Examination of the Newborn. Группа авторов
to review coverage data and to audit and provide oversight/management of referral outcomes.
All NIPE practitioners should be familiar with and use S4N to record all newborn NIPE screening activity (currently not available to record the 6–8 week examination). Always ensure that data is entered in a contemporaneous way and direct any queries to the Trust NIPE Lead.
More information is available at https://phescreening.blog.gov.uk/2019/07/17/smart‐4‐nipe‐s4n‐is‐up‐and‐running/.
The psychosocial and safeguarding agenda
Parental psychosocial influences and adverse lifestyle choices have consistently impacted upon the outcome for newborn infants. Psychopathology morbidity can persist throughout childhood and into adulthood (Hien and Honeyman 2000; Maughan et al. 2001; Dawson 2003; Disney et al. 2008) and mortality in extreme cases (Victoria Climbié Inquiry [Lord Laming Chair] 2003). There are extensive and varied socio‐demographic variables that indicate the complexity of the subject matter (see website that accompanies this book for more information on safeguarding). Co‐morbidities exist between smoking, alcohol and substance misuse, domestic violence, maternal depression and adverse social environments that place the newborn at greater risk of maladaptive behaviours in childhood and adulthood that replicate that of the parents (Leonard et al. 2007). Therefore, the aim of social support and intervention strategies in the prenatal period and beyond is to break the cycle. See Table 1.6 for a summary of fetal and newborn outcome adverse effects related to lifestyle.
TABLE 1.6 Maternal/paternal lifestyle and psychosocial influences.
Sources: Adapted from Hien and Honeyman 2000; Maughan et al. 2001; Dawson 2003; Disney et al. 2008.
| Lifestyle | Fetal effect | Potential neonatal and childhood outcome |
|---|---|---|
| Smoking | Spontaneous abortion Altered placental morphology Chronic hypoxia Intrauterine growth restriction (IUGR) | Abnormal newborn neurobehaviour Increased risk of infant irritability Hypertonia Childhood behavioural problems Lowered immunity SIDS, RSV infection Lower respiratory tract infections Altered pulmonary function Childhood asthma Increased risk of tobacco dependency in adulthood |
| Alcohol use | Fetal alcohol syndrome (FAS) IUGR | FAS Fetal alcohol disorder spectrum Behavioural problems |
| Substance misuse | Risk of transplacental transmission of hepatitis B and C Congenital anomalies Symmetrical IUGR Prematurity Meconium liquor | Neonatal Abstinence syndrome |
| High‐conflict relationships: domestic abuse | Intrauterine death Increased risk of acute obstetric complications that impact on newborn outcome | Child abuse Cognitive psychological impairment Childhood depression |
| Parent in care system | Increased risk of infant in care system Increased risk of child neglect |
Maternal mental health
Maternal mental health and depression should be of significant interest to the NIPE practitioner. The use of psychotropic drugs can affect the newborn in relation to withdrawal symptoms (Wang 2010; NICE 2018a; NICE 2018b). In comparison to withdrawal behaviours in the newborn from illicit substances, the effects from antidepressant medication, particularly the selective serotonin reuptake inhibitors (SSRIs), are perhaps better defined (Sanz et al. 2005; Wang 2010, NICE 2018b). This is very helpful to the NIPE practitioner who is perhaps unsure of the significance of such drugs taken during pregnancy. The following list outlines some associations with the use of antidepressant drug groups:
SSRIs:
Risk of fetal cardiac anomalies has not been confirmed – conflicting evidence.
Increased risk of persistent pulmonary hypertension after 20 weeks of gestation.
Risk of transient neonatal withdrawal syndrome can affect newborns exposed to SSRIs in the weeks preceding birth, causing central nervous system, motor, respiratory and gastrointestinal symptoms (NICE 2018c).
Tricyclic antidepressants (TCAs):
Limited evidence to suggest that TCAs are associated with an overall increased risk of congenital malformation.
Neonatal withdrawal symptoms may be associated with TCA use in pregnancy.
Adapted from NICE (2018b).
The NIPE practitioner must firstly establish when the mother commenced the medication and, secondly, check if the mother is still taking medication. There is an associated risk to the mother if she has abruptly stopped taking the medication at any point without seeking medical advice. This is particularly relevant in the immediate postnatal period and may predispose her to active postnatal depression. If the mother is still taking medication, then the newborn must have a thorough neurological examination. There is some debate as to whether withdrawal from antidepressant medication in the newborn is more of a toxicity reaction (Wang 2010) to the drug as opposed to active drug withdrawal, which would increase the severity and prolong the severity of the symptoms.
Maternity services may have local guidelines in place for postnatal observation on newborns of mothers who have been prescribed antidepressant medication in pregnancy, particularly during the latter stages.
The NIPE practitioner can observe the behavioural interactions between a mother and her newborn at the time of the newborn examination. Any concerns about abnormal attachment behaviour must be relayed to the midwife caring for the mother and newborn, in the first instance. The level of concern may necessitate the activation of the safeguarding pathway. Further information about mental health in pregnancy can be found at https://www.nice.org.uk/guidance/cg192/evidence/full‐guideline‐pdf‐4840896925.
Addressing safeguarding issues when reviewing the antenatal history
Public policy, with reference to safeguarding, has rapidly changed the landscape of history taking. Having been brought into sharp focus on a national scale over the last 30 years since the advent of the Cleveland Report (1988) and the Children's Act of 1989, this issue is high on the agenda within maternity and paediatric services (DfE 2018). Evaluation of the family psychosocial background is an important facet of the newborn examination as in childhood. It is the responsibility of the NIPE practitioner to raise any concerns that have not already been addressed with the safeguarding named midwife. Once this process is activated, the safety of that newborn will become paramount.
Paternal information is often viewed as a lesser priority. However, the father's date of birth is an important demographic in tracing any previous safeguarding issues or domestic violence should concerns be raised. With the date of birth, the police protection services can investigate any previous convictions or concerns. With the movement of some population groups around the country and the fluidity of family units within society, male partners may move from one family unit to another and not disclose any information about previous relationships, e.g. SIDS, congenital anomalies or previous child deaths. It is also important to know the names and dates of birth of other siblings even when not biologically belonging to the mother of the new infant.
It is vital that all aspects