Pedia1.Newborn

Pediatric Nursing

Nursing Care of a Newborn

I. Care of the Newborn

II. Assessment of the NB

III. Newborn Screening Test

IV. Theories of Growth & development

PEDIATRIC NURSING MLNGC,MD, RN3

Newborn or neonate – a baby in the neonatal period (the

first 28 days of life)Nursing Diagnoses

Ineffective airway clearance related to mucus in airwayIneffective thermoregulation related to heat loss from exposure in birthing roomImbalanced nutrition, less than body requirements, related to poor sucking reflexReadiness for enhanced family coping related to birth of planned infantHealth-seeking behaviors related to newborn needs


The Average Newborn


Profile of a Newborn

X “All newborns look alike.” – Every child is unique. -


NEWBORN PRIORITIES IN THE FIRST DAYS OF LIFE

1. Initiation & maintenance of respirations2. Establishment of extrauterine circulation

3. Control of body temperature4. Adequate nourishment5. Waste elimination6. Prevention of infection

7. Infant-parent relationship

8. Developmental care


Immediate Care of the NewbornI. Care of the Newborn at the D.R.

(EXISTING/ OLD PROTOCOL)



Establish and Maintain Respiration.

1. Suctioning - Turn head to one side - Suction gently and quickly - Suction the MOUTH first before the nose - Test patency of the airway - Proper position

a. Ensure an open airway.b. Do not hyperextend head - place neonate supine - head slightly extended


• Suction gently and quickly (5 to 10 seconds). • Prolonged and deep suctioning of the

nasopharynx during the first 5 to 10 minutes of life will stimulate the VAGUS NERVE (located in the esophagus) and cause bradycardia.


POSITIONING OF THE NEWBORN• The position when suctioning should be one that

promotes drainage of secretions – HEAD LOWER THAN THE REST OF THE BODY BUT C.I. if there are signs of increased ICP:head should be higher than the rest of the body

• Vomiting• Bulging, tense fontanels• Dilated scalp veins• Abnormally large head• Increased BP• Decreased PR and RR• Widening pulse pressure• Shrill, high-pitched cry- late sign

NURSING ALERT1. Always humidify to prevent drying of

mucosa

2. Over dosage of 02 can lead to scarring of retina leading to blindness (RETROLENTAL FIBROFLASIA or RETINOPATHY OF PREMATURITY)


Circulation is initiated by lung expansion completed by cutting of cord

Initiation of breathing

Cord is clamped

Placental gas exchange ceases

Cause : increased PaCo2 decreased Pa02 & pH

Transitory asphyxia

Stimulate : carotid & aortic chemoreceptorsSend impulses to the

respiratory center in the medulla

Stimulate respiration

Establishment of extra uterine circulation



CIRCULATION- several circulatory changes are necessary for successful changes from FETAL circulation to NEONATAL circulation.

A. Pulmonary Blood vessel – dilation, begins at first breath

results : lower pulmonary resistance this allows the blood to freely circulate through the lungs to be oxygenated.



B. Ductus Arteriosus

- reversal blood flow increased pressure in aorta and increase O2 in the blood more blood flowing through the pulmonary arteries for oxygenation.

- closure complete w/in 24H - permanent : 3-4 weeks



C. Foramen Ovale

- closes within minutes after birth because of the higher pressure in the LA than in the RA increase blood flow in the lungs decreases pressure in the RA the return of blood from the lungs increases the pressure in the LA

– Closure : permanent approximately 3 months – Failure to close becomes ASD



D. Ductus Venosus

- cord clamped blood ceases flowing from umbilical vein to ductus venosus and into IVC blood now flows through the LIVER and is filtered as in adult circulation

Obliterates : becomes ligamentum venosum at 2 months

CONTROL OF BODY TEMPERATURE

Goal : to maintain not < 97.7 F (36.5 C)NB prone to cold stress (hypothermia)

NB not capable of shiveringNB born wet

CONTROL OF BODY TEMPERATURE

Effects of Hypothermia Hypoglycemia Metabolic acidosis


Maintain Appropriate Body Temperature

*Blot dry/ Rub dry the infant.

1. Wrap the newborn immediately2. Wrap him warmly3. Put him under a droplight/ radiant

warmer4. Kangaroo care


Warmth

• At birth, the newborn must begin thermoregulation (maintenance of body temperature).

3 Factors :• Heat production• Heat retention• Heat loss


1. Heat Production

The newborn produces heat Thermogenesis – through

• general metabolism• muscular activity• nonshivering thermogenesis (unique to the

newborn)

Newborns rarely shiver as adults do to increase heat production.

Shivering in newborns indicates that the metabolic rate has already doubled.


Infant in a cool environment requires more heat

metabolic rate increases producing more heat

– Newborn may cry and have muscular activity when cold, but there is no voluntary control of muscular activity.

– if the newborn’s temperature is not adequately raised through increased metabolism, nonshivering thermogenesis : the metabolism of brown fat begins.


Non Shivering Thermogenesis

- the metabolism of brown fat

Brown fat- special tissue/ fat found only in newborns- appears at about 26-30 wks AOG and increases

until 2-5 wks of age- highly vascularized giving it a brown color- oxidized to produce or conserve heat- located at the back of the neck, intrascapular

region, thorax, around the kidneys and adrenals, in the axillae, around the heart and abdominal aorta and perineal area

• Once the brown fat has been metabolized, the infant no longer has this method of heat production available.



2. Heat Retention

Newborns retain heat by staying in a flexed position.

- reduces the area of skin exposed to the environmental temperature, thus decreasing

heat loss- peripheral vasoconstriction retains heat


Conservation of Heat

1.Brown fat

2. kangaroo care – placing the newborn against themother’s skin and then covering the newborn helps to transfer heat from the mother to the newborn, thus, conserving heat


REWARMING THE BABY SKIN-SKIN• Before rewarming remove the baby’s cold

clothing• Place the newborn skin-skin on the mother’s

chest dressed in a rewarmed shirt open at the front, a diaper, hat and socks.

• Check the temperature every hour until normal.• Keep the baby with the mother until the baby’s

body temperature is in normal range• If baby is small, encourage the mother to keep

the baby in skin-skin contact for as long as possible, day and night

• Be sure the temperature of the room where rewarming takes place is at least 25C.

• If the baby’s temp is not 36.5C or more after 2 Hrs of rewarming, reassess the baby.

• If referral is needed, keep the baby in skin-skin contact or another person on transport.


3. Heat Loss

Newborn - thin skin with blood vessels close to the

surface and little subcutaneous fat to prevent heat l oss

Cold Stress - excessive heat loss


increased metabolism

significant increase in need for oxygen

newborn may experience hypoxia

There may not be enough oxygen for the metabolic rate to increase, and the newborn will not be able to maintain body temperature.


Effects of Cold Stress (temp<36.5)

1. Metabolic Acidosis- increased BMR, anaerobic glycolysis, increased acid production, metabolic

acidosis

2. Hypoglycemia- increased energy requirement to produce

heat- glucose necessary for increased

metabolism is made available when glycogen stores are converted to glucose

- if the glycogen is depleted, hypoglycemia results


4 MECHANISMS OF HEAT LOSS

1. Convection - flow of heat from the newborn’s body surface to cooler surrounding air

2. Radiation - transfer of body heat to cooler solid object not in contact with the baby

3. Conduction - transfer of body heat to cooler solid object in contact with the baby

4. Evaporation -loss of heat through conversion of liquid to vapor


4 MECHANISMS OF HEAT LOSS

• Convection

• Radiation

• Conduction

• Evaporation


ConvectionLoss of heat by the movement of air

EX: air current from the open door or windows, air conditioning or from people moving around increases heat loss


Radiation Loss of heat by transfer to cooler object nearby, but not through direct contact

EX: an infant placed near a cold window loses heat by radiation to the sides of the crib and the window


Conduction Loss of heat by direct contact with cooler object:

EX: newborn touched by cold hands or cold stethoscope newborn placed on a cold surface such as Scale


Evaporation

Loss of heat when water is changed to vapor

EX: When the wet body dries, heat is lost


Other Causes of Heat Loss

1. insulation in newborn is not effective (little subcutaneous fat )

2. shivering is not present


Immediate Assessment of the Newborn


Assessment for Well-being


APGAR SCORE

0 1 2Appeara

nceBlue/Pale

Acrocyanosis

Pink; Ruddy

Pulse Absent < 100 > 100

Grimace None Weak cry Good cry

Activity Flaccid Some ext Flex/ext

Respiration

Absent <30 >60


APGAR SCORE

0 1 2Appearanc

e(Body color)

Blue/Pale Acrocyanosis Pink; Ruddy

Pulse(apical)

Absent < 100 > 100

Grimace(reflex activity)

None Weak cry Good cry

Activity(muscle tone)

Flaccid Some flexion Well flexedFlex/ext

Respiration Absent <30 >60


A ppearance (color) – least important P ulse rate - most important G rimace (reflex activity); irritability A ctivity (muscle tone) R espiration

Per parameter*Lowest individual score is 0.*Highest individual score is 2.


APGAR Scoring System – standard tool to evaluate the condition of the

neonate

Done twice:1st minute: to determine general condition

(NEURO/RESPI/CIRCULATORY CHECK)

5th minute: to determine neonate’s adjustment to extrauterine life


Apgar Scoring System

Score: 9 – highest score 10 – perfect score

0-3: poor, serious, severely depressed, needs CPR

4-6: fair, guarded, moderately depressed, needs suction

7-10: good, healthy


Silvermann Anderson Scoring (Respiratory Distress)


Silverman Anderson Scoring (Respiratory Distress)

Scoring : 0-3 Normal / slight distress 4-7 moderate RDS 7-10 severe RDS

Assessment tool determines respiration of baby


Grading of Neonatal Respiratory Distress (Silvermann Anderson)

Feature observed

0 1 2

1.Chest movement

synchronized lag seesaw

2.Intercostal retractions

None just visible marked

3.Xiphoid retraction

none just visible marked

4.Nares dilatation

none minimal marked

5.Expiratory grunt

none audible by stethoscope

audible by Unaided ear


0: No respiratory distress1 -3: slight distress4-6: moderate distress

7-10: seriously distressed !!!

Grading of Neonatal Respiratory Distress (Silvermann Anderson)


Congenital Anomalies1. Choanal Atresia - a complete blockage

or severe narrowing of the nasal airway at the posterior nares

2. Tracheobronchial fistula - there is a fistula between the trachea and the distal portion of the esophagus

3. Cleft lip and cleft palate

Substances1. drugs2. smoking3. alcohol

How will you know my age if my mommy doesn’t know

her LMP?

http://images.google.com/imgres?imgurl=http://www.thesraid.com/wp-content/uploads/2008/02/image001.jpg&imgrefurl=http://www.thesraid.com/index.php/category/opinion/&h=634&w=572&sz=45&hl=en&start=91&um=1&tbnid=y98Uoal2vhnJEM:&tbnh=137&tbnw=124&prev=/images?q=unconcious+abdominal+thrust+picture&start=80&ndsp=20&um=1&hl=en&rlz=1T4ADBF_enPH268PH268&sa=N

Assessment of GESTATIONAL AGEIt is determined in the first 4 hours after birth so that age related problems can be identified and appropriate care can be initiated.

Second assessment is done within 24 hours.New BALLARD Score is the most commonly used tool

It has 2 elements:External physical characteristicsNeuromuscular maturity


Dubowitz/ Ballard (Maturity Testing Tool)

• done in the first 24 hours– Pre term – born before the 38th week– Post term – born after 42 weeks– Full term – born at 38 to 42 weeks

– Small Gestational Age (SGA) – BW is < 10th percentile• LBW – BW < 2,500 grams• VLBW – BW 1,500 grams

– Large Gestational Age (LGA) – BW > 90th percentile

– Appropriate Gestational Age (AGA) – BW within 10-90th percentile

IUGR - Rate of growth does not meet expected pattern - growth restriction




Neuromuscular maturity1. Posture: With the infant supine and quiet, score as

follows: Arms and legs extended = 0 Slight or moderate flexion of hips and knees = 1 Moderate to strong flexion of hips and knees = 2 Legs flexed and abducted, arms slightly flexed = 3 Full flexion of arms and legs = 4

2. Square Window: Flex the hand at the wrist. Exert pressure sufficient to get as much flexion as possible. The angle between the hypothenar eminence and the anterior aspect of the forearm is measured and scored:

>90 degrees = -1 90 degrees = 0 60 degrees = 1 45 degrees = 2 30 degrees = 3 0 degrees = 4


3. Arm Recoil: With the infant supine, fully flex the forearm for 5 seconds, then fully extend by pulling the hands and release. Score the reaction:

Remains extended 180 degrees, or random movements = 0

Minimal flexion, 140-180 degrees = 1 Small amount of flexion, 110-140 degrees = 2 Moderate flexion, 90-100 degrees = 3 Brisk return to full flexion, <90 degrees = 4

4. Popliteal Angle: With the infant supine and the pelvis flat on the examining surface, the leg is flexed on the thigh and the thigh fully flexed with the use of one hand. With the other hand the leg is then extended and the angled scored:

180 degrees = -1 160 degrees = 0 140 degrees = 1 120 degrees = 2 100 degrees = 3 90 degrees = 4 <90 degrees = 5


5. Scarf Sign: With the infant supine, take the infant's hand and draw it across the neck and as far across the opposite shoulder as possible. Assistance to the elbow is permissible by lifting it across the body. Score according to the location of the elbow:

Elbow reaches or nears level of opposite shoulder = -1 Elbow crosses opposite anterior axillary line = 0 Elbow reaches opposite anterior axillary line = 1 Elbow at midline = 2 Elbow does not reach midline = 3 Elbow does not cross proximate axillary line = 4

6. Heel to Ear: With the infant supine, hold the infant's foot with one hand and move it as near to the head as possible without forcing it. Keep the pelvis flat on the examining surface. Score as shown in the diagram above.


Gestational Assessment (Dubowitz)Finding 0-36 37-38 39 and

overSole creases Anterior

transverse crease

Occasional creases in ant 2/3

Sole covered

w/ creasesBreast nodule

diameter (mm)2 4 7

Scalp hair Fine and fuzzy

Fine and fuzzy

Coarse and silky

Ear lobe Pliable, no cartilage

Some cartilage

Stiffened by thick cartilage

Testes and scrotum

Scrotum empty,

few rugae

Testesdescended. rugae

pendulou

s, full scrotum, ext rugae



External physical characteristics





HIGH-RISK INFANT


PRETERM newborn

• born before 37 weeks of gestation• Weight usually less than 2500 g ( 5 ½ lbs)

• Primary concern : immaturity of all body systems


PRETERM newborn• CAUSES:

– Maternal factor: age, smoking , poor nutrition, placental problems, preeclampsia/ eclampsia

– Fetal Factor : multiple pregnancy, intrauterine growth retardation

• SEVERITY : – The earlier the infant is born, the greater the

chance of complication.• COMPLICATIONs:

1. Respiratory distress syndrome2. Thermoregulatory problem3. Conservation of energy4. Susceptibility to Infection5. Hemorrhage


PE

1. Skin and subcutaneous tissue -thin, transparent2. Increased lanugo3. Decreased plantar creases4. Breast bud scarcely felt5. Pinna flat and shapeless6. Scrotum not pigmented7. Testes not descended8. Labia majora widely separated


PRETERM newborn• Assessment :

1. Respiratory System:Insufficient surfactantApneic episodesRetraction, nasal flaring, grunting, seesaw

pattern of breathing, cyanosisIncreased respiratory rate

2. Thermoregulation: body temperature fluctuates easily

( less muscle & fat )3.NUTRITIONAL status :

Poor sucking and swallowing reflexPoor gag and cough reflexes

4 mL/kg/dose


PRETERM newborn• Assessment :

4. Skin : lacks subcutaneous fat ; reddened; translucent

5.Drainage from umbilicus/eye6.Cardiovascular:

Petecchiae caused by fragile capillaries and prolonged prothrombin time

Increased bleeding at injection site7. Neuromuscular:

Poor muscle toneWeak reflexesWeak , feeble cry


NURSING INTERVENTIONS

1. Maintain respiration at < 60/minute, check q1-2H

2. Administer 02 as ordered : check concentration q 2H to avoid ( retrolental fibroplasia ) while providing oxygenation

3. Auscultate breath sounds to assess lung expansion

4. Encourage breathing with gentle rubbing of back and feet

5. Suction as needed6. Reposition q1-2H for maximum lung expansion

and prevention of exhaustion7. Monitor blood gases and electrolytes


NURSING INTERVENTIONS8. Maintain thermoneutral body temperature

prevent cold stress9. Maintain appropriate humidity level10. Monitor for signs of infection: little Ab

production and decreased resistance11. Feed according to abilities12. Monitor sucking reflex:

* poor – gavage feeding13. Use “preemie” nipple if bottle feeding14. Monitor I&O, wt gain or loss

* easily dehydrated with poor electrolyte balance

15. Monitor hypoglycemia & hyperbilirubinemia


NURSING INTERVENTIONS16. Handle with care : organize care to minimize

disturbance17. Provide skin care with special attention to

cleanliness and careful positioning to prevent breakdown

18. Monitor heart rate and pattern q1-2H : listen to apical for 1 full minute

19. Monitor potential bleeding sites: lowered clotting factor

20. Monitor over-all growth and development of infant, check weight, length and HC

21. Provide complete tactile stimulation when caring for or feeding infant

22.Provide complete explanation for parents23.Encourage parental involvement in infant care


Hypoglycemia

- <40 mg/100 ml- dependent on maternal supply- Birth, continue to produce insulinS/sx: limpness, jitteriness, apnea, twitching

and high pitched cryCX: mental retardationTx: early feeding

D10WNsg: monitor blood glucose level




POST-TERM

• Born after 42 wks of gestation• Assessment :

– Hypoglycemia– Classic sign : Old man’s face– Desquamation – peeling of skin, dry,cracked

almost leather like skin– Long brittle finger nail (fingernails grown well

beyond the end of fingertips)– Wide & alert eyes– Meconium staining possibly present – absence of vernix caseosa


Post-term (>42 weeks)

• INTERVENTIONS:– Provide normal newborn care– Maintain temp– Monitor for meconium aspiration


• Complications:1. may develop polycythemia (oxygenation)2. hypoglycemia


IDENTIFICATION(Existing/ Old Protocol)


Proper Identification

– done in D.R. before being brought to the Nursery

a. Footprints – most reliable

b. ID bands – ankle, wrist

c. Birthmarks




• Ensure newborn’s proper identification

• Footprint newborn and fingerprint mother on identification sheet per agency policies and procedures

• Place matching identification bracelets on mother and newborn.

• REMEMBER! ID band must be checked and compared to the mother’s band each time the baby is brought into the mother’s room.

http://images.google.com/imgres?imgurl=http://appleraszl.com/files/identification.jpg&imgrefurl=http://appleraszl.com/node/15&h=371&w=558&sz=70&hl=en&start=10&um=1&tbnid=TdOUKmfxi600pM:&tbnh=88&tbnw=133&prev=/images?q=Proper+identication+of+the+newborn+picture&um=1&hl=en&rlz=1T4ADBF_enPH268PH268

http://images.google.com/imgres?imgurl=http://cache.viewimages.com/xc/3374388.jpg?v=1&c=ViewImages&k=2&d=89B856506CE54654C6D7ED4C634491B1A55A1E4F32AD3138&imgrefurl=http://www.viewimages.com/Search.aspx?mid=3374388&epmid=1&partner=Google&h=580&w=594&sz=41&hl=en&start=20&um=1&tbnid=9KBQR_fNDfNfyM:&tbnh=132&tbnw=135&prev=/images?q=Proper+identication+of+the+newborn+picture&um=1&hl=en&rlz=1T4ADBF_enPH268PH268


Immediate Care of the Newborn in the Nursery

(Existing/ Old Protocol)


* Note that ID bands of mother and baby are matched.


Special Initial Care1. Initial bath – best done with temp of NB is

stable or at least 37oC– Water bath – 98-100 F or 37-38 C– Water with non-alkaline soap

– Oil – for vernix caseosa– Antimicrobial solution – most preferred in NB if

mother has infection in the vaginal canal.a. Trichomoniasisb. Candidiasisc. Chlamydiad. Gonorrhea


First bath

• Complete bath within an hour after birth to remove vernix caseosa

• For the next 10 days to 2 weeks – sponge bath.• NB are not generally given tub bath until the cord

has fallen off and healing is complete• Nurse giving the first bath to NB must wear

gloves to comply with standard precautions regarding contact with blood or body fluids


2.Taking the Temperature

* Maintain temperature to prevent cold stress

* Use Rectal route

* Meconium - 24-48 hrs



BATHING


3. Initial Cord dressing

• Inspect for A .V. A.• Done with strict aseptic technique practice• Apply cord clamp to prevent bleeding• Application of antiseptic solution

– Povidone iodine– 70% alcohol

to prevent Tetanus Neonatorum and Omphalitis

(streptococcal and staphylococcal infections)


Initial Cord Dressing

CORD: 2 A + 1 V*Practice aseptic technique

Signs of Omphalitis:

*Reddening of the area*Fever*Discharge and foul smell

Application of sterile cord clamp to prevent bleeding within the 1st 24 hours ** The cord will fall off after – 7-10 days



7-10 days Will fall-off


4. Crede’s prophylaxis• Preventive or prophylactic treatment against

OPHTHALMIA NEONATORUM - acquired during passage to the birth canal

• Gonorrheal Conjunctivitis (Neisseria gonorrhea) causes blindness if not treated. Infection can be acquired during delivery from a mother with untreated gonorrhea.

• Medications such as :– Eye ointment : Terramycin , Gentamycin ,

Erythromycin , Chloramphenicol .– Eye drop : Silver Nitrate 1% but this

causes CHEMICAL CONJUNCTIVITIS



CREDE’S PROPHYLAXIS

Ophthalmic drops – BEFORE: Silver Nitrate or AgNO3 1% 1-2 drops

1-2 gtts into the lower conjunctival sac

AT PRESENT:Ointment – inner to outer canthus

TerramycinGentamycinChloramphenicolErythromycin – drug of choice of

Chlamydial TrachomatisChemical Conjunctivitis- usually develops in 3-4 days after application of either ointment or drops


Eye / Crede’s prophylaxis


Erythromycin

- Pull eyelids downward- 0.5-1 cm- Inner to outer canthus- Wipe excess away


5. Vitamin K Injection

• To prevent bleeding because of decreased Vit K synthesis due to sterile GIT

• Facilitates production of clotting factor

• Medications: – Phytonadione – Aquamephyton– Phytomenadione – Konakion

– DOSE : Fullterm : 1 mg = 0.1 ml Preterm : 0.5 mg = 0.05 ml

• ROUTE : IM lateral anterior thigh (Vastus lateralis)



6. Take anthropometric measurements7. Initial feeding8. Physical assessment

INTAKE OF ADEQUATE NOURISHMENT


Nutrition

Recommended Daily Allowances:Calories – 120 cal/kg body weight (KBW)/day

= 50-55 cal/lb body weight/day = more or less 380 cal/day

Proteins – 2.2 grams/KBW/dayFluids – 160-200 cc/KBW/day = 2.5-3 oz/lb body

weight/day = more or less 20 oz/day

Vitamins – Vitamins A, C and D are recommended for both bottlefed and breastfed babies during entire first year of life.


• NB stomach Capacity is only 20 ml (30ml= 1 0z)

• 7 days old – 60-90 ml ( can consume 2-3 0z )

• Gastric capacity = age in months + 2


CRITERIA FOR INITIATING FEEDING 1. no history of excessive oral secretion 2. non-distended, soft abdomen 3. clinically stable 4. RR < 60 CPM


Initial Feeding

1-6 hours after birth

CS : BF after 4 HNSD : ASAP

1 oz of sterile water

Subsequent feeding – by demand


• May breastfeed immediately after birth– Philippine Milk Code EO 51 : Promote

breastfeeding– Rooming-in Act of 1992 RA 7600 : promotes

breastfeeding and requires immediate rooming-in of the newborn


Breastfeeding1. bonding2. uterine contraction3. colostrum 4. Contraceptive5. Cheap6. Right temperature7. Antibacterial – Lactoferrin, Lactobacillus bifidus,

lysozyme, macrophage, T lymphocytes, lactoperoxidase

8. Breastfeed baby has a higher IQ9. Antibodies to E. coli10. Anti-staphylococcus factor11. decreased incidence of dental caries


BREASTFEEDING• Emphasize the importance of

exclusive breastfeeding on demand for the first 6 months of life.

• EXPRESSED MILK SHELF LIFE

Expressed milk Consume w/in 6HFresh frozen expressed milk

Not consumed within the next 24 H ( lasts 48H)

Refrigerated Consumed within 24H


Differences Between Human and Cow’s Milk

NUTRIENTS HUMAN MILK COW’S MILKCHON 8% 20%Fats 50% 50%Carbohydrates

42% 30%Na 7 mEq/l 25 meq/lK 14 mEq/l 36 mEq/lCa 12 mEq/l 61 mEq/lPhosphorus 9 mEq/l 53 mEq/lCl 12 mEq/l 34 mEq/l


Nutrients Human milk

Cows milk

Fe 0.5 0.5Linoleic acid

(+) (-)

Vit D 22 14 Vit A 1898 1025Vit C 43 11Vit K 15 60


• Contraindications of breastfeeding:1. an infant with galactosemia (can’t

digest lactose in milk)

2. herpes lesion on a mother’s nipple3. maternal diet is nutrient restricted,

preventing quality milk production

4. maternal medication inappropriate for feeding

5. maternal exposure to radioactive compounds


• Advantages of breastfeeding : to the baby1. contains secretory immunoglobulins A2.contain lactoferrin ( iron-binding chon in breast milk that interferes with growth of pathogenic bacteria3. contains antibodies4. reduces incidence of diarrhrea( presence of L.Bifidus interferes with colonization of pathogenic bacteria in the GIT)5.contains high amount of mineral and electrolytes6. contains more linoleic acid ( essential fatty acid for skin integrity and less Na,K,Ca and phosporous)


Advantages of breastfeeding : to mother1. serves as protective function in preventing

breast cancer2.release of oxytocin from the post. Pit. Gland aids

in uterine involution3. successful breastfeeding can have an

empowering effect, skill only women can master4.breastfeeding reduces the cost and preparation

time5.provides an excellent opportunity to enhance

true symbolic bonding between mother and child


BREASTFEEDING BOTTLEFEEDING•Non-allergenic•Meet infant ‘s specific nutritional needs•Immunologic properties help prevent infection•Easily digested•Constipation unlikely•Overfeeding less likely•No formula or bottles to buy•No formula and bottle to prepare•Oxytocin release help involution•Mother more likely to eat well balance diet•May help with mother’s weight loss•Enhances mother/infant attachment through skin to skin contact•Frozen -20c (6 mos)•Refrigerated 4c ( 24 H)

•Father or others may feed infant day or night•Feed less frequently (3-4H)•Amount of milk taken at each feeding known

ADVANTAGES


BREASTFEEDING BOTTLEFEEDING•Feed more frequently (2-3 H)•More frequent diaper changes•Amount of milk taken at each feeding unknown•Medications taken by mother present in milk•Discomfort of som mothers to nurse in public•Expense of pumping and storing milk for periods when mother is unavailable ( such as work)

•Expense of formula, bottles•Washing bottles•Fixing and refrigerating formula•Carrying bottles on outings•May cause constipation

DISADVANTAGES

BREASTFEEDINGHealth teaching:1. Proper hygiene2. Best position - upright sitting3. Stimulate & evaluate feeding reflexes

1. Rooting2. Sucking3. ExtrusionCriteria for effective sucking4. baby’s mouth is hiked up to areola5. Mom experiences after pain6. Other nipple is flowing with milk


Breastfeeding• Position for feeding: Teach the mother

to -Make sure the baby’s head and body are in straight line– Make sure the baby is facing the

breast, with the nose opposite the mothers nipple

– Hold the baby ‘s body close to her body

– Cradle hold with infant’s head in the bend of the mother’s elbow and arm supporting the infant’s body

– OTHERS:• Football hold• Side lying position• Across lap

Cradling


BreastfeedingHELP THE BABY TO ATTACH

– Latching on• TEACH THE MOTHER TO

– Touch the baby’s lips with her nipple– Wait until the baby’s mouth is opened

wide, then position the baby’s mouth onto her breast so that the baby’s mouth is well around the areola.

• SIGN OF GOOD ATTACHMENT:– Slow , deep sucks with occasional pauses– Unsatisfactory: try again then reassess– Breast engorged : express small amount of

BM before starting to breastfeed to soften the nipple area and facilitate easier attachment

Cradling


Breastfeeding

• Length of feeding– Varies with each mother /infant unit

• BURPING- – ALL INFANTS REQUIRE BURPING– TO EXPEL THE AIR SWALLOWED

WHEN THE INFANT SUCKS– SOME INFANT SWALLOW MORE

AIR THAN OTHERS AND REQUIRE MORE FREQUENT BURPING

Cradling


BURPING TECHNIQUE

1. OVER THE SHOULDER

2. FACE DOWN ON YOUR LAP

3. SITTING UP


Waste Elimination3 types of stools passed by NB:

1. Meconium – greenish-blackish, viscous - amniotic fluid, intestinal secretions and cells shed from mucosa- take note of time when meconium first passed ( Normally : 24-36H)

Failure to Pass : THINK OF HIM

1. Hirschsprung disease2. Imperforate Anus

3. Meconium Ileus


2. Transitional – passed from 3rd to 10th day3. Milk stool

a. Breast fed infant stool – loose golden yellow in color with sweet odor; 2-3 times a day

b. Bottle fed infant stool – formed, pale yellow with a typical odor; usually passed 1-2 times a day


DIFFERENT STOOLSJaundiced baby Light stoolUnder phototherapy Bright greenMucus mixed with stool Milk allergyObstruction to bile duct Clay colored

After Barium enema Chalk clay coloredGIT bleeding Black stoolAnal fissure Blood flecked stoolIntussusceptions Currant jelly stoolHirschsprung Ribbon like stoolMalabasorption syndrome ( celiac, cystic fibrosis)

Steatorrhea ( fatty foul smelling stool)


Parent/Infant Bonding

• interaction between parents and infant should be promoted as soon as the infant is stable

• The nurse may assist the parents in holding their baby or give them permission to examine the infant


Behavioral Characteristic

During the first 6-10 hours after birth infant has a fairly predictable pattern of behavior called

PERIOD OF REACTIVITY


Period of reactivity

• 2 periods of reactivity occur during the first few hours of life

• Separated by a period of sleep

– FIRST PERIOD OF RACTIVITY• The first 30 minutes after birth• Newborn is awake, alert and active• Primetime for parents/infant interaction• Newborn acts hungry, with strong

sucking reflex• Ideal time to begin breastfeeding• HR , RR are rapid & bowel sounds

seldom heard


Period of reactivity

– FIRST PERIOD OF REACTIVITY– Sleep period

• The newborn enters a sleep period that usually lasts from 2-4 hours.

• Time of deep sleep• Difficult to awaken NB• HR , RR return to baseline and bowel

sounds become audible


Period of reactivity– FIRST PERIOD OF RACTIVITY– SECOND PERIOD OF REACTIVITY

• Lasts from 4 to 6 hours• NB is once again awake and alert• HR , RR with period of apnea w/c causes HR

to decrease• NB may gag, spit up or choke or gastric and

respiratory mucus increases• CLOSE OBSERVATION is a must – maintain

clear airway• First meconium stool is often passed• First voiding may occur


Physical Assessment


Senses

1. hearing- becomes acute after birth, recognizes mothers voice

immediatelyfunctional at birth as soon as the external ear canal is cleaned

2. vision- focuses best on black and white at a distance of 9 to 12 inches. not well developed at birth

4 months of age – clear vision

7 y/o = 20/20 vision


Senses

3. Tactile ( touch) starts in early prenatal life from face, then spreads to limbs and finally to the trunks in cephalocaudal succession.

Pain sensation – not well developed in NB lasts a weekResponse to pain – generalized

movement & crying7-9 months – can localize the site of

pain and withdraw from it.12-16 months – shoves painful away

and bring hand to irritated area


Senses

4. Taste – can taste but unable to distinguish flavor.

3 months old – acute taste discrimination is achieved.

5. Olfactory – observed at birth more acute at later age

PHYSICAL CHARACTERISTICS OF THE NEWBORN

Vital Signs

Anthropometric measurement

General Appearance



• The newborn infant should undergo a complete P.E within 24 hours of birth.– NOTE :

• It is easier to listen to the heart and lungs first when the infant is quiet

• Warm the stethoscope before using to decrease the likehood of making the infant cry


Assessment of The Newborn

• Initial Physical Examination :A. General Guidelines:

• Keep the NB warm during the examination.• Begin with general observations and then

perform assessment that are least disturbing to the NB first.

• Initiate nursing interventions for abnormal findings.

• Document all abnormal findings.


1. Vital Signs• using apical pulse = PMI: Point of Maximum Impulse

(located at MCL 4th- 5th ICS or below the left nipple line)• 1 full minute

– This is done using a stethoscope.– Radial pulse is normally not prominent. – If it is, it may be a sign of congenital heart anomaly

(i.e., PDA).– Femoral or brachial pulses – if absent, indicates,

coarctation of the aorta and hip dislocation.

– Pulse is IRREGULAR, RAPID>160-180 beats/min. at birth

120-140 (stable)



During sleep - 90-110 bpmIf crying, up to 180 bpm

Pulse : heart rate in utero- 120 t0 160 bpm after 1 hr newborn settles, heart rate stabilizes to an average of 120 to 140 bpm- remains irregular because of immaturity of cardiac regulatory center in the medulla- when crying, rate might increase to 180 bpm- may decrease to 90 to 110 bpm during sleep- femoral pulses are more appreciated than radial and temporal pulses ( always palpate for the femoral pulses; their absence suggests coarctation of aorta)


B. Respirations - 1 full minute

- irregular, shallow, rapid w/ brief apneic spells < 15s

60-80 breaths/min at birth

NORMAL: 30–60/minute


Respiration : average is 30 to 60 breaths per minute- respiratory rate, rhythm, depth are likely to be irregular and short periods of apnea ( periodic respiration) are normal- coughing and sneezing are present at birth to clear the airway- newborns are obligate nose-breathers


C. Blood Pressure - not usually measured

*not routinely obtained except for suspicion of Coarctation of the Aorta.

80–60/45–40 mm Hg at birth 100/50 mm Hg at day 10


D. Temperature

Normal range: 36.5C–37.5C (axilla)

Axillary: 36.4C–37.2C Skin: 36.0 C–36.5C Rectal: 36.6C–37.2C

* Temperature 37.2 at birth


Crying - increases body temperature slightly

Radiant warmer - falsely increases axillary temperature


Anthropometric Measurements (Vital Statistics)

BW: 2.5 – 3.4 kgs(5.5 – 7.5 lbs)

* 1 K = 2.2 lbs

BL: 47.5 – 53.75 cm (19 – 21 ½ in)

Average: 50.8 cm/20 in

* 1 inch = 2.54 cm



Physiologic weight loss

- 5-10 % in 10 days

Causes1. no longer under influence of maternal

hormones2. voids and passes out stools3. relatively low nutritional intake4. beginning difficulty establishing sucking


Breastfed infant recaptures birth weight within 10 days

Formula fed infant recaptures weight gain with in 7 days

Then continues to gain weight of 2lb/month( 6-8oz/ wk) for the 1st 6 months of life


HC: 33 – 35 cmCC: 31 – 33 cmAC: 31 – 33 cm

Chest circumference :Should be equal to or 2-3 cm Less than the HC


Anthropometric Measurement


• Length : mature female neonate - 53 cm (20.9 in) mature male - 54 cm (21.3in)

• Head circumference: mature newborn - 34-35 cm (13.5 to 14 in)

Measure with the tape measure drawn across the center of the forehead and around the most prominent portion of the posterior head.

• Chest circumference: term newborn – 2 cm less than head circumference, measured at the level of the nipples



General appearance

- Skin- Head- Eyes- Ears- Neck- Chest- Abdomen- Genitalia- Back- Extremities


General Appearance

• Full term newborns have a flexed posture• The head is flexed• Arms are flexed on the chest• Legs are flexed on the abdomen


Skin

• Plethora ( deep, rosy red color) more common in infants with polycythemia vera but can be seen in an overoxygenated or overheated infant.

• Vernix caseosa – a white creamy substance may thinly cover the skin.

• Lanugo – fine downy hair , may still be seen on the forehead and shoulders or it may all disappear.


Skin

• Pinkish red• Vernix caeosa• Lanugo• Milia• Dry peeling skin• Cyanosis

HypothermiaHypoglycemiaInfectionCardiacRespiratoryNeurological abnormalities

http://images.google.com/imgres?imgurl=http://www.adhb.govt.nz/newborn/TeachingResources/Dermatology/Milia/Milia.jpg&imgrefurl=http://www.adhb.govt.nz/newborn/TeachingResources/Dermatology/BenignLesions.htm&h=480&w=640&sz=25&hl=en&start=5&um=1&tbnid=6YRzXgKPenrjLM:&tbnh=103&tbnw=137&prev=/images?q=milia&um=1&hl=en&rlz=1T4ADBF_enPH268PH268


SKIN Cyanosisa. central ( bluish skin, including the tongue and lips- associated with low oxygen saturation in the

blood and it may be associated with congenital Heart disease ( CHD)

b. Peripheral cyanosis – bluish skin with pink lips and tongue

c. Acrocyanosis - bluish hands and feet only - may be normal for an infant who has just been

born.


2. Skin

Dark red – prematurityAcrocyanosis – up to 48 hoursCentral cyanosis – indicates decreased O2Generalized mottling Gray color - infection Pale color - anemiaYellow color –jaundiceHarlequin sign – pale and pink


Pallor

* Excessive blood loss when cord is cut

* Untimely cutting of the cord

* Inadequate iron stores because of poor maternal nutrition

* Blood incompatibility


MILIA• Newborn sebaceous glands are

immature. At least one pin-point white papule (a plugged or unopened sebaceous gland) can be found in the cheek or across the bridge of the nose of every newborn.

• Disappears by 2-4 wks of age as the sebaceous glands mature and drain.

• Parents should be instructed to avoid scratching or squeezing the papules to prevent secondary infection.


Milia

Benign cystsDisappear Within few weeksAfter birth


ERYTHEMA TOXICUM

• in most normal mature infants - newborn rash• usually appears on the 1st to 4th days of life, but

may appear up to 2 wks of age• Also called Flea bite rash• One of the chief characteristics of the rash is the

lack of pattern.


Lesions are most noticeable 48HAfter birth but may appear as late as

7-10 daysBENIGN RASH resolves spontaneously



Mottling lacy pattern May be seen in the

healthyinfant or infant with 1. Cold stress2. Hypovolemia3. Sepsis

Persistent mottling-referred to as cutis marmorata


Candida albican rashAppears as erythematous plaquewith sharply demarcated edgesskin folds are involved

Treatment :

Nystatin ointment or cream Applied to the rash 4x daily for 7-10 days


Acne Neonatorum

• Lesion typically seen over the check, chin and forehead

• Benign and requires no therapy• Severe cases may require treatment with mild

keratolytic agent such as 3% sulfur salicylic acid


ACNE


FORCEPS MARK

• There may be a circular or linear contusion matching the rim of the blade of the forcep on the infant’s cheek.

• The mark disappears in 1-2 days along with the edema that accompanies it.



Jaundice Types: 1. Physiologic Jaundice / Icterus Neonatorum 2nd day– 7th day – TERM (12mg/dl- indirect bilirubin) 2nd day – 10th day - PRE-TERM 2. Pathologic Jaundice- before the first 24 hours of life

– Causes: Infection Hemolytic disorders Inability of the newborn to conjugate bilirubin

Decreased conversion of bilirubin to urobilirubin

Decreased uptake of free bilirubin by hepatic cells


Normal total serum bilirubin = 15%

Direct bilirubin = 1.7 Indirect bilirubin = 13.2

Breastfed babies have longer physiologic jaundice because human milk has PREGNANEDIOL depresses the action of glucoronyl transferase (enzyme responsible for converting indirect bilirubin to direct bilirubin)


Breastmilk jaundice

Pregnanediol

Decrease glucoronyl transferase

Decrease conversion of indirect to direct bilirubin

jaundice


Goal of treatment: to decrease the bilirubin levels

Management: Bililight (Phototherapy)

Nursing Care:1. Cover eyes with an opaque

mask to prevent blindness.2. Maintain a distance of about 18-

20 inches from source of light.3. Monitor V/S especially temp.4. Cover the genitalia to prevent

PRIAPISM (continuous erection).5. Turning the baby q2hours.6. Hydration.


KERNICTERUS

Accumulation of bilirubin in the brain tissues• SEIZURES• MENTAL RETARDATION• EXCHANGE TRANSFUSION




PHOTOTHERAPY

http://rds.yahoo.com/_ylt=A0S020t127BI.ZMAagyJzbkF;_ylu=X3oDMTBxNDlhNGg0BHBvcwM2BHNlYwNzcgR2dGlkA0kwODZfMTA4/SIG=1qfahgk6o/EXP=1219636469/**http:/images.search.yahoo.com/images/view?back=http://images.search.yahoo.com/search/images?p=PHOTOTHERAPY&sp=1&fr2=sp-top&y=Search&ei=UTF-8&fr=sfp&x=wrt&js=1&ni=21&ei=UTF-8&SpellState=n-2098260049_q-OdIDUYmgSrPjkICRgLIImwAAAA@@&w=500&h=333&imgurl=static.flickr.com/2130/2252877203_137895eb99.jpg&rurl=http://www.flickr.com/photos/danielross/2252877203/&size=86.4kB&name=Kieran+in+Phototherapy&p=PHOTOTHERAPY&type=JPG&oid=4b8a52142cbe2b5e&fusr=Daniel+Ross&tit=Kieran+in+Phototherapy&hurl=http://www.flickr.com/photos/danielross/&no=6&tt=7,822&sigr=11jspu0tp&sigi=11go1ma1g&sigb=15l4rdpg6&sigh=1183kmog8

NURSE ALERT!!!

Most accurate method of assessing the presence of jaundice: Use natural light and blanch skin on the chest or

tip of the nose.


Skin

• Acrocyanosis- hand and feet ; peripheral circulation is sluggish within 24H

• Harlequin sign– Deep pink or red color develop over one side

while the other side remains PALE or normal color

– Indicative of shunting of blood with cardiac problem or sepsis

• Birthmarks


Birth marks• Telangiectatic Nevi ( stork bites) – disappear at

2yrs – pale pink or red, flat , dilated capillaries

• Nevus Flammeus ( portwine stain)– No fading with time – Require surgery in the future– Common on face– Non-elevated, sharply demarcated red to

purple dense area of capillaries• Nevus Vasculosus ( strawberry mark)

– Disappear at 7-9 yrs old– Common in head– Dark red

• Mongolian Spot – fades at 1-2 years old – Bluish black pigmentation– Lumbar dorsal area or buttocks


Common Marks

1. Harlequin Sign - BECAUSE OF IMMATURITY OF CIRCULATION, AN INFANT WHO HAS BEEN LYING ON HIS SIDE WILL APPEAR RED ON THE DEPENDENT SIDE & PALE ON THE UPPER SIDE.

2. Mongolian spots – bluish gray or dark nonelevated pigmentation area over the lower back and buttocks present at birth; primarily nonwhite, disappears at SCHOOL AGE


3. Milia – unopened sebaceous glands; tip of nose and chin of the baby.

• Newborn sebaceous gland is immature. At least one pin-point white papule (a plugged or unopened sebaceous gland) can be found in the cheek or across the bridge of the nose of every newborn.

• Disappears by 2-4 wks of age as the sebaceous glands mature and drain.

• Parents should be instructed to avoid scratching or squeezing the papules to prevent secondary infection.

4. Lanugo - fine downy, hair that covers a newborn’s shoulder, back and upper arms

• Found also in the forehead and ears.• The newborn of 37-39 wks has more lanugo than

the 40th wks old infant.• Post-mature infants have rarely have lanugo• By age of 2 wks, it disappears


Common Marks

5. Desquamation- peeling; at birth, postmaturity• Within 24 hrs. of birth, the skin of most newborns

has become extremely dry• The dryness is particularly evident on the palms

of the hands and soles of the feet.• this is normal and needs no treatment.

6. Vernix Caseosa• White, cream-cheese-like substance that serves

as a skin lubricant, usually noticeable on a newborn skin, prominently seen in the skin folds, at birth in a term neonate.


7. Portwine Stain or Nevus Flammeus – birth; red to purple color, usually flat discoloration commonly on the face or neck; does not grow and does not fade; does not blanch on pressure nor disappear

8. Strawberry Mark or Nevus Vascularis – 2nd most common type of capillary hemangioma. elevated, sharply demarcated or bright or dark red, rough surface swelling. (+) school age or even longer.


9. Erythema Toxicum or Erythema Neonatorum – Newborn rash or fleabite rash/ dermatitis; transient; papules with vesicles at nape, back and buttocks.

• It usually appears in the 1st to 4th day (2nd day) of life, but may appear up to 2 wks of age

• One of the chief characteristic of the rash is the lack of pattern; disappears without treatment.

10. Nevi – stork bites or Telangiectasia Nevi; pink or red flat areas of capillary dilatation at upper eyelids, nose, upper lip, lower occiput bone, nape and neck. can be blanched by the pressure of the finger; usually fade during infancy- 1st and 2nd year.


11. Cutis Marmorata – transitory mottling when exposed to cold

12. FORCEPS MARK• There may be a circular or linear contusion

matching the rim of the blade of the forcep on the infants cheek.

• The mark disappears in 1-2 days along with the edema that accompanies it.


Nevus flammeus/Portwine Stain


Stork’s beak mark


Strawberry Hemangioma


Cavernous Hemangioma


Mongolian Spot


Milia


Erythema toxicum


Head

- largest part of the human body (1/4 of his total body length)

- forehead is large and prominent- chin is receding when startled or crying


Head • 25% of the body length ( cephalocaudal development).

Larger Part• Sutures are palpable • Fontanels are unossified membranous tissue at the junction

of the sutures• Molding is asymmetry of the head resulting from the

pressure in the birth canal, overlapping of sagittal and coronal suture line


SUTURES:Lambdoid (2) Coronal (2) Frontal (1) Sagittal (1)


Fontanels1. Anterior – diamond shape

- closes at 12-18 months - 3-4 cm long/2-3 cm wide - junction of 2 parietal bones and 2 fused

frontal bones- not indented/not depressed- suture lines - never appear widely separated

2. Posterior – triangular in shape- junction of the parietal bones and the occipital bones. - 1 cm wide- closes at 2-3 months of age


Masses from birth trauma• Caput succedaneum – edema of

the soft tissue over bone ( crosses over suture line)– No treatment; subsides in few

days• Cephalhematoma – swelling

caused by bleeding into an area between the bone and its periosteum ( does not cross over suture line )– Absorbed within 6 weeks – No treatment


Comparison between Caput Succedaneum and

CephalhematomaIndicators Caput Succedaneum

Cephalhematoma

Definition Edema of scalp blood b/wLocation Presenting part

of the headperiosteum of skull bone &

bone Extent of Involvement

Both hem; (+) cross suture lines

individual bone; (-) cross suture

lineCause Pressure (as in prolonged labor)

Pressure (rupture of capillaries)

Period of absorption

On or about the 3rd day or 4th

days

Takes several weeks - months

Treatment None Support



CRANIOSYNOSTOSIS - suture lines separated or fontanels prematurely closed; leads to mental retardation.

Craniotabes – localized softening of cranial bones - indented by pressure of a finger – Corrects w/o treatment in weeks or

months.– Common to firstborn because of early

lightening

Hydrocephalus – anterior fontanel open after 18 months

Microcephaly – small growing brain

Anencephaly – absence of cerebral hemisphereFRAGILE

http://images.google.com/imgres?imgurl=http://200.221.3.223/images/articlesimg/blog/06ene01.jpg&imgrefurl=http://blogboasaude.zip.net/arch2008-03-30_2008-04-05.html&h=219&w=214&sz=9&hl=en&start=19&um=1&tbnid=hRxDJhmQ0EwO5M:&tbnh=107&tbnw=105&prev=/images?q=picture+of+craniotabes&um=1&hl=en&rlz=1T4ADBF_enPH268PH268


Molding –overlapping of sagittal and coronal suture lines


• Seborrheic dermatitis – “ Cradle cap”– Scaling greasy-appearing salmon colored

patches, seen on the scalp behind ears and umbilicus

– CAUSE :• Improper hygiene

– Mgt:• Proper hygiene• Oil before shampoo


Signs of ALARM

• fused sutures• bulging or depressed fontanels when quiet• widened sutures and fontanels• craniotabes

http://rds.yahoo.com/_ylt=A0S020t33bBIILAADQGJzbkF;_ylu=X3oDMTBxNDlhNGg0BHBvcwM2BHNlYwNzcgR2dGlkA0kwODZfMTA4/SIG=1lsfeo7v2/EXP=1219636983/**http:/images.search.yahoo.com/images/view?back=http://images.search.yahoo.com/search/images?p=BABY+CRADLE+CAP&sp=1&fr2=sp-top&y=Search&ei=UTF-8&fr=sfp&x=wrt&js=1&ni=21&ei=UTF-8&SpellState=n-1767644795_q-TI.sHMkAAJo3713Q806VtwAAAA@@&w=125&h=114&imgurl=www.motherhood.com.au/assets/images/cradle_cap.gif&rurl=http://www.motherhood.com.au/mother/newborns.htm&size=2kB&name=cradle_cap.gif&p=BABY+CRADLE+CAP&type=gif&oid=0bfa6af3c566d15c&no=6&tt=315&sigr=11g8ni942&sigi=11ip00bv6&sigb=15o2uoe7k


Eyes • Symmetrical and clear• Pupil equal, round , react to light by

accommodation• Blink reflex present• Strabismus common – weak EOM• Ability to track and fixate momentarily• Red reflex present • Eyelid often edematous• Absence of tears• Corneal reflex (+)• Visual acuity = 20/200; 20/800


POTENTIAL Danger (SIGNs of ALARM)

• Congenital cataract• Constricted or dilated pupil• Yellow sclerae• Absence of red reflex, corneal reflex• Inability to follow object or bright light to midline

http://images.google.com/imgres?imgurl=http://weblogs.newsday.com/news/local/longisland/politics/blog/cataract.png&imgrefurl=http://weblogs.newsday.com/news/local/longisland/politics/blog/2008/05/&h=581&w=800&sz=610&hl=en&start=1&um=1&usg=__hEvHtMhIi8b8ohx1aO6_Wnd0YMw=&tbnid=6nDJjtUunoppWM:&tbnh=104&tbnw=143&prev=/images?q=congenial+cataract&um=1&hl=en&rlz=1T4ADBF_enPH268PH268

http://images.google.com/imgres?imgurl=http://www.cosplaysupplies.com/lenses/108.jpg&imgrefurl=http://www.cosplaysupplies.com/lenses/lenses.php?subsection=Custom&h=118&w=200&sz=5&hl=en&start=16&um=1&usg=__IL8pTN-V0l1gI77kQWwzsJ5yeGE=&tbnid=A7AjLKXqL1KrJM:&tbnh=61&tbnw=104&prev=/images?q=yellow+sclera&um=1&hl=en&rlz=1T4ADBF_enPH268PH268


EARS• Symmetrical• Firm cartilage with recoil• Top of pinna/ear should align with inner and

outer canthus of the eye

sense of Hearing – highly developed in NB


Potential Danger: ALARM

• Low set ears & minor abnormalities (chromosomal defect & kidney anomalies)

• Absence of startle reflex in response to loud noise

http://images.google.com/imgres?imgurl=http://image.bio-medicine.org/img/Too-Little-Vitamin-D-May-Soften-Babys-Skull.gif&imgrefurl=http://www.bio-medicine.org/medicine-news-1/Too-Little-Vitamin-D-May-Soften-Babys-Skull-15209-1/&h=166&w=135&sz=6&hl=en&start=25&um=1&usg=__Ul_TyjlimzE4_WtuP0CtJcSnOLg=&tbnid=no710b8Y2F0NGM:&tbnh=99&tbnw=81&prev=/images?q=craniotabes&start=20&ndsp=20&um=1&hl=en&rlz=1T4ADBF_enPH268PH268&sa=N


Nose

• Nasal obligates• Note for marked flaring of alae nasi.

– indicative of airway obstruction

Causes of obstruction:1. secretions2. septal deviation

• Sense of smell – least developed


Mouth• Pink , moist gum• Soft and hard palates intact• Epstein pearl ( small, white cyst ) that may

be present on hard palate • Uvula midline • Symmetrical and free moving tongue• Sucking & crying movement symmetrical• Able to swallow• Gag reflex present


• Common– Natal teeth

• Potential Danger:– Cleft lip– Cleft palate– Large protruding tongue– Profuse salivation or drooling– Candidiasis ( thrush)

http://shw.fotopages.com/9162909/cleft-lip-cleft-palate.html

http://images.google.com/imgres?imgurl=http://www.homeworking.ws/child%20in%20a%20million/kody-barrowman.jpg&imgrefurl=http://www.mymultiplesclerosis.co.uk/million/kody-barrowman.html&h=160&w=150&sz=3&hl=en&start=3&um=1&usg=__4Imvqx4JEvOdSvJWPk-gsz38NOA=&tbnid=d8CEhoQ1OrpMyM:&tbnh=98&tbnw=92&prev=/images?q=PICTURE+PROTRUDING+TONGUE&um=1&hl=en&rlz=1T4ADBF_enPH268PH268&sa=N

http://images.google.com/imgres?imgurl=http://www.riversideonline.com/source/images/image_popup/r7_oralthrush.jpg&imgrefurl=http://www.riversideonline.com/health_reference/Dental-Care/DS00408.cfm&h=291&w=400&sz=28&hl=en&start=11&um=1&usg=__PaffkXX-UGDld8rzRk_i16fYVIw=&tbnid=0OM6RdvOH7Av2M:&tbnh=90&tbnw=124&prev=/images?q=ORAL+THRUSH&um=1&hl=en&rlz=1T4ADBF_enPH268PH268

http://images.google.com/imgres?imgurl=http://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/17284.jpg&imgrefurl=http://www.nlm.nih.gov/medlineplus/ency/imagepages/17284.htm&h=320&w=400&sz=11&hl=en&start=5&um=1&usg=__vrRGlMzzdjpr0ndSuzubpnrGZGA=&tbnid=GM72g0fZk7E7JM:&tbnh=99&tbnw=124&prev=/images?q=ORAL+THRUSH&um=1&hl=en&rlz=1T4ADBF_enPH268PH268


NECK

• Thyroid gland not palpable

• Soft, palpable and creased with skin folds

• Head - rotates freely on the neck and flexes forward and back

• (+) rigidity of the neck- CONGENITAL TORTICOLLIS (injury to SCM sternocleidomastoid)

• NB whose membranes ruptured 24 hours before birth-nuchal rigidity meningitis



CYSTIC HYGROMA

BLOCKAGE OF LYMPHATIC SYSTEM

http://images.google.com/imgres?imgurl=http://www.adhb.govt.nz/newborn/TeachingResources/dermatology/CysticHygroma/CysticHygroma.jpg&imgrefurl=http://www.adhb.govt.nz/newborn/TeachingResources/dermatology/OtherLesions.htm&h=480&w=640&sz=35&hl=en&start=1&um=1&usg=__0jKqDEnYb6rJxAY7A_wl2e2ws10=&tbnid=iOCeEuHgH7bppM:&tbnh=103&tbnw=137&prev=/images?q=CYSTIC+HYGROMA&um=1&hl=en&rlz=1T4ADBF_enPH268PH268

http://images.google.com/imgres?imgurl=http://www.sgrh.com/dept/paedsurg/image012.jpg&imgrefurl=http://www.sgrh.com/dept/paedsurg.htm&h=133&w=177&sz=5&hl=en&start=7&um=1&usg=__ioj4UFf5rCmj_Gw7saeelpE1nGY=&tbnid=B_1McZnRMpvhxM:&tbnh=76&tbnw=101&prev=/images?q=CYSTIC+HYGROMA&um=1&hl=en&rlz=1T4ADBF_enPH268PH268


CHEST

• Circular appearance – AP and Lateral diameter are about EQUAL.

• Diaphragmatic respiration• Bronchial sounds heard on auscultation• Nipples prominent & edematous• Milky secretion common ( witch milk)• Breast tissue present• Clavicles need to be palpated to assess for

fracture• Symmetrically expands (retraction indicates

respiratory distress)

- Breasts may be engorged (due to maternal hormones) There could be passage of thin, transparent watery fluid known as WITCH’S MILK.


• Commonly seen :– Pectus excavatum ( funnel shaped)– Pectus carinatum ( Pigeon chest)– Supernumerary nipples

• SIGN of Potential Danger– Depressed sternum– Marked retraction of chest and ICS ( during

respiration)– Redness & firmness around nipple– Wide spaced nipple


LUNGS

• Abdominal respiration• Cough reflex is absent at birth

– (+) by 1-2 days– Bilateral equal bronchial breath sound

• RESPIRATION: Irregular rate & depth • (+) crackles - after birth


POTENTIAL DANGER

• Inspiratory stridor• Expiratory grunt and retraction• Persistent irregular breathing• Periodic breathing with repeated apneic spells• Seesaw respiration ( paradoxical)• Unequal and diminished breath sound• Persistent fine crackles• Peristaltic bowel sounds on one side with

diminished breath sounds on the same side


HEART

• Located : Apex 4th-5th ICS, lateral to left sternal border

• Heart rate increases with inspiration and decreases with expiration

• Transient cyanosis when crying or straining


POTENTIAL DANGER

• DEXTROCARDIA – heart at right side• Cardiomegaly• Displacement of apex, muffled• (+) murmur or thrills• Persistent cyanosis• Hyperactive precordium


Abdomen• Umbilical cord

– Monitor cord for meconium staining– Assess for umbilical hernia– Note for abdominal depression– Assess for abdominal distention– Monitor bowel sounds – audible 1-2H after birth

• Liver palpable 2-3 cm below right costal margin• Spleen: tip palpable at the end of first week of age• Kidney : palpable 1-2 cm above umbilicus• Umbilical cord : bluish white at birth, 2 arteries and 1

vein• Femoral pulses : equal and bilateral


omphalocele

Gastrochisis

http://images.google.com/imgres?imgurl=http://apps.uwhealth.org/health/adam/graphics/images/en/19188.jpg&imgrefurl=http://apps.uwhealth.org/health/adam/sp/13/100198.htm&h=320&w=400&sz=14&hl=en&start=4&um=1&tbnid=seAzwrDy_7PMYM:&tbnh=99&tbnw=124&prev=/images?q=image+of+newborn+abdomen&um=1&hl=en&rlz=1T4ADBF_enPH268PH268

http://images.google.com/imgres?imgurl=http://www.calicutmedicaljournal.org/2005/3/3/e2/index_files/image006.jpg&imgrefurl=http://www.calicutmedicaljournal.org/2005/3/3/e2/&h=326&w=482&sz=15&hl=en&start=13&um=1&tbnid=rM4aAuMEcpImWM:&tbnh=87&tbnw=129&prev=/images?q=image+of+newborn+abdomen&um=1&hl=en&rlz=1T4ADBF_enPH268PH268


GI SYSTEM• Newborn’s stomach holds about 60-90 ml• Has limited ability to digest fat and starch

because the pancreatic enzymes, lipase and amylase, are deficient for the 1st few months of life

• Because milk, the infant’s main diet for the 1st year is low in Vit. K, intestinal synthesis is necessary for blood coagulation


Abdomen

• Umbilical cord

• ANUS– Ensure anal opening is patent– First stool meconium should pass within first 24H


Potential Danger

• Abdominal distention• Distended veins• Absent bowel sound• Enlarged spleen and liver• Ascites• Visible peristaltic waves• Scaphoid or concave abdomen• Green umbilical cord• Presence of only 1 artery in cord


Genitals• Female :

– Labia edematous , clitoris enlarged– Pseudomenstruation (+)– First voiding occurs within 24H

• Male– Prepuce covers glans skin– Scrotum is edematous– Verify meatus at tip of penis– Testes descended, retracts at cold

tempearture– Assess for hernia or hydrocoele– First voiding occurs w/in 24H


Male Genitalia

– Scrotum may be edematous due to maternal hormones.

- Testes should be present; if undescended - CRYPTORCHIDISM


Conditions for Cryptorchidism

1. Agenesis – absence of an organ2. Ectopic testes – Testes cannot enter the scrotum because opening of the scrotal sac is closed.3. Vas deferens or artery is too short to allow the testes to descend.


– Care of the penis• Uncircumcised –

– do not force retraction of foreskin (complete separation of foreskin and glans penis takes 3-5 y)

– parents should be told to gently test for retraction occasionally during bath

– and when it has occurred, gently clean glans with soap and water


Circumcision – prior to discharge from nursery, preferably end of 1st week

Procedure:1. Vitamin K injected IM2. Infant is restrained; penis is cleansed with soap and water

3. clamp is used4. Petroleum gauze dressing is applied to prevent adherence of circumcised site to the diaper while applying pressure to prevent bleeding



Nursing Care

- Check hourly for bleeding.- Do not attempt to remove exudates which persist for 2-3 days; just wash with warm water. - Diaper must be pinned loosely during the 1st 2-3 days when the base of the penis is tender.


Genitals

Ambiguous Genitalia


URINARY SYSTEM

• The average newborn voids within 24 hrs after birth– Newborns who do not void within this time

should be examined for the possibility of ureteral stenosis or absent kidneys or ureter

• A single voiding in a newborn is only about 15 ml• The daily urinary output for the 1st 1-2 days is

about 30-60 ml total.• The 1st voiding may be pink or dusky because of

uric acid crystals that were formed in the bladder in utero


CONGENITAL MALFORMATIONS OF THE URINARY TRACT

• Epispadias - urethral opening on the dorsal surface of the penis

• Surgical correction


• HYPOSPADIA• Male urethral opening

on the ventral surface of penis, or female urethral opening in vagina

• Surgical reconstruction


HYPOSPADIA


hypospadia

epispadia

http://www.google.com/imgres?imgurl=http://upload.wikimedia.org/wikipedia/commons/thumb/1/1c/Hypospadia.jpg/400px-Hypospadia.jpg&imgrefurl=http://commons.wikimedia.org/wiki/Image:Hypospadia.jpg&h=600&w=400&sz=26&tbnid=OQSw_23-2IQJ:&tbnh=135&tbnw=90&prev=/images?q=hypospadia&hl=en&sa=X&oi=image_result&resnum=1&ct=image&cd=1


Testes should be present: if undescended the condition is called CRYPTORCHIDISM

repair is called ORCHIOPEXY


HYDROCOELE INGUINAL HERNIA


SPINE

• Straight• Posture flexed• Supportive of head momentarily when prone• Arms and legs flexed• Chin flexed on upper chest• Well-coordinated, sporadic movement• Hypotonic or hypertonic indicates CNS

damage


BACK• On prone appears flat, (curves start to form

when child learns to sit or stand)• Note: for mass, hairy nodule and a dimple

along axis. This may be indicative of Spina Bifida.


Extremities

• Flexed• Symmetrical movement• Fists clenched• Ten finger , 10 toes• Legs - bowed• Creases on soles of feet• Pulses palpable• Slight tremor common but could be sign of

hypoglycemia• Assess for hip dysplasia- no click should be heard


Supernumerary = polydactyly; Fused or webbed = syndactyly

Simean line - Asymmetrical movement of upper and lower

extremities - ERB – DUCHENE PARALYSIS - Observe for clubfoot deformities


SYNDACTYLY

POLYDACTYLY

POLYDACTYLY & SYNDACTYLY


Simian crease


Congenital hip dysplasia/dislocation

• 0.1% of infants• with a predilection for females to males of 5:1• infants with a family history (first-degree relative

affected) of CHD, the incidence is 10 times higher• also higher in infants born in the breech position

and infants with certain other congenital abnormalities, including torticollis, clubfoot, metatarsus adductus, and hyperextension of the knee



A. Ortolani’s test

• In this maneuver, the infant is examined in the supine position.

• Place the infant in frog-leg position. Abduct the hip by using the middle finger to apply gentle INWARD and UPWARD pressure over the greater trochanter.

• In the infant with an unstable hip, the examiner will feel a sudden shifting sensation and may hear or feel a "clIck" simultaneously as the hip reduces anteriorly.


Ortolani’s test


B. Barlow’s test

• In this maneuver, the infant is examined in the supine position.

• The examiner holds the infant's pelvis with one hand to stabilize it during manipulation.

• Adduct the hip by using the thumb to apply OUTWARD and BACKWARD pressure over the inner thigh

• In the infant with an unstable hip, a similar "click" may be felt as the hip subluxes posteriorly.


Barlow test


A. Ortolani’s testB. Barlow’s Test

* Assessment on the R and L hips may be done simultaneously


Clubfoot

• A birth deformity in which the front portion of the foot is deformed and turned inward. It can be benefited greatly by surgery.



• IMMUNE SYSTEM– NB receives passive immunity via placenta (IgG)– NB receives passive immunity from colostrum

(IgA)– Infection – IgM– Use aseptic technique when handling NB– Observe standard precaution when handling NB– handwashing– Infection-free staff cares for the NB– Monitor NB temp.

• The newborn is prone to infection– Due to difficulty forming antibodies against

invading antigen until they are about 2 mos. of age.

– This inability to form antibodies early also is the reason that most immunization against childhood diseases are not given to infants younger than 2 mos.


• METABOLIC SYSTEM/GI SYSTEM– NB can digest simple CHO, unable to digest FAT

because lack of lipase– CHON broken down only partially– NB small stomach capacity ( 60-90ml)– Rapid intestinal emptying time 2-3 H– Observe feeding reflexes– Observe for normal stool– Perform NB screening test


• Blood Values– 80-110 ml/kg of body weight or about

300 ml– High WBC at birth about 15,000 to

30,000 cells/mm3

• Increased WBC count should not be taken as evidence of infection

• Blood Coagulation– Most newborns are born with a

prolonged coagulation or Prothrombin time, because their blood levels of Vitamin K are lower than normal.

– It takes 24 hrs. for flora to accumulate and vitamin K to be synthesized

NEUROMUSCULAR


REFLEXES• B – blink reflex– Babinski

• S– Sucking– Swallowing– Startle/ moro reflex – Stepping or walking

• T– Tonic Neck or fencing

• L– Landau reflex

• E– Extrusion reflex

• P– Palmar- Plantar reflex– Placing reflex– Paracheute

• Rooting reflex

• TrunK Incurvation Reflex

BaSTa LEP RoT


– Reflexes

• Blink Reflex - to protect the eye from any object coming near it by rapid eyelid closure


• Babinski’s sign – stroking the sole of the foot from heel upward like an inverter “J” across ball of foot will cause all toes to fan (reverts to usual adult response by 12 mos)


• Sucking Reflex- when newborn’s lips are touched, the baby makes a sucking motion. It diminishes at about 6 months of age.

• if it disappears immediately / if never stimulated - tracheoesophageal fistula

• Swallowing Reflex- food that reaches the posterior portion of the tongue is automatically swallowed


• Moro or Startle Reflex – elicited by sudden disturbance in the infant’s immediate environment, body will stiffen, arms in tense extension followed by embrace gesture with thumb and index finger a “c” formation (disappears by 6 mos)

• can be stimulated by startling the newborn with loud noise or by jarring the bassinet, fades on 4th or 5th month of life

• aka Startle Reflex

If the reflex persists, it is a sign of brain damage, neurological impairment, or motor reflex difficulties.


• Step-in-place or Stepping (walk-in-place) reflex –

– newborn who is held in a vertical position with their feet touching a hard surface will take few alternating steps

– disappears by 3- 4 months of age


Tonic Neck (Fencing) Reflex

-If the Babies' head is rotated to the left,-The left arm (face side) stretches into extension -The right arm flexes up above head Opposite reaction if head is rotated rightward

if it persists after infancy, it may indicate abnormal development of the central nervous system.

http://images.google.com/imgres?imgurl=http://www.winfssi.com/images/neck.jpg&imgrefurl=http://www.winfssi.com/appraisals.html&h=250&w=517&sz=15&hl=en&start=2&um=1&tbnid=cBO-yLTnEfRqyM:&tbnh=63&tbnw=131&prev=/images?q=picture+tonic+neck+reflex+Newborn&um=1&hl=en&rlz=1T4ADBF_enPH268PH268&sa=G

http://images.google.com/imgres?imgurl=http://thumbnail.search.aolcdn.com/truveo/images/thumbnails/E4/E9/E4E95DFD5D8137BDAC0D90.jpg&imgrefurl=http://video.aol.com/video-detail/galants-reflex/654333542&h=90&w=120&sz=9&hl=en&start=12&um=1&tbnid=5TbFoVjSlzfucM:&tbnh=66&tbnw=88&prev=/images?q=picture+tonic+neck+reflex+Newborn&um=1&hl=en&rlz=1T4ADBF_enPH268PH268&sa=G


• Landau reflex-Displayed at about three months of age. When NB is placed on its stomach faced

down, NB will raise her head and arch its back.

This reflex will persist until 1 year old Absence of this reflex suggests problems in

motor development.


EXTRUSION REFLEX-

• a newborn will extrude any substance that is placed in the anterior portion of the tongue.– Protective reflex prevents the swallowing of

inedible substance– Disappears at 6 wks to 3 mos.


• Palmar grasp – pressure on palm elicits grasp (fades by 3-4 mos)


• Placing Reflex- – similar to step-in-place Reflex, except it is

elicited by touching the anterior surface of a newborns leg against the edge of a bassinet or table

– A newborn will make a few quick lifting motions as if to step onto the table

it is obtainable in the normal infant up to the age of six weeks



• PARACHUTE

occurs in the slightly older infant, and is elicited by holding the child upright then rotating the body quickly face forward (as if falling). The arms are reflexively extended as if to break a fall.

http://images.google.com/imgres?imgurl=http://www.winfssi.com/images/parachute.jpg&imgrefurl=http://www.winfssi.com/appraisals.html&h=537&w=526&sz=27&hl=en&start=1&um=1&tbnid=lT9LncbsDaoU5M:&tbnh=132&tbnw=129&prev=/images?q=picture+parachute+reflex+Newborn&um=1&hl=en&rlz=1T4ADBF_enPH268PH268&sa=X

http://thumbnail.search.aolcdn.com/truveo/images/thumbnails/CB/1F/CB1F74E078E7EE.jpg


Rooting Reflex• Turns toward any object

touching/stroking cheek/mouth, opens mouth, and sucks rhythmically when finger/nipple is inserted into mouth (usually disappears by 6 wks.)

http://images.google.com/imgres?imgurl=http://www.winfssi.com/images/Root.jpg&imgrefurl=http://www.winfssi.com/appraisals.html&h=460&w=526&sz=19&hl=en&start=3&um=1&tbnid=yGfsPOGULs3qAM:&tbnh=115&tbnw=132&prev=/images?q=picture+parachute+reflex+Newborn&um=1&hl=en&rlz=1T4ADBF_enPH268PH268&sa=X


TrunK Incurvation Reflex( Gallant reflex)

Trunk incurvation reflex - newborn lies on prone position and is touched along the paravertebral area by probing finger, NB

flexes its trunk and swings pelvis toward the touch


• FEEDING REFLEXES1. Rooting2. Sucking3. Extrusion

• Protective REFLEXES1. Blinking2. Sneezing & coughing3. Yawning4. gagging


Common Health Problems

1.Constipation 2.Loose stools 3.Colic 4.Spitting up5.Diaper rash/Skin irritation6.Miliaria (prickly heat/bungang araw)7.Seborrheic dermatitis/cradle cap 8.Occasional “crossed eyes”

Sleep pattern – babies sleep 16-20 hours a day


Common Health Problems 1. Constipation – more common among bottle-fed infants

Add more fluids or carbohydrates/sugar2. Loose stools – careful history should be taken; management depends on cause

3. Colic – paroxysmal abdominal pain common in infants below three months of ageCauses:

Overfeeding , gas distention Too much carbohydratesTense and unsure mother

Management :Feed by demand. It is the best schedule because it meets the individual needs of the newborn.


4. Spitting up – due to poorly developed cardiac sphincter; more common among bottle-fed infants. Will disappear when coordination with swallowing is achieved and digestion improves.Feed in upright position because gravity will aid in gastric emptying.

Position on right side after feedingBubble/burp more frequently

5. Diaper rash/Skin irritation – maybe due to either poor hygiene or irritation from urine, feces and some laundry products


6. Miliaria (prickly heat/bungang araw) – starch bath or Johnson’s starch powder

7. Seborrheic dermatitis/cradle cap – involves the sebaceous glands; due to poor hygiene. Management: apply mineral oil or Vaseline on the scalp at night before giving shampoo in the morning.

8. Occasional “crossed eyes” – normal in many babies because the eye muscles of coordination have not yet fully developed; will disappear spontaneously


Expanded Program on Immunization

Vaccine Age at 1st dose

Dose Number of Doses

Min Interval

Possible Reaction

BCG At birth

0.05 ml ID

1 Keloid, suppurative adenitis

DPT 6 wks 0.5 ml IM

3 4 wks Fever, restlessness, irritability

OPV 6 wks 2 drops

3 4 wks Paralytic polio rare

Hepa B 6 wksAT BIRTH

0.5 ml IM

3 4 wks ArthralgiaNeuro reactions rare

Measles

9 mos 0.5 ml SC

1 Fever and rash 5-10 days after dose

MMR 12-15 mos

0.5 ml SC

1 Fever, rash,arthralgia, lymphadenopathy,rare – febrile seizures, nerve deafness, encephalitis

Newborn Screening Test

http://www.google.com/imgres?imgurl=http://www.wadsworth.org/images/footdot.jpg&imgrefurl=http://www.wadsworth.org/newborn/footpix.htm&h=400&w=257&sz=74&tbnid=pf8PjOVwuq8J:&tbnh=124&tbnw=80&prev=/images?q=picture+of+newborn+screening+test&sa=X&oi=image_result&resnum=1&ct=image&cd=1


Newborn Screening Act of 2004

REPUBLIC ACT NO. 9288

“…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.”


NEWBORN SCREENING

C 1. Congenital Hypothyroidism ( CH ) 2. Congenital Adrenal Hyperplasia (CAH)

P 3. PHENYLKETONURIA (PKU)

G 4. G6PD DEFICIENCY 5. Galactosemia

http://www.google.com/imgres?imgurl=http://www.wadsworth.org/images/footdot.jpg&imgrefurl=http://www.wadsworth.org/newborn/footpix.htm&h=400&w=257&sz=74&tbnid=pf8PjOVwuq8J:&tbnh=124&tbnw=80&prev=/images?q=picture+of+newborn+screening+test&sa=X&oi=image_result&resnum=1&ct=image&cd=1


NB screen

• Should be done after 24-48 hours of life• After the infant is fed• done through extraction of blood in the heel of

the foot


Disorder Screened

Effect of disorder Benefit if screened & treated

CHCongenital Hypothyroidism

Severe mental retardation

normal

CAHCongenital adrenal hyperplasia

Death Alive and normal

GALGalactosemia

Death, cataract Alive and normal

PKUphenylketonuria

Severe mental retardation

Normal

G6PD Severe anemia, kernicterus

Normal


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


1. CONGENITAL HYPOTHYROIDISM

Dx: low T3 T4, inc TSH

Mx: synthetic thyroid hormone

Nsg Care: Assist parents administer drugs


After 2-3 mos of treatment

Congenital hypothyroidism


2. CONGENITAL ADRENAL HYPERPLASIA

-inability to synthesize cortisol >>> inc ACTH >>> stimulate adrenal glands to enlarge >>> inc androgen

S/sx: masculinization, sexual precocity

Mx: Steroids to decrease stimulation of ACTH


3. G6PD DEFICIENCY Glucose 6 phospate dehydrogenase

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 glucoseGalactose 1 phosphate uridyltransefrase

S/sx: wt loss, vomiting, hepatosplenomegaly, jaundice and cataract

Dx: Beutler test

Tx: decrease lactose – soy based formula regulate diet


5. PHENYLKETONURIA (PKU)- Deficient or absent phenylalanine

hydroxylase w/c converts phenylalanine to tyrosine

S/sx: mental retardation, musty odor of urine, blond hair, blue eyes

Dx: Guthrie bld test

Tx: decrease phenylalanine (Lofenalac) regulate diet



Discharge instructions

a. Bathingb. Cord Carec. Nutrition

Calories 120 kcal/kg body weight/dayCHON 2.2 gms /KBW/dayFluids 160-120 cc/KBW/dayVitamins A,C, D for formula and breastfed

babies


Common Health Problems

1. Constipation 2. Loose stools 3. Colic Causes: Overfeeding Gas distention Too much carbohydrates


Management Feed by demand

Burp infant Feed in upright position

May need to change formula


Diaper RashMiliariaSeborrheic DermatitisOccasional “Crossed Eyes”ClothingSleep Pattern


DANGER SIGNS TO WATCH OUT FOR:

1. Deepening jaundice up to palms and soles or persistent jaundice beyond 2 weeks of life

2. Decreased sucking reflex or refusal to feed3. Unusual sleepiness4. No urine output for >48H5. Temperature instability6. Unusual movement7. Fast breathing with or without cyanosis or pallor


Documents

Pedia1.Newborn