PEDIATRIC

Priorities of the Newborn in the First Day of Life

1. Initiation and maintenance of respiration
2. Establishment of extrauterine circulation.
3. Maintaining fluid & electrolytes balance
4. Regulating temperature
5. Establishing adequate nutritional intake
6. Establishing waste elimination
7. Preventing infection
8. Identification and registration

Initiation and Maintenance of Respiration

1. Position: drain secretion
- Trendelenburg: NSD
- CI: increase ICP
- Side-lying: CS
2. Removal of secretions: wiping the mouth going to the nose ( nasal breather)
3. Suctioning: gentle & intermittent
- not more than 5 secs. (hypoxia)
- side of the mouth
4. Stimulate crying: breathing
- Normal: loud, lusty cry

Abnormal Cry:
- High-pitched: increase ICP/ hypoglycemia
- Weak cry: pre-mature
- Hoarse cry: laryngeal stridor
- Grunting respiration: RDS
- Unable to initiate/ maintain: asphyxia

Establishing Extrauterine Circulation:

- initiate: if with lung expansion
- complete: cord is cut
1. Umbilical vein & ductus venosus constrict after cord is clamped
2. Foramen ovale closes as respirations are established, as well as ductus arteriosus
3. Closure of the ductus arteriosus, foramen ovale, ducuts venosus.
- open for more than a month: congenital heart defect

Cutting of the Cord:

1. 9 inches above umbilicus
2. Dry dressing (prevent infection)
3. Sponge bath only rather than tub bath
4. Tub bath: when cord falls off (within 7-14 days)

Fetal Circulation

Placenta Umbilical vein Ductus Venosus Right Atrium Foramen Ovale (opening)
(opening)
Left Atrium

Right Atrium Ductus Arteriosus Aorta

(opening)
Systemic
 Circulation

Maintaining Fluid & Electolyte:

- Once the baby comes out: fluid loss starts (evaporation)
- Once the baby breathes: fluid loss starts
- Monitor I & O
- normal: 20cc/ hour
- Normal physiologic loss: 10 to 15%; 1 to 2 weeks

Temperature Regulation:
- 2 to 3ºC derease
- Temperature center: inactive
- Body fat
- Brown fat: insulation metabolic acidosis

Cause of Decrease Temperature:

1. Baby is born wet: evaporation
2. Inability to shiver: cold stress
3. Inadequate SQ tissue/ body fat
4. Born Poikilothermic: they copy the temperature of the environment (convection & radiation)

Prevention of Cold Stress:

1. Dry & wrapped the newborn
2. Mechanical measures
a. Radiant warmer
b. Isolette
3. Prevent unnecessarry exposure
4. Use tin foil in absence of electricity
5. Embrace the baby

Effects of Decrease Temperature:

1. Hypoglycemia:
- Normal: 45 mg/ dl
2. Hypoxia: due to cold stress
3. Metabolic acidosis: catabolism of brown fat
4. Increase bilirubin (destroy brain) in the brain: Kernicterus
5. Stressful for the heart:
- Tachycardia: sign of respiratory distress

Establish Adequate Nutritional Intake:

- Advantage: nutrients/ antibodies
- Disadvantage:
a. medication
b. AIDS/ HIV (+)
- Hormone: prolactin- stimulate breast milk production
- Feed:
a. ASAP: NSD
b. after 4 hours: CS

Stages of Breastmilk Production:

1. Colostrum:
- 2nd to 3rd day post partum
- CHON, sugar, fat, water, vitamin, minerals & maternal antibodies (IgA)
2. Transitional milk: 4th to 5th day
3. Mature milk: 10th day & days after
- Breastmilk: at 2-3 hours of birth
1. stored within 24 hours inside the refrigerator
2. stored in a freezer 30 days
3. stored in a deep freezer for 6 mos.
- Bottle feeding: at 3-4 hours

Health Teaching:
- Wash hands befor & after every breastfeeding
- Wash breasts daily at bath & shower time
- Soap & alcohol should never be used on the breasts

Establishing of Waste Elimination:

- GIT: sterile after birth (within 5 hours)
- Expose: mouth, hands & bed linens
1. Meconium: within 24 hours
- greenish black sticky/ tar like
2. Transitional: 2nd to 10th day
- greenish brown/ loose consistency (diarrhea like)
3. Breastfed stools: bright yellow/ sweet smelling
4. Bottlefed stools: pale to light yellow/ odorous
5. With supplementary foods stool: brown and odorous
6. Clay colored: bile duct obstruction
7. Black/ tarry: intestinal bleeding
8. Watery (with stool): milk allergy
9. Bright green: phototherapy

Prevention of Infection:
1. Crede's Prophylaxis: Put it after the mother has seen the baby
a. Erythromycon opthalmic ointment
b. Terramycin
c. Penicillin
d. 2 drops of 1% Silver Nitrate
- prevent opthalmia neonatorun & gonorrheal conjunctivitis result to blindness
- can stain skin or cause redness of the eyes
- Health teaching: wash with NSS
2. Administration of Vit. K
- normal baby: Vit. K is absent
- prevent intracranial bleeding/ internal bleeding
- Risk for neonatal death (1st 48 hours of life)
- method: 0.5 to 1.0 mg within 48 hours of life
- site: lateral anterior thigh/ vastus lateralis

Immunization:
*HAAD
Age Vaccine
At birth - BCG
- Hepa B
End of 2, 4 & 6 months - Hexavalent:
a. Dtap
b. Hepa B
c. IPV
d. PCV 13 (Pneumococcal conjugate)
Enf the 6th month - OPV
End of the 12th month - MMR
 - Varicella
th
End of the 18 month - Tetravalent:
a. Dtap
b.Hib

Age Vaccine
Grade 1 - Dtap, MMR, OPV, Varicella
Grade 9 - Rubella (girls only)
Grade 11 - Dtap, OPV, HPV (girls only; 3 doses)

*NCLEX
Hepa B - Given at birth (within one week)
- Contraindication: Baker's yeast allergy
- If the mom (+) Hepa B, give Hepa B (Ig) to the baby
Dtap/ DPT - Given 2, 4 & 6 months
(Diptheria, Pertussis, Tetanus) - Adverse Effect: signs of Pertussis Allergy
a. seizures
b. fever (more than 100ºF)
c. inconsolable crying more than 3 hours
d. encephalopathy within 7 days
* If (+) give only DT
IPV: Salk vaccine - Contraindication: Neomycin & Streptomycin allergy
- Prevent: Pollo virus
Hib (Hepa B)- - Prevent:
a. Epiglotitis
b. Septicemia
c. Meningitis
Pneumococcal Vaccine 1. Measles only: 2. MMR: single dose
- 15 months - Contraindication
- Contraindication: a. Neomycin
a. allergy to eggs b. Gelatin
b. immunocompromise - SE: Rashes
- Adverse Effect: Notify MD
a. Athralgia
b. Joint pain
- Side Effects: Rashes
Varicella Vaccine - Given to less than 2 years old
- Contraindication: Neomycin & Gelatin
Flu Vaccine/ Influenza Vaccine - Given to more than 2 years old
- Prevent Pneumonia
- Given yearly or lifetime

Containdication to Immunization:
1. Moderate to severe illness with or without fever
2. Blood transfusion: wait 3 months
3. Immunoglobulins: wait 3 months
4. Immunocompromised
5. Severe allergic reaction

Identification & Registration:

1. Identification band
 2. Foot prints
3. Birth Registration

Assessment:
1. APGAR Scoring: asess the baby's adaptation to new environment
- 1st minute: general condition
- needs CPR
- Repeat after 5 minutes: adaptation
- mortality/ morbidity
- Heart rate: most sensitive
- Asphyxia: less than 100 bpm
- Respiratory disease: more than 150 bpm
- After 5 minutes: if APGAR score is low, continue after 5minutes
- After 10 minutes: increase mortality
- if APGAR score still low
- Components:
a. Appearrance (Color): pink/ pink & blue/ blue
b. Pulse Rate: apical pulse (left lower nipple)
c. Grimace: reflex irritability/ facial expression
d. Activity: degree of flexion
e. Respiration: cry (lusty/ weak)
- Evaluation:
a. 7 to 10: good/ healthy
b. 4 to 6: moderately depressed; needs oxygen supplement
c. 0 to 3: severely depressed; NICU/ CPR
- A Score of 9 means acrocyanosis (problem: color)
2. Silverman & Anderson Index: respiratory evaluation
- Criteria:
0 1 2
Chest Movement syncronized see-saw appearance lag
Intercostal Retraction none visible mark
Xiphoid Retraction none visible mark
Nares Dilation none visible mark
Expiratory Grunt none stethoscope audible
* If this complaint by the mother: See a doctor
- Interpretation of results:
a. 0 to 3: good healthy
b. 4 to 6: moderately distress
c. 7 to 10: severely distress

Ballard Scoring/ Dubowitz

- assess gestational & physical maturity
- more than 20 weeks infant
- done within 24 hours
1. Neuromuscular activity
- Assess:
- should be a wake
- in supine position
- done within 24 hours
a. Posture: position of hands & legs
- normal: flex
b. Square Window: degree of flexion of the hands to the wrist
- normal: 90º
- more than 90º: immature
c. Arm Recoil: arms spring/ recoil after pulling
 - normal: arms recoil
d. Popliteal Angle: extend knee then you will drop the knee
e. Scarf Sign: how far you can extend the elbow across the chest
f. Heel to Ear: how close is the heel to the ears
- normal: can't reach heel to ear)
2. Gestational Age: done within 2-3 hours
a. Skin:
- normal: pink & smooth
- abnormal: wrinkled, desquamated
b. Lanugo
- normal: fine downy hair
- abnormal: too much/ absent
c. Plantar Creases: absent/ too much
d. Breast: thick/ edematous
e. Eyes/ Ear
f. Genitalia:
- normal: edematous clitoris (female)
- normal: wrinkled scrotum (male)

Reflexes:
Description Disappear
Babinski - Stroke the outer side of his sole, he spreads his toes out 12 months
Extrusion - Newborn pushes tongue outward when tip of tongue is touched 4 months
with finger or nipple
- Ptotective reflex against airway obstruction
Palmar Grasp - Stroking the palm of the baby's hand causes the baby to close his/ 4 months
her fingers in a grasp
Plantar Grasp - Newborn's toes will curl downward when a finger is placed 8-9 months
against the base of the toes
Landau - Hold the infant face down horizontally. The baby's head will raise
up, while her trunk will be straight & her legs extended
- Also called Superman reflex
Moro's - Bilateral symmetrical extension & abduction of all extremities, 4 months
followed by adduction of extremities & return to relaxed flexion
when newborn's position changes suddenly
- Stimulated when equilibrium is loss
Startle - Same with Moro, stimulated thru sound 4 months
Parachute - If an infant falls, he will extend his arms to try & catch himself
- Lifetime
Rooting - If you touch a newborn on either side oh his mouth. He will turn in 4 months
direction of the touch
Stepping - When the soles of their feet touch a flat surface they will attempt to 4 months
walk
Tonic-neck/ Fencing - When a baby's head is turned to one side, the arm on that side 4 months
stretches out and the opposite arm bends up at the below
- Stimulate head control
Trunk Incurvation - If you stroke along the side of the newborn's spine while he is held
by your hand under his belly, he flexes his whole body to the side
that is stroked
Galant - Develops trunk curvature 4-6 months
Newborn Screening Test/ March of Dimes:
- Preventive tool: 30 disease + hearing impaired
- Detects congenital, genetic, hormonal & metabolic diseases: growth & mental retardation
- Method: heel prick
- Result: after 2 weeks
- Specimen: blood

Newborn:
- Weight: 3000- 3,400 grams/ 3-3.4 kg/ 6.5-7.5 lbs
a. low birth weigth: less than 2,500 grams
b. arbritrary limit: less than 2,000 grams

High Risk Newborn ( NEWBORN)

N- Nipple: prominent or edematous (normal)
E- Enlarged clitoris (female): normal
Edematous scrotum (male): normal
W- Witchmilk: excrete milk on normal nipples
- due to to increase hormones of the mom
B- Born with vernix caseosa: cheesy appearance
O- Observed lanugo: fine downy hair at the trunk, back and arms
R- Red to pink skin/ milia: white spots on the nose
N- Note: Harlequin sign
- a vasomotor response due to an immature circulation
- dependent body side: blue
- independent body side: pink
* Harlequin fetus: Report to MD
- seen after 2 days
- sign of septicemia

Pre-term: 37 weeks or less AOG (TERMA)

T- The creases are absent
E- Extensive lanugo hairs
R- Ruddy appearance (purplish)
- due to little SQ tissue
M- Mostly covered with vernix caseosa
A- Absent surfactant: RDS

Dysmature: small for gestational age (MATURE)

M- Muscle mass are thin
A- Abdomen is sunken
T- Ten percent less than: part of growth chart
U- Uterine growth retardation
R- Reduced SQ tissue
E- Episode of RDS
* Mother is:
- malnourish
- critically ill
* Babies: well in utero

Post-term: out after 42 weeks (OST)

- normal: 38 to 40 weeks
- problem is not the mother but the baby (placenta)
- placenta: oxygen/ nutrients; function ended on 40 weeks
O- Old man face appearance
S- Skin: wrinkled & desquamated
T- The eyes wide open
 Large for Gestational Age (LGA)
L- Largee weight: more than 400 grams/ more than 9 lbs
G- Gestational DM: mother
A- Assess for hypoglycemia
* Mother: macrocomia result to laceration
* Baby: shoulder dystocia

Failure to Thrive
- failure to gain weight
- less than 5% of the growth chart
- 2 Types of Failure to Thrive:
1. Organic: malabsorption (Celiac disease, cystic, fibrosis)
2. Non-organic: abandonement
- S/Sx:
sleep disturbances
rumination: recurrent expulsion of food in the mouth that they would absorb again
delayed growth & development
postures:
- child is stiff/ flappy
- resist cuddling
-Management:
1. Provide consistent care
2. Teach parents with feeding technique:
- quite environment
- encourage child during feeding
- face to face talk of the dead
3. Weigh the baby
4. Effectivity: increase weight