NEWBORN

1. NEWBORN Lecture 12

2. Care of Newborn in Delivery Room: • Adequate breathing pattern established • Mouth suctioned 1st • Nurse wraps infant in warm blanket & places under radiant warmer • Drying motion usually stimulates 1st cry. Drying helps prevent heat loss • Note time of 1st cry & success at breathing attempts. • May need resuscitative attempts. • infant kept unwrapped on clean/dry radiant warmer to promote thermoregulation

3. Apgar Score • Apgar score - assessment scale since 1958 to assess newborn well-being at 1 & 5 min. • Newborn observed & rated on 5 components . • Heart rate • Respiratory effort • Muscle tone • Reflex irritability • Color

4. Apgar score • Score of 0, 1, or 2 - each component • Five scores added & final number @ 1 & 5 min • 9/9 common - 2 on HR, Resp, reflexes, muscle tone & 1 on color d/t acrocyanosis. • Heavy sedation of mother may lower respiratory effort or reflex irritability score. • Score of 4 or less indication that infant most likely needs resuscitative efforts • Score of 4-6 may indicate suctioning and oxygen therapy.

5. Umbilical Cord • Umbilical Cord: After delivery, 2 clamps placed • Cord clamped again 1- 2 inches from umbilicus Vessels counted [2 arteries; 1 vein - AVA]. • Bleeding may occur if clamp not tight • umbilical stump; falls off by 7th - 10th day • Teach: do not bathe infant until site completely healed • Sponge bath

6. Identification of Newborn • Done immediately > delivery by same nurse assisting mother • Prevent giving wrong infant to wrong mom. Identification is 1 band on mom, one on significant other & 2 on baby. • Footprints of infant & mother’s thumb print on footprint sheet.

7. Nurse’s Responsibilities in Delivery Room Eye Care: erythromycin ointment > delivery • Eliminates gonorrhea/chlamydia. Vitamin K Injection: produced in intestinal tract and used by body for coagulation. • Newborn @ risk for bleeding disorders during 1st wk of life. injection given IM within 1st hour [Dose = 0.5 mg. to 1.0 mg.] Site: vastus lateralis • In DR, infant given to mom to begin bonding process & breast feeding started.

8. Nurse’s Responsibilities in Newborn Nursery • Admission to Nursery • Infant transferred to Newborn Nursery. • Report given by L&D nurse to NBN nurse. • Routine newborn care. • Infant under radiant warmer, VS, measurements, head to toe assessment, bath [98.0 R]. • To mom in 4 hrs. if WNL. [98.0] • Universal security system on maternity units - ensure safety of all newborns on unit. • Alarm placed on infant ankle or umbilical cord stump. All doors in unit are alarmed & locked.

9. Newborn Adaptation • Newborn’s ability to adapt successfully depends upon conditions in utero, care it receives during intrapartum period, & newborn period aka neonatal period = 1st 28 days of life. • 2/3rds of all deaths that occur in 1st year of life occur during neonatal period [1st 28 days of life].

10. Head to Toe Assessment of Newborn Head: General appearance • NOTE: Size: ¼ of body size [33-35 cm., 13-14 in. circumference] • Molding: Asymmetry of skull • Cephalohematoma: collection of blood bet. skull bone & periosteum • Caput succedaneum: swelling over presenting part Fontanels: “soft spot” • Anterior fontanel – diamond shaped, measures 2-3 cm. wide & 3-4 cm. long. Closes @ 12-18 months. @ juncture of frontal & parietal bones. Overriding sutures w. NSVD. Level C/S • Posterior fontanel - triangular shaped; small [~0.5 cm.] hard to feel; juncture of occipital & parietal bones. Closes 2 mos. • *Depression indicates dehydration • *Bulging > hydrocephalus • Hair gestational marker; preterm sparse

11. Eyes • Eyes: usually blue or gray • Permanent color develops 3 - 12 mos of age. Iris does not develop color til 3-6 mos. • Lacrimal [tear] glands- not fully mature • Subconjunctival hemorrhage: from stress of vaginal delivery • First 6 wks; transient strabismus; not able to focus. • Constant strabismus < 6 weeks, further assessment needed. Strabismus > 6 weeks, referral needed. • Scant purulent discharge > erythromycin ointment • Pupils round & equal; should constrict - normal response to light • “PERL” =pupils equal & reactive to light

12. Nose • Nose: Infants obligatory “nose breathers”. • Note size & shape, & presence of nasal discharge or stuffiness. • Clean nose with bulb syringe; saline drops. • Observe for nasal flaring

13. Mouth • Mouth: Examine palate with index finger • Cleft lip and/or cleft palate • Epstein’s pearls [small, round, white cysts] • Note size & shape of tongue and length offrenulum membrane • Supranumery teeth aka natal teeth • Sucking reflex- evaluate • Rooting reflex

14. Ears/Neck • Ears: Note position of ears in relation to eyes Pinna should be fully formed and firm. • Term infant: pinna recoils easily • Preterm infant, < 36 wks - relatively shapeless and flat; little cartilage. Slow recoil. • Skin tag – harmless; may be associated w. kidney disease. Hearing test done before newborn D/C home; If fails 2nd time, hearing eval.done as outpt. • Neck: Normal newborn neck short, chubby w.creased skin folds. Head support necessary. Inspect masses, limitation of movement & webbing. Clavicles: straight, palpate each clavicle for intactness; “crepitus” Common in larger infants delivered vaginally

15. Chest • Chest: Inspect shape, symmetry, position, development of nipples; breast tissue. • Chest 12-13 in. [30 –33 cm.]. • Breast engorgement – maternal hormones. • Normal respirations 40 – 60 breaths/minute. Retractions abnormal; indicates respiratory distress. RR can be in 30’s [sleep]. • After 4 hr. transition period, RR 40’s. Grunting [hoarse sound - expiration] • transient d/t mucous in lungs. Suction. • If retractions/grunting not clear by 4-6 hrs, may indicate respiratory distress • TTN; transient tachypnea of NB. RR = 70-80’s for several hrs. [transition period] if more > 4 hrs., NICU.

16. Abdomen/Kidneys • Abdomen: palpate for masses/organs • Umbilical Cord: Inspect 3 vessels (“AVA”); falls off in 7 – 10 days. Let dry. • If only 2 vessels present, artery and vein, observe infant closely d/t association with heart or kidney anomalies. • Kidneys may be felt on right & left side of abdomen by deep palpation. • S/S infection

17. Genitalia - Male • Genitalia: Male: Assess for gestational maturity & sexual ambiguity. • Scrotum in full term infant swollen; + rugae; both R & L testes descended into scrotal sac. • Testes may be in processof descending. If one or both testes are undescended = “cryptorchidism”, • Agenesis [no testes] or closed scrotal sac • Normal length of newborn’s penis = ~ 2cm long. Assess for urethral opening “aka” urinary meatus Abnormal placement on dorsal surface *epispadias*; ventral surface *hypospadias

18. Genitalia - Female • Female: Vulva typically swollen. Labia minora & clitoris large with labia majora covering both • Female infants have “pseudomenstruation” • “Hymenal tag” or small piece of pink tissue protrudes between labia

19. Extremities • Extremities: Assess for muscle tone • Note length of arms/legs; should be symmetrical • Limp arm may have nerve damage [birth injury] “aka” brachial plexuspalsy. • Observe palm: simean crease [single • Assess: syndactyly: webbing of fingers/toes & polydactyly: > than 10 fingers or toes. • Assess sole creases; mature infant: 2/3rds or full sole w.creases

20. Skin • Reddish in color; smooth and puffy • At 24 - 36 hours of age, skin flaky, dry and pink in color. Edema around eyes, feet, genitals. • Acrocyanosis: Bluish discoloration of hands and feet. Lasts for 24-48 hrs. Mucous obstruction may cause central cyanosis • Milia: Pinpoint white papules; Disappear 2-4 wks • Neck: Normal newborn neck short, chubby w. creased skin folds. Support is necessary. Inspect for masses, limitation of movement & webbing Clavicles: straight, palpate for intactness; feel for “crepitus” Commonly found in larger infants delivered vaginally.

21. Skin • Lanugo: fine hair covering newborn’s upper arms, shoulders, & back that decreases as gestational age increases • Vernix caseosa: white, cream cheese like substance; skin lubricant. • Erythema neonatorum [toxicum]: NB rash; red rash with flea-biten appearance. • Stork Bites - a.k.a. telangiectasia - pink spots found on nape of neck, nose, upper eyelids, upper lip. Disappear in 1-2 yrs. • Mottling: Generalized red and white discoloration of skin of exposed infants with fair complexion. • Mongolian Spots: Collections of pigment cells [melanocytes] that appear as patches across infant’s sacral area and buttocks. Tend to occur in newborn’s of Asian, African, or Southern European descent

22. Skin • Capillary Hemangiomas: 3 types, all are vascular • Nevus flammeus: macular (flat), purple or dark red lesions, present @ birth. Aka “port wine stain • Strawberry hemangiomas: raised areas formed by immature capillaries & endothelial cells. Occurs typically in term infant. • Cavernous hemangiomas: Raised; resembles strawberry hemangioma Can be surgically removed

23. Back/Anus/Rectum • Spine: • Assess for intact spine without masses or openings. Small indentation @ base of spine may suggest “pilonidal dimple”. May be pilonidal sinus [opening]; represents possible spina bifida occulta. • Tuft of hair present @ base of spine = Nevus pilosus. • Anus & Rectum: Assess rectal patency [NBN] with 1st temp; lubricated thermometer. If rectum not patent, called imperforate anus

24. Routine Exam of Newborn – Vital Signs • Vital Signs: admission NBN & q shift. • Temperature (ax 97.7 – 98.6 º F) Initial rectal. • Heart Rate: 110 –160 bpm. • Femoral, radial, brachial pulses can be palpated;. Apical pulse used for HR; auscultate 1 min • Respiratory Rate: 40-60 min. Initial rate 80 /min. • BP ~ 80/46 mmHg @ birth. By 10th day, 100/50. Daily: • Weight: 2,500-4,000 gm (5 lb 8oz - 8 lb 13 oz); compare with previous day. 5-10 % weight loss acceptable • Assess feedings daily. # voids/stools in 24 hrs. Done once on admission to nursery: • Length: 45-55 cm = 18-22 in • Head: slightly larger than chest; 13-14 in.= 33-35 cm • Chest: 12-13 in. = 31- 33 cm

25. SENSORY BEHAVIORS OF THE NEWBORN • Tactile • Olfactory • Vision (see black & white best) • Auditory • Taste

26. REFLEXES • Sucking – place finger in mouth; infant sucks right away. • Moro – [“startle reflex”] elicit by loud noise; infant extends arms & legs suddenly. • Rooting – touch cheek; turns head in direction of touch. • Babinski – stroke sole of foot from top to bottom; toes fan out. • Grasping – place finger in newborn’s hand; grabs & hold. • Stepping – hold infant upright w. feet on surface; stepping movements

27. Behaviors – Sleep/Awake Predictable Behaviors: 1st 4 hours > delivery: • 1st period of reactivity: alert, active state; awake, crying, sucking. • Then Sleep phase 4-6 hrs. • 2nd period of reactivity 2-3 hrs. Sleep/awake during day. Sleep States • 1. Deep Sleep • 2. Light Sleep Awake States • Drowsy; Quiet Alert – best time for breast feeding/bonding • Active Alert; Crying

28. Behaviors • Brazelton Neonatal Behavioral Assessment Scale: Scale developed in 1970’s to evaluate newborn’s behavior to stimuli Assesses motor maturity & social behavior. Takes ~ 30 min to do • Ballard Assessment scale: developed 1970’s to assess gestational maturity; takes 2-3 minutes to do. • Assesses physical & neuromuscular maturity. Useful in differentiating between SGA infant & miscalculated due date • SGA infant is mature gestationally. • Full term infant gets score of ~ 3.3 in each category. Compare infants in NICU to those in NBN.

29. Nutrition in Newborn • Bonding process reinforced during feeding – w. breast & bottle. • Approx. 64% of women breast feed in early post partum period • 29 % still nursing @ 6 months; 16% still nursing @ 1 year. • Growth & caloric requirements during neonatal period & early infancy are faster than any other period of life. • Newborns can lose up to 5-10% of birth weight while waiting for breast milk to come in. Colostrum rich in antibodies but has less calories than breast milk. Breast milk has no allergies.

30. Education • Teach mom: ^ calories by 500/day • ^ fluids by 8 glasses/day • Well balanced diet; omit caffeine/alcohol. • Breast feed q2-3 hrs./day; Bottle feed q 3-4 hrs./day • Avoid fish containing mercury. • Teach positions for breast feeding; football hold for C/S. • Any position OK as long as baby has nipple & areola; infant can breathe. Find comfortable position; Use pillows - free up hands.

31. Nutrition in Newborn Daily Requirements: Calories: body maintenance & growth. Birth to 2 months of age: require 110-120 calories/kg/24 hrs. Up to 6 months, require 108 cal/kg/24 hrs. 6 mos. to 1 yr. require 98 cal//kg/24 hrs. • Protein: needed to form new cells; important for rapid growth. • Up to 2 months, 2.2 g/kg/24hrs required. • 6mos.-1yr. 1.6g/kg req. • Fluid: 150-200 mL/kg/24 hrs • 75% of NB body composed of water • Fluids: Need 65 ml/kg [30 ml/lb] daily 1st 2 days of life then 100-150 ml/kg [45-68 ml/lb/day] afterwards. • Voids: 1st few days 2-6 voids/day; > 2-3 days: 6 or more voids.

32. Nutrition in Newborn • Fat: [Linoleic acid] found in both breast milk & formulas • Carbohydrates: Lactose most easily digested of carbohydrate group. Helps to reduce GI illness in newborns by producing stool with gram + bacteria instead of gram negative bacteria. Rare to have infant with lactose intolerance • Iron: Found in breast milk & added to commercial formulas • Flouride: Not found in breast milk or formula; need supplement starting @ 6 mos. if not found in drinking water • Calcium: needed for bone growth • Vitamins: Start supplement @ 6 months of age

33. ADVANTAGES OF BREAST FEEDING • Helps with uterine involution. • May help prevent breast cancer. • Empowering effect on mother; ↑ self esteem. Provides more frequent close contact • Inexpensive. Complete nutrition for baby. Provides extension of immunity for up to 6 mos. Colostrum IgA [immunoglobulin] which binds to bacteria & viruses; proteins/enzymes destroy bacteria. Macrophages produce interferon - interfere with virus growth. Disadvantages of Breast Feeding: Father feels left out. Sore nipples. Painful engorgement. More frequent feeding required so less time with other children. Embarrassment R/T feeding in public. Mastitis. Infections: Hepatitis B & HIV can pass thru milk.

34. ADVANTAGES OF BOTTLE FEEDING • ^^ freedom d/t less frequent feedings; infant sleeps longer periods. • No sore nipples. • No worry over breast feeding in public or pumping at work. • Father can feed infant frequently. • Frees up mom with older children. Disadvantages of Bottle Feeding • More expensive; infant may not tolerate formula • May have to try different formulas before finding right one • More prep time; more shopping time. • ^ waste: discard unused portion > 1 hr. • [^bacteria]. No transfer of passive immunity.

35. General Care of Infant Bathing q day; Teach parents: sponge bathe daily before cord falls off and tub bath > cord falls off & healed. Mild soap Positioning & holding – lay infant on back to sleep; Hold upright to feed formula & burp. Teach breast feeding positions: cradle hold, side lying, & football hold. Vaseline to buttocks w. diapering. Record stools/voids. VS q shift . Teach parents to take temp. if 100.0 R*call MD! Stools: • Meconium: very dk. green/almost black, sticky. • Transitional stool: yellow/green [> meconium] • Breast fed stool: yellow seedy w. sweet odor. • Formula fed stool: green/yellow.

36. Adaptation to Extrauterine Life Adaptation to Extrauterine Life Cardiovascular: NB must initiate respirations & sustain extrauterine oxygenation • When born, infant forced to take in oxygen thru lungs. • Shunts close & vessels clot off & regress Respiratory: First breath also in response to temperature & pressure changes, light & noise. • 1st breath requires great amt.of pressure; 40-70 cm H2O. Small amt of fluid present in lungs. • 1/3 rd of this fluid forced out by pressure of vaginal birth; rest absorbed by lung tissue. C/S infants may need more suctioning & oxygen therapy.

37. Adaptation to Extrauterine Life Renal: Renal function does not fully mature until > 1st yr. 1st void occurs within 1st 24 hrs. • No urine for 36 hrs. needs further eval. for obstruction or absent kidneys. • 1st voiding may be dk.pink/red d/t uric acid crystals. Disappears 1st few days as kidneys mature. Alarming to parents; harmless finding. Gastrointestinal: GI tract sterile @ birth; bacteria enters GI tract thru mouth within 24 hrs.of life. Bacteria needed for prod. Vit.K • Infant: limited ability to digest fats & starches • Meconium passed 1st 24-48 hrs. of life • By 2nd - 3rd day, transitional stool passed

38. Thermogenesis Brown fat : helps conserve body heat; produces heat. Found in upper chest, back of neck, around abdomen. Is deposited in 2nd trimester; Helps regulate body temp>delivery. Radiant warmer - helps regulates body temp. by conserving heat. Newborns can produce sufficient heat in optimal thermal Environment if warm enough. Rapid heat loss occurs in suboptimal environment [cooler]. Infants do not shiver; can go into cold stress quickly. Uses up extra glucose & oxygen to thermoregulate. Leads to: • metabolic acidosis; respiratory distress • Hypoglycemia; Jaundice; decreased surfactant production

39. Thermogenesis Infants Lose heat in 4 ways: • Convection • Evaporation • Conduction • Radiation IMMUNOLOGIC: • Newborn still prone to infection, handwashing important! • IgG: Infant born with passive immunity from mom. Fetus makes own starting @ 20 wks • IgM too large to cross; makes own after delivery. • IgA do not cross placenta. Produced by infant > birth @ 6-12 wks. Found in breast milk.

40. Labs • Hemoglobin: 15-20 g/dl.; Hct: 43-61% • Blood volume: 80-110 ml/kg. or 300 ml. • WBC: 10-30,000 mm • Glucose 45-60 mg/dl - heel stick < 45 & feed with ½ oz formula. Repeat within hour. Send serum blood glucose as per protocol. JAUNDICE: • Breast Fed Jaundice: 1 out of 3 breast feeding infants. Most common cause: insufficient intake - 1st week of life. Bili can reach 12mg/dl. Theory: Enzymes in breast milk thought to interfere with conjugation process. • Feed @ least 8-10 feedings in 24 hrs. • Teach moms: ^^ their own po fluids • Kernicterus rare with breast fed jaundice