nursing management of the newborn!

signs indicating a problem

• nasal flaring, chest retractions

• grunting on exhalation, labored breathing

• generalized cyanosis, flaccid body posture

• abnormal breathing sounds (rhonchi, stridor, wheezing), abnormal respiratory rates

• abnormal heart rates, abnormal newborn size

abcs for newborn resuscitation

• airway

  • place the infant’s head in “sniffing” posture, with the head tilted back and the chin tilted forward to open the airway

  • suction the infant’s mouth, then nose

• breathing

  • use positive-pressure ventilation (ppv) for apnea, gasping, or pulse <100 bpm

  • form a seal around both the mouth and nose when giving breaths. ventilate at a rate of 1 breath per 30 chest compressions

  • look for slight chest movement with each breath

  • auscultate for rising heart rate and audible breath sounds

• circulation

  • start compressions if the heart rate is <60 after 30 seconds of effective ppv

  • give rapid chest compressions, 90 per minute

  • maintain a compression to ventilation ratio of 3:1

  • compressions should be performed with two fingers at the center of the chest, or compress one third of the anterior-posterior diameter of the chest with thumbs

resuscitative measures

• stabilize the infant: dry the newborn thoroughly with a warm towel; provide warmth by placing them under a radiant heater to prevent rapid heat loss through evaporation. position the head in a neutral position to open the airway, clear the airway with a bulb syringe or suction catheter, and stimulate the newborn to breathe by rubbing them with a dry towel. at times, handling and rubbing the newborn with a dry towel may be all that is needed to stimulate respiration.

• assess the infant’s breathing: provide ppv with an ambu bag if the newborn is apneic or gasping

• determine oxygen saturation: place a pulse oximeter on the newborn’s right hand

• provide ongoing ppv if needed

• assess the infant’s heart rate: if it is less than 100 when breathing on their own, or less than 60 and not improving with effective ppv, perform chest compressions using a 3:1 compression to ventilation ratio

• reassess the newborn’s heart rate: if the heart rate remains below 60 despite effective ppv and compressions, administer epinephrine

maintaining thermoregulation

• the infant’s temperature should be taken every 30 minutes for the first TWO hours or until their temperature has stabilized, and then every EIGHT hours until discharge or per hospital protocols

nursing interventions for thermoregulation

• prewarm blankets and hats to reduce heat loss through conduction

• place the newborn under a temperature-controlled radiant warmer

• dry the newborn immediately after birth to prevent heat loss through evaporation

• put a cap on the newborn’s head after it is thoroughly dried after birth

• wrap the infant in warmed blankets to reduce heat loss via convection

• measure the newborn’s axillary temperature soon after birth to establish a baseline

• use a warmed cover on the scale to weight the unclothed baby

• warm stethoscopes and hands before examining the infant or providing care

• delay the initial bath for 6 to 24 hours after birth until the infant demonstrates a stable temperature to prevent heat loss through evaporation

• encourage skin-to-sin contact with a parent, with both parent and infant covered with a warmed blanket, as soon as the newborn is stabilized to prevent heat loss

• avoid placing newborns in drafts or near air vents to prevent heat loss through convection

• avoid placing cribs near cold outer walls to prevent heat loss through radiation

• if oxygen is required, ensure it is heated and humidified

apgar scoring

• done at 1 and 5 minutes after birth

• an additional assessment is done at 10 minutes if the 5-minute score is less than SEVEN points

• a normal newborn score should be between 8-10

• a: appearance (color)

• p: pulse (hr)

• g: grimace (reflex irritability)

• a: activity (muscle tone)

• r: respiratory effort

initial newborn assessment

• signs that may indicate a problem:

  • abnormal newborn size: small for gestational age or large for gestational age

  • generalized cyanosis or pallor

  • labored breathing, nasal flaring, chest retractions

  • abnormal respiratory rate (tachypnea, more than 60 breaths/min, bradypnea, less than 25 breaths/min)

    • grunting on exhalation

    • abnormal breath sounds (rhonchi, crackles, [rales], whezing, and stridor)

    • apnic episodes

  • abnormal hr (tachycardia, more than 160 bpm; bradycardia, less than 100 bpm)

  • flaccid body posture

  • bulging or sunken fontanels on newborn’s head

  • abdominal distention or hernias

maintaining airway patency

• immediately after birth, if fluids are blocking the airways, the newborn may be suctioned to remove fluids and mucus from the mouth and nose

• if suctioning with a bulb syringe is needed to remove large amounts of secretions from the nose and mouth, compress the bulb before placing it into the oral or nasal cavity

• the newborn’s mouth is suctioned first to remove debris and then the nose is suctioned

ensuring proper identification

• infant abductions have been given security code names such as “code pink” in many hospitals

• the mother, the newborn, and the mother’s partner/support person receive id bracelets

• the newborn receives two id bracelets: one on a wrist and one on an ankle

• the mother receives a matching one, usually on their wrist

• the band includes name, sex, date, time of birth, and id number

• the same id number is on the bracelets of all family members

• id bracelets must be secured before the mother and newborn leave the birthing area

vitamin k injection

• action/indication

  • provides the newborn with vitamin k (necessary for the production of adequate clotting factors by the liver) during the first week of birth until the newborn can produce it

  • prevents vitamin k deficiency bleeding in the newborn

• nursing implications

  • administer within SIX hours after birth

  • administer as an intramuscular injection at a 90-degree angle into the outer middle third of the vastus lateralis muscle

  • use a 25-gauge, 5/8 needle for injection

  • hold the leg firmly and inject the medications slowly

  • adhere to standard precautions

  • assess for bleeding at the injection site after administration

erythromycin ophthalmic ointment

• action/indication

  • provides bactericidal and bacteriostatic actions to prevent neisseria gonorrhoae and chlamydia trachomatis conjunctivitis

  • prevents ophthalmia neonatorum

• nursing implications

  • be alert for chemical conjunctivitis for 1-2 days

  • wear gloves, and open the infant’s eyes by placing your thumb and finger above and below the eye

  • gently squeeze the tube or ampule to apply medication into the conjunctival sac from the inner canthus to the outher canthus of each eye

  • do not touch the tip to the eye

  • close the eye to make sure the medication permeates

  • wipe off excess ointment after ONE minute

length

• average length of most newborns is 50 cm (20 in) but it can range from 48 to 53 cm (19 to 21 in)

• measure the length with the unclothed newborn lying on a warmed blanket placed on a flat surface with the knees held in an extended position

• because of the flexed position of the newborn after birth, it is necessary to extend the leg completely and hold it when measuring the length

• use a disposable tape measure or a built-in measurement board located on the side of some scales

• measure from the head to the soles of the feet - and record the measurement in the newborn’s record

weight

• average weight ranges from 5 lb 8 oz to 8 lb 13 oz

• newborns usually lose 7% to 10% of their birth weight within the first 3 to 4 days of life due to loss of meconium, extracellular fluid, and limited food intake

• the infant then gains weight, returning to the birth weight by TWO WEEKS of age

• procedure

  • first balance the scale if it is not balanced

  • place a warmed protective cloth or paper as a barrier on the scale to prevent heat loss

  • recalibrate the scale to zero after applying the barrier

  • next, place the unclothed newborn in the center of the scale

  • keep a hand above the newborn for safety

head circumference

• average is 33 to 35.5 cm (13 to 14 in)

• measure the circumference at the head’s widest diameter

• wrap a flexible or paper measuring tape snugly around the newborn’s head and record the measurement

chest circumference

• average is 30.5 cm to 33 cm (12 to 13 in)

• generally equal to or about 1 to 2 cm less than the head circumference

• measure the newborn’s chest circumference by placing a flexible or paper tape measure around the unclothed newborn’s chest just below the nipple line without pulling it taut

vital signs

• temperature, heart rate, and respiratory rate are assessed frequently within the first FOUR hours of life

• following that, they should be assessed every SIX to EIGHT hours

• take the newborn’s temperature via the axillary method

  • should be 97.7 to 99.5 F

  • rectal temperatures are not taken due to the risk of perforation

• count the apical pulse for one full minute

  • 120-140 beats/min

• assess respirations when newborn is quiet or sleeping

  • place a stethoscope on the right side of the newborn’s chest and count the breaths for one full minute

  • 30-60 breaths/min

• blood pressure is not assessed as part of a newborn examination unless there is a clinical indication

newborn vital signs

• temperature

  • 97.7 to 99.5

• heart rate

  • 120-140 (as low as 70 with sleep, as high as 170+ with activity or crying)

• respirations

  • 30-60

vernix casoesa

• a thick white substance that protects the skin of the fetus

• formed by secretions from the fetus’s oil glands and is found during the first TWO to THREE days after birth in body creases and hair

• it does NOT need to be removed because it will be absorbed into the skin

stork bites or salmon patches

• superficial vascular areas found on the nape of the neck, on the eyelids, and between the eyes and upper lip

• concentration of immature blood vessels

• most visible when the newborn is crying

• considered a normal variant and most fade and disappear completely within the FIRST YEAR

milia

• pearly white or pale yellow unopened sebaceous glands

• frequently found on a newborn’s nose

• form from oil glands and disappear on their own within TWO to FOUR WEEKS

• when the occur in a newborn’s mouth and gums, they are termed epstein pearls

congenital dermal melanocytes

• benign blue and purple splotches that appear solitary on the lower back and buttocks

• occur most often in black, asian, hispanic, and native american newborns

• caused by a concentration of pigmented cells

• usually fade spontaneously by one year and rarely persist after six years of life

• usually benign and does not require treatment

• should not be confused with bruises caused by trauma

erythema toxicum neonatorum (newborn rash)

• benign, idiopathic, generalized transient rash that occurs during the FIRST WEEK of life

• consists of small papules or pustules on the skin resembling flea bites

• common on the face, chest, and bacl

• chief characteristics is lack of pattern

• caused by a newborn’s eosinophils reacting to the environment as the immune system matures

harlequin syndrome

• refers to the dilation of blood vessels only on one side of the body

• distinct midline demarcation

  • pale on the nondependent side and red on the opposite, dependent side

• resolves by THREE weeks of age

• results from immature autonomic vasomotor control with each episode lasting up to 30 minutes

nevus flammeus (port wine stain)

• appears on the newborn’s body, the head and neck are most common

• a capillary angioma located directly below the dermis

• flat with sharp demarcations

• do not regress but grow in proportion to the child’s growth, becoming thicker and darker in color

nevus vasculosus (strawberry hemangioma)

• benign capillary hemangioma in the dermal and subdermal layers

• raised, rough, dark red, and sharply demarcated

molding

• elongated shaping of the fetal head to accommodate passage through the birth canal

• typically resolves within a week after birth without complications

caput succedaneum

• localized edema on the scalp that occurs from the pressure of the birth process

• presents as a poorly demarcated soft tissue swelling that CROSSES suture lines

• swelling will gradually dissipate in a few days

cephalhematoma

• benign localized sub-periosteal collection of blood CONFINED by one cranial bone (does NOT cross suture lines)

• well-demarcated, often fluctuant swelling with no overlying skin discoloration

eyes

• may be marked edema of the eyelids and subconjunctival hemorrhages due to pressure during birth

• blink reflex intact

• perrla

• track objects to the midline

• may have strabismus (normal for 3-6 months)

• a red reflex should be seen bilaterally

• chemical conjunctivits occur within 24 hours of instillation of eye ointment

  • resolves within 48 hours without treatment

neck

• inspect the clavicle (collarbones) which should be straight and intact

• edema, crepitus, decreased or absent movement, and pain or tenderness in the movement of the arm on the affected side may indicate a clavicular fracture

ears

• soft and pliable

• should recoil quickly and easily when folded and released

• ear pinnae should be aligned with outer canthi of the eyes

• to assess hearing, observe the newborn’s response to noises and conversations

  • newborn typically turns toward sounds and startles with loud noises

mouth

• midlien uvula, working gag, swallow, and sucking reflexes

• free-moving tongue

• normal variations may include epstein pearls, erupted nasal teeth that may be removed to prevent aspiration, and thrush

chest

• barrel shaped with equal anteroposterior and lateral diameters

• symmetric

• 2-3 cm smaller than the head circumference

• nipples may be engorged and may secrete a white discharge, dissipating within a few weeks

  • result of exposure to high levels of maternal estrogen while in utero

• newborns respirations are primarily diaphragmatic

  • abnormalities include tachypnea, bradypnea, retracting, grunting, periods of apnea lasting more than 20 seconds, and asymmetry or decreased chest expansion

• point of maximal impulse is a lateral midclavicular line as the fourth intercostal space

abdomen

• inspect the umbilical cord area for the presence of three blood vessels (two arteries and one vein)

• auscultate bowel sounds in all four quadrants

• normal findings include bowel sounds in all four quadrants and no masses or tenderness on palpation

upper extremities

• an arm that hangs limp or does not move with the moro reflex may indicate a brachial plexus injury

lower extremities

• equal length with symmetric skinfolds

• perform ortolani and barlow maneuvers to identify congenital hip dislocation (developmental dysplasia of the hip)

ortolani maneuver

• place the newborn in the supine position and flew the hips and knees to 90 degrees at the hip

• place your fingers on the trochanter and use the thumbs to grip the femur

• abduct the thighs and lift the femur forward

• listen for any sounds and feel for abnormalities during the maneuver. there should be no clunk felt

• a click or pop may be hard but this is considered benign

barlow manuever

• using the same positions of the newborn and the examiner’s hands as those for the otolani maneuver, adduct the thighs while applying outward and downward pressure to the thighs

• feel for a clunk as the femoral head slips out of the acetabulum. a click or pop may be heard; this is considered benigh

newborn reflexes

• sucking

• moro

• stepping

• tonic neck

• rooting

• babinksi

• palmar grasp

• plantar grasp

ballard gestational age assessment

• provides an estimate of gestational age by scoring the specific parameters of physical as well as neuromuscular maturity

• points are giver for each assessment parameter, with a low score of -1 point or -2 points for extreme immaturity to 4 or 5 points for postm

ballard assessment - physical maturity

• skin texture - typically ranges from sticky and transparent to smooth with varying degrees of peeling and cracking to parchmentlike or leathery with significant cracking and wrinkling

• lanugo - soft downy hair on the newborn’s body, which is absent in preterm newborns; appears with maturity and then disappears again with postmaturity

• plantar creases - creases on the soles of the feet, which range from absent to covering the entire foot, depending on maturity (the greater the number of creases, the greater the newborn’s maturity)

• breast tissue - the thickness and size of breast tissue and areola (the darkened ring around each nipple), which range from being imperceptible to full and budding

• eyes and ears - eyelids can be fused or open, and ear cartilage and stiffness determine the degree of maturity (the greater the amount of ear cartilage with stiffness, the greater the newborn’s maturity)

• genitals - in males, evidence of testicular descent and appearance of the scrotum (which can range from smooth to covered with rugae) determine maturity; in females, appearance and size of clitoris and labia determine maturity (a prominent clitoris with flat labia suggests prematurity, while a clitoris covered by labia suggests greater maturity

ballard gestational - neuromuscular maturity

• posture - how does the newborn hold their extremities in relation to the trunk? the greater the degree of flexion, the greater the maturity

• square window - how far can the newborn’s hand be flexed toward the wrist? as the angle decreases, the newborn’s maturity decreases

• arm recoil - how far do the newborn’s arms “spring back” to a flexed position?

• popliteal angle - how far will the newborn’s knees extend? an angle of less than 90 degrees indicates greater maturity

• scarf sign - how far can the elbows be moved across the newborn’s chest? an elbow that does not reach the midline indicates greater maturity

• heel to ear - how close can the newborn’s feet be moved to the ear. the lesser the flexibility, the greater the newborn’s maturity

bathing and hygiene

• until the newborn has been thoroughly bathed, standard precautions should be used when handling the newborn

• bathing is postponed until thermal and cardiorespiratory stability is ensured

  • should be delayed until their temperature is stable

  • delay the bath for at least 6 hours; ideally, wait until 24 hours of age for the first bath

• during the first bath, it is important for the nurse to wear gloves because of potential exposure to the mother’s blood

• perform the bath quickly, drying the baby thoroughly to prevent heat loss

• after bathing, place the newborn under the radiant warmer and wrap them securely in blaknets

• check the baby’s temperature within an hour to make sure it is within normal limits

teaching guidelines - bathing a newborn

• select a warm room with a flat surface at a comfortable working height

• before the bath, gather all supplies needed so they will be within reach

• never eave the newborn alone or unattended at any time during the bath

• undress the newborn down to shirt and diaper

• always support the newborn’s head and neck when moving or positioning them

• place a blanket or towel underneath the newborn for warmth and comfort

• in this order, progressing from the cleanest to the dirtiest areas

  • wipe eyes with plain water, using either cotton balls or a washcloth. wipe from the inner corner of the eyes to the outer with separate wipes

  • wash the rest of the face, including ears, with plain water

  • using baby shampoo, gently wash the hair and rinse with water

  • pay special attention to body creases, and dry thoroughly

  • wash extremities, trunk, and back. wash, rinse, dry, and cover

  • wash diaper area last, using soap and water, and dry; observe for rash

• put on a clean diaper and clean clothes on the newborn after the bath

• sponge bath only (without submersion into the water) until the umbilical cord falls off and the naval area is healed completely (if circumcised, until that area has also healed, usually 1 to 2 week)

elimination and diaper area care

• adhere to standard precautions

• cleanse with clear water and mild soap (or use an unscented commercial baby wipe)

• for females, teach to clean front to back

• for males, do not force the foreskin back, it will retract normally over time

• instruct parents to keep the top edge of the diaper folded down below the umbilical cord to prevent irritation and to allow air to help dry the cord

• for a male infant, point the penis down to prevent urine from wetting the top of the diaper where the umbilicus is located

• the urine is light amber in color

• soaking a minimum of SIX diapers a day indicates adequate hydration

• meconium is passed within the first 48 hours after birth; the stools appear thick, tarry, sticky, and dark green

• transitional stools (thin, brown to green, less sticky than meconium) typically appear by day THREE after initiation of feeding

• breast-feeding newborns typically pass mustard-colored, soft, seedy stools

• formula-fed newborns pass yellow to brown, soft stools with a pasty consistency

preventing diaper rash

• change diapers frequently, especially after bowel movements

• apply a “barrier” cream, such as a&d ointment or desitin, after cleaning with mild soap and water

• use dye and fragrance free detergents to wash cloth diapers

• avoid the use of plastic pants because they tend to hold in moisture

• expose the newborn’s bottom to air several times a day

• place the newborn’s buttocks in warm water after they have had a diaper on all night

take note - rash!

advise parents that a rash that persists for more than THREE days may be fungal in origin and may require antifungal treatment. encourage the parents to notify the health care provider.

diaper care - lotions

• with a moistened cloth, clean any milk spilled into the newborn’s neck folds from breastfeeding or formula

• the use of lotions, baby oils, and powders is NOT recommended

  • oils and lotions can cause skin irritation and rashes

• powders should not be used because they can be inhaled, causing respiratory distress

cord care

• umbilical cord stump begins drying within hours after birth and is shriveled and blackened by the second or third day

• within 7 to 10 days, it sloughs off and the umbilicus heals

• cord bleeding is abnormal and may occur if the cord clamp is loosened

• any cord drainage is also abnormal; it may be caused by infection which requires immediate treatment

• keeping the cord clean and dry and using only soap and water should be emphasized to caregivers

• keep the diaper folded below the cord to keep urine from soaking it and keep the cord stump clean and dry

• expect to remove the cord clamp approximately 24 hours after birth by using a cord-cutting clamp

• if the cord is still moist, keep the clamp in place and ensure a referral to home health care so that the home care nurse can remove it after discharge

teaching guidelines - umbilical cord care

• observe for bleeding, redness, drainage, or foul odor from the cord stump, and report it to the newborn’s primary care provider immediately

• avoid tub baths until the cord has fallen off and the area has healed

• expose the cord stump to the air as much as possible throughout the day

• fold diapers below the level of the cord to prevent contamination of the site and to promote air-drying of the cord

• observe the cord stump, which will change color from yellow to brown to black. this is normal

• never pull the cord or attempt to loosen it; it will fall off naturally

circumcision

• the surgical removal of all or part of the foreskin (prepuce) of the penis

• three commonly used methods: gomco clamp, hollister plastibell device, and the mogen clamp

• during the circumcision procedure, part of the foreskin is removed by clamping and cutting with a scalpel (gombo or mogen clamp) or by using a plastibell

• the plastibell is fitted over the glans and the excess foreskin is pulled over the plastic ring

  • a suture is tied around the rim to apply pressure to the blood vessels, causing hemostasis

  • the excess foreskin is cut away

  • the plastic ring remains in place until healing occurs

  • the plastic ring typically loosens and fall off in approximately ONE WEEK

• petroleum jelly should be applied to the circumcised area after the procedure is done with the gomco or mogen clamp

• analgesic methods may include emla cream, ring block, a dorsal penile nerve block with buffered lidocaine, acetaminophen, skin-to-skin contact, a sucrose pacifier, and swaddling

preoperative circumcision check list

• infant is at least 12 hours old

• infant has received vitamin k prophylaxis (12 hours before)

• infant has voided normally at least once since birth

• infant has not eaten for at least an hour prior to the procedure

• written parental consent has been obtained

• correct identification of the infant brought to the procedure room

circumcision site care

• assess for bleeding every 30 minutes for at least 2 hours

• document the first voiding to evaluate for urinary obstruction or edema

• squeeze soapy water over the area daily and then rinse with warm water. pat dry

• apply a small amount of petroleum jelly with every diaper change if the plastibell was used; clean with mild soap and water if other techniques were used

• fasten the diaper loosely over the penis, avoiding placing the newborn on their abdomen to prevent friction

• if a plastibell was used, it will fall off by itself in about a week

  • advise parents not to pull of earlier

  • instruct parents to check daily for any foul-smelling drainage, bleeding, or unusual swelling

general newborn safety

• have emergency telephone numbers readily available, such as those for emergency medical assistance and the poison control center

• keep small or sharp objects out of reach to prevent them from being aspirated

• do not leave the infant alone in any room without a portable intercom on

• always supervise the newborn in the tub

• make sure the crib or changing table is study, without any loose hardware, and is painted with lead-free tape

• avoid placing the crib or changing table near blinds or curtain rods

• provide a smoke-free environment for all infants

• place all infants on their backs to sleep to prevent sudden unexplained infant death

• employ safe sleep strategies to reduce suffocation deaths of infants

• use car seats properly to reduce motor vehicle crash injuries and deaths

• to prevent falls, do not leave the newborn alone on any elevated surface

• use sun shields on strollers and hats to avoid overexposing the newborn to the sun

• to prevent infection, throughly wash your hands before preparing the formula

• thoroughly investigate any infant care facility before using it

car safety

• do not release any newborn unless the parents have a car seat in place for the newborn’s ride home

• key strategies

  • select a car seat that is appropriate for the child’s size and weight

  • caution caregivers against the placement of car seats on elevated or soft surfaces outside the car to prevent falling

  • all newborns discharged from the hospital should be brought home in rear-facing car safety seats secured in the back seat of the vehicle

  • avoid using a rear-facing car seat in the front seat equipped with a passenger-side airbag

  • never let an infant ride in the arms of an adult while in a moving vehicle

  • use the car seat correctly every time the child is in the car

  • use rear-facing car safety seats for most infants up to 2 years of age or until they reach the highest weight or height allowed by the manufuctuer of the seat

  • make sure the harness (most seats have a three to five-point harness) is in the slots at or below the shoulders

preventing infection

• minimize exposure of newborns to organisms

• report understaffing at your facility as it can lead to nurses missing early signs of infection and thereby cause failure-to-rescue events

• wash your hands before and after providing care, and insist all personnel wash their hands before handling any newborn

• visitors should be limited to those essential for the mother’s well being and care

• do not allow ill staff or visitors to visit or handle newborns

• avoid sharing any infant supplies with another infant

• monitor the umbilical cord stump and circumcision site for signs of infection

• provide eye prophylaxis by instilling prescribed medication soon after birth

• educate parents about appropriate home measures that will prevent infections, such as practicing good hand hygiene before and after diaper changes, keeping the newborn well hydrated, avoiding taking the infant into crowds, ensuring visitors also wash their hands, and keeping health care provider appointments for routine immunizations

promoting sleep

• newborns sleep up to 15 hours daily

• sleep for 3 to 4 hours at a time but do not sleep through the night because their stomach capacity is too small to go long periods without nourishment

• place the newborn on their back to sleep

• sleep in a crib in the same room as the parent for up to a year, at least 6 months

reducing the risk of sids

• always place the baby on their back to sleep for all sleep times, including naps; similarly; to avoid the newborn shifting to a tummy position, do not prop infants on their side when putting to sleep

• room share, not bed share - keep the baby’s sleep area in the same room where the caregiver sleeps

• avoid infant exposure to tobacco smoke during pregnancy and after birth

• avoid wrapping the infant too lightly with a blanket, and stop when the infant can roll over

• encourage breastfeeding as breastfed infants have a 50% lower risk of developing sudden infant death syndrome (sids)

• keep the infant’s sleep area in the same room where parents sleep for the first 6 months or ideally for the first year

• only bring the infant into the parents’ bed to feed or comfort them

• allow supervised awake “tummy time” to counteract back sleeping on muscle development or development of a flattening of the head

• if the infant falls asleep in the car seat, move them to a firm surface laying on their back

• use a firm sleep surface, free from soft objects, toys, blankets, and crib bumpers

• use a pacifer during infant sleep. but do not force its use

genetic issues and inborn errors of metabolism screening

• common screening tests include sickle cell disease, congenital hypothyroidism, and inborn errors of metabolism such as pku and galactosemia

• screening tests for genetic issues and inborn errors of metabolism require a few drops of blood taken from the newborn’s heel

• the trend toward early discharge of newborns can affect the timing of screening and the accuracy of some test results

  • newborns needs to ingest enough breast milk or formula to elevate phenylalanine levels for the screening test to identify pku accurately, so newborn screening for pku testing should NOT be performed BEFORE 24 to 48 hours of age

description of pku

• autosomal recessive inherited deficiency in one of the enzymes necessary for the metabolism of phenylalanine to tyrosine - essential amino acids found in most foods

clinical picture of pku

• irritability, vomiting of protein feedings, and a musty odor to the skin or body secretions of the newborn

• if not treated, cognitive impairment, motor retardation, seizures, microcephaly, and poor growth and development

treatment for pku

• lifetime diet of foods low in phenylalaline (low protein) and monitoring of blood levels

• special newborn formulas available: phenex and lofenalac

timing of screening for pku

• universally screening for in the us

• testing is done 24-48 hours after protein feeding

description for congenital hypothyroidism

• deficiency of thyroid hormone necessary for normal brain growth, calorie metabolism, and development

• may result from hypothyroidism in the mother

clinical picture of hypothyroidism

• increased risk in newborns with low or high birth weight, those of hispanic and asian heritage

• feeding problems

• growth and breathing problems

• if not treated, irreversible brain damage and intellectual disability before age 1

treatment for congenital hypothyroidism

lifelong thyroid replacement therapy

timing of screening for congenital hypothyroidism

• testing (measures thyroxin t₄ and thyroid stimulating hormone t₃ ) is down between days FOUR and SIX of life

description of galactosemia

absence of the enzyme needed for the conversion of the milk sugar galactose to glucose

clinical picture of galactosemia

• poor weight gain, vomiting, jaundice, mood changes

• loss of eyesight, seizures, and intellectual disability

• if untreated, galactose buildup causes permanent damage to the brain, eyes, and liver, and eventually death

treatment for galactosemia

• eliminate milk from diet

• substitute soy milk

• breastfeeding not advised

timing of screening for galactosemia

• first test is done on discharge from the hospital with a follow-up test within one month

description of sickle cell anemia

• recessively inherited abnormality in hemoglobin structure

clinical picture of sickle cell anemia

• anemia developing shortly after birth

• increased risk for infection

• growth restriction

• vaso-occlusive crisis

treatment for sickle cell anemia

• maintenance of hydration and hemodilution

• rest, electrolyte replacement, pain management, blood replacement, and antibiotics

timing of screening for sickle cell anemia

bloodspot obtained at the same time as other newborn screening tests or prior to THREE months of age

hearing screening

• require an initial hearing screening prior to leaving the hospital

• child with a positive screen for atypical hearing thresholds in one or both ears should be referred to an audiologist for diagnostic consultation and testing

• can be screened using either otoacoustic emission or automated auditory brain stem response

otoacoustic emission

• a tiny microphone is placed in the infant’s ear canal and the sound waves produced by the newborn’s inner ear are measured in response to certain tones or clicks presented through the earphone

• test may be done when the infant is awake but the best and quickest results are possible when the newborn is sleeping

automated auditory brain stem response

• an earphone is placed in the ear canal or an earmuff is placed over the newborn’s ear, and a soft, rapid tapping noise is presented

• electrodes placed around the newborn’s head, neck, and shoulders record neural activity from the infant’s brain stem in response to the tapping noises

• tests how well the ear and the nerves leading to the brain work

hypoglycemia

• defined as a plasma glucose less than 30 mg/dL in the first 24 hours of life and less than 45 mg/dL AFTER the first 24 hours

• in newborns, blood glucose levels fall to a low point during the first few hours of life because the source of glucose from the mother is removed when the umbilical cord is cut

newborns at risk for hypoglycemia

• infants of mothers who have diabetes or high body weight

• preterm newborns

• newborns with fetal growth restriction

• newborns born via caesarean delivery

• neonatal hypothermia

• inadequate caloric intake

• sepsis

• asphyxia

• hypothermia

• polycythemia

• glycogen storage disorders

• endocrine disorders

hypogylcemia symptoms

• jitterriness

• sweating

• hypothermia

• irritability

• lethargy

• cyanosis

• apnea

• seizures

• high-pitched or weak cry

• hypothermia

• poor feeding

treatment of hypoglycemia

• rapid-acting source of glucose such as dextrose gel, breastfeeding, or early formula feeding

• in acute, severe cases, intravenous administration of glucose may be required

• monitor for signs of hypoglycemia or identify high-risk newborns prone to this disorder based on perinatal history, physical examination, body measurements, and gestational age

• glucose screening should be performed on at-risk infants and those with clinical signs compatible with hypoglycemia

promoting nutrition

• stomach capacity is limited at birth. the emptying time is short (2 to 3 hours) and peristalsis is rapid. therefore, small, frequent feedings are needed at first, with amounts progressively increasing with maturity

• the immune system is immature at birth, so the baby is at high risk for food allergies during the first 4 to 6 months of life. introducing foods prior to this time increases the risk of developing food allergies

• pancreatic enzymes and bile to assist in the digestion of fat and starch are in limited supply until about 3 to 6 months of age. infants cannot digest cereal prior to this time

• kidneys are immature and unable to concentrate urine until about 4 to 6 weeks of age. excess protein and mineral intake can place a strain on kidney function and can lead to dehydration. infants need to consume more water per unit of body weight than adults do as a result of their high body weight from water

newborn nutritional needs

• an infant’s birth weight doubles in the first 4 to 6 months of life and triples within the first year

• caloric needs range from 110 to 120 cal/kg per body weight

• fluid requirements range from 100 to 150 mL/kg daily

  • can be met through breast feeding or bottle feeding

  • additional water supplementation is NOT needed

• iron-fortified formula should be used for all infants who are not breastfed from birth to 1 year

• the breastfed infant draws on iron reserves for the first SIX months and then needs iron-rich foods or supplementation added at 6 month of age

• all infants need to receive a daily supplement of 400 IU of vitamin d starting within the first few days of life

feeding the newborn

• auscultate bowel sounds, check for abdominal distention, and inspect the anus for patency

  • if these parameters are within normal limits, newborn feeding may be started

• most newborns should be fed on demand and they should be fed when they awaken

• parents are encouraged to feed their newborn every 2 to 4 hours during the day and only when the newborn awakens during the night

• hunger cues

  • placing their fingers or fist in their mouth

  • rooting around

  • sucking

  • crying

• most breastfed newborns need to be fed every 2 to 3 hours, usually nursing for 20 to 30 minutes

• most formula-fed newborns need to be every 3 to 4 hours, finishing a bottle in 30 minutes or less

signs of a well-fed baby

• wets 6 to 10 diapers a day

• produces 3-4 stools a day

• sleeps well

• gaining weight regularly

burping positions

• over shoulder

• sitting on lap

• face-down on lap

breastfeeding

• optimal form of nourishment during the first SIX months of life

• benefits

  • lower incidence of necrotizing enterocolitis and suid and later in life, obesity

  • acute otitis media

  • type 2 diabetes

  • asthma

• parents should CONTINUE to breastfeed during mild illnesses such as colds or flu

• people with hiv and galactosemia are advised NOT to breastfeed

advantages of breastfeeding for the newborn

• contributes to the development of a strong immune system

• stimulates the growth of positive bacteria in the digestive tract

• reduces the incidence of stomach upset, diarrhea, and colic

• begins the immunization process at birth by providing passive immunity

• promotes optimal parent-infant bonding

• reduces the risk of newborn constipation

• promotes greater development gains in preterm infants

• provides easily tolerated and digestible food that is sterile; at proper temperature; and readily available with no artifical coloring, flavorings, or preservatives

• is less likely to result in overfeeding, leading to unhealthy weight gain

• promotes better tooth and jaw development as a result of sucking harder

• provides protection against food allergies

• lowers health care costs due to fewer illnesses

• is associated with avoidance of type 1 diabetes and heart disease

advantages of breastfeeding for the mother

• can facilitate postpartum weight loss by burning extra calories

• stimulates uterine contractions to control bleeding

• lowers risk for ovarian and endometrial cancers

• facilitates bonding with the newborn infant

• lowers risk of type 2 diabetes

• breast milk, unlike formula, is free

• reduces risk of postpartum depression

• promotes uterine involution as a result of the release of oxytocin

• lowers the risk of breast cancer and osteoporosis

• affords some protection against conception, although, it is not a reliable contraceptive method

colostrum

• composition changes over time from colostrum to transitional milk, and finally to mature milk

• colostrum is a thick, yellowish substance secreted during the first few days after birth

  • composed of the macronutrients carbohydrates, protein, and fat

  • rich in immunoglobulin a which helps protect the newborn against infections

  • helps establish a healthy gut microbiome by coating the intestines

transitional milk

• occurs between colostrum and mature milk

• contains all the nutrients in colostrum but it is thinner and less yellow

• replaced by mature milk around day TEN after birth

mature milk

• appears bluish

• not as thick as colostrum

• contains

  • protein, fat, carbohydrates

  • water

  • minerals

  • vitamins

  • enzymes

keys to successful breastfeeding

• initiating breastfeeding within the FIRST HOUR of LIFE if the newborn is stable

• placing the newborn on the birthing parent’s chest or abdomen immediately after birth

• following the newborn’s feeding schedule - 8 to 12 times in 24 hours

• providing unrestricted periods of breastfeeding

• offering no supplement unless medically indicated

• having a lactation consultant observe a feeding session

• avoiding artificial nipples and pacifiers except during a painful procedure

• increasing fluid intake to encourage greater milk production

• feeding from both breasts over each 24-hour period

• relaxing the parent’s shoulders and bringing the infant to the breast, rather than the breast to the infant

• having the mother hold the infant close during breastfeeding, tummy to tummy, nose to nipple

• holding the infant close helps to guild a secure and loving relationship

• watching for indications of sufficient intake from infant

  • 6 to 10 wet diapers daily

  • waking up hungry 8 to 12 times in 24 hours

  • acting content and falling asleep after feeding

• keeping the infant warm throughout the breastfeeding experience

• keeping the newborn with the birthing parent throughout the hospital stay

• availability of the nurse or lactation consultant to guide and support the breastfeeding parent while on the postpartum unit

latch scoring tool

• l: latch

• a: audible swallowing

• t: type of nipple

• c: comfort of nipple

• h: hold (positioning)

“l” for latch

• 0 point

  • sleepy infant, no sustained latch achieved

• 1 point

  • must hold nipple in infant’s mouth to sustain latch and suck

  • must stimulate infant to continue to suck

• 2 point

  • grasps nipple, tongue down, lips flanged, rhythmic sucking

“a” for audible swallowing

• 0

  • none

• 1

  • a few observed with stimulation

• 2

  • spontaneous and intermittent both <24 hours old and afterward

“t” type of nipple

• 0

  • inverted (drawn inward into breast tissue)

• 1

  • flat (not protruding)

• 2

  • everted or protruding out after stimulation

“c” for comfort of nipple

• 0

  • engorged, crack bleeding, blisters or bruises, severe discomfort

• 1

  • filling, reddened, small blisters or bruises, mild to moderate discomfort

• 2

  • soft, nontender

“h” for hold (positioning)

• 0

  • nurse must hold infant to breast

• 1

  • minimal assistance

  • help with positioning, then breastfeeding parent takes over

• 2

  • no assistance needed by nurse