Newborns

Newborn Transitioning

changes involving pulmonary gas exchange

neonatal cardio vascular pattern

stable serum glucose levels

thermoregulation

assess for → hypoxia, cold stress, hypoglycemia (especially for gestational diabetes or regular diabetes in mother), infection, polycythemia (caused by diminished placental blood flow to baby), and hyperbilirubinemia

Newborn Assessment

vital signs especially temp (BP is rarely done)

nutrition and elimination

transition to extrauterine life

activity state

umbilical cord

if indicated → glucose monitoring, bilirubin, and circumcision assessment

Apgar

indicative of the need for resuscitation and not the degree of asphyxia

infant is scored at one and five minutes of life and if needed at ten minutes

Apgar HR

0 → absent

1 → less than 100

2 → over 100 (normal)

Apgar Respirations

0 → absent

1 → weak crying and hypoventilation

2 → good strong crying

Apgar Muscle Tone

0 → limp

1 → some flexion

2 → active motion

Apgar Reflex Irritability

0 → no response

1 → grimace

2 → cry and withdrawal

Apgar Color

0 → blue or pale

1 → body is pink but extremities are blue (most common for 72 hrs - acrocyanosis)

2 → completely pink

normal oxygen sat at birth is 60% and increases to 95% within the first ten minutes

Pulmonary Adaptation

fetal lungs secrete lung fluid throughout the pregnancy

production of lung fluid diminishes 2 to 4 days before the onset of spontaneous occurring labor

80-100 mL remain in the passageway of a full term newborn

during labor and birth the fetal chest is compressed and this squeezes part of the fluid out (c-section babies are more likely to retain lung fluid)

fluid must be expelled or absorbed after delivery

fluid can often be heard in the lungs at delivery as fine crackles

infants who have difficulty clearing the fluid are at a risk to develop a respiratory complication called transient tachypnea of the newborn (TTN)

Chemical Stimuli

first breath is inspiratory gasp → triggered by increased PCO2 and decrease in pH and PO2

changes trigger aortic and carotid chemoreceptors that trigger the brains respiratory center

hormonal → prostaglandins are released by the placenta throughout pregnancy and suppress respiration

when the cord is clamped prostaglandin levels drop and there is an increase in respiratory drive

Mechanical Stimuli

natural rest of a normal vaginal birth as the vaginal thoracic squeeze is released at delivery of the chest allowing for lung expansion

Thermal Stimuli

significant decrease in environmental temperature after birth → stimulates skin nerve endings and newborn responds with rhythmic respiration

warning → excessive cooling of infant may lead to profound depression as the result of cold stress

Sensory Stimuli

intrauterine life → dark, sound dampened, fluid filled environment, weightless

at delivery → light, lots of sounds, effects of gravity, abundance of tactile, auditory, and visual stimuli of birth

Respirations

newborn respiratory rate is 30-60 breaths per minute

initial respirations may be mainly diaphragmatic, shallow, and irregular in depth and rhythm

respiratory rate may increase with crying

it is important to count respirations with a stethoscope in the newborn for a full minute

periodic breathing is common especially in the first few hours, consists of pauses lasting from 5-15 secs

pauses of longer than 20 secs are apnea and need additional assessment

Respiratory Distress

increased of decreased respiratory rate → less than 30 or over 60

nasal flaring

expiratory grunting → humming like noise bc glottis partially closes

see saw breathing → abdomen inflates then chest

retractions → along lower rib line

color changes → usually inspect the torso

circumoral cyanosis (mouth and lips) or general cyanosis (torso)

decreased muscle tone

problems with temperature regulation

increased water loss

Cardiovascular Adaptation

requires the transition from fetal to neonatal circulation with the change from placental to pulmonary gas exchange

fetal lungs are essentially nonfunctional, most blood bypasses the lungs and is shunted to other parts of the body

Fetal Circulation

oxygenated blood returns to the fetus from the placenta through the placental vein → most blood bypasses the liver via the ductus venosus and enters the inferior vena cava

as it enters the right atrium most blood is shunted across the atrium through the foramen ovale to the left atrium

low systemic resistance and high pulmonary resistance → most blood from the right ventricle is shunted through the ductus arteriosus to the umbilical arteries and toward the placenta

Neonatal Circulation

initiation of respirations by the infant and the clamping of the cord as birth shifts the resistance in circulation to be low pulmonary resistance and higher systemic resistance

changes cause a pressure closure of the foramen ovale in the heart, ductus arteriosus begins to constrict almost immediately

blood flow → right atrium, right ventricle, pulmonary arteries, lungs, heart through pulmonary veins, left atrium, aorta, body

Cardiovascular Assessment

should start with color assessment → assess for acrocyanosis, circumoral cyanosis, or general cyanosis

heart rate taken apically at the 4th intercostal space on the left

rate is assessed for a full minutes → normal is 110-160 at rest

may drop to 80-100 when asleep

may accelerate up to 180 when stressed and crying can increase the rate

consistently high above 180 or low below 100 warrants further investigation

commonly hear murmurs, most are non-pathological and disappear by 6 months

murmurs must be investigated and can be accompanied by poor feeding, cyanosis, pallor, or apnea

Acrocyanosis

occurs in the first 7-10 days and is not unusual for hands and feet to remain blue

Circumoral Cyanosis

blue tint to skin surrounding lips but NOT the lips → normal and is a blue color of veins just below the skin

when arterial blood in the lips area diminishes you will be able to see the blue tint of the veins underneath

General Cyanosis

a blue tint to the skin that covers the face, trunk, and extremities

associated with poor oxygenation of the tissues and is an ominous sign

can be respiratory or cardiac in origin

Blood Volume

estimated for an at term infant to be 80 mL of body weight

varies with amount of placental transfusion received by the newborn during expulsion of placenta

increases by 50% with delayed cord clamping

Blood Sample Sites

peripheral blood flow can be sluggish and create RBC stasis → increases RBC stasis

hemoglobin and hematocrit levels higher in capillary blood than in venous blood

blood vessels taken from venous samples are more accurate than capillary samples

Lab Values

total blood volume is 82.3 ml/kg at three days of life with early cord clamping before 30 secs of life

92.6 ml/kg at three days of life with early cord clamping after 30 secs of life

hemoglobin → 14-20 g/dl

hematocrit → 43-64%

WBC → 10,000 - 30,000 mm3

blood glucose → 40-80 for first 6 hours and 45-95 after first 6 hours of life

Infant Feeding

two types → breastfeeding and bottle feeding formula or pumped breastmilk

there are additional benefits to breastfeeding the decision is made by the parents

only ordered formula should be used for the newborn

Feeding Frequency

bottle fed infants should be fed every 3-4 hours unless ordered more frequently

breast milk is digested more easily and quickly than formula, frequency is every 1 and ½ to 3 hours or 8-12 times a day

Glucose Frequency

normal levels are between 40-80 in first 6 hours and 45-90 after that

levels below 40-45 are treated with either a concentrated glucose gel, feeding, or 10% dextrose in sterile water

persistant hypoglycemia can result in neuro damage

hypoglycemia results from inadequate availability of glucose (poor feeding), abnormal endocrine regulation (diabetic mothers), or increase usage of glucose (cold stress or infection)

glucose is primary fuel and is stored in liver as glycoen

hypoglycemia can be life threatening and can cause seizures and learning disabilities

hyperglycemia is more common in premature and small for gestational age infants

Hypoglycemia Signs

frequently absent despite extremely low blood glucose levels

jitteriness and hypothermia (below 97.6) → most common

diaphoresis

hypotonia

irritability, tremors, muscle twitching, seizures

abnormal cry

poor feeding

lethargy

respiratory distress, tachypnea, apnea

cyanosis, tachycardia, cardiac failure, cardiac arrest

Temperature

normal is above 97.6

rarely elevated and below 97.6 is abnormal and can lead to cold stress

instability indicates infection → cannot have a fever so infection lowers temo

can be assessed by axillary skin method, continuous skin probe, rectal route → axillary is preferred

research shows tympanic and digital axillary methods are accurate indicators of temp

Thermoregulation

inappropriate management of heat and cold stress is associated with metabolic complications like hypoglycemia, increased oxygen consumption, increased lactic acid production, increased metabolic acidosis, and death

heat loss in newborns can occur through four mechanisms

conduction → objects in physical contact like a cold surface

convection → air circulation

radiation → babies lose heat to external walls like windows or heating with warmers

evaporation → babies being wet after birth and during bathing

Evaporation

main form of heat loss initially due to amniotic fluid evaporating from the baby’s body

Convection

occurs when a newborn is exposed to cooler surrounding air

heat loss increases with air movement and a baby risks getting cold even at room temp (86) if there is a draught (82-92 if naked and 75-80 if dressed)

Conduction

occurs if the baby is placed on a cold surface (weighing scale or cold mattress)

Radiation

occurs when there is transfer of warmth from the baby to cooler objects in the vicinity (cold wall or window) even if the baby is not actually touching it

Hypothermia

cold stress is a body temp rectally of less than 97.6 with symptoms

if temp is lower than 96.7 repeat the temp on the other arm, if its still low then report immediately → baby should do skin to skin or be in a radiant warmer

smaller and preterm infants are at a higher risk

Hypothermia Symptoms

body cold to touch

hypoglycemia

restlessness, irritability, tachypnea

pallor or mottling

lethargy, decreased activity, and hypotonia

central cyanosis and acrocyanosis

poor feeding and weak sucking

bradycardia

feeble cry, shallow/irregular respirations, and apnea

Thermogenesis

nonshivering occurs when skin receptors perceive a drop in environmental temp

if newborn shiver the metabolic rate doubles

increased muscle activity

BAT is primary source of heat in hypothermic newborns → appears in fetus at 26-30 weeks and increased until 2-5 weeks after birth

newborns respond to hypothermia by increasing metabolism by breaking down their limited brown adipose tissue stores (BAT or brown fat)

BAT is around scapula, kidneys, adrenals, head, neck, heart, great vessels, and axilla

Hypothermia Treatment

dry infant immediately at birth

use hats

keep the room warm

use skin to skin with mother or radiant warmer

delay bathing until over 98 degrees

rewarm after the bath

dress appropriately and use blankets as needed

educate parents on importance of staying warm

monitor temp and for symptoms

return to the radiant warmer if temperature is unstable

Digestion and Absorption

newborn has enough intestinal and pancreatic enzymes to digest simple carbs, proteins, and fats → newborns cannot digest starch

by birth the newborn has experienced swallowing, gastric emptying, and propulsion

breast milk (90% digestable) is digested in 2-3 hours

cows milk formula is digested in 3-4 hours

Elimination

meconium is formed in utero

newborn passes meconium within 48 hours → frequency of bowel movements varies

Voiding

93% void by 24 hours after birth and 100% void by 48 hours after birth → initial bladder volume is 6-44 ml of urine

if newborn does not void within 48 hours the nurse should assess adequacy of fluid intake, bladder distension, restlessness, and symptoms of pain

Immune System

isn’t fully activated until after birth → newborn has poor hypothalamic response to pyrogens

fever is not a reliable indicator of infection and hypothermia is a more reliable indicator of infections

Passive Immunity

lasts 4 weeks

passive acquired immunity occurs during the third trimester

preterm infants may be more susceptible to infection

breastfed newborns may have additional passive immunity from mother

newborns start to produce secretory IgA in the intestinal mucosa at 4 weeks

Pain Face

0 → no particular expression or smile

1 → occasional grimace or frown, withdrawn, disinterested

2 → frequent to constant frown, clenched jaw, quivering chin

Pain Legs

0 → normal position or relaxed

1 → uneasy, restless, and tense

2 → kicking or legs drawn up

Pain Activity

0 → lying quietly, normal position, moves easily

1 → squirming, shifting back and forth, and tense

2 → arched, rigid, or jerking

Pain Cry

0 → no cry awake or asleep

1 → moans or whimpers, occasional complaint

2 → crying steadily, screaming or sobbing, frequent complaints

Pain Consolability

0 → content and relaxed

1 → reassured by occasional touching, hugging, or talking to and can distract

2 → difficult to console or comfort

Sleep States

quiet sleep → deep sleep

active sleep (REM) → can dream and often suck or move

average newborn sleeps between 14-17 hours a day and length of cycle varies depending on age

growth hormone secretion depends on regular sleep patterns

Awake States

drowsy → often after a feeding, dosing off

quiet alert → whining but not a full cry, best time for assessment bc they can respond to environment

active alert

crying

first 30-60 mins after birth, many newborns display quiet alert state

nurses should use alert states to encourage bonding and breastfeeding

increasing wakefulness indicates maturing ability to maintain consciousness

use alert states to facilitate feedings

First Reactivity Period

period lasts about 30 minutes, usual after delivery

newborn is awake and active

appears hungry and has a strong reflex → best time to initiate breastfeeding

natural opportunity to start breastfeeding

vital signs are elevated

Second Reactivity Period

period lasts 4-6 hours in a normal newborn

heart and respiratory rates increase, nurse should be alert for apnea periods

newborn passes meconium

newborn sucks, roots, and swallows

Position and Behavior

newborns tend to stay in a flexed position and will resist straightening

hands remain clenched

infant will sleep a majority of the time and wake for feeding → easily consoles when upset

Behavioral Capabilities

some will assist to adaptation to extrauterine life

includes habituation and self quieting ability

Visual Ability

newborn is able to be alert, follow, and fixate on complex visual stimuli for short periods of time

orientation → preference for sharp contrast between dark and light more so than colors at birth

focal distance sis approx 18 inches with a range from 6-24 inches

Auditory Ability

newborn is able to be alert and search for appealing auditory stimulus

newborn can process and respond to visual and auditory stimulation

habituation → decrease response to stimuli after repeated exposure

Olfactory and Taste

newborn is able to select people by smell

newborn is able to respond selectively to different tastes via suckling

newborn is very sensitive to being touched, cuddled, and held

newborn is able to attend to and interact with the environment

Newborn Prophylaxis

eye prophylaxis

vitamin K

hepatitis B

Newborn Screening

hearing

metabolic screening

transdermal bilirubin/serum bilirubin → jaundice in first 24 hrs is never normal, most often caused by blood Rh incompatibility

jaundice develops from the head down → cephalocaudal

O2 saturation → look for levels below 95% and do echocardiogram

drug screening

glucose

gestational age → earlier ultrasound means more accurate dating of pregnancy

Gabellar Reflex

newborn eyes will blink with the first 4-5 taps on the bridge of the nose

Pupillary Reflex

pupils will respond to light

Dolls Reflex

eyes open when coming to sitting

head initially lags but the baby uses their shoulders to right the heads position

Sucking Reflex

mechanism is divided into 3 steps

front of tongue laps on the finger

back of tongue massages middle of the finger

esophagus pulls on the tip of the finger

reflex disappears at about 12 months

Rooting Reflex

touch newborn on either side of the cheek and the baby will turn to find the breast

disappears at about 4-7 months

Extrusion Reflex

when the tongue is touched the infant will push the tongue outward or forward

Palmar Reflex

give one forefinger to each hand and the baby should grasp

pull the baby to sitting with each finger

disappears by 5-6 months

Plantar Reflex

stroke inner sole and the toes curl around (grasp) the examiners finger

lessens by about 8 months

disappears by 9-12 months

Babinski Reflex

stroke outer sole and the toes spread with big toe dorsiflexion

disappears at about 12 months

Moro Reflex

startle reflex usually triggered by a loud noise or if the infants head falls backward

infant will spread his arms and legs out widely and extend his neck

he will then quickly bring his arms back together and cry

present at birth and disappears. by 3-6 months

Fencing Reflex

tonic neck and is a postural reaction present at birth

with infant lying on back, turn his head to one side causing the arm and leg on the side that he is looking toward to extend or straighten while other arm and leg flex

disappears by 4-9 months

Incurvation Reflex

gallant reflex

if the infant is on his stomach and you stroke the neck to the spinal cord on the middle to lower back it will cause his back to curve towards the side that you are stroking

present at birth and disappears by 3-6 months

Step Reflex

holding the infant under the arms supporting the head and allow the feet to touch a flat surface, the infant will appear to take steps and walk

reflex usually disappears by 2-3 months until it reappear as he learns to walk at around 10-15 months