Hockenberry Chap. 7:

hearing changes associated with transition to extrauterine life

1. After the amniotic fluid has drained from the ears, infants probably have auditory acuity similar to that of adults. Neonates react to loud sounds of about 90 decibels with a startle (Moro) reflex. The newborn's response to sounds of low frequency and high frequency differs; the former, such as a heartbeat, metronome, or lullaby, tends to decrease an infant's motor activity and crying, whereas the latter elicits an alerting reaction. There is an early sensitivity to the sound of human voices. For example, infants younger than 3 days old can discriminate the mother's voice from that of other women. As early as 5 days old, newborns can differentiate between stories repeated to them during the last trimester of pregnancy by their mother and the same stories read after birth by a different woman. The internal and middle ear is large at birth, but the external canal is small. The mastoid process and the bony part of the external canal have not yet developed. Consequently, the tympanic membrane and facial nerve are very close to the surface and can be easily damaged.

tactile changes associated with transition to extrauterine life

1. At birth, infants are able to perceive tactile sensation in any part of the body, although the face (especially the mouth), hands, and soles of the feet seem to be most sensitive. Evidence shows that touch and motion are essential to normal growth and development. Gentle patting of the back or rubbing of the abdomen usually elicits a calming response from infants. In turn, painful stimuli, such as a pinprick, elicit an upset response.

relationship between weight at gestational age and morbidity and mortality

1. Birth weight and gestational age both influence morbidity and mortality 2. the lower the birth weight and gestational age, the higher the morbidity and mortality.

bathing

1. Bath time is an opportunity for the nurse to accomplish much more than general hygiene. It is an excellent time for observing the infant's behavior, state of arousal, alertness, and muscular activity. With the possibility of transmission of viruses (such as hepatitis B virus and HIV via maternal blood and blood-stained amniotic fluid) as part of standard precautions, nurses should wear gloves when handling newborns until blood and amniotic fluid are removed by bathing. Older studies suggested that healthy full-term newborns with a stable body temperature could be safely bathed as early as 1 hour of age without experiencing problems, provided that effective thermoregulation measures are taken after the bath (Behring, Vezeau, and Fink, 2003; Medves and O'Brien, 2004; Varda and Behnke, 2000). More recent studies have demonstrated that early bathing (within the first hour of life), interferes with skin-to-skin holding and breastfeeding, compromising basic protection against neonatal infection (Sobel, Silvestre, Mantaring, et al, 2011). In a large study of more than 800 late preterm infants, researchers concluded that early bathing may interfere with transition to extrauterine life and optimal adaptation of body processes, possibly contributing to problems such as hypothermia and hypoglycemia (Medoff-Cooper, Holditch-Davis, Verklan, et al, 2012). Nursing interventions such as bathing should be based on individualized assessment, and the initial newborn bath should be delayed until completion of initial skin-to-skin holding and breastfeeding. The bath time provides an opportunity for the nurse to involve the parents in the care of their child, to teach correct hygiene procedures, and to learn about their infant's individual characteristics (Fig. 7-10). The appropriate types of bathing supplies and the need for safety in terms of water temperature and supervision of the infant at all times during the bath are stressed. 2. Parents are encouraged to examine their infant closely during bathing. Frequently, normal variations (such as, Epstein pearls, mongolian spots, or "stork bites") cause parents much distress if they are unaware of the significance of such findings. Minor birth injuries may appear as major defects to them. Explaining how these occurred and when they will disappear reassures parents of their infant's normalcy. Common variations are discussed further in Chapter 8. One of the most important considerations in skin cleansing is preservation of the skin's acid mantle, which is formed from the uppermost horny layer of the epidermis; sweat; superficial fat; metabolic products; and external substances, such as amniotic fluid, microorganisms, and chemicals. Infants' skin surface has a pH of about 5 soon after birth, and the bacteriostatic effects of this pH are significant. In addition, newborn skin is covered with host-defense proteins, such as lysozyme and lactoferrin, which contribute importantly to a newborn's defense against bacterial infections (Walker, Akinbi, Meinzen-Derr, et al, 2008). Consequently, use only plain warm water for bathing. If a cleanser is needed, it should be mild and have a neutral pH. Alkaline soaps, oils, powder, and lotions are not used because they alter the acid mantle, thus providing a medium for bacterial growth. Talcum powder has the added risk of aspiration if it is applied too close to the infant's face. Parents should be involved in a discussion regarding the newborn's bath at home. It is recommended that for the first 2 to 4 weeks the infant be bathed no more than two or three times per week with a plain warm sponge bath. This practice helps maintain the integrity of the newborn's skin and allows time for the umbilical cord to completely dry. Routine daily soap bathing for newborns is no longer recommended.

physiologic status of gastrointestinal system associated with transition to extrauterine life

1. The ability of newborns to digest, absorb, and metabolize food is adequate but limited in certain functions. Enzymes are adequate to handle proteins and simple carbohydrates (monosaccharides and disaccharides), but deficient production of pancreatic amylase impairs use of complex carbohydrates (polysaccharides). Deficiency of pancreatic lipase limits absorption of fats, especially with ingestion of foods with high saturated fatty acid content, such as cow's milk. Human milk, despite its high fat content, is easily digested because the milk itself contains enzymes (such as lipase), which assist in digestion. The liver is the most immature of the gastrointestinal organs. The activity of the enzyme glucuronyl transferase is reduced, which affects the conjugation of bilirubin with glucuronic acid and contributes to physiologic jaundice of newborns. The liver is also deficient in forming plasma proteins. The decreased plasma protein concentration probably plays a role in the edema usually seen at birth. Prothrombin and other coagulation factors are also low. The liver stores less glycogen at birth than later in life. Consequently, newborns are prone to hypoglycemia, which may be prevented by early and effective feeding, ideally breastfeeding. Some salivary glands are functioning at birth, but the majority do not begin to secrete saliva until about age 2 to 3 months, when drooling is frequent. Newborn stomach capacity is difficult to determine; however, Bergman (2013) reviewed six published studies exploring this, concluding that stomach capacity is about 20 ml at birth, thus, infants require small feedings at 1 hour intervals. The colon also has a small volume; newborns may have a bowel movement after each feeding. Newborns who breastfeed usually have more frequent feedings and more frequent stools than infants who receive formula. An infant's intestine is longer in relation to body size than that of the adult. Therefore, there are a larger number of secretory glands and a larger surface area for absorption compared with an adult's intestine. Infants have rapid peristaltic waves and simultaneous nonperistaltic waves along the entire esophagus, which propel nutrients forward. The relative immaturity of the peristaltic waves combined with decreased lower esophageal sphincter (LES) pressure, inappropriate relaxation of the LES, and delayed gastric emptying make regurgitation a common occurrence. Progressive changes in the stooling pattern indicate a properly functioning gastrointestinal tract (Box 7-1). 2. The neonatal gastrointestinal mucosa performs an important function as a barrier to foreign antigens. Both immune and nonimmune factors may play a vital role in decreasing the absorption of antigens capable of causing serious neonatal illness; however, the functional capacity of this system may be immature or altered. Feeding an infant human milk increases the effectiveness of this defense mechanism (Le Huërou-Luron, Blat, and Boudry, 2010).

transitional stool

1. Usually appear by third day after initiation of feeding 2. greenish brown to yellowish brown, thin, and less sticky than meconium 3. may contain some milk curds.

basic reflex assessment criteria

1. absence 2. asymmetry 3. persistence 4. weakness

Factors that interfere with fetal oxygenation

1. hypoxemia 2. hypercapnia 3. acidosis

state modulation

1. the ability to make smooth transitions between states 2. ability to regulate sleep-wake states is essential in infants' neurobehavioral development. 3. the more immature the infant, the less able he or she is able to cope with external and internal factors that affect the sleep-wake patterns.

neurologic system

Assessing neurologic status is a critical part of the physical examination of newborns. Much of the neurologic testing takes place during evaluation of body systems, such as eliciting localized reflexes and observing posture, muscle tone, head control, and movement. However, several important mass (total body) reflexes also need to be elicited. These should be tested at the end of the examination because they may disturb the infant and interfere with auscultation. Two common newborn reflexes are elicited. The first is the grasp reflex. Touching the palms of the hands or soles of the feet near the base of the digits causes flexion or grasping (Fig. 7-8, A). The other is the Babinski reflex. Stroking the outer sole of the foot upward from the heel across the ball of the foot causes the big toe to dorsiflex and the other toes to hyperextend (see Fig. 7-8, B).

physiologic status of musculoskeletal system associated with transition to extrauterine life

At birth, the skeletal system contains more cartilage than ossified bone, although the process of ossification is fairly rapid during the first year. The nose, for example, is predominantly cartilage at birth and may be temporarily flattened or asymmetric because of the force of delivery. The six skull bones are relatively soft and are separated only by membranous seams. The sinuses are incompletely formed in newborns. Unlike the skeletal system, the muscular system is almost completely formed at birth. Growth in size of muscular tissue is caused by hypertrophy, rather than hyperplasia, of cells.

neck assessment

Because the newborn's neck is short and covered with folds of tissue, adequate assessment of the neck requires allowing the head to fall gently backward in hyperextension while the back is supported in a slightly raised position. Observe for range of motion, shape, and any abnormal masses and palpate each clavicle for possible fractures.

general measurement: body weight

Body weight should be measured soon after birth because weight loss occurs fairly rapidly. Normally, neonates lose about 10% of their birth weight by 3 to 4 days of age because of loss of extracellular fluid and meconium, as well as limited food intake, especially in breastfed infants. The birth weight is usually regained by the tenth to fourteenth day of life. Most newborns weigh 2700 to 4000 g (6 to 9 pounds), the average weight being about 3400 g (7.5 pounds). Accurate birth weights and lengths are important because they provide a baseline for assessment of future growth.

physiologic status of fluid and electrolyte balance associated with transition to extrauterine life

Changes occur in the total body water volume, extracellular fluid volume, and intracellular fluid volume during the transition from fetal to postnatal life. At birth, the total weight of an infant is 73% fluid compared with 58% in an adult. Infants have a proportionately higher ratio of extracellular fluid than adults. An important aspect of fluid balance is its relationship to other systems. An infant's rate of metabolism is twice that of an adult in relation to body weight. As a result, twice as much acid is formed, leading to more rapid development of acidosis. In addition, immature kidneys cannot sufficiently concentrate urine to conserve body water. These three factors make infants more prone to dehydration, acidosis, and possible overhydration or water intoxication.

Brazelton neonatal behavioral assessment scale

Habituation: Ability to respond to and then inhibit response to discrete stimulus (light, rattle, bell, pinprick) while asleep Orientation: Quality of alert states and ability to attend to visual and auditory stimuli while alert Motor performance: Quality of movement and tone Range of state: Measure of general arousal level or arousability of infant Regulation of state: How infant responds when aroused Autonomic stability: Signs of stress (tremors, startles, skin color) related to homeostatic (self-regulating) adjustment of the nervous system Reflexes: Assessment of several neonatal reflexes

general measurement: head to heel length

Head-to-heel length is also measured. Because of the usual flexed position of infants, it is important to extend the legs completely when measuring total body length. The average length of newborns is 48 to 53 cm (19 to 21 inches) (Fig. 7-3). Foote, Brady, Burke, et al (2011) have developed an evidence-based practice guideline for measuring length in infants and children.

back and rectum

Inspect the spine with the infant prone. The shape of the spine is gently rounded, with none of the characteristic S-shaped curves seen later in life. Any abnormal openings, masses, dimples, or soft areas are noted. A protruding sac anywhere along the spine, but most commonly in the sacral area, indicates some type of spina bifida. A small sinus, which may or may not be communicating with the spine, is a pilonidal sinus. It is frequently covered with a tuft of hair. Although it may have no pathologic significance, a pilonidal cyst may indicate the existence of spina bifida occulta or be a portal of entry into the spinal column. With the infant still prone, note symmetry of the gluteal folds. Report any evidence of asymmetry. Skilled examiners test for developmental dysplasia of the hip (see Chapter 29). The presence of an anal orifice and passage of meconium from the anal orifice during the first 24 to 48 hours of life indicates anal patency. If an imperforate anus is suspected, report this to the primary practitioner for further evaluation.

olfactory changes associated with transition to extrauterine life

Newborns react to strong odors such as alcohol and vinegar by turning their heads away. Breastfed infants are able to smell breast milk and will cry for their mothers when they smell leaking milk. Infants are also able to differentiate the breast milk of their mothers from the breast milk of other women by scent alone. Maternal odors are believed to influence the attachment process and successful breastfeeding. Unnecessary routine washing of the breast may interfere with establishment of early breastfeeding.

attachment behavior assessment

One of the most important areas of assessment is careful observation of behaviors that are thought to indicate the formation of emotional bonds between the newborn and family, especially the mother. 1. Such behaviors include the en face position; undressing and touching the infant; smiling, kissing, and talking to the infant; and holding, rocking, and cradling the child close to the body (see Nursing Care Guidelines box). Because assessment is closely related to interventions that promote attachment (e.g., encouraging these behaviors in parents), assessing attachment behaviors is further discussed later in the chapter.

general measurement: vital signs: pulse and respirations

Pulse and respirations also vary according to the periods of reactivity and the infant's behaviors but are usually in the range of 120 to 140 beats/min and 30 to 60 breaths/min. Both are counted for a full 60 seconds to detect irregularities in rate or rhythm. The heart rate is taken apically with a stethoscope, and the femoral arteries are palpated for equality of strength or fullness.

identification

Proper identification of the newborn is absolutely essential. The nurse must verify that identifying bands are securely fastened and verify the information (name, gender, mother's admission number, date, and time of birth) against the birth records and the child's actual gender. This identification process should take place optimally in the delivery room. Electronic tags that give off a radio frequency may also be used to prevent newborn abductions (Vincent, 2009). A tag is placed on the newborn and removed at the time of discharge by hospital personnel. A proactive hospital emergency plan should be implemented to prevent infant abduction and to respond promptly and effectively in the event one happens. A mock newborn abduction drill is an effective method that can be used to evaluate staff competence and response to the incident (National Center for Missing and Exploited Children, 2015). All hospital personnel should be educated regarding newborn abduction, preventive aspects, and methods to identify the potential risk of such an occurrence. The nurse should discuss safety issues with the mother the first time the infant is brought to her. The National Center for Missing and Exploited Children * (2015) has reported that 58% of infant abductions occur in the mother's room. A written copy of the safety instructions should also be given to the parent. Parents are instructed to look at identification badges of nurses and hospital personnel who come to take infants and not to relinquish their infants to anyone without proper identification. Mothers are also advised not to leave the infant 211alone in the crib while they shower or use the bathroom; rather, they should ask to have the infant observed by a health care worker if a family member is not present in the room. Parents and staff are encouraged to use a password system when the newborn is taken from the room as a routine security measure. The nurse should document in the chart that these instructions were given and that appropriate identification band checks are routinely made throughout each shift. Nursing staff are also educated regarding the "typical" abductor profile and to be constantly aware of visitors with unusual behavior. The typical profile of an abductor is a female between the ages of 12 and 55 years (generally is in early 20s) who is often overweight and has low self-esteem; she may be emotionally disturbed because of the loss of her own child or an inability to conceive and may have a strained relationship with her husband or partner. The typical abductor may also be seen visiting the newborn nursery or neonatal intensive care unit area before the abduction and may ask questions about the care of or the health of a specific newborn. The abductor may familiarize herself with the hospital routine and may also impersonate a health care worker. Parents are made aware of the fact that infant safety measures must be implemented in the home as well. Measures to prevent and decrease infant abduction after discharge to the home include avoiding the publication of birth announcements in the local newspaper and avoiding using yard decorations to announce a newborn's arrival (National Center for Missing and Exploited Children, 2015).*

vitamin K administration

Shortly after birth, vitamin K is administered to prevent hemorrhagic disease of the newborn. Normally, vitamin K is synthesized by the intestinal flora. However, because infants' intestines are relatively sterile at birth and because breast milk contains low levels of vitamin K, the supply is inadequate for at least the first 3 or 4 days. The major function of vitamin K is to catalyze the synthesis of prothrombin in the liver, which is needed for blood clotting. The vastus lateralis muscle is the traditionally recommended injection site, but the ventrogluteal (not the dorsogluteal) muscle can be used. Several countries have noted resurgence in later onset of vitamin K deficiency bleeding (VKDB) after practicing orally administered prophylaxis (American Academy of Pediatrics Committee on Fetus and Newborn, 2003). Current recommendations are that vitamin K be given to all newborns as a single intramuscular dose of 0.5 to 1.0 mg (American Academy of Pediatrics Committee on Fetus and Newborn, 2003; Fetus and Newborn Committee, 2014). Additional study is needed on the efficacy, safety, and bioavailability of oral preparations and on the most effective dosing regimens to prevent VKDB.

general measurement: vital signs: oxygenation

The American Academy of Pediatrics, Section on Cardiology and Cardiac Surgery Executive Committee recommends routine pulse oximetry screening for critical congenital heart disease (CCHD) for all newborns (Mahle, Martin, Beekman, et al, 2012). Delayed diagnosis of CCHD can result in morbidity or mortality to infants. Research has demonstrated that adding pulse oximetry, a noninvasive, painless technology, to newborn assessment can detect CCHD. Practitioners are directed to use motion-tolerant pulse oximeters and to screen infants after 24 hours of age to reduce false-positive results. Oxygen saturation must be measured in the right hand and in one foot; a reading of 95% or greater in either extremity with a 3% or less difference between the upper and lower extremities would be a "pass." Infants with saturation of less than 90% need immediate evaluation.

healthy newborn nursing process: evaluation

The effectiveness of nursing interventions for the newborn and family is determined by continual assessment and evaluation of care based on the following guidelines: • Observe infant's color and respiratory pattern. • Monitor axillary temperature regularly; observe for signs of temperature instability, such as respiratory distress. • Observe for any evidence of infection, especially at the umbilicus or site of circumcision; check identification; and verify administration of prophylactic eye treatment, vitamin K injection, hepatitis B vaccine, and hearing and newborn screening tests, including bilirubin screening. • Monitor infant's feeding ability and oral intake. • Monitor daily weight. • Observe interactions between infant and family members; interview family regarding their feelings about the newborn. • Observe parents' ability to provide care for infant; interview parents regarding any concerns about infant's care at home. • Observe parents' correct use of car safety seat restraint on discharge.

initial assessment: Apgar scoring

The most frequently used method to assess newborns' immediate adjustment to extrauterine life is the Apgar scoring system, which is based on newborn heart rate, respiratory effort, muscle tone, reflex irritability, and color (Table 7-1). Each item is given a score of 0, 1, or 2. Evaluations of all five categories are made at 1 and 5 minutes after birth and repeated until the infant's condition stabilizes. Total scores of 0 to 3 represent severe distress, scores of 4 to 6 signify moderate difficulty, and scores of 7 to 10 indicate absence of difficulty in adjusting to extrauterine life. The Apgar score is affected by the degree of physiologic immaturity, infection, congenital malformations, maternal sedation or analgesia, and neuromuscular disorders.

nose assessment

The nose is usually flattened after birth, and bruises are common. Patency of the nasal canals can be assessed by holding a hand over the infant's mouth and one canal and noting the passage of air through the unobstructed opening. If nasal patency is questionable, report it because most newborns are obligatory nose breathers and are unable to breathe orally in response to nasal occlusion. Sneezing and thin white mucus are common up to several hours after birth.

weight as related to gestational age

The weight of the infant at birth also correlates with the incidence of perinatal morbidity and mortality. However, birth weight alone is a poor indicator of gestational age and fetal maturity. Maturity implies functional capacity—the degree to which the neonate's organ systems are able to adapt to the requirements of extrauterine life. Therefore, 195gestational age is more closely related to fetal maturity than is birth weight. Because heredity influences a newborn's size, noting the size of other family members is part of the assessment process.

healthy newborn & family nursing process: diagnosis

• Readiness for Enhanced Parenting • Risk for Injury • Effective Breastfeeding • Risk for Imbalanced Body Temperature • Readiness for Enhanced Nutrition • Ineffective Breathing Pattern • Risk for Infection • Risk for Neonatal Jaundice

siblings

1. Although the attachment process has been discussed almost exclusively in terms of the parents and infants, it is essential that nurses be aware of other family members, such as siblings and members of the extended family, who need preparation for the acceptance of this new child. Young children in particular need sensitive preparation for the birth to minimize sibling jealousy. In support of family-centered care, siblings are generally encouraged to visit the mother in hospital and to hold the newborn (Fig. 7-16). Another trend has been the presence of siblings at childbirth. Unlike sibling visitation, the evidence supporting this practice has been controversial, yet family-centered care encompasses siblings, grandparents, and other significant persons who comprise the extended family unit. Children exhibit different degrees of involvement in the birth process. Some reported benefits include children's increased knowledge of the birth process, less regressive behavior after the birth, and more mothering and caregiving behavior toward the infant. Some practitioners add facilitated family bonding and assimilation of the newborn into the family as positive outcomes. Parents whose children attended the birth have echoed these same benefits and have expressed their desire to repeat the experience should another pregnancy occur. Despite these positive findings, opponents believe that allowing children to observe a delivery could lead to emotional difficulties, although there is no research to support this contention. As research mounts, birthing centers that allow siblings at the birth are developing more definitive guidelines, such as an age requirement of at least 4 to 5 years old, the presence of a supportive person for the sibling only, and an adequate sequence of preparation in which parents explore all options for preparing their other children. 2. From observations during sibling visitation, there is evidence that sibling attachment occurs. However, the en face position is assumed much less often among the newborn and siblings than between mother and newborn, and when this position is used, it is brief. Siblings focus more on the head or face than on touching or talking to the infant. The siblings' verbalizations are often focused less on attracting the infant's attention and more on addressing the mother about the newborn. Children who have established a prenatal relationship with the fetus have demonstrated more attachment behaviors, supporting the suggestion of encouraging prenatal acquaintance. Additional research is needed to establish theories on sibling bonding as have been constructed for parental bonding.

reciprocity

1. As the mother responds to the infant, the infant must respond to the mother by some signal, such as sucking, cooing, eye contact, grasping, or molding (conforming to other's body during close physical contact). 2. In a good interaction, both partners have synchronized their attention-nonattention cycles. Parents or other caregivers who do not allow the infant to turn away and who continually attempt to maintain visual contact encourage the infant to turn off the attention cycle and thus prolong the nonattention phase. Although this description of reciprocal interacting behavior is usually observed in infants by 2 to 3 weeks of age, nurses can use this information to teach parents how to interact with their newborns. Recognizing the attention versus nonattention cycles and understanding that the latter is not a rejection of the parent helps parents develop competence in parenting.

circumcision

1. Circumcision, the surgical removal of the foreskin on the glans penis, is usually done in the hospital, although it is not a common practice in most countries. In the United States, however, between approximately 40% and 70% of newborn boys are circumcised, depending on the region (Owings, Uddin, Williams, et al, 2013). The Centers for Disease Control and Prevention National Center for Health Statistics reports that the overall national rate of newborn circumcision has fallen from 64.5% of newborns in 1979 to 58.3% of newborns in 2010 (Owings, Uddin, Williams, et al, 2013). Despite the frequency of the procedure in the United States, there is controversy regarding the benefits and risks (Box 7-4). 2. Research has explored the possible link between circumcision and reduced transmission of communicable illnesses, such as human papillomavirus (HPV) and HIV in later life. The American Academy of Pediatrics Task Force on Circumcision (2012) states that current evidence indicates the health benefits of newborn male circumcision outweigh the risks, and that the procedure should be made available to families who choose it. Despite encouraging outcome data, the health benefits are not yet great enough to recommend routine circumcision of all male newborns (American Academy of Pediatrics Task Force on Circumcision, 2012; Jagannath, Fedorowicz, Sud, et al, 2012). The current American Academy of Pediatrics Task Force on Circumcision (2012) statement emphasizes parental autonomy to determine what is in the best interest of their newborn. The policy encourages the primary care practitioner to ensure that parents have been given accurate and unbiased information about the risks, benefits, and alternatives before making an informed choice and that they understand that circumcision is an elective procedure. In addition to examining the medical benefits of male newborn circumcision, the American Academy of Pediatrics recommends that procedural analgesia be provided if parents decide to have their male infant circumcised. Nurses are in a unique position to educate parents regarding the care of their newborns, and they must take responsibility for ensuring that each parent has accurate and unbiased information with which to make an informed decision. Parents need to know the options for pain control, and nurses must be proactive in advocating for circumcision analgesia. Despite adequate scientific evidence that newborns feel and respond to pain, circumcisions may still be performed with either insufficient analgesia or no analgesia at all. Nurses can use the American Academy of Pediatrics Task Force on Circumcision's policy statement (2012) to advocate for the use of optimal pain relief for circumcision. A combination of nonpharmacologic and pharmacologic strategies is recommended for optimal pain prevention and control. Topical eutectic mixture of local anesthetics (EMLA) cream alone is insufficient for neonatal circumcision, although it may be useful for decreasing the pain of needle insertion when used in combination with local anesthesia via subcutaneous ring block of the penis or dorsal penile nerve block (Paix and Peterson, 2012). Nurses should use nonpharmacologic interventions that can reduce the pain of this operative procedure (see Atraumatic Care box). Despite adequate scientific evidence that newborns feel and respond to pain, circumcisions may still be performed with either insufficient analgesia or no analgesia at all.

paternal engrossment

1. Fathers also show specific attachment behaviors to their newborns. This process of paternal engrossment, forming a sense of absorption, preoccupation, and interest in the infant, includes (1) visual awareness of the newborn, especially focusing on the beauty of the child; (2) tactile awareness, often expressed in a desire to hold the infant; (3) awareness of distinct characteristics with emphasis on those features of the infant that resemble the father; (4) perception of the infant as perfect; (5) development of a strong feeling of attraction to the child that leads to intense focusing of attention on the infant; (6) extreme elation; and (7) feeling a sense of deep self-esteem and satisfaction. These responses are greatest during the early contacts with the infant and are intensified by the neonate's normal reflex activity, especially the grasp reflex and visual alertness. In addition to behavioral reactions, fathers also demonstrate physiologic responses such as increased heart rate and BP during interactions with their newborns. The process of engrossment has significant implications for nurses. It is imperative to recognize the importance of early father-infant contact in releasing these behaviors. Fathers need to be encouraged to express their positive feelings, especially if such emotions are contrary to any belief that fathers should remain stoic. If this is not clarified, fathers may feel confused and attempt to suppress the natural sensations of absorption, preoccupation, and interest in order to conform to societal expectations. Mothers also need to be aware of the responses of the father toward the newborn, especially because one of the consequences of paternal preoccupation with the infant is less overt attention toward the mother. If both parents are able to share their feelings, each can appreciate the process of attachment toward their child and will avoid the unfortunate conflict of being insensitive and unaware of the other's needs. In addition, a father who is encouraged to form a relationship with his newborn is less likely to feel excluded and abandoned after the family returns home and the mother directs her attention toward caring for the infant. Ideally, the process of engrossment should be discussed with parents before the delivery, such as in prenatal classes, to reinforce the father's awareness of his natural feelings toward the expected child. Focusing on the future experience of seeing, touching, and holding one's newborn may also help expectant fathers become more comfortable in accepting their paternal feelings. This in turn can assist them in being more supportive toward the mother, especially as the labor and delivery draw near. At the infant's birth, the nurse can play a vital role in helping the father express engrossment by assessing the neonate in front of the couple; pointing out normal characteristics; encouraging identification through consistent referral to the child by name; encouraging the father to cuddle, hold, talk to, or feed the infant; and demonstrating whenever necessary the soothing powers of caressing, stroking, and rocking the child (Fig. 7-15). Fathers are encouraged to be with the mother during labor and delivery, to spend time alone with the mother and newborn after delivery, and to room-in with the mother and infant. Many hospitals and birthing centers have adopted a family-centered focus, including sleeping accommodations that more closely resemble the home environment for the new parents. 2. Fathers, like mothers, may demonstrate attachment not only after the infant's birth but during fetal life as well. Paternal attachment may proceed at a different pace than maternal attachment. Paternal preoccupation with events of labor and delivery and the spouse's health may detract from paternal attachment. Research has noted that, although fathers spend similar amounts of time in interaction with their newborns as do mothers, the nature of their interaction is different. Mothers and infants focus on face-to-face exchange and mutual gazing, co-vocalization, and affectionate touch. Fathers' time with their infants includes quick peaks of high positive emotionality, including joint laughter and open exuberance. Interactions with fathers tend to center on physical games or games with an object focus rather than on face-to-face signals (Feldman, 2007). The nurse observes for the same indications of affection from the father as those expected in the mother, such as making visual contact 223in the en face position and embracing the infant close to the body. When present, such behaviors are reinforced. If such responses are not obvious, the nurse needs to assess the father's feelings regarding this birth, cultural beliefs that may affect his expression of emotions, and other factors that influence his perception of the infant and the mother in order to facilitate a positive attachment during this critical period.

interventions that promote breastfeeding

1. Frequent and early breastfeeding, especially during the first hour of life; immediate skin-to-skin contact; non-separation of mother and infant; and feeding on demand • Direct modeling of the importance of breastfeeding by health care providers, such as implementing demand feeding with no formula supplementation and decreased emphasis on infant formula products • Increased information and support to mothers after discharge, including phone follow-up • Early breast pumping every 2 to 3 hours for 10 to 15 minutes bilaterally if the newborn is unable to breastfeed immediately (increases oxytocin production and thus milk production) Nurses play a significant role in the breastfeeding decision and must make themselves available to families for guidance and support. Several excellent books and organizations, such as La Leche League International,* are available as resources for professionals and breastfeeding mothers.

reasons why propping a bottle during feeding is discouraged

1. It denies the infant the important component of close human contact. • The infant may aspirate formula into the trachea and lungs. • It may facilitate the development of middle ear infections. If the infant lies flat and sucks, milk that has pooled in the pharynx becomes a suitable medium for bacterial growth. Bacteria may then enter the eustachian tube, which leads to the middle ear, causing acute otitis media. • It encourages continuous pooling of formula in the mouth, which can lead to nursing caries when the teeth erupt (see Chapter 12).

maternal attachment

1. Mothers may demonstrate a predictable and orderly pattern of behavior during the development of the attachment process. When mothers are presented with their nude infants, they begin to examine the infant with their fingertips, concentrating on touching the extremities, and then proceed to massage and encompass the trunk with their entire hands. Assuming the en face position, in which the mother's and infant's eyes meet in visual contact in the same vertical plane, is significant in the formation of affectional ties (Fig. 7-14). Some authors have suggested that mothers experiencing depression, as well as adolescent mothers, may have lower rates of secure attachment with their infants (Flaherty and Sadler, 2011), necessitating the need for caregivers to monitor such mothers closely and to model attachment behaviors. Nurses must observe for maternal attachment behaviors and exercise caution in interpreting such behaviors. 2. Several studies have attempted to substantiate the long-term benefits of providing parents with opportunities to optimally bond with their infants during the initial postpartum period. Although there has been some evidence that increased parent-child contact encourages prolonged breastfeeding and may minimize the risks of parenting disorders, conclusions about the long-term effects of such early intervention on parenting and child development must be viewed cautiously. In addition, some authorities claim that the emphasis on bonding has been unjustified and may lead to guilt and fear in parents who did not have early contact with their infants. There is concern that the literal interpretation of "sensitive" or "critical" times for bonding might imply that without early contact, optimum bonding cannot occur or, conversely, that early contact alone is sufficient to ensure competent parenting. The nurse should stress to parents that although early bonding is valuable, it does not represent an "all or none" phenomenon. Throughout the child's life, there will be multiple opportunities for development of parent-child attachment. Bonding is a complex process that develops gradually and is influenced by numerous factors, only one of which is the type of initial contact between the newborn and parent. In a concept analysis of parent-infant attachment, Goulet, Bell, St-Cyr, et al (1998) describes attributes of parent-infant attachment as proximity, reciprocity, and commitment. Within these attributes are further dimensions, which include contact, emotional state, individualization, complementarity, sensitivity, centrality, and parent role exploration. The researchers describe the parent-infant attachment process as one that is complex and therefore cannot be evaluated 222simply by the observations of attitudes and behaviors of parents toward their infants (Goulet, Bell, St-Cyr, et al, 1998). Further research into the reciprocal relationships between infants and parents and the situational factors that influence such relationships is recommended. One component of successful maternal attachment is the concept of reciprocity (Brazelton, 1974). As the mother responds to the infant, the infant must respond to the mother by some signal, such as sucking, cooing, eye contact, grasping, or molding (conforming to other's body during close physical contact). The first step is initiation in which interaction between infant and parent begins. Next is orientation, which establishes the partners' expectations of each other during the interaction. After orientation is acceleration of the attention cycle to a peak of excitement. The infant reaches out and coos, both arms jerk forward, the head moves backward, the eyes dilate, and the face brightens. After a short time, deceleration of the excitement and turning away occur in which the infant's eyes shift away from the parent's and the child may grasp his or her shirt. During this cycle of nonattention, repeated verbal or visual attempts to reinitiate the infant's attention are ineffective. This deceleration and turning away probably prevents the infant from being overwhelmed by excessive stimuli. In a good interaction, both partners have synchronized their attention-nonattention cycles. Parents or other caregivers who do not allow the infant to turn away and who continually attempt to maintain visual contact encourage the infant to turn off the attention cycle and thus prolong the nonattention phase. Although this description of reciprocal interacting behavior is usually observed in infants by 2 to 3 weeks of age, nurses can use this information to teach parents how to interact with their newborns. Recognizing the attention versus nonattention cycles and understanding that the latter is not a rejection of the parent helps parents develop competence in parenting.

head assessment

1. General observation of the contour of the head is important because molding occurs in almost all vaginal deliveries. In a vertex delivery, the head is usually flattened at the forehead, with the apex rising and forming a point at the end of the parietal bones and the posterior skull or occiput dropping abruptly. The usual, more oval contour of the head is apparent by 1 to 2 days after birth. The change in shape occurs because the bones of the cranium are not fused, allowing for overlapping of the edges of these bones to accommodate to the size of the birth canal during delivery. Such molding usually does not occur in infants born by elective cesarean section. Six bones—the frontal, occipital, two parietals, and two temporales—make up the cranium. Between the junction of these bones are bands of connective tissue called sutures. At the junction of the sutures are wider spaces of unossified membranous tissue called fontanels. The two most prominent fontanels in infants are the anterior fontanel formed by the junction of the sagittal, coronal, and frontal sutures and the posterior fontanel formed by the junction of the sagittal and lambdoid sutures (Fig. 7-6, A). 2. The skull is palpated for all patent sutures and fontanels, noting size, shape, molding, or abnormal closure. The sutures feel like cracks between the skull bones, and the fontanels feel like wider soft spots at the junction of the sutures. These are palpated by using the tip of the index finger and running it along the ends of the bones (see Fig. 7-6, B). The anterior fontanel is diamond shaped and measures anywhere from barely palpable to 4 to 5 cm (≈2 inches) at its widest point (from bone to bone rather than from suture to suture). The posterior fontanel is easily located by following the sagittal suture toward the occiput. The posterior fontanel is triangular, usually measuring between 0.5 and 1 cm (<0.5 inch) at its widest part. The fontanels should feel flat, firm, and well demarcated against the bony edges of the skull. Frequently, pulsations are visible at the anterior fontanel. Coughing, crying, or lying down may temporarily cause the fontanels to bulge and become more taut. Palpate the skull for any unusual masses or prominences, particularly those resulting from birth trauma, such as caput succedaneum or cephalhematoma (see Chapter 8). Because of the pliability of the skull, exerting pressure at the margin of the parietal and occipital bones along the lambdoid suture may produce a snapping sensation similar to the indentation of a ping-pong ball. This phenomenon, known as physiologic craniotabes, may be found normally, especially in newborns of breech birth, but also may indicate hydrocephalus, congenital syphilis, or rickets. Assess the degree of head control. Although head lag is normal in newborns, the degree of ability to control the head in certain positions should be recognized. If a supine infant is pulled from the arms into a semi-Fowler position, marked head lag and hyperextension are noted (Fig. 7-7, A). However, as the infant is brought forward into a sitting position, the infant will attempt to control the head in an upright position. As the head falls forward onto the chest, many infants will attempt to right it into the erect position. Also, if the infant is held in ventral suspension (i.e., held prone above and parallel to the examining surface), the infant will hold the head in a straight line with the spinal 199column (see Fig. 7-7, B). When lying on the abdomen, newborns have the ability to lift the head slightly, turning it from side to side. Marked head lag is seen in neonates with Down syndrome, prematurity, hypoxia, and neuromuscular compromise.

preparation of formula

1. Persons preparing infant formula must wash their hands well and then wash all of the equipment used to prepare the formula (including the cans of formula) with soap and water. Sterilizing bottles and nipples may be done in a dishwasher or a commercial home sterilizer (electric or microwave steam sterilizer, or chemical sterilizer), following manufacturer instructions. Equipment may also be sterilized by boiling. Fill a large pan with water and completely submerge all washed equipment, ensuring there are no trapped air bubbles. Cover the pan with a lid and bring it to a rolling boil, making sure the pan does not boil dry. Keep the pain covered until the equipment is needed. Powdered infant formula is not sterile, and it has been associated with severe illness attributable to Cronobacter species (formerly known as Enterobacter sakazakii) and Salmonella enterica (Pickering and American Academy of Pediatrics, Committee on Infectious Diseases, 2012). Careful preparation and handling reduce the risk of illness; reconstitution with water brought to a rolling boil, and mixed when it is at or above 70° C is helpful, because this is hot enough to inactivate Cronobacter and other pathogens (Pickering and American Academy of Pediatrics, Committee on Infectious Diseases, 2012; World Health Organization, 2007). Bottled water is not considered sterile and must be boiled before use. Following the manufacturer's instructions for preparing the formula is essential to ensure the infant receives adequate calories and fluid for adequate growth. Parents are cautioned not to alter the reconstitution or dilution of infant formula except under the specific directions of the primary practitioner. Powdered formula and concentrated formula are prepared and bottled and refrigerated if not used for feeding immediately. Warming the formula is optional, although many parents prefer to warm it before feeding. Any milk remaining in the bottle after the feeding is discarded because it is an excellent medium for bacterial growth. Opened cans of ready-to-feed or concentrated formula are covered and refrigerated immediately until the next feeding. Because of incidents involving contamination of powdered formula with Cronobacter species and subsequent infant death in a neonatal unit, it is now recommended that hospital formula preparation for newborns follow separate guidelines; these are discussed in Chapter 7. Laws governing the labeling of infant formulas require that the directions for preparation and use of the formula include pictures and symbols for non-reading individuals. In addition, manufacturers are translating the directions into foreign languages, such as Spanish and Vietnamese, to prevent misunderstanding and errors in formula preparation. 2. Stress to families that the proportions must not be altered—neither diluted with extra water to extend the amount of formula nor concentrated to provide more calories.

additional bonding tasks associated with a second child

1. Promoting acceptance and approval of the second child • Grieving and resolving the loss of an exclusive dyadic relationship with the first child • Planning and coordinating family life to include a second child • Reformulating a relationship with the first child • Identifying with the second child by comparing this child with the first child in terms of physical and psychological characteristics • Assessing one's affective capabilities in providing sufficient emotional support and nurturance simultaneously to two children

commercially prepared formulas

1. The analysis of human and whole cow's milk indicates that the latter is unsuitable for infant nutrition. Whole cow's milk has a high protein content and low fat and lipid content, and it may cause intestinal bleeding and lead to iron-deficiency anemia in infants. Questions have also been raised regarding the unmodified protein content of whole cow's milk, which may trigger an undesired immune response and thus increase the incidence of allergies in children at an early age. Commercially prepared formulas are cow's milk based and have been modified to resemble the nutritional content of human milk. These formulas are altered from cow's milk by removing butterfat, decreasing the protein content, and adding vegetable oil and carbohydrate. Some cow's milk-based formulas have demineralized whey added to yield a whey-to-casein ratio of 60 to 40. The standard cow's milk-based formulas, regardless of the commercial brand, have essentially the same compositions of vitamins, minerals, protein, carbohydrates, and essential amino acids with minor variations, such as the source of carbohydrate, nucleotides to enhance immune function; and long-chain polyunsaturated fatty acids (LCPUFAs), DHA and AA. DHA and AA are both found in large quantities in human milk but until recently were not present in most infant formulas. Studies suggest both preterm and full-term infants receiving formula supplemented with DHA and AA have improved brain function and visual acuity when compared with those receiving formula without DHA and AA (Tai, Wang, and Chen, 2013). Sources for LCPUFAs include egg yolk lipid, phospholipids, and triglycerides. There do not appear to be any adverse effects associated with LCPUFA supplementation in preterm infants with respect to the incidence of bronchopulmonary disease, necrotizing enterocolitis, or other conditions of prematurity (Kleinman and Greer, 2014). The US Food and Drug Administration regulates the manufacture of infant formula in the United States to ensure product safety. Standard cow's milk-based formulas are sold as low iron and iron fortified; however, the American Academy of Pediatrics states only the iron-fortified formulas meet the requirements of infants (Kleinman and Greer, 2014).

consummatory behavior

1. consists of coordinated sucking and swallowing. 2 Persistent gagging might indicate unsuccessful consummatory behavior.

four main categories of commercially prepared formula

1. cow's milk-based 2. soy-based 3. casein or whey hydrolysate 4. amino acid formulas

prefeeding behavior

1. crying or fussing 2. demonstrates the infant's level of arousal and degree of hunger. 3. to encourage the infant to grasp the breast properly, it is preferable to begin feeding during the quiet alert state before the infant becomes upset.

pain management during circumcision: pharmacological interventions

1. dorsal penal nerve block 2. ring block with topical anesthesia 3. both use EMLA (lidocaine-prilocaine)

steps in reciprocity

1. initiation 2. orientation 3. acceleration 4. deceleration

follow up formula

1. marketed as a transitional formula for infants older than 6 months of age who are also eating solid foods. These generally contain a higher percentage of calories from protein and carbohydrate sources, a higher amount of iron and vitamins, and 220a lower amount of fat than standard cow's milk-based formulas. Many nutrition experts and the American Academy of Pediatrics Committee on Nutrition, however, dispute the necessity of follow-up formulas if the infant is receiving an adequate amount of solid foods containing sufficient iron, vitamins, and minerals (Kleinman and Greer, 2014).

satiety behavior

1. observed when infants let the parent know that they are satisfied, usually by falling asleep

anesthesia and analgesia for newborns undergoing neonatal circumcision

1. ring block 2. dorsal penile nerve block (DPNB) **most effective 3. topical anesthetic (EMLA (prilocaine-lidocaine)) or LMX4 (4% lidocaine)) 4. concentrated oral sucrose

nonpharmacological interventions

1. these accompany the pharm interventions 2. If a Circumstraint board is used, pad it with blankets. 3. Provide the parents, caregiver, or another staff member with the option of being present during the circumcision. Swaddle the upper body and legs to provide warmth and containment and to reduce movement (see Fig. 7-11). If the patient is not swaddled and is unclothed, use a radiant warmer to prevent hypothermia. Shield the infant's eyes from overhead lights. Prewarm any topical solutions to be used in sterile preparation of the surgical site by placing them in a warm blanket or towel. Play infant relaxation music before, during, and after the procedure; allow the parents or other caregiver the option of providing the music of choice. After the procedure, remove restraints and swaddle. Immediately have the parent, other caregiver, or nursing staff hold the infant. Continue to have the infant suck on the pacifier or offer feeding. Combination analgesia is recommended: oral sucrose, acetaminophen, topical anesthetic, and DPNB or ring block in addition to nonpharmacologic comfort measures, such as containment, positioning, nonnutritive sucking, and breastfeeding.

breastfeeding with multiple births

1.If both twins are full term, they can begin feeding immediately after birth (Fig. 7-12); late preterm infants should be evaluated individually but may be breastfed if stable. Simultaneous feeding promotes the rapid production of milk needed for both infants and makes the milk that would normally be lost in the letdown reflex available to one of the twins. When only one infant is hungry, the mother should feed singly. She should also alternate breasts when feeding each infant and avoid favoring one breast for one infant. The suckling patterns of infants vary, and each infant needs the visual stimulation and exercise that alternating breasts provides. 2. A concern mothers may have is the perceived inconvenience or loss of freedom and independence if they chose to breastfeed. Being committed to feeding the infant every 2 to 3 hours can seem overwhelming, especially to women with multiple responsibilities. Many women resume their careers shortly after their pregnancy and may believe bottle feeding is less work than breastfeeding. The preparation, storage, and heating of formula are important considerations for the family when comparing the effort required for bottle feeding versus breastfeeding. Combining breastfeeding and employment is possible, and many employers now provide space for mothers to pump and store their milk. This is likely an acknowledgement of the demonstrated health benefits of breastfeeding—a breastfed infant is far less likely to have infections of any sort; thus, the infant's mother is far less likely to need time away from work to care for an ill infant. Although breastfeeding is the preferred form of infant feeding, mothers' decisions regarding their preferences must be supported and respected. Successful breastfeeding probably depends more on the mother's desire to breastfeed, satisfaction with breastfeeding, and available support systems than on any other factors. Mothers need support, encouragement, and assistance during their postpartum hospital stays and at home to enhance their opportunities for success and satisfaction. Three main criteria have been proposed as essential in promoting positive breastfeeding: (1) absence of a rigid feeding schedule; (2) correct positioning of the infant at the breast to achieve a deep, areolar latch; and (3) correct suckling technique. Correct suckling for breastfeeding is defined as a wide-open mouth, tongue under the areola, and expression of milk by effective alveolar compression (Fig. 7-13).

multiple births and subsequent children

A component of attachment that has special meaning for families with multiple births, monotropy refers to the principle that a person can become optimally attached to only one individual at a time. If a parent can form only one attachment at a time, how can all of the siblings of a multiple birth receive optimum emotional care? Research on bonding and multiple births is still lacking despite the recent increase in multiple births, and even less is known about paternal engrossment and sibling attachment. In regard to mother-twin bonding, the conclusions of different authors vary. Some report that mothers bond equally to each twin at the time of birth even if one twin is ill. Others suggest that mothers of twins may take months or years to form individual attachments to each child or even longer if the twins are identical. Nurses can be instrumental in promoting bonding of multiple births. The most important principle is to assist the parents in recognizing the individuality of the children, especially in monozygotic (identical) twins. The mother should visit with each newborn, including a sick infant, as much as possible after birth. Non-separation and breastfeeding are encouraged. Any characteristics that are unique to each child are emphasized, and each infant is called by name rather than referring to "the twins." Asking the family questions (such as "How do you tell Ashley and Amy apart?" and "In what ways are Ashley and Amy different and similar?") helps point out their individual characteristics. Behaviors on the BNBAS can be used to illustrate these differences and to stress effective strategies for dealing with multiple personalities at the same time. Co-bedding (bed sharing) of twins or other multiples may be done in the hospital with the goal of maintaining the bond between siblings that was formed in utero (Fig. 7-17). Much research is focused 224on exploring the safety and benefits of the practice of co-bedding (Hayward, Campbell-Yeo, Price, et al, 2007) (see also Sudden Infant Death Syndrome, Chapter 10); however, the American Academy of Pediatrics Task Force on Sudden Infant Death Syndrome (2011) has recommended against families co-bedding with infants at home. Because neither the safety nor the benefits of co-bedding for newborns has been documented in the literature, the Academy recommends families are counseled to follow safe sleeping practices, which currently dictate that infants sleep alone for optimal safety.

general measurement: vital signs: temperature

Another category of measurements is vital signs. Axillary temperatures are taken because insertion of a thermometer into the rectum can potentially cause perforation of the mucosa if performed incorrectly (see Table 7-3 and Fig. 7-4). Core body temperature varies according to the periods of reactivity but is usually 36.5° to 37.6° C (97.7° to 99.7° F). Skin temperature is slightly lower than core body temperature. Friedrichs, Staffileno, Fogg, et al (2013) report a significant correlation between rectal temperature and body temperature taken in the left axilla of full term infants. The mean difference between 197rectal and axillary temperature was 0.23° C. The single best method for determining a newborn infant's temperature remains elusive when considering the available studies. Despite their usefulness in older children and adults, the accuracy of tympanic membrane sensors is problematic in infants. A meta-analysis of 101 studies comparing tympanic membrane temperatures with rectal temperatures in children concluded that the tympanic method demonstrated a wide range of variability, limiting its application in a pediatric setting (Craig, Lancaster, Taylor, et al, 2002). Dodd, Lancaster, Craig, et al (2006) concur with this finding, stating that after a systematic review of studies involving almost 4100 children, they found that infrared ear thermometry would fail to diagnose fever in 3 or 4 of every 10 febrile children. FIG 7-4 Mother taking axillary temperature with digital thermometer. The Canadian Paediatric Society, Community Paediatrics Committee (2015) outlines concerns regarding the safety and accuracy of tympanic temperature measurement in newborns because of the size of a newborn's external ear canal relative to the size of the thermometer probe. To ensure accuracy, the probe, which may be up to 8 mm (0.3 inch) in diameter, must be deeply inserted into the ear canal to allow orientation of the sensor near or against the tympanic membrane. At birth, the average diameter of the canal is just 4 mm (0.16 inch); at 2 years old, it is just 5 mm (0.2 inch). The Canadian Paediatric Society concludes that current infrared tympanic thermometry lacks sufficient safety and precision to meet clinical needs for use in newborn infants and children younger than 2 years old. Infrared axillary and digital thermometers are used in many neonatal units because they give rapid readings and are easy to clean; studies demonstrate their usefulness in well, full-term newborns. Jones, Kleber, Eckert, et al (2003) compared rectal temperatures of infants younger than 2 months old with calibrated digital thermometers and mercury glass thermometers; this study of 120 infants found that the digital thermometers measured a higher temperature (mean average of 0.7° F; range, 0° to 1.6° F) than the mercury glass thermometers. The researchers concluded that the error in measurement was attributable to the digital thermometer used. Smith, Alcock, and Usher (2013) conducted an extensive review of the literature on temperature measurement in term and preterm infants. These researchers concluded that the most commonly used route when using digital and electronic thermometers for temperature measurement is the axillary route. Advantages of digital thermometers in neonatal care include relatively easy readability by parents and caretakers in the home, improvement of discharge planning effectiveness, and decreased risk of breakage and associated complications compared with glass thermometers. Temporal artery thermometers (TATs), in which a battery-powered instrument is gently slid across the newborn's forehead, are available for use in the general pediatric population. Beginning research in the neonatal population suggests TAT may be a reasonable method for newborn temperature measurement. Haddad, Smith, Phillips, et al (2012), in a study of healthy newborns in a mother-baby unit, compared TAT with axillary temperature measurement. Although a slightly statistically significant difference was found between TAT and axillary temperatures, the difference was deemed clinically insignificant, and the unit has adopted TAT as their standard of care for healthy newborns. Similarly, Lee, Flannery-Bergey, Randall-Rollins, et al (2011) found that TAT and axillary temperatures did not differ significantly, and they concluded that TAT measurements are a reasonable alternative to axillary temperature for stable, afebrile infants in the neonatal intensive care unit. A benefit of this type of temperature measurement is that it is not necessary to undress the newborn. In most studies regarding newborn temperature, the glass mercury thermometer is the gold standard against which other methods are compared. There is no universal agreement on placement times for glass thermometers, although 3 minutes for rectal temperature and 5 minutes for axillary temperature are considered to be adequate. In 2007, the American Academy of Pediatrics, Committee on Environmental Health reaffirmed its statement recommending that mercury thermometers no longer be used in clinics and homes to decrease mercury exposure hazard (Goldman, Shannon, American Academy of Pediatrics, et al, 2001). Nurses must be cognizant of the many variables involved: Site—axillary, rectal, tympanic, skin Environment—radiant warmer, open crib, incubator, clothing, or nesting Purpose—fever, possible sepsis (in which case the temperature may be lower than normal in newborns), and thermoregulation in the transition phase Instrument—electronic, digital, infrared Nurses must also be able to make clear clinical decisions based on accurate and objective data. Further research is needed to perfect thermometers that accurately reflect infants' core temperature to effectively plan nursing care and maintain a stable temperature.

bottle feeding

Bottle feeding generally refers to the use of bottles for feeding commercial or evaporated milk formula rather than using the breast, 219although human milk may be expressed and fed with a bottle. Bottle feeding is an acceptable method of feeding. Nurses should not assume that new parents automatically know how to bottle feed their infants. One study noted 77% of formula-feeding mothers did not receive instruction on formula preparation from a health professional; consequently, hands, bottles, and nipples were not washed properly, and storage and heating practices were unsafe in many instances (Labiner-Wolfe, Fein, and Shealy, 2008). Parents who choose bottle feeding also need support and assistance in meeting their infants' needs. Providing newborns with nutrition is only one aspect of feeding. Holding them close to the body while rocking or cuddling them helps to ensure the emotional component of feeding. Similar to breastfed infants, bottle-fed infants need to be held on alternate sides of the lap to expose them to different stimuli. The feeding should not be hurried. Even though they may suck vigorously for the first 5 minutes and seem to be satisfied, they should be allowed to continue sucking. Infants need at least 2 hours of sucking a day. If there are six feedings per day, then about 20 minutes of sucking at each feeding provides for oral gratification.

feeding behavior

Five behavioral stages occur during successful feeding. Recognizing these steps can assist nurses in identifying potential feeding problems caused by improper feeding techniques. Prefeeding behavior, such as crying or fussing, demonstrates the infant's level of arousal and degree of hunger. To encourage the infant to grasp the breast properly, it is preferable to begin feeding during the quiet alert state before the infant becomes upset. Approach behavior is indicated by sucking movements or the rooting reflex. Attachment behavior includes activities that occur from the time the infant receives the nipple and sucks (sometimes more pronounced during initial attempts at breastfeeding). Consummatory behavior consists of coordinated sucking and swallowing. Persistent gagging might indicate unsuccessful consummatory behavior. Satiety behavior is observed when infants let the parent know that they are satisfied, usually by falling asleep.

heel puncture

Heel lancing is necessary to obtain blood for newborn blood tests, including newborn screening. Studies have shown that venipuncture performed by an experienced phlebotomist elicited fewer pain responses (as measured by the Premature Infant Pain Profile [PIPP]) from full-term newborns than did heel punctures (Shah and Ohlsson, 2011). Furthermore, the need for additional skin punctures was reduced with venipuncture. Although maternal anxiety was initially higher in the venipuncture group, mothers who observed the venipuncture reported observing less pain response than mothers who observed heel punctures. Oral sucrose and nonnutritive sucking have proved effective in decreasing the pain associated with heel punctures in preterm and full-term infants; however, the exact dose range that proves optimal effectiveness varies among studies (Stevens, Yamada, Lee, et al, 2013). Evidence indicates that as little as 0.05 to 0.5 ml of a 24% oral sucrose solution is effective in decreasing pain in full-term and preterm infants (Stevens, Yamada, Lee, et al, 2013). The best analgesic effect is achieved when sucrose is administered 2 minutes before the painful procedure with a pacifier or syringe and is repeatedly administered in small amounts (i.e., 0.05 to 0.5 ml) at 2-minute intervals throughout the painful procedure. The effect appears to begin at 2 minutes and lasts about 4 minutes, thus analgesic effect may wane if procedures are prolonged (Stevens, Yamada, Lee, et al, 2013). A number of commercially available oral sucrose solutions now exist. When these are not available, the pharmacy may mix an oral sucrose solution to ensure a clean product. Strict attention must be paid to aseptic technique with this method to prevent contamination of the solution and subsequent problems. The American Academy of Pediatrics recommends routine prenatal and perinatal human immunodeficiency virus (HIV) counseling and testing for all pregnant women (Pickering, American Academy of Pediatrics, Committee on Infectious Diseases, 2012). Benefits of early identification of HIV-infected infants are early antiretroviral therapy and aggressive nutritional supplementation; appropriate changes in their immunization schedule; monitoring and evaluation of immunologic, neurologic, and neuropsychologic functions for possible changes caused by antiretroviral therapy; initiation special educational services; evaluation for the need of other therapies, such as immunoglobulin for the prevention of bacterial infections; tuberculosis screening and treatment; and management of communicable disease exposures. Cesarean section performed before the rupture of membranes or the onset of labor, may prevent mother-to-child transmission of HIV in optimally treated women and is associated with a reduction in the risk of mother-to-child transmission among HIV-infected women who are either not receiving antiretroviral therapy or are receiving minimal therapy. For infants whose mother's HIV status is unknown, rapid HIV antibody testing provides information within 12 hours of the infant's birth. Antiretroviral prophylaxis is started as soon as possible, pending completion of confirmatory HIV testing. Breastfeeding is delayed until confirmatory testing is done. For information on additional diseases that may be screened in the newborn period, see Newborn Screening Fact Sheets (Kaye, Committee on Genetics, Accurso, et al, 2006a, 2006b).

breastfeeding

Human milk is the preferred form of nutrition for all infants. Healthy People 2020 has a goal to increase breastfeeding rates in the United States to 81.9% in early postpartum and to 61% for mothers who continue to breastfeed for at least 6 months (US Department of Health and Human Services, 2015). Some have voiced concern that early discharge of new mothers from hospitals, more aggressive marketing of infant formulas to the public, and more employed mothers contributed to the decline of breastfeeding. In addition, some hospital practices may undermine breastfeeding. Early separation of the mother and newborn, delays in initiating breastfeeding, provision of formula in the hospital and in discharge packs, conflicting information by health care workers, and formula coupons given at discharge have been implicated in the decline of breastfeeding after discharge. Rooming-in has correlated positively with successful breastfeeding, but the use of pacifiers has sometimes been associated with earlier weaning from breast to bottle. Studies exploring breastfeeding mothers' reasons for early cessation of breastfeeding suggest several factors contribute to this decision, such as problems with lactation, concerns with newborn or maternal health, and lower maternal education (Odom, Li, Scanlon, et al, 2013). Modifiable factors associated with a decreased risk of early cessation of breastfeeding include professional and social support (Meedya, Fahy, and Kable, 2010; Odom, Li, Scanlon, et al, 2013; Thulier and Mercer, 2009). These findings have important implications for nurses in education and discussion regarding breastfeeding before, during, and after pregnancy. The American Academy of Pediatrics Section on Breastfeeding (2012) has reaffirmed its position recommending exclusive breastfeeding until 6 months old, with continued breastfeeding until at least 1 year old and beyond as long as is mutually desirable by mother and infant. The Academy also supports programs that enable women to continue breastfeeding after returning to work. In its support of breastfeeding practices, the Academy further discourages the advertisement of infant formula to breastfeeding mothers and distribution of formula discharge packs without the advice of a health care provider. The Baby-Friendly Initiative (BFI) is a joint effort of the World Health Organization and the United Nations Children's Fund to encourage, promote, and support breastfeeding as the model for optimum infant nutrition. Ten evidence-informed practices were developed by the BFI as a guideline for caregivers worldwide to promote breastfeeding (World Health Organization, United Nations Children's Fund, and Wellstart International, 2009) (Box 7-5). Research indicates that BFI designation is associated with higher rates of breastfeeding initiation (Abrahams and Labbok, 2009); however, BFI designation did not appear to affect breastfeeding rates among women with higher educational levels in a United States sample (Hawkins, Stern, Baum, et al, 2014). In addition, Atchan, Davis, and Foureur (2013), in a review of the evidence exploring association between BFI status and outcomes, note that the lack of clearly worded and sensitive indicators, inaccurate reporting, and the lack of studies with sufficient sample size has limited the ability of researchers to make conclusive statements about the existence of direct causal effect between breastfeeding practices and the initiative, although there is clearly a positive association. In addition to the physiologic qualities of human milk, the most outstanding psychological benefit of breastfeeding is the close mother-child relationship. The infant is nestled close to the mother's skin, can hear the rhythm of her heartbeat, can feel the warmth of her body, and has a sense of peaceful security. The mother has a close feeling of union with her child and feels a sense of accomplishment and satisfaction as the infant sucks milk from her.

feeding schedules

Ideally, feeding schedules should be determined by the infant's hunger. Demand feedings involve feeding infants when they signal readiness. Scheduled feedings are arranged at predetermined intervals. Although this may be satisfactory for bottle-fed infants, it hinders the breastfeeding process. Breastfed infants tend to be hungry every 2 to 3 hours because of the easy digestibility of the milk; therefore, they should be fed on demand. Supplemental feedings should not be offered to breastfed infants before lactation is well established, because they may satiate the infant and may cause nipple preference. Supplemental water is not needed in breastfed infants even in hot climates (Kleinman and Greer, 2014). Satiated infants suck less vigorously at the breast, and milk production depends on the breast being emptied at each feeding. If milk is allowed to accumulate in the ducts (causing breast engorgement) ischemia results, suppressing the activity of the acini, or milk-secreting cells. Consequently, milk production is reduced. In addition, the process of sucking from a bottle is different from breast nipple compression. The relatively inflexible rubber nipple prevents the tongue from its usual rhythmic action. Infants learn to put the tongue against the nipple holes to slow down the more rapid flow of fluid. When infants use these same tongue movements during breastfeeding, they may push the human nipple out of the mouth and may not grasp the areola properly. Usually by 3 weeks old, lactation is well established. Bottle-fed infants consume about 2 to 3 oz of formula at each feeding and are fed approximately six times a day. The quantity of formula consumed is based on the caloric need of 108 kcal/kg/day; therefore, a newborn who weighs 3 kg requires 324 kcal/day. Because commercial formula has 20 kcal/oz, approximately 16 oz (480 ml) provides the daily caloric requirement. Breastfed infants may feed as frequently as 10 to 12 times a day.

alternate milk products

In the United States, few infants are fed evaporated milk formula, and its use is not recommended by the American Academy of Pediatrics, Committee on Nutrition (Kleinman and Greer, 2014). However, it has advantages over whole milk. It is readily available in cans; needs no refrigeration if unopened; is less expensive than commercial formula; provides a softer, more digestible curd; and contains more lactalbumin and a higher calcium-to-phosphorus ratio. Disadvantages of evaporated milk for infant nutrition include low iron and vitamin C concentrations, excessive sodium and phosphorus, decreased vitamin A and D (except in fortified forms), and poorly digested fat. A common rule for preparing evaporated milk formula is diluting the 13-oz can of milk with 19.5 ounces of water and adding 3 Tbsp of sugar or commercially processed corn syrup. Evaporated milk must not be confused with condensed milk, which is a form of evaporated milk with 45% more sugar. Because of its high carbohydrate concentration and disproportionately low fat and protein content, condensed milk is not used for infant feeding. Likewise, skim and low-fat milk must not be used for infant milk, because they are deficient in caloric concentration, significantly increase the renal solute load and water demands, and deprive the body of essential fatty acids. Goat's milk is a poor source of iron and folic acid. It has an excessively high renal solute load as a result of its high protein content, making it unsuitable for infant nutrition (Kleinman and Greer, 2014). Some believe that goat's milk is less allergenic than other available milk sources and may feed it to their infants to reduce allergic milk reactions. However, infants allergic to cow's milk are just as likely to be allergic to goat's milk; other complications (such as, hypernatremia and metabolic acidosis) may ensue as a result of the high sodium and protein concentration found in goat's milk compared with human milk (Basnet, Schneider, Gazit, et al, 2010). Raw, unpasteurized milk from any animal source is unacceptable for infant nutrition.

early newborn discharge

It was a singleton birth between 38 and 42 weeks of gestation. • Baby was delivered by uncomplicated vaginal delivery. • Birth weight is appropriate for gestational age (AGA). • Physical examination was normal. • Vital signs are within normal range and stable for the 12 hours preceding discharge. • Infant has urinated and passed at least one stool. • Infant has completed at least two successful feedings. • Clinical significance of jaundice, if present, has been determined and appropriate management or follow-up plans put in place. • Appropriate maternal and infant blood tests have been performed. • Appropriate neonatal immunizations have been administered. • Newborn hearing screening has been completed per hospital protocol and state regulations. • Family, environmental, and social risk factors have been assessed. • Documentation is in place that the mother has received usual infant care training and has demonstrated competency. • Support persons are available to assist mother and her infant after discharge. • Continuing medical care is planned, including that infants discharged sooner than 48 hours be examined within 48 hours of discharge from the hospital. 2. Although some mothers and newborns may be safely discharged within 12 to 24 hours without detriment to their health, others require a longer stay. Follow-up home care within days (or even hours after discharge when minor problems are anticipated) appears to be the emerging trend in an effort to curtail hospital costs and provide adequate mother-newborn care with minimal complications (see Community Focus boxes). 3. Despite the changing spectrum of well-newborn health care, the nurse's role continues to be that of providing ongoing assessments of each mother-newborn dyad to ensure a safe transition to home and a successful adaptation into the family unit. The ultimate safety and success of early newborn discharge from hospital are contingent on using clear discharge criteria and having a high-quality early follow-up program. With family structures changing, it is essential that nurses identify the primary caregiver, which may not always be the mother but may be a father, grandparent, or babysitter. Depending on the family 225composition, the mother's primary support system in the care of the newborn may not always be the traditional husband or male companion. Nurses should not assume that terminology associated with mother-infant care is understood. Words relating to the anatomy (e.g., meconium, labia, edema, and genitalia) and to breastfeeding (e.g., areola, colostrum, and let-down reflex) may be unfamiliar to mothers. Mothers with other children do not necessarily understand more words, and younger, less educated mothers may be at particular risk for not understanding teaching. An essential area of discharge counseling is the safe transportation of the newborn home from the hospital. Ideally, this information should be provided before delivery to allow parents an opportunity to purchase a suitable infant car safety seat. When purchasing a car safety seat, parents should consider cost and convenience. The convertible-type seats are more expensive initially but cost less than two separate systems (infant-only model and infant-toddler convertible model). Convenience is a major factor because a cumbersome restraint may be used less often or used improperly. Before buying a car safety seat, it is best to look carefully at different models. For example, some types are too large for subcompact cars. Asking friends about the advantages and disadvantages of their restraints is helpful, but borrowing a car seat or purchasing a used one can be dangerous. Parents should use only a restraint that has directions for use and a certification label stating that it complies with federal motor vehicle safety standards (both should be on the seat). They should not use a restraint that has been involved in a crash. Some service clubs and hospitals have loan programs for restraints. Information about approved models and other aspects of car safety seat restraints is available from several organizations and sources.* Parents are cautioned against placing an infant in the front seat of a car with a passenger-side air bag. It is now recommended that infants and toddlers ride rear facing in a child safety seat in the back seat of the car until they are 2 years old or until they reach the maximum height and weight recommended by the car seat manufacturer (Committee on Injury, Violence, and Poison Prevention and Durbin, 2011; Bull, Engle, Committee on Injury, Violence, and Poison Prevention, et al, 2009). Studies indicate that toddlers (up to 24 months of age) are safer riding in convertible seats in the rear-facing position (Bull and Durbin, 2008). A convertible safety seat is positioned semi-reclined and facing the rear of the car. After the child has outgrown the rear-facing seat, a forward-facing seat with a harness is recommended. 4. Although federal safety standards do not specify the minimum weight of an infant and the appropriate type of restraint, newborns weighing 2 kg (4.4 pounds) receive relatively good support in convertible seats with a seat back-to-crotch strap height of 14 cm (5.5 inches) or less. Rolled blankets or towels may be needed between the crotch and legs to prevent slouching and can be placed along the sides to minimize lateral movements. Placing the infant in a safety seat at a 45-degree angle will prevent slumping and airway obstruction (Committee on Injury, Violence, and Poison Prevention and Durbin, 2011; Bull, Engle, Committee on Injury, Violence, and Poison Prevention, et al, 2009). Seats with shields (large padded surfaces in front of the child) and armrests (found on some older models) are unacceptable because of their proximity to the infant's face and neck. (For a discussion of appropriate car restraints for preterm infants, see Community Focus box, Chapter 8; and for infants, see Motor Vehicle Injuries in Chapters 9 and 11.) In the United States and Canada, all states and provinces have mandated the use of child restraints. Therefore, hospitals and birthing centers should have policies regarding the safe discharge of newborns in car safety seats and provisions for parents to learn to use the devices correctly. In addition, hospital personnel should ensure that infants born before 37 weeks of gestation have a period of observation in the selected car seat to monitor for possible apnea, bradycardia, and oxygen desaturation (Bull, Engle, Committee on Injury, Violence, and Poison Prevention, et al, 2009). Parents are more likely to use a restraint correctly and consistently if the proper use of one is demonstrated and its necessity is stressed.

contraindications to breastfeeding

Maternal chemotherapy antimetabolites and certain antineoplastic drugs • Active tuberculosis not under treatment in the mother • HIV in the mother in the industrialized world: In the developing world, risks to non-breastfeeding infants from malnutrition and infectious disease are significant, so the benefits of breastfeeding may outweigh the risk of acquiring HIV from human milk (American Academy of Pediatrics Section on Breastfeeding, 2012) • Galactosemia in the infant • Maternal herpes simplex lesion on a breast • Cytomegalovirus (CMV): May be a risk to extremely low birth weight preterm infants (<1500 gm). CMV is not a risk for full-term infants whose mother is seropositive for CMV. • Maternal substance abuse with street drugs (e.g., phencyclidine [PCP], cocaine, and cannabis) (Note: Adequately-nourished narcotic-dependent mothers may be encouraged to breastfeed if they are enrolled in a supervised methadone maintenance program and have negative screening for HIV and illicit drugs.) • Human T-cell leukemia virus types I and II 218 • Mothers who are receiving diagnostic or radioactive isotopes or who have had exposure to radioactive materials (for as long as there is radioactivity in milk)

infant behavior in parent-child bonding

Nurses must appreciate the individuality and uniqueness of each infant. According to the individual temperament, infants change and shape the environment, which influences their future development (see Patterns of Sleep and Activity, earlier in the chapter). An infant who sleeps 20 hours a day will be exposed to fewer stimuli than one who sleeps 16 hours a day. In turn, each infant will likely elicit a different response from parents. An infant who is quiet, undemanding, and passive may receive much less attention than one who is responsive, alert, and active. Behavioral characteristics such as irritability and consolability can influence the ease of transition to parenthood and the parents' perception of the infant. Nurses can positively influence the attachment of the parent and child. The first step is recognizing individual differences and explaining to the parents that such characteristics are normal. For example, some people believe that infants sleep throughout the day except for feedings. For some newborns, this may be true, but for many, it is not. Understanding that the infant's wakefulness is part of a biologic rhythm and not a reflection of inadequate parenting can be crucial in promoting healthy parent-child relationships. Another aspect of helping parents' concerns includes supplying guidelines on how to enhance the infant's development during awake periods. Placing the child in a crib to stare at the same mobile every day is not exciting, but carrying the infant into each room as one does daily chores can be fascinating. Infants enjoy human contact and often respond to visual and auditory stimuli in different ways depending on their sleep-wake state and the type of stimuli provided. Infants prefer black and white objects, geometric patterns and shapes, and reflective surfaces, such as mirrors and eyeglasses. However, evidence indicates that infants prefer contact with human faces and enjoy interactions with others more than objects or television images.

neonatal circumcision: benefits

Prevention of penile cancer and posthitis (inflammation of prepuce) Decreased incidence of balanitis (inflammation of glans), urinary tract infections in male infants, and some sexually transmitted infections later in life (herpes, syphilis, gonorrhea) Decreased incidence of human immunodeficiency virus (HIV) infection, human papillomavirus (HPV), and cervical cancer (in female partner) Prevention of complications associated with later circumcision Preservation of male's body image that is consistent with peers (only in countries or cultures where procedure is common)

physiologic status of hematopoietic system associated with transition to extrauterine life

The blood volume of the newborn depends on the amount of placental transfer of blood. The blood volume of a full-term infant is about 80 to 85 ml/kg of body weight. Immediately after birth, the total blood volume averages 300 ml, but depending on how long umbilical cord clamping is delayed or if the umbilical cord is milked, as much as 100 ml can be added to the blood volume (Rabe, Jewison, Alvarez, et al, 2011).

arm recoil test for gestational age

With infant supine, fully flex both forearms on upper arms, hold for 5 seconds; pull down on hands to fully extend and rapidly release arms. Observe rapidity and intensity of recoil to a state of flexion. A brisk return to full flexion—4 score

prepare for discharge and home care

With shorter postpartum hospital stays as well as a trend toward mother-infant care, also called dyad or couplet care, discharge planning, referral, and home visits have become increasingly important components of comprehensive newborn care. First-time, as well as experienced, parents benefit from guidance and assistance with the infant's care, such as breastfeeding or bottle feeding, and with the family's integration of a new member, particularly sibling adjustment. To assess and meet these needs, teaching must begin early, ideally before the birth. Not only is the postpartum stay sometimes very short (as little as 12 to 24 hours), but mothers are also in the taking-in phase, during which they may demonstrate passive and dependent behaviors. On the first postpartum day, as a result of fatigue and excitement about the newborn, mothers may not be able to absorb large amounts of information. This time may need to be spent highlighting essential aspects of care, such as infant safety and feeding. Parents may also be given a list of mother and infant care topics so that they can choose issues they wish to review. Teaching before discharge should focus on newborn feeding patterns, monitoring diapers for voiding and stooling, jaundice, and infant crying. The American Academy of Pediatrics, Committee on Fetus and Newborn (2010) has established guidelines for postpartum discharge (see Family-Centered Care box). The Academy emphasizes that each mother-infant dyad should be evaluated individually to determine the optimal time of discharge.

deceleration in reciprocity

deceleration of the excitement and turning away occur in which the infant's eyes shift away from the parent's and the child may grasp his or her shirt. During this cycle of nonattention, repeated verbal or visual attempts to reinitiate the infant's attention are ineffective. This deceleration and turning away probably prevents the infant from being overwhelmed by excessive stimuli.

orientation in reciprocity

establishes the partners' expectations of each other during the interaction

galactogogues

herbal agents that increase breast milk production

attachment behavior

includes activities that occur from the time the infant receives the nipple and sucks (sometimes more pronounced during initial attempts at breastfeeding

approach behavior

indicated by sucking movements or the rooting reflex.

acceleration in reciprocity

infant reaches out and coos, both arms jerk forward, the head moves backward, the eyes dilate, and the face brightens

initiation in reciprocity

interaction between infant and parent begins

monotropy

principle that a person can become optimally attached to only one individual at a time

risks of neonatal circumcision

• Hemorrhage • Infection • Meatitis (from loss of protective foreskin) • Adhesions • Concealed penis • Urethral fistula • Meatal stenosis • Necrosis or amputation Pain in unanesthetized infants: Long-term consequences unknown, but short-term stresses include increased heart rate, behavior changes, prolonged crying, increased cortisol levels, and decreased blood oxygenation

behavioral assessment

1. Another important area of assessment is observation of behavior. Infants' behavior helps shape their environment, and their ability to react to various stimuli affects how others relate to them. The principal areas of behavior for newborns are sleep, wakefulness, and activity (such as crying). One method of systematically assessing the infant's behavior is the use of the Brazelton Neonatal Behavioral Assessment Scale (BNBAS) (Brazelton and Nugent, 1996). The BNBAS is an interactive examination that assesses the infant's response to 28 items organized according to the clusters in Box 7-3. It is generally used as a research or diagnostic tool and requires special training. 2. In addition to its use as an initial and ongoing tool to assess neurologic and behavioral responses, the scale can be used in assessment of initial parent-child relationships, as a preventive instrument that identifies a caregiver who may benefit from a role model, and as a guide to help parents focus on their infant's individuality and develop a deeper attachment to their child (Bruschweiler-Stern, 2009). Studies have demonstrated that showing parents the unique characteristics of their infant causes a more positive perception of the infant to develop, with increased interaction between infant and parent.

general measurements: head circumference

1. For full-term infants, average head circumference is between 33 and 35.5 cm (13 and 14 inches). Head circumference may be somewhat less immediately after birth because of the molding process that occurs during vaginal deliveries. 2. Usually by the second or third day, the skull is normal in size and contour. 3. Head circumference may be compared with crown-to-rump length, or sitting height.

gustatory changes associated with transition to extrauterine life

1. The newborn has the ability to distinguish among tastes and various types of solutions elicit differing facial reflexes. A tasteless solution elicits no facial expression; a sweet solution elicits an eager suck and a look of satisfaction; a sour solution causes puckering of the lips; and a bitter liquid produces an angry, upset expression.

milk stool

1. Usually appears by fourth day. 2. In breastfed infants, stools are yellow to golden, are pasty in consistency, and have an odor similar to that of sour milk. 3. In formula-fed infants, stools are pale yellow to light brown, are firmer in consistency, and have a more offensive odor.

heel to ear test for gestational age

1. With infant supine and pelvis flat on a firm surface, pull foot as far as possible up toward ear on same side. Measure degree of knee flexion (same as popliteal angle). 2. Knees flexed with a popliteal angle of less than 90 degrees—4

weight large for gestational age (LGA)

1. above the 90th percentile 2. can be presumed to have grown at an accelerated rate during fetal life

distinct sleep-wake states in infants

1. quiet (deep) sleep 2. active (light) sleep 3. drowsy 4. quiet alert 5. active alert 6. crying

healthy newborn nursing process: planning

Numerous outcomes for healthy newborns are discussed 211-225. Expected patient outcomes include: • Newborn airway will remain patent. • Effective breathing pattern will be established. • Thermoregulation will be maintained. • Parent-infant attachment behaviors will be observed. • Breastfeeding or bottle feeding will be established. • Infant will exhibit no evidence of infection; immune status will be maintained. • Newborn will remain free of injury. • Family will demonstrate ability to care for the infant's basic needs. • Newborn jaundice will be detected and monitored effectively.

functional capacity of neonatal organ system

the degree to which the neonate's organ systems are able to adapt to the requirements of extrauterine life

intrauterine growth curves

used to classify infants according to birth weight and gestational age

vision changes associated with transition to extrauterine life

1. At birth, the eye is structurally incomplete. The fovea centralis is not yet completely differentiated from the macula. The ciliary muscles are also immature, limiting the eyes' ability to accommodate and focus on 193an object for any length of time. The infant can track and follow objects. The pupils react to light, the blink reflex is responsive to minimal stimulus, and the corneal reflex is activated by a light touch. Tear glands usually do not begin to function until 2 to 4 weeks of age. Newborns have the ability to focus momentarily on a bright or moving object that is within 20 cm (8 inches) and in the midline of the visual field. In fact, infants' ability to fixate on coordinated movement is greater during the first hour of life than during the succeeding several days. Visual acuity is reported to be between 20/100 and 20/400, depending on the vision measurement techniques. Infants also demonstrate visual preferences: medium colors (yellow, green, pink) over bright (red, orange, blue) or dim colors; black-and-white contrasting patterns, especially geometric shapes and checkerboards; large objects with medium complexity rather than small, complex objects; and reflecting objects over dull ones.

maintain a stable body temperature

1. Conserving the newborn's body heat is an essential nursing goal. At birth, a major cause of heat loss is evaporation, the loss of heat through moisture. The amniotic fluid that bathes the infant's skin favors evaporation, especially when combined with the cool atmosphere of the delivery room. Heat loss through evaporation is minimized by rapidly drying the skin and hair with a warmed towel and placing the infant in skin-to-skin contact with the mother, covered by a blanket. Another major cause of heat loss is radiation, the loss of heat to cooler solid objects in the environment that are not in direct contact with the infant. Loss of heat through radiation increases as these solid objects become colder and closer to the infant. The temperature of ambient or surrounding air has no effect on loss of heat through radiation. This is a critical point to remember when attempting to maintain a constant temperature for the infant because even though the temperature of the ambient air is optimal, the infant can become hypothermic. An example of radiant heat loss is the placement of the crib close to a cold window or air-conditioning unit. The cold from either source will cool the crib walls, and subsequently, the body of the neonate. To prevent this, place cribs as far away as possible from exterior walls, windows, and ventilating units. Heat loss can also occur through conduction and convection. Conduction involves loss of heat from the body because of direct contact of skin with a cooler solid object. Placing the infant on a padded, covered surface and providing insulation through clothes and blankets rather than directly on a cool hard table can minimize heat loss. Placing the newborn skin-to-skin with the mother on her chest or abdomen immediately after delivery is physically beneficial in terms of conserving heat, as well as fostering maternal attachment and breastfeeding. Convection is similar to conduction except that heat loss is aided by surrounding air currents. For example, placing the infant in the direct flow of air from a fan or air-conditioner vent will cause rapid heat loss through convection. Transporting the neonate in a crib with solid sides reduces airflow around the infant.

New Ballard scale: general facts

1. For infants with a gestational age of at least 26 weeks, the examination may be performed up to 96 hours after birth. 2. It is recommended that the initial examination be performed within the first 48 hours of life. 3. In a study of preterm infants ranging from 29 to 35 weeks at birth, Ballard scores completed after 7 days after birth were found to either overestimate or underestimate gestational age by up to 2 weeks 4. In another study, researchers found general agreement between NBS and ultrasonography or last menstrual period. 5. Second study also noted that NBS tends to overestimate gestational age in very preterm newborns and in infants whose mothers had received prenatal corticosteroid therapy.

meconium

1. Infant's first stool; composed of amniotic fluid and its constituents, intestinal secretions, shed mucosal cells, and possibly blood (ingested maternal blood or minor bleeding of alimentary tract vessels). 2. Passage of meconium should occur within the first 24 to 48 hours, although it may be delayed up to 7 days in very low birth weight infants.

patterns of sleep and activity

1. Newborns begin life with a systematic schedule of sleep and wakefulness that is initially evident during the periods of reactivity. After this initial period, it is not unusual for the infant to sleep almost constantly for the next 2 to 3 days to recover from the exhausting birth process. Infants have six distinct sleep-wake states, which represent a particular form of neural control (Table 7-3). As maturity increases, each state becomes more precisely defined according to the behaviors 205observed. State is defined as a "group of characteristics that regularly occur together" (Blackburn, 2013) and includes body activity, eye and facial movements, respiratory pattern, and response to internal and external stimuli. The six sleep-wake states are quiet (deep) sleep, active (light) sleep, drowsy, quiet alert, active alert, and crying. Infants respond to internal and external environmental factors by controlling sensory input and regulating the sleep-wake states; the ability to make smooth transitions between states is called state modulation. The ability to regulate sleep-wake states is essential in infants' neurobehavioral development. The more immature the infant, the less able he or she is able to cope with external and internal factors that affect the sleep-wake patterns. 2. Recognition and knowledge of sleep-wake states is important in the planning of nursing care. It is also important for nurses to help parents and caregivers understand the significance of the infant's behavioral responses to daily caregiving and how these states can be altered. A classic example is a newborn who feeds vigorously in the active alert state but poorly when he or she progresses to the crying state. The neurologic assessment of a newborn in the active alert state will differ significantly from that performed during the deep sleep state. Newborns typically spend as much as 16 to 18 hours sleeping and do not necessarily follow a pattern of light-dark diurnal rhythm. With increasing age, sleep-wake states change, with increasing amounts of time spent in awake alert states and decreasing amounts of sleep time. Approximately 50% of total sleep time is spent in irregular or rapid eye movement sleep.

cry assessment

1. Newborns should begin extrauterine life with a strong, lusty cry. The duration of crying is as variable in each infant as the duration of sleep patterns. Newborns may cry as little as 5 minutes or as much as 2 hours or more per day. Feeding usually terminates the state of crying when hunger is the cause. Holding the infant skin-to-skin, swaddling or wrapping an infant snugly in a blanket (while ensuring the hands remain free to allow for self-calming and avoid overheating) calms infants, promotes sleep, and maintains body temperature. Rocking the infant may reduce crying and induce quiet alertness or sleep. 2. Variations in the initial cry can indicate abnormalities. A weak, groaning cry or grunting during expiration usually indicates respiratory disturbance. Absent, weak, or constant crying requires further investigation for possible drug withdrawal or a neurologic problem.

tests used in assessing gestational age

1. Posture: 2. Square window 3. Arm recoil 4. Popliteal angle 5. Scarf sign 6. Heel to ear

components of neonate assessment

1. The initial assessment, which includes the Apgar scoring system 2. Transitional assessment during the periods of reactivity 3. Assessment of gestational age 4. Systematic physical examination 5. behaviors that signal successful reciprocal attachment between the infant and parents. 6. With shorter hospitalizations, the accomplishment of thorough newborn assessment and parent teaching may be a challenge.

abdomen assessment

1. The normal contour of the abdomen is cylindric and usually prominent with few visible veins. Bowel sounds are heard within the first 15 to 20 minutes after birth. Visible peristaltic waves may be observed in some newborns. Inspect the umbilical cord to determine the presence of two arteries, which look like papular structures, and one vein, which has a larger lumen than the arteries and a thinner vessel wall. At birth, the umbilical cord appears bluish white and moist. After clamping, it begins to dry and appears a dull, yellowish brown. It progressively shrivels in size and turns greenish black. If the umbilical cord appears unusually large in diameter at the base, inspect for the presence of a hematoma or small omphalocele. If the cord is clamped over an existing omphalocele, part of the intestine will be clamped, causing tissue necrosis. One practical rule of thumb is to cut the cord distally 4 to 5 inches from a questionable enlargement until further examination is carried out by a practitioner. The extra length can later be cut if no pathologic condition has been identified. 2. Palpate after inspecting the abdomen. The liver is normally palpable 1 to 3 cm (≈0.5 to 1 inch) below the right costal margin. The tip of the spleen can sometimes be felt, but a palpable spleen more than 1 cm below the left costal margin suggests enlargement and warrants further investigation. Although both kidneys should be palpated, this maneuver requires considerable practice. When felt, the lower half of the right kidney and the tip of the left kidney are 1 to 2 cm above the umbilicus. During examination of the lower abdomen, palpate for femoral pulses, which should be strong and equal bilaterally.

assessing attachment behavior

1. When the infant is brought to the parents, do they reach out for the child and call the child by name? 2. Do the parents speak about the child in terms of identification—who the infant looks like; what appears special about their child compared with other infants? 3. When parents are holding the infant, what kind of body contact is there? Do they feel at ease in changing the infant's position? Are fingertips or whole hands used? Are there parts of the body that they avoid touching or parts of the body they investigate and scrutinize? 4. When the infant is awake, what kinds of stimulation do the parents provide? Do they talk to the infant, to each other, or to no one? How do they look at the infant—direct visual contact, avoidance of eye contact, or looking at other people or objects? 5. How comfortable do the parents appear in terms of caring for the infant? Do they express any concern regarding their ability or disgust for certain activities, such as changing diapers? 6. What type of affection do they demonstrate to the newborn, such as smiling, stroking, kissing, or rocking? 7. If the infant is fussy, what kinds of comforting techniques do the parents use, such as rocking, swaddling, talking, or stroking?

posture test for gestational age

1. With infant quiet and in a supine position, observe degree of flexion in arms and legs. Muscle tone and degree of flexion increase with maturity. 2. Full flexion of the arms and legs—4* score

popliteal angle test for gestational age

1. With infant supine and pelvis flat on a firm surface, flex lower leg on thigh and then flex thigh on abdomen. 2. While holding knee with thumb and index finger, extend lower leg with index finger of other hand. Measure degree of angle behind knee (popliteal angle). 3. An angle of less than 90 degrees—5 score

scarf sign test for gestational age

1. With infant supine, support head in midline with one hand 2. use other hand to pull infant's arm across the shoulder so that infant's hand touches shoulder. 3. Determine location of elbow in relation to midline. 4. Elbow does not reach midline—4 score

square window test for gestational age

1. With thumb supporting back of arm below wrist, apply gentle pressure with index and third fingers on dorsum of hand without rotating infant's wrist. Measure angle between base of thumb and forearm. 2. Full flexion (hand lies flat on ventral surface of forearm)—4 score

clinical assessment of gestational age: New Ballard scale

1. abbreviated Dubowitz scale 2. assesses six external physical and six neuromuscular signs. 3. each sign has a number score, and the cumulative score correlates with a maturity rating of 20 to 44 weeks of gestation.

weight small for gestational age (SGA)

1. below the 10th percentile 2. can be assumed to have intrauterine growth restriction or delay

weight appropriate for gestational age (AGA)

1. between 10th and 90th percentiles 2. presumed to have grown at a normal rate regardless of the time of birth—preterm, term, or postterm

signs of extremely pre-term infants

1. fused eyelids 2. imperceptible breast tissue 3. sticky, friable, transparent skin, no lanugo, and square-window (flexion of wrist) angle of greater than 90 degrees

sleep-wake state: defn

1. group of characteristics that regularly occur together 2. each represents a particular form of neural control 3. As maturity increases, each state becomes more precisely defined according to the behaviors 205observed

criteria for intrauterine growth

1. head circumference 2. birth weight 3. length 4. varies according to race and gender

general measurements

1. head circumference 2. vital signs 3. crown to rump length 4. abdominal circumference 5. head to heel length 6. body weight 7. vital signs

change in stooling patterns of newborns

1. meconium 2. transitional stool 3. milk stool

suggested general schedule for vital signs monitoring

1. once every 30 minutes until the newborn has been stable for 2 hours 2. then, once every 8 hours until discharge. 3. Any change in the infant, such as color, breathing, muscle tone, or behavior, necessitates more frequent monitoring.

cardinal signs of respiratory distress in a newborn

1. tachypnea 2. nasal flaring 3. grunting 4. intercostal retractions 5. cyanosis

physiological changes in neonate associated with loss of placenta

1. transition from fetal or placental circulation to independent respiration (most profound change) 2. loss of complete metabolic support (due to the loss of the placental connection), especially the supply of oxygen and the removal of carbon dioxide. 3. alterations of placental gas exchange patterns (due to normal stresses of labor and delivery) 4. acid-base balance in the blood (due to normal stresses of labor and delivery) 5. cardiovascular activity in the infant (due to normal stresses of labor and delivery)

newborn screening for disease

A number of genetic disorders can be detected in the newborn period. There is no national policy for newborn screening in the United States; therefore, the extent of neonatal screening is determined by state laws and voluntary guidelines. All states require screening for phenylketonuria (PKU) and congenital hypothyroidism; many states also have programs that include screening for sickle cell disease and galactosemia. Because concern has been voiced regarding the inconsistency among states in screening for genetic disorders based on cost, population demographics, resource availability, and political environment, the Task Force on Newborn Screening was formed by the American Academy of Pediatrics and other federal health care agencies to address this issue. A number of resolutions and policies have been developed to better address the issue of newborn screening (Kaye, Committee on Genetics, Accurso, et al, 2006a, 2006b). The nurse's responsibility is to educate parents regarding the importance of screening and to collect appropriate specimens at the recommended time (after 24 hours of age). With early newborn discharge before 24 hours, some authorities recommend a repeat screening for PKU within 2 weeks (Kaye, Committee on Genetics, Accurso, et al, 2006a, 2006b). 212Accurate screening depends on high-quality blood spots on approved filter paper forms. The blood should completely saturate the filter paper spot on one side only. The paper should not be handled, placed on wet surfaces, or contaminated with any substance (see Atraumatic Care box).

general measurement: abdominal circumference

Abdominal circumference need not be routinely measured in newborns but should be done in the event of abdominal distention to determine changes in girth over time. Abdominal circumference is measured just above the level of the umbilicus because the umbilical cord is still attached, making measurements across the umbilicus too variable in newborns. Measuring the abdominal circumference below the umbilical region is unsuitable because bladder status may affect the reading.

physiologic status of renal system associated with transition to extrauterine life

All structural components are present in the renal system, but there is a functional deficiency in the kidneys' ability to concentrate urine and to cope with conditions of fluid and electrolyte stress, such as dehydration or a concentrated solute load. Total volume of urine per 24 hours is about 200 to 300 ml by the end of the first week. However, the bladder voluntarily empties when stretched by a volume of 15 ml, resulting in as many as 20 voidings per day. The first voiding should occur within 24 hours. The urine is colorless and odorless and has a specific gravity of about 1.020.

physical assessment

An essential aspect of the care of the newborn is a thorough physical assessment that includes estimation of gestational age and physical examination to identify normal characteristics and existing abnormalities. These initial and ongoing assessments are critical to establishing baseline data for planning, implementing, and evaluating care and are a nursing priority in caring for the newborn. The discussion of physical examination focuses on normal findings and variations from the norm that require little or no intervention. Readers are encouraged to review Chapter 4 for further discussion of examination techniques. General guidelines for conducting a physical examination are presented in the Nursing Care Guidelines box. Table 7-4 summarizes physical examination of newborns.

mouth and throat assessment

An external defect of the mouth (such as, cleft lip) is readily apparent; however, the internal structures require careful inspection. The palate is normally highly arched and somewhat narrow. Rarely, teeth may be present. A common finding is Epstein pearls, small, white, epithelial cysts along both sides of the midline of the hard palate. They are insignificant and disappear in several weeks. The frenulum of the upper lip is a band of thick pink tissue that lies under the inner surface of the upper lip and extends to the maxillary alveolar ridge. It is particularly evident when the infant yawns or smiles. It disappears as the maxilla grows. The lingual frenulum attaches the underside of the tongue to the lower palate midway between the ventral surface of the tongue and the tip. In some cases, a tight lingual frenulum, formerly referred to as tongue-tie, may restrict adequate sucking. Further evaluation may be required to ascertain adequate sucking, particularly in breastfed infants. The treatment for a tight lingual frenulum advocated by the American Academy of Pediatrics, Committee on Fetus and Newborn (2010) is frenotomy, a safe and effective surgical procedure that may improve comfort, effectiveness, and ease of breastfeeding for the mother and infant (Brookes and Bowley, 2014; Forlenza, Paradise Black, McNamara, et al, 2010). Research continues in an effort to determine how best to select which infants will benefit from the procedure and when to perform it (Emond, Ingram, Johnson, et al, 2014; Power and Murphy, 2015). Elicit the sucking reflex by placing a nipple or nonlatex gloved finger in the infant's mouth. The infant should exhibit a strong, vigorous suck. The rooting reflex is elicited by stroking the cheek and noting the infant's response of turning toward the stimulated side and sucking. The uvula can be inspected while the infant is crying and the chin is depressed. However, it may be retracted upward and backward during crying. Tonsillar tissue is generally not seen in newborns. Natal teeth, teeth present at birth, as opposed to neonatal teeth, which erupt during the first month of life, are seen infrequently and erupt chiefly at the position of the lower incisors. Teeth are reported because they are frequently found with developmental abnormalities and syndromes, including cleft lip and palate. Most natal teeth are loosely attached. However, current thinking suggests preserving them until they exfoliate naturally (Maheswari, Kumar, Karunakaran, et al, 2012) unless the tooth is attached loosely or breastfeeding is impaired by the neonate's biting the breast.

immediate circulatory system adjustments associated with transition to extrauterine life

As important as the initiation of respiration are the circulatory changes that allow blood to flow through the lungs. These changes, which occur more gradually, are the result of pressure changes in the lungs, heart, and major vessels. The transition from fetal to postnatal circulation involves the functional closure of the fetal shunts: the foramen ovale, the ductus arteriosus, and eventually the ductus venosus. (For a review of fetal circulation, see Chapter 23.) Increased blood flow dilates the pulmonary vessels, pulmonary vascular resistance decreases, and systemic resistance increases, thus maintaining blood pressure (BP). As the pulmonary vessels receive blood, the pressure in the right atrium, right ventricle, and pulmonary arteries decreases. Left atrial pressure increases above right atrial pressure, with subsequent foramen ovale closure. With the increase in pulmonary blood flow and dramatic reduction of pulmonary vascular resistance, the ductus arteriosus begins to close. The most important factors controlling ductal closure are the increased oxygen concentration of the blood and the fall in endogenous prostaglandins. The foramen ovale closes functionally at or soon after birth. The ductus arteriosus is closed functionally by the fourth day. Anatomic closure takes considerably longer. Failure of the ductus arteriosus or foramen ovale to close results in persistence of fetal shunting of blood away from the lungs (see Chapter 23). Because of the reversible flow of blood through the ductus during the early neonatal period, a functional murmur occasionally may be heard. In conditions such as crying or straining, the increased pressure shunts deoxygenated blood from the right side of the heart across the ductal opening, which may cause transient cyanosis.

physiologic status of integumentary system associated with transition to extrauterine life

At birth, all of the structures within the skin are present, but many of the functions of the integument are immature. The outer two layers of the skin, the epidermis and dermis, are loosely bound to each other and very thin. Rete pegs, which later in life anchor the epidermis to the dermis, are not developed. Slight friction across the epidermis, such as from rapid removal of adhesive tape, can cause separation of these layers and blister formation. The transitional zone between the cornified and living layers of the epidermis is effective in preventing fluid from reaching the skin surface. The sebaceous glands are active late in fetal life and in early infancy because of the high levels of maternal androgens. They are most densely located on the scalp, face, and genitalia and produce the greasy vernix caseosa that covers infants at birth. Plugging of the sebaceous glands causes milia. The eccrine glands, which produce sweat in response to heat or emotional stimuli, are functional at birth, and by 3 weeks of age palmar sweating on crying reaches levels equivalent to those of anxious adults. The eccrine glands produce sweat in response to higher temperatures than those required in adults, and the retention of sweat may result in milia. The apocrine glands remain small and nonfunctional until puberty. The growth phases of hair follicles usually occur simultaneously at birth. During the first few months, the synchrony between hair loss and regrowth is disrupted, and there may be overgrowth of hair or temporary alopecia. Because the amount of melanin is low at birth, newborns are lighter skinned than they will be as children. Consequently, they are more susceptible to the harmful effects of the sun.

physiologic status of neurological system associated with transition to extrauterine life

At birth, the nervous system is incompletely integrated but sufficiently developed to sustain extrauterine life. Most neurologic functions are primitive reflexes. The autonomic nervous system is crucial during transition because it stimulates initial respirations, helps maintain acid-base balance, and partially regulates temperature control. Myelination of the nervous system follows cephalocaudal/proximodistal (head-to-toe/center-to-periphery) laws of development and is closely related to observed mastery of fine and gross motor skills. Myelin is necessary for rapid and efficient transmission of some, but not all, nerve impulses along the neural pathway. The tracts that develop myelin earliest are the sensory, cerebellar, and extrapyramidal tracts. This accounts for the acute senses of taste, smell, and hearing in newborns, as well as the perception of pain. All cranial nerves are present and myelinated except for the optic and olfactory nerves.

eye assessment

Because newborns tend to have their eyes tightly closed, it is best to begin the examination of the eyes by observing the eyelids for edema, which is normally present for the first 2 days after delivery. The eyes are observed for symmetry. Tears may be present at birth, but purulent discharge from the eyes shortly after birth is abnormal. To visualize the surface structures of the eyes, the infant is held supine, and the head is gently lowered. The eyes will usually open, similar to the mechanism of a doll's eyes. The sclera should be white and clear. The cornea is examined for the presence of any opacities or haziness. The corneal reflex is normally present at birth but may not be elicited unless neurologic or eye damage is suspected. The pupil will usually respond to light by constricting. The pupils are normally malaligned. A searching nystagmus is common. Strabismus is a normal finding because of the lack of binocularity. The color of the iris is noted. Most light-skinned newborns have slate gray or dark blue eyes, and dark-skinned infants have brown eyes. A funduscopic examination may be difficult to perform because of the infant's tendency to keep the eyes tightly closed. However, a red reflex should be elicited. The absence of a red reflex in a newborn may indicate a cataract, glaucoma, retinal abnormalities, or retinoblastoma (see Chapter 4).

care of the umbilicus

Because the umbilical stump is an excellent medium for bacterial growth, various methods of cord care have been practiced to prevent infection. Some methods popular in the past include the use of an antimicrobial agent (such as, bacitracin or triple dye) and agents (such as alcohol or povidone iodine). The use of antiseptic agents has been shown to prolong cord drying and separation (Zupan, Garner, and Omari, 2004). A Cochrane review of 21 studies found no significant difference between cords treated with antiseptics compared with dry cord care or placebo; there were no reported systemic infections or deaths, and a trend toward reduced colonization was found in cords treated with antiseptics (Zupan, Garner, and Omari, 2004). Recommendations for cord care by the Association of Women's Health, Obstetric and Neonatal Nursing (2013) include cleaning the umbilical cord initially with sterile water or a neutral pH cleanser and then subsequently cleaning the cord with water. Nurses working in neonatal care must carefully evaluate the available studies and compare the risks and benefits regarding the method of cord care within their own population of newborns and families. Regardless of the method used, nurses must include cord care teaching in the discharge planning, because it has been demonstrated to be a concern for parents after discharge to the home. Particularly in the developing world, infants may encounter increased risk of potentially life-threatening sepsis; thus, antimicrobial treatment may be appropriate in some settings (Mullany, Darmstadt, Katz, et al, 2009). The diaper is folded in front below the cord to avoid irritation and wetness on the site. The area is kept free of urine and stool and cleansed daily with water if needed. Parents are instructed regarding stump deterioration and proper umbilical care. The stump deteriorates 214through the process of dry gangrene. Cord separation time is influenced by a number of factors, including the type of cord care, type of delivery, and other perinatal events. The average cord separation time is 5 to 15 days. It takes a few more weeks for the cord base to heal completely after cord separation. During this time, care consists of keeping the base clean and dry and observing for any signs of infection.

general appearance assessment

Before each body system is assessed, it is important to describe the general posture and behavior of the newborn. The overall appearance yields valuable clues to the infant's physical status. In full-term neonates, the posture is one of complete flexion as a result of in utero position. Most infants are born in a vertex presentation with the head flexed and the chin resting on the upper chest, the arms flexed with the hands clenched, the legs flexed at the knees and hips, and the feet dorsiflexed. The vertebral column is also flexed. It is important to recognize any deviation from this characteristic fetal position. The infant's behavior is carefully noted, especially the degree of alertness, drowsiness, and irritability; the latter two factors may reflect common signs of neurologic problems. Some questions to mentally ask when assessing behavior include: • Is the infant awakened easily by a loud noise? • Is the infant comforted by rocking, sucking, or cuddling? • Do there seem to be periods of deep and light sleep? • When awake, does the infant seem satisfied after a feeding? • What stimuli elicit responses from the infant? • When disturbed, how much does the infant protest?

general measurement: crown to rump length

Crown-to-rump measurements are usually 31 to 35 cm (12.2 to 13.8 inches), thus head circumference is generally equal to or up to 2 cm more than crown-to-rump length. Comparing neonatal head circumference with crown-to-rump length may provide a means for identifying infants at risk for microcephaly, hydrocephalus, cephalhematoma, subgaleal hemorrhage, and subdural hematoma. Prematurity and intrauterine malnutrition may also disrupt the relationship between head circumference and crown-to-rump length.

maintain a patent airway

Establishing a patent airway is a primary objective in the delivery room. When the newborn is supine, a neutral neck position (i.e., avoiding neck flexion or hyperextension) is critical to achieving and maintaining a patent airway. The American Academy of Pediatrics Task Force on Sudden Infant Death Syndrome (2011) recommends the supine position during sleep for healthy newborns. This recommendation is based on the association between sleeping prone and sudden infant death syndrome (see Chapter 10). Since the initial recommendation in 1992 that all infants be placed in the supine position to sleep, there has been no evidence of an increased number of complications, such as choking or vomiting, when infants are placed in this position (Krous, Masoumi, Haas, et al, 2007; Malloy, 2002). There has, however, been an increase in the number of infants with cranial asymmetry, particularly unilateral flattening of the occiput (American Academy of Pediatrics, Task Force on Sudden Infant Death Syndrome, 2011). Health care professionals must educate parents on prevention of positional plagiocephaly by encouraging alternate positions when infants are awake (Laughlin, Luerssen, Dias, et al, 2011). A bulb syringe is kept near the infant and is used if suctioning is required. If more forceful removal of secretions is required, mechanical suction is used. The use of the properly sized catheter and correct suctioning technique is essential to prevent mucosal damage and edema. Gentle suctioning is necessary to prevent reflex bradycardia, laryngospasm, and cardiac arrhythmias from vagal stimulation. Oropharyngeal suctioning is performed for up to 5 seconds, with sufficient time between each attempt to allow the infant to reoxygenate. 2. mouth before nose; clear pharynx before nasal passages using a bulb syringe

extremities assessment

Examine the extremities for symmetry, range of motion, and signs of malformation. Count the fingers and toes and note any supernumerary digits (polydactyly) or fusion of digits (syndactyly). A partial syndactyly between the second and third toes is a common variation seen in otherwise normal infants. The nail beds should be pink, although slight blueness is evident in acrocyanosis. The palms of the hands should have the usual creases. Full-term newborns usually have creases covering the entire sole of the foot. The soles of the feet are flat with prominent fat pads. Observe range of motion of the extremities throughout the entire examination. The absence of arm movement signals a potential birth injury paralysis, such as Klumpke or Erb-Duchenne palsy. An asymmetric or partial Moro reflex should alert the practitioner to further evaluate upper extremity mobility. Examine the lower extremities for limb length, symmetry, and hip abduction and flexion. Newborns demonstrate full range of motion in the elbow, hip, shoulder, and knee joints. Movements should be symmetric, smooth, and unrestricted. 202 Also assess muscle tone. By attempting to extend a flexed extremity, determine if tone is equal bilaterally. Extension of any extremity is usually met with resistance, and when released, the extremity returns to its previous flexed position. Hypotonia suggests some degree of hypoxia or neurologic disorder and is common in an infant with Down syndrome. Asymmetry of muscle tone may indicate a degree of paralysis from brain damage or nerve damage. Failure to move the lower limbs suggests a spinal cord lesion or injury. Sustained rhythmic tremors, twitches, and myoclonic jerks characterize neonatal seizures or may indicate neonatal abstinence syndrome. (See Neonatal Seizures and Drug-Exposed Infants, Chapter 8.) Sudden asynchronous jerking movements, quivering, or momentary tremors are usually normal.

heart assessment

Heart rate is auscultated and may range from 100 to 180 beats/min shortly after birth and, when the infant's condition has stabilized, from 120 to 140 beats/min. The point of maximum intensity (PMI) may be palpated and is usually found at the fourth to fifth intercostal space, medial to the left midclavicular line. The PMI gives some indication of the location of the heart, which may be displaced in conditions, such as congenital diaphragmatic hernia or pneumothorax. Dextrocardia, an anomaly wherein the heart is on the right side of the body, is reported because the abdominal organs may also be reversed, with associated circulatory abnormalities. Auscultation of the specific components of the heart sounds is difficult because of the rapid rate and effective transmission of respiratory sounds. However, the first (S1) and second (S2) sounds should be clear and well defined; the second sound is somewhat higher in pitch and sharper than the first. A murmur is frequently heard in newborns, especially over the base of the heart or at the left sternal border at the third or fourth interspace. In newborns, a murmur is not necessarily associated with specific cardiac defects but frequently represents the incomplete functional closure of fetal shunts. (See Chapter 4 for other characteristics of murmurs.) However, always record and report all murmurs and other unusual heart sounds.

physiologic status of infection defenses associated with transition to extrauterine life

Infants are born with several defenses against infection. The first line of defense is the skin and mucous membranes, which protect the body from invading organisms. The mature neonatal intestinal mucosal (gut) barrier also plays a vital role as an important defense mechanism against antigens. The second line of defense is the macrophage system, which produces several types of cells capable of attacking a pathogen. The neutrophils and monocytes are phagocytes, which means they can engulf, ingest, and destroy foreign agents. Eosinophils also probably have a phagocytic property because they increase in number in the presence of foreign protein. The lymphocytes (T cells and B cells) are capable of being converted to other cell types, such as monocytes and antibodies. Although the phagocytic properties of the blood are present in infants, the inflammatory response of the tissues to localize an infection is immature. The third line of defense is the formation of specific antibodies to an antigen. Exposure to various foreign agents is necessary for antibody production to occur. Infants are generally not capable of producing their own immunoglobulin until the beginning of the second month of life, but they receive considerable passive immunity in the form of immunoglobulin G (IgG) from the maternal circulation and from human milk (see Human Milk later in chapter). They are protected against most major childhood diseases, including diphtheria, measles, poliomyelitis, and rubella, for about 3 months, provided the mother has developed antibodies to these illnesses.

universal newborn hearing screening

It is estimated that screening children by high-risk factors alone fails to identify approximately 50% of all newborns with congenital hearing loss. Infants who are hard of hearing or deaf, but who receive intervention before 6 months old, score 20 to 40 percentile points higher on school-related measures (language, social adjustment, and behavior), compared with hearing-impaired children who receive later intervention (Patel and Feldman, 2011). For these reasons, the American Academy of Pediatrics, Joint Committee on Infant Hearing (2007) recommends universal hearing screening of all newborns before discharge from the birthing hospital. For infants born by cesarean delivery, it is preferable to delay otoacoustic emission (OAE) testing until after 48 hours of age, because testing earlier than this is associated with significantly higher rates of failure, possibly as a result of retained fluid 213in the middle ear (Smolkin, Mick, Dabbah, et al, 2012). Newborns who fail the initial screening require referral for outpatient retesting and intervention by 1 month old (American Academy of Pediatrics, Joint Committee on Infant Hearing Screening, 2007). A subsequent audiologic assessment should be performed at least once by 24 to 36 months old if the infant has any hearing risk factors despite passing the newborn hearing screening (Harlor, Bower, Committee on Practice and Ambulatory Medicine, et al, 2009).

general measurement: vital signs: blood pressure

Measurement of BP provides baseline data and may indicate cardiovascular problems. BP is most easily and accurately assessed using oscillometry (Dinamap) when the newborn is in a quiet or sleep state using an appropriate cuff width-to-arm ratio of 0.45 to 0.70 (approximately half to three quarters) (Fig. 7-5). For healthy term infants, the average oscillometric systolic/diastolic BP is 65/45 mm Hg on day 1 of life, changing to 69.5/44.5 mm Hg by day 3 (Kent, Kecskes, Shadbolt, et al, 2007). Compare BP in the upper and lower extremities, which should be equal.

transitional assessment: periods of reactivity

Newborns exhibit behavioral and physiologic characteristics that may at first appear to be signs of stress. However, during the initial 24 hours, changes in heart rate, respiration, motor activity, color, mucus production, and bowel activity occur in an orderly, predictable sequence that is normal and indicates lack of stress. For 6 to 8 hours after birth, the newborn is in the first period of reactivity. During the first 30 minutes, the infant is very alert, cries vigorously, may suck his or her fingers or fist, and appears very interested in the environment. At this time, the newborn's eyes are usually open, making this an excellent opportunity for the mother, father, and child to see each other. Because the healthy newborn has a vigorous suck, this is also an opportune time to begin breastfeeding. The infant will usually grasp the nipple quickly, satisfying both the mother and the infant. This is particularly important to point out to the parents because after this initially highly active state, the infant may be sleepy and uninterested in sucking. Physiologically, the respiratory rate during this period is as high as 80 breaths/min, crackles may be heard, heart rate reaches 180 beats/min, bowel sounds are active, mucus secretions are increased, and temperature may decrease. Maintaining appropriate temperature for newborns is best accomplished by practicing skin-to-skin care, whereby only a diaper is worn to allow majority of skin surface to be in contact with the mother's skin. A light blanket is used to cover the mother and newborn. Research has shown that skin-to-skin is effective in ensuring the newborn does not become hypothermic (Moore, Anderson, Bergman, et al, 2012). After this initial stage of alertness and activity, the infant enters the second stage of the first reactive period, which generally lasts 2 to 4 hours. Heart and respiratory rates decrease, temperature continues to fall, mucus production decreases, and urine and stool are usually not passed. The infant is in a state of sleep and relative calm. Any attempt at stimulation usually elicits minimal response. Because of the continued decline in body temperature, undressing or bathing is avoided during this time. The second period of reactivity begins when the infant awakens from this deep sleep; it lasts about 2 to 5 hours and provides another excellent opportunity for child and parents to interact. The infant is again alert and responsive, heart and respiratory rates increase, the gag reflex is active, gastric and respiratory secretions are increased, and passage of meconium frequently occurs. This period is usually over when the amount of respiratory mucus has decreased. After this stage is a period of stabilization of physiologic systems and a vacillating pattern of sleep and activity.

physiologic status of thermoregulation associated with transition to extrauterine life

Next to establishing respiration, heat regulation is most critical to the newborn's survival. Although the newborn's capacity for heat production is adequate, three factors predispose newborns to excessive heat loss: • The newborn's large surface area facilitates heat loss to the environment, although this is partially compensated for by the newborn's usual position of flexion, which decreases the amount of surface area exposed to the environment. • The newborn's thin layer of subcutaneous fat provides poor insulation for conservation of heat. • The newborn's mechanism for producing heat is different from that of the adult, who can increase heat production through shivering. A chilled neonate cannot shiver but produces heat through nonshivering thermogenesis (NST), which involves increased metabolism and oxygen consumption. The principal thermogenic sources are the heart, liver, and brain. An additional source, once believed to be unique to newborns (Zingaretti, Crosta, Vitali, et al, 2009), is known as brown adipose tissue, or brown fat. Brown fat, which owes its name to its larger content of mitochondrial cytochromes, has a greater capacity for heat production through intensified metabolic activity than ordinary adipose tissue. Heat generated in brown fat is distributed to other parts of the body by the blood, which is warmed as it flows through the layers of this tissue. Superficial deposits of brown fat are located between the scapulae, around the neck, in the axillae, and behind the sternum. Deeper layers surround the kidneys, trachea, esophagus, some major arteries, and adrenals. The location of brown fat may explain why the nape of the neck often feels warmer than the rest of the infant's body. Because of these factors predisposing infants to loss of body heat, it is essential that newly born infants are quickly dried and either placed skin-to-skin with their mothers or provided with warm, dry blankets after delivery. Although newborns' ability to conserve heat is usually a matter of concern, they may also have difficulty dissipating heat in an overheated environment, which increases the risk of hyperthermia.

female genitalia assessment

Normally, the labia minora, labia majora, and clitoris are edematous, especially after a breech delivery. However, the labia and clitoris must be carefully inspected to identify any evidence of ambiguous genitalia or other abnormalities. Normally, in a girl, the urethral opening is located behind and below the clitoris. A hymenal tag is occasionally visible from the posterior opening of the vagina. It is composed of tissue from the hymen and the labia minora. It usually disappears in several weeks. Generally, the vaginal vault is not inspected. Vaginal discharge may be noted during the first week of life. This pseudomenstruation is a manifestation of the abrupt decrease of maternal hormones and usually disappears by 2 to 4 weeks of age. Fecal discharge from the vaginal opening indicates a rectovaginal fistula and is always reported. Vernix caseosa may be present in large amounts between the labia; it will disappear after several days with routine bathing and care.

physiologic status of endocrine system associated with transition to extrauterine life

Ordinarily, the endocrine system of newborns is adequately developed, but its functions are immature. For example, the posterior lobe of the pituitary gland produces limited quantities of antidiuretic hormone, or vasopressin, which inhibits diuresis. This renders young infants highly susceptible to dehydration. The effect of maternal sex hormones is particularly evident in newborns. The labia are hypertrophied, and the breasts of both genders may be engorged and secrete milk from the first few days of life to as long as 2 months of age. Female newborns may have pseudomenstruation (more often seen as a milky secretion than actual blood) from a sudden drop in progesterone and estrogen levels.

eye care

Prophylactic eye treatment against ophthalmia neonatorum, infectious conjunctivitis of the newborn, includes the use of (1) silver nitrate (1%) solution, (2) erythromycin (0.5%) ophthalmic ointment or drops, or (3) tetracycline (1%) ophthalmic ointment or drops (preferably in single-dose ampules or tubes). All three are effective against gonococcal conjunctivitis. Chlamydia trachomatis is the major cause of ophthalmia neonatorum in the United States; topical antibiotics (tetracycline and erythromycin) and silver nitrate are not effective in the prevention and treatment of chlamydial conjunctivitis. A 14-day course of oral erythromycin or ethylsuccinate may be given for chlamydial conjunctivitis (Pickering and American Academy of Pediatrics, Committee on Infectious Diseases, 2012). The administration or oral erythromycin to infants younger than 6 weeks old has been associated with the development of infantile hypertrophic pyloric stenosis; therefore parents should be informed of the potential risks and signs of the illness (Pickering and American Academy of Pediatrics, Committee on Infectious Diseases, 2012). Herpes simplex virus may also cause neonatal conjunctivitis; treatment in such cases involves the use of topical and systemic antiviral medications. Recent publications have explored alternate substances for ophthalmia neonatorum prevention, with a focus on growing concerns about the development of antimicrobial resistance. Colostrum (Ghaemi, Navaei, Rahimirad, et al, 2014) and povidone iodine (2.5%) (David, Rumelt, and Weintraub, 2011; Meyer, 2014) have been studied with small samples of infants. These substances may prove to be reasonable alternatives for ophthalmia neonatorum prophylaxis in the future. Because studies on maternal attachment emphasize that in the first hour of life a newborn has a greater ability to focus on coordinated movement than at any other time during the next several days and because eye contact is very important in the development of maternal-infant bonding, the routine administration of silver nitrate or topical ophthalmic antibiotics can be postponed for up to 1 hour after birth. However, practitioners must ensure that the drug is given by 1 hour of age.

ear assessment

The ears are examined for position, structure, and auditory function. The top of the pinna should lie in a horizontal plane to the outer canthus of the eye. The pinna is often flattened against the side of the 200head from pressure in utero. An otoscopic examination may be difficult to perform if the canals are filled with vernix caseosa and amniotic fluid, making visualization of the tympanic membrane difficult. Auditory ability is tested by a number of objective hearing tests. Making a loud noise close to the infant's head may or may not elicit a response; the lack of a response, however, is not a definite indication of hearing loss. The startle reflex (Table 7-2) may be observed when there is a sudden loud noise near the infant or the bassinet is accidentally bumped, but this often depends on the infant's state at the time.

immediate respiratory system adjustments associated with transition to extrauterine life

The most critical and immediate physiologic change required of newborns is the onset of breathing. The stimuli that help initiate the first breath are primarily chemical and thermal. Chemical factors in the blood (low oxygen, high carbon dioxide, and low pH) initiate impulses that excite the respiratory center in the medulla. The primary thermal stimulus is the sudden chilling of the infant, who leaves a warm environment and enters a relatively cooler atmosphere. This abrupt change in temperature excites sensory impulses in the skin that are transmitted to the respiratory center. Tactile stimulation may assist in initiating respiration. Descent through the birth canal and normal handling during delivery help stimulate respiration in uncompromised infants. Acceptable methods of tactile stimulation include tapping or flicking the soles of the feet or gently rubbing the newborn's back, trunk, or extremities. Slapping the newborn's buttocks or back is a harmful technique and should not be done. Prolonged tactile stimulation, beyond one or two taps or flicks to the soles of the feet or rubbing the back once or twice, can waste precious time in the event of respiratory difficulty and can cause additional damage in infants who have become hypoxemic before or during the birth process (American Academy of Pediatrics, Committee on Infectious Diseases, 2011). The initial entry of air into the lungs is opposed by the surface tension of the fluid that filled the fetal lungs and the alveoli. Some lung fluid is removed during the normal forces of labor and delivery. As the chest emerges from the birth canal, fluid is squeezed from the lungs through the nose and mouth. After complete delivery of the chest, brisk recoil of the thorax occurs, and air enters the upper airway to replace the lost fluid. Remaining lung fluid is absorbed by the pulmonary capillaries and lymphatic vessels. In the alveoli, the surface tension of the fluid is reduced by surfactant, a substance produced by the alveolar epithelium that coats the alveolar surface. The effect of surfactant in facilitating breathing is discussed in relation to respiratory distress syndrome (see Chapter 8).

protect from infection and injury

The most important practice for preventing cross-infection is thorough hand washing of all individuals involved in the infant's care. Other procedures to prevent infection include eye care, umbilical care, bathing, and care of the circumcision. Artificial nails are prohibited (World Health Organization, 2009), and long fingernails are discouraged for health care providers because the former have been implicated in the transmission of sepsis. Vitamin K is administered to protect against hemorrhage.

lungs assessment

The normal respirations of newborns are irregular and abdominal, and the rate is between 30 and 60 breaths/min. Pauses in respiration of less than 20 seconds' duration are considered normal. After the initial forceful breaths required to initiate respiration, subsequent breaths should be nonlabored and fairly regular in rhythm. Periodic breathing is commonly seen in full-term newborns and consists of rapid nonlabored respirations followed by pauses of less than 20 seconds; periodic breathing may be more prominent during sleep and is not accompanied by status changes, such as cyanosis or bradycardia. Occasional irregularities occur in relation to crying, sleeping, stooling, and feeding. Perform auscultation when the infant is quiet. Bronchial breath sounds should be equal bilaterally. Any differences in auscultatory findings between symmetric sites are reported. Crackles soon after birth indicate the presence of fluid, which represents the normal transition of the lungs to extrauterine life. However, wheezes, persistence of medium or coarse crackles after the first few hours of life, and stridor should be reported for further investigation.

male genitalia

The penis is inspected for the urethral opening, which is located at the tip. However, the opening may be totally covered by the prepuce, or foreskin, which covers the glans penis. A tight prepuce is a common finding in newborns. It should not be forcefully retracted; locating the urinary meatus is usually possible without retracting the foreskin. Smegma, a white cheesy substance, is commonly found around the glans penis under the foreskin. Small, white, firm lesions called epithelial pearls may be seen at the tip of the prepuce. An erection is common in newborns. The scrotum may be large, edematous, and pendulous in full-term neonates, especially in infants born in breech position. It is more deeply pigmented in dark-skinned infants. A noncommunicating hydrocele commonly occurs unilaterally and disappears within a few months. Always palpate the scrotum for the presence of testes (see Chapter 4). In small newborns, particularly preterm infants, the undescended testes may be palpable within the inguinal canal. Absence of the testes may also be a sign of ambiguous genitalia (disorders of sex development), especially when accompanied by a small scrotum and penis. Inguinal hernias may or may not be manifested immediately after birth. A hernia is more easily detected when the infant is crying. Palpable lymph nodes are most commonly found in the inguinal area.

chest assessment

The shape of the newborn's chest is almost circular because the anteroposterior and lateral diameters are equal. The ribs are flexible, and slight intercostal retractions are normally seen on inspiration. The xiphoid process is commonly visible as a small protrusion at the end of the sternum. The sternum is generally raised and slightly curved. Inspect the breasts for size, shape and nipple formation, location, and number. Breast enlargement appears in many newborns of both genders by the second or third day and is caused by maternal hormones. Occasionally, a milky substance is secreted by the infant's breasts. Supernumerary nipples may be found on the chest, on the abdomen, or in the axilla.

skin assessment

The texture of the newborn's skin is velvety smooth and puffy, especially about the eyes, the legs, the dorsal aspect of the hands and the feet, and the scrotum or labia. Skin color depends on racial and familial background and varies greatly among newborns. In general, white infants are usually pink to red. African-American newborns may appear a pinkish or yellowish brown. Infants of Hispanic descent may have an olive tint or a slight yellow cast to the skin. Infants of Asian descent may be a rosy or yellowish tan. The color of American Indian newborns varies from a light pink to a dark, reddish brown. By the second or third day of life, the skin turns to its more natural tone and is drier and flakier. Several other color changes that may be noted on the skin are described later in this chapter (see Table 7-4). At birth, the skin may be partially covered with a grayish white, cheeselike substance called vernix caseosa, a mixture of sebum and desquamating cells. It is absorbed by 24 to 28 hours. A fine, downy hair called lanugo may be present on the skin, especially on the forehead, cheeks, shoulders, and back.

Hepatitis B vaccine administration

To decrease the incidence of hepatitis B virus in children and its serious consequences (cirrhosis and liver cancer) in adulthood, the first of three doses of hepatitis B vaccine are recommended soon after birth and before hospital discharge for all newborns born to hepatitis B surface antigen (HBsAg)-negative mothers (Pickering and American Academy of Pediatrics, Committee on Infectious Diseases, 2012). The injection is given in the vastus lateralis muscle because this site is associated with a better immune response than is the dorsogluteal area. Giving the infant concentrated oral sucrose can reduce the pain of the injection (Stevens, Yamada, Lee, et al, 2013). Preterm infants born to HBsAg-negative women should be vaccinated as early as 30 days of age regardless of gestational age or birth weight. Infants born to HBsAg-positive mothers should be immunized within 12 hours after birth with hepatitis B vaccine and hepatitis B immune globulin (HBIG) at separate sites, regardless of gestational age or birth weight (Pickering and American Academy of Pediatrics, Committee on Infectious Diseases, 2012). In Canada, hepatitis B vaccine is given to newborns only if their mothers are HBsAg positive at birth (see Immunizations, Chapter 6).