The Newborn

Physiologic Adaptations: Thermogenic System: Heat Loss

-4 modes: Convection, Radiation, Evaporation, and Conduction. -Factors that influence heat loss is: temperature and humidity of the air, flow and velocity of the air, and the temperature of surfaces in contact with and around the infant.

Recommended Infant Nutrition

-American Academy of Pediatrics (AAP) recommends infants be breastfed exclusively for first 6 months of life. -Breastfeeding should continue for at least 12 months and thereafter as desired. -Complementary foods can be introduced after 6 months.

Physiologic Adaptations: Skeletal System: Caput Succedaneum

-Caput succedaneum is a generalized, easily identifiable edematous area of the scalp, most commonly found on the occiput. -disappears spontaneously within 3 to 4 days. -Infants who are born with the assistance of vacuum extraction usually have a caput in the area where the cup was applied. -Bruising of the scalp is often seen in the presence of caput succedaneum.

Physiologic Adaptations: Hematopietic System: Blood groups

-Cord blood samples may be used to identify the infant's blood type and Rh status.

Physiologic Adaptations: Integumentary System: Mongolian Spots

-Mongolian spots, bluish-black areas of pigmentation, may appear over any part of the exterior surface of the body, including the extremities. -They are noted more commonly on the back and buttocks. -These pigmented areas occur most frequently in newborns whose ethnic origins are in the Mediterranean area, Latin America, Asia, or Africa. -They are more common in dark-skinned individuals but may occur in 5% to 13% of Caucasians.

Physiologic Adaptations: Hematopietic System: Platelets

-Range between 150,00 and 300,000 and is essentially the same in newborns as in adults.

Physiologic Adaptations: Renal System: Signs of renal system problems

Enlarged or cystic kidneys can be identified as masses during abdominal palpation.

Physiologic Adaptations: Hematopietic System: RBC and HGB

-At birth the average levels of RBCs, HGB, and HCT are higher than those in the adult. Fall slowly over the first month. -At birth RBC: 4.6 to 5.2 million. HGB: 13.7-20.1 decreasing gradually to 12 to 20 during the first two weeks. HCT: 51-56%, increase slightly in the first few hours or days as fluid shifts from intravascular to interstitial spaces and by 8 weeks are between 39-59%. -Polycythemia (central venous hematocrit greater than 65%) can occur in term and preterm infants as a result of delayed cord clamping, maternal hypertension or diabetes, or IUGR. -Iron stores are sufficient to sustain normal RBC production for 4 to 5 months.

Physiologic Adaptations: Hepatic System: Iron Storage

-At birth the term infant has an iron store sufficient to last 4 to 6 months. -Iron stores of preterm and small-for-gestational age infants are often lower and are depleted sooner than in healthy term infants. -Although both breast milk and cow's milk contain iron, the bioavailability of iron in breast milk is far superior. -The American Academy of Pediatrics (AAP) recommends that breastfed infants should receive a daily oral iron supplement (1mg/kg) beginning at 4 months until feeding includes iron-fortified cereal or other foods fortified with iron. Formula-fed infants should receive a formula that contains supplemental iron.

Benefits of Breastfeeding

*For the Infant*: Reduced risk for: • Nonspecific gastrointestinal infections • Celiac disease • Childhood inflammatory bowel disease • Necrotizing enterocolitis in preterm infants • Clinical asthma, atopic dermatitis, and eczema • Lower respiratory tract infection • Otitis media • SIDS • Obesity in adolescence and adulthood • Types 1 and 2 diabetes • Acute lymphocytic and myeloid leukemia Enhanced neurodevelopmental outcomes, especially in preterm infants *For the mother*: Decreased postpartum bleeding and more rapid uterine involution Reduced risk for: • Ovarian cancer and breast cancer (primarily premenopausal) • Type II diabetes • Hypertension, hypercholesterolemia, and cardiovascular disease • Rheumatoid arthritis Unique bonding experience Increased maternal role attainment *For Families and Society*: • Convenient; ready to feed • No bottles or other necessary equipment • Less expensive than infant formula • Reduced annual health care costs • Less parental absence from work because of ill infant • Reduced environmental burden related to disposal of formula packaging and equipment.

Hemolytic Disorders: Rh Incompatibility

-Difficulty may arise when the mother is Rh negative and the infant is Rh positive. -Multiple gestations, abruptio placentae, placenta previa, manual removal of the placenta, and cesarean birth increase the incidence of transplacental hemorrhage and subsequent isoimmunization. -Because the condition begins in utero, the fetus attempts to compensate for the progressive hemolysis and anemia by accelerating the rate of erythropoiesis. As a result, immature RBCs (erythroblasts) appear in the fetal circulation; thus the term erythroblastosis fetalis. -Sensitization may occur during the first pregnancy if the woman had previously received an Rh-positive blood transfusion.

MANEUVERS USED IN ASSESSING GESTATIONAL AGE

*Posture* 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. Full flexion of the arms and legs =score 4.* *Square Window* 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. Full flexion (hand lies flat on ventral surface of forearm) = score 4.* *Arm Recoil* With infant supine, fully flex both forearms on upper arms and hold for 5 seconds; pull down on hands to extend fully, and rapidly release arms. Observe rapidity and intensity of recoil to a state of flexion. A brisk return to full flexion = score 4.* *Popliteal Angle* With infant supine and pelvis flat on a firm surface, flex lower leg on thigh and then flex thigh on abdomen. 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). An angle of less than 90 degrees =score 5.* *Scarf Sign* With infant supine, support head in midline with one hand; use other hand to pull infant's arm across the shoulder so that infant's hand touches shoulder. Determine location of elbow in relation to midline. Elbow does not reach midline = score 4.* *Heel to Ear* With infant supine and pelvis flat on a firm surface, pull foot as far as possible (without using force) up toward ear on same side. Measure distance of foot from ear and degree of knee flexion (same as popliteal angle). Knees flexed with a popliteal angle of less than 10 degrees = score 4.*

Physiologic Adaptations: Thermogenic System: Hyperthermia

-A body temperature greater than 37.5° C (99.5° F) is considered to be abnormally high and is typically caused by excess heat production related to sepsis or a decrease in heat loss. Hyperthermia can result from the inappropriate use of external heat sources such as radiant warmers, phototherapy, sunlight, increased environmental temperature, and the use of excessive clothing or blankets. -skin vessels dilate, skin appears flushed hands and feet are warm to touch, and the infant assumes a postureof extension. -The newborn who is hyperthermic because of sepsis appears stressed: vessels in the skin are constricted, color is pale, and hands and feet are cool. - Hyperthermia develops more rapidly in a newborn than in an adult because of the relatively larger surface area of an infant. -Sweat glands do not function well. Serious overheating of the newborn can cause cerebral damage from dehydration or even heat stroke and death.

Physiologic Problems: Jaundice

-A majority of newborn infants will experience some level of jaundice during the first few days of life, usually occurring after 24 hours. -physiologic jaundice, caused by increased levels of unconjugated bilirubin; physiologic jaundice is usually self-limiting, requires no treatment, and resolves in a few days. -pathologic jaundice, or hyperbilirubinemia, which is associated with higher levels of unconjugated bilirubin. This type of jaundice can appear in the first 24 hours and often requires phototherapy to resolve. -Jaundice can also be associated with breastfeeding. -To differentiate cutaneous jaundice from normal skin color, the nurse applies pressure with a finger over a bony area (e.g., the nose, forehead, sternum) for several seconds to empty all the capillaries in that spot. -If jaundice is present, the blanched area will appear yellow before the capillaries refill. The conjunctival sacs and buccal mucosa also are assessed, especially in darker-skinned infants. -Assessing for jaundice in natural light is recommended because artificial lighting and reflection from nursery walls can distort the actual skin color. -Breastfeeding is essential in preventing hyperbilirubinemia. Newborns should breastfeed early (within 1 to 2 hours after birth) and often (at least 8-12 times/24hr) Colostrum acts as a laxative to promote stooling, which helps rid the body of bilirubin. -Routine assessment of risk factors for severe hyperbilirubinemia is advised. The most common risk factors include gestational age less than 38 weeks, exclusive breastfeeding (especially in association with breastfeeding difficulties and excessive weight loss), significant jaundice in a sibling, isoimmune or other hemolytic disease (e.g., glucose-6-phosphate dehydrogenase [G6PD] deficiency), cephalhematoma or significant bruising, and East Indian race.

Vitamin K Prophylaxis

-A single intramuscular injection of 0.5 to 1mg of vitamin K is given soon after birth to prevent hemorrhagic disease of the newborn. Administration can be delayed until after the first breastfeeding in the birthing room. -Vitamin K is synthesized by intestinal flora, which are not present at birth. The introduction of bacteria begins with the first feedings, and by the age of 7 days, healthy newborns are able to produce their own vitamin K. -Vitamin K is never administered by the intravenous route for the prevention of hemorrhagic disease of the newborn except in some cases of a preterm infant who has no muscle mass. In such cases, the medication should be diluted and given over 10 to 15 minutes while closely monitoring the infant with a cardiorespiratory monitor. Rapid bolus administration of vitamin K can cause cardiac arrest.

Physiologic Adaptations: Cardiovascular System: Blood Volume

-Ranges from 80 to 100 mL/kg of body weight. -Immediately after birth the blood volume averages 300 mL, but can increase by as much as 100 mL. -Premature newborn has greater blood volume than term newborn. This occurs because the premature infant has a proportionately greater plasma volume, not a greater red blood cell mass. -Delayed clamping expands the blood volume from the so called placental transfusion of blood to the newborn. -Delayed cord clamping has been reported to be beneficial in improving hematocrit and iron status and decreasing anemia, and can last up to 6 months.

Physiologic Adaptation: Integumentary System

-After 35 weeks of gestation the skin is covered by vernix caseosa (a cheeselike, whitish substance) that is fused with the epidermis and serves as a protective covering. -Vernix caseosa is a complex substance that contains sebaceous gland secretions. It has emollient and antimicrobial properties and prevents fluid loss through the skin; it also has antioxidant properties. -Removal of the vernix is followed by desquamation of the epidermis in most infants. There is evidence that leaving residual vernix intact after birth has positive benefits for neonatal skin such as decreasing the skin pH, decreasing skin erythema, and improving skin hydration. -The term infant has erythematous (red) skin for a few hours after birth, after which it fades to its normal color. -The skin often appears blotchy or mottled, especially over the extremities. The hands and feet appear slightly cyanotic (acrocyanosis); this is caused by vasomotor instability and capillary stasis. -Acrocyanosis is normal and appears intermittently over the first 7 to 10 days, especially with exposure to cold. -Creases are located on the palms of the hands and the soles of the feet. -The simian line, a single palmar crease, is often seen in Asian infants and infants with Down syndrome. The soles of the feet should be inspected for the number of creases during the first few hours after birth; as the skin dries, more creases appear. Increasing numbers of creases correlate with a greater maturity rating. Premature newborns have few if any creases.

Physiologic Adaptations: Hepatic System: Pathologic Jaundice

-Although physiologic jaundice is usually considered benign, unconjugated bilirubin (indirect) can accumulate to hazardous levels and lead to a pathologic condition. Pathologic or nonphysiologic jaundice is unconjugated hyperbilirubinemia that is either pathologic in origin or severe enough to warrant further evaluation and treatment. -Jaundice is usually considered pathologic or nonphysiologic if it appears within 24 hours of birth, if total serum bilirubin levels increase by more than 6mg/dL in 24 hours, and if the serum bilirubin level exceeds 15mg/dL at any time. -If increased levels of unconjugated bilirubin are left untreated,neurotoxicity can result as bilirubin is transferred into the brain cells. -Acute bilirubin encephalopathy refers to the acute manifestations of bilirubin toxicity that occur during the first weeks after birth. This can include a range of symptoms such as lethargy, hypotonia, irritability, seizures, coma, and death. Kernicterus refers to the irreversible, long-term consequences of bilirubin toxicity such as hypotonia, delayed motor skills, hearing loss, cerebral palsy, and gaze abnormalities.

Physiologic Adaptations: Reproductive System: Female

-An increase in estrogen during pregnancy followed by a drop after birth results in a mucoid vaginal discharge and even some slight bloody spotting (pseudomenstruation). -External genitalia (i.e., labia majora and minora) are usually edematous with increased pigmentation. In term neonates the labia majora and minora cover the vestibule. -In preterm infants the clitoris is prominent, and the labia majora are small and widely separated. -Vaginal or hymenal tags are common findings and have no clinical significance. -Vernix caseosa may be present between the labia and should not be forcibly removed during bathing.

Physiologic Adaptations: Renal System

-At birth a small quantity (approximately 40╯mL) of urine is usually present in the bladder of a full-term infant. Many newborns void at the time of birth, although this is easily missed and may not be recorded. During the first few days term infants generally excrete 15 to 60╯mL/kg; output gradually increases over the first month. -The frequency of voiding varies from 2 to 6 times per day during the first and second days of life and from 5 to 25 times during the subsequent 24 hours. Approximately six to eight voidings per day of pale, straw-colored urine indicate adequate fluid intake. -Noting and recording the first voiding are important. An infant who has not voided by 24 hours should be assessed for adequacy of fluid intake, bladder distention, restlessness, and symptoms of pain. The pediatrician or neonatal nurse practitioner should be notified. -Full-term newborns have limited capacity to concentrate urine;therefore the specific gravity ranges from 1.001 to 1.020. -The ability to concentrate urine fully is attained by about 3 months of age. After the first voiding the infant's urine may appear cloudy (because of mucus content) and have a much higherspecific gravity. This decreases as fluid intake increases. Normal urine during early infancy is usually straw colored and almost odorless. Sometimes pink-tinged uric acid crystal stains or "brick dust" appear on the diaper; these stains are normal, although they can be misinterpreted as blood. Loss of fluid through urine, feces, lungs, increased metabolic rate, and limited fluid intake results in a 5% to10% loss of the birth weight. This usually occurs over the first 3 to 5 days of life. If the mother is breastfeeding and her milk supply has not come in yet (which occurs by the third or fourth day after birth), the neonate is somewhat protected from dehydration by its increased extracellular fluid volume. The neonate should regain the birth weight within 10 to 14 days, depending on the feeding method(breast or bottle).

Physiologic Adaptation: Immune System

-At birth most of the circulating antibodies in the newborn are immunoglobulin (Ig) G antibodies that were transported across the placenta from the maternal circulation. IgG is key to immunity to bacteria and viruses. -The passive immunity afforded the infant through the placental transfer of IgG usually provides sufficient antimicrobial protection during the first 3 months of life. Production of adult concentrations of IgG is reached by 4 to 6 years of age. -The fetus is capable of producing IgM by the eighth week of gestation. -Breast milk provides the newborn with important immunity. The secretory IgA in human milk acts locally in the intestines to neutralize bacterial and viral pathogens. It may also lessen the risk of allergy and food intolerance through modulation of exposure to foreign milk protein antigens.

Choosing to Breastfeed

-Breastfeeding is a natural extension of pregnancy and childbirth; it is much more than simply a means of supplying nutrition for infants. -Women tend to select the same method of infant feeding for each of their children. If the first child was breastfed, subsequent children will likely also be breastfed. -Cultural factors influence infant feeding decisions. For example, in the Hispanic culture breastfeeding is the norm, whereas formula feeding is more common among African-American families. -There appears to be a relationship between maternal weight and infant feeding decisions. Women who are overweight or obese are less likely to breastfeed than women who are underweight or of average weight. -Social and systemic factors create obstacles or barriers to breastfeeding among women in the United States. These include a lack of broad social support for breastfeeding and the widespread marketing by infant formula companies. In addition, there is a lack of prenatal breastfeeding education for expectant parents and insufficient training/education of health care professionals about breastfeeding. -In some institutions the policies and practices do not support exclusive breastfeeding. There is a lack of support for breastfeeding mothers during the first 2 to 3 weeks after birth when they are most likely to encounter difficulties. -On a more personal level, a major obstacle for women is employment and the need to return to work after birth. A lack of support from the partner and family also creates obstacles to breastfeeding for many women. -Hispanic women BF is the norm African-American families more likely to formula-feed Muslim and Jewish cultures value BF Cultural knowledge about BF Must be comfortable in social settings

Physiologic Adaptations: Integumentary System: Signs of Integumentary Problems

-Bruises or petechiae may be present on the head, neck, and face of an infant born with a nuchal cord (cord around the neck) or in an infant who had a face presentation at birth. Bruising can increase the risk of hyperbilirubinemia. Petechiae can be present if increased pressure was applied to an area. -Petechiae scattered over the infant's body should be reported to the physician or nurse practitioner because their presence can indicate underlying problems such as low platelet count or infection.

Physiologic Adaptations: Skeletal System: Cephalhematoma

-Cephalhematoma is a collection of blood between a skull bone and its periosteum. Therefore a cephalhematoma does not cross a cranial suture line . - Often caput succedaneum and cephalhematoma occur simultaneously. -Low forceps birth and difficult forceps rotation and extraction may also cause bleeding. -This soft, fluctuating, irreducible fullness does not pulsate or bulge when the infant cries. It appears several hours or the day after birth and may not become apparent until a caput succedaneum is absorbed. -The fullness of a cephalhematoma spontaneously resolves in 3 to 6 weeks. It is not aspirated because infection may develop if the skin is punctured.

Circumcision

-Circumcision is a matter of personal parental choice. Parents usually decide to have their newborn circumcised for one or more of the following reasons: hygiene, religious conviction, tradition, culture, or social norms. -Cost and insurance coverage are considerations in the parents' decision-making process. -Circumcision is not performed immediately after birth because of the danger of cold stress and decreased clotting factors but is usually done in the hospital before discharge. The circumcision of a Jewish male infant is commonly performed on the eighth day after birth at home in a ceremony called a bris. This timing is logical from a physiologic standpoint because clotting factors decrease somewhat immediately after birth and do not return to prebirth levels until the end of the first week. -In many settings, the circumcision site is assessed for bleeding every 15 to 30 minutes for the first hour and then hourly for the next 4 to 6 hours. The nurse monitors the infant's urinary output, noting the time and amount of the first voiding after the circumcision. -If bleeding occurs from the circumcision site, the nurse applies gentle pressure with a folded sterile gauze pad. A hemostatic agent such as Gelfoam® powder or sponge can be applied to help control bleeding. If bleeding is not easily controlled, a blood vessel may need to be ligated. In this event, one nurse notifies the physician and prepares the necessary equipment (i.e., circumcision tray and suture material) while another nurse maintains intermittent pressure until the physician arrives. -the nurse washes the penis gently with water to remove urine and feces and, if necessary, applies fresh petrolatum around the glans after each diaper change. The glans penis, normally dark red during healing, becomes covered with a yellow exudate in about 24 hours, which is part of normal healing—not an infective process. -No attempt should be made to remove the exudate, which persists for 2 to 3 days. Parents are taught to apply the diaper so that it does not press on the circumcised area. They are encouraged to change the diaper at least every 4 hours to prevent it from sticking to the penis.

Physiologic Adaptations: Thermogenic System: Cold Stress

-Cold stress imposes metabolic and physiologic demands on all infants, regardless of gestational age and condition. -The respiratory rate increases in response to the increased need for oxygen. In the cold-stressed infant oxygen consumption and energy are diverted from maintaining normal brain and cardiac function and growth to thermogenesis for survival. -If the infant cannot maintain an adequate oxygen tension, vasoconstriction follows and jeopardizes pulmonary perfusion. As a consequence the Po2 is decreased, and the blood pH drops. These changes can prompt a transient respiratory distress or aggravate existing RDS. -The basal metabolic rate increases with cold stress. If cold stress is protracted, anaerobic glycolysis occurs, resulting in increased production of acids. Metabolic acidosis develops; and, if a defect in respiratory function is present, respiratory acidosis also develops. -Hypoglycemia is another metabolic consequence of cold stress.The process of anaerobic glycolysis uses approximately 3 to 4 times the amount of blood glucose, thereby depleting existing stores. If the infant is sufficiently stressed and low glucose stores are not replaced, hypoglycemia, which can be asymptomatic in the newborn, can develop.

Choosing to Formula Feed

-Cultural beliefs and myths and misconceptions about breastfeeding influence women's decision making. -Many women see bottle-feeding as more convenient or less embarrassing than breastfeeding. Some view formula feeding as a way to ensure that the father, other family members, and day care providers can feed the baby. -Some women lack confidence in their ability to produce breast milk of adequate quantity or quality. Women who have had previous unsuccessful breastfeeding experiences may choose to formula feed subsequent infants. -Some women see breastfeeding as incompatible with an active social life, or they think that it will prevent them from going back to work. -Modesty issues and societal barriers exist against breastfeeding in public. -A major barrier for many women is the influence of family and friends.

Physiologic Adaptations: Integumentary System: Desquamation

-Desquamation (peeling) of the skin of the term infant does not occur until a few days after birth. Large generalized areas of skin desquamation present at birth may be an indication of postmaturity.

Physiologic Adaptations: GI System: Feeding Behaviors

-When put to breast some infants feed immediately, whereas others require a longer learning period. -Random hand-to-mouth movement and sucking of fingers are well developed at birth and intensify when the infant is hungry.

Physiologic Adaptations: Skeletal System: Extremities

-Digits may be missing (oligodactyly). Extra digits (polydactyly) are sometimes found on hands or feet. Fingers or toes may be fused (syndactyly). -Signs of DDH are asymmetric gluteal and thigh skinfolds, uneven knee levels, a positive Ortolani test, and a positive Barlow test. The hips are inspected for symmetry. -For the Barlow test the examiner places the middle finger over the greater trochanter and the thumb along the midthigh. The hip is flexed to 90 degrees and adducted, followed by gentle downward pushing of the femoral head. If the hip can be dislocated with this maneuver, the femoral head moves out of the acetabulum, and the examiner feels a "clunk." -The hip is then checked to determine if the femoral head can be returned into the acetabulum using the Ortolani test. As the hip is abducted and upward leverage is applied, a dislocated hip returns to the acetabulum with a clunk that is felt by the examiner.

Physiologic Adaptations: Integumentary System: Sweat Glands

-Distended, small, white sebaceous glands noticeable on the newborn face are known as milia. -Although sweat glands are present at birth, term infants usually do not sweat for the first 24 hours. By day 3 sweating begins on the face and later progresses to the palms.

Nutrient Needs: Fluids

-During the first 2 days of life the fluid requirement for healthy infants (more than 1500g) is 60 to 80mL of water per kilogram of body weight per day. From day 3 to 7 the requirement is 100 to 150mL/kg/day; from day 8 to day 30 it is 120 to 180mL/kg/day. -Breast milk contains 87% water, which easily meets fluid requirements. Feeding water to infants can decrease caloric consumption at a time when they are growing rapidly.

Physiologic Adaptations: Integumentary System: Erythema Toxicum

-Erythema toxicum, a transient rash, is also called erythema neonatorum, newborn rash, or flea bite dermatitis. It first appears in term neonates during the first 24 to 72 hours after birth and can last up to 3 weeks of age.

Physiologic Adaptations: GI System: Signs of GI problems

-Failure to pass meconium can indicate bowel obstruction related to conditions such as an inborn error of metabolism (e.g.,cystic fibrosis) or a congenital disorder (e.g., Hirschsprung's disease or an imperforate anus). -An active rectal "wink" reflex (contraction of the anal sphincter muscle in response to touch) is a sign of good sphincter tone. -Fullness of the abdomen above the umbilicus can be caused by problems such as hepatomegaly, duodenal atresia, or distention. -Abdominal distention at birth usually indicates a serious disorder such as a ruptured viscus (from abdominal wall defects) or tumors. -Distention that occurs later can be the result of overfeeding or signal gastrointestinal disorders. A scaphoid (sunken) abdomen, with bowel sounds heard in the chest and signs of respiratory distress, indicate a diaphragmatic hernia. -Fullness below the umbilicus can indicate a distended bladder.

Physiologic Adaptations: Thermogenic System

-First 12 hours the neonate attempts to achieve thermal balance in adjusting to the extrauterine environmental temperature. -thermoregulation is the maintenance of balance between heat loss and heat production.

Transition to Extrauterine Life: First Period of Reactivity

-First period of reactivity, lasts up to 30 minutes after birth. The newborns heart rate increases rapidly to 160 to 180, then decreases after 30 minutes to baseline. -Respirations are irregular, with a rate between 60 and 80 breaths per minute. Fine crackles can be present on auscultation. -The infant is alert and has spontaneous startles, crying and head movement from side to side. -Bowel sounds are audible, and meconium may be passed.

Nutrient Needs: Energy

-For the first 3 months the infant needs 110kcal/kg/day. From 3 months to 6 months the requirement is 100kcal/kg/day. This level decreases slightly to 95kcal/kg/day from 6 to 9 months and increases to 100kcal/kg/day from 9 months to 1 year. -Human milk provides an average of 67kcal/100╯mL or 20kcal/oz. The fat portion of the milk provides the greatest amount of energy. Infant formulas simulate the caloric content of human milk. -Usually a standard formula contains 20kcal/oz, although the composition differs among brands.

Physiologic Adaptations: Skeletal System: Signs of Skeletal Problems

-Fractured clavicle often occurs in macrosomic infants and in those who had a difficult birth (e.g., shoulder dystocia). Unequal movement of the upper extremities or a crepitant feeling over the clavicular area can indicate fracture. -The feet of the newborn can appear to be abnormally positioned. -This can indicate congenital deformity or be related to fetal positioning in utero.

Physiologic Adaptations: Hepatic System: Carbohydrate Metabolism

-Glucose levels reach a low point between 30 and 90 minutes after birth and then rise gradually. -In most healthy term newborns blood glucose levels stabilize at 50 to 60mg/dL during the first several hours after birth. Within the first week they should be approximately 60 to 80mg/dL. -In general blood glucose levels less than 40mg/dL are considered abnormal and warrant intervention. -The hypoglycemic infant can display the classic symptoms of jitteriness, lethargy, apnea, feeding problems, or seizures; or the infant can be asymptomatic. -Hypoglycemia in the initial newborn period is most often transient and easily corrected through feeding. Persistent or recurrent hypoglycemia necessitates intravenous glucose therapy and possible pharmacologic intervention.

Physiologic Adaptations: Cardiovascular System: HR and Sounds

-HR ranges: 120 to 160 bpm. with brief fluctuations above and below these values. -Sleep HR: 85 to 100; Crying: increase to up to 180. -A HR that is either higher than 160 or lower than 100 should be reevaluated within 30 minutes to 1 hours. -The apical impulse: fourth intercostal space and to the left of the midclavicular line. -The PMI is often visible and easily palpable because of the thin chest wall; also called precordial activity. Full minute. -The first sound S1 is typically louder and duller than the second sound s2, which is sharp. The third and fourth heart sounds are not auscultated in newborns.

Hypocalcemia

-Hypocalcemia is defined as serum calcium levels of less than 7.8 to 8╯mg/dL in term infants and slightly lower (7╯mg/ dL) in preterm infants. -Hypocalcemia is common in critically ill neonates but also can occur in infants of mothers with diabetes or in those who had perinatal asphyxia or trauma, and in low-birthweight and preterm infants. - Infants born to mothers treated with anticonvulsants during pregnancy are also at risk. -Early-onset hypocalcemia usually occurs within the first 24 to 48 hours after birth. Signs of hypocalcemia include jitteriness, high-pitched cry, irritability, apnea, intermittent cyanosis, abdominal distention, and laryngospasm, although some hypocalcemic infants are asymptomatic. Jitteriness is a symptom of both hypoglycemia and hypocalcemia; therefore hypocalcemia must be considered if the therapy for hypoglycemia proves ineffective. -In most instances, early-onset hypocalcemia is self-limiting and resolves within 1 to 3 days. -Treatment usually includes early feeding of an appropriate source of calcium such as fortified human milk or a preterm infant formula.

Hypoglycemia

-Hypoglycemia in a term infant during the early newborn period is defined as a blood glucose concentration less than adequate to support neurologic, organ, and tissue function; -Hypoglycemia that warrants treatment is usually defined as blood glucose levels less than 40 to 45mg/dL, although some experts recommend treatment for levels less than 50mg/dL. -At birth, the maternal source of glucose is cut off with the clamping of the umbilical cord. Most healthy term newborns experience a transient decrease in glucose levels to as low as 30mg/dL during the first 1 to 2 hours after birth, with a subsequent mobilization of free fatty acids and ketones to help maintain adequate glucose levels. -Infants considered to be at risk for hypoglycemia include those who are small for gestational age (SGA) or large for gestational age (LGA), infants of mothers with diabetes, and late preterm infants. -All at-risk infants should be fed within the first hour, with glucose testing done 30 minutes after feeding. For at least the first 24 hours after birth, late preterm and SGA neonates should be fed every 2 to 3 hours, with glucose levels measured before each feeding. LGA infants and infants of diabetic mothers should have glucose screening before feedings for at least the first 12 hours after birth; further testing is done if glucose levels are less than 45 mg/dL. -The clinical signs of hypoglycemia can be transient or recurrent and include jitteriness, lethargy, poor feeding, abnormal cry, hypotonia, temperature instability (hypothermia), respiratory distress, apnea, and seizures. It is important to remember that hypoglycemia can be present in the absence of clinical manifestations. -Late preterm infants are at increased risk for hypoglycemia. They have decreased glycogen stores and lack hepatic enzymes for gluconeogenesis and glycogenolysis. Their hormonal regulation and insulin secretion are immature. The increased risk of cold stress and feeding difficulties adds to the risk for hypoglycemia.

Characteristics of the respiratory system of the neonate.

-Immature Alveoli; decreased size and number of alveoli: risk of respiratory insufficiency and pulmonary problems. -Thicker alveolar wall. decreased alveolar surface area: less efficient gas transport and exchange. -Continued development of alveoli until childhood: possible opportunity to reduce effects of discrete lung injury. -Decreases lung elastic tissue: decreased lung compliance requiring higher pressures and more work to expand; increased risk of actelectasis. -Reduced diaphragm movement and maximal force potential: less effective respiratory movement; difficulty generating negative intrathoracic pressure; risk of atelectasis. -Tendency to nose breath; altered position of larynx and epiglottis: Enhance ability to synchronize swallowing and breathing; risk of airway obstruction; possibly more difficult to intubate. -Small compliant airway passages with higher airway resistance; immature reflexes: risk of airway obstruction and apnea. -Increases pulmonary vascular resistance with sensitive pulmonary arterioles: risk of ductal shunting and hypoxemia with events such as hypoxia, acidosis, hypthermia, hypoglycemia, and hypercarbia. -Increased oxygen consumption: increased respiratory rate and work of breathing; risk of hypoxia. -Increases intrapulmonary right-left shunting: increased risk of atelectasis with wasted ventilation; lower PCO2. -Immaturity of pulmonary surfactant system in immature infants: increased risk of atelectasis and respiratory distress syndrome; increased work of breathing. -Immature respiratory control: Irregular respirations with periodic breathing; risk of apnea; inability to rapidly alter depth of respirations.

Physiologic Adaptations: Thermogenic System: Thermogenesis

-In response to cold the neonate attempts to generate heat (thermogenesis). -Cold infants may cry and appear restless. -Newborns produce heat through non shivering thermogenesis. This is primarily accomplished by metabolism of brown fat (a dark-colored adipose tissue with many blood vessels, involved in the rapid production of heat in hibernating animals and human babies.) -Brown fat has a richer vascular and nerve supply than ordinary fat. Heat produced by intense lipid metabolic activity in brown fat can warm the newborn by increasing heat production as much as 100%. Reserves of brown fat, usually present for several weeks after birth, are rapidly depleted with cold stress. The amount of brown fat reserve increases with the weeks of gestation. A fullterm newborn has greater stores than a preterm infant.

Physiologic Adaptations: Hepatic System: Physiologic Jaundice

-In the first phase bilirubin levels of Caucasian and African-American infants gradually increase to approximately 5 to 6mg/dL by 72 to 96 hours of life and decrease to a plateau of 2 to3mg/dL by the fifth day. -In Asian and Asian-American infants bilirubin levels peak between 72 and 120 hours of age and gradually fall to 2 to mg/dL by the seventh to tenth days. In the second phase of physiologic jaundice bilirubin levels gradually decrease between 5 and 10 days of life, reaching normal adult levels of 2mg/dL or less by 14 days. -This pattern varies according to racial group, method of feeding (breast versus bottle), and gestational age. In preterm formula-fed infants serum bilirubin levels can peak as high as 10 to 12mg/dL at 5 to 6 days of life and decrease slowly over a period of 2 to 4 weeks.

Physiologic Adaptations: Renal System: Fluid and Electrolyte Balance

-In the term neonate approximately 75% of body weight consists of total body water (extracellular and intracellular). -The weight loss experienced by most newborns during the first few days after birth is caused primarily by extracellular water loss. The daily fluid requirement for neonates weighing more than 1500 g is 60 to 80 mL/kg during the first 2 days of life. From 3 to 7 days the requirement is 100 to 150 mL/kg/day; and from 8 to 30 days it is 120 to 180mL/kg/day. -Sodium reabsorption is decreased as a result of a lowered sodium- or potassium-activated adenosine triphosphatase activity. The decreased ability to excrete excess sodium results in hypotonic urine compared with plasma, leading to a higher concentration of sodium, phosphates, chloride, and organic acids and a lower concentration of bicarbonate ions. The infant has a higher renal threshold for glucose than adults. Bicarbonate concentration and buffering capacity are decreased. This can lead to acidosis and electrolyte imbalance.

Hepatitis B Immunization

-Infants born to hepatitis B surface antigen (HBsAg)-negative mothers should receive the vaccine before they leave the hospital. If the mother is positive for hepatitis B, the infant should receive the HepB vaccine and HepB immune globulin (HBIG) within 12 hours after birth; the injections are given in separate sites (only one injection is given in each leg). -When the mother's HBsAg status is unknown, the infant who weighs 2000g or more receives HepB vaccine within 12 hours after birth; infants who weigh 2000g or less should receive HepB vaccine and HBIG during the first 12 hours. -The mother's HBsAg status is determined as soon as possible; if the results are positive, the infant who weighs 2000g or more needs a dose of HBIG before the age of 1 week. -3 series shots given: birth, 1 to 2 months of age, and 6 to 18 months of age.

Physiologic Adaptations: Hepatic System: Conjugation of Bilirubin and Newborn Jaundice

-Jaundice, the visible yellowish color of the skin and sclera, is caused by elevated serum levels of unconjugated (indirect) bilirubin. -The unconjugated (indirect) bilirubin is relatively insoluble and almost entirely bound to circulating albumin, a plasma protein. Bilirubin that is not bound to albumin, or free bilirubin, can easily cross the blood-brain barrier and cause neurotoxicity. -The unconjugated bilirubin must be conjugated so it becomes soluble and excretable. In the liver the unbound bilirubin is conjugated with glucuronic acid in the presence of the enzyme glucuronyl transferase. -The conjugated form of bilirubin (direct bilirubin) is soluble and excreted from liver cells as a constituent of bile. -Colostrum, a natural laxative, facilitates the passage of meconium. -Feeding is important in reducing serum bilirubin levels because it stimulates peristalsis and produces more rapid passage of meconium, thus diminishing the amount of reabsorption of unconjugated bilirubin. Feeding also introduces bacteria to aid in the reduction of bilirubin to urobilinogen. -The newborn is at risk for hyperbilirubinemia because of distinctive aspects of normal neonatal physiology. The higher RBC mass at birth and shorter life span of neonatal RBCs mean that there is the need for greater bilirubin synthesis. The ability of the liver to conjugate bilirubin is reduced during the first few days after birth; it can metabolize and excrete only about two thirds of the circulating bilirubin. In addition, there are fewer bilirubin binding sites because newborns have lower serum albumin levels. In the intestines conjugated bilirubin becomes unconjugated and recirculated through the enterohepatic circulation, which increases serum bilirubin levels. -Among the factors that increase the risk of hyperbilirubinemia,prematurity is the most significant. Prematurity affects liver and brain metabolism and albumin binding sites, placing preterm and late preterm infants at greater risk for hyperbilirubinemia. Infants of Asian and Native American ethnicity have higher bilirubin levels. Breastfeeding infants are at greater risk of hyperbilirubinemia.

Transition to Extrauterine Life: Period of Decreased responsiveness

-Lasts from 60 to 100 minutes. -During this time the infant is pink, and respirations are rapid and shallow (up to 60) but unlabored. Bowel sounds are audible, and peristaltic waves nay be noted over the rounded abdomen. -Newborn either sleeps or has a marked decrease in motor activity.

Physiologic Adaptations: Hematopietic System: Leukocytes

-Leukocytosis is normal at birth (wbc count of 18,000). -The number of wbc's increases to 23,000 to 24000 during the first day after birth. -Prolonged crying, maternal hypertension, asymptomatic hypoglycemia, hemolytic disease, meconium aspiration syndrome, labor induction with oxytocin, surgery, difficult labor, high altitude, and maternal fever can cause neutrophilia.

Physiologic Adaptations: GI System: Stools

-Meconium fills the lower intestine at birth. It is formed during fetal life from the amniotic fluid and its constituents, intestinal secretions (including bilirubin), and cells (shed from the mucosa). Meconium is greenish black and viscous and contains occult blood. The first meconium passed is usually sterile, but within hours all meconium passed contains bacteria. Most healthy term infants pass meconium within the first 12 to 24 hours of life, and almost all do so by 48 hours. The number of stools passed varies during the first week, being most numerous between the third and sixth days. Newborns fed early pass stools sooner. Progressive changes in the stooling pattern indicate a properly functioning gastrointestinal tract.

Interventions: Airway Maintenance

-Most secretions are moved by gravity and brought by the cough reflex to the oropharynx to be drained or swallowed or wiped away. If the infant has excess mucus in the respiratory tract, the mouth and nasal passages can be gently suctioned with a bulb syringe. -Routine chest percussion and suctioning of healthy term or late preterm infants are avoided.

Physiologic Adaptations: Respiratory: Signs of Respiratory Distress

-Nasal flaring, intercostal or subcostal retractions (in drawing of tissue between the ribs or below the rib cage), or grunting with respirations. -Suprasternal or subclavicular retractions with stidor or gasping most often represent an upper airway obstruction. -Seesaw or paradoxical respirations (exaggerated rise in abdomen with respiration as the chest falls) instead of abdominal respirations are abnormal and should be reported. -Evaluate a respiratory rate less than 30 and greater than 60. -Changes in the infants color can indicate respiratory distress, Acrocyanosis, the bluish discoloration of hands and feet, is a normal finding in the first 24 hours of birth. -Duskiness while crying are not uncommon immediately after birth; however central cyanosis is abnormal and signifies hypoxemia. -Tachypnea can result from inadequate clearance of lung fluid, or it can be an indication of newborn respiratory distress syndrome. -The respiratory symptoms can be accompanied by: hypotension, temperature instability, hypoglycemia, acidosis, and signs of cardiac problems.

Physiologic Adaptations: Integumentary System: Nevi

-Nevus simplex, also known as salmon patches, telangiectatic nevi, "stork bites," or "angel kisses" are flat, pink capillary hemangiomas that are easily blanched. -They appear on the upper eyelids, nose, upper lip, lower occiput bone, and nape of the neck. -Facial lesions fade between the first and second years of life, whereas neck lesions can be visible into adulthood. -port-wine stain, or nevus flammeus, is usually visible at birth and is composed of a plexus of newly formed capillaries in the papillary layer of the corium. - It is red to purple; varies in size, shape, and location; and is not elevated. True port-wine stains do not blanch on pressure or disappear. They are found most commonly on the face and neck. -A nevus vascularis, or strawberry hemangioma, is a common type of capillary hemangioma. The typical lesion is a raised, sharply demarcated, bright or dark red, rough-surfaced swelling,usually appearing on the head.

Contraindications of Breastfeeding

-Newborns who have galactosemia should not receive human milk. -Breastfeeding is contraindicated for mothers who are positive for human T-cell lymphotropic virus types I or II and those with untreated brucellosis. -Women should not breastfeed if they have active tuberculosis (TB) or if they have active herpes simplex lesions on the breasts. -Women with active TB can breastfeed when they have been treated for at least 2 weeks and are deemed noninfectious. -Varicella that occurs 5 days before or 2 days after birth and acute H1N1 infection require temporary separation of mother and infant. In both instances it is safe for infants to receive expressed milk. -In the United States maternal human immunodeficiency virus (HIV) infection is considered a contraindication for breastfeeding. -Breastfeeding is not recommended when mothers are receiving chemotherapy or radioactive isotopes (e.g., with diagnostic procedures). -Maternal use of mood-altering drugs ("street drugs") is incompatible with breastfeeding.

Transition to Extrauterine Life: Second Period of Reactivity

-Occurs between 2 to 8 hours after birth. -Lats for 10 minutes to several hours. -Brief periods of tachycardia and tachypnea occur, associated with increased muscle tone, changes in skin color, and mucus production. -Meconium is commonly passed at this time.

Hemolytic Disorders: ABO Incompatibility

-Occurs if fetal blood type is A,B, or AB, and maternal type is O. -Incompatibility rises because naturally occuring anti-A and anti-B antibodies are transferred across placenta to fetus. -Exchange transfusions required occasionally.

Physiologic Adaptations: Cardiovascular System: Signs of Cardiovascular Problems

-Persistent tachycardia can be associated with anemia, hypovolemia, hyperthermia, or sepsis. -Persistent Bradycardia can be a sign of congenital heart block or hypoxemia. -Pallor in the immediate post birth period is often symptomatic of anemia or marked peripheral vasoconstriction as a result of intrapartum asphyxia or sepsis. -Presence of jaundice can indicate ABO or Rh factor incompatibility problems. -Maternal illness such as rubella, metabolic disease such as diabetes. and drug ingestion are associated with an increased risk of cardiac defects.

Phototherapy

-Phototherapy can cause changes in the infant's temperature, depending partially on the bed used—bassinet, incubator, or radiant warmer. When under a phototherapy light, infants are usually clothed only with a diaper. -The infant's temperature should be closely monitored. Phototherapy lights can increase the rate of insensible water loss, which contributes to fluid loss and dehydration. Therefore the infant must be adequately hydrated. Hydration maintenance in the healthy newborn is accomplished with human milk or infant formula. -Feedings of glucose water or plain water have no advantage or benefit because these liquids do not promote excretion of bilirubin in the stools and can actually perpetuate enterohepatic circulation, thus delaying bilirubin excretion. -It is important to closely monitor urinary output as an indicator of hydration status while the infant is receiving phototherapy. Urine output can be decreased or unaltered; the urine can have a dark gold or brown appearance. -The number and consistency of stools are monitored. Bilirubin breakdown increases gastric motility, which results in loose stools that can cause skin excoriation and breakdown. -The infant's buttocks must be cleaned after each stool to help maintain skin integrity.

ASSESSMENT OF PRECONCEPTION, PRENATAL, AND INTRAPARTUM RISK FACTORS

-Preconception • Age • Pre-existing medical conditions: Diabetes, hypertension, cardiac disease, anemia, thyroid disorder, renal disease, obesity • Genetic factors: Family history • Obstetric history: Gravidity, parity, number of living children and their ages, history of stillbirth, previous infant with congenital anomalies, habitual abortion, use of assisted-reproductive technology, interpregnancy spacing • Blood type and Rh status Prenatal • Prenatal care: When started • Nutrition: Weight gain, diet, obesity, eating disorders • Health-compromising behaviors: Smoking, alcohol use, substance abuse • Blood group or Rh sensitization • Medications: Prescription, over-the-counter, and complementary/ alternative medications • History of infection: Sexually-transmitted infections, TORCH infections,* group B streptococci status Intrapartum • Length of gestation: Preterm, late preterm, term, or postterm • First stage of labor: Length, electronic fetal monitoring—internal or external, rupture of membranes (time, presence of meconium), signs of fetal distress (decelerations) • Group B streptococci status: Treatment during labor • Second stage of labor: Length, vaginal or cesarean, instrument assisted—forceps or vacuum extractor, complications (shoulder dystocia, bleeding [abruptio placentae or placenta previa]), cord prolapse, maternal analgesia and/or anesthesia

Elevated PKU >20

-Severe intellectual disability if early detection and treatment not started; eczema, seizures, behavior disorders, decreased pigmentation, distinctive musty or mouselike odor. -More common in Caucasians and Native Americans. -Lifelong dietary management with low-phenylalanine diet; possible tyrosine supplementation.

Physiologic Adaptations: Skeletal System: Subgaleal Hemorrhage

-Subgaleal hemorrhage is bleeding into the subgaleal compartment. -Subgaleal hemorrhage is commonly associated with difficult operative vaginal birth, especially vacuum extraction. -serial head circumference measurements and inspection of the back of the neck for increasing edema and a firm mass are essential. -A boggy scalp, pallor, tachycardia, and increasing head circumference may also be early signs of a subgaleal hemorrhage.

Physiologic Adaptations: Reproductive System: Swelling of Breast Tissue

-Swelling of the breast tissue in term infants of both sexes is caused by the hyperestrogenism of pregnancy. -In a few infants a thin discharge (witch's milk) can be seen. This finding has no clinical significance,requires no treatment, and subsides within a few days as the maternal hormones are eliminated from the infant's body. -The nipples should be symmetric on the chest. -Breast tissue and areola size increase with gestation. -The areola appears slightly elevated at 34 weeks of gestation. By 36 weeks a breast bud of 1 to 2mm is palpable; this increases to 12mm by 42 weeks.

Physiologic Adaptation: Immune System: Risk for Infection

-Temperature instability or hypothermia can be symptomatic of serious infection; newborns do not typically exhibit fever, although hyperthermia can occur (temperature greater than 38° C 100.4° F]). -Lethargy, irritability, poor feeding, vomiting or diarrhea, decreased reflexes, and pale or mottled skin color are some of the clinical signs that suggest infection. -Respiratory symptoms such as apnea, tachypnea, grunting, or retracting can be associated with infection such as pneumonia. -The greatest risk factor for neonatal infection is prematurity because of immaturity of the immune system. -Other risk factors include premature rupture of membranes, chorioamnionitis, maternal fever, antenatal or intrapartal asphyxia, invasive procedures, stress, and congenital anomalies.

Apgar Scoring and Initial Assessment

-The Apgar score permits a rapid assessment of the newborn's transition to extrauterine existence based on five signs that indicate the physiologic state of the neonate: (1) heart rate, based on auscultation with a stethoscope or palpation of the umbilical cord; (2) respiratory effort, based on observed movement of the chest wall; (3) muscle tone, based on degree of flexion and movement of the extremities; (4) reflex irritability, based on response to suctioning of the nares or pharynx; and (5) generalized skin color, described as pallid, cyanotic, or pink. -Scores of 0 to 3 indicate severe distress, scores of 4 to 6 indicate moderate difficulty, and scores of 7 to 10 indicate that the infant is having minimal or no difficulty adjusting to extrauterine life. -Apgar scores do not predict future neurologic outcome but are useful for describing the newborn's transition to the extrauterine environment.

Hemolytic Disorders: Prevention

-The administration of RhIg, a human gamma globulin concentrate of anti-D, to all unsensitized Rh-negative mothers after birth or abortion of an Rh-positive infant or fetus prevents the development of maternal sensitization to the Rh factor. -Infants of mothers already sensitized may be treated by intrauterine transfusion, which consists of infusing blood into the umbilical vein of the fetus. -Exchange transfusion, in which the infant's blood is removed in small amounts (usually 5 to 10╯mL at a time) and replaced with compatible blood (e.g., Rh-negative blood), is a standard mode of therapy for treatment of severe hyperbilirubinemia and is the treatment of choice for hyperbilirubinemia and hydrops caused by Rh incompatibility. Exchange transfusion removes the sensitized erythrocytes, lowers the serum bilirubin level to prevent bilirubin encephalopathy, corrects the anemia, and prevents cardiac failure. Indications for exchange transfusion in full-term infants may include a rapidly increasing serum bilirubin level and hemolysis despite intensive phototherapy.

Physiologic Adaptations: Hepatic System: Coagulation

-The administration of intramuscular vitamin K shortly after birth helps prevent clotting problems. Any bleeding problems noted in the newborn should be reported immediately, and tests for clotting ordered.

Physical Assessment

-The average respiratory rate is 40 breaths/min but will vary between 30 and 60 breaths/min; respiratory rate can exceed 60 breaths/min if the newborn is very active or crying. -The normal heart rate ranges from 120 to 160 beats/min. -Bradycardia is a heart rate less than 100 beats/min. However, a term infant in deep sleep may have a heart rate in the 80s or 90s; the rate should increase when the infant awakens. Tachycardia is defined as a sustained heart rate exceeding 160 beats/min. It is not unusual for a crying infant to have a heart rate greater than 160; the heart rate should decrease when the crying ceases. -Neonatal BP usually is highest immediately after birth and falls to a minimum by 3 hours after birth. It then begins to rise steadily and reaches a plateau between 4 and 6 days after birth. -Systolic pressure in a term neonate averages 60 to 80mm Hg; diastolic pressure averages 40 to 50 mmHg. -The mean arterial pressure should approximate the neonate's week of gestation.

Physiologic Adaptations: Neuromuscular system

-The brain requires glucose as a source of energy and a relatively large supply of oxygen for adequate metabolism. -Spontaneous motor activity can be seen a transient tremors of the mouth and chin, especially during crying episodes, and of the extremities, notably the arms and hands. Transient tremors are normal and can be observed in nearly every newborn. -To differentiate between tremors or jitteriness and seizure activity, consider the following signs (Verklan and Lopez, 2011): • Tremors or jitteriness are easily elicited by motions or voice and cease with gentle restraint of the body part, whereas seizure activity continues. • Seizure activity is associated with ocular changes (eyes deviating or staring) and autonomic changes (apnea, tachycardia, pupil changes, increased salivation); these signs are not associated with jitteriness or tremors. -The posture of the term newborn demonstrates flexion of the arms at the elbows and the legs at the knees. Hips are abducted and partially flexed. Intermittent fisting of the hands is common.

Physiologic Adaptations: Reproductive System: Male

-The foreskin adheres to the glans and is not fully retractable for 3 to 4 years. -The position of the urethra should be at the tip of the penis. - With Nevus simplex, or epispadias the urethral opening is located in an abnormal position, on or adjacent to the glans, although it can be placed on the penile shaft or perineum. -Small, white, firm lesions called epithelial pearls may be seen at the tip of the prepuce. -By 28 to 36 weeks of gestation the testes can be palpated in the inguinal canal, and a few rugae appear on the scrotum. -At 36 to 40 weeks of gestation the testes are palpable in the upper scrotum, and rugae appear on the anterior portion. -After 40 weeks the testes can be palpated in the scrotum, and rugae cover the scrotal sac. The postterm neonate has deep rugae and a pendulous scrotum. -The scrotum is usually more deeply pigmented than the rest of the skin , particularly in darker-skinned infants. A bluish discoloration of the scrotum suggests testicular torsion, which needs immediate attention.

Physiologic Adaptations: GI System

-The full-term newborn is capable of swallowing, digesting, metabolizing and absorbing proteins and simple carbohydrates and emulsifying fats. With the exception of pancreatic amylase, the characteristic enzymes and digestive juices are present even in lowbirth-weight neonates. -Small whitish areas (Epstein pearls) may be found on the gum margins and at the juncture of the hard and soft palates. The cheeks are full because of well-developed sucking pads. These, like the labial tubercles (sucking calluses) on the upper lip, disappear around the age of 12 months when the sucking period is over. -Sucking is a reflex behavior that begins in utero as early as 15 to16 weeks. Sucking behavior is influenced by neuromuscular maturity, maternal medications received during labor and birth, and the type of initial feeding. As early as 28 weeks some infants can coordinate sucking and swallowing while breastfeeding. Bottle-feeding infants may not coordinate sucking and swallowing until 32 to 34 weeks. A special mechanism present in healthy term newborns coordinates the breathing, sucking, and swallowing reflexes necessary for oral feeding. This is well developed in most infants by 37 weeks. -Bacteria are not present in the infant's gastrointestinal tract at birth. Soon after birth oral and anal orifices permit entrance of bacteria and air. Generally the highest bacterial concentration is found in the lower portion of the intestine, particularly in the large intestine. Normal colonic bacteria are established within the first week after birth; and normal intestinal flora help synthesize vitamin K, folate, and biotin. Bowel sounds can usually be heard shortly after birth.

CARE MANAGEMENT: BIRTH THROUGH THE FIRST 2 HOURS: IMMEDIATE CARE AFTER BIRTH

-The infant is placed prone on the mother's abdomen or chest, and the nurse assesses the airway. -Slight extension of the neck helps keep the airway patent. -Drying the infant with vigorous rubbing removes moisture to prevent evaporative heat loss and provides tactile stimulation to stimulate respiratory effort. -The mother and her newborn are covered with a warm blanket -If the neonate is apneic or has gasping respirations, positive pressure ventilation is needed. The heart rate is quickly assessed by grasping the base of the cord or by auscultating the left chest with a stethoscope. Count for 6 seconds and multiply by 10 to calculate the heart rate. It should be greater than 100 beats/min. -The newborn's trunk and lips should be pink; acrocyanosis is a normal finding.

Maintaining Body Temperature

-The infant may react to exposure to cold by increasing the respiratory rate and may become cyanotic. -The ideal method for promoting warmth and maintaining neonatal body temperature is early skin-to-skin contact (SSC) with the mother. The naked infant is placed prone directly on the mother's chest; both mother and infant are then covered with a warm blanket. -Early SSC has distinct short-term and long-term benefits including temperature stabilization, reduced crying, improved breastfeeding initiation and duration, and maternal attachment. -Other interventions to promote warmth include drying and wrapping the newborn in warmed blankets immediately after birth, keeping the head well covered, and keeping the ambient temperature of the nursery or mother's room at 22° to 26° C (72° to 78° F). -If the infant does not remain skin-to-skin with the mother during the first 1 to 2 hours after birth, the nurse places the thoroughly dried infant under a radiant warmer or in a warm incubator until the body temperature stabilizes.

Physiologic Adaptations: Reproductive System: Signs of reproductive Problems

-The infant must be inspected closely for ambiguous genitalia and other abnormalities. -Normally in a female infant the urethral opening is located behind the clitoris. Any deviation from this can incorrectly suggest that the clitoris is a small penis, which can occur in conditions such as adrenal hyperplasia. -Nearly all female infants are born with hymenal tags; absence of such tags can indicate vaginal agenesis. -Fecal discharge from the vagina indicates a rectovaginal fistula. Any of these findings must be reported to the physician or neonatal nurse practitioner for further evaluation. -Hypospadias or epispadias, undescended or maldescended testes, and other abnormalities of the male genitalia must be reported. -Circumcision is contraindicated in the presence of hypospadias or epispadias since the foreskin is used in repair of these anomalies. -Inguinal hernias can be present and become more obvious when the infant cries. They are common, especially in African-American neonates, and usually require no treatment because they resolve with time.

Physiologic Adaptations: GI System: Digestion

-The infant's ability to digest carbohydrates, fats, and proteins is regulated by the presence of certain enzymes. Most of these enzymes are functional at birth except for pancreatic amylase and lipase. -Amylase is produced by the salivary glands after approximately 3 months and by the pancreas at approximately 6 months of age. This enzyme is necessary to convert starch into maltose and occurs in high amounts in colostrum. The other exception is lipase, also secreted by the pancreas; it is necessary for the digestion of fat. -Lactase levels in newborns are higher than in older infants. This enzyme is necessary for digestion of lactose, the major carbohydrate in human milk and commercial infant formula.

Physiologic Adaptations: Respiratory: Initiating Breathing

-The initiation of respirations in the neonate is the result of a combination of chemical, mechanical, thermal and sensory factors. -Chemical factors: the activation of chemoreceptors in the carotid arteries and aorta results from the relative state of hypoxia associated with labor. -Mechanical Factors: Respirations in the newborn can be stimulated by changes in intrathoracic pressure resulting from compression of chest during vaginal birth. Crying increases the distribution of air in the lungs and promotes expansion of the alveoli. The positive pressure created by crying helps keep the alveoli open. -thermal factors: The profound change in environmental temperature stimulates receptors in the skin, resulting in stimulation of the respiratory center in the medulla. -Sensory Factors: Handling the infant, suctioning the mouth and nose, and drying by the nurses. Pain associated with birth. lights sounds and smells can also be involved. Shortly before the onset of labor there is a catecholamine surge that seems to promote fluid clearance from the lungs. -Infants are by preference nose breathers, not present in most infants until 3 weeks after birth.

Physiologic Adaptations: Hepatic System

-The liver and gallbladder are formed by the fourth week of gestation. -In the newborn the liver can be palpated about 1 to 2cm below the right costal margin because it is enlarged and occupies about 40% of the abdominal cavity. -The infant's liver plays an important role in iron storage, carbohydrate metabolism, conjugation of bilirubin,and coagulation.

Physiologic And Behavioral Adaptation of the Newborn

-The neonatal period includes the time from birth through day 28 of life. -During this time the neonate must make many physiologic and behavioral adaptations to extrauterine life. -Physiologic tasks: 1. establishing and maintaining respirations 2. adjusting to circulatory changes. 3. regulating temperature 4. ingesting, retaining, and digesting nutrients 5. eliminating waste. 6. regulating weight. -The major adaptations associated with transition from intrauterine to extrauterine life occur during the first 6 to 8 hours after birth.

Physiologic Adaptations: Cardiovascular System

-The umbilical vein and arteries constrict rapidly within the first 2 minutes after birth. -In utero fetal PO2 is 20 to 30 mm Hg. After birth, when he PO2 level in the arteria; blood approximates 50 mm Hg, the ductus arteriosis constricts in response to increased oxygenation. -With the clamping and severing of the cord, the umbilical arteries, the umbilical vein, and the ductus venosus are functionally closed; they are converted into ligaments within 2 to 3 months.

Physiologic Adaptations: Skeletal System: Spine

-The vertebrae should appear straight and flat. If a pilonidal dimple is noted, further inspection is required to determine whether a sinus is present. A pilonidal dimple, especially with a sinus and nevus pilosis (hairy nevus), is significant because it can be associated with spina bifida.

Eye Prophylaxis

-This is a precautionary measure against ophthalmia neonatorum, which is an inflammation of the eyes resulting from gonorrheal or chlamydial infection contracted by the newborn during passage through the mother's birth canal. -erythromycin or tetracycline or silver nitrate.

Physiologic Adaptations: Hepatic System: Jaundice r/t breastfeeding

-Two forms of breastfeeding related jaundice are recognized: breastfeeding-associated jaundice and breast milk jaundice. -Breastfeeding-associated jaundice (early-onset jaundice) begins at 2 to 5 days of age. Breastfeeding does not cause the jaundice; rather it is a lack of effective breastfeeding that contributes to the hyperbilirubinemia. If the infant is not feeding effectively, there is less caloric and fluid intake and possible dehydration. Hepatic clearance of bilirubin is reduced. With less intake, there are fewer stools. As a result bilirubin is reabsorbed from the intestine back into the bloodstream and must be conjugated again so it can be excreted. -Breast-milk jaundice (late-onset jaundice) usually occurs at 5 to 10 days of age. Infants are usually feeding well and gaining weight appropriately. -Rising levels of bilirubin peak during the second week and gradually diminish. Despite high levels of bilirubin that may persist for 3 to 12 weeks, these infants have no signs of hemolysis or liver dysfunction. -The etiology of breast milk jaundice is uncertain. -However, it seems to be related to factors in the breast milk (e.g.,pregnanediol, fatty acids, and β-glucuronidase) that either inhibit the conjugation or decrease the excretion of bilirubin.

Physiologic Adaptations: Cardiovascular System: Blood Pressure

-Vary with gestational age and weight. -The term newborn infant average systolic is 60 to 80, and diastolic is 40 to 50. The mean arterial pressure should be equivalent to the weeks of gestation. -The BP increases by the second day of life, with minor variations noted during the first month of life. -A drop in systolic BP about 15 mm Hg in the first hour of life is common. -Crying and movement usually cause increases in the systolic BP. -BP is best measure with oscillometric device while infant is at rest.

Heel Stick

-Warming the heel before the sample is taken is often helpful; application of heat for 5 to 10 minutes helps dilate the vessels in the area. A cloth soaked with warm water and wrapped loosely around the foot provides effective warming. -The nurse cleanses the area with an appropriate skin antiseptic, restrains the infant's foot with a free hand, and then punctures the site. A spring-loaded automatic puncture device causes less pain and requires fewer punctures than a manual lance blade. -The most serious complication of an infant heelstick is necrotizing osteochondritis resulting from lancet penetration of the bone. -To prevent this problem, the puncture is made at the outer aspect of the heel and penetrates no deeper than 2.4mm. -Pressure must be maintained over an arterial or femoral vein puncture with a dry gauze square for 3 to 5 minutes to prevent bleeding from the site. -Only venous or capillary blood samples can be used for newborn screening and genetic studies; cord blood is not used for such samples.

Late Preterm Infant

-born between 34 0/7 and 36 6/7 weeks. -Late preterm infants have been called "The Great Impostors" because they are often the size and weight of term infants and are treated as healthy newborns. -Despite their appearance as term infants, late preterm infants are at increased risk for respiratory distress, temperature instability, hypoglycemia, apnea, feeding difficulties, and hyperbilirubinemia.

Early Term Infant

-infants born from 37 0/7 to 38 6/7 weeks of gestation. -Birth at 37 to 38 weeks is associated with higher incidence of breastfeeding difficulties and respiratory problems such as respiratory distress syndrome and transient tachypnea of the newborn (TTNB).

Breast Feeding Among African-American Women

African-American women are least likely to breastfeed than other ethnic groups in the United States. Multiple factors are involved in this phenomenon. There may be a lack of knowledge or misinformation about benefits and management of breastfeeding. -Support for breastfeeding may be lacking. They may believe that formula is nutritionally superior to breastfeeding. -African-American women tend to return to work earlier and are more likely to be employed in environments that are unsupportive of breastfeeding. -Stereotypes about breastfeeding and the idea that breasts are primarily sexual objects can influence the decision to choose formula feeding over breastfeeding. -Cultural traditions are an important factor -African-American breastfeeding mothers, writes: "...African American women have a much steeper road to climb when it comes to breastfeeding, and some believe its roots go as far back as slavery, when our ancestors were 'wet nurses', forced to breastfeed the master's children, often to the exclusion of their own. That created a negative breastfeeding cultural legacy that some believe still permeates our culture today". -African-American women need information and support for breastfeeding. -Many are surrounded by family and friends who advise them to formula feed.

Late Preterm Infant

Born between 34 and 36 6/7 weeks of gestation Referred to as late preterm rather than near term Higher risk for problems related to: Thermoregulation Hypoglycemia Hyperbilirubinemia Sepsis Respiratory function

Postterm Infant

Gestation that extends beyond 42 weeks 3.5% to 15% of pregnancies Cause of delayed labor is unknown Placental dysfunction Significant increase in fetal and neonatal mortality Current fetal distress Increased risk for birth injuries

STANDARD LABORATORY VALUES IN A TERM NEWBORN

Hemoglobin (g/dL) 14.5 to 22.5 Hematocrit (%) 48 to 69 Red blood cells (RBCs)/mcL 4.8 × 106 to 7.1 × 106 Platelet count/mm3 150,000 to 300,000 White blood cells (WBCs)/mcL 9,000 to 30,000 Bilirubin, total <2╯mg/dL Serum glucose 40 to 60╯mg/dL Blood gases Arterial pH 7.31 to 7.49 PCO2 26 to 41mmHg PO2 60 to 70mmHg Venous pH 7.31 to 7.41 PCO2 40 to 50 mmHg PO2 40 to 50mmHg

Newborn Screening for Disease

Inborn errors of metabolism Congenital hypothyroidism Phenylketonuria Use of Guthrie paper Galactosemia Genetic evaluation and counseling

Preterm Infants

Infants born before 37 weeks gestation Immaturity of most organ systems Actual cause unknown Distinct characteristics Small, scrawny Large head Translucent skin Lanugo

Infants of Diabetic Mothers

Large for gestational age • Very plump and full faced • Abundant vernix caseosa • Plethora • Listless and lethargic • Possibly meconium stained at birth • Hypotonia -The nursing care of IDMs involves early examination for congenital anomalies, signs of possible respiratory or cardiac problems, maintenance of adequate thermoregulation, early introduction of carbohydrate feedings as appropriate, and monitoring of serum blood glucose levels. -Some evidence indicates that IDMs have an increased risk of acquiring type 2 diabetes and metabolic syndrome in childhood or early adulthood.

CHANGES IN STOOLING PATTERNS OF NEWBORNS

Meconium • The infant's first stool is 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). • Passage of meconium should occur within the first 24 to 48 hours, although it can be delayed up to 7 days in very low-birth-weight infants. The passage of meconium can occur in utero and can be a sign of fetal distress. Transitional Stools • Usually appear by third day after initiation of feeding • Greenish brown to yellowish brown; thin and less sticky than meconium; may contain some milk curds Milk Stool • Usually appears by the fourth day • Breastfed infants: Stools yellow to golden, pasty in consistency; resemble a mixture of mustard and cottage cheese, with an odor similar to sour milk • Formula-fed infants: Stools pale yellow to light brown, firmer consistency, with a more offensive odor

Associated Complications

Pneumothorax Bronchopulmonary dysplasia Chronic lung disease Retinopathy of prematurity Inhaled nitrous oxide (INO) Extracorporeal membrane oxygenation (ECMO) Necrotizing enterocolitis

Complications of Preterm Birth

Respiratory distress syndrome Hyaline membrane disease Surfactant Absence of the alveolar stability Prolonged hypoxemia Oxygen therapy Endotracheal tube Continuous positive airway pressure (CPAP)

Apgar Scoring Cont.

The Apgar score was developed to provide a rapid systematic method of assessing an infant's condition at birth. When used correctly, it is useful for standardized assessment and provides a mechanism to document the neonate's transition after birth. It is designed to be used for a limited time frame. Apgar scores are affected by factors such as gestational age, maternal medications, trauma, congenital anomalies, hypovolemia, and hypoxia. -Researchers have tried to correlate Apgar scores with various outcomes in the term infant such as intelligence and neurologic development. In some instances, researchers have attempted to attribute causality to the Apgar score, that is, to suggest that the low Apgar score caused or predicted later problems. This use of the Apgar score is inappropriate. -There is a lack of evidence regarding the significance of the Apgar score in preterm infants. It should be used with this population of infants only for ongoing assessment in the delivery room. -The Apgar score is a useful index for monitoring neonatal response to resuscitation, especially in regard to a change in the score from 1 minute to 5 minutes after birth. -However, assigning an Apgar score to a neonate during resuscitation is not equivalent to assigning a score to a newborn who is breathing spontaneously. It is important that health care professionals be consistent in assigning Apgar scores during a resuscitation.

Patient Teaching: Circumscision Care

Wash hands before touching the newly circumcised penis. Check for Bleeding • Check circumcision for bleeding with each diaper change. • If bleeding occurs, apply gentle pressure with a folded sterile gauze square. If bleeding does not stop with pressure, notify primary health care provider. Observe for Urination • Check to see that the infant urinates after being circumcised. • Infant should have a wet diaper 2 to 6 times per 24 hours the first 1 to 2 days after birth and then at least 6 to 8 times per 24 hours after 3 to 4 days. Keep Area Clean • Change the diaper and inspect the circumcision at least every 4 hours. • Wash the penis gently with warm water to remove urine and feces. Apply petrolatum to the glans with each diaper change (omit petrolatum if a PlastiBell was used). Do not use baby wipes because they can contain alcohol. • Do not wash the penis with soap until the circumcision is healed (5 to 6 days). • Apply the diaper loosely over the penis to prevent pressure on the circumcised area. Check for Infection • Glans penis is dark red after circumcision and then becomes covered with yellow exudate in 24 hours, which is normal and will persist for 2 to 3 days. Do not attempt to remove it. • Redness, swelling, discharge, or odor indicates infection. Notify the pediatric health care provider if you think the circumcision area is infected. Provide Comfort • Circumcision is painful. Handle the area gently. • Provide comfort measures such as holding the baby skin-to-skin, cuddling, swaddling, or rocking.

SIGNS OF POTENTIAL COMPLICATIONS: ABNORMAL NEWBORN BREATHING

• Bradypnea (≤30 respirations/min) • Tachypnea (≥60 respirations/min) • Abnormal breath sounds: coarse or fine crackles, wheezes, expiratory grunt • Respiratory distress: nasal flaring, retractions, stridor, gasping, chin tug • Seesaw or paradoxic respirations • Skin color: cyanosis, mottling • Pulse oximetry value: <95%

Suctioning with a bulb syringe

• The bulb syringe should always be kept in the infant's crib. • The mouth is suctioned first to prevent the infant from inhaling pharyngeal secretions by gasping as the nares are touched. • The bulb is compressed and the tip is inserted into one side of the mouth. The center of the infant's mouth is avoided because the gag reflex can be stimulated. • The nasal passages are suctioned one nostril at a time. • When the infant's cry does not sound as though it is through mucus or a bubble, suctioning can be stopped. • The parents should be given demonstrations on how to use the bulb syringe and asked to perform a return demonstration.