PEDS: Chapter 7 - Newborns and Infants

Choking Prevention Foods that result in a decreased risk for choking in the infant include:

-Cooked macaroni -Small pieces of cheese -Soft cooked vegetables such as potatoes -Small pieces of fruit such as bananas, peaches, or pears -Small pieces of toast -Grapes cut into fourths Best practices to prevent choking include: -Thoroughly cook and cut all foods into small pieces. -Remove pits or seeds from fruit. -Grind, mash, and add liquid to foods for younger infants.

Discharge Care for the Circumcised Infant -Notify the physician in the case of: -Care of the Uncircumcised Male:

1. --Persistent bleeding or blood on diaper (more than quarter-sized) --Increasing redness --Fever --Other signs of infection, such as increased swelling or discharge, or the presence of pus-filled blisters --Not urinating normally within 12 hours after the circumcision 2. -Do not force the foreskin over the penis. -Make sure that the penis is cleaned meticulously to prevent infection. -Do not insert any objects under the foreskin to clean it, such as cotton-tip applicators.

Pertaining to the immediate needs of the newborn, the predominant role of the nurse is to assess the newborn in the transition period, protect his or her physical well-being, and promote a family-centered environment. Why is it important to clear the airway? Proceed how? T/F: Thermoregulation is not needed. Explain. The Apgar system measures? Prophylactic medications?

1. Clear the airway -Wipe mouth and nose with the delivery of the head. -If suctioning, suction mouth first, then nose to remove mucus and blood with a bulb syringe. o Depress bulb first and then insert into the orifice to remove secretions. o The infant should be positioned on his or her back with the neck slightly extended or in a "sniffing position." Hyperextension of the neck is contraindicated because it will occlude the airway. ***When inserting the bulb syringe, insert it in the corner of the mouth, not the center. Always suction the mouth first and then the nose. Suctioning the nose first may cause the infant to gasp and thereby force mucus deeper into the respiratory tract 2. Dry and stimulate the infant 3. Maintain thermoregulation: -Immediate drying and removal of wet linens. -Chilling increases oxygen consumption and metabolism through the process of evaporation. 4. Assign the Apgar score o The Apgar scoring system evaluates a neonate's ability to adapt to the birthing process. o It determines the need for resuscitation, the effectiveness of the resuscitation, and the neonate's morbidity and mortality risks. on o The Apgar system measures respiratory rate, heart rate, muscle tone, color, and reflex irritability, assigning an overall score from 0 to 10. The neonate is rated with a zero, a number one, or a number two for each category. Total score of 0 to 2 = severely depressed Total score of 3 to 6 = moderately depressed Total score of 7 to 10 = good condition o Number scores are assigned at 1 and 5 minutes. A higher score indicates adequate adaptation. ***The Apgar score at 1 minute indicates the neonate's ability to transition to extrauterine life, factors occurring during the birthing process, and whether resuscitation is needed. **The Apgar score at 5 minutes indicates the neonate's status and/or the effectiveness of resuscitative efforts, as well as neurological deficits and long-term morbidity and mortality. 5. Band infant with on-demand or barcode on arm and leg (security) 6. Administer baby prophylactic medications Phytonadione (vitamin K1): -Newborns are born with a sterile intestinal tract and do not have the bacteria necessary to synthesize vitamin K. -Therefore, newborns have decreased levels of vitamin K, the nutrient responsible for clotting and preventing hemorrhages. Erythromycin eye ointment -Prevents serious eye infections such as gonorrhea and chlamydia eye infections, and should not be washed away. Hepatitis B immunization -Given to prevent hepatitis B. -Mothers with unknown hepatitis B status are also administered human hepatitis B immunoglobulin G (IgG). 7. Protect the physical well-being of the newborn o Prevent the spread of infection through strict hand hygiene, limited traffic in the labor and delivery room suite, the use of scrub clothing by personnel to minimize infection exposure, and prohibitions against artificial nails and nail polish. o Provide baby cord care, circumcision care, and infant bathing. 8. Foster parent-infant bonding; promote family-centered care

Types of Jaundice: 1. Physiological Jaundice 2. Pathological Jaundice 3. Breast Milk Jaundice 4. Breast Feeding Jaundice

1. Physiological Jaundice -A transient rise in serum bilirubin levels within the first 24 to 48 hours of life -Peaks at 3 to 7 days of life 2. Pathological Jaundice -Pathological jaundice occurs within the first 24 hours of life. -It results from excessive destruction of RBCs, infection, incompatibilities, or metabolic disorders . -Consider if bilirubin levels are levels more than 15 mg/dL in term infant within the first 48 hours of life -Phototherapy is usually begun when less than 1,000 g with levels of 5 to 7 mg/dL -Pathological jaundice is diagnosed with jaundice lasting longer than 1 week in a term newborn or more than 2 weeks in a premature infant 3. Breast Milk Jaundice -Affects 1% to 2% of breastfed babies -Early-onset: poor feeding patterns; bilirubin levels may spike to 19 mg/dL -Late-onset: peaks 2 to 3 weeks after birth, increased absorption of bilirubin resulting from a factor in breast milk that increases absorption of bilirubin from the intestines 4. Breast-Feeding Jaundice -Early-onset of jaundice (within the first few days of life) -Associated with ineffective breastfeeding -Dehydration can occur -Delayed passage of meconium stool promotes reabsorption of bilirubin in the gut Treatment: Encourage early, effective breastfeeding without supplementation of glucose water or other fluids

Newborn Screening/Disorders 7. Krabbe Disease 8. Sickle Cell Disease 9. Cystic Fibrosis

7. -Autosomal recessive genetic disorder that affects the brain and nervous system. -Deletion of galactosylceramidase impairs the ability of the body to grow and repair the myelin sheath (protective lining of the nerve cell). -Disease results in severe deterioration of mental and motor skills, resulting in muscle weakness, hypertonia, seizures, spasticity, fever, irritability, difficulty in swallowing, deafness, and vision loss -Due to the rareness of this disorder and the lack of treatment options, many states allow parents to opt-out of testing 8. -Sickle cell disease is an inherited hematological disease in which red blood cells (RBCs) are sickled in shape, resembling the letter C rather than being round. RBCs carry oxygen and when they are misshapen, they become trapped in small areas such as joints, thus blocking blood flow -This disease results in anemia, pain, infections, acute chest syndrome, vision issues, or stroke. There is no known cure for this disease, but stem cell treatments have been used with some success in limiting symptomology 9. -Exocrine gland disorder that results in problems with digestion and breathing. -The disease produces thickened mucus that becomes trapped in the lungs and digestive system. -Symptoms appear because of blockage in the respiratory system and often in the pancreas. These include coughing, mucus, lung infections, shortness of breath, salty skin, slow growth, and frequent loose, greasy stools

NUTRITION Breastfeeding

Breastfeeding is the optimal method of feeding because it provides all necessary nutrients, minerals, and vitamins -Should begin within the first hour after birth during the initial period of reactivity -Infant should be fed on demand throughout the day and night -Reduces costs and preparation time -Promotes positive bonding between infant and mother -Decreases risk for obesity

Electrocution Suffocation

E -Keep cords unplugged when not needed. -Watch for chewing marks on electrical cords S -Remove excess bedding from the crib. -Remove stuffed toys from the crib. -Keep all plastic garbage bags, shopping bags, and dry cleaning bags out of reach of the infant. -Monitor for issues in sling carriers; make sure that infant does not get wrapped up in clothing and that the head does not fall forward, cutting off the airway.

Developmental Theorists

Piaget (theory of cognitive development): In sensorimotor stage, infants use five senses to explore their world; the theory includes six substages that describe the infant's mental representation. Infants learn about their environments through their senses and begin to engage in goal-directed behaviors Vygotsky (social context of cognitive development): Describes how complex mental functioning originates in infants through social interactions. Cultural factors influence attainment. There is a close correlation between language acquisition and the development of thinking Erikson (psychosocial development): -Highlights trust versus mistrust as the first psychosocial stage during the first year of life. This theory explains how the infant's personality develops. -Trust requires a feeling of physical comfort and a minimal amount of fear and apprehension about the future. It is a time where the infant has certain expectations about the predictability of the environment. If this stage is not attained, the infant feels insecure and learns mistrust -Trust in infancy provides lifelong expectation that the world will be a good and pleasant place to live. Mahler (social development): Describes how an infant develops a sense of self through symbiosis and separation, or individualism Kohlberg (moral development): Describes how moral reasoning aids in the development of ethical behavior and proceeds through six stages

DEVELOPMENTAL MILESTONES Six to Nine Months

Six to Nine Months --All infants should be screened for developmental delays and disabilities at 9 months at the well-child visit --Rolls from back to stomach and stomach to back --Sits unsupported by 8 months --Transfers objects from hand to hand, points at objects, and picks them up at 9 months --Fine motor skills continue to develop --Puts feet in mouth, plays pat-a-cake, loves to see own image in a mirror --Develops and expresses taste preferences --Begins to understand differences between inanimate and animate objects --Displays stranger anxiety --Develops object permanence --Vocalizes with many-syllable vowel sounds and "m-m" with crying --Around 9 months, says "Dada" and "Mama" and understands bye-bye and no --Around 8 to 9 months begins to pull to stand, develops pincer grasp, crawls backward and then forward, and responds to own name --Understands where to look for an object that has been dropped; practices grasp-release movements --Begins to test parent's responses, such as watching the parent while dropping food on the floor --Distinguishes colors --Distance vision --Expresses emotions, including frustration and anger

PHYSICAL DEVELOPMENT: NEWBORN Weight Assessment: Height Assessment: Head Circumference:

Weight Infants who are AGA average between 2,500 g (5.5 lb) and 4,000 g (8.75 lb). The average birth weight is 7.5 lb. Categorizations include: -AGA: between the 10th and 90th percentiles -SGA: below the 10th percentile -LGA: above the 90th percentile -Low birth weight: 2,500 g or less (5.5 lb) -Very low birth weight: 1,500 g or less (3.5 lb) -Intrauterine growth restriction—growth of the fetus does not meet expected norms for gestational age Infants have a larger body surface area in comparison with their total weight Height The average length at birth is 20 inches, and the best predictor of adult height is family history. Head Circumference Head and chest circumference are usually equal, with chest slightly smaller, usually 1 to 2 cm less than head. If the head is smaller than the chest, consider microcephaly, or small head. If the head is more than 1 inch larger than the chest, it can mean increased intracranial pressure or other issues

Nonpharmacological Pain-Prevention Methods

-Breastfeeding -Nonnutritive sucking -Kangaroo care -Swaddling -Limiting environmental stimuli -Attention to behavioral cues

Emotional Abuse An infant may be subject to emotional abuse in the presence of these warning signs: Neglect Infant neglect may be indicated by:

E -Aggressive or withdrawn behavior -Shying away from physical contact with parents or adults -Basic needs of food, warmth, and cuddling not met N -Consistent failure to respond to the child's need for stimulation, nurturing, encouragement, and protection, or failure to acknowledge the child's presence -Actively refusing to respond to the child's needs, such as refusing to show affection -Parents/caregivers expressing the fact that they are not going to spoil the baby or referring to the baby as evil -An infant with a malnourished appearance -Obvious neglect of the child (e.g., dirty, undernourished, inappropriate clothes for the weather, lack of medical or dental care) -Failure to provide necessary medications for chronic conditions, such as inhalers for children with asthma -Delays in calling for help or taking the infant to the doctor

NUTRITION For infants between 6 months and 1 year of age

For infants between 6 months and 1 year of age -Sufficient protein is needed to support growth and development. -Fats are needed to provide calories and support brain development. -Carbohydrates are needed to provide energy. Infants need 100 to 116 kcal/kg/day for basic growth and development. -Adequate fluid and electrolyte intake is necessary. -Fluids, mainly water, should total 120 to 150 mL/kg/day for infants. -Supplemental iron is not necessary for breastfed infants before 6 months of age. -All infants 6 months or older require iron supplementation. Iron can be supplied through lean red meats, fortified infant cereals, spinach, broccoli, green peas, or beans. -Do not feed cow's milk until after 1 year of age. -Soy formula is used for galactosemia, lactose intolerance, and allergies to cow's milk

Discipline Although it is impossible to spoil an infant, discipline at this age should focus on setting limits for the child's safety and well-being. Examples?

--At 6 months of age, when the child is more mobile, use distraction to keep the child away from dangerous areas. --Temper tantrums are the infant's way of expressing frustration, hunger, anger, illness, or fatigue. --Reward good behavior. --Remain calm, firm, and consistent. --Maintain a set routine.

Eye Assessment - Infant

-The eyelids may be edematous from the birthing process; this resolves spontaneously. -The iris should be grayish blue or gray-brown. -The sclera should be blue or white. Jaundiced sclera is an abnormal finding. -Pupils should be equal, round, and reactive to light activity. -The cornea should be clear, and the red reflex should be present. -Glaucoma can occur up to 3 months after birth in Zika-exposed infants Glaucoma in these infants is characterized by increased tearing, swelling, pain, and dullness of the iris. Glaucoma can also occur in neonates not exposed to the Zika virus. -Congenital cataracts can occur in the neonate causing clouding of the lens. -The line from the inner epicanthal fold to the outer canthus to the top notch of the ear where it connects with the scalp should be symmetrical. -Tears are not produced until the second month of life. -Strabismus is an imbalance in ocular motor capacity. -The visual acuity of a newborn is 20/400, improving in the first 2 years of life to 20/30.

Physical Abuse Warning signs of physical abuse in infants include:

-Unexplained or repeated injuries such as welts, bruises, burns, fractured skull, and broken bones, especially spiral fractures -Injuries in the shape of an object (e.g., belt buckle, electrical cord, cigarette) -Injuries that are unlikely given the age or ability of the child, such as broken bones in a child too young to walk or climb -Disagreement or inconsistency in parent/caregiver explanation of the injury -Unreasonable explanation of the injury -Fearful or detached behavior by the infant

Kangaroo Care Purpose? Benefits for infants? Benefits for moms?

1. Kangaroo care (or skin-to-skin contact) has been used as an alternative to conventional methods of neonatal care, with the aim to improve the health and survival of low-birth-weight infants and stabilize thermoregulation in newborns 2. -Stabilization of breathing patterns -Improved oxygenation -More rapid weight gain -Decreased crying -Improved breastfeeding episodes -Earlier discharge 3. -Increased milk supply -Increased sense of parental control -Increased confidence in the care of their child -Increased bonding

Thermoregulatory System Transition and Assessment 1. Cold Stress occurs when: 2. -Cold stress is characterized by: -S/S:

1. a) Occurs when the newborn's body temperature decreases, which results in an increase in oxygen consumption, glucose utilization, and energy. b) This then... -Increases the burning of BAT -Depletes glycogen stores -Decrease in surfactant -Respiratory distress -Metabolic acidosis ***Cold stress can result in significant morbidity and mortality in the newborn infant 2. s/s -Jitteriness -Tachypnea -Grunting -Hypoglycemia -Hypotonia (can exacerbate heat loss) -Pallor -Lethargy -Poor sucking reflex

Hyperbilirubinemia in Infants The function of bilirubin:? Dysfunction? ^ Risk factors for hyperbilirubinemia include:?

1. -Bilirubin pigment released from the breakdown of hemoglobin discolors the skin, sclera, and oral mucous membranes and is known as jaundice when it discolors these areas. -Hyperbilirubinemia is an excessive amount of bilirubin in the blood, mainly due to the infant's immature liver. Unconjugated bilirubin (indirect bilirubin) is fat-soluble, nonexcretable, and binds to albumin. The liver must conjugate, or change, this form of bilirubin via liver enzymes into conjugated (direct) bilirubin so that it can be eliminated in the urine and stool Increased levels of unconjugated bilirubin (indirect bilirubin) that saturate the albumin-binding sites cross the blood-braine barrier and can result in kernicterus, a life-threatening buildup of bilirubin in the brain and spinal cord. 7-9 Physiological pathway for excretion of bilirubin. GI, gastrointestinal; RBC, red blood cell 2. -Mother with diabetes -ABO incompatibility: When mother and baby have different blood types—specifically, the mother has type O and the baby has type A or B—an immune system reaction occurs that results in the excessive breakdown of RBCs and the release of bilirubin. -Rh incompatibility: When the mother is Rh-negative and the baby is Rh-positive, the mother will produce antibodies against the baby's blood, and hemolysis of the neonate's blood will occur. Bilirubin levels rise dramatically, placing the infant at risk for kernicterus and erythroblastosis fetalis, as well as severe hemolytic anemia and jaundice. This condition is preventable with the administration of RhoGAM. -Prematurity -Delayed feeding, which delays the passage of bilirubin-rich meconium -Birth trauma caused by an accelerated breakdown of RBCs in bruising (e.g., cephalhematoma, asphyxia) -Liver immaturity -Stress in the neonate (cold stress, asphyxia, hypoglycemia) -Use of Pitocin in labor -East Asian, American Indian, or Mediterranean descent -Sibling history of jaundice -Breastfeeding

Pain Management

Anything that would be painful to an adult will also be painful to an infant. Assessment of pain in the infant should be based on behavioral and physiological responses. -Repeated exposure to painful stimuli can increase the response to noxious stimuli. -Pain is assessed in newborns and infants by observing facial expressions such as bulged brow, eyes squeezed shut, open mouth, and quivering chin. -Physiological responses are increased heart rate, respiratory rate, elevated systolic blood pressure, and decreased oxygen saturation. -Pain causes increased fluid and electrolyte losses. -Pain causes depression of the immune system through the depletion of mature white blood cells because of heightened stress responses. -Gastric acid production increases. -Dilated pupils and sweating may be observed. -Newborns and infants are susceptible to the detrimental effects of pain because of their inability to communicate -Pain relief for infants should be intravenous or oral; if administering opioids, closely monitor respiratory rate and pulse oximetry -Use EMLA cream or similar topical anesthetics when starting IVs. EMLA requires a physician order and should be administered 60 minutes (90 minutes for darker skin) before the procedure.

DEVELOPMENTAL MILESTONES Birth to 3 Months

Birth to 3 Months -Weight: gains 5 to 7 oz weekly during the first month and then 1 to 2 lb per month -Feeding: Breastfed every 2 to 3 hours, formula-fed every 3 to 4 hours Height: grows 1 inch per month for first 6 months of life Head circumference: grows a half inch per month for first 6 months of life Motor skills: -Wobbly at first, but soon can lift head when on abdomen -Grasps an object, kicks vigorously, and turns head from side to side -Needs to have the head and neck supported -Can get their hands and thumbs to their mouths -Musculoskeletal and orthopedic disorders occur during fetal development; the most common of these disorders is talipes equinovarus (club foot) and developmental hip dysplasia Reflexes: primitive reflexes remain Hearing: should respond to parent's voice and respond to loud noises by blinking, startling, frowning, or waking from light sleep Vision: most newborns focus best on objects about 8 to 10 inches away, or the distance to your face during feeding. Acuity is 20/100; they begin to recognize the mother visually. Can track objects visually with more accuracy. Communication: sensitive to the way they are held, rocked, and fed. By age 2 months, the infant should smile on purpose (social smile), blow bubbles, and coo when spoken to. At 3 months the infant may laugh out loud and express moods

Anticipatory Guidance for Injury Prevention general drowning

Make and keep infant appointments for medical checkups and vaccinations (2 months, 4 months, 6 months, 9 months, and 1 year). -Immunizations are important because children are susceptible to many potentially serious diseases. Consult a local health-care provider to ensure that childhood immunizations are up to date. -Use "Safe to Sleep" positioning. Infants spend most of their time in cribs, which must be safe—no bumper pads, slats no more than 2-3/8 inches apart (JPMA approved). -Prevent diaper rash with frequent diaper changes, and wipe front to back in girls. -Childproof the home. -Have doctor, police, fire, and poison control numbers at the caregiver's fingertips. -Use childproof locks, safety gates, and window guards to prevent accidents and falls. -Encourage good hand washing for anyone in contact with the newborn or infant. This includes siblings. -Keep anyone with a cough, cold, or infectious disease away from the infant. -Call a physician if the infant appears to be sick. -Call a physician if the infant has a fever, refuses to eat, or has vomiting and/or diarrhea. -a physician if the infant is more fussy or quieter than usual, or looks jaundiced. -Call the infant's physician or health-care provider if worried or have questions about the infant's growth or development. -Keep the infant in a smoke-free area. -Keep firearms in a locked cabinet. -Never leave the child home alone or in an enclosed, nonrunning car. The temperature inside the car can change dramatically. -Pay attention to product recalls of both infant equipment and toys. -Install fire/smoke and carbon monoxide detectors on every level of the home -Never leave the infant alone in water or near standing water. -Do not leave the infant to answer the phone or doorbell. -Keep toilet lids closed. -Empty buckets immediately. -Prolonged submersion in water, such as through infant swimming classes, increases the risk for water intoxication, as well as exposure to Escherichia coli contamination, both of which can be fatal. Many learn-to-swim programs limit an infant's pool time to 30 minutes. In addition, contamination of the pool from diapers may result in higher incidence of diarrhea

Colic a) Parents of an infant with colic should be educated about the following: b) Colic is diagnosed under the following circumstances c) Care of the Infant With Colic

Some infants experience a great deal of intestinal gas, resulting in frequent crying known as colic. Colic usually happens at the end of the day. Usually, no medical problem is present, but the infant should be assessed by a pediatrician if it continues. a) --Make sure the infant is burped frequently --Parents should not change formula unless directed by the pediatrician. --If the infant is breastfed, the mother should decrease the intake of spicy or gaseous food; dairy and corn can also cause gastrointestinal disturbances. --Infants tend to be sensitive to stimulation. Try a car ride, movement, infant massage, carrying the infant in a carrier, or creating a white noise environment. --If a pacifier is used, it can help calm the infant; pacifiers have also been shown to decrease the incidence of sudden infant death syndrome (SIDS). Colic usually disappears by about 12 to 16 weeks of age b) -Paroxysms of irritability, fussing, or crying that start or stop without an obvious cause -Crying is turbulent and dysphonic, with a higher pitch -Episodes last 3 hours or longer and occur 3 days a week for at least 2 weeks, peaking at 6 weeks of age Infant thriving c) -Swaddle infant. -Place in a safe area. -Remove yourself from the infant for a 10-minute break once the child is secured in a safe place. -Educate caregivers that colic is not a reflection of their caregiving skills. -Realize that it is a heightened time of stress for caregivers. -Simethicone drops have been prescribed to ease intestinal gas, but never give an infant an over-the-counter medication without consulting the child's pediatrician.

Recognizing Normal Vital Signs (INFANT) a) Temp b) Pulse 120 to________ c) RR: 30 to ______ Hold oral feedings when RR is >_________ d) BP (normal to be lower)______

a) -Normal range: 36.5°C-37.0°C (97.7°F-99.4°F) b) -120-160 bpm (count apical pulse rate for 1 full minute) -Rate increases to 180 bpm if crying and decreases to 100 bpm when sleeping c) -30-60 breaths per minute (count respiratory rate for 1 full minute) -Irregular, diaphragmatic, and abdominal breathing are normal. -Apneic (absence of breathing) is significant if it lasts longer than 15-20 seconds. -Hold oral feedings if respiratory rate is greater than 60 breaths per minute d) -Blood pressure is not a routine part of neonatal vital sign assessments. If requested to perform, blood pressure should be obtained on the arm or leg. Systolic 50-75 mm Hg Diastolic 30-45 mm Hg

Sensory Development

Vision: least-developed sense; infants are attracted to bright colors and black and white because of limited vision; objects appear two-dimensional with poor peripheral vision until 2 to 3 months of age Smell: well-developed sense; especially recognizes smell of own mother Taste: well-developed sense; sweet tastes are preferred Hearing: -Can hear beginning in the womb and can identify mother's voice; differentiates between male and female voices; hearing is critical for language development -A hearing test is administered before discharge, either through otoacoustic emissions or auditory brainstem response. All 50 states, as well as Puerto Rico, Guam, and the District of Columbia, require hearing screening for newborns. -Tests are non-invasive, conducted before discharge by a trained professional, and performed in a quiet environment. Vernix, other fluids, and a withdrawing infant may affect the test. -Auditory brainstem response is a physiological measurement of the brainstem's response to sound. A clicking sound is produced, and the electrical activity response from the nerve is recorded as waveforms on a computer. This non-invasive test requires electrodes to be placed on the infant's scalp with adhesive and is conducted while the infant is sleeping -The otoacoustic emissions method uses an earplug that measures the responses of the cochlea to clicking sounds produced by a microphone. The infant is sleeping during the test. It is a noninvasive procedure Examination of the ears of an infant: -Pull the pinnae straight back and down. -Communications with infants are similar in different cultures, with a higher-pitched voice used when attempting to get the infant's attention; deaf mothers use a slower pattern and sign more often. Touch: -Touch is extremely important for the newborn; gentle touch or massage is calming and pleasurable. Pain is a protective device; the infant responds by extending and retracting the extremities and crying.

DEVELOPMENTAL MILESTONES Nine to Twelve Months

Nine to Twelve Months --Birth weight triples --Birth length increases by 50% --Head and chest circumference are equal --Total of six to eight teeth --Knows name --Creeps along with furniture --Drinks from a cup; should be weaned from a bottle --Stands alone for brief periods of time; raises arms when wants to be picked up --May take first steps or walk alone --Eats with spoon and cup but prefers fingers --Enjoys familiar surroundings and people, expresses dissatisfaction with strangers or strange surroundings (stranger anxiety) --May develop security objects such as favorite toys or blankets --Enjoys books, especially board books --Can understand simple communication or direction; says two or three words beyond Dada and Mama One or both feet may slightly turn in; the infant's lower legs are normally bowed --At around 12 months of age can transition to whole cow's milk; do not use 1% or 2% because the infant needs the fat content for continuing brain development

Stages of Breast Milk

Stage one: -Colostrum, a yellowish fluid, is present in the first 2 to 3 days after birth and can also be secreted in the last trimester of pregnancy. -Colostrum has higher concentrations of protein and lower levels of fat, carbohydrates, and calories than mature milk. -It contains large amounts of IgA and IgG, and assists in the passage of the infant's first stool, known as meconium Stage two: -The milk transitions from colostrum to more mature milk at about 3 to 10 days after birth. -It consists of increasing fat, carbohydrates, and calories Stage three: -Mature milk begins 10 days after birth. This mature milk has approximately 23 calories per ounce and is composed of foremilk and hind milk. -Foremilk is produced and released at the beginning of the feeding; it has a higher water and lactose content and a lower fat content. -The hind milk is released at the end of the feeding and has a higher fat content

Thermoregulatory System Transition and Assessment 1. Normal assessment? 2. Neonates have a higher metabolic rate. Term infants can lose heat even in the first few minutes and hours after birth. Exposure to cold in a newborn sets off alterations in physiological and metabolic processes to generate heat. An infant's response to cold includes the following:

The thermoregulatory system is necessary for sustaining homeostasis and is dependent on external and internal factors. A neutral thermal environment is a temperature the infant requires to minimize metabolic and oxygen needs, prevent metabolic acidosis, and arrest brown fat depletion. 1. -Normal neonatal temperature is 36.5°C to 37.0°C through the axillary method (under the armpit) . -Normal rectal temperatures range from 36.5°C to 37.5°C; in many institutions, these must be ordered and are performed with great care to avoid rectal injury. A rectal temperature may be done initially to assess for anal patency. This is per hospital policy. -Gestational-age term infants have stores of brown fat (brown adipose tissue [BAT]) in the neck, intrascapular region, axillae, groin, and around the kidney area Brown fat is used and burned for heat metabolism. Weight and prematurity affect the infant's ability to regulate body temperature because of decreased brown and subcutaneous fat stores. -Full-term infants have increased body surface area compared with total body mass. 2. -Peripheral vasoconstriction and chemical thermogenesis take place. -Newborns do not shiver. -The sympathetic nervous system responds by decreasing the temperature and stimulation of skin receptors, many in the face, to increase peripheral vasoconstriction. -Brown fat utilization breaks down fat into glycerol and fatty acids to produce heat. Rapid utilization of brown fat can result in metabolic acidosis, jaundice, infection, and poor weight gain because of thermogenesis, which increases oxygen demands and caloric consumption FIGURE 7-6 Sites of "brown fat" (brown adipose tissue stores) in the newborn.

Avoiding Clostridium botulinum Contamination

Infants younger than 1 year should never be given honey or corn syrup because this may result in the ingestion of Clostridium botulinum bacteria, which is a spore-producing organism. The spores are found in improperly stored foods, home-canned foods, processed foods such as potato salad, restaurant-prepared foods, and bottled garlic

NUTRITION Composition of Breast Milk Components of breast milk include:

**Breast milk development begins early in pregnancy through the hormones of estrogen, progesterone, and prolactin. **It is high in IgA and IgG and contains higher levels of a protein with a laxative effect that aids in the passage of meconium. **No immunoglobulins are found in formulas. **Concentration of nutrients differs among women. Infant allergic responses to breast milk are rare. Components of breast milk include -Large water content; (fat content accounts for 52%) -Carbohydrates (lactose, 42% of calories in breast milk) -Protein, specifically whey (60% to 80%) and casein (20% to 40%), makes up approximately 6% of calories in breast milk -Antibodies, bifidus factor (which stimulates the growth of lactobacillus) -Lipase, amylase, and other enzymes -Epidermal growth factor, nerve growth factor, other growth factors, and interleukins

Heat Loss in the Newborn The nurse is responsible for minimizing heat loss through a variety of mechanisms that include the following:

**Heat loss can result in peripheral vasoconstriction, a buildup of lactic acid, and metabolic acidosis. Radiation -Transfer of heat to the cooler air surrounding the neonate. -This can occur when an infant is placed near a window or the cold walls of a single-walled isolette. -The nurse should make sure that if a newborn is placed in an isolette that it is a double-walled isolette. Conduction —Transfer of heat directly from the infant to a cooler surface or equipment. -Place the infant on a warm surface, remove wet linens, and cover the infant's head. -Cover cold surfaces with a warmed blanket. Convection -Transfer of heat through drafts passing over the infant, such as from fans, air drafts, blowing oxygen, if the sides of the radiant warmer are down, or air conditioners. Evaporation -Transfer of heat when water on the surface of the infant's skin is converted to water vapor. -The nurse should make sure that the infant is dried after delivery and after a bath.

EMERGENCY CARE FOR THE INFANT AND NEWBORN Nurses should provide parent education about the following emergency care measures:

--Stay calm—most serious illnesses provide warnings. --Begin rescue breathing if infant is not breathing. Call 911. --Apply pressure with a clean cloth to an area that is bleeding. --If the infant is having a seizure, lower the infant to the floor, turn his or her head to the side, and do not put anything in the infant's mouth. --Do not move a seriously injured infant unless he or she is in an unsafe situation, such as in a burning house, in a car, or underwater. --Stay with the infant until help arrives. --Bring all medication and/or poisons to the emergency department. --Provide an accurate history of the preceding events, including the last time that the child ate and what was eaten.

Nursing functions when assisting with circumcisions include the following

--Administer acetaminophen 1 hour before the procedure. --Provide pain relief with a topical prilocaine-lidocaine (EMLA) cream applied to the distal half of the penis 60 to 90 minutes before the procedure. EMLA can be used for all painful procedures in children with a gestational age of 37 weeks or older. --The infant is positioned on a circumcision board, which positions the arms and legs in a straddled position. --The upper body should be covered to minimize heat loss. --Suction should be available in case of emesis. --Dorsal penile blocks are used. --Small needles are used. --Swaddling aids in increasing comfort. --Sucrose (24% sugar water) solution can help to relieve pain. --Nonnutritive sucking can also help to relieve pain. --Decrease environmental stimuli --Infant must be hospitalized for procedure if older than 1 month. --After the procedure, a petroleum gauze should be applied to the head of the penis to prevent irritation from the diaper. --The penis is assessed every 15 minutes for the first hour and then every 2 to 3 hours depending on institution policy. --The neonate should void within 24 hours of the procedure or before discharge --Instruct parents not to remove the gauze but to allow it to fall off, fasten diapers loosely, observe for bleeding every 4 hours during the first day, and observe for signs and symptoms of infection. --Acetaminophen orally may be ordered every 4 to 6 hours for 24 hours after the procedure for pain --Educate caregivers that the healing penis develops a yellowish eschar, which should not be wiped off or removed because doing so will start the healing process over again.

Sudden infant death syndrome (SIDS) The "Safe to Sleep" campaign highlights the following points

--Always place babies to sleep on their backs during naps and at nighttime. Babies sleeping on their sides are more likely to accidentally roll onto their stomachs; the side position is not safe and is not recommended. -- Avoid products that prop the infant on their side such as wedges. --Do not cover the heads of babies with a blanket or over bundle them in clothing and blankets. --Avoid letting the baby get too hot, indicated by sweating, damp hair, flushed cheeks, heat rash, and rapid breathing. --Dress the baby lightly for sleep. --Infants placed in sleep sacks should not wear a hat; sleep sacks are sleeveless to prevent overheating, a risk factor for SIDS --Place your baby in a safety-approved crib with a firm mattress and a well-fitting sheet --Place the crib in an area that is always smoke free. --Do not allow babies to sleep on adult beds, chairs, sofas, waterbeds, or cushions. --Toys and other soft bedding, including fluffy blankets, comforters, pillows, stuffed animals, bumpers and wedges, should not be placed in the crib with the baby. These items can impair the infant's ability to breathe if they cover the infant's face. --Breastfeed your baby. Experts recommend that mothers feed their children human milk at least through the first year of life. --Baby boxes." These boxes are portable, sturdy cardboard boxes that have firm foam mattresses with tight-fitting sheets, designed to encourage parents to place their infants on their backs to sleep. Most infants can sleep in the baby box until they outgrow it, usually at around 6 months of age. The highest incidence of sudden infant death is between 2 and 4 months of age

Pain Scales Several reliable infant pain scales may be used, including:

--Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) --Neonatal Infant Pain Scale (NIPS): measures five behavioral items and one physiological indicator --FLACC: faces, legs, activity, crying, and consolability --Riley Infant Pain Scale: based on similar criteria as FLACC; used on infants younger than 36 months and those with cerebral palsy --Premature infant pain profile (PIPP): one of the most reliable and validated tools to assess pain in premature infants --CRIES (Crying, Requires Oxygen, Increased Vital Signs, Expression, Sleep): a tool for measuring postoperative neonatal pain

Anticipatory Guidance for Injury Prevention cont. Burns:

--Do not hold infant when smoking, drinking hot liquids, or cooking. --Do not heat formula or breast milk in the microwave because it causes uneven heating and may also inactivate nutrients in breast milk. --An infant's skin is very sensitive to the sun. o Keep infants out of direct sunlight to prevent sunburn. o Use sunscreen for infants older than 6 months. o Infants should wear hats when out in the sun --Turn pot handles away from the outside of the stove, where they can be pulled on by infants beginning to pull themselves to a standing position. --Check the water temperature before putting a child in the tub. --Reduce the water heater setting to less than 120°F to lessen the chance of accidental burning. --Keep electrical cords out of infant reach; cap electrical outlets. --Use flame-retardant sleepwear for the infant

Breastfeeding Success

--Feedings should last between 10 and 30 minutes—shorter times may indicate poor positioning or a sleepy infant; longer times can indicate nonnutritive sucking. --Removing an infant from the breast is accomplished by inserting a clean finger into the corner of the infant's mouth to break the suction. --Successful breastfeeding results in the infant gaining 1/2 to 1 oz per day --Expressed breast milk may be kept for 4 hours at room temperature, for 5 to 7 days in the refrigerator, and for 6 to 12 months in a deep freezer. --Never reheat breast milk in a microwave or leave it on the counter to thaw or warm up. --Thaw in the refrigerator. --The AAP recommends breastfeeding for a full year

Breast Milk Jaundice Nursing Interventions What is the importance of phototherapy?

--Identify infants at risk. --Monitor bilirubin levels through close skin monitoring; digitally compress the skin. --Monitor point-of-care heel sticks, TcB levels, and serum bilirubin levels. --Support early and frequent feedings. Support and work with lactating mothers. --Consult with lactation consultants. --Monitor stooling and voiding patterns. --Monitor and screen for lethargic or sleepy infants. --Monitor for high-pitched cry and arching of the body. -Maintain phototherapy. The blue-green fluorescent light is absorbed into the skin, where it converts unconjugated bilirubin into bilirubin by producing lumirubin, which is water-soluble and thereby allows the infant to excrete bilirubin in the stool and urine When conducting phototherapy, fluorescent lights should be calibrated periodically per the manufacturer's guidelines. The infant's eyes need to be covered to prevent cataracts because retinal damage can occur. Infants should be fully exposed, except for the diaper. Keep male scrotum covered and place the infant in a low-heat-setting isolette Place the phototherapy lamp 2 inches from the top of the isolette The infant should be held only during feedings and then eye patches can be removed. The nurse needs to closely monitor temperature during phototherapy Never use lotions or ointments on the skin while the infant is under phototherapy.

Taking Temperature

--Instruct caregivers to take the infant's temperature if they suspect a fever. --Digital, tympanic, or temporal thermometers are preferred over mercury-filled thermometers. --Rectal temperatures are taken for children younger than 3 years only in the emergency department, newborn nursery, and pediatric units for accuracy. For rectal temperatures, lubricate the end with a water-soluble solution and insert the rectal thermometer no farther than 1/2 inch (2 to 2.5 cm) into the rectum. Hold buttocks and thermometer for safety. Parents are instructed not to take temperatures in this manner. --For axillary temperatures, place the nonlubricated end in the armpit and hold the infant's arm at his or her side for approximately 1 minute; use with infants 3 months or older. This method can be 2 degrees lower than a rectal temperature.

SLEEP

--Newborns sleep on average 8 to 9 hours per day and 8 hours at night. Infants normally do not sleep through the night until age 3 months, when their stomach size has increased so that they can take in more breast milk or formula. --Infants, like adults, go through sleep periods of active and quiet sleep patterns -- Newborn infants spend substantial time in rapid eye movement (REM) sleep indicative of rapid brain growth. At 3 months of age, REM sleep decreases and non-REM sleep occurs Non-REM sleep has four stages: Stage 1: drowsiness Stage 2: light sleep Stage 3: deep sleep Stage 4: very deep sleep --Around 6 months of age, the infant may begin to sleep 8 to 12 hours at night. Sleep patterns for infants, as in adults varies, from infant to infant --Newborns sleep from feeding to feeding; with age, the amount and length of wakeful periods increase. --Newborns can sleep up to 17 hours a day in 3- to 4-hour intervals. Sleep deprivation is a factor for caregivers of newborns. --By 3 months of age, the infant begins to sleep 6 to 8 hours a night. --At 6 months, an infant takes two naps a day. --At 1 year of age, the infant sleeps 15 hours a day—3 hours during the day and 11 hours at night. --Infants' increase in sleep patterns is tied to growth spurts Infant Sleep and Parental Behavior the process is driven by underlying biological forces but is highly dependent on environmental cues, including parental influences. There are links between infant sleep and parental behaviors, cognitions, emotions, and relationships, as well as psychopathology. Parental behaviors are closely related to infant sleeping patterns

NUTRITION Breastfeeding vs bottle-feeding? Age to start/stop breastfeeding?

--Parents of infants younger than 6 months can choose to either breastfeed or bottle-feed a commercially prepared formula. --Because of the infant's developmental stage, he or she will push solids forward and out of the mouth. --The WHO recommends exclusive breastfeeding until the age of 6 months and to continue until the age of 2 years, with no supplementation of water, formula, or solids prior to this point --The decision to breastfeed versus bottle-feeding is dependent on maternal knowledge, past exposure to breastfeeding, education level, perceptions of the benefits of breastfeeding, cultural factors, family and friend support, career barriers, husband or partner support, and support from healthcare providers.

Nursing Interventions to Prevent Hypothermia

--Place infant skin to skin (preferably kangaroo care) with mom or on a radiant warmer to rewarm. --Remove wet linens, which cause heat loss through radiation and conduction. --Maintain dry, warmed linen as the most effective means of rewarming an infant. --Delay the first bath until the infant has regulated and stabilized core body temperature. o The first bath should be completed in the presence of the mother to support infant bonding and completed with kangaroo care. -Keep the infant's head (largest surface area) covered with a stocking cap to prevent heat loss due to radiation and conduction, except if the infant is placed in a sleep sack. -Wrap the infant in a t-shirt, pajamas, and two blankets to decrease heat loss from convection and radiation. If these measures are not effective, place the naked infant on a radiant warmer, place the servo-control probe on the infant's abdomen (avoiding bony prominences, liver, and brown fat areas), and set the temperature at least to 36.5°C. --A radiant warmer only heats the outer surfaces, so do not clothe or cover the infant. --Do not artificially heat an IV bag or K pad device and apply it to rewarm the baby's skin. Burns may result from overheating or uneven heat dispersion. --Closely monitor temperature fluctuations when using a radiant warmer, which may mask the signs and symptoms of temperature instability in the neonate, an indication of sepsis. --Monitor fluid status to determine insensible water losses if using a radiant warmer. --Closely monitor the neonate's temperature, respiratory rate, and glucose levels per institution guidelines. --Recognize that alterations in temperature are directly proportional to gestational age and may indicate the need for physician intervention and notification.

CHRONIC CARE FOR THE INFANT AND NEWBORN Premature Infants

--Prematurity is the primary reason for low birth weight and carries a high risk for developmental and motor delay. Ballard scoring is 37 weeks or less. --The multidisciplinary team focuses on maximizing the infant's long-term outcomes. Neonatologists, pediatricians, cardiologists, pulmonologists, social service workers, physical therapists, and pediatric neurologists are some of the specialists who may be involved. -- Developmental and neurological examinations are performed at routine and serial visits. --Mortality and morbidity are influenced by numerous factors such as prenatal, intrapartum, and fetal issues --The lower the gestational age, the more complications that can occur.

SAFE AND EFFECTIVE NURSING CARE: Understanding Medication Sucrose Solution

--Sucrose solution, which is 24% sucrose and water, provides analgesia for minor procedures. --A pacifier, or a gloved finger if breastfeeding, used in conjunction with sucrose water enhances the analgesic effect. --Do not use more than three doses during a single procedure. --Do not use for infants who require ongoing pain relief; these infants will require acetaminophen or an opioid such as fentanyl or morphine. --Although an infant may cry and show signs of pain when 24% sucrose water is used, studies have consistently shown that the sensation of pain and its negative effects will be diminished --The analgesic effect of 24% sucrose water appears to be reduced after 46 weeks' postconceptual age. --Sucrose water needs to be ordered by a practitioner and documented as an administered medication. --The administration of sucrose and the application of nonnutritive sucking are theorized to activate endogenous opioid pathways (natural pain relievers produced in the brain), with resulting calming and pain-relieving effects. --The analgesic effects of nonnutritive sucking are thought to be activated through nonopioid pathways by stimulation of orotactile and mechanoreceptor mechanisms

Head and Neck Assessment Aspects of head and neck assessment for this population include

--The anterior and posterior fontanels (soft spots) should be assessed with the infant in an upright position. o The anterior fontanel is diamond-shaped, averages 2 to 3 cm wide by 3 to 4 cm long, and closes at 12 to 18 months. You should be able to feel slight pulsations in this area. o Abnormal findings are full or bulging fontanels, sunken fontanels, or closed suture lines. Assessment should be done when the baby is quiet. o The posterior fontanel is triangular, averages 1 to 2 cm wide, and closes in the second month of life. o Bulging fontanels may occur with crying or increased intracranial pressure. o Sunken fontanels indicate dehydration.

SAFE AND EFFECTIVE NURSING CARE: Understanding Medication Neonates and Medication Administration

--Variable weight and differences in body surface area affect medication administration. --Infants are at greater risk for toxic levels that produce untoward effects. --Infants have smaller amounts of pancreatic enzymes. --Kidney function is immature in infants. When administering medication to infants: -Approach infant slowly, at eye level. -Handle infant gently, keep infant on caregiver's lap, and use distraction. -Do not put medications in a bottle of formula or breast milk because the infant must drink the entire amount to receive the appropriate dosage. -Hold the infant in the nursing position, allowing him or her to swallow in between squirts of the medication in the buccal area of the mouth; do not lay the infant down until he or she swallows. -Never give an infant over-the-counter medication. Instruct caregivers to call their practitioner with concerns. -For rectal medications, lubricate the blunted end with water-soluble gel, insert approximately 1/2 inch, and hold the buttocks closed for approximately 10 minutes to allow for dissolution and absorption of the medication. -For injections: In small infants, the nurse should use a 5/8-inch needle with up to 0.5 mL of fluid; with infants, a 1-inch needle with a maximum of 1 mL of fluid should be administered in the vastus lateralis. -For adolescents, the nurse should use a 1- to 1.5-inch needle (22- to 27-gauge) up to 3 mL of fluid maximum.

Bottle Feeding

--When feeding a newborn formula, carefully dilute with water based on the manufacturer's mixing instructions. Some preparations are ready to feed. --Bottles and nipples must be washed thoroughly; use a dishwasher or boil all bottles, rings, and nipples. --If the formula needs to be heated, put it in a pan of hot water (not boiling) or use an electric warmer. --Never microwave, because this can cause uneven heat distribution. --Facilitate parent bonding by holding the infant close --Never prop a bottle because this can cause choking. --Burp the infant frequently to prevent emesis

Anticipatory Guidance for Injury Prevention cont. Car Seat Safety

-Always use a car seat when traveling in a car or airplane. --Use approved car seats correctly. o Check the age and weight limits for the seat. o Put the car seat in the backseat of the car and secure it facing backward. --Check state laws o Never put the infant in a front seat with a safety airbag. o Rear-facing infant seats are used from birth up to 2 years of age, per 2017 AAP guidelines --Parents can contact a certified child passenger safety technician (CPST) to correctly install infant car seats. --Caregivers should never leave an infant in the car unattended.

Newborn Respiratory Assessment and Development When assessing the respiratory system of a newborn, nurses should be aware of the following:

-Assess the nose for patency. -Newborns are obligate nose breathers, but after several months they become nose-and-mouth breathers. -Chest wall symmetry/asymmetry can be a result of pneumothorax. -Respiratory pattern is normally very irregular, sporadic, shallow, and diaphragmatic. -Average rate at birth is 30 to 60 breaths per minute; count for a full minute ). Respiratory rate decreases with age. -A cyanosis (bluish color of hands and feet) is normal in the term infant in the first 24 to 48 hours. After 24 to 48 hours of life, this may be an indication of cardiac disease. In dark-skinned infants, cyanosis is better assessed through the mucous membranes. -Older infants become diaphragmatic breathers.

Signs of Illness in the Newborn and Infant Parents should be instructed to notify the health-care practitioner with any of these concerns:

-Axillary temperature greater than 99.3°F or rectal temperature greater than 100.3°F -Vomiting -Decrease in the number of wet diapers -Sunken or bulging fontanels -Loss of appetite -Foul odor or bleeding from the cord or circumcision -Decreased level of consciousness; lethargy -Increased irritability -Blue or cool hands and feet -Skin rash -Drooling not associated with teething -Refusal to lie down if 8 months of age or older

Anticipatory Guidance for Injury Prevention cont. Choking

-Do not attach pacifiers or other objects to the crib or body with a string or cord. -Keep small objects away from infants, including toys or stuffed animals with small breakaway parts. -Never leave plastic bags or wrappings where the infant can reach them. -Keep objects that are choking hazards away from the infant, such as batteries (especially watch batteries), magnets, and balloons. -Cut or remove pull cords on blinds and drapes. -Anything smaller than an adult pinky finger can cause a choking situation. This includes foods such as hot dogs, whole grapes, raw carrots, raw celery, peanuts, popcorn, chips, candy, marshmallows, pretzels, and peanut butter. -Cut all foods into small-sized bites.

Advancing Feeding in Infants

-Calorie needs per pound of body weight are higher during the first year of life than at any other time -An infant is ready for solid foods at around 6 months of age. At this time, babies are able to move food around in their mouths. -Breastfeeding should be on-demand and average four to seven feedings per day; bottle feeding should average 24 to 32 oz of formula. -No fruit juices should be given. -All foods should be placed on a spoon, not put in a bottle. -Baby rice cereal is usually indicated for the first solid food (2 to 3 teaspoons) because it is iron-fortified and associated with a decreased incidence of allergic reactions. -At around 8 months, strained fruit, vegetables, and strained meats can be introduced. -The caregiver should be taught to introduce a single type of food for 2 to 3 days to observe for reactions such as rashes, diarrhea, abdominal cramping, or vomiting. Use single-ingredient foods and do not add sugar, sweeteners, or corn syrup. The infant should receive only home-cooked food. -Self-feeding should begin when infants can sit up alone, hold their necks steady, draw in their lips when food is introduced into the mouth, and keep the food in their mouths and not push it back out. The extrusion reflex should be gone. -Offer soft, mashed table food. -Always cut up the infant's food into small pieces to prevent choking. The first teeth are biting teeth, not grinding teeth

Signs and Symptoms of Alterations in Respiratory Transitioning Newborns who are experiencing alterations in respiratory transitioning may display:

-Cyanosis -Apnea: cessation of breathing longer than 15 to 20 seconds; may or may not be associated with change in color or heart rate -Gasping: deep, slow, irregular terminal breaths -Flaring: outward flaring movements of the nostrils on inspiration due to forced airflow -Excessive mucus or drooling -Tachypnea: respiratory rate greater than 60 breaths per minute when quiet -Tachycardia: heart rate more than 160 bpm when quiet -Chest wall asymmetry -Grunting: audible expiratory groaning heard on expiration due to partial closing of the glottis -Retractions ------ backward movements of the sternum or intercostal spaces of the ribs due to increased negative pressure; retractions may be suprasternal, supraclavicular, intercostal, subcostal, and/or substernal -Congenital abnormalities ****see pic Stimuli that influence respirations

Care associated with most full-term infants at 38 weeks' gestation primarily protects and supports the neonate during its physiological transition to extrauterine life. Care/preparedness includes:

-Delivery room and transitional care -Maintenance of thermoregulation -Newborn assessment with a review of the maternal history and a complete physical examination -Prophylaxis care to prevent disorders specifically related to respiratory function and decreasing risk for infections -Family education and discharge preparation related to caring for and feeding the newborn

ANTICIPATORY GUIDANCE FOR THE FAMILY OF A NEWBORN Psychological preparation of a caregiver is necessary to alleviate fears and anxiety in the care of the infant. Nurse education for caregivers must include information about the following:

-Developmental milestones -Healthy and safe habits related to injury and illness prevention, such as childproofing the home -Nutrition -Oral health -Family relationships and how they will change -Sibling transition, including regressive behavior such as thumb sucking or bedwetting and aggressive behavior toward the infant (both normal responses); parents can address this transition by showing the child pictures of his or her new sibling, having someone other than the parents bring the new baby into the home, providing a gift from the infant to the sibling, and including the child in small tasks such as bringing the parent diapers -Infant care -Home infection-control measures, such as encouraging hand washing, limiting sick visitors, and keeping their infant in a car seat to limit handling by visitors; encourage all members of the household to get immunized for influenza and pertussis -Parent-infant interactions, including playing, cuddling, the importance of talking to the child, and separation anxiety -The importance of learning infant/child CPR

HOSPITALIZED INFANT AND NEWBORN When caring for a hospitalized infant, the nurse should

-Encourage caregivers to room-in. -Educate caregivers on the normal developmental milestones and stages, noting that a hospitalized infant may regress in behavior. Child life specialists are essential in describing developmental aspects related to play. -Encourage caregivers to provide security items such as a favorite toy or blanket. -Educate caregivers on safety risks in the hospital, such as lowered crib rails, the infant's crawling on the floor, or the presence of items that may not be in the infant's home. -Reinforce the importance of therapeutic play. -Perform the least invasive and least painful procedures first. -Invasive procedures should be performed in the treatment room, not at the crib site. -At 6 months of age, infants suffer separation anxiety and can be sensitive to caregiver cues

SAFETY MEASURES FOR INFANTS AND NEWBORNS Parents and caregivers are responsible for providing a safe environment for infants to decrease the incidence of these events. Injuries and accidents can include:

-Falls -Car accidents -Drownings -Electrocution -Suffocation -Choking -Burns

Dental Care for the Infant

-Feed only formula, breast milk, or water in a bottle. Juice should be delayed until the child is a toddler. -If juice is introduced it should be delayed until 6 to 9 months of age, limited to 4 to 6 ounces, and given in a cup. -Do not put infants to bed at night or for a nap with a bottle. -Brush teeth with a soft cloth once they erupt. -Do not use cold juice to soothe an infant's gums. -Begin regular dental appointments by the first birthday

Abduction Prevention Educate the caregiver as follows:

-In the hospital, infants will be banded with electronic tags to prevent abduction. -Hospital staff should be properly identified with hospital badges to identify that they have access to the postpartum and newborn areas. -Be suspicious of casual acquaintances or strangers who attempt to befriend the parent. -Learn hospital procedures for care after discharge if a visiting nurse is to come to your home. -Demand positive identification before allowing anyone into your home. -Do not post information about the infant on social media. -Under no circumstances should the caregiver give the baby to a stranger. Do not allow casual acquaintances or strangers to babysit the infant. -Never leave the infant alone at home. -Do not place birth announcements in the newspaper. -In shopping areas, do not turn your back on the infant. -Make sure the infant is secured in a car seat that is buckled into a shopping cart. -Place the infant in the car seat in the car, lock the doors, and then load your groceries or items from the store. -Educate family members and friends who babysit the infant about infant security. -Call police anytime you are suspicious or concerned about the infant's safety

Recognizing Hypoglycemia in the Neonate Signs of hypoglycemia in the neonate include:

-Irritability -Jitteriness -Hypotonia -Temperature instability -Apnea -Poor feeding -Lethargy -Seizures

Anticipatory Guidance for Injury Prevention cont. Poisoning

-Keep the poison control number on every phone. -Keep all medicines, cleaning products, nail polish remover, alcohol, and other household chemicals locked in their original containers and out of reach. Take all suspected poisons to the phone when poison control is called to be able to read the ingredients to the center. -Remove lead paint from older cribs, infant furniture, walls, and window sills. -Never leave an infant alone in a yard. -Do not apply sunscreen or perfumed creams or lotions, because they will be absorbed in an infant younger than 6 months of age. -Keep indoor plants out of the infant's reach

When caring for a neonate, the nurse should perform the following interventions related to blood glucose:

-Monitor for signs and symptoms of hypoglycemia. -Recognize risk factors for hypoglycemia. -Assess blood glucose with a glucometer, i-STAT. -Feed the infant when glucose levels are less than 40 mg/dL or as directed by institutional guidelines, generally 5 mL/kg. -Assist with breastfeeding. -Infants of mothers with diabetes should receive 3 to 5 mg/kg/min glucose to prevent overstimulation of insulin secretions -Intrauterine growth-restricted infants should receive 6 to 8 mg/kg/min of glucose if symptomatic. -Term or near-term infants should receive 4 to 7 mg/kg/min glucose if symptomatic -Begin intravenous glucose maintenance and rigorously follow guidelines on repeat blood serum glucose levels. -Maintain a neutral thermal environment to prevent cold stress, which increases the utilization of glucose.

Shaken Baby Syndrome (Abusive Head Trauma)

-Most victims are infants younger than 1 year; the average age is between 3 and 8 months. -Pay special attention when choosing a babysitter. Research suggests that teenage fathers are more likely to cause shaken baby syndrome. -Contrecoup, injuries to the opposite side of the head, are common. -Detached retinas may result. -Permanent brain damage may result. -Death may result.

Genitourinary System Transition and Assessment

-Nephrons are fully functional at 34 to 36 weeks gestation. -The first urine output should occur within 24 hours after birth. o In the first 1 or 2 days, urine may be stained orange or pink because of urate crystals. o Newborns cannot concentrate or dilute urine in response to changes in intravascular fluid status and therefore are at risk for dehydration or fluid overload. Infants are more prone to extracellular fluid loss than intracellular fluid loss. o Neonate is composed of 75% water (40% extracellular fluid, 35% intracellular fluid). Term neonates usually lose 5% to 10% of their weight in the first week of life, almost all of which is water loss. -Fluid requirements during the first 2 days of life are 80 to 100 mL/kg/day, then increase to 100 to 150 mL/kg/day. -Specific gravity averages 1.001 to 1.010 during infancy. -Urine output should be 1 to 3 mL/kg/hr if monitored in the hospital to maintain adequate fluid maintenance . -Strict input and output is essential in the nursing care of any infant in the hospital. -By 3 months of age, infants can concentrate urine. -Normal urine output is calculated based on weight. Six to 10 wet diapers per day are considered normal urine output

Anticipatory Guidance for Injury Prevention cont. Falls

-Never leave the infant alone on a changing table, couch, chair, or bed. -Always keep a hand on the baby. -Use gates at the top of stairwells. -Do not use walkers; they have resulted in serious injuries and even death if they cause the infant to fall downstairs. -Educate caregivers on how young children should hold an infant and protect their head and necks.

Milestone Concerns or Red Flags Developmental concerns for this age group that require intervention by a health-care provider include the following

-No attempts by the infant to lift head when lying facedown -No improvement in head control -Does not respond to loud noises -Extreme floppiness -Lack of response to sounds or visual cues, such as loud noises or bright lights Inability to focus on a caregiver's eyes -Poor weight gain -Does not crawl by 12 months

NUTRITION Nonnutritive Sucking

-Nonnutritive sucking is a self-soothing or comforting measure used by infants. -The infant's sucking ability is necessary for neurological development and survival. -Pacifiers, fingers, or fists are used in self-sucking. Suckling, which the infant does at the breast, requires a different set of mouth movements than does bottle feeding or the use of fingers, fists, or a pacifier. -Avoid using pacifiers in the early days of breastfeeding. -Educate caregivers on the use of a pacifier, such as not using it as a substitute for feeding or holding. -Never tie or clip the pacifier to the child's clothing because this can be a source of strangulation, even in older infants. -Limit the use of the pacifier as the infant gets older to prevent creating a habit that will be difficult to break; distract the infant with an alternative

Play Tips for caregivers include:

-Play is how infants learn about the world and themselves. Infants are primarily sensorimotor focused, so play should involve sensory stimulation. Infants explore the world with their mouths and imitate those around them. -When choosing toys, safety is the number one consideration; avoid detachable or removable pieces or parts. Simple toys should be used because attention span is short. -Opt for unbreakable mirrors, rattles, soft (nonremovable pieces) stuffed animals, large snap toys, and musical pull toys. -Place infants on their stomachs for supervised tummy time. -Engage the infant with soothing tones and use of facial expressions. -Use soothing music. -If other siblings' toys are lying around, safety for the infant requires the caregiver to be aware of small pieces. -Toys should help the infant in physical and fine motor development. -Infants enjoy looking at themselves in mirrors. -Play is essential in a hospitalized environment. The theorist Watson described the importance of positive play in fostering attachment between the infant and the caregiver.

Fostering Positive Parenting Skills Encourage parents of neonates to

-Talk to the infant. -Respond to infant's sounds by repeating and adding words. -Read to the infant; this helps to develop and foster understanding of language and sounds. -Sing to or play music for the infant. -Praise the infant and give the infant attention. -Spend time cuddling and holding the infant so that the infant feels cared for and secure. -Play with the infant when he or she is alert and relaxed. -Watch for signs of being tired or fussy so that the infant can take a break

Skin System Transition and Assessment

-Provide adequate lighting for assessment. -Skin should be pink. Pale or dusky skin may indicate congenital heart disease. Color is influenced by ethnicity. -Observe for jaundice; apply pressure and remove with your fingertip over bony prominences such as the nose, sternum, or sacrum. -Observe for the presence of body hair, fine downy lanugo. -Observe for acrocyanosis (normal and disappears with crying). -Observe for petechiae, skin tags, breaks in the skin, forceps marks on the face or scalp, and electronic fetal monitoring marks on the scalp. -Observe for milia (small white sebaceous cysts), usually present on the face. -Vernix caseosa is a cheesy substance found mainly in the creases of the armpits and groin, but which may cover the entire body. This protective covering should not be removed because it provides an emollient effect to the skin. -Erythema toxicum (newborn rash) are tiny pimples that disappear within the first few weeks. Baby acne consists of small red pimples on the face or body that appear at about 1 month of age. -Grayish, dark blue, or black areas located over the sacral region are called Mongolian spots; these are prominent in certain ethnic cultures from Asia, Africa, and Mediterranean areas -Observe for birthmarks, nevi, or stork bites -Cord begins to dry following the cutting of the cord. The cord clamp should be removed 24 to 48 hours after birth. Cord care includes keeping it dry. Some institutions leave the cord open to the air, apply methylene blue to the cord as a drying agent, or apply alcohol to the cord. Keep the diaper below the cord. As it dries, the cord becomes black and hard, and it falls off within 2 weeks. Be aware that some cultures save the cord detachment -Water should be used to clean the genital and rectal area, wiping in girls from front to back. Nurses need to instruct caregivers to wash their hands following every diaper change. -Diaper rash consists of red and sore areas in the diaper region from urine and stool, often a result of candidiasis. Exposure to air helps. -Heat rash or prickly heat is due to overdressing in warm weather. -Cradle cap is scaly or crusty skin on the scalp due to a buildup of oils, scales, and dead skin. The head should be washed and dried every day

MATERNAL HISTORY During newborn care, a maternal history should be taken that includes:

-Review of prenatal history, including past pregnancies, complications, genetic factors for both mother and father, and previous pregnancies -Infections—prenatal as well as past exposures -Screening tests and risk factors -Labor and delivery problems or risk factors -Perinatal substance abuse exposure

Sexual Abuse Warning signs of sexual abuse in infants include

-Stained or bloody diapers -Genital or rectal pain, swelling, redness, or discharge -Bruises or other injuries in the genital or rectal area -Difficulty eating or sleeping -Excessive crying -Withdrawing from others -Failure to thrive

Gastrointestinal System Transition and Assessment The nurse should be aware of the following when performing gastrointestinal system assessment on a transitioning newborn:

-The abdomen should be cylindrical; a sunken abdomen should be reported. -The stomach is immature but rapidly adjusts. Stomach capacity is 30 to 60 mL at birth and then rapidly increases. -The infant may be in a quiet sleep state and uninterested in feeding. -Both the desire for feeding and stomach size increase rapidly during infancy. -Enzymes are present at birth to digest proteins, moderate fats, and simple sugars. -Decreased esophageal sphincter pressure is present at birth but increases with age. -The first stool is black and tarry, and is known as meconium. Meconium is formed starting around 16 weeks of gestation and usually is passed within 24 to 48 hours of age. o Stool then becomes transitional around day 3 of life, with color and consistency dependent on feeding. Breastfeeding stool beyond transitional is golden and semi-formed. o Bottle-fed stool beyond transitional is drier and pale yellow or greenish-black to brownish o A loose or green stool is considered diarrhea. Most hospitalizations and deaths from diarrhea occur during the first year of life -Breastfed babies eat more frequently because of the increased digestibility of breast milk. Breast milk is composed of 60% whey and 40% casein, whereas cow's milk has 20% whey and 80% casein. Casein forms a hard curd that is difficult to digest. -Constipation does not occur in breastfed newborns. -Breastfed babies often produce stool with every feeding, and by 1 month of age may progress to one stool every day or every other day. -Bottle-fed babies may become constipated from improper formula mixing. Normal elimination patterns for bottle-fed infants are one or two stools a day. -Recommended that newborns receive 400 IU of vitamin D per day after birth until the infant is taking 1 quart of whole milk at 1 year of age. -After 4 months of age in an exclusively breastfed infant, the baby should receive 1 mg/kg/day of a liquid iron supplement until iron-containing solids are introduced at 6 months of age -Mothers who are on strict vegetarian diets need to take an extra B-complex supplement when exclusively breastfeeding -Feedings for infants should be at least every 4 hours but may need to be more frequent in early infancy because of stomach emptying time. Breastfed newborns often want to go to the breast every 45 to 90 minutes, because their stomach capacity is only 20 to 30 mL. -As the infant is weaned from the breast or bottle to solid foods, the consistency of the stool will change. -It is not uncommon to see pieces of food in the stool.

Neurological Transition, Assessment, and Development 1. Nurses who are conducting this assessment should be alert for: 2. Abnormalities are determined by testing the baby's reflexes; they need to be symmetrical on each side of the body. Asymmetry suggests abnormality or weakness. Reflexes present in the neonate include:

-The brain reaches 90% of its total size during infancy. -All neurons are present by the end of the first year of life. 1. -Uncoordinated movements -Tremors in the extremities -Poor muscle control or tone 2. Moro reflex or startle reflex: Occurs when the infant is startled with noise or rapid change in position; the infant throws the arms and legs out, cries, and then recoils the arms and legs. The neonate makes a C with the thumb and forefinger. This reflex disappears around 6 months of age. Rooting reflex: When the side of the mouth is touched or stroked, the infant will turn its head and seek to suck. Disappears between 3 and 6 months of age. Sucking reflex: Reflex is present at birth but disappears at 10 to 12 months of age. Palmar grasp reflex: Grasping of a person's finger in the infant's hand; disappears at about 3 to 4 months of age and is replaced by the voluntary grasp. Plantar reflex: The infant's toes flex in a grasping motion in response to a thumb pressed against the ball of the foot; disappears at about 3 to 4 months of age. Tonic neck or fencing position reflex: The arm and leg are extended while the opposite side of the body is flexed; disappears around 4 to 6 months of age. Babinski reflex: The infant's toes flare when the foot is stroked in an upward motion; normal in children and disappears at 12 months of age. Stepping or dancing reflex: The neonate steps up and down in place when held upright; disappears at 3 to 4 weeks of age.

Immune System Transition and Assessment Nurses caring for transitioning neonates should be aware of the following aspects of immunity:

-The infant in utero is in a sterile environment o The infant is provided with maternal immunity through antibodies that bind to bacteria, viruses, and fungi that enter the body -Following birth, active humoral immunity is provided through acquired immunity from vaccination, or natural immunity from one's own production of antibodies in response to exposure to antigens. -Temporary passive immunity is provided by those maternal antibodies that cross the placenta; the lymphocytes are T and B cells. o Passive immunity is also provided by breast milk, which contains all five immunoglobulins: IgG, IgA, IgD, IgM, and IgE IgG is the only immunoglobulin that crosses the placenta during pregnancy and makes up 75% to 85% of all antibodies in the infant. IgA is primarily found in breast milk. IgM is primarily found in the lymph and bloodstream. IgD is primarily found in the abdomen and chest areas of the body. IgE is found in the lungs, skin, and mucous membranes. -The infant's immune system is not fully developed until 6 months of age, and it begins to produce antibodies at about 2 to 3 months of age. -There is no evidence that delaying the introduction of specific foods beyond 6 months of age prevents allergies. Recent research has indicated that early introduction of potentially allergic foods (at 4 to 6 months of age) might provide a form of protection and prevent allergy -Infants are at risk for infection because of immature immune responses, lack of maternal antibodies, stress that depletes the immune system, and breaks in the skin due to invasive procedures that introduce bacteria or viruses

Dental Development and Assessment

-Tooth buds are present during the third month of pregnancy. -Natal teeth can be present at birth (usually lower central incisors without a root) and can interfere with breastfeeding. -Teething is the eruption of the teeth through the gums. Teeth erupt at 4 to 10 months of age (usually around 6 months), starting with the two lower center teeth; the upper center teeth come in at about 8 to 12 months old. At the end of the first year, the child will have six to eight teeth. -Signs and symptoms of teething including drooling, restlessness or difficulty falling asleep, sucking on the hands, and mild rash around the mouth because of drooling. -Teething is not associated with generalized rash, fever, diarrhea, or prolonged fussiness -Numbing over-the-counter medications are brief in action and may also numb the throat and have a taste that is not pleasant for infants. Infants should never be given any medication with alcohol in the ingredients. The primary teeth are calcifying. -The American Dental Association recommends that the first dental visit occur at the time of the eruption of the first tooth, usually at age 6 months. -A soft clean cloth should be used to clean the teeth as they erupt or to bite down on to decrease the pain of teething

Perinatal Substance Abuse 1) Substance abuse can affect the developing fetus through: 2) Nonpharmacological interventions include 3) Pharmacological interventions are with:

1) -Exposure to nicotine, -selective serotonin-reuptake inhibitors -benzodiazepines, -alcohol -opiates -other substances. Biological neonatal specimens are obtained from meconium, hair, cord blood, and urine for testing. The Finnegan Neonatal Abstinence Scoring Tool is the most widely used tool to assign numbers to neonatal symptoms of exposure, including central nervous system disturbances, gastrointestinal disturbances, and metabolic, vasomotor, and respiratory disturbances 2) -swaddling, comfort, and feeding 3) Morphine sulfate or methadone ---adjusted based on scores greater than 8. Doses are then weaned if scores are less than or equal to 8 for 48 hours or more

Newborn Screening/Disorders 1. Types and purpose? 2. What is Phenylketonuria (PKU)? Interventions?

1. --Metabolic disorders occur when the absence or abnormality of an enzyme or cofactor leads to excessive accumulation or deficiency of a specific metabolite --Disorders of amino acids, organic acids, carbohydrates, and the urea cycle, as well as of mitochondrial, fatty acid, peroxisomal, lysosomal, purine, pyrimidine, and metal metabolism, are some of those tested for in the newborn period --Most tests are performed within the first 24 to 48 hours after birth or at follow-up newborn wellness checks. 2. -Phenylketonuria is an autosomal recessive deficiency of the enzyme phenylalanine and is the most common inborn error of metabolism. o Deficiency prevents the conversion of the essential amino acid phenylalanine to tyrosine. o The elevated levels of phenylalanine can result in mental cognitive impairment caused by defective myelination and degeneration of the white and gray matter of the brain. o This is characterized by developmental delays, poor feeding, irritability, and vomiting -Affected infants must be on feedings for 3 full days so that the liver enzyme that converts phenylalanine to tyrosine will be secreted. -Guthrie blood test is performed. -A low-phenylalanine, low-protein diet must be implemented for the rest of the child's life

Metabolic System Transition and Assessment 1. Glucose is the main source of energy for the brain and the newborn brain depends on glucose metabolism for 90% of its needs. In the last 2 months of fetal life, glucose is stored as glycogen in the liver and is used after birth for: 2. most frequent problem experienced by neonates within the first 48 hours after birth? Nurse interventions and expectations?

1. -Coping with the stress of birth -Breathing -Heat production -Muscular activity 2. Hypoglycemia -Can be r/t Increased glucose utilization demands can be caused by hypothermia, hypoxia, or sepsis. -Prematurity, small for gestational age (SGA), intrauterine growth restriction, and inborn errors of metabolism can result from a decrease in glycogen stores. -A decrease in glucose post-maturity can be caused by deterioration of the placenta, which provides nutrition. -Decreases can also result from maternal intake of certain medications (terbutaline) -Large for gestational age (LGA) babies, infants of mothers with diabetes, erythroblastosis fetalis, and Beckwith-Wiedemann syndrome can result from an overproduction of insulin in the neonate because of high intrauterine glucose levels. Infants of mothers with diabetes have high levels of insulin caused by high levels of circulating maternal glucose. -Alterations in glucose levels can predispose an infant to the development of metabolic acidosis ***The nurse must monitor glucose levels especially closely with evidence of risk factors, congenital metabolic conditions, birth defects, stress, jitteriness, or neonatal depression. ***Ranges for plasma glucose levels should ideally be between 70 and 100 mg/dL, and heel-stick glucose levels need to be greater than 40 mg/dL ***Critical glucose levels less than 40 mg/dL obtained with point-of-care devices such as glucometers must be confirmed by serum levels sent STAT to the laboratory. ***At-risk infants should be fed at 1 hour of age and glucose levels checked 30 minutes after feedings. ***In infants who are poor feeders, tube feedings should be considered

TRANSITION TO EXTRAUTERINE LIFE 1. Changes that occur: 2. Respiratory System Transition occurs when: 3. Several factors influence the first breath, including:

1. -Intrauterine changes are dependent on gestational age, maternal health factors, condition of the placenta, and/or defects and congenital abnormalities. -In utero, the lungs are filled with amniotic fluid, and the placenta is the organ of respiration and waste removal. 2. -The transition occurs when the umbilical cord is clamped and the infant takes his or her first breath. -All body systems of the neonate transition to extrauterine life, but most significant are the respiratory and circulatory system transitions. When the cord is cut, the placenta is no longer the organ of respiration. 3 -Internal stimuli such as chemical changes due to hypoxia and increasing carbon dioxide levels -External stimuli such as thermal changes, sensory changes, or mechanical changes due to the delivery process. o The first breath begins to clear amniotic fluid and fill the lungs with oxygen. --This increases alveoli oxygen tension (Pao2 ), which dilates the pulmonary artery, decreases pulmonary vascular resistance, increases pulmonary blood flow, and increases O2 and CO2 exchange o --Retained alveolar fluid can result in transient tachypnea of the newborn. -- Insufficient surfactant production can result in collapsed alveoli and the development of respiratory distress syndrome (RDS), a disease that results in poor lung compliance, loss of residual capacity, and chronic lung changes. --RDS is prominent in premature infants. --Failure of the normal drop-in pulmonary vascular pressure can result in persistent pulmonary hypertension of the newborn. o --These alterations require specialized medical care in neonatal intensive care units that support the neonate's respiratory system.

Production of Breast Milk How is milk produced? Hormones involved? Early Cues from baby? Late cues from baby?

1. -Lactation is the process of milk production -Once the baby is born, the levels of estrogen and progesterone are eliminated and prolactin becomes the predominant hormone. -Infant stimulation influences supply and demand—as the infant demands, the woman's body supplies. -Oxytocin is released from the posterior pituitary, which affects the breasts and the uterus. Oxytocin produces the letdown reflex, which forces milk into the lactiferous ducts of the breast. -The letdown reflex is responsible for milk ejection. This reflex can occur during sexual stimulation, when hearing a baby cry, or when thinking of the infant. It can be inhibited by anxiety, stress, fatigue, and pain 2. -Rooting -Head bobbing up and down -Stirring and increased arm and leg movement -Burying head in mattress or mother's chest 3. -Crying—extended crying can inhibit latching on to the breast -Agitation

Nursing Interventions 1. Monitoring for hyperbilirubinemia includes the following measures: 2. What is the Coombs test?

1. -Observe the skin of the neonate; jaundice begins on the face and nose, then progresses down the trunk to the extremities. However, this is not an accurate method of assessment, especially in darker-skinned infants. -All neonates should be screened before discharge with a measurement of bilirubin levels and the assessment of clinical risk factors. Bilirubin levels are then plotted on the Bhutani nomogram, an hour-specific tool used for prediction in at-risk neonates who are more than 36 weeks gestation, more than 2,000 g, and otherwise well with no ABO incompatibilities -Infants are rated as low, intermediate, or high risk for the development of clinically significant hyperbilirubinemia. Severely at-risk infants are those with TSB levels greater than the 95th percentile for age in hours 2. -Test looks at the measurement of antibodies attached to the newborn's RBCs that occur with Rh-negative mothers. Rh-negative mothers produce antibodies against the Rh-positive baby or in ABO incompatibilities. If there is an abnormal coating of the neonate's RBCs with an antibody globulin from the mother, it is considered a positive Coombs' test, and the neonate is at a higher risk for hemolytic disease of the newborn -A heel stick is performed with a sharp lancet to remove small drops of capillary blood to test for total, direct, and indirect serum bilirubin levels. -Transcutaneous bilirubin (TcB) measurement: o Noninvasive multiwavelength spectral skin monitoring of bilirubin levels in term or near-term infants via the upper part of the sternum. Up to 15 mg/dL, the TcB correlates with serum blood levels

PHYSICAL DEVELOPMENT: NEWBORN 1. How is physical development assessed? 2. What method is used for measurement? 3. Areas measured using this method?

1. -Physical development of the newborn is assessed to determine the gestational age of the newborn. -Gestational age is calculated from the first start day of the mother's menstrual cycle to the current date or date of delivery. o This age is based on the mother's history, prenatal ultrasounds, or neonatal maturation examination. It can be calculated using the Ballard scoring method. 2. Ballard scoring method---consists of six areas of neuromuscular maturity and six areas of observed physical maturity, and is used to assess gestational age -A score is assigned to each area. The physical maturity scoring should be completed within the first 2 hours of birth, and the neuromuscular scoring should be completed within the first 24 hours. 3. Neuromuscular activity: -Posture: the position of the infant at rest, flaccid, or flexed -Square window: how far the infant's hand can be flexed toward the wrist -Arm recoil: how well the arms recoil back when flexed -Popliteal angle: how far the infant's knees can be flexed -Scarf sign: how far the infant's arm can be moved across the chest -Heel to ear: with the hips on the bed, how far the baby's feet can be moved toward the ear Physical maturity: -Skin: dryness, peeling, moisture -Lanugo: presence or absence -Plantar surfaces: presence or absence of creases and their depth -Breasts: normal 3 to 10 mm, nipples prominent -Ear/eyes: open or fused, amount of cartilage in the pinna; eyes need to be equal and symmetrical, and external canthus of the eyes need to line up with the top of the pinna -Genitalia: the size of the clitoris, labia minor, and labia majora; the urethral opening needs to be in the middle of the head of the penis with both testes palpable in the scrotum **The scores for these are plotted on a graph to provide a gestational age based on weight, length, and head circumference to determine whether the infant is appropriate for gestational age

Cleft Palate Treatment 1. A multidisciplinary treatment approach includes: 2. Post-op Care?

1. -The repair is performed within 2 to 3 months of age up to 18 months with the goal of preventing speech and dental problems. -The infant must be gaining weight and be free of respiratory infections. Surgical repair involves a Z-plasty, which closes the palate in one procedure with a staggered suture line - Multiple surgeries may be required depending on the extent of the defect. Plastic surgeons Nurses Geneticists Oral surgeons Audiologists Otolaryngologists Speech therapists Social workers Psychologists Pediatricians Clergy 2. --NPO immediately after surgery. --Position infant on back or side. --Assess respiratory status. Edema may cause an airway problem. --Logan bow (a thin metal bar) or steristrips are taped to the face to maintain and keep the suture line intact, especially when the child is crying. --The infant may be restrained for approximately 2 to 3 weeks with soft elbow restraints (splints), which are devices to keep his or her hands from disrupting the suture line. --An infant with a cleft palate repair should not be suctioned orally. Infants are provided liquids with a cup and should avoid straws, pacifiers, and eating utensils to protect the suture line. --A soft, rubber-tipped feeder or nipple is preferred and should be introduced in the side of the mouth to avoid the suture line. --Breastfeeding during this time generally is avoided. --Direct the flow of milk away from the defect and to the side. Feed the infant in an upright position and burp frequently. --Clean the suture line after feeding; carefully observe for aspiration. --Raise the head of the bed or place in a seat following feedings. --Rinse the mouth with water after feedings. --Clean the suture line often with half-strength hydrogen peroxide and water or normal saline per physician protocol. --Some surgeons will order a topical antibiotic cream. --Cleft palate repair is similar in postoperative care, although the infant may be placed on the abdomen to facilitate drainage if there is no cleft lip repair involved.

Hepatic System Transition and Assessment Importance of iron/development Coagulation

1. -The full-term neonatal liver is responsible for carbohydrate metabolism, iron storage, bilirubin conjugation, and blood coagulation. -Iron stores in the fetal liver are created in the last weeks of pregnancy. As RBCs are broken down, they are added to the liver stores until future RBCs are produced. -Term infants who are breastfed do not need supplemental iron until 4 months of age. -After 4 months of age in an exclusively breastfed infant, the baby should receive 1 mg/kg/day of a liquid iron supplement until iron-containing solids are introduced at 6 months of age -Term infants who are bottle feeding require an iron-fortified formula. -After age 6 months, all infants require iron supplementation through supplements or iron-rich foods. 2. -Activation of clotting factors II, VII, IX, and X and prothrombin is influenced by vitamin K. At birth, maternal sources of vitamin K are removed. Intestinal flora needed to produce vitamin K are absent in the newborn until after the first feeding, which puts neonates at higher risk for coagulation issues. -Infants receive a 1-mg intramuscular (IM) injection of vitamin K within 1 hour after birth to prevent vitamin K deficiency bleeding -Infants who are breastfed, those deprived of oxygen at birth, or who have mothers who are treated with anticoagulants are at risk for decreased vitamin K levels -Infants can be at risk for clotting delays and potential hemorrhage, called hemorrhagic disease of the newborn. -Newborns have a higher hematocrit, slower bilirubin clearance, shorter RBC life span, and more immature liver conjugation processing. Conjugation is the process of converting lipid-soluble (non-excreted or indirect) bilirubin into a water-soluble (excreted or direct) form

Classes of Immunoglobulins NAME LOCATION FUNCTION IgG IgA IgM IgD IgE

1. IgG LOCATION: Blood and extracellular fluid FUNCTION: -Crosses the placenta to provide passive immunity for newborns -Provides long-term immunity after recovery or a vaccine 2. IgA LOCATION: -External secretions (tears, salvia, etc.) FUNCTION: -Present in breast milk to provide passive immunity for breastfed infants -Found in secretions of all mucous membranes 3. IgM LOCATION: -Blood FUNCTION: -Produced first by the maturing immune system of infants -Produced first during an infection (IgG production follows) -Part of the ABO blood group 4. IgD LOCATION: -B lymphocytes FUNCTION: -Receptors on B lymphocytes 5. IgE LOCATION: -Mast cells or basophils FUNCTION: -Important in allergic reaction (mast cells release histamine)

Newborn Screening/Disorders 3. Congenital Hypothyroidism 4. Congenital Adrenal Hyperplasia 5. Galactosemia 6. Maple Syrup Disease

3. -Caused by an underactive or absent thyroid gland, can lead to mental retardation -Symptoms include hypotonia, lethargy, poor temperature control, and respiratory distress. -Hormone replacement is necessary throughout life. -Parental education stresses the need for replacement hormone and close follow-up 4. -inability to produce cortisol in the adrenal glands is caused by a defect in the enzyme 21-hydroxylase. -Hyperplasia of the adrenal gland develops. -The result is excessive androgen production from the adrenal glands, leading to disorders of sexual identity in the child 5. -common enzyme deficiency that prevents the breakdown of galactose to glucose. -Galactosemia can lead to mental retardation and failure to thrive. 6. -rare autosomal recessive disorder common in those of Amish and Mennonite descent. -Buildup of the metabolic enzyme leads to severe ketoacidosis and encephalopathy.- -A protein-free diet must be implemented for the rest of the infant's life

Common Newborn Characteristics APPEARANCE and SIGNIFICANCE 1. Acrocyanosis 2. Circumoral cyanosis 3. Mottling 4. Harlequin sign 5. Mongolian spots 6. Erythema toxicum

Acrocyanosis APPEARANCE: Hands and/or feet are blue SIGNIFICANCE: -Response to cold environment. -Immature peripheral circulation Circumoral cyanosis APPEARANCE: A localized transient cyanosis around the mouth SIGNIFICANCE: Observed during the transitional period; if it persists it may be related to a cardiac anomaly Mottling APPEARANCE: A transient pattern of pink and white blotches on the skin SIGNIFICANCE: Response to a cold environment Harlequin sign APPEARANCE: One side of the body is pink and the other side is white SIGNIFICANCE: Related to vasomotor instability Mongolian spots APPEARANCE: -Flat bluish discolored area on the lower back and/or buttocks -Seen more often in African American, Asian, Latin, and Native American infants SIGNIFICANCE: -Might be mistaken for bruising -Need to document size and location -Resolves on own by school age Erythema toxicum APPEARANCE: A rash with red macules and papules (white to yellowish-white papule in the center surrounded by reddened skin) that appears on different areas of the body, usually the trunk area -Can appear within 24 hours of birth and up to 2 weeks after birth SIGNIFICANCE: -Benign -Disappears without treatment

Cleft Lip and Palate a) Describe? b) Nursing Interventions?

Cleft lip and palate are craniofacial deformities that occur early in pregnancy that can involve the soft and hard palate, the nose, the nasal septum, and the nasal and maxillary processes. a) -The lip and palate develop separately in utero. Infants can have a cleft lip on only one side of the lip, usually the left side, or on both sides. -The infant can also have a cleft palate that may be the only deformity, or it may be coupled with a one-sided or bilateral cleft lip. -Bilateral clefts are often associated with cleft palate. -A Cleft lip is more common than palate and occurs during the fourth to seventh week of gestation. o A cleft lip is an opening in the formation of the lip and can vary from a slit to a large opening that can extend into the nose. o It can occur on one side, both sides, or in the middle of the lip. -Cleft palate results during the improper fusion of the roof or palate of the mouth during the 7th to 12th week of pregnancy. o Incidence is higher in Asians, Latinos, and Native Americans. o Boys have a higher incidence of cleft lip, whereas girls have a higher incidence of cleft palate -The deformity can occur in the hard palate, which is the roof of the front part of the mouth, or in the soft palate, which is at the back of the roof of the mouth, or both. b) --Feeding problems occur because of the opening in the palate of the infant. --Saliva, formula, or breast milk can flow into the nasopharynx with resulting aspiration. --Infants can have problems creating a seal around a nipple. --An intact lip creates a negative pressure necessary to suck; however, an infant with a cleft lip and an intact palate will be able to breastfeed. --Lactation consultants can help with obtaining a seal "Cleft palates prevent the infant from isolating the oral palate from the nasal sinuses, which does not allow for a negative pressure vacuum needed to successfully draw milk from the breast" --Most infants will require adaptive feeding methods such as special nipples that are either longer to reach past the palate defect or are attached to an artificial palate that is placed into the infant's mouth, closing the defect. Specialized bottles are also used --Fluid intake and nutritional balance need to be maintained to support weight gain while nursing. --Ear infections are common in children who have cleft palate due to the flow of saliva, milk, or breast milk into the middle ear. Repeated ear infections may increase the incidence of hearing loss because of scarring or damage to the Eustachian tubes. --Speech issues in later life are also common. --Dental issues in children with this defect include problems with dental malocclusions. --There is a higher incidence of dental caries. Additional or missing development of dental eruptions may occur.

Ear Assessment: Nose Assessment Mouth Assessment

Ears -Examine for position, structure, and function. -Note absence of clefts, malformations, and cartilage or other abnormalities. -The infant should startle to noise and move eyes to sound. The eyes seek the sound but cannot locate it directly. -The infant should respond to soothing sounds. -Unresponsiveness to noises should be investigated Nose -Check the patency of the nares. Infants are obligatory nose-breathers. -Monitor for nasal flaring. Mouth -The mouth should be symmetrical; the tongue should not protrude between the lips. -The hard and soft palates should be intact and high arched. -Epstein pearls are yellow or white fluid-filled papules on the palate of the mouth that spontaneously resolve.

ALTERNATIVE AND COMPLEMENTARY THERAPIES FOR THE INFANT AND NEWBORN

Infant Massage Stimulates organized sleep patterns Enhances growth May assist with colic in infants Promotes bonding with caregiver Music Therapy Research supports the use of music to improve sucking, weight gain, sleep, and recovery from painful procedures, especially in premature infants Music therapy promotes sleep patterns and circadian rhythms, and slows heart rate. Singing by a caregiver has positive emotional and physiological benefits that aid in communication and language acquisition, and assist in concentration.

COGNITIVE DEVELOPMENT Assessment models for infant cognitive development include the following:

Intellectual growth begins at birth and focuses on memory, problem-solving, exploration of the environment, and understanding concepts. Primitive reflexes, which disappear within months after birth, are controlled by lower brain functions. In this age group, cognitive development occurs quickly and may substantially vary from month to month. Infants develop on all levels and are influenced by cultural context, neurological development, and experience with others. Brazelton Neonatal Behavioral Assessment Scale: -Tests an infant's neurological development, behavior, and responsiveness. It is used only in the neonatal period. Gesell Developmental Schedules: -Test for fine and gross motor skills, language, eye-hand coordination, imitation, object recovery, personal-social behavior, and play response. Denver Developmental Screening Test: -Used to identify problems or delays. -It measures personal/social, fine and gross motor, language, and social skills (6 items) Bayley Scales of Infant Development: -Test the cognitive, behavioral, and motor domains of the infant. -The assessment is used to identify infants with developmental disabilities. -It is a highly reliable tool that uses mental, motor, and behavioral scales to rate an infant's functioning. -The mental test screens for such items as whether the infant turns to a sound or looks for a fallen object. The motor test screens for gross and fine motor skill development.

Common Newborn Characteristics 7. Milia 8. Lanugo 9. Vernix caseosa 10. Epstein's pearls 11. Natal teeth 12. Infant acne

Milia APPEARANCE: White papules on the face; more frequently seen on the bridge of the nose and chin SIGNIFICANCE: -Exposed sebaceous glands that resolve without treatment -Parents might mistake these for "whiteheads" -Inform parents to leave them alone and let them resolve on their own Lanugo APPEARANCE: -Fine, downy hair that develops after 16 weeks gestation -The amount of lanugo decreases as the fetus ages -Often seen on the neonate's back, shoulders, and forehead SIGNIFICANCE: -Gradually falls out -The presence and amount of lanugo assist in estimating gestational age -Abundant lanugo may be a sign of prematurity or a genetic disorder Vernix caseosa APPEARANCE: - A protective substance secreted from sebaceous glands that covered the fetus during pregnancy -It looks like a whitish, cheesy substance -May be noted in the axillary and genital areas of full-term neonates SIGNIFICANCE: -The presence and amount of vernix assist in estimating gestational age -Full-term neonates usually have no vernix or only small amounts Epstein's pearls APPEARANCE: White, pearl-like epithelial cysts on gum margins and palate SIGNIFICANCE: Benign and usually disappear within a few weeks Natal teeth APPEARANCE: -Immature caps of enamel and dentin with poorly developed roots -Usually, only one or two teeth are present SIGNIFICANCE: -They are usually benign but can be associated with congenital defects -Natal teeth are often loose and need to be removed to decrease the risk for aspiration Infant acne APPEARANCE: Small red bumps or pimples on the infant's face or body that usually appear at 1 month of age SIGNIFICANCE: Usually benign but concerning to parents; parents should be taught to keep the infant's face or skin clean and not to apply creams or ointments to the skin unless prescribed by the pediatrician

Cleft palate surgery cont. Nursing Goals: Emergency Care? Acute Care? Chronic Care?

Nursing Goals -Maintain the integrity of the suture line. -Assess respiratory status. -Promote bonding with the infant. -Promote optimal nutritional intake of the infant. -Manage pain. Emergency Care -Explain procedures to caregivers. -Answer caregiver questions as needed. Acute Care -Instruct caregivers that children may require multiple surgeries, repairs, or gum grafts. -Instruct caregivers to keep toys with protruding ends away from the infants, who may put them into their mouths and disrupt their suture lines. -Teach caregivers to promote sucking between meals to help the children develop muscles that are not being fully used during feeding. Chronic Care -Instruct caregivers that psychological assistance may be required for children with facial abnormalities or for parent-infant bonding issues because of the lack of the perfect baby at birth. -Instruct caregivers that children will need to see their dentists early, and that they often will require braces or dental prostheses

DEVELOPMENTAL MILESTONES Three to Six Months

Three to Six Months --Birth weight doubles by 6 months of age --Height increases 1 inch per month for the first 6 months --Can raise the head and support it by 4 months --Reaches and grasps objects, plays with hands, moves objects to mouth, plays with toes --Rolls from the abdomen to back --More stabilized sleeping patterns at 3 months --Opens mouth for the spoon --Binocular vision: ability to see with both eyes coordinated --Primitive reflexes begin to disappear --Begins to drool, chew on toys as teething begins (6 months) --Can sit when propped at 6 months --Can support some weight when held in a standing position --Recognizes familiar objects and people, expresses displeasure when those objects or people are removed, babbles to self

Circulatory System Transition and Assessment Circulatory system transition occurs with the clamping of the cord and the first breath The successful transition is directly influenced by the changes that occur in the respiratory and thermoregulation systems. a) Three fetal structures maintain fetal circulation: b) Nurses conducting an assessment of a newborn's circulatory system should be aware of the following:

a) -The ductus arteriosus, between the pulmonary artery and the aorta -The foramen ovale is the connection between the right and left atria -The ductus venosus in the hepatic system b) -Three vessels should be present in the umbilical cord: two arteries and one vein. -The presence of only two vessel cords may indicate renal agenesis or lack of development. -Cord blood may be obtained from an Rh-negative mom or O blood group. -Blood gases may be obtained if O2 levels are decreased or Apgar scores are depressed at 5 minutes of age. -Newborn heart rate (apical) averages 120 to 160 bpm at rest but can increase with crying and decrease with sleeping. Count for a full minute. Heart rate decreases as the infant ages. -All peripheral pulses should be palpable and normal in intensity. -Blood pressure increases with age -Four extremity blood pressures are indicated with a heart murmur turbulent blood flow heard by a stethoscope as swooshing or whooshing. Murmurs may be present at birth and can be completely normal -Brisk capillary refill should be less than 3 seconds; abnormal is longer than 4 seconds. -Congenital abnormalities are related to failure of the fetal structures to close, structural abnormalities, or blood outflow problems

Latching On to nipple he process of attaching the infant to the breast for feeding is as follows:

a) Hold the breast like a sandwich with the thumb on the top and the other fingers underneath. b) The baby should be held close; as the baby's mouth is opened wide, place the breast fully (including the nipple and areola) into the baby's mouth c) Encourage the infant's mouth to open by stimulating the rooting reflex. d) A successful latch is when the infant's mouth is around the areola with the nipple at the back of the mouth. e) The infant draws the milk forward in the breast. f) The tip of the nose, cheeks, and chin should be touching the breast. Align the breast with the infant's nose. g) Suck and swallow should follow. h) Often infants will feed from only one breast at a time for each feeding.