OB Ch.18-Nursing Management of the Newborn

Stepping Reflex

***Assess the stepping reflex by holding the newborn upright and inclined forward with the soles of the feet touching a flat surface. The baby should make a stepping motion or walking, alternating flexion and extension with the soles of the feet Goes away after 1-2 months

Grasp Reflex

***The newborn exhibits two grasp reflexes: palmar grasp and plantar grasp. Elicit the palmar grasp reflex by placing a finger on the newborn's open palm. The baby's hand will close around the finger. Attempting to remove the finger causes the grip to tighten. Newborns have strong grasps and can almost be lifted from a flat surface if both hands are used. The grasp should be equal bilaterally. The plantar grasp is similar to the palmar grasp. Place a finger just below the newborn's toes. The toes typically curl over the finger Goes away after 3 to 4 months

Umbilical Cord Care

*After 24 hrs clamp comes off *DO NOT MESS WITH THE CORD OR MEDICATE IT IN ANYWAY The umbilical cord begins drying within hours after birth and is shriveled and blackened by the second or third day. Within 7 to 10 days, it sloughs off and the umbilicus heals. During this transition, frequent assessments of the area are necessary to detect any bleeding or signs of infection. Cord bleeding is abnormal and may occur if the cord clamp is loosened. Any cord drainage is also abnormal and is generally caused by infection, which requires immediate treatment.

Circumcision Care

- *washing hands* before providing care - *applying petroleum jelly* to glans penis at *diaper changes* (unless plastic ring was used) for *3-7 days* to prevent adhering to diaper - site typically *heals within 7-10 days* - expect *yellow exudate* on penis after the first day, a *normal part of healing* - use *warm water (without soap)* to remove urine/feces during diaper changes or at least twice daily

Initial Newborn Assessment: Length

-The expected length range of a full-term newborn is usually 44 to 55 cm (17 to 22 in). ***Top of the head to heel for measurement—may have to press legs flat since they are in the fetal position

Newborn Diapering

-Before diapering, make sure all supplies are within reach, including a clean diaper, cleaning agent or wipes, and ointment. -Lay the newborn on a changing table and remove the dirty diaper. -Use water and mild soap or wipes to gently wipe the genital area clean. -Wipe from front to back for girls to avoid urinary tract infections. -Wash your hands thoroughly before and after changing diapers. **Keep folded down so the umbilical cord can dry out

Immediate Nursing Interventions for Newborn: Maintaining Thermoregulation

-Dry the newborn immediately after birth to prevent heat loss through evaporation. -Wrap the baby in warmed blankets to reduce heat loss via convection. -Facilitate skin-to-skin contact with mother as soon as stabilized. -Use a warmed cover on the scale to weigh the unclothed newborn. -Warm stethoscopes and hands before examining the baby or providing care. -Avoid placing newborns in drafts or near air vents to prevent heat loss through convection. -Delay the initial bath until the baby's temperature has stabilized to prevent heat loss through evaporation. -Avoid placing cribs near cold outer walls to prevent heat loss through radiation. -Put a cap on the newborn's head after it is thoroughly dried after birth. -Place the newborn under a temperature-controlled radiant warmer

Bathing and Hygiene Teaching for Newborns

-Gloves -Plain water on face and eyes; mild soap for rest of body -Bump temperate up in room -Keep on a flat surface -Keep all supplies nearby -Undress only when about to bathe -Undress the newborn down to shirt and diaper. -Always support the newborn's head and neck when moving or positioning them. -Place a blanket or towel underneath the newborn for warmth and comfort. -Bathe, dry, then cover up the area ASAP -Always wear gloves for first bathe -Inner to outer canthus for eyes -Use baby shampoo -Get body creases—is vernix is finicky then let it stay because it will absorb into the skin -Save perineum and buttox last -Clean diaper

Nursing Management During the Immediate Newborn Period: Signs Indicating Problems in a Newborn

-Nasal flaring, intercostal retractions -Grunting on exhalation (uh uh sound-trying to push alveoli open like a CPAP), labored breathing -Generalized cyanosis (aka central cyanosis) -Abnormal breath sounds like rhonchi, crackles (rales), wheezing, stridor -Abnormal respiratory rates (tachypnea, more than 60 breaths/min; bradypnea, less than 25 breaths/min; newborns have irregular breathing patterns however which is normal; greater than 10 seconds of apnea and baby changes colors is when we start to get concerned) -Abnormal heart rates (greater than 160 and less than 110) -Abnormal newborn size (small or large for gestational age) -Flaccid body posture (really relaxed and floppy) -Pallor

Elimination and Diaper Area Care Teaching

-Normal urination is 6-12 times a day -Meconium is usually passed within the first 48 hours of life -Breast fed babies will have stool that changes in color and consistency after first poop -If rashes on perineum don't go away then we may need something stronger than an OTC barrier cream Fold diaper down for umbilical cord to dry out (no tub bath until cord falls out; we want to wipe them down with wipes or just soap and water) Diaper on boy-point the penis down because if not their clothes will be wet constantly Document first poop and pee

Physiological Jaundice Prevention and Management

-Promote and support successful breast-feeding practices to make sure the newborn is well hydrated and stooling frequently to promote elimination of bilirubin. -Advise mothers to nurse their infants at least 8 to 12 times per day for the first several days. -Avoid routine supplementation of nondehydrated breast-fed infants with water or dextrose water because that will not lower bilirubin levels. -Ensure all infants are routinely monitored for the development of jaundice and that nurseries have established protocols for the assessment of jaundice. -Jaundice should be assessed whenever the infant's vital signs are measured but no less than every 8 to 12 hours. -Perform a systematic assessment of all newborns of 35 or more weeks' gestation before discharge to prevent the development of severe hyperbilirubinemia. -Provide early and focused follow-up based on the risk assessment. -When indicated, treat newborns with phototherapy or exchange transfusion to prevent acute bilirubin encephalopathy

Common Skin Conditions in Newborns: Nevus vasculosus ("Strawberry Mark")

-a benign capillary hemangioma in the dermal and subdermal layers. It is raised, rough, dark red, and sharply demarcated. It is commonly found in the head region within a few weeks after birth and can increase in size or number. This type of hemangioma may be subtle or even absent in the first few weeks of life, but they proliferate in the first few months. Commonly seen in premature infants weighing less than 1,500 g, these hemangiomas tend to resolve by age 3 without any treatment.

Common Skin Variations in Newborns: Erythema toxicum ("Newborn Rash")

-benign, idiopathic, generalized, transient rash that occurs in up to 70% of all newborns during the first week of life -consists of small papules or pustules on the skin resembling flea bites. -common on the face, chest, and back -one of the chief characteristics of this rash is its lack of pattern -caused by the newborn's eosinophils reacting to the environment as the immune system matures -does not require any treatment and disappears in a few days.

Physiologic Jaundiceb

-common in newborns with the majority demonstrating yellowish skin, mucous membranes, and sclera within the first 3 days of life. -Jaundice is the visible manifestation of hyperbilirubinemia. It typically results from the deposition of unconjugated bilirubin pigment in the skin and mucous membranes. -can be best understood as an imbalance between the production and elimination of bilirubin with a multitude of factors and conditions affecting each of these processes -may go on to cause acute neurologic sequelae (acute bilirubin encephalopathy) -In most infants, an increase in bilirubin production (e.g., due to hemolysis) is the primary cause of physiologic jaundice, and thus reducing bilirubin production is a rational approach for its management. -factors that contribute to the development of physiologic jaundice in the newborn include an increased bilirubin load because of relative polycythemia, a shortened erythrocyte lifespan (80 days compared with the adult 120 days), and immature hepatic uptake and conjugation processes -Normally, the liver removes bilirubin from the blood and changes it into a form that can be excreted. As the red blood cell breakdown continues at a fast pace, the newborn's liver cannot keep up with bilirubin removal. Thus, bilirubin accumulates in the blood, causing a yellowish discoloration on the skin.i

Common Skin Variations in Newborns: Nevus flammeus ("Port Wine Stains")

-commonly appears on the newborn's face or other body areas -made up of mature capillaries that are congested and dilated -does not grow in area or size, it is permanent and will not fade. Port wine stains may be associated with structural malformations, bony or muscular overgrowth, and certain cancers. The optimal time for treatment is before 1 year of age. Recent studies have noted an association between port wine birthmarks and childhood cancer, so newborns with these lesions should be monitored with periodic eye examinations, neurologic imaging, and extremity measurements. Lasers and intense pulsed light have been used to remove larger lesions with some success, but the efficacy of therapy has not improved in several decades, despite numerous technical innovations and pharmacologic interventions.

Initial Newborn Assessment: Head and Chest

30-36 cm is normal chest circumference HEAD IS BIGGER THAN CHEST; chest is usually 2-3 cm smaller than head **Check every visit up until about 2 years

Term Newborn

38 weeks -42 weeks completed

Post Term Newborn

42 weeks completed or greater

Gag Reflex

A normal reflex mechanism that causes retching; activated by touching the soft palate or the back of the throat.

Tonic Neck Reflex

turning the head to one side, extending the arm and leg on that side, and flexing the limbs on the opposite side Goes away in 3 to 4 months

Ballard Neuromuscular Exam: Arm Recoil

Arm recoil—How far do the newborn's arms "spring back" to a flexed position? This measure evaluates the degree of arm flexion and the strength of recoil. The reaction of the arm is then scored from 0 to 4 points based on the degree of flexion as the arms are returned to their normal flexed position. The higher the points assigned, the greater the neuromuscular maturity (e.g., recoil less than a 90-degree angle is scored as 4 points).

Immediate Nursing Interventions for Newborn: Administering Prescribed Medications

During the immediate newborn period, two medications are commonly ordered: vitamin K and eye prophylaxis with either erythromycin or tetracycline ophthalmic ointment. -Vitamin K (prevents hemorrhagic disease like brain bleeds—NOT a vaccine; baby's gut is sterile so they are not able to produce the vitamin K like adults can; *0.5 to 1 mg IM, 5/8 inch needle,90 degree angle, Vastas Lateralis) Administer within 1 to 2 hours after birth. • Administer as an IM injection at a 90-degree angle into the outer middle third of the vastus lateralis muscle. • Use a 25-gauge, 5/8-in needle for injection. • Hold the leg firmly and inject medication slowly. • Adhere to standard precautions. • Assess for bleeding at injection site after administration. -Eye prophylaxis (ophthalmia neaphortorium; needs to be given within 1 to 2 hours after birth; inner to outer canthus; law; given whether C-section or vaginal birth) • Be alert for chemical conjunctivitis for 1 to 2 days. • Wear gloves, and open eyes by placing the thumb and finger above and below the eye. • Gently squeeze the tube or ampule to apply medication into the conjunctival sac from the inner canthus to the outer canthus of each eye. • Do not touch the tip to the eye. • Close the eye to make sure the medication permeates. • Wipe off excess ointment after 1 minute. ***Baby may also get their Hep B shot to if the parents consent to it.

Bonding

Encourage and enhance parent-newborn interaction by involving both parents with the baby and demonstrating appropriate nurturing behaviors: •Say "hello" and introduce yourself to the newborn. Ask the parents' permission to care for and hold the newborn. This helps parents realize they are responsible for their child and reminds nurses of their role. •Show parents the power of a soothing voice to calm the newborn (Fig. 18.21). •Provide care to the newborn in the least stressful way. •Demonstrate ways to gently wake up the newborn for better feeding. •Tell parents what you are doing, why you are doing it, and how they can duplicate what you are doing at home. • Offer the opportunity for parents to perform care while you observe them. •Support their efforts to soothe the newborn throughout the care process. •Help parents interpret the communication cues the newborn uses. Point out the efforts the newborn is making to connect with the parents

*For a normal newborn, how often should vital signs be checked?

Every 2 hours for normal newborn, more frequently if they have any issues

True or False: The nurse can assemble a car seat for a family.

False

ALGO Hearing Screening Test

Hearing screening to measure brain's response to sound Usually done within a few hours of birth Have to follow up with audiologists after a month if they fail 2 tests (to decrease language development delays which requires an intervention by 3 months)

Ballard Neuromuscular Exam: Heel to Ear

How close can the newborn's feet be moved to the ears? This maneuver assesses hip flexibility; the lesser the flexibility, the greater the newborn's maturity. The heel-to-ear assessment is scored in the same manner as the scarf sign. ***pre mature infant will not have resistance

Ballard Neuromuscular Exam: Posture

How does the newborn hold their extremities in relation to the trunk? The greater the degree of flexion, the greater the maturity. For example, extension of arms and legs is scored as 0 points and full flexion of arms and legs is scored as 4 points.

Ballard Neuromuscular Exam: Scarf Sign

How far can the elbows be moved across the newborn's chest? An elbow that does not reach midline indicates greater maturity. For example, if the elbow reaches or nears the level of the opposite shoulder, this is scored as -1 point; if the elbow does not cross the proximate axillary line, it is scored as 4 points. ***Baby who is preterm does not have a lot of tone so arms will wrap all the way around

Ballard Neuromuscular Exam: Square Window

How far can the newborn's hands be flexed toward the wrist? The angle is measured and scored from more than 90 degrees to 0 degrees to determine the maturity rating. As the angle decreases, the newborn's maturity increases. For example, an angle of more than 90 degrees is scored as -1 point and an angle of 0 degrees is scored as 4 points.

Ballard Neuromuscular Exam: Popliteal Angle

How far will the newborn's knees extend? The angle created when the knee is extended is measured. An angle of less than 90 degrees indicates greater maturity. For example, an angle of 180 degrees is scored as -1 point and an angle of less than 90 degrees is scored as 5 points.

Hypoglycemia

Hypoglycemia is the most common metabolic disturbance in the neonatal period. During the first 24 to 48 hours of life, as normal newborns transition from intrauterine to extrauterine life, their plasma glucose levels are typically lower than later in life. Temporary low plasma glucose concentrations are common in healthy newborns. Hypoglycemia affects as many as 40% of all full-term newborns. It is defined as a blood glucose level of less than 30 mg/dL or a plasma concentration of less than 45 mg/dL in the first 72 hours of life (Abramowski & Hamdan, 2020). From a physiologic perspective, a newborn may be said to be hypoglycemic when glucose supply is inadequate to meet demand. In newborns, blood glucose levels fall to a low point during the first few hours of life because the source of maternal glucose is removed when the placenta is expelled. This period of transition is usually smooth, but certain newborns are at greater risk for hypoglycemia: infants of mothers who have diabetes, preterm newborns, and newborns with intrauterine growth restriction (IUGR), inadequate caloric intake, sepsis, asphyxia, hypothermia, polycythemia, glycogen storage disorders, and endocrine deficiencies (Rozance & Wolfsdorf, 2019). Most newborns experience transient hypoglycemia and are asymptomatic. The symptoms, when present, are nonspecific and include jitteriness, sweating, hypothermia, irritability, lethargy, cyanosis, apnea, seizures, high-pitched or weak cry, hypothermia, and poor feeding. If hypoglycemia is prolonged or is left untreated, serious, long-term adverse neurologic sequelae such as learning disabilities and intellectual disabilities can occur (Cranmer, 2019).

Immediate Nursing Interventions for Newborn: Ensuring Proper Identification

IDs are placed at bedside right after birth with band on arm, foot, and security band and foot prints are done too Typically, the mother, the newborn, and the father or any significant other or support person of the mother's choosing receive ID bracelets. The newborn commonly receives two ID bracelets, one on a wrist and one on an ankle. The mother receives a matching one, usually on her wrist. The ID bands usually state name, sex, date and time of birth, and identification number. The same identification number is on the bracelets of all family members.Taking the newborn's picture within 2 hours after birth with a color camera or color video or digital image also helps prevent mix-ups and abduction. Many facilities use electronic devices that sound an alarm if a newborn is taken beyond a certain point on the unit or removed from the area.

Physiological Jaundice Nursing Management

In newborn infants, jaundice can be detected by blanching the skin with digital pressure on the bridge of the nose, sternum, or forehead, revealing the underlying color of the skin and subcutaneous tissue. If jaundice is present, the blanched area will appear yellow before the capillary refill. The assessment of jaundice must be performed in a well-lit room or preferably, in daylight at a window. Jaundice is usually seen first in the face and progresses caudally to the trunk and extremities. Measures that parents can take to reduce the risk of jaundice include exposing the newborn to natural sunlight for short periods of time throughout the day to help oxidize the bilirubin deposits on the skin, providing breast-feeding on demand to promote elimination of bilirubin through urine and stooling, and avoiding glucose water supplementation, which hinders elimination. If or when the levels of unconjugated serum bilirubin increase and do not return to normal levels with increased hydration, phototherapy is used. The serum level of bilirubin at which phototherapy is initiated is a matter of clinical judgment by the physician, but it is often begun when bilirubin levels reach 12 to 15 mg/dL in the first 48 hours of life in a term newborn. Phototherapy involves exposing the newborn to ultraviolet light, which converts unconjugated bilirubin into products that can be excreted through feces and urine. Phototherapy is the most common treatment for hyperbilirubinemia and has virtually eliminated the need for exchange transfusions in newborns now. TAKE NOTE! Exposure of newborns to sunlight represents the first documented use of phototherapy in the medical literature. Sister J. Ward, a charge nurse in Essex, England, recognized in 1956 that when jaundiced newborns were exposed to the sun, they became less yellow. This observation changed the entire treatment of jaundice in newborns When caring for newborns receiving phototherapy for jaundice, nurses must do the following: Closely monitor body temperature and fluid and electrolyte balance. Provide information about phototherapy, and explain the procedure to the parents. Document frequency, character, and consistency of stools. Monitor hydration status (weight, specific gravity of urine, and urine output). Turn frequently to increase the infant's skin exposure to phototherapy. Observe skin integrity (as a result of exposure to diarrhea and phototherapy lights). Provide eye protection to prevent corneal injury related to phototherapy exposure. Encourage parents to participate in their newborn's care to prevent parent-infant separation.

Order for Bathing a Newborn

In this order, progressing from the cleanest to the dirtiest areas: -Wipe eyes with plain water, using either cotton balls or a washcloth. Wipe from the inner corner of the eyes to the outer with separate wipes. -Wash the rest of the face, including ears, with plain water. -Using baby shampoo, gently wash the hair and rinse with water. -Pay special attention to body creases, and dry thoroughly. -Wash extremities, trunk, and back. Wash, rinse, dry, and cover. -Wash diaper area last, using soap and water, and dry; observe for rash. -Put on a clean diaper and clean clothes after the bath.

Breastfeeding Concerns: Engorgement

May occur as the milk comes in around day 3 or 4 after birth of the newborn. Explain to the mother that engorgement, though uncomfortable, is self-limited and will resolve as the newborn continues to nurse. The mother should continue to nurse during engorgement to avoid a plugged milk duct, which could lead to mastitis. Provide the following tips for relieving engorgement: •Take warm to hot showers to encourage milk release. •Express some milk manually before breast-feeding. Lie back to keep the breasts higher because fluids follow gravity. •Wear a supportive nursing bra 24 hours a day to provide support. Feed the newborn in a variety of positions—sitting up and then lying down. •Massage the breasts from under the axillary area down toward the nipple. Increase the frequency of feedings. • Keep infant with you to facilitate frequent breast-feeding. Apply warm compresses to the breasts prior to nursing. Stay relaxed while breast-feeding. • Stand in a shower and let hot water hit the back to relax and release some milk. Use a breast pump if nursing or if manual expression is not effective. •Remember that this condition is temporary and resolves quickly.

Molding

Molding is the elongated shaping of the fetal head to accommodate passage through the birth canal. It occurs with a vaginal birth from a vertex position in which elongation of the fetal head occurs with prominence of the occiput and overriding sagittal suture line. It typically resolves within a week after birth without intervention

Hypoglycemia Nursing Care

Nursing care of the hypoglycemic newborn includes monitoring for signs of hypoglycemia or identifying high-risk newborns prone to this disorder based on their perinatal history, physical examination, body measurements, and gestational age. Glucose screening should be performed on at-risk infants and those with clinical symptoms compatible with hypoglycemia (Martin & Rosenfeld, 2019). Prevent hypoglycemia in newborns at risk by initiating early feedings with breast milk or formula. If hypoglycemia persists despite feeding, notify the primary health care provider for orders such as intravenous therapy with dextrose solutions. Anticipate hypoglycemia in certain high-risk newborns and begin assessments immediately upon nursery admission.

Breast Feeding Concerns: Sore Nipples

Sore nipples are usually caused by improper infant attachment, which traumatizes the tissue. The nurse should review techniques for proper positioning and latching on. It is important to get this correct from the first feed to assist in the prevention of incorrect attachment and associated nipple trauma. Recommend the following to the mother: •Use only warm water, not soap, to clean the nipples to prevent dryness. • Express some milk before feeding to stimulate the milk ejection reflex. • Avoid using breast pads with plastic liners, and change pads when they are wet. •Wear a comfortable bra that is not too tight. •Apply a few drops of breast milk to the nipples after feeding. •Take systemic antiinflammatory drugs such as ibuprofen for discomfort. Rotate positions when feeding the infant to promote complete breast emptying. Leave the nursing bra flaps down after feeding to allow nipples to air-dry. • Inspect the nipples daily for redness or cracks

Immediate Newborn Nursing Interventions: Maintain Patent Airway

Suction Mouth then Nose Typically, the newborn's mouth is suctioned first with a bulb syringe to remove debris and then the nose is suctioned. Suctioning in this manner helps prevent aspiration of fluid into the lungs by an unexpected gasp. When suctioning a newborn with a bulb syringe, compress the bulb before placing it into the oral or nasal cavity. Release bulb compression slowly, making sure the tip is placed away from the mucous membranes to draw up the excess secretions. Remove the bulb syringe from the mouth or nose, and then, while holding the bulb syringe tip over an emesis basin lined with paper towel or tissue, compress the bulb to expel the secretions. Repeat the procedure several times until all secretions are removed or use a towel to wipe away secretions per hospital policy.

When an infant's sucking reflex is not present, what intervention is done?

TPN if loss of sucking reflex is temporary or PEG if longterm

Initial Assessment: Vital Signs

Temperature 97.7-99.5°F (36.5-37.5°C) *no rectal thermometers (probe or axillary) Heart rate (pulse) to 180 during crying 110-160 bpm; can increase Respirations 30-60 breaths/min at rest; will increase with crying (so just work around them) Blood pressure 50-75 mm Hg systolic, 30-45 mm Hg diastolic (normally only done in the NICU)

Introducing Solid Foods

The AAP recommends children be introduced to foods other than breast milk or infant formula when they are about 6 months old (CDC, 2019h). Readiness cues include: • Consumption of 32 oz of formula or breast milk daily (estimated) •Ability to sit up with minimal support and turn head away to indicate fullness Reduction of protrusion reflex so cereal can be propelled to back of throat •Demonstration of interest in food others around them are eating Ability to open mouth automatically when food approaches it •When introducing solid foods, certain principles apply: •New foods should be introduced one at a time and a week apart so that if a problem develops, the responsible item can be easily identified. •Infants should be allowed to set the pace regarding how much they wish to eat. ---New foods should not be introduced more frequently than every 3 to 5 days. ---Fruits are added after cereals, then vegetables and meats are introduced, and eggs are introduced last. A relaxed, unhurried, calm atmosphere for meals is important. A variety of foods are provided to ensure a balanced diet. ---Infants should never be force-fed

Breast Feeding: Milk Composition

The composition of breast milk changes over time from colostrum to transitional milk, and finally to mature milk. Colostrum is a thick, yellowish substance secreted during the first few days after birth. It is high in protein, minerals, and fat-soluble vitamins. It is rich in immunoglobulins A, which help protect the newborn's gastrointestinal tract against infections. It is a natural laxative that helps rid the intestinal tract of meconium quickly. Transitional milk occurs between colostrum and mature milk and contains all the nutrients in colostrum, but it is thinner and less yellow than colostrum. This transitional milk is replaced by true or mature milk around day 10 after birth. Mature milk appears bluish and is not as thick as colostrum. It provides 20 cal/oz and contains: •Protein—Although the content is lower than formula, it is ideal for supporting growth and development for the newborn. The majority of the protein is whey, which is easy to digest. •Fat—Approximately 58% of total calories are fat, but they are easy to digest. Essential fatty acid content is high, as is the level of cholesterol, which helps develop enzyme systems capable of handling cholesterol later in life. •Carbohydrate—Approximately 35% to 40% of total calories are in the form of lactose, which stimulates the growth of natural defense bacteria in the gastrointestinal system and promotes calcium absorption. •Water—Water, the major nutrient in breast milk, makes up 85% to 95% of the total volume. Total milk volume varies with the age of the infant and demand. •Minerals—Breast milk contains calcium, phosphorus, chlorine, potassium, and sodium, with trace amounts of iron, copper, and manganese. Iron absorption is about 50%, compared with about 4% for iron-fortified formulas. • Vitamins—All vitamins are present in breast milk; vitamin D is the lowest in amount. Vitamin D supplementation is recommended by the AAP now. •Enzymes—Lipase and amylase are found in breast milk to assist with digestion

Ballard Score (Neuromuscular Maturity)

The neuromuscular maturity section is typically completed within 24 hours after birth. 1. Posture—How does the newborn hold their extremities in elation to the trunk? The greater the degree of flexion, the greater the maturity. For example, extension of arms and legs is scored as 0 points and full flexion of arms and legs is scored as 4 points. 2. Square window—How far can the newborn's hands be flexed toward the wrist? The angle is measured and scored from more than 90 degrees to 0 degrees to determine the maturity rating. As the angle decreases, the newborn's maturity increases. For example, an angle of more than 90 degrees is scored as -1 point and an angle of 0 degrees is scored as 4 points. 3. Arm recoil—How far do the newborn's arms "spring back" to a flexed position? This measure evaluates the degree of arm flexion and the strength of recoil. The reaction of the arm is then scored from 0 to 4 points based on the degree of flexion as the arms are returned to their normal flexed position. The higher the points assigned, the greater the neuromuscular maturity (e.g., recoil less than a 90-degree angle is scored as 4 points). 4.Popliteal angle—How far will the newborn's knees extend? The angle created when the knee is extended is measured. An angle of less than 90 degrees indicates greater maturity. For example, an angle of 180 degrees is scored as -1 point and an angle of less than 90 degrees is scored as 5 points. 5. Scarf sign—How far can the elbows be moved across the newborn's chest? An elbow that does not reach midline indicates greater maturity. For example, if the elbow reaches or nears the level of the opposite shoulder, this is scored as -1 point; if the elbow does not cross the proximate axillary line, it is scored as 4 points. 6. Heel to ear—How close can the newborn's feet be moved to the ears? This maneuver assesses hip flexibility; the lesser the flexibility, the greater the newborn's maturity. The heel-to-ear assessment is scored in the same manner as the scarf sign.

Guthrie Test

This tests for PKU. The baby should have eaten source of protein first The trend toward early discharge of newborns can affect the timing of screening and the accuracy of some test results. For example, the newborn needs to ingest enough breast milk or formula to elevate phenylalanine levels for the screening test to identify PKU accurately, so newborn screening for PKU testing should not be performed before 24 hours of age. Screening tests for genetic and inborn errors of metabolism require a few drops of blood taken from the newborn's heel (Fig. 18.22). These tests are usually performed shortly before discharge. Newborns who are discharged before 24 hours of age need to have repeat tests done within a week in an outpatient facility.

Ballard Score

To determine a newborn's gestational age (the stage of maturity), physical signs and neurologic characteristics are assessed. Typically, gestational age is determined by using a tool such as the Ballard gestational age assessment or Ballard Scale. It determines a newborn's gestational age between 20 and 44 weeks. A score is assigned to the various parameters, and the total score corresponds to a maturity rating in weeks of gestation

True or False: A newborn with a temperature under 96 degrees is experiencing cold stress. This can lead to respiratory distress so we should place them under a warmer.

True

True or False: A newborn's respiratory rate is irregular with brief periods of apnea.

True

True or False: A really low temperature can indicate sepsis before any other symptoms occur.

True

True or False: It is the law that a baby is must have a car seat in proper placement in order to be discharged.

True 5 point restraint, shoulders not abdomen!

True or False: Estrogen can cause male babies to excrete breast milk and female babies to leak vaginal blood.

True this is okay and should disappear in a few days

Initial Newborn Assessment: Weight

Typically, the full term newborn weighs 2,500 to 4,000 g (5 lb, 8 oz to 8 lb, 14 oz (Birth weights less than 10% or more than 90% on a growth chart are outside the normal range and need further investigation). Newborns can lose up to 10% of their initial birth weight by 3 to 4 days of age secondary to loss of meconium, extracellular fluid, and limited food intake. This weight loss is usually regained by the 10th day of life **we use a digital scale and the baby will be naked

Bottle Feeding Parent Teaching

Wash your hands with soap and water before preparing formula. Mix the formula and water amounts exactly as the label specifies. Always hold the newborn and bottle during feedings; never prop the bottle. Never freeze formula or warm it in the microwave. Place refrigerated formula in a pan of hot water for a few minutes to warm. Test the temperature of the formula by shaking a few drops on the wrist. Hold the bottle like a pencil, keeping it tipped to prevent air from entering. Position the bottle so that the nipple remains filled with milk. Burp the infant after every few ounces to allow air swallowed to escape. Move the nipple around in the infant's mouth to stimulate sucking. Always keep a bulb syringe close by to use if choking occurs. Avoid putting the infant to bed with a bottle to prevent "baby bottle tooth decay." Feed the newborn approximately every 3 to 4 hours. Use an iron-fortified formula for the first year. Prepare enough formula for the next 24 hours. Check nipples regularly and discard any that are sticky, cracked, or leaking. Store unmixed, open liquid formula in the refrigerator for up to 48 hours. Throw away any formula left in the bottle after each feeding.

Weaning Breast Milk

Weaning can be done because the mother is returning to work and cannot keep breast-feeding or because the infant is losing interest in breast-feeding and showing signs of independence. There is no "right" time to wean; it depends on the desires of the mother and infant. Weaning represents a significant change in the way the mother and infant interact, and each mother must decide for herself when she and her infant are ready to take that step. Either one can start the weaning process, but usually it occurs between 6 months and 1 year of age. To begin weaning from the breast, instruct mothers to substitute breast-feeding with a cup or a bottle. Often the midday feeding is the easiest feeding to replace. A trainer cup with two handles and a snap-on lid with a spout are appropriate and minimize spilling. Because weaning is a gradual process, it may take months. Instruct parents to proceed slowly and let the infant's willingness and interest guide them. Weaning from the bottle to the cup also needs to be timed appropriately for mother and infant. Typically, the night bottle is the last to be given up, with cup drinking substituted throughout the day. Slowly diluting the formula with water over a week can help in this process; the final result is an all-water bottle. To prevent the baby from sucking on the bottle during the night, remove it from the crib after the infant falls asleep.

Rooting Reflex

a baby's tendency, when touched on the cheek, to open the mouth and search for the nipple Goes away in 4-6 months

Common Skin Variations in Newborns: Vernix caseosa

a thick white substance that protects the skin of the fetus; formed by secretions from the fetus's oil glands and is found during the first 2 or 3 days after birth in body creases and the hair. It does not need to be removed because it will be absorbed into the skin

Initial Newborn Assessment: APGAR Score

at least a score of 7 or better is normal—done at 1 and then 5 mins and then every 5 mins if we have less than 7 ***0-3 score the baby is severely decompensated and in severe distress

Common Skin Variations in Newborns: Mongolian Spots

benign blue or purple splotches that appear solitary on the lower back and buttocks of newborns but may occur as multiples over the legs and shoulders. They tend to occur in African American, Asian, Hispanic, and Indian newborns but can occur in dark-skinned newborns of all races. The spots are caused by a concentration of pigmented cells and usually disappear spontaneously within the first 4 years of life. They should not be confused with bruises caused by trauma

Cephala Hematoma

bleeding under the skin; does not cross the suture line; skin looks okay but bleeding is the issue (can take weeks to months to get rid of hematoma ) ***Hyperbilirubinemia occurs following the breakdown of the red blood cells within the hematoma. This type of hyperbilirubinemia occurs later than classic physiologic hyperbilirubinemia. Cephalhematoma usually appears on the second or third day after birth and disappears within weeks or months. Large cephalhematomas can lead to increased bilirubin levels and subsequent jaundice.

Ballard Physical Exam: Plantar Creases

creases on the soles of the feet, which range from absent to covering the entire foot, depending on maturity (the greater the number of creases, the greater the newborn's maturity) ***"Slick Foot" is seen more in premature infants.

Ballard Physical Exam: Eyes and Ears

eyelids can be fused or open and ear cartilage and stiffness determine the degree of maturity (the greater the amount of ear cartilage with stiffness, the greater the newborn's maturity) ***ear recoil with full term; preterm baby has sticky ears so it will take a while

Ballard Physical Exam: Genitals

in males, evidence of testicular descent and appearance of scrotum (which can range from smooth to covered with rugae) determine maturity; in females, appearance and size of clitoris and labia determine maturity (a prominent clitoris with flat labia suggests prematurity, while a clitoris covered by labia suggests greater maturity)

Breastfeeding Concerns: Mastitis

inflammation of the breast, causes flu-like symptoms, chills, fever, and malaise. These symptoms may occur before the development of soreness, aching, swelling, and redness in the breast (usually the upper outer quadrant). This condition usually occurs in just one breast when a milk duct becomes blocked, causing inflammation, or through a cracked or damaged nipple, allowing bacteria to infect a portion of the breast. Treatment consists of rest, warm compresses, antibiotics, breast support, and continued breast-feeding (the infection will not pass into the breast milk). Explain to the mother that it is important to keep the milk flowing in the infected breast, whether it is through nursing or manual expression or with a breast pump.

Extremely low birth weight (ELBW)

less than 1,000 g (less than 2.5 lb)

Very low birth weight (VLBW)

less than 1,500 g (less than 3.5 lb)

Low birth weight (LBW)

less than 2,500 g (less than 5.5 lb)

Pre Term Newborn

less than 37 completed weeks

Common Skin Variations in Newborns: Stork Bites (or Salmon Patches)

little pink spots usually near the mouth, eyes, forehead, back of the neck; caused by a concentration of immature blood vessels and are most visible when the newborn is crying. They are considered a normal variant, and most fade and disappear completely within the first year

Caput Succedaneum

localized edema on the scalp that occurs from the pressure of the birth process. It is commonly observed after prolonged labor; appears as a poorly demarcated soft tissue swelling that ***crosses suture lines; pitting edema and overlying petechiae and ecchymosis are noted; swelling will gradually dissipate in about 3 days without any treatment. Newborns who were delivered via vacuum extraction usually have a caput in the area where the cup was used.

Moro Reflex

lose reflex b/w 3 and 6 months The Moro reflex, also called the embrace reflex, occurs when the neonate is startled. To elicit this reflex, place the newborn on their back. Support the upper body weight of the supine newborn by the arms, using a lifting motion, without lifting the newborn off the surface. Then release the arms suddenly. The newborn will throw the arms outward and flex the knees; the arms then return to the chest. The fingers also spread to form a C shape. The newborn initially appears startled and then relaxes to a normal resting position

Common Skin Variations in Newborns: Milia

multiple pearly white or pale yellow unopened sebaceous glands frequently found on a newborn's nose. They may also appear on the chin and forehead. They form from oil glands and disappear on their own within 2 to 4 weeks. When they occur in a newborn's mouth and gums, they are termed Epstein pearls. They occur in approximately 80% of newborns. As most lesions break spontaneously within the first few weeks of life, no therapy is indicated SO DO NOT PICK AT THEM

Hypoglycemia Treatment

reatment of hypoglycemia in the newborn includes administration of a rapid-acting source of glucose such as dextrose gel, breast-feeding, or early formula feeding. In acute, severe cases, intravenous administration of glucose may be required. Continuous monitoring of glucose levels is not only prudent but mandatory in high-risk newborns. Although there is no specific means of preventing hypoglycemia in newborns, it is wise and cautious to monitor for symptoms and intervene as soon as symptoms are noted. Subsequently, early diagnosis and appropriate intervention are essential for all newborns.

Common Skin Variations in Newborns: Harlequin Sign

refers to the dilation of blood vessels on only one side of the body, giving the newborn the appearance of wearing a clown suit. It gives a distinct midline demarcation, which is described as pale on the nondependent side and red on the opposite, dependent side. It results from immature autoregulation of blood flow and is commonly seen in low-birth-weight newborns when there is a positional change. It is transient, lasting as long as 20 minutes, and no intervention is needed.

Ballard Physical Exam: Lanugo

soft downy hair on the newborn's body, which is absent in preterm newborns, appears with maturity and then disappears again with postmaturity ***early preterm babies usually have this; helps preserve body weight; usually gone within a few weeks

If the newborn heart rate is less than 100, what should be done?

start CPR

Transient Tachypnea of the Newborn

temporary increased RR; from delay of fluid excretion; not as common with vaginal delivery; usually resolved within 72 hrs with O2 therapy Transient tachypnea is accompanied by retractions, nasal flaring, expiratory grunting, and/or cyanosis and is relieved by low-dose oxygen therapy. Mild or moderate respiratory distress is typically present at birth or within 6 hours of birth. Transient tachypnea of the newborn is generally a self-limited disorder without significant morbidity. Transient tachypnea of the newborn resolves over a 24- to 72-hour period. Nursing interventions include providing supportive care: giving oxygen support if pulse oximetry or arterial blood gas (ABG) values suggest hypoxemia, ensuring warmth, observing respiratory status frequently, and allowing time for the pulmonary capillaries and the lymphatics to remove the remaining fluid. The clinical course is relatively benign, but any newborn respiratory issue can be frightening to the parents. Provide a thorough explanation and reassure them that the condition will resolve over time.

Ballard Physical Exam: Breast Tissue

the thickness and size of breast tissue and areola (the darkened ring around each nipple), which range from being imperceptible to full and budding ***bigger the more mature; same for female and male b/c they received the same amount of estrogen exposure

Ballard Physical Exam: Skin Texture

typically ranges from sticky and transparent to smooth with varying degrees of peeling and cracking, to parchment-like or leathery with significant cracking and wrinkling ***Sticky and transparent is a sign of a very preterm baby; leathery and crackery is a sign of a very post term baby b/c they use the vernix all the way up and nothing moisturizes the skin anymore

Psychologic Jaundice of the Newborn

usually seen within first 3 days of life; we treat by feeding the baby so extra bilirubin can be excreted by the bowels; phototherapy or exchange transfusion to bring levels down if level reaches 12 to 15); natural sunlight can help too! look at skin integrity, temp, i and os if they are under the light

What does stool of a breast fed infant usually look like?

yellow curds with lots of water

*Nutritional Needs: Calories

•A newborn's caloric needs range from 110 to 120 cal/kg body weight. Breast milk and formulas contain approximately 20 cal/oz, so the caloric needs of young infants can be met if several feedings are given throughout the day. Most full-term infants need a basic formula if the mother chooses not to breast-feed. These formulas are modeled after breast milk, which contains 20 cal/oz. There is no evidence to recommend one brand over the other since all of them are nutritionally interchangeable. All formulas are classified based on three parameters: caloric density, carbohydrate source, and protein composition

*Measures to Decrease Air Swallowing

•Hold the newborn upright with their head on the parent's shoulder. -upright position, NOT the strength of the patting is what makes them burp •Support the head and neck while the parent gently pats or rubs the newborn's back. •Have the newborn sit on the parent's lap, while supporting the baby's chest and head. •Gently rub the newborn's back with the other hand. •Lay the newborn on the parent's lap with the baby's back facing up. •Support the newborn's head in the crook of the parent's arm and gently pat or rub the back.

Prevention of Abduction

•All newborns must be transported in cribs and not carried. •Nurses must respond immediately to any security alarm that sounds on the unit. •Newborns must never be unattended at any time, especially in hallways. All staff must wear appropriate identification at all times. •Encourage mothers to keep the baby/bassinet on the far side, away from the door. •Personnel should be wary of visitors who do not seem to be visiting a specific mother. • The electronic security system should be checked to make sure it works. •Footprint the newborn, take a color photograph, and record the newborn's physical examination within 2 hours of birth. •Discontinue publication of birth notices in local newspapers. • Develop and implement a proactive infant abduction prevention plan. •Ensure the proper functioning and placement of any electronic sensors used on newborns. •Parents should be taught what infant abduction is; why infant security is important; the schedule of nursery, feeding, and visiting hours; rules about visitor access; the facility's security policies and procedures; what parents can do to protect the infant in the hospital; which staff members are allowed to handle the newborn; and what a proper ID looks like.

Sleep Promotion

•Although many parents feel their newborns need them every minute of the day, babies actually need to sleep much of the day at first. Usually newborns sleep up to 15 hours daily. They sleep for 2 to 4 hours at a time but do not sleep through the night because their stomach capacity is too small to go long periods without nourishment. •All newborns develop their own sleep patterns and cycles, but it may take several months before the newborn sleeps through the night. Frequently, newborns have their day and night hours reversed and tend to sleep more during the daytime and less during the night. •Parents should place the newborn on their back to sleep. To prevent suffocation, all fluffy bedding, quilts, sheepskins, stuffed animals, and pillows should be removed from the crib. Parents should be informed that the practice of "co-sleeping" (sharing a bed) is not safe. •Always place the baby on their back to sleep for all sleep times, including naps. •Room share, not bed share—keep the baby's sleep area in the same room where you sleep. •Avoid infant exposure to tobacco smoke during pregnancy and after birth. Avoid wrapping the infant too tightly with a blanket, and stop when infant can roll over. •Breast-fed infants have a lower risk of SIDS. •Keep the infant's sleep area in the same room where parents sleep for the first 6 months or ideally for the first year. •Only bring the infant into the parents' bed to feed or comfort them. If the infant falls asleep in the car seat, move them to a firm surface on the back. Use a firm sleep surface, free from soft objects, toys, blankets, and crib bumpers. Use a pacifier during infant sleep, but do not force its use

*Advantages of Breastfeeding for Mothers

•Can facilitate postpartum weight loss by burning extra calories •Stimulates uterine contractions to control bleeding •Lowers risk for ovarian and endometrial cancers •Facilitates bonding with newborn infant Lowers risk of type 2 diabetes •Breast milk is free unlike formula Reduces risk of postpartum depression •Promotes uterine involution as a result of release of oxytocin •Lowers the risk of breast cancer and osteoporosis •Affords some protection against conception, although it is not a reliable contraceptive method

*Advantages of Breast Feeding for the Newborn

•Contributes to the development of a strong immune system •Stimulates growth of positive bacteria in digestive tract •Reduces incidence of stomach upset, diarrhea, and colic •Begins the immunization process at birth by providing passive immunity •Promotes optimal mother-infant bonding Reduces risk of newborn constipation •Promotes greater developmental gains in preterm infants Provides easily tolerated and digestible formula that is sterile, at proper temperature, and readily available with no artificial colorings, flavorings, or preservatives Is less likely to result in overfeeding, leading to obesity • Promotes better tooth and jaw development as a result of sucking hard •Provides protection against food allergies Lowers health care costs due to fewer illnesses Is associated with avoidance of type 1 diabetes and heart disease

*Nutritional Needs: Fluid Requirements

•Fluid requirements for the newborn and infant range from 100 to 150 mL/kg daily. This requirement can be met through breast-feeding or bottle feeding. Additional water supplementation is not necessary. Adequate carbohydrates, fats, protein, and vitamins are achieved through consumption of breast milk or formula. The AAP (2019b) recommends that iron-fortified formula be used for all infants who are not breast-fed from birth to 1 year of age. The breast-fed infant draws on iron reserves for the first 6 months and then needs iron-rich foods or supplementation added at 6 months of age. The AAP (2019h) also has recommended that all infants (breast-fed and bottle fed) receive a daily supplement of 400 IU of vitamin D starting within the first few days of life to prevent rickets and vitamin D deficiency. It is also recommended that fluoride supplementation be given to infants not receiving fluoridated water after the age of 6 months

*Breast Feeding Positioning

•Help position the newborn so that latching on is effective and not painful for the mother. Placing pillows or a folded blanket under the mother's head may help, or rolling her to one side and tucking the newborn next to her •In the football hold, the mother holds the infant's back and shoulders in her palm and tucks the infant under her arm. Remind the mother to keep the infant's ear, shoulder, and hip in a straight line. The mother supports the breast with her hand and brings it to the infant's lips to latch on. She continues to support the breast until the infant begins to nurse. This position allows the mother to see the infant's mouth as she guides her infant to the nipple. This is a good choice for mothers who have had cesarean births because it avoids pressure on the incision. • The cross cradling position is the one most commonly used. The mother holds the baby in the crook of her arm, with the infant facing the mother. The mother supports the breast with her opposite hand. •In the across-the-lap position, the mother places a pillow across her lap, with the infant facing the mother. The mother supports the infant's back and shoulders with her palm and supports her breast from underneath. After the infant is in position, the infant is pulled forward to latch on. •In the side-lying position, the mother lies on her side with a pillow supporting her back and another pillow supporting the newborn in the front. To start, the mother props herself up on an elbow and supports the newborn with that arm while holding her breast with the opposite hand. Once nursing is started, the mother lies down in a comfortable position. •To promote latching on, instruct the mother to make a C or a V shape with her fingers

*Breast Feeding Assistance

•Keys to successful breast-feeding include: Initiating breast-feeding within the first hour of life if the newborn is stable •Placing the newborn on the mother's chest or abdomen immediately after birth •Following the newborn's feeding schedule—eight to 12 times in 24 hours •Providing unrestricted periods of breast-feeding Offering no supplement unless medically indicated •Having a lactation consultant observe a feeding session •Avoiding artificial nipples and pacifiers except during a painful procedure Increasing fluid intake to encourage greater milk production Feeding from both breasts over each 24-hour period •Watching for indicators of sufficient intake from infant: Six to 10 wet diapers daily Waking up hungry eight to 12 times in 24 hours •Acting content and falling asleep after feeding •Keeping the newborn with the mother throughout the hospital stay Availability of the nurse or lactation consultant to guide and support the breast-feeding mother while on the postpartum unit

LATCH Method for Assessing Breast Feedings

•L: How well infant latches onto the breast •A: Amount of audible swallowing •T: Nipple type (inverted have to have a shield to help) •C: Level of comfort •H: Amount of help mother needs

Infection Prevention

•Minimize exposure of newborns to organisms. •Wash your hands before and after providing care, and insist all personnel wash their hands before handling any newborn. •Visitors should be limited to those essential for the woman's well-being and care. •Do not allow ill staff or visitors to visit or handle newborns. •Avoid sharing any infant supplies with another infant •Monitor the umbilical cord stump and circumcision site for signs of infection. Provide eye prophylaxis by instilling prescribed medication soon after birth. •Educate parents about appropriate home measures that will prevent infections, such as practicing good hand hygiene before and after diaper changes, keeping the newborn well hydrated, avoiding taking the infant into crowds (which may expose them to viruses), observing for early signs of infection (fever, vomiting, loss of appetite, lethargy, labored breathing, green watery stools, and drainage from umbilical cord site or eyes), and keeping pediatrician appointments for routine immunizations.

Suppression of Lactation in the Nonbreastfeeding Mother

•Nonpharmacologic means -Binding no longer recommended •Analgesics •Cabbage leaves •Health promotion education -Avoid stimulation of breasts, nipples until fullness has passed

Umbilical Cord Care Teaching for Caregivers

•Observe for bleeding, redness, drainage, foul odor from the cord stump and report to the provider •Avoid tub baths until the cord has fallen off and the area has healed. •Expose the cord stump to the air as much as possible throughout the day. •Fold diapers below the level of the cord to prevent contamination of the site and to promote air-drying of the cord. •Observe the cord stump, which will change color from yellow to brown to black. This is normal. •Never pull the cord or attempt to loosen it; it will fall off naturally.

*Selected Screenings for Newborns

•PKU (blood test that has to be done before they go home—STATE LAW—via a heel stick; Guthrie Blood Test) •Congenital hypothyroidism (thyroid replacement therapy needed for life; irreversible brain damage) •Galactosemia (S/S?, complications?, have to eliminate all milk from diet; receive soymilk diet) •Sickle cell anemia (risk for infection for the rest of life and vaso occulsive disorders too) •Algo Hearing Screen

*Breast Feeding Education

•Set aside a quiet place where you can be relaxed and won't be disturbed. Relaxation promotes milk letdown. • Sit in a comfortable chair or rocking chair or lie on a bed. Try to make each feeding calm, quiet, and leisurely. Avoid distractions. •Listen to soothing music and sip a nutritious drink during feedings. • Initially, nurse the newborn every few hours to stimulate milk production. Remember that the supply of milk is equal to the demand—the more sucking, the more milk. •Watch for signals from the infant to indicate that they are hungry, such as: -Nuzzling against the mother's breasts -Demonstrating the rooting reflex by making sucking motions -Placing fist or hands in mouth to suck on -Crying and squirming Smacking the lips •Stimulate the rooting reflex by touching the newborn's cheek to initiate sucking. •Look for signs indicating that the newborn has latched on correctly: wide-open mouth with the nipple and much of the areola in the mouth, lips rolled outward, and tongue over lower gum, visible jaw movement drawing milk out, rhythmic sucking with an audible swallowing (soft "ka" or "ah" sound indicates the infant is swallowing milk). •Hold the newborn closely, facing the breast, with the newborn's ear, shoulder, and hip in direct alignment. •Nurse the infant on demand, not on a rigid schedule. Feed every 2 to 3 hours within a 24-hour period for a total of eight to 12 feedings. • Alternate the breast you offer first; identify with a safety pin on the bra. •Vary your position for each feeding to empty breasts and reduce soreness. •Look for signs that the newborn is getting enough milk: At least six wet diapers and two to five loose yellow stools daily Steady weight gain after the first week of age Pale yellow urine, not deep yellow or orange Sleeping well, yet looks alert and healthy when awake •Wake up the newborn if they have nursed less than 5 minutes by unwrapping them. • Before removing the baby from the breast, break the infant's suction by inserting a finger. • Burp the infant to release air when changing breasts and at the end of the breast-feeding session. •Avoid supplemental formula feedings unless indicated for a medical reason. Do not take drugs or medications unless approved by the health care provider.

*Psychologic Changes Related to Nutrition

•Stomach capacity is limited at birth. The emptying time is short (2 to 3 hours) and peristalsis is rapid. Therefore, small, frequent feedings are needed at first, with amounts progressively increasing with maturity. • The immune system is immature at birth, so the baby is at a high risk for food allergies during the first 4 to 6 months of life. Introducing solid foods prior to this time increases the risk of developing food allergies. •Pancreatic enzymes and bile to assist in digestion of fat and starch are in limited supply until about 3 to 6 months of age. Infants cannot digest cereal prior to this time. •The kidneys are immature and unable to concentrate urine until about 4 to 6 weeks of age. Excess protein and mineral intake can place a strain on kidney function and can lead to dehydration. Infants need to consume more water per unit of body weight than adults do as a result of their high body weight from water. • Immature muscular control at birth changes over time to assist in the feeding process by improving head and neck control, hand-eye coordination, swallowing, and the ability to sit, grasp, and chew. At about 4 to 6 months, inborn reflexes disappear, head control develops, and the infant can sit to be fed, making spoon-feeding possible

*Feeding the Newborn and Frequency

•The newborn can be fed at any time during the transition period if assessments are normal and a desire is demonstrated. Before the newborn can be fed, determine their ability to suck and swallow. Clear any mucus in the nares or mouth with a bulb syringe before initiating feeding. Auscultate bowel sounds, check for abdominal distention, and inspect the anus for patency. If these parameters are within normal limits, newborn feeding may be started. Most newborns have on-demand feeding schedules and are allowed to feed when they awaken. When they go home, mothers are encouraged to feed their newborns every 2 to 4 hours during the day and only when the newborn awakens during the night for the first few days after birth. Parents often have many questions about feeding. Generally, newborns should be fed on demand whenever they seem hungry. Most newborns will give clues about their hunger status by crying, placing their fingers or fist in their mouth, rooting around, and sucking. •Newborns differ in their feeding needs and preferences, but most breast-fed newborns need to be fed every 2 to 3 hours, nursing for 10 to 20 minutes on each breast. The length of feedings is up to the mother and newborn. Encourage the mother to respond to cues from her infant and not feed according to a standard or preset schedule. •Formula-fed newborns usually feed every 3 to 4 hours, finishing a bottle in 30 minutes or less. Daily formula intake for an infant should be 1.5 to 2 oz/lb of body weight, but growth is a better measure of health than the amount of formula consumed. If the newborn seems satisfied, wets six to 10 diapers daily, produces several stools a day, sleeps well, and is gaining weight regularly, then they are probably receiving sufficient breast milk or formula.