`

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

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

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.

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.

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

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.
Infants 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

Blue, pale

Body pink, ext.

blue

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

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
NBs 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

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 infants
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.

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.

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

Fig7. Erythema toxicum

Milia small whitish papules made

up of distended sebaceous glands,
usually covering the nose.

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

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

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

Craniotabes: soft area in the parietal bones at the vertex near

sagittal suture.
Caput succedaneum edematous
swelling of the soft tissue of the
scalp.

LUNGS
Variation in rate and rhythm of breathing according to infants
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

HEART
Determine location: Dextrocardia

Fig12. Caput succedaneum

Cephalhematoma subperiosteal
hemorrhage

Fig13. Cephalhematoma

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

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

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

1.
2.

Fig17. Omphalocoele

3.
4.
5.
6.

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

Abnormal dermatoglyphic pattern: Simian crease

Congenital hip dislocation: Ortolanis 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

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

HIGHER FUNCTION AND CRANIAL NERVES

Observe response to breast-feeding, human voice (particularly
mothers 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.

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 isnt about getting and having, its about giving and being.
Kevin Kruse

SKIN AND CORD CARE

Once infants 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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