IMMEDIATE CARE OF THE NEWBORN

I. Care of the Newborn at the DELIVERY ROOM >Establish and Maintain AIRWAY (Respiration) A. Suctioning >Turn the babys head to one side. >Suction gently and quickly (5 to 10 seconds). Prolonged and deep suctioning of the nasopharynx during the first 5 to 10 minutes of life will stimulate the VAGUS NERVE (located in the esophagus) and cause bradycardia. > Suction the MOUTH first before the nose. If thenose is suctioned first, the stimulation of thenasal mucosa will cause reflex inhalation ofpharyngeal material into the trachea and bronchi, causing ASPIRATION. >To test the patency of the airway, occlude one nostril at a time. (REMEMBER: newborns areNOSE BREATHERS.) If a newborn struggles when a nostril has been occluded, additional suctioning is indicated. B. POSITIONING OF THE NEWBORN > The position when suctioning should be one that promotes drainage of secretions HEAD LOWER THAN THE REST OF THE BODY BUT head should be higher than the rest of the body if there are signs of increased ICP: Vomiting Bulging, tense fontanels Abnormally large head Increased BP Decreased PR and RR Widening pulse pressure Shrill, high-pitched cry C. TEMPERATURE REGULATION (THERMOREGULATION) METABOLIC ACTIVITIES. One of the ways by which heat is produced in the newborn is by increasing metabolism. When this occurs, fatty acids accumulate because of the breakdown of brown fats (seen only in newborns). HYPOGLYCEMIA - due to the use of glucose as glycogen o Thermoregulatory center is underdeveloped. HEAT LOSS IN NEWBORN CONVECTION flow of heat from body surface to cooler surroundings RADIATION transfer of body heat to a cooler solid object not in contact with the body EVAPORATION loss of heat through conversion of a liquid to a vapor CONDUCTION transfer of body heat to a cooler solid object in contact with the body D. APGAR Scoring System -standard tool to evaluate the condition of the neonate Done twice: 1st minute: to determine general condition (NEURO/RESPI/CIRCULATORY CHECK) 5th minute: to determine if neonate can adjust to extracellular life Appearance (color) least important criteria Pulse rate (most important criteria) Grimace (reflex activity)- irritability Activity (muscle tone) Respiration *Lowest individual score is 0. *Highest individual score is 2. SCORE: 9 HIGHEST SCORE 10 PERFECT SCORE ADD ALL SCORES AND INTERPRET: 0 3 = POOR, SERIOUS, SEVERELY DEPRESSED, NEEDS CPR 4 6 = FAIR, GUARDED, MODERATELY DEPRESSED 7 10 = GOOD, HEALTHY Dubowitz (Maturity Testing Tool) - done in the first 24 hours Pre term born before the 38th week Post term born after 42 weeks Full term born at 38 to 42 weeks Small Gestational Age (SGA) BW is < 10th percentile LBW BW < 2,500 grams VLBW BW 1,500 grams Large Gestational Age (LGA) BW > 90th percentile

Maintain appropriate Body Temperature. Ch will increase the bodys need for O2. The newborn suffers large losses of heat (cold stress) because he is wet at birth, the delivery room is cold, he does not have enough adipose tissue and does not know how to shiver.
Wrap the newborn immediately Wrap him warmly Put him under a droplight EFFECTS OF COLD STRESS

Appropriate Gestational Age (AGA) BW within 10-90th percentile E. PROPER IDENTIFICATION IS DONE IN THE DR BEFORE BEING BROUGHT TO THE NURSERY. BEST METHOD OF IDENTIFICATION: ** FOOTPRINTING MOST RELIABLE ** ID BANDS ( ANKLE & WRIST) ACCURATE & PRACTICAL ** BIRTHMARKS LESS RELIABLE II. Care of the Newborn at the NURSERY A. Check the ID bands of mother and baby B. THERMOREGULATION C. BATH done if infants skin temperature stabilizes at 36.5C (98.6F); temperature stabilizes 6-8 hours after birth *VERNIX CASEOSA *USE NON-ALKALINIC SOAP *USE OF ANTISEPTIC SOLUTIONS *WARM WATER 2.Taking Temperature Maintain at 35.5C-36.5C to prevent hypoglycemia and acidosis due to hypothermia (cold stress). **Rectal route is preferred in order to check patency of the anus **Passage of meconium should be within 24 to 36 hrs afterbirth. Meconium greenish blackish in color. If there is no meconium: (a) cystic fibrosis (b) imperforate anus D. Initial Cord Dressing CORD: 2 A + 1 V *Practice aseptic technique Use povidone (Betadine); 70% Isoprophyl alcohol to prevent Tetanus Neonatorum and Omphalitis infection of the cord (streptococcal and staphylococcal) Signs of Omphalitis: *Reddening of the area *Fever *Discharge and foul smell Application of sterile cord clamp to prevent bleeding within the 1st 24 hours ** The cord will fall off after 7-10 days E. CREDES PROPHYLAXIS to prevent Ophthalmia Neonatorum or Gonorrheal Conjunctivitis (Neisseria gonorrhea) which causes blindness if not treated.

Infection can be acquired during delivery from a mother with untreated gonorrhea Ophthalmic drops BEFORE: Silver Nitrate or AgNO3 1% 1-2 drops 1-2 gtts into the lower conjunctival sac PRESENT: Ointment inner to outer canthus Terramycin Gentamycin Chloramphenicol Erythromycin drug of choice of Chlamydial Trachomatis *Chemical Conjunctivitis F. Vitamin K Injection Vitamin K facilitates production of the clotting factor; thus, prevents bleeding, should be given within one hour after birth. 1 mg. Aquamephyton (generic: phytonadione) Route: IM into the lateral anterior thigh (Vastus lateralis). In children below 12 months of age who have not yet learned how to walk, this is the preferred site of injection because the gluteal muscles are not yet fully developed. G. Take Anthropometric Measurements (Vital Statistics) BW: 2.5 3.4 kgs *1 K = 2.2 lbs BL: Average: 50.8 cm/20 in *1 inch = 2.54 cm Normal: 47.5 53.75 cm (19 21 in) HC: 33 35 cm CC: 31 33 cm AC: 31 33 cm Note: A reduction of NB weight of about 5-10% of BW (6-10oz) or less known as Physiologic weight loss during the 1st 3-10 days of life is normal. PHYSIOLOGIC WEIGHT LOSS (first 3-10 days of life) Causes: -Infant is no longer under the influence of maternal hormones. -Voids and passes out stools. -Has relatively low nutritional intake -Has beginning difficulty establishing sucking H. Initial Feeding given 1-6 hours after birth 1 oz of sterile water to be given to find out if newborn can swallow without aspirating. Glucose water has been found to be irritating to the lungs if aspirated. Purposes of breastfeeding: *Primarily to promote bonding

*Facilitates uterine contraction through sucking because of release of oxytocin by neurohypophysis *Facilitates release of colostrums (contains antibodies-IgA). I. Physical Assessment 1. Vital Signs Temperature axillary: 36.5 37C (97.91-98F)/ rectal Crying may increase body temperature slightly. Radiant warmer will falsely increase axillary temperature. Pulse using apical pulse = PMI: Point of Maximum Impulse(located at MCL 5th ICS or below the left nipple line) This is done using a stethoscope. Radial pulse is normally not prominent. If it is, it may be a sign of congenital heart anomaly (i.e., PDA). Femoral or brachial pulses if absent, indicates, coarctation of the aorta and hip dislocation. Pulse is IRREGULAR, RAPID >160-180 beats/min. at birth 120-140 (stable) RESPIRATION normally RAPID, QUIET, GENTLE, SHALLOW, IRREGULAR with physiologic APNEA of less than 5 seconds Largely diaphragmatic and abdominal 60-80 breaths/min at birth 30-60 breaths/min (stable) BLOOD PRESSURE

2. Skin Dark red = prematurity Acrocyanosis = body pink, extremities blue normal during the 1st 24-48 hours of life Generalized mottling (cutis marmorata) RUDDY normal (stable) Grayish infection Jaundice 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 Types:

not routinely obtained except for suspicion of Coarctation of the Aorta. BP at birth: 80/48 At 10 days: 100/50

1. Physiologic Jaundice Icterus Neonatorum Causes: Hemolysis Decreased conversion of bilirubin to urobilirubin Decreased uptake of free bilirubin be hepatic cells *Begins from 2nd day 7th day = TERM 2nd day 10th day = PRE- TERM Breastfed babies have longer physiologic jaundice because human milk has PREGNANEDIOL which depresses the action of glucoronyl transferase (enzyme responsible for converting indirect bilirubin to direct bilirubin) 2. Pathologic Jaundice- before the first 24 hours of life Causes: Infection Hemolytic disorders Inability of the newborn to conjugate bilirubin Normal total serum bilirubin concentration = 15mg/dl Direct bilirubin = 1.7 Indirect bilirubin = 13.3 Most accurate method of assessing the presence of jaundice: Use natural light and blanch skin on the chest or tip of the nose. KERNICTERUS-Accumulation of bilirubin in the brain tissues SEIZURES MENTAL RETARDATION EXCHANGE TRANSFUSION Goal of treatment: to decrease the bilirubin levels Management: Bililight (Phototherapy) Nursing Care: Cover eyes with an opaque mask to prevent blindness. Maintain a distance of about 18-20 inches from source of light. Monitor V/S especially temp. Cover the genitalia to prevent PRIAPISM (continuous erection). Turning the baby q2hours. Hydration. MONGOLIAN SPOTS-bluish gray or dark nonelevated pigmentation area over the lower back and buttocks present at birth, primarily nonwhite, disappear at SCHOOL AGE BIRTHMARKS

 Telangiectatic nevi (stork bites) cluster of small, flat, red localized areas of capillary dilatation usually on eyelids, nose, nape of neck; can be blanched by the pressure of the finger; usually fade during infancy Nevus vasculosus (strawberry mark) raised, dermacated, dark red, rough-surfaced capillary hemangioma in dermal and subdural layers; grows rapidly for several months and then begins to fade; usually disappears by 7 y old Nevus flammeus (port wine stain) reddish, usually flat discoloration commonly on the face or neck; does not grow and does not fade Congenital nevus: Congenital nevomelanocytic nevus. Larger nevi are associated with a higher incidence of malignancy and patients should be referred to a dermatologist. Small lesions may be associated with a higher than normal risk of developing melanoma, but the incidence is unknown. To date, there are no uniformly accepted guidelines for treatment. VERNIX CASEOSA-White, cream-cheese-like substance that serves as a skin lubricant, usually noticeable on a newborn skin, prominently seen in the skin folds, at birth in a term neonate. LANUGO-Is the fine downy, hair that covers a newborns shoulder, back and upper arms Found also in the forehead and ears. The newborn of 37-39 wks has more lanugo than the 40th wks old infant. Post-mature infants have rarely have lanugo By age of 2 wks. It has disappear. DESQUAMATION-Within 24 hrs. of 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 is normal and needs no treatment. ERYTHEMA TOXICUM

The mark disappears in 1-2 days along with the edema that accompanies it. BECAUSE OF IMMATURITY OF CIRCULATION, AN INFANT WHO HAS BEEN LYING ON HIS SIDE WILL APPEAR RED ON THE DEPENDENT SIDE & PALE ON THE UPPER SIDE. TRANSITORY MOTTLING ON NBS SKIN WHEN IT IS EXPOSED TO COLD. Newborn sebaceous gland is immature. At least one pin-point white papule (a plugged or unopened sebaceous gland) can be found in the cheek or across the bridge of the nose of every newborn. Disappears by 2-4 wks of age as the sebaceous glands mature and drain. Parents should be instructed to avoid scratching or squeezing the papules to prevent secondary infection.

HARLEQUIN SIGN

CUTIS MARMORATA

MILIA

FORCEPS MARK

In most normal mature infants, newborn rash. It usually appears in the 1st to 4th day of life, but may appear up to 2 wks of age Also called Flea bite rash One of the chief characteristic of the rash is the lack of pattern. There may be a circular or linear contusion matching the rim of the blade of the forcep on the infants cheek.

3. HEAD ASSESSMENT Head is the largest part of the human body (1/4 of his total length); forehead is large and prominent; chin is receding when startled or crying. a. Symmetry of the Head b. Fontanelles 1.Anterior diamond shape; closes at 12-18 months; 34cm long/2-3 cm wide located at the junction of the 2 parietal bones and 2 fused frontal bones Suture lines should never appear widely separated. It indicates Hydrocephalus (abnormal accumulation of CSF in the cranium) 2.Posterior triangular in shape; located at the junction of the parietal bones and the occipital bones. Measures about 1 cm and closes by end of 2nd month. CRANIOSTENOSIS/CRANIOSYNOSTOSIS suture lines are prematurely close leading to mental retardation MOLDING Cephalhematoma-collection of blood under the periosteum of a cranial bone appearing 1-2 d; does not cross suture line; disappears in weeks to months Caput succedaneum localized soft swelling of the scalp often associated with a long and difficult birth; present at birth;

overrides the suture line, fluid is reabsorbed within hours to days after delivery CRANIOTABES-Localized softening of the cranial bones. the bone is so soft that the pressure of an examining finger can indent it It corrects itself without treatment after a few months It is probably caused by the pressure of the fetal skull against the mothers pelvic bone in utero. It is more common in 1st borne infants than in infant born later, because of the lower position of the fetal head in the pelvis during the last 2 weeks of pregnancy in Primiparous women. c. EYES Eyelids of equal size Temporarily gray or blue in color Cry tearlessly during first 3 months due to immature lacrimal ducts Cornea should be round and adult sized Eyes may appear cross-eyed (Strabismus) V.A. of 20/200 to 20/500 d. EARS Top of ear should align with the inner and outer canthus of the eye. If set of ears lower, there could be a kidney malformation or chromosomal defect (Trisomy 21 or Downs Syndrome or Mongoloid) Sense of Hearing highly developed in NB Preauricular skin tag: these represent remnants of the first branchial arch. Although they are often of little significance, they may be seen in serious malformations of branchial arch development involving multiple structures of the head and neck. Surgical removal may be indicated for cosmetic purposes. e. NOSE Note for marked flaring of alae nasi, indicative of airway obstruction Causes of obstruction: Secretions Anatomical defect: septal deviation Sense of smell least developed f. MOUTH Should open evenly when crying. If not, suspect Cranial Nerve VII Paralysis (Bells Palsy). Palate should be intact; no breaks on the lip = cleft palate; cleft lip

Epstein Pearls small round glistening cysts seen on palate and gums, due to extra load of maternal calcium If with tooth (NATAL TOOTH=not covered with gum membrane) should be extracted to prevent aspiration Oral thrush white gray patches usually on the tongue and sides of cheeks due to Candida albicans acquired during the passage of the baby through the birth canal of his mother who has untreated MONILIASIS; ORAL MONILIASIS. g. NECK Thyroid gland is not palpable. Appears soft and palpable and creased with skin folds Head should rotate freely on the neck and flex forward and back. If there is rigidity of the neck, suspect CONGENITAL TORTICOLLIS (injury to sternocleidomastoid muscle). In NB whose membranes were ruptured 24 hours before birth, nuchal rigidity suggests meningitis. h. CHEST As large as or smaller than the head Symmetrically expands (retraction indicates respiratory distress) Breasts may be engorged (due to maternal hormones) There could be passage of thin, transparent watery fluid known as WITCHS MILK. i. Abdomen Normally dome shaped; If scaphoid, suspect DIAPHRAGMATIC HERNIA (bowel sounds heard in the chest). Bowel sounds should be present within 1 hour after birth. j. EXTREMITIES Should be symmetric and of equal length Fingers and toes in equal count. Supernumery = POLYDACTYLY; fused or webbed = SYNDACTYLY Simean line single palmar crease = DOWNS SYNDROME Assymetrical movement of upper and lower extremities may indicate: ERB DUCHENE PARALYSIS Assess for congenital hip dislocation: Ortolanis Maneuver Observe for clubfoot deformities Bell's (facial nerve) Palsy: The prognosis for facial nerve palsies is excellent, and recovery usually occurs in the first

month. In the meantime, prevention of corneal drying is essential. k. SENSES Sight all newborns can see at birth although they cannot see objects past the visual midline (not until 6-8 weeks). The visual field is 20-22 cam or 9 inches. Hearing as soon as amniotic fluid has been absorbed, the newborn can already hear Taste as soon as secretions have been suctioned, newborns can already taste Smell as soon as the nose has been cleared of mucus and fluid, newborns can smell Touch the most developed of all the senses 4. CARDIOVASCULAR SYSTEM As the lung inflate for the 1st time, pressure decreases in the chest generally, and in the pulmonary artery specifically The decrease in pressure in the pulmonary artery plays a role in promoting the closure of the ductus arteriosus. As pressure in the left side of the heart from increased blood volume, the Foramen Ovale closes because of the pressure against the lip of the structure. Blood Values o 80-110 ml/kg of body weight or about 300 ml o High WBC at birth about 15,000 to 30,000 cells/mm3 Increased WBC count should not be taken as evidence of infection

The presence of fluid in the lungs eases the surface tension on alveolar walls and makes the 1st breath easier. Within 10 minutes after birth, newborn has establish a good residual volume. A baby born by CS does have much lung fluid expelled at birth as one born vaginally, so may have more difficulty establishing effective respiration (because of excessive fluid blocks air exchange space)

Blood Coagulation o Most newborn are born with a prolonged coagulation or Prothrombin time, because their blood levels of Vitamin K are lower than normal. o It takes 24 hrs. for flora to accumulate and vitamin K to be synthesized Increased pressure on the left side of the newborns heart results in: Closure of the foramen ovale Change of the ductus arteriosus into a mere ligament (ligamentum arteriosum) o Ductus venosus becomes ligamentum venosum Since no more blood goes through the umbilical vein and arteries, these blood vessels atrophy and degenerate
5. RESPIRATORY SYSTEM

6. GI SYSTEM Newborns stomach holds about 60-90 ml Has limited ability to digest fat and starch because the pancreatic enzymes, lipase and amylase, are deficient for the 1st few months of life. Because milk, the infants main diet for the 1st year is low in Vit. K, the intestinal synthesis is necessary for blood coagulation. 3 types of stools passed by NB: 1. Meconium greenish-blackish viscous; formed during fetal life from amniotic fluid, intestinal secretions and cells shed from mucosa; take note of time when meconium first passed (should be within 24 hours) 2. Transitional passed from 3rd to 10th day Milk stool Breast fed infant stool loose golden yellow in color with sweet odor; 2-3 times a day Bottle fed infant stool formed, pale yellow with a typical odor; usually passed 1-2x a day

Lack of passage of stool on first few days indicates an inborn error of metabolism. Ex., Cystic fibrosis, Hirschsprungs or Aganglionic Megacolon *An active wink reflex is a good sign of anal patency 7. URINARY SYSTEM The average newborn voids within 24 hrs after birth o Newborns who do not void within this time should be examined for the possibility of ureteral stenosis or absent kidneys or ureter A single voiding in a newborn is only about 15 ml The daily urinary output for the 1st 1-2 days is about 30-60 ml total. The 1st voiding may be pink or dusky because of uric acid crystals that were formed in the bladder in utero CONGENITAL MALFORMATIONS OF THE URINARY TRACT Epispadias - urethral opening on the dorsal surface of the penis Surgical correction HYPOSPADIA-Male urethral opening on the ventral surface of penis, or female urethral opening in vagina Surgical reconstruction 8. The GENITALS Female Genitalia May have swollen labia and may pass a slightly bloody vaginal discharge known as PSEUDOMENSTRUATION (due to maternal hormones) Male Genitalia Scrotum may be edematous due to maternal hormones. Foreskin should be retracted to test for PHIMOSIS (tight foreskin) Testes should be present: if undescended the condition is called CRYPTORCHIDISM and repair is called ORCHIOPEXY. Conditions for CRYPTORCHIDISM: Agenesis absence of an organ Ectopic testes testes cannot enter the scrotum because the opening of the scrotal sac is closed. Vas deferens or artery is too short to allow the testes to ascend. Hydrocoele accumulation of fluid around the testes is considered a normal finding Care of the penis o Uncircumcised do not force retraction of foreskin (complete separation of foreskin and glans penis takes

3-5 y); parents should be told to gently test for retraction occasionally during the bath, and when it has occurred, gently clean glans with soap and water o Circumcised (surgical removal of prepuce/foreskin) Ensure signed permission before procedure; provide comfort measures during and after procedure Postprocedure monitor for bleeding and voiding, Teach parents to clean area with warm water squeezed over penis and dry gently; a whitish yellow exudates is normal and should not be removed; if Plastibell is used, report to pediatrician if it has not fallen off in about 8 d 9. IMMUNE SYSTEM The newborn is prone to infection o Due to difficulty forming antibodies against invading antigen until they are about 2 mos. of age. o This inability to form antibodies early also is the reason that most immunization against childhood diseases are not given to infants younger than 2 mos. o Passive antibodies from the mother that have crossed the placenta. PASSIVE NATURAL IMMUNITY type of immunity transferred from mother to newborn Newborns have antibodies from the mother against poliomyelitis, diphtheria, tetanus, pertussis, rubella and measles (present in the infant for one year) but little or no immunity against chickenpox that is why chickenpox can be fatal in newborns. *Newborns have difficulty forming antibodies until 2 months of age (that is why immunizations are started at 2 months). 10. NEUROMUSCULAR SYSTEM o Reflexes Blink Reflex- to protect the eye from any object coming near it by rapid eyelid closure Rooting Reflex turns toward any object touching/stroking cheek/mouth, opens mouth, and sucks rhythmically when finger/nipple is inserted into mouth (usually disappears by 6 wks.)

 Sucking Reflex- when newborns lips are touched, the baby makes a sucking motion. It diminishes at about 6 mos of age Swallowing Reflex- food that reaches the posterior portion of the tongue is automatically swallowed. Extrusion Reflex- a newborn will extrude any substance that is placed in the anterior portion of the tongue. o Protective reflex prevents the swallowing of inedible substance o Disappears at 6 wks to 3 mos. Placing Reflex- similar to step-in-place Reflex, except it is elicited by touching the anterior surface of a newborns leg against the edge of a bassinet or table o A newborn will make a few quick lifting motions as if to step onto the table Palmar grasp pressure on palm elicits grasp (fades by 3-4 mo) Moro or Startle Reflex elicited by sudden disturbance in the infants immediate environment, body will stiffen, arms in tense extension followed by embrace gesture with thumb and index finger a c formation (disappears by 6 mo) Stepping (walk)-in-place reflex when held upright with one foot touching a flat surface, with alternating step (fades 4-5 mo) Babinskis sign stroking the sole of the foot from heel upward like an inverter J across ball of foot will cause all toes to fan (reverts to usual adult response by 12 mo) Landau reflex- a newborn who is held in a prone position with a hand underneath supporting the trunk should demonstrate some muscle tone 11. BACK On prone appears flat, (curves start to form when child learns to sit or stand) Note: for mass, hairy nodule and a dimple along axis. This may be indicative of Spina Bifida.

Fold down diapers so that cord does not get wet during voiding Dab rubbing alcohol (70%) once or twice a day Small pink granulating area may be seen on the day the cord falls off. If it remains moist for a week, advise mother to bring baby to the doctors clinic where cautery with silver nitrate stick will be done to speed healing Nutrition Recommended Daily Allowances Calories 120 cal/kg body weight (KBW)/day = 50-55 cal/lb body weight/day = more or less 380 cal/day Proteins 2.2 grams/KBW/day Fluids 160-200 cc/KBW/day = 2.5-3 oz/lb body weight/day = more or less 20 oz/day Vitamins Vitamins A, C and D are recommended for both bottle-fed and breastfed babies during entire first year of life.

Bathing maybe given anytime convenient for the parents as long as it is not within 30 minutes after a feeding because the increased handling during bathing can cause regurgitation. Sponge baths are done until the cord falls off (7th to the 14th day). Cord Care

Discharge Instructions

Common Health Problems 1. Constipation more common among bottle-fed infants Add more fluids or carbohydrates/sugar 2. Loose stools careful history should be taken; management depends on cause 3. Colic paroxysmal abdominal pain common in infants below three months of age Causes: Overfeeding , gas distention, Too much carbohydratesTense and unsure mother Management : Feed by self-demand. It is the best schedule because it meets the individual needs of the newborn 4. Spitting up due to poorly developed cardiac sphincter; more common among bottle-fed infants. Will disappear when coordination with swallowing is achieved and digestion improves.

Feed in upright position because gravity will aid in gastric emptying. Position on right side after feeding Bubble/burp more frequently

5. Diaper rash/Skin irritation maybe due to either poor hygiene or irritation from urine, feces and some laundry products 6. Miliaria (prickly heat/bungang araw) starch bath or Johnsons starch powder 7. Seborrheic dermatitis/cradle cap involves the sebaceous glands; due to poor hygiene. Management: apply mineral oil or Vaseline on the scalp at night before giving shampoo in the morning. 8. Occasional crossed eyes normal in many babies because the eye muscles of coordination have not yet fully developed; will disappear spontaneously Sleep pattern babies sleep 16-20 hours a day Expanded Program on Immunization Newborn Screening Act of 2004 REPUBLIC ACT NO. 9288 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 2. CONGENITAL ADRENAL HYPERPLASIA -inability to synthesize cortisol inc ACTH stimulate adrenal glands to enlarge inc androgen S/sx: musculinization, sexual precocity Mx: Steroids to decrease 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 converts galactose to glucose S/sx: wt loss, vomiting, hepatosplenomegaly, jaundice and cataract

Dx: Beutler test Tx: decrease lactose soy based formula regulate diet 5. PHENYLKETONURIA (PKU) - Deficient or absent phenylalanine hydroxylase w/c converts phenylalanine to tyrosine S/sx: mental retardation, musty odor of urine, blond hair, blue eyes Dx: Guthrie bld test Tx: decrease phenylalanine (Lofenalac) regulate diet