NORMAL NEONATES

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1. UNIT 6 ASSESSESSMENT & MANAGEMENT OF NORMAL NEONATES By Dr. Anu Joykutty

2. TOPICS Normal Neonate Physiological adaptation, Initial & Daily assessment Essential newborn care, Thermal control, Breast feeding, prevention of infections Immunization Minor disorders of newborn and its management Levels of Neonatal care (level I, II, & III) At primary, secondary and tertiary levels Maintenance of Repots and Records

3. A healthy infant born at term b/w 38-42 wks should have average birth wt, cries immediately following birth, establishes independent rhythmic respiration & quickly adapts to the changed environment. HEALTHY NEWBORN

4. PHYSIOLOGICAL ADAPTATION RESPIRATORY ADAPTATION Initial breathing is probably the result of a reflex triggered by pressure changes, chilling, noise, light and other sensations related to the birth process. Process : The initial entry of air into the lungs is opposed by the surface tension of the fluid in fetal lungs and alveoli. The fetal lung fluid is removed by the pulmonary capillaries and lymphatic vessels & also removed during the normal forces of labour and delivery. As the chest emerges from the birth canal, fluid is squeezed from the lungs through the nose and mouth. After complete emergence of the neonates chest, a brisk recoil of the thorax occurs. Air enters the upper airway to replace the lost fluid.

5. In most cases an exaggerated respiratory reaction follows within 1 minute of birth, and the infant takes the first gasping breath and cries. Following the period of reactivity and after respirations are established, respirations are shallow and irregular, ranging from 30 to 60 breaths per minute Neonatal respiratory function is largely a matter of diaphragmatic contraction. The ribs of the infant articulate with the spine at a horizontal rather than a downward slope; consequently the rib cage cannot expand with inspiration as readily as an adults. The newborn infants chest and abdomen rise simultaneously with inspiration.

6. CARDIOVASCULAR ADAPTATION Fetal circulation ceases, and extrauterine circulation begins. Ductus arteriosus : Within the last 12 hrs of extra uterine life the shunt between the pulmonary artery and the aorta, constricts but anatomic closure takes more time; approximately 80% of these ducts are closed by the end of the third month Ductus venosus (vessel connecting the umbilical vein and inferior vena cava) constricts within 3 to 7 days of birth.

7. Foramen ovale

8. Hematopoietic system Hemoglobin concentration : 14 to 29 g/dl, Hematocri t : 43% to 63% The RBC count : 5.7 to 5.8 per mm WBC count : 10.000 to 30.000 per mm 3 is normal at birth. It increases to about 23,000 to 24,000 per mm 3 during the first day after birth. Normally 11,500 per mm 3 is maintained during the neonatal period Platelet count : 200,000 and 300,000 per mm 3 Cord blood samples may be used to identify the infants blood type and Rh status.

9. Thermoregulation Heat production : the infant produces only two thirds as much heat as an adult but loses twice as much heat per unit area. Large body surface area is partially compensated by the newborns usual position of flexion, which decreases the amount of surface area exposed to the environment. Subcutaneous fat : thin layer of s/c fat conserve body heat Non shivering thermogenesis production of heat is through metabolism of brown fat and by increased metabolic activity in the brain, heart, and liver.

10. Heat loss : in the newborn occurs in four ways: Conduction: the loss of heat from the body surface to cooler surfaces in direct contact. When admitted to the nursery, the newborn is placed in a warmed crib to minimize heat loss. Convection: the flow of heat from the body surface to cooler ambient air. so ambient temperatures are kept at 24 C and newborns are wrapped to protect them from the cold. Radiation: the loss of heat from the body surface to cooler solid surfaces not in direct contact but in relative proximity to each other. So the cribs and examining tables are placed away from outside windows. Evaporation: the loss of heat that occurs when a liquid is converted to a vapour . Evaporation occurs as a result of vaporization of moisture from the skin and is intensified by failure to dry the newborn directly after birth

11. FLUID & ELECTROLYTE IMBALANCE about 4o% of body weight of newborn is ECF Each day the newborn takes in and excrete roughly 600 to 700 ml of water which is 20% of total body fluid The GFR of a newborn is 30 to 50% of adults The decrease ability to excrete excessive sodium result in hypotonic urine compared with plasma. There is a higher concentration of sodium, phosphate, chloride, organic acid and lower concentration of bi carbonate ion Loss of fluid through urine, feces, lungs , increased metabolic rate and internal fluid intake results in a 5% to 10% loss of the birth weight which occurs over the first 3 to 5 days of life. The neonate should regain birth weight within 10 days. Stool water loss is estimated at 5 to 10 ml/kg/day.

12. Renal system Position : kidneys occupy a large portion of the posterior abdominal wall & bladder lies close to the anterior abdominal wall Volume : at birth 40ml will be in bladder. A term infants void 15 to 60 ml of urine per kg/day Colour : cloudy(1 st voiding),normally straw- coloured and odorless, Sometimes pink-tinged uric crystals present. Specific gravity :1.005 to 1.015. Frequency : 2 to 6 times during the 1 st and 2 nd days of life and from 5 to 25 times during the subsequent 24 hours..

13. GASTROINTESTINAL SYSTEM The full term newborn is capable of swallowing, digesting, metabolizing, absorbing proteins and simple carbohydrates, and emulsifying fats. the mucus membrane of the mouth is pink and moist. The hard and soft palate are intact. Small whitish area (Epstein pearls.) may be found on the gum margin and at the junction of hard and soft palate. The cheeks are full. Sucking behaviour is influenced by neuromuscular maturity newborn coordinates the breathing, sucking and swallowing reflexes necessary for oral feeding. Peristaltic activities in the esophagus is uncoordinated in the first few days of life. Teeth begin developing in utero with enamel formation continuing until about 10 years.

14. Normal colonic bacteria are established within the first week after birth. The normal intestine flora help synthesize vitamin K, folic acid and biotin. Bowel sounds can usually be heard shortly after birth. Stomach capacity varies from 30 to 90 ml, depending on size of the infant. The stomach empties intermittently, beginning a few minutes after the start of a feed and emptying 2 to 4 hours after feeding. The cardiac sphincter and nervous control of the stomach are immature, so some regurgitation may occur The infants ability to digest carbohydrates, fats and proteins is regulated by the presence of certain enzymes.

15. Changs in Stooling Patterns of Newborns MECONIUM Infant's first stool; composed of amniotic fluid and its constituents, intestinal secretions, shed mucosal cells, and possibly blood (ingested maternal blood or minor bleeding of alimentary tract vessels). Passage of meconium should occur within the first 24 to 48 hours, although it may be delayed up to 7 days in very low-birth-weight infants. TRANSITIONAL STOOLS Usually appear by third day after initiation of feeding; greenish brown to yellowish brown, thin, and less sticky than meconium; may contain some milk curds. MILK STOOL Usually appears by fourth day. In breastfed infants, stools are yellow to golden, are pasty in consistency, and have an odor similar to that of sour milk. In formula-fed infants, stools are pale yellow to light brown, are firmer in consistency, and have a more offensive odor .

16. MUSCULOSKELETAL CHANGES Bones ossification is not complete Muscles development is complete Moulding occurs during the labour . Neonate have 2 fontanelle : anterior and posterior

17. IMMUNOLOGICAL CHANGES 3 main immunoglobins present are: IgG (crosses placenta and gives immunity to some viral infections), IgA & IgM (do not cross placenta) Passive immunity is caused by breast milk ie colostrums.

18. REPRODUCTIVE SYSTEM CHANGES Ovaries and primordial cells are present in females No spermatogenesis started in male until puberty. Breast engorgement and milk secretion occur in males and females due to withdrawal of maternal hormones. Pseudo-menstruation occur in females

19. NEUROLOGICAL CHANGES This system is also not fully developed Brain growth occur after birth If not started then temperature instability and uncoordinate muscle movements occurs. The reflexes are: Blink, corneal, rooting, palmar grasp, traction, tonic neck, moro , stepping, plantar grasp, babinski .

20. NEWBORN ASSESSMENT Initial assessment with APGAR scoring. Transitional assessment during the periods of reactivity. Physical assessment – head to foot assessment

21. STAGES OF NEWBORN ASSESSMENT INITIAL ASSESSMENT WITH APGAR SCORE The most frequently used method to assess the newborns immediate adjustment to extra uterine life is the APGAR scoring system. It was developed by Virginia Apgar in 1952. the score is based on observation of heart rate, respiratory effort, muscle tone, reflex irritability and colour . Each item is given a score of 0,1 or 2. APGAR scoring is done at 1 min and 5 min after birth and is repeated every 5 minutes until the infants condition stabilizes

22. APGAR scoring SIGN 1 2 MUSCLE TONE (A) Flaccid/limp Some flexion of extremities Active movements/well flexed HEART RATE (P) Absent Slow,<100 >100 REFLEXES (G) No response Grimace Cry, sneeze COLOUR (A) Blue, pale Body pink, extremities blue Completely pink RESPIRATORY EFFORT (R) Absent Slow ,irregular, weak cry Good crying TOTAL Severe depression(0-3) Mild depression (4-7) No depression (7-10) INTERPRETATION 0-3: Severe distress/ asphyxia. 4-6: Moderate distress. 7-10: indicates absence of difficulty in adjusting to extrauterine life. APGAR score is affected by the degree of physiologic immaturity, infection, congenital malformations, maternal sedation or analgesia and neuromuscular disorders

23. TRANSITIONAL ASSESSMENT DURING THE PERIODS OF REACTIVITY Immediate after birth neonate tries to cope up with the extra uterine environment. Newborn during the first 24 hours gets various changes in the vital function such as heart rate, respiration, motor activity, color and bowel activity, these changes occur in an orderly manner. It is known as period of reactivity FIRST PERIOD OF REACTIVITY After birth during first 6-8 hours the newborn passes through the first period of reactivity. During first 30 minutes of period of reactivity the neonate is alert, active cries and has a strong sucking reflex. It is a good time for breast feeding and eye to eye contact with mother. Respiratory rate is over 60 beats per minute. Heart rate is 160 beats per minute. Bowel sound are heard and mucus secretions are increased. Exposure to the environment should be avoided to maintain the vital signs. SECOND PERIOD OF REACTIVITY It starts when neonates awakes from the first deep sleep. It is about 6-8 hours after birth. It lasts for about 2-5 hours. In this stage child is alert, active and responsive. Respiratory and heart rate will slightly increase. Passage of meconium commonly occurs during this stage THIRD PERIOD OF REACTIVITY All the vital come back to normal. No secretion from nose and mouth. Frequently child passes urine. Behavioral assessment should be done at this period. Childs and all other activities becomes normal

24. PHYSICAL ASSESSMENT – HEAD TO FOOT ASSESSMENT General Guidelines Keep warm during examination From general to specific Least disturbing first Document ALL abnormal findings & provide nursing care

25. GENERAL APPEARANCE

26. Posture Full term: Symmetric Face turned to side Flexed extremities Hands tightly fisted with thumb covered by the fingers Special Concerns Asymmetric Fractured clavicle or humerus Nerve injuries (Paralysis) Breech Presentation Knees and legs straightened or in FROG position

27. VITAL SIGNS

28. 051104 Neonatal Care 31 TEMPERATURE Site: Axillary NOT Rectal Duration: 3 mins Normal Range: 36.5 – 37.6 C Stabilizes within 8-12 hrs Monitor q 30 mins until stable for 2 hrs then q 8 hrs Nursing Considerations Keep dry and well-wrapped Keep away from cold objects or outside walls Perform procedures in warm, padded surface Keep room temperature warm

29. Heat Loss Mechanisms Convection Conduction Radiation Evaporation 051104 Neonatal Care 32

30. 051104 Neonatal Care 33 Pulse Awake: 120 – 160 bpm—120 – 140 bpm Asleep: 90-110 bpm Crying: 180 bpm Rhythm: irregular, immaturity of cardiac regulatory center in the medulla Duration: 1 full minute, not crying Site: Apical Nursing Considerations Keep warm Take HR for 1 full minute Listen for murmurs Palpate peripheral pulses Assess for cyanosis Observe for CP distress

31. 051104 Neonatal Care 34 Respiration Characteristics: Nasal breathers, gentle, quiet, rapid BUT shallow; may have short periods of apnea (<15 secs ) and irregular without cyanosis—periodic respirations Rate: 30-60 cpm Duration: 1 full minute Nursing Considerations Position on side Suction PRN Observe for respiratory distress Administer oxygen via hood PRN and as prescribed

32. Blood Pressure NOT routinely measured UNLESS in distress or CHD is suspected At birth: 80/46 mmHg* After birth: 65/41 mmHg* Using Doppler UTZ

33. ANTHROPOMETRIC MESUREMENTS

34. 051104 Neonatal Care 37 Body Measurements Weight : Average weight of an INDIAN child is 2500 gm. The baby loses up to 10% of the birth weight in the initial 3-4 days as it gets adjusted to the extrauterine environment, then slowly weight is regained by tenth day of life. Range of weight: 2500-4300 gms (5.5 to 9.5 lbs ) 70-75% TBW is water LBW = below 2500 gms ; regardless of AOG

35. 051104 Neonatal Care 38 Height/ Length: 45 to 55 cm (18-22 inches) Average:50 cm Techniques: using measuring tape/ Infantometer Supine with legs extended Crown to rump Head to heel

36. 051104 Neonatal Care 39 Head Circumference (HC) : 33 to 35cm (13-14 inches) Technique: using tape measure From the most prominent part of the occiput to just above the eyebrows 1/3 the size of an adult’s head Disproportionately LARGE for its body HC should be = or 2cm > CC

37. 051104 Neonatal Care 40 Chest Circumference (CC) : 30 to 33 cm (12-13 inches) Technique: using tape measure From the lower edge of the scapulas to directly over the nipple line anteriorly CC should be = or < 2 cm than HC

38. Abdominal circumference Measure below umbilicus (not usually measured unless specific indication) Abdomen enlargement after feeding because of lax abdominal muscles Same size as chest Enlarging abdomen between feedings (abdominal mass or blockage in intestinal tract)

39. SKIN COLOR

40. SKIN COLOR Check colour: Inspect and palpate. Under natural light, Inspect naked newborn in well-lit, warm area without drafts; natural daylight provides best lighting. Inspect newborn when quiet and when active Normal evidence: Velvety smooth and puffy esp. at the legs, dorsal aspects of hands & feet and in the scrotum or labia Generally pink Varying with ethnic origin, skin pigmentation beginning to deepen right after birth in basal layer of epidermis Check vernix caseosa : Whitish, cheesy, odourless substance. Variations are absent (post maturity), Excessive (prematurity), Yellow colour fetal anoxia >36 hr before birth, Rh or ABO incompatibility), Green colour (meconium), Odour (intrauterine infection) Acrocyanosis -cyanosis of extremities, especially if chilled Mottling -Transient discoloration of skin when exposed to decreased temperature. Resulting from vasoconstriction, lack of fat, and hypoxia Milia : “Baby pimples” .Pinpoint white papules on cheeks, across bridge of nose, or on chin . Caused by plugged sebaceous glands. Requires no treatment . Disappears in a few weeks  Birth marks : Mongolian spotting  : Dark bruise-like places most often found on buttocks and sacrum • African-American, Asian, Native American, or Hispanic descent • May disappear by school age Stork Bite (Telangiectatic Nevi) • Red spots found on back of neck, bridge of nose, and eyelids • Usually disappear spontaneously between first and second year of life Physiologic jaundice -Yellow discoloration of newborn skin and sclera caused by excessive bilirubin in the blood (greater than 5 mg/dl). Appears after 1st 24°.Peaks-days 2 to4. Common: 60% of newborns. Usually clears up by end of first week. Assess by blanching nose or sternum .Begins in head .Determine how far down it extends Erythema toxicum neonatorum  is a common skin rash affecting healthy newborn babies. It is not serious, does not cause the baby any harm and clears up without any treatment. Desquamation: Dryness/ peeling of the skin. Usually occurs after 24-36 hours . In post maturity

41. ACROCYANOSIS DESQUAMATION MILIA STORK BITE MONGOLIAN SPOT VERNIX CASEOSA JAUNDICE MOTTLING ERYTHEMA TOXICUM NEONATORUM

42. Abnormal Variations: Pathologic jaundice : Jaundice appears in the first 24 hours after birth .Total bilirubin level > 12 mg/dl  Port Wine Stain (Nevus Flammeus ): A type of vascular malformation. Varies in type and location. Will not disappear. Becomes a darker, more purplish colour with age Strawberry marks: Nevus Vasculosus or Capillary Hemangioma . Dark red, raised lobulated tumor in head, neck trunk & extremities. Fade after 7 to 9 years of age Edema on hands, feet; pitting over tibia Pallor : cardiovascular problem, CNS damage, blood dyscrasia , blood loss, twin-to-twin transfusion, nosocomial infection Cyanosis : central (bluish skin, tongue, lips due to low oxygen, hypothermia, infection, hypoglycemia, cardiopulmonary diseases ) & peripheral(bluish skin, pink tongue & lips due to drugs & heredity) Petechiae : clotting factor deficiency, infection Ecchymoses : hemorrhagic disease, traumatic birth

43. PORT WINE STAIN STRAWBERRY MARKS ECCHYMOSES PETECHIAE PALLOR

44. HEAD NORMAL FINDINGS Assess for symmetry, shape, swelling, movement: Soft, pliable, moves easily, with some molding (if NVD); round & well-shaped (if CS) Measure HC: 33-35cm(HC = or > CC) Hairs: Silky, single strands lying flat; growth pattern toward face and neck Fontanelles : “soft spot”: anterior (5 cm diamond)& posterior(triangle, smaller than anterior). Sutures: Overriding or separated Molding: Overlapping of skull bones due to compression during labor and delivery which disappears in few days Forceps Marks : U –shaped bruising usually on the cheeks after forcep delivery Reflex : Head lag Caput Succeedaneum : Swelling of soft tissues of the scalp in the presenting part, due to pressure, crosses the suture lines, resolves 3 days after birth. ABNORMAL FINDINGS HC: increased HC in hydrocephalus. Decreased HC in microcephaly. Hair: Fine, woolly (prematurity), Unusual swirls, patterns, hairline or coarse, brittle (endocrine or genetic disorders) Fontanelles :bulging (tumor, hemorrhage, infection), Large, flat, soft (malnutrition, hydrocephaly, retarded bone age, hypothyroidism), Depressed (dehydration), small(hyperthyroidism, microcephaly), Craniosynostosis(premature closure of the fontanelles ) Sutures: Widely spaced (hydrocephaly) Cephalhematoma : Sub- periosteal hemorrhage with collection blood due to rupture of capillaries as a result of trauma does not crossed suture lines resolves in several weeks

45. CAPUT SUCCEEDANEUM MOLDING FORCEPS MARKS DEPRESSED & BULGING FONTANELLES HYDROCEPHALY CEPHALHEMATOMA CRANIOSYNOSTOSIS

46. 051104 Neonatal Care 50 FACE & EARS Assess: Facial movement & symmetry Symmetry, size, shape and spacing of eyes, nose and ears                    

47. 051104 Neonatal Care 51 EYES Placement: space between each eyes is one third the distance between 2 outer canthus of eyes.  Symmetric in size, shape Discharge:  None  No tears. Tear formation begins @ 2-3 month Eyebrows:  Distinct (not connected in midline) Eyeballs : Both present and of equal size, both round, firm Eyeball movement: Random, jerky, uneven, focus possible briefly, following to midline Pupil :  Present, equal in size, reactive to light Sclera color: white sclera/ Slate gray, brown or dark blue/ Final eye color: after 6-12 months Reflex:  Blink & Glabellar , Doll’s eye

48. 051104 Neonatal Care 52 Abnormal findings: (+) transient strabismus due to weak EOM (+) Edema on eyelids r/t pressure during delivery or effects of medication Discharge: purulent(infection)  Agenesis or absence of one or both eyeballs Small eyeball size (rubella syndrome) Pink color of iris (albinism) Jaundiced sclera (hyperbilirubinemia) Nursing Considerations: Administer eye medication within 1 hr after birth to prevent Ophthalmia neonatorum DOC: Erythromycin 0.5% Tetracycline 1% Silver Nitrate 1% From inner to outer canthus of the eye ( conjunctival sac)

49. 051104 Neonatal Care 53                                                                                                                            

50. 051104 Neonatal Care 54 NOSE Assess: Observe shape, placement, patency, configuration of bridge of nose Small & narrow Flattened, midline Nasal breathers (+) Periodic sneezing Reactive to strong odors Abnormality: (+) Flaring = respiratory distress (+) Low nasal bridge = Down’s syndrome Cyanosis

51. 051104 Neonatal Care 55 EARS Assess: Observe size, placement on head, amount of cartilage, open auditory canal Soft and pliable; with firm cartilage Placement : Pinna should be at the level of outer canthus of the eye Hearing: Responses to voice and other sounds Abnormality : (+) Low set ears = renal or chromosomal abnormalities Prominent or protruding ears Deaf May be congested and hear well after few days

52. 051104 Neonatal Care 56 LOW SET EARS

53. 051104 Neonatal Care 57                                                   Accessory tragus: remnant of 1 st branchial arch Congenital preauricular sinus: ends blindly risk for infection

54. 051104 Neonatal Care 58 Mouth Pink, moist gums Intact soft & hard palates (+) Epstein’s pearls Uvula midline Tongue moves freely, symmetrical with short frenulum (+) Extrusion & Gag reflexes

55. 051104 Neonatal Care 59 Small mouth or large tongue = chromosomal problems (+) white patches on tongue or side of the cheek = Oral thrush