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TOPICS IN NEWBORN CAREKelly Wright, M.D., F.A.A.P.CoxHealth Northside Pediatrics and Adolescents

Effects of maternal fluids on newborns after delivery

Immunizations relevant to newborn care

Vitamin K and erythromycin prophylaxis in newborns

MATERNAL IV FLUIDS: EFFECTS ON NEWBORN POSTPARTUM CARE

For newborns, which fluid mom receives is less important than how much fluid.

The type of fluid mom receives has little effect on newborn blood sugars. Hypoglycemia in newborns is caused by inadequate glycogen storage (i.e. preterm or SGA infants) and/or hyperinsulinemic state (infants of diabetic mothers, LGA infants). The amount of dextrose in D5 has little impact on mother’s or infant’s blood sugar.

The amount of fluids mom receives can impact breastfeeding and neonatal weight loss.

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FLUIDS AND BREASTFEEDING

Large amounts of IV fluid administration can cause third-spacing in breast tissue, delay lactogenesis II (>3 days), and create edema that makes it difficult for baby to latch.

Pitocin is also a natural anti-diuretic that can also impact a mother’s third-spacing.

Reverse Pressure Softening can be a helpful technique for mothers who are very engorged or edematous to improve latch and comfort with nursing and pumping.

REVERSE PRESSURE SOFTENING

FLUIDS AND NEWBORN WEIGHT LOSS

In the case of long labors, lots of IV fluids (common in epidural, cesarean births, and complicated deliveries), the birth weight may be inflated by the fluid administration.

In these cases, the 24 hour weight may be a more accurate representation of the infant’s true weight. Most infants will diurese excess fluids within 12-24 hours.

Using the 24 hour weight for weight loss calculations may help avoid supplementation in breastfeeding infants which improves long term outcomes for breastfeeding.

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IMMUNIZATIONS IN NEWBORN CARE

Maternal Immunizations

Tdap

Influenza

MMR

Neonatal Hepatitis B

COCOONING

Infants can be protected from vaccine-preventable illnesses by immunizing all household contacts.

Immunizing families and other caregivers creates a cocoon of protection around the infant, decreasing the likelihood that the infant will be exposed to an illness.

Image from Georgia Dept of Public Health http://slideplayer.com/6118768/18/images/28/Cocooning+Strategy.jpg

HERD IMMUNITY

Immunization rates need to be above about 85-90% for most vaccines to provide adequate herd immunity.

Herd immunity protects the young, the old, the sick/immunocompromised, and rare vaccine non-responders.

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–Bill Gates

“Treatment without prevention is simply

unsustainable.”

TdapBordetella pertussis: “The 100 Day Cough”

Young children develop apnea, pneumonia, and respiratory failure

Cough can be severe enough to cause rib fractures, pneumothorax, or aortic dissection

Encephalopathy/seizures may occur

2016: 16 million infections world wide and 58,000 deaths

Recent outbreaks in unvaccinated communities in U.S.

Most infants contract the infection from an adult caregiver or adolescent in the home.

Tdap

Tdap is recommended between 27-36 weeks of each pregnancy (regardless of timing of last dose) to boost maternal antibody production and provide transplacental antibodies to infant.

If not given during pregnancy, it should be given to mothers prior to hospital discharge.

Tdap is also recommended for any adolescent in the home or adult caregiver. Immunizations are available through Cox pharmacies.

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INFLUENZA

More than 3 million U.S. cases per year

Mortality rates difficult to determine but range from 4,000-30,000/year in US depending on the season. 150 pediatric deaths/year

Complications include pneumonia, encephalitis, myocarditis

Pregnant and postpartum women and children under age 2 are particularly high risk for complications from influenza

– Paul Offit

Chief of Infectious Diseases

Children’s Hospital of Philadelphia

“It’s not your inalienable right to not get a vaccine if

you’re helping care for vulnerable patients.”

INFLUENZA

Influenza vaccine is effective. Flu vaccine in children for the 2017-2018 season provided about 50% protection. Immunized children who contract flu also tend to have milder symptoms.

Flu vaccine in children prevents hospitalization and death from influenza.

Flu vaccine does not cause the flu or other respiratory illness. It does not cause Gullian-Barre Syndrome. Adverse effects are mild (fever, pain at the injection site, swelling, redness).

Individuals with egg allergies can safely receive flu vaccine in the vast majority of cases.

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RUBELLA

German Measles; mild or asymptomatic primary infection

Rarely causes encephalitis, pneumonia

Miscarriage or Congenital Rubella Syndrome

CRS: deafness, heart defects, cataracts, microcephaly, thrombocytopenia and bone marrow abnormalities, blueberry muffin rash (extramedullary hematopoiesis)

RUBELLA

MMR vaccine is typically given at 12-15 months of age and at 4-5 years of age.

Some individuals do not have a lasting immune response, so pregnant women are screened for rubella immunity.

Women who are rubella non-immune should receive MMR vaccine after delivery.

MMR vaccine should not be given in pregnancy.

HEPATITIS B

Acute and chronic infections; fever, jaundice, liver failure

90% of neonates infected will develop chronic hepatitis

Chronic illness causes cirrhosis and hepatocellular carcinoma.

1/3 of the world’s population infected with 350 million chronic infections; 750,000 deaths/year

Infants of infected mothers who are immunized within 12 hours of birth have 95% reduction in disease transmission.

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WHAT’S THE BIG DEAL?

Hepatitis B testing isn’t perfect. False negative tests can occur.

Mothers will test negative if testing is done prior to seroconversion.

Testing is typically done in the first trimester. Mothers could contract the infection later in pregnancy.

Blood from an individual with hepatitis B is highly infectious. Even casual contact (sharing wash cloths, towels, razors, toothbrush) with an infected person can cause disease transmission.

HEPATITIS B

Current recommendations are to immunize all infants within 24 hours of birth. Infants of hep B positive mothers should receive immunization within 12 hours along with HBIG.

With high immunization rates, hepatitis B infection could be eliminated in the United States within 1-2 generations.

VITAMIN K PROPHYLAXIS

Intramuscular Vitamin K is recommended for all newborns for prevention of hemorrhagic disease of the newborn.

Image credit: https://www.bcfr.org/2012/04/a-mothers-mission/

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WHY DO INFANTS NEED VITAMIN K?

Infants have an immature hepatobiliary system that does not efficiently utilize vitamin K.

Vitamin K storage in newborns is low due to poor placental transfer.

Breastmilk does not naturally contain vitamin K.

Newborns have a sterile gut, so they do not obtain vitamin K readily from gut microorganisms.

Vitamin K is essential for vitamin K dependent clotting factors. Infants have about 20% the amount that adults have.

HEMORRHAGIC DISEASE OF THE NEWBORN

Early onset (first 24 hours): bruising, oozing from venipuncture sites, GI bleeding, intracerebral hemorrhage. This is caused by maternal medications that interfere with vitamin K synthesis (some antibiotics, anticonvulsants, anticoagulants).

Classical (1-4 weeks): bruising, bleeding from mucosal surfaces, GI bleeds

Late onset (3 weeks to 8 months): intracerebral hemorrhage, death

INTRAMUSCULAR VITAMIN K

A single dose of IM vitamin K drops risk of vitamin K deficiency bleeding to almost zero.

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WHY REFUSE VITAMIN K?

Myth: IM Vitamin K increases risk of leukemia

Myth: IM Vitamin K causes jaundice

Black box warning on Vitamin K: anaphylaxis

Toxins: IM vitamin K contains sorbitol, propylene glycol, vinegar, bicarbonate, and salt.

WHY CAN’T WE USE ORAL VITAMIN K?

Oral vitamin K degrades rapidly; serum levels drop within 7 days of administration.

Oral vitamin K is not readily available and must be compounded. A 12 week course of oral vitamin K costs roughly $300.

Oral vitamin K still carries a risk of VKDB (4/100,000).

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WHEN FAMILIES REFUSE

Physicians have a conversation with the family exploring reasons for refusal, providing education, and discussing risks and benefits. An educational binder is available in the newborn nursery.

Physician should have Vitamin K refusal form completed by parents.

Infant should go home on a regimen of weekly oral vitamin K for 12 weeks.

Mother should supplement her diet with 5 mg vitamin K per day to theoretically increase vitamin K levels in breastmilk.

ERYTHROMYCIN OINTMENT

Erythromycin is recommended for all infants at birth for prevention of ophthalmia neonatorum.

Ophthalmia neonatorum is caused by gonorrhea or chlamydia.

ON caused by gonorrhea can cause blindness in the first 24 hours.

MISSOURI LAW

Missouri statute 210.070: “Every physician, midwife, or nurse who shall be in attendance upon a newborn infant or its mother shall drop into the eyes of such infant immediately after delivery a prophylactic solution approved by the state department of health and senior services . . .”

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REASONS FOR REFUSAL

Perceived lack of need: some patients feel they are low risk as they are in long term monogamous relationships.

Desire to avoid any unnatural or unneeded treatment

Concerns with bonding with infant due to temporary blurring of vision

RISKS/BENEFITS

Risks: chemical eye irritation, temporary blurring of vision

Benefits: reduction in ophthalmia neonatorum from all causes including chlamydia, gonorrhea, staphylococcus

WHEN PARENTS REFUSE

Because of Missouri Law, the hospital must file a hotline report for any family that refuses eye ointment.

This generally results in a home visit from Children’s Division after discharge.

Eye ointment refusal form and educational materials are in development and will be available soon.

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REFERENCES

Kujawa-Myles S, Noel-Weiss J, Dunn S, Peterson WE, Cotterman KJ. Maternal intravenous fluids and postpartum breast changes: a pilot observational study. International Breastfeeding Journal. 2015;10:18. doi:10.1186/s13006-015-0043-8.

Noel-Weiss J, Woodend AK, Peterson WE, Gibb W, Groll DL. An observational study of associations among maternal fluids during parturition, neonatal output, and breastfed newborn weight loss. International Breastfeeding Journal. 2011;6:9. doi:10.1186/1746-4358-6-9.

https://kellymom.com/bf/concerns/mother/rev_pressure_soft_cotterman

Chantry CJ, Nommsen-Rivers LA, Peerson JM, Cohen RJ, Dewey KG. Excess Weight Loss in First-Born Breastfed Newborns Relates to Maternal Intrapartum Fluid Balance. Pediatrics. 2011; 127:1

http://www.chop.edu/centers-programs/vaccine-education-center/vaccine-details/influenza-vaccine

Risk of Guillain-Barré syndrome after seasonal influenza vaccination and influenza health-care encounters: a self-controlled studyKwong, Jeffrey C et al. The Lancet Infectious Diseases , Volume 13 , Issue 9 , 769 - 776

Shang M, Blanton L, Olsen SJ, Fry AM, Brammer L. Influenza-Associated Pediatric Deaths in the United States, 2010–2015. Online Journal of Public Health Informatics. 2017;9(1):e077. doi:10.5210/ojphi.v9i1.7656.

Flannery B, Chung JR, Belongia EA, et al. Interim Estimates of 2017–18 Seasonal Influenza Vaccine Effectiveness — United States, February 2018. MMWR Morb Mortal Wkly Rep 2018;67:180–185

http://www.chop.edu/centers-programs/vaccine-education-center/vaccine-details/measles-mumps-and-rubella-vaccines

http://www.chop.edu/centers-programs/vaccine-education-center/vaccine-details/vaccine-hepatitis-b-vaccine

AAP Committee on Fetus and Newborn Policy Statement Controversies Concerning Vitamin K and the Newborn. Pediatrics. 2003;112:1.

Fear NT, Roman E, Ansell P, Simpson J, Day N, Eden OB. Vitamin K and childhood cancer: a report from the United Kingdom Childhood Cancer Study. British Journal of Cancer. 2003;89(7):1228-1231. doi:10.1038/sj.bjc.6601278.

Roman E, Fear NT, Ansell P, et al. Vitamin K and childhood cancer: analysis of individual patient data from six case–control studies. British Journal of Cancer. 2002;86(1):63-69. doi:10.1038/sj.bjc.6600007.

https://evidencebasedbirth.com/evidence-for-the-vitamin-k-shot-in-newborns/

https://evidencebasedbirth.com/is-erythromycin-eye-ointment-always-necessary-for-newborns/

https://www.uspreventiveservicestaskforce.org/Page/Document/EvidenceReportFinal/ocular-prophylaxis-for-gonococcal-ophthalmia-neonatorum-preventive-medication

AAP Committee on Infectious Diseases. “Prevention of Neonatal Ophthalmia” Red Book 2018.