JH Revisions Dec 8 2015 Nurs0147 Final Docx Normal Newborn Care

Nursing Manual
Policy Name
Policy Number
Date this Version Effective
Responsible for Content
Normal Newborn Infant Care

NURS 0147
Feb 2016
Nursing
I. Description
Outlines the care of the newborn immediately following birth and during hospitalization, including
thermoregulation, oxygen therapy in emergent situations, hypoglycemia, phototherapy, and
circumcision.
Table of Contents
I. Description ....................................................................................................................................... 1
II. Rationale.......................................................................................................................................... 1
III. Policy/Procedure .............................................................................................................................. 1
A. Policy ......................................................................................................................................... 1
B. Procedure .................................................................................................................................. 2
Newborn Care Immediately Following Birth in Labor & Delivery ................................................. 2
Thermoregulation in the Newborn Immediately after Birth .......................................................... 5
Emergency Oxygen Therapy for Newborns in Newborn Nursery ................................................ 7
C. Protocol ...................................................................................................................................... 8
Newborn Care ............................................................................................................................ 8
Hypoglycemia in the Newborn .................................................................................................. 15
Phototherapy ............................................................................................................................ 22
Newborn Circumcision Care ..................................................................................................... 26
Safe Sleep.26
IV.
References ......................................................................................................................... 32
V. Reviewed/Approved by .................................................................................................................. 33
VI. Original Policy Date and Revisions ................................................................................................ 33
Figure / Table List

Figure 1. UNC algorithm for infants at risk for hypoglycemia ................................................................ 21
Figure 2. UNC Standing order sheet for transcutaneous bilirubin testing25
Figure 3 UNC Safe sleep teaching plan for Newborn Nursery/NCCC.29
II. Rationale
After birth, a neonate must quickly adapt to extrauterine life, even though many of the neonates
body systems are still developing. During this time of adaptation, the nurse must be aware of
normal neonatal physiologic characteristics and assessment findings in order to detect possible
problems and initiate appropriate interventions.
III. Policy/Procedure
A. Policy
Describes practice utilizing current evidence and clinical guidelines for nursing care as it relates
to managing the normal newborn infant after birth and during hospitalization
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B. Procedure
Newborn Care Immediately Following Birth in Labor & Delivery

Note: Performed by the RN. NA may perform certain aspects as delegated by the RN.
1. Gather Infant Resuscitation Equipment:
Neopuff set
Laryngoscope
#0 and #1 Laryngoscope blades (check bulb before using)
Infant endotracheal tubes (2.5, 3.0, 3.5, 4.0)
Stylettes
Neonatal Code Cart (carts located outside triage 1 and between ORs 2 & 3)
Radiant infant warmer
Baby pack (blanket and towel)
identification bands
Complimentary Foot Print sheet
Disposable gloves
Warm blanket
Infant hat
Thermometer
Erythromycin ophthalmic ointment
Vitamin K
2. Perform hand hygiene.

3. Put on gloves.
4. Provide mother/infant skin-to-skin contact immediately after birth by placing the naked
newborn baby prone on the mothers bare chest for thermoregulation of the infant. If this is
not possible place infant under radiant warmer. (See Newborn Care protocol below). . If the
mother is unable to provide skin-to-skin contact with the infant the other parent should be
considered as an alternative choice.
Key Point:
This practice based on intimate contact within the first hours of life may
facilitate maternal-infant behavior and interactions through sensory stimuli
such as touch, warmth, and odor. Moreover, skin-to-skin contact and
rooming-in are considered critical components for successful breastfeeding
initiation and continuation, but are recommended for all couplets regardless
of feeding method. If skin-to-skin is interrupted for contraindication, it should
be re-introduced as soon as possible.
5. Dry infant, initiate mother/infant skin-to-skin, cover head with hat and cover baby with warm
blankets. Infants loose excessive heat via convection.
6. Assess immediately after birth:
Patency of airway
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Respiratory effort
Need for suctioning
Need for stimulation and resuscitation measures.
7. Assess and assign Apgar Scores at 1 and 5 minutes.
The Apgar score consists of the following parameters:

- respiratory effort
- heart rate
- skin color
- muscle tone
- reflexes
A score of 0 is give if the parameter is not present.
A score of 1 is given if the parameter is somewhat present.
A score of 2 is given if the parameter is fully present.
8. Assess infant continuously for signs of respiratory distress such as grunting, nasal flaring,
chest retractions and cyanosis. Document vital signs every 30 minutes or more frequent as
indicated in the electronic medical record.
9. Take axillary temperature of infant and assess infant for signs of cold stress. Infant
temperature should be 36.4C. If cold stress was not prevented using skin-to-skin, and
infant exhibits signs of cold stress, transport to the NBN is necessary. Hypoxia, acidosis,
hypoglycemia, lethargy and pulmonary vasoconstriction indicate cold stress. For serious
complications contact NCCC immediately.
10. Evaluate thermoregulatory environment. (See the Thermoregulation in the Newborn
Immediately after Birth procedure below).
11. Assess infant for signs of hypoglycemia such as jitteriness and lethargy. (See the
Hypoglycemia in the Newborn protocol below). Symptomatic neonates need to be evaluated
by NCCC.
12. Identify infant:
Place identification bands on infant per unit protocol.
Explain the procedure for checking identification bands with mother and or support
person.
Place security band on infant per Womens hospital protocol.
Educate mother and or support person on the security band (HUGS).
Place infants footprints on complimentary certificate.
13. Verify cord clamp 2.5cm from umbilicus and cut cord above the clamp. The cord clamp is
usually placed by the delivering LIP.
14. Assess the proximity of the cord clamp in relation to the skin around the umbilicus to prevent
injury of the infant.
15. Offer support person the opportunity to cut the cord if the infants condition warrants.
16. Weigh infant after 90 mins of life (unless medically necessary)
17. Encourage mother/infant contact and point out infant feeding cues.
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18. Encourage mother to initiate breastfeeding at the earliest signs of hunger. (See the protocol
in the UNC Hospitals Nursing Breastfeeding and Human Milk Storage and Handling policy).
Key Point:
Mother-baby couplets are likely to initiate breastfeeding within the first hour of
life if left skin-to-skin, uninterrupted. This is the time for encouragement and
more rudimentary guidance including feeding cues and general expectations
for feeding.
19. Transport infant to the Maternity Care Center within 2 hours of birth or immediately if signs
of any of the following occur:
Hypothermia (<36.4)
Respiratory distress
Hypoglycemia (follow hypoglycemic protocol)
If infant is not transferred to Maternity Care Center within 2 hours, document a complete
head to toe assessment in the electronic medical record.
Key Point:
The mother-baby dyad should remain together, throughout transition from

labor and delivery to the Maternity Care Center unless there is a specific
contraindication.
20. Verify Vitamin K and ophthalmic suspension administration per protocol.

Key Point:
Both vitamin K and ophthalmic suspension should be administered

without interrupting mother-infant skin-to-skin.
21. Keep bulb syringe with infant at all times.

22. Instruct mother not to give infant to anyone other than an individual with two appropriate
forms of identification.
23. Report to mother-baby/nursery nurse:
Name and Sex
Time of birth
Method of feeding
Type of delivery
High risk factors/prenatal history
Anomalies
Mothers blood type
Confirmation of cord blood being sent to lab if mother is Rh- or O+
Confirmation of ID band number
Complications
Abnormal findings on review of systems
Infants follow-up care LIP

Key Point:
Transfer must be done by RN or LPN who is prepared in emergency

measures. .
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24. a complete delivery summary form in the electronic medical record and infant MAR.
In patients electronic medical record

o
review of systems within two hours of birth
Vital Signs
Note: This task is to be performed by the RN or LPN.
Per Unit Protocol is defined as
Assess temperature, heart rate and respirations at 30 mins of life and every 30
mins x4. If stable infant may have vital signs obtained once per shift unless
Late Preterm Infants (34 to 36 6/7 weeks gestation) receive vital signs every 4 hours.
CODE SEPSIS- Infants with a blood culture pending receive vital signs every 4 hours
until culture is documented as negative after 48hrs.
Note: If axillary temp greater than 37.5C or less than 36.4C, obtain rectal temperature; If rectal temperature is
less than 36.4C then warm baby using radiant warmer or skin-to-skin with mom and repeat rectal temp within 30
minutes;.
Thermoregulation in the Newborn Immediately after Birth

Note: Performed by the RN. NA may perform certain aspects as delegated by the RN.
Thermoregulation is the ability of the newborn to balance heat production and heat loss in order
to stabilize internal body temperature. Thermoregulation is essential in the neonate for optimal
growth and normal physiological function.
The newborn has special requirements for temperature maintenance due to:
Larger body surface area in relation to body weight.
Blood vessels relatively close to the skin surface.
Less adipose tissue and subcutaneous fat
Underdeveloped sweating and shivering mechanisms.
Increased metabolic processes (non-shivering thermogenesis) produce heat beyond

basal production.
Heat production consumes a large number of calories.
All infants are at risk including:
Term newborns, especially during the first 12 hours of life
Late pre-term infants (34 to 366/7 weeks gestation)
Preterm infants
Small for gestational age infants
Environmental causes (e.g. overheating)
Infection
Dehydration
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Medication effects and drug withdrawal
Infants with disorders of the endocrine, neurologic or cardiorespiratory problems
Infants with congenital anomalies
Hypoglycemic infants
Infants with asphyxia
Maternal fever during labor
Congenital hypothyroidism
Fetal stress manifested as decelerations, meconium-stained fluid, or low Apgar scores

may indicate infant is at risk for impairment of thermoregulatory response.
1. Gather equipment:
Radiant warmer
Skin probe
Warm blankets/towels
Thermometer
Hat
2. Prior to delivery, increase temperature in labor room/recovery room to 75F. This prevents
heat loss due to convection.
3. Pre-warm radiant warmer. This prevents heat loss due to conduction.
4. Place warm blankets/towels under radiant warmer element. This prevents conductive heat
loss in the case that the mother or other support person is not available for skin-to-skin
contact.
5. Place infant skin-to-skin with mother and warm blankets over mother and baby. Skin-to-skin
contact is the best heat source, but both will provide a heat giving environment.
6. Dry infant with warm absorbent blankets and/or towels, and immediately replace used
blankets and/or towels with new warm ones. This prevents evaporative heat loss.
7. Warm hands and stethoscopes before coming in contact with infant. This prevents heat loss
due to conduction.
8. Keep infant away from air conditioning ducts and other drafts. This prevents heat loss from
convection and evaporation.
9. Keep oxygen (if used) directly over infants nose and mouth. This prevents heat loss from
convection and evaporation.
10. Place a hat on the infants head and change when wet or soiled. This prevents heat loss
from evaporation.
11. Maintain the infants temperature 36.4 C to 37.5 C while with mother in Labor &
Delivery.
Key Point:
Place infant next to mothers skin with warm blankets covering them. If cold
stress ensues, use a portable radiant warmer and set skin temperature probe
for 36.7 C to slowly warm infant.
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12. Assess infant for signs of hyperthermia. Usually hyperthermic infants are warm to touch and
exhibit red skin due to vasodilation related to releasing excess heat. Sweating is generally
not present in infants
Key Point:
Infants who attempt to decrease their temperature may be irritable, lethargic,

hypotonic, apneic, feed poorly, tachycardic, tachypneic or present with a
weak or absent cry.
13. Assess infants temperature, per axilla, with electronic thermometer every 30 minutes for the
first 2 hours after birth for a total of 4 times.
14. Transfer infant to nursery and report to care provider on thermoregulatory status if it is not
possible to maintain infants temperature at 36.4 C. Consider obtaining a blood glucose
level if thermoregulation is compromised.
a. Instructions noted in order set: Place under radiant warmer until temperature is >36.7 C.
Remove infant from warmer. Double swaddle or place skin to skin again. Recheck
temperature in 30 mins. If temperature drops again below 36.4 place under warmer for
2nd time and notify LIP. Obtain blood glucose if radiant warmer needed second time.
15. Document infants temperature and nursing actions on appropriate electronic medical
record.
Emergency Oxygen Therapy for Newborns in Newborn Nursery

Note: Performed by the RN or LPN.
Respiratory distress accompanied by central cyanosis, or cyanosis alone, is an indication for
administering O2 per Neopuff set or facemask. Administration of O2, in an emergency situation,
does not require a provider order. Neopuff setups are available in the Newborn Nursery, Labor
and Delivery and 3 Womens.
1. Gather Equipment:
O2 flow meter
Tubing
Neopuff set
2. Assure that the infant is not choking, which is the primary cause of cyanosis.
3. Clear the airway with a bulb syringe if obstructed by mucous in the infants mouth. Stroke
babys back. For excessive mucous in the throat, wall suction may be used.
4. Position the infant on back with the head of crib elevated and neck slightly extended. A
rolled pillowcase may be placed under the back of shoulders to accommodate the
extension.
5. Place the infant on continuous pulse oximetry. (This is a rapid and non-invasive assessment
of the infants oxygenation)
6. Place the facemask securely over the infants nose and mouth and turn O2 source to 8L/min.
and provide blow by oxygen. No longer than 15 minutes.
7. If the mask is held to tightly, pressure will build up in the Neopuff device and be transmitted
to the infants lungs in the form on CPAP or PEEP.
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8. Notify the LIP immediately on call if cyanosis or respiratory distress persists.

9. Initiate Neonatal Code Blue for respiratory/cardiac arrest by pushing the code blue button
located in the NBN.
10. Initiate neonatal resuscitation (NRP)
11. Arrange a transfer to NCCC, if after 15 minutes, cyanosis persists.
12. Document the following on the Newborn electronic medical record:
the time the O2 was initiated and discontinued

the time of LIPs arrival
the time respiratory distress occurred
the time of infants transfer to the NCCC
patient teaching for the mother/caregiver, their level of understanding and responses to
teaching
C. Protocol
Newborn Care
Term newborn infants (37-42 weeks gestation) progress through predictable stages of
adjustment to extrauterine life. Key elements of concern are:
airway patency
oxygenation
ventilation
thermoregulation
adequacy of intake and output
any abnormalities
family attachment
Late pre-term infants (34 to 36 6/7 weeks gestation)

The healthy late pre-term infant may be physiologically stable and able to be admitted directly to
the Maternity Care Center. The primary issues include, but are not limited to:
feeding
maintaining temperature control
stabilizing blood glucose
excreting bilirubin.
Providing family-centered care, with minimal separation of mother and infant, fosters motherinfant attachment and early assumption of the parent role, as well as the parents understanding
of their babys unique needs. Early feeding of this patient population is mutually beneficial to
the mother and infant. It stabilizes blood glucose and stimulates stooling of the infant and
promotes maternal infant bonding. Breastfeeding enhances these benefits by providing nutrition,
which is rich in infection-fighting properties, including immunoglobulins. Breastfeeding also
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promotes skin-to-skin contact with the mother that facilitates temperature regulation of the
infant.
1. Resources
Licensed Independent Practitioners (LIP)
NCCC nurses
Lactation Consultants
2. Assessment
Assess within 30 minutes of admission:
airway patency, breath sounds
cry
skin and mucous membrane color
vital signs (TPR)
weight
activity, muscle tone
condition of scalp, skin, cord, eyes
Moro reflex
fontanels
presence/absence of edema, physical abnormalities, birth
trauma
antepartum/intrapartum maternal risk factors (e.g. diabetes, maternal serology

including HEPB status, HIV, GBS, chorioamnionitis, substance abuse, difficult
delivery, maternal fever, heart disease and previous complications)
Assess every shift:
skin and mucous membrane color
airway patency, cry, breath sounds
vital signs (TPR)
pain score (FLACC scale)
activity, muscle tone
signs of adequate milk transfer and or mL fed from bottle
output
review of systems
cord, eye condition
integrity of electronic security tag
circumcision site, if applicable
Assess infants activities/interaction every 2 hours when with mother/caregiver.
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Assess pulse oximetry if indicated by infants respiratory status. (Refer to the protocol in
the UNC Hospitals Pediatric Cardiorespiratory and Pulse Oximetry Monitoring policy)
Assess Bilirubin:
Please check a transcutaneous bilirubin (TCB) on all babies after 24 hours of life
with batched screening using the handheld bilimeter.
Use Bilitool.org to evaluate risk zone for infant. If HIGH RISK ZONE RN to draw neobili STAT
(may be drawn with newborn screen if lab available.) Notify LIP with results. Otherwise-if
TCB>7mg/dL RN to order neobili with newborn screen
www.bilitool.org
Obtain TCB daily on any infant <37 weeks gestation
draw and send neonatal bilirubin if TCB > 12mg/dL
after 4 AM on day of discharge
draw and send neonatal bilirubin if TCB > 12mg/dL
Day of Discharge- Obtain TCB. RN to order serum if TCB >12mg/dL
Note: Refer to Bhutani curve to identify light level for phototherapy treatment based on
results of neobili and risk level.
Risk factors include: <37 weeks gestation, hemolytic disease, asphyxia, lethargy, temperature
instability, sepsis, acidosis, albumin <3.0g/dL
3. Notify LIP
signs of respiratory distress

o
abnormal breath sounds
pale or cyanotic mucous membranes
glucose < 45 mg/dl x 2 readings taken 30-60 minutes apart
abnormal vital signs

o
Rectal temperature < 36.4 C or > 37.5C
heart rate sustained < 100 or > 180
respiratory rate < 30 or > 60
transcutaneous bilirubin 12 mg/dL
positive direct Coombs or VDRL (Venereal Disease Research Laboratory)
abnormal skin color, rash, or blisters
abnormal or changed cry, e.g. high pitched
weight loss/gain >10 % of birth weight.
abnormal activity or muscle tone, e.g. jitteriness, lethargy
abnormal neurological findings
bulging or sunken fontanels
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edema, physical abnormalities or birth trauma, e.g. palsy, bone crepitations, facial palsy
maternal risk factors requiring immediate follow-up (e.g. increased maternal temperature
at delivery)
inability to feed, rhinitis, excessive drooling or spitting, projectile vomiting
no urine or stool within 24 hours of birth
diarrhea and/or the presence of bright-red blood in stools, urine or mucus
inflammation of cord, circumcision site, or eyes
problems with parents caregiver bonding or providing routine care to the infant
WBC < 9,000 or > 30,000/mm3
4. Administration
Verify administration on Vitamin K (phytonadione) 1 mg I.M. within 1 hour of birth

(usually in Labor and Delivery).
Verify Erythromycin Ophthalmic Ointment given within 1 hour of birth (usually in Labor
and Delivery).
Obtain an order to administer Hepatitis B vaccine.

Note: Consent for Hepatitis B vaccine must be obtained verbally from the mother.
5. Nursing Care
Weigh daily
Maintain a temperature range of 36.4 C. to 37.5 C. axillary.

Note: If initial temperature is < 36.4 C, place infant skin-to-skin with care giver, covering
both with a warmed blanket, or place infant under radiant warmer with
temperature probe on and skin temperature set at 36.7 C. Refer to the
Thermoregulation in the Newborn Immediately after Birth procedure above
Wear gloves during all contact with infant prior to initial bath and all mothers body fluids
are removed.
Take infants temperature before and after bath.
Offer Bath and scalp care only when temperature 36.7C after 24 hours
i.
Exception- Infants born to mothers with active HSV lesions or are HIV positive
should be bathed shortly after birth.
Delay bath/scalp care until the infants temperature has been stabilized at
36.7C (term infants) 36.7 or higher for > 4 hours (near term infants) and
after 24 hours of life.
Bathe infants at mothers request when at least 6 hours old if temperature

stable at 36.7 C.
Place infant skin-to-skin or under warmer if temperature < 36.4C after bath until
temperature reaches at least 36.7C.
Dress infant in shirt and diaper and swaddle in 2 blankets with cap when temperature
stabilizes at 36.7 C. Recheck temperature in 30 mins to ensure thermoregulation has
been accomplished.
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Support optimal mother/caregiver interaction with infant:

a. adjust the mothers room temperature to 74 F
b. encourage skin-to-skin contact
c. encourage frequent breastfeeding
d. encourage non separation to foster maternal infant attachment
Begin feedings as follows:

(1) Breastfed infants: Do not disrupt skin-to-skin contact. If contact is
interrupted, offer breast within 2 hours of birth. Breastfed infants do not
receive water feedings unless ordered by the LIP.
(2) Non-breastfed infants: Allow parents to formula feed 5-10 mL by 4 hours of
age unless infant is at risk for hypoglycemia per protocol requiring feeding by
one hour of life, feeding according to infant hunger and satiety cues. Offer
assistance to family regarding safe bottle feeding practices. (Refer to Baby
Feeding and Diaper Count Chart Formula - Green Sheet.)
If infant has no respiratory distress or GI incompetence, follow with formula not to
exceed 30mLs.
(3) Babies at risk for hypoglycemia must be fed within one hour of life prior to the
first blood glucose level at 90 mins of life.
Assist mother with breastfeeding (or provide non-breastfed infants with formula) every 24 hours after the initial feeding.
Note: Breastfed infants are not to receive supplemental formula feedings unless
requested by the mother or ordered by the LIP. Before supplementation is given,
provide mother with supplementation information sheet which should be
reviewed verbally with patient to ensure adequate understanding of risks of
formula supplementation and attend to mothers desire for supplementation. As
with all patient information, qualified interpreters must be utilized to ensure
informed understanding. Review safe Baby Feeding and Diaper Count Chart
Supplementation (Mixed Feeding) - Yellow Sheet
Observe for signs of milk transfer during a minimum of two feedings prior to discharge.
Signs of milk transfer include suck-swallow-breath cycle and satisfaction at the end of
feeding.
Assist mother/caregiver with physical care.
Check diaper before and after feedings and when infant cries.
Replace cord clamp if oozing occurs or end of cord is not clearly visible past outer edge
of clamp.
May remove cord clamp after 24 hours of life if cord is dry.
Suction with bulb syringe for excessive fluid/mucus in nose, mouth, or throat.
Provide support for family when abnormalities found or if infant transferred to NCCC.
Activate order for serum bilirubin if TCB >12mg/dL (as described in this protocol under
the transcutaneous bilirubin screening guidelines) by ordering a NEW Serum Neobili Do
not use the nursing order for prn neobili as it does NOT communicate with the lab
computer system.
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Obtain an order for newborn metabolic screening & newborn hearing screen prior to
hospital discharge.
Obtain an order for a Rh incompatibility work up and send cord blood or capillary blood
specimen for:
blood type and direct Coombs

Note: Send only for neonates whose mother was Rh negative with a significant
antibody or mother has type O blood or unknown blood type.
Obtain an order for urine and meconium for toxicology on all infants admitted in the first
48 hrs. of life who have any of the following risk factors:
Maternal Risk Factors
history of substance abuse
a) poor prenatal care (prenatal care starting after 16 weeks gestation or less
than 4 prenatal visits)
b) history of child abuse, neglect or court ordered placement of children
outside of the home
c) history of domestic violence
d) history of hepatitis, HIV, syphilis or prostitution
e) unexplained placental abruption
f)
acute alcohol intoxication around the time of delivery
Infant Risk Factors

g) infants with unexplained intrauterine growth restriction or small for
gestational age
h) infants with evidence of drug withdrawal (hypertonia, irritability or
tremulousness
Obtain an order for blood culture and CBC w/differential if mother is:
GBS+, not treated and < 37weeks OR ROM > 18 hrs.
has chorioamnionitis per obstetrician
is GBS unknown and rupture of membranes occurred > 18 hours prior to delivery
was febrile (>38C) during labor and delivery
delivers at < 37 weeks and:
GBS status unknown or > 5 weeks since last culture
infant born with signs of sepsis
has a history of GBS sepsis with a previous delivery
6. Safety
Check identification of infant on admission, prior to visit to mother, before any procedure,
and at discharge.
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The identification bands are to remain intact on the mother and infant. These bands
are left in place to signify that the couplet belong together and not as a patient
identifier.
For mother/baby couplets: At time of discharge assure both patients ID bands are
removed to de-identify them as patients.
Give the patient/family a discharge pass (preferably the mother). Inform the person
providing transportation to wait to get the car until the patient is in the lobby.
The discharge pass identifies the patient as discharged and can be obtained from
the nurses station. Pediatric patients do not require a discharge pass as they should
be accompanied by a responsible adult. The HUGS tag must be removed with the
patient ID band.
Explain mother-baby security procedure.
Teach infant safety by instructing mother/caregiver to:

a) never leave infant unattended in room.
b) never leave infant unsecured on flat surface.
Support infants head, neck, and back at all times.
Position infant on back to sleep.
Provide infant car seat safety screening prior to discharge of infants born <37 weeks
gestation, < 5 LBS (2.23 kg) or with any congenital issue that may compromise airway.
Refer to the procedure in the UNC Hospitals Nursing Car Seat: Screening and ordering
policy.
7. Emergency Measures
Choking:
i)
use bulb syringe or wall suction to clear airway.
j)
administer oxygen if cyanotic.
k) call NCCC for LIP assistance.

l)
Arrange transfer to NCCC if infant requires IV or oxygen for >15 minutes.
m) Transport with portable oxygen.

8. Patient/Caregiver Teaching
Teach parent/caregiver information for the first time visit including:
car seat safety (pamphlet and video)
bulb syringe suctioning and infant positioning in bassinette
period of purple crying
safe sleep protocols
safe infant transport in bassinette
swaddling/hat for thermoregulation
comparison of indent-a-bands
feeding
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diapering
contacting the nurse and/or the nursery
Complete Newborn Nursery Patient/Family instruction sheet prior to discharge.
9. Documentation
Document in patients electronic medical record:

o
assessment findings
interventions and patient responses/outcomes
reported conditions
patient/caregiver teaching and level of understanding
active nursing protocols in chart
Newborn screenings completed and documented in the electronic medical record

prior to discharge include
Newborn Metabolic Screen
Critical Congenital Heart Disease Screen
Newborn Hearing Screen
Hypoglycemia in the Newborn

Transient hypoglycemia in the immediate newborn period is common. In most healthy
neonates, low blood glucose may simply reflect normal metabolic transition to extrauterine life.
This phenomenon is usually self-limited, and glucose levels begin to spontaneously rise within
two to three hours of birth. This shift occurs even if oral feedings are withheld, due to a
physiologic response of glucose release by the liver. However, this process may be disrupted
by several factors, including: antepartum metabolic or nutritional events, intrapartum clinical
management of the mother, congenital disorders, postnatal complications, prematurity and
unnecessary supplementation. Concern arises when low blood glucose levels are prolonged or
recurrent, as they may result in both acute and chronic sequelae. Therefore, monitoring of
blood glucose level is warranted in situations where the infant is at-risk for and/or symptomatic
of hypoglycemia. Conversely, the routine monitoring of blood glucose in healthy term newborns
is not only unnecessary, but potentially harmful to the establishment of a healthy mother-infant
relationship and successful breastfeeding patterns.
In all neonates, thermoregulation is an important preventative measure against hypoglycemia.
Early and prolonged skin-to-skin contact is optimal for adaptation in the first days after birth,
facilitating the maintenance of body temperature and safe blood glucose (BG) levels in the
healthy term infant.
Early and exclusive breastfeeding best meets the nutritional needs of healthy term
neonates and is protective against hypoglycemia. Healthy, term newborns that are
breastfed on-demand need neither supplementation nor routine monitoring of blood
glucose levels. Exclusively breastfed healthy neonates, in general, tend to have and
safely tolerate lower blood glucose concentrations, but higher concentration of ketones,
than formula-fed infants. This is thought to be a protective physiologic mechanism since
exclusively breastfed newborns also have the most effective counter-regulatory release
of glucose by the liver. Healthy, term newborns do not develop symptomatic
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hypoglycemia simply due to underfeeding any symptom that presents suggests an

underlying condition that warrants attention. Obtain a heel stick glucose level with a
blood glucose meter according to the Hypoglycemia in the Newborn protocol below.
1. Resources
Immediate referral to a lactation consultant for breastfeeding difficulties.
Immediate consult from NCCC team for all symptomatic infants or at risk infants not
responding to feedings
2. Assess for:
WARNING:
Notify the Licensed Independent Practitioner (LIP) if infant is symptomatic
a. symptomatic newborns, for whom immediate monitoring of heel stick glucose is

indicated, by observing all newborns for clinical signs of hypoglycemia, including
General findings:
a) abnormal or high-pitched cry
b) persistent hypothermia
c) temperature instability
d) diaphoresis
e) weak or no suck
f) poor feeding ability
Neurological:
a) irritability
b) tremors or jitteriness not resolved by suckling on gloved finger
c) exaggerated Moro reflex
d) lethargy
e) hypotonia
f) seizures
g) abnormal eye movements
Cardiorespiratory:
a) tachypnea
b) apnea
c) cyanosis
d) respiratory distress
e) tachycardia
b. at-risk newborns for which routine monitoring of heel stick glucose is always indicated,
even if asymptomatic.
Neonatal-dependent factors:
Small for gestational age(<10th percentile for weight/2500 grams)
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Large for gestational age(>10th percentile for weight/4000 grams)
Late pre-term infant (34-366/7 weeks)
Maternal-dependent factors:
IDM (infant of diabetic mother)
c. at risk newborns for which monitoring of heel stick glucose may be indicated based
upon assessment findings, the presence of multiple risk factors simultaneously, or LIP
order, even if asymptomatic.
Neonatal-dependent factors:
Discordant twin (10% difference in weight)
Perinatal stress (5 min Apgar 7 or cord pH< 7.2)
Hypoxia-ischemia
Polycythemia (venous Hct>70%)
Hypothermia or cold stress (temperature of 36.4 C despite interventions)
Hemolytic disease of the newborn
Sepsis
Respiratory distress
Known or suspected metabolic or endocrine disorder
Maternal-dependent factors:
Medications (terbutaline, ritodrine, propanolol, oral hypoglycemics)
3. Notify LIP
For all newborns where notification of the LIP is indicated on the hypoglycemia algorithm
Feeding intolerance: inability to suck, swallow, or meet the minimal requirements of

supplementation that is medically indicated
Total supplementation of 3-5 mL/kg without stabilization of heel stick glucose

concentration
Note: Measureable feed includes: 3-5mg/kg of expressed colostrum or breast milk,
donor milk, or formula.
4. Nursing Care
Reduce cold stress by drying and placing all healthy term newborns skin-to-skin
immediately following birth and throughout hospital stay for physiologic
thermoregulation. Begin/continue breastfeeding as described in the algorithm, assisting
the mother with latch and positioning. Page lactation services for immediate assistance
for consultation, if warranted.
If first screening heel stick glucose concentration is below threshold level: Supplement
with 3-5 mL/kg/feeding of expressed colostrum or breast milk, donor human milk, or
substitute formula. Cup or spoon-feeding is preferred over bottle feeding. D5W and
D10W are not acceptable supplements.
o
Newborn should remain skin-to-skin with mother whenever possible, even if being
supplemented. If separation is unavoidable, place infant under radiant warmer.
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Page 17 of 33
Algorithm for Infants at Risk for Hypoglycemia

The target heel stick glucose is 41 mg/dL prior to routine feedings in the first 4 hours of
life and 46 mg/dL after 4 hours of life. The goal is 3 consecutive blood glucose
readings within normal limits prior to discontinuing the screenings UNLESS
ordered differently by the LIP. These 3 consecutive readings may include blood
glucose readings 41 md/dL during the birth to 4 hour timeframe as part of the normal
values.
Note: Cleanse heel stick sites every shift with chlorhexidine and water if irritation
develops.
Note: Use a heel warmer prior to EVERY glucose assessment via heel stick. Cool
extremities may cause extracellular use of glucose resulting in falsely low blood
glucose results.
Symptomatic Newborns:
Obtain heel stick glucose on all symptomatic newborns and notify the LIP Stat for
infants whose heel stick glucose levels are 40 mg/dL.
Note: The recommended treatment in this situation is IV glucose. Oral feedings
and skin-to-skin contact typically may continue during IV glucose therapy
and mothers should be encouraged to breastfeed their babies. Mothers
should begin expressing their milk as soon as possible if not directly
nursing infant or if infant is not latching well. Obtain lactation consultation
for all breastfeeding newborns transferred to NCCC.
At-Risk Asymptomatic Newborns

Birth to 4 hours of life:
Initiate feeding within one hour of life and obtain heel stick glucose at 90
minutes of life regardless of if the infant has fed. Warm the heel with a heel
warmer prior to obtaining blood specimen.
o
If Initial heel stick blood glucose is < 25 mg/dL, continue skin to

skin, feed infant measurable amount and notify NBN LIP
Note: Measurable amount of supplementation is 3-5 mL/kg and can be
expressed breast milk, donor milk, or formula. May feed infant
by cup, syringe, spoon, or bottle.
Note: If after 2nd feeding the blood glucose is < 25mg/dL, notify NBN
LIP for disposition of infant and continue skin to skin
If initial heel stick glucose is 25-40 mg/dL, continue skin to skin,

feed measurable amount and recheck heel stick blood glucose one
hour after initiation of feed.
a. feed with a measurable amount of supplementation
b. check the blood glucose 1 hour after initiation of feeding
c. keep skin to skin
Initial heel stick glucose is 41 mg/dL may feed the infant every 2-3
hours and check BG prior to each feed.
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Page 18 of 33
o
After 4 hours of life:
Feed all at-risk asymptomatic newborns every 2-3 hours.
Obtain heel stick glucose prior to each feeding.

o
If the heel stick blood glucose is < 35 mg/dL feed infant measurable
amount and notify NBN LIP
If the heel stick blood glucose is 35-45 mg/dL

a. feed with a measurable amount of supplementation
b. check the blood glucose 1 hour after initiation of feeding
c. notify NBN LIP if no improvement
If the heel stick blood glucose is > 46 mg/dL may feed the infant
every 2-3 hours and check BG prior to each feed
Evaluate all infants carefully who demonstrate any of the following signs
and/or symptoms:
o
Inability to suck or swallow
Intolerance of feedings
Heel stick glucose concentration that does not increase after a feeding
Total supplementation exceeding 10 mL/kg
Evaluate heel stick sites every shift for skin breakdown and/or signs of
infection and provide wound care when appropriate.
5. Safety
Any infant that becomes symptomatic at any point during the implementation of the
algorithm needs to be evaluated by a LIP in the NBN or NCCC immediately.
Notify NBN LIP if infant has not passed protocol by 12 hours of life.
Per algorithm except for LIP or RN requested spot checks based on clinical judgment
once monitoring of the heel stick glucose is initiated, three consecutive screenings 46
mg/dL must be obtained prior to discontinuing BG checks.
If BG values during birth-4hrs of life are 41 they may be included in the 3 consecutive
passing values. Heel stick values are a screening tool, and may be confirmed by a
formal laboratory plasma glucose value for formal diagnosis.
Discuss causes and symptoms of hypoglycemia. Instruct parents to notify nursing staff if
newborn does not actively suck during feedings or demonstrates other symptoms of
hypoglycemia.
Emphasize importance of skin-to-skin contact and frequent feedings for achieving and
maintaining stable blood glucose levels of hypoglycemic newborns.
Note: Inform parents that oral feedings and skin-to-skin contact usually may continue
during IV glucose therapy if infant is transferred to NCCC.
Reassure breastfeeding mothers that hypoglycemia is not usually a consequence of

underfeeding or inadequate milk supply and that if supplementation is required, it is only
temporary. Instruct mother on use of hand expression and breast pump as soon as
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Page 19 of 33
possible if infant is not latching well or is transferred to NCCC. Provide lactation contact
information.
Encourage verbalization of questions or concerns.
7. Documentation

o
Assessment findings
Interventions and patient responses/outcomes
Reported conditions
Feeding attempts
Amount, type and method of supplement, if given
Patient/caregiver teaching and level of understanding
Accepting Neonatal teams (NCCC) discussion of transfer/pending transfer of the

infant with the family
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Page 20 of 33
Figure 1. UNC algorithm for infants at risk for hypoglycemia
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Page 21 of 33
Phototherapy
Altered metabolism of bilirubin is a common problem during the first week after birth. Excessive
bilirubin production or altered hepatic clearance of bilirubin can lead to hyperbilirubinemia, a
condition associated with kernicterus, especially in preterm and sick newborns. Common
causes of hyperbilirubinemia include: fetomaternal blood group incompatibilities; congenital
enzyme deficiencies; extensive bruising or cephalohematoma; sepsis; polycythemia; delayed
passage of meconium; and altered hepatic function. Hyperbilirubinemia should be suspected in
the following situations: onset of jaundice within 24 hours after birth; persistent jaundice (greater
than one week in the term infant, greater than two weeks in the preterm infant); or a rise in total
bilirubin of greater than 5 mg/dl per day. Phototherapy oxidizes bilirubin into water-soluble
components for excretion and can be given via, Bili-lights (neoBLUE LED Phototherapy
light), traditional bank lights, BiliBed, or Bili-blanket .
Note: Severe neonatal hyperbilirubinemia (> 30mg/dL) is considered a sentinel event and
should be reported to Risk Management.
1. Assessment
Assess every 4 hours:
skin, sclera, and mucous membrane color, i.e. bronzing and jaundice
eyes, noting presence of edema, irritation and drainage
axillary temperature (normal: 36.4C- 37.5 C) Obtain rectal temperature if outside these
parameters
intake and output (feeds, voids, and stools)
level of consciousness and activity, e.g. irritability, jitteriness, lethargy, seizure activity
2. Notify LIP
abnormal temperature
feeding problems, i.e. weak suck, inability to ingest and retain adequate fluids
dehydration (urine output <1 ml/kg/hr.)
delayed passage of meconium
absence of stools for 24 hours
lethargy
signs of hypoglycemia, e.g. tremors/jitteriness
seizure activity
respiratory distress
drainage from eyes
abnormal lab results
3. Nursing Care
a. Obtain an order to monitor results of:
initial blood typing (mother and newborn) and direct and indirect Coombs
serum total/direct bilirubin
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Page 22 of 33
Hct/Hgb and/or CBC with differential if ABO incompatible with positive COOMBS
b. If phototherapy is ordered via Bili-lights (neoBLUE or traditional bank lights) follow the
steps/notes below:
Note: For neoBLUE LED Phototherapy, a setting of high corresponds with intensive
phototherapy traditionally known as double or triple phototherapy. A setting of
low corresponds to conventional phototherapy traditionally known as single
phototherapy.
Phototherapy can be provided in the mother's room. This is optimal to promote nonseparation of mother and infant.
Undress infant completely (except for diaper) while maintaining a neutral thermal
environment with a radiant heat source.
Cover eyes with a bili mask.
Position infant comfortably but for maximum exposure.
Turn Bili-lights on.
Position neoBLUE LED Phototherapy light 12 inches (30.5cm) from infant.
Maintain distance of traditional bank Bili-lights 15 to 18 inches from patient (over

bassinette side panels).
Hold infant for feedings:
Use bili blanket during feedings if possible. remove mask

o
place infant skin-to-skin or dress/cover infant
resume phototherapy immediately after feedings

Note: Infants may be held and fed only for feedings of less than 45 minutes.
Change mask when loose or soiled.
Encourage parents to care for infant during feedings (30-45 minutes when formulafeeding or up to one hour when breastfeeding) unless contraindicated.
c. If phototherapy is ordered via BiliBed follow the steps/notes below:
Place BiliBed in the bassinette after removing mattress.
Place the infant in the Bili-Combi.
Secure the Bili-Combi (and the infant) to the bed with the Velcro strips.
Turn the bed on.

Note: The BiliBed can remain on while giving care, but bed should be off while
holding and feeding.
d. If phototherapy is ordered via Bili-blanket follow the steps/notes below:
Place Bili-blanket under infant's clothing.
Position infant comfortably.
Transport babies with Bili-blankets to mother's rooms, if appropriate.
Change Bili-blanket cover when loose or soiled.
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Page 23 of 33
May leave eyes uncovered when Bili-blanket is used alone unless infant is premature
or undressed, eyes must be covered.
Turn Bili-blanket off while giving care (Bili-blanket may remain on when holding
/feeding infant).
e. Maintain patient temperature between 36.4 and 37.5C.

f.
Change position every four hours.
g. Obtain an order to administer glycerin chip per rectum if no stool for 24 hours.
4. Safety
a. Cover eyes continuously when infant is under Bili-lights.
b. Do not apply lotions, creams, or oils to infants receiving phototherapy in order to prevent
burns.
c. Use principles of each light source for combined therapy.
5. Parent/Caregiver Teaching
a. Depending on the situation, the nurse may instruct caregivers and/or reinforce the
importance of treatment, length of treatment, lab tests, and sufficient fluid.
b. Instruct parents to keep infant's eyes covered during phototherapy unless using a Biliblanket only.
c. Emphasize length of time infant may be out from under Bili-lights (no longer than 45
minutes).
d. Instruct parents/caregiver to inform nurse of intake and output.
e. Instruct parents/caregiver to notify infant's nurse if infant refuses feeding or displays
change in activity level, e.g. twitching, tremors, lethargy.
6. Documentation

o
additional interventions
assessment findings
reported conditions
parent/caregiver teaching and level of understanding
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Page 24 of 33
Bilirubin:
Figure 2
Please check a transcutaneous bilirubin (TCB) on all babies after 24 hours of life with batched screening. If TCB
>7, RN to order neobili with newborn screen.
Use Bilitool.org to evaluate risk zone for infant. If HIGH RISK ZONE RN to draw neobili STAT (may be drawn with
newborn screen if lab available.) Notify LIP with results. www.bilitool.org
Late preterm infants will continue to have serum bili done at 24 hours with newborn screen.
Obtain TCB daily on any infant <37 weeks gestation. After first 24 hours of age, draw and send neonatal
bilirubin if subsequent TCB > 12.
Day of Discharge- Obtain TCB. RN to order serum if TCB >12.
Note: Refer to bilitool.org to assess light level for phototherapy treatment based on results of neobili
and risk level per AAP guideline.
Risk factors include: <37 weeks gestation, hemolytic disease, asphyxia, lethargy, temperature instability,
sepsis, acidosis, albumin <3.0g/dL
Nursing Care
Activate order for serum bilirubin if TCB is as described in this protocol under the transcutaneous
bilirubin screening guidelines by ordering a NEW Serum Neobili Order- nursing cannot use the
nursing order for prn neobili as it does NOT communicate with the lab computer system.
Risk Zone
Light Level
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Page 25 of 33
Newborn Circumcision Care

LIP discusses advantages and disadvantages of circumcision with parent (s)/caregiver. If
circumcision is chosen, the LIP will explain the procedure and pain management to the parent
(s)/caregiver.
The American Academy of Pediatrics (AAP) states that there may be some reduction in STDs
(sexually transmitted disease) transference in circumcised males. The AAP states that
procedural analgesia should be provided, endorsing the dorsal penile block or ring block, and
physiological positioning.
1. Assessment
a. Observe infant during procedure for:
signs and symptoms of pain
spitting up/choking
respiratory distress
b. Observe circumcision site after procedure for bleeding, if still in hospital:
q 15 minutes x 2 or
q 15 minutes until bleeding stops
c. Assess effective pain relief, if still in hospital:
q 30 minutes x 3 then
q 4 hours x 24 hours
d. Assess for signs of infection q shift or with every Vaseline gauze dressing change or
diaper change.
e. Monitor occurrence of voids.
2. Notify LIP
continued oozing from circumcision site
bleeding from site which cannot be controlled by direct pressure
NURS 0147
Page 26 of 33
signs of infection, purulent drainage or excessive irritation of site
failure to void within 8 hours after procedure
3. Nursing Care
a. Withhold feedings a minimum of one hour prior to procedure.
b. Maintain thermo-neutral environment to prevent cold stress.
c. Obtain an order to apply topical anesthetic cream to the foreskin in the area of the
incision and to the penile block site one hour prior to the procedure.
d. Offer infant pacifier dipped in 24% sucrose 2 minutes prior to and during procedure.
Note: 24% sucrose may be administered via syringe (0.1-0.2mL) to breastfed baby
e. Obtain an order to maintain thermo-neutral environment to prevent cold stress.
f.
Ensure that all required equipment is at the bedside for the penile block and
circumcision.
g. Place infant on padded Circumstraint board immediately prior to procedure.

h. Secure restraint on lower extremities.
i.
Secure upper extremities or swaddle upper body with a blanket.
j.
Set timer for 5 minutes to designate wait period between administration of penile block
and procedure.
k. Remove infant from board immediately after procedure, rewrap, and return to
crib/isolette for 15 minutes of nursing observation in the newborn nursery.
l.
Cleanse circumcision site during the first 24 hours only when gauze is soiled by stool:
do not rub area, may cause bleeding.
gently squeeze water and non-alkaline soap over site
rinse with water and pat dry
m. Cleanse site after 24 hours with non-alkaline soap and water with each diaper change
until site is healed.
n. Change the Vaseline gauze within the first 24 hours if the dressing becomes soiled with
stool.
o. Obtain an order to apply Gelfoam to site for bleeding.
4. Safety
Check immediately prior to procedure that:
a signed consent form is in chart

Note: Use a hospital interpreter for the explanation of consent with non-Englishspeaking parent/caregiver.
infant's identification band is on and correctly matched to mother (Newborn Nursery

only)
Obtain an order to discharge after circumcision if circumcision site has not bled for one
hour
breastfeeding infant breastfed well at least once before circumcision

NURS 0147
Page 27 of 33
a. Instruct the mother/caregiver that infant discomfort and anesthetic may interrupt
breastfeeding.
b. Give mother/caregiver UNC Healthcare teaching booklet Caring for Yourself and Your
Baby and one-page patient education guide Circumcision: A Choice (available in
Spanish and English).
c. Instruct mother/caregiver to observe site every 15 minutes for bleeding during first hour
post-procedure or more often if excessive bleeding has occurred.
d. Instruct mother/caregiver to report any of the following:
infants first void post-procedure, if still in the hospital
bleeding from site
signs and symptoms of infection (e.g., drainage with a foul odor)
e. Demonstrate to parent(s)/caregiver:
genital care/circumcision site care
application of Vaseline gauze
6. Documentation
Document in patients electronic medical record

o
time of medication/sucrose administration
time block administered and the time procedure begins and ends
LIP performing procedure
use of Vaseline gauze
assessment findings
reported conditions
parents/caregivers level of understanding
Care of the Newborn using Safe Sleep Guidelines for Newborn Nursery
1. Assessment
Place infants on their backs to sleep for every sleep in the infants bassinet
Observe infants sleeping position each hour during rounding.
2. Notify Licensed Independent Practitioner (LIP)
Vital signs outside normal/ordered parameters.
3. Nursing Care
Place infants on their backs to sleep for every sleep in the infants bassinet
Place Infant on a firm sleep surface such as a crib mattress covered with a fitted
sheet.
Advise Room-sharing without bed-sharing is recommended
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Page 28 of 33
a) The infants crib or other sleeping device should be placed in the parents
bedroom close to the parents bed.
b) Infants may be brought into the bed for feeding or comforting but should be
returned to their own crib when the parent is ready to return to sleep.
c) Infants should not be fed on a couch or armchair when there is a high risk that
the parent might fall asleep.
Avoid soft objects and loose bedding in the crib
4. Patient/caregiver teaching
All Health care professionals, caring for Newborn infants should endorse safe sleep
recommendations from birth.
5. Caregiver Education
a. See Figure 3
6. Documentation
Complete documentation on infants sleep position in the patients electronic medical

record.
Document completed safe sleep teaching in the infants electronic medical record.
Figure 3
Teaching points for parents of Newborn infants

Teaching Point
Rationale
Comments
Sleeping Position:
Place infants on their backs to sleep a.
for every sleep. Have parents
communicate this back to sleep
message with everyone who cares for
their infant.
The risk of SIDS is 7 to 8 times

higher among infants who
normally sleep on their backs
when placed on their stomachs
to sleep.
Side positioning is not recommended.b. Side lying is an unstable

sleeping position because the
If swaddling is needed for comfort or
infant can more easily roll to the
thermoregulation, swaddle below the
prone position
axilla.
Once an infant can roll

from supine to prone and
from prone to supine, the
infant can be allowed to
remain in the sleep
position that he or she
assumes.
Avoid overheating.
Do not cover the infants face or head.
Infants should be dressed in no more
than 1 layer more than an adult would
wear to be comfortable in that
environment.
Supervised, awake tummy time is
recommended to facilitate
development and to minimize
development of positional
plagiocephaly.
NURS 0147
Evaluate infants for signs of

overheating, such as sweating or
the chest feeling hot to touch.
There is insufficient
evidence to recommend
use of a fan.
Tummy time is recommended on

a daily basis, beginning as early
as possible.
Page 29 of 33
Sleeping Surface and Area

Pillows or cushions should not be
substituted for mattresses or in
addition to a mattress. Couches, adult
mattresses, futons, etc. are not
considered a firm sleeping surface.
Appropriately sized sleep

sacks/blanket sleepers
are optimal; avoid
blankets and other loose
bedding.
Sitting devices, such as car safety

seats, strollers, swings, infant carriers
and infant slings are not
recommended for routine sleep in the
hospital or at home.
Bed sharing with

anyone, including
parents, other children
and particularly multiples
is not safe. Pets also
pose a threat to sleeping
infants.
No bumper pads, stuffed toys or any

other objects in the crib.
Avoid commercial devices marketed
to reduce the risk of SIDS,
plagiocephaly and acid reflux
(products include wedges, positioning
aids, rolled blankets).
Avoid plagiocephaly by: limiting time
in car seats, carriers, bouncers, and
other devices; encourage cuddle
time (bonding) by holding
Infants orientation in crib should be
changed regularly.
Monitors are only machines and are
not substitutes for direct observation.
There is no evidence that these

devices reduce the risk of SIDS
or suffocation, or that they are
safe
Do not use home

cardiorespiratory monitors as a
strategy to reduce the risk of
SIDS.
Smoking/Smoke
Clothing exposed to secondhand
smoke should be changed, or a cover
gown provided, prior to handling
infants.
Wash hands after smoking and before
touching infant.
Encourage families to set strict rules
for smoke-free homes and cars to
eliminate secondhand smoke.
Feeding and Positioning
Breast feeding is recommended
Infants may be brought into bed for
feeding or comforting but should be
returned to their own bed when the
NURS 0147
Infants should receive only

breast milk for the first 6 months
of life.
For breastfed infants, avoid
Page 30 of 33
parent is ready to return to sleep.

The infants crib, portable crib, play
yard or bassinet should be placed in
the parents room, close to their bed,
making it more convenient for feeding
and contact.
.Infants should not be fed/held on a
couch, armchair or in bed when there
is a high risk that the parent might fall
asleep.
pacifier use until breastfeeding is

firmly established (approx. 1
month).
Do not force an infant to take a
pacifier.
Educate parents that pacifiers
should not be coated in any
sweet solution, hung around the
infants neck or attached to
clothing while sleeping.
The pacifier does not

need to be reinserted
once the infant falls
asleep.
Pacifiers should not be
placed around the
infants neck or attached
to clothing during sleep.
Stuff toys should not be
attached to the pacifier.
Consider offering a pacifier at nap

time and bedtime.
Skin-to-skin is another method of
thermoregulation but should be used
only when mother is awake.
The protective effect of breastfeeding
increases with exclusivity. However,
any breast milk feeding has been
shown to be more protective against
SIDS than formula feeding.
Prevention of SIDS
Pregnant women should receive
regular prenatal care
There is no evidence that there is a
casual relationship between
immunizations and SIDS.
Recent evidence suggests that
immunizations might have a protective
effect against SIDS.
Avoid smoke exposure during
pregnancy and after birth.
Infants should be immunized in

accordance with the
recommendations of the AAP
and Center for Disease Control
(CDC)
The protective effect persists
throughout the sleep period even
if the pacifier falls out of the
infants mouth.
Avoid alcohol and illicit drugs during

pregnancy and after birth.
Avoid commercial devices marketed
to reduce the risk of SIDS.
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Page 31 of 33
IV. References
Alden, K. (2011). Physiologic and behavioral adaptations of the newborn. In Lowdermilk, D. &
Perry, S.(Editors) Maternity & Womens Health Care (10th ed.) (pp. 639-641). St. Louis:
Mosby/Elsevier.
American Academy of Pediatrics (2012). Male Circumcision. Pediatrics, 130(3). P. 756-785.
American Academy of Pediatrics (2011). Postnatal glucose homeostasis in late-preterm and term
infants. 127(3). p. 575-579
American Academy of Pediatrics Policy Statement: SIDS and other Sleep- Related Infant Deaths:
Expansion of Recommendations for a Safe Infant Sleeping Environment. Pediatrics 2011;128;1030
American Academy of Pediatrics, Task Force of Sudden Infant Death Syndrome. (2011). SIDS and
Other Sleep-Related Infant Deaths: Expansion of Recommendations for a Safe Infant Sleeping
Environment. Pediatrics, 128(5), 1030-1039.
American Academy of Pediatrics Technical Report: SIDS and other Sleep-Related Infant Deaths:
Expansion of Recommendations for a Safe Infant Sleeping Environment. Pediatrics 2011; 128;
e1341
Baddock SA, Galland BC, Bolton DP, Williams SM and Taylor BJ. (2012). Hypoxic and Hypercapnic
Events in Young Infants During Bed-Sharing. Pediatrics, 130, 237-244
Becher, Bhushan & Lyon: Unexpected Collapse in Apparently Health Newborns-a Prospective
National Study of a Missing Cohort of Neonatal Deaths and Near-Death Events, ADC Fetal and
Neonatal Edition(2012). 97; F30-F34.
Helsley L, McDonald JV and Stewart VT. (2010) Addressing In-Hospital Falls of Newborn Infants.
The Joint Commission Journal on Quality and Patient Safety, 36(7), 327-333
Lowdermilk, D.L., & Perry, S.E. (2011). Maternity & Womens Health Care. (10th ed.). St Louis:
Mosby.
Merenstein G and Gardner S(2011) Handbook of Neonatal Intensive Care (7th ed). Maryland
Heights MO: CV Mosby/Elsevier
Moon RY, Oden RP, Joyner BL and Ajao TI.(2010) Qualitative Analysis of Beliefs and Perceptions
about Sudden Infant Death Syndrome in African American Mothers: Implications for Safe Sleep
Recommendations. Journal of Pediatrics, 157, 92-7
National Association of Neonatal Nurses position statement on co-bedding of twins and higherorder multiples. Retrieved 2/3/13 from
http://www.nann.org/uploads/files/Cobedding_of_Twins_or_Higher-Order_Multiples_2011.PDF
neoBLUE LED Phototherapy. Hospital Inservice. http://www.natus.com/documents/051693E.pdf
Schnitzer PG, Covington TM and Dykstra HK.(2012) Sudden Unexpected Infant Deaths: Sleep
Environment and Circumstances. American Journal of Obstetrics, Gynecologic and Neonatal
Nursing, 39, 618-626
Trachtenberg FL, Haas EA, Kinney HC, Stanley C and Krous HF.(2012) Risk Factor Changes for
Sudden Infant Death Syndrome After Initiation of Back-to-Sleep Campaign Pediatrics, 129,630-638
Vennemann MM, Hense HW, Bajanowski T, Blair PS, Complojer C, Moon RY, and KiechlKohlendorfer U.(2012) Bed Sharing and the Risk of Sudden Infant Death Syndrome: Can We
Resolve the Debate? Journal of Pediatrics, 160,44-48
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Page 32 of 33
Verklan MT and Walden M (2010). Core Curriculum of Neonatal Intensive Care Nursing (4th ed).
Philadelphia PA:Saunders.
V. Reviewed/Approved by
Nursing Policy Committee, Womens CPG, UNC Pediatrics
VI. Original Policy Date and Revisions

Oct 1990, Jan 1992, Sep 1992, Dec 1992, Dec 1993, Feb 1994, Apr 1994, Dec 1996, Feb 1997,
Apr 1997, Jan 1999, Oct 1999, Mar 2000, Nov 2007, Aug 2008, May 2010-i, July 2010-i,
Aug 2010-i, Jan 2011-i, April 2011-i, Aug 2011, Oct 2011-i, August 2013-i, Sept 2013-i, Oct 2014,
Apr 2015-I, Dec 2015-i
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Page 33 of 33

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Figure / Table List

Normal Newborn Infant Care

Newborn Care Immediately Following Birth in Labor & Delivery

#0 and #1 Laryngoscope blades (check bulb before using)

Infant endotracheal tubes (2.5, 3.0, 3.5, 4.0)

Radiant infant warmer

Baby pack (blanket and towel)

Complimentary Foot Print sheet

Erythromycin ophthalmic ointment

2. Perform hand hygiene.

Normal Newborn Infant Care

Need for suctioning

Need for stimulation and resuscitation measures.

7. Assess and assign Apgar Scores at 1 and 5 minutes.

The Apgar score consists of the following parameters:

A score of 0 is give if the parameter is not present.

A score of 1 is given if the parameter is somewhat present.

A score of 2 is given if the parameter is fully present.

Place identification bands on infant per unit protocol.

Place security band on infant per Womens hospital protocol.

Educate mother and or support person on the security band (HUGS).

Place infants footprints on complimentary certificate.

Normal Newborn Infant Care

Hypoglycemia (follow hypoglycemic protocol)

The mother-baby dyad should remain together, throughout transition from

20. Verify Vitamin K and ophthalmic suspension administration per protocol.

Both vitamin K and ophthalmic suspension should be administered

21. Keep bulb syringe with infant at all times.

Name and Sex

High risk factors/prenatal history

Mothers blood type

Confirmation of cord blood being sent to lab if mother is Rh- or O+

Confirmation of ID band number

Abnormal findings on review of systems

Infants follow-up care LIP

Transfer must be done by RN or LPN who is prepared in emergency

Normal Newborn Infant Care

In patients electronic medical record

review of systems within two hours of birth

Thermoregulation in the Newborn Immediately after Birth

Larger body surface area in relation to body weight.

Blood vessels relatively close to the skin surface.

Less adipose tissue and subcutaneous fat

Underdeveloped sweating and shivering mechanisms.

Increased metabolic processes (non-shivering thermogenesis) produce heat beyond

Heat production consumes a large number of calories.

All infants are at risk including:

Term newborns, especially during the first 12 hours of life

Late pre-term infants (34 to 366/7 weeks gestation)

Small for gestational age infants

Environmental causes (e.g. overheating)

Normal Newborn Infant Care

Medication effects and drug withdrawal

Infants with disorders of the endocrine, neurologic or cardiorespiratory problems

Infants with congenital anomalies

Infants with asphyxia

Maternal fever during labor

Fetal stress manifested as decelerations, meconium-stained fluid, or low Apgar scores

Normal Newborn Infant Care

Infants who attempt to decrease their temperature may be irritable, lethargic,