How Late Can You Give Routine Newborn Care?

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Patient Presentation
A term, 4-day-old male came to clinic for his health supervision visit. They felt he was breastfeeding well and had only mild jaundice. He was having multiple wet diapers and his stools had transitioned from meconium to normal breastmilk stools.

The past medical history showed he appropriate for gestation age and was born by vaginal delivery that had been induced for maternal hypertension without additional evidence of pre-eclampsia. The family lived about 90 minutes away from the hospital had wanted a home birth but had decided to deliver at a hospital because of the hypertension. They declined several routine screenings and treatments in the hospital including no Hepatitis B vaccine, Vitamin K administration and hearing screening. He did receive antibiotics for his eyes.

The pertinent physical exam showed he was a slightly jaundiced male who had lost only 3% of his birth weight and had gained 10 grams since discharge. His examination was normal and the diagnosis of a well newborn infant was made.

The laboratory evaluation of a transcutaneous bilirubin was 8.4 mg/dL which was well below treatment threshold. The parents indicated that they wished to have him circumcised and were not happy that the pediatricians in the hospital would not perform the procedure as he had not had the Vitamin K. The office pediatrician reiterated the concern for hemorrhagic disease of the newborn and why Vitamin K was recommended. The parents remained unconvinced but said they would re-consider possibly oral Vitamin K and wanted to postpone that discussion for the next appointment. They were agreeable to having an appointment made for outpatient hearing screening to be completed at their next visit in one week. The family did not return for followup and when contacted said they were seeing another child health provider closer to their home.

Discussion
Routine newborn screening and treatment is focused on assisting the infant’s transition to extrauterine life, screening for health problems that may or may not be easily identifiable, and preventing acute or chronic health problems. Healthy infants begin with healthy pregnancies including risk factor assessment and screening of mothers. Such routine maternal screening and treatment does or may include glucose tolerance tests, ultrasound examinations, screenings for maternal blood type (with appropriate administration of Rho(D) immunoglobulin if appropriate), Hepatitis B, Neisseria gonorrhea, Chlamydia, Cytomegalovirus, Syphilis, Rubella, and Group B Streptococcal infection.

Initial assessments of newborns include Apgar scores (initial cardiovascular status at birth) and Ballard scores (estimate of gestation) which are non-invasive. At risk infants may also have additional monitoring for Group B Streptococcal infection and hypoglycemia (ex. small or large for gestational age infant, infants of diabetic mothers). Following recommendations and guidelines, at risk infants are also screened for possible drugs of abuse, and hemolysis (blood type and direct antibody testing).

Around 24 hours of life many common newborn screenings are completed which usually include weighing the infant, and non-invasive screening for hyperbilirubinemia, congenital heart disease, and hearing problems. Invasive (heel-prick) screening for newborn screening for a variety of common genetic traits and inborn errors of metabolism often occurs at this time. Suspected, clinically-relevant hyperbilirubinemia may require invasive testing for confirmation or additional evaluation. Some infants may need car seat tolerance screening as well.

Learning Point
Some families may decline all or particular components of these routine screenings or prophylactic treatment. More commonly declined are those that are invasive requiring drawing blood or medication or vaccine administration. With additional education and shared decision making, many families may choose to allow the testing/treatment to occur. However some families will not consent to give the treatment or want an alternative timing.

The author attempted to find literature or recommendations for the latest these treatment could/should be provided to infants but could not find this specific information. The author does not advocate alternative treatments or schedules.

Common routine treatment that parents may refuse includes:

  • Hepatitis B vaccine is recommended to be given to all medically stable newborns of > 2000 gram birth weight in the United States to prevent vertical transmission and possible chronic hepatitis in the newborn. If an infant is exposed to Hepatitis B virus, there is a high likelihood of infant infection (5-90% of infants) and of those with infant infection almost 90% go on to have chronic infection. The recommendation is to give the vaccine within 24 hours after birth preferably as soon as possible after birth. The World Health Organization and other organization also endorse early vaccine prophylaxis for infants. This birth dose can be the first of the 3-dose vaccine series recommended for all newborns and children. The first vaccine can be given later than the first 24 hours, but its efficacy for preventing vertical transmission declines after this time. Even if the mother screens negative for Hepatitis B, this means the infant has low risk, not no risk, for vertical transmission.
  • Ophthalmia neonatorum is conjunctivitis within the first 4 weeks of life. Neisseria gonorrhea is one of the most clinically relevant as it can cause scarring and blindness and can be prevented with topical antibiotics. In the US erythromycin is routinely used. “Among pregnant persons who are infected [with Neisseria gonorrhea], are not adequately treated, and whose infants do not receive ocular prophylaxis, transmission of infection occurs in 30-50% of infants. Of infected infants, an estimated 20% will develop corneal involvement and 3% will be blind.” Other etiologies for ophthalmia neonatorum include Chlamydial trachomatis, Herpes simplex virus and Pseudomonas aeruginosa. Chlamydia is not treated by erythromycin. Some countries and organizations do not recommend routine prophylactic treatment such as the Canadian Pediatric Society. Young infants presenting with conjunctivitis should have their medical charts reviewed for maternal sexually transmitted infection screening status as well as if actual administration of a topical antibiotic to the infants eyes was documented, remembering that only Neisseria gonorrohea is treated with erythromycin.
  • The World Health Organization in its 2022 guidelines states: “In addition, all newborns should be provided with their hepatitis B birth dose, and in settings in which mothers are not routinely screened for gonorrhoea and chlamydial infection, routine prophylaxis for ophthalmia neonatorum should be administered.”
  • Vitamin K administration can prevents hemorrhagic disease of the newborn (HDN) that can be caused by their immature liver, decreased placental transfer and sterile gut. There are 3 types.
    • The first presents with bleeding in the first 24 hours of life due to maternal drugs (e.g. anti-epileptics, antibiotics, anti-coagulants) that prevent clotting. This cannot be prevented by prophylactic Vitamin K administration. It presents with poor feeding, lethargy, irregular breathing, bulging fontanelle, melena, hemoptysis, and blood loss.
    • The second is the classic disease that presents between days 1-7. Bruising, bleeding from the gastrointestinal tract, umbilicus and circumcision are common.
    • The third is the late onset disease presenting between 7 days and 6 months of life (more often 2 weeks to 3 months). Intracranial hemorrhage is a presentation for 50-80% of patients. Usually these are in exclusively breastfed infants who have not received Vitamin K. It can be seen in patients with neonatal liver problems such as hepatitis, cystic fibrosis or biliary atresia.

    The risk of HDN in infants not receiving Vitamin K at birth is 10.5-80 per 100,000 births. Vitamin K levels reach adult levels around 6 months of age. Almost all HDN can be prevented by one dose of intramuscular Vitamin K as “…it provides a more sustained release of vitamin K in comparison with the rapid metabolism of IV vitamin K and the variability in absorption of oral vitamin K.” In the US there is no US Food and Drug Administration approved oral Vitamin K preparation. However off-label use does occur. Oral Vitamin K is more common in European countries and it requires multiple doses. Oral Vitamin K is more effective for classic HDN than for late onset HDN. Although of unknown benefit and not advocated by the author, given that HDN can present up to 6 months of age and this is when adult levels occur, it would be possible to give Vitamin K up 6 months of age if parents chose to give Vitamin K on a different schedule.

Questions for Further Discussion
1. What are the components of the Apgar Score? A review can be found here
2. How do you counsel parents regarding declination of different newborn cares?
3. What alternative perinatal practices do you see in your patient population?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Infant and Newborn Care

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Watterberg KL, Committee on Fetus and Newborn. Policy statement on planned home birth: upholding the best interests of children and families. Pediatrics. 2013;132(5):924-926. doi:10.1542/peds.2013-2596

Quinn JM, Sparks M, Gephart SM. Discharge Criteria for the Late Preterm Infant: A Review of the Literature. Adv Neonatal Care Off J Natl Assoc Neonatal Nurses. 2017;17(5):362-371. doi:10.1097/ANC.0000000000000406

Jullien S. Vitamin K prophylaxis in newborns. BMC Pediatr. 2021;21(Suppl 1):350. doi:10.1186/s12887-021-02701-4

Moore DL, MacDonald NE and the Infectious Diseases and Immunization Committee. Prevention ophthalmia neonatrorum, Canadian Paediatric Society. 2021. Accessed August 29, 2023. https://cps.ca/en/documents/position/ophthalmia-neonatorum

Nolt D, O’Leary ST, Aucott SW. Risks of Infectious Diseases in Newborns Exposed to Alternative Perinatal Practices. Pediatrics. 2022;149(2):e2021055554. doi:10.1542/peds.2021-055554

Shaw MA, Liu A. Take the Shot: A Review of Vitamin K Deficiency. Pediatr Ann. 2023;52(2):e42-e45. doi:10.3928/19382359-20230102-02

Global Health Sector Strategies. Accessed August 29, 2023. https://www.who.int/teams/global-hiv-hepatitis-and-stis-programmes/strategies/global-health-sector-strategies

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

Published