PDF Guideline: Routine newborn assessment

Queensland Health

Maternity and Neonatal Clinical Guideline

Routine newborn assessment

Queensland Clinical Guideline: Routine newborn assessment

Document title: Publication date: Document number: Document supplement: Amendments: Amendment date: Replaces document: Author: Audience: Review date:

Endorsed by:

Contact:

Routine newborn assessment October 2014 MN14.4-V5-R21 The document supplement is integral to and should be read in conjunction with this guideline. Full version history is supplied in the document supplement. Content endorsed as current in June 2019. Review date extended MN14.4-V4-R19 Queensland Clinical Guidelines Health professionals in Queensland public and private maternity and neonatal services October 2021 Queensland Clinical Guidelines Steering Committee Statewide Maternity and Neonatal Clinical Network (Queensland) Email: Guidelines@health..au URL: health..au/qcg

Cultural acknowledgement

We acknowledge the Traditional Custodians of the land on which we work and pay our respect to the Aboriginal and Torres Strait Islander elders past, present and emerging.

Disclaimer

This guideline is intended as a guide and provided for information purposes only. The information has been prepared using a multidisciplinary approach with reference to the best information and evidence available at the time of preparation. No assurance is given that the information is entirely complete, current, or accurate in every respect.

The guideline is not a substitute for clinical judgement, knowledge and expertise, or medical advice. Variation from the guideline, taking into account individual circumstances, may be appropriate.

This guideline does not address all elements of standard practice and accepts that individual clinicians are responsible for:

? Providing care within the context of locally available resources, expertise, and scope of practice ? Supporting consumer rights and informed decision making, including the right to decline intervention or

ongoing management ? Advising consumers of their choices in an environment that is culturally appropriate and which enables

comfortable and confidential discussion. This includes the use of interpreter services where necessary ? Ensuring informed consent is obtained prior to delivering care ? Meeting all legislative requirements and professional standards ? Applying standard precautions, and additional precautions as necessary, when delivering care ? Documenting all care in accordance with mandatory and local requirements

Queensland Health disclaims, to the maximum extent permitted by law, all responsibility and all liability (including without limitation, liability in negligence) for all expenses, losses, damages and costs incurred for any reason associated with the use of this guideline, including the materials within or referred to throughout this document being in any way inaccurate, out of context, incomplete or unavailable.

? State of Queensland (Queensland Health) 2019

This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives V4.0 International licence. In essence, you are free to copy and communicate the work in its current form for non-commercial purposes, as long as you attribute Queensland Clinical Guidelines, Queensland Health and abide by the licence terms. You may not alter or adapt the work in any way. To view a copy of this licence, visit

For further information, contact Queensland Clinical Guidelines, RBWH Post Office, Herston Qld 4029, email Guidelines@health..au, phone (07) 3131 6777. For permissions beyond the scope of this licence, contact: Intellectual Property Officer, Queensland Health, GPO Box 48, Brisbane Qld 4001, email ip_officer@health..au, phone (07) 3234 1479.

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Queensland Clinical Guideline: Routine newborn assessment

Flow Chart: Routine newborn assessment

Preparation

Family centred care ? Seek parental consent ? Consider cultural needs ? Discuss with parents: purpose,

process, timing and limitations of assessments ? Ask about parental concerns ? Encourage participation

Timing ? Initial exam immediately after

birth and any resuscitation ? Full and detailed assessment

within 48 hours and always prior to discharge ? Follow-up 5? 7 days & 6 weeks ? If unwell/premature ? stage as clinically indicated

Review history ? Maternal medical/obstetric/social

and family ? Current pregnancy ? Labour and birth ? Gender, gestational age, Apgar

scores and resuscitation ? Since birth: medications,

observations, feeding

Environment ? Warmth, lighting ? Correct identification ? Infection control precautions ? Privacy

Equipment ? Overhead warmer if required ? Stethoscope ? Ophthalmoscope ? Tongue depressor ? Pencil torch ? Tape measure, infant scales,

growth charts ? Pulse oximetry (optional) ? Documentation

o Infant Personal Health Record o Medical Health Record

Discharge Review discharge criteria ? Observations, feeding, output

Discuss ? Routine tests (hearing screen,

NNST, Hepatitis B) ? Support Agencies

o GP, Child/Community Health, Lactation support, 13 HEALTH

? Health promotion o Feeding and growth o Jaundice o SUDI, injury prevention o Immunisation o Signs of illness

? Infant Personal Health Record ? Referral and follow-up

o Routine 5?7 days & 6 weeks

Assessment

? Skin colour, integrity,

General

perfusion

? State of alertness

appearance

? Activity, range of

spontaneous movement

? Posture, muscle tone

Growth status

? Chart head circumference,

length, weight on centile charts

Head, face, neck

? Head shape, size ? Scalp, fontanelles, sutures ? Eye size, position structure ? Nose, position, structure ? Ear position, structure ? Mouth, palate, teeth, gums

tongue, frenulum

? Jaw size

Shoulders, ? Length, proportions,

arms, hands

symmetry

? Structure, number of digits

Chest

? Size, shape, symmetry,

movement

? Breast tissue, nipples ? Heart sounds, rate, pulses ? Breath sounds, resp rate ? Pulse oximetry (optional)

Abdomen

? Size, shape, symmetry ? Palpate liver, spleen,

kidneys

? Umbilicus

Genitourinary

? Male - penis, foreskin,

testes

? Female - clitoris, labia,

hymen

? Anal position, patency ? Passage of urine, stool

Hips, legs, feet

? Ortolani and Barlow's

manoeuvres

? Leg length, proportions,

symmetry and digits

Back

? Spinal column, skin ? Symmetry of scapulae,

buttocks

Neurological

? Behaviour, posture ? Muscle tone, spontaneous

movements

? Cry ? Reflexes - Moro, Suck,

Grasp

Discuss Document

Refer

? Discuss findings with

parents

? Document in health

record(s)

? Refer as indicated

Indications for further investigation and/or urgent follow-up are not exhaustive. Use clinical judgement

Further investigation Urgent

Growth and appearance ? Dysmorphic features ? Excessive weight loss

Jaundice < 24 hours of age Central cyanosis ? Petechiae new/unrelated to birth ? Pallor, haemangioma

Head and neck Enlarged/bulging/sunken fontanelle

? Macro/microcephaly Subgaleal haemorrhage

? Caput, cephalhaematoma ? Fused sutures ? Facial palsy/asymmetry on crying ? Hazy, dull cornea ? Absent red eye reflex ? Pupils unequal/dilated/constricted ? Purulent conjunctivitis/yellow sclera

Nasal obstruction ? Dacryocyst ? Cleft lip/palate ? Unresponsive to noise ? Absent ear canal or microtia ? Ear drainage ? Small receding chin/micrognathia ? Neck masses, swelling, webbing ? Swelling over or fractured clavicle

Upper limbs ? Limb hypotonia, contractures, palsy ? Palmar crease pattern

Chest Respiratory distress Apnoeic episodes

? Abnormal HR, rhythm, regularity ? Heart murmurs

Weak or absent pulses Positive pulse oximetry

Abdomen Organomegaly Gastrochisis/exomphalos Bilateral undescended testes Bilious vomiting

? Inguinal hernia ? < 3 umbilical vessels ? Signs of umbilical infection

Genitourinary No urine/meconium in 24 hours Ambiguous genitalia Testicular torsion

? Hypospadias, penile chordee micropenis

Hips, legs and feet ? Risk factors for hip dysplasia ? Positive/abnormal Barlow's and/or

Ortolani manoeuvres ? Contractures/hypotonia ? Fixed talipes ? Developmental hip dysplasia

Back ? Curvature of spine ? Non-intact spine ? Tufts of hair/dimple along intact spine

Neurological ? Weak/irritable/absent cry ? Absent/exaggerated reflexes ? No response to consoling ? Inappropriate carer response to crying ? Seizures

Altered state of consciousness

Urgent follow-up, GP: General Practitioner, HR: Heart Rate, NNST: Neonatal Screening Test, SUDI: Sudden unexpected death in infancy, : greater than

Queensland Clinical Guideline: Routine newborn assessment. Flowchart version: F14.4-1-V1-R21

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Queensland Clinical Guideline: Routine newborn assessment

Abbreviations

BCG CCHD GP NNST RACP SUDI

Bacille Calmette-Guerin Critical congenital heart disease General Practitioner Neonatal screening test Royal Australian College of Physicians Sudden and unexpected death in infancy

Terms

Term

Family centred care

Newborn

Newborn nursery

Routine newborn assessment

Urgent follow-up

Definition

Is an approach to the planning, delivery and evaluation of health care that is grounded in mutually beneficial partnerships among health care providers, patients and families.1,2 It incorporates the core concepts of respect and dignity, information and sharing, participation and collaboration.1 A recently born infant.3 An infant in the first minutes to hours following birth.4

In this document `newborn nursery' may be interpreted to mean neonatal observation or stabilisation area or equivalent as per local terminology.

In this document `routine newborn assessment' is a broad term referring to the assessment of the newborn occurring at various points in time within the first 6?8 weeks after birth. It includes the brief initial assessment, the full and detailed newborn assessment within 48 hours of birth and the follow-up assessments at 5?7 days and 6 weeks.

Immediate and/or life-threatening health concern for the newborn requires urgent (same day) follow-up.

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Queensland Clinical Guideline: Routine newborn assessment

Table of Contents

1 Introduction ..................................................................................................................................... 6 1.1 Family centred care ............................................................................................................... 6 1.2 Clinical standards .................................................................................................................. 6 1.1 Initial brief examination after birth..........................................................................................6 1.2 Full and detailed newborn assessment .................................................................................7 1.2.1 Purpose of the routine newborn assessment ....................................................................7 1.2.2 Timing of the routine newborn assessment.......................................................................7 1.2.3 Unwell and/or premature newborn..................................................................................... 7 1.2.4 Pulse oximetry screening...................................................................................................7

2 Preparation for the full and detailed newborn assessment ............................................................ 8 3 Physical examination......................................................................................................................9

3.1 Isolated abnormalities..........................................................................................................12 3.2 Consultation and follow-up .................................................................................................. 12 4 Discharge planning.......................................................................................................................13 4.1 Health promotion .................................................................................................................14 References .......................................................................................................................................... 15 Appendix A: Pulse oximetry screening ................................................................................................16 Acknowledgements.............................................................................................................................. 17

List of Tables

Table 1. Family centred care ................................................................................................................. 6 Table 2. Pulse Oximetry screening........................................................................................................ 7 Table 3. Assessment preparation .......................................................................................................... 8 Table 4. Newborn examination .............................................................................................................. 9 Table 5. Suggested follow-up actions.................................................................................................. 12 Table 6. Discharge planning discussions ............................................................................................ 13 Table 7. Health promotion ................................................................................................................... 14

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Queensland Clinical Guideline: Routine newborn assessment

1 Introduction

Every newborn requires a brief physical examination within the first few minutes after birth and then a full and detailed assessment within the next 48 hours and prior to discharge from hospital.5 A follow up assessment should be performed later in the first week (by a midwife or General Practitioner (GP) outside the hospital setting) and then at 6?8 weeks after birth. The physical examination component of the newborn assessment is the most important screen for major occult congenital anomalies. There is no optimal time to detect all abnormalities.6 Moss et al7 found 8.8% of newborns had an abnormality on the first detailed examination with an additional 4.4% having abnormalities only diagnosed at follow up examination.

1.1 Family centred care

Adhere to the principles of family centred care when assessing any newborn [refer to Table 1. Family centred care].

Table 1. Family centred care

Aspect

Dignity and respect

Information sharing

Participation and collaboration

Consideration

? Always seek parental consent before examining their newborn ? Listen to and honour parent views and choices regarding planning and

delivery of care ? Respect family values, beliefs and cultural background and consider

culturally appropriate supports (e.g. indigenous liaison personnel or an interpreter)

? Communicate fully and involve the parents as appropriate. This may be a brief reassurance after the initial examination in the birthing room but a more detailed discussion before, during and after a full neonatal assessment for questions and explanations

? Ask the parent/s about their concerns for their newborn8 ? Ensure information is shared in a complete, unbiased and timely manner

to ensure parents can effectively participate in care and decision making

? Parents and families are encouraged to participate in care and decision making at the level they choose

? Wherever possible perform the newborn assessment with at least one parent present5,6

1.2 Clinical standards

? Individual birthing units are responsible for:

o Identifying the clinician responsible for the newborn assessment5,6 o Identifying health discipline specific criteria for performance of the neonatal

assessment. For example, criteria for performance by a midwife may include:

Gestational age greater than 37 weeks and less than 42 weeks Birth weight greater than 2500 g and less than 4500 g Apgar score greater than 7 at 5 minutes of age No antenatal abnormality identified

o Providing access to clinical training5,6 o Establishing appropriate referral pathways6

? Clinicians performing newborn assessment are required to:

o Be appropriately trained in the required assessment skills o Practise and maintain skills to a satisfactory level6,9 o Recognise variances from normality o Seek guidance for management of variance as required and refer appropriately6,10 o Maintain accurate records of the newborn assessment5,6 o Document findings and discuss the results with parents5,6,11

1.1 Initial brief examination after birth

Complete the initial brief assessment after any resuscitation (Refer to Queensland Clinical Guideline Neonatal resuscitation12). Assess the newborn for successful transition to extra-uterine life, any obvious dysmorphic features or gross anomalies which will require immediate attention or discussion with the family. Confirmation of gender is important. The timing of this review should be flexible and not restrict skin-to-skin contact.

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