CARE OF THE NEWBORN IN CARE OF THE NEWBORN IN THE DELIVERY ROOMTHE DELIVERY ROOM

Maintain patent airwayMaintain patent airway drain secretions – put the baby in trendelenberg position drain secretions – put the baby in trendelenberg position

for drainage except when signs of increased ICP id for drainage except when signs of increased ICP id observed: bulging fontanels, high pitched cry(earliest sign), observed: bulging fontanels, high pitched cry(earliest sign), vomiting (surest sign), increased BP, decreased PR, vomiting (surest sign), increased BP, decreased PR, decreased RRdecreased RR

suction newbornsuction newborn suction the mouth first before the nose - to prevent suction the mouth first before the nose - to prevent

aspirationaspiration suctioning should be gentle to prevent laryngospasmsuctioning should be gentle to prevent laryngospasm it should not be more than 1 minute, (otherwise, it will it should not be more than 1 minute, (otherwise, it will

stimulate vagus nerve causing bradycardia )stimulate vagus nerve causing bradycardia ) occlude one nostril at a time to test for patency (since occlude one nostril at a time to test for patency (since

newborn are nasal breather for 4 monthsnewborn are nasal breather for 4 months

observe for characteristics of respirationsobserve for characteristics of respirations normal: irregular for the first 5 mins of life, quite, rapid normal: irregular for the first 5 mins of life, quite, rapid

but shallow, with period of apnea without cyanosisbut shallow, with period of apnea without cyanosis abnormal: noisy breathing indicates airway abnormal: noisy breathing indicates airway

obstruction, chest with retractions, flaring nose, obstruction, chest with retractions, flaring nose, irregular even after 5 mins, rapid and deep, with short irregular even after 5 mins, rapid and deep, with short periods of apnea with cyanosis>20 secperiods of apnea with cyanosis>20 sec

administer oxygen as neededadminister oxygen as needed oxygen concentration should be <40% (to oxygen concentration should be <40% (to

prevent retinal scarring which may lead to prevent retinal scarring which may lead to blindness - retrolental fibroplasiasblindness - retrolental fibroplasias

oxygen is best administered through a tentoxygen is best administered through a tent

Keep the newborn warmKeep the newborn warm The body temperature of newborn at birth is 37.2 C shortly The body temperature of newborn at birth is 37.2 C shortly

after birth. It falls to below normal because of the immature after birth. It falls to below normal because of the immature temperature regulating mechanism and heat loss. In temperature regulating mechanism and heat loss. In addition , the cold temperature of the delivery room addition , the cold temperature of the delivery room contributes to thiscontributes to this

Newborns have difficulty conserving heat because they have Newborns have difficulty conserving heat because they have very little subcutaneous fats to act as insulators. Shivering is very little subcutaneous fats to act as insulators. Shivering is not also present at birth. Because of this, they are prone to not also present at birth. Because of this, they are prone to cold stress which may cause metabolic acidosis as fatty acids cold stress which may cause metabolic acidosis as fatty acids accumulate due to breakdown of fatsaccumulate due to breakdown of fats

Dry newborn immediatelyDry newborn immediately Wrap in a blanketWrap in a blanket Place under radiant warmer or isollette with a temperature Place under radiant warmer or isollette with a temperature

33-34 C33-34 C Place under a droplight which should be 12 – 18’’ from the Place under a droplight which should be 12 – 18’’ from the

newbornnewborn

Take the Apgar scoreTake the Apgar score

Done at 1 minute after birth to know the Done at 1 minute after birth to know the condition of the newborncondition of the newborn

Then at 5 minutes after to determine how Then at 5 minutes after to determine how well the newborn is adjusting to well the newborn is adjusting to extrauterine life extrauterine life

Indicators 0 1 2

Heart rate absent Less than 100 beats /min

More than 100 beats/min

Respiratory rate

absent Slow, irregular, weak cry

Good, vigorous cry

Muscle tone Flaccid, limp

Minimal flexion of extremities

Good flexion, active motion

Reflex irritability

No response

Minimal response to suction or to gentle slap on soles

Responds promptly with a cry or active movement

Skin color Pallor or cyanosis

Body skin normal, extremities blue

Body and extremity skin color normal

InterpretationInterpretation

8 – 108 – 10 no intervention is required no intervention is required except to support the infant’s spontaneous except to support the infant’s spontaneous effortsefforts

4 – 74 – 7gently stimulate. Rub infant’s back. gently stimulate. Rub infant’s back. Administer oxygen to infantAdminister oxygen to infant

0 – 3 0 – 3 infant requires resuscitationinfant requires resuscitation

INITIAL PHYSICAL INITIAL PHYSICAL EXAMINATIONEXAMINATION

General GuidelinesGeneral Guidelines Keep newborn warm during examinationKeep newborn warm during examination Begin with general observations then Begin with general observations then

perform assessment that are leat perform assessment that are leat disturbing to the newborn firstdisturbing to the newborn first

Initiate nursing interventions for abnormal Initiate nursing interventions for abnormal findingsfindings

Document all abnormal findingsDocument all abnormal findings

Vital StatisticsVital Statistics

WeightWeight

average birth weight is 6.5 – 7.5 lbs or 3 – 3.4 Kgsaverage birth weight is 6.5 – 7.5 lbs or 3 – 3.4 Kgs arbitrary limit is 2.5kg or 5.5 lbs. Below this weight, the arbitrary limit is 2.5kg or 5.5 lbs. Below this weight, the

newborn is considered low birth weight infantnewborn is considered low birth weight infant newborn loses 5 – 10% of birth weight during the first few newborn loses 5 – 10% of birth weight during the first few

days of life (physiologic wt loss) due to:days of life (physiologic wt loss) due to: newborn is no longer in the influence of maternal newborn is no longer in the influence of maternal

hormoneshormones newborn voids and passes stoolnewborn voids and passes stool if breast fed, they have limited intake because if breast fed, they have limited intake because

colostrums has low caloric contentcolostrums has low caloric content if bottle fed, sucking is not yet effectiveif bottle fed, sucking is not yet effective birth weight is doubled by 6 mos, tripled by 1 yr, birth weight is doubled by 6 mos, tripled by 1 yr,

quadrupled by 2.5 yearsquadrupled by 2.5 years

LengthLength

45 to 55 cm or 18 to 22 inches45 to 55 cm or 18 to 22 inches

head circumferencehead circumference

measured with a tape measure drawn measured with a tape measure drawn across the center of the forehead and the across the center of the forehead and the most prominent portion of the posterior most prominent portion of the posterior headhead

34 -35 cm or 13.5 to 14 inches34 -35 cm or 13.5 to 14 inches

Chest circumferenceChest circumference

Normal: 31 – 33 cmNormal: 31 – 33 cm 2 cm or 0.75 to 1 inch less than the head 2 cm or 0.75 to 1 inch less than the head

circumferencecircumference Measured at the level of the nipplesMeasured at the level of the nipples Head circumference> chest Head circumference> chest

circumference until 2 yrs of agecircumference until 2 yrs of age

abdominal circumferenceabdominal circumference

normal: 31 – 33 cmnormal: 31 – 33 cm measured at the level of umbilicusmeasured at the level of umbilicus

VITAL SIGNSVITAL SIGNS

temperaturetemperature

at birth, it is 37.2 C and must be maintained at at birth, it is 37.2 C and must be maintained at 35.5 to 36.5 C35.5 to 36.5 C

a newborn losses heat thru the following a newborn losses heat thru the following mechanism:mechanism:

Conduction: heat is transferred to a cooler solid Conduction: heat is transferred to a cooler solid object in contact with the bodyobject in contact with the body

Convection: heat flows from the body surface to Convection: heat flows from the body surface to a cool surrounding aira cool surrounding air

Evaporation: heat loss thru conversion of liquid Evaporation: heat loss thru conversion of liquid to vaporto vapor

Radiation: heat is transferred to a cooler solid Radiation: heat is transferred to a cooler solid object but not in contact with the bodyobject but not in contact with the body

Pulse Pulse

Immediately after birth PR is 100 to 180 Immediately after birth PR is 100 to 180 beats/min as the neonate struggles for beats/min as the neonate struggles for respirationrespiration

Normal is 120 to 140 bpmNormal is 120 to 140 bpm Palpate femoral pulse (absence may Palpate femoral pulse (absence may

indicate coarctation of aorta)indicate coarctation of aorta) Radial pulse not ordinarily palpableRadial pulse not ordinarily palpable

RespirationRespiration

Immediately after birth, it may be as high Immediately after birth, it may be as high as 80 per minas 80 per min

Normal : 30 to 60 per minNormal : 30 to 60 per min Observe movement of abdomenObserve movement of abdomen

Respiratory EvaluationRespiratory Evaluation

Silverman and Andersen Index Silverman and Andersen Index used to estimate degrees of respiratory used to estimate degrees of respiratory

distress in newbornsdistress in newborns newborn is observed and then scored on newborn is observed and then scored on

each of five criteria; each item is given a each of five criteria; each item is given a value of 0,1 and 2 and addedvalue of 0,1 and 2 and added

0 indicates no respiratory distress0 indicates no respiratory distress 4-6 indicates moderate distress4-6 indicates moderate distress 7-10 indicates severe distress7-10 indicates severe distress

Blood PressureBlood Pressure

Not routinely taken unless cardiac Not routinely taken unless cardiac anomaly is suspected anomaly is suspected

At birth, BP is 80/46 mmHgAt birth, BP is 80/46 mmHg After 10 days, 100/50After 10 days, 100/50 The cuff to be used must not be more The cuff to be used must not be more

than 2/3 of the length of the upper arm or than 2/3 of the length of the upper arm or thighthigh

Flush methodFlush method Apply cuff to the extremityApply cuff to the extremity Elevate extremity and apply elastic bandage on Elevate extremity and apply elastic bandage on

the distal part of the extremitythe distal part of the extremity Inflate cuff to 200 mmHgInflate cuff to 200 mmHg Slowly deflate the cuff, while watching the pale Slowly deflate the cuff, while watching the pale

extremityextremity As soon as the extremity turns pink, read the As soon as the extremity turns pink, read the

manometermanometer Only 1 reading will be obtained which is the Only 1 reading will be obtained which is the

average between the diastolic and systolic average between the diastolic and systolic pressure called flush pressure. Normal is 60 at pressure called flush pressure. Normal is 60 at birth and 75 after 10 daysbirth and 75 after 10 days

Administer eye careAdminister eye care

Crede’s prophylaxis to protect the newborn Crede’s prophylaxis to protect the newborn against gonorrheal conjunctivitis acquired from against gonorrheal conjunctivitis acquired from the mother as the infant passes thru the birth the mother as the infant passes thru the birth canalcanal

Dry NB faceDry NB face Open the eye at a time by putting pressure on Open the eye at a time by putting pressure on

upper and lower lidsupper and lower lids Instill 2 drops of 1% Silver nitrate into the lower Instill 2 drops of 1% Silver nitrate into the lower

conjunctival sac. conjunctival sac. If erythromycin ointment is used, squeeze a line If erythromycin ointment is used, squeeze a line

of ointment along the lower conjunctival sac from of ointment along the lower conjunctival sac from the inner canthus outward. Close eye to allow the inner canthus outward. Close eye to allow ointment to spread across conjunctivaointment to spread across conjunctiva

Cord CareCord Care

Inspect for the presence of 2 arteries and Inspect for the presence of 2 arteries and 1 vein1 vein

Assess for possible bleedingAssess for possible bleeding Dress the cord with alcohol to hasten Dress the cord with alcohol to hasten

dryingdrying Keep the cord clean and dryKeep the cord clean and dry

Administer Vit KAdminister Vit K

Vit K is normally synthesized in the Vit K is normally synthesized in the presence of bacterial flora in the intestines presence of bacterial flora in the intestines

It is administered to facilitate production of It is administered to facilitate production of clotting factor clotting factor

Vit K 1mg is injected into the vastus Vit K 1mg is injected into the vastus lateralis IM. lateralis IM.

Initial feedingInitial feeding

If to9 be formula fed: give 1 oz of sterile If to9 be formula fed: give 1 oz of sterile water at 4-6 hours of age. milk is given on water at 4-6 hours of age. milk is given on the 4th feeding the 4th feeding

If to be breastfed: usually 30 min after If to be breastfed: usually 30 min after normal delivery, 4 hours after CSnormal delivery, 4 hours after CS

CircumcisionCircumcision

Surgical removal of penis foreskin usually done Surgical removal of penis foreskin usually done on the 1st or 2nd day of life on the 1st or 2nd day of life

CI: hypospadias, epispadiasCI: hypospadias, epispadias Nursing responsibilities:Nursing responsibilities:

• observe closely and check for bleedingobserve closely and check for bleeding• wrap penis with a strip of petroleum gauze wrap penis with a strip of petroleum gauze

to prevent the diaper from adhering from to prevent the diaper from adhering from the circumcised areathe circumcised area

• don’t wash away film of yellowish mucous don’t wash away film of yellowish mucous which often covers the glanswhich often covers the glans

Physical ExamPhysical Exam

SkinSkin color color

Most newborns have ruddy complexion Most newborns have ruddy complexion Acrocyanosis – extremities are blue and the body is Acrocyanosis – extremities are blue and the body is

pink. This is normal during the first 2 days of lifepink. This is normal during the first 2 days of life Pallor – maybe due to anemia due to blood loss Pallor – maybe due to anemia due to blood loss

when cord was cut few iron stores due to poor when cord was cut few iron stores due to poor maternal nutrition; blood incompatibility; fetal maternal nutrition; blood incompatibility; fetal maternal transfusionmaternal transfusion

Gray – may indicate infectionGray – may indicate infection Jaundice- yellowing of the skin and sclerae due to Jaundice- yellowing of the skin and sclerae due to

inability of the Nb to conjugate bilirubin due to inability of the Nb to conjugate bilirubin due to immature liver functionimmature liver function

Physiologic Jaundice (icterus Physiologic Jaundice (icterus Neonatorum)Neonatorum)

Onset: 2nd to 3rd day Onset: 2nd to 3rd day Duration: 5 – 7 daysDuration: 5 – 7 days Management: - morning sunlight Management: - morning sunlight PhototherapyPhototherapy

Harlequin SignHarlequin Sign

Transient phenomenaTransient phenomena Due to immature circulationDue to immature circulation Neonate lying on his side will appear red Neonate lying on his side will appear red

on the dependent side of the body and on the dependent side of the body and pale on the upper sidepale on the upper side

Change position of infantChange position of infant

BirthmarksBirthmarks HemangiomasHemangiomas

Vascular tumor of the skinVascular tumor of the skin 3 types3 types

Nevus Flammeus – are macular purple or dark Nevus Flammeus – are macular purple or dark red lesions which are also called portwine red lesions which are also called portwine stain; present at birth and found on face and stain; present at birth and found on face and thighsthighs

Strawberry Hemangiomas – elevated areas Strawberry Hemangiomas – elevated areas formed by immature capillaries and endothelial formed by immature capillaries and endothelial cells; associated with high estrogen levelscells; associated with high estrogen levels

Cavernous Hemangiomas – dilated vascular Cavernous Hemangiomas – dilated vascular spaces; raised and resemble strawberry spaces; raised and resemble strawberry hemangioma in appearancehemangioma in appearance

Mongolian SpotsMongolian Spots

Slate gray patches across the sacrum and Slate gray patches across the sacrum and buttocks and consist of a collection of buttocks and consist of a collection of pigment cells, melanocytespigment cells, melanocytes

Usually disappears by school ageUsually disappears by school age

Vernix CaseosaVernix Caseosa

White cream cheese like substance noticeable White cream cheese like substance noticeable on newborn’s skin at birthon newborn’s skin at birth

Disappear by 2 weeksDisappear by 2 weeks Color should be noted because it takes the color Color should be noted because it takes the color

of amniotic fluidof amniotic fluid if yellow, amniotic fluid is yellow from bilirubinif yellow, amniotic fluid is yellow from bilirubin if green, meconium is present in the amniotic if green, meconium is present in the amniotic

fluidfluid harsh rubbing should not be employed or harsh rubbing should not be employed or

vigorous attempts to remove vernix caseosavigorous attempts to remove vernix caseosa

LanugoLanugo

fine dowry hair that covers NB’s shoulders, fine dowry hair that covers NB’s shoulders, back, and upperarms, also on forehead back, and upperarms, also on forehead and earand ear

disappear by age of 2 weeksdisappear by age of 2 weeks

DesquamationDesquamation

drying of NB’s skin within 24 hours of birth drying of NB’s skin within 24 hours of birth which result in areas of peelingwhich result in areas of peeling

evident on palms and soles of feetevident on palms and soles of feet the peeling is similar to sunburnthe peeling is similar to sunburn normal and needs no txnormal and needs no tx

MiliaMilia

pinpoint white papule on cheek or across pinpoint white papule on cheek or across the bridge of the nose the bridge of the nose

disappear by 2-4 weeksdisappear by 2-4 weeks caused by immaturity of the NB’s caused by immaturity of the NB’s

sebaceous glandssebaceous glands

Erythema ToxicumErythema Toxicum

NB’s rash that usually appears in the 1st to 4th NB’s rash that usually appears in the 1st to 4th day of lifeday of life

Begins with papule, increases in severity to Begins with papule, increases in severity to become erythema by the 2nd day and become erythema by the 2nd day and disappears in the 3rd daydisappears in the 3rd day

Sometimes called flea-bite rash because the Sometimes called flea-bite rash because the lesions are minisculelesions are miniscule

A response to irritation to bed sheets and A response to irritation to bed sheets and clothingclothing

Forceps MarksForceps Marks

A circular or linear contusion matching the A circular or linear contusion matching the rim of the blade of the forceps on the rim of the blade of the forceps on the infant’s cheekinfant’s cheek

Disappears in 2-3 days along with edema Disappears in 2-3 days along with edema that accompanies itthat accompanies it

Result of normal forceps usage and does Result of normal forceps usage and does not denote unskilled or too vigorous not denote unskilled or too vigorous application of forcepsapplication of forceps

Skin TurgorSkin Turgor

Should be resilient Should be resilient If grasped between the thumb and fingers, If grasped between the thumb and fingers,

it should feel elastic and when released, it should feel elastic and when released, should fall back to form a smooth surfaceshould fall back to form a smooth surface

HeadHead

Disproportionately large, about ¼ of the Disproportionately large, about ¼ of the total lengthtotal length

Forehead is large and prominent, Forehead is large and prominent, Receding chin which quivers if the infant Receding chin which quivers if the infant

is startled or is cryingis startled or is crying Well- nourished NB have full bodied hair Well- nourished NB have full bodied hair

while those poorly nourished or immature while those poorly nourished or immature NB have stringy, lifeless hairNB have stringy, lifeless hair

Bones of the skull are not fusedBones of the skull are not fused

FontannelsFontannels Unossified membranous tissue at the junction of Unossified membranous tissue at the junction of

the suturesthe sutures Anterior fontanelle normally closes at 12-18 Anterior fontanelle normally closes at 12-18

mos; is at the junction of 2 parietal bones and mos; is at the junction of 2 parietal bones and the 2 fused frontal bones, measures 2-3 cm the 2 fused frontal bones, measures 2-3 cm width and 3-4 cm length, will be felt as soft spot width and 3-4 cm length, will be felt as soft spot and should not appear indented or bulgingand should not appear indented or bulging

Posterior Fontanelle – at the junction of parietal Posterior Fontanelle – at the junction of parietal bones and the occipital bones, triangular in bones and the occipital bones, triangular in shape and measures about 1 cm in length, shape and measures about 1 cm in length, normally closes by the end of the 2nd monthnormally closes by the end of the 2nd month

SuturesSutures

Separating lines of the skull may override at Separating lines of the skull may override at birth because of the extreme pressure exerted birth because of the extreme pressure exerted by the passage of the NB thru the birth canalby the passage of the NB thru the birth canal

Should never appear separated in NB because it Should never appear separated in NB because it denotes increased ICP from abnormal brain denotes increased ICP from abnormal brain formation, abnormal accumulation of CSF in the formation, abnormal accumulation of CSF in the cranium (hydrocephalus) or as accumulation of cranium (hydrocephalus) or as accumulation of blood from birth injury such as subdural blood from birth injury such as subdural hemorrhagehemorrhage

MoldingMolding

Asymmetry of head resulting from Asymmetry of head resulting from pressure in the birth canal pressure in the birth canal

Disappear in about 72 hoursDisappear in about 72 hours

Masses from birth traumaMasses from birth trauma

Caput SuccedaneumCaput Succedaneum Edema of the soft tissue over bone Edema of the soft tissue over bone

(cross over suture line)(cross over suture line) Involves large size of the head or maybe Involves large size of the head or maybe

the size of a goose eggthe size of a goose egg Will gradually be absorbed and disappear Will gradually be absorbed and disappear

about the 3rd day of life about the 3rd day of life Needs no txNeeds no tx

CephalhematomaCephalhematoma

Swelling caused by bleeding into an area Swelling caused by bleeding into an area between the bone and its periosteumbetween the bone and its periosteum

It is usually absorbed within 6 weeks with It is usually absorbed within 6 weeks with no treatmentno treatment

CraniotabesCraniotabes

Localized softening of the cranial bones, Localized softening of the cranial bones, so soft that it can be indented by the so soft that it can be indented by the pressure of the examining fingerpressure of the examining finger

Due to the pressure of fetal skull against Due to the pressure of fetal skull against the mother’s pelvic bone in uterothe mother’s pelvic bone in utero

EyesEyes Cry tearlesslyCry tearlessly Iris are slate gray till the 3rd month of lifeIris are slate gray till the 3rd month of life Edema is usually present around the orbit or on the Edema is usually present around the orbit or on the

eyelids which will remain for 2-3 dayseyelids which will remain for 2-3 days Should appear clear without redness ar purulent Should appear clear without redness ar purulent

dischargedischarge Cornea should be round and adult sized Cornea should be round and adult sized Eyes cross because of weak extraocular musclesEyes cross because of weak extraocular muscles Sometimes, pressure during delivery causes rupture Sometimes, pressure during delivery causes rupture

of capillary resulting in a small subconjunctival of capillary resulting in a small subconjunctival hemorrhage appearing as red spot on the sclera but hemorrhage appearing as red spot on the sclera but needs no treatmentneeds no treatment

Irregularly shaped pupils connote a disease and a Irregularly shaped pupils connote a disease and a white pupil connotes congenital cataract white pupil connotes congenital cataract

EarsEars

Pinna tends to bend easilyPinna tends to bend easily Low set ears associated with Down Low set ears associated with Down

SyndromeSyndrome Level of top part of the ear should be in Level of top part of the ear should be in

line with the upper canthus of the eyeline with the upper canthus of the eye NB should be placed in good alignment NB should be placed in good alignment

when putting them to sleep on their side when putting them to sleep on their side as that ear may assume the position as that ear may assume the position permanentlypermanently

NoseNose

Flat, broad, in center of faceFlat, broad, in center of face Obligatory nose breathingObligatory nose breathing Occasional sneezing to remove Occasional sneezing to remove

obstructionobstruction Nares are patent and should not flareNares are patent and should not flare May appear large for the face May appear large for the face Test for Choanal AtresiaTest for Choanal Atresia

MouthMouth

Pink, moist gumsPink, moist gums Should open evenly when NB cries Should open evenly when NB cries Palate should be intactPalate should be intact Epsteins pearl are presentEpsteins pearl are present Natal teeth maybe present Natal teeth maybe present

NeckNeck

Short and chubby , creased with skin foldsShort and chubby , creased with skin folds Strong enough to support the weight of the headStrong enough to support the weight of the head Trachea maybe prominent in from of the neckTrachea maybe prominent in from of the neck Thyroid gland is not palpableThyroid gland is not palpable If with rigidity, congenital torticullis from injury to If with rigidity, congenital torticullis from injury to

the sternocleidomastoid muscle should be the sternocleidomastoid muscle should be considered; meningitis if with + nuchal rigidityconsidered; meningitis if with + nuchal rigidity

ChestChest

Circular appearance because Circular appearance because anteroposterior and lateral diameters are anteroposterior and lateral diameters are about equalabout equal

Diaphragmatic respiration Diaphragmatic respiration Nipples prominent and often edematous; Nipples prominent and often edematous;

milky secretion commonmilky secretion common

AbdomenAbdomen Contour is slightly protuberant, globular Contour is slightly protuberant, globular Scaphoid or sunken appearance suggest Scaphoid or sunken appearance suggest

missing abdominal contentsmissing abdominal contents Bowel sound should be present within an hour Bowel sound should be present within an hour

after birthafter birth Edge of liver is palpate at 1-2 cm below the right Edge of liver is palpate at 1-2 cm below the right

coastal margincoastal margin For the 1st hr of birth, umbilical cord is white, For the 1st hr of birth, umbilical cord is white,

gelatinous marked with red and blue streaks of gelatinous marked with red and blue streaks of umbilical vein and arteries. After the 1st hour, umbilical vein and arteries. After the 1st hour, cord begins to shrink, dry and be disclosed; 2nd cord begins to shrink, dry and be disclosed; 2nd or 3rd day, turned black, breaks free by the 6th – or 3rd day, turned black, breaks free by the 6th – 10th day leaving a granulating arear a few cm10th day leaving a granulating arear a few cm

There should be no bleeding at cord siteThere should be no bleeding at cord site

Anogenital areaAnogenital area

Check for patency of anusCheck for patency of anus Note the time the infant first passed out Note the time the infant first passed out

meconium. meconium.

Male GenitaliaMale Genitalia

Scrotum is edematous due to maternal Scrotum is edematous due to maternal hormoneshormones

Testes should be present in the scrotumTestes should be present in the scrotum Penis appears small, inspect if urethral Penis appears small, inspect if urethral

opening is at the tip of the glansopening is at the tip of the glans

Female GenitaliaFemale Genitalia

Vulva maybe swollen because of action of Vulva maybe swollen because of action of maternal hormonesmaternal hormones

Mucus and vaginal secretions are present Mucus and vaginal secretions are present which is sometimes blood tinged which is sometimes blood tinged

This discharge should not be mistaken for This discharge should not be mistaken for infection or traumainfection or trauma

BackBack

Spine appears flat in the lumbar and Spine appears flat in the lumbar and sacral areas; curves can be seen only sacral areas; curves can be seen only when child is already able to sit and walkwhen child is already able to sit and walk

Base of spine should be assessed if no Base of spine should be assessed if no pinpoint opening in the skin indicating pinpoint opening in the skin indicating Dermal Sinus Dermal Sinus

ExtremitiesExtremities

Arms and legs appear shortArms and legs appear short Hands are plump and clenched into fistHands are plump and clenched into fist Fingernails are soft and smooth and are long Fingernails are soft and smooth and are long

enough to extent over fingertipsenough to extent over fingertips Arms and legs should move symmetricallyArms and legs should move symmetrically Check the digits for webbing (Syndactyl), extra Check the digits for webbing (Syndactyl), extra

toes or fingers (polydactyl), lacking toes or toes or fingers (polydactyl), lacking toes or fingers(oligodactyl)fingers(oligodactyl)

legs are bowed and short; sole is flat because legs are bowed and short; sole is flat because of extra pad of fat with crisscrossed lines in of extra pad of fat with crisscrossed lines in soles of the feetsoles of the feet

Body Systems Body Systems AssessmentAssessment

Cardiovascular SystemCardiovascular System

In utero, oxygenation takes place in the In utero, oxygenation takes place in the placenta not in the fetal lungs ( so pressure in placenta not in the fetal lungs ( so pressure in the left side is less than the pressure in the the left side is less than the pressure in the right side of heart)right side of heart)

Fetal accessory structuresFetal accessory structures foramen ovale – opening between the right foramen ovale – opening between the right

and left atriaand left atria ductus arteriosus – connects pulmonary artery ductus arteriosus – connects pulmonary artery

and aortaand aorta ductus venosus – bypasses the liverductus venosus – bypasses the liver umbilical vein – carries oxygenated bloodumbilical vein – carries oxygenated blood umbilical arteries – carry deoxygenated blood umbilical arteries – carry deoxygenated blood

As soon as the cord is clamped, the newborn is As soon as the cord is clamped, the newborn is forced to take in oxygen thru the lungs. This forced to take in oxygen thru the lungs. This expansion of the lungs will cause the pressure expansion of the lungs will cause the pressure on the left side of the heart to be higher than the on the left side of the heart to be higher than the pressure in the right side. This in turn will cause pressure in the right side. This in turn will cause the foramen ovale to close and turn into a the foramen ovale to close and turn into a ligament ; ductus arteriosus changes into a ligament ; ductus arteriosus changes into a ligament ; ductus venosus changes into ligament ligament ; ductus venosus changes into ligament ; umbilical vein and arteries will atrophy and ; umbilical vein and arteries will atrophy and degenerate since no more blood goes thru itdegenerate since no more blood goes thru it

A newborn’s blood volume is around 300mLA newborn’s blood volume is around 300mL

Respiratory SystemRespiratory System

A first breath requires a tremendous amount of A first breath requires a tremendous amount of pressure, about 40-70 cm H2Opressure, about 40-70 cm H2O

The presence of fluid in the lungs eases the The presence of fluid in the lungs eases the surface tension on the alveolar walls and surface tension on the alveolar walls and makes a first breath easier, allowing the alveoli makes a first breath easier, allowing the alveoli to inflate more easily than if the lung walls to inflate more easily than if the lung walls were drywere dry

Infants who are immature and whose lung Infants who are immature and whose lung collapsed each time they exhale due to lack of collapsed each time they exhale due to lack of pulmonary surfactants have trouble in pulmonary surfactants have trouble in establishing effective residual capacity and establishing effective residual capacity and respirationsrespirations

Gastrointestinal SystemGastrointestinal System

Sterile at birthSterile at birth Stomach can hold about 30-60 mLStomach can hold about 30-60 mL Has limited ability to digest fat and starch Has limited ability to digest fat and starch Regurgitates easily Regurgitates easily Usually has low glucose and protein Usually has low glucose and protein

serum levelserum level

StoolsStools Meconium – 1st stool that is usually passed 24 hrs after Meconium – 1st stool that is usually passed 24 hrs after

birth; sticky, tarlike, blackish green, odorless material birth; sticky, tarlike, blackish green, odorless material formed from mucus, vernix, lanugo, hormones and formed from mucus, vernix, lanugo, hormones and carbohydrates that accumulated during intrauterine lifecarbohydrates that accumulated during intrauterine life

Transitional Stool – 2nd or 3rd day of life which may Transitional Stool – 2nd or 3rd day of life which may resemble diarrhea resemble diarrhea

About the 4th day, a breastfed newborn passes 3-4 light About the 4th day, a breastfed newborn passes 3-4 light yellow stools per day. These are sweet smelling yellow stools per day. These are sweet smelling because breast milk is high in lactic acid which because breast milk is high in lactic acid which decreases the amount of putrefactive organisms in the decreases the amount of putrefactive organisms in the stool stool

Bottle fed babies passes 2-3 bright yellow stools per day Bottle fed babies passes 2-3 bright yellow stools per day and has slightly noticeable odorand has slightly noticeable odor

If with mucus, suspect milk allergyIf with mucus, suspect milk allergy Gray/clay colored stool – bile duct obstructionGray/clay colored stool – bile duct obstruction Black/tarry stool – intestinal bleedingBlack/tarry stool – intestinal bleeding Blood flecked stools – with anal fissureBlood flecked stools – with anal fissure

Urinary SystemUrinary System

Void within 24 hours after birthVoid within 24 hours after birth Single voiding is about 15 mLSingle voiding is about 15 mL Daily urine output is 30-60 ml/ dayDaily urine output is 30-60 ml/ day Light in color and odorlessLight in color and odorless First voiding may be pink or dusty First voiding may be pink or dusty Males with enough force producing small Males with enough force producing small

projected arcprojected arc Female produce a steady stream Female produce a steady stream

Autoimmune SystemAutoimmune System

Has difficulty forming antibodies/against Has difficulty forming antibodies/against invading antigens, until they are about 2 mos of invading antigens, until they are about 2 mos of ageage

Has antibodies (IgG) from the mother that Has antibodies (IgG) from the mother that crossed the placenta like the antibodies for crossed the placenta like the antibodies for polio, measles, diphtheria, pertussis, rubella, polio, measles, diphtheria, pertussis, rubella, and tetanus and little natural immunity against and tetanus and little natural immunity against varicella and herpes simplexvaricella and herpes simplex

Neuromuscular SystemNeuromuscular System

Occasional limpness or total absence of Occasional limpness or total absence of muscular response to manipulation may muscular response to manipulation may indicate narcosis, shock or cerebral injuryindicate narcosis, shock or cerebral injury

ReflexesReflexes

REFLEX NORMAL RESPONSE ABNORMAL RESPONSE

Rooting and sucking

Newborns turn head in direction of stimulus, open mouth, and begin to suck when cheek, lip, or corner of mouth is touched with finger or nipple.

Weak or no response occurs with prematurity, neurologic deficit or injury, or central nervous system (CNS) depression secondary to maternal drug ingestion (eg. narcotics).

Extrusion Newborn pushes tongue outward when tip of tongue is touched with finger or nipple.

Continuous extrusion of tongue or repetitive tongue thrusting occurs with CND anomalies and seizures.

Swallowing Newborn swallows in coordination with sucking when fluid is placed on back of tongue.

Gagging, coughing, or regurgitation of fluid may occur, possibly associated with cyanosis secondary to prematurity, neurologic deficit, or injury; typically seen after laryngoscopy.

Moro Asymmetrical response is seen with peripheral nerve injury (brachial plexus) or fracture of clavicle or long bone or arm or leg. No response occurs in cases of severe CNS injury.

Bilateral symmetrical extension and abduction of all extremities, with thumb and forefinger forming characteristic “C” are followed by adduction of extremities and return to relaxed flexion when newborn’s position changes suddenly or when newborn is placed on back on flat

Newborn will step with one foot and then the other in walking motion when one foot is touched to flat surface.

Stepping Asymmetrical response is seen with CNS or peripheral nerve injury or fracture of long bone of leg.

Newborn will attempt to crawl forward with both arms and legs when placed on abdomen or flat surface.

Prone crawl

Asymmetrical response is seen with CNS or peripheral nerve injury or fracture of long bone of leg.

Extremities on side to which head is turned will extend, and opposite extremities will flex when newborn’s head is turned to one side while resting. Response may be absent or incomplete immediately after birth.

Tonic neck or “fencing”

Persistent response after 4th month may indicate neurologic injury. Persistent absence seen in CNS injury and neurologic disorders.

Newborn abducts and flexes all extremities and may begin to cry when exposed to sudden movement or loud noise.

Startle Absence of response may indicate neurologic deficit or injury. Complete and consistent absence of response to loud noises may indicate deafness. Response may be absent or diminished during sleep.

Crossed Extension

Newborn’s opposite leg will flex and then extend rapidly as if trying to deflect stimulus to other foot when placed in supine position; newborn will extend one leg in response to stimulus on bottom of foot.

Weak or absent response is seen with peripheral nerve injury or fracture of long bone.

Glabellar “blink”

Newborn will blink with first 4 or 5 taps to bridge of nose when eyes are open.

Persistent blinking and failure to habituate suggest neurologic deficit.

Palmar grasp

Newborn’s finger will curl around object and hold on momentarily when finger is placed in palm of newborn’s hand.

Response is diminished in prematurity. Asymmetry occurs with peripheral nerve damage (brachial plexus) or fracture of humerus. No response occurs with severe neurologic deficit.

Plantar Grasp

Newborn’s toes will curl downward when a finger is placed against the base of the toes.

Diminished response occurs with prematurity. No response occurs with severe neurologic deficit.

Babinski sign

Newborn’s toes will hyperextend and fan apart from dorsiflexion of big toe when one side of foot is stroked upward from heel and across ball of foot.

No response occurs with CNS deficit

G. SensesG. Senses

. Hearing. Hearing A fetus is able to hear in uteroA fetus is able to hear in utero Appear to have difficulty locating sounds Appear to have difficulty locating sounds They respond with generalized activity to They respond with generalized activity to

the sound the sound They recognize their mother’s voice They recognize their mother’s voice

VisionVision

Newborn see as soon as they are born Newborn see as soon as they are born They cannot follow objects past the They cannot follow objects past the

midline of visionmidline of vision

TouchTouch

Most sensitive and most developed of all Most sensitive and most developed of all the sensesthe senses

TasteTaste

Taste buds are developed and functioning Taste buds are developed and functioning before birthbefore birth

They turn away from bitter taste and They turn away from bitter taste and readily accepts the sweet taste of milk or readily accepts the sweet taste of milk or glucose waterglucose water

SmellSmell

Present as soon as the nose is cleared of Present as soon as the nose is cleared of mucus and amniotic fluid mucus and amniotic fluid

Physiologic Adjustment Physiologic Adjustment to Extrauterine Lifeto Extrauterine Life

Periods of ReactivityPeriods of Reactivity

First Period of ReactivityFirst Period of Reactivity

Lasts about half an hourLasts about half an hour During this time, the baby is alert and exhibit During this time, the baby is alert and exhibit

exploring , searching activity, often making exploring , searching activity, often making sucking soundssucking sounds

Heart beat and respiratory rate are rapidHeart beat and respiratory rate are rapid

Resting PeriodResting Period

Heart beat and respiratory rate slowHeart beat and respiratory rate slow Newborn typically sleeps for about 90 Newborn typically sleeps for about 90

minmin

Second Period of ReactivitySecond Period of Reactivity

Between 2 and 6 hours of life, when the Between 2 and 6 hours of life, when the baby wakes again, often gagging and baby wakes again, often gagging and choking on mucus that has accumulated choking on mucus that has accumulated in the mouthin the mouth

The newborn is again alert and The newborn is again alert and responsive and interested in the responsive and interested in the surroundingsurrounding

Assessment of Gestational AgeAssessment of Gestational Age

Usher proposed 5 criteria to evaluate Usher proposed 5 criteria to evaluate gestational maturitygestational maturity

Gestation Age in Weeks

Findings 0 - 36 37 - 38 39 and over

Sole creases Anterior transverse crease only

Occasional creases in anterior two thirds

Sole covered with creases

Breast nodule diameter in mm

2 4 7

Scalp hair Fine and fuzzy Fine and fuzzy Course and Silky

Ear lobe Pliable;no cartilage

Some cartilage Stiffened by thick cartilage

Testes and scrotum

Testes in lower canal; scrotum small, few rugae

intermediate Testes pendoluos, scrotum full; extensive rugae

BallardBallard Modified the Dubowitz maturity scale in the 1970 Modified the Dubowitz maturity scale in the 1970

and again in the 1990and again in the 1990 The assessment consists of two portions: The assessment consists of two portions:

physical maturity and neuromuscular maturityphysical maturity and neuromuscular maturity The first is a series of observations about skin The first is a series of observations about skin

texture, color, lanugo, foot creases, genitalia, texture, color, lanugo, foot creases, genitalia, ear and breast maturity wherein the body parts ear and breast maturity wherein the body parts are inspected and given a score of 0-5, done as are inspected and given a score of 0-5, done as soon as possible after birthsoon as possible after birth

The second half of the examination, observation The second half of the examination, observation and positioning the baby wherein the child is and positioning the baby wherein the child is given numeric scores from 0-5given numeric scores from 0-5

The baby’s gestational age is obtained with the The baby’s gestational age is obtained with the total score in both portions and compared with a total score in both portions and compared with a rating scalerating scale

Using this standard measure of rating maturity is Using this standard measure of rating maturity is helpful in detecting infants who are small for helpful in detecting infants who are small for gestational age and differentiating them from gestational age and differentiating them from those who are immature because of those who are immature because of miscalculated due datemiscalculated due date

An infant who is found to be less than 35 weeks An infant who is found to be less than 35 weeks gestation requires close observation in a special gestation requires close observation in a special care nursery.care nursery.

Assessment of Behavioral Assessment of Behavioral CapacityCapacity

Term newborns are physically active and Term newborns are physically active and emotionally prepared to interact with the emotionally prepared to interact with the people around them.people around them.

Brazelton Neonatal Assessment Brazelton Neonatal Assessment ScaleScale

Rating scale devised by brazelton in the early Rating scale devised by brazelton in the early 1970’s to evaluate newborn’s behavioral 1970’s to evaluate newborn’s behavioral capacity or ability to respond to stimulicapacity or ability to respond to stimuli

Infant is scored on best performance rather than Infant is scored on best performance rather than on average performanceon average performance

An important finding from the scale is that Nb An important finding from the scale is that Nb are able to quiet themselves after cryingare able to quiet themselves after crying

There are 6 major categories of behavior There are 6 major categories of behavior assessed namely:assessed namely:

Habituation – a newborn is capable of diminishing Habituation – a newborn is capable of diminishing stimuli , gradually shutting out and not responding to stimuli , gradually shutting out and not responding to itit

Orientation – newborn gets to be oriented like when a Orientation – newborn gets to be oriented like when a bell rings, a newborn turns toward it or the rooting bell rings, a newborn turns toward it or the rooting reflexreflex

Motor Maturity – a newborn has motor coordination, Motor Maturity – a newborn has motor coordination, flexing and extending to reach a certain objectflexing and extending to reach a certain object

Variation – Newborns have variable degrees of Variation – Newborns have variable degrees of excitementexcitement

Sel-quieting Ability – newborn uses interventions to Sel-quieting Ability – newborn uses interventions to console themselves when disturbed like thumb console themselves when disturbed like thumb suckingsucking

Social Behaviors – responds to being held closelySocial Behaviors – responds to being held closely

Newborn Identification and Newborn Identification and RegistrationRegistration

Identification bandIdentification band A number that corresponds to the mother’s A number that corresponds to the mother’s

hospital number, mother’s full name, and hospital number, mother’s full name, and sex, date and time of the infant’s birth are sex, date and time of the infant’s birth are printed on the band printed on the band

Birth RegistrationBirth Registration

The physician or nurse-midwife who The physician or nurse-midwife who supervised the birth of the infant has the supervised the birth of the infant has the responsibility to see that a birth responsibility to see that a birth registration is filed with the Bureau of Vital registration is filed with the Bureau of Vital Statistics. Statistics.

Infant’s name, mother’s name’ father’s Infant’s name, mother’s name’ father’s name and the birth date and place are name and the birth date and place are recordedrecorded

Birth Record DocumentationBirth Record Documentation

Newborn chart contains the following information:Newborn chart contains the following information: Time of birthTime of birth Time the infant breathedTime the infant breathed Whether respirations were spontaneous or aidedWhether respirations were spontaneous or aided Apgar score at 1 min and at 5 min of lifeApgar score at 1 min and at 5 min of life Whether eye prophylaxis was givenWhether eye prophylaxis was given Whether Vit K was administeredWhether Vit K was administered General condition of the infantGeneral condition of the infant Number of vessels in the umbilical cordNumber of vessels in the umbilical cord Whether cultures were takenWhether cultures were taken Whether the infant voided and whether he or she passed Whether the infant voided and whether he or she passed

a stoola stool

Nursing Care of Nursing Care of Newborns and Family in Newborns and Family in

the Post Partal Periodthe Post Partal Period

BathingBathing

Should be done prior to, not after a Should be done prior to, not after a feeding to prevent regurgitation, spitting up feeding to prevent regurgitation, spitting up or vomitingor vomiting

Room should be warm to prevent chilling, Room should be warm to prevent chilling, and bath water should be around 37 – 38Cand bath water should be around 37 – 38C

Soap should be mildSoap should be mild Should proceed from the cleanest to the Should proceed from the cleanest to the

most soiled areas of the bodymost soiled areas of the body

Procedures for bathing :Procedures for bathing : wash face in clean water to avoid skin irritation by soapwash face in clean water to avoid skin irritation by soap wash infant’s hairwash infant’s hair soap hair with baby lying, then hold infant in one arm soap hair with baby lying, then hold infant in one arm

over the basin of water as you would a football ( Such over the basin of water as you would a football ( Such position supports the infant’s head and back and leaves position supports the infant’s head and back and leaves the mother’s other hand free for assembling or using the mother’s other hand free for assembling or using equipment)equipment)

splash water from the basin against head to rinse the splash water from the basin against head to rinse the hair and then dry it well to prevent chillinghair and then dry it well to prevent chilling

wash each area and rinse well that no soap is left on the wash each area and rinse well that no soap is left on the skin skin

do not soak the corddo not soak the cord in male infants, foreskin of uncircumcised penis should in male infants, foreskin of uncircumcised penis should

not be forced back or constriction of penis may result; not be forced back or constriction of penis may result; wash female vulva by wiping from front to backwash female vulva by wiping from front to back

Diaper Area CareDiaper Area Care

• when changing diapers, the area should be when changing diapers, the area should be washed with clean water and be dried well washed with clean water and be dried well so that ammonia in urine will not irritate the so that ammonia in urine will not irritate the infant’s skininfant’s skin

• an ointment maybe appliedan ointment maybe applied• the diaper when applied should be folded the diaper when applied should be folded

down so that it does not cover the drying down so that it does not cover the drying cordcord

Sleeping Patterns and PositionSleeping Patterns and Position

a newborn sleeps an average of 16 a newborn sleeps an average of 16 hrs/day in the first week at home and an hrs/day in the first week at home and an average of 4 hrs at a timeaverage of 4 hrs at a time

At 4 mos, the baby sleeps 15 hrs/day and At 4 mos, the baby sleeps 15 hrs/day and 8 hrs at a time8 hrs at a time

Most typical time for wakefulness – 6 -Most typical time for wakefulness – 6 -11:00 pm11:00 pm

Position on the back for sleepPosition on the back for sleep

Metabolic Screening TestMetabolic Screening Test

Infant must be screened for phenyketonuria, Infant must be screened for phenyketonuria, hypothyroidism and cystic fibrosishypothyroidism and cystic fibrosis

Done by means of a simple blood test in which 3 Done by means of a simple blood test in which 3 drops of blood from the heel are dropped onto a drops of blood from the heel are dropped onto a special filter paperspecial filter paper

The baby should have received formula or The baby should have received formula or breast milk for 24 hours before the test for PKU breast milk for 24 hours before the test for PKU will be accuratewill be accurate

NEWBORN SCREENINGNEWBORN SCREENING

NUTRITIONAL ALLOWANCES NUTRITIONAL ALLOWANCES FOR A NEWBORNFOR A NEWBORN

CaloriesCalories Growth in neonatal period and in early infancy Growth in neonatal period and in early infancy

is mora rapid than any other periods of life, is mora rapid than any other periods of life, therefore the caloric requirements exceed therefore the caloric requirements exceed those at any other agesthose at any other ages

Infant up to 2 months of age requires 110-120 Infant up to 2 months of age requires 110-120 cal/kg of body wt. every 24 hrs to provide an cal/kg of body wt. every 24 hrs to provide an adequate amount of food for maintenance and adequate amount of food for maintenance and growth.growth.

After 2 mos, the amount declines until the After 2 mos, the amount declines until the requirement at 1 year is 100kcal/kg per day.requirement at 1 year is 100kcal/kg per day.

ProteinProtein

Necessary for formation of new cells Necessary for formation of new cells Has a high requirement during newborn Has a high requirement during newborn

and infancy period (to provide for rapid and infancy period (to provide for rapid growth of new cells as well as growth of new cells as well as maintenance of existing cellsmaintenance of existing cells

Nutritional allowance for first 2 mos of life Nutritional allowance for first 2 mos of life is 2.2g per kg of body wt.is 2.2g per kg of body wt.

FatFat

Linoleic acid ia an essential fatty acid Linoleic acid ia an essential fatty acid necessary for growth and skin integrity of necessary for growth and skin integrity of infantsinfants

CarbohydrateCarbohydrate

Lactose is a dissacharide found in Lactose is a dissacharide found in human milk and added to commercial human milk and added to commercial formulas appears to be the most easily formulas appears to be the most easily digested of the carbohydratesdigested of the carbohydrates

It improves calcium absorption and aids It improves calcium absorption and aids in nitrogen retention’in nitrogen retention’

FluidFluid

It is important to maintain a sufficient It is important to maintain a sufficient fluid intake in newborn because their fluid intake in newborn because their metabolic rate is so highmetabolic rate is so high

A newborns body surface area is large in A newborns body surface area is large in relation to body mass relation to body mass

Newborn needs 150 -200 mL/Kg of Newborn needs 150 -200 mL/Kg of water intake every 24 hours water intake every 24 hours

MineralsMinerals

CalciumCalcium An important mineral in the newborn An important mineral in the newborn

period bec of its contribution to bone period bec of its contribution to bone growthgrowth

IronIron

The term infant of a mother who had an The term infant of a mother who had an adequate iron intake during pregnancy adequate iron intake during pregnancy will be born with iron store that can last will be born with iron store that can last for the first 3 mos of lifefor the first 3 mos of life

Breast milk usually provides an Breast milk usually provides an adequate amount of ironadequate amount of iron

An iron supplement is recommended to An iron supplement is recommended to be added to the formula for the formula be added to the formula for the formula fed infants for the entire first year of lifefed infants for the entire first year of life

FluorideFluoride

Essential for building sound teeth and Essential for building sound teeth and for preventing tooth decayfor preventing tooth decay

formula should be prepared with formula should be prepared with fluoridated water fluoridated water

If there is no source of fluoridated If there is no source of fluoridated water, a fluoride supplement of 0.25mg water, a fluoride supplement of 0.25mg daily may be given to the infantdaily may be given to the infant

VitaminsVitamins

Vitamins A.C and D are incorporated Vitamins A.C and D are incorporated incommercial formulaincommercial formula

Vitamins are naturally included in breast Vitamins are naturally included in breast milkmilk

BreastfeedingBreastfeeding

Provides numerous health benefits to both Provides numerous health benefits to both the mother and infantsthe mother and infants

Considered to be the superior source of Considered to be the superior source of nutrition for the infants thru the first year of nutrition for the infants thru the first year of lifelife

Physiology of Breast milkPhysiology of Breast milk

Breast milk is formed in the Acinar cells or the alveolar Breast milk is formed in the Acinar cells or the alveolar cells of the mammary glandscells of the mammary glands

With the delivery of placenta, the level of Progesterone With the delivery of placenta, the level of Progesterone in mother’s body falls dramatically stimulating the in mother’s body falls dramatically stimulating the production of Prolactin (an anterior pituitary hormone production of Prolactin (an anterior pituitary hormone acting on the acinar cells of the mammary glands acting on the acinar cells of the mammary glands stimulating the production of milkstimulating the production of milk

When the infant sucks at a breast, nerve impulses travel When the infant sucks at a breast, nerve impulses travel from the nipple to the hypothalamus to stimulate from the nipple to the hypothalamus to stimulate production of prolactin-releasing factors. This factor production of prolactin-releasing factors. This factor passes through to the pituitary and stimulates further passes through to the pituitary and stimulates further active production of prolactinactive production of prolactin

Milk flows from the alveolar cells thru small tubules to the Milk flows from the alveolar cells thru small tubules to the reservoir for milk, the Lactiferous Sinusesreservoir for milk, the Lactiferous Sinuses

Foremilk is the constantly forming milk produced in all Foremilk is the constantly forming milk produced in all women 3-4 days after deliverywomen 3-4 days after delivery

For the first 3-4 days following delivery, before milk is For the first 3-4 days following delivery, before milk is oroduced, the milk cells produce Colostrum, a thin, oroduced, the milk cells produce Colostrum, a thin, watery, high protein fluid composed of protein, sugar, fat, watery, high protein fluid composed of protein, sugar, fat, water, minerals, vitamins and maternal antibodies.water, minerals, vitamins and maternal antibodies.

As infant sucks at the breast, Oxytocin is released from As infant sucks at the breast, Oxytocin is released from the posterior pituitary, causing the collecting sinuses of the posterior pituitary, causing the collecting sinuses of the mammary glands to contract, forcing milk forward the mammary glands to contract, forcing milk forward thru the nipples and making it available for the baby.This thru the nipples and making it available for the baby.This is the let down reflex, new milk called the Hind milk is is the let down reflex, new milk called the Hind milk is also producedalso produced

Oxytocin stimulates the expression of milk by causing Oxytocin stimulates the expression of milk by causing the smooth muscles to contract stimulating the uterus to the smooth muscles to contract stimulating the uterus to contractcontract

Advantages of BreastfeedingAdvantages of Breastfeeding

General Principles of General Principles of Growth and DevelopmentGrowth and Development

GrowthGrowth

Increased in physical sizeIncreased in physical size Quantitative changeQuantitative change

DevelopmentDevelopment

Increase in skill or ability to functionIncrease in skill or ability to function Measured by observing a child’s ability to Measured by observing a child’s ability to

perform a task perform a task

Principles of growth and Principles of growth and developmentdevelopment

Growth and development are continuous process from Growth and development are continuous process from conception until deathconception until death

Growth and development proceed in an orderly sequenceGrowth and development proceed in an orderly sequence Different children pass through the predictable stages at Different children pass through the predictable stages at

different ratedifferent rate All body systems do not develop the same rateAll body systems do not develop the same rate Development is cephalocaudalDevelopment is cephalocaudal Development proceeds from proximal to distal body partsDevelopment proceeds from proximal to distal body parts Development proceeds from gross to refined skillsDevelopment proceeds from gross to refined skills There is an optimum time for initiation of experiences or There is an optimum time for initiation of experiences or

learninglearning Neonatal reflexes must be lost before development can Neonatal reflexes must be lost before development can

proceedproceed A great deal of skill and behavior is learned by practiceA great deal of skill and behavior is learned by practice

InfantInfant

0 – 12 months of age0 – 12 months of age Significant Person: mother/ caregiverSignificant Person: mother/ caregiver Fear: stranger anxietyFear: stranger anxiety Body weight is doubled at 6 mos and tripled at 1 yearBody weight is doubled at 6 mos and tripled at 1 year Increase in height by 50% during the first yearIncrease in height by 50% during the first year First baby tooth appears at 6 mos (lower central incisor) First baby tooth appears at 6 mos (lower central incisor)

followed by a new one monthlyfollowed by a new one monthly Play: SolitaryPlay: Solitary Appropriate toys:mobiles, rattles, music box, squezze Appropriate toys:mobiles, rattles, music box, squezze

toys, plastic rings, rubber ducks, teething rings, textured toys, plastic rings, rubber ducks, teething rings, textured toystoys

Developmental MilestonesDevelopmental Milestones

0-1month0-1month

Largely reflexLargely reflex Keep hands fisted, able to follow objects at Keep hands fisted, able to follow objects at

midlinemidline Lifts head intermittently when on proneLifts head intermittently when on prone Momentarily visual fixation on human Momentarily visual fixation on human

faces and objectsfaces and objects

2 months2 months

Makes cooing soundMakes cooing sound Differentiates his cryDifferentiates his cry Social smileSocial smile Responds to familiar voices by moving the Responds to familiar voices by moving the

whole bodywhole body Sheds tearsSheds tears

3 months3 months

Follows objects past midlineFollows objects past midline Laughs aloudLaughs aloud Can raise head but not cheat when on Can raise head but not cheat when on

proneprone Grasp reflex fadesGrasp reflex fades 180 degrees visual arc180 degrees visual arc

4 months4 months

Bears partial weight on feet when held Bears partial weight on feet when held uprightupright

No longer has head lag when pulled No longer has head lag when pulled uprightupright

Grasps objects and bring to mouthGrasps objects and bring to mouth

5 months5 months

Rolls overRolls over Raking graspRaking grasp Moro reflex fadeMoro reflex fade

6 months6 months

Doubles birth weightDoubles birth weight Reaches out in anticipation of being pick Reaches out in anticipation of being pick

upup Sits with supportSits with support Starting stranger anxietyStarting stranger anxiety Eruption of first toothEruption of first tooth Can be pulled from sitting to standing Can be pulled from sitting to standing

positionposition

seven monthsseven months

Plays with feetPlays with feet Says dada or mama but nonspecificSays dada or mama but nonspecific Transfer object from one hand to anotherTransfer object from one hand to another Pivots when on pronePivots when on prone

8 months8 months

Sits securely without supportSits securely without support Peak of stranger anxiety Peak of stranger anxiety

9 months9 months

Can hold bottle with good hand mouth Can hold bottle with good hand mouth coordinationcoordination

CrawlsCrawls Takes some steps when heldTakes some steps when held Neat pincer graspNeat pincer grasp

10 months10 months

Pull self to standPull self to stand Responds to own nameResponds to own name

11 months11 months

Put objects in containerPut objects in container Stands with assistanceStands with assistance Attempts to walk with helpAttempts to walk with help

12 months12 months

Stands aloneStands alone Walks with helpWalks with help Holds cup and spoon wellHolds cup and spoon well Triples birth weightTriples birth weight Can say two words Can say two words

ToddlerToddler

1 to 3 years of age1 to 3 years of age Significant Person: parentsSignificant Person: parents Fear: Separation Anxiety; 3 stages: Fear: Separation Anxiety; 3 stages:

protest, despair, denialprotest, despair, denial Play: ParallelPlay: Parallel Appropriate toys: push pull toys, building Appropriate toys: push pull toys, building

blocks, toys to ride on, pounding pegs, blocks, toys to ride on, pounding pegs, stuffed toysstuffed toys

Developmental MilestonesDevelopmental Milestones Critical for language developmentCritical for language development Favorite word is NO (autonomy)Favorite word is NO (autonomy) Negativistic and difficult to manageNegativistic and difficult to manage Active, curiousActive, curious They have ritualistic behaviorThey have ritualistic behavior They go into temper tantrums ( ignore and direct They go into temper tantrums ( ignore and direct

them to activities that they can master)them to activities that they can master) All deciduous teeth are out by 2.5 to 3 years All deciduous teeth are out by 2.5 to 3 years

Toilet training is the biggest task Toilet training is the biggest task Clues for readiness for toilet training:Clues for readiness for toilet training:

• can already stand alonecan already stand alone• can walk steadilycan walk steadily• can keep himself dry for intervals of at least 2 hourscan keep himself dry for intervals of at least 2 hours• can demonstrate awareness of voiding or defecatingcan demonstrate awareness of voiding or defecating• is able to use words or gestures regarding toileting needsis able to use words or gestures regarding toileting needs• is desirous of pleasing the primary caretakeris desirous of pleasing the primary caretaker

bowel control 18 mosbowel control 18 mos daytime bladder control 2.5 yearsdaytime bladder control 2.5 years nighttime bladder control: 3 yearsnighttime bladder control: 3 years

. PreSchooler. PreSchooler 3-6 years3-6 years Significant Person: FamilySignificant Person: Family Fear: Castration Anxiety, Fear of the darkFear: Castration Anxiety, Fear of the dark Play: associative playPlay: associative play Appropriate toys: housekeeping toys, playground Appropriate toys: housekeeping toys, playground

equipments, tricycles, watercolors, finger paints, clay, equipments, tricycles, watercolors, finger paints, clay, picture, coloring books, material s for cutting and picture, coloring books, material s for cutting and pasting, simple jigsaw puzzlepasting, simple jigsaw puzzle

3 years old: undresses self, run, climbs step one at a 3 years old: undresses self, run, climbs step one at a time, walk backwards, stands on 1 foot, vocabulary of time, walk backwards, stands on 1 foot, vocabulary of 300-900 words300-900 words

4 years old: can do simple buttons, jumps skips, uses 4 years old: can do simple buttons, jumps skips, uses alternate steps when climbing stairs, vocabulary of 1500 alternate steps when climbing stairs, vocabulary of 1500 wordswords

5 years: draws a 6part man, throws over hand, runs well, 5 years: draws a 6part man, throws over hand, runs well, vocabulary of 2100 wordsvocabulary of 2100 words

They asks questions constantlyThey asks questions constantly Favorite word is WHYFavorite word is WHY They are self centeredThey are self centered They have active imaginations, fantasiesThey have active imaginations, fantasies They love to watch adults and imitate their behaviorThey love to watch adults and imitate their behavior Oedipus Complex/ Electra complexOedipus Complex/ Electra complex Masturabtion may be seen in someMasturabtion may be seen in some Sibling RivalrySibling Rivalry

School Age child School Age child 6-12 years of age6-12 years of age Significant persons: Teacher and familySignificant persons: Teacher and family Play: competitivePlay: competitive Appropriate toys: dolls, trains and model kits, jigsaw Appropriate toys: dolls, trains and model kits, jigsaw

puzzles, magic tricks, books, table games, video, puzzles, magic tricks, books, table games, video, records, bicycles, skateboards, collecting objectsrecords, bicycles, skateboards, collecting objects

Fear: Fear of death, fear of replacement in school, loss Fear: Fear of death, fear of replacement in school, loss of privacyof privacy

By age 10 brain growth is completeBy age 10 brain growth is complete They are modest and industriousThey are modest and industrious Thay enjoy collecting itemsThay enjoy collecting items Stealing is a common problem Stealing is a common problem

6 years old6 years old

Jumps, skips, stumblesJumps, skips, stumbles Talk in full sentenceTalk in full sentence Play in groupsPlay in groups First molar may eruptFirst molar may erupt

Seven years oldSeven years old

Withdrawn and moodyWithdrawn and moody Difference in sexes become apparent in Difference in sexes become apparent in

playplay Can tell time in hoursCan tell time in hours Is seldom able to complete taskIs seldom able to complete task School phobia is common School phobia is common

Eight years oldEight years old

Improved coordinationImproved coordination Loves collecting itemsLoves collecting items Prefers playmate of own sexPrefers playmate of own sex Best friends developBest friends develop Onset of secondary sex characteristicsOnset of secondary sex characteristics

Nine years of ageNine years of age

More interested in friends than on familyMore interested in friends than on family Worry and complain great dealWorry and complain great deal Always on the goAlways on the go Gang ageGang age

Ten years oldTen years old

Coordination improvesCoordination improves Cooperative and affectionateCooperative and affectionate Are peer orientedAre peer oriented With secret languageWith secret language Interest in opposite sex is apparentInterest in opposite sex is apparent Interested in rules and fairnessInterested in rules and fairness Enjoy privacy Enjoy privacy

11 years old11 years old

Are critical of adultsAre critical of adults Beginning hero worshipBeginning hero worship Are moodyAre moody More active More active

AdolescentAdolescent

12-18 years old12-18 years old Significant persons: peersSignificant persons: peers Fear: fear of acne, homosexuality, Fear: fear of acne, homosexuality,

displacement from friends, deathdisplacement from friends, death Are bothered by the statement WHO AM IAre bothered by the statement WHO AM I Rebellious, reformers, idealistic, futuristicRebellious, reformers, idealistic, futuristic Use of status symbolUse of status symbol Conscious of body imageConscious of body image

DIFFERENT PRINCIPLES OF GROWTH AND DEVELOPMENT

Principle 1. Growth and Development are Orderly and sequential.

As a child grows, maturation is predictable and follows a general time table. Developmental milestones give indications of the average time that the child will maintain head control, attempt to roll over, crawl walk and say his first words. The occurrence of each milestone typically follows a universal pattern.

Principle 2.Growth and development are continuous and complex.

Although it is an ongoing process, there are varying rates of physical growth resulting in growth sports during infancy and adolescence. Intellectual curiosity increases markedly during the preschool years as language and motor skills advance. This continuous process of growth and development is multifaceted, influenced by biophysical, psychological and environmental factors which contribute to the whole being. Genetic potential is determined with conception and stimulated by the environment.

Principle 3. The pace of Growth and Development is specific for each individual.

Although growth and development are continuous, they do not occur simultaneously. Acquisition of skills and changes in physical appearance or behavior may vary with each individual . Thus, physiologic and psychological maturation varies among people. For example as the child is learning locomotion skills, he may be exerting all of his energies on this tasks, while language skills may not be heightened during this brief period. Because of this variation most developmental assessment guide list a wide spread for norms according to age. Cultural variations can also be observed, e.g. Oriental or Asian children to be smaller than Caucasian children of the same age.

Principle 4. Psychosocial Development is influenced by Many Environment Factors.

Socialization and emotional behavior are learned from family, friends church and community. Values, roles, rules and regulation and determined in different cultural or social groups. The task of clarifying one’s own value system proceed throughout life.

Principle 5. There are Regular Trends in the Direction of Human Development.

Some unifying directions give order to growth and development. Three rudimentary trends can be easily observed. The first trend is that the development is cephalocaudal, meaning that areas such as the brain and head develop first, followed by the trunk, legs and feet. Pictures of an embryo in utero demonstrate the large size of the head in comparison to body size. The second trend is proximodistal development which means that growth progresses from the central axis of the body toward the periphery. Gross motor movements such as learning to roll over are developed earlier than fine motor movements.

Principle 6.Growth and Development are both Quantitative and Qualitative.

During the formative years, the body size of the individual increases continuously. As size increases, differentiation occurs to support refinement of quality functioning. As the nerve pathway form in the neonate, they become more and more specialized for transmitting certain impulses in the growing child.

Another example of differentiation refers to the behavioral changes manifested from a painful stimulus. The newborn responds to pain with his whole body, kicking arms and legs while grimacing and crying. The older child and adult express pain in more specific mannerisms, seen predominantly in the face.

Principle 7. Growth and Development become gradually integrated.

Behavior and function progress from simple to complex as the child builds all previously learned skills to achieve more difficult task. The acquisition of more complex skills proceeds into and throughout the adult years. The young toddler learning to use as spoon combines motor skills from hand-eye. Coordination, cognitive patterning to repeat the act when appropriate and of using as spoon becomes basic ,forming the foundation to learning more advanced skills requiring manual dexterity.

Principle 8. There are vulnerable periods in Development.

The susceptibility of the human organism to certain effects during critical periods has been proposed. Research has verified that during the time of rapid cellular growth of the fetus in the first 3 months, the organism is more prone to insults from viruses, chemicals or drugs, leading to congenital defects.

Principle 9.The Rate and Pattern of Growth and Development can be Modified.

Nutrition is one factor which can effect physiology development at any age. Both positive and negative effect are seen. The child with development at any age. Both positive and negative effects are seen. The child with malabsorption may be small for age on growth charts for height or weight. The adult with chronic ulcerative colitis may appear emaciated and dehydrated. An appropriate response occurs when the infant is able to progress from bottle or breast milk to baby foods or soft table foods and gains weight appropriately. Adult weight appropriately. Adult weight , size and tone are best maintained through regular exercise and daily meals prepared from the four basic food groups.

Principle 10. Different aspects of Growth and Development occur at Different stages and at different Rates.

Muscles and bone growth both occur most rapidly during the first year of life, increasing the integration of neuro muscular function. During the toddler and preschool years, muscle fibers increase in strength and size, whereas bone growth slows.

DIFFERENT FACTORS THAT INFLUENCE GROWTH AND DEVELOPMENT

A. GENETIC INFLUENCE

1.Gender- on the average, females are born weighing less and measuring less in length. (less an inch or two). Than males.

Boys tend to keep his height and weight advantage until pre puberty.2. Race and nationality- person of the some races and nationalities. Tend to be

taller or shorter than others.3. Intelligence- children who high intelligence do not generally grow faster than

other children but they do not tend to advance faster in motor skills.4. Health- a children who is chronically ill may not grow or develop as well as

the healthy child, depending on type or illness and the treatment or care available.

DIFFERENT FACTORS THAT INFLUENCE GROWTH AND DEVELOPMENT

B. ENVIRONMENTAL INFLUENCE

1. Quality nutrition- the quality of nutrition during growing years has a significant inference on eventual health and status.

2. Socioeconomic level- because health care and good nutrition require sufficient income a family of reduced socioeconomics means may not be able to provide its children with either.

3. Parent-child relationship- parent child love is very difficult to define or measure. Children who have love thrive better than who are not. Either parent or a non – parent care giver may serve as the primary care giver or form the primary child relationship. It is the quality of time spent with children not the amount of time is important. Loss of love form primary care giver occurring with the prolonged hospitalization, divorce or in adequate parent love, can interferes with the child desire to eat, improve and advance.

4. Ordinal position- the position of the child in the family, whether a first born child, some are middle child, the “baby” can only child or one with large family, will have some bearing on his or her growth and development.

5. Health- disease that come from the environmental sources, have as strong influence on growth and developmental as generally inherited disease infants cared for in neonatal intensive care units may have their bearing affected by the over stimulation of sound, so that their health becomes directly influence by the environment.

THEORIES OF GROWTH AND DEVELOPMENT

I. PSYCHOSEXUAL DEVELOPMENT: The theory of SIGMUND FREUD

II. PSYCHOSOCIAL DEVELOPMENT: The theory of ERIK ERIKSON

III. COGNITIVE DEVELOPMENT: The theory of JEAN PIAGET

STAGE PSYCHOSEXUAL STAGE NURSING IMPLICATION

INFANT ORAL STAGE Feeding produce pleasure and sense of comfort/safety, feeding should be pleasurable & provided when required

TODDLER ANAL STAGE Toilet training should be a pleasurable experience and appropriate phase that can result on a personality development

Freud’s Theory of Personality Development

PRESCHOOLER PHALLIC STAGE The child identifies with parent of opposite sex and later takes on a love relationship outside the family

SCHOOL AGE CHILD LATENT STAGE Encourage child with physical and intellectual persuits.

ADOLESCENT GENITAL STAGE Encourage separation from parents achievements of independence and decision making.

Erikson’s Theory of Personality Development

STAGE DEVELOPMENT TASK NURSING IMPLICATION

Infant To form a sense of trust vs. Mistrust

Provide a primary care giver

Toddler To form a sense of autonomy vs. shame

Provide opportunities for decision making such as offering choice of clothes to wear or play with.

Preschooler To form a sense of initiative vs. guilt

Provide opportunities for exploring new places of activities

School-age child To form a sense of industry vs. inferiority

Provide opportunities such as allowing child to assemble and complete a short project so that child feels rewarded for any accomplishment.

Adolescent To form a sense of identity vs. confusion

Provide opportunities for adolescent to discuss feeling about events important to him or her .Offer support and frame for which involves uniting self identity.

Young or early adult To form sense of intimacy vs. isolation

Provide opportunities for new choices and offer support

Middle Adult To form a sense of generativity vs. stagnation

A time of concern for the generation and griding one’s own children, friends, etc.

Older Adult To form a sense of integrity vs. despair

Old ages allows for the terminiscence of life events with the attainment of purpose and fulfillment.

STAGE OF DEVELOPMENT

AGE SPAN NURSING IMPLICATION

SENSORI MOTOR

Neonatal reflex

Primary circular reaction

1 month

1-4 mos.

Stimuli are assimilated into beginning mental images. Behavior entirely reflexive.

Hand, mouth and ear-eye coordination develop. Infant spend much time looking objects and separating self from them. Enjoyable activities for this period a rattle or tape with parents voice.

Secondary circular reaction

Coordination of Secondary reactions

4-8 months

12-18 mos.

Infant learns to initiate, recognize and respect pleasurable experiences from environment. Memory traces are present, infant anticipate familiar events. Good toy for his period: mirror game.

Recognize shapes and size with familiar objects.

Because of increased sense of separateness, infant experiences separation anxiety when primary care giver leaves. Ex. Colored boxes

Tertiary circular reaction

Intervention of new means through mental combinations

12-18 mos.

18-24 mos

Child is able to experiment to discover new properties of objects and events. Capable of space perception as well as permanence object outside self are understood or cause of actions. Good for this period: throw and retrieve.

Transitional means or phase to the pre operational through out period. Uses memory and imitation to act, can solve basic problems, for see maneuvers that will succeed or fail. Good toys for this period those with period those w/ several uses as books, colored plastic rings.

2-7 yrs Concept of time and how, concept of distance is only as far as he/she can see centering on a single aspect

CONCRETE OPERATIONAL TOUGHT

7-12 yrs. Child is aware of reversibility an opposite operations or continuation of reasoning back to a starting paint. Good activity for this period collecting and classifying natural objects such as native plants, seashells, etc. Expose child to other viewpoints by asking questions such as now do you think you’re feel it were a nurse too bad to tell a boy to stay in bed.

FORMAL OPERATIONAL THOUGHT

12 yrs. Can solve hypothetical problems with scientific resuming understands casuality and deal with the past present and future. Adult or mature thought. Good activity for this period “talk time” to sort through attitudes and opinions.

INTERPERSONAL MODEL (SULLIVAN)INTERPERSONAL MODEL (SULLIVAN)

AGE GROUP LEARNING TABLE

INFANCY0-18 months

Other will satisfy needs

CHILDHOOD18 months- 6 years

Learn to delay need gratification

JUVENILE6-9 years

Learn to relate pears

PREADOLESCENCE9-12 years

Learn to relate to friends of same sex

EARLY ADOLESCENCE12-14 years

Learn independence and how to relate to opposite sex

LATE ADOLESCENCE14-21 years

Develop intimate relationship with person of opposite sex

COGNITIVE THOERY(PIAGET)COGNITIVE THOERY(PIAGET)

A. 0-2 years sensorimotor Reflexes, repetition of acts

B. 2-4 years preoperational No cause and effect reasoning; egocentriism; use of symbols, magical thinking

C. 4-7 years intuitive Beginning of causation

D. 7-11 years Concrete operations Uses memory to learn aware of reversibility

E. 11-15 years Formal operations Reality, abstract thought can deal with the past, present and futire

E. KOHLEBERG’S STAGES OF E. KOHLEBERG’S STAGES OF MORAL DEVELOPMENTMORAL DEVELOPMENT

LEVEL I. PRECONVENTIONALLEVEL I. PRECONVENTIONALStage 1 Age :2-3Stage 1 Age :2-3 Punishment or obedience (heteronomous Punishment or obedience (heteronomous

morality)morality) A chiild does the right thing because a parent A chiild does the right thing because a parent

tells him or her to avoid punishmenttells him or her to avoid punishment

STAGE II - Age : 4-7STAGE II - Age : 4-7 Individualism, Instrumentalism, and Individualism, Instrumentalism, and

excahngeexcahnge Child carries out action to satisfy own Child carries out action to satisfy own

needs rather than society’s.The child does needs rather than society’s.The child does something for another if that person does something for another if that person does something for him in returnsomething for him in return

LEVEL II. CONVENTIONALLEVEL II. CONVENTIONAL

STAGE 3 Age : 7-10STAGE 3 Age : 7-10 ““Good boy/girl”Good boy/girl” Orientation to interpersonal relations of Orientation to interpersonal relations of

mutualitymutuality A child follows rules because of a need to A child follows rules because of a need to

be a good person on own eyes and in the be a good person on own eyes and in the eyes of otherseyes of others

STAGE 4 Age : 10-12STAGE 4 Age : 10-12 Law and orderLaw and order Maintenance of social order, fixed rules Maintenance of social order, fixed rules

and authoritiesand authorities Child follows rules and authority figures as Child follows rules and authority figures as

well as parents to keep the system well as parents to keep the system workingworking

LEVEL LEVEL III:POSTCONVENTIONALIII:POSTCONVENTIONAL

STAGE 5 Age : older than 12STAGE 5 Age : older than 12 Social contract utilitarian law making Social contract utilitarian law making

perspectiveperspective Child follows standards of society for the Child follows standards of society for the

good of all peoplegood of all people

STAGE 6 : older than 12STAGE 6 : older than 12 Principal consciencePrincipal conscience Universal ethical principle orientationUniversal ethical principle orientation Child follows internalized standards of Child follows internalized standards of

conductconduct

Breastfeeding positionsBreastfeeding positions Perhaps the most frequently used breastfeeding position is the Perhaps the most frequently used breastfeeding position is the

cradlecradle, or , or cuddlecuddle, hold. Whether you use a chair or are sitting in , hold. Whether you use a chair or are sitting in bed, make sure your arm is well supported so it doesn't become bed, make sure your arm is well supported so it doesn't become tired before your baby is finished nursingtired before your baby is finished nursing

Place your baby across your stomach, tummy to tummy. Her face Place your baby across your stomach, tummy to tummy. Her face and knees should be close into, and facing, your body. and knees should be close into, and facing, your body.

Her head should be in the bend of your elbow, with her mouth Her head should be in the bend of your elbow, with her mouth directly in front of your nipple.directly in front of your nipple.

Her body should be in a straight line from her ear to Her body should be in a straight line from her ear to her shoulder and to her hip. You can tuck her lower arm around her shoulder and to her hip. You can tuck her lower arm around your waist, so it is out of the way.your waist, so it is out of the way.

  

If you have difficulty feeding your baby in the cradle hold, If you have difficulty feeding your baby in the cradle hold, try the try the footballfootball, or , or clutchclutch, hold. It can also work well for: , hold. It can also work well for:

Mothers who had c-sectionsMothers who had c-sectionsSmall babies.Small babies.Mothers experiencing difficulty on one side.Mothers experiencing difficulty on one side.Mothers with large breasts Mothers with large breasts Mothers with flat nipples.Mothers with flat nipples.Babies who are having problems latching on. Babies who are having problems latching on.

Lie baby beside you, you might like to put her on pillows Lie baby beside you, you might like to put her on pillows to support her and your arm. with her head will be in the to support her and your arm. with her head will be in the palm of your hand and her back wil lay on your inner palm of your hand and her back wil lay on your inner forearm. Tuck her feet slightly behind you. forearm. Tuck her feet slightly behind you.

The The cross-cradlecross-cradle, or , or transversetransverse, hold is another good , hold is another good position to use if you are having trouble latching on, or if position to use if you are having trouble latching on, or if you are feeding a small or premature baby. Because you you are feeding a small or premature baby. Because you have more control of your baby's head and can see the have more control of your baby's head and can see the latch more clearly, it may be a better position than the latch more clearly, it may be a better position than the cradle hold. cradle hold.

Your baby's position will be the same as in the cradle Your baby's position will be the same as in the cradle hold, but you will be holding her in the arm opposite the hold, but you will be holding her in the arm opposite the breast from which she will latch onto. As in the cradle breast from which she will latch onto. As in the cradle hold, make sure she is at the level of your breast, with hold, make sure she is at the level of your breast, with her body turned toward you. You may be able to tuck her her body turned toward you. You may be able to tuck her bottom into the crook of your armbottom into the crook of your arm

The lying down position is very useful, especially if you sleep

with your baby.

Lie on one side and support your head and back with pillows so that you are comfortable. You might like one of those "body pillows" which are very long. I think they can be bought for about ten dollars. You can also bend one arm under your head and use the other hand to support your

breast.

Line the baby up with her tummy to yours. Your nipple should be opposite her mouth. If she is still very young, you might want to place a pillow or rolled up blanket behind her to keep her from

rolling back.

She will nurse on the lower breast. You can support it with your upper

hand if neccessary. Many mothers like to reposition themselves on their other side to feed from the other breast. You can cuddle your baby on your chest, support her head and gently roll yourselves over. Often, you can just lean further over with the upper side instead of getting up and rolling over to switch sides. Make sure she is still postioned well in relation to your breast.

The The tailortailor position is great for older babies position is great for older babies and toddlers. You can place a pillow on and toddlers. You can place a pillow on your lap to raise a smaller infant up to the your lap to raise a smaller infant up to the right level.right level.

Latching OnLatching On    The best way to ensure successful breastfeeding is getting your baby to The best way to ensure successful breastfeeding is getting your baby to

latch on well. A baby who latches on well gets milk successfully. A baby who latch on well. A baby who latches on well gets milk successfully. A baby who latches on poorly has difficulty getting milk. A poor latch may also cause the latches on poorly has difficulty getting milk. A poor latch may also cause the mother nipple pain and trauma. If a baby is not latched well and not mother nipple pain and trauma. If a baby is not latched well and not receiving milk well, she will often stay on the breast for long periods, thus receiving milk well, she will often stay on the breast for long periods, thus increasing the mother's pain from the improper latch.increasing the mother's pain from the improper latch.

   Steps to a Successful Latch:Steps to a Successful Latch: Get comfortable, position baby at the Get comfortable, position baby at the

breast, and relax.breast, and relax.    PPlace four fingers under breast and thumb on top, well back from nipple and lace four fingers under breast and thumb on top, well back from nipple and

areola. areola. LLightly tickle baby's lower lip with nipple. Have patience. ightly tickle baby's lower lip with nipple. Have patience. WWait for her to open up her mouth ait for her to open up her mouth widewide, as if yawning, then quickly pull her , as if yawning, then quickly pull her

towards you onto the nipple. Several tries may be necessary. towards you onto the nipple. Several tries may be necessary. Remember: Remember: bring the baby to the breast, NOT the breast to the baby bring the baby to the breast, NOT the breast to the baby

DDon't let her latch onto the nipple, get as much of the areola on't let her latch onto the nipple, get as much of the areola into the mouth as possible. into the mouth as possible.

IIf she is positioned correctly, her nose will be resting on top f she is positioned correctly, her nose will be resting on top of your breast and not buried in breast tissue. Do not press of your breast and not buried in breast tissue. Do not press down on your breast to create breathing space. Even if her down on your breast to create breathing space. Even if her nose is pressed slightly against your breast, her nostrils nose is pressed slightly against your breast, her nostrils should flare out at the sides allowing her to breathe. If you should flare out at the sides allowing her to breathe. If you are concerned reattach her. are concerned reattach her.

CCheck the latch. If it is correct her mouth will be open wide heck the latch. If it is correct her mouth will be open wide with flanged ("turned back") lips. Her tongue will be covering with flanged ("turned back") lips. Her tongue will be covering the lower gum, perhaps extending to her lower lip. Her chin the lower gum, perhaps extending to her lower lip. Her chin will pressed into your breast with her nose resting on top. If will pressed into your breast with her nose resting on top. If the latch isn't right (the baby has only part of the nipple in the latch isn't right (the baby has only part of the nipple in her mouth) you are likely to experience nipple pain. her mouth) you are likely to experience nipple pain.

IIf your baby was angry, hungry or crying when f your baby was angry, hungry or crying when put to the breast, the tongue may on top of the put to the breast, the tongue may on top of the nipple, making the "milking movement" of the nipple, making the "milking movement" of the mouth impossible. Break the suction with your mouth impossible. Break the suction with your finger, try to calm the baby and try again. finger, try to calm the baby and try again.

LListen for swallowing. If she is feeding well you isten for swallowing. If she is feeding well you will see a suck- swallow motion with pauses in will see a suck- swallow motion with pauses in between. The jaw movement goes past the ears, between. The jaw movement goes past the ears, sometimes even making the ears wiggle. sometimes even making the ears wiggle.

IIf she starts wiggling around during the feed she f she starts wiggling around during the feed she may need to burp. Take her off the breast, may need to burp. Take her off the breast, remembering to break the suction first, offer a remembering to break the suction first, offer a burp and then latch her on again. burp and then latch her on again.