THE NEWBORN

A. The Profile of a Newborn:

Physiologic Function and Appearance
Objectives:
 Describe the normal characteristics of a term newborn.
 Use critical thinking to analyze ways that the care of a term newborn can be more family
centered.
 Assess a newborn for normal growth and development.
 Formulate nursing dx r/t NB or the family of the NB
 Identify expected outcomes for a NB and family during the first 4 weeks of life
 Plan nursing care to augment development of a NB, such as ways to aid parent-child bonding
 Implement nursing care of a NB
 Evaluate outcome criteria for achievement and effectiveness of care
 Identify areas r/t NB assessment and care that could benefit from additional nursing research/
application of evidenced-based practice
 Integrate knowledge of NB G and D and immediate care needs with the nursing process to
achieve quality maternal and child health nursing care.

Newborn
 A.k.a “neonate”
 Undergoes profound/ intense physiologic changes at the moment of
birth
 Sudden change of environment (from the uterine env’t to the
outside env’t)
 Newborns undergo profound physiologic changes at the moment
of birth (and, probably, psychological changes as well), as they are
released from a warm, snug, dark, liquid-filled environment that
has met all of their basic needs into a chilly, unbounded, brightly lit,
gravity-based, outside world. Within minutes after being plunged
into this strange environment, a newborn has to initiate respiration
and adapt a circulatory system to extrauterine oxygenation.
 Within 24H: complete functioning: Neurologic, renal, endocrine, GI, and metabolic sustain life

Neonatal Period
 From the time the child was born to his/her 28 days of life

National Health Goals dealt directly with the NB period:

 Increase of at least 75% the proportion of mothers who breastfeed their babies in the early postpartal
period from a baseline of 64%
 Increase to at least 50% the proportion of women who continue breastfeeding until their babies are 5-
6 months old from a baseline of 29%
 Increase to 70% the percentage of healthy full-term infants who are put to sleep on their backs from a
baseline of 35%.
 Increase to 60% from a baseline of 43% the number of women who breastfeed exclusively until their
infant is 3 months of age; from 13% to 25% for those who breastfeed exclusively until 6 months.
 Increase to at least 75% the proportion of parents and caregivers who use feeding practices that
prevent baby-bottle tooth decay.
 Reduce the neonatal mortality rate to no more than 2.9 per 1000 live births from a baseline of 4.8 per
1000 live births (http://www.nih.gov)
Benefits of Breastfeeding
 Best for baby, best for mommy - bonding
 Reduces the incidence of allergies - because all the contents of the breast milk are natural
 Economical - do not have to buy
  Antibodies to protect baby against infection
 IgA - binds to large molecules of proteins that keeps baby away from microorganisms attacking
the GI tract
 lactoferrin - is an iron-binding protein that is found in breast milk w/c interferes w/ the growth of
pathogenic bacteria more particularly w/ staphylococcus aureus and E. coli
 Lysozyme in breast - actively dissolves the cell wall of the bacteria making it more effective as
an antibody
 Leukocyte in breast milk - provides protection against common respiratory infectious agents; for
low birthweight infant I who suffered hypoxia during delivery, provide additional protection against
acute necrotizing enterocolitis
 Macrophage - engulf and digest certain bacteria through phagocytosis; helps destroy polio,
influenza and diphtheria
 Interferon - will protect neonate by interfering with the viral growth; interferon (a protein that
protects against viruses), help interfere with virus growth. The bifidus factor is a specific growth
promoting factor for the beneficial bacteria Lactobacillus bifidus. The presence of L. bifidus in
breast milk interferes with the colonization of pathogenic bacteria in the gastrointestinal tract,
reducing the incidence of diarrhea
 Sterile and Pure - always fresh and not need to be boiled
 Temperature is always ideal - resembles to temperature of the body of nsg mother
 Fresh milk never goes off - so long as there is continuous suckling of the nipple that there will be
continuous production of milk
 Prolactin - released from anterior pituitary gland and will stimulate the acini cells that is present in
the breast in order to produce milk also known as the “milk secretion reflex”
 Oxytocin - when nipples is suckled by neonate, it causes the contraction of myoepithelial cells
surrounding the milk glands w/c causes milk to flow towards the lactiferous sinuses or the
lactiferous ducts. Now this hormone is secreted from the posterior pituitary glands as the nipple
has been stimulated through suckling.
 Easy to prepare and to digest -
 Eradicates feeding difficulties -
 Develop mother and child bonding -
 Immediately available -
 Nutritionally optimal -
 Gastroenteritis greatly reduced -

Other Advantages of BF
 It contains ideal electrolytes and mineral composition for human infant growth
 It is high in lactose- an easily digested sugar (rapid brain growth)
 The ratio of cysteine to methionine in BM favors rapid brain growth in early months.
 It contains more linoleic acid- an essential acid for skin integrity
 It has less Na, K, Ca and P
 It has better balance of trace elements like Zn.
 BF helps prevent excessive weight gain in infants

Advantages for a Mother

 Serve a protective function in preventing breast cancer.
 Release of oxytocin from the posterior pituitary gland
aids in uterine involution.
 Successful BF can have an empowering effect, because
it is a skill only a woman can master.
 It reduces the cost of feeding and preparation time.
 It provides an excellent opportunity to enhance a true
symbiotic bond between mother and child.
Advantages for infant
 Women who have a familial history of allergy are usually encouraged to
breastfeed to try and eliminate the possibility of exposing their infant to
cow’s milk protein, which could be allergenic this early in life (Hampton,
2008).
 Decreased calcium levels in a newborn can lead to tetany (muscle
spasm). The increased concentration of fatty acid in commercial
formulas may bind calcium in the gastrointestinal tract, increasing the
danger of tetany. Breastfeeding may also help prevent excessive weight
gain in infants (Box 19.3).
 A great deal of discussion about the benefits of breastfeeding has
centered on the effects of breastfeeding on the formation of the dental
arch, because babies suck differently from a breast than from a bottle
(Fig. 19.2). Babies pull their tongue backward as they suck from a breast.
They thrust their tongue forward to suck from a rubber nipple. That may
make breastfeeding the best preparation for forming common speech
sounds (Ferguson & Molfese, 2007).

Nursing Responsibilities:
a) Beginning Breastfeeding- should begin soon after birth (woman is still in
the birthing room while infant is in the first reactivity period)
 Let-down reflex:
 Called as milk ejection reflex
 Continuous or spontaneous flow of milk due to oxytocin’s
action
 Oxytocin is released from the PPG as the NB infant sucks at the breasts causing the
collecting sinuses (lactiferous sinuses) of the mammary gland to contract milk moves
forward through the nipples.
 Oxytocin causes smooth muscle contraction (Uterine) prevents excessive bleeding; aids
in uterine involution
 Breastmilk Transition:
1. Colostrum: First 2 – 4 days:
 ↓ CHO, ↓ Fat, ↑ CHON, ↑ Fat-soluble vitamins
 thin, watery, yellow fluid composed of protein, sugar, fat minerals, vitamins and maternal
antibodies.easy to digest and capable of providing adequate nutrition
2. Transitional Milk: 4 – 14 days:
 ↑ lactose, ↑ minerals, ↑ water-soluble vitamins

3. Mature Milk:
 beyond 14th day:
 ↑ CHO, ↑ Fats, ↓ CHON
 New milk, called hind milk, is formed after the let-
down reflex. Hind milk, higher in fat than fore milk, is
the milk that makes a breastfed infant grow most
rapidly. Release of oxytocin has a second advantage
in that, by causing smooth muscle contraction, it
helps contract the uterus. As a result, a woman may
feel a small tugging or cramping in her lower pelvis
during the first few days of breastfeeding (afterpains)
(Pavone & Purinton, 2007).
 Techniques of breastfeeding
 Physical preparation such as nipple rolling,
advised in the past as a way of making a woman’s
nipples more protuberant, is not necessary
because few women have inverted or non
protuberant nipples. In addition, oxytocin, which is
released by this maneuver, could lead to preterm
labor (nipple rolling is used to create uterine
contractions for stress tests). The occasional
woman who has inverted nipples may need to
wear a nipple cup (a plastic shell) to help her
nipples become more protuberant.
 Practicing breast massage to move the milk
forward in the milk ducts (manual expression of
milk) may be helpful. This can help a woman who
feels hesitant about handling her breasts grow
accustomed to doing so, and allows her to assist
with milk production in the first few days after birth.
Manual expression consists of supporting the
breast firmly, then placing the thumb and forefinger on the opposite sides of the breast, just behind the
areolar margin, first pushing backward toward the chest wall and then downward until secretions
begins to flow (Box 19.4). During the last months of pregnancy and immediately after birth, the fluid
obtained will be colostrum. By the third day of infant life, milk will be obtained. Teach women to wash
their breasts with clear water because soap tends to dry and crack nipples.

b) Provide information regarding lactation and proper positioning

techniques. Cross - cradle hold, football hold,
 Breast milk looks like nonfat milk. It is thin and almost blue- laid back, side lying
tinged in appearance. Some women may need assurance that
this color and consistency are normal; otherwise, they may
think their milk is not nutritious enough.
 Before breastfeeding, recommend that a woman wash her
hands to be sure they are free of pathogens picked up from
handling perineal pads or other sources. Washing her breasts
is not necessary unless she notices caked colostrum on the
nipples. When she is first attempting to breastfeed, lying on her
side with a pillow under her head is a good position to use (Fig.
19.3). This relieves fatigue because it allows her infant to rest
on the bed.
 Shows a sitting position with a pillow under the
baby. Using a football hold with the baby
supported on a pillow also may be helpful,
especially if a mother had a cesarean birth.
 Brushing the infant’s cheek with a breast nipple
stimulates a newborn’s rooting reflex. The baby
then turns toward the breast. Do not try to initiate
a rooting reflex by pressing a baby’s face against
the mother’s breast; this will cause the child to
turn away from the mother and toward your hand.
 If a woman has large breasts, the infant may have
trouble breathing while nursing because breast
tissue presses against the nose. A woman can
prevent this happening by grasping the areolar
margin of her breast between her thumb and
forefinger, holding the bulk of the breast supported
while her infant feeds. This also makes the nipple
 more protuberant.
 During the first few days of life, because they are receiving only colostrum and need the nutrients
and fluid obtained by frequent sucking, babies should be fed as often as they seem hungry (every
2 to 3 hours). Frequent feeding also is advantageous to sustain a milk supply, because the more
often breasts are emptied, the more efficiently they fill and continue to maintain a good supply of
milk.
 As important as making certain that infants grasp the breast areola is helping them to break away
from the breast when they are through feeding. Teach a woman to insert a finger in the corner of
the infant’s mouth or pull down the infant’s chin to release suction. Otherwise, the baby may pull
too hard on the nipple, causing cracking or soreness.

 Before BF- mother performs handwashing

 REPUBLIC ACT No. 10028
 AN ACT EXPANDING THE PROMOTION OF BREASTFEEDING, AMENDING FOR
THE PURPOSE REPUBLIC ACT NO. 7600, OTHERWISE KNOWN AS “AN ACT
PROVIDING INCENTIVES TO ALL GOVERNMENT AND PRIVATE HEALTH
INSTITUTIONS WITH ROOMING-IN AND BREASTFEEDING PRACTICES AND FOR
OTHER PURPOSES”
 Be it enacted by the Senate and House of Representatives of the Philippines in Congress
assembled:
 Section 1. Short Title. – This Act shall be known as the “Expanded Breastfeeding
Promotion Act of 2009”.
 Section 2. Section 2 of Republic Act No. 7600 is hereby amended to read as follows:
 Sec. 2. Declaration of Policy. – The State adopts rooming-in as a national policy to
encourage, protect and support the practice of breastfeeding. It shall create an
environment where basic physical, emotional, and psychological needs of mothers and
infants are fulfilled through the practice of rooming-in and breastfeeding.
 Observe proper position when BF
c) Provide immediate support if problems arise
 When handled intelligently by health care personnel, the common
problems that arise with breastfeeding usually pass and seem
unimportant to a woman. Handled otherwise, they can complicate
breastfeeding and discourage a woman from continuing. It is
unfortunate when complications deter a woman from using the most
natural and least complicated of all infant feeding methods.
d) Provide information regarding techniques for burping the breast-fed baby
 It is helpful to burp NB after they have emptied the first breast and
again after the total feeding
  Placing the baby over one shoulder and gently patting or stroking the back; laying the baby prone
across the lap
 Placing the baby over one shoulder and gently patting or stroking the back is an acceptable
position. However, this position is not always satisfactory for a small infant, who has poor head
control. In addition, a parent may have difficulty supporting the baby’s head and patting the back
at the same time.
 Holding the baby in a sitting position on the lap, then leaning the child forward against one hand,
with the index finger and thumb supporting the head, is often the best position to use. This
position provides head support but leaves the other hand free to pat the baby’s back (Fig.19.5).
Parents usually need to be shown this method, because it does not seem as natural as placing a
baby against the shoulder. Laying the baby prone across the lap is another alternative position.
 Some infants seem to swallow little air when they breastfeed, whereas others swallow a great
deal. As a rule, it is helpful to bubble (burp) newborns after they have emptied the first breast and
again after the total feeding
e) Support for a mother who is breastfeeding multiple infants.
 Provide support by ensuring that they drink adequate fluid and help them to organize their time.
 Assure women that the average woman can easily produce enough milk to feed multiple infants.
f) Prevent or relieve engorgement.
 Engorgement- breast distention, accompanied by hardness, tenderness, and perhaps heat in
their breasts. The skin appears red, tense, and shiny.
 caused by vascular and lymphatic congestion arising from an increase in the blood and
lymph supply to the breasts.
 Nursing interventions:
1) Empty the breasts of milk by having the infant suck more often, or at least continue to suck
as much as before.
2) Good breast support from a firm-fitting bra helps prevent a pulling, heavy feeling
3) Apply warm packs to both breasts or standing under a warm shower for a few minutes
before feeding, combined with massage to begin milk
flow.
4) Manual expression or the use of a breast pump to
complete emptying of the breasts after the baby has
nursed.
g) Promote healing of sore nipples.
 Painful nipples result from the strong sucking action of a
newborn.
 It can be worsened by:
a. Improper positioning of an infant (failure to grasp
the areola as well as the nipple)
b. Forcefully pulling an infant from a breast
c. Allowing an infant to suck too long at a breast after
the breast is emptied
d. Permitting a nipple to remain wet from leaking milk
 Nursing interventions:
1) Encourage a mother to position her baby slightly differently
for each feeding.
2) Advise to expose nipples to air by leaving her bra
unsnapped for 10 to 15 minutes after feeding.
3) Discourage the use of plastic liners that come with nursing
bras; it is preferable to have air always circulating around the
breasts.
4) Apply vitamin E lotion after air exposure may toughen the
nipples and prevent further irritation
5) Applying a few drops of breast milk to the nipples after
feeding and gently massaging it into the areola.
6) Advise women not to use a hand pump with sore nipples,
because the pressure may cause fissures to worsen.
h) Anticipate potential problems and suggest methods for resolving them
 Fatigue can be another problem on returning home if a woman does not take adequate measures
to conserve her energy. Sitting relaxed in a comfortable chair with her feet elevated, feeding her
baby, and enjoying this time is an excellent way to rest.
 Remind women that adequate maternal fluid intake is necessary to maintain an adequate milk
supply. Women who are breastfeeding should drink at least four 8-oz glasses of fluid a day, and
many need to drink six glasses. They need to increase their calorie intake by about 500 calories a
day.

i) Provide information on supplemental feedings.

 A breastfeeding woman may leave her child during the day or evening in the care of a babysitter or
another care provider, just as a formula-feeding woman may. She can express breast milk manually
and leave it in a bottle in the refrigerator or prepare a single bottle of formula for the time she is away.
 Bottles used for storage should be washed using normal dishwashing practice. Breast milk then may
be refrigerated for 24 hours, frozen for 30 days, or placed in a deep freezer for 6 months. Use of
commercially prepared formula or powder formula is appropriate and convenient to replace a single
feeding because one bottle at a time can be prepared. The bottle used should be glass or opaque,
nonshiny plastic as shiny types may contain polycarbonate, a compound that can leech into stored
milk and is associated with chromosomal aberrations (Raloff, 2007).
 Once breastfeeding has been established (after about 6 weeks), missing one feeding will not affect
milk production enough to make a difference at the next feeding. There is no need for a mother to
express milk manually to safeguard a supply while the infant takes a supplemental feeding, although
she may prefer to do so to reduce tension and discomfort.
 j) Provide information for a mother who works outside the home.
 Many women return to work while continuing to breastfeed by bringing
their infant with them to their workplace. Others express breast milk for a
caregiver to give by bottle while they work. As there are many
considerations to think about, women should review with an employer the
best way for them to continue breastfeeding at their worksite
(Abdulwadud & Snow, 2009) (Box 19.6).
k) Provide information on weaning
 It is best for infants if they are exclusively breastfed for at least 6 months .
Women breastfeed for varying lengths of time, however. Some do it for 1,
2, or 3 months and then wean their children from breast to formula.
Others continue until their children are 6 to 12 months of age and then
wean directly to a small cup or glass. Some continue to breastfeed until
the child is of toddler or preschool age. The AAP recommends that
infants be breastfed for a full year; the World Health Organization (2002)
recommends exclusive breastfeeding for 6 months and continuation for 2
years.
 At any age, breastfeeding should be discontinued gradually to prevent
engorgement and pain in a mother’s breasts while still providing satisfaction for the infant. To do this,
a woman could first omit one breastfeeding a day, substituting a formula feeding or milk from a glass
or cup. Then she could omit two breastfeedings, then three, and so on, until her infant is feeding
entirely from a bottle, glass, or cup. If breasts are not emptied by regular feedings, the resulting
pressure leads to milk suppression and natural, gradual discontinuance of milk secretion. If weaned
before 12 months, infants should be weaned to formula, not whole milk, so that they continue to
receive the added vitamins and the low solute load of commercial formulas.
 Urge women who have discontinued breastfeeding to explore whether there is a breast milk bank in
their community that would appreciate breast milk donors. Such milk is used to feed hospitalized
infants, especially preterm infants. Being fed breast milk can help prevent necrotizing enterocolitis, a
possibly fatal bowel infection.

Formula Feeding
a) Preparing for formula feeding
 Commercial Formulas
 TYPES:
 Milk based- formulas are used for the average newborn
 Soy based- devised for infants who are allergic to cow’s milk protein
 casein hydrolysate formulas have protein particles too small to be recognized by the immune
system
 Elemental (fat, protein, and carb hydrate content is modified, such as in lactose-free formula)
Reminders!
 Parents should be advised to purchase types with added iron to ensure that their newborn receives
enough of this element to prevent iron deficiency anemia (Marotz, 2009)
 Formulas for term newborns contain 20 cal/oz when diluted according to directions (the same number
of calories as breast milk).

4 forms of commercial formulas

 Powder that is combined with water
 Condensed liquid that is diluted with an equal amount of water
 Ready-to-pour type, which requires no dilution
 Individually prepackaged and prepared bottles of formula

b) Provide information regarding formula preparation

 Infant formula of any type must be prepared with careful attention to cleanliness to prevent pathogenic
microorganisms from growing in it.
 When using presterilized formula, the parent need only do the following to prepare a full day’s supply
of formula:
  Wash off the top of the can with warm, soapy water and rinse.
 Open the can and pour the desired amount of formula and water into each previously cleaned
bottle (cleaning a dishwasher is best).
 Put on the nipples, taking care not to handle the nipple projection.
 Place the bottle caps over the nipples and refrigerate.
 To prepare a single bottle, the parent simply combines clean water and liquid or powdered formula in
a previously cleaned bottle, caps the bottle, and shakes it to mix the ingredients.
c) Provide information regarding feeding techniques
 warm and cooled formula
 take precaution in warming the formula milk stored in bottles.
 Whether to warm formula or not is a parental decision: infants who are fed cooled formula
directly from the refrigerator thrive as well as those who are fed warmed formula. The best
method to warm formula is to stand the bottle in a bowl of warm water or hold it under a
faucet of running hot water for a few minutes. Caution parents not to use a pan on the stove
to warm formula because if the pan boils dry, the bottle of milk will burst. Disposable bottles
with plastic liners should definitely not be heated on the stove; the liner tends to melt and then
leak during feeding.
 It also is not recommended to warm bottles in a microwave oven, because the milk in the
center of the bottle can become hotter than that near the sides. If parents do not follow this
recommendation, caution them to heat no longer than 30 seconds for a 4-oz bottle and 45
seconds for an 8-oz bottle (Goldenring, 2007). After warming, they should add the nipple and
shake the bottle well to mix the cool and warm portions. Finally, with all warming methods.
parents should test the temperature of the formula by allowing a drop or two to fall onto the
inside of a wrist, to make sure it is not hot enough to burn the baby’s mouth.
 With any type of bottle, any contents remaining after a feeding should be thrown away, not
stored and reused. When sucking, an infant exchanges a small amount of saliva for milk.
Because milk is a good growth medium for bacteria and the baby’s mouth harbors many
bacteria, the bacterial content in reused formula is likely to be high.

d) Use a comfortable chair (as does a nurse who feeds babies) and adequate time (at least half an hour)
to enjoy the process and not rush the baby.
 Like breastfeeding, formula feeding an infant is a skill that must be learned. A parent needs a
comfortable chair (as does a nurse who feeds babies) and adequate time (at least half an
hour) to enjoy the process and not rush the baby.
e) Hold the baby with the head slightly elevated.
 Holding the baby with the head slightly elevated reduces the danger of aspiration and
retention of air bubbles.
f) Ensure the nipple is kept filled so that the baby is sucking milk, not air.
 A parent should be sure the nipple is kept filled so that the baby is sucking milk, not air. He or
she can be assured a baby is sucking effectively if small bubbles rise in the bottle.
 g) Babies in the early weeks should be bubbled (burped) after every ounce of milk taken. The technique is
the same as that used for breastfed infants.
h) Do not to prop up bottles, because babies:
 Remind parents not to prop up bottles, because babies are in danger of aspiration if a bottle
is propped. In addition, an increased incidence of otitis media has been associated with
bottle-propping, because the infant’s head is not upright and formula may enter the
eustachian tube. Propping also can limit the amount of parent–child interaction.
i) Do not to put a baby to bed with a bottle of formula, because this can lead to “baby-bottle syndrome,” or
cavities of the lower teeth

Signs of a Well-fed Baby:

a) Steady weight gain of 150-240 g/ week during the 1st 6 months to120 g/week at the end of 1 year
b) Normal growth and development pattern
c) Happy, active and contented when awake
d) Regular and undisturbed sleep
e) Has normal bowel movements and elimination

VITAL STATISTICS: WEIGHT

 Varies among race, nutritional, intrauterine and genetic
fxs present during pregnancy
 The average birth weight (50th percentile) for a white,
mature female newborn in the United States is 3.4 kg (7.5
lb); for a white, mature male newborn, it is 3.5 kg (7.7 lb).
Newborns of other races weigh approximately 0.5 lb less.
Birth weight exceeding 4.7 kg (10 lb) is unusual, but weights as high as 7.7 kg (17 lb) have been
documented. Second-born children usually weigh more than first-born. Birth weight continues to
increase with each succeeding child in a family.
 Arbitrary lower limit of normal for all races: 2. 5kg (5.5 lbs.)
 Normal Birth weight range: 2500 g- 4000 g (5 lbs 8 oz- 8 lbs 13 oz)
 Average: 3500 g
 Birth weight of 4.7 kgs: macrosomic; associated with DM
 Physiologic Weight Loss
 5- 10% of NB BW is lost for the 1st few days of life
 6-10 oz weight loss
 Causes:
a) No salt and fluid-retaining maternal hormone influence
b) Diuresis
c) Passing out of meconium
 Because approximately 75% to 90% of a newborn’s weight is fluid, all three of these
measures reduce weight.

d) Limited caloric intake until about the 3rd day of life

 Breastfed NB: regains weight within 10 days
 Formula fed newborns: gains within 7 days
 Weight Gain among NB: about 2lbs per month (6-8 oz per week) for the 1st 6 months of life.
 Weight Gain:
 BW doubles at 5 to 6 mos and triples at 1 year.
 2 yrs of age: 4x the BW
 Infants generally gain approximately 20- 25 g/ day or 150- 210 g/ week during the 1st 5 months of
life
 3years: 5x BW
 5 years: 6x BW
 7 years: 7x BW
 10 years: 10x BW

 Abnormal Findings:
  Low birth weight/ SGA: <2,500 grams
 Very low birth weight: <1,500 grams
 Extremely low birth weight: <1,000 grams
 BW > 4000 g is known as Large for Gestational Age (LGA) infant.
 Weight loss of more than 10%
 Importance:
 Identify NB who are at risk because of their small size
 Separates small for gestational age (SGA- NB who have suffered IUGR) from preterm infants
 (infants who are healthy but small only because they were born early)
 Establishes a baseline for future evaluation.
 Good determinants of health and normal nutrition (together with height)

 Nursing Considerations in weighing NB:

 Undress NB infants before weighing.
 Keep a protective hand over an infant on an infant scale (hovering but not touching)
 Always cover scales with scale paper before weighing
 The same weighing scale should be used every time the infant’s weight is measured
 Plotting BW in a neonatal graph helps to identify NB at risk because of their small or too large size
 Weight should be compared with height and head circumference to see any disproportions that
indicates risk conditions

VITAL STATISTICS: LENGTH

 Average birth length (50th percentile): 53 cm (20.9
inches)
 Normal Range: 46-56 centimeters
 For mature males, the average birth length is 54 cm
(21.3 in).
 Nursing Considerations in taking NB length:
 Measure from top/ crown of the head to heel
using a tape measure.
 One person should hold the infant in place while
the other completes the measurement

VITAL STATISTICS: HEAD CIRCUMFERENCE

 Normal Measurement: 33-35 centimeters (13- 14
inches)
 The HC is usually greater than the chest
circumference by 2 centimeters.
 Head circumference is measured with a tape
measure drawn across the center of the forehead
and around the most prominent portion of the
posterior head
 It is ¼ of the total body length
 1 st 4 mos: HC increases by ½ inch a month and ¼
inch a month in the next 8 months.
 The ff are changes in the HC:
 At birth, HC may be equal or greater than the CC due to molding
 After 2-3 days, HC is greater than the CC by 2-3 cm
 After 6 months, HC is = to CC
 After 1 year, HC is < than CC

 Abnormal Findings:
 HC < 32 centimeters = microcephaly in term infants
 HC that is 4 centimeters and greater than CC or more than 37 centimeters = neurologic px
(Hydrocephalus)
VITAL STATISTICS: Chest Circumference
 Term newborn: about 2 cm (0.75 to 1 in) less than the head circumference measured at the level of
the nipples.
 A CC < than 30 cm indicates prematurity.
 An enlarged heart may make the left side of the chest larger.

VITAL STATISTICS: Abdominal Circumference

 Approximately the same as the CC
 Measured just above the umbilicus

VITAL STATISTICS: Vital Signs- TEMPERATURE

 The temperature of NB: about 99° F (37.2° C) at birth
 Temperature fluctuates during the first few hours post-birth
 The temperature of birthing rooms, approximately 68° to 72° F (21° to 22° C) adds to heat loss

 4 Mechanisms of heat loss among NB

a) Convection
 is the flow of heat from the
newborn’s body surface to
cooler surrounding air.
 The effectiveness of convection
depends on the velocity of the
flow (a current of air cools
faster than nonmoving air).
 Nsg Axn: Eliminate drafts from
windows or air conditioners
reduces convection heat loss.
b) Conduction
 transfer of body heat to a cooler
solid object in contact with a
baby.
 a baby placed on a cold
counter or on the cold base of a
warming unit quickly loses heat
to the colder metal surface.
 Nsg Axn: Covering surfaces with a warmed blanket or towel helps to minimize conduction
heat loss.
c) Evaporation
 loss of heat through conversion of a liquid to a vapor.
 Nsg Axn:
 dry newborns as soon as possible (face, hair, head)
 Covering the hair with a cap after drying it further reduces the possibility of evaporation
cooling.
 Be certain to remove any wet blankets used to dry the infant immediately place the infant
on a warm, dry blanket
 Drying and wrapping newborns and placing them in warmed cribs, or drying them and
placing them under a radiant heat source
d) Radiation
 transfer of body heat to a cooler solid object not in contact with the baby, such as a cold
window or air conditioner and examination tables near the NB.
 Nsg Axn:
 Move the infant far from the cold surfaces as possible helps reduce this type of heat loss.

NB loss heat easily because….

a) Immature temperature regulating system
b) Very little amount of subQ fats to provide heat in their body.
 c) Little ability to conserve heat by changing posture and inability to adjust own clothes in response to
thermal stress.
d) They tend to take on the temperature of their environment

NB conserve heat by:

a) constricting blood vessels
b) moving blood away from the skin
c) Burning brown fat, a special tissue found in mature newborns, that helps to conserve or produce body
heat by increasing metabolism.

NB Produce Heat by:

a) Increasing muscular activity (kicking and crying) increase metabolic rates HEAT
b) Burning brown fat- present only in NB; forms at 17 weeks of gestation; the less mature the infant, the
less brown fat
HYPOTHERMIA
 Occurs when body temperature drops below 36.5 C
 The NB infant is most sensitive to hypothermia during the stabilization period
 Effects of Hypothermia
 Acidosis
 Hypoxemia - a below-normal level of oxygen in your blood, specifically in the arteries.
 Hypoglycemia
 Immediate interventions for hypothermia:
 Remove wet cloth
 Place the baby under heat source
 Encourage BF
 Start oxygen administration if the baby has respiratory distress or cyanosis
 Notify the physician

HYPERTHERMIA
 NB are also at risk of hyperthermia (T= >37. 5̊C)
 CAUSES:
 Too hot external environment
 Too many covers/ clothes on baby
 Infection
 S/Sx:
 Irritability/ fussy
 Abdomen and extremities are warm to touch
 Red, flushed skin
 Hot and dry skin
 Lethargy
 Stupor; at risk for convulsions (41 C)
 Interventions:
 Place NB in a cool environment (25-28 C)
 Keep away from sources of heat (direct sunlight)
 Undress the NB partially or fully, if necessary.
 Measure the T q 1̊until within the N range
 Sponge the baby if T > 39 C. Do not use cold/ ice water.
 If the NB has been under a radiant warmer, reduce the T setting until it becomes N
 Examine for signs of infection

Vital Signs- Heart Rate

 The heart rate of a fetus in utero averages 120 to 160 beats per minute (bpm).
 Immediately after birth, as the newborn struggles to initiate respiration, the heart rate may be as rapid
as 180 bpm.
 HR: determined by listening for an apical heartbeat for a full minute
  Within 1 hour after birth, as the newborn settles down to sleep, the heart rate stabilizes to an average
of 120 to 140 bpm
 HR of a newborn: often remains slightly irregular because of immaturity of the cardiac regulatory
center in the medulla.
 During crying: HR may rise to 180 bpm.
 Sleep periods: HR can decrease during sleep, ranging from 90 to 110 bpm.

Vital signs: Blood Pressure

 At birth: The BP of NB is approximately 80/46 mm Hg.
 By the 10th day of life : rises to about 100/50 mm Hg.
 BP tends to increase with crying (and a newborn cries when disturbed and manipulated by such
procedures as taking blood pressure).
 A Doppler method may be used to take blood pressure. Hemodynamic monitoring is helpful when
continuous assessment is necessary.

 AbN finding:
 Calf systolic pressure 6-9 mmHg less than the systolic pressure in the UE may be indicative of
coarctation of the aorta
 NOTE: For an accurate reading, the cuff width used must be no more than two thirds the length of
the upper arm or thigh.

Vital Signs: Respiration

 RR ranges to an average of 30 to 60 breaths per minute when the newborn is at rest.
 periodic respiration - Respiratory depth, rate, and rhythm are likely to be irregular, and short periods of
apnea (without cyanosis) which last less than 15 seconds are normal.
 RR: observed thru’ watching the movement of a newborn’s abdomen, because breathing primarily
involves the use of the diaphragm and abdominal muscles
 NB are obligate nose breathers.
 Signs of Respiratory Distress
 Nasal flaring
 Chest retraction, indrawing of the chest when breathing
 See-saw respiration
 Cyanosis other than the hands and feet
 Respiratory grunting- noisy respiration
 Adventitious breath sounds in NB
 Rhonchi - This is a low-pitched sound that resembles snoring.
 Rales - This is a fine, high-pitched crackling or rattling sound that can occur when you inhale.
 Stridor - This is a high-pitched, loud sound that sometimes sounds like a cough or bark.
 Wheezing - This is a high-pitched sound, almost like a long squeak, that can occur as you inhale
or exhale.
 Grunting
 Absent/ diminished breath sounds

 Can be done every after 5min until baby

is stable
 1st min - need for immediate resuscitation
is assessed
 5min - reliable predictor for neurologic
deficit particularly mortality
 <100 - extensive depletion of oxygen
 >160 - cardiopulmonary distress
 Best landmark is apical pulse
 Delayed cord clamp prevents anemia
 Once the cord has been cut&clamped, a
pulse may often be palpated by placing
an index finger and thumb at the base of
the cord.

 Rise and fall of abdomen

 Obligate nasal breathers (3mos; 4-6mos)
 Nasal flaring - respiratory distress among
newborn
 Choanal atresia - occluded nare

 A baby whose mother was heavily

sedated will probably demonstrate a low
score
 Do not go beyond 10sec of suctioning
because it over stimulate vigorous nerve
that will lead to bradycardia
 37.2 - normal temp at birth but may go
down( - 2 to 3 degrees)
 Opposite of APGAR
 Signs of respiratory distress are: nasal
flaring, cyanosis, intercostal retraction,
subcostal retraction, xyphoid retraction,
tachypnea, accessory muscles, mouth
breathers
 PKU is a disease of metabolism that is
inherited as an autosomal recessive trait.
Absence of the liver enzyme phenylalanine
hydroxylase prevents conversion of
phenylalanine, an essential amino acid, into
tyrosine (a precursor of epinephrine,
thyroxine, and melanin). As a result,
excessive phenylalanine builds up in the
bloodstream and tissues, causing permanent
damage to brain tissue and leaving children
severely cognitively challenged
 Cystic fibrosis is a disease in which there is
generalized dysfunction of the exocrine
glands. This results in malabsorption and
tenacious pulmonary secretions, leading to
infection and pneumonia. Lung
 transplantation can be used to replace the
diseased lung tissue and increase the child’s
life span.
 Congenital adrenal hyperplasia is a syndrome
that is inherited as an autosomal recessive
trait. The primary defect is an inability of the
adrenal glands to synthesize cortisol from its
precursor.
 Congenital hypothyroidism occurs as a result
of an absent or non functioning thyroid
gland. The condition is discovered by a blood
test at birth. The therapy is oral
administration of synthetic thyroid hormone
 Galactosemia is a disorder of carbohydrate
metabolism that is characterized by abnormal
amounts of galactose in the blood
(galactosemia) and in the urine
(galactosuria).
 Maple syrup urine disease is a rare disorder,
inherited as an autosomal recessive trait, in
which there is a defect in metabolism of the
amino acids leucine, isoleucine, and valine
that leads to cerebral degeneration similar to
that observed in children with PKU.
 Sickle cell disease is a blood disorder in
which the hemoglobin is damaged and can't
carry oxygen to the tissues.
 Biotinidase deficiency is an inherited
disorder in which the body is unable to
recycle the vitamin biotin. If this condition
is not recognized and treated, its signs and
symptoms typically appear within the first
few months of life, although it can also
become apparent later in childhood.
optimum temp of 24 degree celsius or 75
degrees farenheit for DR & nursery rooms
should maintain
Mother is the best source of heat
For preterm, kangaroo mother care
Hemorrhagic dse of the NB
- bleeding through umbilicus
- intracranial bleeding
- black tarry stool
PHYSIOLOGIC FUNCTIONS: CARDIOVASCULAR SYSTEM
 Acrocyanosis (go back to previous discussion)
 The peripheral circulation of a newborn remains sluggish for at least the first 24 hours.
 feet feel cold to the touch
1) Blood Values:
 Blood volume: 80 to 110 mL per kilogram of body weight OR about 300 mL total blood
volume
 Hemoglobin level average: 17 to 18 g/100 mL of blood
 Hematocrit: between 45% and 50%
 High erythrocyte count at birth: 6M/ mm3
 At the end of 3rd month: Hgb level drops to 11-12 mg/100 ml and RBC count is as low as 3-
4M/ mm3
 Erythropoeisis - decrease in RBC production; specific amount of Fe & RBC will be
maintained from 5-6 mos
 Physiologic anemia - 6-8 wks expected that production of RBC will slow down
 High WBC count at birth: about 15,000 to 30,000 cells/mm3; can go as high as 40,000
cells/mm3 if birth has been stressful or difficult; only exemption if and only if the baby has
other evidences supporting infectious process(for example if 2-3 days he has fever, and
moister at umbilical area with abnormal discharge)
 1 month of age: lymphocytes become the predominant WBC
 Fe at birth: 100-200 ug/ 100ml
 @ 4months to 2 years of age: ranges from 40-100 ug/ 100 ml
 Fe stores of infant = enough supply until 5-6 months of age
 Capillary heel stick may reveal false high hct and hgb counts because of sluggish blood flow
  In order to avoid false high hct and hgb counts prior to extraction of blood, must warm first
the foot of the child
 The time at which the cord is cut has significant effects on the
circulatory system, about 50 to 100 ml of placental blood is
transfused to the NB if cord is clamped after pulsation has
stopped
In every 80mL of placental blood gives NB additional 50mg
of Fe w/c adds up to Fe stores of child
Among premature infants, allowing the movement of blood
from placenta towards infant prior to clamping will
decrease episodes of anemia in 1 out of 3 (1 out of 2?) in
premature infants and at the same time helps prevent
hemorrhage (1 out of 7 in term babies)
 Effects of delayed cord clamping:
 Decreased incidence of Respiratory Distress
 More Fe stores
 Increased blood volume
 Decreased anemia

**When a baby is born vaginally, the squeezing effect brought by

the pelvic brim, can help release excessive secretions that are
present in the tracheobronchial tree and clearance of the
presence of nasal and oral secretions coming from pelvic area,
can contribute to airway clearance of child (not observed in
children who were delivered via CS)

SPECIAL STRUCTURES (check video of fetal circulation)

 Ductus arteriosus
 Closes functionally at the 4th day after birth
 Initial respiration and pulmonary blood flow → lung inflation → ↓ pressure in right atrium
and ventricle and pulmonary artery → closure of ductus arteriosus → ligamentum
arteriosum
 Foramen ovale
 Functional closure occurs immediately after birth; anatomical closure occurs at 3 months
of age
 ↑ pulmonary blood flow → ↑ pressure in the left atrium → closure of foramen ovale →
fossa ovalis
 Umbilical vein and arteries
 Umbilical arteries are converted to umbilical ligaments and umbilical veins to teres hepatis
(ligamentum teres) after 2-3 months
 Ductus venosus
 Cord clamping and cutting → clotting of blood and vessel atrophy → ligamentum
venosum (3 months)

2. Blood Coagulation (Review notes on preventing hge)

 Because most newborns are born with a lower than normal level of vitamin K, they have a prolonged
coagulation or prothrombin time. Vitamin K, synthesized through the action of intestinal flora, is
necessary for the formation of factor II (prothrombin), factor VII (proconvertin), factor IX (plasma
thromboplastin component), and factor X (Stuart-Prower factor). Because a newborn’s intestine
is sterile at birth unless membranes were ruptured more than 24 hours before birth, it takes about 24
hours for flora to accumulate and for vitamin K to be synthesized. Because almost all newborns can
be predicted to have this diminished blood coagulation ability, vitamin K (AquaMEPHYTON) is usually
 administered intramuscularly into the lateral anterior thigh, the preferred site for all injections in a
newborn, immediately after birth.
 factor II - prothrombin
 factor VII - proconvertin
 factor IX - plasma thromboplastin component
 factor X - Stuart - Power factor
IMMUNE SYSTEM
 PD 996 - PROVIDING FOR COMPULSORY BASIC IMMUNIZATION FOR INFANTS AND CHILDREN
BELOW EIGHT YEARS OF AGE
 Maternal antibodies are transferred to the fetus: natural passive Immunity: IgG
 Passed from maternal blood to fetus via placenta passing through umbilical cord
 IgA, IgD, IgE: commonly found in breastmilk going to child
 Presence of IgM in NB circulation = exposure to infection during fetal life
 Newborns are routinely administered hepatitis B vaccine during the first 12 hours after birth to
protect against this disease (American Academy of Pediatrics [AAP], 2009).

Urinary System
 The average newborn: voids within 24 hours after birth.
 NB who does not void within this time should be examined for the possibility of urethral
stenosis or absent kidneys or ureters
 Fetal kidneys produce urine as early as the 4th month in utero
 NB Kidneys: do not concentrate urine well → usually light-colored and odorless
 Sp Gr: ranges from 1.008 - 1.010
 Diapers can be weighed to determine the amount of urine output. (1g= 1mL of urine)
 Males should void with enough force to produce a small projected arc; females should
produce a steady stream
 In 2- 3 days, she can void from at least 5 to 6 times per day. As she starts to feed with
adequate hydration after 1 week she can void 15 - 20 times per day
 daily urinary output for the first 1 or 2 days: about 30 -60 mL total
 Bladder capacity: 40mL
 Pink tinge - uric acid crystal that were formed in bladder while infant was still in utero
Neuromuscular
 Mature newborns demonstrate:
 neuromuscular function by moving their extremities
 attempting to control head movement
 exhibiting a strong cry
 demonstrating newborn reflexes
 The brain is 10% of the total body weight at birth.
 Intactness of the nervous system is demonstrated by:
 State of alertness
 Resting posture
 Cry
 Muscle tone
 Motor activity
 Nervous system: immature at birth but endowed with inborn reflexes important for protection
and survival
 Myelinization is completed at 6-12 months
 Intactness of the nervous system is demonstrated by the ff: state of alertness, resting posture,
cry, muscle tone, motor activity
 REFLEXES
 Involuntary actions/ movements
 Disappears as voluntary control is developed
 Identify normal brain and nerve activity

This reflex disappears at 6weeks to 3mos of age.

Abnormal: inverted “U” position: poor muscle tone

Gastrointestinal Tract
 Sterile GIT upon birth; bacterial culture at 5- 24 hours
 Volume 60-90 mL (approximation of gastric capacity: add age to 2 oz)
 Gastric emptying at 2-3 hours for neonates and 3-6 hours for older infants
 Deficient in pancreatic enzymes lipase and amylase
 Immature cardiac sphincter
 Immature liver
 Incapable of conjugating indirect bilirubin to direct bilirubin
 Inability to form plasma protein
 Inadequate stores of glycogen
 Signs of abnormalities
 (-) passage of stool within 24 hours
 Clay-colored
 (+) mucus
 Black or tarry (more than 3 days)
 Watery and forceful ejection
 Abdominal distention
 Projectile vomiting

 Elimination
 Monitor first stool or voiding
 Meconium
 Within 24-48 hours
 Negative: imperforate anus
 Voiding
 First voiding within 24 hours
 Negative: dehydration, little intake for the first 24 hours, urethral stenosis, absent kidneys
or ureters
 Change diapers as soon as soiled
 Cuddling
 Always support head
 Baby should not be lifted in the arms or armpits until 3 months old
 Do not apply vigorous shaking
 Ways of carrying a baby:
a. Cradle carry
b. Shoulder carry
c. Hip carry—for older babies who have mastered head and neck control
 d. Front-face carry
 Integumentary System
 All structures of the IS are present at birth but skin’s function is immature
 Smooth and elastic with fair amount of subcutaneous tissues
 Preterm infants have lesser subcutaneous tissues so skin appears almost transparent
 subQ tissues are important for insulation
 Brown fats - responsible for additionally, providing with insulation : located in perineum, chest
areas, intrascapular areas
 Post-term infants have paler, dry, peeling skin
 Skin Color
 Ruddy complexion- ruddiness fades slightly over the first month
 Bright red at the first day
 Twin transfusion phenomenon
 Acrocyanosis is normal for the first 24-48 hours; central cyanosis is not
 central cyanosis, or cyanosis of the trunk, is always a cause for concern. Central cyanosis
indicates decreased oxygenation. It may be the result of a temporary respiratory obstruction or an
underlying disease state.
 Mucus obstructing a newborn’s respiratory tract causes sudden cyanosis and apnea. Suctioning of
the mucus relieves this. Always suction the mouth of a newborn before the nose, because
suctioning the nose first may trigger a reflex gasp, possibly leading to aspiration if there is
mucus in the posterior throat. Follow mouth suctioning with suction to the nose, because the
nose is the chief conduit for air in a newborn.

 Mottling
 Irregular discoloration of the skin due to cold exposure, lack of fat, or hypoxia
 Cutis marmorata—transient mottling when infant is exposed to decreased temperature
 Hyperbilirubinemia
 leads to jaundice, or yellowing of the skin (Beachy, 2007)
 Globin is a protein component that is reused by the body and is not a
factor in the developing jaundice.
 Heme is further broken down into iron (which is also reused and not
involved in the jaundice) and protoporphyrin.
 Protoporphyrin is further broken down into indirect bilirubin.
 Indirect bilirubin is fat soluble and cannot be excreted by the
kidneys in this state. For removal from the body, it is converted by
the liver enzyme glucuronyl transferase into direct bilirubin, which
is water soluble. This is incorporated into stool and then excreted in feces. Many newborns have such
immature liver function that indirect bilirubin cannot be converted to the direct form; it therefore
remains indirect.
 As long as the buildup of indirect bilirubin remains in the circulatory system, the red coloring of the
blood cells covers the yellow tint of the bilirubin. After the level of this indirect bilirubin has risen to
more than 7 mg/100 mL, however, bilirubin permeates the tissue outside the circulatory system and
causes the infant to appear jaundiced.
 If the level rises to more than 10 to 12 mg/100 mL, treatment is usually considered. Phototherapy
(exposure of the infant to light to initiate maturation of liver enzymes) is a common therapy. If this is
necessary, the incubator and light source can be moved to the mother’s room so that the mother is not
separated from her baby. Some infants need continued therapy after discharge and receive
phototherapy at home (Mills & Tudehope, 2009).

 Physiologic jaundice (90 days -- lifespan of RBC in NB)

 Occur after 24 hours of life (2-3 days); infant’s skin and the sclera of the eyes appear noticeably yellow
 Due to destruction of high fetal RBC built up in utero
 Pathologic bilirubinemia
 Pregnanediol - a component of hormone progesterone that interferes with the action of glucuronyl
transferase
 Occur within 24 hours after birth
 Jaundice lasts for more than 10 days
 May lead to kernicterus
 Above-normal indirect bilirubin levels are potentially dangerous because, if enough indirect
bilirubin (about 20 mg/100 mL) leaves the bloodstream, it can interfere with the chemical
synthesis of brain cells, resulting in permanent cell damage, a condition termed kernicterus. If this
occurs, permanent neurologic damage, including cognitive challenge, may result.

Protoporphyrin indirect bilirubin glucuronyl transferase (liver enzyme) direct bilirubin

 Harlequin’s sign
 clear color division of the skin with lower half of the body
pinkish in color and the upper half pale when the infant is
on side lying position
Fair complexion
Pallor—d/t anemia
 Pallor (pinkish) - reddish pink because of pulling of blood
 Anemia -- poor nutrition of mother; destruction of fetal RBC
 Excessive blood loss when the cord was cut
 Inadequate flow of blood from the cord into the infant at birth
 Fetal–maternal transfusion
 Low iron stores caused by poor maternal nutrition during pregnancy
 Blood incompatibility in which a large number of red blood cells were hemolyzed in utero. It also
may be the result of internal bleeding.

Birthmarks
Hemangioma- vascular tumors of the skin
TYPES:
Stork bite — a macular purple or dark-red lesion present over the eyelids,
above the bridge of the nose, face and thighs; does not blanch with pressure;
does not fade with age.
 A.k.a. port - wine strain
 they can be covered by a cosmetic preparation later in life or removed
by laser therapy, although lesions may reappear after treatment (Berger,
2009).

Stork’s Beak marks or Telangiectasia

 lighter, pink patches at the nape of the neck
 Mostly in females
 Does not fade w/ age
Strawberry hemangioma/nevus vasculosus
 dark-red, raised, and strawberry-like in appearance found at the
head d/t dilated immature capillaries occupying the dermal and
subdermal layers of the skin; also associated with connective tissue
hypertrophy
 Most are present at birth in the term neonate or may appear up to 2
weeks or months after birth.
 may continue to enlarge from their original size up to 1 year of age.
 Completely disappears by school age
 Typically, they are not present in the preterm infant because of the immaturity of the epidermis.
Formation is associated with the high estrogen levels of pregnancy. They may continue to enlarge from
their original size up to 1 year of age. After the first year, they tend to be absorbed and shrink in size.
By the time the child is 7 years old, 50% to 75% of these lesions have disappeared. A child may be
10 years old before the absorption is complete. Application of hydrocortisone ointment may speed the
disappearance of these lesions by interfering with the binding of estrogen to its receptor sites.
 Surgery to remove strawberry hemangiomas is rarely recommended because it can lead to secondary
infection, resulting in scarring and permanent disfigurement. Large lesions that are disfiguring can be
removed by laser therapy.
 MNGT: Application of hydrocortisone ointment may speed the disappearance of these lesions

Cavernous hemangioma
 appears like strawberry hemangioma but primarily d/t dilated vascular spaces
 consist of a communicating network of venules in subcutaneous tissue and do not fade with age
 Present at birth or appear several months after
 does not disappear with time

Mongolian Spots
 are collections of pigment cells (melanocytes) that appear as slate-gray patches across the sacrum or
buttocks and possibly on the arms and legs.
 They tend to occur in children of Asian, southern European, or African ethnicity.
 They disappear by school age without treatment.
 Be sure to inform parents that these are not bruises; otherwise, they may worry their baby sustained a
birth injury.
 Bluish - to black; bluish to blue
 Abused child - varying degrees of healing

Vernix Caseosa
 is a white, cream cheese–like substance that serves as a skin lubricant in utero.
 Formed from old cutaneous cells and secretions of sebaceous glands while in utero
 Document the color of vernix, because it takes on the color of the amniotic fluid. For example, a yellow
vernix implies that the amniotic fluid was yellow from bilirubin; green vernix indicates that
meconium was present in the amniotic fluid.

Lanugo
 is the fine, downy hair that covers a newborn’s shoulders, back and upper
arms, on the forehead and ears.
 1 st appearance: 19 weeks of fetal life
 Most obvious at 27- 28 weeks of fetal life
 Babies born between 37 to 39 weeks of gestation: more lanugo than a
newborn of 40 weeks’ gestational age.
 Disappears: 2 weeks post life
 Rubbed away by: friction of bedding and clothes against the newborn’s skin
Desquamation
 areas of peeling similar to those caused by sunburn.
 Caused by drying of the NB skin within 24H of life
 Particularly evident on the palms of the hands and soles of the feet.
 Mngt: hand lotion to prevent excessive dryness if they wish.

Milia
 All newborn sebaceous glands are immature. At least one pinpoint white papule (a
plugged or unopened sebaceous gland) can be found on the cheek or across the
bridge of the nose disappear by 2 to 4 weeks of age, as the sebaceous.
 Teach parents to avoid scratching or squeezing the papules, to prevent secondary
infections
Erythema Toxicum
 Appears in the first to fourth day of life but may appear up to 2 weeks of age.
 Begins as papules that develop in a hive like elevations with a center containing
clear fluid as a reaction of the skin to the clothes and sheets; become erythema
by the second day, and then disappears by the third day.
 Caused by a NB’s eosinophils reacting to the environment as the immune
system matures.
 Requires no treatment
 It is sometimes called a flea-bite rash because the lesions are so minuscule.
 It is caused by a newborn’s eosinophils reacting to the environment as the
immune system matures. It requires no treatment.

Skin Turgor
 An indicator of the hydration status of the NB
 Well hydrated: feel resilient
 Elastic and immediately returns back to normal contour when grasped b/n the thumb and fingers

EYES
 Absence of tears (tear glands matures at about 3 months of age)
 Corneal and blink reflexes in response to touch
 Pupillary reflex in response to light
 (+) strabismus and nystagmus until 4 months the sclera may be blue because of its thinness.
 Infant eyes assume their permanent color between 3 and 12 months of age.

**Subconjunctival hemorrhage - red spots on the sclera d/t rupture of

subconjunctival capillaries appears as a red spot on the sclera, usually on the
inner aspect of the eye, or as a red ring around the cornea.
 The bleeding is slight, requires no treatment, and is completely
absorbed within 2 or 3 weeks.
 Usually edematous (periorbital, eyelids)
 This remains for the first 2 or 3 days, until the newborn’s kidneys are
capable of evacuating fluid more efficiently.
 Optimal visual field: 9-12 inches away
EARS
 pinna, cartilage present
 Position: top of pinna in line with outer canthus of the eye
 Flat against head = premature
 Skin tags may be present

Mouth
 opens evenly when crying
 Presence of sucking, rooting, gagging, and extrusion reflexes
 Absent or minimal salivation; tongue appears large and prominent in the mouth
** Epstein’s pearls
 small round, glistening, well circumscribed cysts on the hard palate; d/t deposition of extra load of
calcium in utero
 disappears within 1 week
 It is highly unusual for a newborn to have teeth, but sometimes one or two (called natal teeth) will
have erupted. Any teeth that are present must be evaluated for stability. If loose, they are usually
extracted (they remove easily) to prevent possible aspiration during feeding.
 a parent may mistake them for thrush, a Candida infection, which usually appears on the tongue and
sides of the cheeks as white or gray patches and needs therapy with an anti-fungal drug

ABDOMEN
 Normal contour: Slightly protuberant
 Scaphoid (sunken appearance) > diaphragmatic hernia
 + barrel chest, wherein intestines are positioned going to the chest; bowel goes to the chest
 Bowel sound should be present within 1 hour after birth
 Edge of liver palpable 1-2 cm below right costal margin
 Edge of spleen palpable 1-2 cm below left costal margin
 Cord stump 1st Hr: white, gelatinous structure marked with the blue and red streaks of the umbilical
vein and arteries
 1 artery in cord = CHD or renal abnormality
 Brown (after 2-3 hours)
 black (2-3 days)
 breaks free by day 7 - 10

Anogenital Area
 Male genitalia
 penis of newborns: appears small, approximately 2 cm
long
 Scrotum: rugae present; deep pigmented; with 2 testicles
 Cryptorchidism—absence of testicle or both
Causes of cryptorchidism:
 Agenesis - absence of organ
 Undescended testicles
 Ectopic testis - scrutal sac is closed
 Positive cremasteric reflex maybe absent until 10 days old

**Penis—2 cm or more
 Epithelial pearls—small, firm, white lesions at the tip of prepuce
 Erection or priapism
 Chordee—lateral curvature of the penis
**Urethral opening
 Hypospadias—urethral opening on the ventral surface of the penis
 Epispadias—urethral opening on the dorsal surface of the penis

 Female genitalia
 Labia and clitoris usually edematous
 Urethral meatus below clitoris
 Vernix caseosa maybe found between labia
 Pseudomenstruation—blood-tinged or mucoidal discharge d/t maternal hormone
 Hymenal tag maybe present

Anus/rectum
 Patent
 Imperforate - An imperforate anus happens when the anus is missing or doesn't have a hole.
 (+) anal reflex

Back
 surface; no dimpling, opening, or masses
 dermal sinus or spinal bifida occulta.
 Tuft of hair along the spine
 (+) trunk incurvation reflex

Extremities
 Symmetrical
 10 fingers and toes
 Polydactyly - is the presence of one or more additional fingers or toes. These extra fingers are
often just cartilage or skin tags, and removal is simple and cosmetically sound.
 Syndactyly - (two fingers or toes are fused), the fusion is usually caused
by a simple webbing; separation of the digits into two sound and
cosmetically appealing ones is usually successful.
 Phocomelia - a rare birth defect characterized, in most instances, by
severe malformation of the extremities.
 Hemimelia - born with a short or missing fibula (one of the two bones in the lower leg).
 Fingertips should reach over the proximal thigh
 Unusually short arms: achondroplastic dwarfism
 Full ROM
 Soft and smooth nails; Nailbeds pink, with transient cyanosis
immediately after birth
 Simian crease—Down syndrome
 Creases on anterior 2/3 of sole
 Sole usually flat
 Clonus—rapid alternating contraction and relaxation of the foot
after dorsiflexion; may indicate neurologic involvement
 Hallux - hallux valgus (HV), also known as a bunion, is one of the most common forefoot deformities.
 Ortolani’s sign—clicking sound upon upward rotation of the thigh
Neck
 short and chubby, with creased skin folds
 Head should rotate freely
 Present tonic neck reflex
 Torticollis (wry neck)—head held to one side with chin pointing to
opposite side as a result of injury to the sternocleidomastoid muscle
 Nuchal rigidity - Nuchal rigidity simply refers to neck stiffness.
Fine motor skills are small movements --
such as picking up small objects and spoon--
that use the small muscle of the fingers, toes,
wrists, lips, and tongue.
Gross motor skills are the bigger movements
-- such as rolling over and sitting -- that use
the large muscles in the arms, legs, torso, and
feet.
 Child's critical thinking is enhanced
 Number literacy among kids develop
 Communication literacy by simply
looking at pictures(colors, shape, fruit)

Needs a lot of patience

 Cerebral palsy complete
 Allow child to experience the skill (don’t
rush)
 Delay may happen but relearn can happen
(just take time)

 Had a control over head, neck and back

 THE FAMILY PLANNING
Definition:
 The conscious process by which a couple decides on the number and spacing of children and the timing
of births.
Nursing responsibilities:
1. Understand one’s own philosophy, beliefs, and standards.
2. Tell: Tell the client about the methods available based on clients’ needs and knowledge.
3. Help: Help the client make a decision about contraception
4. Explain: Explain how to use the method the clients had chosen
5. Return/Refer: Tell the clients when to return for routine follow-up; or refer the clients for services or
methods not offered by your site

CONTRACEPTION. The voluntary prevention of pregnancy.

Considerations When Choosing a Contraceptive Method:
1. Safety
2. Interference with spontaneity
3. Protection from Sexually Transmissible Infections
4. Availability
5. Effectiveness
6. Expense
7. Convenience
8. Preference
9. Education needed
10. Religious and personal beliefs
11. Side effect
12. Culture

CONTRACEPTIVE METHODS
I. Natural Family Planning (NFP) Methods
A. Ovulation Method
 Mode of Action: Allows a woman to determine her infertile and fertile periods by observing
and recording changes in her cervical mucus.
B. Basal Body Temperature (BBT)
 Mode of Action: Allows a woman to determine her infertile and fertile periods by observing
changes in her Basal Body temperature.
 C. Sympto-Thermal Method
 Mode of Action: Allows a woman to determine her infertile and fertile periods by observing
and recording the characteristics of the cervical mucus, and other changes which occurs during
ovulation.
Effectiveness Rate: 80%
Advantages of NFP Methods:
1. Inexpensive
2. No health-related side effects
3. Increases self-awareness and knowledge of reproductive functions
4. Acceptable to most religions
5. Not dependent on medically qualified personnel
Disadvantages of NFP Methods:
1. Requires high level of motivation
2. Extensive educational need
3. Requires abstinence for large part of each cycle
4. High risk of pregnancy from error
5. Many factors may change ovulation time
II. INJECTABLE CONTRACEPTIVES (ex. Depo-Provera)
 Effectiveness: 99.7%
 Mode of Action:
 Inhibits ovulation
 Thickens cervical mucus
 Thins endometrial lining
 Advantages:
1. Long-acting
2. Does not interrupt sex
3. Does not affect breastmilk
 Disadvantages:
1. Must get an injection every three months
2. Client cannot discontinue the method on her own
3. May cause side effects and complications
4. Does not protect against STI/HIV transmission
 Side Effects:
1. Weight gain
2. Delayed return to fertility
3. Menstrual disturbance, spotting and amenorrhea
 WARNING Signs of Complications:
1. Signs of pregnancy
2. Menstrual periods become twice as long or twice as much as usual

III. SUBDERMAL IMPLANTS

 Effectiveness: 99.9%
 MOA: Same as injectable contraceptives
 Advantages: --- do --- 4. Fertility returns promptly after the rods/capsules are removed
 Disadvantages:
1. Expensive at the time of insertion
2. Not as effective in women weighing more than 150 lbs
 Side Effects:
1. Menstrual disturbance, spotting and amenorrhea
2. Weight gain, nausea, headache, depression

IV. ORAL CONTRACEPTIVES

  Effectiveness: 97%
 Mode of Action:
 Inhibits ovulation
 Thickens cervical mucus
 Inhibits ovum transport to uterus
 Advantages:
1. Regulates menstrual flow
2. Does not interrupt sex
3. Can be stopped at any time by the client
 Disadvantages:
1. Client must take 1 pill a day for as long as she does not want to get pregnant
2. May cause side effects and complications
3. Does not protect against STI/HIV transmission
 Side Effects:
1. Weight gain, nausea, headache, depression

 WARNING Signs of Complications:

 A - abdominal pain
 C - chest pain
 H - headache (severe)
 E - eye problem
 S - severe leg pain (calf and thigh)

V. INTRAUTERINE DEVICE (IUD)

 Effectiveness:
 Hormonal IUD = 98%
 Copper = 99.2%
 Mode of Action:
 Prevents fertilization
 Interferes with sperm transport
 Advantages:
1. Has no hormone thus no systemic effect (copper)
2. Low long-term cost
 Disadvantages:
1. The device may be expelled
2. High initial cost
3. Potential side effects or complications
4. Does not protect against STI/HIV transmission
 Side Effects:
1. Mild abdominal pain
2. Longer and heavier menstrual periods
 WARNING Signs of Complications:
 P - Period late (with symptoms of pregnancy), abnormal spotting or bleeding
 A - Abdominal pain or pain during intercourse
 I - Infection or abnormal discharge
 N - Not feeling well, fever or chills
 S - String missing, longer, or shorter

BARRIERS
Mode of Action: Prevent sperm and egg from meeting
I. CONDOMS
  Effectiveness Rate:
 Male = 88%
 Female = 79%
 Advantages:
1. No prescription needed
2. Best protection available against STDs/HIV transmission
3. Inexpensive per single use
4. Can be carried discreetly
5. Quick and easy
6. Vaginal condom: Increases women’s control over contraceptive use and protection from
STIs
 Disadvantages:
1. Must be checked for expiration date and holes
2. Can break or slip off
3. Can be used once only
4. Vaginal condom: May seem unattractive

II. DIAPHRAGM
 Effectiveness Rate: 82%
 Advantages:
1. Can be inserted several hours before coitus
2. Offers some protection against STI/HIV transmission
 Disadvantages:
1. Initially: Expensive. Requires nurse, midwife, or physician to fit
2. Requires education on proper use
3. Added spermicide necessary for repeat coitus
4. Possibility of Toxic Shock
5. Must be refitted after each birth or weight change of 10 or more pounds
6. Pressure against bladder may cause infections

III. CERVICAL CAP

 Effectiveness Rate:
 Parous women:64%
 Nulliparous women: 82%
 Advantages:
1. Smaller than diaphragm
2. Requires less spermicide and no additional spermicide for repeated intercourse
3. No pressure against bladder
4. Less noticeable than diaphragm
5. Can remain in place 48 hours
6. Offers some protection against STIs/HIV transmission
 Disadvantages:
1. Sizes are limited
2. Initially expensive and requires education on proper use
3. Somewhat more difficult to insert than diaphragm
4. Can be dislodged during intercourse
5. Possibility of Toxic Shock
6. Must be refitted each year and after birth, abortion, or surgery

IV. CHEMICAL SPERMICIDES

 Effectiveness Rate: 79%
  Advantages:
1. Quick and easy
2. No prescription needed
3. Inexpensive per single use
4. Offers some protection against STIs/HIV
 Disadvantages:
1. Films and suppositories must melt to be effective
2. Usually effective for only 1 hour
3. May be messy
4. New application needed for subsequent intercourse

STERILIZATION
I. FEMALE STERILIZATION (BILATERAL TUBAL LIGATION)
 Effectiveness Rate: 99.6%
 Mode of Action: Prevents egg and sperm from meeting
 Side Effects: Minor pain or swelling at operative site

 WARNING Signs:
1. Signs of infection
2. Signs of pregnancy

II. MALE STERILIZATION (VASECTOMY)

 Effectiveness Rate: 99.85%
 Mode of Action:
 Prevents passage of sperm into the vagina
 No meeting of sperm and egg
 Side Effects: Minor pain, swelling at operative site
 WARNING Signs:
1. Signs of pregnancy of the partner
2. Signs of infection
 Advantages of Sterilization:
1. Ends concern about contraception
2. Although expensive initially, long term cost is low
3. Tubal ligation: Can be performed right after child birth or as an outpatient at another time
4. Vasectomy: May be performed in physician’s office under local anesthesia
 Disadvantages of Sterilization:
1. Does not protect against STI/HIV transmission
2. Reversal is difficult, expensive, and potentially impossible
3. With potential complications of all surgeries
4. Vasectomy: Requires another contraceptive method until semen is free of sperm

LACTATIONAL AMENORRHEA METHOD (LAM)

 Mode of Action: Inhibits ovulation
 Advantages:
1. Universally available
2. Contributes to improved maternal and child health nutrition
 Disadvantages:
1. Effective only for a maximum of six months postpartum
2. Decreased effectiveness if mother and child are separated for extended period of times
3. Full or nearly full breast-feeding for six months may be difficult to maintain
4. Does not protect against STI/HIV transmission
COITUS INTERRUPTUS
 Effectiveness Rate: 81%
 Advantages:
1. Acceptable to most religions
2. Not dependent on medically qualified personnel
 Disadvantages:
1. Requires great control on the part of the man
2. May be unsatisfying for both partners

Theories of Growth and Development

1. Sigmund Freud (Psychosexual Theory)
 1856-1939, Austrian neurologists. Founder of psychoanalysis
 offered personality development
 Stages/ Phases:
a. Oral Phase 0-18 months
 Mouth: site of gratification
 activity of infant- biting, sucking crying
 why do babies’ suck? - enjoyment and release of tension
 provide oral stimulation even if baby was placed on NPO
 Pacifier
 never discourage thumb sucking
 Oral receptive - stronger tendency of dissatisfaction; drink, smoke, overeat
 Oral aggressive - manifesting the biting of nails; cope or address anxiety; tend to curse or to
bring harmful words to somebody; tend to enjoy gossiping ; too dependent on others; easily
fooled
b. ANAL- 18 months-3 years
 site of gratification- anus
 activity- elimination, retention or defecation of feces make take place
 principle of holding on or letting go.
 mother wins or child wins
 child wins- stubborn, hardheaded antisocial (anak pupu na, child holds pupu, child wins)
 mother wins- obedient, kind, perfectionist, meticulous
 OC-anal phase
 help child achieve bowel and bladder control even if child is hospitalized.
c. Phallic- 3-6 years
 site of gratification - genitals
 activity- may show exhibitionism
 increase knowledge of a sexes
 accept child fondling his/her own genitalia as normal exploration
 answer child’s question directly
 right age to introduce sexuality – preschool
 Oedipus complex - attraction to mother : unconscious sexual desire on mother
d. Latent- 7-12 years
 period of suppression- no obvious development
 child’s libido or energy is diverted to more concrete type of thinking
 helps child achieve (+) experience so ready to face conflict of adolescence
e. Genital- 12-18 years
 site of gratification - genitals
 achieve sexual maturity
 learns to establish relationships with opposite sex
 give an opportunity to relate to opposite sex
  Freud’s Personality Components  Id overpowers ego - impulsive and
1. Id always seeks pleasure (the child)
 Operates on pleasure principle  Superego overpowers ego - person will
 Speaks up until one’s needs are met become harsh and judgemental on self
 I want and others
 Selfish personality  Freud believes that personality develops
2. Ego during the childhood.
 Operates using the reality principle
 Person is no longer selfish
 Consider needs of others
 The deciding agent of the personality
3. Superego
 Develops near the end of the preschool years
 Likened to conscience
 Knowing right or wrong
 Morals are cultivated by the people surrounding you
 Tend to involve the role of morality

2. ERIC ERIKSON (psychosocial theory)

 stresses importance of culture and society to the development of one’s personality
 environment
 Culture

 TASKS:
A. trust vs mistrust – 0-18 months
 foundations of all psychosocial task
 to give and receive is the psychosocial theme
 know to develop trust baby
 Too much or too little satisfaction can lead to fixation
 Principle of holding on and letting go
 Oral receptive - stronger tendency of dissatisfaction; drink, smoke, overeat
 Oral aggressive - manifesting the biting of nails; cope or address anxiety; tend to curse or
to bring harmful words to somebody; tend to enjoy gossiping; too dependent on others;
easily fooled
 Anal retentive/ retention - type of fixation
 Anal expulsive - messy; disorganized
a. satisfy needs on time - breastfeed
b. care must be consistent and adequate -both parents- 1st 1 year of life
c. give an experience that will add to security - touch, eye to eye contact, soft music
VALUES: Hope and Optimism

B. Autonomy vs shame and doubt- 18 mos-3 years

 independence /self gov’t
 develop autonomy on toddler
 give an opportunity of decision making like offer choices.
 encourage to make decision rather than judge.
 set limits
 Maladaptation - much autonomy and less shame and electra complex
 Jump into things without consideration
 Malignancy - too much negative and less positive
 Compulsiveness - too much perfection
  Determination - balanced negative and positive
 Weak or confused sexual identity - tend to engage in masturbation (cosmopolitan, tabloid,
FHM)
 Strictly follow rules without mistakes
VALUES: Willpower, Determination, Self Control

C. initiative vs guilt- 3-6 years

 learns how to do basic things
 let explore new places and events
 activity recommended- modeling clay, finger painting will enhance imagination and
creativity and facilitate fine motor dev’t.
VALUES: Direction and Purpose; Courage

D. industry vs inferiority (School-Age) 7-12 yrs old

 child learns how to do things well
 give short assignments and projects
VALUES: Method and Competence

E. Identity vs role confusion or diffusion (Adolescence)- 12-18 yrs of age

 learns who he/she is or what kind of person he/ she will become by adjusting to new body
image and seeking emancipation form parents
 freedom from parents.
VALUES: Devotion and Fidelity

F. Intimacy vs isolation (Young Adulthood)-20-40 yrs old

 looking for a lifetime partner and career focus
VALUE: Love

G. generativity vs. stagnation- Middle Adulthood (40- 60 or 45-65 yrs)

VALUE: Caring

H. ego integrity vs. despair: Older Adults (60’s)

VALUE: Wisdom

3. JEAN PIAGET (Cognitive Theory)

 Swiss psychologist
 develop reasoning power

 Development of thought
a. 0-2 yrs: sensorimotor
1. Neonatal reflex (1 mo.)
 Stimuli are assimilated into beginning mental images; behavior entirely reflexive.
2. primary circular reactions (1–4 mo)
 Hand–mouth and ear–eye coordination develops
 Infant spends much time looking at objects and separating self from them.
 Beginning intention of behavior is present (the infant brings thumb to mouth for a purpose:
to suck it).
 Enjoyable activity for this period: a rattle or tape of parent’s voice.
3. secondary circular reactions (4–8 mo)
 Infant learns to initiate, recognize, and repeat pleasurable experiences from environment.
 infant anticipates familiar events like a parent coming near him will pick him up
 Good toy for this period: mirror; good game: peek-a-boo
 4. coordination of secondary schemata (8–12 mo.)
 infant can plan activities to attain specific goals.
 Can search for and retrieve toy that disappears from view.
 Recognizes shapes and sizes of familiar objects.
 infant experiences separation anxiety when primary caregiver leaves.
 Good toy for this period: nesting toys (i.e., colored boxes).
5. Tertiary circular reaction (12–18 mo)
 Capable of space perception and time perception as well as permanence.
 Objects outside self are understood as causes of actions.
 Good game for this period: throw and retrieve
6. Invention of new means through mental combinations (18–24 mo)
 Transitional phase to the preoperational thought period.
 use memory and imitation to act; solves basic problems, foresee maneuvers that will
succeed or fail.
 Good toys for this period: blocks, colored plastic rings
 Schema: refers to cognitive structures by which individuals intellectually adapt to and
organize their environment

b. 2-7 yrs: preoperational thought

 the child can make mental presentations and is able to pretend
 child is closer to the use of symbols (child pretends to be drinking from a glass of water, glass
turning into rocket ship or telephone)
 Child is egocentric: unable to see the viewpoint of another.
 Displays static thinking: inability to remember what they started to talk about that at the end of
a sentence they talk about another topic.
 Concept of time- now
 Concept of distance- only as far as they can see
 Centering or focusing on a single aspect of an object causes distorted reasoning.
 Have an inability to reverse thinking and unable to state cause–effect relationships, categories,
or abstractions.
 Good toy for this period: items that require imagination (ex: modeling clay)

c. 7-12 yrs: concrete operations

 includes systematic reasoning. Uses memory to learn broad concepts (fruit) and subgroups of
concepts (apples, oranges).
 Marked by the ff:
1. Decentering
 ability of the child to perceive different features of objects and situations; no
longer focused to one aspect but more logical in dealing wit concrete objects and
situations.
2. Reversibility
 an opposite operation or continuation of reasoning back to a starting point
(follows a route through a maze and then reverses steps)
 Ex: a ball of clay can be shaped into a dinosaur can again be rolled back into a
ball of clay.
3. Conservation
 ability to know that certain properties of object like mass, volume, number or
area do not change even if there is a change in appearance
 Ex: A child can now judge right that the amount of water in the taller glass but
narrower container is the same as when the water was in the shorter but wider
glass.
4. Seriation
  ability to order/ arrange things in series based on dimension (ex: weight, volume,
size)
 Good activity for this period:
 collecting and classifying natural objects such as native plants, sea shells,
and the like
 Expose child to other viewpoints by asking questions

d. 12 years: formal operations

 Can solve hypothetical/ abstract problems with scientific reasoning; understands causality and
can deal with the past, present, and future.
 Adult or mature thought.
 Good activity for this period: “talk time” to sort through attitudes and opinions

DEVELOPMENTAL MILESTONES
A. Period of infancy
a. Play- Infancy- solitary plays
 solo, mom interactive
 facilitate motor and sensory dev’t
 safety- important age appropriate
 solitary play- mobile, teeter, music box, rattle
b. fear of infancy- stranger anxiety begin @ 6-7 mos, peaks @ 8 mos, diminishes @ 9 mos

 1 month- dance reflex disappears looks at mobile

 2 months - holds head up when in prone
social smile,
baby coos “doing sound”
cry with tears (dependent on structural and functional maturity)
closure of posterior fontanel: 2-3 months
head lag when pulled to sitting position
 3 months
 holds head and chest up when prone
 follows obj. past mid line
 grasp and tonic neck reflex fading
 hand regard (looks at hand)
 4 months
 turns from front to back
 head control complete
 needs space to turn
 laughs aloud, babbling sounds
 5 months
 turn both ways “roll-over”
 teething rings
 handles rattle well
 moro reflex disappears (4-5 months)
 6 months
 reaches out in anticipation of being picked up
 sits with support
 uses palmar grasp
 eruption of 1st temp teeth 6-8 months 2 lower incisors
 say vowel sounds “ah”, “oh”
 handles bottle well
 7 months
  transfers obj. hand to hand
 likes objects that are good size
 8 months
 sits without support
 peak of stranger anxiety
 plantar reflex disappears @ 8-9 months in prep for walking
 9 months
 creeps or crawls
 neat finger grasp reflex
 combine 2 syllables “mama” and “papa”
 needs space for creeping
 10 months
 pulls self to stand
 understands “no”
 responds to own name
 peak a boo, pat a cake
 can clap
 11 months
 cruises
 stands with assistance
 12 months
 stands alone takes 1st step
 walks with assistance
 drinks from cup, cooperates in dressing
 says 2 words mama and dada
 pots and pans, pull toy, nursery rhymes

 Toddler
 parallel play
 2 toddlers playing separately
 provide with similar toys
 squeaky toy to squeeze
 waddling duck to pull
 trucks to push-push pull toy
 building blocks, pounding peg
 toys to ride on
 fear- separation anxiety
 begin 9 months
 peak 18 months
 3 phases of separation anxiety (in order)
1. p - protect
2. d - despair
3. d - denial
 don’t prolong goodbye
 say goodbye firmly to develop trust- say when you’ll be back

 15 months
 plateau stage
 walks alone
 lateness in walking- mild mental retardation
 puts small pellets into small bowl
 holds spoon well
  seats self on chair
 creeps up stairs
 4 - 6 words
 18 months
 height of possessiveness
 favorite word- “mine”
 bowel control achieved (bowel 1st before bladder)
 no longer rotates spoon
 can run and jump in place
 walks up and down stairs holding railing or persons hand
 1-20 words
 names body part
 puts both feet on 1 step before advancing.
 24 months
 terrible two
 can open doors by turning door knobs
 unscrew lids
 can walk upstairs alone –using both feet on same step at same time
 50-200 words (2 words sentences)
 daytime bladder control achieved (daytime
 1 st - next night time bladder control)
 30 months or 2 ½ years
 makes simple lines or stroke for crosses with a pencil
 can jump down from chairs
 knows full name
 copies a circle
 holds up finger to show age
 temp. teeth complete
 post molar- last temp teeth to appear
 deciduous teeth -20
 beginning of toothbrush – 2-2 ½ yrs
 tooth brushing with little assistance - 3 yrs
 tooth brushing alone – 6 yrs
 right time to bring to dentist- when temporary teeth complete
 36 months or 3 yrs
 “trusting 3”
 unbutton buttons (unbutton before learn to button)
 draw a +
 learns how to share
 knows full name and sex (gender identity)
 speaks fluently
 nighttime bladder control
 300-900 words
 ride a tricycle

 Characteristic traits of toddler

 negativistic- “NO!”
 way to search for independence
 limit questions
 modify questions to a statement
 rigid, ritualistic and stereotype
  ritualism- for mastering
 prominent abdomen-due to underdeveloped abdominal muscles
 physiologic anorexia
 due to preoccupation with environment
 food jag that last for short period of time
 loves rough and tumbling play
 temper tantrums
 head banging, screaming, stamping feet, holds breath
 Mngt of temper tantrums:
 Ignore behavior (but should be observed from self-injury or anything in the environment
which can be a source of injury.
 Be calm and be patient
 Remove him from immediate cause of tantrum with the adult whom he knows loves him
 Avoid restraining the child
 Care after a tantrum:
 Make few comments of his behavior
 He should not be punished
 Wash face and hands if he cooperates
 Give a toy to divert attention
 Characteristic traits of toddler
 loves toilet training
 failure of toilet training- unreadiness
 Clues of toilet readiness:
 can stand, squat walk alone
 can communicate toilet needs
 can maintain dry for 2 hours
 Pre schoolers
 associative or cooperative play
 bahay-bahayan – play house
 role playing
 fear-body mutilation or castration
 fear of dark places, witches
 fear of thunder and lightning
 fear of ghosts

 4years old
 “furious 4” , noisy, aggressive, stormy
 can button buttons
 copy a square
 jumps and skips
 laces shoes
 vocabulary 1,500
 knows four basic colors
 5 years old
 “frustrating 5”
 copy a triangle
 draw a 6-part man
 imaginary playmates
 2,100 words

 Character Traits of Pre-schooler:

 curious, creative imaginative, imitative
  2 favorite words- why and how
 complexes- word identification to parent of same sex and attachment to parent of opposite sex
 ex. Oedipal complex- boy to mom, Electra complex- girl to dad
 Cause of incest marital discord
 Death associated with sleep only
 Behavior problems: Preschool
 telling tall tales-over imagination
 imaginary friend- to release tension and anxieties
 sibling rivalry - jealousy to newly delivered baby.
 regression- going back to early stage
 thumb sucking (should be oral stage only)
 baby talk
 bed wetting
 fetal position
 masturbation- sign of boredom
 divert attention - offer a toy

 School Age
 Play- competitive play
 Ex. Tug of war, track and field, basket ball

 Fear
1. school phobia
 orient to new environment
2. displacement from school
 teacher and peer of same sex
3. loss of privacy
 Wants bra
4. fear of death
 7-9 yrs old: death is personified
 death - permanent loss of life

Significant Development
 Boys - prone to bone fracture; mature vision 20/20

 6 years
 temp teeth begin to fall
 permanent teeth appear- 1 st molar
 1 st temp teeth- 5 months
 1 st perm teeth- 6 yrs
 yr of constant motion
 recognizes all shapes
 1 st grade teacher becomes authority figure
 nail biting
 begin interest in God.
 7 yrs
 assimilation age
 copy a diamond
 enjoys teasing and playing alone
 quieting down period
 8 yrs
 expansive age
  smoother mouth
 loves to collect objects
 count backwards
 9 yrs
 coordination improves
 tells time correctly
 hero worship
 stealing and lying are common
 takes care of body needs completely
 teacher finds this group difficult to handle
 10 yrs
 age of special talent
 writes legibly
 ready for competitive games
 more considerate and cooperative
 joins orgs.
 well-mannered with adult
 critical of adults
 11-12 yrs
 pre adolescents
 full of energy and constantly active
 secret language are common
 share with friend’s secrets
 sense of humor present
 social and cooperative

 Character Traits School Age

1. industrious
2. modest
3. can’t bear to lose- will cheat
4. love collections- stamps
 Signs of sexual maturity
 GIRLS: Thelarche-Adrenarche-Menarche (in sequential order)
 I-increase size of breast and genitalia
 thelarche- 1 st sign sexual maturation
 W- widening of hips
 A- appearance axillary, pubic hair (adrenarche)
 M- menarche- last sign sexual maturation
 BOYS:
 A - appearance –axillary pubic hair (1st sign sexual maturity)
 D - deepening voice
 D - development of muscles
 I - increase in testes and penis size
 P- produces viable sperm (last sign sexual maturity)
 Adolescent
 Fear
1. obesity
2. acne
3. homosexuality
4. death
5. replacement from friends
6. significant person- opposite sex
 Significant development
1. experiences conflict b/n his needs for sexual satisfaction and societies’ expectation
2. change of body image and acceptance of opposite sex
3. nocturnal emission – wet dreams
4. distinctive odor- due to stimulation apocrine glands
5. sperm is viable by 17 yrs
6. testes & scrotum increase until age 17
7. breast and female genitalia increase until age 18
 Personality Traits
 idealistic
 rebellious
 reformers
 conscious with body image
 adventuresome
 Problems:
 vehicular accident
 smoking
 alcoholism
 drug addiction
 premarital sex