Postnatale zorg in de algemene kindergeneeskunde

Initiatief: NVK Aantal modules: 12

Startpagina - Postnatale zorg in de algemene kindergeneeskunde

Waar gaat deze richtlijn over?

Deze richtlijn bevat 3 modules:

Module 1 Screening, preventie en behandeling van neonatale hypoglycemie

Module 2 Beleid en vacuümextractie

Module 3 Consult kinderarts perinataal of bij pasgeborene

 

Module1

  • Definitie van neonatale hypoglykemie en de begrippen streefwaarden en interventiegrenzen voor 1-2 uur (resp ≥2,0 mmol/L en ≤1,5 mmol/L) en voor 2-24 uur (≥2,6 mmol/L en <2,0 mmol/L) na de geboorte worden besproken.
  • De indicaties voor screening op hypoglykemie met de stopcriteria worden gemotiveerd. Voor prematuren en SGA (<P10) wordt een screening van tenminste 24 uur en voor kinderen van diabetische moeders behandeld met medicatie en LGA (> P90) tenminste 12 uurs geadviseerd.
  • Veel pasgeborenen met een geboortegewicht <P10 of >P90 liggen om een andere reden dan de glucosecontroles in het ziekenhuis (bijvoorbeeld maternale indicatie (SC, PE, Hypertensie), voedingsproblemen, verdenking infectie, etc). Zie het Implementatieplan.
  • De voor- en nadelen en valkuilen van de bepalingsmethoden worden besproken
  • Maatregelen ter preventie van neonatale hypoglykemie worden besproken waarbij geadviseerd wordt om niet routinematig bijvoeding toe te passen.
  • De behandeling van hypoglykemie wordt besproken waarbij de hypoglykemie wordt ingedeeld in mild/matig/ernstig/zeer ernstig. Bij elke mate van hypoglykemie wordt een behandeling middels een stappenplan, welke geïndividualiseerd moet worden op basis van 5 criteria, geadviseerd.
  • Dit alles wordt samengevat in een Stroomschema.

 

Module 2

  • De werkgroep adviseert om alle pasgeborenen na een vacuumextractie (VE) ten minste zes uur te observeren op kliniek (geprikkeld zijn, pijn bij verzorging, huilen, spugen, kreunen, voedingsproblemen, kleur, activiteit/gedrag, ademhaling en hartfrequentie). Hierbij moet het hoofd regelmatig worden geïnspecteerd op locatie, aspect en een eventuele toename van de zwelling, om de complicatie van een subgaleale bloeding (SGH) tijdig te onderkennen. Een SGH vereist een snelle behandeling om overlijden en schade door hypovolemie, anemie en stollingsstoornissen te voorkomen.
  • Actieve controle op SGH bij de pasgeborene verlaagd de mortaliteit.
  • Risicofactoren, zoals karakteristieken van de zwangere (nullipara versus multipara, obesitas, leeftijd), van het kind (ligging, geboortegewicht, mate van indaling) en VE (indicatie, aantal tracties, losschieten cup, plaatsing van de cup, mislukken VE, duur VE), worden wisselend als onafhankelijke risicofactor in de literatuur beschreven en kunnen daarom (nog) niet discrimineren welke pasgeborene met een goede start mogelijk geen observatie nodig heeft na een VE.
  • De werkgroep adviseert om pasgeborene na een vacuümextractie niet standaard paracetamol toe te dienen.

 

Module 3

Deze module is geschreven voor verder gezonde pasgeborenen bij een zwangerschapsduur ≥ 35 0/7 weken en geboortegewicht ≥ 2000 gram. Bij kinderen geboren na een kortere zwangerschapsduur of met een lager geboortegewicht is een consult kinderarts altijd geïndiceerd vanwege pre- of dysmaturiteit. De module beschrijft wanneer een consult kinderarts is aanbevolen bij a) indicaties die tijdens de zwangerschap al bekend zijn, b) indicaties die tijdens de partus ontstaan/duidelijk worden of c) indicaties naar aanleiding van lichamelijk onderzoek of klinische conditie van het kind.

 

Wat is het doel van de richtlijn?

Praktijkvariatie is inherent aan weinig evidence of het ontbreken van consensus. Het doel van de richtlijn is om de kwaliteit van zorg te verbeteren door aanbevelingen te geven op basis van de best beschikbare evidence  en de bestaande praktijkvariatie te verminderen om zodoende bruikbare data te kunnen verzamelen om betere evidence te verkrijgen waaraan wij het beleid kunnen staven en zo nodig aanpassen.

De huidige praktijkvariatie betekent ook, dat onafhankelijk van welke aanbeveling er geformuleerd wordt, een aantal ziekenhuizen hun beleid in meer of mindere mate zal moeten aanpassen. Zie het Implementatieplan.

 

Voor wie is deze richtlijn bedoeld?

Het doel van deze richtlijn is om handvatten te bieden voor de algemene kindergeneeskundige zorg voor de (bijna) à terme pasgeborenen ten aanzien van het beleid rondom neonatale hypoglykemie en beleid na vacuümextractie. Het gaat hierbij om pasgeborenen die vanwege een medische indicatie in het ziekenhuis geboren of opgenomen worden en bij wie de (algemeen) kinderarts zorg levert of zou moeten leveren. Prematuren met een zwangerschapsduur <35 weken en pasgeborenen met een indicatie voor intensive care opname vallen niet onder deze richtlijn. Ook andere zorgverleners binnen de integrale geboortezorg kunnen gebruik maken van de informatie uit deze richtlijn.

 

Voor patiënten

In deze richtlijn worden adviezen aan de kinderarts gegeven over de controles op en de behandeling van lage bloedsuikers bij baby’s met een grotere kans op een lage bloedsuiker en de controles van baby’s geboren met een vacuümpomp. Het gaat hierbij om baby’s die om een medische reden in het ziekenhuis worden geboren. Zie de Patiënteninformatie.

 

Toepassen

Zie het Stroomschema.

Onderbouwing

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Volgende:
Screening, preventie en behandeling van neonatale hypoglycemie