CHĂM SÓC THIẾT YẾU

TRẺ SƠ SINH KHỎE MẠNH

CARE FOR THE WELL TERM NEWBORN

Giảng viên: ThS.BS Dương Ngọc Mai

dnmai@medvnu.edu.vn
Lớp: Y2015
Tháng 4. 2020

Bài giảng lý thuyết trực tuyến Khoa Y – ĐHQG HCM |1

OBJECTIVES

 Understand the unique features of the physiology of the

newborn and how care of the newborn addresses these
elements
 Explain the concept of the neutral thermal environment
 Discuss the different interventions and tools to provide
thermal protection for newly born infants
 Understand the elements involved in feeding the neonate, as
well as ways breastfeeding can be encouraged

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GOALS OF CARE

Goals of postnatal neonatal care for low-risk newborns:

 Ensure transition to extra-uterine life
 Prevent or treat neonatal conditions
 Ensure a successful transition to home care

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ANTICIPATORY CARE

MATERNAL ILLNESSES
Cardiovascular Gastrointestinal Infection Autoimmune
Respiratory Renal Allergic Psychiatric
Endocrine and metabolic Neurological Haematological Malignant
MATERNAL ILLNESSES

Source: Rennie & Roberton's Textbook of Neonatology

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*Maternal illnesses that may seriously affect the baby
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IMMEDIATE NEWBORN CARE
THE FIRST 90 MINUTES
Immediate drying and additional stimulation Initiate of breastfeeding
Provide warmth Vitamin K
Skin-to-skin contact
Source: Textbook of Neonatal Resuscitation (NRP), 7th Ed. American Academy of Pediatrics and American Heart Association | 12
 Source: Early essential
newborn care: Clinical practice
pocket guide. WHO
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IMMEDIATE DRYING AND ADDITIONAL STIMULATION

Source: Textbook of Neonatal Resuscitation, 7th, American Academy of Pediatrics

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PROVIDE WARMTH

 Remove wet cloth and place baby in skin-to-skin contact

with the mother
 Cover the baby and mother with a clean warm cloth
 Cover the baby’s head with a bonnet

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SKIN-TO-SKIN CONTACT IN THE FIRST HOUR OF LIFE

Textbook of Neonatal Resuscitation, 7th, American Academy of Pediatrics

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SKIN-TO-SKIN CONTACT IN THE FIRST HOUR OF LIFE

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If the mother cannot keep the baby in skin-to-skin contact
because of complications:
 Wrap the baby in a clean, dry, warm cloth;
 Place in a cot;
 Cover with a blanket;
 Encourage another family member to keep the baby in skin-
to-skin contact or use a radiant warmer if room is < 28°C.

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INITIATION OF BREASTFEEDING

 All newborns, including low-birth-weight babies who are

able to breastfeed
 Be put to the breast as soon as possible after birth
 When the mother and baby are ready

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PREVENT HEAT LOSS
AT BIRTH

 DRYING
 WRAPPING
 SKIN-TO-SKIN
CONTACT
 BREASTFEEDING
Source: Thermal protection of the newborn: a practical guide, WHO

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NEONATAL RESUSCITATION

Source: Textbook of Neonatal Resuscitation, 7th, American Academy of Pediatrics

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SUCTION IN NEWBORNS
WHO DO NOT START BREATHING ON THEIR OWN

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Source: Textbook of Neonatal Resuscitation, 7th, American Academy of Pediatrics

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APGAR SCORE

 A standardized way to communicate the clinical status of a

newborn infant

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Source: Early essential newborn care: Clinical practice
pocket guide. WHO

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 VITAMIN K PROPHYLAXIS

 All newborns
 1 mg of vitamin K
intramuscularly [IM]
[after the first hour during which
the infant should be in skin-to-
skin contact with the mother
and breastfeeding should be
initiated].

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PHYSICAL EXAMINATION. KEEP WARM. EXCLUSIVE BREASTFEEDING. CORD CARE. IMMUNIZATION

NEWBORN CARE
EXAMINATION IN THE DELIVERY ROOM

After the baby has detached from the breast:

 Wash hands;
 Examine the baby:
 usually confined to ensuring that the infant looks well and that
there are no major abnormalities requiring immediate
attention or explanation to the parents
 Put an identifcation tag around the ankle; and
 Weigh the baby and record
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ASSESSING GROWTH AND GESTATIONAL AGE

 This process starts at birth with basic measurements,

including weight, head circumference, and length
 SGA < 10th percentile or -2SD
 LGA > 90th percentile or +2SD
 When the gestational age or due dates are uncertain, a
gestational age assessment is completed using the Ballard
examination

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CHECK FOR POSSIBLE BIRTH INJURIES

 Soft-tissue Injuries
 Cranial Injuries: extracranial, intracranial
 Nerve Injuries
 Fractures
 Intraabdominal Injuries
 Long Bone Fractures

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CRANIAL INJURIES
EXTRADURAL FLUID COLLECTIONS
Source: Birth Injuries in Neonates. Gangaram Akangire, Brian Carter. Pediatrics in Review Nov 2016, 37 (11) 451-
462; DOI: 10.1542/pir.2015-0125
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(A) (B)

NERVE INJURIES
(A) FACIAL NERVE INJURY. (B) BRACHIAL PLEXUS LESION
Source: Birth Injuries in Neonates. Gangaram Akangire, Brian Carter. Pediatrics in Review Nov 2016, 37 (11) 451-
462; DOI: 10.1542/pir.2015-0125
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LOOK FOR MALFORMATIONS

(A) (B) (C)

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DETAILED NEONATAL EXAMINATION

 Initial newborn assessment: during the first 24 hours

 At least three additional postnatal contacts (detailed
examination):
• Day 3 (48–72 hours)
• Between day 7–14
• 6 weeks afer birth

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Four main functions to the examination:
 Detecting common serious problems: congenital heart
disease, developmental dysplasia of the hip, eye defects
 Checking for many very rare but serious conditions
 Noting and explaining the normal variations and minor
anomalies
 Health promotion

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ASSESSMENT OF THE NEWBORN: DANGER SIGNS
 Not feeding well
 History of convulsions
 Cyanosis
 Floppy or stiff
 T >37.5oC, or <35.5oC, or not
rising after rewarming
 HR constantly >180/min
 Fast breathing, slow breathing,
gasping, severe chest in-
drawing, grunting
 Abdominal overdistension
 Umbilicus draining pus
 Bleeding from stump or cut
 Any jaundice in first 24 hours,
or yellow palms and soles at
any age
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Main features of
routine
examination of
the newborn

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EXCLUSIVE BREASTFEEDING

 Breast milk contains exactly the nutrients a baby needs

• easily digested and efficiently used by the baby’s body
• protects a baby against infection
 Breastfeeding should start within 1 hour of birth
 Encourage breastfeeding on demand, day and night
 Exclusively breastfed until 6 months of age

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EXCLUSIVE BREASTFEEDING: ATTACHMENT & POSITIONING

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EXCLUSIVE BREASTFEEDING: MONITORING BREASTFEEDING

 Frequency of feeds
 Number of wet nappies
 Weighing the baby should be done only when there is
concern

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KEEPING THE NEWBORN WARM
 Ensure the room is warm (25–28 °C) and draft-free
 Appropriate clothing of the baby for ambient temperature is
recommended:1–2 layers more than adults and a hat
 Bathing should be delayed to after 24 hours of birth or at least 6
hours
 Do not place the baby near cold objects/ directly on a cold
surface
 The mother and baby should stay in the same room 24 hours a
day

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THERMAL NEUTRAL RANGE
Effects of heat and cooling
on metabolic rate and body
temperature

Core Concepts: Thermoregulation in the Newborn Part I: Basic Mechanisms. Steven A. Ringer. NeoReviews Apr 2013, 14 (4) e161-e167; DOI: 10.1542/neo.14-4-e161 | 45
HEAT LOSS
Four way a newborn may loose heat to the environment
Source: Thermal protection of the newborn: a practical guide, WHO
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Resistance to heat loss of a clothed, wrapped baby is three times
greater than that of a naked one
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THE BABY WITH A RAISED BODY TEMPERATURE (ABOVE 38°C)

 There are only two explanations:

 Increased set point temperature
 Overheated
 In a study of a large number of term babies: a raised body
temperature was found in 1% in the early neonatal period.
Of these, 10% had a bacterial infection and 90% were
overheated.

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 Babies with a raised set point
temperature behave as if they
are cold
 The overheated baby needs a
cooler environment, not a
series of painful investigations
to find an infec tive cause for
the ‘fever’

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DRY CORD CARE

 Clean, dry cord care is recommended for newborns born in

health facilities
 The cord usually drops off naturally within 2 week

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DRY CORD CARE
 Keep cord stump loosely
covered with clean clothes;
 Fold diaper below the
stump;
 Put nothing on the stump;
 Seek care if the umbilicus is
red/ draining pus

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HYGIENE: PREVENTION OF INFECTION ON A POSTNATAL WARD

 Handwashing
 Baby washing and bathing:
• Wipe the baby’s face, neck and underarms with a damp cloth
daily.
• Wash the buttocks when soiled. Dry thoroughly
• Bathe after 24 hours
 Visitors

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WASH YOUR
WASH HANDSHANDS PROPERLY
PROPERLY
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BATHING THE NEWBORN
Not before 6 hours of birth Source: Thermal protection of the newborn: a practical guide, WHO
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IMMUNIZATION

 First dose of hepatitis B vaccine as soon as possible afer

birth, preferably within 24 hours.
 In settings where tuberculosis is highly endemic: a single
dose of BCG vaccine should be given to all infants

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SCREENING

 Routine monitoring of blood glucose concentration is only

recommended for symptomatic infants and infants at risk for
hypoglycemia
 Congenital hypothyroidism
 G6PD deficiency
 Congenital adrenal hyperplasia

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JAUNDICE
Refer urgently if jaundice is present:
 on face of a baby < 24 hours old; or
 on palms and soles of a baby at any age

Kramer's scale: Zones for estimating the cephalocaudal progression

of jaundice

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WEIGHT LOSS

Estimated percentile
curves of percentage
weight change by time
after birth

Weight Change Nomograms for the First Month After Birth, Ian M. Paul, Eric W. Schaefer, Jennifer R. Miller, Michael W. Kuzniewicz, Sherian X. Li, Eileen M. Walsh, Valerie J. Flaherman,
Pediatrics Dec 2016, 138 (6) e20162625; DOI: 10.1542/peds.2016-2625
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VOIDING AND STOOLING PATTERNS

 Typically within the first 24 hours

 It is not rare for an infant to pass stool with nearly every
breastfeeding when the mother’s milk is in because of the
gastrocolic reflex signaling the colon to empty.
 Delayed passage of stool >48 hours: serious problems
 Urine color: urate crystals, vaginal discharge

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COUNSELLING

CARE PRIOR TO DISCHARGE

DISCHARGE INSTRUCTION

 Do a thorough examination prior to discharge

 Discharge no earlier than 24 hours after birth
 Advise newborn screening tests
 Schedule postnatal contacts

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ANTICIPATORY GUIDANCE

 Safe sleep
 Support unrestricted, on demand breastfeeding, day and night
 Ensure warmth of the baby
 No exposure to smoking
 Promote timely vaccinations
 Counsel the mother on prompt recognition of the danger signs

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  Place your baby on his or her back for all sleep times – naps and at night
SAFE SLEEP  Use a firm sleep surface, in a safetyapproved crib
FOR BABIES  Keep soft bedding (blankets, pillows, soft toys…) out of baby’s sleep area
 Have baby share your room, not your bed Source: CDC | 64
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TUMMY TIME

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SUMMARY

 Most materal illnesses have no serious effects on the baby

 Most newborns make the cardiorespiratory transition to
extrauterine life without intervention
 Without external support, newborns can readily lose heat
 Initiate breastfeeding as soon as possible after birth. Exlusive
breastfeeding until 6 months of age
 First dose of hepatitis B vaccine preferably within 24 hours
 Back to Sleep, Tummy to Play
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REFERENCES
 Nelson Textbook of Pediatrics
 Rennie & Roberton's Textbook of Neonatology
 Textbook of Neonatal Resuscitation 7th, American Academy of Pediatrics
 Care for the well newborn, AAP
 Early essential newborn care: Clinical practice pocket guide, WHO

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vnuhcm.edu.vn | 69