Mastering Common Nursery Situations
“Babies are like gummy bears. There are a limited number of flavors and once you’ve tasted them all you know
what to expect the next time you see a red one.”
Within this concept lies the fact that a limited number of situations present themselves to you in the nursery, giving
you a wonderful opportunity to master many of them in a short period of time.
So what are the most common nursery situations you are likely to be presented with?
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Jaundice
Emesis or Abdominal Distension
Fever or Polycythemia
Cyanosis
Anemia, Acidosis
Tachypnea
Jaundice
Important Concepts
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Newborns get jaundiced because they are born with higher hemoglobin (up to the 60’s) and their
immature liver is slow to handle the hemoglobin breakdown products (bilirubin).
Breastfed babies have higher bilirubin levels than bottle-fed babies.
Bilirubin is often higher in babies who have:
o higher hemoglobin (polycythemia, cephalohematoma, excessive bruising, vacuum delivery).
o abnormal liver function (sepsis, acidosis, primary hepatobiliary disorders).
o delayed excretion on bilirubin in stool (breast milk, delayed feeding, or poor feeding).
Magnesium exposed babies, who are hypotonic and poor feeders.
Blood type incompatibility (ABO, Rh)
Other hemolytic process (congenital spherocytosis, G6PD deficiency)
Management Approach
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What’s the serum bilirubin level? Or get a serum bilirubin if the bili-meter is >10.
Is there any reason to suspect sepsis? What’s the GBS status of mom? Did she have chorioamnionitis?
Is this baby NPO? Breastfeeding? Feeding poorly in general?
Is this baby hemolyzing? What is the mother’s blood type? (Rh neg?, O? – O is more often associated
with ABO incompatibility).
Use AAP Phototherapy Guideline to determine need for phototherapy [also can use www.bilitool.org/]
Use Bhutani graph to determine need for f/u bili [> 75 th percentile needs follow-up within 24 – 48
hours. Remember: the Buthani graph is only used for term babies with physiologic jaundice and only
for risk stratification.]
Labs:
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Serum Total bilirubin
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Check maternal history (GBS, Chorioamnionitis, fever, blood type, Magnesium)
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Consider: CBCD, CRP, Blood culture if at risk for sepsis
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Order Type and Coombs on cord blood if mom is blood type O, Rh negative or if bilirubin is
approaching treatment range.
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Get a Reticulocyte count to help determine hemolysis if Coombs positive.
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Start phototherapy if bilirubin is in treatment range (see appendix).
Emesis or Abdominal Distension
Important Concepts
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Babies spit up a lot, but bilious emesis is a very worrisome sign.
Bilious emesis is bright green (not yellow).
Swallowed blood in the stomach is irritating.
Maternal History: polyhydramnios? Abnormal ultrasound?
Did the baby have low Apgars?
Magnesium exposed babies have relaxed smooth muscle tone and are more likely to regurgitate and less
likely to feed well.
Check the plumbing: any obstruction from mouth to anus can cause distension - the higher up, the quicker
the symptoms.
Has the baby passed meconium?
Is this a premie?
NEC (necrotizing enterocolitis) is a very serious disease;
Management Approach
If it appears to be just a little spitting up and especially if there is swallowed maternal blood in stomach: consider
gastric lavage (there is a protocol in the nursery). If needed: NPO, IV D10w at 80% maintenance, careful
observation.
If emesis is persistent or if distension is significant: NPO, IV 80-100 ml/kg/day, KUB, Orogastric tube to low
intermittent suction. If Xray is normal and symptoms resolve, you may re-try feedings 12-24 hrs later. Screen for
sepsis (CBCD, BC, consider CRP).
If you check and notice an imperforate anus or the x-ray looks like obstruction: NPO, IV @ 100ml/kg/day,
Orogastric tube to low suction, screen for sepsis, if baby sick looking with poor perfusion: treat for sepsis. Will need
transfer for Pediatric Surgical evaluation at CHO.
If NEC is suspected, always be proactive, call the peds attending!
Fever
Important Concepts
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Babies are not perfect with their temperature regulation yet, so the environment is important: check for over
wrapping.
Maternal Chorioamnionitis? Maternal GBS status? Intrapartum Antibiotics? ROM?
If mom got intrapartum antibiotics was the first (?only) dose given less than 4 hrs ago?
Preterm labor is often brought on by maternal infection…consider ruling out sepsis in all preterms.
Management Approach
If the baby looks well and no risk for sepsis: you may unwrap and recheck in an hour. If still febrile start sepsis
screen: CBCD, Blood Culture and CRP (if >12 hr old).
If baby looks ill, or has high-risk history (prolonged ROM (>18 hours), no intrapartum antibiotics circulating for > 4
hrs, GBS+, maternal infection): Screen for sepsis and consider starting IV and Ampicillin and Gentamicin.
Order a follow-up CBCD and CRP in am. (CRP only helpful if after 12hrs).
Sepsis predictors on lab: low WBC, low ANC (<6,000), low platelets, high CRP.
Negative predictors of sepsis: nl CBC, nl CRP and negative Blood Cultures.
Polycythemia
Important Concepts
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Infants of diabetic mothers have higher incidence of polycythemia.
Delayed clamping of cord can lead to polycythemia.
A heel stick HCT can be 10+ higher than a venapunctured HCT.
Symptoms of real polycythemia are due to hyperviscosity syndrome: jitteriness, plethora, irritability,
emesis, poor feeding, jaundice, hypoglycemic.
Management Approach
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Check maternal history
Check CBC or Hct
o If initial value is high, repeat as a central hct (venipuncture)
Treatment of polycythemia with symptoms is partial exchange transfusion: may need to be transferred for
this.
Cyanosis
Important Concepts
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Vital signs
Is the baby cold? Hypoglycemia?
Pulmonary problem is #1, but if persistent, think cardiac disease
Was there emesis?? (Aspiration? Obstruction?)
Polycythemic babies may look cyanotic
Consider Sepsis
Management Approach
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Check pulse oxy (sats should be > 90%).
Consider CBCD, BC, electrolytes, Blood Gas, glucose (chemstrip stat)
Consider CXR.
Consider hyperoxia test ( in pulmonary disease sats should improve significantly if you give 100% O2 over
10 min, if there is no improvement consider cardiac disease).
Take your direction from the history, the baby’s presentation and his response to interventions.
A truly cyanotic baby will probably need umbilical lines, possible intubation and transfer for further
evaluation.
Acidosis
Important Concepts
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Was there fetal distress? Low Apgars?
What are the Cord gases like (you will find them under mother’s name in Meditech).
Check maternal history? Especially history of prior neonatal or unexplained death.
If acidosis occurs >12-24 hrs think of metabolic disorders or sepsis
Management Approach
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Make sure BP is normal (see appendix)
Blood gas
Treat with IV fluids: 10cc/kg Bolus of LR or NS once or twice
Support with Oxygen as needed
NPO (an acidotic GI tract doesn’t function well.)
Anemia
Important Concepts
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Compression of the umbilical cord enough to block umbilical venous flow in to the baby but not enough to
block umbilical arterial flow OUT of the baby can lead to anemia and loss of iron stores
Hemolysis can lead to anemia and jaundice…but not loss of iron stores.
Some maternal viral illnesses such as Parvo can lead to hemolysis.
Nursery standard is to order type and coombs automatically on babies of Rh negative moms
Type O moms may have an ABO incompatibility with the baby…so consider ordering the type and
Coombs on baby with unsuspected anemia
o Type A, B and AB rarely have ABO incompatibility.
Weird stuff happens: fetal to maternal transfusion, or twin to twin transfusion: these babies can be gravely
ill and may need Type O negative blood immediately.
Management Approach
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Support vital signs
Give Oxygen as needed to support
Make sure chemstrip (or serum glucose) is normal (start IV D10W if necessary.)
Follow CBC…consider Retic count to gauge hemolysis
If hemolysis is suspected check Type and Coombs on the baby’s cord blood.
If baby is stable and has low Hct send home on FeSO4: 4 - 6 mg/kg/day
Tachypnea
Important Concepts
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The most common symptom seen in the nursery
Retained fluid in lungs takes a while to be absorbed in some babies; especially C-sections and precipitous
deliveries are thought to be at higher risk.
Tachypnea is also seen if baby is:
o Cold
o Hypoglycemic (IDM, SGA, LGA)
o Hypovolemic (Cord issues)
o Acidotic (any fetal distress?)
o In meconium aspiration syndrome.
o Pneumothorax (precipitous delivery, Meconium, PPV?)
o Polycythemic (IDM, delay in cord clamping?)
o Cardiac Disease
o Septic (ROM, GBS, chorio, preterm labor?)
o Metabolic disease (did sx start after feeding?)
Management Approach
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Check Vitals, Chemstrip, O2 Saturation and cord gases (esp base excess) and consider CBCD, CXR, Blood
Gas, Blood culture, Lytes, Glucose
o Vital signs plus chemstrip
 make sure infant temp and glucose is normal
 support with warmer and oxygen as needed
o Check perfusion
 Prolonged cap refill may also be due to hypothermia and hypoglycemia
o Check cord gases if done. Order new gas if needed:
 Treat acidosis and hypovolemia with 10cc/kg bolus of LR or NS
o Check for pulses and heart murmur
 Consider getting BP and sats in all 4 limbs
Appendix
AAP Guidelines (July 2004) for phototherapy [use these to determine treatment]:
Nomogram for designated Risk (Bhutani data): [use this to determine need for f/u lab]
Normal Neonatal Vital Signs
[from The Harriet Lane Handbook]
HR 120 to 160 bpm
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Some well full term babies’ HR can dip into the 80’s while asleep
RR 40 to 60 breaths/min
Blood Pressure (is a function of birthweight and GA)
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Mean Art BP = gestational age in weeks + 5.
Four limb blood pressures can be used to assess for coarctation of the aorta; pressure
must be measured in both the right and left arm because of the possibility of an aberrant
subclavian artery.