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Newborn care in the first few weeks

8 minutes

04/10/2020

Experienced clinical nurse specialist Kathryn Mikulencak summarizes the advice from evidence-based healthcare authorities relating to newborn follow-up care in the first few weeks. Follow-up care begins with hospital discharge, then well-baby visits with a pediatrician/healthcare provider for health assessments including feeding, immunizations and mental health.

Discharge from hospital

Postpartum hospital stay is based on the mother’s recovery and ability to care for herself and her infant. The length of stay may range from 48 hours for an uncomplicated vaginal delivery to 72 hours for a cesarean delivery, not including the day of delivery. Shorter stays may be considered once minimal discharge criteria has been met for both mother and infant.

After birth, if the mother or baby need ongoing care they will be admitted to a maternal-infant postpartum unit where they can be observed. The length of stay will be dependent on the delivery history whether the mother had a spontaneous vaginal delivery, induction or cesarean section either elective or emergent. Other factors affecting the length of stay may include a delivery was assisted by forceps or vacuum extraction, vaginal tearing requiring stitches or on-going monitoring on pregnancy or health related condition, e.g. pre-eclampsia, diabetes or if the baby needs monitoring for feeding difficulties or other health issues e.g. jaundice.

Newborns discharged after delivery before 48 hours should have an appointment to see a healthcare practitioner within 48 hours of discharge.1 Follow-up visits can take place at home, in a clinic or outpatient setting. The practitioner examining the infant should be competent in the assessment of newborns. The results of the follow-up visit should be reported to the infant’s primary care provider or designee on the day of the visit.

Contact in the immediate postnatal period

The American College of Obstetricians and Gynecologists believes that to optimize the health of both women and infants, postpartum care should be an ongoing process, starting with the first visit. They recommend that all women have contact with their obstetrician-gynecologist within the first 3 weeks postpartum with ongoing individualized care as needed, concluding with a comprehensive postpartum visit.

The postpartum period is a time of adjustment for the whole family. At each visit key topics for discussion with parents should include, emotional wellbeing, bonding and attachment, feeding, safe sleep, immunizations, social support and coping strategies for managing the day-to-day and maternal physical wellbeing.1,2

At 10–14 days after birth, the National Institute for Health and Care Excellence guidelines recommend that all women should be asked about their mental wellbeing, including anxiety and depression, this should be repeated at every contact. Consideration should also be given to partner mental wellbeing due the impact on the family’s health overall.1,2,13

Adequate parental support and education is essential for both mother and baby. Scheduled follow-up visits set the family up for success and can help identify concerns early on. Home visits when available can also extremely beneficial. Follow-up and/or home visits can be used to provide education on newborn care including breastfeeding support, keeping the baby warm, voiding and stooling expectations, promotion of proper hand washing, umbilical cord care, newborn skin care, safe sleep, immunizations and car seat safety. These care recommendations include, but are not limited to:1,8

  • Feeding

  • Infant skin care and bathing. Delayed bathing until at least 24 hours after birth has been shown to be beneficial and improve breastfeeding. Delay of bathing until at least 24 hours after birth (or for at least six hours if 24 hours is culturally unacceptable)

  • Diapering and skin care

  • Keeping the umbilical cord clean and dry

  • Appropriate clothing of the baby for ambient temperature is recommended. This means one to two layers of clothes more than adults, and no hats/caps to be worn in doors

  • Safe sleep positioning and Sudden Infant Death Syndrome (SIDS)

  • Signs of illness or other common infant problems

  • Immunizations

  • Car seat safety

Assessment of the newborn

When assessing the baby at each primary care provider visit, the America Academy of Pediatrics recommends that referral for further evaluation should be made if any of the following signs are present, and the family should be encouraged to seek help if they identify them between visits:1,2

The different danger signs during the postnatal period

Danger signs during the postnatal period:

  • Breathing rate: Apnea (infant stops breathing), tachypnea with respirations ≥ 60 breaths per minute or severe retractions.

  • Changes in skin color: Jaundice (yellow discoloration of the skin), cyanosis (bluish discoloration of lips, tongue or skin), paleness or pallor, skin mottling.

  • Feeding: Stopped feeding well or refusing to eat, either breast or bottle. Decreased urinating or stooling.

  • Temperature: Infant’s temp is < 97.5 °F (36.3°C) or ≥ 99.5°F (37.5°C).

  • Movement: History of seizures or unusual movements e.g. jitteriness, irritability or no spontaneous movement.

Feeding

The American Academy of Pediatrics and World Health Organization currently recommend that infants be exclusively breastfed for the first six months of life.3,4 To facilitate breastfeeding, it is recommended that newborns who are able to breastfeed are put to the breast as soon as possible after birth, ideally within the first hour, if the mother and baby are ready.1,7,8 The Baby-Friendly Hospital Initiative describes how mothers can be supported to breastfeed, including the following steps for after discharge home:10

  • Provide infant feeding counselling during all postpartum visits

  • Offer community support, including mother support groups and community-based health promotion and education activities

Immunization

The Center for Disease Control (CDC) recommends vaccinations as one of the best ways parents can protect infants, children, and teens from potentially harmful diseases.6 The WHO continues to strive to ensure that every person is protected from vaccine-preventable diseases.9 In the US, immunizations should be offered to all children and their parents.

It is important that both parents and their child’s primary care provider maintain records of the child’s vaccination history and any adverse reactions that might have occurred. Each state has an immunization information system (IIS) that allows healthcare providers and public health clinics to save and update vaccination records.

Where necessary, local planning should aim to target excluded or at-risk families (including refugees, the homeless, travelling families, very young mothers, those not registered with a primary care provider and those who are new to an area). The current routine immunization schedule, together with additional vaccines recommended for each age groups, can be found on the CDC Vaccines and Preventable Diseases page.

Supporting perinatal mental health

Healthcare providers should be available to promote maternal and partner mental health; 1 in 4 women will experience perinatal illness. Healthcare providers are able to assess for risk and signs of mental health problems, supporting mild to moderate perinatal mental illness and referring on to a mental health specialist when needed.1,2 Mood changes, irritability and episodes of tearfulness are common after giving birth. These symptoms are often referred to as the “baby blues”, which affect around half of new mothers and lasts approximately 5 to 14 days.2

If these symptoms of low mood and anxiety are more persistent, then it is possible it could be postpartum depression.13 Perinatal mental health problems such as depression and anxiety can impact 1 in 4 women during pregnancy and the first year after having a baby.11 Symptoms include those of depression such as crying, feelings of helplessness, loss of appetite, as well as acute panic and anxiety, and can in some instances lead to self-harm and suicide.11,12,13

During postpartum visits with new mothers, new fathers and their partners should be asked about their experience of becoming a parent and explore feelings and expectations. Healthcare providers can play an important role by educating both mothers, fathers and partners about postnatal depression and anxiety so that they are able to access help if they notice any of the signs and symptoms in themselves or their partners.11,12.13,14

Ensuring optimal infant mental health

Promoting maternal mental health is key to a healthy baby-parent relationship. Babies need parents to attend to their feelings to help them grow into healthy adults.1 Children’s brains develop fastest and are at their most impressionable while in the womb and in the early years of life. During this period, the brain is primed and ready for learning and growing; it is a time of rapid cognitive, linguistic, social, emotional and motor development. Holding, cuddling and talking to the child both stimulate brain growth and promote emotional development. Being kept close to the parents and have their physical needs met on demand (consoling, feeding, diapering and attachment) ensures the infant feels a sense of emotional security and well-being.15

Parent-infant relationships are vitally important and healthcare providers visitors play an important role during their interactions to ensure optimal social, emotional and mental development of a baby. Healthcare providers can help provide practical guidance to new parents on cues to understand a baby’s needs and how to soothe and nurture their development from birth.15

To learn more about caring for and nurturing newborns’ skin, read about common neonatal and infant skin concerns here.

References
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1American Academy of Pediatrics & the American College of Obstetricians and Gynecologists (2017) Guidelines for Perinatal Care, Eighth Edition. Elk Grove Village, IL.

2The American College of Obstetricians and Gynecologists (2018) Optimizing Postpartum Care. ACOG Committee Opinion #736. Presidential Task Force on Redefining the Postpartum Visit Committee on Obstetric Practice. Obstetrics & Gynecology Vol. 131,# 5. Retrieved August 15, 2020 from: https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/05/optimizing-postpartum-care

3American Academy of Pediatrics (2012) Breastfeeding and the use of human milk. Pediatrics 129(3), e827-e841. Retrieved August 30,2020 from: https://doi.org/10/1542/peds.2011-3552

4World Health Organization. WHO recommendations on newborn health [online] May 2017. Available from: https://apps.who.int/iris/bitstream/handle/10665/259269/WHO-MCA-17.07-eng.pdf;jsessionid=5DF176702DB432D2BEAEC5E65E009F96?sequence=1 [last accessed August 2020]

5American Academy of Pediatrics (2018) AAP Schedule of Well-Child Care Visits. Healthychildren.org. Retrieved August 15,2020 from: https://www.healthychildren.org/English/family-life/health-management/Pages/Well-Child-Care-A-Check-Up-for-Success.aspx

6Center for Disease Control and Prevention (2016) Vaccines and Preventable Diseases. Retrieved August 20, 2020 from:https://www.cdc.gov/vaccines/vpd/vaccines-age.html

7World Health Organization. Ten steps to successful breastfeeding [online] 2020. Available from: https://www.who.int/activities/promoting-baby-friendly-hospitals/ten-steps-to-successful-breastfeeding [last accessed August 2020]

8World Health Organization. Infant and young child feeding [online] 2018. Available from: https://www.who.int/news-room/fact-sheets/detail/infant-and-young-child-feeding [last accessed August2020]

9World Health Organization. Immunization [online] 2020. Available from: https://www.who.int/topics/immunization/en/ [last accessed August 2020]

10Center for Disease Control and Prevention. (2020) Finding and updating records. Retrieved August 21, 2020 from: https://www.cdc.gov/vaccines/parents/records/find-records.html?CDCAArefVal=https%3A%2F%2Fwww.cdc.gov%2Fvaccines%2Fparents%2Frecords-requirements.html

11American College of Obstetricians and Gynecologists (2016) ACOG Statement on Depression. Retrieved August 20, 2020 from: https://www.acog.org/news/news-releases/2016/01/acog-statement-on-depression-screening

12American College of Obstetricians and Gynecologists(2018) ACOG Postpartum Toolkit for healthcare providers. American College of Obstetricians and Gynecologists, 409 12th Street SW, PO Box 96920, Washington, DC 20090-6920

13NICE, Antenatal and postnatal mental health: Clinical management and service guidance (2014) National Collaborating Centre for Mental Health

14Baldwin, S., Kelly, T. A Guide to Postnatal Depression in Fathers (2014), Wheel. UK: KMMD

15Kaneshiro,N. (2019) Well-Child Visits. Retrieved from MedlinePlus August 20, 2020 from: https://medlineplus.gov/ency/article/001928.htm

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