Neonatal Early Assessment Program (NEAP)

SLHD: Royal Prince Alfred Hospital Guideline Women and Babies: Neonatal Early Assessment Program (NEAP)

TRIM Document No

Policy Reference RPAH_GL2016_059

Related MOH/SLHD Policy N/A

Keywords Newborn examination, anthropometry, body fat, risk assessment, cardiac screening, observations, hypoglycaemia

Applies to Midwifery, obstetric and neonatal staff

Clinical Stream(s) Women’s Health, Neonatology

Date approved GM, RPA 02/12/2016

Date approved by RPA Policy Committee 15/11/2016

Author Staff specialist neonatologist

Status Active

Review Date November 2021

Risk Rating N

Replaces RPAH_GL2013_019

Version History V1

Date 06/12/2016

Sydney Local Health District – Royal Prince Alfred Hospital Policy No: RPAH_GL2016_059

Date Issued: November 2016

Compliance with this Guideline is Recommended 2

Women and Babies: Neonatal Early Assessment Program (NEAP)

CONTENTS

Women and Babies: Neonatal Early Assessment Program (NEAP) ...................................... 3

1. Introduction ................................................................................................................ 3

2. The Aims / Expected Outcome of this Guideline ......................................................... 3

3. Risk Statement ........................................................................................................... 3

4. Scope ......................................................................................................................... 3

5. Resources .................................................................................................................. 3

6. Implementation ........................................................................................................... 3

7. Key Performance Indicators and Service Measures ................................................... 3

8. Guidelines .................................................................................................................. 4

8.1 Early Risk Factor Assessment ............................................................................. 4

8.2 First physical examination ................................................................................... 4

8.3 Oxygen saturation screening ............................................................................... 4

8.4 Anthropometry ..................................................................................................... 5

8.5 Body composition - Fat measurement (fat mass, fat free mass and body fat %) .. 6

9. Definitions .................................................................................................................. 7

10. Consultation ............................................................................................................ 7

11. Links and tools ........................................................................................................ 7

11.1 Associated Policies and guidelines .................................................................. 7

11.2 NSW Health Policies/Guidelines ...................................................................... 7

11.3 Level of Evidence & Recommendation (NHMRC)25 .......................................... 7

11.4 Overview for performing NEAP ........................................................................ 8

11.5 Early physical examination of the newborn ...................................................... 9

11.6 Physical examination referral pathway ........................................................... 10

11.7 Oxygen saturation referral pathway ............................................................... 11

11.8 Anthropometry referral pathway ..................................................................... 12

11.9 PeaPod quick reference user guide ............................................................... 13

12. References ........................................................................................................... 14

12.1 National Standard .......................................................................................... 15




Women and Babies: Neonatal Early Assessment Program (NEAP)

1. Introduction The Neonatal Early Assessment Program (NEAP) consists of a risk factor assessment and four sets of measurements within the first 6 hours after birth:

1. the first physical examination. 2. the first lower limb oxygen saturation. 3. anthropometry 4. body fat (percentage) by Air Displacement Plethysmography (ADP).

2. The Aims / Expected Outcome of this Guideline • To familiarise midwifery, neonatal nursing and medical staff with the evidence,

indications and practical management of a neonate undergoing the NEAP. • Babies with physical abnormalities, cardiac defects, or increased risk of

hypoglycaemia will be identified and appropriately managed.

3. Risk Statement SLHD Enterprise Risk Management System (ERMS) Risk # 106 – Recognising & Responding to Clinical Deterioration in Acute Health Care.

• Clinical risk of neurological damage or death of babies as a result of physical abnormalities, cardiac defects, or neonatal hypoglycaemia going undetected and untreated.

4. Scope • Mothers and newborns • Midwifery staff • Neonatal staff • Obstetric staff

5. Resources • Within existing resources • Air displacement plethysmography machine (known as the PeaPod) maintained and

calibrated at appropriate intervals.

6. Implementation • Notification and distribution of this Guideline will be communicated to midwifery,

obstetric and neonatal staff via email, SLHD / RPAH intranet and education programs.

• Education and orientation regarding the NEAP and operation of the PeaPod by CMEs and other appropriate midwifery, neonatal or medical staff.

7. Key Performance Indicators and Service Measures • Incidents and accidents related to the NEAP reported via the Incident Information

Management System (IIMS) Guidelines




8. Guidelines

8.1 Early Risk Factor Assessment The overall goal of the early assessment is to identify risk factors for early neonatal problems that will require regular postnatal observations, as well as identifying congenital and acquired abnormalities which may have an immediate impact on the baby’s care and/or wellbeing.

• All babies should be reviewed for risk factors for the five main problem areas as identified on the Standard Newborn Observation Chart (SNOC SMR 110.014) and Women and Babies Newborn Care Plan (MR504). These include:

o risk of hypoglycaemia o respiratory distress (includes maternal opiates <4 hours of birth) o risk of subgaleal haemorrhage / trauma from instrumental delivery o risk of sepsis o risk of jaundice

• Assessment of risk of hypoglycaemia will include the anthropometric measurements

and percentage body fat as outlined below.

• Babies identified with risk factors will need observations in accordance with RPAH_PD2016_002 Newborn Observations.pdf.

8.2 First physical examination

• The goal of this examination is to identify obvious external anomalies, as well as other congenital and acquired problems that may have an immediate impact on the baby’s care or well-being. This would include (but not be confined to) problems such as:

o respiratory distress, o consequences of birth trauma (e.g. bruising, subgaleal haemorrhage, nerve

palsy) o cleft palate, imperforate anus, abnormal genitalia and other dysmorphology.

• The examination should include a complete ‘head to toe to back’ inspection of the

baby as detailed in 11.4 and 11.5

• The findings should be documented in the relevant section of Newborn Care Plan (NBCP) MR504.

8.3 Oxygen saturation screening In the first minutes of life, there is a transition from the placenta being the main organ of gas exchange to the newborn lungs. Toth et al demonstrated in 50 healthy newborns that it takes between 12 and 14 minutes to achieve saturations > 95%.1

• Routine oxygenation saturation screening of well newborns has been shown to improve early diagnosis of congenital heart disease (CHD) 2 with a low false positive rate and minimal impact on resources.

• About half of the babies with a low saturation screen (<95%) will have either congenital heart disease (~1/3rd) or other significant pathologies which include respiratory disease, delayed transition to extra-uterine life (persistent pulmonary hypertension of the newborn), sepsis or metabolic conditions (~2/3rd). 3

• Saturation measurement within the first 4 to 6 hours of birth has a lower accuracy for detection of CHD but greater sensitivity for non-cardiac pathology while screening after 24 hours (late screen) has greater sensitivity for detection of CHD, especially left heart ductal dependent lesions.

http://intranet.sswahs.nsw.gov.au/SSWPolicies/pdf/RPA/RPAH_PD2016_002.pdf




At RPAH, both early and late oxygen saturation screening will be performed in accordance with Oxygen Saturation Screening for Congenital Heart Disease http://intranet.sswahs.nsw.gov.au/rpa/neonatal/policy/default.htm.

8.3.1 How to perform oxygen saturation screening

Early oxygen saturation screening will be performed in accordance with the existing guideline

• Perform screening when the infant is quiet.

• Place the probe around one foot with light source and receiver on each side of foot. Secure with Coban® tape. To ensure good blood flow to the foot, do not secure too tightly and do not hold the probe around the foot.

• Switch on oximeter and allow signal to stabilise. Read when stabilised and there is a good plethysmographic light pulse.

• Follow referral pathway 11.6 if indicated

8.4 Anthropometry Newborn measurement of weight, length, and head circumference reflects fetal nutrition and forms the basis on which future growth measurements.4,5,7,8 Refer to Anthropometry Referral Pathway where indicated (section 11.7).

8.4.1 Measure weight

• The newborn is bare weighed using the scales on the PeaPod for accurate measurement of weight to the nearest gram.

• The weight percentile is calculated using the Beeby electronic calculator on the computer in the NEAP room, or if unavailable the weight is plotted on New South Wales population-based birthweight percentile charts (less accurate).9

8.4.2 Measure length • The length-board measurement, infantometer, has been shown to be the most

reliable and accurate measurement of neonatal length 6,10,11 and more recent designs have improved ease of use such as the Easy-Glide Bearing Infantometer (Perspective Enterprises, Portage, MI, USA).

• Place the newborn supine and unclothed on the board and gently hold with his or her body aligned and head in a neutral position.

o One person stands at the top of the length board and holds the baby’s head in contact with the headboard while another extends the left leg by placing the hand over the left knee, depressing the knee, straightening the leg and moving the footboard to touch the plantar surface of the foot at a right angle to the leg.

o Recheck that the head has not moved from the headboard before taking the measurement.

o The actual reading is marked by an arrow as there is an offset for greater ease of reading and accuracy.

• The length percentile is calculated using the Beeby electronic calculator on the

computer in the NEAP room or plotted on New South Wales population-based birth length percentile charts 9 (less accurate).

8.4.3 Measure head circumference

• Head circumference is measured using disposable paper circumference tapes at the maximum occipito-frontal circumference.

http://intranet.sswahs.nsw.gov.au/rpa/neonatal/policy/default.htm




• Two reproducible measurements are required. • The head circumference percentile is calculated using the Beeby electronic calculator

on the computer in the NEAP room or plotted on New South Wales population-based birth head circumference percentile charts 9 (less accurate).

8.5 Body composition - Fat measurement (fat mass, fat free mass and body fat %) Accurately determining the nutritional status of newborns is a major public health problem. Furthermore undernourished neonates that survive are at risk of long term health outcomes, including hypertension, stroke, type 2 diabetes, obesity and cardiovascular disease.12,13 Neonatal undernutrition or ‘wasting’ is a clinical diagnosis often characterised by diminished subcutaneous tissues and underlying muscles with loose wrinkled skin of the arms, thighs, elbows and knees. However this clinical sign is, in our experience at RPAH, not well recognised by a range of health providers. Thus defining who is undernourished is problematic.

Conventional approaches include the use of population based percentiles (< 3rd , 5th or 10th percentiles) or customised growth charts. Population based charts rely on a large cross section of neonates and use weight for gestational age by sex. Customised charts account for more maternal variables, however there is not strong evidence to support their use at present. 14,15 An alternative to birth weight is the use of body composition or body fat % (BF%). The wasted, undernourished newborn is characterised by loss of the normal fat accretion in the last 4-6 weeks of pregnancy. As fat is used by the newborn as an alternative substrate to glucose for brain metabolism, BF% is a potentially very useful measure indicating degree of undernutrition and directly related to neonatal metabolic outcomes. The additional advantage is that it can distinguish the normal fat SGA (weight less than 10th percentile) from the low fat, undernourished SGA newborn and define the low fat AGA newborn at high risk of hypoglycaemia, currently not possible with any other methods. Recently a new technology using air displacement plethysmography (ADP) has become available to non-invasively, accurately and quickly measure BF% in infants from birth to 6 months of age. ADP has been validated against the four-compartment model and biological and physical phantoms16,17 and is considered the criterion method for determining BF% in neonates.18-22 Several studies have investigated the BF% as an indicator of neonatal nutritional status using ADP. 20-25 Body fat is a better measure than customised charts for assessing neonatal morbidity and as good as population based charts.26 The advantage of this method is it is accurate, easy, reliable, non-invasive and acceptable to parents. The cut offs for low and high fat are shown in the flow chart. These were determined by significantly better Receiver Operator Curves (ROCs) for combined morbidity assessed by 3 pre-specified outcomes (temp <36.5C, prolonged hospital stay, poor feeding (2 of 3 objective criteria). The cut off was determined by the highest sensitivity balanced by the best specificity. 26

8.5.1 Measure body composition

• This is performed in the NEAP room just after the measurement of length and weight using the PeaPod (CosMed, USA) see11.3 and 11.8




9. Definitions

Air Displacement Plethysmography

A recognised and scientifically validated densitometric method to measure human body composition

Anthropometry The scientific study of the measurements and proportions of the human body

Abbreviations:

SCG

AGA

Small for Gestational Age

Appropriate for Gestational Age

10. Consultation Nil

11. Links and tools

11.1 Associated Policies and guidelines

• Newborn Observations RPAH_PD2016_002.pdf • Neonatal Clinical Emergency Response System RPAH_PD2016_025.pdf • Oxygen Saturation Screening for Congenital Heart Disease


11.2 NSW Health Policies/Guidelines

• NSW Health, Recognition and management of patients who are clinically deteriorating PD2013_049 http://www0.health.nsw.gov.au/policies/pd/2013/pdf/PD2013_049.pdf

11.3 Level of Evidence & Recommendation (NHMRC)25

Air displacement plethysmography (ADP) non-invasively, accurately and quickly measures BF% in infants from birth to 6 months of age.

Level of evidence: 3 Strength of recommendation: A

Body fat is a better measure than customised charts for assessing neonatal morbidity

Level of evidence: 3 Strength of recommendation: A




http://www0.health.nsw.gov.au/policies/pd/2013/pdf/PD2013_049.pdf

http://www0.health.nsw.gov.au/policies/pd/2013/pdf/PD2013_049.pdf




11.4 Overview for performing NEAP




11.5 Early physical examination of the newborn The routine newborn assessment should include all aspects of the checklist on page 1 of the NCPOC. The schema below moves from head to toe, front to back (adapted from Queensland Maternity and Newborn Clinical Guidelines Program 61).27 This examination does not replace the discharge check which will include the red reflex, the heart and the hips.

Head

Palpate: • Sutures • Fontanelle • Trauma (check sub-galeal

haemorrhage)

Face Inspect: • Morphology • Eyes, Ears • Nose, Jaw

Mouth Visualise and feel palate (hard and soft)

Chest

Check: • Respiratory rate • No recession • Palpate neck

Abdomen

Check: • No distension • Palpate for masses • Umbilicus • Umbilical vessels (x3)

Anogenital

Check normal: • External genitalia • Anus patency, appearance &

position

Limbs

Check normal: • Hands and Feet • Digits • Movements

Back

Check in ventral suspension: • Straight spine • No skin markings over spine

General

Check: • Skin & Colour • Symmetrical • Proportioned




11.6 Physical examination referral pathway




11.7 Oxygen saturation referral pathway




11.8 Anthropometry referral pathway




11.9 PeaPod quick reference user guide




12. References 1. Toth B, Becker A, Seelbach-Gobel B. Oxygen saturation in healthy newborn infants immediately after birth measured by pulse oximetry. Arch Gynecol Obstet 2002 April: 266 (2)105-107

2. A. Meberg, A. Andreassen, L. Brunvand, T. Markestad, D. Moster, L. Nietsch, I. E. Silberg, and J. E. Skålevik, 'Pulse Oximetry Screening as a Complementary Strategy to Detect Critical Congenital Heart Defects', Acta Pædiatrica, 98 (2009), 682-86.

3. A. Meberg, S. Brugmann-Pieper, R. Due, Jr., L. Eskedal, I. Fagerli, T. Farstad, D. H. Froisland, C. H. Sannes, O. J. Johansen, J. Keljalic, T. Markestad, E. A. Nygaard, A. Rosvik, and I. E. Silberg, 'First Day of Life Pulse Oximetry Screening to Detect Congenital Heart Defects', J Pediatr, 152 (2008), 761-5.

4. T. S. Johnson, J. L. Engstrom, and D. K. Gelhar, 'Intra- and Interexaminer Reliability of Anthropometric Measurements of Term Infants', J Pediatr Gastroenterol Nutr, 24 (1997), 497-505.

5. T. S. Johnson, J. L. Engstrom, J. A. Warda, M. Kabat, and B. Peters, 'Reliability of Length Measurements in Full-Term Neonates', J Obstet Gynecol Neonatal Nurs, 27 (1998), 270-6.

6. A. J. Wood, C. H. Raynes-Greenow, A. E. Carberry, and H. E. Jeffery, 'Neonatal Length Inaccuracies in Clinical Practice and Related Percentile Discrepancies Detected by a Simple Length-Board', J Paediatr Child Health, 49 (2013), 199-203.

7. T. H. Lipman, K. D. Hench, T. Benyi, J. Delaune, K. A. Gilluly, L. Johnson, M. G. Johnson, H. McKnight-Menci, D. Shorkey, J. Shults, F. L. Waite, and C. Weber, 'A Multicentre Randomised Controlled Trial of an Intervention to Improve the Accuracy of Linear Growth Measurement', Arch Dis Child, 89 (2004), 342-6.

8. T. H. Lipman, K. D. Hench, J. D. Logan, D. A. DiFazio, P. M. Hale, and C. Singer-Granick, 'Assessment of Growth by Primary Health Care Providers', Journal of Pediatric Health Care, 14 (2000), 166-71.

9. P. J. Beeby, T. Bhutap, and L. K. Taylor, 'New South Wales Population-Based Birthweight Percentile Charts', J Paediatr Child Health, 32 (1996), 512-8.

10. D. P. Davies, and R. E. Holding, 'Neonatometer: A New Infant Length Measurer', Arch Dis Child, 47 (1972), 938-40.

11. A. F. Roche T. G. Lohman, & R. Martorell (eds.), Anthropometric Standardization Reference Manual (Champaign, IL: Human Kinetics Books, 1988).

12. D. J. Barker, J. G. Eriksson, T. Forsen, and C. Osmond, 'Fetal Origins of Adult Disease: Strength of Effects and Biological Basis', Int J Epidemiol, 31 (2002), 1235-9.

13. J. C. Wells, S. Chomtho, and M. S. Fewtrell, 'Programming of Body Composition by Early Growth and Nutrition', Proc Nutr Soc, 66 (2007), 423-34.

14. A. E. Carberry, A. Gordon, D. M. Bond, J. Hyett, C. H. Raynes-Greenow, and H. E. Jeffery, 'Customised Versus Population-Based Growth Charts as a Screening Tool for Detecting Small for Gestational Age Infants in Low-Risk Pregnant Women', in Cochrane Database of Systematic Reviews John Wiley & Sons, Ltd 2011 ).

15. A. E. Carberry, C. H. Raynes-Greenow, R. M. Turner, and H. E. Jeffery, 'Customized Versus Population-Based Birth Weight Charts for the Detection of Neonatal Growth and Perinatal Morbidity in a Cross-Sectional Study of Term Neonates', American Journal of Epidemiology, August 21 (2013)..




16. A. Frondas-Chauty, I. Louveau, I. Le Huerou-Luron, J. C. Roze, and D. Darmaun, 'Air-Displacement Plethysmography for Determining Body Composition in Neonates: Validation Using Live Piglets', Pediatric research, 72 (2012), 26-31.

17. K. J. Ellis, M. Yao, R. J. Shypailo, A. Urlando, W. W. Wong, and W. C. Heird, 'Body-Composition Assessment in Infancy: Air-Displacement Plethysmography Compared with a Reference 4-Compartment Model', Am J Clin Nutr, 85 (2007), 90-5.

18. G. Ma, M. Yao, Y. Liu, A. Lin, H. Zou, A. Urlando, W. W. Wong, L. Nommsen-Rivers, and K. G. Dewey, 'Validation of a New Pediatric Air-Displacement Plethysmograph for Assessing Body Composition in Infants', Am J Clin Nutr, 79 (2004), 653-60.

19. A. Urlando, P. Dempster, and S. Aitkens, 'A New Air Displacement Plethysmograph for the Measurement of Body Composition in Infants', Pediatr Res, 53 (2003), 486-92.

20. M. Yao, L. Nommsen-Rivers, K. Dewey, and A. Urlando, 'Preliminary Evaluation of a New Pediatric Air Displacement Plethysmograph for Body Composition Assessment in Infants', Acta Diabetol, 40 Suppl 1 (2003), S55-8.

21. G.S. Andersen, T. Girma, J.C.K. Wells, P. Kæstel, K.F. Michaelsen, and H. Friis, 'Fat and Fat-Free Mass at Birth: Air Displacement Plethysmography Measurements on 350 Ethiopian Newborns', Pediatr Res, 70 (2011), 501-06.

22. D.A. Fields, J.M. Gilchrist, P.M. Catalano, M.L. Giannì, P.M. Roggero, and F. Mosca, 'Longitudinal Body Composition Data in Exclusively Breast-Fed Infants: A Multicenter Study', Obesity, 19 (2011), 1887-91.

23. B. E. Lingwood, A. M. Storm van Leeuwen, A. E. Carberry, E. C. Fitzgerald, L. K. Callaway, P. B. Colditz, and L. C. Ward, 'Prediction of Fat-Free Mass and Percentage of Body Fat in Neonates Using Bioelectrical Impedance Analysis and Anthropometric Measures: Validation against the Pea Pod', Br J Nutr, 107 (2012), 1545-52.

24. P. Roggero, M. L. Gianni, O. Amato, P. Piemontese, D. Morniroli, W. W. Wong, and F. Mosca, 'Evaluation of Air-Displacement Plethysmography for Body Composition Assessment in Preterm Infants', Pediatric research, 72 (2012), 316-20.

25. A. Fields, P. B. Higgins, and D. Radley, 'Air-Displacement Plethysmography: Here to Stay', Curr Opin Clin Nutr Metab Care, 8 (2005), 624-9.

26. A. E. Carberry, C. H. Raynes-Greenow, R. M. Turner, L. M. Askie, and H. E. Jeffery, 'Is Body Fat Percentage a Better Measure of Undernutrition in Newborns Than Birth Weight Percentiles', Pediatric Research, Advance online publication 02 October (2013).

27. Queensland Maternity and Neonatal Clinical Guidelines Program, 'Examination of the Newborn Baby', ed. by Queensland Health (Queensland Queensland Health, 2009).

12.1 National Standard

Standard 1: Safety and Quality in Health Service Organisations

Standard 9: Recognising and Responding to Clinical Deterioration in Acute Health Care

Neonatal Early Assessment Program (NEAP)

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