ch 22b: physiologic and behavioral adaptations of newborn

immune system 5

Immature at birth → ↑ susceptibility to infection

passive immunity from mother

B cells & T cells = present, but immature

slower inflammation response

immunoglobulins GAMED

IgG: passed in last 3 months of pregnancy passively from mother

IgM: Made by fetus from 8 weeks gestation; low at birth; responds to blood-borne pathogens

igA: Present in breast milk (not formula); protects GI tract (allergies/intolerance)

igD and igE: Develop gradually, reach full levels in early childhood.

tdap

TDAP vaccine given to mom at 28 weeks/third trimester to pass to baby

baby cant get vaccine until 2 months

signs of infection 9

Hypothermia (more than fever)

hypotonia

Poor feeding

vomiting/diarrhea

Lethargy

irritability

Pale/mottled skin

unusual discharge or rash

resp distress: Apnea, tachypnea, grunting, retractions

rfs

• 5 important italics

• 8 total

Prematurity (most significant)

Prolonged rupture of membranes

Maternal fever

chorioamnionitis

Invasive procedures

Asphyxia (before or during labor)

Congenital anomalies

Stress (physical or metabolic)

integumentary system

• 6

All skin layers present at birth; skin is thin & loosely bound.

covered in vernix caseosa

Initial erythema, fades to normal tone.

Mottling common, especially in extremities.

Acrocyanosis (blue hands/feet) normal first 48 hrs, may reappear with cold.

Desquamation: Normal peeling occurs a few days after birth.

• excess = postmaturity

COMMON SKIN FINDINGS

• 4

Sweat Glands & Milia

• Sweat glands present but inactive at birth.

• Milia: white sebaceous cysts on face; normal.

Mongolian spots/CONGENTIAL MELANOCYTOSIS

Nevus simplex (Stork bites/Angel kisses)

• Flat, pink, blanchable spots

Infantile hemangioma

• Bright red or bluish raised lesion

Signs of Integumentary Problems

• 4 total

abnormal skin color: Pallor, central cyanosis, jaundice

Petechiae: if scattered → possible infection or low platelets.

Bruising: from birth trauma; ↑ risk for hyperbilirubinemia

hematoma

reproductive female 3

labial edema

Vernix caseosa may be present between labia – do not forcibly remove.

mucoid or bloody vaginal discharge (normal) from Estrogen withdrawal after birth

reproductive male

• 2 normals

• 2 abnormals

Epithelial pearls (small white lesions on glans): benign.

Hydrocele: fluid-filled sac; transilluminates, usually resolves.

Bluish scrotum: possible testicular torsion → emergency.

testes should be descende, if undescended (Cryptorchidism)

• usually resolves spontaneously

Breast Tissue (Both Sexes)

Swelling due to maternal estrogen

May secrete “witch’s milk”

Resolves spontaneously

Signs of Reproductive Abnormalities 4

Fecal discharge from vagina: vaginal fistula

Hypospadias/epispadias: Abnormal urethral opening

• circumcision contraindicated

Undescended testes: Cryptorchidism

Inguinal hernia; May resolve; more visible when crying

Molding, caput, cephalhematoma, subgaleal hemorrhage

• describe/key details

M: Overlapping of skull bones during birth

caput: Edema across scalp (crosses suture lines)

cephal: Blood between skull & periosteum (does not cross suture lines)

subgaleal: Blood under scalp aponeurosis

Signs of subgaleal hemorrhage: 6

int: 2

Boggy scalp

pallor

↑ head circumference

Ear displacement

tachycardia

edema at neck

Needs immediate imaging + blood replacement

Spine

should be straight and midline; easily flexed

pilonidal dimple: may indicate spina bifida if sinus or hairy nevus present

• sinus: hollow space

• HN: pigmented bm; nexus + hair

IMAGING

Extremities

• NORMALS 2

• ABNORMAL 3

Limbs should be symmetric, equal in length

Nails present on all digits

ABNORMAL

• Oligodactyly Fewer than 5 digits

• Polydactyly Extra digits

• Syndactyly Fused fingers/toes

Developmental Dysplasia of the Hip (DDH) rfs 4

Breech birth

first-born

female

family history

SIGNS OF DDH

• 2

• tests 2

Asymmetric gluteal/thigh folds

Uneven knee height

Positive Barlow test (dislocates hip)

Positive Ortolani maneuver (relocates hip)

⚠ Only trained clinicians should perform Barlow/Ortolani tests.

Neuromuscular System: BRAIN

• growth rate

• needs

Rapid growth in infancy/early childhood

Slows during later childhood & adolescence

requires high oxygen and glucose for energy → assess hypoglycemia risk

Tremors vs. Seizures 3

• cause

• touch

• changes

Transient tremors (mouth, chin, arms, hands) are normal in first few weeks

Persistent or full-body tremors → pathologic

newborn reflexes

• Sucking

• rooting

• swallowing

• palmar and plantar grasp

• glabellar

reflexes 2

• tonic neck

• moro reflex

• stepping/walking

• babinski

• Trunk Incurvation (Galant)

Brazelton Neonatal Behavioral Assessment Scale (NBAS) – Clusters

Real Hot Moms Rarely React After Overeating

sleep wake states

6 total: 2 sleep, 4 awake

sleep pattern/cycle

Sleeps 16–19 hours/day (early weeks)

Wakefulness increases → initially hunger-driven, later includes social interaction

factors influencing newborn behavior

Gestational Age

Time

Environmental Stimuli

Maternal Medications

gest age/time

Gestational Age: affects CNS maturity

TIme:

• Time since birth: affects initial behavioral organization.

• Time since last feeding and time of day: influence alertness and responsiveness.

env stimuli/maternal meds

env stimuli

• Infants react to sounds, lights, and emotional tone of caregivers.

• Overstimulation (e.g., NICU alarms, bright lights, loud noises) can impact stability.

• Infant may sense caregiver stress or tension, which affects behaviors like feeding.

maternal meds

• No proven direct effect of labor epidurals on neonatal behavior.

• Opioids during postpartum: may pass through breast milk → CNS depression, sedation, respiratory depression in infant.

levels of behavioral organization

autonomic, motor, state, attention/interaction

1. Autonomic Regulation:
   Controls involuntary functions (HR, temp, breathing)

2. Motor Organization:
   Muscle tone, control of movement, reduction of random activity

3. State Regulation:
   Ability to modulate between states (sleep/wake, alertness)

4. Attention & Interaction:
   Responds to visual/auditory stimuli, maintains alertness, social engagement

Behavioral Cues: engaged vs disengaged

senses + vision and hearing

v: 2; h 3

all senses developed at birth

vision

• immature at birth; least well developed

• see 8-12 inches

hearing

• bonding: Prefer mother’s voice and high-pitched tones

• screening before d/c

• heartbeat rhythm and lullabies are soothing

senses 2

• smell 3

• taste/touch 2

smell

• well devt at birth

• React to strong odors (e.g., vinegar) by turning away; Attracted to sweet smells

• can recognize mother’s scent and milk

taste

• Prefer sweet tastes

• Early oral sensitivity helps with feeding and soothing

touch

• Most sensitive: mouth, hands, feet

• Sensitive to pain and comforting touch

Response to Environmental Stimuli

o Temperament

o Habituation

o Consolability

o Cuddliness

o Irritability

o Crying

Temperament – Individual behavioral style or response pattern to stimuli

Habituation – Decreased response to repeated or continuous stimulation

Consolability – Infant’s ability to self-soothe or be soothed by others

Cuddliness – Degree to which an infant relaxes and molds into the caregiver when held

Irritability – Sensitivity to stimuli; how easily an infant becomes upset

crying

primary communication tool

➤ Hunger

➤ Pain

➤ Discomfort

➤ Desire for attention

➤ Overstimulation

high pitched cry

A potentially abnormal cry that may signal neurologic issues