prof . Pavlyshyn H.A.

1. New born child. Peculiarities of the newborn  period. Main components of neurological and psychological development in children of early age. Transitory states in a new-born period • prof. Pavlyshyn H.A.

2. TERMS: • Neonatology: Thebranchofpediatricsthatdealswiththediseasesandcareofnewborns. Neonatalperiod: Frombirthtothe 28th dayoflife (4 weeksafterbirth).Perinatalperiod: Fromthe 28th completedweekofgestationtothe 7th dayafterbirth.

3. Classification of the neonates By birth weight By gestational age By both GA and BW

4. TERMS: According to gestational age • Full term infant: An infant born at a gestational age between 37 and 42 completed weeks Preterminfant:Aninfantthatisbornpriorto 37 weeksofgestation(22 -37 weeks or weight greater than 500g). Post-terminfant: Aninfantthatisbornafterthe 42nd weekofgestation

5. According to relationship between GA and BW • AGA ( appropriate for gestational age) Infants with birth weight for their gestational age that falls between the 10th and 90th centiles. SGA ( small for gestational age) Infants with birth weight for their gestational age that falls below the 10th centiles. LGA ( large for gestational age) Infants with birth weight for their gestational age that falls above the 90th centiles.

6. GA 40 w, BW3000g GA 34 w, BW2000g

8. Apgar Score of the Newborn

9. Significance of Apgar score • Healthy newborn: 7-10 at both 1 and 5 minutes • Moderately depressed newborn: 3-6 (Need resuscitation ) • Severely depressed newborn: 1-3 (Intensive resuscitation )

10. The Apgar score is used to evaluate • brain function at birth • circulatory status at birth • the effectiveness of respiratory and circulatory adaptations thereafter • which babies need active assistance (resuscitation).

11. Purpose The APGAR scoring chart is used to • evaluate the conditions of the baby at birth, • determine the need for resuscitation, • evaluate the effectiveness of resuscitative efforts, • to identify neonates at risk for morbidity and mortality.

12. Take Anthropometric Measurements • Weight – 2, 500g – 4, 000g • Physiologic weight loss - it is normal for the newborn infant to loose 5-10% of weight in the first 4 to 5 days of life (causes: low nutritional intake, defecation, urination); • Length – 45-55 cm • HC – 33-55 cm, 2-3 cm larger than chest CC – 30-33cm, AC-29-33 cm

13. Assessment of Growth

14. Head Circumference HC – 33-55 cm, 2-3 cm larger than chest

15. Take Anthropometric Measurements Head Circumference Chest Circumference Abdomen Circumference

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

17. Respiratory system • Fetal lung development • Filled with fluid • Surfactant synthesis: begins at 24-28w, peak at 35w • Establishment of breathing after birth - opening of the alveoli by mechanical,chemical,thermal, sensory stimuli • Characteristics of Newborn respirations • Normal RR 30-60, shallow and irregular, • 5-15 second periods of apnea • Apnea: no breathing for periods of greater than 15 sec • Abnormal findings: retractions, grunting, nasal flaring, more 15 sec apnea; abnormal rate

18. Cardiovascular System

19. Circulatory system • Heart rate: ranges from 140 to 160 per minute. • Heart murmur: • Transient murmurs may result from the incomplete closure of the fetal circulation (the ductus arteriosis or foramen ovale) • 90% of all murmurs are transient and not associated with anomalies. • Blood pressure: from 46 to80 mmHg(systolic)

21. Hemotological system • High: RBC 4.8-7.1; Hgb 14-24; Hct 44-64 • 18,000 @ birth; 23-25,000 @ 1 day with relative neutrophilia • Coagulation: Vit K dependent clotting factors are decreased. • Platelet counts ok (150,000-350,000) WBC: After the first few days (5 days or so ) the white cell count is likely to be below 10 000/ mm3 with characteristically relative lymphocytosis of infancy and early childhood. • These characteristics are essential to provide adequate oxygenation in utero and during the first few postnatal days before the lungs expand fully. • Oxygenation improves during the first two weeks of life to the extent that a high red cell count and hemoglobin are no longer necessary, and haemolysis occurs.

22. Gastrointestinal System • sucking becomes coordinated @32 wks • little saliva until 3 months of age • Stomach hold 60 to 90 ml. • Regurgitates easily because of an immature cardiac sphinter between the stomach and esophagus. • Immature liver function may lead to lowered glucosed and protein serum level.

23. Alimentary system

24. Hepatic Function • Liver produces substances essential for clotting of blood. • Stores needed iron for the first few months. Preterm & small infants have lower iron stores than full term (full term infants stores last 4-6 mo) • Physiologic Jaundice - after 24-48 hs of age, d/t increased breakdown of RBC’s and immature liver functioning. • This is a yellow discoloration that may be seen in the infant's skin or in the sclera of the eye. • Jaundice is caused by excessive amounts of free bilirubin in the blood and tissue.

25. JAUNDICE

26. Urinarysystem • Renal function: GFR - glomerular filtration rate is lower, about one fourth to one half of that in an adult. • Kidneys not fully functional until child is 2 years of age. • Urine often contains protein in small amounts. • Urine may contain an abundance of urates which may give the diaper a pink stain during the first week of life. • The ability to dilute urine is good, but the time taken to reach the maximal ability is relatively long, so newborns are apt to become water overloaded.

27. Kidneys and Urination • initial urine: cloudy, scant amounts, uric acid crystals-> reddish stain on diaper • Urine pH ranges from 5 to 7, specific gravity ranges from 1.006 to 1.020. • The first urination occurs within 24 hrs. It ranges from 4 to 6 times/day in the first days and 20 times or so /day in later days of the neonatal period. • Kidneys not fully functional until child is 2 years of age.

28. Immune System • Limited specific and Non-specific immunity at birth • passive immunity(from mom- IgG) for the first 3 months of life ~ this will be reduced if baby is born premature • breastfeeding = ^ passive immunity (IgA)

29. Neuromascular System • Mature newborns demonstrate neuromuscular function by moving their extremities, attempting to control head movement, exhibiting a strong cry and demonstrating newborn reflexes. • A newborn occasionally makes twitching or flailing movements of the extremities in the absence of stimulus because of the immature of the nervous system.

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

31. Sucking place a finger in the neonate’s mouth neonate sucks on the finger

32. Newborn Reflexes • Rooting reflex - If the check is brushed or stroke near the corner of the mouth, a newborn infant will turn the head in that direction. • This reflex serves to help a newborn find food: when a mother holds the child and allows her breast to brush the newborn’s cheek, the reflex makes the baby turn toward the breast. • This reflex disappear at about the sixth week of life.

33. Rooting touch a finger to the neonate’s cheek or the corner of mouth. neonate turns the head toward the stimulus, opens the mouth and searches for the stimulus

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

35. MORO reflex Baby is held horizontally, then swiftly lowered a few inches, or the head may be lowered a few inches, or a loud sudden noise will make baby's arms fling out and then come together as hands open then clutch. Absence or weakness of this reflex may suggest a severely disturbed CNS

36. Startle reflex • sudden loud noise causes abduction of the arms wit flexion of elbow, hand remain clenched • disappears by age of 4 months

37. Palmar Grasp Reflex • newborn grasp an object placed in their palm by closing fingers on it. • Mature newborn grasp so strongly that they can be raised from a supine position and suspended momentarily from an examiner’s fingers. • Reflex disappears to 3 months of age.

38. Grasp • place a finger in the neonates palm • neonate grasps the finger

39. PLANTERS GRASP • Pressing thumbs against the balls of baby's feed will make his toes flex. Absence of this reflex may indicate damage to the spinal chord.

40. Stepping reflex • Hold the neonate in an upright position and touch one foot lightly to a flat surface (such as the bed) neonate makes walking motions with both feet

41. BABKIN • When both of baby's palms are pressed, her eyes will close, mouth will open and her head will turn to one side. • Absence of this reflex or if it reappears after vanishing around 3-4 mos., it may signify a malfunctioning CNS

42. BABINSKI • Baby's foot is stroked from heel toward the toes. • The big toe should lift up, while the others fan out. • Absence of reflex may suggest immaturity of the CNS, defective spinal chord, or other problems.

43. Tonic neck reflex Fencing posture • When newborn lie on their backs, their head usually turn to one side or the other. • The arm and the legs on the side toward which the head turns extend, and the opposite arm and leg contract. • This is also called the boxer or fencing reflex. • The reflex disappears between the second and third months of life.

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

45. Thermoregulation • Newborn physiology • Normal temperature: 36.5–37.5°C • Hypothermia: < 36.5°C --Significant contribution to deaths in low birth weight infants and preterm newborns • Stabilization period: 1st 6–12 hours after birth • The body temperature is likely to be influenced by the environmental temperature. • Neutral environmental temperature: the environmental temperature at which the core temperature of the infant at • rest is between 36.7 and 37.3°C and oxygen consumption and caloric utilization are lowest

46. Temperature Regulation • Newborn’s temperature may drop several degrees after delivery because the external environment is cooler than the intrauterine environment • Rapid heat loss in a cool environment occurs by conduction, convection, radiation and evaporation; • Cold stress in the newborn → an increase in the metabolic rate --> increased O2 demands and caloric consumption, metabolic acidosis

47. SKIN Observation and palpation

48. SKIN • Common variations • Acrocyanosis - result of sluggish peripheral circulation.

49. Physiologic jaundice Neonatal jaundice is often seen in infants around the second day after birth, lasting until day 8 in term births, or to around day 14 in premature births.

50. Milia • all newborn sebaceous glands are immature. • White papule can be found on the cheek or across the bridge of the nose of every newborn. • Disappear by 2 to 4 weeks of age, as sebaceous glands mature and drain.