1. The Neonate

2. Immediate Needs of the Newborn
Address temp. then ABCs!
Maintenance of body temperature to prevent cold stress and metabolic acidosis (drying, hat, warm blankets, skin to skin)
Aspiration of airway mucus
Evaluation by use of Apgar score 1 and 5 minutes following birth
Constant observation of physical condition
Eye care, Vitamin K, Hepatitis B (with consent)
ID bands (one on wrist; one on ankle; one on each parent); security sensors
Bath/shampoo when temp. is stable

3. NRP
Handout in class

4. Cold Stress

5. Thermoregulation: Heat Loss in the Newborn

6. Heat Loss in the Newborn
Evaporation: occurs when the baby is wet and exposed to the air
Conduction: occurs when the baby comes in contact with cold objects (hands/stethoscope)
Radiation: occurs when the baby is exposed to cool objects that the baby is not in direct contact with (windows/walls)
Convection: occurs when the baby is exposed to the movement of cool air—for example air conditioning currents

7. Apgar Assessment
Assesses the newborn’s cardiorespiratory adaptation at birth
Score is determined at 1 and 5 minutes of life
Total score ranges from 0-10
Indicators scored are: heart rate, respiratory effort, muscle tone, reflex irritability and skin color
A score of 8-10 is good; 5-7 requires stimulation and oxygen; 0-4 requires resuscitation

8. Apgar Scoring 1 2 Activity Pulse Grimace Appearance (Skin Color)
SIGN 1 2
Activity
(Muscle Tone)
Absent
Arms and legs slightly flexed
Fully flexed extremities; active movement
Pulse
Slow (below 100 bpm)
Above 100 bpm
Grimace
(Cry/Reflex Irritability)
No response
Coughs, sneezes, pulls away
Appearance (Skin Color)
Blue-gray, pale all over
Pink except for hands/feet
Entire body is pink
Respirations
Slow, irregular
Good, crying

9. Critical Thinking Exercise
Baby boy at 1 minute of life
Heart rate—160
Respiratory effort—good, crying vigorously
Activity/Muscle tone—active movement, well-flexed
Grimace/Cry—coughing, sneezing, crying, pulling away
Color—body pink, feet and hands cyanotic
Score:______
Interpretation:____________________________

10. Critical Thinking Exercise
Baby girl at 5 minutes after birth
Heart rate—102 beats per minute
Respiratory effort—slow, irregular
Muscle tone/Activity—some flexion of extremities
Grimace/Cry—no response
Color—pale
Score:______
Interpretation:____________________________

11. Normal Newborn Lab Values
Laboratory Data
Normal Range
Hemoglobin
14-20 g/dL
Hematocrit
43%-63%
WBC
10,000-30,000/mm3
Platelets
150, ,000/mm3
Glucose
O2 Saturation
40-80 mg/dL
95% or greater

12. Newborn Senses
Vision: term infant sees 9-12 inches away from eyes. Sees black and white
Hearing: turn toward sound. Can discriminate parents’ voices. Mother’s preferred
Taste: can taste. Prefers sweet over salty
Smell: highly sensitive. Exhibit physiologic change when exposed to strong odors
Touch: very sensitive to touch and pain

13. Circumcision Board

14. Gomco Clamp Circumcision

15. Circumcision Teaching
Considered an elective procedure
August American Academy of Pediatricians now states “health benefits outweigh the risks”. Current research suggests that circumcisions decrease incidence of infections, cancers, HIV
Main complications are hemorrhage and infection
Important to comfort the infant during and after the procedure; glucose water on pacifier is soothing
A post-procedure intervention is to keep petroleum on the site. Keeps the diaper from sticking to incision
Yellow exudate that forms on the second day should not be removed. It is a sign of healing, not infection

16. The Face of Neonatal Pain

17. FLACC PAIN ASSESSMENT TOOL
FACE
No particular expression or smile 1
Occasional grimace or frown, withdrawn, disinterested 2
Frequent to constant frown, clenched jaw, quivering jaw
LEGS
Normal position or relaxed
Uneasy, restless, tense
Kicking or legs drawn up
ACTIVITY
Lying quietly, normal position, moves easily
Squirming, shifting back and forth, tense
Arched, rigid or jerking
CRY
No cry
(Awake or asleep)
Moans or whimpers
Crying steadily. Screams or sobs
CONSOLABILITY
Content, relaxed
Reassured by occasional touching, hugging, or “talking to.” Distractible
Difficult to console or comfort
Note: Ideally the score should be 0/10

18. Major Danger Signals in the Newborn
Central Nervous System
Lethargy, high-pitched cry, jitteriness, seizures, bulging fontanels
Respiratory System
Apnea, tachypnea, flaring nares, retractions, see-saw breathing, grunting, abnormal ABGs
Cardiovascular System
Abnormal rate/rhythm, persistent murmurs, dusky skin color, circumoral cyanosis
Gastrointestinal System
Absent feeding reflexes, vomiting, abdominal distention, changes in stool patterns, no stool
Metabolic System
Hypoglycemia, hypocalcemia, hyperbilirubinemia, labile temp.
Birth Weight Risks
Low Birth Weight SGA< 2500 gm
Large for Gest. Age LGA>4000 gm

19. Newborn Genetic Screening
State law therefore test must be ordered by physician however parents can refuse
Done at discharge; repeated at 7-10 days of age
Blood test that screens for 29 genetic/metabolic disorders including:
PKU (phenylketonuria)
Hypothyroidism
Galactosemia
Maple Syrup Urine Disease
Sickle Cell Anemia
Tay Sachs Disease

20. Phenylketonuria (PKU)
Results from a deficiency of the enzyme phenylaanine dehydrogenase
Unable to digest high protein foods
Without treatment, newborns become mentally retarded; eventual death
Treatment: Special diet low in phenylalanine

22. Newborn Discharge Teaching
Follow-up with pediatrician in approx. 2 days
Report any of the following:
Poor feeding
Temp. >38.0 C/100.4 F or < 36.6 C/97.8 F
Projectile or frequent vomiting
Lethargy, difficulty waking, listlessness
Inconsolable infant or continuous high-pitched cry
Cyanosis with or without crying
Excessive, watery stools; abdominal distention
No/insufficient wet diapers (>6/day after day 4)
Jaundice or abnormal body rash
Reddened umbilical cord or circumcision site
Eye discharge

23. THE COMPLICATED
NEWBORN EXPERIENCE

24. Selected Problems of the Newborn
Hemolytic Disease
Jaundice
Respiratory Complications
Risks Associated with Gestational Age and Birth Weight

25. Hyperbilirubinemia/Jaundice
50% of all infants affected
Bilirubin is by-product of RBC breakdown
Newborn liver is immature; inability to process and excrete from body
Circulates in blood causing yellow discoloration of skin, mucous membranes, sclera, internal organs
Pathological vs. physiological jaundice
Treatment: Phototherapy; hydration, increased nutritional intake*
*Note: Bilirubin binds with protein found in formula and breastmilk; this
will facilitate removal of the bilirubin via stool/urine

26. Phototherapy

27. Physiological vs. Pathological Jaundice
Seen in >50% of all neonates
Symptoms occur after first 24 hours of life
Cause: Inability to metabolize bilirubin related to immature liver
Pathological
Less common but more serious condition
Infant is jaundiced at birth; or within first 24 hours of life
Cause: Hemolysis in-utero related to Rh factor or ABO incompatibilities

28. Jaundice Testing Microbilirubin level (MBR)
Diagnostic Testing
Microbilirubin level (MBR)
Levels greater than 12 mg/dL usually require phototherapy
Severe case becomes kernicterus which is bilirubin encepholopathy. Bilirubin plaque deposits in the brain
Causes permanent brain damage

29. Kernicterus

30. ABO Blood Incompatibilities
More common than Rh incompatibility but less serious
Occurs when maternal blood type is O and fetal blood type is A, B, or AB
O mothers naturally produce anti-A and anti-B antibodies which cross the placenta
These antibodies will cause red blood breakdown in the fetus with A, B, or AB blood types
Causes hyperbilirubinemia; phototherapy is the treatment

31. Coombs Test Direct Coombs Test Indirect Coombs Test
Performed on infant’s cord blood
Determines if maternal antibodies are in the fetal blood
Positive Coombs tests suggests increased risk of jaundice in neonate
Indirect Coombs Test
Performed in antepartum period on mothers who are Rh negative
Determines if mother has developed antibodies in response to a Rh+ fetus
This test now rarely ordered as nothing can be done until after the baby is born. At that time, Direct Coombs will be ordered.

32. Respiratory Complications in the Newborn
TTN: Transient Tachypnea of the Newborn
Respiratory Distress Syndrome
Meconium Aspiration Syndrome
34 week preterm
baby grunting

33. Intercostal Retractions

34. Transient Tachypnea of the Newborn or “Wet Lungs”
Mild respiratory problem which lasts hours
Caused by the delayed absorption of fetal lung fluid after birth
At risk: prematurity, SGA, smoker diabetic mother and c/s without labor
Common signs: RR BPM, labored breathing, grunting, flaring, retractions, cyanosis
Treatment: oxygen, using mechanical ventilation if required, providing proper nutrition, medication use is minimal

35. Fluid in the Lungs
During vaginal births, especially with full-term babies, the pressure of passing through the birth canal squeezes some of the fluid out of their lungs. Hormonal changes during labor may also lead to absorption of some of the fluid.
Babies who are small or premature or who are delivered via rapid vaginal deliveries or C-section don't undergo the usual squeezing and hormone changes of a vaginal birth. So they tend to have more fluid than normal in their lungs when they take their first breaths.

36. Respiratory Distress Syndrome
Occurs when lungs are immature; lack of surfactant (facilitates gas exchange in the alveoli)
Risk of atelectasis if not treated
High risk of long-term respiratory neurologic complications
Treatment: Oxygen, surfactant. Curosurf (poractant alfa) administered via ET tube

37. Meconium Aspiration Syndrome
Usually related to fetal distress during labor. Also occurs in post-term infants
Hypoxia inutero causes relaxation of anal sphincter
Diagnosis: observe the vocal cords for meconium staining; ABG studies, X-ray
Treatment: Chest physiotherapy, antibiotics, oxygen therapy, mechanical ventilation if required

38. Hypoglycemia (<40mg/dL)
Normal range mg/dL
Infants of diabetics at greater risk
Because glucose crosses the placenta, fetus produces more insulin in response to these high glucose levels
After birth, maternal glucose supply stops abruptly but the baby is still producing insulin. This excess insulin causes hypoglycemia in the newborn
Severe hypoglycemia may result in seizures
Hypoglycemia and hypo/hyperthermia may also be indicative of infective process

39. Neonatal Infections Risk Factors Premature delivery
Recent maternal infection or illness
Rupture of membranes longer than 24 hours
Instrumentation at delivery or in the nursery (placing lines, tubes, and intubation for example)

40. Clinical Signs of Sepsis
Respiratory distress:
Tachypnea, retractions, grunting, nasal flaring and apnea. Oxygen required
Abnormal skin perfusion:
Mottling, pale color, gray color, delayed cap refill
Temperature instability:
Hypothermia and rarely hyperthermia
Feeding intolerance:
Vomiting, abdominal distention, poor feeding pattern
Abnormal vital signs:
Tachycardia, bradycardia, hypotension
Abnormal neurological status
Lethargy, hypotonia, seizures

41. Infection: Lab/Diagnostics
Blood cultures
CBC with differential
Chest X-ray if respiratory distress is present
Serious cases:
Urinalysis
Lumbar puncture

42. Group Beta Strep Infection: Known as the “Baby Killer”
Represents the leading cause of life- threatening perinatal infection in U.S.
Includes: chorioamnionitis, neonatal sepsis, pneumonia and meningitis
Mother screened at weeks gestation. If positive, antibiotics given prophalactically in labor. Mother must receive 2 doses of IV antibiotics at least 4 hours before birth for infant to be considered safe. If not, CBC/ blood culture on infant to rule out infection

43. Large for Gestational Age: Skeletal Injuries
Skull fractures (molding)
Clavicale fracture (most common #)
Humerus/femur fractures

44. Paralysis Facial Nerve: Usually unilateral. Permanent damage is rare
Brachial Nerve: Erb-Duchenne paralysis. Most common type. Involves upper arm.
Phrenic Nerve: Usually associated with brachial plexus injury. May be unilateral or bilateral and results in diaphragmatic paralysis. Requires mechanical ventilatory support for first few days after birth

45. Erb’s Palsy

46. Fractured Clavicle