Newborn Nursing Care Pathway

Perinatal Services BC
Newborn Guideline 13
Newborn Nursing Care Pathway
August 2013
(v2 March 2015)
Table of Contents
Introduction
About the Newborn Nursing Care Pathway . . . . . . . . . . . . . . . . . . . . 2
Who Updated the Newborn Nursing Care Pathway. . . . . . . . . . . . . . . . 2
Statement of Family Centered Care . . . . . . . . . . . . . . . . . . . . . . . . 2
Referring to a Primary Health Care Provider (PHCP). . . . . . . . . . . . . . . . 3
Referrals to Other Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Goals and Needs – Health Canada’s National Guidelines. . . . . . . . . . . . . 3
Needs – World Health Organization (WHO). . . . . . . . . . . . . . . . . . . . . 4
Timeframes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Newborn Physiological Stability . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Newborn Pain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Physiological Health
Head . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Nares . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Eyes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Ears. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Mouth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Chest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Abdomen/Umbilicus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Skeletal/Extremities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Skin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Perinatal Services BC Neuromuscular . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
West Tower, #350 Genitalia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
555 West 12th Avenue Elimination
Vancouver, BC Canada V5Z 3X7 Urine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Tel: (604) 877-2121 Stool. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
www.perinatalservicesbc.ca Vital signs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Weight. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Behavioral . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Crying. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Infant Feeding
Breastfeeding. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Breast Milk Substitute – Formula Feeding . . . . . . . . . . . . . . . . . . . . 36
Health Follow-Up
While every attempt has been
made to ensure that the information
Health Follow-Up. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
contained herein is clinically accurate Immunization and Communicable Diseases . . . . . . . . . . . . . . . . . . . 39
and current, Perinatal Services BC Safety and Injury Prevention. . . . . . . . . . . . . . . . . . . . . . . . . . . 41
acknowledges that many issues remain
controversial, and therefore may be Screening/Other
subject to practice interpretation.
Newborn Blood Spot Screening. . . . . . . . . . . . . . . . . . . . . . . . . 42
Hearing Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Biliary Atresia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Glossary of Abbreviations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
References & Endnotes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Revision Committee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
© Perinatal Services BC, 2013
Introduction
About the Newborn Nursing Care Pathway
The Newborn Nursing Care Pathway identifies the needs for care of newborns and is the foundation for the British
Columbia Newborn Clinical Path. To ensure all of the assessment criteria are captured, they have been organized
into five main sections:
• Physiological health (organized from head to toe)

• Behavioural
• Infant feeding
• Health follow-up
• Screening/other
While the newborn assessment criteria are presented as discrete topic entities it is not intended that they be
viewed as separate from one another. For example, the newborn physiological changes affect her/his feeding
and behaviour. To assist with this, cross referencing will be used throughout the document (will be seen as
“Refer to…”). This will also be evident with the cross referencing to the Postpartum Nursing Care Pathway as the
newborn and mother are considered to be an inseparable dyad with the care of one influencing the care of the
other. An example of this is with breastfeeding as it affects the mother, her newborn and bonding and attachment.
In this document, assessments are entered into specific periods; from immediately after birth to 7 days
postpartum and beyond. These are guidelines and are used to ensure that all assessment criteria have been
captured. Once the newborn and her/his mother are in their own surroundings, details of physical assessments
will be performed based on the individual nursing judgment in consultation with the mother.
Who Updated the Newborn Nursing Care Pathway

Perinatal Services BC (formerly BC Perinatal Health Program)1 coordinated the updating of this document. It
represents a consensus opinion, based on best evidence, of an interdisciplinary team of health care professionals.
The team included nurses form acute care and public health nursing representing each of the Health Authorities
as well as rural and urban practice areas. Clinical consultation was provided by family physicians, obstetricians,
pediatricians and other clinical experts as required.
Statement of Family Centered Care

In conjunction with Women Centred Care, which places the woman at the center of care, family-centered
maternity care, is an attitude/philosophy rather than a policy, and is based on guiding principles2. Key principles
have been adapted and are reflected in the Newborn Nursing Care Pathway.
• Women and families have diverse birthing experiences (philosophies, knowledge, experience, culture, social,
spiritual, family backgrounds and beliefs) thus approaches to care need to be adapted to meet each family’s
unique needs
• Relationships between women, their families, and the variety of health care providers are based on mutual
respect and trust
• In order to make knowledgeable and responsible informed decisions in providing newborn care, women and
their families require support and information
• Parents need to and should be provided with information about newborn screening/treatments (E.g.-eye
prophylaxis, vitamin K and newborn screening) including why the treatment is recommended, advantages,
side effects and risks if not performed – if parents decline screening/treatment, a signed and witnessed
informed refusal is required3
• The family (Using Women Centred Care principles and as defined by the woman) is encouraged to support
and participate in all aspects of newborn care
• While in hospital (whenever possible), assessments and procedures should be performed in the mother’s
room (to ensure mother-infant togetherness and to provide anticipatory guidance and information)
2 Perinatal Services BC
Introduction
• Prior to, during, and following procedures that may cause newborn discomfort/pain, mothers should be
encouraged to comfort their newborns through breastfeeding or skin-to-skin contact
Referring to a Primary Health Care Provider (PHCP)

Prior to referring to a Primary Health Care Provider (PHCP) a specific or newborn global assessment4 (physical
and feeding) including history of the pregnancy and labour and birth, will be performed by the nurse. Whenever
possible, the woman/her family (supports) are present at the assessment and included in the planning, and
implementation of the newborn’s care. In the intervention sections it will be referred to as Nursing Assessment.
Referrals to Other Resources

To support nursing practice the following resources are available. Links for many specific resources are included
throughout the document. Key resources for parents are:
• Healthy Families BC Website – This website is filled with up-to-date and practical information, useful tools
and resources for women, expectant parents, and families with babies and toddlers up to 3 years of age.
www.healthyfamiliesbc.ca/parenting/
• HealthLink BC – www.healthlinkbc.ca/kbaltindex.asp
• HealthLink BC – Telephone number accessed by dialing 8-1-1
(Services available – health services representatives, nurses pharmacists, dietitians, translation services and
hearing impaired services)
Goals and Needs - Health Canada’s National Guidelines

As indicated by Health Canada’s National Guidelines5 the postpartum period is a significant time for the mother,
baby, and family as there are vast maternal and newborn physiological adjustments and important psychosocial
and emotional adaptations for all family members or support people. The following are the goals, fundamental
needs, and basic services for postpartum women and their newborns, adapted from Health Canada’s National
Guidelines which are to:
• Assess the physiological, psychosocial and emotional adaptations of the mother and baby
• Promote the physical well-being of both mother and baby
• Promote maternal rest and recovery from the physical demands of pregnancy and the birth experience
• Support the developing relationship between the baby and his or her mother, and support(s)/family
• Support the development of infant feeding skills
• Support the development of parenting skills
• Encourage support of the mother, baby, and family during the period of adjustment (support may be from
other family members, social contacts, and/or the community)
• Provide education resources and services to the mother and support(s) in aspects relative to personal and
baby care
• Support and strengthen the mother’s knowledge, as well as her confidence in herself and in her baby’s health
and well-being, thus enabling her to fulfill her mothering role within her particular family and cultural beliefs
• Support the completion of specific prophylactic or screening procedures organized through the different
programs of maternal and newborn care, such as: Vitamin K administration and eye prophylaxis, immunization
(Rh, Rubella, Hepatitis B), prevention of Rh isoimmunisation and newborn screening
• Assess the safety and security of postpartum women and their newborns (families) (e.g. car seats, safe infant
sleeping, potentially violent home situations, substance use)
Newborn Guideline 13: Newborn Nursing Care Pathway 3

Introduction
• Identify and participate in implementing appropriate interventions for newborn variances/problems
• Assist the woman in the prevention of newborn variances/problems
Needs – World Health Organization (WHO)

The WHO6 stated that “postpartum care should respond to the special needs of the mother and baby during this
special phase and should include: the prevention and early detection and treatment of complications and disease,
and the provision of advice and services on breastfeeding, birth spacing, immunization and maternal nutrition.”7
The twelve specific WHO newborn needs continue to be:
• Easy access to the mother

• Appropriate feeding
• Adequate environmental temperature
• A safe environment
• Parental care
• Cleanliness
• Observation of body signs by someone who cares and can take action if necessary
• Access to health care for suspected or manifest complications
• Nurturing, cuddling, stimulation
• Protection from disease, harmful practices, abuse/violence
• Acceptance of sex, appearance, size
• Recognition by the state (vital registration system)
Timeframes
The first 12 hours are considered to be the period of transition where the normal newborn adapts to extra-uterine
life.8 Thus, the guidelines determined the first 12 hours following the third stage of birth as the Period of Stability
(POS) followed by >12-24 hours, >24-72 hours, and >72 hours - 7 days and beyond.
NOTE: In order to capture key parent teaching/anticipatory guidance concepts, concepts will be located in the
>12-24 hour timeframe. It is at the individual nurse’s discretion to provide this information/support earlier
or later.
Newborn Physiological Stability

The Newborn Nursing Care Pathway has adapted Consensus Statement #11, in the BC Postpartum Consensus
Symposium9 and recommended that the six following criteria define infant physiologic stability following term
vaginal delivery:
• Respiratory rate between 40-60/ min

• Axillary temperature of 36.5- to 37.4 C10 and stable heart rate (100-160 bpm)11
• Suckling/rooting efforts and evidence of readiness to feed
• Physical examination reveals no significant congenital anomalies
• No evidence of sepsis
• No jaundice developing <24 hrs
Introduction
Newborn Pain
Newborn pain is generally alleviated by interventions such as holding the baby skin-to-skin, breastfeeding,
cuddling, rocking and/or lightly swaddling.
Although the measurement of pain is not usually required for a healthy term infant, there may be times when
newborn pain requires further assessment.
For information to increase knowledge of assessing newborn pain the “Behavioral Indicators of Infant Pain” (BIIP)
is available. It is an evidence-based, standardized way of assessing pain and is designed for term and preterm
infants. Currently, this assessment tool is being used in hospitals around the world and in several BC hospitals’
neonatal intensive care units (NICUs). Research on the development of the BIIP has been published in peer
reviewed journals and the BIIP has been used to assess pain in a number of studies.12,13
If a pain assessment is required, it may be done before a routine handling session (such as during the diaper
change) and measured a second time at a subsequent handling to see if a change has occurred. This type of
assessment would be equivalent to taking a temperature to see if the baby is in more or less distress over a short
period of time (e.g. 2 hours). This measurement then forms part of the nursing documentation to report in the
event treatment is needed.

Physiological 0 – 12 hours
>12 – 24 hours >24 – 72 hours >72 hours – 7 days and beyond
Assessment Period of Stability (POS)
Head
Assess: Norm and Normal Variations Norm and Normal Variations Norm and Normal Norm and Normal Variations
• Shape • Head round, symmetrical Refer to POS Variations • Refer to POS
• Size • May have moulding, some • Refer to POS • Moulding resolves ~ 3 days
• Fontanelles overlapping of sutures Parent Education / Anticipatory • Average head circumference
• Circumference prn • Anterior & posterior fontanelles Guidance Parent Education/ 33 – 35 cm once moulding
flat and soft • Anterior fontanel: 2 – 4 cm long, Anticipatory Guidance disappears (ensure consistent
Assess mother’s/family/ • Neck short and thick diamond shape, closes at 12 – 28 • Refer to >12 – 24 hr way of measuring)14
supports understanding of
Newborn Guideline 13: Newborn Nursing Care Pathway
• Full range of motion months

newborn physiology and • Posterior fontanel: smaller than Parent Education / Anticipatory
capacity to identify variances Parent Education / Anticipatory anterior, triangular shape Guidance
that may require further Guidance • Refer to >12 – 24 hr
• Supine (back) sleep position
assessments • Place baby skin-to-skin • Carry baby and alternate head • Prevent plagiocephaly (flat spots
• Discuss variances and positions (to avoid flattened head) on head) and strengthen neck
Refer to:
when they should resolve • Prevention of SIDS muscles by placing baby on
• Behavior
(caput succedaneum, abdomen when awake (tummy
• Postpartum Nursing Care cephalohematoma etc.) – refer time) for several short periods
www.healthlinkbc.ca/healthfiles/
Pathway: Bonding & to variance >12 – 24 hr each day
hfile46.stm
Attachment Care when handling infant’s • Carrying infant in arms
head (vs. in infant seat) assists with
• Refer to >12 – 24 hr prevention of flat head
And promotes bonding
Refer to: Healthy Families BC Website – www.healthyfamiliesbc.ca/parenting
Physiological Health: Head

7
Physiological Health: Head
8
HEAD Variance Variance Variance Variance – Cradle cap

(Continued) • Caput succedaneum crosses • Refer to POS • Refer to 0 – 24 hr Intervention – Cradle Cap
suture lines (edema caused by • Caput succedaneum – • Apply non-perfumed oil, use
Intervention
sustained pressure of occiput disappears spontaneously mild non perfumed shampoo
against cervix)15 • Refer to 0 – 24 hr to remove oil.19
within 3 – 4 days17
• Cephalohematoma – • Infants who birth with Variance – Plagiocephaly
collection of blood between assistance of vacuum (flattening of 1 side of the skull)
skull bone & periosteum extraction may have caput
caused by pressure against and bruising Intervention – Plagiocephaly
maternal pelvis or forceps – • Cephalohematoma – • Carrying and the use of an
does not cross suture lines16 increases first 3 – 4 days, upright ring type carrier
• Bruising, excoriation, disappears in 2 – 3 wks • Supervised tummy time when
lacerations and may affect the bilirubin awake
• Bulging or sunken fontanelles screen18
Variance – Enlarged
• Neck webbing, limited range • Risk of jaundice if head fontanelles
of motion trauma and/or bruising

• Remarkably enlarged
• Masses Intervention fontanelles/splayed suture
• Hydrocephaly lines
Refer to POS
• Microcephaly • Head appears abnormally
Intervention large & looks ‘heavy’-signs of
hydrocephalus
• Nursing assessment
• Refer to appropriate PHCP Intervention – Enlarged
prn fontanelles
• Refer to PHCP prn

Nares
Assess: Norm and Normal Variations Norm and Normal Variations Norm and Normal Variations Norm and Normal Variations
• Symmetry • Nose breathers • Refer to POS • Refer to POS • Refer to POS
• Air entry both nares • Symmetrical, no nasal flaring
• Assess mother’s/ • Thin, clear nasal discharge,
family/supports Parent Education/ Anticipatory Parent Education/ Parent Education/ Anticipatory
sneezing common
understanding of newborn Guidance Anticipatory Guidance Guidance
• After mucous and amniotic
physiology and capacity to • Refer to POS • Refer to POS • Refer to POS
fluids are cleared from nasal
identify variances that may

passages, infant differentiates
require further assessments
pleasant from unpleasant Variance Variance Variance
Refer to: odors • Refer to POS • Refer to POS • Refer to POS
• Vital signs • Nares patent
• Milia present on nose
Intervention Intervention Intervention
Parent Education/ Anticipatory • Refer to POS • Refer to POS • Refer to POS
Guidance
• Sneezing common
Variance
• Nasal congestion
Intervention
Physiological Health: Nares

9
Physiological Health: Eyes
10
Eyes
• Symmetry • Outer canthus aligned with • Refer to POS • Refer to POS • Refer to POS and
• Placement upper ear • Resolving or decreasing >24-72 hr
• Clarity • Dark or slate blue color edema of eyelids and • May have transient strabismus
Parent Education/ Anticipatory
• Risks for eye/vision • Blink reflex present chemical conjunctivitis or nystagmus until 3 – 4 months
Guidance
problems (family history) • Edematous lids • May have slight jaundice of
• Eye care
• Sclera clear sclera
Clean from inner canthus to Parent Education/ Anticipatory
Assess mother’s/ family/ • No tears outer edge with warm water Guidance
supports understanding of • Pupils equal and reactive when bathing Parent Education/ Anticipatory • Parent Education
newborn physiology and to light Guidance
• Newborn’s vision • Refer to >12 – 72 hr
capacity to identify variances
• May see subconjunctival Nearsighted – see most • Refer to 12 – 24 hr • No tears- tear ducts patent ~
that may require further
hemorrhage clearly when objects 8-10
assessments • Jaundice progression/ 5 – 7 months

• Administer eye prophylaxis inches from face treatment
(after completion of initial Show attention by looking,
Refer to: feeding or by 1 hour after lifting upper eyelids,

birth) 20 ‘brightening’
• Skin
promotes initiation of Attracted to human face
feeding and maternal/infant Display visual abilities most
eye contact consistently in quiet alert
• Uncoordinated movement state
• May see chemical
conjunctivitis due to eye
ointment

Guidance
• Eye prophylaxis – prevention
of ophthalmia neonatorum
• Refer to >12-24 hr

Eyes Variance Variance Variance Variance

(Continued) • Hazy, dull cornea • Refer to POS • Refer to POS • Refer to POS and
• Pupils unequal, dilated • Conjunctivitis >24 – 72 hr
constricted Intervention Intervention
• Refer to POS Intervention
Intervention • Refer to POS and
• Teach eye care
>24 – 72 hr
• Nursing Assessment • Refer to appropriate health
• Refer to appropriate PHCP care provider prn
Variance -
prn
Blocked tear duct
Intervention -
Blocked tear duct
• Watch and wait
• May want to use a warm
compress
• Ensure there is no infection
• If unsure refer to PHCP
Variance – Obvious strabismus

or nystagmus >3 – 4 months
Intervention – Obvious
strabismus or nystagmus
>3 – 4 months
• Refer to PHCP. may
need referral to Pediatric
Ophthalmology
Physiological Health: Eyes

11
Physiological Health: Ears
12
Physiological 0 – 12 hours >72 hours – 7 days and

>12 – 24 hours >24 – 72 hours
Assessment Period of Stability (POS) beyond
Ears
• For well-formed cartilage • Well formed cartilage • Refer to POS Refer to POS • Refer to POS
• Ears level with the eyes • Ears level with eyes – top of
pinna on horizontal plane with
Parent Education/Anticipatory Parent Education/ Anticipatory Parent Education/ Anticipatory
Assess mother’s/ family/ outer canthus of eye
Guidance Guidance Guidance
supports understanding • May have temporary
• Cleaning of ears e.g. do not • Refer to >12 – 24 hr • Refer to >12 – 24 hr
of newborn physiology asymmetry from unequal
use a cotton tipped swab • Able to distinguish mother and
and capacity to identify intrauterine pressure on the
variances that may require • Higher-pitched sounds father’s voice within 2 weeks
sides of the of head
further assessments generally gain the infant’s and responds with distinct
• Startles/reacts to loud noises
attention rather than lower reaction pattern to each
• Ear canal may contain vernix pitched sounds • Monitor for normal hearing and
(short external auditory ear
• Provincial Hearing Screening speech patterns
canal)
Program • Exposure to second hand
smoke increases risk of ear
Parent Education/ Anticipatory • www.healthlinkbc.ca/ infection
Guidance healthfiles/hfile71b.stm • Review factors associated with
• Refer to >12-24 hr increased risk of hearing loss
such as
Family history
Low birth weight
Jaundice – requiring
transfusion
Infections21

>12 – 24 hours >24 – 72 hours
EARS
(Continued) Variance Variance Variance Variance
• Unresponsive to noise • Refer to POS • Refer to POS • Refer to POS
• Ear tags, ear pits – could • Exposure to ototoxic
indicate a brachial cleft duct or medications especially
Intervention Intervention
cyst (risk for infection and may aminoglycosides, such as:
need surgical intervention) • Refer to POS • Refer to POS Gentamycin
• Low set ears Kanamycin

• Drainage present Neomycin
• Family history of childhood Streptomycin
sensory hearing loss Tobramycin
• Cranial facial anomalies of • Bacteria meningitis

pinna or ear canal
Intervention
Intervention • Nursing Assessment
• Nursing Assessment • Refer to PHCP prn
• Refer to appropriate PHCP prn
Physiological Health: Ears

13
Physiological Health: Mouth
14
Mouth
Assess: Norm and Normal Variations Norm and Normal Norm and Normal Norm and Normal Variations
• Lips for colour • Mucosa moist smooth and pink Variations Variations • Refer to POS
• Tongue midline • May have epithelial pearls • Refer to POS • Refer to POS
Parent Education/ Anticipatory Guidance
• Frenulum • Tongue midline and can extend out to • May have sucking
• Refer to >12 – 24 hr
• Palate edge of lower lip blister on lips
Parent Education/ • Oral hygiene
• Reflexes • May have noticeable sublingual Anticipatory • Tongue may be
coated white from • Look into baby’s mouth regularly
• Oral health and care frenulum Guidance Wipe gums with soft, clean damp cloth daily
• Intact lips feeding
prior to the eruption of the first teeth
Assess mother’s/ family/ • Jaw symmetrical • www.healthlinkbc. Prevention of tooth decay
supports understanding • Intact palate (soft, hard) ca/healthfiles/ Parent Education/ • www.cda-adc.ca/en/oral_health/cfyt/dental_
of newborn physiology • Reflexes hfile19a.stm Anticipatory Guidance care_children/tooth_decay.asp
and capacity to Rooting • Refer to >12 – 24 hr
identify variances that Sucking
Variance
Variance
may require further • Refer to POS

assessments Parent Education/ Anticipatory • Refer to POS Variance
Guidance Intervention
• Refer to POS
• Refer to >12 – 24 hr • Refer to POS and >24 – 72 hr
Refer to: Intervention
Variance Variance – Thrush Candida (fungus)
• Feeding • Refer to POS Intervention
• Tight frenulum (tongue tie) or heart • White, cheesy patches on the tongue, gums or
• Refer to POS
shaped tongue mucous membranes – won’t rub off
• If latching difficulty
• Cleft lip/palate • Diaper area – red rash
persists due to tight
• Short or protruding tongue-large frenulum or tongue
tongue (macroglossia) Intervention – Thrush Candida (fungus)
refer to PHCP
• Small receding chin (micrognathia) • Discuss signs, symptoms & treatment
• Dry mucosa (may be dry after crying) • Assess mother’s nipples for thrush (red, itchy,
• Mouth drooping or opens persistent sore nipples, burning, shooting pain)
asymmetrically (may be facial palsy) • Both mother and baby need treatment
• May affect baby’s feeding
Intervention
• If using soother – may want to discontinue as
• Assess baby’s ability to latch without
may contribute overgrowth of yeast 22
causing pain and damage to nipple
• Refer to Maternal Guidelines (Breasts)
• Feeding variations to cope with
• Refer to PHCP for antifungal treatment
variances
• PSBC (2013) Breastfeeding Healthy Term
• Dry mucosa, assess hydration status
Infants

Chest
Assess: Norm and Normal Variations Norm and Normal Norm and Normal Norm and Normal Variations
• Symmetry • Circumference about 1cm < head Variations Variations • Refer to POS
• Shape circumference • Refer to POS • Refer to POS • Breast enlargement usually
• Respirations • Round, symmetrical; protruding xiphoid resolves by the second week of
• Heart rate process life
Parent Education/ Parent Education/
• Cardiovascular • Clavicle intact Anticipatory Guidance Anticipatory Guidance
function • Chest sounds clear
• Normal newborn • Refer to >12 – 24 hr Parent Education/ Anticipatory
• Hiccoughs and sneezing common breathing Guidance

Assess mother’s/ family/ • Breasts may be swollen with clear/milky • Hiccoughs resolve on • Refer to >12 – 24 hr
supports understanding nipple discharge own Variance
of newborn physiology • Mucous • Occasional sneezing is • Refer to POS
and capacity to More common in Cesarean births Variance
infant’s mechanism to
identify variances that Dark brown mucous – potential clear nasal passages • Refer to POS
Intervention
may require further swallowing of mucous/blood during birth • Do not squeeze swollen
assessments • Refer to POS
Parent Education/ Anticipatory Guidance breasts – they are due to Intervention
• Refer to >12 – 24 hr maternal hormones
• Refer to POS
Variance
• Mucousy / noisy respirations Variance
• Signs of respiratory distress • Refer to POS
Retractions
Grunting Intervention
Nasal flaring
• Refer to POS
Tachypnea
• Deviation in chest shape

• Fractured clavicle
• Asymmetrical movement
• Breasts inflamed
• Supernumerary nipples
• Coughing
Intervention
Physiological Health: Chest

15
Physiological Health: Abdomen/Umbilicus
16
Physiological 0 – 12 hours >72 hours – 7 days

>12 – 24 hours >24 – 72 hours
Assessment Period of Stability (POS) and beyond
Abdomen/ Norm and Normal Variations Norm and Normal Variations Norm and Normal Norm and Normal
Umbilicus • Abdomen • Cord Variations Variations
Slightly rounded, soft and Clean and dry or slightly moist • Refer to • Refer to
Assess:
symmetric Cord clamp secure if present >0 – 24 hr 0 – 24 hr
• Symmetry
Bowel sounds present • Cord clamp, if • Cord separates
• Bowel sounds Parent Education/ Anticipatory Guidance
Skin: pink, smooth, present, may be within 1 – 3 weeks
• Cord Parent Education
opaque removed if cord • Slight bleeding
• Umbilical area • Wash hands with soap & water before and after contact with is dry
A few large blood vessels may occur with
umbilical area
may be visible • When infant separation
• Review/demonstrate cord care during bath discharged with
Assess mother’s/ • Cord Parent Education/
Clean cord with water & air dry cord clamp on,
family/supports Two arteries and one vein Anticipatory
Water on cotton tipped applicator or washcloth to clean removal of cord
understanding of Cord clamp secure Guidance
newborn physiology gently around the base of the cord clamp to be
Parent Education/Anticipatory Clean around the base of the cord after bathing and at diaper carried out as per • Refer to
and capacity to >12 – 24 hr
Guidance changes agency policy/
identify variances
• Refer to >12 – 24 hr Fold diaper below the cord to prevent irritation and to keep it procedures • Normal cord
that may require
dry and exposed to air separation
further assessments Variance Parent Education/
Avoid buttons, coins, bandages or binders over navel Variance
• One artery Anticipatory
Encourage skin-to-skin with mother – to promote colonization
• Umbilical hernia Guidance • Refer to
with non pathogenic bacteria from mother’s skin flora • Refer to 0 – 24 hr
• Masses • S & S infection – redness or swelling >5mm from umbilicus, >12 – 24 hr Intervention
• Bleeding fever, lethargy, and/or poor feeding
• Drainage • Refer to
• Absent bowel sounds www.healthlinkbc.ca/kbase/topic/special/tp22060spec/sec1. >0 – 24 hr
• Sensitive with palpation htm Variance
• Green emesis &/or feeding • Refer to
intolerance Variance >0 – 24 hr
• Bright blood emesis • Refer to POS
• Cord – Foul odor, redness or swelling >5 mm from umbilicus
Intervention
• S & S of systemic infection – fever, lethargy, and/or poor
• Nursing assessment feeding) Intervention
• Refer to PCHP prn • Refer to
Intervention >0 – 24 hr
• Refer to POS
• Do not remove cord clamp if cord is moist or “mucky”
• Urgent care if S & S of systemic infection

>12-24hours >24- 72 hours
Skeletal/ Norm and Normal Variations Norm and Normal Norm and Normal Norm and Normal
Extremities • Symmetrical in size, shape, movement & flexion Variations Variations Variations
• Intact, straight spine Refer to POS Refer to POS • Refer to POS
• Full range of motion
Assess:
• Clavicles intact Parent Education/ Parent Education/ Parent Education/
• Symmetry Anticipatory Guidance
• Bow-legged, flat-footed Anticipatory Anticipatory Guidance
• Intact and straight spine Ensure hip check done by
• Equal gluteal folds Guidance • Refer >12 – 24 hr
• Full range of motion physician
• Equal leg length • Refer >12 – 24 hr
Assess mother’s/ family/ Variance

Parent Education/ Anticipatory Guidance Variance Variance
supports understanding • Refer to POS
• Refer to >12 – 24 hr • Refer to POS • Refer to POS
of newborn physiology
and capacity to identify Intervention
variances that may require Intervention
Variance Intervention • Refer to POS
further assessments • Refer to POS
• Asymmetrical extremities • Refer to POS
• Curvature of spine
• Non-intact spine
• Tufts of hair along an intact spine – may require
ultrasound to rule out spina bifida
• Coccygeal dimple
• Fractures
• Poor range of motion
• Hypertonia/ contractures of extremities
• Skeletal abnormalities
• Talipes equinovarus (club foot)
• Congenital hip dislocation
Intervention
• Nursing Assessment
Physiological Health: Skeletal/Extremities

17
Physiological Health: Skin
18

>12 – 24 hours >24 – 72 hours
Skin
Norm and Normal Norm and Normal Variations Norm and Normal Variations Norm and Normal Variations
Assess in natural Variations • Refer to POS • Refer to 0 – 24h • Jaundice usually peaks
light:
• May have • Acrocyanosis resolved • About 60 percent of all infants by day 3 – 4, resolves
• Skin color (acrocyanosis) in one – two weeks
have some jaundice, it generally
• Turgor peripheral cyanosis clears up without any medical • Refer to 0 – 72 hr
• Integrity Parent Education/ Anticipatory Guidance
• Skin intact – may be treatment26
• Factors that dry with some peeling; • Refer to POS
• Bilirubin levels – refer to CPS
• Skin variations Parent Education/
increase newborn lanugo on back; vernix Guideline27
Anticipatory Guidance
risk for jaundice in the creases Milia
www.cps.ca/english/statements/ • Refer to 0 – 72 hr
(refer to BCPHP • May have erythema Cracks
FN/FN07-02.pdf
Guideline) toxicum (newborn Peeling
rash) milia, mongolian Hemangiomas
Assess mother’s/ spots, capillary Mongolian spots – frequently in darkly Parent Education/ Anticipatory
Guidance
family/supports hemangiomas, harlequin pigmented infants such as Asian, First

understanding of sign Nation, African-American • Refer to 0 – 24h
newborn physiology • Skin pinch immediately > Most often found in the lumbosacral • Relationship between poor
and her capacity to returns to original state region, but can be found anywhere feeding, hydration & jaundice and
identify variances that • Skin is sensitive to on the body23,24 the need to monitor
may require further touch • Skin care – avoidance of perfumed • Management of jaundice –
assessments products feeding, waking sleepy baby,
• Delay first bath until baby stable and monitoring output
Parent Education/
Anticipatory Guidance completed transition period
Refer to:
• Parents encouraged to do the first bath www.healthlinkbc.ca/kb/content/
• Feeding • Skin-to-skin
with nursing support mini/hw164159.html#hw164161
• Need for tactile
stimulation • Bathing:
Refer to vital signs re stability
Not required every day
Immersion preferable to sponge bath
(less chance for heat loss)25

Amount of water, lukewarm
temperature, soap can be irritating, use

unscented lotions/oils

>12 – 24 hours >24 – 72 hours
Skin Variance Variance Variance Variance

(Continued) • Pallor (may be genetic) • Refer to POS • Refer to POS • Refer to POS
• Generalized cyanosis or increased • New, unresolved or
cyanosis with activity unexplained rashes
• Unexplained skin rashes/
• Refer to POS • Refer to POS
• lacerations/ breaks in skin Intervention
• Hemangiomas • Refer to POS
Variance-Jaundice Variance – Jaundice
• Petechia
• Refer to POS • Risk factors present for evidence of
• Bruising (ecchymosis)
jaundice (such as family history of Variance – Jaundice
jaundice, LBW, preterm, bruising) • Severe or increasing level of
Intervention Intervention –
• Infant difficult to rouse jaundice
Jaundice
• Nursing Assessment • Feeding poorly • Refer to >24 – 72 hr
• Assess level of
• Refer to PHCP prn • Parent does not demonstrate ability to
jaundice including
skin color, hydration monitor feeding, output, behavior and
Intervention – Jaundice
Variance – Jaundice colour
• Assess feeding • Refer to >24 – 72 hr
• Any jaundice in first 24 hours effectiveness-
including output & Intervention – Jaundice
weight • Nursing assessment
Intervention – Jaundice
• Contact PHCP • Bilirubin level as per facility guide or
PHCP orders
• Care plan to support and educate
parents in monitoring for newborn
jaundice
• Assess feeding effectiveness
Physiological Health: Skin

19
Physiological Health: Neuromuscular
20

>12 – 24 hours >24 – 72 hours
Neuromuscular Norm and Normal Variations Norm and Normal Norm and Normal Norm and Normal
• Extremities symmetrical, full range of motion (ROM), flexed, good Variations Variations Variations
muscle tone • Refer to POS • Refer to POS • Refer to POS
Assess:
• Infant reflexes present
• Muscle tone and
Babinski
movement Parent Education/ Parent Education/ Parent Education/
Grasping
• Reflexes are present Anticipatory Guidance Anticipatory Anticipatory
Moro Guidance Guidance
and appropriate for • Encourage skin-
Palmar
developmental/ to-skin and • Refer to >12 24 hr • Refer to >12 – 24
Planter breastfeeding – if hr
• If mom on SSRIs /
Rooting concerned about risk SNRIs, ensure
Stepping for low blood sugar a follow-up
Assess mother’s/ family/ Variance
Sucking • Baby’s alertness and appointment
supports understanding • Refer to POS
• APGAR scores between 7 and 10 at 5 minutes readiness to feed is booked for
of newborn physiology
• Positioning, 3 – 5 days post
and capacity to Parent Education/ Anticipatory Guidance
movement, reflexes, discharge Intervention

identify variances that • Refer to >12 – 24 hr muscle tone • Refer to POS
may require further
assessments Variance • Jitteriness vs seizure
activity – jittery Variance
• Asymmetrical facial/limb movement
• Abnormal foot posture movements stop • Refer to POS
when infant is held
• Facial palsy
• Brachial palsy Intervention
• Limbs not flexed Variance • Refer to POS
• Lack of muscle tone/resistance (hypotonicity) • Refer to POS
• Seizure activity
• Jitteriness – rule out low blood sugar (<2.6mmol/L) 28 Intervention
• Abnormal or absent reflexes • Refer to POS
• Arching
Intervention
• Nursing assessment (including maternal medication/drug use)
• Jitteriness differentiated between hypoglycemia and seizure activity
www.camh.net/Publications/Resources_for_Professionals/
Pregnancy_Lactation/psychmed_preg_lact.pdf

Genitalia Norm and Normal Variations Norm and Normal Variations Variance Norm and Normal Variations
• Anus patent • Refer to POS • Refer to POS • Refer to POS
• Females • Swelling of labia and scrotum
Assess:
Labia swollen resolves about day 3 – 4
• Genitalia Parent Education/ Anticipatory Intervention
Labia majora to midline
Guidance • Whitish mucoid or
• Refer to POS
Urethral open behind clitoris – in front of vaginal pseudomenses subsides by end
Assess mother’s/ • Keep baby clean & dry
opening of first week
family/supports • Females
Clitoris maybe enlarged
understanding Do not remove vernix
Hymenal tag is normally present
of newborn Clean from front to back

Vernix caseosa present between labia Guidance
physiology and • Males
capacity to Whitish mucoid or pseudomensus
Do not retract foreskin • Refer to >12 – 24 hr
identify variances • Males • If circumcised teach care and
Provide information to
that may Scrotum swollen – rugae present S & S of complications
support informed decision
require further Testes descended palpable bilaterally Bleeding
making re circumcision prn
assessments Central urethral opening Infection
Circumcision not covered
Foreskin not retractable Edema
under Medical plan
Epithelial pearls may be present on penile shaft • For diaper rash
Refer to:
Smegma may be found on foreskin Frequent diaper changing
• Elimination www.healthlinkbc.ca/kbase/
Erections common Keep clean and dry (Refer to
topic/special/hw142449/sec1.
Parent Education/ Anticipatory Guidance htm Skin)
Exposure to air
Use of barrier cream prn
Variance Variance
• Undifferentiated • Refer to POS
Variance
• Female
• Refer to POS
Fusion of labia Intervention
• Rash that does not clear after
• Male • Refer to POS several days
Urethral opening below/above tip of penis
(hypospadius)
Unequal scrotal size Intervention
Testes palpable in inguinal canal or not palpable • Nursing Assessment
Hydrocele • May refer to PHCP
Intervention
• Refer to PCHP prn
Physiological Health: Genitalia

21
Physiological Health: Elimination – Urine
22
Elimination – Norm and Normal Norm and Normal Variations Norm and Normal Variations Norm and Normal Variations
Urine Variations • Voids within 24 hr • 24 – 48 hr: 1 – 2 wet, clear, pale • Day 3 – 5: 3 – 5 wet, clear, pale
• One clear void with • ≥ 1 wet, clear, pale yellow yellow diapers/ day30 yellow diapers/day32
possible uric acid crystals diaper(s)29 • 48 – 72 hr: 2 - 3 wet clear pale • Day 5 – 7: 4 – 6 wet, clear, pale
Assess: (orange/brownish color) • Uric acid crystals in the first yellow diapers /day 31 yellow diapers/day33
• Bladder output and • Urine pale yellow and 24 hr • Day 7 – 28: many wet diapers
color of urine is normal odorless daily and pale yellow34
for baby’s age. Parent Education/ Anticipatory
• Adequate hydration/ Parent Education/ Anticipatory Guidance
elimination (refer to Parent Education/ Guidance • Refer to >12 – 24 hr Parent Education/ Anticipatory
breastfeeding) Anticipatory Guidance • Relationship between feeding Guidance
• Refer to >12 – 24 hr and output – elimination • Refer to >12 – 24 hr
Variance
is a component of feeding
• Less than 1 – 2 wet diapers/ day
assessment (normal voiding for
Variance • Urine concentrated Variance
the first 72 hours)
Assess mother’s/ family/ • Refer to >12 – 24 hr • Inadequate hydration/elimination • Refer to >24 – 72 hr
• Assessing for adequate

supports understanding (poor skin turgor, fontanelles, dry • Uric acid crystals may indicate
hydration
of newborn physiology mucous membranes, lethargy, dehydration after 72 hours
Intervention • Encourage use of elimination
and capacity to identify irritability)
• Refer to >12 – 24 hr record prn • Urine concentrated
variances that may require
• Yellowing of the skin • < 5 wet diapers/day
further assessments
Variance
• No voiding in 24 hrs
• Refer to >12 – 24 hr • Refer to >12 – 24 hr
Refer to: • Urine concentrated
• Feeding
• Weight Intervention
• Ensure effective feeding
• Reassess within 24 hr

Elimination – Norm and Normal Norm and Normal Variations Norm and Normal Variations Norm and Normal Variations
Stool Variations • >1 meconium passed within • Meconium & transitional stools Breastfed
Assess • Active bowel sounds 24 hours35 • Day 2 – 3 >1 meconium or • Day 3 – 5: 3 – 4 loose, yellow transitional
• Normal stooling for greenish brown36 stools
baby’s age Parent Education/ Parent Education/ Anticipatory • Day 5 – 7: 3 – 6 yellow or golden
Anticipatory Guidance Guidance Parent Education/ Anticipatory • Day 7 – 28: 5 – 10+ yellow37
Assess mother’s/ • Refer to >12 – 72 hr • Assess feeding/oral intake Guidance • Stools colours vary – may be yellow/
family/supports • Relationship between feeding • Refer to >12 – 24 hr mustard or brown with mustard seed
understanding of and output-elimination is consistency or occasionally green (may
• Changes in bowel pattern

newborn physiology a component of feeding reflect mothers diet)
• Frequent effective feeding
and capacity to assessment • Around 3 – 4 weeks of age individual bowel
identify variances that • Encourage pattern (may go several days without a soft/
may require further loose bowel movement)
Breastfeeding
assessments Watery, mustard color
Skin-to-skin
Hand expression of • Mild odour

colosturm • May pass stool with each feed
Refer to: • Expected stool pattern –
• Feeding colour, consistency, amount,
changes Formula fed
• Weight
• Encourage intake of colostrum • Formed
– acts like a laxative • Pale yellow to light brown
• Strong odour
Formula Fed • May be dark green with iron fortified formula
• As above except for • Often 1 – 2 daily for first weeks
information directly related to • Around 3 – 4 weeks baby may have a bowel
breastfeeding movement every 1 – 2 days

• Provide parents with BC Infant Stool Colour
Card and review with them; advise them to
check baby’s stool colour every day for the
first month after birth and contact the BC
Infant Stool Colour Card Screening program
if baby has abnormal coloured stools
Physiological Health: Elimination – Stool

23
Physiological Health: Elimination – Stool
24
0 – 12 hours
Physiological
Period of Stability >12 – 24 hours >24 – 72 hours >72 hours – 7 days and beyond
Assessment
(POS)
Elimination –
Stool Variance Variance Variance Variance
(Continued) • Abdominal • No stools passed within • ≤ 1 stools passed within 48 hr • < 3 stools on day 4 in combination without
distension 24 hours • Diarrhea obvious breast filling
• Absence of bowel • Green, foul smelling, mucousy stool • Does not have 2 or more stools per day
sounds after 4 – 5 days of age38
Intervention
• Displaying signs of jaundice lasting longer
• Nursing Assessment Intervention
than two weeks (yellowing of the baby’s
Intervention • Reassess within 24 hrs if • Nursing Assessment skin or eyes), with pale yellow, chalk white,
• Check if meconium no stool passed • Assess feeding and assist family in or clay coloured stools
passed at birth • Refer to PHCP prn developing plan to monitor output, report • A jaundiced baby tends to have increased
• Nursing ongoing variance frequency of stools
Assessment • Refer to PHCP prn may be loose, greenish in colour and
sometimes explosive
• Diarrhea (very loose, foul smelling)
• Constipation – rare in exclusively breastfed
infants (stools dry, hard difficulty in
passing)
• Bloody stool
Intervention

>72 hours –
Physiological 0 – 12 hours >24 – 72
>12 – 24 hours 7 days and
Assessment Period of Stability (POS) hours
beyond
VITAL SIGNS Norm and Normal Variations Norm and Normal Variations Norm and Norm and
Assess: General • Presents with normal newborn examination and no major CNS Normal Normal
• Vital signs and include Centrally pink and good tone concerns – is one of the criteria to indicate the infant is ready to Variations Variations
– history and risks Temperature move to care by parent40 • Refer to • Refer to
• Frequency of • Refer to POS >12 – 24 hr >12 – 24 hr
• Axilla 36.5 – 37.4oC
assessment following Parent Education/ Anticipatory Guidance
• Use of toque until infant stabilization
organization’s policy achieved39 and skin-to-skin care • How (including normal values) and when to assess temperature, Parent Parent
Suggested frequency for Circulation respirations Education/ Education/
vital signs: • How to clear mucous Anticipatory Anticipatory
• Heart rate: 100 – 160
• Within 15 minutes in Prone, head lowered, and stroke back Guidance Guidance
• Femoral and brachial pulses palpated

the first hour of life and Avoiding the use of mechanical aids in nose • Refer to • Refer to
• SpO2: ≤ 1 h ≥88%
• At 1 and 2 hours E.g. cotton tipped applicators & bulb aspirators >12 – 24 hr >12 – 24 hr
> 1 h >94%
following the first vital • Heat control in infants
signs and if stable Respirations
Skin-to-skin with blanket over infant and mother • If mom on
• At hour 6 • Effortless 30 – 60/min SSRIs /
Loosely wrap baby with hands free – avoid swaddling
• Once per shift until • Clear sounds SNRIs,
Feeling back of neck to determine if baby is too warm
hospital discharge • May be irregular ensure a
• Bathing
including • Some mucus follow-up
Including information such as hygiene, mouth care, bonding
Temperature • Easy respirations when mouth closed appointment
and engagement, reflexes, behaviours and feeding cues and is booked
Respirations • Sneezing common (<3 – 4 times/ physiological changes (sight, hearing) for 3 – 5
• Rate interval) • Identifying changes in newborn vital signs if utero exposure to days post
• Respiratory effort • May have slightly wet sounding psychotropic drug exposure (Opioids, benzodiazepines, SSRIs, discharge
Circulation lungs for the first 15 – 30 min and is SNRIs).41 S & S of disorganized infant, such as
• Heart rate improving and there is good colour, Metabolic/ vasomotor/ respiratory (T, HR, RR, weight,
• Heart sounds tone and normal heart rate sneezing)

Include: Parent Education/ CNS (cry, tremors, muscle tone, sucking, swallowing)
• Colour GI (feeding, vomiting, stooling, excoriation)

• Tone • Nursing – hands on physical • Although codeine no longer recommended, if exposure to
SpO2 if required assessment with parent(s) in codeine in breast milk
• Then as required by attendance CNS depression – exhibited as not feeding well, not waking up
nursing judgement and • Initial bath after baby has completed to be fed, not gaining weight gain, limpness
hospital policy Baby should be examined by PHCP if mother shows
a stable transition period (universal
precautions until bath) symptoms of CNS depression42
• Use of toque/head covering indoors • When newborn ready for discharge perform global (physical and
not required after infant stabilization feeding) assessment43 with parent
• Refer to >12 – 24 hr • When to seek help from PHCP
See variances POS
Fever

Physiological Health: Vital Signs
25
Physiological Health: Vital Signs
26
>72 hours –
Physiological 0 – 12 hours >24 – 72
>12 – 24 hours 7 days and
Assessment Period of Stability (POS) hours
beyond
Vital Signs
(Continued) Variance Variance Variance Variance
Review: • Temperature instability • Refer to POS • Refer to • Refer to
• Maternal pregnancy • Heart murmur • Uterine exposure to SSRI/ SNRIs POS POS
and labour & birth Persistent tachycardia >160 or
history for
bradychardia ≤ 100 bpm Intervention Intervention
Use of SSRIs Intervention
Weak/absent femoral or brachial
/ SNRIs in late • Refer to POS • Refer to • Refer to
pulses POS POS
pregnancy44
• Mucousy/noisy respirations that are
Group B Strep or
not improving
ROM >18 hours –
• Signs of respiratory distress
vital signs q4h45
Indrawing
Fever during labour
Grunting
& birth
Nasal flaring
• Maternal use of
codeine postpartum46 • Apneic episodes >15 sec
• Bradypnea <25 per minute
Assess mother’s/ family/ • Tachypnea >60 per minute
supports understanding • Diaphoresis
of newborn physiology • Mottling
and capacity to • Poor colour
identify variances that Dusky
may require further Jaundice
assessments
• Poor feeding
• Decreased activity
Refer to: • For infants exposed to SSRIs / SNRIs
• Chest during pregnancy, monitor SpO2:
• Skin (jaundice) at one hour of life
every 4 hours x 24 hours
at discharge
Intervention

0 – 12 hours
Physiological
Assessment
(POS)
Weight Norm and Normal Norm and Normal Variations Norm and Normal Norm and Normal Variations
Variations • Refer to >72 hr – 7 days and Variations • Evidenced-base expected weight loss and when weight
Assess: • Refer to >72 hours – beyond • Refer to >72 hr – 7 should start to be regained are not yet established47
• Weigh baby naked 7 days and beyond days and beyond • Consensus that return to birth weight by about 2
on tummy on a • Normal birth weight weeks48
warm blanket for term infants is • When milk is in about day 3 – 4 expect wt gain of 20 –
Guidance Parent Education/
(anecdotal reports 2500 – 4000 gm 30 gms/day (about an ounce)49
• Weight is only one component Anticipatory Guidance
indicate infants • Weighing of newborn • Consistent weight gain of about 140 – 200 gm/wk
of a newborn’s wellbeing and
startle and cry less after completion of • Refer to >12 – 24 hr (about 4 – 7 ounces) per week for the first 4 months50
the feeding assessment

– giving a more initial feeding or skin-
to-skin (may be up to • Mother aware that hydration & Parent Education/ Anticipatory Guidance
accurate weight –
and less stressful) 2 hours) elimination affect weight (intake Variance • Refer to >12 – 24 hr
and output) • Refer to >12 – 24 hr • Signs of adequate hydration
• Weight gain/loss for
appropriate age • Feeding indicators of adequate • Excessive weight loss • After stability is established, the newborn is weighed
Parent Education/ hydration around 3 – 4 days and at around 7 – 10 days (this latter
• Signs of adequate may be due to
Anticipatory Guidance • Normal expected weight loss weighing may be done during the follow-up by the
intake poor feeding
• Refer to >12 – 24 hr to day 3 – 4 (especially with (inadequate milk PHCP assessment within one week of discharge)51,52
exclusive breastfeeding) transfer), poor
Assess mother’s/ Variance
Variance • Normal expected weight gain latch, poor suck,
family/supports • Refer to >24 – 72 hr
after day 3 – 4 (especially with infrequent feeds
understanding of • Refer to >12 – 24 hr • Weight loss that continues after day 3 – 4 warrants
exclusive breastfeeding) low maternal milk
newborn physiology close assessment of the feeding situation53
• Discharge weight prn production
and capacity to • No weight gain by day 5
identify variances that Intervention illness
• Has not returned to birth weight by about 2 weeks
may require further • Refer to >12 – 24 hr Variance
assessments Intervention
• Newborn Conditions that may Intervention
require daily weight • Refer to >24 – 72 hr
• Gestational age <37weeks • Assess feeding and develop a feeding plan with mother
Refer to:
• SGA • Have a follow-up plan
• Vital Signs
• Receiving phototherapy • Depending on the variance, may need to initiate
• Feeding
breast expression/ pumping q 3 – 4 hours and/ or
• Behavior supplemental feedings
• Elimination Intervention • A combination of hand expression, followed by
• Skin • Nursing assessment pumping with breast compression while pumping
• Postpartum • Ongoing feeding assessment supports the production of milk54
Nursing Care • Teaching and support • Refer to appropriate PHCP prn
Pathway: Breasts
Physiological Health: Weight

27
Behavioral Assessment
28
Behavioral 0 – 12 hours >72 hours – 7 days

>12 – 24 hours >24 – 72 hours
Behavior Norm and Normal Variations Norm and Normal Variations Norm and Norm and Normal
• Alert for the 1st 1 – 2 hours after • Demonstrates Normal Variations
Assess Infant’s: birth Early feeding cues: infant wiggling, moving arms and Variations • Refer to
• Behavior states • Sleeps much of the remaining POS legs, mouthing, rooting, fingers or hands to mouth55 • Refer to >24 – 72 hr
(transition to extrauterine life) Later feeding cues: fussing, squeaky noises, >12 – 24 hr
• Behavior cues
• May be sleepy or unsettled due to restlessness, progressing to soft intermittent crying56 • Wakes 8 or
• Response to
delivery Organized state movement from quiet alert to crying more times in Parent Education/
consoling
• Responds to consoling efforts Minimal crying but is strong and robust (if occurs) 24 hours for Anticipatory
Responds to consoling efforts feeding Guidance
Assess mother’s/ • Cry – strong and robust
• Refer to
family/supports >12 – 24 hr
• Understanding of Parent Education/ Anticipatory Parent Education/ Anticipatory Guidance Parent
normal newborn Guidance Education/
• Refer to POS
behavior Anticipatory
• Expect baby to become more • Review/discuss Guidance
• Response to wakeful after POS Behavior states
newborn cues/ • Refer to

• Feeding cues-refer to Norm and • Deep sleep – if aroused will not feed
needs >12 – 24 hr
Normal Variations >12 – 24 hr • Quiet sleep
• Capacity to identify • “Back to Sleep” • Drowsy
variances that may • Responds to consoling
require further • Quiet alert: optimal state for feeding and infant-parent
assessments interactions
• Active alert: time for feeding
• Crying: late feeding cue
Refer to: • Behavioral feeding cues indicating readiness to feed (refer
• Vital Signs to Norm and Normal Variations >12 – 24 hr, above)
• Crying Satiety Cues
• Elimination • Sucking ceases
• Feeding • Muscles relax
• Head • Infant sleeps/removes self from breast57
• Review/discuss infant attachment behavior – any behavior
infant uses to seek and maintain contact with and elicit a
response from mother/caregiver

Behavioral 0 – 12 hours >72 hours – 7 days
>12 – 24 hours >24 – 72 hours
Behavior Variance Variance Variance Variance

(Continued) • Weak or irritable high pitched cry • Refer to POS • Refer to • Refer to
• Does not respond to consoling • Arching 0 - 24 hr 0 - 24 hr
efforts Intervention Intervention
Intervention
• In utero exposure to SSRIs/SNRIs • Refer to
• Refer to POS • Refer to
• Exposure to codeine in breastmilk 0 – 24 hr 0 – 24 hr
• Refer to Parent Education/Anticipatory Guidance
• Exposure to substances
• Assess factors which may influence behaviors
Intervention Environmental stimuli
• Complete a full newborn Correct sleeping position

assessment Gestational age
• Refer to appropriate HCP prn Medicated labor
• Mother/caregiver education re Pregnancy substance use

effect on newborn and follow-up • Refer to appropriate PHCP
care
Behavioral Assessment
29
Behavioral Assessment: Crying
30
0 – 12 hours
Behavioral
Assessment
(POS)
Crying Norm and Normal Norm and Normal Variations Norm and Normal Norm and Normal Variations
Variations • Refer to POS Variations • Refer to POS
Assess: • Minimal crying but is • Refer to POS
• Crying patterns strong, robust
Parent Education/ Anticipatory Parent Education/ Anticipatory Guidance
• Quality • Responds to
Guidance Parent Education/ • Refer to >12 – 24 hr
consoling – includes
• Duration • Review infant behavior states Anticipatory • Crying is a late signal from infant
feeding
• Fussy periods • Breastfeeding/skin-to-skin during Guidance
• Family strategies to respond to crying
• Parental painful procedures • Refer to >12 – 24 hr • Review & discuss amount of crying
• Interpretation Parent Education/ • Crying Period of PURPLE Crying resource
of crying Anticipatory Guidance Is a late feeding cue Begins at about 2 weeks
• Coping strategies • Refer to >12 – 24 hr Assist parents in developing Continues until about 3-4 months61
soothing techniques • Discuss normal feeling of frustration and potential
Assess: mother’s, • Soothing and consoling techniques to anger when infant inconsolable
family, supports establish trust/bonding60 • If consoling techniques do not work and

understanding of Skin-to-skin
parents feel frustrated ensure baby is in a safe
normal newborn crying Feeding environment and leave the room
and her capacity to Showing mother’s face
• Infant may continue to cry despite soothing efforts
• Use consoling Talking in a steady, soft voice (is not related to parenting capability)
techniques Holding arms close to body • Healthy infants can look like they are in pain when
• Identify variances Holding/carrying crying – even when they are not
that require further Movement: swaying, rocking, • Care for the caregivers
assessments walking Breaks
• Discuss Support system(s)
That infants cry Exercise
Refer to:
Importance of responding to infant
• Web reference for parents on prevention of
• Behavior crying, but that infant may continue shaken baby syndrome/ infant crying:
• Feeding to cry despite soothing efforts www.purplecrying.info
• Maternal
Postpartum
Nursing Care
Pathway: Bonding
& Attachment

Behavioral 0 – 12 hours
Crying Variance Parent Education/ Anticipatory Variance Variance

(Continued) • Infant does not respond to Guidance (cont’d) • Refer to POS • Inconsolable constant crying
consoling techniques • Review The Period of PURPLE • Refer to POS
• Unusual, high-pitched crying Crying resource
Intervention
(neurological) www.purplecrying.info
• Refer to POS Intervention
• Weak irritable cry
• Refer to POS
• No cry (along with other
Review signs that indicate that • Rule out medical concerns – ensure baby
symptoms may reflect illness,
baby may be ill is thriving, i.e. not crying due to hunger,
e.g. sepsis)
• Fever medical concern

• Inappropriate parental/caregiver
• Vomiting • Discuss potential scenarios related to
response to baby’s crying
• Infant states difficulty in consoling infant
Not responding to infant crying
• Discuss choosing appropriate support
Making negative comments
people
about infant’s behavior
Variance
• Refer to POS
Intervention Variance – Baby at risk for harm
• Refer to Parent Education/ • Shaking an infant
Intervention
>12 – 24 hr • Refer to POS
Intervention – Baby at risk for harm
• Nursing Assessment • Nursing Assessment
• Refer to appropriate • Refer to appropriate PHCP prn
PHCP prn • Encourage use of family/support network for
support
• Consider consulting social services/ child
protection services
Behavioral Assessment: Crying

31
Infant Feeding: Breastfeeding
32
Infant Feeding 0 – 12 hours >72 hours – 7 days

>12 – 24 hours >24 – 72 hours
Breastfeeding Norm and Normal Norm and Normal Variations Norm and Normal Variations Norm and Normal
Variations • Feeds ≥ 5 feedings in first 24 hours and may • Feeds 8 or more times/24 hours Variations
Assess feeding
effectiveness • Skin-to-skin immediately cluster feed64 and frequently during the night • Refer to > 24 – 72
after birth • Variable frequency and duration – different for initially hours
• Active feeding
• Offer breast when he/she each mother-infant dyad65 • Shows signs of adequate • Frequency of feeds
• Positioning
shows signs of readiness • Wakes to complete feeds hydration may decrease once
• Latch (usually with in first 1 – 2 milk supply established
• Contented and satiated after
• Hydration hours) feeding • Baby gaining weight
• Frequency • Baby latchs and begins Parent Education/ Anticipatory Guidance regularly
• Duration to suck • Refer to POS • Content after most
• Sucking • Assist mother to watch/look for feeding cues Parent Education/ Anticipatory
• Actively feeds feedings
Wiggling arms and legs
Guidance
• Swallowing • Tolerates feeds • Pattern of breast usage
Hands to mouth • Refer to >12 – 24 hr
• After initial feed baby may may change (e.g. one
Rooting • Amount eaten at each individual or both breasts per
Assess mother’s ability not be interested in further
Mouthing66
feeding increases as milk supply feed)
feeding during this period.
to initiate & complete

increases
feeds • May have small emesis • Crying is a late feeding cue67 • Changes in feeding
• Aware that frequent feedings patterns where infants
• Observe of mucous or undigested • Infants aroused from deep sleep will not
assists in milk production feeds more frequently
Feeding milk following feeds feed68
(10 mls or less) • Breastfeeding throughout night – for several days
Mother’s response • Support early & frequent breast feeding
stimulates milk production, relieves (commonly called
to feeding (provides antibodies)
breast fullness discomfort, helps growth spurts)
If < 48h old to have
Parent Education/ • Normal newborns eat 15±11gms over the prevent engorgement72
2 successful feeds Anticipatory Guidance first 24 hours
• Signs of effective feeding
documented before • The benefits of skin-
Stomach capacity and amount of each
8 or more feedings after the first
discharge62,63 to-skin during the individual feeding are unknown69
24 hours
establishment of • Duration varies for each feeding and mother-
Hear a “ca” sound during
breastfeeding infant dyad (may last ~20 – 50 min) 70
Refer to: feeding
• Discuss that a satiated infant is relaxed, Coordinated suck and swallow
• Elimination
sleepy & disengages from breast
• Weight Refer to elimination re numbers
• Burping positions
• Skin of wet diapers and bowel
• Elimination and hydration status should be movements
• Behavior components of the feeding assessment71 Returns to birthweight by about
• Postpartum Nursing
two weeks
Care Pathway:
PSBC (2013) Breastfeeding Healthy Term Evidence of milk transfer
Breasts and Infant
Infants
Feeding
www.healthlinkbc.ca/kbase/topic/special/
hw91687/sec1.htm

>12 – 24 hours >24 – 72 hours
BREASTFEEDING Parent Education/ Anticipatory Parent Education/ Anticipatory

(Continued) Guidance Guidance
• Refer to >12 – 24 hr • Refer to >12 – 24 hr
Assess mother’s/ family/supports
• Importance of breastfeeding • Resources
understanding of
• Effective positioning • PHN
• Breastfeeding
• Active feeding • Community Health Services
• Need for vitamin supplement
• Effective latch • Support Groups
• Positioning • Exclusive breast feeding for the first six
Assess mother’s capacity to months74
• Frequency and duration
identify variances that may

• Newborns who are breastfed or • Introduction of complementary solids
require further assessments and/
receiving breastmilk should receive recommended at or around six months
or intervention
a daily vitamin D supplement of with continued breastfeeding for up to
10 µg (400 IU) from birth to at least two years and beyond
12 months of age.
• Hydration www.healthlinkbc.ca/healthfiles/
• Show all mothers how to hand hfile69c.stm
express73 (especially if newborn is
LGA, SGA or risk for hypoglycemia –
infants of diabetic mothers)
www.hc-sc.gc.ca/fn-an/nutrition/
infant-nourisson/index-eng.php
Active Feeding – Breast – several bursts of sustained sucking at both breasts each feeding
including effective positioning, latch and evidence of milk transfer
Positioning – chest to chest, skin-to-skin, nipple to nose
Effective Latch – Chest to chest, nose to nipple, wide open mouth, flanged lips, no dimpling of
cheeks, may hear audible swallow, rhythmic sucking, baby doesn’t easily slide off the breast, no
nipple damage or distortion after feed
Adequate hydration – moist mucous membranes, elastic and responsive skin turgor
Evidence of milk transfer – audible swallowing, rhythmical sucking, adequate output (refer to
Elimination) appropriate weight loss for age (refer to Weight)

33
34
Infant Feeding 0 – 12 hours >72 hours – 7 days and

>12 – 24 hours >24 – 72 hours
BREASTFEEDING Variance Variance Variance Variance

(Continued) • Infant shows no signs of interest • Refer to POS • Refer to 0 – 24 hr • Refer to 0 – 72 hr
in feeding • Dimpling of cheeks
• Poor/absent latch • Smacking sounds Intervention Intervention
• Does not latch: prior to initial while feeding
• Refer to 0 – 24 hr • Refer to 0 – 72 hr
latch may lick, nuzzle or root for • Not feeding
nipple effectively Parent Education/ Anticipatory Guidance
• Poor feeding position Vitamin D Supplement: Parent Education/
Parent Education/
• Uncoordinated suck/swallow/ Anticipatory Guidance Norm and Normal Variations Anticipatory Guidance
breathing pattern • Cases of Vitamin D deficiency still occur in • In individual practice, the
• Newborns who are
• Coughing, choking Canada among infants who do no receive decision to discontinue
breastfed or receiving
• Respiratory distress with feeding breastmilk should supplements the supplement beyond
• Does not settle following feeds receive a daily • Vitamin D is an essential nutrient 12 months of age can
• Congenital anomalies (e.g. vitamin D supplement that helps the body use calcium and be informed by a dietary
tongue tie, cleft palate) of 10 µg (400 IU) from phosphorous to build and maintain strong assessment of other
• Mother chooses to provide birth until at least bones and teeth contributors of vitamin D,
additional milk when no medical 12 months of age. www.hc-sc.gc.ca/fn-an/nutrition/infant- such as cow milk.
indications for supplementation nourisson/recom/index-eng.php
• For advice about vitamin D for infants
and young children who are not breastfed
or receiving breastmilk see: In practice:
Talking to families about infant nutrition.
www.hc-sc.gc.ca/fn-an/nutrition/infant-
nourisson/recom/index-eng.php#a12
• Newborns who are not given any
breastmilk and are receiving commercial
formula do not need a vitamin D
supplement as the formula contains
vitamin D.

>12 – 24 hours >24 – 72 hours
Breastfeeding Intervention Intervention Variance Variance

(Continued) • Assess reason for • Refer to POS/Parent Education/ • Refer to 0 – 24 hr • Refer to 0 – 72 hr
variance Anticipatory Guidance >12 – 24 hr • Intervention
• Assess feeding to • Nursing Assessment to include: • Refer to 0 – 24 hr
reassure mother that Position and Latch • May require feeding alternatives (by mother’s Intervention
infant’s needs are met by Encourage skin-to-skin informed decision) if there is evidence that the • Refer to 0 – 72 hr
breastfeeding Support the upper back and baby needs more milk than he/she is getting
• Ensure that concerns shoulders, cradling the neck/base (e.g. by spoon, cup, dropper, bottle)
about feeding are of the skull, no pressure on baby's • Feeding plan in place, such as
addressed
head Improve latch & position

• Provide sufficient Skin-to-skin or light clothing – baby Increase frequency of feeding
information to ensure is not wrapped Stimulate baby
that the mother is Tummy to tummy with baby's
Hand express after feeding
aware of the effects bottom tucked close to mom Express/pump q 2 – 3 hr
of unnecessary If breast large, support breast
Express and top up
supplementation on (fingers well back from areola) Top up with___________
mother and baby Touch baby’s lips with nipple
• Provide teaching as • Refer to appropriate PHCP
Wait until mouth open wide
needed. Aim nipple towards the roof of
• Follow-up in 24 – 24 hr infant’s mouth – the bottom lip Variance – Ineffective feeding
• Refer to appropriate is well back from the base of the • Baby not getting enough milk based on clinical
HCP prn nipple assessment
• Waking/latching techniques80
• Breast stimulation
Intervention – Ineffective feeding
Refer to Postpartum Nursing Care
Pathway
• Assist with latch
• Refer to appropriate PHCP
• Hand expression with breast compression
• Assess for jaundice
• Techniques for waking sleepy baby (stimulating
baby – skin-to-skin, not over dressing)
• Provide EBM if infant unable to effectively
transfer milk
• Medically indicated supplementation: use EBM,
donor milk or formula (start with small amounts)

35
Infant Feeding: Breast Milk Substitute
36
0 – 12 hours
>72 hours – 7 days and
Infant Feeding Period of Stability >12 – 24 hours >24 – 72hours
beyond
Assessment (POS)
Breast milk Norm and Normal Norm and Normal Variations Norm and Normal Norm and Normal
Substitute Variations • Every 2 – 4 hr Variations Variations
Feeding • Skin-to-skin for all • Cue based feeding • Refer to >12 – 24 • Baby is content between
(Formula) babies regardless hr feedings
• Signs of fullness
• Provide of feeding method • Formula prepared safely
information as • Tolerates feed
Parent Education/ Anticipatory Guidance – Formula Fed Infants Parent Education/
necessary for
Anticipatory Parent Education/
informed decision • Choice of formula (ready-to-feed and concentrated are sterile until
Parent Education/ Guidance Anticipatory Guidance
making and opened; powdered formula is not sterile)
Anticipatory * If no variances • Formula feeding your
understanding • Equipment
the difficulty of Guidance Equipment needed
• Refer to >12 – 24 baby
reversing the • Information about Cleaning of equipment
hrs
www.healthlinkbc.ca/
decision to formula the importance • Preparation, storage and warming formula (refer to BC Health File) • For lactation healthfiles search for
feed and maternal and • Safety at room temperature suppression – Healthfile #69a and 69b
• Explore feeding infant benefits of • Positioning: Refer to

• Refer to >12 – 24 hrs
options-address breast milk and Hold baby close during feeding Postpartum
Nursing Care • Cue based feeding
mother’s specific breastfeeding Have baby’s head higher than body, supporting baby's head
Pathway: Breasts • Signs of fullness
concerns about • Address maternal Hold bottle so most of the artificial nipple is in baby’s mouth and
specific concerns • 3 – 7 days
infant feeding formula fills the nipple
6 – 10 feedings per
regarding feeding Never prop the bottle
issues 24hrs
Assess • Encourage mother to observe baby to recognize early feeding cues
60 – 90 ml per feed
• Coordinated • Refer to Infant wriggling and moving arms and legs
>12 – 24 hr Fingers or hand to mouth • 1 – 2 weeks

suck and swallow
Rooting 6 – 8 feedings per
(active feeding)
Mouthing81, 82 24 hrs
• Hydration
• Crying is a late feeding cue83 60 – 90 ml per feed
• Frequency
• Infants aroused from deep sleep will not feed84 • 3 weeks – 2 months
• Duration • Follow baby’s cues re amount to give – newborns may drink small 5 – 7 feedings per
• Able to consume amounts at a feeding, as little as 30 ml at a feeding 24 hrs
appropriate • Burping positions 120 – 150 ml per feed
volume for age/ • Stop feeding when baby shows signs of fullness – closing mouth, Introduction of
weight turning away, pushing away, falling asleep complementary solids
• Not to coax to finish bottle at about 6 months
Resources: BC Health Files
• Formula Feeding Your Baby: Getting Started
www.healthlinkbc.ca/healthfiles/hfile69a.stm
• Formula Feeding Your Baby: Safely Preparing and Storing
Formula
www.healthlinkbc.ca/healthfiles/hfile69b.stm
Infant Feeding 0 – 12 hours >72 hours – 7 days and
>12 – 24 hours >24 – 72 hours
Breast milk Substitute Variance Variance Variance Variance

(Formula) Feeding • Babies at high risk for • Inappropriate formula preparation • Refer to >0 – 24 hr • Refer to 0 – 24 hr
(Continued) allergies or type • Inappropriate formula
Intervention • Incorrect preparation and
Assess mother’s/ family/supports Intervention www.healthlinkbc.ca/healthfiles/ storage
• Awareness of the importance of hfile69b.stm • Overfeeding
• Correct hypo-allergenic
breast milk and breast feeding formula (e.g. protein
• Understanding of normal newborn hydrolysate) Vomiting or frequent large Intervention
feeding
regurgitation • Refer to 0 – 24 hr
• Knowledge of • Fussy
Variance
Appropriate formula
• Babies of vegan parents • Irritable, crying
Safe formula preparation
• Arching
Safe formula storage
• Gassy
Cost Intervention
• Loose stools
Potential health concerns with • May use soy based formula
formula
• Ability to initiate & complete feeds Intervention
• Observe • Nursing assessment
Newborn feeding • Assessing feeding and burping
Mother’s response to feeding techniques
Refer to: • Assessing hunger cues vs satiated
cues to avoid overfeeding
• Elimination
• Inquire food intolerance/allergies in
• Weight
family
• Skin
• Follow-up assessment in 24 – 48 hr
• Behavior
• Refer to nutritionist/ PHCP/other
• Postpartum Nursing Care resources prn
Pathway: Infant Feeding
Infant Feeding: Breast Milk Substitute

37
Health Follow-Up Assessment
38
Health Follow-Up 0 – 12 hours >72 hours – 7 days

>12 – 24 hours >24 – 72 hours
Health Norm and Normal Norm and Normal Variations Norm and Normal Norm and Normal
follow-up Variations • Parents/caregiver have a plan for follow-up with PHCP Variations Variations
• Vitamin K given IM • Newborn ready to move to be cared for by parent (caregiver) • Refer to 0 – 24 hr • Refer to 0 – 24 hr
Baby to receive based on birth weight85 Normal newborn exam
Vitamin K • Administer after Caregiver recognition of normal newborn changes and informs
Parent Education/ Parent Education/
completion of initial PHCP of abnormal findings Anticipatory Anticipatory
feeding (within 6 hr of Newborn feedings are successfully initiated and completed
Assess mother’s/ Guidance Guidance
birth) 86 while skin-to- Parent/caregiver response to newborn cues and needs
family/supports • Aware of need • Refer to 0 – 72 hr
skin Support system in place
• Understanding of for a hands on
appropriate health assessment at
care follow-up Parent Education/ 3 – 4 days and Variance
Parent Education/Anticipatory Guidance
• Capacity to Anticipatory Guidance within 7 – 10 • Refer to 0 – 24 hr
• Parents/caregiver aware when discharged <48 hr after birth:
Identify • Vitamin K administration days91,92, 93
arrangements made for evaluation (as per clinical care paths for
variances – prevention of • Need for further Intervention
assessment and care) within 48 hours of discharge by a Health Care
that may hemorrhagic disease of follow-up

Professional87,88, 89 • Refer to 0 – 24 hr
require further the newborn appointment
• Parents aware of the need for a newborn physical and feeding
assessments with PHCP within
assessment around 3 – 4 days of life90
Access Health first 6 weeks of
Variance • Growth and development of newborn newborn’s life
Care
• Parents refuse IM www.healthlinkbc.ca/kbase/topic/special/hw42229/sec1.htm
injection
Follow agency policy Variance
for identification of Intervention Variance • Refer to 0 – 24 hr
high risk clients • Oral dose Vitamin K • Parents do not have a PHCP or a plan for follow-up with PHCP
E.g. Consider use is 2 mg at time of first
• Parents do not have knowledge or capacity to identify variances in
of Nursing Priority feeding, repeated at Intervention
newborn
Screening Tool 2 – 4 weeks and at • Refer to 0 – 24 hr
(Parkyn, BC 6 – 8 weeks
adaptation 2010) Variance Intervention
• Refer to >12 – 24 hr • Nursing assessment
• Identify barriers and support family with solutions
• Alternative medical/ health care follow-up
Intervention
• Consult social workers/services
• Refer to >12 – 24 hr • Ministry of Children and Family Development
www.gov.bc.ca/mcf/
• Childcare resources and referrals www.ccrr.bc.ca/
Health Follow-Up 0 – 12 hours >24 – 72 >72 hr – 7 days and
>12 – 24 hours
Assessment Period of Stability (POS) hours beyond
Immunization Norm and Normal Variations Norm and Normal Variations Norm and Norm and Normal
and • Refer to >12 – 24 hr • Aware of appropriate immunizations and schedules Normal Variations
Communicable • No exposure to Hepatitis B, Hepatitis C or Variations • Refer to
Diseases HIV • Refer to >12 >12 – 24 hr
Parent Education / Anticipatory Guidance
– 24 hr
• Review
Assess mother’s/ Parent Education/ Anticipatory Guidance Parent Education/
Benefits of immunization
family/supports Parent Anticipatory
• Refer to >12 – 24 hr www.caringforkids.cps.ca/immunization/index.
understanding of: Education/ Guidance
htm
• Immunization Variance • Refer to
Diseases for which immunizations available Anticipatory

(including • Refer to >72 hr – 7 days and beyond >12 – 24 hr
Schedule Guidance
informed consent)
Intervention Side effects • Refer to >12
• Child Health
• Refer to >72 hr – 7 days and beyond Where to access immunizations – 24 hr Variance
Passport
Child Health Passport • Refer to 0 – 24 hr
• Hepatitis B
www.healthlinkbc.ca/kbase/topic/special/
protocols prn Variance – Hep B Exposure Variance
immun/sec1.htm
• Hepatitis C • Fetal exposure • Refer to Intervention
protocols prn Mother is HBsAg (Hepatitis B Surface POS and • Refer to 0 – 24 hr
• HIV protocols prn Antigen) positive Hepatitis B >72 hr – 7
• Varicella fetal / Mother has risk factors for Hepatitis • Disease transmission days and
beyond Variance –
infant exposure infection (IV drug user, sex worker/status
No immunizations
Assess mother’s unknown) www.healthlinkbc.ca/kbase/topic/detail/drug/zb1228/
Primary care giver or household contact • Does not plan
capacity to identify detail.htm Intervention
acute or chronic Hepatitis B infection to have baby
variances that may www.bccdc.ca/NR/rdonlyres/328189F4-2840-44A1- • Refer to
Primary care giver has risk factors for
immunized
require further 9D13-D5AB9775B644/0/Epid_GF_HepBControl_ POS and
assessments Hepatitis B infection (such as IV drug Intervention –
June2004.pdf >72 hr – 7
user, sex worker, men who have sex with No immunizations
days and
men) and infectious state unknown • Explore reasons
Refer to: beyond
Household member(s) from an area where www.phac-aspc.gc.ca/hcai-iamss/bbp-pts/hepatitis/ • Provide information
• Postpartum Hepatitis is endemic hep_b-eng.php prn
Nursing Care
Pathway: • Refer to appropriate
Communicable Intervention – Hep B Exposure www.who.int/csr/disease/hepatitis/ PHCP prn
Diseases • Administer Hep.B immunization and HBIG whocdscsrlyo20022/en/index.html
as per BCCDC protocol
Health Follow-Up Assessment: Immunization and Communicable Diseases

39
Health Follow-Up: Immunization and Communicable Diseases
40
Health Follow-Up 0 – 12 hours >24 – 72 >72 hr – 7 days and

>12 – 24 hours
Assessment Period of Stability (POS) hours beyond
Immunization Variance- Hep C Exposure Parent Education/ Anticipatory Guidance

and • Fetal exposure to Hepatitis C Hepatitis C
Communicable
Diseases • Recommend: infant to have a blood test (for PCR/RNA)
Intervention – Hep C Exposure at 6 weeks and, unless initial test positive, antibody
(Continued)
• Support breastfeeding (breastfeeding not test at 12 months.96
contraindicated94,95
• If nipples are cracked or bleeding - discard www.cps.ca/english/statements/ID/id08-05.htmSOGC
breast milk during this time as HCV is Guideline
transmitted through blood
• HCV is a blood borne pathogen and is not
transmitted by urine or stools www.sogc.org/guidelines/public/96E-CPG-
October2000.pdf
Variance – HIV Exposure

HIV
• Fetal exposure to HIV

• BCPHP Guideline
www.bcphp.ca//sites/bcrcp/files/Guidelines/
Intervention - HIV Exposure Obstetrics/HIVJuly2003Final.pdf
• Breastfeeding contraindicated • Oak Tree Clinic
• Follow HIV Protocol: refer to www.bcwomens.ca/Services/HealthServices/
>12 – 24 hr Parent Education/ Anticipatory OakTreeClinic/default.htm
Guidance
Varicella
Variance – Varicella • BCCDC Guideline
• Fetal exposure to Varicella www.bccdc.ca/NR/rdonlyres/0065F4AD-
• Newborn exposure to Varicella 0EEC-430F-B1B5-9634115528D4/0/Epid_GF_
VaricellaZoster_July04.pdf
Intervention
• Follow Varicella Protocol – refer to > 12 – 24
hr Parent Education / Anticipatory Guidance

0 – 12 hours
Health Follow-Up >72 hr – 7 days and
Period of >12 – 24 hours >24 – 48 hours
Assessment beyond
Stability (POS)
Safety Norm and Norm and Normal Variations Norm and Norm and Normal
and Injury Normal • Parents able to provide a safe environment for newborn Normal Variations
Prevention Variations Variations • Refer to >12 – 24 hr
Newborn • Refer to
identified as per • SIDS prevention /Safe Sleep environment97 >12 – 24 hr
Assess mother’s/
organization’s Supine (back lying) position for sleep Parent Education/
family/ supports
policy Safe sleeping environment: sleep surfaces, well fitting, firm mattress, bottom Anticipatory Guidance
knowledge of common
sheet firmly tucked in, blanket tucked in at the bottom, avoid pillow, toys, soft Parent • Refer to >12 – 24 hr
safety risks and ability • Refer to
Education/
to access support >12 – 24 hr objects, bumper pads in crib • Need to reassess

Smoke free environment – second hand and third hand (parent/caregiver/other Anticipatory safety risks as
when needed
Parent persons handling infant with smoke on clothing and skin after smoking, smoke Guidance infant’s development
Education/ lingering in a car)98 • Refer to changes (e.g. change
Anticipatory Sleeping in close proximity in the same room (on a separate safe sleep >12 – 24 hr table)
Guidance surface) for the first six months: www.perinatalservicesbc.ca99 • Encourage to read
• Refer to • Hot liquid burns safety labels and
>12 – 24 hr Keep hot adult beverages away from infant warranties
Variance
Adjust hot water temperature to prevent scalds during bathing – below 49oC
Refer to: • Refer to
Variance • Shaken Baby Syndrome • Refer to
• Postpartum >12 – 24 hr
Period of PURPLE Crying resources: www.purplecrying.info Baby’s Best Chance
Nursing Care • Refer to
Pathway: >12 – 24 hr • Supporting head and neck Toddler’s First Steps
Lifestyle – Tobacco • Pets, siblings Intervention Safe Start
Use • Safety of baby products such as • Refer to Health Files
Intervention
Car seat, crib, stroller, change table, soothers, powders, wipes >12 – 24 hr
• Refer to
• Community resources Variance
>12 – 24 hr
Variance • Refer to >12 – 24 hr
• Parents unable to provide a safe environment for newborn
• Nursing assessment • Refer to >12 – 24 hr
• Identify barriers and support family with solutions
Alternative medical/ health care follow-up
Consult social workers/services
Ministry of Children and Family Development: www.gov.bc.ca/mcf/
Childcare resource and referral: www.ccrr.bc.ca/
Health Follow-Up: Safety and Injury Prevention

41
Screening/Other: Newborn Blood Spot Screening
42
0 - 12 hours
Screening >72 hr – 7 days
Period of Stability >12 – 24 hours >24 – 72 hours
Assessment and beyond
(POS)
Newborn Blood Norm and Normal Norm and Normal Variations Norm and Normal Norm and Normal
Spot Screening Variations • Newborns screened between 24 and 48 or prior to hospital discharge. If not Variations Variations
• Refer to completed during this timeframe, collection should be done no later than 7 days • Refer to • Refer to
Assess mother’s/ >12 – 24 hr • Some Health Authorities have early home follow-up programs in place where >12 – 24h >12 – 24h
family/supports staff can collect blood spot specimen in the home setting
understanding of • For home births Registered Midwives will collect the specimens
Parent Education/ Parent Education/ Parent
normal newborn
Anticipatory Anticipatory Education/
screening and Parent Education/ Anticipatory Guidance
Guidance Guidance Anticipatory
capacity to follow-
• Refer to • Parent adequately informed • Refer to Guidance
up on variances
>12 – 24 hr • PSBC Neonatal Guideline 9 Information Sheet >12 – 24h • Refer to
that require further
assessments • Newborn screening for HCP and families >12 – 24h
www.newbornscreeningbc.ca
Variance Variance
• Healthlink Newborn Screening Test
BC’s Newborn • Refer to • Refer to Variance
www.healthlinkbc.ca/healthfiles/hfile67.stm#E46E4
Screening Program >12 – 24 hr >12 – 24h • Refer to
screens for 22 >12 – 24h
disorders.100 Variance – Discharge before 24 hours of age
Intervention • Discharge less than 24 hours or transfer to another health care facility before Intervention
• Refer to 24 hours of age • Refer to Intervention
>12 – 24 hr >12 – 24h • Refer to
Intervention – Discharge before 24 hours of age >12 – 24h
• Specimen collected prior to discharge. The NB Screening Laboratory at BCCH
will request, via the baby’s primary care provider need for a repeat sample to be
collected by 2 weeks (14 days) of age
Rationale: The first blood screen will identify over 80% of disorders and
will help prevent life threatening events

The second screen optimizes detection of PKU, CF and Hcy
which are time sensitive and cannot be reliably detected until
≥ 24 hours after birth101
Variance – Refusal / Deferral

• Parental informed refusal or request for deferral
Intervention – Refusal / Deferral

• Discuss & address questions
• Parent(s) signs Informed Refusal or Informed Deferral Form also signed by PHCP
(one copy on infant chart, one copy to PHCP)

Screening 0 – 12 hours >72 hr – 7 days
>12 – 24 hours >24 – 72 hours
Hearing Screening Norm and Normal Norm and Normal Variations Norm and Normal Norm and Normal
Nursing assessment and Variations • Newborn Hearing Screening completed by Hearing Variations Variations
follow-up not required. • Refer to >12 – 24 hr Screening Program (in smaller facilities screening of • Refer to >12 – 24 hr • Refer to >12 – 24 hr
infants done in the community)
Newborn Hearing Screening is Parent Education/ • PSBC Newborn Record Completed by newborn Parent Education/ Parent Education/
carried out by Hearing Program Anticipatory Guidance screening staff Anticipatory Guidance Anticipatory Guidance
staff • Refer to >12 – 24 hr Parent Education/ Anticipatory Guidance • Refer to >12 – 24 hr • Refer to >12 – 24 hr
• Newborn Hearing Screen
Screening Program staff will Variance Variance Variance
www.phsa.ca/AgenciesServices/
assess mother’s/ family/ • Refer to >12 – 24 hr Services/BCEarlyHearingPrgs/ForFam/ • Refer to >12 – 24 hr • Refer to >12 – 24 hr
supports understanding of NewbornHearingScreening/default.htm
a normal newborn hearing Intervention Intervention Intervention
Brochures
screening assessment and • Refer to >12 – 24 hr • Refer to >12 – 24 hr • Refer to >12 – 24 hr
capacity to follow-up variances • www.phsa.ca/AgenciesServices/Services/
requiring further assessments BCEarlyHearingPrgs/ForFam/Resources/
Brochures.htm
Variance
• Passed with risk factors for delayed onset
• Newborn Hearing Screening not completed
• Parental Refusal
Intervention
• No intervention required by nursing
• Newborn Hearing Screening staff will:
Discuss & address questions
Refer to public health unit for hearing screening if
missed in hospital
Have parent(s) sign Informed Refusal
Arrange follow-up at community level prn
BILIARY ATRESIA Variance

• Refer to Elimination -
Assess mother's/ family/ Stool section
supports understanding of the
BC Infant Stool Colour card and Intervention
capacity to identify variances in • Refer to Elimination -
stool colour Stool section
Screening/Other: Hearing Screening

43
Glossary of Abbreviations
BCCH British Columbia Children’s Hospital Mm Millimetres
Bpm Beats per minute NICU Neonatal Intensive Care Unit
BIIP Behavioral Indicators of Infant Pain POS Period of Stability
CF Cystic fibrosis PHCP Primary Health Care Provider
Cm Centimetres PCR/RNA The best approach to confirm the
CNS Central Nervous System diagnosis of hepatitis C is to test for HCV RNA
E.g. For example (Ribonucleic acid) using a sensitive assay such
as polymerase chain reaction (PCR)
EBM Expressed Breast milk
PKU Phenylketonuria
GI Gastrointestinal
Prn As needed
Gm Gram(s)
PSBC Perinatal Services BC
> Greater than
RR Respiratory Rate
≥ Greater than or equal to
ROM Rupture of Membranes
HBIG Hepatitis B Immune Globulin
SGA Small for Gestational Age
Hcy Homocystinuria
SSRI Selective Serotonin Reuptake Inhibitors
HR Heart Rate
SNRI Selective Norepenephrine Reuptake Inhibitors
Hr Hours
SIDS Sudden Infant Death Syndrome
i.e. That is
S&S Signs and Symptoms
IV Intravenous
T Temperature
LGA Large for Gestational Age
Vs Versus
< Less than or equal to
WHO World Health Organization
Min Minute
Ml Millilitre(s)
References
ACoRN Neonatal Society. (2006). ACoRN – Acute Care of at Risk First Nations, Inuit & Metis Health Committee, Canadian
Newborns (1st Ed) ACoRN Neonatal Society. Vancouver, Pediatric Society (2007). Vitamin D Supplementation:
BC. Recommendations for Canadian Mothers and Infants
www.cps.ca/english/statements/II/FNIM07-01.htm
Bryanton, J., Walsh, D. Barrett, N., Gaudet. (2003). Tub bathing
www.caringforkids.cps.ca/pregnancy&babies/VitaminD.htm.
versus traditional sponge bathing for the newborn. JOGNN.
33: 704-712. Health Canada (2000) Family-Centred Maternity and Newborn
Care: National Guidelines (4th Edition). Ottawa. Ontario.
BC Centre for Disease Control (BCCDC). (2006). Hepatitis C
Public Health Nurse Resource. BC Hepatitis Services. Health Canada (2004). Exclusive breastfeeding duration – 2004
BCCDC. Health Canada recommendation.
www.hc-sc.gc.ca/fn-an/nutrition/child-enfant/infant-
British Columbia (BC) Women’s (2002). Neonatal Observation
nourisson/excl_bf_dur-dur_am_excl-eng.php.
Sheet. Fetal Maternal Newborn and Family Health Policy
& Procedure Manual. Author. Kenner, C. & McGrath, M (2004) Developmental Care of
Newborns and Infants – A Guide for Health Professionals.
Centre for Addiction and Mental Health (CAMH) ; Mother Risk
Elsevier, Philadelphia. PA.
(2007). Exposure to Psychotropic Medications and Other
Substances during Pregnancy and Lactation. A Handbook Lowdermilk, D. L. & Perry, S. E. (2007). Maternity & Women’s
for Healthcare Professionals. Toronto: CAMH Health Care (9th ed.). St. Louis, MI: Mosby.
www.camh.net/Publications/Resources_for_Professionals/ Parkyn JH. (1985). Identification of At-Risk Infants and Preschool
Pregnancy_Lactation/psychmed_preg_lact.pdf Children Public Health Nurses using a weighted multifactor
Canadian Paediatric Society (CPS); College of Family Physicians risk assessment form. Early Identification of Children at Risk
Canada (2009). Routine administration of vitamin K to An International Perspective. Eds: Frankenburg WK, Sullivan
newborns. Position Statement CPS. Ottawa: Ontario. JW. Plenum Press, New York.
CPS (2005). Exclusive breastfeeding should continue to six Perinatal Services BC (PSBC). (2013). Breastfeeding Healthy Term
months. Paediatr Child Health 10(3):148. Infants. Author.
www.cps.ca/english/statements/N/BreastfeedingMar05.htm PSBC. (2002). Report on the Findings of the Postpartum
CPS (2008). Pregnancy and Babies, Breast feeding. Caring for Consensus Symposium. Author.
Kids. CPS Ottawa: Ontario. www.caringforkids.cps.ca/ PSBC. (2010). Newborn Screening (Updated) Guideline. PSBC.
pregnancy&babies/Breastfeeding.htm.
References, cont.
PSBC (BCRCP). (2003). Hepatitis C in the Perinatal Period. Sio, J., Minwalla, F., George, R., (1987). Oral Candida:
Obstetrical Guideline No.18. Author. Is Dummy Carriage the Culprit? Arch Dis Child. 62(4):406-8.
PSBC (2013). Antidepressant use during pregnancy: SOGC. (2000). The Reproductive Care of Women Living with
Considerations for the newborn exposed to SSRI / SNRIs. Hepatitis C Infection. Clinical Practice Guideline. No. 96.
Author. SPGC. SOGC www.sogc.org/guidelines/documents/.
PSBC (2013). BC Infant Stool Colour Cards Screening Program World Health Organization (1998) Health Topics, Pregnancy,
for Biliary Atresia. Author. Making Pregnancy Safer, All Publications, Postpartum
Province of British Columbia. (2010). Baby’s Best Chance. care, Postpartum care of Mother and Newborn: A Practical
Second revision sixth edition. Queen’s Printer of British Guide. www.who.int/en/.
Columbia, Canada.
Endnotes
1. Perinatal Services BC (formerly BC Perinatal Health 22. Sio, J., Minwalla, F., George, R., (1987). Oral Candida: Is
Program) is a program of the Provincial Health Services Dummy Carriage the Culprit? Arch Dis Child. 62(4):406-8.
Authority. 23. Reece R, Ludwig S. Child Abuse – Medial Diagnosis and
2. Health Canada. (2000). Family-Centred Maternity and Management (2nd Edition). Lippincott, Williams & Wilkins,
Newborn Care: National Guidelines (4th Edition) p. 1.8-1.10. Philadelphia, PA. 2001.
3. Perinatal Services BC (PSBC). (2010). Newborn Screening 24. Helfer M, Kempe R, Krugman R. The Battered Child (5th
(Updated) Guideline. Edition). University of Chicago Press, Chicago. 2006.
4. BCRCP (BCPHP) Postpartum Consensus Symposium, 25. Bryanton, J., Walsh, D. Barrett, N., Gaudet. (2003). Tub
(2002). bathing versus traditional sponge bathing for the newborn.
5. Health Canada (2000) Chapter 6, Early Postpartum Care JOGNN. 33: 704-712.; Lowdermilk, D. L. & Perry, S. E.
of the Mother and Infant and Transition to the Community, (2007). Maternity & Women’s Health Care (9th ed.), St. Louis,
Family-Centred Maternity and Newborn Care: National MI: Mosby, p. 746.
Guidelines (4th Edition). 26. Agency for Healthcare Research and Quality (AHRQ) (2009).
6. World Health Organization (WHO) (1998). Postpartum Care www.ahrq.gov/clinic/uspstf/uspshyperb.htm.
of Mother and Newborn: A Practical Guide. 27. Canadian Paediatric Society. (2007) Guidelines for detection,
7. Ibid. p. 2. management and prevention of hyperbilirubinemia in term
and late preterm newborn infants (35 or more weeks’
8. BCPHP. Postpartum Consensus Symposium. (2002).
gestation). Paediatrics and Child Health Vol 12 Suppl B May/
9. Ibid. June 2007, p5B. Access from:
10. Province of British Columbia. (2010). Baby’s Best Chance. www.cps.ca/english/statements/FN/FN07-02.pdf.
Second revision sixth edition. Queen’s Printer of British 28. BCW (2007). Policy CH0200-Hypogycemia: Newborn. Fetal
Columbia, Canada. Maternal Newborn and Family Health Policy & Procedure
11. ACoRN Neonatal Society. (2006). ACoRN – Acute Care Manual.
of at Risk Newborns (1st Ed) ACoRN Neonatal Society. 29. PSBC. (2011) Breastfeeding the Healthy Term Infant.
Vancouver, BC.
30. Province of BC. (2010). Baby’s Best Chance.
12. Holsti L, Grunau RE. Initial valization of the Behavioral
31. PSBC. (2011). Breastfeeding the Healthy Term Infant.
Indicators of Infant Pain (BIIP). Pain 2007;137:264-272.
32. Ibid.
13. Holsti L, Grunau RE, Oberlander TF, Osiovich L. Is it painful
or not? Discriminant validity of the Behavioral Indicators of 33. Ibid.
Infant Pain (BIIP) Scale. Clin J Pain 2008;24:83-88. 34. Ibid.
14. Lowdermilk, D. L. & Perry, S. E. (2007). Maternity & 35. Ibid.
Women’s Health Care (9th ed.), St. Louis, MI: Mosby, p. 36. Ibid.
683.
37. Ibid.
15. Ibid. p. 646.
38. Province of BC. (2010). Baby’s Best Chance.
16. Ibid. p. 647.
39. Lang N, Bromiker R, Arad I. The effect of wool vs. cotton
17. Ibid. p. 646. head covering and length of stay with the mother following
18. Ibid. p. 647. delivery on infant temperature. Int J of Nursing Studies.
19. Province of BC. (2010). Baby’s Best Chance. 2004:41;843-846.
20. BCPHP (2001) Eye Care and Prevention of Opthalmia 40. BCPHP (2002) Postpartum Consensus Symposium.
Neonatorum. BCPHP Newborn Guideline 11. Author. 41. Koren G, Finkelstein Y, Matsui D and Berkovich M. Diagnosis
21. Province of BC. (2010). Baby’s Best Chance. and Management of Poor Neonatal Adaptation Syndrome
in Newborns Exposed In Utero to Selective Seretonin/
Norepinephrine Reuptake Inhibitors. JOGC 2009:4;348-350.

Endnotes, cont.
42. Madadi P, Moretti M, Djokanovic N, et al. Guidelines for 71. BCPHP (2002). Consensus Symposium. Consensus
maternal codeine use during breastfeeding. Canadian Statement #13.
Family Physician 2009:55;1077-1078. Motherisk Update 72. PSBC. (2011). Breastfeeding the Healthy Term Infant.
available at www.cfp.ca and www.motherisk.org.
73. Ibid.
43. BCPHP. (2002). Postpartum Consensus Symposium.
74. Health Canada (2004).
44. Koren G, Finkelstein Y, Matsui D and Berkovich M.
Diagnosis and Management of Poor Neonatal Adaptation
Syndrome in Newborns Exposed In Utero to Selective 76. Canadian Pediatric Society (CPS); (2007) Vitamin D
Seretonin/Norepinephrine Reuptake Inhibitors. JOGC supplementaton: Recommendatons for Canadian mothers
2009:4;348-350. and infants. Paediatr Child Health. 12(7):583-9.
www.cps.ca/englis/statements/II/FNIM07-01.htm.
45. BCPHP Obstetrical Guideline #12. www.bcphp.ca//sites/
bcrcp/files/Guidelines/Obstetrics/GBSJuly2003Final.pdf. 77. Canadian Pediatric Society (CPS); (2007) Vitamin D
supplementaton: Recommendatons for Canadian mothers
46. Madadi P, Moretti M, Djokanovic N, et al. Guidelines for
and infants. Paediatr Child Health. 12(7):583-9.
maternal codeine use during breastfeeding. Canadian
Family Physician 2009:55;1077-1078. Motherisk Update
available at www.cfp.ca and www.motherisk.org 78. Canadian Pediatric Society (2007). Vitamin D
Supplementation: Recommendations for Canadian Mothers
and Infants.
48. Lowdermilk, D. L. & Perry, S. E. (2007). Maternity & www.cps.ca/english/statements/II/FNIM07-01.htm;
Women’s Health Care (9th ed.), St. Louis, MI: Mosby, p. 719. www.caringforkids.cps.ca/pregnancy&babies/VitaminD.htm.
49. Ibid. p. 723. 79. Canadian Pediatric Society (CPS); (2007) Vitamin D
50. Ibid. p. 719. supplementaton: Recommendatons for Canadian mothers
51. BCPHP. (2002). Postpartum Consensus Symposium. and infants. Paediatr Child Health. 12(7):583-9.
52. www.sogc.org/guidelines/documents/190E-PS-April2007.
pdf. 80. Province of BC. (2010). Baby’s Best Chance.
53. PSBC. (2011). Breastfeeding the Healthy Term Infant. 81. PSBC. (2011). Breastfeeding the Healthy Term Infant.
54. Morton J, Hall JY, Wong RJ et al. (2009). Combining 82. Ibid.
hand techniques with electric pumping increases milk 83. Ibid.
production in mothers of preterm infants. J Perinatology. 84. Ibid.
Nov:29(11):757-64.
85. Canadian Paediatric Society (CPS); College of Family
55. PSBC. (2011). Breastfeeding the Healthy Term Infant. Physicians Canada (2009). Routine administration of vitamin
56. Ibid. K to newborns. Position Statement.
57. Ibid. 86. Ibid.
58. Koren G, Finkelstein Y, Matsui D and Berkovich M. 87. BCPHP. (2002). Postpartum Consensus Symposium.
Diagnosis and Management of Poor Neonatal Adaptation 88. SOGC www.sogc.org/guidelines/documents/190E-PS-
Syndrome in Newborns Exposed In Utero to Selective April2007.pdf.
Seretonin/Norepinephrine Reuptake Inhibitors. JOGC.
89. CPS www.cps.ca/english/statements/FN/fn96-02.htm.
2009:4;348-350.
90. BCPHP (2002) Consensus Symposium. Consensus
59. Madadi P, Moretti M, Djokanovic N, et al. Guidelines for
Statement #12.
maternal codeine use during breastfeeding. Canadian
Family Physician. 2009:55;1077-1078. Motherisk Update 91. Ibid.
available at www.cfp.ca and www.motherisk.org. 92. www.sogc.org/guidelines/documents/190E-PS-April2007.
60. Province of BC. (2010). Baby’s Best Chance. pdf.
61. www.purplecrying.info/sections/index.php?sct=1&. 93. www.cps.ca/english/statements/FN/fn96-02.htm.
62. SOGC Policy Statement No. 190, 2007. www.sogc.org/ 94. BCPHP (BCRCP). (2003). Hepatitis C in the Perinatal Period.
guidelines/documents/190E-PS-April2007.pdf. Obstetrical Guideline No.18. Author.
63. CPS joint statement with the SOGC. www.cps.ca/ 95. SOGC. (2000). The Reproductive Care of Women Living with
ENGLISH/statements/FN/fn96-02.htm. Hepatitis C Infection. Clinical Practice Guideline. No. 96.
SPGC. SOGC www.sogc.org/guidelines/documents/.
96. BC Centre for Disease Control (BCCDC). (2006). Hepatitis
65. Ibid.
C Public Health Nurse Resource. BC Hepatitis Services.
66. Ibid. BCCDC.
67. Ibid. 97. Perinatal Services BC (2011). Safe Sleep Environment
68. Ibid. Guideline for Infants 0 to 12 Months of Age. Health
69. Santoro W, Martinez FE & Jorge SM. 2010. Colostrum Promotion Guideline 1.
ingested during the first day of life by exclusively breastfed
healthy newborn infants. Journal of Pediatrics. 156(1):29-32.
Endnotes, cont.
98. Sleiman M, Gujdel LA, Pankow JF, et al. Formation of 99. Perinatal Services BC (2011). Safe Sleep Environment
carinogens indoors by surface-mediated reactions of Guideline for Infants 0 to 12 Months of Age. Health
nicotine with nitrous acid, leading to potential thirdhand Promotion Guideline 1. www.perinatalservicesbc.ca.
smoke hazards. Proceedings of the National Academy 100. Perinatal Services BC Neonatal S Guideline 9: Newborn
of Sciences. 2010;Sptil 107(15); 6576 – 6581. accessed Screening (2010). www.perinatalservicesbc.ca.
April 21, 2010 from www.pnas.org/cgi/doi/10.073/
101. Ibid.
pnas.0912820107.
Revision Commitee
Members of the Newborn Nursing Care Pathway Revision Commitee

Perinatal Services BC would like to acknowledge the working committee who revised the BC Newborn Nursing
Care Pathway. Committee members included:
Barbara Selwood Project Lead, Health Promotion and Prevention, PSBC

Taslin Janmohamed-Velani Coordinator, Knowledge Translation, PSBC
Laurie Seymour Project Consultant
Jacqueline Koufie Clinical Nurse Educator, St. Paul’s Hospital
Radhika Bhagat Clinical Nurse Specialist, 0-5 years, Vancouver Community
Kathy Hydamaka Program Leader, Healthy Babies and Families, Richmond
Joan Brown Clinical Educator for the Early Years Team, North Shore Health
Yvonne Law Perinatal Clinical Educator – Postpartum, BC Women's Hospital
Monica Carey Staff Nurse, BC Women's Hospital
Marina Green Lactation Consultant, BC Women's Hospital
Tammy MacDonald Educator, Surrey Memorial Hospital
Kate McCulloch Regional Clinical Nurse Educator – Aboriginal Health, Fraser Health Public Health
Tanya Jansen Clinical Nurse Educator Maternal Child Program, Ridge Meadows Hospital
Pam Munro CNS Maternal, Infant, Child & Youth Program, Fraser Health Public Health
Elaine Klassen Clinical Nurse Educator, Fraser Health Public Health
Bev Grossler Patient Care Coordinator, Lillooet Hospital
Anita Gauvin NICU Clinical Resource Coordinator, Kamloops Hospital
Patty Hallam Public Health Nursing Program Consultant – ECD, Kamloops
Jennifer Stubbings Team Leader, Thompson Cariboo Shuswap Public Health
Christine Moffitt Clinical Practice Educator, Labour and Delivery, Royal Inland Hospital
Lynn Popien Regional Perinatal Education Coordinator, Royal Inland Hospital
Tamara Kropp Program Manager Medical & Maternity, Quesnel Hospital
Sharron Sponton Community Health Nurse, Smithers
Grace Dowker Maternity RN/Educator, Campbell River Hospital and Community
Amber Thomas Public Health Nurse, Courtenay
Grace Park Family Physician, White Rock
Wilma Aruda Pediatrician, Nanaimo

West Tower, #350
555 West 12th Avenue
Vancouver, BC Canada V5Z 3X7
Tel: (604) 877-2121
www.perinatalservicesbc.ca
While every attempt has been made to

ensure that the information contained
herein is clinically accurate and current,
Perinatal Services BC acknowledges
that many issues remain controversial,
and therefore may be subject to
practice interpretation.
© Perinatal Services BC, 2013

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Perinatal Services BC

• Physiological health (organized from head to toe)

Who Updated the Newborn Nursing Care Pathway

Statement of Family Centered Care

Referring to a Primary Health Care Provider (PHCP)

Referrals to Other Resources

Goals and Needs - Health Canada’s National Guidelines

Newborn Guideline 13: Newborn Nursing Care Pathway 3

Needs – World Health Organization (WHO)

The twelve specific WHO newborn needs continue to be:

• Easy access to the mother

Newborn Physiological Stability

• Respiratory rate between 40-60/ min

Newborn Guideline 13: Newborn Nursing Care Pathway 5

• Full range of motion months

Refer to: Healthy Families BC Website – www.healthyfamiliesbc.ca/parenting

Physiological Health: Head

HEAD Variance Variance Variance Variance – Cradle cap

of motion trauma and/or bruising

Refer to: Healthy Families BC Website – www.healthyfamiliesbc.ca/parenting

identify variances that may

Refer to: Healthy Families BC Website – www.healthyfamiliesbc.ca/parenting

Physiological Health: Nares

assessments • Jaundice progression/ 5 – 7 months

Refer to: feeding or by 1 hour after lifting upper eyelids,

Parent Education/ Anticipatory

Refer to: Healthy Families BC Website – www.healthyfamiliesbc.ca/parenting

Eyes Variance Variance Variance Variance

Blocked tear duct

Variance – Obvious strabismus

Refer to: Healthy Families BC Website – www.healthyfamiliesbc.ca/parenting

Physiological Health: Eyes

Physiological 0 – 12 hours >72 hours – 7 days and

 Low birth weight

Refer to: Healthy Families BC Website – www.healthyfamiliesbc.ca/parenting

• Low set ears  Kanamycin

• Drainage present  Neomycin

• Family history of childhood  Streptomycin

sensory hearing loss  Tobramycin

• Cranial facial anomalies of • Bacteria meningitis

Refer to: Healthy Families BC Website – www.healthyfamiliesbc.ca/parenting

Physiological Health: Ears

may require further • Refer to POS

Refer to: Healthy Families BC Website – www.healthyfamiliesbc.ca/parenting

• Hiccoughs and sneezing common breathing Guidance

• Deviation in chest shape

Refer to: Healthy Families BC Website – www.healthyfamiliesbc.ca/parenting

Physiological Health: Chest

Physiological 0 – 12 hours >72 hours – 7 days

Refer to: Healthy Families BC Website – www.healthyfamiliesbc.ca/parenting

Assess mother’s/ family/ Variance

Refer to: Healthy Families BC Website – www.healthyfamiliesbc.ca/parenting

Physiological Health: Skeletal/Extremities

Physiological 0 – 12 hours >72 hours – 7 days

rash) milia, mongolian  Hemangiomas

family/supports hemangiomas, harlequin pigmented infants such as Asian, First

 Not required every day

 Immersion preferable to sponge bath

(less chance for heat loss)25

temperature, soap can be irritating, use

Refer to: Healthy Families BC Website – www.healthyfamiliesbc.ca/parenting

Skin Variance Variance Variance Variance

Refer to: Healthy Families BC Website – www.healthyfamiliesbc.ca/parenting

Physiological Health: Skin

Low birth weight

• Low set ears Kanamycin

• Drainage present Neomycin

• Family history of childhood Streptomycin

sensory hearing loss Tobramycin

rash) milia, mongolian Hemangiomas

Not required every day

Immersion preferable to sponge bath

of newborn Clean from front to back

Hand expression of • Mild odour

• Colour GI (feeding, vomiting, stooling, excoriation)

every 4 hours x 24 hours

• Complete a full newborn Correct sleeping position

• Mother/caregiver education re Pregnancy substance use

head Improve latch & position

>12 – 24 hr Fingers or hand to mouth • 1 – 2 weeks

Diseases for which immunizations available Anticipatory

Consult social workers/services

Ministry of Children and Family Development: www.gov.bc.ca/mcf/

Childcare resource and referral: www.ccrr.bc.ca/