Pediatrics I 1.

CARE OF THE NEWBORN Dr. Jerome Wangdali

OUTLINE  Receives pulmonary return and inferior vena cava return

I. PRINCIPLES OF CARE AT BIRTH which has passed through the foramen ovale
II. PLAN OF ACTION: ROUTINE
CARE
III. NURSERY CARE
RIGHT VENTRICLE OUTPUT
IV. WELL BABY  Passes to lungs through the ductus arteriosus
V. HIGH-RISK BABY INFERIOR VENA CAVA RETURN
VI. SICK BABY  Combines with SVC return passes through the foramen
VII. DIAGNOSTIC WORK-UP ovale to the left atrium
VIII.
 Oxygenated blood to inferior vena cava via ductuc venosus
 Deoxygenated blood to the placenta via umbilical arteries
 Oxygenation in the placenta

I. PRINCIPLES OF CARE AT BIRTH B. INITIAL MANAGEMENT

1. ABC: Airway. Breathing, Circulation
1. Establishment of respiration  Normal Respiratory Rate for Newborn: 40-60 cpm
2. Prevention of hypothermia  Pulse Rate for newborn: 120-160 bpm
3. Establishment of breastfeeding
4. Prevention of infection Peripheral acrocyanosis of the Newborn
5. Prevention of the hemorrhagic disease of the newborn
 a normal transient condition of the newborn characterized
6. Identification of the high-risk neonates
by pale cyanotic discoloration of the hands and feet,
especially the fingers and toes. The blueness fades as the
A. CARDIO-PULMONARY ADAPTAION
baby begins to breathe easily but returns if the baby is
FETO-PLACENTAL CIRCULATION:
allowed to become chilled.

2. Temperature control
 During pregnancy the baby's temperature is kept fairly
constant inside the mother's body at about 37.7oC.
 Once born, babies still have only a limited ability to
regulate their own body temperature.
 Babies can move a little but are unable to shiver.
 They can sweat, but only the glands in their head, neck
hands and feet are active (being about 25 to 30% of their
total body size).
 To keep warm, baby may try to curl up into the fetal
position, move or cry
 ideally the baby's temperature should be no lower than
36.0oC

Brown Adipose Tissue (or 'BAT')

 a baby's main source of heat production
 starts to be produced at 26 to 30 weeks of the pregnancy
and makes up about 2 to 7 % of the baby's total body
weight at birth

3. Cord dressing

II. PLAN OF ACTION: ROUTINE CARE

A. ADMISSION PROCEDURES

1. Transition and initial physical Assessment

APGAR
LEFT VENTRICLE

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  is a quick test performed on a baby at 1 and 5 minutes  Ophthalmic ointment containing 0.5%erythromycin, within
after birth. 1 hour of birth as prophylaxis against gonococcal
 1-minute score determines how well the baby tolerated ophthalmia.
the birthing process.
 5-minute score tells the doctor how well the baby is doing 3. General laboratory evaluation
outside the mother's womb. 3a. CBC, Blood type, Coomb’s test
 total score of 1 to 10. The higher the score, the better the
baby is doing after birth.
 A score of 7, 8, or 9 is normal and is a sign that the
newborn is in good health. A score of 10 is very unusual,
since almost all newborns lose 1 point for blue hands and Coombs' test
feet, which is normal for after birth.  test for antibodies that may stick to your red blood
 lower than 7: is a sign that the baby needs medical cells and cause red blood cells to die too early.
attention.  A normal result means there were no clumping of
 A lower Apgar score does not mean a child will have cells (agglutination), meaning you have no antibodies
serious or long-term health problem. The Apgar score is to red blood cells.
not designed to predict the future health of the child.
3b. Glucose Screening
Causes of low APGAR score: Neonatal Hypoglycemia
 Difficult birth  is the most common metabolic problem in neonates.
 C-section
 Fluid in the baby's airway In children:
 a blood glucose value of less than 40 mg/dL (2.2 mmol/L)
Intervention for child with low Apgar score: represents hypoglycemia.
 Oxygen and clearing out the airway to help the baby
breathe In newborn:
 Physical stimulation to get the heart beating at a healthy  A plasma glucose level of less than 30 mg/dL (1.65
rate mmol/L) in the first 24 hours of life and less than 45 mg/dL
(2.5 mmol/L) thereafter represents hypoglycemia.
2. Vitamin K
 all babies need vitamin K
 vitamin K helps blood to clot and prevents serious bleeding CLINICAL MANIFESTATIONS:
 babies have low levels of vitamin K in their bodies  may be asymptomatic or may present with severe central
 without vitamin K, babies are at risk of getting a rare nervous system (CNS) and cardiopulmonary disturbances.
bleeding disorder  altered level of consciousness
 the bleeding disorder is called VKDB (vitamin K deficiency  seizure
bleeding) or HDN (haemorrhagic disease of the newborn)  vomiting
 VKDB is serious and can cause brain damage or death  unresponsiveness
 a single vitamin K injection given at birth is the most  lethargy.
effective way of preventing VKDB  diminished oral intake
 Poor sucking
3. Eye prophylaxis
 refers to the practice of eye drops or ointment containing COMPLICATION:
an antibiotic medication being placed in a newborn's eyes  hypoxemia
after birth  ischemia
 is required to protect the baby from an unknown  brain damage that may permanently impair neurologic
Gonorrhea or Chlamydia infection in the mother's body. development
 primary signs of an eye infection (conjuctivitis) in a
newborn are redness and swelling of the lids and sclera of CAUSES OF HYPOGLYCEMIA IN NEONATES:
the eye.  Inappropriate changes in hormone secretion
 Inadequate substrate reserve in the form of hepatic
Neonatal conjunctivitis glycogen
 also known as ophthalmia neonatorum, is a form of  Inadequate muscle stores as a source of amino acids for
conjunctivitis contracted by newborns during delivery. gluconeogenesis
 The baby's eyes are contaminated during passage through  Inadequate lipid stores for the release of fatty acids
the birth canal from a mother infected with
either Neisseria gonorrhoeae or Chlamydia trachomatis. CAUSES OF HYPOGLYCEMIA FOUND IN ALL AGES:
 gram-negative sepsis

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  endotoxin shock
 ingestions, including of salicylates, alcohol, hypoglycemic
agents, or beta-adrenergic blocking agents.
 Excluding insulin therapy, almost all hypoglycemia in
childhood occurs during fasting.
 Postprandial hypoglycemia is rare in children in the
absence of prior gastrointestinal (GI) surgery.
Hyperinsulinism, or persistent hyperinsulinemic hypoglycemia of
infancy (PHHI)
 is the most common cause of hypoglycemia in the first 3
months of life.
 It is well recognized in infants of mothers with diabetes.
3c. Newborn Screening
 is a simple procedure to find out if your baby has a
congenital metabolic disorder that may lead to mental
retardation and even death if left untreated. 4. Voiding and stooling
 is ideally done on the 48th hour or at least 24 hours from Meconium
birth. Some disorders are not detected if the test is done
earlier than 24 hours.
 A negative screen means that the result of the test
indicates extremely low risk of having any of the disorders
being screened.
 A positive screen means that the baby is at increased risk
of having one of the disorders being screened.
 Disorder Screened: CH (Congenital Hypothyroidism), CAH
(Congenital Adrenal Hyperplasia), GAL
(Galactosemia), PKU (Phenylketonuria) and G6PD
Deficiency
III. NURSERY CARE
1. Bathing and dressing 5. Behavior
 Bathing is done 6 hours after birth. 6. Color
2. Umbilical cord care
Taking care of the stump:
 Keep the stump clean
 Keep the stump dry
 Let the stump fall on its own
Signs of Infection:
 Appears red and swollen around the cord
 Continues to bleed
 Oozes yellowish pus
 Produces a foul-smelling discharge
3. Feeding
 Most newborns need eight to 12 feedings a day — about
one feeding every two to three hours.
 <6 months old: Exclusive breastfeeding
 Recommended breastfeeding up to 2 years of age.
Colostrum
 has high concentrations of nutrients and antibodies
 has a mild laxative effect, encouraging the passing of
the baby's first stool, which is called meconium.
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 clears excess bilirubin
 contains large numbers of antibodies called
"secretory immunoglobulin" (IgA) that help protect
the mucous membranes in the throat, lungs, and
intestines of the infant.
Signs of Efficient baby latching on and sucking:
 There is a tight seal between the baby's mouth and
the areola
 Much of the areola (at least a one-inch radius) is
inside baby's mouth.
 Baby's tongue is between the lower gum and your
breast.
 You hear baby swallowing
 Milk does not leak much from the corners of baby's
mouth
 You do not see dimpling (the middle of baby's cheeks
caving in) during sucking.
 consists of black, tarry stools passed after birth, changing
to brownish green. At the fourth or fifth day, stools change
according to the type of feeding.
 Breastfed babies who are not on solids may pass stool
four times a day or more, or only once every seven days.
 Formula-fed babies normally need to poop every day to
feel comfortable and avoid constipation.
Voiding:
 (-) urine output 24 hours after birth: normal
 Six or more wet diapers in a 24-hour period show that the
infant is getting enough fluids. The color of the urine
should be pale yellow.
A QUICK INITIAL PHYSICAL EXAM SHOULD BE PERFORMED AT
THE DELIVERY ROOM
To check for:
 No major anomalies
 No birth injuries
 Tongue and body appear pink
 Breathing is normal
 If mother has hydramnios, a feeding tube
should be passed into the stomach to
exclude esophageal atresia
ROUTINE DETAILED PHYSICAL EXAMINATION TO BE DONE
WITHIN 24 HOURS
 To detect congenital anomalies not
identified at birth
 To identify common neonatal problems
and initiate their management or
reassure parents
 Check for potential problems arising from
maternal dse, familial disorders or those
detected during pregnancy
 IV. WELL BABY  Large for Gestational Age: is a term used to describe
babies who are born weighing more than the usual
 AOG 38-42 weeks amount for the number of weeks of pregnancy. LGA babies
 Delivered vaginally have birthweights greater than the 90th percentile for
 APGAR score of greater or equal to 7 their gestational age, meaning that they weigh more than
90 percent of all babies of the same gestational age.
A. NORMAL VALUES
1. Anthropometric  Breech:
 Weight: 2.5-4 Complications of breech delivery:
 Length: 45-55 Intracranial Hemorrhage due to rapid moldin, Neck
 Head circumference: 32.6-37.2 Trauma due to traction, ruptured viscus (Kidney or liver),
 BP: AOG related genital edema due to caput formation, khoulder and arm
trauma on delivery of arms, cord prolapse (more common
in Footling Breech) and hip and leg trauma from traction
2. Cardiac system
 Normal pulse rate: 120-160 bpm
 Rhythm: regular, sinus  Caesarean section: Complication
 EKG: sinus rhythm, RV dominant -Immature lungs and breathing problems
-Injury during the delivery
3. Respiratory system  APGAR: <3 inVI.
1 min,
SICK<6 in 5 min
BABY
 Respiratory rate: 40-60 bpm
 ABG: pH of 7.30-7.40  Abnormal VS
 PaCO2: 35-45  Congenital anomalies requiring surgery
 PaO2: 60-100  Intrauterine infection
 BE/BD: (-)5- 0  Asphyxiated

4. Haematologic VII. DIAGNOSTIC WORK-UP

 Hgb: 16.5 gms/dL
 Hct: 53.0%  CBC, reticulocyte count, Coomb’s test
 NRBC: 500 mm3  Mother and baby blood typing
 Reticulocyte count: 2-7%  ABG
 Blood volume:  ECG, 2D echo
Full term: 80mL/kg  Chest x-ray: check for cardiac shadow, aeration, perfusion,
Preterm: 100ml/kg air in bowel and bones
 Hepa profile
5. Renal system
 Urine output: 1-2 ml/kg/hour VIII. REVIEW QUESTIONS
 Specific gravity: 1.005-1015
 Passage of urine: on or after first 24 hours CASE STUDY 1:
Baby boy R.:
6. Gastrointestinal system  39 weeks gestation born to a 25 year old mother G1P0
 0- pregnant woman
 Meconium passage
 (+) ROM 12 hours before delivery
 Passage of meconium (mixture of epithelial debris &
 (+) maternal fever
mucopolysaccharide with conjugated sbilirubin) within the
 APGAR score 7-9
1st 24 hours  transitional stools (greenish soft stools) in
 baby is 0+
the next 4 days  milk stools (normal pasty consistency
QUESTIONS:
and yellow color)
What are the high-risk factor?
 Adequate levels of pancreatic enzymes except for amylase ________________________________________________________
and lipase
________________________________________________________
________________________________________________________
V. HIGH-RISK BABY

 AOG: <37- >42 weeks What problems are you anticipating?

 Small for Gestational Age: are those who are smaller in ________________________________________________________
size than normal for the gestational age, most commonly ________________________________________________________
defined as a weight below the 10th percentile for the ________________________________________________________
gestational age

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 6. A bleeding disorder of a newborn due to insufficient Vitamin K.
Physical Examination: ____________________________________________________
 Occipital cephalhematoma
 bruises over face 7. Is a form of conjunctivitis contracted by newborns during delivery
from a mother infected with either Neisseria
Course in the nursery: gonorrhoeae or Chlamydia trachomatis.
 fed poorly at 36 hours of age ______________________________________________________
 appears somewhat lethargic and icteric
8. A common eye prophylaxis against gonococcal ophthalmia.
Lab. Test: ______________________________________________________
 CBC, blood culture
 TB: 15 mg/dl 9. A newborn’s normal blood glucose level. ___________________
 (+) Coomb’s
10. 5 clinical manifestations of a hypoglycemic baby.
CASE STUDY 2: ________________________________________________________
Baby S. ________________________________________________________
 Born by precipitous delivery
________________________________________________________
 19 years old mother G1P0 after 32 weeks gestation
 (-) prenatal care
11. 5 disorders screened during newborn screening.
 APGAR score 5-8
In the nursery:
________________________________________________________
 RR: 80 CPM
 Cyanotic, grunting ________________________________________________________
________________________________________________________

QUESTIONS: 12. Normal age of gestation. _____________________

Identify the high risk factors.
________________________________________________________ 13. Normal newborn weight. _____________________
________________________________________________________
________________________________________________________ 14. Normal blood volume of a preterm newborn.

What is the most likely diagnosis? ________________________________________________________

________________________________________________________
________________________________________________________ 15. 5 high-risk baby.
________________________________________________________
___________________________________________________________________
What other diagnosis should be considered? ___________________________________________________________________
________________________________________________________ ___________________________________________________________________
________________________________________________________
________________________________________________________

What laboratory studies should you order?

________________________________________________________
________________________________________________________
________________________________________________________

QUESTIONS 3.
1. What is the normal respiratory rate for newborn? _________
2. What is the normal pulse rate for newborn? _________
3. Left ventricle receives pulmonary return and inferior vena cava
return which has passed through the __________________.

4. At birth, what is a baby's main source of heat production?

_____________________________________________

5. What is a well-baby APGAR score? ___________________

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