I. NEWBORN NURSERIES

The overall goal during rotations through the newborn nursery by the first and third year residents is to acquire basic knowledge and experience necessary for the evaluation, care and discharge planning of the term and near-term neonate, and to gain experience in the resuscitation and stabilization of these neonates in the delivery room and in the immediate post-delivery period. To accomplish these goals, the first year resident will spend one to two months in the newborn nursery whereas the third year resident will spend one month.

A. First Year Resident

The goals of the first year pediatric resident are outlined below.

• To recognize the normal and abnormal variants in the term and near-term neonate using the physical exam and pregnancy history and to be able to estimate gestational age using the Ballard examination.
  
• To be able to recognize, diagnose and treat problems commonly observed in the term and near-term neonate, including hypoglycemia, polycythemia, anemia, jaundice, sepsis, respiratory distress, congenital heart disease, and various skin rashes.
  
• To be able to manage the term or near-term neonate in the delivery room following meconium stained amniotic fluid, maternal chorioamnionitis, and elective repeat cesarean section. To enhance this training experience, the first year resident will undergo NRP training and certification.
  
• To gain experience in maternal teaching and anticipatory guidance of the family prior to infant discharge. The first year house officer will learn to address typical common questions posed by parents, understand the need for car seats, be able to discuss the importance of immunizations and well baby follow-up, become knowledgeable about assessing the readiness of the mother to care for her child, and be able to discuss with the parents methods of breast and bottle feedings and how to recognize illness.
  
• To be able to determine and manage the transition from hospital to home, which includes recognizing the need for subsequent weight checks, bilirubin evaluations, repeat hematocrits, and identification of potential problems (e.g., breast feeding for the primigravid and young mother).
  
• To understand the role of the pediatric nurse practitioner and how to work as a team.
  
• To understand the complications and indications for circumcision.

B. Third Year Resident

The rotations for the third year pediatric resident in the newborn nursery are designed to "reintroduce" the resident to the common problems and care of the term and near-term neonate, planning hospital discharge, and to reexpose the resident to the methods of neonatal resuscitation and stabilization. At the present time two third year residents are assigned to the newborn nursery who will have the opportunity to divide their month rotation into two parts in order to accomplish these goals, which are outlined in more detail below.

• Rotation within the newborn nursery.
  
  
  • To supervise the third year medical students and be available to review their history and physical exams.
    
  • To assume primary care responsibility for 5 neonates each day, performing the admission and discharge physical exams, maintaining the chart, and providing maternal education regarding breast feeding, infant nutrition, immunizations, post-discharge care and the need for subsequent follow-up.
    
  • To obtain NRP recertification, which will be needed for subsequent hospital privileges, if the resident desires.
    
  • To provide night call coverage in the Neonatal Intensive Care Nursery every fourth night in order to update and maintain their skills and recognition of the high-risk and sick neonate and how to stabilize these infants for subsequent care. They also provide backup coverage for labor and delivery during the day.
    
  • To reintroduce the residents to the needs and indications for circumcision and provide the "option" to perform circumcisions.
    
    
• Rotation within the labor and delivery suite
  
  
  
  • To attend at all high-risk deliveries with the resuscitation team in order to reestablish their expertise in neonatal resuscitation and stabilization.
    
  • To act as a supervisor and teacher of first year residents in Labor and Delivery where indicated.
    
  • To admit newborns from the delivery room to the Neonatal Intensive Care Nursery, which includes a written history, physical exam and admission orders in order to further enhance their skills at recognition, care and stabilization of the sick newborn. They also will work with the postdoctoral fellows to triage neonates to the NBN.
    
  • To take night call in the Neonatal Intensive Care Nursery every fourth night in order to maintain their skills in stabilization and care of the sick newborn.

II. NEONATAL INTENSIVE CARE NURSERY

The overall goal and objective of the rotations for the pediatric residents in the Neonatal Intensive Care Nursery is to gain extensive experience in the recognition and care of the high-risk, low-birth-weight, preterm (<2200gm or <34wks) and term neonate who requires intensive or intermediate care, surgery, or evaluation by other pediatric specialists. During the course of the three year pediatric residency the first year residents will rotate through the Neonatal Intensive Care Nursery for two months on average and one month during the second year.

A. First Year Pediatric Residents

The following goals have been established for the first year pediatric residents rotating through the Neonatal Intensive Care Unit. These are primarily aimed at gaining experience in the intermediate care area (i.e., less acute) during the first rotation and with the sicker neonate in the second rotation.

• To understand the importance of obtaining a thorough family and maternal history, which includes pertinent information regarding prior pregnancies, the current pregnancy and events related to labor and delivery.
  
• To understand the differences in the examination of the preterm, term and sick neonate of all ages, how this differs from older infants and children, and how to assess the clinical estimate of gestational age using the Ballard examination.
  
• To understand the basic needs of the preterm and sick neonate, which includes temperature regulation, fluid and electrolyte therapy, metabolic requirements, and nutritional needs, including the use of parenteral nutrition, oral alimentation, and special formula needs. In addition, the resident will learn how to maintain and utilize growth curves in order to recognize problems of inappropriate nutrition and growth.
  
• To familiarize themselves with appropriate chart documentation, including admission notes, daily notes, and notes regarding major events during the course of the day.
  
• To gain experience with common procedures used in the care and stabilization of the sick neonate, which include spinal taps, superpubic bladder aspiration, umbilical venous and arterial catheter placement, neonatal intubation and stabilization, the placement of chest tubes versus the use of thoracentesis for treatment of pneumothorax, and to understand the indications for each procedure.
  
• To thoroughly understand common medical conditions seen in the preterm and sick term neonate, including respiratory distress syndrome, transient tachypnea of the newborn, apnea and bradycardia of prematurity, neonatal sepsis and pneumonia, congenital infections, patent ductus arteriosus, chronic lung disease, cyanotic congenital heart disease, hyperbilirubinemia, hemolytic anemia of the newborn, stabilization and care of the infant of the diabetic mother, hypoglycemia, fetal growth restriction, necrotizing enterocolitis, intracranial hemorrhage, ischemic encephalopathy, retinopathy of prematurity, and recognition of common surgical problems seen in the neonate, both congenital and noncongenital.
  
• To understand and appreciate the problems that parents of the low-birth-weight, preterm and sick neonate experience, including the need for social service intervention, the use of child protective agencies, and counseling for parents with an infant that is likely to die. Also, to learn how to deal with these parents on a daily basis as part of patient care.

B. Second Year Pediatric Resident

While the rotation as a first year resident through the Neonatal Intensive Care Nursery introduces the resident to the problems of the preterm and sick neonate, the primary emphasis is on the care of the preterm infant without major complications. In the second year the one month rotation is directed toward understanding more of the physiology and pathophysiology of the sick neonate. Therefore, this house officer has a primary role in the care of neonates assigned to the intensive care area of the Neonatal Intensive Care Nursery. The goals of their rotation include those noted above and as follows.

• To enhance their knowledge of the mechanisms of neonatal resuscitation and stabilization and recognition of the at-risk fetus in utero based on the maternal antenatal and intrapartum course.
  
• To be able to stabilize and initiate care for the very high-risk, very-low-birth-weight neonate (<1500gm) as well as the term infant that requires intensive care.
  
• To achieve confidence in the performance of common procedures utilized in the supportive care of the sick neonate, including spinal taps, superpubic bladder aspirations, placement of umbilical venous and arterial catheters, intubation and resuscitation, placement of chest tubes, performance of chest thoracentesis, and importantly, to understand the indications for these procedures.
  
• To throughly understand the fluid, electrolyte and metabolic needs of the extremely-low-birth-weight neonate (<1000gm) and how to modify these needs appropriately based on birth weight, gestational age, and postnatal age.
  
• To understand the normal development of the lung, common causes of respiratory diseases, mechanisms used to monitor oxygenation, and how to make decisions regarding respiratory management.
  
• To understand how to initiate and maintain nutritional needs of the very-low-birth- weight infant, including gavage feeds and parenteral nutrition.
  
• To become comfortable with speaking to parents of very high-risk, sick neonates and providing them guidance regarding their neonate and the potential outcomes based on statistics obtained from the Intensive Care Nursery, and where appropriate, learn to discuss with the parents changes in therapy and outcome.
  
• To recognize and understand all of the disease processes noted above.