New born child. Peculiarities of the newborn

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New born child. Peculiarities of the newborn 
period. Main components of neurological and
psychological development in children of early
age. Transitory states in a new-born period

• prof. Pavlyshyn H.A.

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TERMS
Neonatology The branch of pediatrics that deals
with the diseases and care of newborns.
Neonatal period From birth to the 28th day of
life (4 weeks after birth). Perinatal period
From the 28th completed week of gestation to the
7th day after birth.
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Classification of the neonates
By birth weight
By gestational age
By both GA and BW
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TERMS
According to gestational age

• Full term infant An infant born at a gestational
  age between 37 and 42 completed weeks

Preterm infant An infant that is born prior to
37 weeks of gestation (22 -37 weeks or weight
greater than 500g).
Post-term infant An infant that is born after
the 42nd week of gestation
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According to relationship between GA and BW

• AGA ( appropriate for gestational age) Infants
  with birth weight for their gestational age that
  falls between the 10th and 90th centiles. SGA (
  small for gestational age) Infants with birth
  weight for their gestational age that falls below
  the 10th centiles. LGA ( large for gestational
  age) Infants with birth weight for their
  gestational age that falls above the 90th
  centiles.

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GA 40 w, BW3000g GA 34 w, BW2000g
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Apgar Score of the Newborn
SIGNSCORE 0 1 2
Heart rate Absent lt100 beats/min gt100 beats/min
Respiratory effort Absent Weak, irregular Strong cry
Muscle tone Flaccid Some flexion Well
Reflex irritability (response to catheter in nostril) No Grimace Cough or sneeze
Skin colour Blue, pale extremities blue pink
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Significance of Apgar score

• Healthy newborn 7-10 at both 1 and 5 minutes
• Moderately depressed newborn 3-6 (Need
  resuscitation )
• Severely depressed newborn 1-3 (Intensive
  resuscitation )

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The Apgar score is used to evaluate

• brain function at birth
• circulatory status at birth
• the effectiveness of respiratory and
  circulatory adaptations thereafter
• which babies need active assistance
  (resuscitation).

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Purpose

• The APGAR scoring chart is used to
• evaluate the conditions of the baby at birth,
• determine the need for resuscitation,
• evaluate the effectiveness of resuscitative
  efforts,
• to identify neonates at risk for morbidity and
  mortality.

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Take Anthropometric Measurements

• Weight 2, 500g 4, 000g
•  Physiologic weight loss - it is normal for the
  newborn infant to loose 5-10 of weight in the
  first 4 to 5 days of life (causes low
  nutritional intake, defecation, urination)
• Length 45-55 cm
• HC 33-55 cm, 2-3 cm larger than chest CC
  30-33cm, AC-29-33 cm

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Assessment of Growth
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Head Circumference
HC 33-55 cm, 2-3 cm larger than chest
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Take Anthropometric Measurements
Head Circumference
Chest Circumference
Abdomen Circumference
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Fontanelles
The anterior fontanel is located at the
intersection of the sutures of the two parietal
bones and the frontal bones. Anterior diamond
shape about 2-3-4 cm, will close in about 12 to
18 mos
The posterior fontanel is located between of the
sutures of the 2 parietal bones and occipital
bone. It is small, triangular shaped, normally
closes at 1,5 to 3 mos of age.
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Respiratory system

• Fetal lung development
• Filled with fluid
• Surfactant synthesis begins at 24-28w, peak at
  35w
• Establishment of breathing after birth - opening
  of the alveoli by mechanical,chemical,thermal,
  sensory stimuli
• Characteristics of Newborn respirations
• Normal RR 30-60, shallow and irregular,
• 5-15 second periods of apnea
• Apnea no breathing for periods of greater than
  15 sec
• Abnormal findings retractions, grunting, nasal
  flaring, more 15 sec apnea abnormal rate

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Cardiovascular System
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Circulatory system

• Heart rate ranges from 140 to 160 per minute.
• Heart murmur
• Transient murmurs may result from the incomplete
  closure of the fetal circulation (the ductus
  arteriosis or foramen ovale)
• 90 of all murmurs are transient and not
  associated with anomalies.
• Blood pressure
• from 46 to 80 mmHg (systolic)

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Hemotological system

• High RBC 4.8-7.1 Hgb 14-24 Hct 44-64
• 18,000 _at_ birth 23-25,000 _at_ 1 day with
  relative neutrophilia
• Coagulation Vit K dependent clotting factors
  are decreased.
• Platelet counts ok (150,000-350,000)

WBC
After the first few days (5 days or so ) the
white cell count is likely to be below 10 000/
mm3 with characteristically relative
lymphocytosis of infancy and early childhood.

• These characteristics are essential to provide
  adequate oxygenation in utero and during the
  first few postnatal days before the lungs expand
  fully.
• Oxygenation improves during the first two weeks
  of life to the extent that a high red cell count
  and hemoglobin are no longer necessary, and
  haemolysis occurs.

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Gastrointestinal System

• sucking becomes coordinated _at_32 wks
• little saliva until 3 months of age
• Stomach hold 60 to 90 ml.
• Regurgitates easily because of an immature
  cardiac sphinter between the stomach and
  esophagus.
• Immature liver function may lead to lowered
  glucosed and protein serum level.

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Alimentary system
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Hepatic Function

• Liver produces substances essential for clotting
  of blood.
• Stores needed iron for the first few months.
  Preterm small infants have lower iron stores
  than full term (full term infants stores last 4-6
  mo)
• Physiologic Jaundice - after 24-48 hs of age,
  d/t increased breakdown of RBCs and immature
  liver functioning.
• This is a yellow discoloration that may be seen
  in the infant's skin or in the sclera of the eye.
• Jaundice is caused by excessive amounts of free
  bilirubin in the blood and tissue.

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JAUNDICE
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Urinary system

• Renal function GFR - glomerular filtration rate
  is lower, about one fourth to one half of that in
  an adult.
• Kidneys not fully functional until child is 2
  years of age.
• Urine often contains protein in small amounts.
• Urine may contain an abundance of urates which
  may give the diaper a pink stain during the first
  week of life.
• The ability to dilute urine is good, but the time
  taken to reach the maximal ability is relatively
  long, so newborns are apt to become water
  overloaded.

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Kidneys and Urination

• initial urine cloudy, scant amounts, uric acid
  crystals-gt reddish stain on diaper
• Urine pH ranges from 5 to 7, specific gravity
  ranges from 1.006 to 1.020.
• The first urination occurs within 24 hrs. It
  ranges from 4 to 6 times/day in the first days
  and 20 times or so /day in later days of the
  neonatal period.
• Kidneys not fully functional until child is 2
  years of age.

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Immune System

• Limited specific and Non-specific immunity at
  birth
• passive immunity(from mom- IgG) for the first 3
  months of life this will be reduced if baby is
  born premature
• breastfeeding passive immunity (IgA)

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Neuromascular System

• Mature newborns demonstrate neuromuscular
  function by moving their extremities, attempting
  to control head movement, exhibiting a strong cry
  and demonstrating newborn reflexes.
• A newborn occasionally makes twitching or
  flailing movements of the extremities in the
  absence of stimulus because of the immature of
  the nervous system.

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Newborn Reflexes

• Sucking reflex
• When a newborn lips are touched, the baby makes
  a sucking motion.
• This reflex helps a newborn find
• food when the newborn lips touch the mothers
  breast or bottle, the baby sucks and takes food.
• The sucking reflex begins to diminish at about
  6 months of age

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Sucking
place a finger in the neonates mouth
neonate sucks on the finger
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Newborn Reflexes

• Rooting reflex - If the check is brushed or
  stroke near the corner of the mouth, a newborn
  infant will turn the head in that direction.

• This reflex serves to help a newborn find food
  when a mother holds the child and allows her
  breast to brush the newborns cheek, the reflex
  makes the baby turn toward the breast.
• This reflex disappear at about the sixth week of
  life.

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Rooting
touch a finger to the neonates cheek or the
corner of mouth.
neonate turns the head toward the stimulus, opens
the mouth and searches for the stimulus
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Newborn Reflex

• Blink Reflex - bright light shinning in eyes or
  clap hands near eyes - closes eyelids quickly
• A sudden movement to ward the eye can elicit the
  blink reflex.
• Swallowing reflex - food that reaches the
  posterior portion of the tongue, automatically
  swallowed.
• Gag, cough, and sneeze reflexes are present to
  maintain airway in the event that normal
  swallowing does not keep the pharynx free from
  obstructing mucous.

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MORO reflex
Baby is held horizontally, then swiftly lowered a
few inches, or the head may be lowered a few
inches, or a loud sudden noise will make baby's
arms fling out and then come together as hands
open then clutch.
Absence or weakness of this reflex may suggest a
severely disturbed CNS
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Startle reflex

• sudden loud noise causes abduction of the arms
  wit flexion of elbow, hand remain clenched
• disappears by age of 4 months

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Palmar Grasp Reflex

• newborn grasp an object placed in their palm by
  closing fingers on it.

• Mature newborn grasp so strongly that they can
  be raised from a supine position and suspended
  momentarily from an examiners fingers.
• Reflex disappears to 3 months of age.

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Grasp

• place a finger in the neonates palm
• neonate grasps the finger

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PLANTERS GRASP

• Pressing thumbs against the balls of baby's feed
  will make his toes flex.

Absence of this reflex may indicate damage to the
spinal chord.
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Stepping reflex

• Hold the neonate in an upright position and
  touch one foot lightly to a flat surface (such as
  the bed)

neonate makes walking motions with both feet
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BABKIN

• When both of baby's palms are pressed, her eyes
  will close, mouth will open and her head will
  turn to one side.
• Absence of this reflex or if it reappears after
  vanishing around 3-4 mos., it may signify a
  malfunctioning CNS

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BABINSKI

• Baby's foot is stroked from heel toward the toes.
• The big toe should lift up, while the others fan
  out.

• Absence of reflex may suggest immaturity of the
  CNS, defective spinal chord, or other problems.

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• Tonic neck reflex
• Fencing posture

• When newborn lie on their backs, their head
  usually turn to one side or the other.
• The arm and the legs on the side toward which the
  head turns extend, and the opposite arm and leg
  contract.
• This is also called the boxer or fencing reflex.
• The reflex disappears between the second and
  third months of life.

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Extrusion Reflex

• Extrusion Reflex - newborn extrudes any
  substance that is placed on the anterior portion
  of the tongue.
• This protective reflex prevents the swallowing
  reflex of inedible substance.
• It disappears at about 4 months of age

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Thermoregulation

• Newborn physiology
• Normal temperature 36.537.5C
• Hypothermia lt 36.5C --Significant contribution
  to deaths in low birth weight infants and preterm
  newborns
• Stabilization period 1st 612 hours after birth
• The body temperature is likely to be influenced
  by the environmental temperature.
• Neutral environmental temperature the
  environmental temperature at which the core
  temperature of the infant at
• rest is between 36.7 and 37.3C and oxygen
  consumption and caloric utilization are lowest

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Temperature Regulation

• Newborns temperature may drop several degrees
  after delivery because the external environment
  is cooler than the intrauterine environment
• Rapid heat loss in a cool environment occurs by
  conduction, convection, radiation and
  evaporation
• Cold stress in the newborn ? an increase in the
  metabolic rate --gt increased O2 demands and
  caloric consumption, metabolic acidosis

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SKIN
Observation and palpation
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SKIN

• Common variations
• Acrocyanosis - result
• of sluggish peripheral
• circulation.

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Physiologic jaundice
Neonatal jaundice is often seen in infants around
the second day after birth, lasting until day 8
in term births, or to around day 14 in premature
births.
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• Milia
• all newborn sebaceous glands are immature.
• White papule can be found on the cheek or across
  the bridge of the nose of every newborn.
• Disappear by 2 to 4 weeks of age, as sebaceous
  glands mature and drain.

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Erythema Toxicum

• Erythematous macules and firm 1-3 mm yellow or
  white papules or pustules
• Pustules contain eosinophils and are sterile
• Appear in the first 3-4 days of life
• Range Birth to 14 days
• Benign and self limited

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• Lanugo
• Is the fine hair, downy hair that covers a
  newborns shoulder, back and upper arm.
• It maybe found also on the forehead and ears.
• A baby born after 37 to 39 weeks of gestation has
  more lanugo than a newborn of 40 weeks.
• By 2 weeks of age it disappear

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• Vernix Caseosa
• At birth the infant is generally covered with
  vernix caseosa, a cream cheesy-white substance
  adherent to the skin that serves as a skin
  lubricant.
• It is helpful for protecting the baby against
  infections, and should not be taken off.

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• Mongolian spots
• Are collections of pigment cells

• 90 of African infants, 81 of Asian, and 9.6 of
  Caucasian infants
• Slate-gray to blue-black lesions
• Usually over lumbosacral area and buttocks
• Accumulation of melanocytes within the dermis
• They disappear by school age without treatment

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Features in appearance of normal term neonate and
preterm neonate
preterm
term
Dark-red,edema,transparent,more fine-hair
pink,well-nurished, Less fine-hair
Skin
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ear
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Sole markings
preterm
Shallow and less
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Enlargement of the breasts

• Enlargement of the breasts and production of
  milk may occur at the age of 3 to 5 days in some
  newborn boys or girls. This stops at the
  postnatal age of 2 to 3 weeks.
• This is also caused by transmission and
  withdraw of maternal hormones. This no requires
  management.

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Essential Newborn Care Interventions

• Clean childbirth and cord care
• Prevent newborn infection
• Thermal protection
• Prevent and manage newborn hypo/hyperthermia
• Early and exclusive breastfeeding
• Started within 1 hour after childbirth
• Initiation of breathing and resuscitation
• Early asphyxia identification and management

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The End