NEW BORN

1
TERMS:

Neonatology: The branch of pediatrics that deals with

the diseases and care of newborns.

Neonatal period: From birth to the 28th day of life (4

weeks after birth).

Perinatal period: From the 28th completed week of

gestation to the 7th day after birth.
Classification of the neonates

By birth By gestational
age
weight

By both GA and BW
TERMS:

Full term infant: An infant born

at a gestational age between 37
and 42 completed weeks
Preterm infant: An infant that is
born prior to 37 weeks of gestation
(22 -37 weeks or weight greater than 500g).

Post-term infant: An infant that

is born after the 42nd week of
gestation
AGA ( appropriate for gestational age)
Infants with birth weight for their gestational
age that falls between the 10th and 90th
centiles.
Infants
SGA ( with birth
small weight
for for their gestational
gestational age) age
that falls below the 10th centiles.
LGA ( large for gestational age)
Infants with birth weight for their gestational age
that falls above the 90th centiles.
GA 40 w,

BW3000
g GA 34
w,
BW2000
g
 CONT
…

• Weight:-The average weight of a normal full term

newborn is about 2.9 kg with a variation of 2.5-3.9
kg or more. The weight is very variable from country
to country .

• The newborn loses 5% to 10% of its birth weight

during the first week of life, then regains the birth
weight by 10th day and gains weight rapidly
afterward.
• The baby continues to gain weight about 20-30
g/day for next 3 months of age.

• Length:- At birth the average crown heel length of

the term infant is 50 cm with the range of 48-53 cm.

• Head circumference:-The head circumference

usually varies from 33-37 cm, with the average of
35cm.

• The chest circumference in a mature newborn is 2

cm less than the head circumference.
• Chest circumference is measured at the level of the nipple
using a tape measure. The chest is rounded rather than
flattened anteroposteriorly.

• Skin is pinkish but bluish hand and feet (Acrocynosis)

• It may covered with vernix Caseosa, milia and laugo hair,

especially at back.

• Ear:-Ear cartilage is firm and fully curved, showing good

elastic recoil.
• Externa auditory canal is relatively short and straight

• Eardrum is thick and Eustachian tube is short and broard

• Eyes:-Eyes are largely covered with eye lids

• Breast:-Breast nodules is palpable measuring over 5mm

in diameter.

• Abdomen:- Prominent with short neck and large head

• The trunk is relatively larger and the extremities are
short.

• Kidney, liver, and spleen may be palpable

• Scrotum (in male) :-It shows palpable testes and shows

adequate rugae with deep pigmentation

• Genetilia (in females) The labia majora covers the labia

minora and the clitoris.

• Foot:- prominent deep creases .

 VITAL
STATISTICS
Paramete Average
r• Weight 6.5 to 7.5 lbs (2.9 kg -3kg)
• Length 50 cm (20 inches)
• Head circumference 33 to 35 cm (13 to
• Chest circumference 13.7 in)
31 to 33 cm or2cm less
• Abdominal circumference than head
circumference
31 to 33 cm
 VITAL
SIGNS
• Vital Sign Immediately At Birth AfteBirth

• Temperature 36.5 to 37.2 Celsius

• Pulse 180 beats/minute 120-140 B/M

• Respiration 80 brths/m 30-50b/m

• Blood Pressure 80/46 mmHg 100/50 mmHg

(by 10th day)
• The newborn’s color on the first 15 to 30 minutes of life is
still acrocyanotic, and after 2 to 6 hours, there are quick
color changes that may occur with movement or crying.

• The temperature within the first 15 to 30 minutes after

birth falls from the intrauterine temperature of 100.6⁰F or
38.1⁰C then stabilizes at 37.6⁰C after 2 to 6 hours.

• The rapid heart rate of a newborn is as much as 180 BPM

on the first 15 to 30 minutes of life will have wide swings
in rate with activity as it slows to 120-140 BPM.
• The newborn’s respirations are irregular in the first few
minutes of life, then slows to 30-60 breaths per minute
after 30 minutes and will become irregular again only
during activity.

• The newborn would be alert in the first 15 to 30

minutes of life, and later on, will alternate between
the sleeping and awakening phases. A neonate spends
about 20 hours a day in sleeping.
• The energy requirement initially is 55 cal/kg/day
which increases to about 120 cal/kg/day at the end
of the first week of age.

• The bowel sounds can be heard after the first 15

minutes of life and becomes present afterwards.

• The normal blood volume of neonate is about 80

ml/kg of body weight with RBC 6-8 million/cmm,
Hb% 18 g%, WBC 10000 to 17000/cmm, platelets
350000/cmm.
• The period from birth to 28 days of life is called neonatal
period and the infant in this period is termed as
neonate or newborn baby. The first week of life is
known as early neonatal period and the late neonatal
period extends from 7th to 28th days of age.

• The healthy newborn infant born at term, between

38 to 42 weeks, cries immediately after birth,
establishes independent rhythmic respiration, quickly
adapts with the extra uterine environment ,having an
average birth weight and no congenital anomalies .
• Assessment of the newborn, as soon as possible
after birth are vital responsibility of the nurses
working in the hospital or in the community. The
assessment should include details history of
prenatal and intranatal period and genetic history of
family along with head to foot examination and
review of maternal investigation.
• The purpose of initial assessment are mainly to assess
the need for resuscitation,

• To ascertain the gestational age,

• To detect presence of any congenital anomalies or any

disorders which may affect the well being of the baby.

• It should be done at the place of birth by the trained

personnel immediately after delivery of the neonate.
• The assessment in the postnatal period should be
done at least for three times, first postnatal
assessment should be done within 24 hours, second
assessment within 2 weeks of age and third
assessment within 4-6 weeks of age of baby.

• In home delivery, the first postnatal assessment

should be done within 3 days and others are same
as institutional delivery.
• The initial assessment of neonate is very important
activity immediately after birth. The most essential
assessment is the “first cry”. Good cry helps in
establishment of satisfactory breathing .The
respiration, heart rate and skin color are the basic
criterias which should be evaluated immediately
to determine the need for life saving support.
Another significant assessment of the neonate is
“Apgar scoring” as described Dr Virginia Apgar
 ABGAR
SCORE
• CRITERIA 0 1 2
• Respiration. Absent Slow Irregular GoodCrying

• Heart Rate. Absent Slow(Below 100) Morethan 100

• Muscle tone. Flaccid Some flexion of extremities Active body

movements.
• Reflex response. No response Grimace Cry
.
• Skin colour. Blue, Body pink extremities blue Completely pink
pale

• Total score=10
• .No depression:7-10
• .Mild depression:4-6
• .Severe depression:0-3
• Assessment should be done in a comfortable warm
room with good light. Safety measures should be
followed especially, about prevention of infection.
All information should be recorded immediately, if
possible mother should be allowed to be along with
baby to promote bonding process
 Assessment:

The initial assessment:

APGAR scoring
system
Purpose:
is to assess the newborn´S immediate
adjustment to extrauterine life

8
 Apgar Score of the Newborn

SIGNSCORE 0 1 2

Heart rate Absent <100 beats/min >100 beats/min

Respiratory effort Weak, Strong cry
Muscle tone Absent irregular Some Well
Reflex irritability flexion Cough or
(response to Flaccid Grimace sneeze
catheter in nostril)
No
Skin colour Blue, extremities pink
blue
pale
 Significance of Apgar score

Healthy newborn: 7-10 at both 1 and 5

minutes
Moderately depressed newborn : 3-6
(Need resuscitation )
Severely depressed newborn: 1-3
(Intensive resuscitation )
 The Apgar score is
used to evaluate

• brain function at birth

• circulatory status at birth
• the effectiveness of respiratory
and circulatory adaptations
thereafter
• which babies need active
assistance (resuscitation).
 Purpose

The APGAR scoring chart is used

to
evaluate the conditions of the baby
at birth,
determine the need for
resuscitation,
evaluate the effectiveness of
resuscitative efforts,
to identify neonates at risk for
assessment (Periods of
reactivity):

First period of reactivity:

13
 Stage
1:
During the first 30 min. through
which the baby is characterized
as Physiologically unstable (
), very
alert, cries vigorously, may suck
a fist greedily, &
appears very
interested in the environment.
14
Stage 2:
It lasts for about 2-4 hours, through
this period; all V.S & mucus
production are decreased. The
newborn is in state of sleep and
relative calm.

15
Second period of
reactivity
It lasts for about 2-5 hours,
through which the newborn is alert
and responsive, heart &
respiratory rate, gastric &
respiratory
secretions are increased & passage
of meconium commonly occurs.

16
Following this stage is a period
of stabilization through
which the
baby & a becomes
stable vacillating pattern
physiologically
of sleep and activity.

17

– PHYSICAL CHARACTERISTICS
• Hair texture and distribution on
scalp
• Skin texture and opacity
• Breast nodule and nipple
formation
• Ear cartilage
• Genitalia-Female
• Planter creases
• Genitalia-Male
TERM BABY
Silky, black coarse and individual strants
Pink, scanty lanugo and only large veins
are seen. Good elasticity and turgor
More than 10mm diameter breast
tissue and nipple raised above skin level
Pinna is firm with definite cartilage and
Instant recoil
Entire sole covered with deep creases
At least one testes descends in the
scrotum
Prominent rugae and deep pigmentation
Labia majora completely cover the
labia minora and clitoris.
 PHYSICAL
EXAM
• A complete physical exam is an important part of newborn
care. The healthcare provider checks each body system is
carefully for health and normal function. The provider also
looks for any signs of illness or birth defects. Physical
exam of a newborn often includes:

• General appearance. This looks at physical activity, muscle

tone, posture, and level of consciousness.

• Skin. This looks at skin color, texture, nails, and any rashes.

• Head and neck. This looks at the shape of head, the soft
spots (fontanelles) on the baby’s skull, and the bones across
the upper chest (clavicles).
• Face. This looks at the eyes, ears, nose, and cheeks.
• Mouth. This looks at the roof of the mouth (palate),
tongue, and throat.
• Lungs. This looks at the sounds the baby makes when
he or she breathes. This also looks at the breathing
pattern.
• Heart sounds and pulses in the groin (femoral)
• Abdomen. This looks for any masses or hernias.
• Genitals and anus. This checks that the baby has open
passages for urine and stool.
• Arms and legs. This checks the baby’s movement and
development
 Take Anthropometric
Measurements

Weight – 2, 500g – 4, 000g

Physiologic weight loss - it is normal for
the newborn infant to loose 5-10% of weight in
the first 4 to 5 days of life (causes: low nutritional
intake, defecation, urination);

Length – 45-55 cm
HC – 33-55 cm,2-3 cm larger than chest CC
– 30-33cm, AC-29-33 cm
Assessment of Growth
 Head Circumference

HC – 33-55 cm,
2-3 cm larger than chest
Take Anthropometric Measurements

Head Circumference Chest Circumference

Abdomen Circumference
 Fontanelles
The anterior fontanel is located
at the intersection of the sutures
of the two parietal bones and
the frontal bones.
Anterior: diamond shape about 2-
3-4 cm, will close in about 12 to
18 mos;
The posterior fontanel is located
between of the sutures of the 2
parietal bones and occipital bone.
It is small, triangular shaped,
normally closes at 1,5 to 3 mos of
age.
 Respiratory system

Fetal lung development

Filled with fluid
Surfactant synthesis: begins at 24-28w, peak at 35w
Establishment of breathing after birth - opening
of the alveoli by mechanical,chemical,thermal, sensory stimuli
Characteristics of Newborn respirations
Normal RR 30-60, shallow and irregular,
5-15 second periods of apnea
Apnea: no breathing for periods of
greater than 15 sec
Abnormal findings: retractions, grunting, nasal flaring,
Cardiovascular System
 Circulatory system
Heart rate: ranges from 140 to 160 per minute.
Heart murmur:
Transient murmurs may result from the incomplete closure
of the fetal circulation (the ductus arteriosis or foramen
ovale)
90% of all murmurs are transient and not associated with
anomalies.

Blood pressure:
from 46 to 80 mmHg (systolic)
 Hemotological system

High: RBC 4.8-7.1; Hgb 14-24; Hct 44-64

WBC: 18,000 @ birth; 23-25,000 @ 1day with r
elati
neutrophilia
ve
After the first few days (5 days or so ) the white cell count is
likely to be below 10 000/ mm3 with characteristically relative
lymphocytosis of infancy and early childhood.
Coagulation: Vit K dependent clotting
factors are decreased.
Platelet counts ok (150,000-350,000)
•These characteristics are essential to provide adequate oxygenation in utero and
during the first few postnatal days before the lungs expand fully.
•Oxygenation improves during the first two weeks of life to the extent that a high
red cell count and hemoglobin are no longer necessary, and haemolysis occurs.
 Gastrointestinal System

–sucking becomes coordinated @32 wks little

saliva until 3 months of age Stomach hold 60
to 90 ml.
–Regurgitates easily because of an immature cardiac
sphinter between the stomach and esophagus.
–Immature liver function may lead to lowered
glucosed and protein serum level.
Alimentary system
 Hepatic Function
Liver produces substances essential for clotting
of blood.
Stores needed iron for the first few Preter
months
& . have lower iron stores than full term (full mterm
small infants
infants stores last 4-6 mo)
Physiologic Jaundice - after 24-48 hs of age,
d/t increased breakdown of RBC’s and
immature liver functioning.
This is a yellow discoloration that may be seen in the
infant's skin or in the sclera of the eye.
Jaundice is caused by excessive amounts of free
bilirubin in the blood and tissue.
JAUNDICE
 Urinary system

Renal function: GFR - glomerular filtration rate is

lower, about one fourth to one half of that in an
adult.
Kidneys not fully functional until child is 2 years of age.
Urine often contains protein in small amounts.
Urine may contain an abundance of urates which may
give the diaper a pink stain during the first week of life.
The ability to dilute urine is good, but the time taken to
reach the maximal ability is relatively long, so newborns
are apt to become water overloaded.
 Kidneys and Urination
initial urine: cloudy, scant amounts, uric acid
crystals-> reddish stain on diaper
Urine pH ranges from 5 to 7, specific gravity ranges
from 1.006 to 1.020.
The first urination occurs within 24 hrs. It ranges
from 4 to 6 times/day in the first days and 20 times or
so /day in later days of the neonatal period.
Kidneys not fully functional until child is 2 years of
age.
Immune System

Limited specific and Non-specific immunity at

birth
passive immunity(from mom- IgG) for the first 3 months of
life ~ this wil be reduced if baby
is born premature
breastfeeding = ^ passive immunity (IgA)
 Newborn Reflexes

Sucking reflex

•When a newborn lips are

touched, the baby makes a sucking
motion.
•This reflex helps a newborn find
food: when the newborn lips touch
the mothers breast or bottle, the
baby sucks and takes food.
•The sucking reflex begins to
diminish at about 6 months of age
 Sucking

place a finger in the

neonate’s mouth
n
e
 Newborn Reflexes

Rooting reflex - If the check is brushed or stroke near the corner

of the mouth, a newborn infant will turn the head in that direction.

•This reflex serves to help a

newborn find food: when a
mother holds the child and
allows her breast to brush the
newborn’s cheek, the reflex
makes the baby turn toward
the breast.
•This reflex disappear at
about the sixth week of life.
Rooting

touch a finger to
the neonate’s
cheek or the
corner of mouth.

neonate turns the head toward the stimulus, opens the mouth and
searches for the stimulus
 Newborn Reflex

Blink Reflex - bright light shinning in eyes or clap

hands near eyes - closes eyelids quickly
A sudden movement to ward the eye can elicit the blink
reflex.
Swallowing reflex - food that reaches the posterior
portion of the tongue, automatically swallowed.
Gag, cough, and sneeze reflexes are present to maintain airway
in the event that normal swallowing does not keep the
pharynx free from obstructing mucous.
 MORO reflex

Baby is held horizontally, then swiftly lowered a few inches,

or the head may be lowered a few inches, or a loud sudden
noise will make baby's arms fling out and then come together
as hands open then clutch.

Absence or weakness of this

reflex may suggest a severely
disturbed CNS
 Startle reflex

sudden loud noise

causes abduction
of the arms wit
flexion of elbow,
hand remain
clenched
disappears by age
of 4 months
 Palmar Grasp Reflex

•newborn grasp an object

placed in their palm by
closing fingers on it.

•Mature newborn grasp so strongly

that they can be raised from a
supine position and suspended
momentarily from an examiner’s
fingers.
•Reflex disappears to 3 months of
age.
 Grasp

–place a finger in the neonates palm

neonate grasps the finger
 PLANTERS GRASP

Pressing thumbs against the

balls of baby's feedwill make
his toes
flex.

Absence of this reflex

may indicate damage to
the spinal chord.
 Stepping reflex

•Hold the neonate in an

upright position and touch
one foot lightly to a flat
surface (such as the bed)

neonate makes walking motions

with both feet
 BABKIN

When both of baby's palms are

pressed, her eyes will close, mouth will
open and her head will turn to one
side.
Absence of this reflex or if it reappears
after vanishing around 3-4 mos., it may
signify a malfunctioning CNS
 BABINSKI
Baby's foot is stroked from heel toward the toes.
The big toe should lift up, while the others fan
out.

Absence of reflex may

suggest immaturity of the
CNS, defective spinal
chord, or other problems.
 Tonic neck reflex
Fencing posture

When newborn lie on their backs,

their head usually turn to one side or
the other.
The arm and the legs on the side
toward which the head turns extend,
and the opposite arm and leg contract.
This is also called the boxer or fencing
reflex.
The reflex disappears between the
second and third months of life.
Extrusion Reflex

Extrusion Reflex -
newborn extrudes any
substance that is placed on
the anterior portion of the
tongue.
This protective reflex
prevents the swallowing
reflex of inedible substance.
It disappears at about 4
months of age
Thermoregulation

Newborn physiology
•Normal temperature: 36.5–37.5°C
•Hypothermia: < 36.5°C --Significant contribution to
deaths in low birth weight infants and preterm newborns
•Stabilization period: 1st 6–12 hours after birth

The body temperature is likely to be influenced by

the environmental temperature.

Neutral environmental temperature: the environmental

temperature at which the core temperature of the infant at
rest is between 36.7 and 37.3°C and oxygen consumption
and caloric utilization are lowest
Temperature Regulation

Newborn’s temperature may drop several degrees

after delivery because the external environment
is cooler than the intrauterine environment
Rapid heat loss in a cool environment occurs by
conduction, convection, radiation and evaporation;

Cold stress in the newborn → an increase in

the metabolic rate --> increased O2 demands
and caloric consumption, metabolic
acidosis
the infant lost his/ her
body temperature:

1- Evaporation:
Heat loss that
resulted from expenditure of
internal thermal
energy to convert liquid on an
exposed surface to gases, e.g.:
amniotic fluid, sweat.
Prevention:
Carefully dry the
infant after delivery or after
53
 Heat loss
occurred from direct contact
between body surface and
cooler solid object.
Prevention:
Warm all
objects before the infant
comes into contact with
them.

54
 infant to direct source of
air draft.
Prevention:
·Keep infant out
of drafts
·Close one end of heat
shield in incubator
to reduce velocity of
air.
55
4- Radiation:
It occurred

from body surface to

relatively distant objects
that are cooler than skin
temperature.

56
 ‫‪:‬هيميلعتالفادهدال عبات‬
‫همادختسإ تمي يتمو فيكو راجبأ سايقمل هنوكمال رصانعالةفرعم ‪3.‬‬
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‫بهيانعالةفيك ةفرعم‬
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‫هيعيبطالاهتلدعم لوح هيويحالت‪ooo‬املعال‪.‬‬
‫‪.‬هعاضرال ءاطعإ يف ركبمالءدبالتازيممو ةيمهأ كاردإ ‪6‬‬
‫بءاوس يهعيبط‪.‬ال‬
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‫‪57‬‬
 SKIN
Observation and palpation
SKIN

Common
variations
Acrocyanosis - result
of sluggish peripheral
circulation.
 Physiologic jaundice

Neonatal jaundice
is often seen in
infants around the
second day after
birth, lasting until
day 8 in term
births, or
to around day 14
in premature
births.
Mili
-a all newborn
sebaceous glands are
immature.
- White papule can be
found on the cheek or
across the bridge of
the nose of every
newborn.
- Disappear by 2 to 4
weeks of age, as
sebaceous glands
mature and drain.
 Erythema Toxicum
Erythematous macules and
firm 1-3 mm yellow or
white papules or pustules
Pustules contain eosinophils
and are sterile
Appear in the first 3-4 days
of life
Range: Birth to 14 days
Benign and self limited
 Lanug
o

- Is the fine hair, downy hair

that covers a newborn’s
shoulder, back and upper
arm.
- It maybe found also on
the forehead and ears.
- A baby born after 37 to 39
weeks of gestation has more
lanugo than a newborn of 40
weeks.
- By 2 weeks of age it disappear
 Vernix Caseosa

- At birth the infant is generally

covered with vernix caseosa, a
cream cheesy-white substance
adherent to the skin that serves
as a skin lubricant.

- It is helpful for protecting the

baby against infections, and
should not be taken off.
 Mongolian
spots
Are collections
of pigment cells

90% of African infants, 81% of Asian, and

9.6% of Caucasian infants
Slate-gray to blue-black lesions
Usually over lumbosacral area and
buttocks
Accumulation of melanocytes within the
dermis
They disappear by school age without
 Features in appearance of normal term
neonate and preterm neonate

term preterm

pink ， well- Dark-

nurished ， Less fine- red,edema ， e
hair transparent ，
mor fine-hair
Skin
 ear
term preterm

Good ear figuration, well- soft ear stick to the skull,

developed cartilage
poor figuration
 Sole markings
ter preter
m m

Obvious, over all the sole Shallow and less

 Enlargement of the breasts

• Enlargement of the
breasts and production of
milk may occur at the age of
3 to 5 days in some newborn
boys or girls. This stops at
the postnatal age of 2 to 3
weeks.

This is also caused by

transmission and withdraw
of maternal hormones. This
no requires management.
 Essential Newborn Care
Interventions
• Clean childbirth and cord care
– Prevent newborn infection
• Thermal protection
– Prevent and manage newborn
hypo/hyperthermia
• Early and exclusive
breastfeeding
– Started within 1 hour after childbirth
• Initiation of breathing and resuscitation
– Early asphyxia identification and
The End