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Growth and

Development: TheNewborn Baby

Manal Kassab

Nur. 346

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Fetal Circulation: CirculatoryPathways

Placenta:

The organ responsible for1. Delivery of nutrients

2. Removal of waste products

3. Delivery of oxygenatedblood to the fetus.

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Circulatory Pathways:

Fetal lungs: Are filled with fetal lung liquid

not used to oxygenate blood. Because the alveoli are filledwith liquid

most of the arteries and arterioles are surrounded by

liquid which increases resistance to blood flow through thevessel

This results in most of the blood flow bypassing the lungsand therefore directed to the systemic periphery.

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4http://www.youtube.com/watch?v=52DQHL7xrTI&feature=related

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Figure 21-33a

Placental Blood SupplyB l ood f l ows t o t hep l a cen ta:

through a pair ofumbilicalarteries which enter umbilicalcordB l ood r e tu rn s f r omp l a cen ta:

in a single umbilical veinwhich drains into ductusvenosus (l iver(Ductus venosus:

empties into inferior venacava

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Umbilical vein & DuctusVenosus: Average oxygen saturation of blood

is 80% in the umbilical veinbefore it mixes with unoxygenated

blood in the ductus venosus. After mixing, the oxygen saturation

is approximately 67%.


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2Fetal Pulmonary

Circulation Bypasses1.Foramen ovale:

Inter-atrial opening

covered by valve-like flap

directs blood from right to left atrium

2.Ductus arteriosus:

short vessel connects pulmonary andaortic trunks

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Foramen ovale: The majority ofinferior venacava blood flow crosses theforamen ovale and into theleft atrium bypassing the lungs,

some blood flow enters the rightventricle.

The foramen ovale is anatomicalopening between the right atriumand left atrium which closesshortly after birth.


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Ductus arteriosus: A vessel that connects the

main pulmonary artery tothe aorta.


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The blood flow that does enter the right atrium(mainly from the superior vena cava) enters the

right ventricle and then the main pulmonary arterywhere the blood flow then enters the ductusarteriosus which connects to the aorta.

Once again, most blood flow bypasses the lungs

and is directed to the systemic circulation. Bloodflow is flowing in a right to left direction. Theductus arteriosus should functionally close within15 hours and structurally within a few weeks (inmature infants).


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Umbil ical arteries: 2 vessels that allows unoxygenated

blood to flow from the descendingaorta back to the placenta.


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Changes at Birth

The First Breath: The lungs are filled with air

instead of fluid. Higher oxygen levels in theblood and alveoli filled with

air instead of fluid allows forvascular resistance to decrease. This results in a greaterincrease in pulmonary

blood flow.

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Anatomical Changes: Placenta is removed from circulation

Higher pressure in the left atrium due toincreased pulmonary blood flow cause the foramanovale to close Higher concentrations of oxygen in the blood,decreased prostaglandin levels and decreased

pulmonary vascular resistance closes the ductusarteriosus When the umbilical cord is clamped, the umbilical vein

closes, systemic vascular resistance is increasedand this causes the ductus venosus to close.

Changes at Birth

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14Figure 28.13

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Physiologic adjustment toextrauterine life: First period of reactivity:

lasts for hour, baby is alert & exhibit exploringsearching activities, making sucking sounds, rapidH.R & R.R.

Resting period: lasts 90 minutes, baby generally sleeps, slower H.R

& R.R.

Second period of reactivity: between 2-6 hours of life. Baby is a wake, gagging

and choking on mucus. Gain alert & responsive and interest to surrounding.

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Assessment of well being:

Apgar Scoring Is an assessment scale

applied at 1 minute, 5 and10 minutes after birth.

Give a score (0,1, or 2) foreach sign.

It serves as a baseline forfuture evaluation.

http://www.youtube.com/watch?v=Vtxsxv1BQek&feature=related

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Apgar scoreA score under 4 is in

serious danger and need

resuscitation.A score of 4-6 may need

clearing of the airway

and O2 supplement.A score of 7-10 is good

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Weight: differs depending on the race, nutritional, intrauterine

and genetic factors. Normal rates 2.7-4.0 kg

Newborn loses 5-10% of birth weight during the1st few days because of: No longer under the influence of salt & fluid-retaining maternal

hormones. Diuresis: to remove part of body fluids. Limited by low caloric content of colostrum. Time needed to establish sucking. Stools.

The Newborn Baby

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The Newborn Baby Recaptures birth wt within

10 days

Head-to-heel length: birthlength is 4853 cm

H.C: 33-35 cm.

C.C: 2 cm less than H.C.

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Classification of infants based ongestational ages and birth weights

Preterm or premature: infant bornbefore the end of 37 weeks,regardless of weight

Term or full term: born between38 & 42 weeks, regardless of weight Postterm: an infant born after42weeks regardless of weight Low birth weight: any infant at birth

who weighs less than 2.500 gm
http://upload.wikimedia.org/wikipedia/commons/2/2b/Weight_vs_gestational_Age.jpg

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Small for gestational age(SGA): any newborn whose weight is below the 10 th percentile(according to intrauterine growthcurve)

Appropriate for gestation age(AGA): any newborn whoseintrauterine growth has been normalfor that length of gestation

Large for gestational age(LGA): any infant born whoseweight is above the 90 thpercentile regardless of gestation Intrauterine growth restrict ion(IUGR): failure of fetus to grow as

expected during gestation
http://upload.wikimedia.org/wikipedia/commons/2/2b/Weight_vs_gestational_Age.jpg

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Flexion posture

Looks, red or cyanotic

Body covered with varying

amount of lanugo andvernix caseosa.

Appearance of newborn
http://www.pregnancy-leads-to-new-babies.com/Pregnancy-Babies-And-Baby-Makes-Three.html

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Vital signs Temp:

37.2 at birth fall because of heat loss, littles.c fat & immature tempreature.

Regulating center (drying, wrapping, & putthem under the radiant heat + kangaroocare).

Pulse: 120-160 bpm. at the moment of birth to 180 bpm. 1 hour after birth to 120-140 bpm.

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Respiration: first few minutes 80 b/m to 30-60 b/m when newborn at rest. Usually irregular with short periods of apnea

Blood pressure:

80/60 mm/Hg at 10th day to 100/50 mm/Hg.

Vital signs

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HeadLarge head, overridden sutures

Head molded to fit cervix.

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Caput succedaneum: Edema of the soft scalp t issue at the presenting part of the

head. Accumulation of serum in the tissues above the bone Cross suture lines Disappear in few days

Head

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Head Cephalhematoma:

Localized collection ofblood between theskull bone and its periosteum May involve one or both parietal bones Weeks to resolve

Dose not cross sutures

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Caput succedaneum

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cephalheamatoma

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Molding of infants head

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Fontanelles

6 fontanel les. Anterior fontanelle, diamond shaped, 2.5-4 cm, will closes at

12-18 mon.

Posterior fontanelle, triangular, 0.5-1.0 cm, closed at 2 mon.

Pair of anteriolateral fontanelle close at 3 mon.

Pair of posteriolateral fontanelle close at 12 mon.

http://www.youtube.com/watch?v=KfrLqTzaXq0
http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0

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Head Laghttp://www.youtube.com/watch?v=WkoGQldC8qU&NR=1

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Eyes: tearless cry (lacrimal ducts mature at 3months)

permanent eye color between 3-12 mon.

Ears: pinna tends to bend easily. Nose: large for face. Mouth: prominent, large, & short tongue.

Natal teeth are unusual. Thrush indicates candida infection.

Neck: short & chubby with many folds. Head lags
http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0

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Skeletal system Arms are slightly longer than legs. Hands clenched into fists. 3 normal creases. Flat sole of the feet

Hips inspect for symmetryskin folds shouldmatch

ortolani maneuver for hip dysplasia Check for tufting of hair at base of spine

(spina bifida, occulta) Clubfoot

Absence of limb or digit
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Skin

Vernix casoesa

Acrocyanosis

Lanugo Bruising, petechiae from

birthing

Mongolian spotsgenerally back andbuttocks

Milia
http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0

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Milia Small, whitish-

yellow papules

found close tothe skin surface

Particularly

common aroundeyes andmidface
http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0

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Skin Down syndromesimian

crease on palm

Strawberry marknevous

Vasculosushemangioma

Erythema toxicum-newbornrash

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Strawberry marknevous

VasculosushemangiomaErythema toxicum

Vasculosushemangioma
http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://en.wikipedia.org/wiki/File:Capillary_haemangioma.jpg

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Chest: looks small (compared to head), Engorged breasts (maternal hormone) Ronchi because of mucus

Abdomen:

protuberant. Bowel sound should be present within an hour. Umbilical cord white gelatinous structure with red & bluestreaks for the 1st hour.

Begin to dry breaks free by 6th- 10th day. Check for concave abdomen

Appearance of newborn
http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0

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Resting 100-160 > 160 or < 100 should be reevaluated Blood volume: 80-85 ml/kg, average about 300 ml but

can have an additional 100 ml if cord is not cut inreasonable length of time

Hg 14-24 g/dl Infant Hgb Fhigher O2 affinity Hgb A production largely replaces Hgb F by 4months Iron stores good for 5 months Blood coagulation: born with long coagulation time

(lower level of vit. K).

Circulatory & hemopoietic
http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0

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GI SYSTEM

Baby learns to coordinate breathing, sucking and swallowing Bacteria not present in gut vitamin k

Digestion of simple CHO and protein (Starches and fats arenot easily digested at this time)

Feeding variescues hand to mouth movement and suckingfingers intensify when hungry

Prevent regurgitation by not overfeeding, frequent burping and positioning the head slightly elevated
http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0

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GI 2 Stoolmeconiumgreenish

black

Stools change and the

stooling pattern change

indicates good bowel

functioning

Color time and character of

first stool should bedocumented.

Diarrhea stoolloss of fluid

quickly
http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0

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Patent anus (check forimperforate anus).Meconium within 24 hour.

Male genitalia: edematous scrotum, check forundescended testicles, epi or hypospadias.

Female genitalia: swollen vulva (maternal

hormones), pseudomenstruation. bloodtinged vaginal discharge caused by maternalestrogen's effect on a baby girl's

Anogenital
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Passive immunity from mom (IgG)

Immunoglobulins gradually develop and

completed about 6 months old

High risk of infection in first few month

abnormal discharges or rashes should be

evaluated

Immune system
http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0http://www.youtube.com/watch?v=KfrLqTzaXq0

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Renal system Should void in first 24 hour

Frequency depends on intake

Not able to concentrate urine (1

st

3 mon) May see blood in diaper of female

Birth defect Hypospadias (Male only) Extrophy of bladder

(bladder inside-out)

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Hepatic system Iron storage

Conjugation of bilirubinfunction not well developed at birth

Physiologic jaundiceafter 24 hrspreterm increase and moresevere

Pathologic jaundicebefore 24 hrs Kernicterusbil l iruben higher than 25(neurological condition that occurs in some newborns with severe

jaundice)

Early stage: Extreme jaundice; Absent startle reflex; Poor feeding
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The newborn is born with certain specificresponses that are triggered by specific stimuli

Some of these reflexes, such as rooting andsucking, appear to have survivalimplications Other reflexes appear to be precursors for

later voluntary motor behavior The newborns reflexes may also give

information about the health of the childsnervous system.

Neuromuscular system
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Sucking Onset: ~28weeks GA

Well-established: 32-34 weeksGA

Disappears: starting around 12months

Elicited by the examiner stroking

the lips of the infant.
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This reflex begins when the corner of the

baby's mouth is stroked or touched. The

baby will turn his/her head and openhis/her mouth to follow and "root" in the

direction of the stroking. This helps the

baby find the breast or bottle to begin

feeding.

http://www.youtube.com/watch?

v=xneStHZ0Kho&feature=related

Rooting
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The Moro reflex is often called a startle reflexbecause it usually occurs when a baby is startled

by a loud sound or movement. In response to thesound, the baby throws back his/her head, extendsout the arms & legs, with fingers extended in cshape, cries, then pulls the arms and legs back in.lasts about five to six months.

http://www.youtube.com/watch?v=PhOleckx1-Y&feature=re

Moro Reflex
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Grasp reflex Stroking the palm of a baby's

hand causes the baby to close

his/her fingers in a grasp. Thegrasp reflex lasts only a couple ofmonths and is stronger inpremature babies

http://www.youtube.com/watch?v=FV-qWSVNFt8&NR=1

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When a baby's head is turned to one side,

the arm on that side stretches out and the

opposite arm bends up at the elbow. lastsabout six to seven months.

http://www.youtube.com/watch?

v=UWqafotPxTg&feature=related

Tonic Neck Reflex

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Babinski reflex

When the sole of the foot is firmly

stroked, the big toe bends back toward

the top of the foot and the other toes fan

out. This is a normal reflex up to about 2

years of age.

http://www.youtube.com/watch?v=oI_ONptx2Ns&NR=1

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Step reflex This reflex is also called the

walking or dance reflex because a

baby appears to take steps ordance when held upright with

his/her feet touching a solid

surface.

http://www.youtube.com/watch?v=cZYHwCWSKiE&feature=related

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Senses

Hearing: able to hear in utero, within days after birth hearing

become acute

Vision: see as soon as they are born (blinking reflex).

Cant follow objects past the midline.

Best focus on black & white.

Newborns see best using peripheral vision (out of the corner

of their eyes)

and when objects are about 9-12 in. 22.86-30.48 cm( away.

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Touch: The sense of touch in newborns is

well developed, particularly around the

mouth. They are sensitive to temperature,pressure, and pain.

Smell: well developed, newborns are often

able to recognize the smell of their mother

within the first few days of life. Taste: prefer sweet tastes and usually do not

like sour, bitter, and salty tastes.

Senses

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The Newborns States

Sleeping Newborns sleep an average of16-18

hours daily. Newborns usually follow a sleep-wake

cycle of around 4 hours of sleepfollowed by 1 hour of wakefulness.

By 3 or 4 months newborns usuallysleep through the night.
http://basilio.jammrock.com/Avery/images/unhappy.jpg

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The Newborns States Crying Basic Cry

Starts softly and builds in volume andintensity. Often seen when the child ishungry Mad Cry

More intense and louder Pain Cry

Starts with a loud wail, followed by longpause then gasping. Be calm and patient Do not shake baby Know signs of emergencies
http://basilio.jammrock.com/Avery/images/unhappy.jpg

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