Growth
and
development
in
newborn
presented by
Mohamed kheder
master degree
Objectives
At the end of the lecture the candidate should
be able to:
 Define
growth and development.
 List principles of growth and development.
 Identify patterns of growth.
 List stages of growth.
 Define the newborn stage.
 list the normal characteristics of the newborn.
Cont.
 apply
the Apgar score
 Illustrate the
physical assessment of the
 Newborn
 Apply
the neurological assessment of newborn
 Apply
nursing process in management of newborn.
Outline
 Introduction.
 growth
and development.
 principles of growth and development.
 patterns of growth.
 stages of growth.
 Normal characteristics of the newborn.
 Apgar score.
 physical assessment of the Newborn.
 nursing management of newborn.
Introduction

Growth and development, usually referred to as
a unit, express the sum of the numerous changes
that take place during the lifetime of an
individual.

The entire course is a dynamic process that
encompasses several interrelated dimensions.
Growth and development
Growth : is defined as increasing in physical
size of the whole body or any of its parts can be
measured by pounds, inches or cm and kg ,it
means quantitative changes.
 An
increase in number and size of cells as they
divide and synthesize new proteins; results in
increased size and weight of the whole or any of
its parts.
Cont.
 Development :is defined as a progressive
increasing in skills and capacity of functions it
causes qualitative changes in child’s functions
can be measured through observations.

A gradual change and expansion; advancement
from lower to more advanced stages of
complexity; the emerging and expanding of the
individual’s capacities through growth,
maturation, and learning.
Differentiation

processes by which early cells and structures are
systematically modified and altered to achieve
specific and characteristic physical and chemical
properties.
Principles of Growth and
Development

Growth is an orderly process, occurring in
systematic fashion.

Rates and patterns of growth are specific to
certain parts of the body.

Growth and development are influenced by
multiple factors.
Principles
Cont.
 Development
proceeds from the simple to the
complex and from the general to the specific.
 Development occurs in a cephalocaudal and a
proximodistal progression.
 There are critical periods for growth and
development.
 Rates in development vary.
 Development continues throughout the individual's
life span.
Patterns of Growth and
Development

There are definite and predictable patterns in
growth and development that are universal and
basic to all human beings, but each human being
accomplishes these in a manner and time unique to
that individual.
1)Directional Trends
 Cephalocaudal,
or head-to-tail, direction.
 Proximodistal,
or near-to-far, trend applies to the
midline-to-peripheral concept.
 Differentiation,
describes development from
simple operations to more complex activities and
functions.
Directional Trends
2)Sequential Trends
 In
all dimensions of growth and development,
there is a definite, predictable sequence, with
each child normally passing through every
stage.
 Children
crawl before they creep, creep before
they stand.
3)Developmental Pace
 Although
development has a fixed, precise
order, it does not progress at the same rate or
pace.
 There
are periods of accelerated growth and
development .
4)Sensitive Periods
 There
are limited times during the process of
growth when the organism interacts with a
particular environment in a specific manner.
 Periods
termed critical, sensitive, vulnerable,
and optimal are the times in the lifetime of an
organism when it is more susceptible to positive
or negative influences.
5)Individual Differences
 Each
child grows in his or her own unique and
personal way.

Great individual variation exists in the age at
which developmental mile-stones are reached.
Stages of Growth and
Development
 Infancy
(Birth to12 Months)
 Neonate
Birth to 27 or 28 days
 Infancy
1 month to 1 year
 Early
Childhood (1to 6 years)
 Toddler
1-3 years
 Preschool
3-6 years
Stages of Growth and
Development
Middle
Childhood
 School age
6 to 12 years
Late
Childhood
 Adolescent
13 years to approximately 18 years
Newborn
newborn
A newborn or neonate is a child from birth to 28
days of age.
Gestational age (G.A)
Gestational age (G.A.).
It is the length of time from conception to delivery.
The no. of weeks the neonate has been in the uterus.
Term infant: (one with gestational age of 38 – 42
wks.
Pre- term infant: (one with GA of 37 wks. or less).
Post term infant: (one with GA. After 42 wks.
Adjustment to extra uterine
environment
Respiratory system
Most critical and immediate change required is onset
of breathing.
 Stimuli that help to initiate respiration are: Chemical stimuli
low oxygen, high carbon di oxide , low ph.
 Thermal stimuli
sudden chilling of the baby who leaves warm
intrauterine environment and enters a cooler
atmosphere.
Respiratory system
 Respiratory rate is 40-60 breaths/min
Circulatory system
 Circulatory changes that allow blood to flow.
 Changes are the result of pressure changes in the
lung , heart & other major blood vessels.
 Transition from fetal circulation ensures that the
vital organs and tissue receive maximum
concentration of oxygenated blood.
Major changes in blood
vessels after birth
Structure Before birth After birth
Umbilical vein
Brings arterial blood to
heart.
Obliterated; becomes
round ligament.
lungs
Contain no air & very little
blood ,filled with fluid.
Filled with air ,well
supplied with blood.
Pulmonary arteries
Ductus arteriosus
Brings very little blood to
lungs.
Shunts arterial and some
venous blood from
pulmonary artery to aorta.
Brings much blood to
lungs.
Obliterated; becomes
ligamentum arteriosum.
aorta
Receives blood from both
ventricles.
Receives blood only
from left ventricle.
Inferior vena cava
Brings venous blood from
Brings blood only to
body and arterial blood from right atria.
placenta.
Growth and development
milestones of newborn
1- Physical growth

Growth measurements:-




Weight
Length
Head circumference
Chest circumference
 Vital
signs:-
 Pulse
 Respiration
 Temperature
 Blood pressure

Reflexes
Cont.
2- Motor development


Gross motor
Fine motor
3- sensory development
4- Language development
BABY AT BIRTH
WEIGHT


Average birth weight 3.400g.
Normal range between 2700 to 4000 g.
Lose about 10%in first 5-4days after birth but
regains weight by 12-10days (30g per day(.

Height

Average length of full term babies is 50 cm (20
inches(

Normal range is 48 cms to 53 cms (18inches to
22 inches(

In the first month babies typically grows 2.5cms
(up to 2-4 cm(
Head circumference

Average head circumference is about 34.5 cms at
birth (13.5 inches(

Range of head circumference at birth is 33 cms 35.5 cm

By the end of first month it increases to about 37.6
cm
Chest circumference
 At
birth chest circumference
33 cms.
will be 30.5 cms to
 Head
circumference will be approximately equal to
chest circumference for first 24-48 hours of life.
3-2days head circumference will be greater
than chest circumference by 2-3 cms.
After
Hemopoetic system
 Blood volume depends on placental transfer of
blood.
 Blood volume of full term baby is about 80-85ml
/kg.
 Total blood volume averages to 300ml.
 Depending on how long newborn is attached to
placenta as much as 100 ml can be added to blood
volume
Thermoregulation
 Heat loss is through conduction , convection,
radiation and evaporation.
 Large surface area facilitate heat loss
Newborn produces heat
through non shivering
mechanism
 Vasoconstriction occurs in infants
 primary response is increasing heat production
from brown fat metabolism which is known as
non shivering thermogenesis.
Fluids and electrolytes
 At term fetus is comprised of 73% of fluid
 Have high ECF hence high levels of Na and Chloride
 Lower levels of potassium ,phosphate and magnesium
 Rate of fluid exchange is 7 times higher than adults &
metabolism is twice as great in relation to body weight

Twice as much acid is produced.

High risk for rapid development of acidosis.

Immature kidneys cannot concentrate urine.
Gastro intestinal system
 Ability to digest, absorb & metabolize food is adequate but
limited.
 Enzymes are available to catalyse proteins and simple
carbohydrates.
 Deficiency in pancreatic lipase limits fat absorption which has
high unsaturated fatty acid(cows milk).
Liver-immature.
Activity of glucuronic transferase is reduced to conjugation
of bilirubin with glucuronic acid.
Physiological jaundice.
Gastro intestinal system
cont.
 Some Salivary glands are functioning at birth. But majority
begin to secrete saliva by 3-2months only.
 Stomach capacity range from 5ml in first day to 60 ml in
day3.
 Intestine is longer in relation to body size than adults larger
number of secretory glands &larger surface area for
absorption.
 Cardiac spinchter is immature- regurgitation is common.
Gastro intestinal system
cont.
 First stool-meconium -should occur within 24-48 hours
(amniotic fluid, intestinal secretions , shed mucosal cells &
possibly blood).
 Transitional stool occur within 3rd day after initiation of
feed.
 Greenish-brownish, thin ,less sticky than meconium.
 Milk stool appear by4th day.
 Yellow –golden , pasty & has odour similar to sour milk.
Genitourinary system
 Total urinary output in 24 hours is 200-300ml.
 Bladder involuntarily empties when stretched by volume of
15ml.
 First voiding occur with in 24 hours- colourless ,odourless ,
specific gravity of 1.020.
Male genitalia develop at birth
 Testes descend to scrotum before birth.
 Foreskin & gland penis separate beginning in prenatal period
and completes in 3-5 years.
 Female degnit doolb , nellows ylthgils eb yam ailatineg
anigav morf degrahcsid eb yam sucum.
 This is due to hormonal withdrawal from mother at birth.
Integumentary system
 All strustructures with in the skin are present but their
functions are immature.
 Vernix caseosa( a cheese like material covers the skin).
 Milia –seen in nose & chin & disappears in few weeks.
 Sebaceous glands are effective late in fetal stage and early in
neonates because of high levels of maternal androgens.
 They are located mostly on scalp , face & genitalia.
Musculoskeletal system
 Skeletal system consists of large amount of cartilage.
 6 skull bones are soft & not yet fused, anterior & posterior
fontanelles are present.
 Sinuses are incompletely formed at birth.
 Growth insize of muscle is caused by hypertrophy than
hyperplasia.
Immune system
 First line of defense is skin & mucous membrane-protection
from invading organism.
 Second line of defense is immunologic system-cells capable
of attacking pathogens.
 Inflammatory response of tissues to localize infection is
minimal.
 Third line of defense is formation of specific antigen to
antibody.
 Newborns are not capable of producing immunoglobulins
until 2 months.
 But receive passive immunity from breast milk.
Neurologic system
 At birth nervous system is incompletely integrated but
sufficiently developed to extrauterine life.
 Myelination occurs in cephalocaudal –proximodistal laws &
is closely related to mastery of fine motor & gross motor
skills.
 All cranial nerves are myelinated except optic & olfactory.
Sensory functions
Vision
 Eyes are structurally incomplete at birth.
 Cornea centralization-not yet completely differentiated
from macula.
 Pupils reflect to light.
 Blink reflex & corneal reflex is present.
 Able to momentarily fix on bright/moving objects
within 20 cms in visual field.
 Ability to fixate & coordinate movements are greater in
1st hours of life.
 Visual preference )red , orange ,blue ,black ,contrasting
patterns & larger objects(.
Hearing
 Once amniotic fluid is cleared new-born's hearing acuity is
similar to that of adults.
 Detects sounds of about 90 decibels.
 There is early sensitivity to human voice.
Smell
 Reacts to strong odour by turning head away.
 Able to smell breast milk.
Taste
 Can differentiate taste & elicit different facial expression
Touch
 Perceive tactile sensations.
 Face hands & soles are most sensitive.
Reflexes
STATES OF CONSCIOUSNESS
 A normal newborn usually moves through 6 stages of
Consciousness:1. Deep sleep : lies quietly without movement.
2. Light sleep : moves little while sleeping , startles to noises.
3. Drowsiness : eyes may close baby may be dozing.
4. Quiet alert state : eyes are open wide & body is calm.
5. Active alert state : face & body move actively.
6. Crying: The infant cries or screams and the body.
Cognitive / intellectual
development
 According to piaget birth to 2 years –sensorimotor
stage (total 6substages).
 Substage (0-1month) reflex schemas exercised :
involuntary rooting , sucking , grasping , looking.
 By 12 days they are able to imitate facial gestures of
adults.
 Prefers sharply contrasting colours,large squares,
medium bright objects
 Achievements consists largely of coordinating
sensory perceptions &simple motor
behaviours.
Psychosocial development
 According to Erickson
 Trust vs mistrust
Infants trust adults usually their parents/caregivers
A negative outcome of period of infancy is mistrust
Psychosexual development
 Oral stage
play
Onlooker play
Sensorimotor stimulation
Needs
 Feeding.
 Cord care.
 Bonding process.
 Maintaining body temperature.
 Prevention from infection.
 Diaper changes & bathing.
 Protection from injury.
 Immunization.
 Growth assessment.
 Screening.
Problems
 Birth injuries.
 Feeding difficulties.
 Infections.
 Low birth weight.
 Congenital disorders.
 Umbilical sepsis.
 Neonatal jaundice.
AFTER BIRTH
NEED FOR
ASSESSMENT….
HOW TO
ASSESS….?
WHEN TO
ASSESS…..?
Assessment of newborn
A. Initial assessment:
it include Apgar score.
B. Late assessment:
includes physical assessment and gestational age.
Apgar score
 It
is done in 1st and 5th minute immediately
after birth.
 It
includes 5 standardized observations (HR,RR,
muscle tone, reflex and color).
 HR is counted by taking apical pulse and
counting for full minute 120-160 bt/min in alert
and quiet state.
 RR: is counted by observing no of respiration
(30-60 br\min).
Cont.

Reflex: is done by stimulating the newborn to
evoke response as by suctioning nares or lightly
flicking the sole of foot.

Muscle tone : Is assessed by observing the
neonate’s spontaneous return to a state of
flexion.

Color :last observation and started with
cyanosis then pink color of neonate.
APGAR SCORE
observation
0
1
2
Heart rate
Absent
Slow(below100)
Over 100
Respiratory
rate
Absent
Slow,
Good ,sustained
irregular, shallow cry, regular
respiration
Reflex
irritability
No response
Grimace ,frown
Sneeze,
cough, cry
Muscle tone
Limp,
completely
flaccid
Some flexion of
extremities, some
resistance to
extension
Active motion,
good muscle
tone,spontanous
flexion
color
Cyanosis ,pale
Body pink,
extremities pale
Completely pink
APGAR SCORE
 score
of 7 to 1o is in a good condition and will only
need suction of the nose and mouth and routine
observation.
 score
of 4 to 6 indicates a moderately depressed infant
who will need some of resuscitation along with close
observation during 1st 24 hours of life .
 score
of 0 To 3is considered severely depressed and will
need ventilatory assistance and intensive care.
Gestational age assessment

Is done within 96 hours after birth.

It assesses neuromuscular and physical maturity.
Later physical assessment.
 General

appearance.
It provides index of growth and well nourished
neonate (skin color, skin turgor ,lanugo hair
,milia and Mongolian spots).
Vernix caseosa
Mongolian Spots
Milia
Jaundice
Skull
A. Overlapping sutures(molding).
B. Anterior fontanel.
C. posterior fontanel(open or closed).
D. Caput succedaneum.
E. Cephalhematoma.
Caput succedaneum
Cephalhematoma
Caput succedaneum
An edematous swelling on the presenting portion
of the scalp during birth ,caused by the pressure
of the presenting part against the dilating cervix.
Caput succedaneum extends across the midline
and over suture lines. Caput succedaneum does
not usually cause complications and usually
resolves over the first few days.
Management consists of observation only.
Cephalhematoma
 Cephalhematoma is a subperiosteal collection of
blood secondary to rupture of blood vessels
between the skull and the periosteum, in which
bleeding is limited by suture lines (never cross the
suture lines).
Face
a) Asymmetric face.
b) Facial nerve palsy (forceps).
c) Facial edema.
Eyes
The eyes should appear clear without redness or
observe eyelids, pupil, iris, tears) for
a. Eye lid swelling.
b. Subconjunctival hemorrhage.
c. Lens opacities.
d. Corneal opacities.
e. Congenital glaucoma.
Subconjunctival
Hemorrhage
Congenital Glaucoma
Ears
 Abnormal shape , or unusual size of ears is
usually familial.
Normal Ears
Mouth
Should be inspected for mucous membrane ,tongue
,palate, and gum and observe for
a)
b)
c)
d)
e)
High arched palate.
Cleft lip and palate.
Large tongue.
Tongue tie.
Natal tooth.
Natal Tooth
87
Nose
 The neonate’s nose may appear large or
slightly flattened.
A . Deformity
B.Choanal atresia
c. Nasal Flaring
Neck
 The neck of neonate is short and there are creases
with skin folds
Observe any abnormalities : Thyroid gland enlargement.
 Clavicles should be palpated (possible fracture).
 Hypotonia may indicate prematurity or hypoxia).
 (hyperextension may associated with neurological disorders.
Chest
A. Breast enlargement (neonatal gynecomastia): It
occurs in both males and females due to stimulation of
mammary tissue growth by maternal estrogens
(transplacental)
B. Usual examination of chest: Auscultation of
intestinal sounds may indicate diaphragmatic hernia.
C. Retractions of the intercostals space
 Heart:
Apex- lies between 4th & 5th intercostal
space.
91
Abdomen
 The normal contour of the abdomen
is cylindrical and usually prominent
with few visible veins.
 scaphoid abdomen may indicate
diaphragmatic hernia.
Normal Umbilical Cord
 Bluish white at birth
with 2 arteries &
one vein.
Genitalia
 Male and female or ambiguous genitalia.
Normal Male genitalia
 Urethral opening is at tip of penis .
 Testes are palpable in each scrotum.
 Scrotum is usually pigmented, pendulous &
covered with rugae.
95
Female genitalia
Cont.
 Labia & Clitoris are usually edematous.
 Urethra is located behind the clitoris.
 Vernix caseosa is present between labia.
96
Extremities
We should inspect positions of arms and legs
,no of fingers and toes for extra digits or
fusion.
Back
Also examined for spinal defects.
Acrocyanosis
98
Common feet abnormalities
Club Feet
99
Neurologic and sensory assessment
 Reflexes:

Survival (rooting-sucking).

Primitive (stepping).

Early (indicator of child neurological function).
Reflexes
 Rooting reflex:Is stimulated by lightly stroking the cheek at
side of the mouth will stimulate the newborn
to turn the head in that direction (disappears at
9 or12 weeks).
 Sucking reflex:Is stimulated by touching the baby’s lips or
placing an object in mouth.
The moro reflex

Moro reflex:-
The reflex is initiated by pulling the infant up from
the floor and then releasing him ; he spreads his
arms ,pulls his arms in and cries (0-4month)
With sudden extension of the head, the arms
abduct and move upward and the hands form a
“C.”
Tonic neck reflex
While lying supine, extremities are extended on
the side of the body to which the head is turned
and opposite extremities are flexed )also called the
“fencing” position).
present at one month of age and disappears at four
months.
reflexes
cont.

Swallowing reflex :is stimulated by food on the
posterior portion of the tongue.

Grasp reflexes :palmer by exerting pressure on
the palmer surface of the hand (disappears at 4 to 6
months).

Planter reflex: by placing an object on the sole
of the foot (disappears 8 to 9 month of age).
stepping reflex
 The
walking or stepping reflex is present at
birth;, when the soles of the feet touch a flat
surface the newborn infant will attempt to 'walk'
by placing one foot in front of the other.
This reflex disappears at 4-8 weeks as an
automatic response and reappears as a voluntary
behavior at around eight months to a year old.
stepping reflex
Babinski
Touching palms of hands or soles of feet near base
of digits causes flexion of fingers and toes palmar
grasp lessens after age 3 month to be replaced by
voluntary movement; plantar grasp lessens by 8
month of age.
Blinking or corneal reflex
Infant blink at sudden appearance of a bright light
or at approach of an object toward cornea persist
of head life.
Sneeze
spontaneous response of nasal passage to irritation
or obstruction persist throughout life.
Gag
Stimulation of posterior pharynx by food, suction,
or passage of tubes cause infant to gag.
Extrusion

When tongue is touched or depressed, infant
respond by forcing it outward.
 Disappear by age 4 months.
Yawn
 Spontaneous
response to decrease oxygen by
increasing amount of inspired air.
 Persist throughout life.
Cough
 Irritation
of mucous membrane of larynx or
trachobroncial tree causes coughing.
 Usually
present after first day of life.
sensory examination
 Vision:pupils react to light ,limited ability to focus on an object
tear glands don’t begin until 2- 4 weeks momentarily focus on
a bright on moving object with in 20 cm
 Hearing:
present at birth
listen to mothers ( voice , eye , movements, & crying )
 taste:-differ between bitter & sweet taste .
 Smell:- :as soon as nose is clear mothers body scent is
recognized.
 Touch:-well developed in facial area ,hands soles of feet.
Nursing care immediate

Airway - Clean mouth and nose.

Thermoregulation – Warmth.

APGAR.

Identification.

Bonding – safety against infection.

Medications.
Nursing Management
 Nutrition.
 Breast
feeding.
 Bottle
feeding.
 promote
 Prepare
parent – infant bonding attachment.
for discharge & home care.
Parent Education

Periods of reactivity and expected newborn responses.

Normal physical characteristics of the newborn.

The bonding process.

The infant’s capabilities for interaction.

The role of touch in facilitating parent-infant interaction.

Comforting techniques.
Discharge Education

Safety measures.

Voiding and stool characteristics.

Circumcision care.

Cord care.

Waking and quieting the newborn.

Car safety.

Immunizations.
Reference

Kyle, T.& Carman, S(2013). ESSENTIALS of
Pediatric Nursing. 2ND ed., Lippincott:
Wolters.

Hochenberry, M. &Wilson, D. (2015).
Wong's Clinical Manual of pediatric
Nursing.9th ed., London: Mosby.