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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.

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.

Classification of the neonates

By both GA and BW

By birth

weightBy gestational

age

TERMS:

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

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.

GA 40 w, GA 40 w, BW3000gBW3000gGA 34 w, GA 34 w, BW2000gBW2000g

Apgar Score of the Newborn

SIGNSCORE 0

1 2

Heart rate Absent <100 beats/min >100 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

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 )

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).

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.

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

Assessment of Growth

Head Circumference

HC – 33-55 cm, 2-3 cm larger than chest

Take Anthropometric Measurements

Head Circumference Chest Circumference

Abdomen Circumference

FontanellesThe 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.

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

Cardiovascular System

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)

Hemotological system

High: RBC 4.8-7.1; Hgb 14-24; Hct 44-64 18,000 @ birth; 23-25,000 @ 1 day with relative

neutrophilia

Coagulation: Vit K dependent clotting factors are decreased.Platelet counts ok (150,000-350,000)

•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.

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.

WBC:

Gastrointestinal System

sucking becomes coordinated @32 wks little saliva until 3 months of ageStomach 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.

Alimentary system

Hepatic FunctionLiver 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 RBC’s 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.

JAUNDICE

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.

Kidneys and Urination initial urine: cloudy, scant amounts, uric acid

crystals-> reddish stain on diaperUrine 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.

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)

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.

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

Sucking

place a finger in the neonate’s mouth

neonate sucks on the finger

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 newborn’s cheek, the reflex makes the baby turn toward the breast. • This reflex disappear at about the sixth week of life.

Rooting

touch a finger to the neonate’s cheek or the corner of mouth.

neonate turns the head toward the stimulus, opens the mouth and searches for the stimulus

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.

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.

MORO reflex

Absence or weakness of this reflex may suggest a severely disturbed CNS

Startle reflex

sudden loud noise causes abduction of the arms wit flexion of elbow, hand remain clenched

disappears by age of 4 months

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 examiner’s fingers. • Reflex disappears to 3 months of age.

Grasp

place a finger in the neonates palmneonate grasps the finger

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.

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

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

BABINSKI

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

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

out.

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.

Tonic neck reflex

Fencing posture

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

Extrusion Reflex

Thermoregulation

Newborn physiology •Normal temperature: 36.5–37.5°C•Hypothermia: < 36.5°C --Significant contribution to deaths in low birth weight infants and preterm newborns•Stabilization period: 1st 6–12 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 atrest is between 36.7 and 37.3°C and oxygen consumption and caloric utilization are lowest

Newborn’s 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 --> increased O2 demands and caloric consumption, metabolic acidosis

Temperature Regulation

SKIN Observation and palpation

SKIN

Common variationsAcrocyanosis - result of sluggish peripheral circulation.

Physiologic jaundice

Neonatal jaundice is often seen in infants around the second day after birth, lasting until day 8 in term births, orto around day 14 in premature births.

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.

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

Lanugo

- Is the fine hair, downy hair that covers a newborn’s 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

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.

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

Features in appearance of normal term neonate and preterm neonate

pink ， well-nurished，Less fine-hair

term

Dark-red,edema ， transparent ， more fine-hair

preterm

SkinSkin

soft ear stick to the skull,

poor figuration

preterm

Good ear figuration, well-developed cartilage

term

earear

preterm

Shallow and less

term

Obvious, over all the sole

Sole markingsSole markings

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.

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

The End