The Postnatal Ward Handbook:



The Postnatal Ward Handbook:

Authors:

Kornilia Nikaki, Tracy Lawson, Dr. Lisa Husband, July 2012

Minor update March 2017 by Dr Khalid

Updated 30/07/2020 Dr Heather MacMillan; ANNP Team

|Guideline History |

|Date |Comments |Approved By |

|2012 |First edition |Neonatal Clinical management group |

|2017 |Updates | |

|Sept 2020 |Updated to current practice and guideline formatting |Chairman’s action, noted at NGG |

| | |MDT review outside NGG |

Please note:

The clinical guideline links in this handbook are correct as at the publication date. If a link does not work, please inform a member of the NICU team so the document can be updated accordingly.

The full list of neonatal guidelines can be found on the trust intranet.

Contents

Page no

General duties and responsibilities of the Postnatal Team 3

Baby Check (NIPE) Role 4

Transitional Care (TCU) Role 5

Postnatal Ward (JBW) Role 6

Learning opportunities 7

Seeking help 7

Bleeps and telephone numbers 7

Badger entries 8

BCG protocol 8

Follow up appointments 8

Common reasons to review babies

Babies on antibiotics 9

Babies on Kaiser pathway for suspected sepsis 9

Babies on phototherapy/ with suspected jaundice 10

Babies with weight loss/ poor feeding 11

Babies with hypoglycaemia 12

Babies on NAS observations 12

Prescribing Vitamin K 13

Referrals 14

Appendices

1- NIPE questions 15

2- Carrying out a newborn infant physical examination (NIPE) 16

3- NCOT eligibility criteria 20

4- Physiotherapy referral form 21

5- Hepatitis B Immunisation form 23

6- Genetics referral form and consent form 24

7- Other concerns Cardiovascular 27

Respiratory 29

Neurological 30

Gastrointestinal 32

Musculoskeletal/orthopaedics 34

Renal 39

Genitourinary 41

Eyes 44

Dysmorphic features 46

General duties and responsibilities of the Postnatal Team

There are 3 postnatal ward SHOs/ANNPs during the week – one for the Transitional Care Unit (TCU), one for Joan Booker Ward (JBW -the postnatal ward) and one trainee from the paediatric ward to carry out baby checks in the Postnatal Nursery and support the postnatal role on JBW.

At the weekend, only one person covers all 3 roles so please complete as many planned jobs as possible during the week to make their workload more manageable.

Morning handover is in the NICU seminar room at 0900hrs. TCU and JBW are handed over first by the night team and all 3 members of the postnatal team should attend. Once this part of handover is completed, please collect the postnatal bleep and TCU handover book and go downstairs for the 0915hrs daily huddle with the TCU nurse, infant feeding team and MEON (Midwife allocated for well baby checks). This will allow any other unstable babies to be identified and a plan of the workload over the day for each person to be made.

There is a safety huddle at 1200hrs by the JBW main desk where the midwife in charge will identify potential discharges and any further concerns.

The postnatal bleep holder should aim to handover the bleep and updated jobs book by 1630hrs to the NICU long day SHO/ANNP so they are free for the evening ward round at 1700hrs. They will be covering all areas of NICU, labour ward, Joan Booker and TCU from this time so please do not leave any unnecessary jobs for them to do if possible.

Baby Check (NIPE) Role

Prior to starting this placement please complete the e-learning module to learn how to complete a NIPE. The link to access the module can be found below. You should use your usual e-lfh log-in to access the module.

NIPE module -

There is also a local NIPE guideline (see appendix 2).

You will have an induction on baby checks and need to ensure you have a NIPE log in prior to starting. You will be based with a MEON who can help support you until you feel happy to do baby checks on your own. The NICU team will also be around if you have any questions or pick up any abnormalities which you would like looked at. You should try and get a mini-cex done for your portfolio.

The Baby check doctor should identify and carry out all Newborn Infant Physical Examinations (NIPEs) for babies requiring paediatric involvement on JBW (not including TCU). This includes babies who required resuscitation at birth, babies under 2.5kg, babies born under 37 weeks and babies with known antenatal concerns. It is also essential to check the High Risk folder which can be located on the T:drive to identify any babies who have delivered with an antenatal plan and ensure all aspects of their plan have been followed. A full list of criteria for paediatric NIPEs can be found on the notice board in the postnatal nursery. Please ensure all paediatric NIPEs are complete by 1600hrs for all babies being discharged that day.

Prior to carrying out a NIPE, please check maternal and baby history carefully, including obstetric notes on Maternity Badger and results on ICE to identify potential risk factors requiring further interventions and referrals. Attention should be given to maternal and paternal family history, maternal medical history, and pregnancy, labour and delivery details. Use the questions in the baby’s red book to guide history taking and gaining consent (see appendix 1).

The MEON working alongside will be able to direct and support with issues such as documentation and prioritisation of complex babies and those ready for discharge. If the MEON has a large workload and all paediatric checks have been completed, please alleviate pressure by also carrying out some well baby checks.

BCG vaccines must be prescribed for all babies identified by the MEON as requiring vaccination. They will run a BCG clinic in the afternoon and will require all drug charts and consent forms to be completed by this time.

Once all baby check duties have been completed, please support the postnatal role with daily reviews of NICU outliers.

The TC/Postnatal SHO/ANNP or NICU team are available should you need to discuss any referrals/abnormalities.

High Risk Babies

There are a number of babies delivered at SPH who require particular care at or after birth, although they may appear entirely well. These babies usually fall into 2 categories:

1) Those with an anomaly detected antenatally. The mothers of these babies will have been seen by the fetal medicine team at SPH who will have performed detailed scans and tracked the progression of the anomaly during the pregnancy. Sometimes they will also have been seen by other specialists (eg: fetal cardiology, paediatric renal).

2) Those with a strong family history or circumstance that puts them at higher risk of anomaly which needs to be investigated /excluded postnatally (eg: maternal lupus predisposing to congenital heart block.)

It is therefore ESSENTIAL that anyone undertaking NIPE examinations takes the time to review all of the available antenatal information on BadgerNet, including postnatal management plans, prior to examining and making plans for the baby.

A wealth of information is available on the ‘pregnancy summary’ page on BagerNet but in particular please pay particular attention to the information in the ‘Management Plan’ and ‘Fetal Medicine Management Plan’ boxes. Note also ‘Scan Results’. Examples below:

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Please refer to the postnatal ward handbook and intranet guidelines for specific management and referral pathways. Document your review and actions as a ‘specialist review’ on the baby tab of the mother’s BadgerNet as well as completing the usual NIPE records.

Transitional Care Role

The TCU SHO/ANNP is responsible for carrying out the daily ward round by reviewing all TCU babies in Room 5 and the amenity rooms, with the TCU nurses’ input. Please clearly document daily plans for these babies in clinical notes’ folders and complete daily Badger updates and discharge summary updates on Neonatal Badger.

To prevent a backlog of work, please begin preparations for discharge as early as possible by ordering TTOs, arranging follow up appointments, updating Badger discharge summaries and ensuring any outstanding NIPEs are completed on all TCU babies. Any babies requiring BCG should be identified for the MEON to include in the BCG afternoon clinics. At the end of the shift, please ensure the TCU jobs book is updated for evening handover at 1630hrs.

Admitting babies to TCU

There are strict criteria for TCU eligibility (see TCU guideline for details: ). Please ensure you discuss any potential admissions with the TCU nurse and the nurse in charge on NICU.

On admission, please review baby and communicate with the TCU nurse the plan regarding feeding, observations, medications and any treatment or investigations needed. i.e. blood tests, scans etc. Clearly document examination and plan in clinical notes. Please also complete admission on Neonatal Badger with clear communication regarding decision to admit and management plan. If the baby has been transferred from JBW, please also document decision to admit on Maternity Badger and inform the mother’s midwife so she can be physically transferred to TCU if necessary and to prevent miscommunication.

Daily reviews

Ensure the baby is stable and responding well to current management plan. Liaise closely with TCU nurse, Infant Feeding Team and SALT team if any concerns have been identified. i.e. poor weight gain, reluctance to feed, tongue ties etc. Many babies will be transferred to TCU at 34/35 weeks to ensure they can be with their mother but are not yet ready to progress to full sucking feeds. It is important not to rush these babies but support with NGT feeding for a week or longer to slowly introduce sucking feeds and prevent lethargy or weight loss. The TCU nurses can guide with the pacing of these progressions. Similarly, many of these babies may have poor thermal control so may require a hot cot initially. Late preterm pathways have been developed to guide the care of these babies for issues such as feeding and temperature control (late pretem pathways can be found on the NICU guidelines page: ).

Discharging babies from TCU

If baby is going home, ensure that all aspects of the discharge checklist are completed. The TCU nurse will provide guidance on the specific discharge plans for each baby. The baby will require discharge from both Neonatal and Maternity Badger (liaise with the midwife in charge so they can inform the midwifery community team). A Neonatal discharge summary should be printed and shown to the parents to ensure all details are correct. Correct follow up appointments should be requested from the NICU ward clerk and any other referral letters/emails should be completed and a copy filed in the notes. i.e. audiology or hip referrals. Ensure any eligible babies are known to the Neonatal Community Outreach Team (NCOT) prior to discharge to ensure they are followed up in the community in a safe and timely manner (see appendix 3). NCOT should also be provided with a copy of the badger discharge summary for those babies eligible for NCOT follow up once finalised.

For babies being discharged from TCU to JBW care, please ensure the Neonatal Badger discharge is completed and a copy placed in the baby’s clinical notes. A specialist review entry must be completed on Maternity Badger to reflect the move from Transitional Care to Postnatal Care with a clear management plan for the midwives to follow. Please also inform the Infant Feeding Team who will continue to support with feeding concerns and the midwifery nursery nurse team if observations are still required.

Postnatal Ward (JBW) Role

The JBW SHO/ANNP carries the postnatal bleep and should review all NICU/TC outlier babies after carefully reviewing the baby’s history using available information on Maternity Badger/ ICE etc. Liaise with the feeding team and nursery nurses during the 0915hrs huddle as they can identify additional babies on observations which may have been missed. Please inform all relevant members of the midwifery and feeding team the current management plan and any updates after each review, and document these plans clearly to ensure any changes are not missed over the next 24 hours. Most babies (but not all at present) will require an entry in both Neonatal and Maternity Badger systems. These include:

| |Neonatal Badger Daily Update |Maternity Badger Specialist Review |

|Babies on antibitoics | ✓ |✓ |

|Babies on phototherapy | ✓ |✓ |

|NAS babies | ✓ |✓ |

|Any baby under 2.5kg | |✓ |

|Babies under 1.8kg | ✓ |✓ |

|Babies under 37 weeks | |✓ |

|Babies under 36 weeks | ✓(For 48 hours) |✓ |

|Babies under 35 weeks | ✓(For 7 days) |✓ |

|Babies on Kaiser observations |✓ |✓ |

In addition, the postnatal bleep holder will be called to review any babies with midwifery concerns on labour ward, postnatal ward or the Abbey Birthing Centre (ABC). As this can be quite a busy role, it is important to clearly communicate with the other 2 members of the postnatal team to ensure a reasonable division of workload is achieved throughout the shift and a team approach is adopted. These babies will all require a paediatric NIPE so it is good practise to try and combine this with the daily review if possible.

Any outstanding postnatal jobs are documented in the TCU jobs book under a JBW section, so please check this in the morning. At the end of the shift, update the book including documenting any jobs which need to be carried out the next day and ensure the bleep is stored with the TCU jobs book on NICU.

Once all postnatal jobs have been completed, please report to the HDU consultant on NICU who can identify any learning opportunities on the unit that day, and any areas requiring additional support.

Learning Opportunities on NICU

Monday 1200hrs Cranial Ultrasound meeting

1230hrs M&M meeting (3rd Monday of Month)

Tuesday 1315hrs X-ray meeting

1430hrs SIM training

Wednesday 1400hrs Paediatric Trainee teaching

Thursday 1100hrs Psychosocial meeting

1400hrs Group Case-based discussion

Friday 1230hrs Grand Round

1400hrs Perinatal meeting (4th Friday of Month)

Seeking help

• For medical issues concerning the baby, please initially ask colleagues within the postnatal team for support and advice.

• For feeding concerns, discuss with Infant Feeding team (based in feeding hub next to NIPE nursery).

• For maternity or discharge issues, discuss with Midwife-in-charge.

• For issues concerning TCU including admissions, discuss with TCU nurse and NICU nurse-in-charge.

• For more complex issues, please contact the HDU registrar or HDU consultant on NICU.

• The HDU registrar should visit TCU as part of the daily ward round. However, if NICU is busy this may not always happen, so please bleep with concerns and to get advice.

Useful bleeps and telephone numbers

|5363 |Postnatal bleep (carried 9-5 weekdays, 9-6 weekends) |

|5302 |Short day Registrar bleep (for senior support) |

|5125 |NICU SHO/ANNP bleep (for out of hours postnatal concerns) |

|5268 |NICU Nurse-in-charge bleep |

|3238 |TCU |

|2291 |JBW |

|2392 |Infant Feeding Team Hub |

|3897 |NICU Room 3 |

|3435 |NICU Notes room |

Badger entries

Please see Badger videos on the T Drive (location to follow) for details and training on:

Neonatal Badger admission

Neonatal Badger daily updates

Neonatal Badger discharges

Maternity Badger Specialist Review

For all complex Badger queries, please seek help from one of the postnatal team in the first instance. The designated leads for Neonatal Badger on NICU are Emily Kemmish (ANNP) and Elaine Ball (Data and Team Administrator) for specific concerns or for further training.

BCG protocol

It is very important to recognise early the need to offer BCG vaccine to all babies at high risk of TB to give plenty of opportunity to administer prior to discharge. BCG vaccines are given by the MEON to all eligible babies on TCU and JBW and this is usually carried out in the afternoon after all NIPEs have been completed. If a MEON is unavailable, babies may need to have BCG administered on NICU but this is not a preferred option due to movement of the baby to another clinical area.

See guideline for full details of identifying babies requiring BCG; gaining consent; preparing and administering BCG; aftercare and documentation (under Infection Control section of Neonatal Guidelines page: ).

Follow up appointments

There is a guideline which details which follow up appointments are needed for individual babies (see Outpatient Appointment Guideline on Neonatal Guideline page: ).

The routine 6-8 week outpatient follow up appointments are usually booked by the NICU ward clerks and appointments should be booked with the attending consultant unless you are told otherwise. If a ward clerk is not available then a note can be left in the receptionist’s book with the baby’s details and information regarding when you would like the appointment booked for.

If a cardiac or neurological outpatient appointment is required with one of the neonatal consultants, please email them with brief details of the baby so they are aware of why this appointment is needed.

On TCU, some babies will be eligible to be followed up by the Neonatal Community Outreach Team (see appendix 3). Please ensure they are made aware of these babies as soon as discharge looks likely so they can begin preparations to support the baby at home and provide them with a discharge summary.

Common reasons to review babies

Babies on antibiotics

See Early Onset of Sepsis guideline in the Sepsis section of the neonatal guidelines page:

These babies will have clear maternal risk factors for sepsis to be started on antibiotics but have to date been clinically well so it is deemed safe to allow them to stay on the postnatal ward under close observation from the midwifery team. Babies will have 4 hourly observations and a daily review from the Neonatal team. Prior to commencing antibiotics, these babies will have a partial septic screen of bloods including FBC and CRP and a blood culture sent for analysis.

Before reviewing the baby, check for any new laboratory results for baby and mother. A second CRP level check will be needed for the baby at 18 hours and if the 36 hourly blood culture result is negative and CRP is less than 4 for both readings, babies can usually stop antibiotics from 36 hours. A rise in CRP will require discussion with the HDU consultant as the baby may require a lumbar puncture and a positive blood culture result will usually require at least a 5 day course of antibiotics.

Babies usually only receive observations whilst they are receiving antibiotics (at least for 24 hours), but it is possible to extend observations if there are any concerns. Once the review has been completed, please clearly document plan for treatment, observations and any additional support on both Badger systems.

Once antibiotics have been completed, if baby remains stable they can be discharged to postnatal care. Please ensure Neonatal Badger discharge is completed and transfer of care is clearly communicated to the midwifery and feeding team. The antibiotic prescription must be crossed off the drug chart which is kept on NICU in the annexe.

Babies on Kaiser pathway for suspected sepsis

See Kaiser pathway section within the early onset sepsis guideline (on Neonatal Guidelines page: ).

These babies have been identified as having maternal risk factors for sepsis, but not requiring antibiotics at this point. The Kaiser pathway tool gives a calculation of risk and recommends subsequent actions. This includes regular observations for 24 hours, partial septic screen of blood culture sample and observations, or partial screen, treatment with antibiotics and observations. It is very important to closely examine any midwifery concerns with these babies, as any abnormal observations or ‘soft’ concerns such as temperature instability or poor feeding can be an early sign of sepsis and will change the management plan.

Each baby will have a review at 24 hours and this must be clearly documented on Maternity Badger. If all observations have been stable and the baby appears clinically well, they will usually be discharged to postnatal care. Please ensure transfer of care is clearly communicated via a Specialist Review in Maternity Badger and verbally to the midwifery and feeding team to ensure correct support is continued.

Babies on Phototherapy/with suspected Jaundice

See Neonatal Jaundice guideline on neonatal guidelines page:

Most babies with jaundice present due to feeding issues but it is essential to exclude any pathological causes so a clear history and assessment is needed. Close collaboration with the feeding team is needed to ensure feeding is optimised and the mother is supported to feed successfully by time of discharge. All babies started on phototherapy require a Group & DAT, should have a paediatric review and should be admitted onto Neonatal Badger. The nursery nurses or midwives do serum bilirubin readings (SBRs) but additional bloods such as blood gases or FBC need to be carried out by the postnatal team.

If the midwives are concerned about jaundice during a baby’s admission they will do a SBR and inform you if it is above the treatment line. Once babies are at home the community midwives will perform transcutaneous bilirubin readings (TBRs) and refer to the feeding team if they are concerned. The feeding team will then do an SBR and assess feeding before informing us if it is above the treatment line or if they are otherwise concerned about the baby.

After the review, determine the probable cause and develop a management plan including any further bloods to be done and whether feeding top-ups are required. Admit onto Neonatal Badger and document the plan on both Maternity and Neonatal Badger systems. Add the baby’s details to the TCU book to ensure they are reviewed daily.

Bilirubin levels are plotted on maternity Badger. Phototherapy should be started if the SBR is on or above the treatment line. Depending on the level you need to decide how many lights to start with and when to repeat the level. If the SBR is particularly high (over halfway between the phototherapy and exchange transfusion lines), the baby may require admission to TCU or NICU. If you aren’t sure, please speak with the HDU registrar.

Phototherapy can be stopped once the SBR is below the treatment line, usually at least 5 boxes below, however in some cases it can be stopped before this, as long as it is below the treatment line and if the SBR is deemed to have reduced adequately in proportion to the original SBR that resulted in the infant requiring phototherapy to begin with. A rebound must be performed 10-12 hours later and if this is reassuring, the baby can be discharged back to postnatal care if there are no other issues requiring ongoing admission.

Babies with Prolonged Jaundice

Babies who remain jaundiced after 2 weeks will be referred by their community midwives or health visitors for a prolonged jaundice screen. The forms for this can be found in the blue phlebotomy clinic folder in the notes room on NICU. You should complete this form while taking the referral and then also complete the form requesting the bloods (split bilirubin only for initial screen rather than LFTs). If you inform the ward clerk on NICU they will contact the parents and book the appointment. Results will then be chased by one registrar each week and a letter sent to parents with results and follow-up as needed.

NICE has published a guideline on the management of Neonatal Jaundice. The Quick reference guide can be found here:



The Treatment Threshold Charts (Bilirubin Charts) can be found here:



Babies with weight loss/ poor feeding

See Weighing Babies and Well Baby Clinic Pathway Guideline on Neonatal Guidelines page:

Term babies may lose 4-7% of their weight after birth and breast fed babies tend to lose more (5-10%) than bottle fed babies (2-6%). Term babies usually regain their birth weight in the 2nd week of life and pre-term babies in the 3rd week of life.

Weight loss of > 10% of birth weight is a cause for concern and will require a feeding plan to be implemented. If weight loss if >12.5%, a blood gas is required to check for hypernatraemia and may require an adjusted feeding plan to safely and slowly reduce elevated sodium levels (see hypernatraemia guideline on neonatal guidelines page: ).

The commonest cause of weight loss is due to poor intake (delayed milk supply or mechanical problems such as tongue tie) but can also be a sign of infection, inborn error of metabolism, malabsorption or congenital cardiac disease. It is therefore essential to take a detailed history to exclude other issues which may require prompt treatment.

A thorough feeding history must be taken including frequency and duration of feeding; any problems with latching/sucking; any history of vomiting; passage of urine and stool (and nature of stool); any history or lethargy and presence of jaundice.

Management plan:

1. Consider admission to NICU or TCU.

2. Assess clinically for signs of dehydration, jaundice, cardiac disease and treat as appropriate

3. Investigations: Consider U&E’s, LFT’s, blood gas, BSL, FBC, CRP, B/C, urine MC&S

4. Consider starting antibiotics if there are risk factors for infection perinatally or the baby looks clinically unwell

5. Involve the infant feeding team to optimise feeding regime, check for any mechanical problems and support mother’s feeding preference

6. Consider top up feeds via cup/bottle and support regular expressing if breastfeeding

7. Review daily and weigh regularly to ensure feeding plan is working and baby’s clinical condition is stable/ improving

Babies with hypoglycaemia

Babies who are at increased risk of hypoglycaemia (i.e. macrosomic babies; preterm and growth restricted babies; infants of diabetic mothers or infants of mothers on beta blockers or thyroid medications) will have their blood sugar level (BSL) monitored by the midwifery team as per the unit guideline. They should treat BSLs between 1.0 and 2.0mmol/L with 0.5ml/kg of 40% dextrose gel followed by a feed.

Any baby with hypoglycaemia who has had 3 BSLs below 2mmol/L or a single BSL below 1mmol/L must be reviewed and a detailed history taken to understand the cause of the hypoglycaemia and determine if the baby is symptomatic or not.

After 3 ‘rounds’ of dextrose gel, if the blood sugar is still between 1.0mmol/L to 2.0mmol/L and the baby remains asymptomatic, top-up milk supplements should be offered (MEBM if available for breast fed babies, and formula if unavailable) at 10mls/kg per feed (this equates to approximately 60mls/kg/day).

If a baby has a BSL of 5mm is considered to be abnormal. Mild cases with will have a repeat scan at 34 weeks at St. Peter’s Hospital. More severe cases may be scanned more frequently, or referred to St.George’s Hospital for further management.

At 34 weeks

AP diameter < 6mm is normal and no further intervention is required.

AP diameter >10 mm is abnormal and should be further investigated.

AP diameter 6 – 9 mm is a grey area, and management is highly controversial. Currently our ultrasonographers may report this group as “normal”, or report the actual diameter.

Postnatal

Our radiologists consider RPD > 7mm to be abnormal (if USS performed after 48 hours and before 6 weeks). After 6 weeks postnatal age >10mm is considered to be abnormal.

Management plan:

Perform a physical examination to detect the presence of an abdominal mass (possible PUJ or MCDK) or palpable bladder (PUV). Check to see that the baby has passed urine since birth and if male ask if anyone has seen the stream.

← RPD 6 - 9mm at 34 week scan or RPD 10 - 15 mm at 34 week scan

1. Start prophylactic antibiotics – Trimethoprim 2mg/kg once daily. Please prescribe on a drug chart, inform the midwife looking after them, document on badger and do a TTO so it will be available for discharge.

2. Ultrasound scan (USS) of kidneys at 4 - 6 weeks

3. Arrange outpatient appointment for 6 – 8 weeks; ideally indicate on USS request form when the date of the OPA is, as the radiology department will then ensure the USS is carried out prior to the clinic appointment.

← RPD >15mm at 34 weeks

1. Start prophylactic antibiotics – Trimethoprim 2mg/kg once daily. Please prescribe on a drug chart, inform the midwife looking after them, document on badger and do a TTO so it will be available for discharge.

2. Request early USS (ideally at 72 hours).

3. Suspect bladder outlet obstruction if bilateral in a male. This requires urgent investigation with USS and MCUG to exclude posterior urethral valves - see management of bladder outlet obstruction.

See full guideline on neonatal guideline page:

7) Genitourinary

Ambiguous genitalia/ Disorders of sexual development

If there is uncertainty over the sex of a baby review the baby as a matter of urgency.

Underlying causes include Congenital Adrenal Hyperplasia which may cause hyponatraemia crisis.

Initial Management:

← Contact the HDU Registrar/ Consultant urgently.

← Check U&Es and a Blood Sugar Level urgently

← Do not assign a gender

Further Management:

← Chromosomes need to be checked after obtaining parental written consent

← Check urinary and blood steroid profile

← Arrange for an USS of the pelvis (to establish whether the baby has a uterus)

* Remember not to designate a gender until the baby is fully investigated*

Undescented testes (Cryptorchidism)

3% male term infants vs 33% male premature infants

Majority descend in the first few months after birth.

If remain undescended beyond first few years of life:

← Increased incidence of testicular cancer (x20)

← Increased incidence of infertility (sperm count reduced if testes in abdomen).

Management plan:

← Unilateral Undescended Testes: Refer to GP to review at 6 weeks; they will refer to surgeons if testes remain undescended at that point.

← Bilateral Undescented Testes: Discuss with the Registrar, as this raises the possibility of a virilised female infant – see ambiguous genitalia above. An abdominal USS may be required to visualise the testes and confirm absence of a uterus.

Hypospadias / Chordee / Buried penis / Webbed penis

Referral to Paediatric Urologists may be required for hypospadius and chordee.

Discuss with HDU Registrar regarding need for referral.

Advise the family not to have the baby circumcised, at least until the baby is seen by the urologists.

Hydrocele vs Inguinal Hernias

Hydrocele:

Accumulation of fluid in tunica vaginalis due to persistence of a narrow patent processus vaginalis.

Typically scrotal, can be large, smooth and non tender.

Transilluminates and is not reducible.

Majority resolve in first 6-12 months (obliteration of patent processus vaginalis continues after birth) and so no initial surgical follow up indicated.

If persist beyond a year GP should refer to surgeons.

Inguinal Hernia:

1-2% term newborns - 90% males

Increased incidence in preterm babies (20-30% premature males).

Majority direct (1% indirect)

Right > Left - 5%-10% are bilateral

Present as intermittent swelling in the groin or scrotum especially on crying or straining.

Refer to Paediatric surgeons for operative repair at diagnosis.

Risk of incarceration: baby presents as unwell (crying, irritable), vomiting, abdominal distension, mass becomes red, tender and irreducible.

8) Eyes

Absent Red Reflex & Retinoblastoma

The red reflex test is used to screen for abnormalities of the back of the eye (posterior segment) and opacities in the visual axis, such as a cataract or corneal opacity.

An ophthalmoscope held close to the examiner’s eye and focused on the pupil is used to view the eyes from 12 to 18 inches away from the subject’s eyes.

To be considered normal, the red reflex of the 2 eyes should be symmetrical.

Dark spots in the red reflex, a blunted red reflex on 1 side, lack of a red reflex, or the presence of a white reflex (retinal reflection) are all indications for referral to an ophthalmologist.

Infants or children in high-risk categories, including relatives of patients with:

← Retinoblastoma

← Infantile or juvenile cataracts

← Retinal dysplasia, glaucoma

← Other vision-threatening ocular disorders that can present in infancy

These babies should have red reflex testing performed in the nursery and also be referred to an ophthalmologist who is experienced in examining children for a complete eye examination regardless of the findings of the red reflex testing by the pediatrician.

Management plan:

← All babies with an absent red reflex need to be reviewed by the HDU Registrar and referred to the Ophthalmologist.

← For the neonates in the high-risk category please arrange a follow up in clinic with NICU opthalmologist (please send a referral letter with the details of the patient and the reason for the request).

9) Dysmorphic features

Cleft lip and/or palate

The condition is usually detected antenatally.

Cleft lip and/or palate can be an isolated finding or part of a syndrome. Check baby carefully for any other congenital abnormalities.

An isolated cleft palate is more easily missed, so remember to visualise the palate during the baby check. The baby may also present with milk regurgitation through the nose.

If the baby is term and there are no other abnormalities, the baby can be nursed on the postnatal ward or special care unit. Breastfeeding is often possible but may need a bottle with a special teat.

Cleft lip is usually repaired at around 3 months and palate between 6 and 9 months.

Management plan:

← Perform a thorough examination of the baby and exclude any other abnormalities.

← If the diagnosis was made antenatally, the family will be known by South Thames Cleft Lip and Palate service (CLAPA team). Please inform the CLAPA team once the baby is delivered on 07717571931.

← If the condition was noted once the baby was born, please request a senior review from the HDU Registrar and/or Consultant. Contact the CLAPA team as soon as possible.

See full guideline:

Down’s Syndrome

If you are suspecting the diagnosis of Down's syndrome on a newborn baby please inform the parents of the specific findings you have and record them in your notes. Do not give parents a diagnosis of Down's at this stage.

Inform the Neonatal Registrar or Consultant urgently to review.

If the diagnosis is still considered bloods will be required for FISH and Chromosomes – please obtain written parental consent and fill in the relevant forms.

A useful source of information for parents and professionals is the Down's Association Syndrome website:

Please see full guideline on Neonatal Guidelines page: for full management plan and referrals/ follow up.

Finally, please ensure that the patient details are accurate and that the named consultant is always aware and copied into any referrals.

Equality Impact Assessment

|Background |

|Who was involved in the Equality Impact Assessment |

|Guidelines chair |

|Methodology |

|A brief account of how the likely effects of the policy was assessed (to include race and ethnic origin, disability, gender, culture, religion or |

|belief, sexual orientation, age) |

|The data sources and any other information used |

|The consultation that was carried out (who, why and how?) |

|All groups of staff and patients considered |

|Key Findings |

|Describe the results of the assessment |

|Identify if there is adverse or a potentially adverse impacts for any equalities groups |

|No evidence of discrimination |

|Conclusion |

|Provide a summary of the overall conclusions |

|No evidence of discrimination |

|Recommendations |

|State recommended changes to the proposed policy as a result of the impact assessment |

|Where it has not been possible to amend the policy, provide the detail of any actions that have been identified |

|Describe the plans for reviewing the assessment |

|Appropriate for general use |

a. Document Checklist

To be completed (electronically) and attached to any document which guides practice when submitted to the appropriate committee for approval or ratification.

Title of the document:

Policy (document) Author:

Executive Director:

| | |Yes/No/ Unsure/NA |Comments |

|1. |Title | | |

| |Is the title clear and unambiguous? |Y | |

| |Is it clear whether the document is a guideline, policy, |Y | |

| |protocol or standard? | | |

|2. |Scope/Purpose | | |

| |Is the target population clear and unambiguous? |Y | |

| |Is the purpose of the document clear? |Y | |

| |Are the intended outcomes described? |Y | |

| |Are the statements clear and unambiguous? |Y | |

|3. |Development Process | | |

| |Is there evidence of engagement with stakeholders and users? |Y | |

| |Who was engaged in a review of the document (list committees/ |Y | |

| |individuals)? | | |

| |Has the policy template been followed (i.e. is the format |Y | |

| |correct)? | | |

|4. |Evidence Base | | |

| |Is the type of evidence to support the document identified |Y | |

| |explicitly? | | |

| |Are local/organisational supporting documents referenced? |Y | |

|5. |Approval | | |

| |Does the document identify which committee/group will |Y | |

| |approve/ratify it? | | |

| |If appropriate, have the joint human resources/staff side |Y | |

| |committee (or equivalent) approved the document? | | |

|6. |Dissemination and Implementation | | |

| |Is there an outline/plan to identify how this will be done? |Y | |

| |Does the plan include the necessary training/support to ensure |Y | |

| |compliance? | | |

|7. |Process for Monitoring Compliance | | |

| |Are there measurable standards or KPIs to support monitoring | | |

| |compliance of the document? | | |

|8. |Review Date | | |

| |Is the review date identified and is this acceptable? |Y | |

|9. |Overall Responsibility for the Document | | |

| |Is it clear who will be responsible for coordinating the |Y | |

| |dissemination, implementation and review of the documentation? | | |

|10. |Equality Impact Assessment (EIA) | | |

| |Has a suitable EIA been completed? |Y | |

|Committee Approval (Neonatal Guidelines Committee) |

|If the committee is happy to approve this document, please complete the section below, date it and return it to the Policy (document) Owner |

|Name of Chair |S. Edwards |Date |24 Sept 2020 |

| |

|Ratification by Management Executive (if appropriate) |

|If the Management Executive is happy to ratify this document, please complete the date of ratification below and advise the Policy (document) Owner |

|Date: n/a |

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