Newborn Priorities in the First Days of Life

All newborns have a number of needs in the first few days of life that take priority.

They include:

1. Initiation and maintenance of respirations

2. Establishment of extrauterine circulation
3. Maintenance of fluid and electrolyte balance
4. Control of body temperature
5. Intake of adequate nourishment
6. Establishment of waste elimination
7. Prevention of infection
8. Establishment of an infant–parent/caregiver relationship
9. Institution of developmental care or care that balances physiologic needs and
stimulation for best development

Indications a newborn is having difficulty making the transition from intrauterine to

extrauterine life may be first apparent by a low Apgar score rating. Not all newborns will be
able to achieve full wellness because of extreme insults to their health during pregnancy or at
birth or because of difficulty preparing for extrauterine life.

INITIATING AND MAINTAINING RESPIRATIONS

Ultimately, the prognosis of a high-risk newborn depends primarily on how the first
moments of life are managed because most deaths occurring during the first 48 hours
after birth result from the newborn’s inability to establish or maintain adequate
respirations (National Vital Statistics Service [NVSS], 2011)

An infant who has difficulty breathing may experience residual neurologic morbidities as a
result of cerebral hypoxia. Most infants are born with some degree of respiratory acidosis, but
this is rapidly corrected by the spontaneous onset of respirations. By 2 minutes after birth, the
development of severe acidosis is already well under way. Newborn defense mechanisms then
become inadequate to reverse the process. (Dani, Bresci, Berti, et al., 2013).

An infant who sustains any degree of asphyxia in utero may already be experiencing acidosis at
birth and may have difficulty before the first 2 minutes of life. Struggling to breathe and
circulate blood, the infant is forced to use available serum glucose quickly and so may
become hypoglycemic, compounding the initial problem even further.. (Wyckoff et al., 2015).
COMMON FACTORS THAT PREDISPOSE INFANTS TO RESPIRATORY DIFFICULTY AND SO MAY
REQUIRE RESUSCITATION

Factors Predisposing Infants to Respiratory Difficulty in the First Few Days of Life
Low birth weight
 Intrauterine growth restriction
 Maternal history of diabetes
 Premature rupture of membranes
 Maternal use of barbiturates or narcotics close to birth
 Meconium staining
 Irregularities detected by fetal heart monitor during labor
 Cord prolapse
 Lowered Apgar score (<7) at 1 or 5 minutes
 Postmaturity (postterm)
 Small for gestational age
 Breech birth
 Multiple birth
 Chest, heart, or respiratory tract anomalies

RESUSCITATION
The American Academy of Pediatrics (AAP) has instituted a Neonatal Resuscitation Program
updated at intervals that lists steps and rationales for newborn resuscitation. 10% of newborns
require some assistance to begin breathing at birth, according to the AAP; this can vary from
facility to facility and infant to infant. (Sawyer, Umoren, & Gray, 2017).

Establish an airway, expand the lungs, and initiate and maintain effective positive pressure
ventilation in a newborn. If respiratory depression becomes so severe that a newborn's heart
begins to fail (heart rate is less than 60 beats/min)  resuscitation should then also include chest
compressions.. (Wyckoff et al., 2015).

AIRWAY
For a well, term newborn, usually warming, drying the baby by rubbing the back is enough to
initiate respirations. A rubber bulb syringe is a standard piece of equipment in most birthing
rooms and was often used in the past to suction infants' noses and mouths. But because
bradycardia can be associated with bulb suctioning, it is no longer recommended.
(Wyckoff et al., 2015).

If a newborn infant does not initiate spontaneous breathing following gentle stimulation, place
the infant under a radiant heat warmer in a "sniffing" position. Assess a precordial pulse over
the heart and attach a pulse oximeter to monitor oxygen saturation. It is reasonable to consider
the application of a 3-lead cardiac monitor during resuscitation to obtain an accurate heart rate
quickly.. (Wyckoff et al., 2015).

A newborn whose amniotic fluid was meconium stained at birth but is breathing does not need
suctioning to clear the airway. If the newborn has poor muscle tone and inadequate breathing,
it is important to begin the initial steps of resuscitation under the warmer. Positive pressure\
ventilation should be initiated immediately if the newborn is not breathing or the heart rate is
less than 100 beats/min. (Wyckoff et al., 2015).

IN MOST NEWBORNS, MECHANICAL SUCTIONING IS NOT NECESSARY, BUT SHOULD BE USED

ONLY IF THERE IS AN OBSTRUCTION SUCH AS A MUCUS PLUG THAT IS INTERFERING WITH
EFFECTIVE BREATHING.

Suctioning a newborn with mechanical suction controlled by a finger valve. The suction is
applied as the catheter is withdrawn. If the catheter is rotated as it is withdrawn, the risk of
traumatizing the membrane is reduced.

During the first few seconds of life, a newborn may take several weak gasps of air and then
almost immediately stop breathing; the heart rate begins to fall. After 1 or 2 minutes of primary
apnea, an infant again tries to initiate respirations with a few strong gasps. Most infants cannot
maintain this effort for more than 4 or 5 minutes before they enter secondary apnea - a period
when breathing becomes increasingly difficult and may be ineffective. Both types of apnea
occur in utero and resuscitation must be started as soon as possible.. (Wyckoff et al., 2015).

Both types of apnea may occur in utero. Resuscitation must always be started as if secondary
apnea is occurring. Laryngoscope and endotracheal tube insertion should be present at the
birth of infants identified as high-risk for apnea. (Wyckoff et al., 2015)

LARYNGOSCOPE
INSERTION IS EASY IN THEORY; IN PRACTICE, THE WIDE VARIATION IN THE SIZE OF INFANTS’
POSTERIOR PHARYNGES AND TRACHEAS AND THE EMERGENCY CONDITIONS PRESENT UNDER
WHICH IT IS ATTEMPTED, MAKE IT AN OFTEN DIFFICULT PROCEDURE

Intubation. Place the head in a neutral position with a towel under the shoulders. The blade of
the laryngoscope is inserted to reveal the vocal cords. An endotracheal tube for ventilation is
then passed into the trachea, past the laryngoscope.

They are inserted through a tube called an endotracheal tube (think of a thin coffee straw) into
the trachea. Infants under 1,000 g need a 2.5-mm laryngoscope; those over 3,000g need a 4.0-
mm instrument; preterm infants are prone to haemorrhage because of capillary fragility, so
gentle care is crucial.

LUNG EXPANSION
When an infant needs air or oxygen by bag and mask to aid lung expansion, be certain the mask
covers both the mouth and nose. Air (or oxygen if needed) should be administered at a rate of
40 to 60 ventilations per minute. The pressure needed to open lung alveoli for the first time can
be as high as 40 cm\rH2O. After that, pressures of 15 to 20 cm H2O are generally adequate to
continue.. (Wyckoff et al., 2015).

THE PRESSURE FROM ANESTHESIA BAGS IS CONTROLLED SOLELY BY THE PRESSURE A

HEALTHCARE PROVIDER USES WHEN THE HAND SQUEEZES AGAINST THE BAG. OTHER TYPES
OF BAGS SUCH AS THE SELF-INFLATING (AMBU) BAG CAN BE SET WITH A BLOWOFF VALVE
THAT LIMITS THE PRESSURE IN THE APPARATUS TO BE CERTAIN ONLY GENTLE PRESSURE IS
APPLIED

Types of ventilation bags used in neonatal resuscitation.

(A) The flow-inflating (anaesthesia) bag requires a compressed gas source for inflation but is
able to deliver 100% oxygen. (B) The self-inflating (Ambu) bag remains inflated at all times and
is not dependent on a compressed gas source. It is limited to delivering oxygen concentration
to about 40%.

If a newborn is not breathing adequately, there is little chance of survival if they are not given
adequate ventilation, so it is important to monitor their oxygen saturation and pressure in
addition to auscultating the chest for the sounds of air movement. It is important not to let
oxygen levels in a newborn fluctuate because this can cause bleeding from immature cranial
vessels. (Wyckoff et al., 2015).

The endotracheal tube is probably in the trachea and not the respiratory tract (the area where
air enters and exits the lungs). If air can be heard on only one side or sounds are not symmetric,
the tube is likely blocking the air from entering one of the main-stem bronchi. Pulling the tube
back half a centimetre will usually allow oxygen to flow to both lungs. If the resuscitation has
continued for over 2 minutes, insert an or gastric tube (through the mouth to the stomach
instead of through the nose to the nose) because babies are obligate nose breathers.

DRUG THERAPY
Few medications are necessary for newborn resuscitation. Even if an infant's respiratory
episode appears to be related to the administration of a narcotic such as morphine or Demerol,
naloxone (Narcan) should not be routinely administered because it has little effect and may
cause seizures in a newborn. (Leone, Finer, & Rich, 2012). Instead, resuscitation efforts should
focus on effective ventilation and airway support for the persistently apneic newborn (Wyckoff
et al., 2015). If heart rate continues to be inadequate (less than 60 beats/min), epinephrine
1:10,000 may be administered intravenously (IV) to stimulate heart action. Preterm infants may
receive surfactant to replace the natural surfactant that has not yet formed in their lungs.

VENTILATION MAINTENANCE
The first few hours after birth are crucial for a newborn's ability to breathe in and out of air. A
steadily increasing respiratory rate, grunting, and nasal flaring are often the first\signs of
obstruction or respiratory compromise in newborns. Place a newborn who is having difficulty
with maintaining respirations under an infant radiant warmer to help prevent cooling and
acidosis. "Bagging" the infant with a mask and ventilation bag for a minute before suctioning
will usually improve the baby's oxygen level.

ESTABLISHING EXTRAUTERINE CIRCULATION

if an infant has no audible heartbeat, or if the cardiac rate is below 60 beats/min, chest
compressions should be started. Hold the infant with fingers encircling the chest and wrapped
around the back and depress the sternum at a rate of at least 100 times per minute. (Wyckoff
et al., 2015). A newborn's heart rate should be monitored closely to ensure adequate
ventilation. If the heart rate is not above 60 beats/min after 30 seconds of positive-pressure
ventilation and chest compressions, intravenous epinephrine to stimulate heart action may be
prescribed. It is possible to palpate a femoral pulse. Wyckoff et al., 2015). Following
cardiopulmonary resuscitation, newborns should be transferred to a transitional or high-risk
nursery for continuous cardiorespiratory observation and care to be certain cardiac function is
maintained

MAINTAINING FLUID AND ELECTROLYTE BALANCE

Infants with hypoglycaemia are treated initially with intravenous 10% dextrose in water to
restore their blood glucose level. Dehydration may also result from increased insensible water
loss caused by rapid respirations. Sodium, additional glucose, and potassium are added as
needed according to electrolyte\laboratory results. When using a radiant warmer, remember
there is a tendency for water loss from either convection or radiation. A newborn on a warmer
may require more fluid than if he or she were placed in a double-walled incubator. Be certain to
monitor the rate of fluid administration conscientiously in high-risk infants. Monitor fluid status
both by urine output and urine specific gravity values. An output less than 2 ml/kg/hr or a
specific gravity greater than 1.015 to 1.020 suggests inadequate fluid intake. If hypervolemia is
present immediately after birth, the cause is usually fetal blood loss from placenta previa or
twin-to-twin transfusion. The haematocrit may be normal for some time after acute blood loss,
however, because blood cells present are in proportion to plasma. An isotonic solution (usually
saline) may be administered to increase blood volume. A vasopressor such as dopamine may be
given to increase pressure and improve cell perfusion.

REGULATING TEMPERATURE

All high-risk infants may have difficulty maintaining temperature because, in addition to stress
from an illness or immaturity, the infant s body is often exposed for long periods during
procedures such as resuscitation. It's important to keep newborns in a neutral-temperature
environment because it places less demand on their metabolism. If their environment is too
hot, they are forced to decrease metabolism to cool their body. If it's too cold, they must
increase their metabolism to warm body cells. Increased metabolism can be destructive
because it calls for increased oxygen, and without this available, body cells become hypoxic.
In addition to covering the newborn with an infant cap, wiping the body and head dry with a
towel or blanket, and using a radiant warmer or prewarmed incubator suggest skin-to-skin
contact with one of the parents. Additional measures that can be used to ensure the infant’s
temperature stays between 36.5°C and 37.5°C (97.8°F and 99.5°F) axillary are plastic wrap,
increasing the room temperature, and warmed mattresses (Wyckoff et al., 2015). To prevent
heat loss, be certain during any procedure that the infant is not placed on a cool X-ray table or
scale.

A neutral thermal environment. (A) A neonate in anintensive care bed with overhead radiant
warmer can be examined periodically with ease. (B) Use of an incubator allows maintenance of
a neutral thermal environment for neonates not requiring minute-tominute interventions.

RADIANT HEAT SOURCES

Radiant heat warmers are open beds that have an attached overhead source of radiant heat
and provide both warmth and visibility for observation. Such units have small probes, covered
by a small shield, often silver metallic, which when placed on the infant's skin, register the
baby's temperature. Abdominal skin temperature, when measured, should be 95.9° to 97.7°F
(35.5° to 36.5 °C). If an infant's temperature falls below this level, an alarm on the unit can be
set to sound.

INCUBATORS
The temperature of incubators varies with the amount of time portholes remain open and the
temperature of the area in which the incubator is placed. Placing one in direct sunlight or near
a warm radiator can increase the internal temperature markedly. For these reasons, a
newborn's temperature must be assessed at frequent intervals when in an incubator to be\
certain the temperature level is being maintained. Some incubators have sensors that monitor
an infant's body temperature and change the temperature of the incubator as needed. Dress
the infant as if he or she is going to be in a bassinet, then set the temperature about 2°F (1.2°C)
below normal. After a half hour, assess whether the infant is able to maintain body.
Temperature. If not, the process should be slowed or stopped until the baby is more mature or
better able to self-regulate temperature.

SKIN-TO-SKIN CARE
Kangaroo care is the use of skin-to-skin contact with a parent to maintain body heat for an
infant. This method of care not only supplies heat but also encourages parent–child bonding,
according to the American Academy of Family, Child and Human Services (AAPH). (Moore,
Anderson, Bergman, et al., 2012).

ESTABLISHING ADEQUATE NUTRITIONAL INTAKE

If an infant's respiratory rate is so rapid that the infant cannot suck effectively, gavage feedings
may be necessary. Others with a long-term nutrition concern may have gastrostomy tubes
placed. Preterm infants should be fed breast milk if at all possible because of the immune
protection this offers. When an infant is too young to breastfeed, a mother can express her own
breast milk or use a breast pump to initiate and continue her milk supply until the time the
infant is mature enough to breast feed. Her expressed breast milk can then be used in the
baby's gavage feeding. (Martin et al., 2016). Be certain when bottled breast milk is that it is
well marked with the infant's name, date and time it was pumped, and medical record number
or breast milk errors can occur the same as those caused by medication errors (Centers for
Disease Control and Prevention [CDC], 2016). It should be stored in polycarbonate- (bisphenol
A) free plastic bags or bottles, which can leech into stored milk and possibly lead to endocrine
disruptions (Trasande, 2014).
INFANTS WHO ARE ILL AT BIRTH OFTEN NEED SUPPLEMENTAL FEEDINGS BY NASOGASTRIC
OR GASTROSTOMY TUBE.

Preterm infants who use a pacifier at feeding times are more likely to show signs of hunger -
such as rooting, crying and sucking motions - than those who are gavage or gastrostomy fed. In
immature infants, this may be because they need oral stimulation from non-nutritive sucking so
seem to enjoy using the pacifier more. (Alm, Wennergren, Möllborg, et al., 2016). Exceptions
include infants who must not swallow air, such as those with a tracheoesophageal fistula
awaiting surgery; or those mature enough to breastfeed. The techniques of gavage feeding and
gastrostomy feeding are discussed.

ESTABLISHING WASTE ELIMINATION

Most immature infants void within 24 hours of birth, but they may void later as their blood
pressure may not be high enough to supply their kidneys. Immature infants also may pass stool
later because meconium has not yet reached the end of the intestine's intestine-rat birth stage.
Carefully document any voiding’s that occur during resuscitation because this is proof that
hypotension is improving and the kidneys are being perfused.
PREVENTING INFECTIONS
Infections in high-risk newborns may occur from prenatal, perinatal, or postnatal causes. The
risk of preterm premature rupture of the membranes is what places the infant in a ‘high-risk
category’ for developing brain and nervous system damage. (Committee on Practice Bulletins-
Obstetrics, 2016). Contracting an infection has the potential to drastically complicate a high-risk
newborn’s ability to adjust to extrauterine life, another reason breastfeeding is good for such
infants because, beginning with colostrum, it supplies important immune protection (Verardo,
Gómez- Caravaca, Arráez-Román, et al., 2017). Perinatal infections are those contracted from
the vaginal canal during birth, such as herpes simplex 2 and hepatitis B. Early-onset sepsis is
most commonly caused by group B streptococcus, Escherichia coli, Klebsiella, and Listeria
monocytogenes. Hospital-acquired infections are probably most commonly spread to newborns
from healthcare personnel. All persons coming in contact with or caring for infants should
observe good hand washing techniques.

ESTABLISHING PARENT–INFANT BONDING

Parents of high-risk babies should be offered a tour of a neonatal intensive care unit (NICU)
during pregnancy so they will be more comfortable in the high-tech environment. They should
also be able to visit the special nursing run it where the infant is admitted as soon as possible
and as often as they choose. If an infant does not survive initial illness, these interactions can
also help make the death more real and can help parents work through their feelings. If an
infant dies despite newborn resuscitation attempts, parents need to see the baby when no
longer attached to equipment. Urge parents to spend as much time with their infant in the
intensive care unit as possible. Viewing the baby can help reassure them that the baby was a
perfect newborn in every other way except lung function or whatever was the infant's specific
fatal disorder.

ANTICIPATING DEVELOPMENTAL NEEDS

High-risk newborns need special care to ensure the amount of pain they experience is limited.
Most high-risk infants experience "catch-up" growth once they stabilize from trauma of birth.
Some parents may need support before and after their infant is discharged home. Discussing
usual growth and development of infants can help prepare them and look forward to the next
developmental step.

Follow-Up of the High-Risk Infant at Home

Parents should assess their level of knowledge about their child's condition and development
each time they visit a special intensive care nursery. Transporting a preterm infant in a car will
require special measures, including a commercial head support because a very small infant
does not fit securely into a standard infant car seat. Some preterm infants experience episodes
of oxygen desaturation, apnea or bradycardia when seated in standard car safety seats. (Davis,
2015). To detect if this will occur, the AAP recommends all preterm infants be assessed for
cardiorespiratory stability in their car seat prior to discharge from the healthcare facility—the
“car seat challenge” (AAP,2012).

High-Risk Infants and Child Maltreatment

When a child is born ill or preterm, the expected reaction of parents is to protect them even
more than they would if they were healthy. This may be related to the feeling they are
"different" or because they were separated from the parents for a long time following birth.
(Nandyal, Owora, Risch, et al., 2013).