TOPIC 31: Neonatal Medications and Immunizations – Counsel parents on routine neonatal medications and immunizations
OFFICIAL ABP TOPIC:
Counsel parents on routine neonatal medications and immunizations
BACKGROUND
Intramuscular vitamin K, erythromycin ophthalmic ointment, and vitamin D supplementation are routinely administered medications for newborns. Newborns also receive the hepatitis B vaccine shortly after birth. Engaging parents in shared decision-making and counseling them on the indications and benefits of these interventions is a key responsibility for pediatric health care professionals.
COUNSELING PARENTS ON ROUTINE NEONATAL MEDICATIONS AND IMMUNIZATIONS
Despite the proven effectiveness and safety of routine neonatal medications, some parents are choosing to refuse them for their newborns. This makes appropriate counseling by pediatric healthcare professionals all the more crucial. As the most trusted source of information for parents, pediatricians should provide a strong recommendation for these interventions, using a combination of scientific evidence and personal anecdotes to effectively communicate their importance.
While shared decision-making is essential, pediatricians should also acknowledge the legal requirements for certain interventions (e.g., ophthalmic prophylaxis) and the potential consequences of refusal. Depending on the circumstances, refusal of neonatal medications and immunizations can also result in referrals to child protective services. Ultimately, parents may refuse these interventions, but pediatricians should strive to provide accurate, evidence-based information to help parents make informed decisions.
COMMUNICATION STRATEGIES
The following techniques can help foster productive conversations with parents about neonatal medications and immunizations:
- Assume parents will accept the interventions; present the medications and immunizations as the standard of care
- Give your strong recommendation; share your personal and professional experiences
- Seek to understand the context of parents’ questions and concerns before responding; listen carefully and acknowledge their perspective
- Discuss the diseases and complications that these interventions prevent, not just the interventions themselves
- Be respectful of cultural, religious, and philosophical beliefs; counsel that these interventions protect the individual child and the community
- Provide written resources like CDC Vaccine Information Statements and AAP patient education handouts
VITAMIN K PROPHYLAXIS
Vitamin K is administered to all newborns to prevent vitamin K deficiency bleeding (VKDB) during the first few days of life. The AAP recommends:
- Using preservative-free formulation if available to avoid potential toxicity from benzyl alcohol preservative
- For infants weighing >1500 g: 1 mg vitamin K1 IM within 6 hours of birth
- For preterm infants ≤1500 g: 0.3-0.5 mg/kg vitamin K1 IM
Counseling parents:
- Emphasize importance of prophylaxis to prevent life-threatening bleeding
- Discuss extremely rare but serious risk of VKDB if prophylaxis is declined
- Provide written information on benefits of vitamin K (e.g., CDC fact sheet)
- Allow opportunity to ask questions; listen carefully and address concerns empathetically
VITAMIN D SUPPLEMENTATION
The AAP recommends that all breastfed and partially breastfed infants receive a daily supplement of 400 IU of vitamin D beginning in the first few days of life. This is because breast milk alone does not provide adequate vitamin D. For formula-fed infants, a vitamin D supplement is also recommended unless they are consuming at least 32 ounces of vitamin D-fortified formula per day.
OPHTHALMIC PROPHYLAXIS
Erythromycin 0.5% ophthalmic ointment is routinely administered within 2 hours of birth to prevent gonococcal ophthalmia neonatorum. This practice is mandated by law in many US states.
- Instill 1 cm ribbon of ointment in each conjunctival sac
- Avoid irrigation after application to avoid decreasing efficacy
- Chemical conjunctivitis is the most common side effect; usually mild and resolves within 48 hours
Counseling parents:
- Emphasize importance of prenatal screening and treatment for gonorrhea and chlamydia
- Explain prophylaxis prevents serious eye infections that can cause blindness
- Note practice is legally required in many states
HEPATITIS B VACCINE
The first dose of the HepB vaccine is recommended shortly after birth to prevent perinatal transmission from the mother and to provide early protection for infants who may be unknowingly exposed to HBV-infected household members.
- Administer monovalent HepB vaccine IM in the anterolateral thigh within 24 hours of birth
- Complete the HepB vaccine series with additional doses at ages 1-2 months and 6-18 months
Counseling parents:
- Discuss the importance of the birth dose to prevent vertical transmission of hepatitis B from the mother to the infant and to protect infants from possible HBV exposures from household members during the first few days of life
- Explain that HepB vaccination can prevent lifelong HBV infection acquired at birth that can lead to liver failure and cancer
- Ask open-ended questions, listen to concerns, and provide empathetic responses
REFERENCES
https://downloads.aap.org/AAP/PDF/ChildhoodGuide-2024-update.pdf
https://www.cdc.gov/vaccines-children/hcp/conversation-tips/
https://www.uptodate.com/contents/gonococcal-infection-in-the-newborn/
https://www.healthychildren.org/English/healthy-living/nutrition/Pages/vitamin-d-on-the-double.aspx