Care of the Newborn

NEWBORN PRIORITIES IN THE FIRST DAYS OF Congenital Anomalies

LIFE 1. Choanal Atresia
2. Tracheobronchial fistula
1. Initiation & maintenance of respirations 3. Cleft lip and cleft palate
2. Establishment of extra uterine circulation Substances
3. Control of body temperature 1. drugs
4. Adequate nourishment 2. smoking
5. Waste elimination 3. alcohol
6. Prevention of infection Dubowitz (Maturity Testing Tool)
7. Infant-parent relationship – 1st 24 hrs
8. Developmental care Full Term - 38-42 weeks AOG
Preterm - < 38 weeks
Immediate Care of the Newborn Postterm - > 42 weeks
I. Care of the Newborn at the D.R. AGA – 10th – 90th percentile
A. Establish and Maintain Respiration SGA <10th percentile
1. Suctioning LGA > 90th percentile
- Turn head to one side Low birthweight <2500 gm
- Suction gently and quickly Very Low Birthweight <1500 gm
- Suction the MOUTH first before the nose Extremely Low Birthweight <1000 gm
- Test patency of the airway IUGR - Rate of growth does not meet expected pattern -
- Proper position growth restriction
B. Maintain Appropriate Body Temperature
Prematurity
< 37 weeks AOG
Risk Factors:
1. Wrap the newborn immediately
2. Wrap him warmly 1. Fetal
3. Put him under a droplight 2. Placental
Effects of Cold Stress 3. Maternal
- temp < 36.5 4. Infection
1. Metabolic Acidosis
Problems:
- Increased BMR, anaerobic glycolysis,
Inc acid production, metabolic acidosis •Respiratory adaptation
•Susceptibility to infection
2. Hypoglycemia
- Inc energy requirement to produce heat •Hyperbilirubinemia
•Cold stress
Non shivering Thermogenesis
Brown fat
•Hypoglycemia
- Special tissue
Hypoglycemia
- Intrascapular region, thorax, perineal area
- oxidized to produce heat -<40 mg/100 ml
4 MECHANISMS OF HEAT LOSS
-Dependent on maternal supply
•Convection -Birth, continue to produce insulin
•Radiation S/sx: limpness, jitteriness, apnea, twitching and ↑ pitched cry
CX: mental retardation
•Conduction Tx: early feeding
D10W
•Evaporation Nsg: monitor blood glucose level

PE of the premature child

Immediate Assessment of the Newborn •Skin and SC tissue – thin, transparent
APGAR SCORE
•Inc lanugo
A ppearance (color) – least important •Dec plantar creases
P ulse rate - most important
G rimace (reflex activity); irritability •Breast bud scarcely felt
A ctivity (muscle tone) •Pinna flat and shapeless
R espiration
•Scrotum not pigmented
Apgar Scoring System •Testes not descended
•Labia majora widely separated
1st minute: general condition
(NEURO/RESPI/CIRCULATORY CHECK)
5th minute: adjustment to extrauterine life Management
Score: 9 – highest score; 10 – perfect score •Maintain patent airway
0-3: poor, serious, severely depressed, needs CPR
4-6: fair, guarded, moderately depressed, needs •Incubator care
suction •VS monitoring
7-10: good, healthy
•O2 therapy
Grading of Neonatal Respiratory Distress •Feeding
(Silvermann Anderson)
•Infection precautions
 * 1 K = 2.2 lbs
Nursing Intervention BL: 47.5 – 53.75 cm
•Meet physiologic needs (19 – 21 ½ in)
Average: 50.8 cm/20 in
•Meet psychological needs * 1 inch = 2.54 cm
•Foster healthy family relationships
Physiologic weight loss
•Provide education - 5-10 % in 10 days
Causes
1. No longer under influence of maternal hormones
C. Proper Identification
2. Voids and passes out stools
– done in D.R. before being brought to the
3. Relatively low nutritional intake
Nursery
4. Beginning difficulty establishing sucking
a. Footprints – most reliable 
b. ID bands – ankle, wrist Initial Feeding
c. Birthmarks 1-6 hours after birth
Immediate Care of the Newborn in the Nursery 1 oz of sterile water
Subsequent feeding – by demand
* Note that ID bands of mother and baby are matched.
Special Care Breastfeeding
1. Initial Bath – temp stabilizes 36.5ºC 6-8 after birth 1. Bonding
- Vernix caseosa - use oil 2. Uterine contraction
- Warm water during the 1st week 3. Colostrums
-Don’t use soap 4. Contraceptive
-Hexachlorophene (Phisohex) – infected 5. Cheap
passageway 6. Right temperature
2. Taking the Temperature 7. Antibacterial – Lactoferrin, Lactobacillus bifidus,
* Maintain temperature to prevent cold stress lysozyme, macrophage, T lymphocytes,
* Use Rectal route lactoperoxidase
* Meconium - 24-48 hrs Differences between Human and Cows Milk
3. Initial Cord Dressing Physical Assessment
* Inspect for A .V. A. 1.Vital Signs
* Aseptic technique a. Pulse - 1 full minute; use apical pulse
* Povidone (Betadine); 70% Isopropyl alcohol - prevent - Irregular, rapid
Tetanus Neonatorum and Omphalitis (streptococcal
and staphylococcal) >160-180 at birth
Signs of Omphalitis:
1. Reddening of the area NORMAL: 120–160 bpm
2. Fever During sleep - 90-110 bpm
3. Discharge or foul smell If crying, up to 180 bpm
* Application of sterile cord clamp - prevent bleeding b. Respirations - 1 full minute
w/n 1st 24 hours (Omphalangia) - irregular, shallow, rapid w/ brief apneic spells < 15s
4. Crede’s Prophylaxis 60-80 breaths/min at birth
* Legal requirement for all NB (US) NORMAL: 30–60/minute
* Infection - acquired during delivery from a mother c. Blood Pressure - not usually measured
with untreated gonorrhea Medications: 80–60/45–40 mm Hg at birth
a. Opthalmic drops – Silver Nitrate or AgNO3 1% 1-2 100/50 mm Hg at day 10
drops d. Temperature
- Lower conjunctival sac NORMAL: 36.5C–37.5C (axilla)
- Wash with sterile NSS after 1 minute to prevent Axillary: 36.4C–37.2C
chemical conjunctivitis Skin: 36.0 C–36.5C
b. Ointment Rectal: 36.6C–37.2C
Terramycin * Temperature 37.2 at birth
Gentamycin Crying - increase body temperature slightly
Chloramphenicol Radiant warmer - falsely increase axillary temperature
Erythromycin 2. Skin
Erythromycin Dark red – prematurity
- Pull eyelids downward Acrocyanosis – up to 48 hours
-0.5-1 cm Generalized mottling
Gray color - infection
-Inner to outer canthus Pallor due to anemia because of:
-Wipe excess away * Excessive blood loss when cord is cut
* Untimely cutting of the cord
5. Vitamin K Injection * Inadequate iron stores because of poor maternal
- Sterile GIT nutrition
- facilitates production of clotting factor * Blood incompatibility
- 1 mg. Aquamephyton Jaundice
- IM - lateral anterior thigh (Vastus lateralis) Types:
1. Physiologic Jaundice / Icterus Neonatorum
6. Take Anthropometric Measurements 2nd day – 7th day - TERM
(Vital Statistics) 2nd day – 10th day - PRE-TERM
BW: 2.5 – 3.4 kgs Causes:
(5.5 – 7.5 lbs)
 a.Hemolysis - closes 12-18 months; 3-4 cm long/2-3 cm wide
b.Decreased conversion of bilirubin - junction of 2 parietal bones and 2 fused frontal
turobilirubin bones
c.Decreased uptake of free bilirubin by - not indented depressed
hepatic cells - suture lines - never appear widely separated
2. Pathologic Jaundice
Normal total serum bilirubin = 15% 2. Posterior – triangular in shape
Direct bilirubin = 1.7 - junction of the parietal bones and the occipital
Indirect bilirubin = 13.2 bones.
Causes: - 1 cm
- closes by end of 2nd month
 a. Infection

 b. Hemolytic disorders Sutures

Lambdoid (2)
 c. Inability of the newborn to conjugate
Coronal (2)
bilirubin
Frontal (1)
Breastmilk jaundice
Sagittal (1)
Pregnanediol
CRANIOSYNOSTOSIS - suture lines separated or
Decrease glucoronyl transferase
fontanels prematurely closed; leads to mental retardation
Decrease conversion of indirect to direct bilirubin
Molding –overlaping of sagittal and coronal suture line
Jaundice
Craniotabes – localized softening of cranial bones;
Management
indented by pressure of a finger. Corrects w/o treatment
1. Early feeding
in weeks or months. Common to first borns because of
2. Phototherapy
early lightening
· Cover eyes with opaque mask to prevent
blindness. Comparison between Caput Succedaneum and
· distance - 18-20 in from source of light. Cephalhematoma
· Monitor V/S especially temp
· Cover genitalia to prevent PRIAPISM 4. Eyes
· Adequate hydration - Eyelids of equal size
· Turn NB q 2º to expose all body surfaces - temporarily gray or blue in color (d/t thinness)
Common Marks - Cry tearlessly 1st 3 months
1. Harlequin Sign - Cornea round and adult sized
2. Mongolian spots – (-) school age - Pupils round, not keyholed (Coloboma)
3. Milia – unopened sebaceous glands; tip of nose and chin - cross-eyed (Strabismus)
of the baby. (-) 2-4 weeks - see object at 8 inches; V.A. of 20/200 to 20/500
4. Lanugo – fine downy hair on shoulders, upper arms, 5. Ears
back; (-) 2 weeks. -Top of ear should align with inner and outer canthus of
5. Desquamation- peeling; at birth, postmaturity the eye
6. Vernix Caseosa - sense of Hearing – highly developed in NB
7. Portwine Stain or Nevus Flammeus – birth; red to 6. Nose
purple color; do not blanch on pressure nor disappear; - Nasal obligates
face - Note for marked flaring of alae nasi, indicative of
8. Strawberry Mark or Nevus Vascularis – 2nd most airway obstruction
common type of capillary hemangioma. elevated, Causes of obstruction:
sharply demarcated or bright or dark red, rough 1. Secretions
surface swelling. (+) school age or even longer. 2. septal deviation
9. Erythema Toxicum or Erythema Neonatorum – - Sense of smell – least developed
Newborn rash or fleabite dermatitis; transient; papules 7. Mouth
with vesicles at nape, back and buttocks. (+) 2nd day; - open evenly when crying. If not, suspect CN VII
disappears without treatment. Paralysis (Bell’s Palsy).
10. Cutis Marmorata – transitory mottling when exposed - Palate intact; no breaks on the lip - cleft palate; cleft
to cold lip
11. Nevi – stork bites or Telangiectasia Nevi; pink or red - Eptein’s Pearls – small round glistening cysts; palate
flat areas of capillary dilatation at upper eyelids, and gums, due to extra load of maternal Ca
nose, upper lip, lower occiput bone, nape and neck. (-) - NATAL TEETH
1st and 2nd year. - Oral thrush – white gray patches on the tongue and
sides of cheeks due to Candida
8. Neck
•Nevus flammeus - Thyroid gland not palpable
•Stork’s beak mark - soft, palpable and creased with skin folds
•Strawberry hemangioma - Head - rotate freely on the neck and flex forward
and back. (+) rigidity of the neck- CONGENITAL
•Cavernous hemangioma TORTICOLLIS (injury to SCM)
3. Head – largest part of the human body (1/4 of his -NB whose membranes ruptured 24 hours before
total length); birth, nuchal rigidity - meningitis.
-forehead is large and prominent; 9. Chest
-chin is receding when startled or crying. - As large as or smaller than the head
- Symmetrical
- Breasts may be engorged
Fontanelles 10. Abdomen
1. Anterior – diamond shape; - dome shaped; If scaphoid - DIAPHRAGMATIC
HERNIA Vitamins A,C, D for formula and
- Bowel sounds should be present within 1 hour after breastfed babies
birth Common Health Problems
- Liver, spleen and kidneys are palpable at birth. 1. Constipation
11. Extremities 2. Loose stools
- symmetric and of equal length 3. Colic
- Fingers and toes equal count Causes:
Supernumerary = polydactyly; Overfeeding
fused or webbed = syndactyly Gas distention
Simean line Too much carbohydrates
- Asymmetrical movement of upper and lower Management
extremities - ERB – DUCHENE PARALYSIS Feed by demand
- congenital hip dislocation: Ortolani’s Maneuver Burp infant
- Observe for clubfoot deformities Feed in upright position
12. Anogenital Area May need to change formula
3 types of stools passed by NB: Diaper Rash
1. Meconium – greenish-blackish viscous; - amniotic Miliaria
fluid, intestinal secretions and cells shed from Seborrheic Dermatitis
mucosa Occasional “Crossed Eyes”
- take note of time when meconium first passed Clothing
2. Transitional – passed from 3rd to 10th day Sleep Pattern
3. Milk stool SYSTEMIC EVALUATION
a. Breast fed infant stool – loose golden yellow in I. Cardiovascular System
color with sweet odor; 2-3 times a day Fetal Circulation
b. Bottle fed infant stool – formed, pale yellow with a
typical odor; usually passed 1-2 times a day •Oxygen exchange occurs in placenta
13. Female Genitalia
– swollen labia and pass a slightly bloody vaginal discharge
•pressure on the left side of the heart < right side
-“PSEUDOMENSTRUATION” •(+) accessory structures
Male Genitalia Accessory Structures:
– Scrotum may be edematous due to maternal Foramen ovale
hormones. Ductus arteriosus
- Testes should be present; if undescended - Ductus venosus
CRYPTORCHIDISM Umbilical vein
Conditions for cryptorchidism: Umbilical arteries
1. Agenesis – absence of an organ Neonatal/Adult Circulation
2. Ectopic testes – Testes cannot enter the scrotum - With 1st breath, oxygenation takes place in lungs
because opening of the scrotal sac is closed. - Lung expansion occurs
3. Vas deferens or artery is too short to allow the - Increase pressure on left side of heart > right side
testes to ascend. results in:
Circumcision – prior to discharge from nursery, Closure of accessory structures and
preferably end of 1st week obliteration of umbilical vessels
Procedure:
1. Vitamin K injected IM II. Neuromuscular system
2. Infant is restrained; penis is cleansed with soap Reflexes
and water blink reflex
3. clamp is used Rooting reflex – (-) 6 wks old
4. Petroleum gauze dressing is applied to prevent Sucking reflex –(-) 6 mos
adherence of circumcised site to the diaper while Extrusion Reflex – (-) 4 mos
applying pressure to prevent bleeding Swallowing reflex
Nursing Care: Tonic neck Reflex – (-)2-3 mos
Babinski reflex – (-) 3 mos
- Check hourly for bleeding
- Do not attempt to remove exudates which persist Landau reflex
for 2-3 days; just wash with warm water. Palmar/Grasp (-) 3-4 mos
- Diaper must be pinned loosely during the 1st 2-3 Plantar reflex – (-) 8 mos
days when the base of the penis is tender. Stepping reflex (-) 1 mo
14. Back Moro reflex- (-) 4-5 mos
- On prone appears flat Trunk Incurvation reflex – (-) 2-3 mos
- Note for mass, hairy nodule and dimple along axis - III. Gastrointestinal
Spina Bifida. Meconium – mucus, vernix, lanugo, hormones
- Cremasteric reflex – test for integrity of spinal Transitional stools – 2-10 days of life
nerves (T8 thru T10) Breastfed babies stools
III. Discharge Instructions Formula fed babies stools
a. Bathing IV. Urinary
b. Cord Care Females – strong urine stream
c. Nutrition Males – projected arc
Calories 120 kcal/kg body weight/day V.Autoimmune
CHON 2.2 gms/KBW/day Passive natural immunity – mother to child
Fluids 160-120 cc/KBW/day (+) Ab from the mother against Polio, DPT, Rubella and
Measles
* immunization starts usually at 2 mos
Expanded Program on Immunization
VI. Senses

1. Sight – at birth (9 inches)

2. Hearing-at birth
3. Taste – at birth
4. Smell-at birth
5. Touch-at birth

Newborn Screening
REPUBLIC ACT NO. 9288
Newborn Screening Act of 2004

“…ensure that every baby born in the Philippines is

offered the opportunity to undergo newborn
screening and thus be spared from heritable
conditions that can lead to mental retardation and
death if undetected and untreated.”

1. CONGENITAL HYPOTHYROIDISM
Thyroid hypofunction or enzyme defect reduced T3, T4
Females
S/sx: excessive sleeping, enlarged tongue, noisy
respiration, poor suck, cold extremities, slow pulse and
respiratory rate, lethargy and fatigue, short and thick
neck, dull expression, open mouthed, slow DTR, obesity,
brittle hair, delayed dentition, dry, scaly skin
Dx: low T3 T4, inc TSH
Mx: synthetic thyroid hormone
Nsg Care: Assist parents administer drugs
2. CONGENITAL ADRENAL HYPERPLASIA
-inability to synthesize cortisol inc ACTH stimulate
adrenal glands to enlarge inc androgen
S/sx: musculinazation, sexual precocity
Mx: Steroids to dec stimulation of ACTH
3. G6PD DEFICIENCY
- reduction in the levels of the enzyme G6PD in RBC leads
to hemolysis of the cell upon exposure to oxidative stress
Dx: blood smear – heinz bodies
rapid enzyme screening test, electrophoresis
Mx: avoid drugs ie ASA, sulfonamides, antimalarials, fava
beans
4. GALACTOSEMIA
(-) enzyme that converts galactose to glucose
S/sx: wt loss, vomiting, hepatosplenomegaly, jaundice and
cataract
Dx: Beutler test
Tx: dec lactose – soy based formula
regulate diet
5. PHENYLKETONURIA (PKU)
- dec phenylalanine hydroxylase w/c converts
phenylalanine to tyrosine
S/sx: mental retardation, musty odor, blond hair, blue
eyes
Dx: Guthrie bld test
Tx: dec phenylalanine (Lofenalac)
regulate diet