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Optum Neonatal Clinical Management Guidelines

Guideline Summary

Optum Neonatal Clinical Management Guidelines 9th Edition

The following Key Points Summary represents significant subject matter in the 9th edition of the Optum Neonatal Clinical Management Guidelines. Complete references are listed in the Guideline publication.
 
Feeding Guideline: Applies to all infants in the neonatal intensive care unit (NICU) or special care nursery
  • Human milk provides unique short- and long-term benefits.
  • Cue based is the physiologically sound approach to oral feedings.
  • Feedings consisting of solely human milk with multidisciplinary team support provide the greatest chance of success of exclusive breastfeeding
Apnea, Bradycardia and Desaturation Guideline: Applies to all infants in the neonatal intensive care unit (NICU) or special care nursery
  • Due to a paucity of available evidence, there is a variable approach to the management of infants with suspected apnea, bradycardia and desaturation events.
  • Apnea, bradycardia and desaturation may persist following hospital discharge in clinically asymptomatic, maturing preterm infants.
  • American Academy of Pediatrics (AAP) supports home monitoring for early detection of events.
Thermoregulation Guideline: Applies to infants requiring an incubator for thermal stability
  • Physiologic status, as opposed to arbitrary weight or post menstrual age, should be used to determine crib readiness.
  • Incubator weaning to an open crib can proceed safely without adverse effects on oral feeding or weight gain.
Sepsis Guideline: Applies to infants ≥ 35 weeks gestation being treated for possible sepsis/pneumonia
  • Early onset sepsis (EOS) is defined by the identification of a pathogen from a sterilely obtained blood culture acquired in the first 3 to 7 days of life.
  • Risk factors that increase the likelihood of sepsis include maternal chorioamnionitis, inadequately treated maternal group B streptococcal colonization, prematurity, and prolonged rupture of membranes (18 hours).
  • This guideline draws on 2010 recommendations from the Centers for Disease Control and Prevention (CDC) and a series of guidelines authored by the American Academy of Pediatrics (AAP) Committee on Fetus and Newborn (COFN) or committee members between 2012 and 2014 (Polin 2012; Polin et al 2012; Brady and Polin 2013, Polin, Watterberg, Benitz, et al 2014). That the current CDC and AAP guidelines are not perfectly congruent reflects a continuing evolution of approach based on changing consensus opinion in response to emerging evidence.
  • CDC and AAP guidelines do agree in two important areas.
  1. An infant with clinical signs consistent with sepsis should undergo a full diagnostic evaluation and receive antibiotic treatment with antimicrobials targeted to likely neonatal pathogens. If an infant has no risk factors for sepsis, a clinician may choose to withhold antibiotics while observing the infant for a limited period of time to determine whether the infant will demonstrate transitional improvement.
  2. When antibiotics are initiated in a well-appearing infant due to maternal chorioamnionitis (treated or untreated) and the blood culture obtained at birth is negative, antibiotics should be discontinued at 48 hours in a term infant and no later than 72 hours in a preterm infant if the infant remains clinically well, even if one or more diagnostic laboratory studies were abnormal.
  • Common laboratory tests, including complete blood counts with differentials and acute phase reactants such as (-reactive protein), have a low positive predictive value for sepsis. One or more of these laboratories is likely to be abnormal in well-appearing infants born to mothers with chorioamnionitis.
Phototherapy Guideline: Applies to infants ≥ 35 weeks gestation
  • American Academy of Pediatrics (AAP) presents recommendations for initiation of phototherapy based on gestation, age and risk factors.
  • Outpatient monitoring of bilirubin level(s) is supported once phototherapy is discontinued.
Neonatal Drug Exposure/Withdrawal Guideline: Applies to infants who have been prenatally exposed to substances that cause signs of toxicity or withdrawal
  • Neonatal abstinence syndrome (NAS) is a constellation of neonatal signs of withdrawal consequent to exposure to certain drugs.
  • Most infants who develop NAS have been antenatally exposed to opioids. Concomitant antenatal exposure to maternal SSRis, benzodiazepines, and smoking  exacerbate signs of NAS.
  • Postnatal exposure to opioids and/or benzodiazepine due to treatment of critical illness can also result in NAS.
  • Instruments that evaluate the severity of NAS typically assist in treatment decisions. These tools were developed specifically for signs of opioid withdrawal. Initial therapy should focus on effective non-pharmacologic treatments including optimization of the environment of care, involvement of family caregivers as feasible and prudent, and breast-feeding as indicated.
  • If drug therapy for withdrawal becomes clinically indicated, first line therapy in general should employ a drug from the same class as the principal drug contributing to the signs of withdrawal.
  • The evidence-based literature does not identify the optimal pharmacologic treatment regimen for infants with opioid withdrawal. Typically oral morphine or methadone is the first line treatment choice. If needed, second-line therapy choices include phenobarbital and clonidine. The use of buprenorphine continues to be evaluated (Clinics in Perinatology.  2013; 40(3):509-524).
  • New research has demonstrated that adherence to a standardized protocol of evaluation, treatment, and weaning of medication reduces length of hospital stay.
Discharge Guideline: Applies to all infants in the neonatal intensive care unit (NICU) or special care nursery
  • American Academy of Pediatrics (AAP) physiologic-based discharge criteria are utilized.
  • Family disposition and discharge needs should be addressed early in the care continuum.