We review basics of the newborn nursery rotation for residents at Parkland Memorial Hospital. We are joined by Abby Patterson, MD, Assistant Professor of Neonatal-Perinatal Medicine at the University of Texas Southwestern Medical Center.
Dr. Neeta Goli:
Welcome to Newborn News, a podcast where we discuss educational topics for medical professionals who care for newborns. I'm your host, Dr. Neeta Goli, a pediatrician in the UT Southwestern newborn nursery.
Dr. Neeta Goli:
Welcome to our podcast, Newborn News. For our inaugural educational episode, we'll be discussing what we like to call newborn nursery basics, which is really a big picture overview of caring for babies in the well-baby nursery. We're joined today by Dr. Abby Patterson, who's been faculty in the newborn nursery at UT Southwestern since 2015, and as a newborn nursery education coordinator for our residents and medical students. Dr. Patterson, thank you for joining us today.
Dr. Abby Patterson:
Thanks for having me.
Dr. Neeta Goli:
To start off with, can you give us an overview of what kind of babies get admitted to the newborn nursery?
Dr. Abby Patterson:
So for babies to get admitted to the newborn nursery, we want them to be essentially well babies. Every unit varies a little bit in their criteria, so consult your individual policies, but I'll talk in general about what types of things we look at.
Dr. Abby Patterson:
So we first want the baby to be old enough, basically that they're of a high enough gestational age that we can trust them to remain with their mom. I've seen anywhere between 34 and 36 weeks as the minimum age. Our center uses 35 weeks as the minimum age to be admitted to well-baby. The second thing we look at is: is the baby big enough? So we want to make sure that they are big enough to be able to be in an open crib and to maintain their temperature. Our unit uses 2100 grams as our minimum weight. Again, this may vary. We want the baby to have normal vital signs, and we want the baby to have successfully transitioned to extrauterine life, which basically means that either they didn't require resuscitation or if they did, they responded well to resuscitation. And then lastly, we want to make sure that the baby doesn't have any major congenital anomalies. A baby that has multiple anomalies, or is needing multiple subspecialty consults, may be better served in another location.
Dr. Abby Patterson:
Essentially when you boil it all down, you want this to be a baby that you trust to be in a dark room with a sleeping mother. If you don't trust them to do that, we've got to think twice about whether or not they're on well-baby.
Dr. Neeta Goli:
So, once these babies are admitted to us, what kind of things should we be following?
Dr. Abby Patterson:
Yeah, so we basically are just monitoring the babies to make sure they're staying well. So the first thing we do is we do a daily physical exam on every baby to again, make sure that that's remaining normal. We watch their feeding and their output. We want to make sure that babies are feeding frequently enough and giving us enough output. For a breastfed baby, we expect the baby to feed eight to 12 times in 24 hours, and for the feedings to have been long enough. If the baby latches and takes two sucks, that doesn't count. We want them to feed very well; I usually say about 10 to 15 minutes is the minimum for a feeding, but that can vary a little bit depending on what happened at the feeding.
Dr. Abby Patterson:
And then we want to make sure that their output is okay. I usually use one wet and one dirty per day of life. So in the first 24 hours, you need one pee one poop, second, 24 hours, two of each and so on and so on up to six to seven a day. Babies may vary a little bit off of those, but it's easy to remember and easy to teach parents as what to expect as normal.
Dr. Abby Patterson:
And then at Parkland, we do vital signs every eight hours for term babies that are greater than 2,500 grams. If they don't meet those criteria, they get more frequent vitals. We'll also do a daily weight on every baby. We usually do that around midnight, and then we do a transcutaneous bilirubin every morning, usually about 4:00 AM. Most centers, I think, will also monitor daily weights, bilis and vitals, but the frequencies and timings may be different on those.
Dr. Neeta Goli:
And in terms of daily weight, how much weight is acceptable for a baby to lose?
Dr. Abby Patterson:
Yeah, so we say up to 10% total is normal. However, I usually say to look for about 3% a day is what to expect. If you see a baby drop to 8% in a day, I'd still probably be a little worried. And analyzing the weight loss, I like to look at it globally to see not just what the weight is, but also what is the output? What is the feeding? What does the baby look like? And using the whole picture to decide, is this weight loss pathologic, or is it probably within normal limits? Another thing to think about is that none of our tools are perfect. So especially if you see a baby that's lost a lot of weight in a short period of time to think, was that first weight, correct? Was the second weight correct? And making sure to think critically about it instead of having a knee jerk reaction to a single number.
Dr. Neeta Goli:
That's a good teaching point. And then just for our listeners, in terms of the transcutaneous bili, we'll have a future episode about jaundice evaluation and management, so you can listen to that for more guidance on how to interpret the transcutaneous bilirubin measurements that we get on these babies.
Dr. Neeta Goli:
So what medications do we give all newborns while they're in the hospital?
Dr. Abby Patterson:
Okay. So there's a few medications that are standard to give essentially across the country. The first one is intramuscular vitamin K injection, which that prevents against hemorrhagic disease of the newborn. The second is erythromycin eye ointment, and then the third is hepatitis B vaccination. At Parkland, we add a fourth medication, which is a single dose of intramuscular penicillin, and that is part of our GBS prevention strategy.
Dr. Neeta Goli:
And actually, if you want more on each of these medications, there is a newborn medications episode that goes into each one of these in much more detail that you can listen to.
Dr. Neeta Goli:
So if I have just admitted a baby, how long should I expect the baby to remain in the hospital with us?
Dr. Abby Patterson:
Yeah, usually we keep the babies and moms together whenever possible. So we send the baby home about the time the mom is ready to go home. After a vaginal delivery, typically, that's about 36 to 48 hours after delivery. For a C-section, that's 48 to 72 hours after delivery. Of course, those numbers may be adjusted a little bit depending on if mom or baby is having any complications.
Dr. Neeta Goli:
And what are our discharge criteria?
Dr. Abby Patterson:
So, we want to make sure that the baby is clinically stable. We want to make sure their weight loss is within normal limits, or we have a plan to reassess and help the baby's feeding. We want to make sure similarly that the baby's jaundice is at an acceptable level where we don't expect them to get into trouble before their next appointment. We want the baby to have had stable vital signs for 24 hours. If the baby has had any feeding problems, we want to have addressed those and make sure that we have a good home feeding plan. And we want to make sure all of their screenings were complete, that their state newborn screen has been completed, their hearing screen has been completed, their CCHD screen has been completed and passed, and CCHD is critical congenital heart defect screening. And then we also want to make sure, like I alluded to earlier, that the baby has appropriate follow-up. Typically that's about two to three days after delivery, but it can vary based on the baby's clinical situation.
Dr. Abby Patterson:
And then we also want to make sure that the mom is comfortable taking care of the baby at home. So we want to make sure that we've done teaching with the mom about care at home, ED warning signs, safe sleep, and a whole list of other topics.
Dr. Neeta Goli:
And for our residents at Parkland listening, you all are actually responsible for doing the discharge teaching, so if you'd like to listen to one of our faculty give her discharge teaching talk, so you know what kind of things to say, that is also a future episode. So stay tuned.
Dr. Neeta Goli:
So to our listeners, we hope that now you feel comfortable with the basic management of a healthy, well newborn in the newborn nursery. So Dr. Patterson to end the episode today, do you have any tips for success for our listeners while taking care of newborns?
Dr. Abby Patterson:
So something I always remind my learners of is that they need to be patient with the baby. So they don't know what's going on. They've just came into this world. So often if you're a patient and calm, the baby can feel that, and they'll often be a lot easier to examine if you give them some time to settle, and if you're calm to help them center themselves as well, you'll get a better exam out of them.
Dr. Neeta Goli:
Okay. Thanks so much for joining us today.
Dr. Abby Patterson:
Thanks for having me.
Dr. Neeta Goli:
Thanks for listening to Newborn News, we hope you join us next time. If you like what you hear, make sure to subscribe and leave us a review. If you have questions, comments, feedback, or suggestions for future episodes, please email me at NewbornNews@utsouthwestern.edu. As a reminder, this content is educational and is not meant to be used as medical advice. Views or opinions expressed in this podcast are those of myself and my guests and do not necessarily reflect the views of the university.