B.

MUDI INFANT

INFANT I

Learning Objectives

At the end of the course, the student should be able to:

1. Describe the structure and physiological changes of a new-born.

2. Demonstrate competence in the examination and care of the new-born.

3. Describe the component of infant nutrition.

4. Discuss the steps in the follow-up and discharge of the new-born.

INTRODUCTION

• An infant (from the Latin word infans, meaning "unable to speak" or "speechless") is the
more formal or specialised synonym for "baby", the very young offspring of a human.

• A newborn is an infant who is only hours, days, or up to one month old.

• In medical contexts, newborn or neonate (from Latin, neonatus, newborn) refers to an

infant in the first 28 days after birth; the term applies to premature, full term, and
postmature infants.

• The term "infant" is typically applied to young children under one year of age; however,
definitions may vary and may include children up to two years of age. When a human
child learns to walk, the term "toddler" may be used instead.

A healthy infant

A healthy infant born at term (between 38-42 weeks) should have an average birth weight
that usually exceed 2500 gm. crises immediately following birth, establishes independent
rhythmic respiration and quickly adapts to changed environment

FEATURES OF THE NEWBORN

While each baby is a unique individual there are certain characteristics and behaviors that are
common to newborns. This section will describe some of the physical and behavioral traits you
may notice in the newborn during the first few weeks of life.

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PHYSICAL CHARACTERISTICS

• A newborn's shoulders and hips are wide, the abdomen protrudes slightly, and the arms
and legs are relatively long with respect to the rest of their body.

Length

• The average total body length of a newborn is 35.6–50.8 cm (14.0–20.0 in), although
premature newborns may be much smaller.

• The way to measure a baby's length is to lay the baby down and stretch a measuring tape
from the top of the head to the bottom of the heel.

• Head circumference – 33- 35 cm

• Chest circumference - 31- 33 cm

• Weight

• The average birth weight of a full-term newborn is approximately 3.0 kg and is typically
in the range of 2.5–3.99kg

• Over the first 5–7 days following birth, the body weight of a term neonate decreases by
3–7%, and is largely as result of the reasorption and urination of the fluid that initially
fills the lungs, in addition to a delay of often a few days before breastfeeding becomes
effective. After the first week, healthy term neonates should gain 10–20 grams/day

• Posture

• The newborn assumes the attitude of its intrauterine life , i.e.

• extremities flexed and fists clenched.

VITAL SIGNS

• Temperature regulation. The infant's body temperature drops immediately after birth in
response to the extrauterine environment. the internal organs are poorly insulated and the
skin is very thin and does not contain much subcutaneous fat. The infant's heat regulating
mechanism has not fully developed. their temperature rapidly reflects that of his
environment. The flexed position that the infant assumes is a safeguard against heat loss

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because it substantially diminishes the amount of body surface exposed. The infant's
axillary temperature is maintained at 36.4 to 37.2o C.

• Pulse. The normal pulse range for an infant is 120 to 140 beats per minute (bpm). The
rate may rise to 160 bpm when the infant is crying or drop to 100 bpm when the infant is
sleeping. The apical pulse is considered the most accurate .

• Blood Pressure. The normal blood pressure(BP) of an infant at birth ranges from 60-
70/31-45mmHg. BP is directly related to gestational age and birth weight of the infant.

• Respirations. The respirations of a newborn infant are irregular in depth, rate, and rhythm
and vary from 30 to 60 beats per minute. Respirations are affected by the infant's activity
(that is, crying).

Head

Shape: Because of pressure before or during birth, your baby’s head may be temporality
misshapen. Normal head shape usually returns by the end of the first week. Babies delivered by
Cesarean usually don’t have as much of this head molding.

Fontanelles/Soft spots: newborn has two obvious soft spots or fontanelles. One is on the top of
the head and the other is near the back of the head. Both the fontanelles are covered by a tough
membrane and with normal handling care, the soft spots can not be damage when shampooing,
brushing, or stroking the newborns head.

Eyes

Color, tears, and swelling: Caucasian infants usually have grayish-blue eyes at birth. Infants of
other ethnic backgrounds may have grayish-brown or brown eyes. However, an infant’s true eye
color may not be known for several months. Tears are usually not produced in noticeable
amounts with crying until your baby is one to two months of age. Swollen and puffy eyelids or
red hemorrhages on the white conjunctivae are normal after birth and result from pressure during
birth. Swelling and inflammation usually go away in a few days.

Eye discharge: Occasionally, a baby may have irritation from the antibiotic ointment given at
birth. You may notice a small amount of yellow discharge from your baby’s eyes during your
hospital stay. This usually clears within 24 hours. If you notice a small amount of yellow

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discharge form your baby’s lids or lashes after you get home, just gently wipe it away with a
warm moist cloth or cotton ball. If the discharge is purulent (yellow or green), in large amounts
and accumulates frequently, please notify us; this can be a symptom of an infection or a blocked
tear duct in need of antibiotic drop therapy.

Ears

Newborns have a wide variety of ear sizes, shapes, and positions that are normal. At birth your
baby’s ears may bend easily. In time, the ear will feel firmer.

Ear Discharge: It is normal for a baby’s ears to produce wax. It is not normal for them to
produce any other kind of discharge. If you think the discharge from your baby’s ears is not
wax, please call us. Cotton swabs should not be used in your baby’s ears at any time; one can
inadvertently be tamping wax down into the canal deeply without realizing it. Ears can be
cleaned well with the corner of a clean, damp washcloth. Just clean what you can see.

Breasts

Swollen breasts: During the first days after birth, it is normal for both boys and girls to have
swollen breasts. This swelling is caused by hormones a baby gets from the mother during
pregnancy. Occasionally a baby may produce a small amount of milk. If your baby does
produce milk or have breast swelling, do not attempt to squeeze out the milk, as this might cause
infection. The swelling will go down as the baby’s body metabolizes the mother’s hormones. If
the breasts are markedly swollen, tender or reddened, please call us so that we can evacuate the
child for the possibility of mastitis.

Skin

Color: The skin is thin and dry. You may see some veins through it. The skin is the Caucasian
newborn is a pink or reddish color. As babies cry, they may become a deeper red. In the Black
infant, the skin color appears as a reddish-black color that darkens as the baby gets older. In
Asian babies the skin is a tea rose color. Frequently, dark bluish spots may appear on the lower
portion of the back or buttocks of babies of Black, Asian, or Mediterranean descent. These are
called Mongolian spots. They are caused by a temporary accumulation of pigment under the
skin and they fade without treatment during preschool years. Despite the names, these spots

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have nothing to do with Mongolism or Down ’s syndrome. In the newborn it is common for the
baby’s hands and feet to appear bluish. This is called acrocyanosis. This is common in the first
few days of life and decreases gradually.

Milia: These are tiny white spots often seen on the nose and chin. They are caused by
obstruction of oil or sebaceous glands. You should not squeeze these spots. They usually
disappear in several weeks.

Lanugo: baby’s body is covered with fine downy hair. This hair is most noticeable on the back,
shoulders, and ear lobes. It will fall out in time.

Vernix: A white, cheese-like substance called vernix at one time covered your baby’s skin to
protect it while in the bag or waters. Traces of it are usually found in the body’s creases. It is
not necessary to scrub this off.

Peeling: Most babies’ skin peels after birth because they have been in fluid for many months.
This generalized peeling is completely normal and requires no treatment, including oils or
lotions.

Rashes: A temporary rash, called erythema toxicum, may occur during the first few weeks. It is
small areas of redness with raised yellowish-white centers and it may resemble a flea bite or
hives. This rash requires no treatment. Washing clothing with a mild detergent, such as Dreft or
Ivory, omitting fabric softeners and double rinsing if necessary, will help minimize rashes.

Red blotches: Many babies have reddened areas of skin on their upper eyelids and forehead.
These are areas of dilated blood vessels. These areas usually fade with time (months to years) as
the blood vessels contract and as the baby’s skin grows thicker and less transparent. Redness
may reappear when your baby cries. These are often called Stork Bites or Angel Kisses and are
distinct from the deeper purple Port-Wine stains which are permanent. They are areas of tangled
capillaries. As the baby gets older, these vessels contract and the visible redness fades.

Diaper rash: Diaper rash is often caused by irritants in the urine or stool. To minimize diaper
rashers, be sure to change your baby’s diaper frequently (every two to three hours during the
day). Always wash the diaper area with plain water at each change. If you launder your own
diapers, double rinses with one-half cup of vinegar per rinse load may help eliminate any soap

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and neutralize the ammonia. If your baby develops a rash in spite of these precautions, try to
change diapers more frequently and expose the reddened area to the air several times a day. A
diaper rash ointment (vaseline or A&D) applied to the rash area after air-drying may be helpful.
Occasionally babies develop a yeast infection of the diaper area. This is usually a deep red
colored rash covering a continuous area and with accentuation in the skin folds and satellite
lesions at the outer edge. If you suspect this, use Lotrimin AF ointment (clotrimazole) which is
available over-the-counter or call us for further guidance.

Genitals- Swelling & Vaginal Discharge: The genitals of both boys and girls are usually large
and swollen from hormones passed from the mother through the placenta. Girls may also have a
white, mucoid, and sometimes blood-tinged vaginal discharge. As your baby metabolizes your
hormones, these changes will disappear.

INBORN REFLEXES

Moro (Startle): The Moro reflex is a sudden reaction to a loud noise or change in position. It
appears as jerky, generalized muscular activity with a flinging out of your baby’s arms and legs,
then bringing them back in towards the body.

Rooting: When an object touches your baby’s cheek, your baby turns his head toward the side
touched, opens his mouth and begins to suck.

Sucking and Swallowing: Touching your baby’s lips will trigger the sucking reflex which is
followed by the swallowing reflex.

Gag: The gag reflex helps your baby get rid of mucus in his stomach that he swallowed during
birth or to regurgitate excess milk taken at a feeding.

Hiccups: Hiccups are a common occurrence. They do not bother your baby and will go away
without any special treatment.

Cough & Sneeze: These reflexes help your baby remove irritating substances from him nose and
throat. They are not necessarily signs of a cold.

Blinking: Your baby’s eyes will blink when they are exposed to bright light. Blinking also
protects the eyes from foreign objects.

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Walking: When you hold your baby around the chest in an upright position with his feet
touching a hard surface, he will make prancing movements with his feet.

Grasping: This reflex is present in both the hands and the feet. Your baby will grasp any object
put into his hands, hold it briefly and then drop it.

SLEEP/WAKE STATES

Deep Sleep: In this state your baby is nearly still except for an occasional startle or twitch.
Breathing is regular. There are no eye movements and few facial movements. It is very difficult
to arouse your baby in this state.

Light Sleep: In this state your baby shows some body movement. Breathing is irregular. You
can see rapid eye movements beneath the eyelids and your baby may smile or briefly fuss. This
state usually comes just before awakening or you may be able to awaken your baby to feed at
this time.

Drowsy: In the drowsy state you baby’s activity level varies. The eyes may open and close
occasionally and seem heavy. Breathing is also irregular in this state. Your baby may go back to
sleep or awaken more.

Quite Alert: When your baby is in the quiet alert state, his eyes are wide open, his breathing is
regular, and he is very attentive to what is going on around him. During this time, your baby is
most interested in eating and learning about his new world.

Active Alert: In this state your baby becomes very active and may fuss. His breathing is again
irregular and he is increasingly sensitive to stimulation or personal needs such as hunger,
discomfort, fatigue, etc. At this time it is best to comfort your baby and bring him to a lower
state.

Crying: Crying is your baby’s way of telling you that he needs something or that something is
bothering him. Some causes of crying include hunger, physical discomfort, fatigue, boredom,
needing to be burped, being over stimulated, or needing close physical contact. As you live with
your baby, you will learn to tell the difference in his cries and discover what works best to soothe
him.(clinical paediatrics associates,2018).

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TRANSITION AT BIRTH

Transition to extrauterine life is characterized by changes in circulatory pathways, initiation of

ventilation and oxygenation via the lungs instead of the placenta, and many changes in
metabolism. Important physiologic changes during transition to extrauterine life Increased
systemic vascular resistance with separation from the low-resistance placental vasculature
Closure of right-to-left shunts Foramen ovale (closes when left atrial pressure greater than right
atrial pressure) Ductus arteriosus (left-to-right flow within minutes of ventilation, then closure
over days) Rapid lowering of pulmonary vascular resistance with onset of ventilation Clearance
of fluid from airways via active sodium absorption and changes in airway pressure owing to
ventilation Increased metabolic rate leading to higher glucose needs Increased catecholamine
levels to support blood pressure Successful transition from fetal to postnatal circulation requires
clamping of umbilical cord and removal of the placenta increased pulmonary blood flow, Shunt
closure from left to right. initiation of respirations in the Mechanical Chemical Sensory/
Thermal factors. mechanical Compression of fluid from the fetal lung during vaginal delivery
establishes the lung volume As the chest passes through the birth canal the lungs are compressed
Subsequent recoil of the chest wall produces passive inspiration of air into the lungs Negative
inspiratory pressures of up to 70-100 cm H2O are initially required to expand the alveoli which
facilitate lung expansion by overcoming airways resistance inertia of fluid in the airways surface
tension of the air/fluid interface in the alveolus. Chemical event with cutting of the cord, remove
oxygen supply, Asphyxia occurs, CO2 and O2 and pH becomes acidic. Acidotic state stimulates
the respiratory center in the medulla and the chemoreceptors in carotid artery to initiate
breathing. Thermal/sensory events consist of decrease in environmental temperature after
delivery is a major stimulus of breathing Tactile nerve endings in the skin are stimulated Visual
change from a dark world to one of light, Auditory sound in the extra uterine environment
stimulates the infant.

PHYSIOLOGICAL CHANGES IN THE NEWBORN

CARDIOVASCULAR SYSTEM.

Blood Circulation in the Fetus and Newborn

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During pregnancy, the fetal circulatory system works differently than after birth, The fetus is
connected by the umbilical cord to the placenta, the organ that develops and implants in the
mother's uterus during pregnancy. Through the blood vessels in the umbilical cord, the fetus
receives all the necessary nutrition, oxygen, and life support from the mother through the
placenta. Waste products and carbon dioxide from the fetus are sent back through the umbilical
cord and placenta to the mother's circulation to be eliminated. The fetal circulatory system uses
two right to left shunts, which are small passages that direct blood that needs to be oxygenated.
The purpose of these shunts is to bypass certain body parts in particular, the lungs and liver that
are not fully developed while the fetus is still in the womb. The shunts that bypass the lungs are
called the foramen ovale, which moves blood from the right atrium of the heart to the left atrium,
and the ductus arteriosus, which moves blood from the pulmonary artery to the aorta. Oxygen
and nutrients from the mother's blood are transferred across the placenta to the fetus. The
enriched blood flows through the umbilical cord to the liver and splits into three branches. The
blood then reaches the inferior vena cava, a major vein connected to the heart. Most of this blood
is sent through the ductus venosus, also a shunt that passes highly oxygenated blood through the
liver to the inferior vena cava and then to the right atrium of the heart. A small amount of this
blood goes directly to the liver to give it the oxygen and nutrients it needs. Waste products from
the fetal blood are transferred back across the placenta to the mother's blood.

Blood enters the right atrium, the chamber on the upper right side of the heart. When the blood
enters the right atrium, most of it flows through the foramen ovale into the left atrium. Blood
then passes into the left ventricle (lower chamber of the heart) and then to the aorta, (the large
artery coming from the heart). From the aorta, blood is sent to the heart muscle itself in addition
to the brain. After circulating there, the blood returns to the right atrium of the heart through the
superior vena cava. About two thirds of the blood will pass through the foramen ovale as
described above, but the remaining one third will pass into the right ventricle, toward the lungs.
In the fetus, the placenta does the work of breathing instead of the lungs. As a result, only a small
amount of the blood continues on to the lungs. Most of this blood is bypassed or shunted away
from the lungs through the ductus arteriosus to the aorta. Most of the circulation to the lower
body is supplied by blood passing through the ductus arteriosus. This blood then enters the
umbilical arteries and flows into the placenta. In the placenta, carbon dioxide and waste products

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are released into the mother's circulatory system, and oxygen and nutrients from the mother's
blood are released into the fetus' blood.

At birth, the umbilical cord is clamped and the baby no longer receives oxygen and nutrients
from the mother. With the first breaths of life, the lungs begin to expand. As the lungs expand,
the alveoli in the lungs are cleared of fluid. An increase in the baby's blood pressure and a
significant reduction in the pulmonary pressures reduces the need for the ductus arteriosus to
shunt blood. These changes promote the closure of the shunt. These changes increase the
pressure in the left atrium of the heart, which decrease the pressure in the right atrium. The shift
in pressure stimulates the foramen ovale to [Link] closure of the ductus arteriosus and
foramen ovale completes the transition of fetal circulation to newborn circulation. (children
hospital philadephelia 2018)

RESPIRATORY SYSTEM

Significant pulmonary changes are triggered at the onset of labor. Surfactant is a mixture of
lipids and proteins that reduces the surface tension within airways by forming a monolayer at the
liquid–air interface. Surfactant secretion into the fetal lungs is stimulated by labor. Alveolar
stretch as a result of initiation of ventilation further increases the secretion of surfactant. These
polar molecules function to lower surface tension in the lungs, allowing for inflation at lower
[Link] initiation of breathing is a complex process that involves the interaction of
biochemical, neural and mechanical factors (Alvaro & Rigatto, 2005). Pulmonary blood flow,
surfactant production, and respiratory musculature also influence respiratory adaptation to
extrauterine life. Umbilical cord clamping decreases oxygen concentration, increases carbon
dioxide concentration, and decreases the blood pH. This stimulates the fetal aortic and carotid
chemoreceptors, activating the respiratory centre in the medulla to initiate respiration.
Mechanical compression of the chest during the vaginal birth forces approximately 1/3 of the
fluid out of the fetal lungs. As the chest is delivered, it re-expands, generating a negative
pressure and drawing air into the lungs. Passive inspiration of air replaces fluid. As the infant
cries, a positive intrathoracic pressure is established which keeps the alveoli open, forcing the
remaining fetal lung fluid into the lymphatic circulation. In order for the respiratory system to
function effectively, the infant must have:

1. Adequate pulmonary blood flow

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2. Adequate amount of surfactant

3. Respiratory musculature strong enough to support respiration (Askin, 2008)

Umbical cord cut and clamped ventilation

Decreased blood flow lung expansion

Decreased vascular resistance pulmonary dilatation

Decreased pressure on the Rt increased bld flow to the left

Closure of FO, DA, & DV. Increased pressure on the left

BODY TEMPERATURE

At birth, infants emerge covered in liquid, resulting in potential heat loss via evaporation. If
newborns are not held skin to skin or wrapped in a warm blanket, hypothermia can ensue
because of conduction, convection, and radiant heat losses. Relative to older children, neonates
have a higher body surface area, limited capacity to generate heat via shivering, and decreased
subcutaneous fat for insulation. Brown adipose tissue lipolysis triggered by norepinephrine can
generate heat, and peripheral vasoconstriction can minimize heat loss. Thyroid hormones surge
after birth, possibly in response to the relatively cold extrauterine environment.

Superficial deposits of brown fat are located : • Between the scapulae. • Around the neck. • In the
axillae. • Behind the sternum. • Deeper layers surround the kidneys. • Trachea • Esophagus. •
Some major arteries, and adrenals

Factors responsible for thermoregulation

Anatomical factors. Environmental factors.

1. Large surface area 1. evaporation

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2. Less adipose tissue 2. conduction

3. Low humidity 3. convection
4. Thin epidermis 4. radiation
5. Presence of fluid in the body

Responses

Hypothermia hyperthermia

a. Vasoconstriction vasodilatation
b. Increased metabolic activities increased oxygen consumption
c. Increased muscular activities increased water loss.
d. Non shivering thermogenesis
e.

Hematologic Changes/ Hematopoietic System

After birth, the production of fetal hemoglobin decreases and there is a concomitant increase in
hemoglobin β chain production such that normal levels of adult hemoglobin are achieved by 4 to
6 months of age. Exposure to the increased oxygenation of the extrauterine environment leads to
decreased erythropoietin, leading to lower rates of erythropoiesis in the neonate compared with
the fetus. The blood volume of the newborn depends on the amount of placental transfer of
blood. The blood volume of a full-term infant is about 80 to 85 ml/kg of body weight
Immediately after birth. The total blood volume averages 300 ml.

Metabolic Changes

Glucose and amino acids are transported actively to the fetus across the placenta, a process that
is stopped by separation from the placental circulation. Generally, smaller mammals have higher
metabolic rates. However, the fetus has a low metabolic rate despite a small size, with a
metabolic rate similar to that of the pregnant woman. After delivery, there is a progressive
increase in metabolic rate, which occurs more slowly in preterm infants. Mitochondrial density
increases as the metabolic rate increases.

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To maintain blood glucose levels after separation from the placental circulation, the newborn
experiences a surge in catecholamine and glucagon levels and a decrease in insulin amounts.
Gluconeogenesis and glycogenolysis in the liver ensures stable blood glucose until oral intake
volumes improve over the first few days after birth. Ketone bodies and lactate provide additional
energy for the brain, with hepatic ketogenesis increasing after the first 12 hours of age.

LIVER

The liver is the most immature of the gastrointestinal organs. The activity of the enzyme
glucuronyl transferase is reduced which Affects the conjugation of bilirubin with glucuronic acid
and contributes to physiologic jaundice of newborns. The liver is also deficient in forming
plasma proteins. Gastrointestinal System The decreased plasma protein concentration probably
plays a role in the edema usually seen at birth. The liver stores less glycogen at birth than later in
life. • Consequently, newborns are prone to hypoglycemia.

GASTROINTESTINAL TRACT

A baby's gastrointestinal system doesn't fully function until after birth. In late pregnancy, The
ability of newborns to digest, absorb, and metabolize foodstuff is adequate but limited in certain
functions. Enzymes are adequate to handle proteins and simple carbohydrates. Deficient
production of pancreatic amylase impairs use of complex carbohydrates. Deficiency of
pancreatic lipase limits absorption of fats, especially with ingestion of foods with high saturated
fatty acid content such as cow’s milk. Human milk, despite its high fat content, is easily digested
because the milk itself contains enzymes such as lipase, which assist in digestion. Some salivary
glands are functioning at birth, but the majority do not begin to secrete saliva until about age 2 to
3 months, when drooling is frequent. Stomach capacity varies in the first few days of life, from
about 5 ml on day 1 to about 60 ml on day 3. • thus, infants require frequent small feedings
Gastrointestinal System. An infant’s intestine is longer in relation to body size than that of the
adult. • Therefore, there are a larger number of secretory glands and a larger surface area for
absorption compared with an adult’s intestine. Meconium is an Infant’s first stool; composed of
amniotic fluid and its constituents, intestinal secretions, shed mucosal cells, and possibly blood
(ingested maternal blood or minor bleeding of alimentary tract vessels). Passage of meconium
should occur within the first 24 to 48 hours, although it may be delayed up to 7 days in very
low–birth-weight infants. Transitional Stools, Usually appear by third day after initiation of

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feeding; greenish brown to yellowish brown, thin, and less sticky than meconium; may contain
some milk curds. Milk Stool, Usually appears by fourth day In breastfed infants stools are yellow
to golden, are pasty in consistency, and have an odor similar to that of sour milk. In formula-fed
infant’s stools are pale yellow to light brown, are firmer in consistency, and have a more
offensive odor. At birth the [Link] is structurally complete but functionally [Link]
membrane is pink and moist, teeth are buried in the gums, ptylin secretion is low sucking and
swallowing reflexes are coordinated. Cardiac sphincter is weak predisposing to regurgitation of
milk. Gastric emptying is normally 2-3hrs .

URINARY SYSTEM

The developing baby's kidneys begin producing urine by 9 to 12 weeks into the pregnancy. After
birth, the newborn will usually urinate within the first 24 hours of life. The kidneys become able
to maintain the body's fluid and electrolyte balance. The rate at which blood filters through the
kidneys (glomerular filtration rate) increases sharply after birth and in the first 2 weeks of life.
Still, it takes some time for the kidneys to get up to speed. Newborns have less ability to remove
excess salt (sodium) or to concentrate or dilute the urine compared to adults. This ability
improves over time. Total volume of urine per 24 hours is about 200 to 300 ml by the end of the
first week. the bladder voluntarily empties when stretched by a volume of 15 ml, resulting in as
many as 20 voidings perday. • The first voiding should occur within 24 hours. The urine is
colorless and odorless and has a specific gravity of about 1.020. Inability to concentrate urine
which makes infant susceptible to dehydration and electrolyte imbalance.

Musculoskeletal System

At birth, the skeletal system contains more cartilage than ossified bone, although the process of
ossification is fairly rapid during the first year. • The six skull bones are relatively soft and are
separated only by membranous seams. The sinuses are incompletely formed in newborns. •
muscular system is almost completely formed at birth.

Integumentary System

At birth, all of the structures within the skin are present, but many of the functions of the
integument are immature. The growth phases of hair follicles usually occur simultaneously at
birth. During the first few months, the synchrony between hair loss and re growth is disrupted,

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and there may be overgrowth of [Link] eccrine glands, which produce sweat in response to
heat or emotional stimuli, are functional at birth, and palmer sweating on crying reaches levels
equivalent to those of anxious adults by 3 weeks of age. The eccrine glands produce sweat in
response to higher temperatures than those required in adults, and the retention of sweat may
result in miliaria.

IMMUNE SYSTEM

The immune system begins to develop in the baby, and continues to mature through the child's
first few years of life. The womb is a relatively sterile environment. But as soon as the baby is
born, he or she is exposed to a variety of bacteria and other potential disease-causing substances.
Although newborn infants are more vulnerable to infection, their immune system can respond to
infectious organisms. Newborns do carry some antibodies from their mother, which provide
protection against infection. Breastfeeding also helps improve a newborn's immunity. (U.S
national library of medline, medline plus, 2017

Endocrine System

Ordinarily, the endocrine system of newborns is adequately developed,but its functions are
immature. The effect of maternal sex hormones is particularly evident in newborns. • The labia
are hypertrophied, and the breasts of both genders may be engorged and secrete milk from the
first few days of life to as long as 2 months of age. • Female newborns may have
pseudomenstruation (more often seen as a milky secretion than actual blood) from a sudden drop
in progesterone and estrogen levels.

REFERENCES.

1. Clinical paediatrics associates, understanding your newborn, 2018.

2. Children hospital of Philadelphia, blood circulation in the fetus and newborn, 2018.
3. US national library, us dept of health and human services, national institute of health, last
updated 2018.

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IMMEDIATE CARE OF THE NEWBORN

Goals:

 To establish, maintain and support respirations.

 To provide warmth and prevent hypothermia.
 To ensure safety, prevent injury and infection.
 To identify actual or potential problems that may require immediate attention.

According to Daisy, (2009), the immediate care includes the following:

1. Establishment of respiration and maintenance of clear airway

The most important need for the newborn immediately after birth is a clear airway to
enable the newborn to breathe effectively since the placenta has ceased to function as an
organ of gas exchange. It is in the maintenance of adequate oxygen supply through
effective respiration that the survival of the newborn greatly depends. Newborns are
obligatory nose breathers. The reflex response to nasal obstruction, opening the mouth to
maintain airway, is not present in most newborns until 3 weeks after birth.
Therefore, to establish and maintain respiration immediately:
1. Wipe mouth and nose of secretions after delivery
of the head.
2. Suction secretions from mouth and nose.
 Compress bulb syringe before inserting or if using
mucus extractor, lubricate the nasal tube before
inserting.
 Suction mouth first, then, the nose
 Insert bulb syringe/mucus extractor in one side of the mouth

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3. A crying infant is a breathing infant. Stimulate the baby to cry if baby does not cry
spontaneously or if the cry is weak by

 Rubbing the soles of the feet.

 Stimulating to cry after secretions are removed.
 The normal infant cry is loud and husky. Observe for the following abnormal cry:
o High, pitched cry – indicates hypoglycemia, increased intracranial pressure.
o Weak cry – prematurity
o Hoarse cry – laryngeal stridor

4. Oral mucous may cause the newborn, to choke, cough or gag during the first 12 to 18
hours of life. Place the infant in either of the following positions to promote drainage of
secretions.

 Trendelenburg position – head lower than the body

 Side lying position – If Trendelenburg position is contraindicated, place infant in side
lying position to permit drainage of mucus from the mouth. Place a small pillow or rolled
towel at the back to prevent newborn from rolling back to supine position.

5. Keep the nares patent. Remove mucus and other particles that may be causing
obstruction.

2. Note time of birth

3. Dry and keep infant warm

4. Care of the Eyes

It is part of the routine care of the newborn to give prophylactic eye treatment against
gonorrhea conjunctivitis or opthalmia neonatorum. Neisseria gonorrhea, the causative
agent, may be passed on the fetus from the vaginal canal during delivery. This practice
was introduced by Crede, a German gynecologist in1884. Silver nitrate, erythromycin
and tetracycline ophthalmic ointments are the drugs used for this purpose.

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Erythromycin or tetracycline Opthalmic Ointment:

1. These ointments are the ones commonly used now adays for eye prophylaxis because
they do not cause eye irritation and are more effective against Chlamydial conjunctivitis.
2. Apply over lower lids of both eyes, then, manipulate eyelids to spread medication over
the eyes.

5. Administration of Vitamin K or Aquamephyton

Give vitamin K (1mg intramuscularly) immediately after [Link] newborn has a sterile
intestine at birth, hence, the newborn does not possess the intestinal bacteria that
manufactures vitamin K which is necessary for the formation of clotting factors. This
makes the newborn prone to bleeding. As a preventive measure, injection Vitamin K or
aquamephyton 0.5mg and 1 mg (for preterm and full term babies respectively) is injected
Intra-muscularly in the newborn’s vastus lateralis (lateral anterior thigh) muscle.
6. Care of the cord
The cord is clamped and cut approximately within
30 seconds after birth. In the delivery room, the
cord is clamped twice about 8 inches from the
abdomen and cut in between. When the newborn is
brought to the nursery, another clamp is applied ½
to 1 inch from the abdomen and the cord is cut at
second time. The cord and the area around it are cleansed with antiseptic solution. The
manner of cord care depends on hospital protocol. What is important is that the principles
are followed. Cord clamp maybe removed after 48 hours when the cord has dried. The
cord stump usually dries and fall within 7 to 10 days leaving a granulating area that heals
on the next 7 to 10 days.
Instruction to the mother on cord care:

1. No tub bathing until cord falls off. Do not sponge bath to clean the baby. See to it that
cord does not get wet by water or urine.
2. Do not apply anything on the cord such as baby powder or antibiotic, except the
prescribed antiseptic solution which is 70% alcohol.

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3. Avoid wetting the cord. Fold diaper below so that it does not cover the cord and does not
get wet when the diaper soaks with urine.
4. Leave cord exposed to air. Do not apply dressing or abdominal binder over it. The cord
dries and separates more rapidly if it is exposed to air.
5. If you notice the cord to be bleeding, apply firm pressure and check cord clamp if loose
and fasten.
6. Report any unusual signs and symptoms which indicates infection.
 Foul odor in the cord
 Presence of discharge
 Redness around the cord
 The cord remains wet and does not fall off within 7 to 10 days
 Newborn fever

7. THE APGAR SCORING SYSTEM

Determine Apgar score. The APGAR Scoring
System was developed by Dr. Virginia Apgar as a
method of assessing the newborn’s adjustment to
extra uterine life. It is taken at one minute and five
minutes after birth. With depressed infants, repeat
the scoring every five minutes as needed. The
1minute score indicates the necessity for

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resuscitation. The 5 minutes’ score is more reliable in predicting mortality and neurologic
deficits. The most important is the heart rate, then the respiratory rate, the muscle tone,
reflex irritability and color follows in decreasing order. A heart rate below 100 signifies
an asphyxiated baby and a heart rate above 160 signifies distress.

The five criteria of the Apgar score according to Reiter & Walsh (2010)

 Appearance/complexion: Is the baby blue or pale all over, is the body pink, or is the baby
blue at extremities?
 Pulse rate: Is the baby’s heart rate absent, slow (<100 beats per minute (bpm), or fast
(>100 bpm)?
 Reflex irritability: Does the baby have no response to stimulation, does she grimace and
give a feeble cry, or does she cry and pull away when stimulated?
 Activity: Does the baby exhibit no activity, have some flexion (joint movement), or does
she have flexed arms and legs that resist extension?
 Respiratory effort: Is the baby breathing, does she have a weak, irregular respiratory
effort, or is her cry really strong

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Scores of 1-3 are critically low, 4-6 are below normal, and 7+ are normal. A low score indicates
that a baby is likely to need medical intervention; the lower the score, the more alert the medical
team should be to the possibility of intervention. For example, a baby with a low score is more
likely than a baby with a high score to need resuscitation. When a baby requires resuscitation, it
means that she needs help for her heart, her blood pressure, and/or she needs help to breathe or to
start breathing. Some components of the Apgar score are subjective and certainly there are cases
in which a score is high, but urgent medical treatment for the baby may be needed nonetheless.

If the score remains low at later times, such as at 10, 15, or 30 minutes after birth, there is a risk
that the child will suffer long-term neurological damage, and there also is a small but significant
increase of the risk of cerebral palsy. Higher Apgar scores, however, do not rule out the
possibility that the baby has a brain injury, such as hypoxic ischemic encephalopathy (HIE). It is
important to remember, though, that the purpose of the Apgar score is to quickly determine
whether a newborn needs immediate medical care; it was not devised to make-long term
predictions regarding the baby’s health (Reiter & Walsh, 2010).

Causes of low Apgar Score (Reiter & Walsh, 2010).

 body impinges on it) or nuchal cord (cord is wrapped around the baby’s neck)
 Placental abruption, which occurs when part of the placenta tears away from the uterus.
 Uterine rupture, which occurs when the wall of the uterus (womb) tears open.
 Trauma to the baby’s head can occur during labor if forceps or vacuum extractors are
used to help deliver Umbilical cord problems, such as a prolapsed cord (cord exits in
front of the baby and the baby’s the baby. Also, macrosomia (large baby), cephalopelvic
disproportion (mother’s pelvis is too small for the size of the baby), a malpositioned baby
(such as breech, face, or brow presentation), or the shoulder getting stuck on the mother’s
pelvic bone (shoulder dystocia) all can increase the likelihood of head trauma during
delivery
 Excessive uterine activity can occur when Pitocin or Cytotec are used during labor and
the medication causes very strong and frequent contractions that deprive the baby of
oxygen.

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 Undiagnosed or improperly treated maternal infections, such as chorioamnionitis and

villitis, Group B Strep (GBS), and herpes simplex virus (HSV)
 Severe preeclampsia (high maternal blood pressure)
 Amniotic fluid embolism, which is a condition in which amniotic fluid, fetal cells, or
other debris enters the mother’s blood stream, which triggers an allergic reaction that
causes cardiorespiratory collapse in the mother, which then causes rapid deterioration of
the baby
 Excessive vaginal bleeding

ESSENTIAL NEWBORN CARE

High-quality universal newborn health care is the right of every newborn

everywhere. Babies have the right to be protected from injury and infection, to breathe
normally, to be warm and to be fed. All newborns should have access to essential newborn care,
which is the critical care for all babies in the first days after birth. Essential newborn care
involves immediate care at the time of birth, and essential care during the entire newborn period.
It is needed both in the health facility and at home.

Essential newborn care includes:

 Immediate care at birth (delayed cord clamping, thorough drying, assessment of

breathing, skin-to-skin contact, early initiation of breastfeeding)
 Thermal care
 Resuscitation when needed
 Support for breast milk feeding
 Nurturing care
 Infection prevention
 Assessment of health problems
 Recognition and response to danger signs
 Timely and safe referral when needed

RESUCITATION OF THE NEWBORN

The goal of resuscitation of newborn is:

1. Establish and maintain clear airway to ensure circulation

2. Correct acidosis
3. Prevent hypothermia, hypoglycemia and hemorrhage.

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Indication

1. Prolonged period of asphyxia.

2. Heart rates falls

3. Baby who didn’t cry immediately after birth.

4. Baby born with below 7 Apgar score.

Degrees of resuscitation:

The resuscitative requirement is varies from the condition of the baby at the one min of age.

1. Baby born with Apgar score 7 to 10 has blood pH is 7.20 to 7.40 2.

2. The baby with an Apgar score of 4 to 6 has a blood pH 7.09 to 7.19.(moderate acidosis)
3. The baby with Apgar score 0 to 3 has blood pH of 7.00 or below (sever acidosis)
1. Baby born with Apgar score 7 to 10 has blood pH is 7.20 to 7.40. This baby has the
minimal depression & normal transition period. Suction the oropharynx and then the nose
to clear the airway to provide the tactile stimulation. Dry the infant and provide the
warmth. Continue to observe the transition closely.
2. The baby with an Apgar score of 4 to 6 has a blood pH 7.09 to 7.19.(moderate acidosis)
This baby has moderate depression probably reflecting a period of primary apnea. Dry
the infant Place the infant under the radiant heat source Suction the oropharynx and then
nose to clear airway and provide tactile stimulation; give free flow oxygen by nasal
cannula . If infant is still not apneic or has heart rate below 100, begins the positive
pressure ventilation by face mask attached to the self inflating bag with oxygen reservoir
both give nearly 100% oxygen. Continue free flow oxygen after infant has established
good respiratory efforts
3. The baby with Apgar score 0 to 3 has blood pH of 7.00 or below (sever acidosis) this
baby has severe depression reflecting secondary apnea Suction the infant to clear the
airways Dry the baby Place in front under the radiant heat source Begin positive pressure
ventilation, If the positive pressure ventilation dose not ensures the bag and

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mask ,performed endotracheal intubation. If heart rate is less than 60 after 30 seconds
after adequate ventilation begin the cardiac massage until the infant can sustain heart rate
over the 80 with ventilation alone.

Equipment's for resuscitation-

 Need of flat surface

 Two towel
 Different size of mask Laryngoscope
 AMBU bag with pop of valve
 Stethoscope
 Different size of airway Suction catheter no. 6,8 & 10 Clock
 Oxygen with flow meter and tubing
 Medication for resuscitation: Epinephrine – 1:10,000 ampoules(1ml) dosage- 0.01-
0.03mg/kg give rapidly IV or ET repeated it 3 to 5 min (ET – diluted to 1-2 ml with NS)
Naloxone 0.4 mg /ml , 1.0mg/ml dosage-0.25 mg/ml give rapidly IV or ET. Volume
expanders- Ns or RL, sodium bicarbonate 4.2% (1mEq/ml),Dextrose 10% concentration
250 ml, sterile water 30 ml.

Procedure

Initial steps:

 1. Preventing the heat loss

 2. Positioning of the baby
 3. Suctioning
 4. Evaluation • Vital signs for respiration, heart rate and color. Respiration are normal go
on evaluating the heart rate, if respiration are not normal(apneic)begins the positive
pressure ventilation. If heart rate is over the 100 beats /m go on evaluating color, if less
than 100 b/m initiate the positive pressure ventilation. If infant is pink no action is
necessary, if there is central cyanosis administer the free flow of oxygen.
 Positive pressure ventilation Indication-  Infant apneic  Heart rate less than 100 b/m

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Procedure :

 Receives the baby and starts the clock

 Dry and stimulate the baby for 30 seconds
 wrapped the baby to keeping the baby warm and make sure that chest is open in order to
assess the baby in terms of tone, color breathing and heart rate.
 Ensure the head in the neutral position if the head is extended or flexed the airway will
closed.

• Chose the appropriate mask for the baby.

• Hold the mask as it covers the baby's nose and mouth and deliver the five inflation breath
(3 seconds inflation breaths ).

• If the chest wall dose not move perform a single person jaw thrust (make sure fingers are
on the bone not on the soft tissue)

• Observe the movement of chest wall if it is not moving and you have an assistance use
the two person technique for inflation breaths.

• If the chest wall is not moving then we need to consider advanced airway technique such
as guedel airway, if chest wall has a movement then we must go on and assess the baby in term
of tone, color, breathing and heart rate.

• If the heart rate is less than 60 or not improving we must move on for chest compression,
if you are alone you can use the single person technique delivering the chest compressions with
two fingers below the nipple line and at the sternum at a rate of 3,2,1;

• if you have a assistance you can use the double person technique to archive the rate of 30
breath of a minute after 30 sec you must reassessed the heart rate if heart rate are improving you
must continues the ventilation breaths at a rate of 30 per minute.

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• If the heart rate is less than 60 still not improving must continues the CPR if there is no
sign of life no heart rate no breathing for 20 min consider to stop the resuscitation. Post
resuscitation care

• Cover the baby and prevent the heat loss.

• Close monitoring of baby

• O2 should be administer

• Shift to the NICU

ASSESSMENT OF THE NEWBORN

INTRODUCTION

A newborn should have a thorough evaluation performed within 24 hours of birth to identify any
abnormality that would alter the normal newborn course or identify a medical condition that
should be addressed (eg, anomalies, birth injuries, jaundice, or cardiopulmonary disorders) [1].
This assessment includes review of the maternal, family, and prenatal history and a complete
examination. Depending upon the length of stay, another examination should be performed
within 24 hours before discharge from the hospital.

INITIAL ASSESSMENT OF THE NEWBORN

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It is important that the newborn be carefully examined as soon as possible after birth, primarily
for the detection of any life threatening abnormalities, evidence of trauma, and for evaluating the
infant’s ability to adjust to extra uterine life.

Initial assessment of the newborn is done by using the APGAR scoring system which involves
the following:

Apgar scoring system

The Apgar score is one of the first checks of a baby's health. The Apgar score is assigned in the
first few minutes after birth to help identify babies that have difficulty breathing or have a
problem that needs further care. The baby is checked at one minute and five minutes after birth
for heart and respiratory rates, muscle tone, reflexes, and color.
SUBSEQUENT ASSESSMENT OF THE NEWBORN
The subsequent assessment of the newborn involves assessing the following:

 Birthweight
A baby's birthweight is an important indicator of health. The average weight for term babies
(born between 37 and 41 weeks gestation) is about 7 lbs. (3.2 kg). In general, small babies and
very large babies are at greater risk for problems.

Other measurementsinclude the following:

 Head circumference. The distance round the baby's head.

 Abdominal circumference. The distance around the abdomen.
 Length. The measurement from crown of head to the heel.

Vital signs:
 Temperature. Able to maintain stable body temperature of 98.6°F (37°C) in normal room
environment
 Pulse. Normally 120 to 160 beats per minute
 Breathing rate. Normally 30 to 60 breaths per minute
 Physical assessment
 Neurological assessment

PHYSICAL ASSESSMENT OF THE NEWBORN

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 B. MUDI INFANT

A complete physical examination is an important part of newborn care and assessment. Each
body system is carefully examined for signs of healthy and normal function.

Overall Inspection

 In general does he look ill or well? Is he normally active? Is the cry normal? Are there
any obvious malformations? In particular, is the baby funny-looking, e.g. with Down
Syndrome?
 What of his colour? Pallor?Pallid cyanosis of shock? Cyanosis? Plethora? Jaundice? If
pallor of skin, what of mucus membranes and nail beds? Is the cyanosis generalized or
localized? Does the upper surface of the tongue look blue? What is the response of the
cyanosis to oxygen and on crying?
 Is the cord yellow? What of respiration? Chest movements? Is there a grunt? Is there
dyspnoea? The apex beat is frequently visible on inspection.
 What of the shape of the head? Do the bones move freely against each other along the
suture lines?
 If the infant is small for dates or unusually skinny, suspect fetal malnutrition. Check on
weight for length and look for other evidence of fetal malnutrition, such as dry scaly skin
on abdomen and extremities and/or abdominal skin creases and lack of normal
subcutaneous fat. (These babies need to be watched for hypoglycaemia and fed early).

 General appearance: Physical activity, tone, posture, and level of consciousness.

 Skin: Color, texture, nails, presence of rashes.

 Head and neck:

o Appearance, shape, presence of molding (shaping of the head from passage through the birth
canal)

o Fontanels (the open "soft spots" between the bones of the baby's skull)

o Clavicles (bones across the upper chest)

 [Link], ears, nose, cheeks.

 [Link], tongue, throat.

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 Lungs. Breath sounds, breathing pattern.

 Heart sounds and femoral (in the groin) pulses.

 Abdomen. Presence of masses or hernias.

 Genitals and anus. For open passage of urine and stool

 Arms and legs. Movement and development.

NEUROLOGICAL ASSESSMENT OF THE NEWBORN

Newborn reflexes are sometimes referred to as developmental reflexes, primary reflexes, or

primitive reflexes. These reflexes do not require functional brain above the diencephalon (the
area of the brain that includes the thalamus, hypothalamus, subthalamus, and epithalamus).
Neurological assessment of the newborn involves assessing the following:

Primitive Reflexes

 Sucking Reflex: usually present at birth but weaker in premature babies and dependent on
gestational age; elicited by stroking or touching the lips.
 Rooting Reflex: infant's head turns toward the stimulus; elicited by stroking the face,
cheek, or corner of the mouth.
 Palmar Grasp: infant tightens the grip of the hand to grasp a finger; elicited by stroking
the palmar surface of the hand; test bilaterally.
 Plantar Grasp: infant tightens the grip of the toes as if grasping the examiner's finger;
elicited by stroking the foot upward toward the toes; test bilaterally.
 Tonic Neck Reflex: to elicit, when infant is supine, turn the head to one side, the arm
extends on the side the head is turned; the opposite arm flexes.
 Stepping Reflex: to elicit, hold the infant upright and barely allow the feet to touch a flat
surface; infant picks up the feet alternating them as if stepping.
 Moro and Startle Reflex: a sensation of falling; a response where the arms extend with
palms open then the infant flexes and closes the fists and may cry; a Startle is an
incomplete Moro and may be elicited by a loud noise or accidently bumping the crib.
 TruncalIncurvation (Galant) Reflex: while holding the infant in a ventral position, stroke
one side of the trunk along the spine, infant flexes toward the stroked side.

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 Babinski Reflex: to elicit, stroke the sole of the foot and the infant either curls or flexes
the toes; abnormal if present after 18 months.

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