Care of the Newborn 2010

8/8/2019 Care of the Newborn 2010

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Care of the NewbornDr Daphne R. Miranda RN, MAN, MD

NEWBORN PRIORITIES IN THE FIRST DAYS OF LIFE

1. Initiation & maintenance of respirations

2. Establishment of extrauterine circulation

3. Control of body temperature

4. Adequate nourishmentNEWBORN PRIORITIES IN THE FIRST DAYS OF LIFE

5. Waste elimination

6. Prevention of infection

7. Infant-parent relationship

8. Developmental careESSENTIAL NEWBORN CARE

Time bound immed drying, SSC, cord clamping, non separation of NB fr mother,breastfeeding

Non time bound immunization, eye care, Vit K admin, weighing, washing

Unnecessary routine suxning, routine separation for observation, prelacteal admin,footprinting

BASIC, CRITICAL CARE

DRYING, WARMINGRAPID ASSESSMENTBreastfeeding w/n first hour of birthUmbilical cord careExclusive breastfeedingEye careImmunizing the NBPreventing infectionRecognizing and caring for common NB problemsNB resuscitation for LBW infantsNB examSpecial care

Preparing to meetbabys needs

2 clean and warm towelsNB size self inflating bagInfant masks: normal and small

NBSuction device


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Rolled up piece of clothClean, dry, warm surfaceWarm delivery room

A. Time Bound Procedures

immed drying

SSCcord clampingnon separation of NB fr motherbreastfeeding

1. Drying the NBDry body and head well

Remove wet cloth

Wrap baby in cleandry cloth covering the

head

Do not remove vernix2. Skin-to-skin Contact (SSC)

*at least 1-2 hrs after birth and often during the day for the first few weeks; baby is dried off andplaced vertically on mothers chest and abdomen

Provides warmthImproves bondingProtection from infection by

exposure of the baby togood bacteria of the mother

Increases blood sugar ofthe baby

HIV AND NB CARE AT BIRTHuniversal precautionsMay have immediate SSCBreastfeeding may begin when baby is ready after deliveryDo not give baby any other food or drinkGood attachment and positioningIf replacement feeding, prepare formula for mother for the first few weeks

FIRST 2 HRS AFTER BIRTH

Weigh or measure baby, bathe babyDress baby, Eye care, vit K and immunization

3. Initial Cord CareNon immediate clamping to allow free BT, dec anemia, dec transfusion risk and intraventricular

hge

Do not apply any substance to the stump


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Do not bind or bandage the stumpLeave the stump uncovered

*after deliv of placenta, monitor mother and baby q 15 min*after cutting cord, assess baby for sx of illness*if baby well, cont SSC

* Inspect for A .V. A.

* aseptic technique* Povidone (Betadine); 70% Isoprophyl alcohol - prevent Tetanus Neonatorum and Omphalitis

(streptococcal and staphylococcal)

Signs of Omphalitis:

1. Reddening of the area2. Fever3. Discharge or foul smell

* Application of sterile cord clamp - prevent bleeding w/n 1st 24 hours (Omphalangia)

4. Kangaroo Mother CareProvides NB w/ benefits of incubator careWell small babies (preterm or lbw) may benefitOnce stable, KMC may begin

Adv for baby:lives next to mothers skin, inside clothes to keep baby warm; stabilize temp, HR and RR; keep

O2 consumption andbld glucose equal

better than conventional txMaintains sleep patternsless stress, less cryingReady access to breast

Adv for mother:Strong emotional bond with baby

Emphasis of role on survival and well being of babyMore confidence, less stressMore likely to breastfeed exclusivelyLower capital investment and

recurrent costsInexpensive form of careLess need for incubatorsEarlier discharge and

reduced admission rates


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Important points - mothersAll mothers can do itWillingAvailableGen health must be goodHas to be near baby and hosp to start KMC when baby ready

Supportive family and communityWhen to start KMC - baby

Baby should breathe on its ownFree of life threatening illness/ malformationHave ability to coordinate sucking and swallowing not essentialKMC may begin after initial assessment and basic resuscitation

WHAT SHOULD BABY WEAR?- Surrounding temp is 22-24 deg, baby is nakedin pouch except for diaper, warm hat and sock- < 22 deg, additional sleeveless cotton shirt open in front to allow face, chest, abdomen, arms,

legs to remain in contact w/ moms chest and abdomen

Head PositionBabys head should be turned to one side and slightly extended to keep airway open and allow

eye contactTop of binder beneath babys ear

Thermal Care/Warm chainDraft free, warm room, at least 25-28 degImmed drying of NBSSCHelp the mother to breastfeed w/n an hr after birthPostpone bathing 6-24hrs after birth

Wrap or dress the newborn immediately and warmlyPut him under a droplight

4 MECHANISMS OF HEAT LOSSConvection

Radiation

Conduction

Evaporation

Non shivering Thermogenesis

Brown fat

- special tissue

- intrascapular region, thorax, perirenal area

- oxidized to produce heatEffects of Cold Stress

- temp < 36.5


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

2. Hypoglycemia- inc energy requirement to produce heat

5. Breastfeeding1. bonding

2.uterine contraction3. colostrum

4. Contraceptive5. Cheap6. Right temperature7. Antibacterial Lactoferrin, Lactobacillus bifidus, lysozyme, macrophage, T lymphocytes,lactoperoxidase

Differences BetweenHuman and Cows Milk

Breastfeeding and SSCGive baby to mother for

SSCLet baby feed when ready

SIGNS OF READINESS- baby looking around- mouth open- searching

POSITIONING AND ATTACHMENTNeck not flexed or twistedNB facing mother, nose opposite nipple

Hold NB body close to bodySupport whole bodyWait until mouth is wide openMove NB quickly to breast, aiming lower lip below nipple

*Areola shld be visible above babys mouth*sucking slow, deep with some pauses*if attachment not good, try again and reassess

First breast feedCheck attachment and positioningLet baby feed on both breasts as long as he wantsKeep mother and baby together for as long as possible after delivery

Delay tasks such as weighing, washing, eye care, injections until after the first feed

*if baby doesnt feed in 1 hour, examine baby*if healthy, leave baby w/ mother to try later. Asess in 3 hrs or earlier if baby is small*If mother unable to breastfeed, help her express breastmilk and feed by cup*if unable to initiate breastfeeding, plan for alternative feeding*if mother HIV + & chooses replacement feeding, feed accrdly

B. Non Time Bound Procedures1.Immunization


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2.eye care

3.Vit K admin

4.Weighing

5. washing1. Expanded Program on Immunization

2. Credes Prophylaxis

* Legal requirement for all NB (US)

* Infection - acquired during delivery from a mother with untreated gonorrhea

Medications:

* previously, Silver Nitrate or AgNO3 1% 1-2 drops- lower conjunctival sac- wash with sterile NSS after 1 minute to prevent chemical conjunctivitis

Eye care:Wipe eyesApply antimicrobial w/n 1 hr after birth

b. OintmentTerramycinGentamycin

ChloramphenicolErythromycin- pull eyelids downward

0.5-1 cmInner to outer canthusWipe excess away

3. Vitamin K Injection

- sterile GIT

- facilitates production of clotting factor

- 1 mg (term) or 0.5 (preterm) Aquamephyton

- IM - lateral anterior thigh (Vastus lateralis)

4. Take Anthropometric Measurements(Vital Statistics)

BW: 2.5 3.9 kgs


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(5.5 8.6 lbs)* 1 K = 2.2 lbs

BL: 47.5 53.75 cm(19 21 in)

Average: 50.8 cm/20 in* 1 inch = 2.54 cm

Special Care5. Initial Bath temp stabilizes 36.5C 6-8 after birth

warm water during the 1stweek

Dont use soap

hexachlorophene (Phisohex) infected passageway

C. Unnecessary1.routine suxning

2. routine separation for observation

3.prelacteal admin

4. footprinting

1. 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

2. Routine separation for observationImmediate assessment

Physical assessment

3. Initial Feeding

- hrs after birth after babyhas rested

If the baby shows feeding


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cues (opening of mouth, tonguing, licking, rooting), encourage mother to encourageNB to move toward breast

Health workers not to touch NB unless w/ medl indicDo not give sugar water, formula or other prelactealsDo not give bottles or pacifiersDo not throw away colostrum

Advice for HIV positive mothers

4. Proper Identification done in D.R. before being brought to the Nursery

a. Footprints most reliable

b. ID bands ankle, wrist

c. Birthmarks

Immediate Assessmentof the Newborn

APGAR SCORE

Appearance (color) least importantP ulse rate - most important

Grimace (reflex activity); irritability Activity (muscle tone) Respiration

Apgar Scoring System

1st minute: general condition (NEURO/RESPI/CIRCULATORY CHECK)

5th minute: adjustment to extrauterine life

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

Grading of Neonatal Respiratory Distress(Silvermann Anderson)

Congenital Anomalies


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1. Choanal Atresia2. Tracheobronchial fistula3. Cleft lip and cleft palate

Substances1. drugs

2. smoking3. alcohol

Dubowitz (Maturity Testing Tool) 1st 24 hrs

Full Term - 38-42 weeks AOG

Preterm - < 38 weeks

Postterm - > 42 weeks

AGA 10th 90th percentile

SGA 90th percentile

Low birthweight


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Risk Factors:

1. Fetal

2. Placental

3. Maternal

4. Infection

Problems:Respiratory adaptationSusceptibility to infectionHyperbilirubinemiaCold stressHypoglycemia

anemiaHypoglycemia


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Physiologic weight loss- 5-10 % in 10 days

Causes1. No longer under influence of maternal hormones2. Voids and passes out stools3. relatively low nutritional intake

4. beginning difficulty establishing sucking

Physical AssessmentExamination

After birth: at around 1 hr, before d/c from hosp (not less than 12 hrs of age), maternal concernabt babys condition, danger sign during monitoring

After leaving hosp: 1st week of life at routine visit, ff up, sick visit

WHY DO WE EXAMINE?Overall assessment, initial set of observations, provide appropriate care and tx

Before d/c and therafter: reassess and monitor, prov approp tx if condition changed, give

guidance to mother

* Wash hands first!!!DANGER SIGNS

Hx of convulsionDiff feedingTemp > 37.5Temp < 35.5Mvmt only when stimulatedRR 60 bpm or moreSevere chest indrawing

* If present, POSSIBLE SERIOUS ILLNESSTREAT AND ADVISE

Give 1st dose of 2 IM AbxRefer urgentlyExplain need for referral to parentsSafe transportSend mother w/ baby if possibleSend referral note w/ babyInform referral center by phone or radio

1. Vital Signs

a. Pulse - 1 full minute; use apical pulse- irregular, rapid

>160-180 at birth

NORMAL: 120160 bpm

During sleep - 90-110 bpm


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If crying, up to 180 bpm

b. Respirations - 1 full minute

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

60-80 breaths/min at birth

NORMAL: 3060/minute

Babies < 2.5 kg or


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Gray color - infection

Pallor due to anemia because of:

* Excessive blood loss when cord is cut

* Untimely cutting of the cord

* Inadequate iron stores because of poor maternal nutrition

* Blood incompatibility

JaundiceTypes:

1. Physiologic Jaundice / Icterus Neonatorum2nd day 7th day - TERM

2nd day 10th day - PRE-TERM

Causes:a.Hemolysis

b.Decreased conversion of bilirubin to urobilirubinc.Decreased uptake of free bilirubin by

hepatic cells

2. Pathologic JaundiceNormal total serum bilirubin = 15%

Direct bilirubin = 1.7Indirect bilirubin = 13.2

Causes: a. Infection

b. Hemolytic disordersc.Inability of the newborn to conjugate bilirubin

Breastmilk jaundicePregnanediol

Decrease glucoronyl transferase

Decrease conversion of indirect to direct bilirubin

jaundice

Management1. Early feeding2. Phototherapy

Cover eyes with opaque mask to prevent blindness. distance - 18-20 in from source of light.

Monitor V/S especially temp Cover genitalia to prevent


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PRIAPISM and sterility Adequate hydration Turn NB q 2 to expose all body surfaces

Common Marks1. Harlequin Sign

2. Mongolian spots (-) school age

3. Milia unopened sebaceous glands; tip of nose and chin of the baby. (-) 2-4 weeks

4. Lanugo fine downy hair on shoulders, upper arms, back; (-) 2 weeks.

5. Desquamation- peeling; at birth, postmaturity

6. Vernix Caseosa

7. Portwine Stain or Nevus Flammeus birth; red to purple color; do not blanch on pressure nordisappear; face

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 ageor even longer.

9. Erythema Toxicum or Erythema Neonatorum NB rash or fleabite dermatitis; transient;papules with vesicles at nape, back and buttocks. (+) 2nd day; disappears w/o tx.

10. Cutis Marmorata transitory mottling when exposed to cold

11. Nevi stork bites or Telangiectasia Nevi; pink or red flat areas of capillary dilatation at uppereyelids, nose, upper lip, lower occiput bone, nape and neck. (-) 1st and 2nd year.

Nevus flammeus

Storks beak mark

Strawberry hemangioma

Cavernous hemangioma3. Head

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

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

Fontanels1. Anterior diamond shape;- closes 12-18 months; 3-4 cm long/2-3 cm wide

- junction of 2 parietal bones and 2 fused frontal bones- not indented depressed- suture lines - never appear widely separated


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2. Posterior triangular in shape- junction of the parietal bones and the occipital bones.- 1 cm- closes by end of 2nd month

SuturesLambdoid (2)

Coronal (2)

Frontal (1)

Sagittal (1)

CRANIOSYNOSTOSIS - suture lines separated or fontanels prematurely closed; leads tomental retardation

Molding overlaping of sagittal and coronal suture line

Craniotabes localized softening of cranial bones; indented by pressure of a finger.Corrects w/o treatment in weeksor months. Common to first bornsbecause of early lightening

Comparison between Caput Succedaneum and Cephalhematoma

4. Eyes- no discharge

- Eyelids of equal size

- temporarily gray or blue in color (d/t thinness)- Cry tearlessly 1st 3 months

- Cornea round and adult sized- Pupils round, not keyholed (Coloboma)- cross-eyed (Strabismus)- see object at 8 inches; V.A. of 20/200 to 20/500

5. Ears-Top of ear should align with inner and outer canthus of the eye

- sense of Hearing highly developed in NB

6. 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 developed7. Mouth


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- open evenly when crying. If not, suspect CN VII Paralysis (Bells Palsy).- lips, gums, palate intact; no breaks on the lip - cleft palate; cleft lip- Epteins Pearls small round glistening cysts; palate and gums, due to extra load of

maternal Ca- NATAL TEETH- Oral thrush white gray patches on the tongue and sides of cheeks due to Candida

8. Neck- Thyroid gland not palpable

- soft, palpable and creased with skin folds- Head - rotate freely on the neck and flex forward and back. (+) rigidity of the neck-CONGENITAL TORTICOLLIS (injury to SCM)-NB whose membranes ruptured 24 hours before birth, nuchal rigidity - meningitis.

9. Chest- As large as or smaller than the head

- Symmetrical

- Breasts may be engorged10. Abdomen

- dome shaped; If scaphoid - DIAPHRAGMATIC HERNIA- Bowel sounds should be present within 1 hour after birth

- Liver, spleen and kidneys are palpable at birth.

- Abdomen pushes out w/ each breath

11. Extremities

- symmetric and of equal length- Fingers and toes equal count

Supernumerary = polydactyly;fused or webbed = syndactylySimean line

- Asymmetrical movement of upper and lower extremities - ERB DUCHENE PARALYSIS- congenital hip dislocation: Ortolanis Maneuver- Observe for clubfoot deformities

12. Anogenital Area3 types of stools passed by NB:

1. Meconium greenish-blackish viscous; - amniotic fluid, intestinal secretions and cellsshed from mucosa- take note of time when meconium first passed

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 1-2times a day


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13. Female GenitaliaFemale swollen labia and pass a slightly bloody vaginal discharge

-PSEUDOMENSTRUATION on day 2-3 up to day 7

Male Scrotum may be edematous due to maternal hormones.

- Testes should be present; if undescended - CRYPTORCHIDISM

- foreskin retracted easily

- urethra opens at end of penis

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 thediaper 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 warmwater.

- Diaper must be pinned loosely during the 1st 2-3 days when the base of the penis istender.

14. Back

- On prone appears flat

- Note for mass, hairy nodule and dimple along axis - Spina Bifida.

- Cremasteric reflex test for integrity of spinal nerves (T8 thru T10)

Systemic Evaluation

I.Cardiovascular System

Fetal CirculationOxygen exchange occurs in placentapressure on the left side of the heart < right side(+) accessory structures


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II. Neuromuscular systemReflexes

blink reflexRooting reflex (-) 6 wks oldSucking reflex (-) 6 mos

Extrusion Reflex (-) 4 mosSwallowing reflexTonic neck Reflex (-)2-3 mosBabinski reflex (-) 3-12 mos

Landau reflexCrossed extension reflex (-) 1 mo

Palmar/Grasp (-) 3-4 mosPlantar reflex (-) 8 mosStepping reflex (-) 1 moMoro reflex- (-) 4-5 mos

Parachute reflex (-) 8-9 mos

Trunk Incurvation reflex (-) 2-3 mos

III. Gastrointestinal

Meconium mucus, vernix, lanugo, hormonesTransitional stools 2-10 days of lifeBreastfed babies stoolsFormula fed babies stools

IV. Urinary

Females strong urine streamMales projected arc

V.Autoimmune

Passive natural immunity mother to child(+) Ab from the mother against Polio, DPT, Rubella and Measles

* immunization starts usually at 2 mosExpanded Program on Immunization

VI. Senses

1. Sight at birth (9 inches)2. Hearing-at birth3. Taste at birth4. Smell-at birth


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5. Touch-at birth

Common Health Problems1. Constipation

2. Loose stools3. Colic

Causes:OverfeedingGas distentionToo much carbohydrates

ManagementFeed by demand

Burp infant

Feed in upright position

May need to changeformula

Diaper Rash

Miliaria

Seborrheic Dermatitis

Occasional Crossed Eyes

Clothing

Sleep Pattern

Newborn ScreeningREPUBLIC ACT NO. 9288

Newborn Screening Act of 2004

ensure that every baby born in the Philippines is offered the opportunity to undergo

newborn screening and thus be spared from heritable conditions that can lead to mentalretardation and death if undetected and untreated.

1. CONGENITAL HYPOTHYROIDISM

Thyroid hypofunction or enzyme defect reduced T3, T4Females


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S/sx:excessive sleeping, enlarged tongue, noisy respiration, poor suck, cold extremities, slowpulse and respiratory rate, lethargy and fatigue, short and thick neck, dull expression,open mouthed, slow DTR, obesity, brittle hair, delayed dentition, dry, scaly skin

Dx: low T3 T4, inc TSH

Mx: synthetic thyroid hormone

Nsg Care: Assist parents administer drugs

2. CONGENITAL ADRENAL HYPERPLASIA-inability to synthesize cortisol inc ACTH stimulate adrenal glands to enlarge inc

androgen

S/sx: musculinazation, sexual precocity

Mx: Steroids to dec stimulation of ACTH

3. G6PD DEFICIENCY

- reduction in the levels of the enzyme G6PD in RBC leads to hemolysis of the cell uponexposure to oxidative stress

Dx: blood smear heinz bodiesrapid enzyme screening test, electrophoresis

Mx: avoid drugs ie ASA, sulfonamides, antimalarials, fava beans

4. GALACTOSEMIA

(-) enzyme that metabolizes galactose

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

Dx: Beutler test

Tx: dec lactose soy based formularegulate diet

5. PHENYLKETONURIA (PKU)

- dec phenylalanine hydroxylase w/c converts phenylalanine to tyrosine

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

Dx: Guthrie bld test

Tx: dec phenylalanine (Lofenalac)regulate diet (tofu, shellfish, organ meat, cheese, milk, egg, chocolates, watermelon,

cod)


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Thank You!Discharge Instructions

a. Bathingb. Cord Care

c. Nutrition

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

SUMMARY OF NB CAREMake sure delivery area is readyUniversal precautionsKeep DR warmResuscitation eqpt near bedClean warm towels readySterile kit to tie/clamp and cut cordAntimicrobials to eye

Immunizations vit k, hepa B, bcgSSC to encourage breastfeeding

Documents

Care of the Newborn 2010