2.1a Newborn Care

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Dra. Grace Padilla

PEDIATRICS I 2.1A NEWBORN CARE

January 07,

2015 Emilio Aguinaldo College – School of Medicine o Ductus arteriosus OBJECTIVES 1.     2.     

1. 2. 3. 4. 5. 6.

To introduce normal newborn findings and behavior pattern. Recognize the context of a normal pregnancy outcome. Describe the process of transition from intrauterine to extra uterine existence. Perform a complete physical examination of the newborn infant. Perform a concise neurodevelopment assessment of the newborn infant. To be aware of what constitute a comprehensive newborn care. Formulate a risk assessment list Perform basic steps in neonatal resuscitation Provide immediate care for the newborn Continuing care Discharge procedure with adequate instruction PERINATAL HISTORY Demographic and social date socioeconomic status, age, race Past medical illnesses in the family – cardiopulmonary disease, infection, genetic disorder Prior maternal reproductive problems – still births, prematurity Events occurring in the present pregnancy – vaginal bleeding, medications, acute illness, duration of pregnancy Description of labor – duration, fetal presentation, fetal distress, presence of fever Delivery – normal, c-section, anesthesia of sedation, forceps

Fig1. Fetal Circulation

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PREGNANCY RISK CLASSIFICATION CLASS A Low risk mother with low risk newborn – normal uncomplicated pregnancies and normal labor pattern. CLASS B High risk mother with low-risk newborn – mothers who are sick but in stable condition and therefore presents a minimal risk to the baby. Example: Gravidocardiac, primagravida >35 years or < 16 years, malignant disease not receiving therapy, pulmonary disorder, hematologic disorder

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CLASS C Low risk mother with high risk newborn Example: History of habitual abortion and stillbirth, abnormal ultrasonographic findings, abnormal biophysical profile, prolonged or early gestation, evidence if IUGR, multiple gestation, rupture of membranes, abnormal fetal heart rate or pattern, meconium staining of amniotic fluid, etc.

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CLASS D High risk mother with high risk newborn – fetus and newborns are compromised because of maternal illness. Example: Chronic hypertension, pre-eclampsia/eclampsia, diabetes mellitus (uncontrolled), renal/cardiac failure, viral or bacterial infections, choroiamnionitis, 2nd or 3rd trimester bleeding, etc.

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FETAL PHYSIOLOGY CIRCULATORY SYSTEM Normally complete by 40th week of gestation Fetal circulation with 3 shunts: o Ductus venosus o Foramen ovale

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FETAL CIRCULATION Placenta  umbilical vein  Ductus venosus  Inferior vena cava  Right atrium  Foramen ovale  Left atrium  Left ventricle  Ascending aorta  Head and upper part of the body Superior vena cava  Right atrium  Right ventricle  Pulmonary artery  Ductus arteriosus  Descending aorta  Lower half of the body Blood flows in parallel rather than in series. Mainly affected by high pulmonary resistance brought about by non-expansion of the lungs. RESPIRATORY SYSTEM Formation starts from the airways proceeding to alveolation. Alveolar epithelium excretes lung fluid that fills the alveoli. Surfactant produced by type II alveolar cells by 20th week of gestation. Adequate surfactant lowers surface tension of the alveolar epithelium preventing alveolar collapse. Respiratory movements occur as early as 18th week of gestation but ceases as fetus approaches term. At term, fetus breathes ONLY if a hypoxic stimulus is applied. THE TRANSITION Passage of the fetus through the birth canal  Chest wall is compressed lung fluid is expelled  Elastic chest wall recoils back  High negative intra-thoracic pressure. Infant’s first cry replaces lung fluid with air. Fluid in the alveoli is absorbed into the lung tissue and replaced by air. The oxygen in the air is able to diffuse into the blood vessels that surround the alveoli. Alteration of the lungs eliminate the hypoxic state causing vasodilation of lung vessels. Decrease in pulmonary vascular resistance and pressure  More blood enter the lungs and return to the heart  Left atrial pressure increases causing physiologic closure of the foramen ovale. Increase in oxygen content causes the muscular constriction and functional closure of the patent ductus arteriosus. APGAR SCORE Practical method of systematically assessing newborn infants immediately after birth to help identify those requiring resuscitation and to predict survival in the neonatal period. SAMONTE, JBMM

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Pediatrics I 

2.1 NEWBORN CARE

Not designed to predict neurological outcome 

SIGN Heart rate Respiratory effort Muscle tone

0 Absent Absent

1 < 100 Slow irregular

2  100 Good crying

Limp

Active motion

Response to catheter in nostril Color

(-) Response

Some flexion of ext. Grimace

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Blue, pale

Body pink, ext. blue

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EXPANDED BALLARD SCORE Assessment of gestational age by determining state of maturity. Use of physical features and neurological responses. Extremely prematures assessed as early as 12 hours, term infants may be assessed even up to 72 hours.

Cough sneeze

Pink all over

1 minute score – signal the need for immediate resuscitation. 5 minute score – probability of successfully resuscitating an infant. May be extended to 10, 15, 20 minutes until score of 7 is reached. NEONATAL RESUSCITATION Drying, warming, positioning, suction, Tactile stimulation Oxygen Bag-mask ventilation Endotracheal intubation Chest compressions Medications

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Inverted pyramid reflecting the appropriate relative frequencies of neonatal resuscitative efforts. ESSENTIAL NEWBORN CARE Protocol promulgates by the WHO and endorsed by DOH to decrease neonatal mortality. Evidence based intervention. Emphasizes on core sequence of actions performed step by step. Four core steps: 1. Immediate and thorough drying. 2. Early skin to skin contact. 3. Properly timed cord clamp. 4. Non-separation of the newborn and mother for early initiation of breastfeeding.

Within 30 seconds objective: To stimulate breathing, provide warmth.

-Put on double gloves -Dry thoroughly -Remove wet cloth -Quick check of NB’s breathing -Suction only if needed

TIME-BOUND INTERVENTIONS After thorough Up to 3 minutes drying post-delivery objective: To objective: To provide reduce anemia warmth, in term & bonding, preterm; IVH and prevent transfusions in infection & preterm. hypoglycemia. -Put prone on chest/abdomen skin to skin -Cover with blanket, bonnet -Place identification on ankle -Do not remove vernix

-Remove 1st set of gloves -Clamp and cut cord after cord pulsations stop. (13 mins) -Do not milk cord. -Give oxytocin 10 mg IM to mother.

Within 30 minutes of age objective: To facilitate initiation of breastfeeding through sustained contact. -Uninterrupted skin to skin contact. -Observe NB for feeding cues. Counsel on positioning & attachment. -Do eye care, injections, etc after 1st breastfeeding.

SAMONTE, JBMM

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Pediatrics I PHYSICAL MATURITY Skin Lanugo Plantar surface Breast Eyes/ears Genitalia

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2.1 NEWBORN CARE

NEUROMUSCULAR MATURITY Posture Square window Arm recoil Popliteal angle Scarf sign Heel to ear

PHYSICAL EXAMINATION OF THE NEWBORN Initial examination performed as soon as possible after delivery o To detect abnormalities and o To establish a baseline for subsequent examinations 2nd examination: within 24 hours after birth 3rd examination: within 24 hours of discharge Tailored to fit both the gestational and postnatal age of an infant. Requires patience and procedural flexibility to return to do part of the examination in order to stay within the limits of an infant’s tolerance. Requires gentleness. Anthropometric measurements: weight, length, head circumference, chest circumference and abdominal circumference. Vital signs: o Pulse rate: 120-160 beats/min. o Respiratory rate: 30-60 breaths/in. o Temperature, color, activity: Monitored every 30 mins after birth for 2 hours or until stabilized.

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SKIN Vasomotor instability and peripheral circulatory sluggishness – deep redness or purple lividity during crying. Acrocyanosis of the hands and feet Mottling – associated with severe illness or related to transient fluctuation of skin temperature.

Vernix caseosa - also known as vernix, is the waxy or cheese-like white substance found coating the skin of newborn human babies. Vernix starts developing on the baby in the womb around 18 weeks into pregnancy. Plethora – Polycythemia Lanugo – fine, soft immature hair on scalp, brow and face; especially among prematures.

Fig4. Vernix caseosa

Fig5. Lanugo 

Mongolian spots – slate blue, welldemarcated areas of pigmentation seen over the buttocks, back – tend to disappear within the 1st year of life.

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Erythema toxicum – small white occasionally vesiculopustular papules on an erythematous base seen on the face, trunk and extremities – appears 1-3 days after birth and persists for as long as 1 week.

Fig6. Mongolian spots

GENERAL APPEARANCE Physical activity: absent, deceased, vigorous crying Muscle tone: Active or passive Take note of unusual posture Coarse tremulous movements vs. convulsive twitchings Edema: Generalized or localized

Fig2. Mottling 

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Fig7. Erythema toxicum 

Milia – small whitish papules made up of distended sebaceous glands, usually covering the nose.

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Salmon patch - (also called stork bites) appear on 30%-50% of newborn babies. These marks are small blood vessels (capillaries) that are visible through the skin. They are most common on the forehead, eyelids, upper lip, between the eyebrows, and the back of the neck. Often, these marks fade as the infant grows. Hemangiomas benign (noncancerous) vascular tumors composed of cells that normally line the blood vessels (endothelial cells).

Fig8. Milia

Harlequin color change – extraordinary division of the body from the forehead to the pubis into red and pale halves; transient and harmless condition. Fig3. Harlequin color change Pallor – represents asphyxia, anemia, shock or edema. 

Fig9. Salmon patch

Fig10. Hemangiomas SAMONTE, JBMM

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Pediatrics I   

2.1 NEWBORN CARE

HEAD Molding: Usually among first born, parietal bones tend to override the occipital and frontal bones. Suture lines: Check for premature fusion = craniosyntosis Anterior and posterior fontanels: check for abnormal size

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NECK Relatively short Abnormalities not common: Goiter, cystic hygroma, brachial cleft vestiges, sternocleidomastoid hematomas Redundant skin or webbing: Turner syndrome Clavicular fracture

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CHEST Breast hypertrophy common Supernumerary nipples occasionally seen Milk may be present (witch’s milk) Retractions (intercostal/subcostal): Respiratory distress

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Craniotabes: soft area in the parietal bones at the vertex near sagittal suture. Caput succedaneum – edematous swelling of the soft tissue of the scalp.

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LUNGS Variation in rate and rhythm of breathing according to infant’s physical activity. RR > 60/min: Respiratory, cardiac or metabolic disease Breathing is diaphragmatic – “paradoxical movement” Prematures: Cheyne-stokes rhythm = periodic breathing Breath sounds – bronchovesicular Expiratory grunting : Respiratory distress

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HEART Determine location: Dextrocardia

 Fig12. Caput succedaneum 

Cephalhematoma – subperiosteal hemorrhage

Fig13. Cephalhematoma

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FACE Dysmorphic features – epicanthal folds, widely spaced eyes, microphthalmia, low set ears. Asymmetry: Abnormal fetal posture, 7th nerve palsy Facial nerve paralysis – The forehead on the affected side is smooth, eye cannot be closed, nasolabial fold is absent, corner of mouth drops.

MOUTH Precocious dentition: o Natal – present at birth o Neonatal – eruption after birth Soft and hard palate: Check for complete or submucosal cleft, check for contour Epstein pearls: Retention epithelial cells cysts seen on the hard palate and gums. Tongue: Short frenulum

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Fig15. Dextrocardia Transitory benign murmur are common Congenital heart disease may not initially produce the murmur that will appear later. Palpation of pulses in the upper and lower extremities: Coarctation of the aorta.

Fig14. Facial nerve paralysis   

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EYES Conjunctival and retinal hemorrhages usually benign. Check for bilateral red reflex. Leukocoria: White pupillary reflex = cataracts, tumors, chorioretinitis, ROP EARS Deformitis of the pinnae Preauricular skin tags NOSE Patency and symmetry of the nares Assymetry: Dislocation of nasal cartilage from the vomerian groove. Choanal atresia – may lead to respiratory distress

Fig16. Coarctation of the aorta ABDOMEN SAMONTE, JBMM

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Pediatrics I      

2.1 NEWBORN CARE

Prominent, globular but not distended Liver usually palpable 2 cm below the rib margin. Tip of the spleen may be felt less commonly Abnormal masses: Renal pathology most common. Scaphoid abdomen: Diaphragmatic hernia. Abdominal wall defects: Omphalocoele vs gastroschisis

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Fig17. Omphalocoele

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Fig18. Gastrochitis               

Fig19. Gastroschisis VS Ompalocoele Air in the GIT vary, present in the rectum by radiograph by 24 hours of age. Umbilicus: 2 arteries and 1 vein

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Abnormal dermatoglyphic pattern: Simian crease Congenital hip dislocation: Ortolani’s maneuver NEUROLOGICAL EXAMINATION POSTURE Resting, unrestrained posture Flexion and adduction of the hips, flexion of the knees, arms adducted and flexed at the elbow, fists often clenched. STATE OF WAKEFULNESS Deep sleep – no movement, regular breathing Light sleep – with eye movements, hypotonic and irregular breathing Quiet, awake – eyes closed or half-open, with slight activity Fully awake – eyes open, alter with some movements Fully awake, active – with plenty of movements Fully awake, crying The neurodevelopmental exam is most reliably done in states 3 or 4 Rooting, licking, sucking reflexes reflect level of responsiveness. Observe eye opening, yawning, facial expressions and stretching. TONE Observe for posture Frog leg position suggests flaccidity Passive tone: Observe by performing vertical suspension and horizontal suspension. Active tone: Pull to sit maneuver Ankle clonus of >10 beats probably abnormal Differentiate tremulousness from seizures REFLEXES Deep tendon: patellar reflex test (L2-L4) Less easy to elicit: biceps, ankle, truncal innervation Primitive: assessed for presence or absence, symmetry, completeness, persistence Moro, palmar and plantar grasp, rooting, sucking, placing reflexes at birth Tonic neck reflex at later days

GENITALIA Maternal hormones – enlargement and secretion of breasts, prominent female genitalia with non-purulent discharge. Testes may not be fully descended but are palpable in the canals. Prepuce normally tight and adherent. Ambiguity in external genitalia requires further investigation. Fig21. Moro reflex

Fig22. Grasp reflex

Fig20. Ambiguous genitalia  

ANUS Check for patency Passage of meconium by 48 hours of life

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EXTREMITIES Check of effect of fetal posture Poly or syndactyly Clubfoot

Fig23. Rooting reflex

Fig24. Asymmetric tonic reflex

SAMONTE, JBMM

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Pediatrics I

2.1 NEWBORN CARE      

Fig25. Placing reflex   

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HIGHER FUNCTION AND CRANIAL NERVES Observe response to breast-feeding, human voice (particularly mother’s voice) Capable of visual fixation and limited tracking during alert periods. Especially responsive to the human face IMMEDIATE CARE FOR THE NEWBORN THERMOREGULATION Relative to body weight, body surface area of a newborn infant is approximately 3x that of an adult. Estimated rate of heat loss in a newborn is approximately 4x that of an adult. Maintain 36.6-37.2 C Skin to skin contact with the mother is the optimal method to maintain temperature in the stable newborn.

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Latch-on within 30-45 mins after birth or as soon as the infant shows signs of readiness. Proper technique in breastfeeding. No pacifiers or other artificial forms of feeding. On demand deeding preferred. NEWBORN SCREENING Collection of blood samples form the sole of the feet of newborn infants, placed on filter paper. For detection of: o Congenital hypothyroidism o Congenital adrenal hyperplasia o Phenyketonuria o Galactosemia o Glucose 6 phosphate dehydrogenase deficiency DISCHARGE PROCEDURE Continue exclusive breastfeeding Cord care Bathing Signs of illness, contact numbers, emergency room Well baby visit schedule END OF TRANS

Life isn’t about getting and having, it’s about giving and being. –Kevin Kruse

SKIN AND CORD CARE Once infant’s temperature has stabilized, entire skin and cord should be cleaned with warm water and milk non-medicated soap. Careful removal of blood and meconium, do not remove vernix. Cord may be treated daily with bactericidal or anti-microbial; agents such as triple dye or bacitracin. 2x daily alcohol soaking until cord falls off reduces colonization, exudates and foul odor of the umbilicus. Hand washing of nursery personnel is mandatory. EYE CARE Instillation of 1% silver nitrate drops or erythromycin 0.5% or tetracycline ophthalmic ointment. To prevent gonococcal eye infections. VITAMIN K ADMINISTRATION Water-soluble vitamin K (phytonadione) given by intramuscular injection. 0.5 mg for premature infants, 1.0 mg for term infants To prevent hemorrhagic disease of the newborn. IMMUNIZATION Hepatitis B and BCG Babies of mothers with reactive HBsAg should receive both Hepatitis B immune globulin and vaccine. CONTINUING CARE ROOMING-IN Within 2 hours after birth or as soon as possible. Clear bassinet to allow easy monitoring and care. Advise on thermoregulation and hand washing. Mother directly responsible for the routine care of the infant during rooming-in.

BREASTFEEDING SAMONTE, JBMM

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