CHARACTERISTICS OF THE TYPICAL NEWBORN INFANT

GENERAL

The nurse is in a unique position to aid the newborn infant in the stressful transition from a warm, dark, fluid-filled environment to an outside world filled with light, sound, and novel tactile stimuli. During this period of the newborn adjusting from intrauterine to extrauterine life, the nurse must be knowledgeable about a newborn's normal biopsychosocial adaptations to recognize any deviations.

 To begin life as an independent being, the baby must immediately establish pulmonary ventilation in conjunction with marked circulatory changes. These radical and rapid changes are crucial to the maintenance of life. All other neonatal body systems change their functions or establish themselves over a longer period of time. The nurse performs an initial assessment to evaluate the neonate, its immediate postbirth adaptations, and the need for further support

Port Wine Stain Erythema toxicum

Cheesy-white Normal Antibacterial properties Protects the newborn skin

The newborn infant's head represents onefourth of his total body length. Its circumference is equal to that of his abdomen or chest. The average size is 13" to 14" (33-35 cm). The head is shaped or molded as it is forced through the birth canal in vertex presentations.

Molding. During delivery, for the large head to pass through the small birth canal, the skull bones may actually overlap in a process referred to as molding. Such molding reduces the diameter of the skull temporarily. This elongated look usually disappears a few hours after birth as the bones assume their normal relationships

The infant's skull is separated into six bones one from another along the suture lines .Where more than two bones come together, the space is called a fontanel. This is the unossified space or soft spot between the cranial bones of the skull in an infant. The infant's pulse is sometimes visible there. The anterior fontanel is located at the intersection of the sutures of the two parietal bones and the frontal bones.

It is diamond-shaped and strongly pulsatile. It normally closes at 9 to 18 months of age. The posterior fontanel is located at the junction of the sutures of the 2 parietal bones and 1 occipital bone. It is small, triangular shaped, and less pulsatile. It normally closes at 1 1/2 to 3 months of age. The anterior fontanel is the larger of the two.

This is a collection of blood between a cranial bone and its overlying periosteum. Bleeding is limited to the surface of the particular bone. It is caused by pressure of the fetal head against the maternal pelvis during a prolonged or difficult labor. This pressure loosens the periosteum from the underlying bone, therefore rupturing capillaries and causing bleeding.

It may be apparent at birth but sometimes are not seen until 24 to 48 hours of life because subperiosteal bleeding is slow. It varies in size, rather firm to the touch and tends to increase in size from 1 to 3 days and then become softer and more fluctuant. Most cephalhematomas are absorbed within several weeks. No treatment is required in the absence of unexplained neurologic abnormalities

Not crossing suture line

Cephalhematoma is a collection of blood between the surface of a cranial bone and the periosteal membrane.

This is an abnormal collection of fluid under the scalp on top of the skull that may or may not cross the suture lines, depending on the size. Pressure on the presenting part of the fetal head against the cervix during labor may cause edema of the scalp . This diffuse swelling is temporary and will be absorbed within 2 or 3 days

Crossing suture line

Caput succedaneum is a collection of fluid (serum) under the scalp.

a. Temperature Regulation. (1) The infant's body temperature drops immediately after birth in response to the extrauterine environment. His internal organs are poorly insulated and his skin is very thin and does not contain much subcutaneous fat. The infant's heat regulating mechanism has not fully developed. His temperature rapidly reflects that of his environment. The flexed position that the infant assumes is a safeguard against heat loss because it substantially diminishes the amount of body surface exposed.

Nursing implications are centered on regulating an environment to provide constant body temperature of a neutral thermal environment. The infant is placed in blankets, hat, and a controlled temperature environment after birth to counteract the drop in body temperature that occurs immediately after birth. After admission to the nursery, the infant is placed in isolation (isolette) and a temperature probe may be used for continuous monitoring. The infant's axillary temperature is maintained at 36.4 to 37.2o C.

NOTE: An isolette is a self-contained unit that controls the temperature, humidity, and oxygen concentration for an infant.

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.

The average blood pressure(BP) of an infant at birth is 72/42. A drop in systolic BP of about 15 mm Hg the first hour after birth is common. The newborn's BP may be taken with a Doppler blood pressure device. This greatly improves accuracy.

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). Normally, respirations are gentle, quiet, rapid, and shallow. They are most easily observed by watching abdominal movement because the infant's respirations are accomplished mainly by the diaphragm and abdominal muscles (see figure 7-1). No sound should be audible on inspiration or expiration

The endocrine glands are considered better organized than other systems. Disturbances are most often related to maternally provided hormones (estrogen, luteal, and prolactin) that may cause the following conditions

Vaginal discharge and/or bleeding may occur in female infants. This discharge is white mucoid in color. Bleeding may occur as a result of withdrawal from maternal hormones at the time of birth. There are usually only a few blood spots seen on the diapers. The entire process terminates in one to two days

Enlargement of the mammary glands may occur in both sexes. This is particularly noticeable about the third day of life. Breast secretion may also occur. Swelling usually subsides in two to three weeks. The breast should not be squeezed; it only increases the chances of infection and injuries to the tender tissue.

The newborn infant exhibits remarkable sensory development and an amazing ability for self-organization in social interactions. The infant's muscles are firm and resilient. He has the ability to contract when stimulated, but lacks the ability to control them. He wiggles and stretches, but movements are uncoordinated.

Cephalo-Caudal (Head to Toe) in Development. Gross motor development occurs first, followed by finer motor development. Reflex actions present at birth serve the infant until neuromuscular development is improved. Absence of reflex activity often indicates some form of brain damage

Actions in response to specific stimuli that are present in newborn infants. These are unconditioned reflexes and not learned or developed through experience. Normally developing neonates or infants are expected to respond to specific stimuli with a specific, predictable behaviour or action.

ELICITED BY :
PLACING THE BABY IN SEMI UPRIGHT POSITION

SUDDEN DROPING OF HEAD IN RELATION TO TRUNK AND CATCHING THE FALLING HEAD DISAPPEARS AT 3 TO 6 MTHS

OPENING OF HAND

EXTENSION AND ABDUTION OF UPPER EXTRIMITIES ANTERIOR FLEXION OF UPPER EXTRIMITIES

AUDIBLE CRY

ABNORMALITIES:
DEPRESSED OR ABSENT
GENERALISED DEPRESSION OF CNS

ASYMMETRICAL RESPONSE
FRACTURE CLAVICLE ERB PALSY HEMIPARESIS

EXAGERGERATED RESPONSE
KERNECTERUS

It is variant of Moros Reflex.

Ellicited by: sudden loud noise or by tapping the sternum Response is like Moros reflex but elbow remain flexed and hands closed

Elicited By: Placing finger or object in open palm of each hand Response: Infant grasp the object and with attempted removal grip reinforced

Appears at 28 weeks of gestation and disappears at 2-3 months of life Persistence beyond 6mths: Athetoid CP

ASYMMETRIC TONIC NECK REFLEX

Elicited By: Passive rotation of head in supine position Response: Extension of upper limb of same side and flexion of upper limb of opposite side

Appears at birth and disappear at 3 months Persistence > 3 months: Spastic CP

Importance: Prevents body from rolling

Elicited By: Passive extension of head in prone position Response: Extension of both UL & flexion of both LL

Appears in 3 mths and disappear in 6mths Persistence > 6mths : CP

Importance: When baby learn to turn to prone position chocking over bed may asphyxiate him so if baby lift his chin by extension of neck both upper limbs extend automatically and chocking avoided.

Elicited By: Holding the child in ventral suspension or placed in prone position and running finger down in paravertebral area on one side Response: Swinging of pelvis towards stimulated side

Appears at birth disappear by 1 year Used for mapping sensory level of trunk

Elicited By: Touching the corner of mouth lightly with finger Response: Bottom lip is lowered on same side and tongue moves towards the point of stimulation as finger slides away head turns to find it.

Appear 28 week & disappear 4-7 mths Importance:

Absence at birth and persistence beyond 7 months indicate developmental delay Helps the baby for finding the breast

Elicited By: Introducing finger into babies mouth Response: Baby starts sucking vigorously Appear at 28 week disappear at 4-7 months Absence sucking at birth indicate sickness, persistence beyond 7 mths developmental delay

Elicited by: Bringing the anterior aspect of tibia against edge of table Response: Lifts leg on the table Appear at birth and disapper at 6 weeks.

Elicited by: holding the baby upright over the table so that sole of foot presses against the table
Response: Reciprocal flexion and extension of leg simulating walking Appears at birth and disappear at 6 week

Elicited by: Pressing the palm Response: Opening of mouth Appear at birth and disappear at 3 year

Elicited By: Holding the child in ventral suspension and suddenly brought down the baby towards ground from height Response: Extension of both UL in attempt to avoid injury

Appears at 6-9 months persists life long. Absent in CP and hemiplegia of affected limb

By the end of this presentation the learner should. Understand the prenatal gestational age assessment tools Classify the size differences between IUGR, SGA, AGA, & LGA infant Complete the physical maturity portion of the neonatal gestational age assessment tool Conduct the neuromuscular portion of the neonatal gestational age assessment Compile the maturity score on the neonatal gestational age assessment tool Identify those common differential findings found on newborn exam

Calculation by the mother estimated date of confinement (EDC) Collection of prenatal data First fetal movement (16-20 weeks) Fetal heart tones (20 weeks) (with doppler 9-12 weeks) Fundal height (One cm = 1 week after 18-20 weeks) 20 weeks (fundus normally at umbilicus) Term (fundus at xyphoid) Amniotic fludi creatinine levels Maternal serum and urine estriols Fetal US

FETAL US MEASUREMENTS

Crown to rump length Biparietal diameter Femur length Abdominal Circumference Head Circumference Placental grade

 Review the perinatal history for clues to potential pathology Begins with conception and includes events that occurred throughout gestation Genetic history Labor & delivery history Assess the infants color for clues for potential pathology Auscultate in a quiet environment Keep infant warm during exam Calm the infant before exam Handle gently

Growth for dates can be determined by weight, length, and head circumference Plotted on a graph appropriate for gestation
Preterm before 37 weeks Term 38-41 weeks Post term after 42 weeks

Using the gestational age score the weight, height and head circumference can be plotted on the infants growth chart This information is how the infant is diagnosed as SGA, LGA, or AGA

SGA- small for gestational age-weight below 10th percentile AGA-weight between 10 and 90th percentiles (between 5lb 12oz (2.5kg ) and 8lb 12 oz (4kg). LGA-weight above 90th percentile IUGR-deviation in expected fetal growth pattern, caused by multiple adverse conditions, not all IUGR infants are SGA, may or may not be head sparing

The physical maturity part of the examination should be done in the first two hours of birth The neuromuscular maturity examination should be completed with 24 hours after delivery Derived to look at various stages in an infants gestational maturity and observe how physical characteristics change with gestational age Neonates who are more physically mature normally have higher scores than premature infants Points are awarded in each area -2 for extreme prematurity to 5 for postmature infants

Skin Lanugo Plantar surface Breast Eyes & Ears Genital

Examine the texture, color and opacity As the infant matures: More subcutaneous tissue develops Veins become less visible and the skin becomes more opaque

Physical Maturity

Skin
Before 28 weeks-

gelatinous red, friable 28-37 weeks-skin over abdomen thin, translucent, pink with visible veins 37-39 weeks smooth, pink, increased thickness, rare veins over abdominal wall

Physical Maturity

Skin
40 Weeks-

vessels have now appeared, skin may be leathery with deep cracking

Scalp Electrode

Forcep Marks

Vacuum Bruising

Milia-exposed sebaceous glands No treatment necessary

Sebaceous hyperplasia More yellow than milia Result of maternal androgen in utero Resolves in time

Mongolian BlueGrey Spots Most common in Asian, Hispanic, and African descent Gradual fade over the first years

Skin Tags Most common on ears Usually tied off or clipped

Salmon patches or nevus simplex Angel kisses Stork bites

Erythema toxicum White or yellow papule or pustule With erythematous base No treatment necessary

Caf Au Lait spots Increased amount of melanin, may increase in number in age Presence of 6 or more- greater then 0.5 cm in size may be indicative of neurofibromatosis

 Physical Maturity Lanugo

After 20 weeks-begins to appear 28 weeks-abundant After 28 weeks-thinning, starts to disappear from the face first 38 weeks-bald areas slight amount may be present on shoulders

Vernix

Before 34 weeks-vernix thick and covers entire body 34-38 weeks-vernix is absorbed gradually, portions over shoulder and neck is the last to be absorbed 38-40 weeks-vernix only present in folds of skin After 40 weeks-no vernix present

Plantar Surface

Before 28 weeks-no creases 28-32 weeks-virtually no sole creases, faint thin red lines over anterior aspect of foot 34-37 weeks-1-2 anterior creases 37-39 weeks-creases now over the anterior 2/3 of the sole

Bilateral Club Feet

Syndactyly

Polysyndactyly

Physical Maturity
Breast
Before 28 weeks-nipples imperceptible 28-32 weeks-nipple barely visible, no areola 32-37 weeks-well defined nipple areola 38-40 weeks-well defined nipple raised areola

 Physical Maturity
Eyes
Eyes are evaluated as either fused as seen in extremely premature infants or open Before 26 weeks eyes are fused

Congenital Cataracts Eyelid Edema Subconjunctival Hemorrhage

 Physical Maturity
Ears
Before 34 weeks-pinna is very immature cartilage not present, lies flat, remains folded 34-37 weeks-pinna curved with soft recoil 37-40 weeks-formed, firm instant recoil After 40 weeks-thick cartilage ear stiff

Ear Tags Ear Pits (Preauricular pits) Lop Ear Prominent Ear

Physical Maturity
Genitalia-Male
Before 28 weeks-scrotum empty and flat 28-30 weeks-testes undescended into scrotal sac 30-36 weeks testes descending with a few rugae over the scrotum 36-39 weeks-testes have descended into scrotum which is now pendulous and complete with rugae

Genitalia-Female
Before 28 weeks-clitoris prominent labia flat 28-32 weeks-prominent clitoris, enlarging labia minora 33-36 weeks-labia majora widely spaced with equally prominent labia minora 33-39 weeks-labia extends over the labia minora but not over the clitoris 39 weeks-labia majora completely covers the labia minora and clitoris

Hydrocele

Undescended testicles

Hypospadias

Hymenal Tag

 Neuromuscular Maturity
Posture & Tone Square Window Arm Recoil Popliteal Angle Scarf Sign Heel to Ear

 Neuromuscular Maturity
Posture/Tone-Total body muscle tone is reflected in the infants preferred posture at rest and resistance to stretch of individual muscle groups
Make sure infant is quiet The more mature an infant is the greater their tone will be A more flexed position indicated greater tone

 Neuromuscular Maturity Posture & Tone

Before 30 weekshypotonic, little or no flexion seen 30-38 weeks-varying degrees of flexed extremities 38-42 weeks-may appear hypertonic

Neuromuscular Maturity

Square Window-wrist flexibility and/or resistance to extensor stretching resulting in angle or flexion at wrist
Flex hand down to wrist-

measure the angle between the forearm & palm

Before 26 weeks-wrist cant be flexed more than 90 degrees Before 30 weeks-wrist can be flexed no more than 90 degrees 36-38 weeks-wrist can be flexed no more than

 Neuromuscular Maturity
Arm Recoil-measures the angle of recoil following a brief extension of the upper extremity For 5 seconds flex the arms while infant is in the supine position, pulling the hands fully extend the arms to the side, then release-measure the degree of arm flexion & strength (recoil)
Before 28 weeks-no recoil 28-32 weeks-slight recoil 32-36 weeks-recoil does not pass 90 degrees 36-40 weeks-recoils to 90 degrees After 40 weeks-rapid full recoil

Neuromuscular Maturity
Popliteal Angle-assesses maturation of passive flexor tone about the knee joint by testing resistance to extension of the leg The angle decreases with advancing gestational age
Before 26 weeks-angle 180 degrees 26-28 weeks-angle 160 degrees 28-32 weeks-angle 140 degrees 32-36 weeks angle 120 degrees

Neuromuscular Maturity
Scarf Sign-tests the passive tone of the flexors about the shoulder girdle Increased resistance to this maneuver with advancing gestational age
Before 28 weeks-elbow passes torso 28-34 weeks-elbow passes opposite nipple line 34-36 weeks-elbow can be pulled past midline, no resistance 36-40 weeks-elbow to midline with some resistance After 40 weeks-doesnt reach midline

Neuromuscular Maturity
Heel to Ear-measures passive flexor tone about the pelvic girdle by testing passive flexion or resistance to extension of the posterior hip flexor muscles Breech infants will score lower than normal Before 34 weeks-no resistance 40 weeks-great resistance may be difficult to perform

Aby, J. (2008). Stanford School of Medicine. Newborn Nursery at LPCH. Retrieved October 10th, 2009 from http://newborns.stanford.edu/RNMDEducatio n.html Ballard J. (1991). New Ballard Score, expanded to include extremely premature infants. Journal of Pediatrics, 119, 417-423. Tappero, E. & Honeyfield, M. (1996). Physical assessment of the newborn. Santa Rosa, CA: NICU Ink Publishers.

Hypothermia is common Wet newborns rapidly lose heat Use a warm, dry, soft towel Any absorbent material:
Shirt T-shirt Socks Battle dressings

Then let the mother hold the baby Her body heat will help keep the baby warm Cover the head to prevent heat loss

Keep the baby on its back or side, not on its stomach Neither extend nor flex the head. Either may obstruct the airway. Newborn babies normally make this adjustment themselves. If depressed, however, you may need to position the head to get a good airway.

May need to help them clear mucous and amniotic fluid from the airway Use a bulb syringe Use it gently If bulb syringe is not available, use any suction device, including a small hypodermic syringe without the needle.

Breathing Color Heart Rate Tactile stimulation (rubbing) with a towel.may effectively stimulate a mildly depressed baby

Pink

Acrocyanosis

Most newborns have acrocyanosis (body is centrally pink, but hands and feet are blue Cyanosis requires treatment:

Cyanosis

Oxygen Airway Ventilation

If not breathing following brief stimulation, ventilate Ideally, bag/mask, 100% oxygen, pressure gauge, flow control valve May need to use mouth-tomouth Cover nose and mouth Use shallow puffs to ventilate

Normal newborn rate is >100 Palpate umbilical cord or brachial artery If pulse <100, ventilate the baby, using whatever skills and equipment you have

Keep the airway open Keep the head covered Use any available cloth or heat-retaining material Check temp several times: 97.7-99.3F axillary

0 Points Heart Rate Respiratory Effort Muscle Tone Reflex Irritability Color Absent Absent Flaccid No Response Blue, pale

1 Point <100 Slow, Irregular Some flexion of extremities Grimace Body pink, extremities blue

2 Points >100 Good, crying Active motion Vigorous cry Completely pink

Breast feeding is better If mother not available:

Formula Warm to body temperature If formula not available, use sugar water Avoid cows milk unless there is no alternative and baby formula is not expected soon.

Cheesy-white Normal Antibacterial properties Protects the newborn skin

1% silver nitrate 1% TTCN ophthalmic ointment 0.5% erythromycin ointment

Vitamin K
First few hours 0.5-1.0 mg IM Prevents hemorrhagic disease

Clean & dry Alcohol wipe once a day Topical antiseptic only in contaminated areas