Normal Newborn

Normal Newborn

Nicole Houser MSN, RN

Definitions

Neonatal period: Birth to 28 days
Infancy: 29th day to one year of age

Neonatal Period

Physiologic Adjustment Tasks

Behavioral Tasks

Establish behavioral temperament.
Process, store, and organize multiple stimuli.
Establish relationship with caregivers & environment.

Transition to Extrauterine Life

First 6-8 hours after birth: Critical transition phase.
- Birth through 30 minutes: First period of reactivity.
- 30 minutes – 2 hours of life: Period of decreased responsiveness.
- 2 hours – 8 hours of life: Second period of reactivity.

Physiologic Adaptations

Respiratory System

Breathing: Most critical adaptation.
Air substitutes for fluid.
Various changes occur:
- Mechanical changes
- Sensory and temperature changes
- Chemical changes
Characteristics:
- Breathing pattern: shallow, irregular at a rate of 30-60 per minute.
- Apneic periods may last less than 15 seconds.
- Newborns are obligate nose breathers.

Signs of Respiratory Distress

Nasal flaring
Retractions
Grunting expirations
Use of intercostal muscles
Seesaw respirations
Cyanosis

Cardiovascular System

Significant pressure changes in circulatory system.
Closure of:
- Foramen ovale
- Ductus arteriosus
- Umbilical arteries and vein
- Ductus venosus
Heart Rate:
- Resting: 100-160 bpm
- Awake: 120-160 bpm
- Sleeping: 80-100 bpm
- Crying: can increase up to 180 bpm.

Thermogenic System

Heat regulation: The third most critical adaptation for newborn survival.
Thermoregulation: Balance between heat loss and heat production.
Danger: Hypothermia.
Goal: Achieve a neutral thermal environment.
- Newborns cannot shiver.
- Have less thermal insulation.
- Positioning (flexed) to minimize heat loss.
- Nonshivering thermogenesis via brown fat.

Four Modes of Heat Loss

Conduction
Convection
Radiation
Evaporation

Renal System

First void: Expected within 24 hours of birth.
Presence of uric acid crystals may occur.
Pseudomenstruation: Possible in females
Tracking Diapers by Day:
- Day 1: 1+ wet, 1 poop (meconium)
- Day 4: 4-6 wet, 4+ poops
- Day 5-7: 5+ wet, 3/4+ poops
- Beyond Day 7: 6-8+ wet, variable poops.

Gastrointestinal System

Capable of swallowing, digesting, metabolizing, and absorbing proteins and simple carbohydrates; however, has limited ability to digest fats.
All digestive enzymes present except pancreatic amylase and lipase.
A special mechanism coordinates breathing, sucking, and swallowing.
Lack of normal intestinal flora present in the gut.
Bowel sounds may be present along with variable stomach capacity.

Feeding Behaviors/Hunger Cues

Early Cues

These cues signal hunger:
- Stirring
- Mouth opening
- Turning head
- Stretching
- Physical movement
- Hand to mouth

Mid Cues

Indicate increased hunger:
- Crying
- Agitation
- Turning red

Hepatic System

Enlarged liver at birth.
Functions: Iron and vitamin storage, carbohydrate metabolism, conjugation of bilirubin.
Distinction between physiologic and pathologic jaundice.

Immune System

Passive immunity is transferred from the mother.
Breastfeeding plays a crucial role in developing the newborn's immune system.
Newborns are at a high risk for infections.

Integumentary System

The epidermis and dermis are very thin at birth.
Presence of vernix caseosa (a protective covering).
Skin may appear blotchy or mottled, and conditions like acrocyanosis may occur.

Common Findings

Plump appearance
Lanugo - fine hair on the body
Presence of creases (palmar and plantar)
Desquamation - shedding of skin post-birth.

Skin Conditions

Milia: Small cysts on the skin.
Mongolian spots: Blue-gray marks, typically on the back or buttocks.
Stork bites: Nevi on the nape of the neck (telangiectatic nevi).
Strawberry mark: Nevus vasculosus.
Port wine stain: Nevus flammeus.
Erythema toxicum: Mild rash that appears in the first week.

Skin Color Observations

Visual checks for pallor, plethora, petechiae, central cyanosis, jaundice, or bruising should be recorded.

Reproductive System

Female

All ova are present at this stage.
Possible occurrence of pseudomenstruation due to maternal hormones.
Edema and increased pigmentation may be noted in labia.

Male

Testes present with scrotal rugae and pigmentation.
Examination of urethral meatus for conditions like hypospadias or epispadias.
Both genders may show breast buds and "witches' milk" (milk from infant's mammary glands).

Skeletal System

The head is approximately 1/4 of body length at birth with signs of molding.
Fontanelles are present and can be assessed for normalization, including anterior and posterior fontanelles.
Conditions like caput succedaneum and cephalhematoma may be present following birth.

General Assessments

Symmetry and Equality: Assess digit count and presence of any skeletal abnormalities.
Spinal Checks: Look for dimples or pilonidal sinuses indicating possible anomalies.

Neuromuscular System

Almost fully developed at birth with rapid brain growth continuing after birth.
Presence of transient tremors during the early days may indicate limited neuromuscular control.
Newborn Reflexes:
- Rooting reflex
- Sucking reflex
- Hand-to-mouth reflex
- Swallowing reflex
- Extrusion reflex

Additional Newborn Reflexes

Palmar grasp
Tonic neck reflex
Moro reflex (startle reflex)
Stepping reflex
Plantar reflex
Babinski reflex
Trunk incurvation reflex
Magnet reflex
Landau reflex

Behavioral Characteristics

Newborns exhibit great variation in activity levels, feeding patterns, sleeping patterns, and responsiveness.
- Sleep/Wake States: Includes deep sleep, light sleep, drowsy, quiet alert, active alert, and crying.
- Factors Affecting Behavior: Gestational age, external stimuli, medication effects.

Sensory Behaviors

Vision: Limited; prefers high contrast.
Hearing: Responsive to sound.
Smell: Can recognize mother's scent.
Taste: Can differentiate between sweet and bitter.
Touch: Sensitive to tactile stimuli.

Response to Environmental Stimuli

Temperament: Individual differences in responses to stimuli.
Habituation: The process of becoming accustomed to stimuli over time.
Crying: Expression of needs; varies in sound and intensity.
Consolability: The ability to be soothed when distressed.
Cuddliness: Preference for physical contact.

Care of the Newborn

First Two Hours of Life

Assessment and stabilization of newborn condition.
APGAR Scoring: Evaluates the newborn's immediate health at 1 and 5 minutes post-delivery.
- Score Key:
- 0-3: Severe distress
- 4-6: Moderate difficulty
- 7-10: No difficulty adjusting to extrauterine life.

APGAR Score Components

Score	Appearance	Pulse	Grimace	Activity	Respiration
2	Pink	> 100 bpm	Cries and pulls away	Active movement	Strong cry
1	Extremities blue	< 100 bpm	Grimaces or weak cry	Arms, legs flexed	Slow, irregular
0	Pale or blue	No pulse	No response	No movement	No breathing

Initial Physical Assessment

Components:
- External examination
- Chest assessment
- Abdominal examination
- Neurologic assessment
- Genitourinary check
- Identification of gross anomalies.

Implementation of Care

Essential elements include:
- Identification
- Stabilization
- Maintenance of oxygenation (use of bulb syringe)
- Maintenance of body temperature (thermoregulation)

Therapeutic Interventions

Eye prophylaxis (erythromycin) is mandatory in the US.
Administration of vitamin K (aquaMephyton).
Care for the umbilical cord.
Encouraging parent-infant interaction.

Growth and Development Assessments

Evaluate birth weight, length, and head circumference.
Gestational age determined within 48 hours after birth.

Neuromuscular Maturity Assessment

Key Indicators:
- Posture evaluation
- Square window test (wrist flexibility)
- Arm recoil test
- Popliteal angle measurement
- Scarf sign (arm wrapping)
- Heel to ear flexibility assessment

Classification of Birth Weight

LGA (Large for Gestational Age): >90th percentile.
AGA (Appropriate for Gestational Age): Between 10-90th percentile.
SGA (Small for Gestational Age): <10th percentile.
LBW (Low Birth Weight): <2500g.
IUGR (Intrauterine Growth Restriction): Indicates preterm growth.

Classification by Gestational Age

Preterm or Premature: <37 weeks.
Late Preterm: 34-36 6/7 weeks.
Early Term: 37-38 6/7 weeks.
Term: 37-42 weeks.
Post Term: After week 42 (post-date).

Head to Toe Assessment

General Review Prior to Physical Examination

Consider maternal medical history, prenatal care, and labor records for potential problems like length of gestation, gravidity/parity, ROM (rupture of membranes), type of delivery, medications, and fetal well-being in labor.

Components of Physical Examination

General Appearance

Evaluate color, posture, state of alertness, cry, general proportions, flexion, and tonicity.

Vital Signs

Respiratory rate assessment, including apical pulse and peripheral pulses, temperature, blood pressure, and pulse oxygen saturation.

Measurements

Weight: 2500g - 4000g
Length: 45 - 55 cm
Head Circumference: 32 - 36.8 cm
Chest Circumference: 30 - 33 cm
Abdominal Circumference: 30 - 33 cm.

Skin Assessment

Color, presence of birthmarks, turgor, vernix caseosa, and lanugo should be evaluated.

Head Examination

Check for molding, presence of caput succedaneum, cephalhematoma, condition of fontanelles and suture lines, and overall hair patterns.

Facial and Neck Assessment

Appearance of eyes, eyebrows, nose, ears, and overall facial symmetry.

Mouth Assessment

Evaluation of mouth, circumoral cyanosis, presence of Epstein's pearls, tongue appearance, palate integrity.

Extremities Examination

Check flexion, range of motion, arms, hands, fingers, legs, feet, toes, and assess for acrocyanosis, webbing, syndactyly, polydactyly, and nail condition.

Inferior and Lateral Assessments

Hip dysplasia detection through gluteal folds evaluation and leg length comparisons.
Back examination for normal structure and integrity.
Anus inspection for patency and proper closure.

Common Problems in Newborns

Physical Injuries/Birth Trauma

Possible causes include: prolonged or precipitous labor, preterm labor, fetal macrosomia, cephalopelvic disproportion, abnormal presentation, congenital anomalies, and type of delivery.

Types of Injuries

Soft Tissue Injuries:
- Cephalhematoma
- Caput succedaneum
- Subconjunctival and retinal hemorrhages
- Bruises, abrasions, lacerations, edema
- Petechiae
Skeletal Injuries:
- Clavicular fracture
- Fractures of the humerus, femur, and skull
Nerve Injuries:
- Brachial plexus injury
- Phrenic nerve injury
- Facial nerve injury

Common Physiological Conditions

Physiologic Jaundice: Common in newborns.
Hypoglycemia: Blood glucose levels <40 mg/dl.

Common Lab & Diagnostic Tests

Blood glucose, bilirubin, complete blood count (CBC), drug screenings.
Genetic screenings for conditions such as PKU, galactosemia, hypothyroidism, sickle cell disease, maple syrup urine disease, adrenal hyperplasia, and newborn hearing assessments.

Provision of Protective Environment

Infection control practices in nursery settings must be emphasized, including handwashing, gloving, and abduction prevention.

Common Procedures

Heel stick for blood collection.
Intramuscular injections including hepatitis B vaccine.
Circumcision and pain management for newborn procedures.

Promotion of Parent-Newborn Interaction

Assessment of behavioral attachment and education provided on newborn behaviors and cues.
Encouraging interaction during the quiet alert state, aiding interpretation of crying and regulation of responses.

Discharge Teaching

Key points include monitoring temperature, respirations, basic CPR, feeding techniques, positioning during feedings, elimination patterns, and rashes occurrences.
Additional topics for education: nail care, bathing practices, umbilical and circumcision care, nonnutritive sucking, proper car seat usage, and general clothing recommendations.
Important signs for parents to recognize when to seek assistance from healthcare providers.