IMMEDIATE CARE OF THE NEWBORN BY: MRS. FLORENCIA T. MALDIA 1.

Establish and maintain patent airway Postural drainage Suction mouth first then nose not more than 10 seconds Stimulate crying 2. Prevent hypothermia Newborn utilizes non-shivering thermogenesis by fat (brown fat) breakdown to produce heat Cold stress causes metabolic acidosis and hypoglycemia Dry and wrap the baby immediately after delivery Place under drop lite or warmer 3. Apgar Scoring 1 minute AS determines the general condition at birth 5 minute AS determines how well the newborn adjust to extrauterine environment Interpretation: 0-3 needs immediate resuscitation 4-7 with good response to appropriate intervention but needs further suction 8-10 good general condition CRITERIA Heart Rate Respiratory Effort Muscle Tone Reflex Irritability Color Absent Absent Weak, flaccid No response Blue 0 100 Weak cry With some flexion Weak cry, grimace Extremities blue Body - pink 1 100 Good strong cry Well flexed extremities Good strong cry sneezes, coughs Pink 2

4. Assessment of gestational age Most accurate basis of gestational age is LMP Most accurate basis of prematurity and maturity is AOG

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CRITERIA Scalp hair Earlobe Breast tissue

PREMATURE Fine, fuzzy Soft, no cartilage 7 mm Male - few rugae, Undescended testes Female prominent clitoris and labia minora Upper 2/3

TERM Coarse, silky Stiff, with cartilages 7 mm Male full of rugae, descended, pendulous testes Sole covered with creases

Genitalia Sole creases

5. Identification of the newborn ID bands Foot prints 6. Measurements and weight HC = 33-35 CC = 31-33 AC = 31-33 L = 50-55 W = 6.0-7.5 Physiologic weight loss = 5-10% (6-10 oz) during the 1st 10 days of life 7. Routine care V/S: RR = 30-60/min diaphragmatic and abdominal, rapid and shallow, normal apnea not more than 10 sec., PR (apical pulse) = 120-140/min, BT taken rectally Oil bath Aseptic cord dressing Credes prophylaxis against Opthalmia neonatorum - 2 drops 1% silver nitrate at the mid conjuctiva or terramycin ophthalmic ointment applied from inner to outer cantus Vitamin K (1 mg aquamephyton) IM into the vastus lateralis to promote clotting or prevent bleeding. Intestinal flora required to synthesize vitamin K is absent in newborn NEWBORN ASSESSMENT SKIN Color normally red color of the skin because of increased concentration of RBCs and decreased subcutaneous fats, and blood vessels become visible Acrocyanosis body pink, extremities blue. Normal during the first 24 to 48 hours after birth Jaundice yellowish discoloration of the skin due to inability to conjugate bilirubin. In full term infant bilirubin level peaks on the 3rd day of life, and in the preterm infant bilirubin level peaks on the 6th to 10th day from birth.

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 Mongolian spots gray patches seen across the buttocks that consists of pigment cells (melanocytes) Lanugo fine downy hair that covers shoulder, back, and upper arms Desquamation drying of the newborns skin Milia unopened sebaceous glands found on the nose, chin, and cheeks; disappear spontaneously by 2 to 4 weeks HEAD Anterior fontanel closes 12-18 months Posterior fontanel closes 2-3 months Pulsating fontanel is normal Bulging, tensing fontanel sign of ICP Caput succedaneum Scalp edema Crosses the suture line Disappears 3-4 days Blood between periosteum and skull Confined to an individual bone Disappears after one week Craniosynostosis premature closure of the fontanels that leads to mental retardation.

Cephalhematoma

Craniotabes localized softening of the cranial bones. It can be indented by fingers. It is corrected even without treatment after few months EYES

Strabismus normally disappears at 6th month Purulent discharge on the 3rd to 4th day indicates Opthalmia neonatorum
EARS Top part of external ear in line with or higher than outer cantus of the eyes Low set ears may indicate DS or congenital anomaly in the kidney MOUTH Epstein pearl glistening cyst on the palate, which are due to excess Ca during intrauterine life Oral thrush white patches on the tongue and sides of cheeks due to C. Albicans CHEST Symmetrical Breast may be engorged and with witch milk ABDOMEN Liver, spleen and kidneys are palpable Normally dome shaped; scaphoid (boat-shaped) indicate diaphragmatic hernia Cord stump falls off at 7th day. Patency of the anus is confirmed with passage of meconium within the first 24 hours and ability to insert rectal thermometer Meconium greenish black, odorless first stool

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GENITALIA FEMALE

Breastfed golden yellow, mushy, more frequent (3 to 4 times a day) sweet-smelling Bottle-fed pale yellow, firm, less frequent (2-3 times a day) with more noticeable odor Colic onset is 2nd to 3rd week of life and disappears by the third month ANUS Patent, with passage of meconium within 24-48 hours

MALE

labia are swollen With psuedomenstruation

Scrotum may be edematous Phimosis - Tight foreskin indicate Cryptorchidism - Undescended testes Hypospadias urethral opening on the ventral side of the penis or below the glans penis. Repair is done between ages 6-18 months. Circumcision and repair are done at the same time Epispadias urethral opening on the dorsal side of the penis Hydrocele fluid in the scrotum Post circumcision (a) After plastic bell circumcision, plastic ring is left on the penis and falls off in about 5-7 days. Do not use A and D ointment (b) After Hogan circumcision with Gomco clamp, the penis will appear reddened with raw edges around it. Apply A and D ointment 4-6 times a day with each diaper change to keep the penis from adhering to the diaper and provide comfort (c) Check penis for bleeding. Normal small spotting of blood in diaper may occur in the first few hours to 24 hours

Upper Extremities Arms and legs are short and move symmetrically. Erb-Duchenne paralysis or brachial plexus paralysis Resulting from excessive traction of the neck The infant cannot abduct the arm at the shoulder The infant cannot externally rotate the arm or supinate the forearm Moro reflex on the involved side is absent. Management: Abduct the affected arm in external rotation position with the elbow flexed

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Polydactyly extra digits Syndactyly partial or complete fusion of two or more digits Amelia absence of a limb

Lower extremities No resistance when abducted and adducted No resistance when both legs are flexed onto the abdomen When both feet are placed on the flat surface and bend the knees, the knees should be at the same height Hip dislocation Assymetry of the gluteal, popliteal, and thigh folds Limitation in abduction of leg on the affected side Ortolanis sign audible clicking sound when abducting and externally rotating the hip on the affected side. Galeazzis sign or Allis sign apparent shortening of the femur; when feet are placed on flat surface and knees are bent, the knees are unequal. Trendelenburg gait Waddling gait and lordosis when the child begins to walk Management: Proper positioning legs slightly flexed and abducted. The child should be carried astride mothers hip Frejka pillow a pillow splint that maintains abduction of the legs Pavlik harness Hip spica cast from the waist to below the knee Bryants traction

Club foot the most common type is talipes equinovarus; the foot is fixed on plantar flexion (downward) and deviated medially (inward). It is managed by Denis Browne splint (a crossbar with shoes AUTOIMMUNE SYSTEM Passive natural immunity is the type of immunity transferred from the mother to the newborn Antibodies transferred from the mother to the newborn: IgA through breastfeeding, IgG through the placenta Antibodies present in the newborn for the first year of life transmitted by the mother - Diptheria - Tetanus - Measles - Mumps - Pertussis - Rubella - Poliomyelitis

SENSES are all functional at birth. The most developed of all is the sense of touch.

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GROWTH AND DEVELOPMENT Definition of terms Growth - refers to increase in size and weight Development - refers to increase in skills and complexity of functions and maturity.

Perinatology refers to care of the mother and the fetus during pregnancy, labor and delivery and during the first 28 days of life. Eugenics refers to the practice of the principles that will improve the hereditary qualities of the future generation PRINCIPLES OF GROWTH AND DEVELOPMENT 1. Cephalocaudal 2. Proximodistal 3. Simple to complex 4. Interdependent 5. Sequence or pattern of development is the same in all individuals 6. Rate of development is variable 7. Growth and development is influence by Nutrition Heredity Environment Diseases, endocrine dysfunction Culture GROWTH MONITORING WEIGHT Birth weight 6 months 12 months 2 years 5 years 10 years HEIGHT BH 6 months = 50 55 cm = BH + 1 in/month 6 7 lbs = BW x 2 = BW x 3 = BW x 4 = BW x 6 = BW x 10

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12 months More than 1 year 2 yrs old x 2 + 32 = 4 + 32 = 36 inches tall DENTITION

= BH + 1.5 in/month = age in yr. X 2 + 32 =HT (inch)

Eruption begins at 6 months Number of teeth = age in month minus 6 (example: 8 months 6 = 2 teeth) Age in month = No. of teeth + 6 ( 2 teeth + 6 = 8 months ) Complete temporary teeth at 2-21/2 years old Dental visit begins at age 2 years

NUTRITION (1) Initial feeding one oz. of sterile water to test if NB swallows without aspiration (2) Breast milk for at least one year. Breastfeeding begins anytime after delivery (3) 120 calories/KBW/day 3 kilos X 120 calories 360 calories per day 2-3 oz per feeding (20 cal/oz) 2-3 x 20 calories = 40-60 calories per feeding 360/40-60 calories = 6 9 feeding per day Frequency of feeding = every 3 4 hours (4) 20 cal/oz cows milk or breast milk - Babys stomach capacity has increased from 10 to 20 ml. at birth to approximately 200 ml at 4 months. The majority of the digestive processes began to function at about 3 to 4 months. At about 3 to 4 months children are able to force the tongue outward called extrusion reflex, is fading (5) Iron stores from birth are depleted at 4 months (6) Avoid honey or syrup in milk to prevent botulism (7) Never mix food or medication with formula (8) Introduce solid foods beginning 4 months 4 6 months rice cereals/grains to increase iron content of feeding 6 months yellow then green fruits and vegetable 9 months meat then egg Solid foods interval of 4 days to easily assess food reaction or sensitivity; most common reaction is eczema Avoid nuts, foods with seeds raisins and pop corn

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SLEEP AND REST PATTERN Dev. Level Infant Toddler Duration and Sleep Pattern 16 to 20 hr/day; 6 to 12 months with 12/night 12 to 14 hr/night Dawdles at bedtime May ask to sleep with bottle May rebel against going to sleep

Preschooler

10 to 12 hours/night Difficult falling asleep Fear of the dark May begin to have nightmares Nighttime waking

Schooler

8 to 12 hours/night Nightmares common Awakens early in morning Likes to stay up late

Adolescent

10 to 14 hours/night May complain of excessive fatigue

PLAY Purposes of play: 1. Education 2. Recreational 3. Social 4. Therapeutic Criteria for toy selection 1. Safety 2. Compatibility with childs age, experience, and developmental age 3. Usefulness

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Types of Play and Toys Dev. Level Infant Toddler Types of Play Solitary Parallel Types of Toys Rattles, stuffed toys, musical toys, crib gym, squeeze toys, metallic mirror, mobile, peek-a-boo, pat-a-cake Push and pull toys, rocking horse, swing and slide, pounding board, play telephone, puzzle with big few pieces Tricycle, bicycle, erector set, construction set, tool kit, dollhouses, trucks, cars, crayons, paint, scissors, blocks, puzzles. Play by the rule provides sense of belongingness (cooperative). Team play (game, sports) helps learn value of individual skills, team accomplishment and nature of accomplishment Board games, collections, books, cards Swimming, hiking, skating,

Preschooler

ive

Associat

Schooler

tive

competi

Greatest Fears

Infant Stranger anxiety begins at 6th month

Shows preference for parents, searches for parents with eyes Protest manifested by cries, clings to mother, reject contact with strangers Despair sad face, no interest in environment Can be distracted with talking and sucking opportunities

Toddler Separation anxiety most acute at 2 3 years old Protest manifested by screams, cling to parents, force parents to stay, cries, bite, kicks strangers Despair apathetic, withdrawn, tries to comfort self with rocking, head banging, thumb sucking Security object helps resolve separation anxiety Ritualistic behavior provides security in an inconsistent world Preschooler Body mutilation/castration and intrusive behavior (a) Believes that illness is punishment for bad behavior because of fantasies and active imagination (b) Views death as temporary or reversible (c) Explain the procedures using simple words

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Allow the child to touch and play instruments. Play encourages expression of feelings (e) Resist going to bed at night. Keep a night-lite on in the childs room, read him story and allow him to play in bed until he falls asleep help to resolve fear and phobia. (f) Normally, experiences nightmares Schooler Fear of replacement and displacement in school (a) Loss of privacy (b) Fear of body injury, pain and death (c) Bargain for postponement of painful or unpleasant procedure (d) Disturbed by separation from best friend, peers, family and school activities Adolescent altered body image (a) Threatens body image, disfigurement, loss of function, change in appearance (b) Resist change in lifestyle (activity limitation, dietary restrictions) (c) Fear of loss of control, independence and identity (d) Feels threatened by separation from friends, peer group (e) Feels isolated, lonely, rejected

(d)

Accidents and Mortality in Pediatric AGE First 28 days of life Age 1 year 19 Age 1-12 months DEATH Congenital anomalies Aspiration SIDS Accidents MVA ACCIDENT

PERSONALITY DEVELOPMENT THEORIES ERIK ERIKSON - Describes 8 stages psychosocial development - With positive and negative aspect in each stage - Crisis of each stage is resolved when new level of functioning is achieved at the end of each stage SIGMUND FREUD - Describes 5 stages of development - Different parts of the body serving as the focus of gratification of sexual drive at different stages JEAN PIAGET - Describes 4 stages of cognitive development - Child acquires sequentially predictable cognitive abilities

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ERIKSON INFANCY (0-1) INFANCY

FREUD (0-1) INFANCY

PIAGET (0-1)

- Trust vs. Mistrust - Trust develops through consistent maternal-child interaction, oral need gratification, relief from discomfort, warmth, touch, stimulation

- Sexuality arise in relation to bodily function and exploration of body parts through reflexes and motor skills (oral exploration) - Oral need gratification - Basically non-sexual

- Sensorimotor using reflexes and sensorimotor to interact with environment results to repetition of acts and imitative behavior - Object permanence the object continues to exist even not present in the senses TODDLER SENSORIMOTOR TO PRECONCEPTUAL (1-3)

TODDLER AUTONOMY VS. SHAME/DOUBT

(1-3)

TODDLER ANAL

(1-3)

- Sense of independence results to negativism and selfishness - Temper tantrums expression of frustration - Pounding board provides way for anger to be sublimated - Ritualistic behavior provides sense of security - To deal with negativism, reduce opportunities of a NO answer - Provide opportunities to choose - Ignore temper tantrums with safe environment - Discipline consistently, immediately, appropriately, friendly approach, acceptable limitation - Best intervention for misbehavior is time-out

- Bowel and bladder control is an act of gratification - Bowel training and control accomplished before bladder training and control Signs of readiness - Desire to please parents - Pleasure in imitating adult - Desire to develop autonomy and to master primitive impulses - Adequate motor development, including ability to sit, walk, and squat

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ERIKSON PRESCHOOLER INITIATIVE - Imitate adult - Balance between daring and caution - Initiate activities and enjoy accomplishment - To develop initiative, provide play materials, satisfy curiosity with patience and understanding, encourage socialization and independence with adult supervision (3-6)

FREUD PRESCHOOLER PHALLIC OEDIPAL - Gender identity - Explore body parts - Males with fear of castration - Females with penis envy - Sexual curiosity and masturbation provides gratification - Unconscious non-libidinal sexual attraction to parent of opposite sex (3-6)

PIAGET PRESCHOOLER PREOPERATIONAL - Magical thinking results to association of two unrelated events - Animistic thinking attributes life-like characteristic with inanimate object - Self-centered whatever they thinking and talking is automatically magically understood by others - Self-centeredness or egocentricity results to selfishness SCHOOLER CONCRETE - Inductive reasoning from specific to general - Logical thought, reasoning, and self-regulation begins to develop - Can relate to feelings and thought of others (6-12) (3-6)

SCHOOLER INDUSTRY

(6-12)

SCHOOLER 12) LATENCY

(6-

- Childrens sexual urges are submerged. They put their energies into acquiring skills and develop sense of industry and capacity for mastery of objects and concepts and accomplish goal.

- Childrens sexual urges are submerged and they put their energies into acquiring skills

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ADOLESCENT IDENTITY

(12-18)

ADOLESCENT 18) GENITAL

(12-

ADOLESCENT 18) FORMAL

(12-

- Establish identity based on peer approval and acceptance - Need to conform with peer group identity - Adjust to rapid growth and maturation - Stress related to family pressure dependency/independency, ambivalence

- Physiological (sexual) maturation leads to sexual identity, specific sexual behavior

- Abstract thinking - Deductive reasoning general to specific

PRINCIPLES OF GROWTH AND DEVELOPMENT 1. 2. 3. 4. 5. 6. 7. Cephalocaudal Proximodistal Simple to complex Interdependent Sequence or pattern of development is the same in all individuals Rate of development is variable Growth and development is influence by Nutrition Heredity Environment Diseases Culture

MOTOR, SOCIAL AND SPEECH DEVELOPMENT I. MOTOR SKILLS First 3 months grasping reflex 4 months Hands brought together at the midline Grasp object with both hands Brings object to mouth Turn to sides

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5 months - Rolls over 6 months - Holds bottle independently 7 months Transfers object from one hand to another Thumb finger grasp Grasps his feet and pulls them to mouth 9 months With good hand mouth coordination Neat pincer grasp Drink from cup 11 months - Can put objects in a container and remove them 2 years - Can turn pages; Build 6-7 blocks 3 years - Can do self-feeding completely; uses spoon effectively Build 9-10 blocks Unbutton the shirts Brushes teeth & combs hair with less supervision Draws figure (CIRCLE) 4 years Button the shirt Lacing the shoes Draws figure (SQUARE) Uses scissors 5 years - Drawing recognizable figure (TRIANGLE) - Tying the shoelace CEPHALOCAUDAL DEVELOPMENT Newborn complete head lag, no head control increases risk of SIDS 1month with head lag, no head control

2 months - Diminished head lag 3 months Complete disappearance of head log ------------------------------------------------------------------------------------3 months - Lifts head and head held erect, steady 4 months - Lifts chest Roll to side

5 months - Lifts abdomen Roll over ------------------------------------------------------------------------------------6 months - Sits with support; can be pulled from sitting to standing position 7 months - Sits leaning forward on his hands

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8 months - Sits steadily without support ------------------------------------------------------------------------------------------------------------------------------------------------------------------------9 months - Creeps and crawls ------------------------------------------------------------------------------------10 months - Pulls self up 11 months - Walks with support 12 months Walks with support; sits from standing position without assistance ------------------------------------------------------------------------------------15 months - Walks without support; Creeps upstairs but cant go down ------------------------------------------------------------------------------------18 months - Walks backward with broad based gait ------------------------------------------------------------------------------------2 years - Goes up and down, steps one at a time; Kick the ball forward ------------------------------------------------------------------------------------3 years - Can ascend steps with alternating feet; Rides a tricycle ------------------------------------------------------------------------------------4 years - skips, throwing the ball and catches a ball Hops on one feet, riding a tricycle ------------------------------------------------------------------------------------SPEECH AND SOCIAL DEVELOPMENT 2 3 4 6 months months months months Social smile Babbles and coos Laughs aloud, evidence of pleasure in social contact Smiling at the mirror Shows desire to be picked up Dada not specific, no meaning Understands simple gestures, waves bye-bye, Enjoys peak a boo Continue to imitate gestures Scolding elicits strong reaction Looks and follows objects in a book Mama, dada with meaning Drops object deliberately to marvel sound to gain attention 2 years 3 years Speech progresses from HOLOPHRASES (expressive words like up, go) to multi word like ma go. Uses 3 word phrases Vocabulary of 300 words

8 months 9 months 10 months

11 months

4 years

Vocabulary of 900 words Talks in 3-4 word sentences and speaks in short phrases Constantly asks questions 1,600 word vocabulary

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Daily Routine Care

Bathing - should be done after the cord falls off on the 7th to 14th day of life.
Sponge bath may be given before the cord fall off Cord care use Betadine or 70% alcohol in cord care and leave the cord uncovered to keep it dry. Keep the baby warm Types of feeding Natural feeding refers to breast feeding Complementary feeding is given in addition to breast-feeding. Supplementary feeding is given in place of the breast-feeding. Mixed feeding is bottle feeding and breast feeding Self demand feeding when the feeding schedule of the baby fits his individual needs Comparison of human milk and cows milk Human Milk Less (lactalbumin) More Less Less Soft, flocculent Alkaline More rapid digestion emptying Cows More (casein) Less More More Hard, large Acid Slow digestion and emptying

Protein Carbohydrates Fat Minerals Curd Reaction GIT

and

Cows milk needs to be diluted because of high protein and mineral contents. The kidneys become overwhelmed of high protein and mineral contents Both human milk and cows milk are sufficient in vitamins A and B complex but deficient in vitamins C and D. Weaning refers to substitution of breast milk with other forms of nourishment. Weaning begins when the baby is 6 months old.

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The most appropriate first food to add to the diet of exclusively breastfeed infant should be iron fortified Cereals (rice, oatmeal, barley) Yellow then green fruits and vegetables Meat then egg (egg is allergenic)

The new food to be introduced should not be mixed with formula The new food should be introduced one at a time with 4-7 days interval To assess food allergy or sensitivity The new food should be introduced gradually Other additional food supplements for the breastfeed infant - Fluoride if the water is not fluorinated - B12 if the mother is a strict vegetarian

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