WHAT TESTS ARE DONE ON ALL NEWBORNS IN THE HOSPITAL & CAN YOU REFUSE THEM?

Before newborns can go home from the hospital they have to take some tests. Well, what are those tests? And can you refuse them?

There are four tests (also called screenings) that are done on all newborns in the hospital.

They are:

• Hearing Test
• Bilirubin Test
• Critical Congenital Heart Defect Test
• Newborn Screening Test

Parents may refuse all of these tests. If any of the tests are refused, parents may have to sign a refusal form stating that they understand the importance of the test and the risks of not having it done.

Keep reading to learn more about these tests, including the pain or discomfort they may cause.

THE HEARING SCREEN

There are two different types of tests that screen babies for hearing loss, and which one your baby will have done depends on which test your hospital has chosen to use. Both are pretty similar.

The Auditory Brainstem Response (ABR) test is performed by placing sticky earphones around the outside of the ears, and sticky electrodes to the forehead, back of the neck, and the shoulder. Soft clicking sounds are played, and the test measures if the brain stem responds to the sounds.

The Otoacoustic Emissions (OAE) test is performed by placing soft earphones into the ear canals and playing gentle sounds. The OAE test then measures an echo that usually occurs in ears with normal hearing. If there’s no echo, that could be an indicator of hearing loss.

So, does the ABR or OAE hearing tests cause pain or discomfort?

The only time your baby may feel pain or discomfort during the hearing test is when the sticky electrodes (used during the ABR test) are removed.

The ABR test is the one I was trained to do, and I would be careful when removing the electrodes because it’s like pulling off little bandaids. Some babies may cry, but most babies don’t even notice it at all, especially if they’re sleeping.

The time that it takes for a hearing screen to be completed can vary. It can be as quick as 1 minute or it can take as long as a half an hour, but they usually don’t last longer than 15 minutes.

A tip to help the hearing screen go quicker is to have it performed after your baby has been fed and is asleep. The screening machine will get a much faster result if your baby is still and quiet.

It’s best practice to have the test completed after your baby is 12 hours old. This is because they can still have amniotic fluid and/or vernix (that cheesy white stuff they were covered in at birth) in their ears after they’re born, and that can interfere with passing the screening. It’s best to wait at least 12 hours to let the fluid and vernix absorb which will help ensure a more accurate result.

The hearing test is over when the machine has determined to either “pass” or “refer” your baby. There’s no such thing as “failing” here!

If your baby “refers”, the test will be repeated later that day or the next day, depending on when you’re planning to discharge to home. If your baby doesn’t pass the repeat test (this is actually more common than you’d think), they will be scheduled to have a follow up appointment with a pediatric audiologist to repeat the test again within the next several weeks.

There actually used to be another type of hearing test back in the olden days and it was called the “bang-a-pot-and-pan-together-by-your-baby’s-head-to-see-if-they’re-startled-by-it” hearing test.

This test could still work today, but you’d run the risk of causing some hearing loss, ironically.

So, thank you modern technology!

THE BILIRUBIN TEST

We all have bilirubin in our bodies.

It’s an orange-yellow pigment that occurs when red blood cells break down.

It’s filtered through the liver and comes out of our body through our poop and pee.

Newborns can have higher levels of bilirubin (aka- hyperbilirubinemia) because their livers are immature and can’t filter the bilirubin as efficiently as a mature liver in adults can. So, bilirubin can back up in their system.

This causes something called “jaundice”, which is when the skin and whites of the eyes have a yellow-orangish cast.

Sometimes it’s so subtle that only doctors and nurses can notice it. It may not even be visible at all in babies with darker skin.

Jaundiced skin first develops in the face, then moves down to the chest. Bilirubin levels are at their highest when the whites of the eyes become yellow.

If bilirubin levels are too high, it can cause brain damage.

Bilirubin usually reaches its highest levels at three to four days old, and usually goes away by one to two weeks after birth.

Remember that bilirubin comes as a result from broken red blood cells. Newborns who have bruising (aka- broken red blood cells) are at a higher risk of having higher bilirubin levels. Newborns can have bruises on their head and face, most commonly from a vacuum or forceps being used during delivery.

Babies born prematurely (aka- before 37 weeks, or 3 weeks before their due date) are also at a higher risk for jaundice since their red blood cells have a shorter life span. That means they’ll have more red blood cells to break down and since their livers are more immature due to being born early, most will have increased bilirubin levels.

Mother’s with “O” blood types are at a higher risk to have babies who are positive for a factor in their blood called “Coombs”.

Being positive for Coombs means that the baby has antibodies in their blood that causes their immune system to destroy red blood cells, which means that there’s more bilirubin in their blood stream. And that usually means a higher bilirubin level.

If your baby is premature or Coombs positive their bilirubin level may be checked as early as 12 hours old.

Newborns who are born after 37 weeks and who are Coombs negative typically have their bilirubin level checked around 24 hours old.

So, how is the bilirubin test done, and is it painful?

The bilirubin test can be done without needing a blood sample if the hospital where you’re at has a special meter that can read the bilirubin level through the skin (also known as a transcutaneous bilirubin test or a TCB). This meter usually requires three gentle presses onto your baby’s forehead. This is painless and babies rarely even show signs of discomfort. This is a great screening tool because it avoids a prick for blood.

But unfortunately, not all hospitals have these meters because they’re expensive.

If that’s the case, a small amount of your baby’s blood will need to be collected through a prick on their heel. This method, known as a serum bilirubin test or a TSB, will be a little painful due to the needle prick. In addition, they may feel a little annoyed by having their foot held while their blood is being collected into a small tube.

If you’re breastfeeding, your baby may have less poop and pee because they’re not consuming a lot of volume until your breastmilk comes in, which is not usually until 3-5 days after giving birth.

This may cause breastfed babies to have more bilirubin build up in their system.

The more milk your baby drinks, the more poop and pee they’ll have. So, an effective treatment for a breastfed baby is to increase the volume of milk they’re drinking.

This can be done by giving them pumped breastmilk or formula, in addition to breastfeeding, if that’s what you desire. This is known as “supplementing”.

The pumped breastmilk and/or formula is given either with a bottle, a tube and syringe with a finger, or with a tube and syringe while breastfeeding.

Your baby may even be given some of your expressed breastmilk with a tiny cup or a spoon. Your nurse should help you with this.

If you intend to breastfeed, try to avoid giving a bottle during this time, since the milk from a bottle comes out much quicker than at the breast. Your baby will definitely show a preference for the fast flow of milk from a bottle over the hard work they must do for the slow flow of milk that comes from the breast.

By “supplementing” with breastmilk or formula, your baby will get the extra volume they need to help them poop and pee more which will help lower their bilirubin level.

Another way to help decrease bilirubin levels is by exposing your baby’s skin to sunlight. Sunlight helps to breakdown bilirubin. People used to place their newborns outside or next to a window to help decrease their jaundice.

This can still be done, of course. Just make sure your baby isn’t in direct sunlight so they won’t get burned.

However, if your baby’s bilirubin levels are high in the hospital the therapeutic qualities of the sun can be mimicked with “phototherapy” (aka-light therapy).

This is when a heatless, fluorescent light is shined over your baby in their crib, or their isolate if they’re in the NICU.

This light imitates natural sunlight which helps breakdown the broken red blood cells so they can be filtered through their liver easier, therefore decreasing bilirubin levels.

Unfortunately, babies can’t be swaddled with a blanket during phototherapy because as much skin as possible needs to be exposed to get the most therapeutic benefits. Your baby’s nurse will check their temperature more often to make sure they aren’t getting cold.

Also, if your baby needs phototherapy, they’ll have to wear a soft cover over their eyes (aka- an eye shield) so their eyes are not exposed to the light.

Phototherapy is one of the only instances when a pacifier is offered for free by the hospital where I work, and that’s because babies are usually more fussy under the phototherapy lights. Which is shocking because who doesn’t love being naked and blindfolded?!

Babies may be taken out from under the lights for feedings, diaper changes, or if they’re upset. Ideally, they’re out for no longer than 30 minutes at a time, but it can be longer depending on the circumstances.

After your baby has been under phototherapy for a determined about of time (usually less than 24 hours) a repeat blood test will be done to follow up that the bilirubin level has leveled off or has gone down.

THE CRITICAL CONGENITAL HEART DEFECT TEST

Critical Congenital Heart Defects are heart defects that are so serious that they are life-threatening and may require surgery. It is also known as Critical Congenital Heart Disease or CCHD.

Some of these heart defects are:

• Tetralogy of Fallot
• Pulmonary Atresia
• Total Anomalous Pulmonary Venous Drainage (TAPVD)
• Atrial Heart Defect
• Ventricular Septal Defect
• Tricuspid Atresia, Coarctation of the Aorta
• Hypoplastic Left Heart Syndrome.

One in one hundred babies are born with these critical congenital heart defects, making it the most common birth defect.

Most defects will be found during pregnancy with an ultrasound.

But what if it’s accidentally missed?

And what if you didn’t go to the doctor while you were pregnant, or what if you missed some appointments?

Babies who are born with these heart defects are born looking and acting perfectly healthy.

Their vital signs are stable.

Before the CCHD Test was done, these babies would be discharged to home at 1-2 days old with a clean bill of health.

They would have absolutely no signs of their deadly condition until after they left the hospital. Around 3-4 days old they’d turn blue and stop breathing.

Turning blue and stopping breathing may be the FIRST SIGN that something is wrong.

The CCHD Test is done on newborns when they’re around one day old to help find a heart defect before a baby shows any signs of having one.

So, is the Critical Congenital Heart Defect Test is painful?

No, it’s not painful. The CCHD Test may only cause a little discomfort when the sticky bandage that’s wrapped around the hand and the foot are removed. Just like the hearing test, the discomfort from the sticky bandage coming off is quick. It may make your baby cry for a very short time, but they’re usually not bothered by it.

It’s such a quick, simple test, and it’s completely non-invasive, meaning it doesn’t require a blood sample.

These readings are done by wrapping a sticky bandage around the baby’s right hand and on one of their feet. This bandage has a heatless light sensor on it which will measure how much oxygen is in their blood. The nurse may also place a soft wrap called a “posey” over the bandage. This may help to get a better reading and a quicker result.

This is also called a pulse oximetry test (aka- a heart oxygen test).

Once the bandage is placed around the baby’s hand or foot, a result should show up quickly on the machine it’s attached to.

A baby’s blood should be 93% to 100% oxygenated.

If it’s consistently lower than 93%, that’s a cause for concern.

However, even if the oxygen level is at 93%-100%, that isn’t enough to rule out a CCHD.

If the hand and foot have a difference of 3% from each other, that’s also a concern and may indicate that the baby has a congenital heart defect.

If this happens, the next step is to take blood pressure readings on both of the baby’s arms and legs (aka- a 4-point blood pressure), and the nurse will call the baby’s doctor.

Next, the doctor may order the baby to have additional tests to either confirm or rule out a congenital heart defect.

These tests may include an electrocardiogram (aka- EKG) to look at the electrical activity of the heart, and an echocardiogram (aka- echo) which is an ultrasound that provides pictures of the structure and function of the heart.

THE NEWBORN SCREENING TEST

Just like how there may be no signs that your baby has a heart defect, there may also be no signs or symptoms after birth if they have a genetic disorder.

Think your baby looks perfectly healthy? Well, they may not be.

That’s where the Newborn Screening test comes in.

The Newborn Screening test is a blood test that can discover if your baby has a genetic, metabolic, hormone-related, or blood-related disorder that may not be apparent at birth. This test is also known as a PKU test, a newborn genetic test, or a blood spot screening.

Just like all of the other tests that newborns have done before they go home from the hospital, the purpose of the Newborn Screening test is to identify harmful disorders that would’ve otherwise gone unnoticed because babies do not show signs or symptoms of them until they’re older.

Early detection will lead to earlier treatment, which in turn will lead to a better outcome, and may even save your baby’s life.

The Newborn Screening test is done sometime between 12-48 hours after your baby is born. Either your baby’s nurse or a lab technician (aka- phlebotomist) will collect some of your baby’s blood. This most likely will be done in your hospital room, but if your baby is taken to a nursery for the blood draw you can always request to go with them.

Your baby’s blood will not be collected through their veins. It will be collected through a prick on the side of their heel.

A little warm pack may be placed on your baby’s heel for a short time. Applying a warm pack before a heel prick increases blood flow to the site, and therefore the procedure may go quicker and babies will cry for a shorter time.

The heel will be wiped clean with either a wet saline wipe or an alcohol wipe. Then, the side of your baby’s heel will be pricked by a little device called a lancet.

The prick is actually a tiny little slit in the skin. A tiny slit versus a circular poke from a needle has been proven to help blood flow (which will help the test go faster), and also has been shown to do less nerve damage.

The nurse or phlebotomist will collect your baby’s blood onto a special filter paper. They will fill in 1/2 inch circles with drops of your newborn’s blood.

So, is the Newborn Screening test painful?

Yes, it may be from the poke, but not for long. Your baby may not cry at all, or they may cry throughout the entire blood collection. All newborns react differently. The prick may startle them and give them sudden pain, but just like if you get a poke from a needle, the pain is gone quickly. However, they may continue to cry throughout the entire test due to wanting to be held and consoled after the initial prick.

If the blood is flowing quickly from the heel prick, the circles can be filled with blood under a minute. However, if the blood flow is slow, it can take up to several minutes, and may even require a second prick.

The paper with the blood will be sent to your state’s department of public health, and the results should be available within a couple of weeks.

No news is good news! You’ll be contacted if something is wrong, but it’s always good just to double check with your pediatrician. They are the ones who get sent the official results.

The Newborn Screening test is required by all states, but the different disorders that the Newborn Screening tests for vary from state to state. For example, California tests for 75 disorders, and New York tests for 40.

There are certain disorders that all states test for and those include phenylketonuria (PKU), cystic fibrosis, and sickle cell disease. Check on your state’s department of public health website to find out more about which exact disorders your state tests for.

While the Newborn Screening test is required in all states, parents are still allowed to refuse it. Some states only allow parents to refuse on the grounds that the test conflicts with their religious practices.

I’ve seen parents refuse it before, but it’s very uncommon. The biggest reason why parents refuse it is mostly because they don’t want their baby to be pricked.

However, once parents learn more about the test from their nurse or pediatrician, most change their minds and agree that the Newborn Screening test is worth the poke.

SO, YOU CAN REFUSE TESTS, BUT SHOULD YOU?

Today I’ve explained the four tests that are done on all newborns before they can leave the hospital.

Those are the Hearing Test, the Bilirubin Test, the Critical Congenital Heart Defect Test, and the Newborn Screening Test.

They all have their own special importance.

However, they all share one common purpose, and that’s to detect health issues before you would ever even know a problem was there.

So, should you refuse any of these tests?

Ultimately, that decision is yours to make as a parent.

But, if you want my opinion,

I wouldn’t refuse any of them.

While it’s distressing to see your baby uncomfortable or in pain, it’s worth it for a short time if it means discovering your baby has hearing loss, or has a heart defect, or is at risk for having brain damage.

I assure you that your baby won’t remember the pain or discomfort they had for a few minutes during these tests.

And they’ll definitely be forever grateful to you if you improved their quality of life, or even saved their life, by having these newborn tests done.

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Disclaimer:
The content that I share on Purely Postpartum is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. I encourage you to always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions.