Care of the Newborn

Dr 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 nourishment
NEWBORN PRIORITIES IN THE FIRST DAYS OF LIFE

5. Waste elimination

6. Prevention of infection

7. Infant-parent relationship

8. Developmental care
ESSENTIAL 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, WARMING
RAPID ASSESSMENT
Breastfeeding w/n first hour of birth
Umbilical cord care
Exclusive breastfeeding
Eye care
Immunizing the NB
Preventing infection
Recognizing and caring for common NB problems
NB resuscitation for LBW infants
NB exam
Special care

Preparing to meet
baby’s needs
2 clean and warm towels
NB size self inflating bag
Infant masks: normal and small
NB
Suction device
Rolled up piece of cloth
Clean, dry, warm surface
Warm delivery room
A. Time Bound Procedures

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

1. Drying the NB
Dry body and head well

Remove wet cloth

Wrap baby in clean

dry cloth covering the
head

Do not remove vernix

2. 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 and
placed vertically on mother’s chest and abdomen

Provides warmth
Improves bonding
Protection from infection by
exposure of the baby to
good bacteria of the mother
Increases blood sugar of
the baby

HIV AND NB CARE AT BIRTH

universal precautions
May have immediate SSC
Breastfeeding may begin when baby is ready after delivery
Do not give baby any other food or drink
Good attachment and positioning
If replacement feeding, prepare formula for mother for the first few weeks

FIRST 2 HRS AFTER BIRTH

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

3. Initial Cord Care

Non immediate clamping to allow free BT, dec anemia, dec transfusion risk and intraventricular
hge

Do not apply any substance to the stump

Do not bind or bandage the stump
Leave 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 area

2. Fever
3. Discharge or foul smell

* Application of sterile cord clamp - prevent bleeding w/n 1st 24 hours (Omphalangia)
4. Kangaroo Mother Care
Provides NB w/ benefits of incubator care
Well small babies (preterm or lbw) may benefit
Once stable, KMC may begin

Adv for baby:

“lives” next to mother’s skin, inside clothes to keep baby warm; stabilize temp, HR and RR; keep
O2 consumption and
bld glucose equal
better than conventional tx
Maintains sleep patterns
less stress, less crying
Ready access to breast

Adv for mother:

Strong emotional bond with baby
Emphasis of role on survival and well being of baby
More confidence, less stress
More likely to breastfeed exclusively
Lower capital investment and
recurrent costs
Inexpensive form of care
Less need for incubators
Earlier discharge and
reduced admission rates
 Important points - mothers
All mothers can do it
Willing
Available
Gen health must be good
Has to be near baby and hosp to start KMC when baby ready
Supportive family and community
When to start KMC - baby
Baby should breathe on its own
Free of life threatening illness/ malformation
Have ability to coordinate sucking and swallowing not essential
KMC may begin after initial assessment and basic resuscitation

WHAT SHOULD BABY WEAR?

- Surrounding temp is 22-24 deg, baby is naked
in 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/ mom’s chest and abdomen

Head Position
Baby’s head should be turned to one side and slightly extended to keep airway open and allow
eye contact
Top of binder beneath baby’s ear

Thermal Care/Warm chain

Draft free, warm room, at least 25-28 deg
Immed drying of NB
SSC
Help the mother to breastfeed w/n an hr after birth
Postpone bathing 6-24hrs after birth
Wrap or dress the newborn immediately and warmly
Put him under a droplight
4 MECHANISMS OF HEAT LOSS
Convection

Radiation

Conduction

Evaporation

Non shivering Thermogenesis

Brown fat

- special tissue

- intrascapular region, thorax, perirenal area

- oxidized to produce heat

Effects of Cold Stress
- temp < 36.5
 1. Metabolic Acidosis
- increased BMR, anaerobic glycolysis,
inc acid production, metabolic acidosis

2. Hypoglycemia
- inc energy requirement to produce heat
5. Breastfeeding
1. bonding
2. uterine contraction
3. colostrum
4. Contraceptive
5. Cheap
6. Right temperature
7. Antibacterial – Lactoferrin, Lactobacillus bifidus, lysozyme, macrophage, T lymphocytes,
lactoperoxidase
Differences Between
Human and Cows Milk

Breastfeeding and SSC

Give baby to mother for
SSC
Let baby feed when ready

SIGNS OF READINESS
- baby looking around
- mouth open
- searching
POSITIONING AND ATTACHMENT
Neck not flexed or twisted
NB facing mother, nose opposite nipple
Hold NB body close to body
Support whole body
Wait until mouth is wide open
Move NB quickly to breast, aiming lower lip below nipple

*Areola shld be visible above baby’s mouth

*sucking slow, deep with some pauses
*if attachment not good, try again and reassess
First breast feed
Check attachment and positioning
Let baby feed on both breasts as long as he wants
Keep 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 doesn’t 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 Procedures
1.Immunization
2.eye care

3.Vit K admin

4.Weighing

5. washing
1. Expanded Program on Immunization

2. Crede’s 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 eyes
Apply antimicrobial w/n 1 hr after birth

b. Ointment
Terramycin
Gentamycin
Chloramphenicol
Erythromycin
- pull eyelids downward
0.5-1 cm
Inner to outer canthus
Wipe 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
 (5.5 – 8.6 lbs)
* 1 K = 2.2 lbs
BL: 47.5 – 53.75 cm
(19 – 21 ½ in)
Average: 50.8 cm/20 in
* 1 inch = 2.54 cm

Special Care
5. Initial Bath – temp stabilizes 36.5ºC 6-8 after birth

warm water during the 1st

week

Don’t use soap

hexachlorophene (Phisohex)
– infected passageway
C. Unnecessary
1.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 observation

Immediate assessment

Physical assessment

3. Initial Feeding

- ½ hrs after birth after baby

has rested
If the baby shows feeding
 cues (opening of mouth, tonguing, licking, rooting), encourage mother to encourage
NB to move toward breast
Health workers not to touch NB unless w/ medl indic
Do not give sugar water, formula or other prelacteals
Do not give bottles or pacifiers
Do 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 Assessment
of the Newborn
APGAR SCORE

A ppearance (color) – least important

P ulse rate - most important
G rimace (reflex activity); irritability
A ctivity (muscle tone)
R espiration

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
1. Choanal Atresia
2. Tracheobronchial fistula
3. Cleft lip and cleft palate

Substances
1. drugs
2. smoking
3. 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 <10th percentile

LGA > 90th percentile

Low birthweight <2500 gm

Very Low Birthweight <1500 gm

Extremely Low Birthweight <1000 gm

IUGR - Rate of growth does not meet expected pattern - growth restriction
DEFINING THE SMALL BABY
- SMALL BABY – 32-35 wks AOG OR
- 1-2 mos early OR
- BW bet 1500 g and 2,500g

VERY SMALL BABY - <32 wks AOG OR

- > 2 mos early OR
- BW < 1,500 g

Prematurity
Risk Factors:

1. Fetal

2. Placental

3. Maternal

4. Infection

Problems:
Respiratory adaptation
Susceptibility to infection
Hyperbilirubinemia
Cold stress
Hypoglycemia
anemia
Hypoglycemia
<40 mg/100 ml
dependent on maternal supply
Birth, continue to produce insulin
S/sx: limpness, jitteriness, apnea, twitching and hi pitched cry
CX: mental retardation
Tx: early feeding
D10W
Nsg: monitor blood glucose level
PE of the premature baby
Skin and SC tissue – thin, transparent
Inc lanugo
Dec plantar creases
Breast bud scarcely felt
Pinna flat and shapeless
Scrotum not pigmented
Testes not descended
Labia majora widely
separated

Management
Maintain patent airway
Incubator care
VS monitoring
O2 thearpy
Feeding
Infection precautions
Nursing Intervention
Meet physiologic needs
Meet psychological needs
Foster healthy family relationships
Provide education
 Physiologic weight loss
- 5-10 % in 10 days
Causes
1. No longer under influence of maternal hormones
2. Voids and passes out stools
3. relatively low nutritional intake
4. beginning difficulty establishing sucking

Physical Assessment
Examination
After birth: at around 1 hr, before d/c from hosp (not less than 12 hrs of age), maternal concern
abt baby’s 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 convulsion
Diff feeding
Temp > 37.5
Temp < 35.5
Mvmt only when stimulated
RR 60 bpm or more
Severe chest indrawing

* If present, POSSIBLE SERIOUS ILLNESS

TREAT AND ADVISE
Give 1st dose of 2 IM Abx
Refer urgently
Explain need for referral to parents
Safe transport
Send mother w/ baby if possible
Send referral note w/ baby
Inform referral center by phone or radio
1. Vital Signs

a. Pulse - 1 full minute; use apical pulse

- irregular, rapid

>160-180 at birth

NORMAL: 120–160 bpm

During sleep - 90-110 bpm

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: 30–60/minute

Babies < 2.5 kg or <37 wks AOG may have mild chest indrawing and periodically stop breathing
for a few sec

c. Blood Pressure - not usually measured

80–60/45–40 mm Hg at birth

100/50 mm Hg at day 10

d. Temperature

Maintain temperature to prevent

cold stress

* Use Rectal route

* Meconium - 24-48 hrs

*Normal range: 36.5C–37.5C (axilla)

Axillary: 36.4C–37.2C
Skin: 36.0 C–36.5C
Rectal: 36.6C–37.2C
* Temperature 37.2 at birth

Crying - increase body temperature slightly

Radiant warmer - falsely increase axillary temperature

2. Skin

Dark red – prematurity

Acrocyanosis – up to 48 hours

Generalized mottling
 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

Jaundice
Types:
1. Physiologic Jaundice / Icterus Neonatorum
2nd day – 7th day - TERM
2 day – 10th day - PRE-TERM
nd

Causes:
a.Hemolysis
b.Decreased conversion of bilirubin to urobilirubin
c.Decreased uptake of free bilirubin by
hepatic cells

2. Pathologic Jaundice
Normal total serum bilirubin = 15%
Direct bilirubin = 1.7
Indirect bilirubin = 13.2

Causes:
a. Infection
b. Hemolytic disorders
c.Inability of the newborn to conjugate bilirubin
Breastmilk jaundice
Pregnanediol

Decrease glucoronyl transferase

Decrease conversion of indirect to direct bilirubin

jaundice

Management
1. Early feeding
2. 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
 PRIAPISM and sterility
· Adequate hydration
· Turn NB q 2º to expose all body surfaces

Common Marks
1. 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 nor
disappear; 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 age
or 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 upper
eyelids, nose, upper lip, lower occiput bone, nape and neck. (-) 1st and 2nd year.

Nevus flammeus

Stork’s beak mark

Strawberry hemangioma

Cavernous hemangioma
3. 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.

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

Sutures
Lambdoid (2)

Coronal (2)

Frontal (1)

Sagittal (1)

CRANIOSYNOSTOSIS - suture lines separated or fontanels prematurely closed; leads to

mental 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 weeks
or months. Common to first borns
because 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. Secretions
2. septal deviation
- Sense of smell – least developed
7. Mouth
 - open evenly when crying. If not, suspect CN VII Paralysis (Bell’s Palsy).
- lips, gums, palate intact; no breaks on the lip - cleft palate; cleft lip
- Eptein’s 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 engorged

10. 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 = syndactyly
Simean line
- Asymmetrical movement of upper and lower extremities - ERB – DUCHENE PARALYSIS
- congenital hip dislocation: Ortolani’s Maneuver
- Observe for clubfoot deformities
12. Anogenital Area
3 types of stools passed by NB:
1. Meconium – greenish-blackish viscous; - amniotic fluid, intestinal secretions and cells
shed from mucosa
- take note of time when meconium first passed
2. Transitional – passed from 3rd to 10th day
3. 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 1-2
times a day
 13. Female Genitalia
Female– 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 IM
2. Infant is restrained; penis is cleansed with soap and water
3. clamp is used
4. Petroleum gauze dressing is applied to prevent adherence of circumcised site to the
diaper 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 warm
water.

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

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 Circulation
Oxygen exchange occurs in placenta
pressure on the left side of the heart < right side
(+) accessory structures
 II. Neuromuscular system
Reflexes

blink reflex
Rooting reflex – (-) 6 wks old
Sucking reflex –(-) 6 mos
Extrusion Reflex – (-) 4 mos
Swallowing reflex
Tonic neck Reflex – (-)2-3 mos
Babinski reflex – (-) 3-12 mos

Landau reflex
Crossed extension reflex – (-) 1 mo
Palmar/Grasp (-) 3-4 mos
Plantar reflex – (-) 8 mos
Stepping reflex (-) 1 mo
Moro reflex- (-) 4-5 mos
Parachute reflex – (-) 8-9 mos
Trunk Incurvation reflex – (-) 2-3 mos

III. Gastrointestinal

Meconium – mucus, vernix, lanugo, hormones

Transitional stools – 2-10 days of life
Breastfed babies stools
Formula fed babies stools

IV. Urinary

Females – strong urine stream

Males – 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 mos

Expanded Program on Immunization
VI. Senses

1. Sight – at birth (9 inches)

2. Hearing-at birth
3. Taste – at birth
4. Smell-at birth
5. Touch-at birth

Common Health Problems

1. Constipation
2. Loose stools
3. Colic
Causes:
Overfeeding
Gas distention
Too much carbohydrates

Management
Feed by demand

Burp infant

Feed in upright position

May need to change

formula

Diaper Rash

Miliaria

Seborrheic Dermatitis

Occasional “Crossed Eyes”

Clothing

Sleep Pattern

Newborn Screening
REPUBLIC 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 mental
retardation and death if undetected and untreated.”

1. CONGENITAL HYPOTHYROIDISM

Thyroid hypofunction or enzyme defect reduced T3, T4

Females
S/sx:excessive sleeping, enlarged tongue, noisy respiration, poor suck, cold extremities, slow
pulse 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 upon
exposure to oxidative stress

Dx: blood smear – heinz bodies

rapid 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 formula

regulate 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)
 Thank You!
Discharge Instructions
a. Bathing
b. Cord Care
c. Nutrition
Calories 120 kcal/kg body wt/day
CHON 2.2 gms/KBW/day
Fluids 160-120 cc/KBW/day
Vitamins A,C, D for formula and breastfed babies
SUMMARY OF NB CARE
Make sure delivery area is ready
Universal precautions
Keep DR warm
Resuscitation eqpt near bed
Clean warm towels ready
Sterile kit to tie/clamp and cut cord
Antimicrobials to eye
Immunizations vit k, hepa B, bcg
SSC to encourage breastfeeding