow (displacing from socket)Risk factorsGirlBreechFamily history of hip dysplasiaSee AAP Technical Report (2000) andSee AAP Practical Guideline (2000) for when to schedule FU hip ultrasounds. See also 2006 Review article, Sacral DimplesSee 2011 Peds in Review article, and 2014 Pediatric Annals article with “Simple Dimple” rules, . Neonatal Abstinence Syndrome (NAS)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.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).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.Please see flyer by white board regarding MOM trial and call if baby might be candidate for this research study of treating babies exposed to methadone or other opiate not including buprenorphine.See methadone protocol in white reference book in NBN conference roomSee morphine protocol (attached)See Breastfeeding & Substance Abuse Guideline (attached)NEWBORN MANAGEMENT OF INFANTS BORN TO MOTHERS WHO ARE GBS (+) OR GBS UNKNOWNtc "NEWBORN MGMT. OF INFANTS BORN TO GBS (+) OR UNKNOWN MOTHERS" \f C \l 1For >37 weeks asymptomatic infants born to GBS+ mothers who received optimal intrapartum antibiotics (i.e. received antibiotics >4 hrs prior to delivery using penicillin, ampicillin or cefazolin): If the baby does not show any signs of sepsis, observation may occur at home after 24 hours if other discharge criteria have been met, access to medical care is readily available, and a person who is able to comply fully with instructions for home observation will be present. If any of these conditions is not met, the infant should be observed in the hospital for at least 48 hours and until discharge criteria are achieved. Establish that the mother understands the risk of infection to her infant and her ability to make appropriate arrangements for follow-up care, including transportation to follow-up care during regular working hours for outpatient medical facilities. Any mother considered for discharge before 48 hours must leave with a specific follow-up appointment arranged by the discharge provider to have the infant seen within 24-48 hours from time of discharge and have adequate family support (at minimum access to a telephone and transportation for emergencies). Care for asymptomatic infants <37 weeks born to GBS+ mothers who received optimal intrapartum antibiotics will be individualized based on clinical factors including whether the preterm delivery occurred spontaneously or was induced for maternal For asymptomatic infants <37 weeks gestation or born after rupture of membranes of >18 hours born to incompletely treated GBS+ mothers (i.e. received antibiotics <4 hrs. prior to delivery or use of antibiotic other than penicillin, ampicillin or cefazolin). This category also includes infants <37 weeks born to mothers with negative rapid GBS as this test is not appropriate in patients at <37 weeks gestational age; instead they should receive intrapartum antibiotic prophylaxis if they do not have a negative GBS culture within four weeks.Observe infant carefully for signs and symptoms of sepsis or pneumonia. This is particularly important in the first 6 hours of life during the transition period.Anticipate a minimum 48 hours hospital stay.Perform a limited work-up with CBC and blood culture on arrival at NBN or ICN-3. If the infant appears ill, obtain a CBC and blood culture immediately and consider starting antibiotics before arranging transfer to the NICU. Start antibiotics if WBC < 5.0 or I/T ratio >0.2.If the infant does not demonstrate symptoms of pneumonia or sepsis, observe for 48 hours. Start antibiotics if the infant has a change in clinical course or blood cultures become positive.If at any time after the transition period the infant becomes symptomatic, obtain CBC and evaluate blood culture results and initiate antibiotics. For asymptomatic infants >37 weeks gestation without ROM of >18 hours born to incompletely treated GBS+ mothers (i.e. received antibiotics <4 hrs. prior to delivery or use of antibiotic other than penicillin, ampicillin or cefazolin):Observe infant carefully for signs and symptoms of sepsis or pneumonia. This is particularly important in the first 6 hours of life during the transition period.A CBC and blood culture is no longer recommended in this group.Anticipate a minimum 48 hours hospital stay.If the infant does not demonstrate symptoms of pneumonia or sepsis, observe for 48 hours. Start antibiotics if the infant has a change in clinical course or blood cultures become positive.If at any time after the transition period the infant becomes symptomatic, obtain CBC and blood culture results and initiate antibiotics if clinically indicated. For asymptomatic infants born to mothers with an unknown routine or rapid GBS culture status who did not receive intrapartum antibiotics, determine if the mother had risk factors (see criteria below). Note: The OB provider must document in the OB chart the presence or absences of GBS risk factors. If there are no risk factors, the infant is >37 weeks gestation, and the mother received prenatal care, the infant may be discharged at 24 hrs. with a follow-up appointment scheduled by the discharging provider within 24-48 hrs. Signs and symptoms of sepsis must be explained to the parents and the parents must be instructed where to bring the baby if any signs or symptoms develop.If the mother with GBS unknown has risk factors, the infant will be observed for 48 hours and a limited work-up performed with CBC and blood cultures upon NBN or ICN-3 admission and consideration of ordering a CBC. No early discharge.Nursing considerations for all infants born to mothers who are GBS positive or GBS unknown with risk factorsDuring the 48-hour observation period the nurse should do vital signs every 4 hours and the house officers should be notified if signs and symptoms of sepsis are present. Other considerationsMothers undergoing elective cesarean section (and mother did not begin labor) do not need prophylaxis regardless of their culture status.GBS bacteruria should be treated when diagnosed and the mother should also receive antibiotic prophylaxis in labor. Risk factors are gestational age<37 weeks, ROM > 18 hours, maternal fever in labor, maternal urine culture positive for GBS during current pregnancy or history of prior infant with GBS disease * Full diagnostic evaluation includes a blood culture, a complete blood count (CBC) including white blood cell differential and platelet counts, chest radiograph (if respiratory abnormalities are present), and lumbar puncture (if patient is stable enough to tolerate procedure and sepsis is suspected). ? Antibiotic therapy should be directed toward the most common causes of neonatal sepsis, including intravenous ampicillin for GBS and coverage for other organisms (including Escherichia coli and other gram-negative pathogens) and should take into account local antibiotic resistance patterns. § Consultation with obstetric providers is important to determine the level of clinical suspicion for chorioamnionitis. Chorioamnionitis is diagnosed clinically and some of the signs are nonspecific. ? Limited evaluation includes blood culture (at birth) and CBC with differential and platelets (at birth and/or at 6–12 hours of life). ** See table 3 for indications for intrapartum GBS prophylaxis. ?? If signs of sepsis develop, a full diagnostic evaluation should be conducted and antibiotic therapy initiated. §§ If≥37weeks’gestation,observation may occur at home after 24 hours if other discharge criteria have been met, access to medical care is readily available, and a person who is able to comply fully with instructions for home observation will be present. If any of these conditions is not met, the infant should be observed in the hospital for at least 48 hours and until discharge criteria are achieved. ?? Some experts recommend a CBC with differential and platelets at age 6–12 hours.Title: Infant of a Positive or Unknown Group B Strep. Mother/Mother with Suspected Chorioamnionitis-Newborn Nursery/Mother-Baby UnitNBN/MBU Educational GuidelineEvaluation of the healthy appearing term/near term infant born to a mother with a fever in laborMaternal Temp >38.4°C: CBC/Diff and Blood culture Treat infant with antibiotics regardless of GBS status or intrapartum antibiotic. Neonatal team to write antibiotics when they come to delivery if between 1600 and 0730.Infant brought to Newborn nursery within 45 minutes for blood draw and initiate antibiotics 2) Maternal Temp 38.0° to 38.3°C times two (includes within 2 hrs postpartum)a) If any of the following: FHR >160 for 20 minutes or longer, ROM >24 hrs, < 37 weeksCBC/Diff and Blood Culture Treat infant with antibiotics regardless of GBS status or intrapartum antibioticInfant brought to Newborn nursery within 45 minutes for blood draw and initiate antibiotics b) If none of the above factors CBC/Diff and Blood Culture Treat with antibiotics if Immature/Total (I/T) ratio on the CBC is ≥ 0.2 or total WBC count is <5.0Arrive at NBN within 2 hours of birth for blood drawAmpicillin 50 mg/kg/dose q 8 hours (100 mg/kg/dose q 12 if in NBICU or ICN-3)Gentamicin 4 mg/kg/dose q 24 hours for term infants, < 38 weeks dose q 36 hours. Approved August 2010 Maternal Child Health Committee and Medical Directors of L &D, MBU, NICUUNMH Critical Congenital Heart Disease Screening ProtocolEDUCATIONAL GUIDELINEBilirubin Screening in the Healthy or Late Preterm NewbornBRIEF STATEMENT OF THE EVIDENCEThe 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.BACKGROUNDNewborns 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.PROCEDURECord Blood ScreeningAll newborns will have a DAT (Coombs) sent from cord blood at birth.A newborn’s cord blood will also be sent for blood type if his or her mother:Is Rh-negative,Has a positive AST (antibody screening test), orHas Blood Type ONewborns with a positive DAT (Coombs+) will have their cord blood tested for blood type (if not already done).Bilirubin ScreeningNewborns with a positive DAT (Coombs+) will have a TSB (total and direct serum bilirubin) and Hemoglobin (Hemacue) sent.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.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. After 24 hours of life all newborns will have a TCB (transcutaneous bilirubin) checked prior to 8 am nursing rounds if the newborn has not had a serum bilirubin drawn since midnight the night before, has not received phototherapy within the past 48 hours, andis not >96 hours oldA visual assessment for jaundice will be performed at least once per nursing shift (12 hours).A nurse may check a TcB at his or her discretion if a newborn <24 hours old appears jaundiced ora newborn >24 hours old appears jaundiced and has a cephalohematoma or bruising, was born at <38 weeks gestation, is not feeding well, orthe jaundice appears to have developed rapidly.A serum bilirubin will be sent if the TcB is at or above light level, orthe TcB is ≥ 13 (regardless of the day of life or inpatient/outpatient status)Notification of ProvidersNurses are to notify a newborn’s medical provider (or NBICU after hours) with results of TSB as follows:If TSB is above light levelIf provider has asked to be notified Phototherapy 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.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. 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.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 ProvidersProviders 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.Providers should consider further evaluation or transfer to a higher level of care ifTSB is significantly above light level, especially if newborn is <24 hours,TSB continues to rise despite phototherapy, orTSB is rising much more rapidly than expected (>0.2 mg/dL/hr).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. Suggested evaluation includes a CBC with differential, reticulocyte count, and peripheral blood smear.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.REFERENCESAAP, 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.AAP, Subcommittee on Hyperbilirubinemia, “Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation,” Pediatrics. 2004;114(1):297-316.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.Maisels, M.J., “Managing the jaundiced newborn: a persistent challenge,” CMAJ. 2015;187(5):335-343.Maisels, M.J., et al., “Hyperbilirubinemia in the Newborn Infant ≥ 35 Weeks’ Gestation: An Update with Clarifications,” Pediatrics. 2009;124: 1193-1198.Shahid, R. & Graba, S., “Outcome and cost analysis of implementing selective Coombs testing in the newborn nursery,” J. of Perinatology. 2012;32:966-969.Valsami, S., “Importance of Direct Antiglobulin Test (DAT) in Cord Blood: Causes of DAT (+) in a Cohort Study,” Pediatrics and Neonatology. 2015;56:256-260Light Level Table (from Bilitool & Bhutani Nomogram)Hour of Life38+ weeks/Coombs-<38 weeks or Coombs+<38 weeks AND Coombs+4~7~6~45~7.6~6.2~4.66~7.8~6.3~4.77~7.9~6.6~4.98~8~6.8~59~8.4~7~510~8.6~7~5.111~8.8~7.2~5.5129.17.76139.37.96.2149.58.16.3159.88.36.516108.46.71710.28.66.81810.48.871910.697.22010.89.27.32111.19.47.52211.39.57.72311.59.77.82411.79.982511.910.18.1261210.28.32712.210.48.42812.310.58.52912.510.78.73012.710.88.83112.8118.9321311.19.13313.111.39.23413.311.49.33513.411.69.53613.611.79.63713.711.89.83813.911.99.9391412.110.14014.212.210.2Short 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/doseScore 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 17-20Weaning 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 9-12Re-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 etcTiming 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 escalationAdapted 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 GuidelineIntroduction: 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.GuidelineBreastfeeding SupportedBreastfeeding should be supported/encouraged in mothers who have a history of occasional use of alcohol or marijuana and who:quit when they discovered they were pregnant in the first or second trimester orcontinued to use occasionally in pregnancy , i.e.., small amounts and not every day, andplan 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). 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.In a mother with a known history of substance abuse during the current pregnancy, breastfeeding should be supported/encouraged under the following circumstances:Mother’s urine toxicology screen is negative for illicit drugs and opiates at delivery (excepting opiates given during labor), andshe 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), andshe indicates she does not intend to use illicit drugs or non-prescribed opiates while breastfeeding her baby, andshe has received consistent prenatal care starting prior to 26 weeks estimated gestational age 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. Breastfeeding Generally Discouraged 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: 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. OrMother did not receive prenatal care during this pregnancy. 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. Breastfeeding Dependent on Healthcare Provider DiscretionIn 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: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. Mother only obtained sobriety in an inpatient setting, including incarceration. Again, provider should talk with mother’s prenatal providers and/or substance abuse counselors.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. Provider ConsiderationsWhen deciding whether to encourage/support a mother’s decision to breastfeed in the hospital, providers may consider:mother’s history of drug use (e.g., serious history of abuse vs. history of occasional recreational use).mother’s participation in a substance abuse treatment program.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).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. Provider CounselingWhether 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:mother being impaired in her ability to care for her infant,baby becoming sleepy or agitated or having difficulty sleeping depending on the drug,the possibility of long-term effects on her baby’s neurobehavioral development, andthe possibility of legal repercussions if baby is found to be positive for an illicit substance or non-prescribed opiate.Infectious Diseases Mothers who are Hepatitis C or Hepatitis B positive and would otherwise be encouraged to breastfeed, may breastfeed unlessthey have cracked and bleeding nipples orhave another contraindication to breastfeeding.Mothers who are HIV (Human Immunodeficiency Virus) or HTLV (Human T-cell Lymphotropic Virus Type I or Type II) positive should not breastfeed.Mothers who have active, untreated tuberculosis should not breastfeed and should be separated from their babies until the mother has received 2 weeks of treatment and it is documented that mother is no longer infectious.Babies may receive mother’s expressed breast milk as tuberculosis is not transmitted via breast milk.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.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. ReferencesAAP Section on Breastfeeding, “Breastfeeding and the Use of Human Milk”, Pediatrics, 129:3 (2012).The Academy of Breastfeeding Medicine Protocol Committee, “ABM Clinical Protocol #21: Guidelines for Breastfeeding and the Drug-Dependent Woman,” Breastfeeding Medicine, 4:4 (2009).Nice, FJ, Luo, AC, “Medications and Breast-feeding: Current Concepts,” JAPhA, 52:1, 86-94 (2012).Garry, A, et al., “Cannabis and Breastfeeding,” J. Toxicol. 2009; 2009:596149.Djulus, J, Moretti, M, Koren, G, “Marijuana Use and Breastfeeding,” Canadian Family Physician, 51:349-350 (2005).AAP Committee on Drugs, “The Transfer of Drugs and Other Chemicals Into Human Milk” Pediatrics 2001; 108; 776.Sharma, P, Murthy, P, Bharath, MMS, “Chemistry, Metabolism, and Toxicology of Cannabis: Clinical Implications,” Iran J Psychiatry. 2012 Fall; 7(4): 149–156. CDC, Breastfeeding: Diseases and Conditions. , Tuberculosis and Pregnancy. Approved UNM Maternal and Child Health Committee December 2013 ................
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