newborn prof J

THE NORMAL NEWBORN

ADAPTING TO EXTRAUTERINE LIFE

  • After birth, the infant must transition to extrauterine life. This transition period lasts 6 to 8 hours.
      - Phases of Transition:
        - First Phase of Reactivity: Occurs 1 to 2 hours after birth; the infant is awake and alert. Optimal for initiating breastfeeding and bonding.
        - Second Phase of Transition: A time of sleep may last several hours.
        - Final Phase of Transition: Second phase of reactivity occurs between 2 and 8 hours after birth. Meconium often passed during this time.

Respiratory Adaptation Cues

  • Cues to Start Breathing: Include chemical, mechanical, and thermal factors.
      - Chemical: Upon cord clamping, the cessation of placental gas exchange induces mild hypoxia, stimulating breathing.
      - Mechanical: The squeezing during birth aids in fluid absorption in the lungs.
      - Thermal: Transition from a warm liquid environment to a cooler, drier atmosphere stimulates breathing.

  • Assessment of Neonatal Respiratory Status: Essential for identifying distress.

NEWBORN CARE IN THE DELIVERY ROOM

  1. Immediate Actions:
       - Dry the infant under a warmer.
       - Suction mouth/nose with a bulb syringe.
       - Assess airway status.

  2. Signs of Respiratory Distress:
       - Retractions
       - Tachypnea
       - Dusky color
       - Expiratory grunt
       - Flaring nares

  3. Apgar Scoring: Conduct at 1 and 5 minutes post-birth:
       - Components:
         - Heart Rate
           - Absent: 0
           - <100 bpm: 1        - >100 bpm: 2
         - Respiratory Effort
           - Absent: 0
           - Slow, irregular: 1
           - Good cry: 2
         - Muscle Tone
           - Limp: 0
           - Flexion: 1
           - Motion: 2
         - Reflex Irritability
           - No response: 0
           - Grimace: 1
           - Cry: 2
         - Color
           - Pale: 0
           - Body pink, extremities blue: 1
           - All pink: 2
       - Total Score Interpretation:
         - 7–10: Reassuring
         - 4–6: Moderately abnormal
         - 0–3: Low

Table of Signs of Respiratory Distress

  • Signs:
      - Cyanosis
      - Apnea
      - Tachypnea
      - Retractions (intercostal or substernal)
      - Grunting
      - Nasal flaring
      - Seesaw breathing
      - Stridor
      - Gasping

  • Clinical Considerations:
      1. Acrocyanosis is normal in the first 24 hours postpartum.
      2. Central cyanosis (bluing of the lips/chest) is abnormal.
      3. Apnea of 20 seconds or more is concerning. Shorter periods may be normal but should be monitored.
      4. Neonates typically breathe at a rate of 30-60 breaths/min.
         - Sustained tachypnea indicates potential issues (e.g., respiratory distress syndrome).
      5. Grunting indicates increased lung pressure for better oxygen diffusion.
      6. Nasal flaring indicates reduced airway resistance.

Temperature Adaptation

  • **Heat Loss Factors: **
      - Conduction: Direct contact with cold surfaces.
      - Convection: Air movement causing heat loss.
      - Evaporation: Loss of heat from water on the skin.
      - Radiation: Heat loss to surroundings, particularly cold surfaces nearby.

  • Prevention: Minimize heat loss by drying, swaddling, and maintaining skin-to-skin contact with the mother.

PEDIATRIC ASSESSMENT

  1. Weight Loss and Gain:
       - Neonates typically lose 5% to 10% of their birth weight within the first 3 to 5 days; should regain it within 2 weeks.

  2. Urination Frequency:
       - Infants urinate 6 to 8 times daily; fewer than 5 wet diapers in 24 hours should be reported.

  3. Risk for Hypoglycemia:
       - Treatment typically begins with breastfeeding or formula feeding.

  4. Risk for Jaundice:
       - Evaluation for bilirubin levels required.

NEWBORN BEHAVIORS

Brazelton Neonatal Behavioral Assessment Scale

  • Assessment Categories:
      - Habituation: Adjustment to audio and light stimulation.
      - Motor: Muscle tone and control maturity.
      - Self-regulation: Ability to console oneself or respond to comfort.
      - Stress Response: Threshold of stimulation response.
      - Social Interactive Capacity: Responsiveness to stimuli.

Sleep-Wake States

  • States of Activity:
      - Deep Sleep: Regular breathing, no movement.
      - Light Sleep: Irregular breathing, some body movement, rapid eye movement.
      - Drowsy: Muscle movement, irregular breathing, variable eye states.
      - Quiet Alert: Optimal for breastfeeding, awake and engaged.
      - Active Alert: Body movements, possible fussiness, irregular respiration.
      - Crying: Intense crying, high agitation, irregular breathing.

Vital Signs

  • Assessments:
      - Temperature: Normal range 97.9°F - 98.6°F.
      - Apical Heart Rate: Range 110-160 bpm.
      - Respirations: Range 30-60 breaths/min.
      - Blood Pressure: Normal 65-95/30-60 mmHg.

PHYSICAL EXAMINATION

  • Head and Scalp: Molding and caput succedaneum are common.
      - Fontanels should be slightly depressed, symmetrical head shapes should be noted.

  • Eyes and Ears:
      - Symmetry, minimal rotation and normal position relative to eyes.

  • Mouth: Structures should be symmetric, intact, moist, with a heart-shaped tongue being an indicator of tongue-tie.

  • Male Genitalia: Urinary meatus at the tip of the penis; testes palpable in scrotum.

  • Female Genitalia: Labia majora should cover labia minora; pseudomenses normal.

  • Musculoskeletal: Symmetry of arms and legs, full range of motion.

Reflexes

  • Infant Reflexes:
      - Rooting: Turns toward mouth or cheek stimulus.
      - Sucking: Coordination of sucking, swallowing, and breathing during feeding.
      - Extrusion: Pushes tongue outward when touched.
      - Palmar Grasp: Fingers curl around an object in hand.
      - Plantar Grasp: Toes curl around an object placed on them.
      - Moro Reflex: Abducts and extends arms upon startle.
      - Babinski Reflex: Toes fan outward when foot is stroked laterally.
      - Stepping Reflex: Makes walking motions when feet touch a surface.
      - Fencing Reflex: Extends arm and leg on one side when head turned.

Important Genetic and Screening Tests

  • Routine Tests: Blood glucose, urinalysis, bilirubin levels, complete blood count (CBC), genetic screening, hearing screening.

  • Medication Prophylaxis: IM Vitamin K, erythromycin ointment, Hepatitis B vaccine, glucose screening.

INFANT FEEDING

  • Breastfeeding Benefits: Exclusive breastfeeding is recommended for the first 6 months; supports maternal and infant health.

  • Feeding on Demand: Recommended for both breastfed and formula-fed infants. Breastfed infants typically feed 8 to 12 times daily. Holding infants head elevated during formula feeding is advised.

Ten Steps to Successful Breastfeeding (WHO/UNICEF)

  1. Policy on breastfeeding communicated to all staff.

  2. Healthcare staff trained in breastfeeding skills.

  3. Inform pregnant women on breastfeeding benefits.

  4. Assist in initiating breastfeeding within the first hour post-birth.

  5. Educate mothers on maintaining lactation.

  6. Limit newborns to breast milk only until medically indicated otherwise.

  7. Continuous mother-infant rooming-in.

  8. Encourage on-demand breastfeeding.

  9. Avoid use of pacifiers for nursing infants.

  10. Establish and refer to breastfeeding support groups.

Infants' Feeding Positions

  • Recommended positions include cradle, football, cross-cradle, and side-lying.

Caution on Nipple Pain in Breastfeeding

  • Addressing nipple pain involves evaluating latch technique to prevent bruising during breastfeeding.

  • A good latch includes:
      - Flanged lips,
      - Chin and tip of the nose applied to the breast,
      - Wide-open mouth,
      - Full cheeks,
      - Audible swallowing observed.

Closing Notes

  • Recognize that Apgar scores assess immediate infant status post-birth and are not indicative of cognitive ability. Apgar range scores from 0–10 help determine infant health and require ongoing assessment for optimal care.