Dr.

Mazin PEDIATRICS 27/9/2016

Well baby clinic

Learning objectives :
• Describe the purpose of prenatal history.
• Recognize the significance of common abnormalities found shortly
after birth.
• Selects a careful steps in examination of the newborn
• Explain when and what are the appropriate outpatient follow-up
for the healthy Infant.
History :
• The mother:
• Parent’s blood groups and Rh antigen,
• Duration of labour,
• Whether or not there was an operative delivery,
• Drugs and anaesthetics.
• Antenatal Ultrasound Findings (heart, brain and kidneys)
• The baby:
• Condition at birth and Apgar scores at 1 and 5 minutes after birth
and
• Details of any resuscitative measures used.
• Vitamin K administration

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The 1st 24 hours of Life
The first 24 hours of life is a very significant and a highly
vulnerable time due to critical transition from
intrauterine to extrauterine life

Immediate Care of the Newborn:

• Airway &Breathing
• Temperature

Airway & Breathing

• Suction gently & quickly using bulb syringe or suction catheter
• Starts in the mouth then, the nose to prevent aspiration

Temperature
• Dry immediately
• Wrap warmly

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APGAR Scoring:
 Standardized evaluation of the newborn
 Perform 1 minute and 5 minutes after birth
 Involves (5) indicators:
• Activity
• Pulse
• Grimace
• Appearance
• Respirations

Immediately after birth

• Proper Identification

• Gender determination

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Care of the Newbornin the Nursery

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Components) im)
 Anthropometric Measurements
 Bathing
 Cord Care
 Dressing/ Wrapping
 Eye prophylaxis
 Foot screening program
 Gender identification & Genitalia exam.
 Human milk (encourage breast milk)
 Injection of Vitamin K

Anthropometric Measurements
• Weight:
 2.5-4 kg
 Low Birth Weight = below 2.5 kg

• Length:
Average: 50 cm

• Head Circumference (HC):

33 to 35.5 cm

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• Bathing
 Oil bath or complete warm water bath
 From cleanest to dirties part

• Cord Care---Daily
 Keep cord dry and clean & clamp secured
 Apply 70% isopropyl alcohol to the cord with each diaper change and
at least 2-3x a day.
 Note for any signs of bleeding or drainage from the cord and other
abnormalities
 Sponge bath until cord falls off.
 DO NOT cover with diaper

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Cord Care

• Eye Prophylaxis
Protect the baby from an unknown Gonorrhea or Chlamydia
infection in the mother’s body

Erythromycin ointment is the antibiotic most commonly used

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• Foot neonatal screening program in Iraq

Disorder If not screened If screened
Screened
Congenital Severe mental Normal
Hypothyroidis retardation
m
Galactosemia Death or Alive and
Cataracts normal
Phenylketonuria Severe mental Normal
retardation
Performed after 24 hours of life up to 3 days

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•Genitalia exam & Gender Identification

• Female:
• Labia: edematous
• Clitoris: enlarged
• (+) Smegma
• Pseudomenstruation possible
• Visible “hymen tag”
• First voiding within 24 hrs
• Male:
• Prepuce covers glans penis
• adherent foreskin =
Phimosis
• Scrotum: edematous
• Enlarged = Hernia
• Meatus: central
• Ventral/ dorsal =
Hypo/epispadias
• Testes: descended
• Undescended =
Cryptorchidism

•Human milk, hyeigen

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•Injection of vitamin K

Reduces the risk of hemorrhagic disease in the newborn.

Daily Care
1. Nutrition/ Feeding
2. Elimination
3. Weight
4. Bathing & Hygiene
5. Obtain vital signs
6. Rooming-in (allow the baby stay
with mother throughout
hospital stay)
7. Note for any abnormalities

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NEWBORN ASSESSMENT

Assessment of the newborn is essential to ensure a successful

transition

General Guidelines
• Keep warm during examination
• From general to specific
• Least disturbing first
• Document all abnormal findings & provide nursing care

Examination

1. Earliest possible detection of deviations from

normal.
A. Major deviations: Serious correctable congenital
malformations;
i. Early Dx. enables Rx. that makes the difference between life
& death, e.g. oesophageal atresia, imperforate anus, and
diaphragmatic hernia.
ii. Early Dx. enables Rx. that reduce the incidence of permanent
& severe disability, e.g. congenital dislocation of the hips &
club feet
B. Minor deviations: Enables the doctor to give parents a clear
explanation about minor deviations from usual (if present, eg
birth marks, acrocyanosis) which if not explained are likely to
cause concern.
2. Establishes a baseline for subsequent examinations.

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Examination :
• When
Immediately after birth
Within the 1st 24 hours after birth
Before discharge from maternity unit
As a scheduled visits for 2 years (due to the rapid growth and change
that occurs during infancy).
Whenever there is any concern about the infant's progress
Examination
• General
It is important that a few exact measurements be made and recorded:-
 Weight
 Crown-heel length
 Head circumference.
 Record respiratory rate & heart rate with infant quiet.
 Routine examination should be flexible.
Examination
• Overall Inspection
 In general does he look ill or well?
 Is he normally active?
 Is the cry normal?
 Are there any obvious malformations? (e.g. with Down Syndrome?)
 What is his colour? Pallor? Cyanosis? Plethora? Jaundice?
 What is his respiration? Chest movements? Is there a grunt?
 The apex beat is frequently visible on inspection.
 What is the shape of the head?

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• Skin Color
o Cyanosis/ Acrocyanosis
o Pallor
o Jaundice
o Meconium staining

Acrocyanosis

•Bluish discoloration of palms of hands &

soles of feet
•Due to immature peripheral circulation
•Exacerbated by cold temperatures
•Occurs in full term and premature newborn
•Normal within 1st 24 hrs

Acrocyanosis of the newborn

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Pallor/ Cyanosis
May indicate hypothermia, infection, anemia, hypoglycemia, cardiac,
respiratory or neurological problems

Jaundice
• Under natural light
• Blanch skin over the chest or tip of the nose

Meconium Staining
• Over the skin, fingernails & umbilical cord
• Due to passage of meconium in utero r/t fetal hypoxia

Birth marks:
Mongolian Spots
Blue-green or gray pigmentation
Lower back, sacrum & buttocks
Disappears by 4 years of age

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Birth Marks (Mongolian spot)

Abdomen
• Umbilical Cord
 2 arteries; 1 vein
 White & gelatinous immediately after birth
 Begins to DRY between 1-2 hrs following birth
 Dried & gradually falls off by 7 days

• GIT:
o Bowels sounds; (+) within 1-2 hrs after birth
o Presence of mass, distention depression or protrusion
o Scaphoid = diaphragmatic hernia
o Distended = LGIT obstruction/ mass

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Anus
Imperforate anus

Stools of newborn
First stool (Meconium) – Transition/normal stool
within 1st 24 hrs Yellow; Within 2- 10 days
Sticky, tarlike, blackish-green, after birth
odorless material

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Well-Baby examination

• At birth
• Head to-toe exam. With special attention to:
• Gestational age
• Head circumference
• Genitalia
• Presence of neonatal reflexes
• Metabolic screen
• Blood glucose screening should be performed on infants at risk for
hypoglycemia, e.g. infants of diabetic mothers
• Vitamin K administration after delivery
• Recommend human milk for all infants (except if there is a
contraindication)

•
Discharge
• Most infants are ready for discharge at 48 hours after a vaginal
delivery and 72 to 96 hours after a cesarean section delivery.
• The infant is medically ready for discharge when:
 He or she has stable vital signs for at least 12 hours
 Appears healthy and has normal physical examination
 Passed stool and voided
 Is feeding well
 Has completed all screening tests, and
 Has appropriate follow-up care planned.
Norms in the first few days after birth
• The 4- to 5-day-old infant who is consuming an adequate amount
of human milk should have 6 to 8 voids and yellow, seedy stools
daily and have lost no more than 7% to 8% of birth weight.
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• Most infants void by 12-24 hours of age and pass stool by 48
hours.
• Achieving the same birth weight at 10-14 days of life
Well-Baby examination
• The Pediatrician should see the infant for a check-up
o At birth,
o Two weeks,
o Two months,
o Four months,
o Six months,
o Nine months,
o 12 months,
o 15 months,
o 18 months,
o 24 months, and
o Annually thereafter.
Well-Baby examination
• A well-baby exam consists of :
o Answer parent’s questions about the baby's general health and
development
o Physical exam: measurements of length/ height, weight and head
circumference, vital signs, and a general physical examination.
Weight is a pediatric vital sign, because of dosing
considerations and the importance of growth as an indicator
of chronic disease in children.
o Special attention is paid to whether the baby has met normal
developmental milestones.

Well-Baby examination
• At two weeks: The first well-baby visit occurs.
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Complete head to-toe exam
Developmental milestones that represent a normal progression of
physical & mental maturity should be assessed
Immunisation: If BCG, Oral Polio Vaccine, Hepatitis B vaccine were
not given in the hospital, the first shot may be given at this visit.

• The two-month visit will be a repeat of the two week visit with a
physical exam, developmental and behavioral assessment, guidance
for upcoming developmental changes, and immunizations (DPT, polio
and hepatitis B).

• The four & six-month exam

o Physical exam, developmental and behavioral.
o Discuss adding solid foods to the baby's diet, usually in the form of
cereal then crushed food.
o Immunization
• The 9-mo & 1-yr exam : quite a change in baby from birth.
o Answer questions regarding the baby's sleep habits, feeding
patterns, teething, standing up, walking and talking.
o The physical exam is performed, plotted on the standard growth
curve, and any deviations are noted.
o A blood test for anemia may be performed

Growing up Involves three major dynamic processes:

• Growth
• Development
• Sexual Maturation

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Average physical growth parameters

Age OCCIPITOFRONTAL HEIGHT WEIGHT DENTITION
CIRCUMFERENCE
Birth 35 cm 50.8 cm 3 to 3.5 kg Central incisors—
+2cm/mo (0 to 3 mo) Regains birthweight by 2 6mo
+1cm/mo (3 to 6 mo) + 25.4cm wk Lateral incisors—
+0.5cm/mo (6 to 12 Doubles birthweight by 5 8mo
mo) mo
Mean = 1cm/mo
1 year 47 cm 76.2 cm 10kg First molars—14
+ 2cm + 12.7 cm Triples birthweight mo
Canine –19 mo
2year 49 cm 88.9 cm 12 to 12.5 kg Second molars—
24mo

…THE END…

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