NEONATAL CARE AND ASSOCIATED CHALLENGES

Newborn Care

During neonatal life, marked physiological transitions occur in all organ systems. The infant
also learns to respond to many forms of external stimuli. Any description of the neonate’s
developmental status includes consideration of the parent’s role as well. This is because
infants thrive physically and psychologically only in the context of their social relationships.
Medical and health workers are promoters of health. Their first duty (especially to mothers
and children) is to advise about better health practices, namely: - Preventive measures,
Health Promotion (promotive) measures, and Curative measures.

Preventive measures comprise of: vaccinations, safe water supplies and hygiene, clean
deliveries, newborn temperature management, antibiotics for premature rupture of
membranes, among others.
Health promotion (promotive) measures: e.g family planning, basic education for children,
parents, hand washing after visiting toilets or before eating, among others.
Curative services/measures: Taking medications to treat an existing illness (tablets,
injections, ointments, ORS treatment for dehydration, among others.)

Nutrition and Feeding of Neonates

Feeding in neonates is critical, especially for preterm or sick infants. Neonates who are
unable to feed orally may require tube feeding or intravenous nutrition (parenteral
nutrition). Breast milk is the preferred source of nutrition and provides antibodies essential
for immune protection.

Examination of a Newborn

A newborn should be examined from head to toe. Components of Neonatal physical

examination comprise of: Colour, Birth weight, age, head (circumference, eyes, ears. Sutures,
all fontalles, any scalp oedema, nose and mouth).

A newborn normally appears pink in colour; this is indicative of good circulation of

oxygenated blood.
Normal birth weight range from 2.5kg to 4.1 kg (with the average being 3.1kg). There’s a
gradual weight loss of a newborn during the first 2 – 3 days but this should not exceed 10%
of birth weight. If more than 10% of birth weight occurs, investigate for other causes of
weight loss. Weight gain after 3 days is 20 -30 grams/day if normal feeding is maintained.

As far as newborn age is concerned, gestational age is 38 – 41 weeks for term infant.
Estimation of gestational age is by: (1) Dates: This is considered unreliable since L.M.P is
sometimes forgotten; (2) Clinical: by physical examination (e.g. Dubowitz method, among
others).

As far as head examination is concerned, (a) Head Circumference has a normal range of
thirty three to thirty seven centimetres (33cm to 37cm). Newborns with less than 33cm of
head circumference are considered to have microcephaly/microcephalus, whereas those
with head circumference greater than thirty seven centimetres (37cm) are categorizes as
having macrocephaly/macrocephalus. The newborn head grows 12cm in circumference in
the first 12months, but 6cm of this is during the first 3 months; during the next 3 months it
grows 3cm more and a further 3 cm during the rest of the year. In a normal infant, the head
circumference is greater than the chest circumference, up to one year; the head and chest
circumference are equal for another 6 months but then the chest circumference becomes
greater than the head circumference after 18 months of life. The head circumference is
measured by taking the greatest distance around the forehead and the back of the head
above the ears (i.e. maximum fronto-occipital circumference).
As for the fontanelles, these consist of the anterior fontanelle, posterior fontanelle and
third fontanelle. The anterior fontanelle opens at birth and pulsates in a newborn; it is also
diamond shaped. The posterior fontanelle may also be patent at birth. The third fontanelle
may be found on temporal region; if present, this may be associated with hypothyroidism.
Measurement of Mid – Upper Arm Circumference (MUAC):
The circumference of the middle of the upper arm increases fairly rapidly to about 16cm by
the age of one year; it then remains nearly constant from 1 – 5 years, during which period it
increases only by about 1cm to 17 cm.

MUAC is an important parameter in the assessment of malnutrition (I.e. when determining

the type of malnutrition in malnourished children). Details in this regard will be discussed
under malnutrition.

Neonatal Reflexes
Neonatal reflexes are automatic, involuntary movements or responses to specific stimuli
that are present at birth and are important for the survival and development of newborns.
Neonatal reflexes are assessed to monitor neurological development, and the presence or
absence of certain reflexes can indicate potential neurological or developmental disorders.

In a nutshell, neonatal reflexes are fundamental for assessing infant development and
neurological health. Early identification of abnormal reflexes can lead to early intervention
and treatment. The patterns of reflex development offer insight into the maturation of the
central nervous system and motor coordination.

The neonate is subsequently examined for neonatal reflexes. Spontaneous neonatal reflexes
are normally present. Absence of neonatal reflexes is abnormal. The best time to test
neonatal reflexes is two hours after the neonate has been fed. The neonatal reflexes
disappear by the 4th month of life; hence the baby is abnormal if (i) neonatal reflexes are
initially absent or (ii) neonatal reflexes persist beyond 4 months of life.
The reflexes related with feeding (i.e. they are absent if baby is satisfied).

Classification of Reflexes

These reflexes can be classified into:

(I) Primitive reflexes and

(II) Postural reflexes: persist throughout life.

Primitive reflexes typically disappear as the infant grows. Neonatal reflexes are therefore in
this category.

The commonly elicited neonatal reflexes are: (i) Sucking reflex, (ii) Rooting reflex, (iii)
Swallowing reflex, (iv) Moro reflex, (v) Placing reflex, (vi) Grasping reflex, (vii) Stepping
reflex and (viii) Asymmetric tonic neck reflex.

The reflexes are described in the following section.

1. Moro Reflex (Startle Reflex)

Description:
The Moro reflex is an involuntary response to a sudden loss of support or a loud sound.
When an infant experiences this stimulus, they will throw their arms and legs outward, then
quickly bring them back to the center of their body, often accompanied by crying.

Clinical Significance:
The Moro reflex typically disappears by 4-6 months of age. Persistence or asymmetry of this
reflex beyond this period may indicate neurological problems such as cerebral palsy or brain
injury.

2. Rooting Reflex

Description:
When the corner of a newborn's mouth or cheek is stroked, the baby will turn their head
towards the stimulus and begin rooting (searching for the breast or nipple). This reflex helps
the infant to latch and breastfeed.

Clinical Significance:
The rooting reflex usually disappears by 3-4 months. Its absence or delay may be indicative
of issues with feeding or neurological development.

3. Sucking Reflex

Description:
This reflex is triggered when the roof of the infant's mouth is touched. The baby will begin
sucking, which is essential for feeding.

Clinical Significance:
The sucking reflex is critical for successful breastfeeding and usually disappears by 2-3
months. Weakness or absence of this reflex may suggest developmental or neurological
disorders.

4. Palmar Grasp Reflex

Description:
When an object or finger is placed in the infant’s palm, they will grasp it tightly. This reflex
helps infants cling to their caregiver, although it is more of an involuntary response rather
than intentional gripping.
Clinical Significance:
The palmar grasp reflex is typically present at birth and fades by 5-6 months of age. A
prolonged or absent grasp reflex could suggest neurological issues, such as a brain injury or
developmental delay.

5. Plantar Grasp Reflex

Description:
Similar to the palmar grasp, the plantar grasp occurs when the sole of the infant's foot is
stroked. The baby will curl their toes around the stimulus, creating a "grasp" of the foot.

Clinical Significance:
This reflex fades around 9-12 months. Persistent plantar grasp after this age could indicate I
ssues with motor or neurological development.

6. Tonic Neck Reflex (Fencing Reflex)

Description:
When the infant's head is turned to one side, the arm and leg on that side will extend, while
the opposite arm and leg will flex. This is known as the "fencing position" and helps develop
motor skills and coordination.

Clinical Significance:
This reflex appears around 2-3 months and disappears by 6 months of age. Persistence
beyond this age may be associated with developmental issues like cerebral palsy.

7. Babinski Reflex

Description:
When the sole of the foot is stroked from heel to toe, the baby’s big toe will extend and fan
out, while the other toes may curl downward. This reflex is typically seen in newborns.

Clinical Significance:
The Babinski reflex is normal in infants but disappears by 2 years of age. If the reflex is
present beyond this point in life, it may indicate neurological problems, such as damage to
the upper motor neurons.

Reference:

 Brazelton, T. B., & Nugent, J. K. (2011). Neonatal Behavioral Assessment Scale. Mac
Keith Press.

8. Stepping Reflex

Description:
When an infant is held upright with their feet touching a flat surface, they will make stepping
motions as if walking. This reflex appears in early infancy.
Clinical Significance:
This reflex generally disappears by 2 months of age. If it persists longer, it could indicate
delayed motor development.

9. Galant Reflex

Description:
When the infant’s lower back is stroked along one side of the spine, the baby will curve
toward the side being stimulated. This reflex is associated with early postural control.

Clinical Significance:
The Galant reflex fades by 3-6 months. Retention beyond this age can indicate problems
with motor control and balance.

10. Asymmetric Tonic Neck Reflex (ATNR)

Description:
This reflex is similar to the tonic neck reflex but asymmetric. When the head is turned to one
side, the arm and leg on that side extend while the opposite arm and leg flex.

Clinical Significance:
ATNR appears around 2-3 months of age and typically disappears by 6 months. Persistence
after 6 months may suggest a developmental delay.

Summary of Key Points:

1. Primitive Reflexes: These reflexes are automatic and disappear as the infant's
central nervous system matures.
2. Postural Reflexes: Some reflexes, like the righting reflexes, are integral to posture
and movement and remain active throughout life.
3. Developmental Significance: The presence, absence, or persistence of certain
reflexes can indicate potential developmental or neurological problems.

BIRTH ASPHYXIA

Definition/Description

Birth Asphyxia is a condition where a newborn suffers from a lack of oxygen (hypoxia) and
sometimes inadequate blood flow (ischemia) during the birth process. This can lead to
significant damage to the organs, primarily the brain, if not promptly identified and treated.
Birth asphyxia is often linked to abnormal labor, placental complications, cord accidents, or
maternal issues such as hypertension. In other words, birth asphyxia refers to inability to
communicate or sustain effective respiration in a newborn.

Causes of Birth Asphyxia

(1) Obstruction of the airways: Meconium aspiration or cord prolapse can block the infant's
airway. (2) Uteroplacental insufficiency: Compromise in the blood flow to the placenta (e.g.,
maternal hypertension, preeclampsia, placental abruption).(3) Infection: Maternal infections
such as chorioamnionitis can affect oxygenation. (4) Trauma during delivery: Prolonged or
difficult labor, forceps delivery, or shoulder dystocia. (5) Umbilical cord accidents: Cord
prolapse, cord rupture, or cord knots.

Pathophysiology of Birth Asphyxia

The affected newborn is exposed to low oxygen tension (hypoxia). This causes hypo-
perfusion of all body tissues. Subsequently, asphyxia occurs, resulting in end-organ damage.
The main problem in birth asphyxia is hypoxic-ischemic injury to the newborn's brain and
other organs. This is caused by a decreased oxygen supply or impaired blood flow. The body
responds by attempting to preserve oxygenated blood for vital organs, especially the brain,
but without intervention, this can lead to: Cellular injury, Inflammation, Metabolic acidosis
and Neurological damage (e.g., cerebral palsy, seizures).

Clinical Presentation of Birth Asphyxia

Symptoms can appear immediately after birth or develop over the first hours of life.
Common signs include: Cyanosis: Bluish skin and mucous membranes due to lack of oxygen.
Tachypnea or bradypnea: Rapid or slow [Link] muscle tone: Floppiness, reduced
reflexes. Lethargy: Difficulty in maintaining alertness or sucking. Abnormal heart rate:
Bradycardia (slow heart rate), irregular heart rate. Seizures: Due to brain injury from hypoxia.

Diagnosis of Birth Asphyxia

The diagnosis of birth asphyxia is often clinical, based on the infant's symptoms, history, and
physical exam findings. However, additional tests may be used to confirm the diagnosis and
determine the severity of asphyxia: ‘APGAR’ score is a quick assessment made at 1 and 5
minutes after birth. Scores of 0-3 suggest severe asphyxia. ‘APGAR’ acronymn represents:
Appearance, Pulse rate, Grimace (response to stimulation of the skin on the newborn’s feet),
Activity (muscle tone movements) and Respiratory rate. The score is made as tabulated,
giving a minimum of ‘0’ and a maximum score of ‘10’, depending on the first assessment
during the first minute of birth, repeated every 5 minutes for up to 20 minutes or more,
depending on whether or not the newborn has asphyxia and/or its complications. The
management of the newborn will depend on the APGAR score. Other investigations include:
Blood gases: Arterial or venous blood gas tests to assess oxygen and carbon dioxide levels
and determine the degree of acidosis. Neuroimaging: MRI or cranial ultrasound to assess
brain injury in severe cases. Electroencephalogram (EEG): Used if seizures are present to
assess brain function.

APGAR 0 1 3

Appearance Pale & Grey Cyanosed Pink

Pulse Rate Absent <100 bpm >100 bpm

Grimace Absent Weak cry Strong cry

Activity Lying/Limb Some muscle tone Well flexed muscles

Respiration Absent Irregular gasps Regular gasps

APGAR Score Interpretation

APGAR Score may be categorized as follows: Normal newborn: score of 9 – 10; just keep
baby warm. Mild asphyxia: score of 7 – 8; management involves clearing the airway by
suction then oxygen therapy administration. Moderate asphyxia: score of 5 – 6; requires
active resuscitation. Severe asphyxia: score of 0 – 4; requires active resuscitation. APGAR
Score that is abnormal during first 5 minutes should be repeated after about 20 minutes.

Uses of APGAR Score

The score is useful for: (i) early diagnosis of asphyxia, (ii) early onset of resuscitation and (iii)
estimating prognosis of asphyxia (e.g. brain damage/death, and/or the grade of post -
asphyxia encephalopathy - PAE).

Early Complications of Birth Asphyxia

CVS Complications: Circulatory collapse, Persistent foetal circulation, Pulmonary

hypertension, Ischaemic Heart Disease; Renal Complications: Acute Renal Failure; R/S
complications: Lung collapse; Respiratory Distress Syndrome (RDS); Haematological
Complications: Anaemia; Thrombocytopenia; Disseminated Intravascular Coagulopathy
(D.I.C); Haemolytic Disease of the Newborn (HDN).

Late Complications of Birth Asphyxia

If birth asphyxia is not managed quickly and appropriately, it can lead to significant long-
term complications:

Neurological Sequelae (CNS Complications): Cerebral palsy (a group of disorders affecting

movement and posture),Intellectual disability (mental challenge/retardation): Cognitive
impairment, developmental delays, Blindness, Deafness, Hydrocephalus, Post - Asphyxial
Encephalopathy (PAE), Seizure disorders (often seen in children with significant birth
asphyxia), Hypoxic-ischemic encephalopathy (HIE): Brain injury due to lack of oxygen,
leading to long-term neuro-developmental issues. Organ damage: Cardiovascular
complications: Persistent pulmonary hypertension, heart failure. Renal failure: Acute kidney
injury due to reduced blood flow and oxygenation. Liver failure: In severe cases, liver
dysfunction can develop.

Management of Birth Asphyxia (Summary)

Mechanical Resuscitation Measures (’ABCD’): A - Airway clearance; B – Breathing

stimulation (ambubag; oxygen); C – Cardiac stimulation (External cardiac massage or
electrical stimulation); D – Drugs: Cardiac/Respiratory stimulants: Cardiac stimulants
[Adrenaline; Dopamine; Calcium gluconate]; Respiratory stimulants: Aminophylline; NaHCO3
(correct metabolic acidosis). N.B: Aim at correcting respiratory acidosis first before
correcting metabolic acidosis.
 Maintenance Measures: Oxygen p.r.n, Correct acid/base balance (IV fluids), Parenteral
feeding (NG/IV) p.r.n, Manage complications. N.B: As early as possible, upon suspicion of BA,
inform: Paediatrician, Newborn unit, Anaesthetist.

Immediate Resuscitation at Birth

 Airway management: Clearing the airway to ensure adequate ventilation (suctioning

if meconium aspiration or obstruction is suspected).
 Ventilation: If the infant is not breathing or has poor respiratory effort, positive
pressure ventilation (PPV) with a bag-valve mask (BVM) or intubation may be
required.
 Chest compressions: In cases of bradycardia (heart rate less than 60 beats per
minute), chest compressions may be initiated.
 Administration of medications:

o Epinephrine: For bradycardia unresponsive to ventilation and chest

compressions.
o Volume resuscitation: Intravenous fluids if hypovolemia is suspected.

Supportive Care

 Thermoregulation: Preventing hypothermia by keeping the infant warm.

 Oxygen therapy: Supplemental oxygen to correct hypoxia and maintain oxygen
saturation within safe limits (usually 90-95%).
 Monitoring: Continuous monitoring of vital signs, blood gases, and neurological
status.

Therapeutic Hypothermia (Cooling Therapy)

 Indication: Cooling is indicated for infants with moderate to severe hypoxic-ischemic

encephalopathy (HIE).
 Procedure: The infant is cooled to a target temperature of 33.5°C for 72 hours,
which has been shown to reduce brain injury and improve neurodevelopmental
outcomes.
 Timing: Cooling should begin within 6 hours of birth.

Long-Term Management

 Neurological follow-up: Regular monitoring for developmental delays, seizures, and

motor skills.
 Physical and occupational therapy: To aid in motor and cognitive development.
 Anticonvulsant medications: For infants who develop seizures.
 Multidisciplinary care: Involvement of pediatric neurologists, physical therapists,
speech therapists, and other specialists as needed.

Prevention
Prevention is focused on minimizing risk factors during pregnancy and labor:

 Prenatal care: Monitoring maternal health, detecting infections, hypertension, or

placental issues.
 Proper management of labor: Including timely cesarean delivery for cases of
obstructed labor, abnormal fetal heart rate patterns, or cord accidents.
 Fetal monitoring: Continuous monitoring of fetal heart rate during labor to detect
signs of distress.
 Prompt intervention: Immediate resuscitation and care for infants showing signs of
asphyxia.

Grading of PAE

Perinatal asphyxia: is the commonest cause of neonatal convulsions. Infants sustain

hypoxic-ischaemic compromise during labour in about 90% of cases; About 10% of cases
have postnatal causes of asphyxia. Asphyxiated infants show a consistent pattern of
neurological abnormality that develops over the first day of life, remain constant for a day or
more and then starts to resolve. The severity of Post - Asphyxial Encephalopathy (PAE) can
be classified as tabulated. Only infants with moderate and severe PAE develop seizures and
apnoea. About 0.2% (2 per 1000) of full-term infants develop post-asphyxial fits.

Grade I Grade II Grade III

(Mild PAE) (Moderate PAE) (Severe PAE)

General Irritable Lethargic Comatose

Condition

Seizure Hyper - Moderate seizures Prolonged seizures

Status alert

Muscle Mild Differential tone Severe hypotonia

Tone hypertonia

Feeding Poor Requires tube feeding Respiratory Failure (Not

Status feeding feeding)
Resuscitation of a newborn is also called Asphyxia Neonatorum.

The Indications of Resuscitation of a newborn are:

(i) Mild Asphyxia

(ii) Moderate Asphyxia

(iii) Severe Asphyxia

Objectives of Resuscitation of a Newborn:

(i) To establish and maintain a clear airway

(ii) to perform artificial ventilation

(iii) To perform cardiac massage in a newborn

(iv) To prevent complications (especially, Hypothermia and Hypoglycaemia)

Procedure of Resuscitation:

Whenever you suspect asphyxia in a newborn baby:

(i) Inform the paediatrician/paediatrics clinician if available.

(ii) Inform the Newborn Unit of your institution to be ready (assuming you are
conducting/participating in the delivery at the time)

(iii) Inform the anaesthetist to be ready (in case the newborn will need to be rushed to
theatre).

Meanwhile, complete the delivery process by ensuring that:

The umbilical cord is cut and appropriately ligated.

Avoid hypothermia: Quickly ensure the newborn is kept warm while on the resuscitation
table. Ensure the baby is dry by wrapping with a dry clean towel then discard that towel and
wrap the baby with another clean, dry towel.

Assess the APGAR Score of the baby 1 minute; repeat again at 5 minutes.

Management of Mild - to - Moderate Asphyxia:

Quickly re-assess the drugs given to the mother during labour (some of them may have
depressed the neonatal breathing (especially if narcotics such as pethidine or morphine was
used during labour).

If these drugs were used within the last three hours prior to labour/delivery, Intravenous
Naloxone Hydrochloride should be administered at a dose of 0.01mg/kg of body weight
(averaging to about 0.03mg for the newborn). This will reverse the effects of the narcotics.

Place the newborn in supine position, with the head tilted/extended slightly backwards.

Ensure the airway is cleared (using a clean swab then suck out any secretions (such as
meconium or mucus).
Insert the infant airway in place, to prevent obstruction then inflate ambu-bag and pump air
accordingly (inflate and pump air twice then give 3-5 chest compressions between the
inflations).

In case meconium aspiration has occurred, a skilled health worker (e.g. obstetrician or
paediatrician or experienced midwife) will need to intubate in order to perform suction from
deeper airways (in bronchi or bronchioles).

The ambu-bag will also need to be connected to a continuous oxygen supply, if available and
ensure the ambu- bag is properly positioned to effectively supply the needed oxygen.
Continue APGAR scores every five minutes.