FALL 2011 Newborn Care

Health Promotion in the Pregnant Family

As with every lecture faculty prepare, we do our best to provide you with accurate, up-to-date information. The newborn lecture is currently being modified. In an attempt to provide YOU with information, I have made an abbreviated version. How do you know if you are on the right track? ANSWER THE OBJECTIVES.

Note to the student

Note to the student

How do you know if you are on the right track? ANSWER THE OBJECTIVES! Ask yourself why or how does this make a difference. What will I teach the patient? How do I know they understood me?

Apgar ScoresBabys First Test

Done at 1 minute & 5 minutes old. Scores from 0-10. - 7-10 = WNL
- 4-7 = needs some resuscitation or resp. support - under 4 = needs immediate resuscitation

WHY do we do this? WHEN do we do it? WHAT do we do with the information?

Apgar Criteria
Sign
Heart rate Respiratory effort Muscle tone Reflex irritability Color Blue all over or pale No response Absent Flaccid Weak, irregular Some ext. flexion Grimace or week cry Acrocyanosis Good, crying Active ext. movement Good cry Pink all over

Score=0
Absent

Score=1
Below 100

Score-2
Above 100

Other first tests

Weight & length State Mandated newborn screening 1. PKU (phenylkentonuria) 2. Hypothyroidism 3. Galactosemia (intolerance to milk r/t deficient enzyme galactose) 4. Hearing Screen 5. Bilirubin Jaundice
(varies per state)

Normal Physiological Characteristics of the Newborn

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Head

Fontanels: there are two soft spots on the babys skull

Openings at place where bones of the skull meet

Anterior: diamond-shaped, larger Posterior: smaller, triangular (May pulsate when baby cries)

Anterior & posterior

Fontanelles & Head Molding

Fontanelles =soft spots. Ant. = diamond shaped; closes by 18 mths. Post. = triangle shaped; closes by 3 mths. During vertex (head first) vaginal birth, head molds to vaginal canal.

Length, Head

Length: average is 20 inches

Head: at birth, your babys head is 1/3 the size of an adults head (Head should measure greater than the chest measurement) Circumference is about 32-37 cm (12.5-14.5 in.)

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Caput Succedaneum

Collection of serosanginous subq fluids. Crosses suture lines. Resolves within a few days of life.

Cephalhematoma

Collection of blood between skull & periosteum. Well defined & doesnt cross suture lines. May occur 48 hrs post birth. Reabsorbs by 3 months of age.

Variations

If baby is born breech or c-section, head is very round (head did not mold to the birth canal) fuzz on face and body, called lanugo (may be fine black hair on shoulders and back of newborn) Babies blink in response to bright light

Eyes

Blue, blue/gray or dark brown Eye color usually established at 3 months Common for eyes to appear crossed strabismus Tearless

Limited ability to focus

because the structure that makes tears is immature at birth

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Eye Medications at Birth

Erythromycin Tetracycline Drugs used to prevent opthalmia neonatorium in the newborn. Targeted organisms are chlamydia and gonorrhea.

Nose

Nose: usually small, narrow Babies are nose-breathers Sneezes are the means in which babies clear obstructions Your baby can smell

Knows moms scent and can smell breast milk

Mouth
Mouth: lips pink; may see sucking blister Sometimes see small teeth - called Epsteins pearlsthey are actually small, harmless cysts, may feel firm to touch

Skin Variations
Skin may be mottled with reddish patches May see Mongolian spot Hands and feet have peeling skin Milia are white acne-like spots but this is not acne, so leave baby alone

Weight

Weight: 3405g (7# 8oz) African American or Asian may be smaller Factors that influence

Age, size of parents, health of mother, interval between pregnancies

*What things can decrease birth weight?

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Weight
Weight increases at rate of 7 oz per day Initially, newborns have a physiologic wt loss of 5-10% due to fluid shifts *Wt loss > than that indicates the need for intervention?

Umbilical Cord

Father participation cut the cord Cord looks white, similar to gelatin; soft How many vessels and what kind? Cord clamp-a plastic device put in place to allow cord to close then purple dye used Cord will fall off in 7-10 days

Clean with alcohol after every diaper change (controversial) Diaper fold below cord

Chest

May see prominent chest bone (xyphoid) May see enlarged breast tissue in both sexes

*What causes this?

May see extra nipples

Respirations
Normal rate of breathing is 30-60 breaths per minute May see abdominal and diaphragm movement in newborns Transient tachypneatemporary increased breathing rate

Genitalia

Females: may see enlarged labia, perhaps even a slight vaginal discharge. It may be white or even blood tinged Males: scrotum is usually large, appears swollen, covered with rugae

Deeply pigmented in dark-skinned ethnic groups

Elimination patterns

Meconium stool: Transitional stool: Constipation:

Elimination

Breast-fed stools: Bottle-fed stools:

Infant Stools

Meconium= 1st BMs. Average=2-10/day. Breastfed babies-looser stools. If diarrhea, fear is dehydration (green color) If constipation, glycerine suppository (prune or apple juice depends on age)

Elimination
Urination

Most babies urinate immediately after birth Amount of urine is decreased until your baby starts feeding. You may see voids of 2-6 times in first two days of life; then 5-25 times as a newborn!

Reflexes

Rooting: Sucking: Swallow: Gag:

So, there are several reflexes. Do you know the normal/expected response? What will you teach the parents? How do you know your teaching is effective?

Reflexes

Tonic neck: Dance: Babinski: Extrusion:

So, there are several reflexes. Do you know the normal/expected response? What will you teach the parents? How do you know your teaching is effective?

Newborn care

Bathing

Scalp: does not need to be washed every day

Eyes: wash first; use index finger and separate part of washcloth for each eye Ears: clean behind ear and external lobe. NO cotton swabs! Face: clean with washcloth, NO soap!

cradle cap

*Why do we not recommend soap?

Bathing
Look at babys skin. Any rashes? Any redness?

Check diaper area for rash *What would you teach as far as diaper rash goes?

Heat Loss

Convection: loss of heat from the warm body surface to cooler air currents

Evaporation: loss of heat incurred when water is converted to vapor

Example:

Example:

Heat Loss

Conduction: loss of heat to a cooler surface by direct skin contact.

Radiation: loss occurs when heat transfers from the heated body rise to cooler surfaces and objects not in direct contact with the body.

Example

Example

The surgical removal of the foreskin of penis

60% of males are circumcised Circumcision females are also circumcised in some cultures

What are your personal feelings regarding circumcision? *Is it medically necessary? Mutilation?

*What is the care for circumcised penis? *What is care for uncircumcised penis?

Does the baby feel pain? Religious practices? Cultural considerations?

Care of Genitalia
Female

Front to back Circumcised: use of lubricant and gauze initially (retraction of foreskin) Uncircumcised: retraction of foreskin during bath

Male

Temperature: What is Normal? Rectal:

What are the differences? When is each used/done? TRADE in MERCURY Thermometers hazardous material

Baby Talk- Crying

How babies communicate their needs. -hot or cold? -tired or bored? -hungry? -wet or uncomfortable? -overexcited? -in pain or distress? Normal NB averages about 2.5-3 hrs crying/day.

Colic

Colic

Common in infants < 3 mo. of age Abdominal cramping expressed by crying and drawing legs toward abdomen May be related to allergy to cows milk; parental smoking

Ways to manage colic:

Is there an allergy to cows milk? What types of foods is the breastfeeding mom eating? Avoid soy formulas *What can you suggest to the new mom?

14 ways to calm a crying baby

Feed baby Burp baby. Wrap baby snuggly. Talk soothingly. Play music. Change position Change diapers. Check to see if baby is too warm or cool. Hold baby. Put baby down. Put baby to bed. Offer baby a toy (if over 3 mths old). Take baby outside. Take baby away from overstimulating environment.

Feeding Baby

Choices are breast or bottle feeding. Although Breastfeeding is best & encouraged, decision is the familys (ultimately, mom). Deciding factors can be: -money - job -culture/religion - ease -SE status -peer group -maternal/neonatal health status

Breastfeeding

Most common now. Most infants are breastfed x 1 year & do well. Encourage use of lactation specialist when problems develop or a breastfeeding support group within their community

D i s a d v a n t a g e s

Breastfeeding

Advantages

Breastfeeding

Positioning

Ears, shoulders and hips in same line; infant turned toward breast Must take nipple and areola into mouth Cradle hold, side-lying, football hold

Breastfed babies eat q 2-4 hours. *Is it better to feed on demand or on a schedule?

Breastfeeding

The nurse will assess you for the following: L Latch A Audible swallowing T Type of nipple

C Comfort (breast & nipple) H Hold (positioning)

inverted, flat; engorged breasts

Bottlefeeding

Advantages

Disadvantages

Bottle Feeding

Keep baby on same formula-dont switch. Easier on mom; allows dad time with baby. Can be expensive!-varies with type -ready-to-use -concentrate -powder

Bottle Feeding

Variety of Formulas

Cow milk base: Similiac, Enfamil, Gerber, Carnation Good Start Soy protein base: Prosobee, Isomil, Gerber Soy Special: Nutramagen, Alimentumused if allergy or intolerance to cows milk

Bottlefeeding

Hold baby for all feedings-never prop them up!! Position to avoid ear infections To avoid ingestion of air, ensure nipple is full of liquid at all times. Burping *Should a baby be fed every time he cries? Wash bottle items in dishwasher (Why no more Boiling bottles?)

Wash nipples by hand-will last longer

Burping

-Results

from air in esophagus esp. when lying down. -Most needed under 2 months old. -Should be done at middle, or after 2oz. Of formula & at the end of each feeding.

Burping cont.
Between switching breasts if breastfeeding *What position should baby be placed in after feeding? Use of bulb syringe *What if baby spits up?

Is Baby Eating Enough?

Will vary day-to-day. How many wet/dirty diapers/day? Any signs of hunger from baby? Steady weight gain? Dont start cereals until 4-6 months/old.

Nutrition

Expected weight gain/loss:

Weight loss of _________ for term newborn is considered within normal limits.

1.5#/month for 5 months; slows during next 6 months of life Breast-fed infants typically gain less than bottle-fed infants

Infant Weight Gains

Introduction of Solid Foods

M e a t s

Introduction of Solid Foods

Cereal

O n e

a Vegetables t One at a time for a few days a t

High iron content Mix with breast milk or formula May use fruit juice after 6 months to mix

Baby Baths

Sponge bath until umbilical cord gone & circumcision healed. Dont need daily baths, 1-2x/wk. Keep bath area warm & draft-free. Bathe head-to-toe; genitals last (front-to-back).

Bath Safety

Never leave infant in bath alone!! Water should be under 120 degrees. (test water on wrist) No Q-tips. NO lotions, powders, or oils.

Bonding

What is Bonding? When does Bonding Start? Benefits of Bonding? Who benefits? What about siblings?

Dad & Baby

Couvade Have you heard of this? Its in Olds check it out!

Hold infant & make eye contact soon after birth. Feed baby. Change diapers. Be there esp. in times of illness.

Sibling Rivalry

Have sibling meet baby at hospital. Involve older child in infants care. Spend time alone with older child. Praise older child for routine good behavior.

Infant Safety in the Home

Install fire and Carbon monoxide detectors. Post emergency #s near the phone. If paint flaking, have it tested for lead. Use non-slip pads under small rugs. Keep heavy & breakable objects out of reach. Place furniture away from hazards. (especially cords on blinds, etc.)

Infant Safety in the Nursery

Crib slats no more than 2 3/8 apart (use care with old cribs). Position crib away from windows, heaters, decorations, blind cords. No soft, fluffy crib pillows, comforters. Mattress should fit snuggly (less than 2 fingers-width between). No mobiles over crib. Strap on changing table. Fire resistant linens & sleepwear.

Car Seats

MVA leading cause of death in children. All children under 40# need car seats All children under 12 should be in back seat. For babies under 1, middle of backseat. should face rear of vehicle. Be sure seat meets federal standards (especially if it has previously been used Ex: rummage sales)

Preventing Abduction

Never let baby out of your sight! Get references for nannies & babysitters. No announcement in papers. No stork on lawns. No Home Health people without ID.

Warning Signs

Teach parents to call the doctor when.. Less than 4 wet diapers/day No BMs Jaundice after 7 days old. Diarrhea Temp over 100F (a) Vomiting more than 2-3x/day Refuses to feed or nurses poorly

Nursing Diagnoses
Normal newborn

Effective breastfeeding Ineffective protection Ineffective thermoregulation Risk for infection Risk for injury

Nursing Diagnoses.

Parent

Chronic sorrow Risk for impaired parent/infant attachment Parenting, impaired Parenting, risk for impaired Patient education