The Normal Newborn: Assessment, Care, Feeding

1. The Normal Newborn:Assessment, Care, Feeding • Presented by, • Joy Haskin, RN, MS

2. Joke for the day…. Should children witness childbirth?

3. TERMS: • Neonatal Period: • Birth --> 28 days of life • Term Infant: • 38 - 42 weeks of gestation • Transition Period: Phases of instability during the first 6-8 hours after birth

4. Viability • Capacity to live outside of the uterus - about 22 to 24 weeks since the last menstrual period, or fetal weight greater than 500 g. • In the past was 28 weeks - with technology and advancements this is becoming shorter and shorter…...

5. Physiologic Changes of the NB to adjust to extrauterine life:What happens during birth to the neonate?

6. Circulatory: • Transitional Circulation = acrocyanosis • Peripheral circulation = sluggish • High: RBC 4.8-7.1; Hgb 14-24; Hct 44-64 • WBC 18,000 @ birth; 23-24,000 @ 1 day • Coagulation: Vit K dependent clotting factors are decreased. • Platelet counts ok (150,000-350,000)

7. Respiratory • Before birth O2 needs met by placenta • L/S ratio should be > 2:1 • After delivery need mature lungs that are vascularized, have surfactant and sacules - usually adequate by 32-35 weeks- • at term the lungs hold approx. 20 ml of fluid/kg • What initiates respiration?

8. Periodic Breathing -vs- Apnea • Apnea: no breathing for periods of greater than 15 seconds should be evaluated. Periodic Breathing: Notify MD if resp < 30 or > 60

9. Gastrointestinal System • Immature at birth, reaches maturity at 2-3 years of age • place food at back of tongue • sucking becomes coordinated @32 wks • little saliva until 3 months of age • bowel sounds after 1 hour of birth

10. Gastrointestinal (continued) • NB have difficulty digesting complex starches and fat • Abdomen becomes easily distended after eating • Initial fecal material = meconium • No normal flora at birth in GI system to synthesize Vit. K

11. Immune System • Limited specific and Non-specific immunity at birth • passive immunity(from mom- IgG) for the first 3 months of life ~ this will be reduced if baby is born premature • breastfeeding = ^ passive immunity (IgA)

12. Temperature Regulation • Non-Shivering thermogenesis: • brown fat is the primary source of heat production. Brown fat is broken down into glycerol & fatty acids producing heat. • Brown fat is found @ the nape of the neck, axillae, around the kidneys and in the mediastinum. • Slightly warmer to touch than nml skin.

13. Cold Stress • An increase in the metabolic rate associated with non-shivering thermogenesis --> increased O2 demands and caloric consumption • It’s important to provide a neutral thermal environment to prevent metabolic acidosis and prevent depleted brown fat.

14. Kidneys and Urination • 92% of all healthy infants void in the first 24 hrs of birth • initial urine:cloudy, scant amounts, uric acid crystals-> reddish stain on diaper • Kidneys not fully functional until child is 2 years of age.

15. Hepatic Function • Liver produces substances essential for clotting of blood. • Stores needed iron for the first few months. Preterm & small infants have lower iron stores than full term and heavier infants. (full term infants stores last 4-6 mo) • NB at risk for Physiologic Jaundice after 24 hours of age, d/t increased breakdown of RBC’s and immature liver functioning.

16. Increased Bilirubin Levels • Jaundice in the 1st day is NOT normal • Bilirubin level greater than 12 at any time needs further attention • Maternal causes of increased bilirubin levels in the NB: epidural use, oxytocin induced labor, infection, hepatitis • Ethnic Influences: Asian infants levels may be double other ethnic groups.

17. Kernicterus • Complication of neonatal hyperbilirubinemia --> encephalopathy • basal ganglia and other areas of the brain and spinal card are infiltrated w/ bilirubin (produced by the breakdown of hemoglobin -> levels of 20 - 25 or more). • Poor prognosis if untreated.

18. Neurologic • All neurons are present, but many are immature: • uncoordinated movements • poor muscle control • startle easily • tremors in extremities

19. Weight Loss • It is normal for the newborn infant to loose 5-10% of weight in the first 4 to 5 days of life.

20. Infants at Risk • “RED FLAGS” after birth include: • gagging --> turning blue (esp. after fdg) • generalized cyanosis • weak cry • grunting or respiratory distress • decreased or absent movements • excessive twitching or trembling • OTHERS>>>>>

21. Nursing Diagnosis: • Ineffective Airway Clearance R/T excessive oropharyngeal mucus • Ineffective Thermoregulation R/T newborn transition to extrauterine life • High Risk for infection R/T maturational factors, immature immune system • PC: Hypoxemia PC: Hyperbilirubinemia • (W) Beginning Integration of NB into Family Unit

22. Nursing Care to Meet NB Needs • Prevent infection: • handwashing, stay away from large groups or ill individuals, prophlactic agents (EES, cord care, bathing) • Vernix • Breastfeeding

23. Warmth • Bath after temperature is stable • warmer/isolette/bundle • hat • keep out of drafts • skin to skin

24. Position of sleep/prevent SIDS • Back to sleep • feet to foot of bed • no stuffed animals or excessive blankets in bed • don’t cover head in stroller • don’t keep house too warm • No smoking around infant

25. Cleanliness • No tub baths until cord off and healed • clean around organs of elimination and mouth after soiling to prevent skin break down • daily head to toe bath not necessary • OK to clean and touch the “soft spot” • fold diapers away from umbilicus • NEVER leave child alone in tub!!

26. Research and Cord Care • 1,811 NB’s- 2 groups - one receiving cord care with alcohol and one group not: • * equal # infections in infants who received and did not receive cord care • *cord separation ~ alcohol use: 9.8 days • no alcohol used: 8.16 days

27. Carseats • “AS a condition for licensure, public and private hospitals, birth centers, and clinics must have a written policy on the dissemination of child passenger restraint system information to parents or the person to whom the child is released” (SB503 REQ)

28. Genital Care • Male Infant: if penis is uncircumcised DO NOT RETRACT THE FORESKIN--- “leave it alone” • Female Infant: wipe front to back. If “smegma” has accumulated in the labial folds it can be carefully removed

29. Infant Feeding • Why may a mother decide to Breast Feed? • Discussion

30. Formula feeding • Why may a mother decide to formula feed her infant? • Discussion

31. Frequency of Feedings • Breastfeeding: successful latch-on and feeding should occur every 1.5 to 3 hours daily. • Formula Feeding: 3-4 oz every 3-4 hours for full-term babies. • Baby should have 6-10 wet diapers/day • calculate amnt of formula mult. baby’s wt in lbs by 2 then 3, this is oz per day. • (EX: 8lb. Baby~ 8 X2 = 16; 8 x3 = 24 therefore 16-24oz of formula per day is needed for adequate nutrition)

32. Nursing Diagnosis • Effective Breastfeeding • Risk for Altered Nutrition (more or less than body requirements) R/T (insufficient caloric intake or excessive caloric intake)

33. Circumcision • Elective Procedure • Not pd for by medi-cal • Decision made based on tradition, religion, culture, or personal factors • VALUE • OPPOSITION

34. Procedure • Usually delayed 12 to 24 hours until NB is stabilized • Do not feed 1 hr prior to procedure • Consent required from one parent • Methods: Gomco or Plastibell • Restraint required • Anesthetic is physician dependent

35. After Care • Comfort measures • keep wound clean and dry (warm water) • ck urination w/in 12 hrs after procedure • monitor for bleeding • s/s of infection will not occur immediately after procedure

36. Periods of Reactivity • REVIEW • 1st period of reactivity:after birth of baby, bursts of rapid movements. Quiet times during this period are ideal for breastfdg & interacting • Deep Sleep - lasts 60-100 minutes • 2nd period of reactivity: occurs 4-8 hrs after birth lasts 10 min to several hours. Periods of tachycardia & tachypnea. Increased muscle tone, skin color, mucus production, pass meconium

37. The end….