Newborn Discharge Exam: Resources
EMR & Discharge Exam
To document a well newborn discharge check on the EMR, follow these steps:
- Create a new "Neonatal Progress Note" document
- Utilize the acronym expansion "dccheck" which can be imported from user Michael Hewson.
- This is a template for documentation - note that it's not necessary to repeat maternal history already recorded in the EMR
- Before saving, select the "Document Info" tab and in the "Document Topic" box, write "Discharge Exam".
Note: Do NOT use the "Neonatal Discharge Summary" document type to document the discharge examination of the well newborn.
The well newborn never admitted to the nursery does not require a medical discharge summary.
Queensland Guideline
A useful summary of a systematic approach to routine newborn assessment
Newborn Check in 3 minutes
A quick run through of the standard elements of newborn discharge exam
Hips: Background and Exam Technique
see www.ddheducation.com/ (Slides 8 & 9 for exam technique)
View on desktop computer: the website uses flash and won't run on most mobile phone browsers
Eyes: the fundal (red) reflex
Watch from 13 - 24 minutes for key how-to. The entire video is worth watching.
Abnormal findings are:
- eyes have different colour or brightness
- dark patch within reflex
- absent reflex
Note that while the fundal reflex is typically red in infants with fair skin colour, the fundal reflex colour is typically paler with yellow or white colours in black infants
Discuss any concerns with newborn eye exam with the Neonatal Paediatrician. Conditions such as congenital cataract are emergencies.
Refer urgently to paediatric ophthalmologist if abnormal fundal reflex
Refer to Paeds opthalmology at WCH
Alternatively Dr Sinkar may be able to see urgently in private clinic (gap charge may apply)
Examination for cleft palate
Antenatal Renal Abnormality
Post-natal follow up required if the third trimester scan shows:
A-P renal pelvis dilation (APRPD) of 7 mm or more
Persistent calyceal dilatation
Dilated ureter
Dilated / thickened bladder
Other concerning features such as cystic dysplastic kidney, reduced amniotic volume (without known cause), malpositioned or duplex kidney, or solitary kidney
First renal scan Day 3 -7 if:
APRPD > 15 mm
Bilateral APRPD > 10 mm (the concern is that the infant may have obstructed bladder outlet / posterior urethral valves)
Solitary kidney
Suspected obstructed duplex kidney
Dilated / thickened bladder
Suspected bladder outlet obstruction
Ectopic (pelvic kidney): order ultrasound for Day 3 to 7, and refer to Paeds Urology at WCH (will be seen at 3 months)
Solitary kidney: order ultrasound for Day 3 to 7, and refer to Paeds Nephrology at WCH (will be seen at 3 months)
First renal scan 4 - 6 weeks if:
Antenatal APRPD 7 - 14 mm
With or without central calyceal dilatation
But no other antenatal renal abnormality
Follow-up of 4 - 6 week scan:
- Only abnormality APRPD < 10 mm: Discharge.
- Only abnormality APRPD 10 - 14 mm (with or without central calyceal dilatation): Repeat ultrasound 6 months
- Other abnormalities: Discuss with Neonatologist.
Developmental Dysplasia of Hips
New screening strategy 2025
Barlow & Ortolani Test pre-discharge:
Normal exam: routine care
Uncertain / equivocal exam: discuss with neonatologist
Abnormal exam: see below
We no longer request screening ultasound based on risk factors
Clinical exam abnormal?
Clicky hips with otherwise normal exam:
Clicks are not significant. If unsure either:
Re-examine in a day or two, or
Ask registrar or consultant to examine
Reduced but Subluxable/dislocatable hips:
Discuss with neonatologist who may order an ultrasound
Refer to Mr Allcock by internal referral form for clinical review at two weeks
(Mr Paul Allcock is the local (LMH) paediatric orthopaedic surgeon)
If still unstable at 2 weeks will treat with Pavlik Harness
If stable at 2 weeks Mr Allcock will arrange 6 week scan
Dislocated but reducible hips:
Refer to Mr Allcock via on call ortho registrar
Pavlik harness to be applied before discharge
Dislocated and irreducible hips:
Book Ultrasound for confirmation
Refer to Mr Allcock via internal referral form
Mr Allcock will attempt closed reduction under GA when old enough
May need open reduction at about 1 year
Interpreting screening scans
Graf Classification
Graf |
alpha |
beta |
Implications |
1 |
> 60 |
< 55 |
Normal |
2a |
50 - 59 |
< 55 |
Immature: repeat at 3 months |
2b |
50 - 59 |
< 55 |
Persisting at 3 months: urgent referral to Mr Allcock via call to LMH Ortho Reg and internal referral form for Pavlik harness |
2c or worse |
<50 |
≥ 55 |
Urgent referral to Mr Allcock via via call to LMH Ortho Reg and internal referral form for Pavlik harness |
Early Discharge 4 - 24 hours of age
Criteria which must be met prior to early discharge:
- At least two successful feeds
- Normal discharge examination
- Vit K administered (or non-consent documented)
- Hep B immunisation administered (if consented)
- Mother instructed to contact BAUL if infant has not passed urine by 24 hours of age or passed meconium by 48 hours of age
- Home-visiting midwifery follow up available for next day
Discharge prior to 24 hours not recommended if:
- Significant evidence of intrapartum hypoxia (any of cord lactate > 6 mmol/L, positive pressure ventilation required, 5 minute Apgar < 7)
- Gestation < 37 weeks
- Birth weight < 2500g
- Inadequate intrapartum antibiotics after either GBS +ve OR ROM > 18 hours
- On-going need for blood sugar monitoring
- Temperature instability
- Heart rate while awake < 100/min (sleeping heart rate 80 - 100 is acceptable)
- Heart rate > 180/min
- Respiratory rate > 60 or respiratory distress
- Any visible jaundice (urgent SBR required for Day 1 jaundice)
- Congenital abnormality (discuss with neonatal paediatrician)
A history of meconium stained liquor is not a contra-indication to early discharge in an otherwise well infant
Heart Murmurs
Post-natal murmurs are often due to congenital heart disease:
30 to 50% of murmurs heard are due to CHD
Note that half of newborns with significant CHD don't have a murmur
Murmur heard?
Perform thorough cardiac exam
Pre- and post-ductal sats
Post-ductal sats should be ≥ 95% in air
4-limb blood pressures only required if femorals abnormal or baby unwell
Ask reg or consultant to examine
Follow-up options include:
Re-examine prior to discharge
Referral to WCH cardiology for echo: if significant concern for congenital heart disease
Follow up in 2 weeks by GP: if examination features are benign
Note that 3 to 4 weeks is typical timing for development of heart failure in moderate to large VSD
Elevated Cord Lactate
The SA PPG guides assessment of infants at risk of HIE who may require transfer and hypothermia
Cord lactate thresholds
Cord lactate > 4 is common (data on 17,000 vigorous newborns)
Cord lactate of 8 equates to pH 7.15 See Gjerris 2008
There's no evidence that a saline bolus improves outcome in normovolemic infant with elevated lactate
Cord lactate unexpectedly high in well newborn:
Cord lactate 8 or more:
Review at 2 - 3 hours including behaviour (?HIE)
Evaluate sepsis risk (calculator)
Check capillary lactate at 4 hours
No routine repeat lactate if cord lactate < 8
Cord lactate high after resus required: infant now appears well:
Review at 2 - 3 hours including behaviour (??HIE)
Evaluate sepsis risk (calculator)
Check capillary lactate at 4 hours
No routine repeat lactate if cord lactate <8
Cord lactate high after resus required: infant is unwell:
Manage as appropriate:
Consider HIE. On-going evaluation.
Evaluate sepsis risk (calculator)
Consider other causes eg anemia
Repeat lactate as clinically indicated
Subgaleal Haemorrhage
Refer to the form "Subgaleal haemorrhage surveillance observations" (MR 130)
This outlines criteria for observations for infants with or at risk of subgaleal bleed
MR 130 form is available in Special Care Nursery
Always notify neonatal paediatrician urgently if you identify a subgaleal bleed
There is a very good review in J Paed Child Health 2014
Maternal Hep B and Hep C
Maternal Hepatitis B
Background
See SA PPG (above) for discussion of maternal testing, intrapartum care, and postnatal care
Mother is HBsAg Positive OR HBV DNA Positive:
HBIG and HB Vaccine given to baby within 12 hours of birth
Follow Up:
Provide infant's parents with a request form for blood testing for HBsAg and HBsAb and Hepattis B core antibody at 12 months of age
Book follow up clinic with Dr Yumin Chan (Paeds ID) to review results at 13 months of age
Maternal Hepatitis C
Background
See guideline for discussion of maternal testing, intrapartum care, and postnatal care including issues around breastfeeding
Overall the risk of transmission to infant is no more than 5%
Follow Up
Perinatal HCV exposure: Give infant's mother a form for Hep C antibodies at 12 months of age and arrange outpatient clinic with Dr Yumin Chan (Paeds ID Clinic) at 13 months
HSV Risk
Follow the SA PPG
High Risk Scenarios
Always discuss these infants with Consultant:
- Mother has genital lesions at delivery but no prior history of HSV:
- Mother with documented primary infection within 12 weeks of delivery
- Mother has sero-converted prior to birth
- Cesarean delivery
- Maternal suppressive antivirals
This may represent primary infection which is very high risk to newborn
The mother may still be shedding virus at delivery even if no visible lesions
Protective factors in these cases include
Consider early pre-emptive treatment with aciclovir
Intermediate Risk Scenario
Mother with past history of HSV and recurrent genital lesions at delivery:
Surveillance swabs and urine at 24 hours
Appropriate advice to parents re signs of illness
Low Risk Scenario
Mother with past history of HSV but no recurrent genital lesions at delivery:
No additional investigations are required
Maternal Thrombocytopenia
Background:
Thrombocytopenia is relatively common in pregnancy
Causes include:
Gestational thrombocytopenia
ITP
PET & HELLP
Gestational thrombocytopenia:
Commonest cause of maternal low platelets
Maternal platelet count seldom < 100
Entirely benign condition
No risk of neonatal thrombocytopenia
Maternal ITP:
Causes 10% of thrombocytopenia in pregnancy
Maternal platelet count may be below 100
10% of newborns will have platelet count below 50
Newborn platelet nadir may be Day 2 to 5
Neonatal testing:
No need for newborn FBC in gestational thrombocytopenia with maternal platelets > 100
Maternal ITP: obtain neonatal FBC (eg cord)
If newborn platelet count < 150: repeat in 24 hours
Moderate or severe neonatal thrombocytopenia will require appropriate investigation and management
Maternal Thyroid Disease
Maternal Graves Disease
Background
Transplacental passage of thyroid stimulating antibodies (TSHR-Ab aka TRAB) can cause neonatal hyperthyroidism
Between 2% and 12% of infants of mother with Graves develop hyperthyroidism
The newborn usually presents within the first 10 days
A negative maternal screen for TSHR-Ab makes this complication very unlikely
The precise level of TSHR-Ab as measured in 3rd trimester may be very helpful in quantifying the risk in a given newborn.
TSHR-Abs can persist after maternal treatment
The low risk infant:
If maternal TSHR-Ab negative the risk to infant is low
No TFTs unless symptomatic
No need for extended observation
The at risk infant:
SCN admission if maternal TSHR-Abs more than 5-fold above top of reference range
Minimum 48 hours observation (on post-natal) before discharge for at-risk
Check TFTs at Day 3 and Day 10
Signs and Symptoms in newborn:
Findings may include:
Tachycardia and heart failure
Low birth weight and poor weight gain
Feeding difficulty
Irritability
Any role for cord TSHR-Ab levels?
Some sources recommend obtaining cord blood for TSHR-Ab levels if maternal testing was not done...
if negative this moves infant to a low risk class (see above).
In practice Cord TSHR-Ab is seldom helpful because the test is only run on Thursdays
Maternal Hashimoto Disease
Background
Can cause both hyper and hypothyroidism in the newborn
However risk of either is quite low
No more than routine Guthrie screening required
Maternal Hypothyroidism
If due to treatment of previous Graves Disease, see above.
For other conditions the risk of thyroid problems in infant is low
Neonatal Hypoglycaemia
Follow the SA PPG
Further investigation of hypoglycaemia
If hypoglycemia is unusually severe, or prolonged, or lacks an obvious cause...
Perform critical hypoglycaemia bloods (under Blood Tests) during an episode
Echogenic Cardiac Focus
What is an echogenic cardiac focus?
A fetal ultrasound soft marker for aneuploidy
Found in 5 to 25 % of fetal scans (ethnicity dependent)
Represents mineralisation in papillary muscle
Long term outcome:
In the absence of aneuploidy there are no long term implications
Routine echocardiogram is not required
No increased risk of rhythm disturbance: no need for ECG
Approach to the newborn:
Complete a standard neonatal examination
No additional investigations or follow up required
Appropriate reassurance
Green (bilious) vomiting
Why it matters?
A single green vomit in a newborn may be the only early warning sign of malrotation and volvulus
Perhaps 30% of infants with green vomit have a surgical pathology
Any delay in diagnosis of malrotation with volvulus can result in bowel loss
What colour is bile?
Although any colour of vomit can be serious we are most concerned about green vomitus
Compare with this colour swatch
Colours 5 to 8 are significant green vomits
Management of infant with green vomit:
Discuss urgently with neonatal paediatrician (including over night)
History / examination / AXR / gas / blood culture usually indicated
Urgent abdominal ultrasound or upper GI study often required
Other causes of green vomit:
Consider sepsis
Consider other causes of bowel obstruction
Often no pathology is identified
The Anterior Fontanelle
Normal Size Variations
Normal variants include:
- Small: just 1 cm diameter
- Large: up to 6 cm diameter
Red Flags - Small Fontanelle
- microcephaly
- abnormal skull shape
- dysmorphic features
Red Flags - Large Fontanelle
- macrocephaly
- hypotonia / feeding problems / neurological abnormality
- dysmorphic features
Follow Up
In general follow up with GP
GP will review head growth and shape at 2 and 6 weeks
Neonatal Clinic Review is not required
If concerned about "red flags" as above, discuss with senior medical staff
Sacral Dimple
What is a sacral dimple?
A dimple or pit below the intergluteal crease
Sacral pits are rarely significant
More concerning features?
Asymmetric intergluteal crease
Midline lipoma or vascular birthmark
Very hairy overlying skin
Base of pit not visible
Follow-up if concerned:
Sacral ultrasound in 2 to 4 weeks
Follow up in Virtual Clinic
Talipes Equinovarus (Clubfoot)
What is Talipes Equino Varus?
Management of TEV:
Physiotherapy referral pre-discharge
Early treatment with exercise / splinting improves outcomes
Casting and surgery may be required
Mild variants
Very mild positional talipes has a mobile foot easily manipulated into a normal neutral position
These cases may not need further referral
Discuss with neonatologist
Undescended Testes
Concerning features? Urgent endocrine referral:
Hypospadias
Microphallus
Excessive scrotal pigmentation
Hypoglycemia or hyponatremia
No concerning features?
Testes may not reach scrotum till 3 to 4 months of age
Ultrasound to locate testes is not usually indicated
Document in the Blue Book
Recommend GP review at 4 months
Should be referred to Paeds Surgeon if not in scrotum by 4 months
Vitamin D for term babies post-discharge
The main options
Ostelin Infant Vit D Drops (2.4 mL) 400u = 1 drop
Pentavite (30mL) 400u=0.45 mL
Ostelin Vit D (50 mL) 1000u = 0.5 mL
All are purchased "over the counter" rather than prescription
Cost is similar for all the above (about $5 - $7 per month)
We recommend Ostelin Infant Drops
Easy to administer one drop = 400u
No bitter taste or bad smell
No unwanted extra vitamins
Doesn't stain clothes
80 doses per bottle
$10 - $15 (cheapest at "warehouse" pharmacies)
Weight Loss
What weight loss is normal?
Term infant of appropriate birth weight: up to 10% weight loss is normal
Preterm infant or SGA infant: up to 7% weight loss is normal
Cesarean delivery increases the likelihood of > 10% weight loss
Flaherman et al Peds 2015 has detailed normative data on weight loss
Managing abnormal weight loss:
Excessive weight loss is usually due to problems with lactation and breast feeding
Provide practical support for breast feeding
The SA PPG Breastfeeding is a very useful resource around breastfeeding, weight loss, and practical strategies.
Consider possible illness in infant
Discuss with consultant if weight loss 12% or more in term infant
Discuss with consultant if weight loss 10% or more in preterm or SGA infant