NEWBORN

LP4 The Newborn

Neonatal Period

• Definition: The neonatal period is defined as the time from birth to 28 days.

Transition to Extrauterine Life

• Biological/Physiological Adaptations:
    - Essential for all systems to function effectively at the close of the neonatal interval.

Respiratory System

• Critical Adjustment: Establishing respirations is the most critical adjustment post-birth.

• Respiratory Pattern:
    - Normal rate is 30 – 60 breaths per minute.
    - Characteristically irregular and shallow with intermittent apnea (periods of not breathing under 15 seconds).
    - Newborns are primarily nose breathers.

• Assessment:
    - Respiratory rate should be evaluated over a full minute.

• Lung Function: Need for lung expansion and surfactant to achieve normal lung operation.

Cardiovascular System

• Importance: The second most critical adjustment revolves around the cardiovascular system.

• Changes at Birth:
    - Fetal circulation halts upon the first breath:
      - Closure of the foramen ovale and ductus arteriosus.
    - The umbilical cord contains 2 arteries and 1 vein.

• Heart Rate:
    - Normal range for healthy term newborns is 120 – 160 bpm (average is approximately 140 bpm).
    - Heart rates may decrease to 80 – 120 bpm during sleep and can exceed 160 bpm if the infant is crying.

• Monitoring: Apical pulse should be measured for one minute. Blood pressure readings are typically not performed.

Liver

• Pathways of fetal circulation include:
    - Ductus arteriosus, foramen ovale, placenta, ductus venosus.

Thermogenic System

• Third Critical Adjustment
    - Involves achieving balance between heat loss and heat production.

• Normal Temperature:
    - Newborn axillary temperature is typically between 97.7°F and 98.9°F (36.5°C to 37.2°C).
    - Note: Rectal temperatures are contraindicated.

Types of Heat Loss

• Convection: Heat loss due to airflow from cooler surroundings.

• Conduction: Heat loss due to direct contact with a cooler surface.

• Evaporation: Loss of heat when liquid on the skin surface turns to vapor (most significant cause of heat loss in the initial few days).

• Radiation: Heat loss from a cooler surface not in direct contact with the newborn.

Nursing Interventions for Heat Conservation

• Monitoring and practices to prevent excessive heat loss include:
    - Keeping the newborn warm through skin-to-skin contact, proper swaddling, adequate room temperature, and head coverings.

Temperature Regulation and Cold Stress

• Risks of Excessive Heat Loss:
    - Can lead to cold stress which may:
      - Deplete brown fat stores.
      - Elevate oxygen demands, potentially resulting in respiratory distress.
      - Cause hypoglycemia and hypoxia.

• Interventions:
    - Employ warm surfaces, skin-to-skin contact, swaddling, and use of hats.

Renal System

• Maturity Timeline: Immature until about 3 months of age.

• Voiding Norms:
    - Most newborns void soon after birth, ideally within the first 24 hours.
    - Average norm is about 6 – 8 voids per day, indicating proper fluid intake.

Gastrointestinal System

• Maturity Timeline:
    - Immature until approximately 2 – 3 years of age.

• Functions:
    - Involves swallowing, digesting, metabolizing, and absorbing food efficiently.

• Bacterial Colonization:
    - Gastrointestinal bacteria colonize within 24 hours.   - Vitamin K is administered prophylactically to prevent bleeding complications.

• Stomach Capacity:
    - Ranges from 30 – 90 ml by the end of the first week.
    - Initial feeding typically comprises 5 – 7 ml.

• Weight Loss: It is normal for newborns to lose 5 – 10% of birth weight due to factors such as caloric intake insufficiency and fluid shifts.

Bowel Elimination

• First Stool:
    - Known as meconium, which is thick and black, typically passes within the first 24 hours.

• Transitional Stool:
    - Follows meconium, characterized as greenish and less sticky, afterwards transitioning to milk stools.

• Influence of Feeding:
    - Newborns fed earlier tend to pass stools sooner, mitigating elevated bilirubin levels.

Hepatic System

• Liver Functions:
    - Responsible for carbohydrate metabolism, iron storage, bilirubin conjugation, and blood coagulation.
    - Newborns have sufficient iron stores lasting 4 – 6 months.
    - Carbohydrate metabolism reserves are low which places infants at risk for hypoglycemia.

• Normal Blood Glucose Level: Must be greater than 40 mg/dL.

• Bilirubin Conjugation:
    - The liver's ability to metabolize bilirubin is crucial; an increase in bilirubin can result in jaundice, seen in more than 50% of newborns.

• Bilirubin Types:
    - Unconjugated: Fat-soluble, bound to albumin, serum concentration should not exceed 12 mg/dL.
    - Conjugated: Water-soluble form excreted through urine and stool.

Immune System

• Protection:
    - Infants are provided passive immunity during the first 3 months but are somewhat immuno-compromised at birth.
    - Colostrum and breast milk are essential as they supply IgA, the second most abundant immunoglobulin.

Skeletal System

• Development:
    - Rapid development during the first year of life; must assess the base of the spine for any closed dimples and conduct hip dysplasia checks using the Ortolani’s maneuver.

Newborn Appearance

• Cone-Shaped Head: Occurs as a result of molding from overriding sutures.

• Breast Buds: Common in both sexes, with inverted nipples also being prevalent.

• Enlarged Genitals: Normal physical presentation.

• Vernix: Protective coating on the skin.

• Birth Marks:
    - Include telangiectatic nevi (stork bites) and Mongolian spots.
    - Variations like strawberry marks and port wine stains also noted.

• Erythema Toxicum: A common newborn rash.

• Oral Structures:
    - Presence of Epstein's pearls, ossification centers, and fontanelles (anterior and posterior).

Neuromuscular/Neurologic System

• Awakening Difficulty: Immediate attention required if an infant is hard to awaken.

• Behavioral Characteristics: Various states of consciousness including; deep sleep, light sleep, drowsy, quiet alert, active alert, and crying.

• Influencing Factors:
    - Gestational age impacts responsiveness; preterm infants may be more easily overstimulated, while time since birth and day timing can also affect reactions.

• Response to Stimuli:
    - Innate responses to loud noises, bright lights, and tension observed.

Sensory Behaviors

• Vision:
    - Best visual distance is approximately 8 to 12 inches, sensitive to light, and prefers black and white patterns initially.
    - Color detection improves by 2 months, developing ability to track moving objects, notably parents’ eyes.

• Hearing:
    - Infants respond positively to mother's voice, singing, or heartbeat. Newborn hearing screenings are standard.

• Smell:
    - Breastfed infants can differentiate maternal breast milk from other lactating women.

• Taste:
    - Infants can identify sweet from sour by 72 hours old.

• Touch:
    - Highly developed tactile sense; reflexes can be elicited indicating sensitivity to pain.

Newborn Reflexes

• Reflex Types:
    - Moro (Startle): Present at birth, typically disappears by 6 months.
    - Grasp Reflex: This reflex lessens by 3-4 months.
    - Tonic Neck (Fencing), Sucking, Rooting, Swallowing, Babinski: Disappears after 1 year.
    - Stepping reflex present for about 3-4 weeks.
    - Glabellar and Trunk Incurvation reflexes also present.

APGAR Score

• Components:
    - Appearance (color), Pulse (heart rate), Grimace (reflex irritability), Activity (muscle tone), Respiration (respiratory effort).

• Scoring:
    - 7 to 10 indicates normal limits, 4 to 6 suggests moderate distress, and 0 to 3 indicates severe distress.

Physical Assessment of the Newborn

• Temperature Maintenance: Essential to keep newborn warm to ensure temperature stability.
    - Assessment should proceed understandably, starting from least to most invasive.

• General Assessment Items:
    - General Appearance: Flexed posture and coordinated movements, verifying count of extremities and overall skin color.
    - Head: Assessment of molding, and fontanelles.
    - Eyes/Ears/Mouth: Examining pupils for equality, location of ears, palatal reflexes (rooting and sucking), and checking for Epstein’s pearls.

Assessment of Head Trauma

• Caput Succedaneum:
    - Boggy, edematous swelling of fetal scalp that crosses suture lines and typically resolves without treatment.

• Cephalohematoma: Localized swelling that does not cross suture lines.

Chest and Abdomen Assessment

• Chest: Apical heart rate auscultation for one minute, monitoring respiratory patterns.

• Abdomen: Bowel sounds should be noted, alongside counting of the cord vessels (2 arteries, 1 vein) and checking brachial pulses.

Skin Assessment

• Skin Observations: Blanching on torso and thighs/knees, presence of lanugo (fine hair), jaundice, erythema toxicum, nevi variations, acrocyanosis (blue extremities), milia, and vernix.

Genitalia Assessment

• Physical Observations:
    - Assess for any edema of labia or scrotum, ensure testes are descended, check for dimple at base of spine, and monitor for hip dislocation with Ortolani’s maneuver.

Vital Signs

• Temperature Ranges: Axillary readings of 36.5°C to 37.2°C.

• Respiration Ranges: Between 30 – 60 breaths per minute.

• Heart Rate: Apical pulse of 120 – 160 beats per minute.

• Physical Measurements: Baseline measures for length, weight (average newborn is 8 lbs 4 oz), and occipitofrontal circumference (head circumference).

Newborn Procedures

• Weighing & Measuring Protocols: Standardized education emphasizing the importance of metrics.

Plan of Care/Implementation

• Stabilization:
    - Focus on maintaining body temperature, implementing interventions within 1 – 2 hours following birth.
    - Procedures include eye prophylaxis, vitamin K prophylaxis, umbilical cord care, and promoting bonding between parent and infant.

Newborn Procedures: Antibiotic Ointment

• Purpose: Protects newborn from eye infections and potential blindness caused by vaginal bacteria.
    - Erythromycin 0.5% ophthalmic ointment is commonly administered within 1-2 hours post-birth.

Vitamin K Administration

• Aquamephyton:
    - Given to assist newborn in blood clotting, administered within 1-2 hours following birth.

Care of a Stable Newborn

• Routine care is given from 2 hours post-birth up until discharge.

• Care environment must be protective of the infant, ensuring assessments are conducted to monitor for maturity utilizing the Ballard scale, classifying by gestational age and birth weight (LGA, AGA, SGA).

Estimation of Gestational Age by Maturity Rating

• Neuromuscular Maturity Indicators:
    - Various assessments including posture, square window test, arm recoil, popliteal angle, scarf sign, and heel to ear test contribute to determining maturity rating.

Newborn Procedures: Genetic Screening

• Conditions Screened:
    - Phenylketonuria (PKU), galactosemia, sickle cell disease, hypothyroidism, cystic fibrosis, and maple syrup urine disease, encompassing screening for over 12 disorders via heel prick.

Newborn Procedures: Circumcision

• Guidance from AAP:
    - Scientific evidence indicates potential medical benefits; however, does not endorse routine neonatal circumcision.

• Methods:
    - Plastibell technique falls off within 5-7 days; Gomco clamp requires Vaseline application during diaper changes.

• Patient Teaching: Instruct to observe for bleeding, monitor first void post-procedure, and ensure infection prevention.

Neonatal Pain Management

• Assessment Tool: Neonatal Infant Pain Scale (NIPS).

• Management Strategies:
    - Nonpharmacological methods such as swaddling and non-nutritive sucking; pharmacological methods include xylocaine and concentrated sucrose solutions.

Discharge Planning and Teaching

• Teaching Topics:
    - Home temperature maintenance, illness signs, call times for the physician, safety practices, positioning, SIDS prevention, clothing needs, and infant follow-up care.

Immunization Schedule

• Timeline:
    - At Birth: Hepatitis B (Hep B)
    - 2 Months: DTaP, RV, IPV, Hib, PCV, Hep B
    - 4 Months: DTaP, RV, IPV, Hib, PCV
    - 6 Months: DTaP, IPV, PCV, Hep B, RV, Hib
    - 6-12 Months: Seasonal influenza vaccination yearly.

Newborn Nutrition and Feeding

• AAP Recommendations:
    - Exclusive breastfeeding for the first 6 months of life is advised.

• Benefits of Breastfeeding:
    - Fresh supply, easily absorbed nutrients, immune factors protection against respiratory infections and otitis media, and reduced SIDS risk.

Nutrient Needs for Newborns

• Energy Requirements: Approximately 110 cal/kg/day for the first 3 months.

• Carbohydrates: Should constitute 40-45% of total calorie intake with lactose as primary source.

• Fats: Represent 15% of caloric intake; human milk fat allows better digestion and absorption.

• Proteins: Higher requirement at this life stage, human milk is suited to meet this demand.

• Fluids: Human milk is approximately 87% water; introduction of water can lead to toxicity.

• Vitamins and Minerals: Human milk is considered adequate and a daily Vitamin D supplement is recommended.

Overview of Lactation

• Hormonal Changes Post Delivery:
    - Decline of estrogen and progesterone, with prolactin levels peaking in the first ten days post-birth triggers milk secretion, following a supply and demand model.

• Role of Oxytocin: Essential for the let-down reflex of milk.

Uni-Unique Aspects of Human Milk

• Nutritional Complexity: Contains antibodies such as IgA that provide broad infection protection.

• Milk Composition: Differentiates between foremilk and hindmilk, each serving different roles in infant nutrition.

Role of the Nurse in Lactation Support

• Educational Role: Nurses play a crucial part in educating and assisting with lactation, fostering connections with lactation consultants and community resources.

• Immediate postpartum intervention for breastfeeding initiation is vital, with continual support following hospital discharge.

Bottle Feeding Guidelines

• Safety Recommendations:
    - Do not prop bottles, avoid laying infants supine during feeding; maintain a 45-degree angle to prevent airway obstruction.
    - Maintain nipple filled with formula and discard any unused formula after one hour post-opening.

Response to Parental Concerns

• Common Inquiry: When faced with concerns regarding feeding amounts, reassure by explaining newborns generally consume small volumes (about 1 ounce) at a time, signifying appropriate nourishment.

Maternal Substance Abuse

• Definition and Influence: All substance abuse including alcohol and drugs during pregnancy can result in anomalies and neurobehavioral changes in the newborn.

• Fetal Alcohol Spectrum Disorder (FASD):
    - Occurs from in utero alcohol exposure, leading to characteristic facial features, growth restrictions, and neurodevelopmental challenges.

Newborn Complications Related to Maternal Substance Abuse

• Symptoms of Withdrawal: Monitor neonates for signs of abstinence such as high-pitched cries, irritability, and poor feeding.

• Nursing Care: Medication regime may include Phenobarbital for those at risk of seizures.

Newborn Complications Overview

• Respiratory Distress Syndrome: Arises from surfactant deficiency, shows signs like tachypnea and nasal flaring.

• Hypoglycemia: Defined when serum glucose dips under 40 mg/dL; influenced by birth stress or maternal diabetes.

• Hyperbilirubinemia:
    - Physiological Jaundice: Typically benign, appears post 24 hours of birth; bilirubin levels should remain beneath 12 mg/dL.
    - Pathological Jaundice: Emerges before 24 hours or persists beyond day 7, often due to blood group incompatibilities.

Nursing Care for Phototherapy

• Responsibilities: Observing neonates while ensuring protection for the eyes, maintaining warmth and providing frequent feedings is crucial.

Newborn Complications: Prematurity and Posterm

• Preterm Infants: Born between 20 and 38 weeks, often display signs such as increased apnea episodes and low birth weight.

• Post-term Infants: Born beyond 42 weeks, exhibiting dry skin and signs of placental aging.

Developmental Dysplasia of the Hip

• Abnormal development can result in hip structure issues presenting at birth, requiring monitoring and potentially corrective interventions.

Birth Trauma

• Fractured Clavicle: Common injury, requiring assessment especially in the event of delivery involving forceps.

• Brachial Plexus Injury: Assess for complications related to cervical nerves in the event of shoulder dystocia.

Shaken Baby Syndrome

• Causes and Effects: The act of violently shaking a child leads to severe brain injury; signs such as difficulty waking, poor feeding, or seizures must be monitored.

Closing Quote

• Charles Osgood: "Babies are always more trouble than you thought…and more wonderful."