NCM 107

CARE OF MOTHER, CHILD AND ADOLESCENT

COURSE/SUBJECT: NCM 107 Care of Mother, Child and Adolescent

MODULE NO: 3

MODULE TITLE: Review of Systems

TOPIC: Integumentary, Neuromuscular, Respiratory, Gastrointestinal, Renal, Cardiovascular, Immune

Systems

WRITER: Dulce Corazon O. Tan, RM RN

Lecture/Discussion

A. Integumentary System
1. All structures of the integumentary system are present at birth but the skin’s function is immature.
2. The skin of the newborn is smooth and elastic with fair amount of subcutaneous tissue.
3. Preterm infants have lesser subcutaneous tissue so their skin appears almost transparent.
4. Postterm infants have paler, dry and peeling skin

Skin Color
a. Newborns have normal ruddy complexion at birth, High erythrocyte count and small amount of
subcutaneous fat makes blood vessels under the skin more visible.
 This skin color changes as the infant gets older depending on her race.
 It is not unusual for the skin to be redder when the infant is upset and crying.
b. Bluish coloration of hands and feet is acrocyanosis and is normal during the 1 st 24hrs of life.
c. Mottling – irregular discoloration of the skin may occur when the newborn is exposed to cold
temperature, this is caused by vasoconstriction, lack of fat and hypoxia. This reaction disappears as the
infant gets older.

d. Harlequin’s Sign
 When the infant is lying on her side, the dependent portion of the body develops a deep
red color and the upper half turns pale.
 This is caused by constriction of blood vessels of the lower side and dilation on the
upper side. The skin regains its normal coloration when the infant assumes a different
position or cries vigorously.

5. Mongolian Spot
 It is the bluish discoloration of the lower back and buttocks seen mostly in children of
African and Asian ancestry
 This type of skin discoloration requires no treatment and disappears by school age.
6. There is a low melanin level at birth that results in the newborn to have a fairer complexion than
adult. Because of poor melanin production, the newborn is more susceptible to the harmful effects of
the sun.
7. Abnormal findings:
 Infant turns cyanotic when crying but becomes pink when asleep and quiet
 Soles of the feet do not turn pink when rubbed
 Cyanosis persisting beyond the second day of life
 Central cyanosis or cyanosis of the trunk
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 Gray color indicates infection

 Pallor indicate anemia which can be caused by:
 Excessive blood loss during cutting
 Poor blood flow from cord to the infant during birth
 Rh incompatibility in which massive fetal RBC destruction occurred in utero
 Fetal-maternal transfusion
 Fetal low iron stores related to poor maternal nutrition
Skin Turgor
1. Skin turgor is an indicator of the hydration status of the newborn.
2. To test for skin turgor, pinch the skin. The skin automatically recoils. If not, it indicates poor skin
turgor and dehydration.

Sweat Glands
1. The eccrine glands which produce sweat are present and functional however they produce sweat in
response to higher temperature than that required of adults.
2. Normal sweating similar to adult begins after a month.

Sebaceous Glands
1. Sebaceous glands begin to function in utero in response to androgen hormones of the mother.
Sebaceous glands located in the scalp, face and genitalia are very active late in fetal life in producing
vernix caseosa.

2. Vernix Caseosa
 Vernix Caseosa is a white cheese like substance in the newborn’s skin that is found particularly
abundant in skin creases. It is composed of accumulation of old cutaneous cells and secretions
of sebaceous glands while in utero.
 Acts as lubricant that protects the skin of the fetus from maceration, present at birth until 2 to 3
days after it is absorbed by the newborn’s skin and washed off during bathing.
 Vernix Caseosa takes on the color of the amniotic fluid. If the amniotic fluid is meconium
stained vernix Caseosa will assume a greenish color. If it is yellowish, it means that the
amniotic fluid is also colored yellow due to bilirubin.
 Although it provides protection to the skin, it is also a good medium of bacterial growth.
 It is an important indicator of gestational age as absence of minimal amount of vernix
signifies postmaturity while excessive amount of it signifies prematurity.

3. Milia
 These are clogged and distended sebaceous glands found on the newborn’s face,
particularly the nose and chin.
 It disappears without treatment within 2 to 4 weeks after birth when the glands mature
and drain.
Hair
1. Lanugo
 It is a fine downy hair that usually covers the infant’s shoulders, back, forehead, ears,
cheek and upper arm.
 It first appears at 19 weeks fetal life and becomes most obvious at 27 to 28 weeks. It
disappears within 2 weeks after birth.
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 Like vernix, it is also an indicator of gestational age. The more lanugo there is, the higher
the gestational age, the less lanugo is present, the more immature the newborn. Post
mature infant may not have lanugo at all.
2. In early infancy, hair growth and hair fall is temporarily disrupted so that a newborn may have hair
overgrowth or alopecia. Boy’s hair grows faster than girl’s hair.

Erythema Toxicum Neanatorum

1. A harmless rash, also known as flea bite rash that is found in many newborns. It is not present at birth
but appears anytime during the first four hours of life and persists up to 3 weeks.
2. The lesion begin as papules that develop in hive like elevations with a center containing clear fluid. It
lacks pattern and develop sporadically and unpredictably.
3. It is a reaction of the infant’s skin to clothes and sheets. It subsides with treatment.
4. It is important to explain to concerned parents that newborn rash is harmless, do not require special
intervention and subsides spontaneously.

Desquamation
1. Newborn skin usually becomes dry one day after birth. This leads to peeling during the first 2 to 4
weeks.
2. Post mature infants experience more desquamation than normal term infants.

Cyanosis
1. Cyanosis refers to bluish discoloration of the skin
2. Acrocyanosis is the bluish discoloration of the hands and feet of the newborn that is due to poor
peripheral circulation. It should be seen only during the first 24 to 48 hours of life.
3. Acrocyanosis disappears when the infant cries vigorously and when soles of the feet are rubbed.

Neonatal Physiologic Jaundice

Jaundice is a yellowish discoloration of the skin caused by buildup of bile pigment, bilirubin. It is among
the most common conditions that require medical attention in newborns, Normal physiologic jaundice
occurs in almost 50% of newborn infants. Jaundice appears first in the face and forehead progressing to
the abdomen and the extremities.

Risk Factors
1. Race: Incidence is higher in East Asians and American Indians and is lower in African Americans.
2. Geography: Incidence is higher in populations living at high altitudes. Greeks living in Greece have a
higher incidence than those living outside of Greece.
3. Genetics and familiar risk: Incidence is higher in infants with siblings who had significant neonatal
jaundice and particularly in infants whose older siblings were treated for neonatal jaundice.
4. Nutrition: Incidence is higher in infants who are breastfed or who receive inadequate nutrition.
5. Maternal factors: Infants of mothers with diabetes have higher incidence. Use of some drugs may
increase the incidence, whereas others decrease the incidence.
6. Birthweight and gestational age: Incidence is higher in premature infants and in infants with low
birthweight
7. Congenital Infection:
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Causes of Physiologic Jaundice

1. The fetus needs additional RBC while in utero because fetal circulation is less efficient at oxygen
transport than the lungs. With the initiation of respiration in the lungs at birth, these extra RBC are no
longer needed.
2. The infant is born with higher number of fetal red blood cells that have shorter life span of 90 days
only compared to adult RBC that have a lifespan of 120 days. Because of shorter lifespan, rapid fetal red
blood cells destruction occurs after birth. Fetal RBC is gradually replaced by postnatal RBC that although
not as efficient in carrying oxygen, has a longer lifespan.
3. Indirect bilirubin tends to accumulate in the newborn

Characteristics of Physiologic Jaundice

1. Appears 24 hours after birth
2. Total serum bilirubin is less than 12 mg/dl
3. Direct serum bilirubin is less than 1-2 mg/100 ml
4. Total serum bilirubin does not increase more than 5mg /100ml per 24 hours
5. Infant does not show any signs of illness or cardiac decompensation
6. Jaundice disappears in one week in full term and in two weeks in preterm infants

Assessment of Jaundice
1. Blanc the skin by applying direct pressure over bony prominence such as the nose and sternum.
2. Observe color of nails, sclera, mucous membrane, skin of palms and soles.
3. In dark skinned infant, check the conjunctiva, sclera and oral mucous membrane

Management
1. Early feeding to speed passage of meconium through the intestines and prevent bilirubin
reabsorption.
2. Phototherapy or exposure to early morning sunlight to hasten liver cell maturity.
3. Breastmilk jaundice results from breastfeeding
 It occurs during the 5th to 6th day of life when breastmilk supply is established. It is caused by
pregnanediol, a substance present in breastmilk that interferes with the action of glucoronyl
transferase. No damage in newborn has been reported from breastmilk jaundice.
 No newborn damage has been reported from breastmilk jaundice.

Pathologic Jaundice
This is jaundice that occurs before 24 hours after birth and which is caused by RH incompatibility, ABO
incompatibility, or hepatitis. When serum bilirubin level rises excessively, it can cause death and lifelong
neurologic damage called kernicterus. Kernicterus occurs when bilirubin reaches the brain and damage
brain cells. Jaundice is also considered pathologic if unconjugated bilirubin levels is beyond 12mg/100ml
or persists for more than a week in term infants and more than 2 weeks in preterm infants.

Causes of Pathologic Jaundice

1. Rh incompatibility
2.Liver damage
3. blood dyscrasias
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4. Sepsis
5. Increased bruising
6. Polycythemia
7. Alterations in bowel elimination
8. Endocrine disorders and metabolic disorders among others

Management of Pathologic Jaundice

1. Frequent feedings to hasten the passage of feces in the bowel and prevent reabsorption of bilirubin.
2. Phototherapy – it is the main form of therapy. The infant’s skin is exposed to intense fluorescent light
that decompose bilirubin by the process of photo oxidation.
a. During phototherapy, the following should be observed:
- unclothe the infant during treatment. Irradiating a large skin surface area is more efficient than
irradiating a small area.
- shield eyes with an opaque mask, close eyes first. This is to prevent retinal damage.
- cover genitals with diaper to prevent damage
- check the distance between the infant’s skin and light source. With fluorescent lamps, the distance
should be no greater than 50cm. This distance may be reduced down to 10-20 cm if temperature
homeostasis is monitored to reduce the risk of overheating.
- cover the inside of the bassinet with reflecting material; white linen works well. Hang a white curtain
around the phototherapy
-unit and bassinet. These simple measures can multiply energy delivery by several fold.
- when using spotlights, ensure that the infant is placed at the center of the circle of light, since photo
energy drops off towards the circle’s perimeter.
- exposure to heat can cause increased insensible water loss. Monitor weight loss, urine output, and
urine specific gravity
- check vital signs every four hours
- while on phototherapy, serum bilirubin level of the infant should be monitored. Phototherapy is
discontinued when serum bilirubin level fall 25-50 umol/L

Side effects:
 Loose green stool
 Bronze baby syndrome – bronzing or greenish brown discoloration of the skin if baby has liver
disease.
 Hyperthermia
 Priapism
 Lethargy and water loss

3. Exchange Transfusion – this treatment removes bilirubin more rapidly and directly from the blood. It
is used in infants with kernicterus and ABO incompatibilities.

4. Barbiturate Phenobarbital – Phenobarbital is an inducer of hepatic bilirubin metabolism; it induces a

rise in bilirubin glucorinade that results in decrease serum bilirubin concentration.
a. Phenobarbital maybe administered prenatally in the mother or postnatally in the infant. It can
be used prophylactically during pregnancy to prevent the occurrence of neonatal jaundice, especially
when it is given two weeks before EDC. It is also effective in reducing serum bilirubin level in the first
week after birth.
b. its side effects to the fetus include:
 Respiratory Depression
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 Inability to suck well

 Decreased responsiveness

Birthmarks

1. Vascular Nevi
a. Nevus flammeus or port white stain:
 A dark red lesion composed of newly formed capillaries, is colored red to purple, of varying size
and does not blanch with pressure.
 The lesion is usually found in the face but may also appear in other parts of the body such as the
thighs.
b. strawberry marks or nevus vasculosus
 These are elevated areas of the skin that are bright to dark red and with a rough surface. They
are so called because they resemble the outside of a fresh strawberry.
c. Stork bites or telangiectatic nevi
 This type of birthmark is common among fair skinned newborns and occurs more frequently in
girls than in boys.
 They are pink and easily blanch under pressure
 They appear mostly in the nape of the neck and sometime in the eyelid.
 Not associated with other disorders and fade quickly
d. Cavernous hamangiomas
 This type of lesions is found in the subcutaneous tissue and usually do not affect the skin over it.
Sometimes, a strawberry mark or port white stain is found on the overlying of the skin.
 It may be present at birth or appear several months after
 They undergo a period of rapid growth before they begin to recede on their own. They may
require surgical intervention if they manifest problems like bleeding or rapid growth
2. Pigmented Nevi
a. Nevus spilus
 This skin lesion is more commonly known as mole
 It is flat, hairless and with coloration that can vary from pale yellow to brown or black.
 This nevus does not require any intervention unless it is located in an area where it can easily be
irritated that removal is necessary.
b. Nevus pilosus
 This type of nevus that is rarely found in newborn is a mole with short fine or coarse hair
 The presence of a hairy nevus found along the spine requires further examination as it may be
associated with spina bifida this mole requires no intervention but if it is an unsightly
appearance, it can be removed surgically.

NEUROMUSCULAR SYSTEM

1. The brain is 10% of the total body weight.

2. Myelinization is completed at 6 to 12 months. The cranial nerves are present and myelinated except
for the optic and olfactory nerves.
3. Intactness of the nervous system is demonstrated by the newborn’s:
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 State of alertness
 Resting posture
 Cry
 Muscle tone
 Motor activity
4. The nervous system is immature at birth but the newborn is endowed with inborn reflexes important
for protection (extrusion, blink, gag and cough) and survival (rooting and sucking)
5. Reflexes are involuntary movements or actions. Reflexes help identify normal and nerve activity.
Newborn reflexes disappear as voluntary control is developed.

1. Moro Reflex
 It is considered as the most important reflex of the newborn as its presence indicates integrity
of the nervous system.
 Stimulus – Hold the infant in a supine position and with the head, neck and spine appropriately
supported and allow the infant to drop slightly.
 Reaction – Arms and legs extend then drawn inward in an embracing position. The arms and legs
should extend symmetrically. The infant will also fan his fingers and form a “c” shape with the
index finger and thumb. It ends with the infant returning to a relaxed position.
 Duration – Present from 32 weeks’ gestation to 4-5 months after birth.
 Abnormal Reaction
a. absence of moro reflex indicates brain damage
b. asymmetric arm movement could be due to paralysis of the arm
c. persistence beyond six months of age requires further neurologic examination

2. Babinski Reflex
 The infant should be awake and the head in midline when testing this reflex.
 Stimulus – Stroke the lateral aspect of the soles of the foot in an inverted J-curve from heel
upward to the base of the toes.
 Reaction – Fanning of toes (adult flexes toes)
 duration – from birth to three months
 Abnormal – persistence beyond specified duration and abnormal movement of toes require
further neurologic examination

3. Plantar Grasp Reflex

 Stimulus – touch the sole of the foot at the base of the toes
 Reaction – The toes will curl downward or flex
 Duration – birth to 8 months after birth, may be present during sleep for a longer period

4. Palmar grasp Reflex

 Stimulus - Place a finger or object on the palms of the newborn
 Reaction - The infant will automatically grasp the finger or object by closing her fingers on it
 Duration – Present at early as 28 weeks’ fetal life to 6 weeks after birth

5. Neck-righting Reflex
 Stimulus – Place infant in supine then turn head to one side
 Reaction – Infant’s shoulder and trunk should follow the head’s position.
 Duration – birth to 10 months
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6. Rooting Reflex
 Stimulus – stroke infant’s cheek with a finger
 Reaction – the infant will open mouth and turn the side stimulated
 Duration – birth to six weeks

7. Sucking Reflex
 Stimulus – touch lips of infant
 Reaction – the infant has a tendency to suck any object that touches its lips.
 Duration – birth to 7-9 months

8. Extrusion Reflex
 Stimulus – place a sterile substance on the anterior of the infant’s tongue
 Reaction – infant will make sucking movements
 Duration – birth to 4 months

9. Stepping, Dancing, Walk-in-Place Reflex

 Stimulus – hold infant in standing position with feet touching a firm surface
 Reaction – The infant will make stepping motions
 Duration – Birth to three months of age
 Abnormal – Stiffness, crossing of the legs and scissoring

10. Crawling Reflex

 Stimulus – Place infant in prone position
 Reaction – infant will make crawling movements
 Duration – birth to six weeks

11. Tonic Neck or Fencing Reflex

 Stimulus – Place infant in supine position and turn head to right and left side with the jaw over
the shoulder
 Reaction – The arm and leg on the side where the head is turned will extend and the arm and
leg on the opposite side will flex
 Duration – birth to two-three months
 Abnormal – Persistence in an alert infant beyond 6 months is a sign of major cerebral damage

12. Trunk Incurvation or Galant Reflex

 Stimulus – Place infant in prone position and stroke one side of the infant’s back from shoulder
to buttocks
 Reaction – The infant curves the body towards the side stroked
 Duration – birth to 3 months

13. Parachute Reflex

 Stimulus – Place infant in vertical suspension and suddenly lower toward a flat surface.
 Reaction – Forward extension of both arms and dorsiflexion of the infant’s hands during
movement

14. Magnet Reflex – test of spinal cord integrity

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 Stimulus – Place newborn in supine position on a flat surface Apply pressure on the soles of the
feet
 Reaction – Newborn pushes back against the pressure
15. Cross Extension Reflex – test of spinal cord integrity
 Stimulus – Place newborn in supine position, extend one leg and rub the sole of that leg with a
sharp object such as thumbnail.
 Reaction – Infant raise the opposite leg and extends it as if trying to push away the hand
irritating the other leg.

Special Senses
1. Vision
 Eyes are structurally complete at birth but muscles are immature resulting in strabismus and
nystagmus until 4 months
 Newborns can see at birth, their clearest vision is at the distance of 9 to 12 inches
 Tear gland begin to function after two weeks
 They can detect color at 2 months
 At 6 months, the vision of the infant is as acute as that of the adult
 Visual Acuity of 20/20 is achieved at 7 years
 They prefer human face and recognizes strangers at 6 months’ old

2. Hearing
 Fetus can hear in utero and infants have well developed sense of hearing at birth. They can hear
as soon as after the external ears have been drained of amniotic fluid.
 They stop crying and tend to relax when they hear low pitched sounds
 They prefer sounds that have regular rate and rhythm because they have been accustomed to
the mother’s heartbeat in the utero
 By 3 days of age, they can recognize their mother’s voice.

3. Touch
 The most highly developed of all senses in the newborn
 The newborn respond to touch on all parts of its body
 Their sense of touch can be demonstrated by the rooting, sucking, Babinski and palmar grasp
reflex.

4. Taste
 The newborn has a well-developed sense of taste at birth. Sense of taste is functioning before
birth as demonstrated by the fetus swallowing more rapidly when glucose is added to amniotic
fluid.

5. Smell
 The newborn has a well-developed sense of smell at birth
 The newborn’s sense of smell is demonstrated when newborn
a. turn head away from strong odors like alcohol
b. turn to the mother’s breast while being held because she recognizes the smell of milk
c. cry for the mother when the maternal breast is engorged or leaking with milk
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RESPIRATORY SYSTEM

Initiation of Respiration
1. Initiation of respiration is the most critical and important task a newborn must accomplish at birth.
The lungs, previously filled by the amniotic fluid, begin to function as an organ of gas exchange. But
before effective respiration can be achieved, the lungs must be emptied first of fluid. This can be
achieved by:
a. compression of the chest as the fetus pass through the narrow pelvic space squeeze out some fluid
from the lungs
b. suctioning of the infant after delivery
c. remaining fluid is absorbed by the lymphatic and lung vessels

2. The first breath is initiated by:

a. chemical stimulus
 Low oxygen level in the blood
 High carbon dioxide level in the blood
 Low pH
b. thermal stimulus – chilling that occurs after the infant is born to an environment that is much cooler
that the mother’s womb.
c. other stimulants – reflex response to changes in pressure, noise, light, and other stimulus and
sensations related to birthing process.

3. Newborns will have difficulty establishing respiration if:

a. they are born by CS because they have more lung fluid
b. they are premature infants because they have less surfactant, a substance necessary to keep the
alveoli expanded

Obligatory Nose Breather

1. Newborns are obligatory nose breathers; they breathe only through their noses. The newborn does
not yet know to open her mouth in response to nasal obstruction. That is why, it is necessary to keep
the nostrils patent and free from obstruction.

2. Nasal obstruction usually results in sudden cyanosis and apnea. This requires suctioning of the mucus
to remove the obstruction and allow the newborn to breathe normally.

Indicators of Lung Maturity

1. Phosphatidyglycerol – appears at 35 to 36 weeks’ gestation
2. Lecithin/sphingomyelin (L/S ratio) of 2:1

GASTROINTESTINAL SYSTEM

1. The newborn’s gastrointestinal system is not fully developed at birth; it attains maturity at 2 to 3
years of age.
2. The gastrointestinal tract is sterile at birth. Bacteria enter via the oral and fecal route within 24 hours.
Normally intestinal flora is present at one week. Since the newborn’s intestines does not contain the
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beneficial bacteria that forms Vitamin K, a nutrient necessary in the formation of clotting factors.
Aquamephyton is given to all newborns to guard against bleeding.
3. The most immature gastrointestinal organ is the liver. The liver has inadequate stores of glycogen
making the newborn prone to hypoglycemia.
4. Enzymes for digesting simple carbohydrates and protein are present at birth but not enzymes for
complex carbohydrates and fats.
5. Most of the newborn’s salivary glands are not yet functional at birth until two to three months of age
6. During the first few days, regurgitation after feeding is due to the immature cardiac sphincter.
7. Gastric capacity is only up to 90 ml at birth. For this reason, the newborn needs small frequent
feedings.

Stool
1. Meconium – is the first stool passed by the infant consisting of swallowed amniotic fluid, intestinal
secretions and old cells shed by the GIT in utero
2. Transitional stool appears from 2nd to 4th day. It is composed of m ilk and some meconium. It appears
brownish to yellow green, more watery than meconium, thin and slimy.
3. Normal Stool after 4 days of life. Its characteristics will depend largely on the milk fed to the infant.

Teeth
Teeth development begins in the uteru with enamel formation lasting up to 10 years of age. A baby
maybe born with one or two teeth, if loose, this must be removed because of the danger of being
aspirated.

Signs of Abnormalities
1. Not passing of stool within 24 hours after birth is indicative of imperforate anus and Hirschprung
disease.
2. Clay colored stool indicates obstruction of the bile ducts
3. Presence of mucus in stool may indicate milk allergy
4. Stool that remains black or tarry for several days indicate GIT bleeding. The infant should pass black
stool during the first 3 days of life only.
5. Forceful ejection of stool and water ring around the stool is a sign of diarrhea
6. Abdominal distention after birth may indicate tumors
7. Projectile vomiting is a sign of esophageal atresia and tracheoesophageal anomalies.

RENAL SYSTEM

1. The fetal kidneys produce urine as early as the fourth month in utero.
2. The normal newborn should void within 24 hours after birth
3. The first urine voided may have a pinkish color due to the presence of uric crystals that were formed
in the bladder in utero
4. The kidneys do not concentrate urine well so that newborn urine is dilute: appear light and colorless
with a specific gravity ranging from 1.008 to 1.010
5. Bladder capacity at birth is about 40 ml. Daily urinary output is about 30 to 60 ml during the first few
days and increasing to 300 ml after a week with each voiding about 15ml in volume.
6. During the first two to three days, the newborn voids 5 to 6 times a day. With adequate hydration
after the first week, the newborn voids as frequently as 15 to 20 times a day.

CARDIOVASCULAR SYSTEM
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Blood Volume
1. The newborn has about 10% more blood volume and 20% more red blood cells than the adult. The
blood volume at birth is about 80 to 90 ml/kg body weight. Total blood volume is about 300 ml.
2. The time of which the cord is cut has significant effect on the circulatory system.; about 50 to 100 ml
of placental blood is transfused to the newborn if cord is clamped after the pulsation has stopped.
Effects of delayed cord clamping are:
 Higher tendency to develop pulmonary crackles and transient cyanosis
 Decreased incidence of respiratory distress
 More iron stores, 80 ml of placental blood yields 50 mg of iron
 Increased blood volume
3. Disadvantage of delayed cord clamping include hyperbilirubinemia and the danger of circulatory
overload
4. After birth, hemolysis occurs resulting in a drop in RBC count until the 3 rd month, this leads to
physiologic anemia.

Blood Values
1. Newborn’s blood volume is around 80 to 110ml per kilogram of body weight
2. The newborn have a high erythrocyte count at birth, about 6 million per cubic millimeter.
3. Hemoglobin level averages 17 to 18 per 100 ml and hematocrit is 45% to 50%. At the end of the third
month, hemoglobin level drops to 11 to 12 mg/100ml and RBC count is as low as 3 to 4 million per cubic
millimeter.
4. Delayed clamping of the cord results in the rise of hematocrit, hemoglobin and RBC values.
5. Erythropoiesis or RBC production slows down during the first six to eight weeks after birth and fetal
RBC continue to break down during the first 5 months of infancy. These conditions results in the
neonate’s RBC and hemoglobin level to drop at around 2-3 months of age that result in a condition
called physiologic anemia.
6. Iron stores of the infant are enough to supply her need until 5 to 6 months
7. It is normal for leukocyte count, particularly neutrophils, to be very high at birth; this is thought to be
due to the trauma experienced by the infant during the birth process.
8. By 6 years of age, the blood values of the child are almost similar to that of adult.
9. A newborn has 100 to 200 ug/100 ml of iron at birth.
10. Capillary heels sticks may reveal false high hematocrit or hemoglobin value because of sluggish
peripheral circulation.

Immune System
1. During the first month of life, the newborn is not capable of producing its own antibodies. But late in
pregnancy, maternal antibodies are transferred to the fetus.
2. The antibodies found in cord blood are: tetanus antitoxin, diphtheria antitoxin, smallpox agglutinins,
antistreotolysins, toxoplasma antibodies, salmonella H antibodies, and Rh blocking antibodies.
3. There is lack of IgA, IgD, and IgE. These antibodies can be obtained by the infant from the mother via
the breastmilk.
4. The presence of IgM in newborn circulation indicates exposure to infection during fetal life.
5. Antibodies which are needed in the protection against gram negative and some gram positive
organisms do not cross placenta so the newborn is susceptible to these kind of microorganisms.
6. The infant has about half of adult level of IgG at one year of age, the same adult level of IgM at 9
months, and has a IgA in saliva and tears at 2-5 weeks.
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CARE OF INFANT

Cord Care
1. During the first hours after delivery, the cord should be inspected periodically. Oozing or bleeding
which occurs mostly between the second and sixth hour of life is usually due to passage of meconium
and crying.
2. Cod clamp may loosen as the umbilical cord sink and dry. Reclamp
or retie the cord as indicated.
3. No lotions, powder, cream or antibiotics should be applied on the cord.
4. The cord should be kept dry until it falls off.
5. Recommended methods of hastening cord separation, healing, drying and prevention of infection
such as:
a. application of 70% alcohol to hasten drying and prevent infection
b. cleaning the cord with sterile water or a neutral Ph cleanser
c. Using antiseptic on the cord such as bacitracin or triple dye.
6. Average cord separation time is about 10-14 days.
7. On discharge, the parents should be instructed to call the physician or health care provider if the
umbilical area:
a. appears red and swollen around the cord
b. continues to bleed
c. oozes yellowish pus
d. produces a foul-smelling discharge

Rooming-in
- involves keeping the newborn at the mother’s room rather than in the nursery after immediate care is
rendered to him.
a. full rooming-in – allows the mother and baby to stay together during the entire time of
hospital stay
b. partial rooming-in – allows the mother to send the baby back to the nursery at night,
specifying if she want to be awakened for night time feedings or not.

Kangaroo Mother Care (KMC)

1. KMC method of newborn care allows prolonged skin contact between mother and baby. KMC can be
started as soon as the baby is stable. This method of newborn care has proven especially beneficial to
low birth weight and preterm infants and in areas where no thermal equipment are available to keep
the newborn’s temperature stable.
2. Babies with severe illness or requiring special treatment should wait until they are reasonably stable
before KMC can be initiated.
3. KMC have shown to increase breastfeeding rates, improve newborn growth and provides effective
thermal control and reduce risk of newborn hypothermia.
4. Skin-to-skin contact start gradually, with a smooth transition from conventional care to continuous
KMC.
5. When mother is not available, other family member such as grandmother, father or relative can
provide KMC.
6. Early skin-to-skin contact in the first few hours after birth is more than just a measure for preventing
hypothermia. It also:
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a. provides warmth
b. enables early breastfeeding
c. prevents hypoglycemia
d. encourages bonding
e. expose the baby to the mother’s skin bacteria

Bonding
1. Bonding is the initial psychological reaction that takes place between parents and child in which the
parents claim the infant as their own infant.
2. The length of time that is necessary for mothers to “bond” or “identify” with their newborns depend
on the circumstances surrounding the pregnancy and labor, the opportunities the mother had to
interact with her child and whether or not the infant has met the expectations of the parents.
3. The nurse or midwife can help in the bonding process as early as immediately after birth by showing
the newborn to the mother and establishing eye contact before the two are separated.
4. Sign of poor mother and child bonding includes: mother cannot find attributes in the baby to admire,
picks up the infant without warning, speaks of infant as ugly, does not make eye contact with baby,
cannot discriminate between signs of hunger, sleep, discomfort, thinks that the baby has some defect
even though this possibility has been ruled out and gets angry when baby vomits or drool.

Sensory Stimulation
1. Sensory stimulation is one important need of a newborn infant. Optimal development of physiological
function of the brain depends on amount of stimulation.
2. Newborns are more alert when they are in upright position.
3. Signs of attention in the newborn are: face brightens, pupils dilate, arm and leg movements cease,
and sucking rate decreases, heart rate and respiratory rate decreases, and head turns toward stimulus.

Touch
- the infant needs to feel skin to skin contact, they like gentle and soothing caresses
- mothers should handle infants with gentleness, provide them with clothes made of soft fabric and
which are comfortable, and keep diapers dry.
-some authorities believe that during the first three months , newborns have right sided preference.

Sight
- newborns enjoy looking at similar faces, simple black and white patterns and like to look at people’s
eyes.
- at two weeks, they like looking at blank and red striped objects, simple drawing of faces of man and
woman.
- infants enjoy watching their mother’s faces and eyes.

Hearing
- infants can hear as soon as amniotic fluid is drained from the ears.
- the more speech the infant hear, the earlier they learn to talk and the more likely they are to reach
their potential for mental skills.
- speech stimulates the development of the left hemisphere of the brain while music stimulates the right
side of development
- for infants, higher pitched sounds are stimulating, while low bass sounds are consoling and quieting.

Taste
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- newborns prefer sweet tasting substances

-mothers are discouraged from giving their newborn infants sour tasting substances in order that the
infant would not associate the mother with unpleasant stimuli.
- the temperature of the milk should not be too hot nor too cold.

Smell
- infants can differentiate the smell of their mother’s breasts pads as early as 5 days of life.
- the olfactory senses is also important in the bonding process
- the most powerful smell stimulus is breastmilk, followed by body scents of parents.

Circumcision
1. It is the surgical incision or removal of all parts of the foreskin, or prepuce of the penis.
2. Jewish infants are routinely circumcised on the 8 th day of life
3. if circumcision is to be done, it is best performed the first and second day of life after the newborn’s
condition has stabilized and when the mother is still in the hospital
4. the foreskin separate from the tip of the penis until it can be pulled back away.

Benefits
a. makes cleaning of the penis easier
2. decreases chances of UTI by preventing accumulation of smegma under the foreskin and STD later in
life.
3. may prevent cancer of the penis, posthitis, balanitis

Complication
- infection, hemorrhage, meatal stenosis, hematoma formation, urethral fistula, adhesions, dehiscence

Bathing
The initial newborn bath is performed after vital signs, particularly the temperature, has
stabilized.
Because of the presence of blood and other body fluids in the newborn’s skin that can be
potential sources of contamination like HIV, it is part of standard precautions for health workers
handling the baby to wear gloves until after the first bath.
The baby should be sponge bath until the cord falls off.
Daily bathing is not necessary for all infants except in very hot weather

Important considerations
o The use of colognes, scented powders, lotions and strong soaps is discouraged because of the
sensitivity of the baby’s skin.
o The baby should be bathed before feeding to prevent spitting up when bathing is done after
feeding.
o The temperature of the room should be warm, about 75˚F or 24˚C to prevent chilling.
o Materials needed for bathing an infant comprise of water, mild soap, a washcloth and towel,
clean comb, clean diaper and shirt.
o The bath should proceed from the cleanest area of the body to the most soiled parts, that is
from the eyes and face, ears, scalp, neck, upper extremities, lower extremities, the buttocks and
the genital area.
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Care of the diaper area

 Diapers should be changed as soon as they are wet and soiled. Disposable diapers may take
more than 4 hours before getting completely saturated with urine. Waiting this long before
changing diapers can result in skin irritation. To maintain good skin hygiene in the diaper area, it
is best to change diapers every 2-4 hours.

Diaper rash
-characterized by a skin in the diaper area appearing reddish and sore. It is more common in babies
below 15 months of age.
Cause
 Irritation of skin from stool and urine (ammonia dermatitis)
 Introduction of new foods that can change the content of stool
 Allergy or irritation from a new product
 Bacterial or yeast infection as the diaper region and soiled diaper is a good breeding ground for
bacteria and yeast being warm and moist
 Skin sensitivity
 Mechanical irritation
 Antibiotics

Management
 Keep skin clean and dry always
 Apply baby oil, petroleum jelly or protective ointments such as vitamin A and D in the baby’s
diaper area.
 Expose the affected skin to air and light several times a day
 Do not over tighten the diaper
 Dry the diaper under the sun
 Rinsing the diaper thoroughly

Rest and Sleep

1. a newborn sleeps an average of 16n hours in every 24 hours, often in 3 to 4 hours’ periods. Usually
the newborn falls asleep while feeding and awakens when wet and hungry
2. the infant should be placed on different positions when sleeping to prevent flattening of the head on
one side and also to prevent pooling of mucus on respiratory secretions in one lung
3. if infant awakens at night provide soft music, rocking, pacifier dim light
4. health teachings
 Avoid stimulation during night time feedings and diaper change
 Keep noise to minimum and avoid bright lights
 Do not place anything in the crib, that may interfere with the infant’s breathing
 Establishing a bedtime ritual like bathing, reading or singing can help a bay to relax and
sleep

Nail Trimming
a. use a baby nail clipper, cut the nails when baby is asleep or after bathing.

Cleaning the nose

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a. during the first few days of life, it is important to keep the nose clean and clear of any obstruction
because the infant is an obligatory nose breather
b. instruct the mothers not to use a cotton swab or rolled up tissue to clean inside of the baby’s nose. If
the baby is stuffy, suction out the mucus with a baby nasal aspirator. Saline drops may soften the mucus
first. Cradle the baby or sit up. Squeeze the bulb and place the tip in one nostril. Release bulb and draw
the mucus out. Rinse the bulb and repeat.

Clothing
a. baby’s clothes should be cool and comfortable
b. the choice of diaper is also a major decision to make. Cloth diapers or disposable diapers have their
own advantages and disadvantages.

Handling and Positioning

1. when handling infants, always consider that infants have no real control of head movements and so
the head, being also so large and heavy must always be supported properly.
2. do not use pillow under the head, instead use rolled or folded blankets to elevate the head slightly.
3. the infant may be carried in many ways: cradle hold (sleeping), football hold (bathing), shoulder hold
(burping)
4. It is also important that the baby be made aware before she is picked up.

There are four best ways to carry a baby.

1. cradle carry – used for small infants, the cradle carry lets the mother cradle her baby in one of her
arms as she walk
2. Shoulder carry – some babies are more comfortable resting on a shoulder. The head should be
supported until the baby has learned to carry her or his own head.
3. hip carry – the hip carry is for older babies who’ve mastered head and neck control
4. front-face carry – place one arm under the baby’s buttocks, and wrap the other arm around her chest
to hold her close.

Infant Massage
1. Babies thrive on touch. Studies have shown that skin to skin contact contributes to growth and
development, soothe baby’s discomfort such as colic, helps baby sleep more, and strengthens the bond
between the mother and baby.
2. General guidelines:
a. do not massage when: ill, after surgery, has skin cuts/abrasions or irritations.
b. schedule massage on times when baby is quiet and relaxed.
c. place baby on a soft surface such as a folded blanket or a big pillow
d. keep baby warm and cover body parts not being massaged
e. before starting to massage, talk to the baby in soothing voice to help baby to relax and
provide more stimulation
f. allow the baby to change in different positions as she or he wants during the massage.
g. apply only a little amount of unscented baby oil on the hands and use light pressure while
massaging the baby

Pacifiers
Many infants suck their thumbs and fingers but this habit usually stops by 6 to 7 months of age. Some
babies do not suck their fingers but suck on pacifiers. No reliable findings have been found to support
the claim that they cause the baby medical or psychological problem.
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Teething
Teething begins at different times for different babies; teeth eruption usually begins around 4 months
for many babies. The first tooth to erupt is the middle lower central incisors. These are followed around
4 to 8 weeks later by the four front upper teeth.
Signs of teething
- periodontal membrane is swollen
- drooling
- ear pulling
- coughing due to excessive saliva
- chin or facial rashes
- redness in gums
- wakefulness
- cheek rubbing
- irritability
- diarrhea
- low-grade fever
- loss of appetite
- difficulty breastfeeding

Significance of Baby’s cry

1. Infants usually cry when they are hungry, wet or uncomfortable, or when they are suddenly
awakened from sleep
2. The character of the infant’s cry is a good indicator of his need
 Unclothe the infant during treatment
 A fretful cry with fingers in the mouth and flexed, tense extremities signals that the baby is
hungry
 A fretful cry accompanied by green stool and passage of gas could be to indigestion
 A loud, insistent cry with legs flexed at the knees and drawn to the abdomen signifies gas pains
or colic
 A whining cry signifies that the baby is ill, premature or very weak
 A high shrill cry signifies injury to the nervous system and increased intracranial pressure

Taking the baby out of the house

1. When taking the baby out of the house, the following baby’s items should be packed:
- extra clothing, diapers, diaper wipes, plastic storage bag, pacifier, hat, towel or cloth diaper, formula,
and bottles.

Infant Safety
Cribs, infant seats, child car safety seats, strollers, baby bathtub

Signs of illness
a. sleepiness
b. dry hot skin, sweating and flushed complexion
c. poor appetite
d. noisy respiration
e. excessive mucus
f. diarrhea, unusual color or stool
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g. chest retraction
h. cyanosis
i. convulsions

Infant Nutrition
Definition of Terms
1. Nutrition – the study of food in relation to health.
2. Nutrient – is a chemical component needed by the body to provide energy, to build and repair body
tissues and to regulate life processes.
3. food – is any substance which when ingested by the body and provide nutrient for growth and
maintenance of life
4. Minimum daily requirement – is the least amount of nutrient needed by the person to attain good
health
5. Recommended Daily allowance – is the minimum daily requirement plus an additional amount for
consideration to individual’s variations in body storage of nutrients, state of health, nutrient utilization,
etc
5. Metabolism – is the process by which the body utilizes food or the different nutrients derived from
food
6. Nutritional status – is the condition or status of the body resulting from utilization of nutrients.

Fluids
1. the daily fluid consumption of an infant is equivalent to 10% to 15% of his body weight
2. Infants have higher metabolic rate than adults so they need more water. Inability of the urine to
concentrate urine because of immaturity and increased metabolic rate result in increased urinary
output. Infants have more extracellular fluid than adult.
Dehydration – when water loss is over 10% of the total body water
Manifestations:
- thirst
- dryness of skin
- hemoconcentration
- decreased urine output
- impaired kidney function
- high specific gravity of urine
- acidosis, oliguria, uremia, death

Overhydration – occurs when water intake is greatly increased or too much fluid is given intravenously
Manifestations
- cramps
- water intoxication
- headache
- convulsions
- edema
- circulatory failure

Calories
1. Calorie refers to the energy content of food, or the unit of energy of food. Metabolism of food creates
heat and heat is utilized by the body as energy to perform its different functions in order to maintain
life.
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2. Infancy is the period of most rapid growth. Deficiency in calorie results in stunting and loss of weight
while excess leads to obesity

Protein
1. the main function of protein is for repair and building of body tissues. As an important component of
body fluids, enzymes, hormones and antibodies, it also regulates different processes in the body to
maintain life.
2. Because of rapid growth, infants need more protein than adults. The recommended protein intake of
infant during the first 6 months is 2.2 gm/kg and 2.0 gm/kg during the next six months. The need for
protein declines during preschool and school age years due to slowing of growth rate. It increases during
infections, periods of rapid growth, pregnancy, lactation, aging and injury.
3. Human milk has 1.2 gm/100ml of protein and cow’s milk has three times protein than human milk.
This high protein content of cow’s milk may not be tolerated well by the infant’s immature kidney.
4. Protein sources include : milk, meat, chicken, fish, peanut butter, foods containing milk (yogurt and
cheese), nuts and beans.

Fats
Important functions:
a. concentrated source of energy as one gram of it provides 9 kcal.
b. largest storage form of potential energy
c. fat surrounding organs act as protective pad and provide support
d. fat under the skin conserves heat in the body by preventing rapid heat loss
e. spares protein and carbohydrates
f. carrier of fat soluble vitamins

Carbohydrates
Functions:
a. main and cheap source of energy
b. lactose also acts as laxative
c. protein sparer
d. regulator of fat metabolism
e. only source of energy for brain and nerve tissues

Water Soluble Vitamins

Vitamin C
Breastmilk content of Vitamin C is only 22 mg per 750 ml and the infant RDA is 40-50 mg, thus
supplementation of ascorbic acid is given.

Vitamin B12
Breastmilk generally meets the newborn’s requirements for vitamin B12 if the mother’s diet is
adequate. Breastfed infants of vegetarian mothers are most likely to be deficient in Vitamin B12

Vitamin B6 or Pyridoxine
Infants requirement for Vitamin B6 during the first four to six months of age can be met by breastmilk.

Fat Soluble Vitamins

Vitamin A
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Vitamin A is a generic term for a group of retinoids with similar biological activity. The term includes
retinal, retinol, retinoic acid and substances considered to be pro-vitamin A because they can be
transformed into retinol.
After birth vitamin A is transferred to the infant through human milk. Infants have higher vitamin A
requirements during periods of infection.

Vitamin D
Vitamin D is synthesized in the skin and may be obtained from the diet. The most important function of
Vitamin D is related to calcium and phosphate metabolism. Vitamin D concentration in human milk
depend on maternal vitamin D status. Human milk contains very low levels of vitamin D.

Vitamin K
The newborn’s intestine is sterile at birth. This is the main reason why Aquamephyton is given to all
newborn at birth. After 2 to 3 days, the infant’s intestine acquire the bacteria that synthesizes vitamin K.

Minerals
1. Iron – human milk is a poor source of iron even if the mother receives iron supplementation. Iron
stores of the infant is enough to supply his iron requirements.
2. Calcium and Phosphorus - because of rapid growth, including the bones, during infancy, RDA for
phosphorus and calcium is high. Calcium content of human milk is fairly constant throughout lactation
and is not influenced by maternal diet. The calcium requirement of infant is met by breastmilk if
exclusive breastfeeding.

Methods of Feeding the Infant

A. Breastfeeding
1. Breastfeeding directly from the breast
2. Breastfeeding baby breast milk – expressed

B. Artificial Feeding, Bottle Feeding or Formula Feeding

Artificial or bottle feeding refers to the use of bottles for feeding the infant.

C. Mixed Feeding
Mixed feeding is when the baby receives both breastfeeding and bottle feeding.
a. supplemental – when a bottle is substituted for a breast
b. complemental – when a bottle is given after the breast to complete the feeding

Feeding Schedules
1. demand feeding- feeding infant whenever the infant signals readiness or desire to be nursed
2. Scheduled Feedings – feeding infant at scheduled intervals of 2 to 4 hours

Physiology of breastmilk production

Breast structures involved in lactation
Acini cells- milk producing cells
Lactiferous ducts – the passage way of milk
Lactiferous sinus (milk pockets) – dilated portion of the ducts located just behind the nipple that serves
as storage areas of milk
Prolactin – stimulates the acini cells to produce milk
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Oxytocin – causes contraction of the thin muscle layer surrounding the acini cells and the storage areas
of milk to express the milk out, which is called let down reflex.

Milk Secretion reflex – when the baby sucks, specific nerve ending in the nipple send message to the
anterior pituitary gland to release prolactin. This hormone stimulates the acini cells to produce milk.

Types of breast milk

1. colostrum – thick, yellowish substance secreted by the breast during the first 5 days after delivery
2. transitional milk – produced from about 6 th to the 14th day after delivery which is a combination of
mature milk and colostrum
3. Mature milk – the human milk that is produced during lactation, thinner than colostrum but contains
all the nutrients needed by the infant in right amount
4. Preterm milk – type of milk produced by a mother who delivered a preterm infant

Advantages of breastfeeding
1. nutritional benefits – best milk for baby as it is designed by nature to meet the needs of the human
infant during the first half year of life.
2. immunologic benefits – has lactobacillus acidophilus which prevents the growth of bacteria that
causes diarrhea.
3. bonding
4. practicality
5. contraceptive effect
6. beneficial to mother’s figure
7. dental development
8. hypoallergenic

Contraindications to breastfeeding
1. Infections – active tuberculosis, advance heart disease, HIV infection, hepatitis infection, active herpes
lesions on the breast
2. psychosis
3. use of drugs that are passed to the breastmilk
4. maternal substance abuse
5. maternal therapy
6. chronic disease such as diabetes and thyroid disorder
7. pregnancy
8. severe malnutrition

Infant condition
1. cleft lip and palate
2. facial paralysis
3. Galactosemia, phenylketonuria, lactose intolerance

Problems associated with breastfeeding

1. engorgement – characterized by hard, swollen and very painful breasts
2. sore nipples – sore or cracked nipples are very painful and can be caused by incorrect positioning of
the baby’s mouth over the nipple and areola, breastfeeding too long, improper way of detaching baby
from nipple after feeding.
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3. plugged milk ducts – a-tender-to=the-touch lump anywhere on the breast or in the underarm area
usually indicates plugged milk ducts. Plugged ducts occur usually if the breast is not adequately drained
during breastfeeding.
4. Breast pain – if breast pain
Occurs when the baby starts nursing, it is a normal sign that the body is releasing milk. Application of
warm or cold compress in between feedings often helps to relieve discomfort.

Bottle Feeding
Infant formulas – different types of formulas can substitute breastmilk.
Specific types of infant formula include:
a. standard milk-based formulas
b. soy protein formulas
c. formulas for premature infants
d. formulas for infants with metabolism problems

Signs of a well-fed baby

1. steady weight gain of 150 to 240 g a week
2. normal growth and development pattern
3. is happy, active and contented when awake
4. regular and undisturbed sleep
5. has normal bowel movements and elimination

Introduction of solid foods

Indicators of readiness for solid food
1. Infants are physiologically ready to eat solid foods when:
The extrusion reflex has disappeared
Infant show readiness to chew when objects are brought to their mouth
Swallowing reflex is sufficiently coordinated so they do not choke when they swallow solid foods
The gastrointestinal system has matured enough so that solid foods can be eaten without the danger of
allergy
Breastmilk or formula milk can no longer supply the needed nutrients of the infant, this is usually around
4-6 months.
2. infants are developmentally ready when:
They can balance their head well
They can sit alone
They can turn away from foods that they disliked or when they are already satisfied
Teeth eruption has begun to facilitate chewing and biting

Sequence of introduction of solid foods

1. cereals
2. fruits and vegetables
3. meat
4. fish
5. egg yolk and cheese that do not contain excessive sodium
6. desserts and sweets

Guideline when introducing solid foods

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1. introduce one food at a time with an interval of several days to identify foods that are allergic to the
infants and to accustom the infant to the taste and texture of food.
2. Use a very small spoon to feed solid foods
3. start with small servings, 1-2 tsp. increase serving gradually on the next feedings
4. Introduce food first in the same position as when it is infant is nursed except the head and the
shoulders should be slightly elevated
5. do not mix new foods with the formula or milk
6. introduce foods before milk is given
7. the infant should be allowed to touch the food
8. If the infant refuses a certain kind of food, do not coax or encourage the infant
9. place food at the back of the tongue
10. foods prepared at home should not contain salt or sugar and other additives
11. always prepare infant foods with fresh fruits and vegetables, meat and other ingredients, clean
hands and utensils
12. follow the 2-hour rule – once opened, do not leave baby foods or liquids at room temperature for
more than 2 hours.
13. avoid serving foods that may choke an infant.

Weaning
Weaning is when the infant ceases to feed from the breast or bottle and begins to drink from a cup.

Common problems related to nutrition

1. diarrhea
Acute, chronic (more than 7 days), intractable ( more than 2 weeks)
Causes – bacteria and viruses, excessive sugar, early feeding of starch
Management – fluid replacement to prevent dehydration
Vomiting
Causes – regurgitation and spitting-up of 5-10 ml of milk is normal up to six months because of
immaturity of the cardiac sphincter, associated with intestinal obstruction, increased intracranial
pressure, infection

Food Sensitivity – adverse reactions to food such as cow’s milk, wheats, eggs, citrus fruits and soybeans
Symptoms – diarrhea, vomiting, abdominal pain, wheezing, rhinitis, otitis media, rash, itching, eczema
and even sleeplessness

Constipation –breastfed infants under 1 year seldom experience constipation

Colic – production and accumulation of excess gas causes abdominal distention resulting in paroxysmal
cramps.