NEWBORN CARE
Newborn undergo physiologic and psychological changes at moment of Birth
Major Adjustments Depends
Genetic Composition
The competency of the recent intrauterine environment
The care received during labor, birth, and newborn or neonate period
The Profile of a Newborn
Vital Statistics
Measured in newborn are Weight, Length and Chest Circumference
Weight
Newborn weight determine maturity and establish baseline data
Birth weight varies depending on the:
Racial
Nutritional
Intrauterine and genetic factors that were present during conception and pregnancy
Plotting birth weight helps Identify newborns at risk
Small for their gestational age
Newborns who have suffered Intrauterine Growth Restriction (Preterm infants)
Plotting weight in conjunction with height and head circumference is helpful (highlights disproportionate measurement)
Average birth weight (White)
Male - 3.5 kg
Female - 3.4 kg
Newborns of other races weigh approximately 0.5lb less. The arbitrary lower limit of normal for all races is 2.5kg (5.5lbs)
Newborns weighing more than 4.7 kg (10lbs) is macrosomic
Newborns loses 5% to 10 % of birth weight during dew days after birth
Diuresis occur and remove a part of the infants high fluid load, voids and passes stool
After inital loss, baby will regain the weight
the breastfed newborn recaptures birth weight within 10 days
A formula-fed infant accomplishes this gain within 7 days
After this, a newborn begins to gain about 2lb per month (6-8 oz per week) for the first 6 months of life
Length
The average birth length
Male - 54 cm
Female - 53 cm
The lower limit of normal length is arbitrarily set at 46 cm (18 in).
Rare babies with lengths as great as 57.5 cm (24 in) have been reported.
Head Circumference
Mature newborn - 34 - 35 cm
Head circumference is measured across the center of the forehead (Above the eyebrows) and around the most prominent portion of the posterior head.
Mature newborn with head greater than 37 cm or less than 33 cm should be carefully assessed for neurologic involvement
Head abnormalities
Hydrocephaly - Accumulation of excess CSF
Microcephaly - Fetal brain grows slowly
Ancephaly - Absence of Cranial Bones
Chest Circumference
Chest in a term newborn - 2cm less than head circumference (31-33cm)
Measured at level of the nipples
If large amount of breast tissue or edema, or if breast is present, this measurement will not be accurate until the edema has subsided.
Vital Statistics
Temperature
Temperature of newborns is about 99° F (37.2° C) at birth
Temperature fall almost immediately to below normal because of heat loss
The temperature of birthing rooms, approximately 68° to 72° F (21° to 22° C), can add to this loss of heat.
Heat loss occurs in Four Mechanisms
Convection
flow of heat from the newborn’s body surface to cooler surrounding air
Wrap the newborn and avoid unnecessary exposure when performing procedures
Radiation
is the transfer of body heat to a cooler solid object not in contact the baby
Moving an infant as far from the cold surface as possible helps to reduce this type of heat loss
Evaporation
loss of heat through conversion of a liquid to a vapor.
Unang Yakap (Skin to Skin contact with the mother)
Conduction
the transfer of body heat to a cooler solid object in contact with a baby
Do not put the newborn on cold, unlined surfaces
Newborns exposed to cool air tend to kick and cry to increase their metabolic rate and produce more heat
Newborn’s temperature stabilizes at 98 F 4 hrs after birth
BROWN FAT - Located at intrascapular region, thorax, and perirenal area
Pulse
HR of a fetus in utero averages 120-160 bpm
Immediately after birth, as newborn struggles to initiate respiration HR increases 180 bpm
Within 1 hour after birth, the heart stabilizes to an average of 120 to 140 bpm
HR remains slightly irregular because of cardiac regulatory center immaturity
Transient murmurs may results from the incomplete closure of fetal circulation shunts
Newborns HR is determined by listening for an apical heartbeat for a full minute (5th intercostal, left midclavicular)
HR increases at 180 during crying, heart rate can decrease during sleep, ranging from 90 to 110 bpm.
Be able to palpate brachial and femoral pulses in newborn
Respiration
RR first few minutes of life as high as 80 breaths/min
As respiratory activity established and maintained rate settles to an average of 30-60 breaths/min when newborns is at rest
Respiratory depth, rate, and rhythm irregular, short periods of apnea (Without cyanosis) lasts less than 15 seconds (Periodic Respirations)
RR is observed the movement of a newborns abdomen
breathing involves the use of the diaphragm and abdominal muscles.
Newborns are “obligate nose breathers” , and shows signs of acute distress if their nostril become obstructed
Blood Pressure
Approximately 80/46 mm Hg at birth
By the 10th day - it rises to 100/50 mm Hg and remain at that level for the infant year.
NOT ROUTINELY MEASURED UNLESS A CARDIAC ANOMALY IS SUSPECTED
Cuff width used must be no more than 2/3 the length
A Doppler method may be used to take blood pressure
Physiologic Functions
Cardiovascular System
When the cord is clamped, neonate is forced to take in oxygen through the lungs.
With the firsth breath, blood pressure decreases in the pulmonary artery, ductus arteriosus begins to close
Increase blood flow to the left side of the heart cause foramen ovale to close
Umbilical veins, 2 umbilical arteries and ductus venosus, no longer receiving blood from the placenta begins to close
Blood Values:
A newborn has an elevated RBC count - 6 million cells per cubic millimeter
Blood volume is 80-110 ml/kg of body weight (300 ml total) hematocrit is between 45% and 50%
Once proper lung oxygenation has been established the need for the high RBC diminishes, within a matter of days, a newborn’s RBC begin to destroyed, and cells are broken down and bilirubin released
Bilirubin is a byproduct of the breakdown of RBC
Newborns produce more bilirubin than adults because of greater production and faster breakdown of red blood cells in the first few days of life.
A newborn'simmature liver often can't remove bilirubin quickly enough, causing an excess of bilirubin.
Physiologic jaundice - normal jaundice in newborn and typically appears on the second or third day of life.
Respiratory System
All newborns have some fluid in their lungs from intrauterine life that allows alveoli to inflate more easily than if the lung walls were dry
About a third of this fluid is forced out of the lungs by the pressure of vagina birth
First breath becomes much easier for a baby within 10 mins after birth once the alveoli have been inflated
A newborn with difficulty establishing respiration at birth should be examined
Cardiac murmur
Indication of patent fetal cardiac structures (Patent ductus arteriosus)
Gastrointestinal System
Baby is sterile at birth, bacteria drom GIT in most babies within 5 hrs after birth from all babies at 24 hrs of life
Bacteria enter through
Newborns mouth from airborne
Vaginal Secretions
Hospital Bedding
Contact at the breast
Accumulation of bacteria in the gastrointestinal tract is necessary for digestion and for the synthesis of vitamin K
babies have very little vitamin K stored in their bodies because only small amounts passto them through the placenta from their mothers.
good bacteria that produce vitamin K are not yet present in the newborn'sintestines.
Newborn has limited ability to digest especially fat and starch
Regurgitate easily - Sphincter between the esophagus and stomach is immature
STOOL
Meconium – is the first stool usually passed within 24 hours after birth
a sticky, tarlike, blackish-green, odorless material formed from mucus, vernix, lanugo, hormones, carbohydrates that accumulated during intrauterine life
If a newborn does not pass a meconium stool by 24 to 48 hours after birth infant is suspected of
Meconium ileus
Imperforate anus
Volvulus
Transitional Stool - 2nd or 3rd day stool changes in color and consistency, becoming green and loose. and it may resemble diarrhea to the untrained eye.
Breastfed babies pass
3 or 4 light yellow stools per day on the 4th day of life, sweet-smelling, high in lactic acid, which reduces the amount of putrefactive organisms in the stool.
Newborn who receives formula
2 or 3 bright yellow stools a day, have a slightly more noticeable odor, compared with the stools of breastfed babies.
Urinary System
Specific gravity ranges from 1.008 to 1.010
30 to 60 mL total - daily urinary output for the first 1 or 2 days
By week 1, total daily volume rises to about 300 mL.
Newborns who do not void within this time should be examined for the possibility of urethral stenosis or absent kidneys or ureters.
Immune System
Newborn have difficulty forming antibodies against invading antigens until about 2 months of age, newborns are prone to infection
This inability to form antibodies is the reason that most immunizations against childhood diseases are not given to infants younger than 2 months of age
Newborns born with passive antibodies (immunoglobulin G) from their mother that crossed the placenta.
Newborns are routinely administered hepatitis B vaccine during the first 12 hours after birth to protect against this disease
Neuromuscular System
Mature Newborns demonstrate neuromuscular function
Moving extremities
Attempting to control head movement
Exhibiting strong cry
Demonstrating Newborn Reflexes
Limpness or total absence of a muscular response to manipulation is never normal and suggests narcosis, shock or cerebral injury
NEWBORN REFLEXES
Blink Reflex
Serves to protect the eye from any object coming near by rapid eye closure
It may be elicited by shining a strong light
Rooting Reflex
if the cheek is brushed or stroked near corner of mouth a newborn infant will turn the head in that direction
This reflex serves to help a newborn find food
Sucking Reflex
When a newborn’s lips are touched, the baby makes a sucking motion
when the newborn’s lips touch the mother’s breast or a bottle, the baby sucks and so takes in food.
The sucking reflex begins to diminish at about 6 months of age. It disappears immediately flex disappears at about the sixth week of life
Swallowing Reflex
Food that reaches the posterior portion of the tongue is swallowed
Gag, cough, and sneeze reflexes also are present in newborns to maintain a clear airway in the event that normal swallowing does not keep the pharynx free of obstructing mucus.
Extrusion Reflex
Extrudes any substance that is placed on the anterior portion of the tongue
Protective reflec to prevent from swallowing inedible substance
Disappears at about 4 months of age
Palmar Grasp Reflex
Newborns grasp and object placed in their plam by closing their fingers on it
Reflex disappears at about 6 weeks to 3 months of age
Step (Walk) in place Reflex (Walking Reflex)
Newborns held in vertical position with feet touching hard surface will take few, quick alternating steps
This reflex disappears by 3 months of age.
By 4 months, babies can bear a good portion of their weight unhindered by this reflex.
Tonic Neck Reflex (Fencing Reflex)
When newborns lie on their backs, their heads usually turn to one side or the other
. The arm and the leg on the side toward which the head turns extend, and the opposite arm and leg contract.
Moro (Startle) Reflex
hold newborns in a supine position and allow head to drop by 1 inch
In response to this sudden head movement, they abduct and extend their arms and legs.
It is strong for the first 8 weeks of life and then fades by the end of the fourth or fifth month, at the same time an infant can roll away from danger.
Babinski Reflex
When the sole of the foot is stroked d in an inverted “J” curve from the heel upward, a newborn fans the toes (positive Babinski sign)
. It remains positive (toes fan) until at least 3 months of age, when it is supplanted by the downturning or adult flexion response.
Magnet Reflex
If pressure is applied to the soles of the feet of a newborn lying in a supine porition, he/she pushes back against the pressure.
Crossed Extension Reflex
If one leg of a newborn lying supine is extended and the sole of that foot is irritated (by rubbing with sharp object - Thumbnail) the infant raises other leg and extends it as if trying to push the hand irritation the other leg
Trunk Incurvation Reflex
When newborns lie in a prone position and are touched along the paravertebral area by a probing finger, they flex their trunk and swing their pelvis toward the touch
Landau Reflex
A newborn who is held in a prone position with a hand underneath, supporting the trunk, should demonstrate some muscle tone
Babies may not be able to lift their head or arch their back in this position but neither should they sag into an inverted “U” position
The latter response indicates extremely poor muscle tone, the cause of which should be investigated
THE SENSES
Vision
Newborn see as soon as they are born an possibly have been “seeing” light and dark in utero for the last few months of pregnancy
Newborns demonstrate sight at birth by blinking at a strong light (blink reflex) or by following a bright light or toy a short distance with their eyes
Newborn focus best on black and white objects at a distance of 9-12 inches
Touch
The sense of touch is well developed at birth.
Newborns demonstrate this by quieting at a soothing touch and by sucking and rooting reflexes, which are elicited by touch.
Reacts to painful stimuli
Taste
A newborn has the ability to discriminate taste and taste buds are developed and functioning even before birth.
The swallowing decreases if a bitter flavor is added.
A newborn turns away from a bitter taste such as salt but readily accepts the sweet taste of milk or glucose water
Smell
The sense of smell is present in newborns as soon as the nose is clear of lung and amniotic fluid
Newborns turn toward their mothers’ breast partly out of recognition of the smell of breast milk and partly as a manifestation of the rooting reflex.
Their ability to respond to odors can be used to document alertness
Appearance of Newborn
Skin
Color
Most term newborns have a ruddier complexions - due to increased concentration of RBC in blood vessels and a decrease in the amount of subcutaneous fat, which makes blood vessels more visible.
Ruddiness fades over the first month
Infants with poor central nervoussystem control or respiratory difficulty may appear pale and cyanotic.
Gray Color - indicates infection
Cyanosis - mottling of the skin
Acrocyanosis (cyanosis of extremities) - prominent in some newborns that appears as ifsome stricture were cutting off circulation, with usual skin color on one side and blue on the other
normal phenomenon in the first 24 to 48 hours after birth
Central Cyanosis (Cyanosis of the trunk) - indicates decreased oxygenation. It may be the result of a temporary respiratory obstruction or an underlying disease state
Hyperbilirubinemia - leads to neonatal jaundice
occurs on the 2nd or 3rd day of life in about 50% of all newborns, as a result of a breakdown of fetal RBC .
Pallor - anemia (blood loss due to cord cutting)
A newborn’s lips, hands, and feet are likely to appear blue from immature peripheral circulation.
Treatment
Phototherapy - exposure of the infant to light to initiate maturation of liver enzymes
Incubator - light source can be moved to the mother’s room so that the mother is not separated from her baby.
Birthmarks
Three Types
Nevus Flammeus
macular purple or dark-red lesion (port wine stain) present at birth, appear on the face, and often found on the thighs
Those present above the bridge of the nose tend to fade, others are less likely to do so
Strawberry Hemangioma
refers to elevated areas formed by immature capillaries and endothelial cells
Formation is associated with the high estrogen levels of pregnancy. They may continue to enlarge up to 1 year of age
Application of hydrocortisone ointment may speed the disappearance of these lesions A child may be 10 years old before the absorption is complete.
Cavernous Hemangioma
are dilated vascular spaces. They are usually raised and resemble a strawberry hemangioma in appearance.
Do not disappear with time and can be removed surgically.
Vernix Caseosa
white, cream cheese–like substance that serves as a skin lubricant in utero, noticeable on a term newborn’s skin
Color of Vernix Caseosa
Yellow Vernix - Amniotic Fluid is yellow from bilirubin
Green Vernix - Meconium is present in amniotic fluid
Lanugo
the fine, downy hair that covers a newborn’s shoulders, back, and upper arms, forehead and ears.
A baby born between 37 to 39 weeks of gestation has more lanugo than a newborn of 40 weeks’ gestational age.
Postmature infants more than 42 weeks of gestation rarely have lanugo.
Lanugo is rubbed away by the friction of bedding and clothes against the newborn’s skin. By 2 weeks of age, it has disappeared
Desquamation
Within 24 hours after birth, the skin of has become extremely dry.
The dryness is evident on the palms of the hands and soles of the feet.
This is normal and needs no treatment.
Parents may apply hand lotion to prevent excessive dryness if they wish
Milia
white papule can be found on the cheek or across the bridge of the nose of almost every new born
Disappear by 2 to 4 weeks of age, as the sebaceous glands mature and drain.
Teach parents to avoid scratching or squeezing the papules, to prevent secondary infections
Erythyma Toxicum
Flea bite rash
papule, increases in severity to become erythema by the second day, and then disappears by the 3rd day.
appears in the 1st to 4th day of life but may appear up to 2 weeks of age.
caused by a newborn’s eosinophils reacting to the environment as the immune system matures. (No Treatment)
Skin Turgor
Mongolian Spots
collections of pigment cells (melanocytes) that appear as slate-gray patches across the sacrum or buttocks and on the arms and legs
They disappear by school age without treatment
Inform parents that these are not bruises, they may worry their baby sustained a birth injury.
Fontanelles
The fontanelles are the spaces or openings where the skull bones join
Anterior Fontanelle
Located at the junction of the two parietal bones. It is diamond shaped and measures 2 to 3 cm in width and 3 to 4 cm in length.
The anterior fontanelle normally closes at 12-18 months of age
Posterior Fontanelle
located at the junction of the parietal bones and the occipital bone. It is triangular and measures about 1 cm (0.4 in) in length
The posterior fontanelle closes by the end of the second month.
Caput Succedaneum
edema of the scalp that forms on the presenting part of the head
The edema which crosses the suture lines is gradually absorbed and disappears at about the 3rd day of life with no treatment
Cephalotoma
collection of blood between the periosteum of a skull bone and bone itself, caused by rupture of a periosteal capillary, cause by pressure of birth
Often takes weeks for the blood to be absorbed
Craniotabes
a localized softening of the cranial bones caused by pressure of the fetal skull against the mother’s pelvic bone in utero
Harlequin Sign
immature circulation, a newborn who has been lying on his or her side appears red on the dependent side of the body and pale on the upper side, as if a line had been drawn down the center of the body
a transient phenomenon; with no clinical significance.
The odd coloring fades immediately if the infant’s position is changed or the baby kicks or cries vigorously
Rest of the Body
Eyes
Newborns cry tearlessly, because their lacrimal ducts do not fully mature until about 3 months of age.
Infant eyes assume their permanent color between 3 and 12 months of age.
A newborn’s eyes should appear clear, without redness or purulent discharge
Ears
external ear is not as completely formed, the pinna tends to bend easily.
The pinna should be strong enough to recoil after bending.
The level of the top part of the external ear should be on a line drawn from the inner canthus to the outer canthus of the eye
Nose
nose tends to appear large for the face. As the infant grows, the rest of the face grows more than the nose does
Test for choanal atresia (blockage at the rear of the nose) closing the newborn’s mouth and compressing one naris at a time with your fingers.
Note:
Any discomfort or distress while breathing
Nasal flaring upon inspiration (respiratory distress)
Record any evidence of milia on the nose
Mouth
mouth should open evenly when he or she cries. If one side of the mouth moves more than the other, cranial nerve injury is suggested.
The tongue is short, the frenulum membrane is attached close to the tip of the tongue, creating the impression that the infant is “tongue tied.”
Inspect the palate of a newborn to be sure it is intact.
Neck
The head should rotate freely on it.
Congenital torticollis - is the rigidity of the neck, caused by injury to the sternocleidomastoid muscle during birth, might be present.
The neck of a newborn is not strong enough to support the total weight of the head
Chest
The chest looks small because the head is large in proportion, approximately2 inchessmaller in circumference
Not until a child is 2 years of age does the chest measurement exceed that of the head.
Newborn’s chest should appear symmetric side to side.
Abdomen
The contour of a newborn abdomen looks slightly protuberant
Bowel sounds should be present within 1 hour after birth.
Inspect the cord clamp to be certain it is secure 2nd or 3rd day - it has turned black 6 to 10 - heals during the following week
A moist or odorous cord suggests infection
Anogenital Area
Anus
Inspect the anus of a newborn to be certain it is prese nt, patent, and not covered by a membrane (imperforate anus)
Test for anal patency by gently inserting the tip of the gloved and lubricated little finger
Note the time after birth at which the infant first passes meconium.
Male Genitalia
The scrotum in most male newborns is edematous and has rugae (folds in the skin)
Both testes should be present in the scrotum
The penis of newborns appears small, approximately 2 cm long
Inspect the tip of the penis to see that the urethral opening is at the tip of the glans
Both testes should be present in the scrotum. If one or both testicles are not present (cryptorchidism); CAUSES
Agenesis (absence of an organ)
Ectopic testes (the testes cannot enter the scrotum, scrotal sac is closed)
undescended testes (the vas deferens or artery is too short to allow the testes to descend).
Female Genitalia
The vulva in female newborns may be swollen because of the effect of maternal hormones.
Some female newborns have a mucus vaginal secretion, blood-tinged (Pseudo menstruation). caused by the action of maternal hormones.
The discharge disappears as soon as the infant’s system has cleared the hormones.
Back
The spine of a newborn appears flat in the lumbar and sacral areas.
Inspect the base of a newborn’s spine to be sure there is no pinpoint opening, dimpling, or sinus tract in the skin
Inspect for the presence of Spinal bifida (Neural tube defect ) due to lack of folic acid during pregnancy
Extremities
The arms and legs of a newborn appear short.
The hands are plump and clenched into fists.
Newborn fingernails are soft and smooth, and usually long enough to extend over the fingertips
Assess;
Syndactyl - is a condition wherein two or more digits are fused together (Webbing)
Polydactyly - the hand has one or more extra finger or an extra toe on the foot