Transitional Care

TRANSITIONAL CARE

Following the initial assessment and routine care of a healthy neonate, continued close observation is necessary for the subsequent stabilization-transition period (the first 6 to 12 hours after birth) to identify any problems that may arise. The following findings should raise concern and result incloser observation: temperature instability; change in activity, including refusal of feeding; unusual skin coloration; abnormal cardiac or respiratory activity; abdominal distention; bilious vom-iting; excessive lethargy or sleeping; delayed or abnormal stools; and delayed voiding.

Following delivery, all newborns should receive pro-phylactic application of antibiotic ointment (containing erythromycin [0.5%] or tetracycline [1%]) to both eyes to prevent the development of gonococcal ophthalmia  neonatorum. This is recommended regardless of the modeof delivery. This prophylactic measure can be delayed up to 1 hour to allow for breastfeeding.

Every newborn should also receive a parenteral dose of natural vitamin K1 oxide (phytonadione, 0.5 to 1 mg) fol-lowing delivery to prevent vitamin K-dependent hemor-rhagic disease of the newborn. This form of administration is efficacious, and no commercial oral vitamin K prepara-tion is approved for use in the United States at this time. This measure also can be delayed for up to 1 hour to allow breastfeeding in the first hour of life.

A newborn infant’s voiding pattern and bowel move-ments should be closely observed within the first 24 hours following birth. Concern about an obstruction or congen-ital defect of the urinary tract is appropriate if voiding has not occurred within the first day of life. Ninety percent of newborns pass stool within the first 24 hours. A congenital abnormality such as imperforate anus should be consid-ered if this does not occur. For the first 2 or 3 days of life, the stool is greenish-brown and tar-like in consistency. With the ingestion of milk, the stool becomes yellow in color and semisolid.

Circumcision

Circumcision is the surgical removal of a distal portion ofthe foreskin. It is usually performed within the first 2 days of life on healthy term infants. Circumcision is an electiveprocedure; therefore, parents should be given accurate and impartial information to allow them to make an informed deci-sion. Circumcision should always involve the administra-tion of an anesthetic; both ring blocks and dorsal penile blocks have proved effective. Complications from circum-cision are rare and include local infection and bleeding.

Jaundice

Jaundice, which occurs in most newborns, is usually benign, but because of the potential toxicity of bilirubin, all newborns should be assessed prior to hospital discharge to identify those at high risk for severe hyperbilirubinemia. Two methods of assessment can be used: (1) predischarge measurement of total serum bilirubin or transcutaneous bilirubin levels in infants who are jaundiced in the first 24 hours, and (2) application of clinical risk factors for pre-dicting severe hyperbilirubinemia. Late preterm (35 to 37 weeks gestation) infants are at higher risk for hyperbiliru-binemia than are term infants. Acute bilirubin encephalopa-thy or kernicterus is associated with total serum bilirubin levels greater than 30 mg/dL.

If possible, the cause of the hyperbilirubinemia should be determined. Breastfeeding has a significant effect on unconjugated hyperbilirubinemia (breast milk jaundice and “breast-non-feeding jaundice”). Jaundice that persists for 2 weeks requires further investigation, including measure-ment of both total and direct serum bilirubin concentra-tions. Elevation of the direct serum bilirubin concentration always requires further investigation and possible interven-tion, which include phototherapy or exchange transfusion.