New born, infant and toddler

1
 Objectives
At the end of this lecture the student will be able to:
1 Define neonatal period
2 Explain neonatal adaptation to extra uterine
environment
3 Describe normal and abnormal finding of physical
assessment
4 List prevention measures of Suden Infant Death
Syndrom(SIDS).
5 Identify neonatal reflex
6 Enumerate nursing care for new born infant.
 Out Line
1-Definition of neonatal period
2- Neonatal adaptation
3- Assessment of newborn
- Physical assessment of the newborn:-
• General measurement.
• Vital signs.
• Head-to-toe assessment
4- Sudden Infant Death Syndrome (SIDS).
5- Nursing care for new born infant
 NEONATAL ADAPTATION
-The neonatal period is the period from birth to
age of 28 days.
Neonatal adaptation
-It is physiologic and behavioral changes during the
first 24 hrs. after delivery which the neonate makes
the transition from the intrauterine to extra uterine
environment.
Type:
a. Immediate adjustments
- Respiratory system
- Circulatory system
b. Physiologic status of other system
 a- Immediate adjustments

Respiratory system
1- At the first breath the air must rapidly
replace lung fluid. Normally, the neonate
breathes within 20 sec of delivery.
2-Surfactant decreases the surface tension of
lung, and prevents alveolar collapse.
3-Breathing stimuli
- Asphyxia, heat loss, tactile stimulation, pain,
bright lights, stimulate the medullary respiratory
center and diaphragmatic contraction.
Cardiovascular system
-Fetal circulation must convert to neonatal
circulation during the transitional period.
- Some factors as crying, stress in NICU may •
increase the pressure to the right atrium that
passes the unoxygenated blood to left atrium
from opened shunt.
* Blood volume
Neonate - full term 80 to 85 ml/kg
- preterm 90 to 105 ml/kg
* N.B. Depend on the amount of blood from placenta
 Superior
vena cava Aorta
Aorta
Ductus arteriosus
Lung Lung
Foramen
oval
Liver
Ductus
venosus
Gut
Umbilical vein

Umbilical
arteries
Normal Fetal Circulation
Normal Fetal Circulation
 Foramen ovale
functional closure soon after birth. and
anatomical closure within several months
(1st year)
Ductus arterioses
Functional closure in about 4 days after birth
and anatomical closure within 3-4 weeks.
Ductus venosus
function closure immediately after clamping the
cord and anatomical closure by 1-2 week.
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 Hematopoietic system
1 RBCs
- Fetal RBCs life span is 90 days
- Full term neonate life span is 60-70 day
- preterm ---------------35- 50 days
So neonates babies may have physiological
anemia.
Hepatic system
Liver excretes the conjugated bilirubin in
the urine and stool.
* Neonates have high risk for haemorrage
because lack the bacterial action in GIT to
synthesize adequate vitamin K. vitamin K
catalyzes synthesis of prothrombin by liver
to activate four coagulation factor (II, VII,
IX, X). Vitamin K is produced in the
intestine by bacteria.
 Fluid and Electrolytes
• Newborn body weight is 73% fluid (adult is 58%
fluid).
• Infant has higher ratio of extracellular fluid than
adult.
• Acid forms very quickly, leading to rapid
development of acidosis.
• Immature kidneys cannot concentrate urine to
conserve body fluid.

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Gastrointestinal system
vGastric capacity is 40-60 ml on the 1st day
after birth and increased by feeding.
vMany neonates regurgitate a small amount of
ingested water 1-2 ml after feeding because of
an immature cardiac sphincter (a muscular ring
constricting the esophagus).
v Enzyme deficiencies limit absorption of
carbohydrates and fats.
v The first stool is meconium, dark green odorless
fetal substance consisting of amniotic fluid, bile
and epithelial cell. Neonate passes the first
meconium within 24 hrs of birth.
 Assessment of newborn
- assessment of newborn following delivery
can be divided into four phases:
1. The initial assessment using the Apgar
scoring system.
2. Transitional assessment during the
period of reactivity.
3. Assessment of gestational age.
4. Systematic physical assessment.
 Physical assessment of the newborn
Physical assessment of the newborn:-
• General measurement.
• Vital signs.
• Head-to-toe assessment: Skin, Head, Eyes.
Ears, Nose, mouth and throat, neck, chest,
lunge, heart, abdomen, female male
genitalia , extremities,…..etc.
 **weight
-Normal birth weight: 2500- 4000gm.
-Loss 5 -10 % of birth weight in the first week
-Gain 30 gm daily during neonatal period

Length
Range: 46 - 54 cm.
- growth 2.5cm per month for first 6 months.
Head circumference Range: 35 - 37 cm
-2cm greater than chest circumference
Chest circumference Range: 33 – 35 cm
 Vital sign
Pulse: 120-160 b/min
-80/minute relaxed, sleeping babies.
-180/minute during activity.
Blood pressure.
-The range is wide and varies with both weight and
gestational age. 70/50 mm Hg (At birth), 80/55
mmHg (by the fourth day ).
Respiration: 35- 59 br⁄min
The breathing of newborns is almost entirely
diaphragmatic
Temperature: 36.5- 37.5 c
Head
- Round, symmetric, soft and
moves easy.
**Head molding
During a head first birth,
pressure on the head caused by
the tight birth canal may 'mold'
the head into an oblong rather
than round shape. Newborn
head molding is a common
occurrence that usually
disappears after a few days.
 Head trauma
Caput succedaneum:
The swelling area accumulated in the tissue
above the bone and extends beyond the
bone margins(suture lines). No specific
treatment is needed and will subside within
the few days.
Cephalhematoma is formed when blood
vessel rupture during labor to produce
bleeding into the area between the bone and
its periosteum. It doesn’t extend beyond the
bone margins(suture lines). Complicated
cephalhematoma needs treatment, it
absorbed within 2 weeks to 3 months. 19
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**Fontanelles
Anterior Fontanelles:
2-3 cm wide and 3-4cm long
(diamond shape) and
closed at 12-18 month.
Posterior Fontanelles:
1-2 cm at birth( triangle shape)
and closed 8- 12 weeks.
- Moderate bulging with crying,
stooling and pulsation with heart
beat.
- Overlapping of anterior fontanel
(malnourished, preterm baby )
- Moderate or sever pulsation( vascular
problems ).
- Bulging ( increase intracranial hemorrhage
and meningitis ).
- Sunken ( dehydration ).
Abdomen
-Slight prominence of the abdomen is a
normal feature of the newborn.
-umbilical cord dries and sloughs 6th-10th
day, has two arteries and one vein.
Skin (color)
Pale pink skin of a term
infant

Thin, transparent skin in

preterm infants

Wrinkled peeling skin of

dysmaturity in an IUGR
infant
New born infant with marked New born infant with
jaundice marked central cyanosis
-Mongolian spots: Bluish areas of pigmentation over
the back and buttocks, occasionally elsewhere,
unknown cause, presented in 80% of oriental
newborn infants, and disappear within 1-2 y.
- Milia: Small yellowish white papules over the
nose and face.
-Vernix caseosa: Greasy whitish material over
body. It is decreasing in amount as term
approaches.
Reflexes
- Protective reflex ( blink, gag, sneeze )

- Feeding reflex ( rooting, sucking, gagging and

swallowing ).

- Neurological reflex ( moro, tonic neck , )

MORO REFLEX( startle)

We can do it by Dropping the head,

Making a loud noise near the baby’s
ear, Withdrawal of blankets
underneath the infant THE
RESPONSE: Abduction of the arms
at the shoulders and extension of
the forearm at the elbow. the hands
and fingers are held wide open. A
vigorous cry follows these
movements.
- Disappear at 4-5 months
Tonic neck reflex:
Placing the infant in a supine
position. Lateral rotation of the
head to one side

extension of the arm and leg towards

which the head is turned
+ flexion of the limbs on the
opposite side.
-Absence of the reflex spinal cord and
cerebral disease
- Disappears at 2-3 months
Sudden Infant Death Syndrome
•Sudden Infant Death Syndrome (crib
death) the sudden death of an infant,
usually under 1 year of age, which
remains unexplained after a complete
investigation.
Position of sleep/prevent SIDS
• Back or side to sleep
•no excessive blankets in bed, don’t
cover head
 Nursing care of the newborn
1- Maintain a patent airway:
- Initiation of breathing and resuscitation-
- Early asphyxia identification and
management
• Proper position of sleep/prevent SIDS
2- Maintain stable body temperature
• Prevent all methods of heat loss or heat gain
3 Provide optimal nutrition
4 Immunization
5- Protect from infection and injuries:
- Eye and cord care care, no tub baths until cord
off and healed, sponge bath in the 1st two
weeks, fold diapers away from umbilicus
- NEVER leave child alone in tub!!
6Promote parent-infant bonding (attachment)
Skin-to-skin contact first few hours after birth
promotes bonding and enables early breast
feeding.
7 Prepare for discharge and home care
(Feeding, circumcision, cord and eye care,
newborn screening,..etc).
Outlines:
1. Biologic development
1. Proportional changes
2. Maturation of system
3. Teething
4. Fine and gross motor development
5. Locomotion development
6. Language

Promoting optimum health during infancy

Objectives
1. State biologic development and
proportional changes.
2. Discuss maturation of systems
3. List fine and gross motor development
4. List health promotion during infancy
• Biologic development
qFine and gross motor skills occurs in an orderly
cephalocaudal and proximodistal sequence.
qRapid growth especially 1st 6 months
1. Proportional change
Weight:
At the first 6
months

- Infants gain 680g/month until 5 month

- Double birth weight at 5-6 months
- Average weight at six month is 7.26 kg
At the 2nd 6
months
- Triple birth weight by one year
- Average weight at 1 year is 9.75 kg
• Height:
• It is sudden spurts rather than slow gradual pattern
• It occurs in the trunk rather than legs
At the first 6
months

- Height increases 2.5cm/month until 6 month

- Average height at six month is 65 cm
At the 2nd 6
months

- Height increases 1.25cm/month until 12 month

- Average height at 1 year is 74 cm.
• Head: it is rapid growth
At the first 6
months

- H.C increases 1.5cm/month

- Average size at six month is 43 cm.
- Posterior fontanel closed at 6-8 weeks of age.
At the 2nd 6
months

- H.C increases 0.5cm/month

- Average size at 1 year is 46 cm (33%).
- Anterior fontanel closed by 12-18 months of age.
- Chest circumference:
- The chest circumference approximately equals head
circumference by the end of 1st year.
• System maturation:
• RR: 30-50 br/m.
(respiratory rate slows than previous stage with
abdominal movement).
- Several factors predispose the infant to more severe &
acute respiratory problems:
1. The close proximity of trachea to bronchial transmits
infection from one location to another rapidly
2. Small airway easily blocked with secretion or particles
3. The short, straight Eustachian tube closely communicate
with the ear, allowing ascending infection from the pharynx to
the middle ear.
4. Low immunity (IgA in mucosal lining) of the child.
•System maturation:
•HR: 70 b/m. (asleep) to 150 (awake) by apical
pulse.
•(heart rate slows than previous stage and the
rhythm is often sinus arrhythmia which the rate
increases with inspiration and decreases with
expiration).
•B.P: 85/60 mmHg.
Systolic pressure increase at 1st 2mo. & diastolic
pressure decrease at 1st 3mo.
•The digestive process
•relatively immature GIT low amount of enzymes
are secreted until 4 to 6 months as
*amylase (ptyalin) acts on complex carbohydrates
but it effects food stuffs
*lipase acts on fat
*trypsin acts on protein and is sufficient at birth.
*Hydrochloric acid and rennin enzymes acts on
casein to formulate curds to retain milk in the
stomach for digestion.
-breast milk compensate deficiency of gastric
enzyme activity that help infant to receive optimal
nutrition.
•Teething eruption
- Eruption of deciduous/primary teeth is started
between 6-8 months of age.
- Deciduous teeth (20) are completed by 2.5-3
years.
- Formula is used to calculate number of teething
- number of teeth= age of child in month-6
- teething is normal process of development and
doesn’t respiratory problems and fever,…..etc.
- physiologic process with teething such as
drooling, increase finger sucking, bitting on hard
object or mother’s nipple, irritability, mild
elevation of temperature & decrease appetite.
 Motor Development
Fine motor Gross motor

• Grasps object, age 2 to 3 months• Head control

• Transfers object between hands,• Rolls over—age 5 to 6
age 7 months months

• Pincer grasp, age 10 months • Sits alone—age 7

months
• Removes objects from
• Moves from prone to
container, age 11 months
sitting position—age
• Builds tower of two blocks, age 10 months
12 months
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 Locomotion
• Cephalocaudal direction of
development
• Crawling—age 6 to 7 months
• Creeping—age 9 months
• Walk with assist—age 11
months
• Walk alone—age 12 months

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Language

• Crying is first verbal communication

• Vocalizations
– Coo, gurgles, and laugh by 4 months
– Imitative sounds by 6 months
– Understand the word ―NOǁby 9 months
– Combine syllables by 10 to 11 months
– Three to five words with meaning by age 1
year
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Needs of infants
1- warmth & comfort
2-sleep
3- Feeding
4- Sensory stimulation & sucking pleasures
5- Love & security
Health promotion:
1- nutrition (breast feeding + weaning)
2- sleep and activity 9-11 or 11-15 hrs/24 hr with
1-2 naps , average 15 hrs
3 dental health
4 immunization
5 injury prevention
Growth and development of
Toddler (1-3 years)
Outlines :-
1. Biologic development
1 proportional changes (wt, Ht, H.C,
C.C, teething…..)
2 sensory changes
3 maturation of system
4 fine and gross motor development
2 language development
3 Personality traits of toddler
4 Red flags in toddler child development
5 care of toddler
objectives:-
1 identify biologic development and
proportional changes.
2 discuss maturation of systems
3list fine and gross motor development
4- explain personality traits of toddler
5 identify red flag for toddler child
6 Recognize readiness for toilet training
Toddler ( 1-3 years):
-Terrible two s is term used to describe toddler
years because it is a time of intensive exploration of
environment so toddler child attempts to find out
how things work and how to control others through
temper tantrum, negativism,……..etc.
-it is an important period for intellectual growth
and development.
• Biologic development
- Slow physical growth, steady growth curve (step pattern
rather than straight linear pattern).
1- Proportional change
Weight:
- Quadruple birth weight by 2.5years.
- child gains 1.8 to 2,7 kg/year.
- Weight calculation formula :- Wt = age x 2 + 8
Height:
- It occurs in elongation of legs rather than the trunk.
- Height increases 7.5cm/year.
- Average height at 2 years is 86.6 cm.( adult height is twice
two years height).
- Height calculation formula :- Ht = age x 5 + 80
v -***The toddler retains a squat, ‘ pot bellied’
appearance because of the less developed
abdominal musculature ( prominent abdomen) and
short legs.
-The legs retain a slightly bowed or curved appearance
during the second year from the weight of large
trunk So they walk with unsteady gait.

Neurobehavioral organization:
- Rapid growth of neurobehavioral organization.

-Brain size developed 90% of brain adult size.

 Maturation of Systems
• Most physiologic systems relatively mature by
the end of toddlerhood
• Upper respiratory infections, otitis media, and
tonsillitis are common among toddlers
• Voluntary control of elimination
– Sphincter control age 18 to 24 months
* bladder control at day during 2-3 years
* bladder control at night during 3-5
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Gross and Fine Motor Development
-Improved coordination between ages 2 and 3
-Fine motor development
-Throw ball by age 18 months
Language
– Increasing level of comprehension
– Increasing ability to understand
–More than 300 words in vocabulary by
age 2
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Personality traits (Character of independent)
-Negativism
•-Ritualistic behavior
•-Temper tantrum
•-Slowly to carry out request
Negativism:
- It is the persistent negative response to request
by using word no. it is not an expression of being
stubborn or insolent but a necessary assertion of
self control.
Management:-
1 reduce questions that increase opportunity for a
no answer ( do you want to go sleep? but say that
it is a time to go to sleep)
2 enhance choice pattern ( you may have meat or
chicken).
Ritualistic behavior:
It is doing certain action in ritual manner in
several times to provide a sense of comfort.
** traditional objects such as doll, toys,
blanket, a warm and fuzzy stuffed animal are
sources of security
Temper tantrums:
It is universal during toddler period when they
can’t able to control their emotions, child may
assert their independence by violently action ( lie
down on the floor, kick their feet, hold one breath
so child may liable for fainting but the
accumulation of carbon dioxide will stimulate the
respiratory control center so there is no physical
harm…….).
Management
1 ignore this behavior
2 offer the child options
2- praise and encourage acceptable behavior
 Red flags in toddler child development
1- unable to walk alone at 18 months.
2- failure to speak at 2 years.
3abnormal pincer grasp at 15 months.
4- delay bowel control till after 2 years.
Needs of toddler
1 love and security
2 graded independence
3 control body functioning ( bowel and bladder
control).
4 learning language
 Care of toddler
1 Brushing the teeth
2Clothing should be light bright color
3-Freedom to play
4 Sleep ( 12-14 hrs/day and 1-2 naps)
5Safety measures (accident prevention)
6- immunization
7- nutrition(Toddlers enjoy doing things
independently so they enjoy finger foods. Fast
foods are tasty but also exceptionally high in fat
and salt so it should be avoided)
Assessing Readiness for Toilet Training
• Voluntary sphincter control
• Able to stay dry for 2 hr
• Fine motor skills to remove clothing
• Willingness to please parents
• Curiosity about adult’s or sibling’s
toilet habits
• Impatient with wet or soiled diapers
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