Normal NewbornNormal Newborn

Dr Varsha Atul ShahConsultantDept. of Neonatal& Dev MedicineSingapore General Hospital

Newborn Adaptation At BirthNewborn Adaptation At Birth

Circulatory changes (gas exchange from placenta to the lungs)

Reabsorption of fetal lung fluid Closure of patent ductus arteriosus Stabilization of cardiac rhythm Establishment of regular breathing Temperature regulation Changes in carbohydrate metabolism

Circulatory changesCirculatory changes

Reduction of pulmonary vascular resistance, increased PBF by 10 folds

Increase in left atrial pressure Closes foramen ovale Increase systemic vascular resistance Rt to lt flow at PDA diminishes, closes PDA PS: failure to achieve reduce PVR cause PPHN

Fetal Circulation

Circulation in thenormal newborn

Lung changesLung changes

Lung fluid absorption (failure cause TTNB, Transient Tachypnea of Newborn)

RR rises to 60/min Transient grunting, mild retraction, ala nasi flare

may be seen

Carbohydrate MetabolismCarbohydrate Metabolism

Cessation of maternal glucose supply Decline in glucose level by 2 hrs 20-30% CHO comes from milk Gluconeogenesis from AA, glycerol, lactate

Temperature regulationTemperature regulation

Low ambient temp, evaporation, radiation, convection, conduction loss of heat –Hypothermia

Achieve Neutral thermal environment Drying, swaddling, skin-skin contact, radiant warmer,

leave vernix, wrapping, early feeding

Immediate care after birthImmediate care after birth

Prevent hypothermiaPrevent hypothermia

Eye, skin, cord careEye, skin, cord care

Give injection vitamin K Give injection vitamin K

Breastfeed within ½ hour of birthBreastfeed within ½ hour of birth

Search for malformationsSearch for malformations

Increased risk of malformationIncreased risk of malformation

Single umbilical arterySingle umbilical artery

Simian creaseSimian crease

Dysmorphic featuresDysmorphic features

Asymmetric cry due to absence of Asymmetric cry due to absence of Depressor Angularis Oris Muscle Depressor Angularis Oris Muscle

Excessive drooling of salivaExcessive drooling of saliva

Quick screening for Quick screening for malformationsmalformations

Screen from top to bottom and in midlineScreen from top to bottom and in midline Orifice examination Orifice examination

Anal openingAnal opening Oesophagus patency*Oesophagus patency* Choanal atresiaChoanal atresia

** SGA baby, polyhydramnios, excessive SGA baby, polyhydramnios, excessive drooling, drooling, • single umbilical arterysingle umbilical artery

Essential postnatal careEssential postnatal care

Nurse in thermal comfortNurse in thermal comfort

(warm to touch, pink soles)(warm to touch, pink soles)

Check umbilicus, skin, eyesCheck umbilicus, skin, eyes

Good sucking at breast Good sucking at breast

Screen for danger signalsScreen for danger signals

Advice on immunizationAdvice on immunization

Care of umbilical stumpCare of umbilical stump

Inspect 2 to 4 hours after ligation for Inspect 2 to 4 hours after ligation for bleedingbleeding Do not apply anything, keep cord Do not apply anything, keep cord

clean and dryclean and dry Inspect for discharge or infection till healing Inspect for discharge or infection till healing occursoccurs

Care of the skinCare of the skin

Dry using soft prewarmed clean clothDry using soft prewarmed clean cloth Bathing soon after birth is not Bathing soon after birth is not recommended recommended Do not make vigorous attempts to Do not make vigorous attempts to

remove vernix caseosaremove vernix caseosa Inspect for superficial infections Inspect for superficial infections

Care of the eyesCare of the eyes

Clean at birth and subsequently dailyClean at birth and subsequently daily

For sticky eyes use normal saline or For sticky eyes use normal saline or appropriate medication appropriate medication Nasolacrimal duct blockage, Nasolacrimal duct blockage, Massaging helpsMassaging helps

Danger signsDanger signs

LethargyLethargy

HypothermiaHypothermia

Respiratory distressRespiratory distress

CyanosisCyanosis

ConvulsionsConvulsions

Abd distensionAbd distension

BleedingBleeding

Yellow palms/ soleYellow palms/ sole

Excessive wt lossExcessive wt loss

VomitingVomiting

DiarrhoeaDiarrhoea

Infant ClassificationInfant Classification-by Gestational Age-by Gestational Age

Term : 37-41+6/7 weeks

Preterm: <37 weeks

Post-term: 42 or more weeks

Infant ClassificationInfant Classification-by birthweight-by birthweight

Macrosomia: 4000 gm or more

Normal birthweight: 2500-3999 gm

Low birthweight: <2500 gm

Very low birthweight: <1500 gm

Extremely low birthweight: <1000 gm

Term infantTerm infant

A well term infant loses up to 10% of birth weight in the first week of life;

Birth weight is regained by 10-14 day and thereafter gains 30g/day.

His caloric intake/requirement is 100-120 kcal/kg/day

with 2-5 g/kg/day of protein for cellular growth.

Infant ClassificationInfant Classification-by Gestational Sizes-by Gestational Sizes

Appropriate for gestational age

Large for gestational age

Small for gestational age classify based on maturity

and intrauterine growth PS:Energy stores in the fetus builds up mostly during the 3rd trimester of the pregnancy.

Gestational Age AssessmentGestational Age Assessment

Maternal dates

Early Ultrasound dating

Dates of first recorded fetal activity

Dates of first recorded fetal heart sounds

Dubowitz or Ballard scores

Decreasing lanugo hair over the back is aDecreasing lanugo hair over the back is a

sign of increasing gestational age.sign of increasing gestational age.

Dubowitz L, Dubowitz V:

Gestational Age of the Newborn

Physical ExaminationPhysical Examination of the Newborn of the Newborn

Purpose

- detect malformations or deformations

- determine manifestations of various neonatal diseases

- evaluate the effects of labour and delivery on newborn

Physical ExaminationPhysical Examination General appearance

- cyanosis, nasal flaring, intercostal retractions, grunting, meconium staining of skin, perfusion, level of spontaneous activity, tone, cry

Vital signs

- HR (120-160 beats/min), RR (30-60 breaths/min), To, b/p, Wt, length and OFC In term healthy infants, the core temperature will fall after birth by about 0.8-2 degrees Celsius.

Gestational age assessment

Physical ExaminationPhysical Examination Skin

- harlequin color change, hair tufts, mongolian spots, naevus flammus, malia malenocytic naevus, haemangiomas, pustular melanosis, erythema toxicum

Skull

- cranial synostosis, fontanels, craniotabes, caput succedaneum, subgaleal hemorrhage

Milia

Erythema Toxicum

Epstein Pearls

Mongolian Spots

Capillary Haemangioma

Physical ExaminationPhysical Examination Face

- facial asymmetry, preauricular tags/pits/sinus,low setears, hypertelorism, cleft lip/palate, red reflex, white reflex

Neck and chest- sinuses, cystic hygromas, sternomastoid tumour, webbed neck,

thick nuchal folds, clavicular fracture,chest wall asymmetry, breast tissue formation, supernumerary nipples

Physical ExaminationPhysical Examination Lung examination

- RR, breath sounds, shift of cardiac impulse, bowel sounds

Heart- normal heart sounds, murmurs, peripheral pulses, b/p

Abdomen- distension, masses, umbilical hernia, omphalocoele,

omphalitis, gastroschisis

Umbilical CordUmbilical Cord

Physical ExaminationPhysical Examination Genitalia examination

- testicular descend, scrotal pigmentation, vaginal discharge, mucosal tags, imperforate hymen, clitoral enlargement

Extremities- symmetry, polydactyl, syndactyl, simian creases, absent fingers,

clubfoot, fracture

Spine- sacral tufts, scoliosis, lipoma, meningomyelocele

Milky white or blood-streaked vaginal

discharge is the result of maternal

hormone withdrawal.

Physical ExaminationPhysical Examination Hip assessment

- Barlow test, Ortolani manoeuver to determine whether femoral head can be displaced from acetabulum and replaced respectively

Neurologic assessment- tone, alterness, primitive reflexes (Moro’s, palmar grasp,

rooting reflex), deep tendon reflexes, spontaneous motor activity, cranial nerves

Neonatal Immunization In Neonatal Immunization In

SingaporeSingapore

ImmunizationImmunizationAgeAge Vaccine OptionalVaccine Optional 0-7 days0-7 days BCG, Hep B BCG, Hep B 1 month1 month 22ndnd Hep B Hep B 3 months3 months OPV,DPT, OPV,DPT, Hib/Pneumococ/RotaHib/Pneumococ/Rota4 months4 months OPV,DPT, OPV,DPT, Hib/Pneumococcal Hib/Pneumococcal5 months 5 months OPV, DPT, OPV, DPT, Hib/Pneumococ/Rota Hib/Pneumococ/Rota6 Months6 Months Hep BHep B15 months 15 months MMRMMR Chicken Pox/flu Chicken Pox/flu18 months 18 months OPV, DPT Hib/PneumococcalOPV, DPT Hib/PneumococcalSchool entry(4-5 yrs) School entry(4-5 yrs) OPV, DTOPV, DT

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