Care of the newborn infant Variations exist from place to place in the care of the newborn infant. However, although often neglected, their basic needs are the same. Infants who are unwell or have congenital abnormalities fall short of the mother’s expectation of a beautiful bundle of joy. All mothers require urgent and sensitive counselling. For more information about the authors and reviewers of this module, click here

How should I study this module? This self-directed learning (SDL) module has been designed primarily for medical students but may also be of use to healthcare providers especially at the primary care level. We suggest that you first read the learning outcomes and try to keep these in mind as you go through the module slide by slide and at your own pace. Answer the MCQ at the end to assess your learning. You should research any issues that you are unsure about. Look in your textbooks, access the on-line resources indicated at the end of the module and discuss with your peers and teachers. Finally, enjoy your learning! We hope that this module will be easy to study and complement your learning about newborn care from other sources.

Learning outcomes After studying this module, you should be able to Describe the routine clinical assessment of newborn infants Describe some common congenital abnormalities Describe the essential elements of the routine management of newborn infants including hygiene, cord care, feeding and rooming-in Describe what routine immunisations are required during infancy Discuss what information is required by mothers prior to discharge

Clinical assessment After delivery of the baby and in the absence of any immediate problems, essential newborn care begins with a thorough general clinical assessment. This should be done on all infants soon after birth to detect signs of illness and congenital abnormalities. The following slides describe the assessment that should be performed routinely in all infants. This initial assessment should indicate where more detailed clinical assessment is required. A resident doctor washing her hands up to the elbows prior to examination Hand washing with soap and water before and after a baby is handled goes a long way in reducing the risk of infection

Clinical assessment First steps and appearance Start by congratulating the mother on the arrival of her new baby and ask if she has any concerns. The mother is usually the first person to notice any problems. Ask about feeding and the passage of urine and stools. The infant should pass meconium (the first black, tarry stools) within 24 hours of birth. General observation: inspect colour, breathing, alertness and spontaneous activity. Well infants have a flexed, posture. Partially flexed posture is found in hypotonia or prematurity Well term infant showing typical well flexed posture Note the abduction of the hips in this partially flexed preterm infant (“froglike” posture)

Clinical assessment Examine skin for prematurity or dismaturity Thin, transparent skin in preterm infants Pale pink skin of a term infant (hair shaved to site IV line) Wrinkled peeling skin of dysmaturity in an IUGR infant

Clinical assessment Skin: some common normal findings Vernix caseosa: a cream/white cheesy material on the skin at birth which cleans off easily with oil. Lanugo; fine downy hairs seen on the back and shoulders especially in preterm infants. Milia: pinpoint whitish papules on nose and cheeks due to blocked sebaceous glands. Mongolian blue spots: grey/bluish pigment patches seen in the lumbar area, buttocks and extremities in dark skinned babies.They usually disappear by one year. Capillary heamangiomas (“stork bite” naevi): red flat patches which blanch with gentle pressure. Commonly occur on upper eyelids, forehead and nape of the neck. Erythema toxicum: small white/yellow papules or pustules on a red base seen on face, trunk and limbs. Develop 1 – 3 days after birth and usually disappear by one week.

Clinical assessment Colour Note palor or plethora Cyanosis: the baby should be uniformly pink Blueness of the hands and feet (peripheral cyanosis) may be due to cold extremeties. Blueness of the mucous membranes and tongue is central cyanosis and is usually due to lung or heart problems Bruising (ecchymosis) is common after birth trauma. Unlike cyanosis, bruising does not blanch on gentle pressure. A Caucasian infant with marked central cyanosis

Clinical assessment Jaundice Jaundice is common in the first week of life and may be missed in dark skinned babies Blanch the tip of the nose or hold baby up and gently tip forward and backward to get the eyes to open. Teach mother to do the same at home in the first week and report to hospital if significant jaundice is observed. Blanching the tip of the nose Two infants with jaundice; note yellow sclerae

Clinical assessment Head After these general observations, examine the infant starting with the head and moving down the body. Observe the size and shape of the head (micro- or macrocephaly; cephalhaematoma) Check the anterior and posterior fontanelles and that the skull sutures feel normal Form and position of ears (low set ears occur in chromosomal abnormalities, e.g. Down syndrome) Cephalhaematoma limited to the right parietal region Huge encephalocoele. Head is disproportionately small

Clinical assessment Eyes and face Examine eyes for ocular anomalies and check for red reflex using the ophthalmoscope (to exclude cataract) Examine the face for dysmorphic features and normal movements Examine lips and palate for clefts Bilateral cleft lip and palate. Also note purulent left eye discharge Facial asymmetry due to left facial palsy

Clinical assessment Cardiovascular and respiratory Feel femoral and radial pulses for volume, rate and rhythm. In aortic coarctation, femoral pulse is reduced, absent or not synchronous with radial pulse. If child is sick, measure blood pressure. Locate the apex beat and listen to the heart sounds for murmurs. Count the respiratory rate normal 30 – 40 breaths/min in term infants faster in preterms. > 60 / minute abnormal Observe for respiratory distress: nasal flaring, intercostal and subcostal recession.

Clinical assessment Abdomen Inspect the umbilical cord for presence of 2 arteries and a vein. Abnormal components may be a pointer to the presence of intra-abdominal anomalies e.g. renal. Look for umbilical abnormalities, e.g. hernia, omphalocoele, exompholos Gently palpate the abdomen the liver may be palpable upto 2cm below the costal margin the lower pole of the right kidney may also be palpable Large omphalocoele. Surounding erythema indicates cellulitis.

Clinical assessment Spine and genitalia Examine: The spine for dimples, tuft of hair (spina bifida occulta) or cystic swellings (spina bifida cystica) Remove the diaper to examine the genitalia. In boys, confirm that both testicles have descended into the scrotum. Designate the infant’s sex Inspect the perineum and check anus for position and patency (can be done by gently checking rectal temperature) Spina bifida cystica

Clinical assessment Dysmorphic features Examine hands. Note single palmar crease in chromosome abnormalities. Inspect the feet. Note effects of foetal posture should be noted. Check hips for dislocation Limitation of limb movements occurs in fractures and nerve injury Short stuby fingers and single palmar crease of Down syndrome Talipes affecting the left leg

Clinical assessment Routine measurements Weight normal 2.5 – 3.99kg Length normal 48 – 52cm Occipitofrontal circumference (OFC) normal 33 – 37cm Measurement of OFC using a non-stretchable tape measure

Routine care of the well newborn Any problems identified during the initial assessment will need specific management. However, newborn infants are a highly susceptible group and high-quality routine care prevents a multitude of problems. The major elements of routine care include: Cord care Thermal control 24 hour rooming in Feeding Immunization Maternal education on hygiene and every other aspect of routine care Click on the links for more information on these important elements of routine care Hand washing with soap and water every time a baby is handled goes a long way in reducing the risk of infection!

Click to reveal correct answers Quiz: Concerning care of the newborn Write “T” or “F” on the answer sheet. When you have completed all 5 questions, click on each box and mark your answers. Click to reveal correct answers Nursing a newborn with the mother rather than in the nursery predisposes the child to infections Hand washing with soap and water before handling a newborn significantly reduces the risk of infection in the baby Fortified infant formula is superior to mother’s breast milk in a sick term newborn Newborn babies cannot be kept warm without the use of incubators Jaundice cannot be detected early in dark skinned babies a b c d e

A sterile clamp applied to the umbilical cord Cord care The umbilical stump needs particular attention as there are risks of bleeding and infection. Good cord care includes: Cutting cord with sterile equipment or a new razor blade depending on the setting Ligation with a sterile plastic clamp or clean thread Keeping cord stump exposed, clean (with 70% alcohol, 4% chlorhexidine or simple soap and water) and dry A sterile clamp applied to the umbilical cord Binding, use of powders and traditional practices like application of cow dung, broken glass or herbs are harmful and should be discouraged! back

Thermal control Regulation of body temperature is immature in newborn infants. Also, energy reserves are low which may compromise the ability to cope with thermal stress. Even in tropical countries, infants may become hypothermic especially when temperature drops at night. Measures to prevent hypothermia include: Delivery in a warm environment Immediate drying of the infant to minimize heat loss by evaporation Keep out of drafts Skin to skin contact with mother Proper clothing and wrapping up with linen including use of booties and bonnets Regular feeds A well dressed baby back

A postnatal ward showing mothers with their babies Rooming in Rooming in refers to the practice of nursing babies with their mothers rather than keeping them in a separate nursery. Advantages: Promotes bonding Makes exclusive breastfeeding easy Early exposure of baby to maternal bacterial flora Reduces risk of nosocomial infections Mother is able to keep a close watch on her infant. She should be encouraged to report any concerns that she has to the health care staff. A postnatal ward showing mothers with their babies back

Breast feeding a low birthweight infant Breast feeding remains the best method of feeding the newborn and has the following advantages: Breastmilk is nutritionally balanced It reduces the risk of infection especially in unhygienic situations Protects against diarrhoea and other infections in infancy Promotes mother-child bonding It is readily available It helps in child spacing Breast feeding a low birthweight infant When breast feeding is not feasible (e.g. an HIV positive mother who chooses not to breastfeed, an infant whose mother dies) infant formula is the most suitable alternative. It should be prepared with clean boiled water under hygienic conditions. Cup and spoon feeding is safer than bottle feeding in settings with limited resources. back

Routine immunization Immunization: should be commenced soon after birth irrespective of gestational age according to national immunization schedules Example of an immunisation schedule At birth BCG, Oral polio & HBV1 6 weeks DPT1, Oral polio & HBV2 10 weeks DPT2, Oral polio 14 weeks DPT3, Oral polio & HBV3 9 months Measles, yellow fever 18 months DPT4 DPT- diptheria, pertussis, tetanus; HBV – hepatitis B vaccine back

Sources of information Pocket book of Hospital care for children; guidelines for the management of common illnesses with limited resources. WHO http://www.who.int/child-adolescent-health/publications/CHILD_HEALTH/PB.htm Essential newborn care http://www.who.int/reproductive - health/publications/ Nelson Textbook of Pediatrics: 16th Edition. Richard E. Behrman Robert Kliegman, Hal B. Jenson (Editors),

Authors and reviewers Authors: Dr. O. Tongo, Lecturer and Consultant Paediatrician, College of Medicine, University of Ibadan, Ibadan, Nigeria. Mrs A. Alao, System analyst, College of Medicine, University of Ibadan, Ibadan, Nigeria. Dr. Stephen Allen, Reader in Paediatrics and Honorary Consultant Paediatrician, The School of Medicine, Swansea University, Swansea, UK We would like to acknowledge the of the Association of Commonwealth Universities, London for awarding the Fulton Fellowship which supported Dr. Tongo and Mrs Alao in developing this module Back

û Answer to question 1a The statement is False. Nursing a newborn with the mother exposes baby to mother’s normal flora early and this helps to prevent colonization by pathogenic bacteria. Nursery care delays this and exposes the infant to nosocomical infections. Back

ü Answer to question 1b The statement is True. Hand washing with soap is the single, most important factor in the prevention of infections in the newborn!! ü Back

û Answer to question 1c The statement is False. Mother’s milk is the most suitable in composition for adequate growth of a term infant. In sick term newborns, it has added advantage of protecting against necrotizing enterolitis because it does not favour bacterial proliferation and has less solute load than infant formula. Back

û Answer to question 1d The statement is False. Well babies including preterms can be kept warm by proper clothing or direct skin to skin care with mothers or other care givers even in the absence of incubators Back

û Answer to question 1e The statement is False. Though jaundice is difficult to detect in dark skinned babies, it is possible to detect early jaundice in them by blanching the skin of the tip of the nose to ellicit yellowness. This must be performed before discharge and mothers should be taught to do same at home Back