Pediatric Nursing

Nursing Care of a Newborn

I. Care of the Newborn

II. Assessment of the NB

III. Newborn Screening Test

IV. Theories of Growth & development

 Newborn or neonate – a baby in the
neonatal period (the first 28 days of
life)
Nursing Diagnoses
Ineffective airway clearance related to mucus in airway
Ineffective thermoregulation related to heat loss from
exposure in birthing room
Imbalanced nutrition, less than body requirements, related to
poor sucking reflex
Readiness for enhanced family coping related to birth of
planned infant
Health-seeking behaviors related to newborn needs

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The Average Newborn

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 Profile of a Newborn

X “All newborns look alike.” –

 Every child is unique. -

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 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

5. Waste elimination

6. Prevention of infection

7. Infant-parent relationship

8. Developmental care
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Immediate Care of the Newborn
I. Care of the Newborn at the D.R.
(EXISTING/ OLD PROTOCOL)

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 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
a. Ensure an open airway.
b. Do not hyperextend head
- place neonate supine
- head slightly extended

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• 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.

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 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 C.I. if there are signs of increased ICP:
head should be higher than the rest of the body
• Vomiting
• Bulging, tense fontanels
• Dilated scalp veins
• Abnormally large head
• Increased BP
• Decreased PR and RR
• Widening pulse pressure
• Shrill, high-pitched cry- late sign

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 NURSING ALERT

1. Always humidify to prevent drying of mucosa

2. Over dosage of 02 can lead to scarring of retina

leading to blindness (RETROLENTAL
FIBROFLASIA or
RETINOPATHY OF PREMATURITY)
 Establishment of extra uterine circulation
Circulation is initiated by lung expansion completed by cutting of cord

Cord is clamped

Placental gas exchange ceases

Transitory asphyxia
Cause : increased PaCo2
decreased Pa02 & pH

Stimulate : carotid & aortic chemoreceptors

Send impulses to the

respiratory center in the medulla

Stimulate respiration

Initiation of breathing
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 Establishment of extra uterine circulation

CIRCULATION
- several circulatory changes are necessary for successful
changes from FETAL circulation to NEONATAL
circulation.

A. Pulmonary Blood vessel – dilation, begins at first breath

results : lower pulmonary resistance
this allows the blood to freely circulate
through the lungs to be oxygenated.

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 Establishment of extra uterine circulation

B. Ductus Arteriosus

- reversal blood flow increased pressure in aorta and

increase O2 in the blood more blood flowing through the
pulmonary arteries for oxygenation.

- closure complete w/in 24H

- permanent : 3-4 weeks

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 Establishment of extra uterine circulation

C. Foramen Ovale

- closes within minutes after birth  because of the higher

pressure in the LA than in the RA increase blood flow in
the lungs  decreases pressure in the RA the return of
blood from the lungs increases the pressure in the LA
– Closure : permanent approximately 3 months
– Failure to close becomes ASD

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 Establishment of extra uterine circulation

D. Ductus Venosus

- cord clamped blood ceases flowing from umbilical vein

to ductus venosus and into IVC blood now flows through
the LIVER and is filtered as in adult circulation

Obliterates : becomes ligamentum venosum at 2 months

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CONTROL OF BODY TEMPERATURE

Goal : to maintain not < 97.7 F (36.5 C)

NB prone to cold stress (hypothermia)
NB not capable of shivering
NB born wet
 CONTROL OF BODY TEMPERATURE

Effects of Hypothermia
 Hypoglycemia
 Metabolic acidosis
 Maintain Appropriate Body Temperature

*Blot dry/ Rub dry the infant.

1. Wrap the newborn immediately

2. Wrap him warmly
3. Put him under a droplight/ radiant warmer
4. Kangaroo care

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 Warmth

• At birth, the newborn must begin thermoregulation

(maintenance of body temperature).

3 Factors :
• Heat production
• Heat retention
• Heat loss

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 1. Heat Production

The newborn produces heat Thermogenesis – through

• general metabolism
• muscular activity
• nonshivering thermogenesis (unique to the newborn)

Newborns rarely shiver as adults do to increase heat production.

Shivering in newborns indicates that the metabolic rate has
already doubled.

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 Infant in a cool environment
requires more heat
metabolic rate increases
producing more heat

– Newborn may cry and have muscular activity when cold,

but there is no voluntary control of muscular activity.

– if the newborn’s temperature is not adequately raised

through increased metabolism, nonshivering thermogenesis
: the metabolism of brown fat begins.

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 Non Shivering Thermogenesis

- the metabolism of brown fat

Brown fat
- special tissue/ fat found only in newborns
- appears at about 26-30 wks AOG and increases until 2-5 wks of
age
- highly vascularized giving it a brown color
- oxidized to produce or conserve heat
- located at the back of the neck, intrascapular region, thorax,
around the kidneys and adrenals, in the axillae, around the
heart and abdominal aorta and perineal area

• Once the brown fat has been metabolized, the infant no longer
has this method of heat production available.
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 2. Heat Retention

Newborns retain heat by staying in a flexed position.

- reduces the area of skin exposed to the environmental

temperature, thus decreasing
heat loss
- peripheral vasoconstriction retains heat

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 Conservation of Heat

1.Brown fat

2. kangaroo care – placing the newborn against the

mother’s skin and then covering the newborn helps to transfer
heat from the mother to the newborn, thus, conserving heat

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 REWARMING THE BABY SKIN-SKIN
• Before rewarming remove the baby’s cold clothing
• Place the newborn skin-skin on the mother’s chest dressed in a
rewarmed shirt open at the front, a diaper, hat and socks.
• Check the temperature every hour until normal.
• Keep the baby with the mother until the baby’s body
temperature is in normal range
• If baby is small, encourage the mother to keep the baby in
skin-skin contact for as long as possible, day and night
• Be sure the temperature of the room where rewarming takes
place is at least 25C.
• If the baby’s temp is not 36.5C or more after 2 Hrs of
rewarming, reassess the baby.
• If referral is needed, keep the baby in skin-skin contact or
another person on transport.

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 3. Heat Loss

Newborn
- thin skin with blood vessels close to the surface and
little subcutaneous fat to prevent heat l oss

Cold Stress - excessive heat loss

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 increased metabolism

significant increase in need for oxygen

newborn may experience hypoxia

There may not be enough oxygen for the metabolic rate to

increase, and the newborn will not be able to maintain body
temperature.

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 Effects of Cold Stress (temp<36.5)

1. Metabolic Acidosis
- increased BMR, anaerobic glycolysis,
increased acid production, metabolic acidosis

2. Hypoglycemia
- increased energy requirement to produce heat
- glucose necessary for increased metabolism is made
available when glycogen stores are converted to glucose
- if the glycogen is depleted, hypoglycemia results

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 4 MECHANISMS OF HEAT LOSS

1. Convection - flow of heat from the newborn’s body surface to

cooler surrounding air
2. Radiation - transfer of body heat to cooler solid object not in
contact with the baby
3. Conduction - transfer of body heat to cooler solid object in
contact with the baby
4. Evaporation -loss of heat through conversion of liquid to vapor

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 4 MECHANISMS OF HEAT LOSS

• Convection

• Radiation

• Conduction

• Evaporation

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 Convection
Loss of heat by the movement of air

EX: air current from the open door or windows, air

conditioning or from people moving around increases
heat loss

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 Radiation
Loss of heat by transfer to cooler object nearby,
but not through direct contact

EX: an infant placed near a cold window loses

heat by radiation to the sides of the crib and
the window

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 Conduction
Loss of heat by direct contact with cooler object:

EX: newborn touched by cold hands or cold

stethoscope newborn placed on a cold surface such
as Scale

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 Evaporation

Loss of heat when water is changed to vapor

EX: When the wet body dries, heat is lost

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 Other Causes of Heat Loss

1. insulation in newborn is not effective

(little subcutaneous fat )
2. shivering is not present

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Immediate Assessment
of the Newborn

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Assessment for Well-being

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 APGAR SCORE

0 1 2
Appearan Blue/Pal Acrocyanosi Pink;
ce e s Ruddy
Pulse Absent < 100 > 100
Grimace None Weak cry Good cry
Activity Flaccid Some ext Flex/ext
Respiratio Absent <30 >60
n

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 APGAR SCORE

0 1 2
Appearance Blue/Pale Acrocyanosis Pink; Ruddy
(Body color)

Pulse Absent < 100 > 100

(apical)

Grimace None Weak cry Good cry

(reflex activity)

Activity Flaccid Some flexion Well flexed

(muscle tone) Flex/ext
Respiration Absent <30 >60
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 A ppearance (color) – least important
P ulse rate - most important
G rimace (reflex activity); irritability
A ctivity (muscle tone)
R espiration

Per parameter
*Lowest individual score is 0.
*Highest individual score is 2.

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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 neonate’s adjustment to extrauterine

life

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   Apgar Scoring System

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

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Silvermann Anderson Scoring
(Respiratory Distress)

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 Silverman Anderson Scoring
(Respiratory Distress)

Assessment tool determines respiration of baby

Scoring : 0-3 Normal / slight distress

4-7 moderate RDS
7-10 severe RDS
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 Grading of Neonatal Respiratory Distress
(Silvermann Anderson)
Feature 0 1 2
observed
1.Chest synchronized lag seesaw
movement
2.Intercostal None just visible marked
retractions

3.Xiphoid none just visible marked

retraction
4.Nares none minimal marked
dilatation
5.Expiratory none audible by audible by
grunt stethoscope Unaided ear
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 Grading of Neonatal Respiratory Distress
(Silvermann Anderson)

  0: No respiratory distress
1 -3: slight distress
4-6: moderate distress
  7-10: seriously distressed !!!

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Congenital Anomalies
1. Choanal Atresia - a complete blockage or severe
narrowing of the nasal airway at the posterior
nares
2. Tracheobronchial fistula - there is a fistula
between the trachea and the distal portion of
the esophagus
3. Cleft lip and cleft palate

Substances
1. drugs
2. smoking
3. alcohol
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How will you know my age
if my mommy doesn’t know
her LMP?
 Assessment of GESTATIONAL AGE
It is determined in the first 4 hours after birth so that age
related problems can be identified and appropriate care
can be initiated.

Second assessment is done within 24 hours.

New BALLARD Score is the most commonly used tool
It has 2 elements:
External physical characteristics
Neuromuscular maturity
 Dubowitz/ Ballard (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
– Appropriate Gestational Age (AGA) – BW within 10-90th
percentile
IUGR - Rate of growth does not meet expected pattern - growth
restriction

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 Neuromuscular maturity
1. Posture: With the infant supine and quiet, score as follows:
Arms and legs extended = 0
Slight or moderate flexion of hips and knees = 1
Moderate to strong flexion of hips and knees = 2
Legs flexed and abducted, arms slightly flexed = 3
Full flexion of arms and legs = 4

2. Square Window: Flex the hand at the wrist. Exert pressure sufficient to
get as much flexion as possible. The angle between the hypothenar
eminence and the anterior aspect of the forearm is measured and
scored:
>90 degrees = -1
90 degrees = 0
60 degrees = 1
45 degrees = 2
30 degrees = 3
0 degrees = 4

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3. Arm Recoil: With the infant supine, fully flex the forearm for 5
seconds, then fully extend by pulling the hands and release. Score the
reaction:
Remains extended 180 degrees, or random movements = 0
Minimal flexion, 140-180 degrees = 1
Small amount of flexion, 110-140 degrees = 2
Moderate flexion, 90-100 degrees = 3
Brisk return to full flexion, <90 degrees = 4

4. Popliteal Angle: With the infant supine and the pelvis flat on the
examining surface, the leg is flexed on the thigh and the thigh fully
flexed with the use of one hand. With the other hand the leg is then
extended and the angled scored:
180 degrees = -1
160 degrees = 0
140 degrees = 1
120 degrees = 2
100 degrees = 3
90 degrees = 4
<90 degrees = 5
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5. Scarf Sign: With the infant supine, take the infant's hand and draw it
across the neck and as far across the opposite shoulder as possible.
Assistance to the elbow is permissible by lifting it across the body.
Score according to the location of the elbow:
Elbow reaches or nears level of opposite shoulder = -1
Elbow crosses opposite anterior axillary line = 0
Elbow reaches opposite anterior axillary line = 1
Elbow at midline = 2
Elbow does not reach midline = 3
Elbow does not cross proximate axillary line = 4

6. Heel to Ear: With the infant supine, hold the infant's foot with one
hand and move it as near to the head as possible without forcing it.
Keep the pelvis flat on the examining surface. Score as shown in the
diagram above.
 

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 Gestational Assessment (Dubowitz)
Finding 0-36 37-38 39 and
over
Sole creases Anterior Occasional Sole
transverse creases in covered w/
crease ant 2/3 creases
Breast nodule diameter 2 4 7
(mm)
Scalp hair Fine and Fine and Coarse and
fuzzy fuzzy silky
Ear lobe Pliable, no Some Stiffened
cartilage cartilage by thick
cartilage
Scrotum Testes pendulous,
empty, few descended. full
Testes and scrotum rugae rugae scrotum,
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External physical
PEDIATRIC characteristics
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HIGH-RISK INFANT
 PRETERM newborn

• born before 37 weeks of gestation

• Weight usually less than 2500 g ( 5 ½ lbs)

• Primary concern : immaturity of all body systems

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 PRETERM newborn
• CAUSES:
– Maternal factor: age, smoking , poor nutrition, placental
problems, preeclampsia/ eclampsia
– Fetal Factor : multiple pregnancy, intrauterine growth
retardation
• SEVERITY :
– The earlier the infant is born, the greater the chance of
complication.
• COMPLICATIONs:
1. Respiratory distress syndrome
2. Thermoregulatory problem
3. Conservation of energy
4. Susceptibility to Infection
5. Hemorrhage
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 PE

1. Skin and subcutaneous tissue -thin, transparent

2. Increased lanugo
3. Decreased plantar creases
4. Breast bud scarcely felt
5. Pinna flat and shapeless
6. Scrotum not pigmented
7. Testes not descended
8. Labia majora widely separated

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 4 mL/kg/dose

PRETERM newborn
• Assessment :
1. Respiratory System:
Insufficient surfactant
Apneic episodes
Retraction, nasal flaring, grunting, seesaw pattern of
breathing, cyanosis
Increased respiratory rate
2. Thermoregulation: body temperature fluctuates easily
( less muscle & fat )
3.NUTRITIONAL status :
Poor sucking and swallowing reflex
Poor gag and cough reflexes

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 PRETERM newborn
• Assessment :
4. Skin : lacks subcutaneous fat ; reddened; translucent
5.Drainage from umbilicus/eye
6.Cardiovascular:
Petecchiae caused by fragile capillaries and prolonged
prothrombin time
Increased bleeding at injection site
7. Neuromuscular:
Poor muscle tone
Weak reflexes
Weak , feeble cry

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 NURSING INTERVENTIONS

1. Maintain respiration at < 60/minute, check q1-2H

2. Administer 02 as ordered : check concentration q 2H to
avoid ( retrolental fibroplasia ) while providing oxygenation
3. Auscultate breath sounds to assess lung expansion
4. Encourage breathing with gentle rubbing of back and feet
5. Suction as needed
6. Reposition q1-2H for maximum lung expansion and
prevention of exhaustion
7. Monitor blood gases and electrolytes

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 NURSING INTERVENTIONS
8. Maintain thermoneutral body temperature  prevent cold
stress
9. Maintain appropriate humidity level
10. Monitor for signs of infection: little Ab production and
decreased resistance
11. Feed according to abilities
12. Monitor sucking reflex:
* poor – gavage feeding
13. Use “preemie” nipple if bottle feeding
14. Monitor I&O, wt gain or loss
* easily dehydrated with poor electrolyte balance
15. Monitor hypoglycemia & hyperbilirubinemia
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 NURSING INTERVENTIONS
16. Handle with care : organize care to minimize disturbance
17. Provide skin care with special attention to cleanliness and
careful positioning to prevent breakdown
18. Monitor heart rate and pattern q1-2H : listen to apical for 1
full minute
19. Monitor potential bleeding sites: lowered clotting factor
20. Monitor over-all growth and development of infant, check
weight, length and HC
21. Provide complete tactile stimulation when caring for or
feeding infant
22.Provide complete explanation for parents
23.Encourage parental involvement in infant care

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 Hypoglycemia

- <40 mg/100 ml
- dependent on maternal supply
- Birth, continue to produce insulin
S/sx: limpness, jitteriness, apnea, twitching and high
pitched cry
CX: mental retardation
Tx: early feeding
D10W
Nsg: monitor blood glucose level

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 POST-TERM

• Born after 42 wks of gestation

• Assessment :
– Hypoglycemia
– Classic sign : Old man’s face
– Desquamation – peeling of skin, dry,cracked almost leather
like skin
– Long brittle finger nail (fingernails grown well beyond the
end of fingertips)
– Wide & alert eyes
– Meconium staining possibly present
– absence of vernix caseosa
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 Post-term (>42 weeks)

• INTERVENTIONS:
– Provide normal newborn care
– Maintain temp
– Monitor for meconium aspiration

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• Complications:
1. may develop polycythemia (oxygenation)
2. hypoglycemia

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 IDENTIFICATION
(Existing/ Old Protocol)

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Proper Identification

– done in D.R. before being brought to the Nursery

a.    Footprints – most reliable 

b.    ID bands – ankle, wrist

c. Birthmarks

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• Ensure newborn’s proper identification
• Footprint newborn and fingerprint mother on
identification sheet per agency policies and
procedures
• Place matching identification bracelets on
mother and newborn.
• REMEMBER! ID band must be checked and
compared to the mother’s band each time the
baby is brought into the mother’s room.

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 Immediate Care
of the Newborn in the Nursery
(Existing/ Old Protocol)

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* Note that ID bands of mother and baby are matched.

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 Special Initial Care
1. Initial bath – best done with temp of NB is stable or at least
37oC
– Water bath – 98-100 F or 37-38 C
– Water with non-alkaline soap

– Oil – for vernix caseosa

– Antimicrobial solution – most preferred in NB if mother
has infection in the vaginal canal.
a. Trichomoniasis
b. Candidiasis
c. Chlamydia
d. Gonorrhea
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 First bath

• Complete bath within an hour after birth to remove vernix

caseosa
• For the next 10 days to 2 weeks – sponge bath.
• NB are not generally given tub bath until the cord has fallen
off and healing is complete
• Nurse giving the first bath to NB must wear gloves to comply
with standard precautions regarding contact with blood or
body fluids

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2.Taking the Temperature

* Maintain temperature to prevent cold stress

* Use Rectal route

* Meconium - 24-48 hrs

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 BATHING

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 3. Initial Cord dressing

• Inspect for A .V. A.

• Done with strict aseptic technique practice
• Apply cord clamp to prevent bleeding
• Application of antiseptic solution
– Povidone iodine
– 70% alcohol
to prevent Tetanus Neonatorum and Omphalitis
(streptococcal and staphylococcal infections)

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Initial Cord Dressing

CORD: 2 A + 1 V
*Practice aseptic technique

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
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 7-10 days
Will fall-off

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 4. Crede’s prophylaxis
• Preventive or prophylactic treatment against
OPHTHALMIA NEONATORUM - acquired during
passage to the birth canal

• Gonorrheal Conjunctivitis (Neisseria gonorrhea)

causes blindness if not treated. Infection can be
acquired during delivery from a mother with
untreated gonorrhea.

• Medications such as :
– Eye ointment : Terramycin , Gentamycin ,
Erythromycin , Chloramphenicol .
– Eye drop : Silver Nitrate 1% but this causes
CHEMICAL CONJUNCTIVITIS

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CREDE’S PROPHYLAXIS

Ophthalmic drops –
BEFORE: Silver Nitrate or AgNO3 1% 1-2 drops
1-2 gtts into the lower conjunctival sac

AT PRESENT:
Ointment – inner to outer canthus
Terramycin
Gentamycin
Chloramphenicol
Erythromycin – drug of choice of
Chlamydial Trachomatis
Chemical Conjunctivitis- usually develops in 3-4
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Eye / Crede’s prophylaxis

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 Erythromycin

- Pull eyelids downward

- 0.5-1 cm
- Inner to outer canthus
- Wipe excess away

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 5. Vitamin K Injection

• To prevent bleeding because of decreased

Vit K synthesis due to sterile GIT
• Facilitates production of clotting factor

• Medications:
– Phytonadione – Aquamephyton
– Phytomenadione – Konakion

– DOSE : Fullterm : 1 mg = 0.1 ml

Preterm : 0.5 mg = 0.05 ml
• ROUTE : IM lateral anterior thigh (Vastus lateralis)
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6. Take anthropometric measurements
7. Initial feeding
8. Physical assessment

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INTAKE OF ADEQUATE NOURISHMENT
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

bottlefed and breastfed babies during entire first year of
life.
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• NB stomach Capacity is only 20 ml (30ml= 1 0z)

• 7 days old – 60-90 ml ( can consume 2-3 0z )

• Gastric capacity = age in months + 2

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CRITERIA FOR INITIATING FEEDING
1. no history of excessive oral secretion
2. non-distended, soft abdomen
3. clinically stable
4. RR < 60 CPM

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Initial Feeding

1-6 hours after birth

CS : BF after 4 H
NSD : ASAP

1 oz of sterile water

Subsequent feeding – by demand

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• May breastfeed immediately after birth
– Philippine Milk Code EO 51 : Promote breastfeeding
– Rooming-in Act of 1992 RA 7600 : promotes breastfeeding
and requires immediate rooming-in of the newborn

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 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
8. Breastfeed baby has a higher IQ
9. Antibodies to E. coli
10. Anti-staphylococcus factor
11. decreased incidence of dental caries
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 BREASTFEEDING
• Emphasize the importance of exclusive
breastfeeding on demand for the first 6 months
of life.

• EXPRESSED MILK SHELF LIFE

Expressed milk Consume w/in 6H

Fresh frozen expressed Not consumed within the
milk next 24 H ( lasts 48H)
Refrigerated Consumed within 24H

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 Differences Between Human and Cow’s Milk

NUTRIENTS HUMAN MILK COW’S MILK

CHON 8% 20%
Fats 50% 50%
Carbohydrates 42% 30%

Na 7 mEq/l 25 meq/l
K 14 mEq/l 36 mEq/l
Ca 12 mEq/l 61 mEq/l
Phosphorus 9 mEq/l 53 mEq/l
Cl 12 mEq/l 34 mEq/l
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Nutrients Human milk Cows milk
Fe 0.5 0.5
Linoleic acid (+) (-)
Vit D 22 14
Vit A 1898 1025
Vit C 43 11
Vit K 15 60

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• Contraindications of breastfeeding:
1. an infant with galactosemia (can’t digest lactose
in milk)
2. herpes lesion on a mother’s nipple
3. maternal diet is nutrient restricted, preventing
quality milk production
4. maternal medication inappropriate for feeding
5. maternal exposure to radioactive compounds

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• Advantages of breastfeeding : to the baby
1. contains secretory immunoglobulins A
2.contain lactoferrin ( iron-binding chon in breast milk that
interferes with growth of pathogenic bacteria
3. contains antibodies
4. reduces incidence of diarrhrea
( presence of L.Bifidus interferes with colonization of
pathogenic bacteria in the GIT)
5.contains high amount of mineral and electrolytes
6. contains more linoleic acid ( essential fatty acid for skin
integrity and less Na,K,Ca and phosporous)

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Advantages of breastfeeding : to mother
1. serves as protective function in preventing breast cancer
2.release of oxytocin from the post. Pit. Gland aids in uterine
involution
3. successful breastfeeding can have an empowering effect, skill
only women can master
4.breastfeeding reduces the cost and preparation time
5.provides an excellent opportunity to enhance true symbolic
bonding between mother and child

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 BREASTFEEDING BOTTLEFEEDING
•Non-allergenic •Father or others may feed
•Meet infant ‘s specific nutritional infant day or night
needs •Feed less frequently (3-4H)
A •Immunologic properties help prevent •Amount of milk taken at
D infection each feeding known
V •Easily digested
A •Constipation unlikely
N •Overfeeding less likely
T •No formula or bottles to buy
A •No formula and bottle to prepare
G •Oxytocin release help involution
E •Mother more likely to eat well balance
S diet
•May help with mother’s weight loss
•Enhances mother/infant attachment
through skin to skin contact
•Frozen -20c (6 mos)
•Refrigerated 4c ( 24 H)

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 BREASTFEEDING BOTTLEFEEDING
•Feed more frequently (2-3 H) •Expense of formula, bottles
•More frequent diaper changes •Washing bottles
D
•Amount of milk taken at each feeding •Fixing and refrigerating
I
unknown formula
S •Medications taken by mother present •Carrying bottles on outings
A in milk •May cause constipation
D •Discomfort of som mothers to nurse in
V public
A •Expense of pumping and storing milk
N for periods when mother is unavailable
T ( such as work)
A
G
E
S

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 BREASTFEEDING
Health teaching:
1. Proper hygiene
2. Best position - upright sitting
3. Stimulate & evaluate feeding reflexes
1. Rooting
2. Sucking
3. Extrusion
Criteria for effective sucking
4. baby’s mouth is hiked up to areola
5. Mom experiences after pain
6. Other nipple is flowing with milk
 Breastfeeding
• Position for feeding: Teach the mother to
-Make sure the baby’s head and body are in
straight line
– Make sure the baby is facing the breast,
with the nose opposite the mothers nipple
– Hold the baby ‘s body close to her body
– Cradle hold with infant’s head in the bend
of the mother’s elbow and arm supporting
the infant’s body
– OTHERS:
• Football hold
• Side lying position
• Across lap

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 Breastfeeding
HELP THE BABY TO ATTACH
– Latching on
• TEACH THE MOTHER TO
– Touch the baby’s lips with her nipple
– Wait until the baby’s mouth is opened wide, then
position the baby’s mouth onto her breast so that the
Cradling baby’s mouth is well around the areola.
• SIGN OF GOOD ATTACHMENT:
– Slow , deep sucks with occasional pauses
– Unsatisfactory: try again then reassess
– Breast engorged : express small amount of BM
before starting to breastfeed to soften the nipple area
and facilitate easier attachment

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 Breastfeeding

• Length of feeding
– Varies with each mother /infant unit

Cradling • BURPING-
– ALL INFANTS REQUIRE BURPING
– TO EXPEL THE AIR SWALLOWED
WHEN THE INFANT SUCKS
– SOME INFANT SWALLOW MORE AIR
THAN OTHERS AND REQUIRE MORE
FREQUENT BURPING

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 BURPING TECHNIQUE

1. OVER THE SHOULDER

2. FACE DOWN ON YOUR LAP

3. SITTING UP

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 Waste Elimination
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
( Normally : 24-36H)

Failure to Pass :
THINK OF HIM
1. Hirschsprung disease
2. Imperforate Anus
3. Meconium Ileus

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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

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 DIFFERENT STOOLS
Jaundiced baby Light stool
Under phototherapy Bright green
Mucus mixed with stool Milk allergy
Obstruction to bile duct Clay colored

After Barium enema Chalk clay colored

GIT bleeding Black stool
Anal fissure Blood flecked stool
Intussusceptions Currant jelly stool
Hirschsprung Ribbon like stool
Malabasorption syndrome Steatorrhea ( fatty
( celiac, cystic fibrosis) foul smelling stool)

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 Parent/Infant Bonding

• interaction between parents and infant should be

promoted as soon as the infant is stable
• The nurse may assist the parents in holding their baby or
give them permission to examine the infant

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 Behavioral Characteristic

During the first 6-10 hours after birth infant has a fairly
predictable pattern of behavior called PERIOD OF
REACTIVITY

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 Period of reactivity

• 2 periods of reactivity occur during the first few hours of

life
• Separated by a period of sleep

– FIRST PERIOD OF RACTIVITY

• The first 30 minutes after birth
• Newborn is awake, alert and active
• Primetime for parents/infant interaction
• Newborn acts hungry, with strong sucking reflex
• Ideal time to begin breastfeeding
• HR , RR are rapid & bowel sounds seldom heard

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 Period of reactivity

– FIRST PERIOD OF REACTIVITY

– Sleep period
• The newborn enters a sleep period that usually lasts
from
2-4 hours.
• Time of deep sleep
• Difficult to awaken NB
• HR , RR return to baseline and bowel sounds become
audible

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 Period of reactivity
– FIRST PERIOD OF RACTIVITY
– SECOND PERIOD OF REACTIVITY
• Lasts from 4 to 6 hours
• NB is once again awake and alert
• HR , RR with period of apnea w/c causes HR to
decrease
• NB may gag, spit up or choke or gastric and
respiratory mucus increases
• CLOSE OBSERVATION is a must – maintain clear
airway
• First meconium stool is often passed
• First voiding may occur
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Physical Assessment

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 Senses

1. hearing- becomes acute after birth,

recognizes mothers voice immediately
functional at birth as soon as the external ear canal
is cleaned

2. vision- focuses best on black and white at a

distance of 9 to 12 inches. not well developed at
birth

4 months of age – clear vision

7 y/o = 20/20 vision

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 Senses

3. Tactile ( touch) starts in early prenatal life from face,

then spreads to limbs and finally to the trunks in
cephalocaudal succession.

Pain sensation – not well developed in NB lasts a

week
Response to pain – generalized
movement & crying
7-9 months – can localize the site of pain
and withdraw from it.
12-16 months – shoves painful away and
bring hand to irritated area

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 Senses

4. Taste – can taste but unable to distinguish flavor.

3 months old – acute taste discrimination is achieved.

5. Olfactory – observed at birth more acute at later age

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PHYSICAL CHARACTERISTICS
OF THE NEWBORN

Vital Signs

Anthropometric measurement

General Appearance
 Immediate Assessment of the Newborn

• The newborn infant should undergo a complete P.E within 24

hours of birth.
– NOTE :
• It is easier to listen to the heart and lungs first when the infant
is quiet

• Warm the stethoscope before using to decrease the likehood of

making the infant cry

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 Assessment of The Newborn

• Initial Physical Examination :

A. General Guidelines:
• Keep the NB warm during the examination.
• Begin with general observations and then perform
assessment that are least disturbing to the NB first.
• Initiate nursing interventions for abnormal findings.
• Document all abnormal findings.

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 Assessment of The Newborn
1. Vital Signs
• using apical pulse = PMI: Point of Maximum Impulse (located at MCL
4th- 5th ICS or below the left nipple line)
• 1 full minute
– 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)

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During sleep - 90-110 bpm
If crying, up to 180 bpm

Pulse : heart rate in utero- 120 t0 160 bpm after 1 hr newborn

settles, heart rate stabilizes to an average of 120 to 140 bpm
- remains irregular because of immaturity of cardiac
regulatory center in the medulla
- when crying, rate might increase to 180 bpm
- may decrease to 90 to 110 bpm during sleep
- femoral pulses are more appreciated than radial and temporal
pulses
( always palpate for the femoral pulses; their absence suggests
coarctation of aorta)

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B. Respirations - 1 full minute

- irregular, shallow, rapid w/ brief apneic spells < 15s

60-80 breaths/min at birth

NORMAL: 30–60/minute

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Respiration : average is 30 to 60 breaths per minute
- respiratory rate, rhythm, depth are likely to be irregular and
short periods of apnea ( periodic respiration) are normal
- coughing and sneezing are present at birth to clear the airway
- newborns are obligate nose-breathers

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C. Blood Pressure - not usually measured
*not routinely obtained except for suspicion of
Coarctation of the Aorta.

80–60/45–40 mm Hg at birth
100/50 mm Hg at day 10

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D. Temperature

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

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     Crying - increases body temperature slightly

      Radiant warmer - falsely increases axillary temperature

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Anthropometric Measurements
(Vital Statistics)

 BW: 2.5 – 3.4 kgs

(5.5 – 7.5 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
     

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 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

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 Breastfed infant recaptures birth weight within 10 days
 Formula fed infant recaptures weight gain with in 7 days
 Then continues to gain weight of 2lb/month( 6-8oz/ wk) for
the 1st 6 months of life

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 HC: 33 – 35 cm
CC: 31 – 33 cm
AC: 31 – 33 cm

Chest circumference :
Should be equal to or 2-3 cm
Less than the HC

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Anthropometric Measurement

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• Length : mature female neonate - 53 cm (20.9 in)
mature male - 54 cm (21.3in)

• Head circumference:
mature newborn - 34-35 cm (13.5 to 14 in)

Measure with the tape measure drawn across the center of the
forehead and around the most prominent portion of the posterior
head.
• Chest circumference: term newborn – 2 cm less than head
circumference, measured at the level of the nipples

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Immediate Assessment of the Newborn

General appearance

- Skin
- Head
- Eyes
- Ears
- Neck
- Chest
- Abdomen
- Genitalia
- Back
- Extremities

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 General Appearance

• Full term newborns have a flexed posture

• The head is flexed
• Arms are flexed on the chest
• Legs are flexed on the abdomen

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 Skin

• Plethora ( deep, rosy red color) more common in

infants with polycythemia vera but can be seen in an
overoxygenated or overheated infant.

• Vernix caseosa – a white creamy substance may thinly

cover the skin.

• Lanugo – fine downy hair , may still be seen on the

forehead and shoulders or it may all disappear.

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 Skin

• Pinkish red
• Vernix caeosa
• Lanugo
• Milia
• Dry peeling skin
• Cyanosis
Hypothermia
Hypoglycemia
Infection
Cardiac
Respiratory
Neurological abnormalities
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 SKIN
Cyanosis
a. central ( bluish skin, including the tongue and lips
- associated with low oxygen saturation in the blood
and it may be associated with congenital Heart
disease ( CHD)

b. Peripheral cyanosis – bluish skin with pink lips and tongue

c. Acrocyanosis - bluish hands and feet only

- may be normal for an infant who has just been born.

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 2. Skin

Dark red – prematurity

Acrocyanosis – up to 48 hours
Central cyanosis – indicates decreased O2
Generalized mottling
Gray color - infection
Pale color - anemia
Yellow color –jaundice
Harlequin sign – pale and pink

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 Pallor

 * Excessive blood loss when cord is cut

* Untimely cutting of the cord

* Inadequate iron stores because of poor maternal nutrition

 
* Blood incompatibility

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 MILIA

• Newborn sebaceous glands are 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.

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Milia

Benign cysts
Disappear
Within few weeks
After birth
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 ERYTHEMA TOXICUM

• in most normal mature infants - newborn rash

• usually appears on the 1st to 4th days of life, but may appear up
to 2 wks of age
• Also called Flea bite rash
• One of the chief characteristics of the rash is the lack of
pattern.

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 Lesions are most noticeable 48H
After birth but may appear as late as
7-10 days
BENIGN RASH resolves spontaneously

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 Mottling lacy pattern
May be seen in the
healthy
infant or infant with
1. Cold stress
2. Hypovolemia
3. Sepsis

Persistent mottling-
referred to as cutis
marmorata

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Candida albican rash

Appears as erythematous
plaque
with sharply demarcated
edges
skin folds are involved

Treatment :

Nystatin ointment or cream

Applied to the rash 4x daily
for
7-10 days

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 Acne Neonatorum

• Lesion typically seen over the check, chin and forehead

• Benign and requires no therapy
• Severe cases may require treatment with mild keratolytic
agent such as 3% sulfur salicylic acid

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 ACNE

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 FORCEPS MARK

• There may be a circular or linear contusion matching the rim

of the blade of the forcep on the infant’s cheek.
• The mark disappears in 1-2 days along with the edema that
accompanies it.

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     Jaundice
     Types:
    1. Physiologic Jaundice / Icterus Neonatorum
2nd day– 7th day – TERM (12mg/dl- indirect bilirubin)
2nd day – 10th day - PRE-TERM
   2. Pathologic Jaundice- before the first 24 hours of life
– Causes:
Infection
Hemolytic disorders
Inability of the newborn to conjugate bilirubin
Decreased conversion of bilirubin to urobilirubin
Decreased uptake of free bilirubin by hepatic cells

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Normal total serum bilirubin = 15%
Direct bilirubin = 1.7
Indirect bilirubin = 13.2

Breastfed babies have longer physiologic jaundice because

human milk has PREGNANEDIOL depresses the action of
glucoronyl transferase (enzyme responsible for converting
indirect bilirubin to direct bilirubin)

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 Breastmilk jaundice

Pregnanediol

Decrease glucoronyl transferase

Decrease conversion of indirect to direct bilirubin

jaundice

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Goal of treatment: to decrease the bilirubin levels
Management: Bililight (Phototherapy)

Nursing Care:
1. Cover eyes with an opaque mask to
prevent blindness.
2. Maintain a distance of about 18-20
inches from source of light.
3. Monitor V/S especially temp.
4. Cover the genitalia to prevent
PRIAPISM (continuous erection).
5. Turning the baby q2hours.
6. Hydration.

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 KERNICTERUS

Accumulation of bilirubin in the brain tissues

• SEIZURES
• MENTAL RETARDATION
• EXCHANGE TRANSFUSION

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PHOTOTHERAPY

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 NURSE ALERT!!!

Most accurate method of assessing the presence of

jaundice: Use natural light and blanch skin on the
chest or tip of the nose.
 Skin

• Acrocyanosis- hand and feet ; peripheral circulation is

sluggish within 24H
• Harlequin sign
– Deep pink or red color develop over one side while the
other side remains PALE or normal color
– Indicative of shunting of blood with cardiac problem or
sepsis
• Birthmarks

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 Birth marks
• Telangiectatic Nevi ( stork bites) – disappear at 2yrs
– pale pink or red, flat , dilated capillaries
• Nevus Flammeus ( port- wine stain)
– No fading with time
– Require surgery in the future
– Common on face
– Non-elevated, sharply demarcated red to purple dense
area of capillaries
• Nevus Vasculosus ( strawberry mark)
– Disappear at 7-9 yrs old
– Common in head
– Dark red
• Mongolian Spot – fades at 1-2 years old
– Bluish black pigmentation
– Lumbar dorsal area or buttocks
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 Common Marks

1. Harlequin Sign - 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.

2. Mongolian spots – bluish gray or dark nonelevated

pigmentation area over the lower back and buttocks
present at birth; primarily nonwhite, disappears at
SCHOOL AGE

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3. Milia – unopened sebaceous glands; tip of nose and chin of the
baby.
• 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.
4. Lanugo - fine downy, hair that covers a newborn’s 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 disappears   
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 Common Marks

5. Desquamation- peeling; at birth, postmaturity

• 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.

6. 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.

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7. Portwine Stain or Nevus Flammeus – birth; red to purple color,
usually flat discoloration commonly on the face or neck; does
not grow and does not fade; does not blanch on pressure nor
disappear

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.

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9. Erythema Toxicum or Erythema Neonatorum – Newborn rash
or fleabite rash/ dermatitis; transient; papules with vesicles at
nape, back and buttocks.
• It usually appears in the 1st to 4th day (2nd day) of life, but may
appear up to 2 wks of age
• One of the chief characteristic of the rash is the lack of
pattern; disappears without treatment.

10. 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. can be blanched by the
pressure of the finger; usually fade during infancy- 1st and 2nd
year.

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11. Cutis Marmorata – transitory mottling when exposed to cold
12. FORCEPS MARK
• There may be a circular or linear contusion matching the rim
of the blade of the forcep on the infants cheek.
• The mark disappears in 1-2 days along with the edema that
accompanies it.

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Nevus flammeus/
Portwine Stain

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Stork’s beak mark

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Strawberry Hemangioma

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 Cavernous Hemangioma

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Mongolian Spot

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 Milia

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Erythema toxicum

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 Head

- largest part of the human body (1/4 of his total body length)
- forehead is large and prominent
- chin is receding when startled or crying

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 Assessment of The Newborn

Head
• 25% of the body length ( cephalocaudal development). Larger Part
• Sutures are palpable
• Fontanels are unossified membranous tissue at the junction of the sutures
• Molding is asymmetry of the head resulting from the pressure in the birth
canal, overlapping of sagittal and coronal suture line

 SUTURES:
Lambdoid (2)
Coronal (2)
Frontal (1)
Sagittal (1)
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 Fontanels
1.  Anterior – diamond shape
- closes at 12-18 months
- 3-4 cm long/2-3 cm wide
     - junction of 2 parietal bones and 2 fused frontal bones
- not indented/not depressed
- suture lines - never appear widely separated

2. Posterior – triangular in shape

- junction of the parietal bones and the occipital bones.
- 1 cm wide
- closes at 2-3 months of age

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 Masses from birth trauma

• Caput succedaneum – edema of the soft

tissue over bone ( crosses over suture line)
– No treatment; subsides in few days
• Cephalhematoma – swelling caused by
bleeding into an area between the bone and
its periosteum
( does not cross over suture line )
– Absorbed within 6 weeks
– No treatment

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 Comparison between
Caput Succedaneum and Cephalhematoma
Indicators Caput Succedaneum Cephalhematoma

Definition Edema of scalp blood b/w

Location Presenting part of periosteum of
the head skull bone & bone
Extent of Both hem; (+) individual bone; (-)
Involvement cross suture lines cross suture line
Cause Pressure (as in Pressure (rupture
prolonged labor) of capillaries)

Period of On or about the Takes several

absorption 3rd day or 4th days weeks - months
Treatment None
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 CRANIOSYNOSTOSIS - suture lines separated or fontanels
prematurely closed; leads to mental retardation.

Craniotabes – localized softening of cranial bones

- indented by pressure of a finger
– Corrects w/o treatment in weeks or months.
– Common to firstborn because of early lightening

Hydrocephalus – anterior fontanel open after 18 months

Microcephaly – small growing brain

Anencephaly – absence of cerebral hemisphere

FRAGILE
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Molding –overlapping of sagittal and coronal
suture lines

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• Seborrheic dermatitis – “ Cradle cap”
– Scaling greasy-appearing salmon colored patches, seen on
the scalp behind ears and umbilicus
– CAUSE :
• Improper hygiene
– Mgt:
• Proper hygiene
• Oil before shampoo

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 Signs of ALARM

• fused sutures
• bulging or depressed fontanels when quiet
• widened sutures and fontanels
• craniotabes

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 Eyes

• Symmetrical and clear

• Pupil equal, round , react to light by accommodation
• Blink reflex present
• Strabismus common – weak EOM
• Ability to track and fixate momentarily
• Red reflex present
• Eyelid often edematous
• Absence of tears
• Corneal reflex (+)
• Visual acuity = 20/200; 20/800

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 POTENTIAL Danger (SIGNs of ALARM)

• Congenital cataract
• Constricted or dilated pupil
• Yellow sclerae
• Absence of red reflex, corneal reflex
• Inability to follow object or bright light to midline

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 EARS
• Symmetrical
• Firm cartilage with recoil
• Top of pinna/ear should align with inner and outer canthus
of the eye
sense of Hearing – highly developed in NB

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 Potential Danger: ALARM

• Low set ears & minor abnormalities (chromosomal defect &

kidney anomalies)

• Absence of startle reflex in response to loud noise

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 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

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 Mouth
• Pink , moist gum
• Soft and hard palates intact
• Epstein pearl ( small, white cyst ) that may be present on
hard palate
• Uvula midline
• Symmetrical and free moving tongue
• Sucking & crying movement symmetrical
• Able to swallow
• Gag reflex present

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• Common
– Natal teeth

• Potential Danger:
– Cleft lip
– Cleft palate
– Large protruding tongue
– Profuse salivation or drooling
– Candidiasis ( thrush)

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 NECK

•   Thyroid gland not palpable

•    Soft, palpable and creased with skin folds

• Head - rotates freely on the neck and flexes forward

and back

• (+) rigidity of the neck- CONGENITAL

TORTICOLLIS (injury to SCM
sternocleidomastoid)

• NB whose membranes ruptured 24 hours before birth-

nuchal rigidity  meningitis
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 CYSTIC HYGROMA

BLOCKAGE OF LYMPHATIC SYSTEM

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 CHEST

• Circular appearance – AP and Lateral diameter are about

EQUAL.
• Diaphragmatic respiration
• Bronchial sounds heard on auscultation
• Nipples prominent & edematous
• Milky secretion common ( witch milk)
• Breast tissue present
• Clavicles need to be palpated to assess for fracture
• 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 WITCH’S MILK.

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• Commonly seen :
– Pectus excavatum ( funnel shaped)
– Pectus carinatum ( Pigeon chest)
– Supernumerary nipples
• SIGN of Potential Danger
– Depressed sternum
– Marked retraction of chest and ICS ( during respiration)
– Redness & firmness around nipple
– Wide spaced nipple

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 LUNGS

• Abdominal respiration
• Cough reflex is absent at birth
– (+) by 1-2 days
– Bilateral equal bronchial breath sound
• RESPIRATION: Irregular rate & depth
• (+) crackles - after birth

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 POTENTIAL DANGER

• Inspiratory stridor
• Expiratory grunt and retraction
• Persistent irregular breathing
• Periodic breathing with repeated apneic spells
• Seesaw respiration ( paradoxical)
• Unequal and diminished breath sound
• Persistent fine crackles
• Peristaltic bowel sounds on one side with diminished breath
sounds on the same side

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 HEART

• Located : Apex 4th-5th ICS, lateral to left sternal border

• Heart rate increases with inspiration and decreases with
expiration
• Transient cyanosis when crying or straining

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 POTENTIAL DANGER

• DEXTROCARDIA – heart at right side

• Cardiomegaly
• Displacement of apex, muffled
• (+) murmur or thrills
• Persistent cyanosis
• Hyperactive precordium

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 Abdomen
• Umbilical cord
– Monitor cord for meconium staining
– Assess for umbilical hernia
– Note for abdominal depression
– Assess for abdominal distention
– Monitor bowel sounds – audible 1-2H after birth
• Liver palpable 2-3 cm below right costal margin
• Spleen: tip palpable at the end of first week of age
• Kidney : palpable 1-2 cm above umbilicus
• Umbilical cord : bluish white at birth, 2 arteries and 1 vein
• Femoral pulses : equal and bilateral

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 Gastrochisis

omphalocele

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 GI SYSTEM
• Newborn’s 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 infant’s main diet for the 1st year is
low in Vit. K, intestinal synthesis is necessary for
blood coagulation

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 Abdomen

• Umbilical cord

• ANUS
– Ensure anal opening is patent
– First stool meconium should pass within
first 24H

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 Potential Danger

• Abdominal distention
• Distended veins
• Absent bowel sound
• Enlarged spleen and liver
• Ascites
• Visible peristaltic waves
• Scaphoid or concave abdomen
• Green umbilical cord
• Presence of only 1 artery in cord

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 Genitals
• Female :
– Labia edematous , clitoris enlarged
– Pseudomenstruation (+)
– First voiding occurs within 24H
• Male
– Prepuce covers glans skin
– Scrotum is edematous
– Verify meatus at tip of penis
– Testes descended, retracts at cold tempearture
– Assess for hernia or hydrocoele
– First voiding occurs w/in 24H

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 Male Genitalia

– Scrotum may be edematous due to maternal hormones.

- Testes should be present; if undescended -

CRYPTORCHIDISM

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 Conditions for Cryptorchidism

1. Agenesis – absence of an organ

2. Ectopic testes – Testes cannot enter the scrotum
because opening of the scrotal sac is closed.
3. Vas deferens or artery is too short to allow the
testes to descend.

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– Care of the penis
• 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 bath
– and when it has occurred, gently clean glans
with soap and water

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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

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 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.

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 Genitals

Ambiguous Genitalia

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 URINARY SYSTEM

• The average newborn voids within 24 hrs after birth

– 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

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CONGENITAL MALFORMATIONS OF THE
URINARY TRACT

• Epispadias - urethral opening

on the dorsal surface of the
penis
• Surgical correction

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 • HYPOSPADIA
• Male urethral opening on
the ventral surface of penis,
or female urethral opening
in vagina
• Surgical reconstruction

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HYPOSPADIA

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hypospadia

epispadia

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 Testes should be present:
if undescended the condition is called CRYPTORCHIDISM
repair is called ORCHIOPEXY
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HYDROCOELE INGUINAL HERNIA
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 SPINE

• Straight
• Posture flexed
• Supportive of head momentarily when prone
• Arms and legs flexed
• Chin flexed on upper chest
• Well-coordinated, sporadic movement
• Hypotonic or hypertonic indicates CNS
damage

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 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.

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 Extremities

• Flexed
• Symmetrical movement
• Fists clenched
• Ten finger , 10 toes
• Legs - bowed
• Creases on soles of feet
• Pulses palpable
• Slight tremor common but could be sign of hypoglycemia
• Assess for hip dysplasia- no click should be heard

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 Supernumerary = polydactyly;
Fused or webbed = syndactyly
    Simean line
   - Asymmetrical movement of upper and lower extremities -
ERB – DUCHENE PARALYSIS
- Observe for clubfoot deformities

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POLYDACTYLY

POLYDACTYLY &
SYNDACTYLY SYNDACTYLY
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Simian crease

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 Congenital hip dysplasia/dislocation

• 0.1% of infants
• with a predilection for females to males of 5:1
• infants with a family history (first-degree relative affected) of
CHD, the incidence is 10 times higher
• also higher in infants born in the breech position and infants
with certain other congenital abnormalities, including
torticollis, clubfoot, metatarsus adductus, and hyperextension
of the knee

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 A. Ortolani’s test

• In this maneuver, the infant is examined in the supine position.

• Place the infant in frog-leg position. Abduct the hip by using

the middle finger to apply gentle INWARD and UPWARD
pressure over the greater trochanter.

• In the infant with an unstable hip, the examiner will feel a

sudden shifting sensation and may hear or feel a "clIck"
simultaneously as the hip reduces anteriorly.

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Ortolani’s test

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 B. Barlow’s test

• In this maneuver, the infant is examined in the supine position.

• The examiner holds the infant's pelvis with one hand to
stabilize it during manipulation.
• Adduct the hip by using the thumb to apply OUTWARD and
BACKWARD pressure over the inner thigh
• In the infant with an unstable hip, a similar "click" may be felt
as the hip subluxes posteriorly.

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 Barlow test

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A. Ortolani’s test
B. Barlow’s Test

* Assessment on the R
and L hips may be
done
simultaneously

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 Clubfoot

• A birth deformity in which the front portion of the foot is

deformed and turned inward. It can be benefited greatly by
surgery.

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• IMMUNE SYSTEM
– NB receives passive immunity via placenta (IgG)
– NB receives passive immunity from colostrum (IgA)
– Infection – IgM
– Use aseptic technique when handling NB
– Observe standard precaution when handling NB
– handwashing
– Infection-free staff cares for the NB
– Monitor NB temp.

• The newborn is prone to infection

– Due to difficulty forming antibodies against invading antigen
until they are about 2 mos. of age.
– 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.

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• METABOLIC SYSTEM/GI SYSTEM
– NB can digest simple CHO, unable to digest FAT because
lack of lipase
– CHON broken down only partially
– NB small stomach capacity ( 60-90ml)
– Rapid intestinal emptying time 2-3 H
– Observe feeding reflexes
– Observe for normal stool
– Perform NB screening test

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• Blood Values
– 80-110 ml/kg of body weight or about 300 ml
– High WBC at birth about 15,000 to 30,000
cells/mm3
• Increased WBC count should not be taken as
evidence of infection
• Blood Coagulation
– Most newborns are born with a prolonged
coagulation or Prothrombin time, because their
blood levels of Vitamin K are lower than
normal.
– It takes 24 hrs. for flora to accumulate and
vitamin K to be synthesized

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NEUROMUSCULAR
• B REFLEXES
– blink reflex
– Babinski
• S
– Sucking
– Swallowing
– Startle/ moro reflex
– Stepping or walking
• T BaSTa LEP RoT
– Tonic Neck or fencing
• L
– Landau reflex
• E
– Extrusion reflex
• P
– Palmar- Plantar reflex
– Placing reflex
– Paracheute
• Rooting reflex

• TrunK Incurvation Reflex

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– Reflexes

• Blink Reflex - to protect the eye from any object

coming near it by rapid eyelid closure

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• Babinski’s 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 mos)

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• Sucking Reflex- when newborn’s lips are
touched, the baby makes a sucking motion. It
diminishes at about 6 months of age.
• if it disappears immediately / if never stimulated-
tracheoesophageal fistula

• Swallowing Reflex- food that reaches the posterior

portion of the tongue is automatically swallowed

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• Moro or Startle Reflex – elicited by sudden disturbance in the infant’s
immediate environment, body will stiffen, arms in tense extension followed
by embrace gesture with thumb and index finger a “c” formation
(disappears by 6 mos)
• can be stimulated by startling the newborn with loud noise or by jarring the
bassinet, fades on 4th or 5th month of life
• aka Startle Reflex

If the reflex persists, it is a sign of brain damage,

neurological impairment, or motor reflex difficulties .

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• Step-in-place or Stepping
(walk-in-place) reflex –
– newborn who is held in a
vertical position with their
feet touching a hard surface
will take few alternating
steps
– disappears by 3- 4 months
of age

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 Tonic Neck (Fencing) Reflex

-If the Babies' head is rotated to the left,

-The left arm (face side) stretches into extension
-The right arm flexes up above head
Opposite reaction if head is rotated rightward

if it persists after infancy, it may indicate abnormal development

of the central nervous system.
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 • Landau reflex-

Displayed at about three months of age.

When NB is placed on its stomach faced down, NB will
raise her head and arch its back.
 This reflex will persist until 1 year old
 Absence of this reflex suggests problems in motor
development.

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EXTRUSION REFLEX-

• a newborn will extrude any substance that is

placed in the anterior portion of the tongue.
– Protective reflex prevents the swallowing of inedible
substance
– Disappears at 6 wks to 3 mos.

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• Palmar grasp – pressure on palm elicits grasp
(fades by 3-4 mos)

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• 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
– A newborn will make a few quick lifting motions as
if to step onto the table

it is obtainable in the normal infant up

to the age of six weeks

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• PARACHUTE

occurs in the slightly older infant, and is elicited by

holding the child upright then rotating the body quickly
face forward (as if falling). The arms are reflexively
extended as if to break a fall.

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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.)

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 TrunK Incurvation Reflex
( Gallant reflex)

Trunk incurvation reflex - newborn lies on prone

position and is touched along the paravertebral area by
probing finger, NB flexes its trunk and swings pelvis
toward the touch

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• FEEDING REFLEXES
1. Rooting
2. Sucking
3. Extrusion

• Protective REFLEXES
1. Blinking
2. Sneezing & coughing
3. Yawning
4. gagging
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Common Health Problems

1. Constipation
2. Loose stools
3. Colic
4. Spitting up
5. Diaper rash/Skin irritation
6. Miliaria (prickly heat/bungang araw)
7. Seborrheic dermatitis/cradle cap
8. Occasional “crossed eyes”

Sleep pattern – babies sleep 16-20 hours a day

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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 carbohydrates
Tense and unsure mother

Management :
Feed by demand. It is the best schedule because it meets the
individual needs of the newborn.
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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

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6. Miliaria (prickly heat/bungang araw) – starch bath or
Johnson’s 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

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 Expanded Program on Immunization

Vaccine Age at Dose Number Min Possible

1st dose of Doses Interval Reaction
BCG At birth 0.05 ml 1   Keloid,
ID suppurative
adenitis
DPT 6 wks 0.5 ml 3 4 wks Fever,
IM restlessness,
irritability
OPV 6 wks 2 drops 3 4 wks Paralytic polio
rare

Hepa B 6 wks 0.5 ml 3 4 wks Arthralgia

AT BIRTH IM Neuro reactions
rare
Measles 9 mos 0.5 ml 1   Fever and rash
SC 5-10 days after
dose

MMR 12-15 0.5 ml 1   Fever,

mos SC rash,arthralgia,
lymphadenopat
hy,rare – febrile
seizures, nerve
deafness,
encephalitis

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Newborn Screening Test
 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.”

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 NEWBORN SCREENING

C
1. Congenital Hypothyroidism ( CH )
2. Congenital Adrenal Hyperplasia (CAH)

P
3. PHENYLKETONURIA (PKU)

G
4. G6PD DEFICIENCY
5. Galactosemia

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 NB screen

• Should be done after 24-48 hours of life

• After the infant is fed
• done through extraction of blood in the heel of the foot

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Disorder Screened Effect of disorder Benefit if screened &
treated

CH Severe mental normal

Congenital retardation
Hypothyroidism
CAH Death Alive and normal
Congenital adrenal
hyperplasia
GAL Death, cataract Alive and normal
Galactosemia
PKU Severe mental Normal
phenylketonuria retardation
G6PD Severe anemia, Normal
kernicterus

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 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

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287
 1. CONGENITAL HYPOTHYROIDISM

Dx: low T3 T4, inc TSH

Mx: synthetic thyroid hormone

Nsg Care: Assist parents administer drugs

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 Congenital hypothyroidism

PEDIATRIC NURSING MLNGC,MD,

After 2-3 mos RN
of treatment
289
 2. CONGENITAL ADRENAL HYPERPLASIA

  -inability to synthesize cortisol >>> inc ACTH >>> stimulate

adrenal glands to enlarge >>> inc androgen

S/sx: masculinization, sexual precocity

Mx: Steroids to decrease stimulation of ACTH

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 3. G6PD DEFICIENCY
Glucose 6 phospate dehydrogenase 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

  

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 4. GALACTOSEMIA

(-) enzyme that converts galactose to glucose

Galactose 1 phosphate uridyltransefrase

S/sx: wt loss, vomiting, hepatosplenomegaly, jaundice

and cataract

Dx: Beutler test

Tx: decrease lactose – soy based formula

regulate diet

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 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

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 Discharge instructions

a. Bathing
b. Cord Care
c. Nutrition
Calories 120 kcal/kg body weight/day
CHON 2.2 gms /KBW/day
Fluids 160-120 cc/KBW/day
Vitamins A,C, D for formula and breastfed babies

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 Common Health Problems

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

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Management
Feed by demand
Burp infant
Feed in upright position
May need to change formula

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Diaper Rash
Miliaria
Seborrheic Dermatitis
Occasional “Crossed Eyes”
Clothing
Sleep Pattern

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 DANGER SIGNS TO WATCH OUT FOR:

1. Deepening jaundice up to palms and soles or persistent

jaundice beyond 2 weeks of life
2. Decreased sucking reflex or refusal to feed
3. Unusual sleepiness
4. No urine output for >48H
5. Temperature instability
6. Unusual movement
7. Fast breathing with or without cyanosis or pallor

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