Newborn Care and Assessment Notes

Environmental Factors Affecting Newborn Temperature

• Radiation: Heat loss to a cold environment. This is relevant both in the hospital and at home.
  • Avoid placing the baby's bassinet or bed near windows, especially in winter.
  • Even in summer, direct heat over the baby's bed should be avoided.

Newborn Vital Signs

• Respiratory Rate: 30-60 breaths per minute.
  • Below 30 or above 60 requires contacting a healthcare provider.
• Heart Rate: 110-160 beats per minute.
  • For the 1-minute Apgar score, the heart rate should be above 100 bpm.
• Temperature: Axillary or temporal temperatures are used; rectal temperatures are avoided.

Hypoglycemia in Newborns

• The placenta acts as the baby's liver during pregnancy.
• After birth, the baby must maintain its own blood sugar.
• Feeding Schedules:
  • Breastfed babies can be fed immediately after birth.
  • Formula-fed babies are typically first fed three hours postpartum to allow the digestive system to adjust.
• Heel Stick Blood Sugar Checks:
  • For complicated births or perinatal complications, check blood sugar every hour for the first three hours.
  • Target blood sugar level: above 45 mg/dL.
• Signs of Hypoglycemia:
  • Hyperactive Signs: Jitteriness, high-pitched cry, seizures.
  • Hypoactive Signs: Poor muscle tone, respiratory difficulty, low temperature, lethargy.
• Blood sugar monitoring should occur every hour until levels normalize.

Vitamin K Injection

• Administered within the first hour of birth to assist in blood clotting.
• The baby's liver is just starting to produce clotting factors.
• Critical for preventing hemorrhaging, especially in circumcised boys.
• A case study was shared of a baby who had complications due to delayed follow-up after circumcision
  • Highlights the importance of frequent checks for bleeding (every hour).

Respiratory Distress in Newborns

• Indicators:
  • Persistent cyanosis (other than hands and feet).
  • Grunting with breathing.
  • Nasal flaring.
  • Sternal retractions.
  • Sustained respiratory rate higher than 60 breaths per minute.
  • Sustained heart rate greater than 160 or less than 110.
  • Low temperature.

Newborn Assessment

• Follow the same seven systems used for adult assessments.
• Pay special attention to neurological reflexes unique to newborns.

Neurological Reflexes

• Moro Reflex (Startle Reflex):
  • When the baby's hand is pulled out to the side and released, the baby extends arms and then brings them towards the body. Absence may indicate neurological problems.
• Rooting Reflex:
  • Stroking the baby's cheek causes the baby to turn its head and open its mouth, indicating readiness to eat.
• Tonic Neck Reflex (Fencing Reflex):
  • When the baby is lying flat, one arm extends while the other is bent.
• Grasp Reflexes:
  • Palmar grasp: The baby grasps when a finger is placed in their palm.
  • Plantar grasp: The baby's toes curl when the sole of the foot is stroked.
• Babinski Reflex:
  • Stroking the sole of the baby's foot from heel to toe causes the toes to fan out; this reflex response changes in adulthood.
• Sucking Reflex:
  • Necessary for feeding
• Frenulum Assessment:
  • Check the tissue under the tongue to ensure the baby can have a strong sucking response.
  • A tight frenulum (tongue-tied) may require a frenotomy.

Head Assessment

• Skull Bones: Five bones in the baby's head (frontal, two parietal, occipital).
• Palpate to ensure all bones are present.
• Missing bones may indicate congenital anomalies.
  • Frontal Bone: Located at the front
  • Parietal Bones: There are two which sit on either side of the head. These bones will slide over each other in order for the baby to fit through the pelvis during delivery
  • Occipital Bone: Located in the back
• Fontanelles:
  • Anterior fontanelle: Diamond-shaped; closes around 18 months to two years to allow for brain growth.
  • Posterior fontanelle: Triangular-shaped at the back of the head; closes in 8-10 weeks.

Head Shape Variations

• Molding:
  • Overlapping of parietal bones during delivery. It's normal, and you can feel the ridge of the overlapping bones.
• Caput Succedaneum:
  • Generalized swelling over the entire head.
• Cephalohematoma:
  • Collection of blood on one side of the head. It does not cross suture lines.

Ear Assessment

• Ensure the top of the baby's ears aligns with the outer canthus of their eyes.
• Low-set ears may indicate congenital anomalies.
• Ear Tags: Skin tags may appear and are usually tied off by the obstetrician.
  • If a skin tag has a nail bed, it could be an extra digit and requires surgical removal.

Apgar Score

• Five objective signs measured at one and five minutes after birth to assess acclimation.
• Based on heart rate, respiratory effort, muscle tone, reflexes, and color.
• Vital Signs: Heart rate, level of consciousness, and respiratory rate.
  • Heart Rate: Skin color.
  • Neuro: Muscle tone and reflexes.
• Score of 0-2 is given for each sign.
  • A score of one at one minute and five minutes for their color due to acrocyanosis which is blue hands and feet.

Initial Newborn Examination

• Physician or midwife does initial assessment to identify any obvious congenital anomalies.
• Nurses also assess and communicate any skin changes or issues to parents (e.g., port-wine stain, Mongolian spots).

Skin Changes

• Lanugo: Fine hair all over the body, more common in preterm infants, disappears within the first week of life.
• Vernix Caseosa: Cheese-like substance protecting the baby's skin, more prevalent in preterm infants. Do not aggressively scrub off.
• Milia: White pinpoint spots on the nose and cheeks due to plugged sebaceous glands; resolve on their own.
• Mongolian Spots: Bluish-grey spots common in babies of color; fade over time.

Locomotion, Prehension, and Perception

• Assess gross and fine motor activity.
• Important milestones:
  • By two months: Baby should be able to push their chest off a firm surface.
  • By four months: Start rolling over.
  • By six months: Grasp things with thumb and fingers, and can feed themselves.
  • By 11 months: Should be able to walk.
• Confirm milestones with parents during pediatric visits.
• Can help with early identification of developmental delays (autism, ADD).

Infant Development

• Encourage parents to read to their children at an early age to promote speech development.
• Start babbling and making simple sentences by around two years of age.

Umbilical Cord Assessment

• Check for three vessels: two arteries and one vein (AVA).
• The presence of only two vessels may indicate congenital abnormalities.

Lactation

• After placental delivery, the brain releases prolactin to stimulate milk production.
• Breastfeeding:
  • Feed for at least 20 minutes on each breast to ensure the baby receives hind milk, which is higher in fat.
  • Massage from armpit to nipple to ensure proper milk flow.
  • Connect with lactation consultants for support.
• Formula feeding:
  • To suppress the process of lacation, for formula fed mothers, use one size smaller bra in order to reduce milk flow.

Maternal Nutrition and Breastfeeding

• Breastfeeding mothers need an extra 500 calories per day.
• Breast milk is tailored to the baby's individual needs.

Sucking Needs

• Non-nutritive sucking (pacifier) is important for babies. There are different types pacifiers for preterm babies versus term babies.

Mastitis

• Inflammation of breast tissue often occurs within the first month.
• Symptoms: Breast pain, swelling, warmth, and redness.
• Management: Hot showers, frequent emptying of the breast, antibiotics (pump and dump milk while on antibiotics).

Formula Preparation

• Follow instructions for proper dilution of powder formula.
• Avoid microwaving breast milk or formula to prevent hot spots and preserve nutrients.
• Do not refrigerate breast milk or formula
• Feed the baby breast milk or formula every three to four hours because neither is easily digested by the infant's GI tract

Key Reminders

• Know the summary information in chapter 12 regarding fontanel closure, diminishing reflexes, and weight gain milestones.