Newborn
Terms







Acrocyanosis
Appropriate for gestational age
Caput succedaneum
Cephalhematoma
Circumcision
Cold stress
Conduction
Terms







Convection
Cryptorchidism
Down’s syndrome
Epispadias
Epstein’s pearls
Erythema toxicum neonatorum
Evaportation
Terms








Foremilk
Gynecomastia
Hindmilk
Hallux varus
Hydrocele
Hyperbilirubinemia
Hypospadius
Kernicterus
Terms








Lanugo
Large for gestational age
Meconium
Milia
Molding
Mongolian spots
Myelomeningocele
Nevus flammeus
Terms



Radiation
Theromoregulation
Psuedomenstration
Acrocyanosis

Although some
newborn infants are
uniformly pink in
color, many have
some degree of
"acrocyanosis." This
means that the central
portion (chest) is pink,
but the extremities,
particularly the hands
and feet, are blue or
purple.

Acrocyanosis is
normal for a newborn
during the first few
hours, disappearing
over the next day. It is
due to relatively
sluggish circulation of
blood through the
peripheral structures,
related to immaturity
or inexperience of the
newborn blood flow
regulatory systems.
Acrocyanosis


Appropriate for Gestational Age

Assigning size is a
way to measure
and monitor the
growth of the
infant throughout
the pregnancy as
well as at the time
of birth.
The measurement is
calculated based on
the estimated
gestational age (how
many weeks the
mother was pregnant)
in comparison to what
is considered normal
height, weight, head
size, and
developmental level
for a child of the same
gestational age and
gender.
Appropriate for Gestational Age
Graphs are available
showing the upper
and lower normal
limits for different
gestational ages
from the mid-20s
through 42 weeks
of gestation. See
pg 1561, Figure
54-20
An appropriate for
gestational age
full-term infant is
heavier than 2500
grams (about 5.5
lbs.) and lighter
than about 4000
grams (about 8.75
lbs.).
Caput Succedaneum

Caput succedaneum is
swelling of the scalp in
a newborn. It is most
often brought on by
pressure from the
uterus or vaginal wall
during a head-first
(vertex) delivery.
Symptoms

Soft, puffy swelling of part
of the scalp in a newborn
infant

Swelling may or may not
have some degree of
discoloration or bruising

Swelling may extend over
the midline of the scalp

Most often seen on the
portion of the head which
presented first

May be associated with
increased molding of the
head
Caput Succedaneum


TreatmentNo treatment is
necessary, and it usually
heals spontaneously within
a few days.
CausesA caput
succedaneum is more
likely to form during a
prolonged or difficult
delivery. This is especially
true after the membranes
have ruptured, because
the amniotic sac is no
longer providing a
protective cushion for the
baby's head. Vacuum
extraction can also
increase the chances of a
caput succedaneum.

A caput succedaneum is
sometimes identified by
prenatal ultrasound even
before labor or delivery
begins. It has been found
as early as 31 weeks of
pregnancy. More often
than not, this is associated
with either premature
rupture of the membranes
or too little amniotic fluid
(oligohydramnios). All
other things being equal,
the longer the membranes
are intact, the less likely it
is that a caput will form.
Pg 1554
Cephalhematoma

swelling caused by
subcutaneous
bleeding and
accumulation of blood.
It may begin to form
in the scalp of a fetus
during labor and
enlarge slowly in the
first few days after
birth. It is usually a
result of trauma, often
caused by forceps.

Large
cephalhematomas
may become
infected, require
surgical drainage,
and take several
months to resolve.
Also called
cephalhaematoma.
Caput Succedaneum vs
Cephalhematoma

Important! Know how to recognize the difference between the two.
Circumcision
Breathing
Four Factors
• Physical
• Thermal
• Chemical
• Sensory
Immediate Needs




Airway
Newborns are usually nose
breathers-if nose is stuffy-will open
mouth to breathe
Suctioning usually done by bulb
syringe at birth
Airway must be kept clear
Needs



Breathing
Pressure factors, chilling, noise light,
environmental stimuli encourage
initial newborn breath
Breathing movements began in
uterus at about 11 weeks
Breathing




At term 20 ml of fluid/kg in lungs
Air is substituted for the fluid with
the first breath
Fluid moves into chest wall as trunk
emerges at birth
As more air enters the lungs, more
fluid moves interstitial
Breathing




Fluid is absorbed during the first day
after birth
May hear wet sounds in the lung
After birth or soon after birth
Wet sounds are more prominent on
c-section infants
Chemical factors





Arterial oxygen decreases-Carbon dioxide increases--Respiratory center is stimulated----Infant takes first breath
Usually within 1 minute of birth
Thermal factors


Change in temperature from uterus
to environment is 20 degrees
Cool environment is a stimulus to
breathe
Sensory factors


Auditory, visual, touch stimuli are
increased when born
All the stimuli are new and increase
the stimuli to breathe
Circulation changes
Pulmonary blood vessels
 Begin with the first breath
 Lungs inflate and reduces pulmonary
vasculature resistance
 Reduces pulmonary artery pressure
 Dilation occurs and allows blood to
flow for O2 in the lungs
Circulation



Pressure in the right atrium
Decreases-- allowing increased
pulmonary return to the left side of
the heart
Increased pressure in the left atrium
promotes closure of the foramen
ovale
Circulation
Ductus arteriosus
 Blood is shunted from the pulmonary
artery to the descending aorta before
birth
 Closes soon after birth and
permanently closed within 3-4
months of life
Circulation
Foramen ovale
 Before birth the opening allows blood
to flow directly to left atrium
 Functionally closes at birth and
permanently closes in a few months
Circulation
Ductus venosus
 Connection of umbilical vein and
inferior vena is present before birth
at birth the umbilical
cord is cut…
 With blood loss from the umbilical
vein, the connection closes and
becomes ligamentum arteriosum
Warmth




Thermoregulation must begin at
birth-balance of heat loss and heat
production
When cold, the infant needs to raise
the metabolism to increase the heat
Infants do not shiver when cold
Infant will break down brown fat on
body to increase metabolism
Warmth




Brown at is on back of neck, between
scapula, around kidneys and around
adrenals
Brown fat is deposited at 26-30
weeks
Increased metaboism requires more
oxygen
Infant may present with hypoxia
Heat retention


Infant normaly lays in fetal or flexed
position to maintain heat
Vasoconstriction allows head
retention
Heat loss





Newborn heat moves from internal to
periphery to external environment
Excess heat loss is cold stress
Infant becomes cold and begins to
break down brown fat …
To increase metabolism
Increased metabolism requires more
oxygen…hypoxia can develop
Heat loss


Prolonged cold stress reduces
surfactant production which
increases lung resistance and
respiratory distress
When glucose stores depleted;
Hypoglycema develops… from brown
fat breakdown, fatty acids are
released=metabolic acidosis
Heat loss

Excess fatty acid release causes less
bilirubin to be transported to the
liver and jaundice may develop
Heat loss methods

Conduction: direct contact with a
cool object
• Hands, stethoscope

Convection: movements of air
• Air conditioning, open door

Evaporation: water is changed into
vapor
• Drying of wet infant
Heat loss methods

Radiation
• cooler objects near sides of crib walls of
isolette
• Reduced by keeping cribs away from
drafts
APGAR
2
Heart rate
1
0
over 100
Below 100
absent
good cry
Slow
absent
active
Some flexion
flaccid
(Pulse)
Inspiratory
effort
(Rate and effort)
Muscle tone
(Activity)
Color
(Appearance)
Reflex
irritability
(Grimace)
Completely pink body pink
pale blue-gray
extremities blue
vigorous cry,
pulls away,
sneezes
Grimace
w/stimulation
None
Newborn Test

The newborn is commonly
assessed with the APGAR
score, a quick test
performed at 1 and 5
minutes after birth to
determine the physical
condition of the newborn.
The five categories
assessed are heart rate,
respiratory effort, muscle
tone, reflex irritability, and
color. Each of these
categories is scored 0, 1,
or 2, depending on the
observed condition of the
newborn.
Resucitation




Usually suctioned with bulb syringe
after birth
May need wall suction/ suction trap
for excess mucus
May need oxygen
RN or Physican will apply O2, suction
as needed
Thermal environment



Infant temperature should be 97-99 f
Warmth is important
Infant is placed under warmer after
birth and in isolette in the nursery
until infant can maintain own heat
Identification/ bonding




Identification: identification bands on
one leg, one hand, foot prints (bold
numbers on the band)
May breastfeed in delivery room
Parents may hold infant
Infant is usually very awake during
the first hour after birth
Prophylactic care



Vitamin k: given in delivery room in
left vastus lateralis IM
Infant does not make vitamin K until
food is present in intestine
Usually about 8 days of age vitamin
K is produced
Prophylactic care

Erythromycin ointment: placed in
both eyes in delivery room to
prevent inflammation/ eye problems
from gonorrhea or chlamydia
Umbilical cord




Cord is checked for 3 vessels
Cord is clamped until cord is dry
Cord is usually short and cleaned
with alcohol
Cord clamp is removed when the
cord is dry
Umbilical cord


Cord may be kept long for Rh
negative mother and Rh positive
infant cord may be kept damp with
normal saline dressings
Some hospitals clean the cord with
triple dye-purple color
Physical characteristics



Weight: 2500-4000g 5 lb 8 oz-8lb
and 13 oz
Neonates loose 10% of birth weight
and will gain weight back by 10-14
days of life
Average infant : 7 lbs 8 ounces and
20 inches long
Height






45-55 cm or range 19-21 inches
Head averages 13-14 inches and
chest 12-13 inches
Resp rate 30-60/min
Heart rate 120-160/min
Axillary temp 97.6--98.6 f
(Hospitals 97-99f)
Skin






Generally pink
Acrocyanosis of hands and feet
Lanugo on shoulders or forehead
Vernix caseosa-in creases
Physiologic jaundice after 24 hours
Pathologic jaundice before 24 hours
Head






Circumference 13-14 inches
Molding
Anterior fontanel-junction of saggital and
coronal sutures
Diamond shaped 5 cm in size
Closes by 18 months
Posterior fontanel-at junction of
lambdoidal and saggital sutures-closes by
2 months—may not be palpable
Eyes







Sclera: white and clear
Pupils: react to light
Do not accommodate
Strabismus (cross eyed): common for 3-4
months
Dolls eyes: for 10 days common
Color: slate blue, grey, brown
Color established in 3 months
Ears




Ears: symmetrical in shape and size
Top of ear aligns with inner and outer
canthi of eyes
Hearing test should be done for all
infants
Loud noise will create the startle
reflex
Ear Alignment

Top of ear aligns
with inner and
outer canthi of
eyes
Neck/ Chest


Neck is
symmetrical
without webbing
neck short, thick,
several folds,
flexible
Allows free
movement of the
head from side to
side

Chest:
circumference 1213 inches
measured at the
nipple line
symmetrical
Abdomen





Symmetrical/round
Moves with breathing
Bowel sounds audible
Umbilical cord clamped-whitish blue
color, 3 vessels
Cord dries and falls of about 2 weeks
after birth
Meconium

Meconium passed
within 24 hours
Genitalia






Mature for gestational age
Check for descent of testicles
Scrotum covered with rugae
Voiding should occur within 24 hours
Rust stained urine (uric acid crystals)
may occur
Vernix in folds
Back



Spine should be straight and easily
flexed
No limitation of movement or
abnormality of spinal column
No bumps or tufts of hair seen
Extremities







Check: the number of toes and fingers
Absence of digits
Excess digits
Syndactly-webbing of fingers
Symmetrical
Range of motion
Creases on anterior 2/3 of sole of foot
Variations of newborn


Vernix caseosa
yellowish white
cream substance
on body
Jaundice after 24
hours-yellow color
on chest, face,
sclera



Acrocyanosis
bluish color of
hands/ feet
Ecchymosis
bruising
Petechiae
small spots of
bruising
Acrocyanosis

Blue discoloration
of hands and feet
after birth and for
about 24 hours but
can last as long as
7-10 days
Variations

Milia: Tiny white
papules (plugged
sebaceous glands)
located over nose,
cheek, and chin.
Variations

Newborn rash/
erythema
toxicum
neonatorum:
hivelike rash
that disappears
without
treatment
Variations
Talangietactic
nevi/ stork bites:
 Flat pink or red
marks on eyelids,
nose, neck
 Dilated capillaries
and will disappear
at 1-2 years of age
Variations
Mongolian spots:
 pigmentation of
lumbar dorsal/
buttocks area
 Look like black and
blue spots
 Seen in dark
skinned persons
 Will dissapear in
time
Variations
Nevus flammeus:
 Port wine colored
reddish/purple
discoloration on
face or neck
 May be lightened
or treated by laser

Nevus
Variations
vascularis/
strawberry
birthmark=enla
rged superficial
blood vessels
often on head ,
face, neck,
arms, may
disappear by
school age
Variations
Molding:
 will disappear in a
day or two after
delivery
Caput Succedaneum

Swelling of the soft
tissue of the scalp
caused by pressure
of the fetal head
on a cervix that is
not fully dilated.
Swelling crosses
suture line and
decreases rapidly
in a few days after
birth.
Cephalhematoma

Subperiosteal
extravasation of blood due
rupture of vessels.
Swelling increases in size
on second and third day
after delivery. Often
associated with delivery by
forceps. Swelling does not
cross suture line and may
take several weeks after
birth. Jaundice may occur
as blood cells are broken
down as the swelling
resolves.
Face






Face movements symmetrical
Epstein’s pearls on hard palate
Precocious teeth-if loose remove
Nystagmus dissapears in 3-4 months
Usually does not produce tears
Check for candidia infection
Eyes





Eyelids edematous to ointment
Strabismus common
Can see 8-10 inches from face
Ears pinna located with outer
canthus of eye
Low set ears= may indicate
chromosome disorder
Chest



Engorged breasts
may be present
due to estrogen
nipples excrete
whitish fluidWitches milkfrom day three to
two weeks after
birth
Will stop without
treatment
Abdomen



Check: umbilical cord,bowel sounds,
bowel movement
Patent anus
Elimination: psuedomentration to
estrogen withdrawal during first
week blood tinged mucus from
vagina
will stop without
treatment
Stool



First stool is black-green and thick
called meconium
Transitional stool is greenish brown
to yellowish brown and thinner
Milk stool= about day 4 with yellow
to golden stool breastfed infants
have a looser stool than formula fed
infants
Stool





Green watery stool is diarrhea and is
serious in the newborn
This is not a normal stool
Notify physician immediately
Infant can dehydrate quickly
Monitor for: hydrocele,
cryptochidism, phimosis (foreskin),
epispadias (urethra displacement),
hypospadius (urethra displacement)
Cryptorchidism

In normal fetal
development, during the
last months of birth, the
testicles develop in the
abdomen and descend into
the scrotum in the male
fetus. Sometimes at birth,
one or both testicles may
fail to descend into the
scrotum. If the testicle has
not descended within the
first year of the baby's life,
surgery may be
recommended to return
the testicle to its proper
position in the scrotum.
Hydrocele

A hydrocele is a collection of
fluid inside the area of the
scrotum, surrounding the
testicle. Hydroceles are
common in newborn infants
and normally resolve after a
few months after birth. The
main symptom is a painless,
swollen testicle, on one or
both sides, which feels like a
water-filled balloon.
Hydroceles are usually not
dangerous, and they are
usually only treated when
they cause discomfort or
embarrassment, or they get
so large that they threaten
the blood supply of the
testicle.
Extremities






Spine straight
Extremities symetrical and move
freely
Polydactyly=extra digits
Syndactly=webbing of hands or feet
Hip dysplasia-one leg longer
Down’s syndrome-one crease across
hand
Syndactly/Polydactyly
Hip dysplasia


One leg longer
than other
Asymmetrical skin
folds
Downs Syndrome
Simian Line
Reflexes





Rooting: touch face or corner of
infant mouth and infant turns toward
touch
Sucking: usually strong at birth
Blink/ yawn/ gag: at birth
Cough/ swallow: at birth
Hiccup/sneeze: at birth
Reflexes

Extrusion: tip of tongue touched or
depressed infant will force tongue
outward
• Disappears at 4 months

Grasp/palmar: infants fingers
tighten on finger when a finger is
placed in the infants palm
• Present for 4 months
Reflexes

Plantar: toes curl downward when fingers
are placed at the base of the toes
• Disappears at 8 months

Tonic neck reflex (Fencing position) : when
infants head is turned to one side, the arm
and leg on that side will extend while the
opposite arm and leg will flex
• disappears in 3-4 months
Reflexes

Startle (Moro reflex):
sudden jarring causes extension and
abduction of extremities index finger and
thumb form a c
• Disappears in 3-4 months

Trunk incurvation(gallant): Infant prone
run finger down back 1 ½ -2 inches from
spine on one side and the other. Trunk is
flexed and pelvis moved toward the
stimulated side
• Disappears 1 month
Relfexes

Dancing or stepping reflex: when
held, sole of foot touches hard
surface there will be flexion and
extension of leg as if walking
• Disappears 3-4 weeks
Reflexes

Babinski: sole of foot is stroked from
heel to toe , the toes will fan out with
dorsiflexion of the big toe
• Disappears in 12-18 months
Normal periods of reactivity




First period of reactivity-first 30
minutes after birth
Infant is alert good time fore
breastfeeding
Spontaneous startle reflex, crying,
tremors
Sleep will last 2-4 hours
Second period of reactivity





Can range in time from 10 minutes
to several hours
Have increased muscle tone, often
mucus production
May spit up
Brazelton behavioral states: quiet
sleep=eyes closed
Active sleep=stretch,face changes
Sleep states




Drowsy state=eyes open
Quiet alert=focus on environment
Active alert=fussy
Crying state=crying, jerking
movements
Gestational assessment




External physical characteristics
Resting posture=newborn is flexed
Skin=preterm has transparent skin
newborn may have cracking of skin
at ankles and feet
Lanugo=abundant at 28-30 weeks
Gestational assessment



Lanugo: full term
Slight on shoulders, ears, side of
forehead
Plantar creases= develop at 32
weeks and cover 2/3 of sole by 37
weeks , cover entire sole at 40
weeks
Gestational assessment



Breast size= 1 cm at term
Eye/ear=32 weeks minimal ear
cartilege
Full term= cartilage springs back
when folded
Neuromuscular maturity


Square window=bend wrist so palm
is flat against the arm
Scarf sign= arm is drawn across
body toward opposite shoulder until
resistance is felt
Birth classifications


Small for gestational age= infant is
below 10th percentile for gestational
age
Appropriate for gestational
age=infant is between 10th and 90th
percentile for gestational age
LGA / sleep position



Large for gestational age
Infant is above the 90th percentile for
gestational age
Sleep position= infant on back to
prevent sudden infant death
syndrome
Infant bath




In hospital: usually one hour after
birth or when infant can maintain
temperature
Washed with hypoallergenic soap
Cord cleaned with alcohol
Diaper foldes under cord
Infant bath






At home
Sponge bath
Room temperature 75 degrees free
of drafts
Water 100 degrees
Clean each eye= inner canthus to
outer canthus with separate area of
wash cloth
Use water for face
Infant bath





Infant not to have tub bath until cord
falls off
Clean front to back on perineal area
Never leave infant alone during bath
Do not use q tips to clean ears
Dry well wrap in blanket
Circumcision



For: easy cleaning, religious reasons,
prevent surgery later, reduce urinary
tract infections
Against: painful, infection,
adhesions, hemorrhage
Parent= signed consent required
infant on circumcision board some
physicians use lidocaine for nerve
block
Circumcision





Hospitals may use: 20% sucrose solution
for infant
Sucking or pacifier
Methods: gomco clamp or plastibell
Petroleum gauze used and changed with
diaper change
Assess for voiding and for bleeding may
use a&d ointment or petroleum jelly for
moisture after procedure
Circumcision

Circumsicion of a newborn
boy is usually done before
he leaves the hospital. A
numbing medication (local
anesthesia such as
Xylocaine) is injected into
the penis to reduce pain.
Ring-type clamps are
placed around the foreskin,
tightened like a tourniquet
to reduce bleeding, and
the foreskin is removed
below the clamp.
Sometimes a plastic clamp
is used (Plastibell). The
Plastibell will fall off in 5 to
8 days, after the surgical
site has healed.
Aftercare

For both newborns and older
children, circumcision is
considered a very safe
procedure with complete
healing expected. Healing
time for newborns usually
takes about 1 week. Apply
petroleum jelly after diaper
changes to protect the
healing incision. Some initial
swelling and yellow crust
formation around the incision
is normal. Healing time for
older children and adolescents
may take up to 3 weeks. In
most instances, the child will
be discharged from the
hospital on the day of the
surgery.
Breastfeeding positions




Cradle=infant across mothers lap
Foot ball hold=infant under mothers
arm
Lying down=mother lying on her side
Infant is on the side
facing mother
Breast feeding



Benefits:
Correct temperature, inexpensive,
immunoglobins, better jaw and tooth
alignment,
Bonding, no allergies, antibodies,
hormones reduce uterus
Breast milk



Colostrum=produced for 2-4 days
Transitional milk or foremilk is
thinner and is more watery- more
calories than colostrum
Hindmilk or mature milk present in
about 2 weeks has lactose, protein,
minerals and vitamins
Formula






Thicker and richer
Feed q 3-4 hours
Vitamin d may be supplemented
Soy milk may be used for allergies
Burp freqently
Do not heat formula or food in the
microwave
Hyperbilirubinemia





Physiologic or pathologic jaundice
Management: increase feeding
Feed q3h, bilirubin lights if neededeye patches on when under the light
Bilirubin levels daily monitor
temperature q2h
If severe=exchange blood
transfusion
Respiratory distress




Preterm infant or deficient surfactant
Isolette with o2,cpap, o2 sat
continuously, monitor heart rate,
resp rate, vs, retractions,
Expiratory grunt, flaring of nares,
cyanosis
Iv fluid or tpn, artificial surfactant
Hydrocephalus


Excess cerebral spinal fluid in the
ventricles
Monitor: fontanells for buldging, vital
signs, head circumference daily,
change position q2h, careful handling
Spina bifida




Etiology: failure of the spinal column
to close
Category: spina bifida cystica
Meningocele=external sac containing
meninges and spinal fluid =protrudes
through defect in vertebral column
Visible at birth
Spina bifida




Myelomeningocele=often in
lumbosacral area
Covered with fragile thin membrane
Sac contains cerebral spinal fluid,
meninges, nerves
Associated with motor and sensory
deficits below lesion of the cord
Spina bifida


Mylomeningocele=associated with
downward displacement and
improper development of part of the
brain, hydrocephalis which may not
be present at birth
Prefer delivery by c-section to
prevent rupture of the sac
Spina bifida


Management; Surgical repair
Prevent infection- from leaking csf
from the sac, side lying or prone
position, crede method to empty
bladder, measure head
circumference, neuro assessment,
monitor sensation, movement, keep
clean and dry
Down syndrome



Trisomy of # 21 chromosome
Flat occiput, small: ears, nose and
mouth, protruding tongue, broad
short hands with stubby fingers,
simian palmar crease,
Broad, stubby feet with wide space
between big toe and second toe,
mental retardation
Talipes equinovarus




Club foot: foot and ankle are twisted
out of normal position
Foot seems c shaped ; pointing
downward and inward
Management: splint, cast, special
shoes
Treatment begins soon after birth
Infant of a diabetic mother




Neonatal conditions:
Macrosomia, hypoglycemia,
polyhydramnios, pre term birth, fetal
lung immaturity
Birth trauma polycythemia
Hyperbilirubinemia
Infant of hiv positive mother




Clean skin with soap and water
before injections given
Zidovudine given for 6 weeks
following delivery
If infant is positive=treatment with
combination of antiretroviral
medications
Typically asymptomatic at birth
Hiv positive infants



May be low birthweight
May develop opportunistic infections
within the first two years
Some children who are positive show
no symptoms for 8-10 years
Substance abuse


Alcohol=fas=short eyelid opening,
flat midface, flat upper lip groove,
thin upper lip, microcephaly,
hyperactivity, developmental delays
Cocaine=prematurity, poor feeding,
difficult to console, developmental
delays, prune belly, skull defects
Substance abuse


Heroin=low birth weight, poor
feeding, vomiting, shrill cry, crying
incessantly, convulsions,tachypnea,
tremors, sweating
Tobacco=low birth weight, bronchitis,
pneumonia, developmental delays
Infant screening tests





Pku=phenylketonuria
Maple sugar disease=problems using
fats,protein
Hypothyroid
Galactosemia
Medium chain acyl-coa dehyrogenase
deficiency=unable to convert fat into
energy
Newborn tests



Homocystinuria=problems breaking
down protein
Congenital adrenal hyperplasia=
Adrenals do not make enough
cortisol