Care of the Newborn NEWBORN PRIORITIES IN THE FIRST DAYS OF LIFE 1. Initiation & maintenance of respirations 2.

Establishment of extra uterine circulation 3. Control of body temperature 4. Adequate nourishment 5. Waste elimination 6. Prevention of infection 7. Infant-parent relationship 8. Developmental care Immediate Care of the Newborn I. Care of the Newborn at the D.R. A. Establish and Maintain Respiration 1. Suctioning - Turn head to one side - Suction gently and quickly - Suction the MOUTH first before the nose - Test patency of the airway - Proper position B. Maintain Appropriate Body Temperature 1. Wrap the newborn immediately 2. Wrap him warmly 3. Put him under a droplight Effects of Cold Stress - temp < 36.5 1. Metabolic Acidosis - Increased BMR, anaerobic glycolysis, Inc acid production, metabolic acidosis 2. Hypoglycemia - Inc energy requirement to produce heat Non shivering Thermogenesis Brown fat - Special tissue - Intrascapular region, thorax, perineal area - oxidized to produce heat 4 MECHANISMS OF HEAT LOSS

Congenital Anomalies 1. Choanal Atresia 2. Tracheobronchial fistula 3. Cleft lip and cleft palate Substances 1. drugs 2. smoking 3. alcohol Dubowitz (Maturity Testing Tool) – 1st 24 hrs Full Term - 38-42 weeks AOG Preterm - < 38 weeks Postterm - > 42 weeks AGA – 10th – 90th percentile SGA <10th percentile LGA > 90th percentile Low birthweight <2500 gm Very Low Birthweight <1500 gm Extremely Low Birthweight <1000 gm IUGR - Rate of growth does not meet expected pattern growth restriction Prematurity < 37 weeks AOG Risk Factors: 1. Fetal 2. Placental 3. Maternal 4. Infection Problems:

•Respiratory adaptation •Susceptibility to infection •Hyperbilirubinemia •Cold stress •Hypoglycemia

•Convection •Radiation •Conduction •Evaporation
Immediate Assessment of the Newborn APGAR SCORE A ppearance (color) – least important P ulse rate - most important G rimace (reflex activity); irritability A ctivity (muscle tone) R espiration Apgar Scoring System 1st minute: general condition (NEURO/RESPI/CIRCULATORY CHECK) 5th minute: adjustment to extrauterine life Score: 9 – highest score; 10 – perfect score 0-3: poor, serious, severely depressed, needs CPR 4-6: fair, guarded, moderately depressed, needs suction 7-10: good, healthy Grading of Neonatal Respiratory Distress (Silvermann Anderson)

-<40 mg/100 ml -Dependent on maternal supply -Birth, continue to produce insulin
S/sx: limpness, jitteriness, apnea, twitching and ↑ pitched cry CX: mental retardation Tx: early feeding D10W Nsg: monitor blood glucose level PE of the premature child

•Skin and SC tissue – thin, transparent •Inc lanugo •Dec plantar creases •Breast bud scarcely felt •Pinna flat and shapeless •Scrotum not pigmented •Testes not descended •Labia majora widely separated

•Maintain patent airway •Incubator care •VS monitoring •O2 therapy •Feeding •Infection precautions

Nursing Intervention

•Meet physiologic needs •Meet psychological needs •Foster healthy family relationships •Provide education
C. Proper Identification – done in D.R. before being brought to the Nursery a. Footprints – most reliable  b. ID bands – ankle, wrist c. Birthmarks Immediate Care of the Newborn in the Nursery * Note that ID bands of mother and baby are matched. Special Care 1. Initial Bath – temp stabilizes 36.5ºC 6-8 after birth - Vernix caseosa - use oil - Warm water during the 1st week -Don’t use soap -Hexachlorophene (Phisohex) – infected passageway 2. Taking the Temperature * Maintain temperature to prevent cold stress * Use Rectal route * Meconium - 24-48 hrs 3. Initial Cord Dressing * Inspect for A .V. A. * Aseptic technique * Povidone (Betadine); 70% Isopropyl alcohol - prevent Tetanus Neonatorum and Omphalitis (streptococcal and staphylococcal) Signs of Omphalitis: 1. Reddening of the area 2. Fever 3. Discharge or foul smell * Application of sterile cord clamp - prevent bleeding w/n 1st 24 hours (Omphalangia) 4. Crede’s Prophylaxis * Legal requirement for all NB (US) * Infection - acquired during delivery from a mother with untreated gonorrhea Medications: a. Opthalmic drops – Silver Nitrate or AgNO3 1% 1-2 drops - Lower conjunctival sac - Wash with sterile NSS after 1 minute to prevent chemical conjunctivitis b. Ointment Terramycin Gentamycin Chloramphenicol Erythromycin Erythromycin - Pull eyelids downward

* 1 K = 2.2 lbs BL: 47.5 – 53.75 cm (19 – 21 ½ in) Average: 50.8 cm/20 in * 1 inch = 2.54 cm Physiologic weight loss - 5-10 % in 10 days

Causes 1. No longer under influence of maternal hormones 2. Voids and passes out stools 3. Relatively low nutritional intake 4. Beginning difficulty establishing sucking Initial Feeding 1-6 hours after birth 1 oz of sterile water Subsequent feeding – by demand Breastfeeding 1. Bonding 2. Uterine contraction 3. Colostrums 4. Contraceptive 5. Cheap 6. Right temperature 7. Antibacterial – Lactoferrin, Lactobacillus bifidus, lysozyme, macrophage, T lymphocytes, lactoperoxidase Differences between Human and Cows Milk Physical Assessment 1.Vital Signs a. Pulse - 1 full minute; use apical pulse - Irregular, rapid >160-180 at birth NORMAL: 120–160 bpm During sleep - 90-110 bpm If crying, up to 180 bpm b. Respirations - 1 full minute - irregular, shallow, rapid w/ brief apneic spells < 15s 60-80 breaths/min at birth NORMAL: 30–60/minute c. Blood Pressure - not usually measured 80–60/45–40 mm Hg at birth 100/50 mm Hg at day 10 d. Temperature NORMAL: 36.5C–37.5C (axilla) Axillary: 36.4C–37.2C Skin: 36.0 C–36.5C Rectal: 36.6C–37.2C * Temperature 37.2 at birth Crying - increase body temperature slightly Radiant warmer - falsely increase axillary temperature 2. Skin Dark red – prematurity Acrocyanosis – up to 48 hours Generalized mottling Gray color - infection Pallor due to anemia because of: * Excessive blood loss when cord is cut * Untimely cutting of the cord * Inadequate iron stores because of poor maternal nutrition * Blood incompatibility Jaundice Types: 1. Physiologic Jaundice / Icterus Neonatorum 2nd day – 7th day - TERM 2nd day – 10th day - PRE-TERM Causes:

-0.5-1 cm -Inner to outer canthus -Wipe excess away
5. Vitamin K Injection - Sterile GIT - facilitates production of clotting factor - 1 mg. Aquamephyton - IM - lateral anterior thigh (Vastus lateralis) 6. Take Anthropometric Measurements (Vital Statistics) BW: 2.5 – 3.4 kgs (5.5 – 7.5 lbs)

turobilirubin c.Decreased uptake of free bilirubin by hepatic cells 2. Pathologic Jaundice Normal total serum bilirubin = 15% Direct bilirubin = 1.7 Indirect bilirubin = 13.2 Causes:

a.Hemolysis b.Decreased conversion of bilirubin

- closes 12-18 months; 3-4 cm long/2-3 cm wide - junction of 2 parietal bones and 2 fused frontal bones - not indented depressed - suture lines - never appear widely separated 2. Posterior – triangular in shape - junction of the parietal bones and the occipital bones. - 1 cm - closes by end of 2nd month Sutures Lambdoid (2) Coronal (2) Frontal (1) Sagittal (1) CRANIOSYNOSTOSIS - suture lines separated or fontanels prematurely closed; leads to mental retardation Molding –overlaping of sagittal and coronal suture line Craniotabes – localized softening of cranial bones; indented by pressure of a finger. Corrects w/o treatment in weeks or months. Common to first borns because of early lightening Comparison between Caput Succedaneum and Cephalhematoma 4. Eyes - Eyelids of equal size - temporarily gray or blue in color (d/t thinness) - Cry tearlessly 1st 3 months - Cornea round and adult sized - Pupils round, not keyholed (Coloboma) - cross-eyed (Strabismus) - see object at 8 inches; V.A. of 20/200 to 20/500 5. Ears -Top of ear should align with inner and outer canthus of the eye - sense of Hearing – highly developed in NB 6. Nose - Nasal obligates - Note for marked flaring of alae nasi, indicative of airway obstruction Causes of obstruction: 1. Secretions 2. septal deviation - Sense of smell – least developed 7. Mouth - open evenly when crying. If not, suspect CN VII Paralysis (Bell’s Palsy). - Palate intact; no breaks on the lip - cleft palate; cleft lip - Eptein’s Pearls – small round glistening cysts; palate and gums, due to extra load of maternal Ca - NATAL TEETH - Oral thrush – white gray patches on the tongue and sides of cheeks due to Candida 8. Neck - Thyroid gland not palpable - soft, palpable and creased with skin folds - Head - rotate freely on the neck and flex forward and back. (+) rigidity of the neck- CONGENITAL TORTICOLLIS (injury to SCM) -NB whose membranes ruptured 24 hours before birth, nuchal rigidity - meningitis. 9. Chest - As large as or smaller than the head - Symmetrical - Breasts may be engorged 10. Abdomen - dome shaped; If scaphoid - DIAPHRAGMATIC

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a. Infection b. Hemolytic disorders

c. Inability of the newborn to conjugate bilirubin Breastmilk jaundice Pregnanediol Decrease glucoronyl transferase Decrease conversion of indirect to direct bilirubin Jaundice Management 1. Early feeding 2. Phototherapy · Cover eyes with opaque mask to prevent blindness. · distance - 18-20 in from source of light. · Monitor V/S especially temp · Cover genitalia to prevent PRIAPISM · Adequate hydration · Turn NB q 2º to expose all body surfaces Common Marks 1. Harlequin Sign 2. Mongolian spots – (-) school age 3. Milia – unopened sebaceous glands; tip of nose and chin of the baby. (-) 2-4 weeks 4. Lanugo – fine downy hair on shoulders, upper arms, back; (-) 2 weeks. 5. Desquamation- peeling; at birth, postmaturity 6. Vernix Caseosa 7. Portwine Stain or Nevus Flammeus – birth; red to purple color; do not blanch on pressure nor disappear; face 8. Strawberry Mark or Nevus Vascularis – 2nd most common type of capillary hemangioma. elevated, sharply demarcated or bright or dark red, rough surface swelling. (+) school age or even longer. 9. Erythema Toxicum or Erythema Neonatorum – Newborn rash or fleabite dermatitis; transient; papules with vesicles at nape, back and buttocks. (+) 2nd day; disappears without treatment. 10. Cutis Marmorata – transitory mottling when exposed to cold 11. Nevi – stork bites or Telangiectasia Nevi; pink or red flat areas of capillary dilatation at upper eyelids, nose, upper lip, lower occiput bone, nape and neck. (-) 1st and 2nd year.

•Nevus flammeus •Stork’s beak mark •Strawberry hemangioma •Cavernous hemangioma

3. Head – largest part of the human body (1/4 of his total length); -forehead is large and prominent; -chin is receding when startled or crying.

Fontanelles 1. Anterior – diamond shape;

HERNIA - Bowel sounds should be present within 1 hour after birth - Liver, spleen and kidneys are palpable at birth. 11. Extremities - symmetric and of equal length - Fingers and toes equal count Supernumerary = polydactyly; fused or webbed = syndactyly Simean line - Asymmetrical movement of upper and lower extremities - ERB – DUCHENE PARALYSIS - congenital hip dislocation: Ortolani’s Maneuver - Observe for clubfoot deformities 12. Anogenital Area 3 types of stools passed by NB: 1. Meconium – greenish-blackish viscous; - amniotic fluid, intestinal secretions and cells shed from mucosa - take note of time when meconium first passed 2. Transitional – passed from 3rd to 10th day 3. Milk stool a. Breast fed infant stool – loose golden yellow in color with sweet odor; 2-3 times a day b. Bottle fed infant stool – formed, pale yellow with a typical odor; usually passed 1-2 times a day 13. Female Genitalia – swollen labia and pass a slightly bloody vaginal discharge -“PSEUDOMENSTRUATION” Male Genitalia – Scrotum may be edematous due to maternal hormones. - Testes should be present; if undescended CRYPTORCHIDISM Conditions for cryptorchidism: 1. Agenesis – absence of an organ 2. Ectopic testes – Testes cannot enter the scrotum because opening of the scrotal sac is closed. 3. Vas deferens or artery is too short to allow the testes to ascend. Circumcision – prior to discharge from nursery, preferably end of 1st week Procedure: 1. Vitamin K injected IM 2. Infant is restrained; penis is cleansed with soap and water 3. clamp is used 4. Petroleum gauze dressing is applied to prevent adherence of circumcised site to the diaper while applying pressure to prevent bleeding Nursing Care: - Check hourly for bleeding - Do not attempt to remove exudates which persist for 2-3 days; just wash with warm water. - Diaper must be pinned loosely during the 1st 2-3 days when the base of the penis is tender. 14. Back - On prone appears flat - Note for mass, hairy nodule and dimple along axis Spina Bifida. - Cremasteric reflex – test for integrity of spinal nerves (T8 thru T10) III. Discharge Instructions a. Bathing b. Cord Care c. Nutrition Calories 120 kcal/kg body weight/day CHON 2.2 gms/KBW/day Fluids 160-120 cc/KBW/day

Vitamins A,C, D for formula and breastfed babies Common Health Problems 1. Constipation 2. Loose stools 3. Colic Causes: Overfeeding Gas distention Too much carbohydrates Management Feed by demand Burp infant Feed in upright position May need to change formula Diaper Rash Miliaria Seborrheic Dermatitis Occasional “Crossed Eyes” Clothing Sleep Pattern SYSTEMIC EVALUATION I. Cardiovascular System Fetal Circulation

•Oxygen exchange occurs in placenta •pressure on the left side of the heart < right side •(+) accessory structures

Accessory Structures: Foramen ovale Ductus arteriosus Ductus venosus Umbilical vein Umbilical arteries Neonatal/Adult Circulation - With 1st breath, oxygenation takes place in lungs - Lung expansion occurs - Increase pressure on left side of heart > right side results in: Closure of accessory structures and obliteration of umbilical vessels II. Neuromuscular system Reflexes blink reflex Rooting reflex – (-) 6 wks old Sucking reflex –(-) 6 mos Extrusion Reflex – (-) 4 mos Swallowing reflex Tonic neck Reflex – (-)2-3 mos Babinski reflex – (-) 3 mos Landau reflex Palmar/Grasp (-) 3-4 mos Plantar reflex – (-) 8 mos Stepping reflex (-) 1 mo Moro reflex- (-) 4-5 mos Trunk Incurvation reflex – (-) 2-3 mos III. Gastrointestinal Meconium – mucus, vernix, lanugo, hormones Transitional stools – 2-10 days of life Breastfed babies stools Formula fed babies stools IV. Urinary Females – strong urine stream Males – projected arc V.Autoimmune Passive natural immunity – mother to child (+) Ab from the mother against Polio, DPT, Rubella and Measles

* immunization starts usually at 2 mos Expanded Program on Immunization VI. Senses 1. Sight – at birth (9 inches) 2. Hearing-at birth 3. Taste – at birth 4. Smell-at birth 5. Touch-at birth Newborn Screening REPUBLIC ACT NO. 9288 Newborn Screening Act of 2004 “…ensure that every baby born in the Philippines is offered the opportunity to undergo newborn screening and thus be spared from heritable conditions that can lead to mental retardation and death if undetected and untreated.” 1. CONGENITAL HYPOTHYROIDISM Thyroid hypofunction or enzyme defect reduced T3, T4 Females S/sx: excessive sleeping, enlarged tongue, noisy respiration, poor suck, cold extremities, slow pulse and respiratory rate, lethargy and fatigue, short and thick neck, dull expression, open mouthed, slow DTR, obesity, brittle hair, delayed dentition, dry, scaly skin Dx: low T3 T4, inc TSH Mx: synthetic thyroid hormone Nsg Care: Assist parents administer drugs 2. CONGENITAL ADRENAL HYPERPLASIA -inability to synthesize cortisol inc ACTH stimulate adrenal glands to enlarge inc androgen S/sx: musculinazation, sexual precocity Mx: Steroids to dec stimulation of ACTH 3. G6PD DEFICIENCY - reduction in the levels of the enzyme G6PD in RBC leads to hemolysis of the cell upon exposure to oxidative stress Dx: blood smear – heinz bodies rapid enzyme screening test, electrophoresis Mx: avoid drugs ie ASA, sulfonamides, antimalarials, fava beans 4. GALACTOSEMIA (-) enzyme that converts galactose to glucose S/sx: wt loss, vomiting, hepatosplenomegaly, jaundice and cataract Dx: Beutler test Tx: dec lactose – soy based formula regulate diet 5. PHENYLKETONURIA (PKU) - dec phenylalanine hydroxylase w/c converts phenylalanine to tyrosine S/sx: mental retardation, musty odor, blond hair, blue eyes Dx: Guthrie bld test Tx: dec phenylalanine (Lofenalac) regulate diet