The Newborn

By: Zosi Farah W. Fernandez, RN

APGAR SCORING

• Developed by Dr. Virginia Apgar to provide a valuable index for assessing newborn’s condition at birth

• Used to evaluate the newborn in five specific categories at 1 and 5 minutes after birth

• The one minute score reflects transitional values

• The five minutes provides the best direction for the planning of newborn care

Ballard Scoring

• is a commonly used technique of gestational age assessment. It assigns a score to various criteria, the sum of all of which is then extrapolated to the gestational age of the baby. These criteria are divided into Physical and Neurological criteria. This scoring allows for the estimation of age in the range of 26 weeks-44 weeks. The New Ballard Score is an extension of the above to include extremely pre-term babies i.e. up to 20 weeks.

Respiratory Evaluation

• Can be used to estimate the degree of respiratory distress in newborns.

• Each item is given a value of 0,1, or 2; the values are then added

• A total score of 0 indicates no respiratory distress, score of 4 to 6 indicate moderate distress, score of 7 to 10 indicate severe distress

Hygenic Care and Safety

DELIVERY ROOMA. Initiate, establish and maintain respirations and heartbeat- Suction the mouth first then the nose with the bulb suction

B. Prevent heat loss1. Dry infant immediately after birth2. Wrap newborn warmly, cover head or place in especially warm area3. Place newborn in warm surface4. Skin to skin contact with the mother

C. Identify mother and infant with matching bands

1. Apply ID band or bracelet to infant

D. Perform rapid all physical and neurologic examination

1. Identify obvious congenital anomalies2. Identify injuries from birth trauma3. Perform APGAR scoring at 1 and 5 minutes after birth4. Place infant in Trendelenburg’s position5. Suction gently6. Administer oxygen PRN7. Promote bonding8. Transfer to nursery at appropriate time

E. Administer medication as ordered1.0.5% erythromycin or 1% Tetracycline into

conjuctival sacs2.Vitamin K3.Hepatitis B vaccineF. Measure and weigh newbornE. Stabilize TemperatureF. Assess for physiologic jaundiceG. Perform Screening test before discharge

Newborn Screening

• Republic Act No. 9288, otherwise known as the Newborn Screening Act of 2004 institutionalizes a comprehensive, integrative and sustainable national newborn screening system to ensure that every newborn baby in the Philippines have the chance to undergo newborn screening, which will ultimately spare them from either mental retardation, serious health complication or death from heritable diseases that are left untreated and undetected.

What disorders does the Newborn Screening test for?

• Congenital Hypothyroidism - A lack or absence of thyroid hormone, which is necessary for growth of the brain and the body. Treatment is required within the first four weeks to prevent stunted physical growth and mental retardation.

• Congenital Adrenal Hyperplasia - An endocrine disorder that causes severe salt loss, dehydration, and abnormally high levels of male sex hormones. Left undetected and untreated, a baby may die within seven to 14 days.

• Galactosemia - A condition in which babies are unable to process galactose. or the sugar present in milk. Increased galactose levels in the body lead to liver and brain damage, and to the development of cataracts.

• Phenylketonuria - The inability to properly utilize the enzyme phenylalanine, which may lead to brain damage.

• Glucose-6-Phosphate Dehydrogenase (G6PD) Deficiency - A condition where the body lacks the enzyme called G6PD, which may cause hemolytic anemia resulting from exposure to oxidative substances present in certain drugs, foods and chemicals. Parents of G6PD-positive babies are given a list of these substances.

How is Newborn Screening administered?

• Your baby will be pricked at the heel and three drops of blood are taken. This process is ideally done during the 48th to 72nd hour of life.

A negative screen means that results are normal. A positive screen will require the newborn to be brought back to her pediatrician for further testing.

Normal Newborn

A. Weight1. Average between 2750g and 3800g at term2. Under 2750g: small for gestational age3. Over 3800g large for gestational age4. Initial loss of 5%-10% weight normal during first few days,

should be regained in 1-2 weeksB. LengthAverage 46-55.9 cmUnder 45.7 in SGAOver 55cm in LGA

C. Head Circumference1. Average 33-33.5 cm equal to or 2-3 cm slightly larger than

chest2. Under 31.7 cm is microcephaly3. Over 36.8cm hydrocephalya. Caput succedaneum- Swelling of the soft tissue of the scalp because of pressure

from the cervix against presenting part.- It disappears in 3-4 days without interventionb. Cephalhematoma- Subperiosteal hemorrhage with collection of blood between

periosteum and bone; swelling does not cross suture linesc. Molding- Overlapping of skull bones caused by compression during labor

and delivery

D. Fontanels1. Anterior fontanel- Diamond shaped; palpable- Generally closes in 12-18 months2. Posterior fontanel- triagular, may obliterated because of molding- Closes in 2-3 months

Physiologic Adaptation of the Newborn

Transition to Extrauterine Life- infant undergo phases of instability during the

first 6 to 8 hours after birth- First phase of transition period last up to 30

minutes after birth and is called the first period of reactivity.

• The newborn heart rate increases rapidly 160 to 180/min. But gradually falls by 30 min. To a baseline rate between 100 to 120 beats/min

• Respiratory rate are irregular with a rate between 60 and 80 cycles/min.

• Crackles may be present on auscultation, audilble grunting, nasal flaring and retractions of the chest may also be noted.

• Brief periods of apnea may occur• Body temperature may decrease

• The infant is alert and may have spontaneous startles, tremors, crying and movement of the head from side to side

• After the first period the newborn sleeps or has a marked decrease in motor activity, last from 60 to 100 minutes and is followed by a second period of activity

• The second period of reactivity occurs roughly between 4 to 8 hours after birth and lasts from 10 minutes to several hours

• Meconium is commonly passed at this time

Cardiovascular System

Changes in fetal circulation at birthStructure Before Birth After Birth

Umbilical Vein Brings arterial blood to the heart

Obliterated; becomes round ligament of the liver

Umbilical Arteries

Bring arteriovenous blood to placenta

Obliterated; becomes vesical ligaments on anterior abdominal wall

Ductus venousus Shunts arterial blood into inferior vena cava

Obliterated; becomes ligamentum venosum

Ductus Arteriosus Shunts arterial and some venous blood from the pulmonary artery to aorta

Obliterated; becomes ligamentum arteriosum

Foramen Ovale Connects right and left auricles Obliterated usually; at all times

Lungs Contain no air and very little blood; filled with fluid

Filled with air and well supplied with blood

Pulmonary arteries Bring little blood to lungs Bring much blood to lungs

Aorta Receive blood from both ventricles Receive blood only from left ventricle

Inferior vena cava Brings venous blood from body and arterial blood from placenta

Brings blood only to right auricle

Peripheral circulation is sluggishPulse rate is 120 to 160 beats per minute while awake and 100 beats per minute while asleepBlood pressure average 80/46 mmHg

Circulatory events at birth• Drying or clamping of the umbilical cord and stimulation of cord receptors

• Increased PCO2, decreased PO2, and increasing acidosis

• First breath

• Decreased Pulmonary artery pressure

Increased PO2 Closure of foramen ovale

• Closure of ductus Closure of ductus venousus and arteriosusumbilical arteries and vein due to

Decreased flow

Thermoregulation and Metabolic Changes

• 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

Pulse

• The heart rate may often remains slightly irregular because of immaturity of the cardiac regulatory center in the medulla

• Transient murmurs may result from the incomplete closure of the fetal circulation

• During crying the heart rate rise again to 180 bpm• Heart rate decrease during sleep ranging from 90 to 110 bpm

Respiration

• In the few minutes of life may be high as 90 breaths per minute

• As respiratory activity is established and maintained, the rate settles to an average of 30 to 60 per minute

• Respiratory depth, rate and rhythm are likely to be irregular, and short period of apnea, sometimes called periodic respirations

• Newborn are obligate nose-breathers and show signs of acute distress if their nostrils become obstructed

• Coughing and sneezing reflexes are present at birth to clear the airway.

Gastrointestinal System

• Accumulation of bacteria in the gastrointestinal tract is necessary for digestion and the synthesis of Vitamin K.

• 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.

• First stool of a newborn is usually passed within 24 hours after birth, called as meconium.

• If a newborn does not pass a meconium stool by 24 to 48 hours after birth, the possibility of meconium ileus, imperforated anus, or bowel obstruction should be suspected

• About the second or third day of life, a newborn stool changes in color and consistency, becoming green and loose, this is termed transitional stool

• Breast feed babies pass three or four light yellow stool per day

• Formula usually passes two or three bright yellow stools a day

Urinary System

• Average newborn voids within 24 hours after birth. A newborn who does not take in much fluid for the first 24 hours may void later than this, but the 24 hours point is a good general rule

• Newborn who do not void within this time should be examined for the possibility of urethral stenosis or absent kidneys or ureters.

• Single void in a newborn is only about 15 mL, the daily urine output for the first 1 or 2 days is about 30 to 60 mL total.

• A small amount of protein may be normally present in voiding for the first few days life, until the kidney glomeruli are more fully mature.

Immune System

• Newborn routinely administered hepatitis B vaccine during the first 12 hours after birth to protect against this disease.

• They have difficulty forming antibodies against incading antigen until about 2 months of age, newborns are prone to infection. This inability to form antibodies is the reason that most immunizations against childhood disease are not given to infants younger than 2 months of age

Neuromascular System

• Mature newborns demonstrate neuromuscular function by moving their extremities, attempting to control head movement, exhibiting a strong cy 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.

Newborn Reflex• Blink Reflex- In a newborn serves the

same purpose as it does in an adult-to protect the eye from any object coming near it by shining a strong light such as a flashlight or otoscope light on an eye. A sudden movement to ward the eye sometimes can elicit the blink reflex.

• 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. It about time, newborn eyes focus steadily.

• 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.

• Swallowing reflex- In a newborn is the same

as in adult. Food that reaches the posterior portion of the tongue id 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.

Extrusion Reflex- A 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

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 at about 6 weeks to 3 months of age.

Step-in-place reflex- Newborn who are held

in a vertical position with their feet touching a hard surface will take a few quick, alternating steps.

- This reflex disappears by 3 months of age.

Placing reflex- Is similar to the step-in-place reflex, except that it is elicited by touching the anterior surface of the newborn’s leg against a hard surface

Plantar Grasp Reflex- When an object

touches the sole of a newborn’s foot at the base of the toes, the toes grasp in the same manner as the finger do.

- Reflex disappears at about 8 to 9 months.

Tonic neck reflex- 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.

Moro Reflex- Can be initiated by startling

a newborn with a loud noise or by jarring the bassinet. The most accurate method to eliciting the reflex is to hold a newborns in a supine position and allow their heads to drop backward about 1 inch. In response to this sudden head movement, they abduct and extend their arms and legs.

Babinski Reflex- When the side of the

sole of the foot is stroked in an inverted “J” curve from the heel upward, a newborn fans the toes

- It remains positive until at least 3 months of age.

Magnet Reflex- If pressure is applied to

the soles of the feet of a newborn lying in a supine position, he or she pushes back against the pressure.

Crossed Extension Reflex- If one leg of a newborn

lying supine is extended and the sole of that foot is irritated by being rubbed with a sharp object, the infant raises the other leg and extends it, as if trying to push away the hand irritating the first leg

Trunk Incurvation Reflex- When newborns lie in a

prone position and are touched along the paravertebral area by a probing finger, their trunk and swing their pelvis toward the touch.

Landau Reflex- A newborn who is held in

a prone with a hand underneath, supporting the trunk, should demonstrate some muscle tone. Babies may not be able to lift their head or arch their back in this position

Deep Tendon Reflex- A patellar reflex can be

elicited in a newborn by tapping the patellar tendon with the top of the finger.

- The lower leg moves perceptibly if the infant has an intact reflex.

- Is a test for spinal nerve L2 through L4

The Senses

Hearing- As soon as amniotic fluid drains or is absorb from the middle

ear by way of the eustachian tube- within hours after birth – hearing becoming acute.

- Newborns appears to have difficulty locating sounds.

Vision- Newborns seen as soon as they are born and possibly have

been “seeing” light and dark into utero for the last few months of pregnancy.

- Newborns focus on black and white objects at a distance of 9 to 12 inch.

Touch- The sense of touch is also well developed at birth.- Demonstrate this by quieting at a soothing touch and by

positive sucking and rooting reflexes.

Taste- A newborn has the ability to discriminate taste, because taste

buds are developed and functioning even before birth.

Smell- The sense of smell is present in newborns as soon as the nose

is clear of mucus and amniotic fluid.

BirthmarksHemangiomas- Are vascular tumors of the skin.Three types of hemangiomas occur:

1.Nevus Flammeus- Is a macular purple or dark-red lesion that is present at birth- Sometimes called a port-wine stain- These lesion typically appear on the face, although they often

found on the face; it is less likely to fade.- Can be covered by a cosmetic preparation later in life or

removed by laser therapy, although lesions may reappear after treatment.

2. Strawberry Hemangioma

- Are elevated areas formed by immature capillaries and endothelial cells.

- Most are present at birth in term neonates, although may appear up to 2 weeks after birth.

- Application of hydrocortisone ointment may speed the disappearance of the lesions by interfering with the binding of estrogen to its receptor site.

3. Cavernous Hemangioma- Are dilated vascular spaces, they are usually raised and

resemble a strawberry hemangioma in appearance. However they do not disappear with time as the strawberry hemangioma.

- Suncutaneous infusions of interferon-alfa-2a can be used to reduce these lesions in size, or they can be removed surgically.

- Usually their hematocrit levels assed at health maintenance to evaluate for possible internal blood loss

Mongolian Spot- Are collections of

pigment cells that appears as slate-gray patches across the sacrum or buttocks and possibly on the arms and legs.

- They disappear by school age without treatment.

Vernix Caseosa- Is a white, cream cheese-like

substance that serves as a skin lubricant.

- It is noticeable in on a term newborn’s skin, at least in the skin folds, at birth.

Lanugo- Is the fine hair, downy hair

that covers a newborn’s shoulder, back and upper arm. It maybe found also on the forehead and ears.

- A baby born after 37 to 39 weeks of gestation has more lanugo than a newborn of 40 weeks.

- Is rubbed away by the friction of bedding and clothes against the newborn’s skin.

- By 2 weeks of age it disappear

Desquamation- Within 24 hours after 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 results in areas of peeling similar to those caused by sunburn.

Milia- all newborn sebaceous

glanda are immature.- At least one pinpoint 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.

Erythema Toxicum- In most normal mature infants, a

newborn rash - This usually appears in the first to

fourth day of life, but may appear up to 2 weeks of age.

- It begins with papule, increases in severity to become erythema by the second day, and then disappears by the third day

- Sometimes called flea-bite rash- Caused by a newborn’s eosinophils

reacting to the environment as the immune system matures.

Epstein’s Pearls- One or two small round, glistening, well circumscribed cysts

are present on the palate, as a result of the extra load of calcium that was deposited in utero.

Nursing Diagnosis

• Risk for ineffective thermoregulation related to newborn’s transition to extrauterine environment

• Risk for ineffective airway clearance related to presence of mucus in mouth and nose at birth

• Risk for infection related to newly clamped umbilical cord and exposure of eyes to vaginal secretions