Primitive reflexes Primitive reflexes These reflexes noted at birth and indicate the functional integrity of the brain stem , as These reflexes noted at birth and indicate the functional integrity of the brain stem , as a group they are symmetric and disappear at 4-6 month of age , indicating the normal a group they are symmetric and disappear at 4-6 month of age , indicating the normal maturation of the descending inhibitory cerebral influences . maturation of the descending inhibitory cerebral influences .

These are some of the primitive reflexes :These are some of the primitive reflexes :

Reflex descriptionappearance

Age of disappearanc

e

Origin

Moro reflex Suddon head extension causes extension followed by flexion of the arms and legs

Birth 4-6 month Brain stem and vestibular nuclei

Grasp Placing a finger in palm result in flexion of the infant hand with flexion at elbow and shoulder .

Birth 4-6 month Brain stem and vestibular nuclei

Rooting Tactile stimulus about the mouth results in turning mouth or the head toward the stimulus , an attempt to find the nipple for feeding .

Birth 4-6 month Brain stem and trigeminal system .

Placing Infant places foot on examining surface when dorsum of foot is brought into contact with the edge of the surface .

Birth 4-6 month Spinal cord

Atonic neck reflex

If head is turned to one side , arms and legs extend on same side and flex on opposite side .

Birth , 2-4 wk

4-6 month Brain stem and vestibular nuclei

Landau With the infant held about the waist and suspended ( in prone position ), extension of the neck produces extension of the arms and legs .

6-8 month

15 mo- 2 yr Brain stem

Trunk incurvation

Infant withdraws from stroking stimulus along the ventral margin .

Birth 6-9 month Spinal cord

Parachute With the infant sitting , tilting to either side result in extension of the epsilateral arm in a protective fashion .

6-8 month

Never Brain stem vestibular nuclei

Moro ReflexMoro Reflex

Moro ReflexMoro Reflex

Rooting ReflexRooting Reflex

Grasp reflex , Babiniski signGrasp reflex , Babiniski sign

Automatic reflex , stepping or placing reflexAutomatic reflex , stepping or placing reflex

** these reflexes if not present at their proper ages of appearance indicate some abnormalities and if they persist more than their proper ages of disappearance also indicate abnormalities .

** planter reflex bilaterally up going .

Normal growth measurements :-Birth weight : 2.5-4.5 kg ( average 3.5 kg ) .

Length : 50 cm ( average ) .

Head circumference : 35 cm ( average ) .

Chest circumference : 35 cm ( average ) .

Pulse rate : 80 – 180 beats / min .

Respiratory rate : 30-50 cycle / min .

** there are 2 major fontanels at birth ( but some time 6 fontanels are present ) , these are anterior and posterior fontanel ( Anterior closed at age of 9-18 month , while posterior closed few weeks after birth ) . Measurement of anterior fontanel about 3-5 cm in diameter .

Assessment of gestational age :- Gestational age is determined by assessing various physical signs and neurological

characteristics that vary according to fetal age and maturity .

A. Rapid delivery room assessment.

The most useful clinical signs in differentiating among premature, borderline mature, and full-term infants are (in order of usefulness): creases in the sole of the foot, size of the breast nodule, nature of the scalp hair, cartilaginous development of the ear lobe, and scrotal rugae and testicular descent in males.

B. New Ballard Score.

The Ballard maturational score has been expanded and updated to include extremely premature infants. It has been renamed the New Ballard Score (NBS). The score now spans from 10 (correlating with 20 weeks' gestation) to 50 (correlating with 44 weeks' gestation). It is best performed at <12 h of age if the infant is <26 weeks' gestation.

C. Grading System for assessment of gestational age by examination of the anterior vascular capsule of the lens.

Grading System for assessment of gestational age by examination of the anterior vascular capsule of the lens.

Preterm , Full termPreterm , Full term

Neurological criteria that mature with gestational age include increasing flexion of the legs , hips and arms , increasing tone of the flexor muscles of the neck and decreasing laxity of the joints . These signs are determined during the 1st day of life and are assigned scores . The cumulative score is correlated with a gestational age , which is usually accurate to with in 2 wk .

Newborn life support ( resuscitation council ) :- Passage through the birth canal is a hypoxic experience for the fetus , since

significant respiratory exchange at the placenta is prevented for the 50-70 sec duration of the average contraction , though most babies tolerate this well , the few that do not may require help to establish normal breathing at delivery , NLS is intended to provide this help and comprises the following elements .

1- drying and covering the newborn baby to conserve heat .2- assessing the need for any intervention .3- opening airways ( cleaning airways ) .4- lung aeration .5- rescue breathing .6- chest compression .7- administration of drugs ( if indicated ) .

Sequence of actions :-Follow the ABC…..

1) Keep the baby warm and assess :- Babies are born small and wet , they got cold very easily , especially if they

remain wet and in a draught . First make sure that the cord is securely clamped and then dry the baby and cover the baby with dry towels .

place the preterm baby in radiant heater , in order to prevent hypothermia especially in a very low birth weight babies . Drying the babies will provide significant stimulation and will allow time to assess color , tone , breathing and heart rate , heart is better to be assessed by listening with a stethoscope or it can be felt by gently palpating the umbilical cord .

2) Airway :- Before the baby can breathe effectively the airways must be cleaned

( opened ) , the best way to achieve this is to place the baby on his back with the head in the neutral position . Cleaning of the airway can be achieved by suctioning the airways using N-G tube .

3) Breathing :- If the baby is not breathing adequately by about 90 sec give 5 inflation

breaths . If the H.R. was below 100 beats /min initially then it should rapidly increase as oxygenated blood reaches the heart , if the H.R. does increases then you can assume that you have successfully aerated the lungs , if H.R. increase but the baby does not start breathing for himself , then continue to provide regular breaths at a rate of 30-40 /min .

Continue till the baby take spontaneous breathing . If the H.R. does not increase following inflation breaths , then search for the possible causes .

4) Chest compression :- It should be started only when you are sure that the lungs have been aerated

successfully . The best way is to grip the chest in both hands in such a way that the two thumbs can press on the lower third of the sternum , just below an imaginary line joining the nipples , with the fingers over the spine at the back . The ratio of compression to inflations in newborn resuscitation is 15 : 2 .

5) Drugs :- Drugs are needed only if there is no significant cardiac output despite effective lung

inflation and chest compression . Drugs like Adrenaline ( 0.1 mg /kg ) , Sodium bicarbonate ( 4.2% ) , Dextrose ( 10%) , and other drugs if indicated ( like Naloxone ). These drugs usually given via umbilical venous catheter .

*** Apgar score should be assessed every 5-10 min during resuscitation .

** Drugs which are given routinely in delivery room .Silver nitrate 1% eye drops : instilled both eyes to prevent neonatal gonococcal

ophthalmia , but it may cause chemical conjunctivitis and it is not effective against Chlamydia infection , so Erythromycin eye drops is better .

Vitamin K 1mg given I.M. to prevent hemorrhagic diseases of the newborn .

Bag and mask ventilation of the neonateBag and mask ventilation of the neonate