Newborns & Infants

Conduction heat loss of newborn

Transfer of heat directly from infant to cooler surface/equipment Place infant on warm surface, remove wet linens, cover infant's head Cover cold surfaces w/ warmed blanket

Convection heat loss of newborn

Transfer of heat through drafts passing over infant (fans, air drafts, blowing oxygen, sides of radiant warmer are down, air conditioner)

Evaporation heat loss of newborn

Transfer of heat when water on surface of infant's skin is converted to water vapor Ensure infant is dried after delivery and after a bath

Mottling

Transient pattern of pink and white blotches on the skin Response to cold environment

Lanugo

Fine, downy hair that develops after 16 weeks gestation Amount of lanugo decreases as fetus ages Often seen on neonate's back, shoulders, forehead Gradually falls out Presence and amount of lanugo assist in estimated gestational age Abundant lanugo may be sign of prematurity or genetic disorder

Mongolian spot

Flat bluish discolored area on lower back and/or buttocks Seen more in AA, Asian, Latin, and NA infants Might be mistaken for bruising Need to document size and location Resolves on own by school age

Physiological Jaundice

Transient rise in serum bilirubin levels w/in first 24-48 hours Affects 60% term infants and 80% preterm infants Peak TSB levels result in phototherapy if level is at/above 15mg/dL w/in 24-48 hrs Bilirubin levels are benign and usually don't exceed 15mg/dL Levels of 17-18mg/dL may be accepted as normal in term infants past 72 hours old

Sickle Cell Disease

Inherited hematological disease RBCs sickled in shape, become trapped in small areas (ex: joints) and block blood flow More common in blacks and Hispanics (U.S.); common among people in Africa, Caribbean, Mediterranian Results in: - Anemia - Pain - Infections - Acute chest syndrome - Vision issues - Stroke No known cure Stem cell treatments have been used w/ some success in limiting symptoms

Erikson

Psychosocial development Highlights trust vs. mistrust as first psychosocial stage during first year of life Explains how infant's personality develops If stage not attained, infant feels insecure and learns mistrust Trust in infancy provides lifelong expectation that world will be a good and pleasant place to live

Immediate needs of the newborn

- Clear the airway (position infant on their back w/ neck slightly extended "sniffing position". Suction mouth first, then nose. Insert syringe in corner of mouth. - Dry and stimulate the infant - Maintain thermoregulation (immediate drying and removal of wet linens) - chilling increases O2 consumption and metabolism - Assign APGAR score (1 min and 5 min) - Band infant w/ on-demand or barcode on arm & leg, corresponding bands applied to mother and SO - Prophylactic meds (Vit K, Erythromycin eye ointment, Hep B) - Protect physical well-being of newborn - Foster parent-infant bonding

Ear Assessment of Newborn

- Examine position, structure, function - Note absence of clefts, malformations, cartilage, other abnormalities - Infant should startle to noise and move eyes to sound; eyes seek sound but can't locate directly - Infant should respond to soothing sounds - Unresponsiveness to noises should be investigated

Developmental Milestones for 6-9 Months

- All infants should be screened for developmental delays and disabilities at 9 months at 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, 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 mirror - Develops and expresses taste preferences - Begins to understand differences b/w inanimate and animate objects - Displays stranger anxiety - Develops object permanence - Vocalizes w/ many syllable vowel sounds and "m-m" w/ crying - Around 9 months, says "dada", "mama" and understands bye-bye and no - Around 8-9 months begins to pull to stand, develops pincer grasp, crawls backward and then forward, 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, ex: watching parent while dropping food on the floor - Distinguishes colors - Distance vision - Expresses emotions, including frustration and anger

Head/Neck Assessment of Newborn

- Anterior and posterior fontanels should be assessed w/ infant in upright position - Anterior fontanel = diamond shaped; avg 2-3 cm wide by 3-4 cm long; closes at 12-18 mos; should feel slight pulsation - Posterior fontanel = triangular; avg 1-2 cm wide; closes by 2 mos - Abnormal fontanels = full or bulging, sunken, closed suture lines; assessment should be done when baby is quiet (bulging may occur w/ crying or increase ICP; sunken may indicate dehydration) - Avg head circumference = 35 cm (avg 33-37) - Molding of head occurs w/ normal vaginal deliveries (misshapen or elongated scalp) - Bruising/swelling of scalp may occur d/t difficult delivery/use of vacuum or forceps - Bleeding of skull and outer covering may cause small bump, reabsorbs in few weeks - Caput succedaneum = cone shape to back of head that crosses suture lines; occurs when blood and tissue become edematous from pushing against mother's cervix - Cephalhematoma = swelling on one or both sides of scalp that doesn't cross suture lines; result of bleeding over skull bone or w/in periosteum d/t pressure against pelvic bone; can be life-threatening b/c of blood loss; can increase jaundice as blood is broken down - Craniosynostosis = premature closure of one or more of cranial sutures Abnormalities d/t Zika virus (+) mom: - Microcephaly = small head - Intracranial calcifications - Other brain/eye abnormalities (glaucoma) - Infant presenting w/ S/S should have urine and serum tested for Zika virus RNA NAT (nucleic acid test) IgM antibodies - Ideally test w/in 2 days after birth but can be tested weeks to months after birth w/ some success

Newborn Respiratory Assessment/Development

- Assess nose for patency (obligate nose breathers, after several months nose-and-mouth) - Chest wall symmetry (pneumothorax) - Resp. pattern = very irregular, sporadic, shallow, diaphragmatic - Rate 30-60 breaths/min - Resp. rate decreases w/ age - Acrocyanosis is normal first 24-48 hours; after this may indicate cardiac disease (assess in dark-skinned infants through mucous membranes) - Older infants become diaphragmatic breathers

Developmental Milestones for 3-6 months

- Birth weight doubles by 6 months - Height increases 1 inch/month first 6 months - Can raise head and support it by 4 months - Reaches and grasps objects, plays w/ hands, moves objects to mouth, plays w/ toes - Rolls from abdomen to back - More stabilized sleeping patterns at 3 months - Opens mouth for spoon - Binocular vision: ability to see w/ both eyes coordinated - Primitive reflexes start 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 standing position - Recognizes familiar objects and people, expresses displeasure when those objects or people are removed, babbles to self

Developmental Milestones for 9-12 Months

- Birth weight triples - Birth length increases by 50% - Head and chest circumference are equal - Total of 6-8 teeth - Knows name - Creeps along furniture - Drinks from a cup, should be weaned from bottle - Stands alone for brief periods of time, raises arms when wants to be picked up - May take first steps or walk alone - Eats w/ spoon and cup but prefers fingers - Enjoys familiar surroundings and people, expresses dissatisfaction w/ 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 2-3 words beyond Dada and Mama - One or both feet may slightly turn in, infant's lower legs are normally bowed - Around 12 months, can transition to whole cow's milk (do not use 1-2% b/c infant needs fat content for continuing brain development)

Neuro Transition/Assessment of Newborn

- Brain reaches 90% total size during infancy - All neurons present by 1 yr - Maturation follows cephalocaudal, proximodistal progression and mass to specific - Positional plagiocephaly (positional skull flattening) treated by changes in position or physical therapy; custom helmets restricted to severe cases Assessment: Be alert for - Uncoordinated movements - Tremors in extremities - Poor muscle control or tone - Test reflexes, should be symmetrical on each side of body (asymmetry may be abnormality or weakness) Reflexes of neonate: - Moro or startle reflex - Rooting reflex - Sucking reflex - Palmar grasp - Plantar - Tonic neck or fencing position - Babinski - Stepping or dancing reflex

Nose Assessment of Newborn

- Check patency of nares - Obligatory nose breathers - Monitor for nasal flaring

Eye Assessment of Newborn

- Eyelids may be edematous from birthing process; resolves spontaneously - Iris should be grayish blue or gray-brown; sclera should be blue or white; abnormal - jaundiced sclera - Pupils should be equal, round, reactive to light activity; cornea should be clear; red reflex should be present - Glaucoma can occur up to 3 mos after birth in Zika exposed infant; increased tearing, swelling, pain, dullness of iris; glaucoma can also occur in neonates not exposed to Zika - Congenital cataracts can occur in neonate, clouding of lens - Line from inner epicanthal fold to outer canthus to top notch of ear where it connects w/ scalp should be symmetrical - Tears not produced until 2 mos - Strabismus = imbalance in ocular motor capacity - Visual acuity of newborn is 20/400, improves by 2 yrs to 20/30

Neck Assessment in Newborn

- Head should move freely from side to side - Infant should not move head past shoulder - Neck is short and thick, skin folds present - No masses should be felt or observed

Immune System Transition/Assessment of Newborn

- Infant in utero = sterile environment - Infant provided w/ maternal immunity thru antibodies that bind to bacteria, viruses, fungi that enter body - After birth, active humoral immunity is provided thru acquired immunity (vaccination) or natural immunity (from one's own production of antibodies in response to exposure to antigens) - Temporary passive immunity = provided by maternal antibodies that cross placenta (lymphocytes - T & B cells) - Passive immunity also provided by breast milk (IgA) Immunoglobulins: maternal antibodies that cross placenta and provide passive immunity - IgG = only immunoglobulin that cross placenta during pregnancy and makes up 75-85% of all infant's antibodies - IgA = found in breast milk - IgM = found in lymph and bloodstream - IgD = found in abdomen and chest areas of body - IgE = found in lungs, skin, and mucous membranes - Infant's immune system not fully developed until 6 mos; begins to produce antibodies at 2-3 mos - No evidence that delaying intro of specific foods beyond 6 mos prevents allergies (early introduction of potentially allergic foods at 4-6 mos may provide form of protection and prevent allergy) - Infants at risk for infxn b/c of immature immune response, lack of maternal antibodies, stress that depletes immune system, breaks in skin d/t invasive procedures that introduce bacteria/viruses

S/S of Hypoglycemia in Neonate

- Irritability - Jitteriness - Hypotonia - Temp instability - Apnea - Poor feeding - Lethargy - Seizures - Lack of s/s does not always indicate absence of alteration

Mouth Assessment of Newborn

- Mouth should be symmetrical, tongue should not protrude b/w lips - Hard and soft palates should be intact and high arched - Epstein pearls spontaneously resolve

GU System Transition/Assessment of Newborn

- Nephrons fully functional at 34-36 weeks gestation - Fetus produces urine w/in first 3 months of gestation - First urine output should occur w/in first 24 hours after birth - First 1-2 days urine may be stained orange/pink b/c of urate crystals - Newborns can't concentrate/dilute urine in response to intravascular fluid status (at risk for dehydration or fluid overload) - Infants more prone to extracellular fluid loss than intracellular fluid loss - Term neonate composed of 75% water (40% extracellular, 35% intracellular); usually lose 5-10% weight in first week of life (almost all water loss) - Fluid requirements during first 2 days of life are 80-100 mL/kg/day, then increase to 100-150 mL/kg/day - GFR decreases at birth - Specific gravity averages 1.001-1.010 during infancy

Maternal History taken during newborn care

- Review prenatal history (past pregnancies, complications, genetic factors for both mother and father) - Infections (prenatal as well as past exposures) - Screening tests and risk factors - Labor and delivery probs or risk factors - Perinatal substance abuse exposure (nicotine, SSRIs, benzos, alcohol, opiates, etc)

Genitalia Assessment of Newborn

- Scrotum first appears edematous and disproportionately large - Hypospadias = urethral opening on underside (ventrum) of penis - Epispadias = urethral opening on upper portion (dorsum) of penis - Circumcision delayed so prepuce can be used for surgical correction - Observe for vaginal tags - Observe for ambiguous genitalia (genetic defect in which outward appearance of genitalia does not resemble boy/girl; penis may be very small, clitoris may be very large, labia may be fused resembling scrotum - Pseudomenstruation = thin white or blood-tinged mucus may be present b/c of w/d of maternal hormones - Breasts may be enlarged in both male/female infants at birth; preterm/postmature infants may have decreased breast tissue

Skin System Transition/Assessment of Newborn

- Skin should be pink (pale/dusky skin may indicate congenital heart disease) - Observe for jaundice (apply pressure and remove over body prominence - sternum, nose, sacrum) - Observe for lanugo - Observe for acrocyanosis (normal, disappears w/ crying) - Observe for petechiae, skin tags, breaks in skin, forceps marks on face/scalp, EFM marks on scalp - Observe for milia (usually on face) - Vernix caseosa (usually found in armpoints/groin) should not be removed; emollient effect to skin - Erythema toxicum (newborn rash) = tiny pimmples that disappear w/in first few weeks - Baby acne = small red pimples on face/body that appear at about 1 month of age - Mongolian spots (gray, dark blue, black areas located over sacral region; Asia, Africa, Meditarranean descent) - Observe for birthmarks, nevi, stork bites Cord care: cord starts to dry following cutting cord; cord clamp should be removed 24-48 hrs after birth; keep it dry; leave open to air (some institutions apply methylene blue/alcohol to cord as drying agent). Cord will become black and hard as it dries and falls off w/in 2 weeks. Some cultures save cord detachment. Do not submerge in tube of water until cord has dried and come off (sponge baths only). Diapering: baby should have b/w 6-10 wet diapers/day. Use water to clean genital and rectal area, wipe girls from front to back. Wash hands after every diaper change. Diaper rash: often result of candidiasis; expose to air

Dental Development and Assessment

- Tooth buds present during 3rd month of pregnancy - Natal teeth can be present at birth; can interfere w/ breastfeeding - Teething = eruption of tooth thru gums; usually erupt 4-10 mos (6 mos) - Two lower center teeth around 6 mos - Upper center teeth at 8-10 mos - 1st yr, child has 6-8 teeth S/S of teething: - Drooling - Restlessness - Difficulty falling asleep - Sucking on hands - Mild rash around mouth b/c of drooling - NOT associated w/ generalized rash, fever, diarrhea, or prolonged fussiness - Numbing OTC meds are brief in action, may also numb throat, taste may not be pleasant for infants; DO NOT give any med w/ alcohol in ingredients - Primary teeth are calcifying - ADA recommends first dental visit at eruption of first tooth (6 mos) - Soft clean cloth should be used to clean teeth as they erupt or to bite down on to decrease pain of teething DENTAL CARE: - Feed only formula, breast milk, or water in a bottle - Delay juice until toddler; introduce around 6-9 mos, limit 4-6 oz, give in cup - Do not but infants to bed at night or nap w/ bottle - Brush teeth w/ soft cloth once they erupt - Do not use cold juice to sooth infant's gums - Begin regular dental appts by 1 yr

Full-term Infant Definition

Born b/w first day of 38th week and first day of 42nd week of pregnancy

Newborn/Neonate Definition

28 days old or younger Can refer to any preterm, term, or post mature child

Fluid Intake for Newborn/Infant

<10kg = 100 ml/kg 10-20kg = 1,000ml for first 10kg, +50ml/kg over 10kg >20kg = 1,500ml for first 20 kg, +20ml/kg over 20kg

APGAR Scoring

A= appearance P= pulses G= grimace A= activity R= reflexes 1 minute score = indicates neonate's ability to transition to extrauterine life, factors occurring during birthing process, and whether resuscitation is needed 5 minute score = indicates neonate's status and/or effectiveness of resuscitative efforts, neuro deficits, long-term morbidity and mortality

Weight

AGA 2,500-4,000g (5.5-8.75lb) Avg birth weight = 7.5 lb AGA: b/w 10-90th percentile SGA: below 10th percentile LGA: above 90th percentile LBW: 2,500g or less (5.5 lb) VLBW: 1,500g or less (3.5 lb) IUGR: growth of fetus does not meet expected norms for gestational age Infants have larger BSA in comparison with total weight

Congenital Hypothyroidism

Caused by underactive or absent thyroid gland Can lead to mental retardation S/S: - Hypotonia - Lethargy - Poor temp control - Respiratory distress HRT for life

Breastfeeding Jaundice vs. Breast Milk Jaundice

Affects 1-2% breastfed babies Breastfeeding Jaundice = Early Onset: - W/in first few days of life - Poor feeding patterns - Bilirubin levels may spike to 19 mg/dL - Ineffective breastfeeding - Delayed passage of meconium stool promotes reabsorption of bilirubin in gut Treatment: - Encourage early, effective breastfeeding w/o supplementation of glucose water/other fluids Breast Milk Jaundice = Late Onset: - After 3-5 days - Peaks 2-3 weeks after birth - Increased absorption of bilirubin resulting from factor in breastmilk that increases absorption of bilirubin from intestines - Breastmilk composition in some women increases enterohepatic circulation of bilirubin Treatment: - Continue breastfeeding in most infants - In cases where bilirubin levels excessively high, breastfeeding may be interrupted and formula feedings given for several days; resume breastfeeding when bilirubin levels decline

Infancy Definition

Age 1 month - 1 year

Tonic Neck or Fencing Position Reflex

Arm and leg extended while opposite side of body is flexed Disappears 4-6 mos Response after 6 mos may indicate cerebral palsy

GI System Transition and Assessment of Newborn

Assessment: - Abdomen should be cylindrical (sunken abdomen should be reported) - Stomach is immature but rapidly adjusts - Stomach capacity = 30-60 mL at birth (rapidly increases) - Infant may be in quiet sleep state and uninterested in feeding - Desire for feeding and stomach size increase rapidly in infancy - Enzymes are present at birth to digest proteins, moderate fats, simple sugars - Decreased esophageal sphincter pressure present at birth but increases w/ age - First stool = black and tarry (meconium); formed around 16 weeks gestation and usually passed w/in 25-48 hours of age - Stool becomes transitional around day 3 (color and consistency depends on feeding) - Breastfeeding stool beyond transitional = golden, semiformed - Bottle-fed stool beyond transitional = drier, pale yellow/greenish/black to brownish - Loose or green stool = diarrhea; most hospitalizations/deaths from diarrhea occur during first yr of life - Breastfed babies eat more frequently b/c of increased digestability of breastmilk (60% whey, 40% casein); cow's milk is 20% whey, 80% casein (casein forms hard curd that is difficult to digest) - Constipation does not occur in breastfed newborns - Breastfed babies often produce stool w/ every feeding; by 1 month old may progress to 1 stool/day or every other day - Bottle-fed babies may become constipated w/ improper formula mixing; normal elimination pattern = 1-2 stools/day - AAP recommendation 400IU of vit D/day after birth until infant is taking quart of whole milk at 1 year of age - Moms on strict vegetarian diets need extra B-complex supplement when exclusively breastfeeding - After month 2, stool increases in volume, decreases in frequency - Feedings for infants should be at least q4 hrs; may be more frequent early infancy b/c of stomach emptying time - Breastfed babies often want to go to breast q45-90 min (stomach capacity only 20-30mL) - As infant weaned from breast/bottle to solid foods, consistency of stool will change; not uncommon to see pieces of food in stool

Phenylketonuria (PKU)

Autosomal recessive deficiency of enzyme phenylalanine Most common inborn error of metabolism Prevents conversion of essential acid phenylalanine to tyrosine Elevated levels of phenylalanine = mental cognitive impairment d/t defective myelination/degeneration of white and gray matter of the brain Characterized by: - Developmental delays - Poor feeding - Irritability - Vomiting Affected infants must be on feedings for 3 full days so liver enzyme that converts phenylalanine to tyrosine will be secreted Guthrie blood test performed Low-phenylalanine, low-protein diet must be implemented for life

Krabbe Disease

Autosomal recessive genetic disorder; affects brain and NS 1/100,000 children Deletion of galactosylceramidase impairs ability of body to grow and repair myelin sheath Results in severe deterioration of mental and motor skills --> muscle weakness, hypertonia, seizures, spasticity, fever, irritability, difficulty swallowing, deafness, vision loss Very rare disorder, lack of treatment options = many states allow parents to opt out of testing

IgD

B lymphocytes Receptors on B lymphocytes

IgM

Blood Produced first by maturing immune system of infants Produced first during infection (IgG production follows) Part of ABO blood group

IgG

Blood and ECF Crosses placenta to provide passive immunity for newborns Provides long-term immunity after recovery or a vaccine

Phototherapy for Neonatal Jaundice

Blue green fluorescent light absorbed into skin, converts unconjugated bilirubin to conjugated bilirubin by producing lumirubin (water-soluble, allows infant to excrete bilirubin in stool and urine) Infants' eyes need to be covered to prevent cataracts (retinal damage can occur) infants should be fully exposed except for diaper, keep male scrotum covered Low-heat setting isolette Lamp should be 45-50 cm away from infant (2 inches from top of isolette) Infant should be held only during feedings and eye patches can be removed Closely monitor temp Never use lotions/ointments Dual therapy = overhead lights and bili blanket Fluid requirements may increase during therapy (insensible water loss); fluid supplementation not supported if temp homeostasis and fluid output maintained Rebound bilirubin levels rise 1-2 mg/dL once phototherapy dc'd

Galactosemia

Common enzyme deficiency Prevents breakdown of galactose to glucose Can lead to mental retardation and FTT

Ballard Maturational Scoring

Consists of 6 areas neuromuscular activity + 6 areas of physical maturity; used to assess gestational age Physical maturity should be completed w/in first 2 hrs birth: - Skin: dryness, peeling, moisture - Lanugo: presence/absence - Plantar surfaces: presence/absence of creases and their depth - Breasts: normal 3-10 mm, nipples prominent - Ears/eyes: open/fused, amount of cartilage in pinna, eyes should be equal and symmetrical, external canthus of eyes need to line up w/ top of pinna - Genitalia: size of clitoris, labia minor, labia majora; urethral opening needs to be in middle of head of penis, w/ both testes palpable in scrotum Neuromuscular activity should be assessed w/in first 24 hours: - Posture: position of infant at rest, flaccid/flexed - Square window: how far infant's hand can be flexed toward wrist - Arm recoil: how well arms recoil back when flexed - Popliteal angle: how far infant's knees can be flexed - Scarf sign: how far infant's arm can be moved across chest - Heel-to-ear: w/ hips on bed, how far baby's feet can be moved toward ear Scores plotted on graph to provide gestational age based on weight, length, and head circumference to determine if infant appropriate for gestational age; term infants have higher scores than premature infants

Cleft Lip and Palate

Craniofacial deformities that occur early in pregnancy and can involve soft and hard palate, nose, nasal septum, and nasal and maxillary processes Causes unknown; genetics and environment thought to play a role Deficiency in folic acid intake during pregnancy, alcohol consumption, smoking increase risk; also certain meds during pregnancy (isotretinoin/Accutane, antiseizure drug phenytoin/Dilantin) - Lip and palate develop separately in utero - Can have cleft lip on only one side of lip, usually left side, or both sides - Can also have cleft palate that may be only deformity, or may be coupled w/ one-sided or bilateral cleft lip - Bilateral clefts often associated w/ cleft palate - Cleft lip more common than palate; occurs during 4-7 weeks gestation - Cleft lip = opening in formation of lip and can vary from slit to large opening that extends into nose; can occur one side, both sides, or middle of lip - Cleft palate = results from improper fusion of roof/palate of mouth during 7-12 weeks gestation; higher incidence in Asians, Latinos, and NA; can occur hard palate or soft palate, or both Boys have higher risk of cleft lip; girls have higher incidence of cleft palate INTERVENTIONS: - Feeding probs occur b/c of opening - Saliva, formula, breast milk can flow into nasopharynx w/ resulting aspiration - Can have probs creating seal around a nipple - Infant w/ cleft lip and intact palate will be able to breastfeed; lactation consultant can help obtain seal - Most require adaptive feeding methods (special nipples that reach past palate defect; nipples attached to artificial palate placed in infant's mouth, specialized bottles) - Ear infections are common w/ cleft palate due to flow of saliva, milk, breast milk into middle ear; repeated infxn may increase risk of hearing loss b/c of scarring/damage to Eustachian tubes - Speech issues later in life common - Dental issues (dental malocclusions) - Higher incidence dental caries - Additional/missing development of dental eruptions may occur TREATMENT: - Repair w/in 2-3 mos, up to 18 mos; goal of preventing speech/dental probs - Correcting before 12 mos = better outcomes in speech and need for future corrections - Infant must be gaining weight and free from respiratory infxn - Surgical repair involves a Z-plasty (closes palate in one procedure w/ staggered suture line) - May need multiple surgeries POST-OP CARE: - NPO immediately after surgery - Position infant on back or side - Assess respiratory status; edema may cause airway prob - Logan bow (thin metal bar) or steristrips are taped to face to maintain and keep suture line intact, esp. when child is crying - May be restrained for 2-3 weeks w/ soft elbow restraints to prevent disrupting suture line (remove every 2 hours one arm at a time) - Infant w/ cleft palate repair SHOULD NOT be suctioned orally; infants provided liquids w/ a cup ( avoid straws, pacifiers, eating utensils) to protect suture line - Soft, rubber tipped feeder or nipple preferred; introduce in side of mouth to avoid suture line - Breastfeeding usually avoided during this time - Direct flow of milk away from defect and to side - Feed in upright position and burp frequently - Raise HOB or place in seat following feedings - Rinse mouth w/ water after feedings - Clean suture line often w/ half hydrogen peroxide and water or NS - Some surgeons will order abx cream - Cleft palate = similar post op care, infant may be placed on abdomen to facilitate drainage if no cleft lip repair involved - Often will require braces or dental prostheses

Hyperbilirubinemia of Newborn

Excessive amount of bilirubin in the blood, mainly d/t immature liver Unconjugated bilirubin is fat-soluble, nonexcretable, and binds to albumin; liver must conjugate to be eliminated in urine/stool Increased levels of unconjugated bilirubin that saturate the albumin-binding sites cross the blood-brain barrier and can result in kernicterus Kernicterus - life threatening; buildup of bilirubin in brain/spinal cord Total serum bilirubin (TSB) = combination of direct and indirect bilirubin Risk factors: - Mom w/ diabetes - ABO incompatability (specifically mom type O and baby type A/B = immune system reaction results in excessive breakdown of RBCs / release of bilirubin) - RH incompatability (prevent w/ administration of RhoGAM) - Prematurity - Delayed feeding (delays passage of bilirubin rich meconium) - Birth trauma (bruising, cephalhematoma, asphyxia) - Liver immaturity - Stress in neonate (cold stress, asphyxia, hypoglycemia) - Use of Pitocin in labor - East Asian, American Indian, Mediterranean descent - Sibling hx of jaundice - Breastfeeding Interventions: - Observe skin (jaundice begins face and nose, then progresses down trunk to extremities) - Screen all neonates before d/c (measures bilirubin levels, risk factors); levels plotted on Bhutani nomogram (hour specific tool for prediction in at-risk neonates >36 weeks gestation, >2,000g, otherwise well w/ no ABO incompatabilities - Severely at risk = TSB level > 95th percentile in age hours - Coombs test also for monitoring (heel stick) - Transcutaneous bilirbuin measurement (TcB) = noninvasive multiwavelength spectral skin monitoring of bilirubin levels int erm/near term infants via upper part of sternum; up to 15 mg/dL; correlates w/ serum blood levels

Cystic Fibrosis

Exocrine gland disorder; results in probs w/ digestion and breathing Produces thickened mucus that becomes trapped in lungs and digestive system Symptoms appear b/c of blockage in respiratory system and often pancreas S/S: - Coughing - Mucus - Lung infections - SOB - Salty skin - Slow growth - Frequent loose, greasy stools

IgA

External secretions (tears, saliva, etc.) Present in breast milk to provide passive immunity for breastfed infants Found in secretions of all mucous membranes

Hepatitis B Immunization

Given to prevent Hep B Mothers w/ unknown Hep B status are also administered human hepatitis B immunoglobulin G (IgG) Hep B can cause serious chronic liver disease and cancer of the liver Side effects: - Pain at injection site Administration: - Vaccinate all newborns w/ monovalent vaccine before d/c (0.5 mL IM for first dose) - Given w/in 12 hours of hep B IgG if mother is hep B + or unknown status - Given at d/c if mother's status is known to be - Special Considerations: - Follow immunization schedule for administration, some parents defer to first pediatrician appt - Series of 3 doses, given in vastus lateralis

Palmar Grasp Reflex

Grasping of person's finger in infant's hand; can be pulled to sitting position Disappears 3-4 mos and replaced w/ voluntary grasp Absent or weak response indicates possible CNS defect or nerve or muscle injury

Height

Growth charts used to compare child's measurements w/ those of other children same age Specific charts for infants of Asian descent and those w/ Down Syndrome Avg length at birth = 20 inches Best predictor of adult height = family history

Acrocyanosis

Hands and/or feet appear blue Response to cold environment Immature peripheral circulation

Head Circumference

Head and chest circumference roughly equal, chest slightly smaller (1-2cm) if head < chest, consider microcephaly If head more than 1 inch large than chest, may be increased ICP/other issues

Natal teeth

Immature caps of enamel and dentin w/ poorly developed roots Usually only 1-2 teeth present Usually benign, but can be associated w/ congenital defects Natal teeth are often loose and need to be removed to decrease risk for aspiration

Red Light Reflex

Important test to determine life-altering abnormalities (cataracts, glaucoma, retinoblastoma, retinal abnormalities, systemic abnormalities) Light used to reflect off ocular fundus of eye, should result in reddish-orange color Obstructions can occur w/ mucus or abnormalities; differences depending on race, ethnicity, pigmentation of fundus Need to be performed by pediatrician or other PCP before d/c from newborn nursery

Congenital Adrenal Hyperplasia

Inability to produce cortisol in adrenal glands; caused by defect in enzyme 21-hydroxylase Autosomal recessive disorder Affects 1/15,000 gen pop, but 1/680 Eskimos Hyperplasia of adrenal gland develops Results in excessive androgen production from adrenal glands --> disorders of sexual identity in child

Benefits of Kangaroo Care

Infant Benefits: - Stabilization of HR - Stabilization of breathing patterns - Improved oxygenation - More rapid weight gain - Decreased crying - Improved breastfeeding episodes - Earlier d/c Mother benefits: - Increased milk supply - Increased sense of parental control - Increased confidence in care of child - Increased bonding

Post Mature Infant Definition

Infant born after 42 weeks of pregnancy

Preterm Infant Definition

Infant born before end of 37th week of pregnancy

Babinski Reflex

Infant's toes flare when lateral foot is stroked in upward motion Disappears 12 mos Absent or weak response may indicate possible neuro defect

Plantar Reflex

Infant's toes flex in grasping motion in response to thumb pressed against ball of foot Disappears 3-4 mos Weak or absent response may indicate possible spinal cord injury

Periods of Reactivity

Initial Period of Reactivity: - Initial 30 min after birth - Active and very interested in environment - Bursts of eye movements - Responds to external stimuli - Excellent bonding time for fam and infant - Eyedrops and ointment should be delayed (30 min) until fam has made eye contact - Excellent time for breastfeeding - HR, RR, and mucous production increase - Brief periods tachypnea, tachycardia, apnea, cyanosis Period of Relative Inactivity: - Begins 30 min-2 hrs after birth - Infant very sleepy and unresponsive to stimuli in environment - Difficult period for feeding - HR, RR, mucous production decrease Second Period of Reactivity: - Begins 2-8 hrs after birth - Alert and responsive - HR and RR increase - Increased stooling - Increased muscle tone

Circumoral cyanosis

Localized transient cyanosis around the mouth Observed during transitional period If it persists, may be r/t cardiac anomaly

IgE

Mast cells or basophils Important in allergic reaction (mast cells release histamine)

Coombs Test

Measurement of antibodies attached to newborn's RBCs that occur w/ Rh(-) moms Rh(-) moms produce antibodies against Rh(+) baby or in ABO incompatabilities Positive test: Abnormal coating of neonate's RBC w/ antibody globulin from mom Positive test result = increased risk for hemolytic disease of newborn

Kohlberg

Moral development Describes how moral reasoning aids in development of ethical behavior and proceeds through 6 stages

Newborn Thermoregulatory System Transition/Assessment

Necessary for maintaining homeostasis and dependent on internal/external factors Neutral thermal environment (NTE) = temp infant requires to minimize metabolic and oxygen needs, prevent metabolic acidosis, and arrest brown fat deposition Assessment: - Temp: 36.5-37.0C (axillary), 36.5-37.5C (rectal); rectal may be done initially to assess for anal patency - Term infants have stores of brown fat (brown adipose tissue/BAT) in neck, intrascapular region, axillae, groin, and around kidneys; used/burned for heat metabolism; weight/prematurity affect infant ability to regulate body temp b/c of decreased BAT and subcutaneous fat stores - Full term infants have increased BSA compared w/ total body mass - Neonates have higher metabolic rate; term infants can lose heat in first few min-hours after birth; exposure to cold sets off alterations in physiological and metabolic processes to generate heat Infant response to cold: - Peripheral vasoconstriction and chemical thermogenesis take place - Do not shiver - Sympathetic NS responds by decreasing temp and stimulation of skin receptors (many in face) to increase peripheral vasoconstriction) - Brown fat utilization (breaks down into glycerol and fatty acids to produce heat); rapid utilization can lead to metabolic acidosis, jaundice, infection, poor weight gain (thermogenesis increases oxygen demands and caloric consumption)

Hepatic System Transition/Assessment of Newborn

Neonatal liver responsible for: - Carb metabolism - Iron storage - Bilirubin conjugation - Blood coagulation Iron stores in fetal liver created in last weeks of pregnancy Term infants who are breastfed do not need iron supplementation until 4 months After 4 months breastfed infants should receive 1 mg/kg/day of liquid iron supplement until iron-containing solids are introduced around 6 months Infants who are bottle-fed require iron-fortified formula Coagulation: - Higher hematocrit - Slower bilirubin clearance - Shorter RBC life span - More immature liver conjugation processing - Vit K administered at birth - At risk for decreased vit K if breastfed, deprived of O2 at birth, mother treated w/ anticoagulants - Hemorrhagic Disease of Newborn = infants are at risk for clotting delays and potential hemorrhage - Conjugation: process of converting lipid-soluble (nonexcreted/indirect) bilirubin into water-soluble (excreted/direct) bilirubin

Stepping or Dancing Reflex

Neonate steps up and down in place when held upright Disappears 3-4 weeks Diminished response may indicate hypotonia

Vitamin K (Phytonadione)

Newborns born w/ sterile intestinal tract and don't have bacteria necessary to synthesize vitamin K Newborns have decreased levels of vit K - nutrient responsible for clotting and preventing hemorrhages Enhances liver's synthesis of clotting factors II, VII, IX, and X Side effects: - Pain at injection site Administration: - Single dose of 0.5 mg (preterm) - 1.0 mg (full term) IM w/in 1 hour of birth - Vastus lateralis muscle (lies lateral to midline of thigh) Special considerations: - Protect from light - Mandated by state laws

Neonatal abstinence syndrome

Occurs secondary to opioid exposure Results in CNS irritability, ANS dysfunction, GI and respiratory dysfunction Finnegan Neonatal Abstinence Scoring Tool is most widely used tool to assign numbers to neonatal symptoms of exposure (CNS disturbances, GI disturbances, metabolic, vasomotor, respiratory disturbances); scoring should occur every 3 hours before feedings Nonpharm interventions: - Swaddling - Comfort - Feeding Pharm interventions: (for score >8 for 48+ hours) - Morphine sulfate - Methadone AAP recommends opioid replacement therapy for infants who don't respond to nonpharm mgmt to alleviate S/S of neonatal abstinence syndrome and prevent seizures, weight loss, other long-term complications

Radiation heat loss of newborn

Occurs thru transfer of heat to cooler air surrounding neonate Can occur when infant is placed near window/cold walls of single-celled isolette Ensure if newborn placed in isolette that it is double-walled

Newborn Circulatory Transition/Assessment

Occurs w/ clamping of cord and first breath Fetal circulation maintained by 3 structures: - Ductus arteriosus (b/w pulmonary artery & aorta) - Foramen ovale (connection b/w left and right atria) - Ductus venosus (in hepatic system) Assessment: - Umbilical cord: 2 arteries, 1 vein (2 vessels only may indicate renal agenesis/lack of development) - Cord blood may be obtained from Rh(-) mom or O blood group, blood gases may be obtained if O2 levels decreased/APGAR depressed at 5 min - Newborn HR = 120-160bpm (can increase w crying/decrease w/ sleep), decreases as child ages - Peripheral pulses should be palpable and normal in intensity - BP increases w/ age - 4 extremity BPs indicated w/ heart murmur (turbulent blood flow heard by stethoscope as swooshing/whooshing), may be present at birth and completely normal - Brisk cap refill < 3 sec, abnormal > 4 sec - Congenital abnormalities r/t failure of fetal structures to close, structural abnormalities, blood outflow probs

Pathological Jaundice

Occurs w/in first 24 hours of life Results from excessive destruction of RBCs, infection, incompatabilities, metabolic disorders Consider if bilirubin levels > 15mg/dL in term infant w/in 48 hours of life Consider w/ bilirubin levels that increase more than 5mg/dL/day Preterm infants phototherapy usually begun when less than 1,000g w/ levels of 5-7 mg/dL Diagnosed w/ jaundice lasting longer than 1 week in term newborn or more than 2 weeks in premature infant

Moro Reflex (Startle Reflex)

Occurs when infant is startled w/ noise or rapid change in position Throws arms and legs out, cries, then recoils arms and legs Makes C w/ thumb and forefinger Disappears by 6 mos (startle by 4 mos) Slow response might occur w/ preterm infants or sleepy neonates Asymmetrical response may be r/t to temp or perm birth injury to clavicle, humerus, or brachial plexus

S/S of cold stress

Occurs when newborn body temp decreases --> increase in oxygen consumption, glucose utilization, energy; increases burning of BAT, depletion of glycogen stores, decrease in surfactant, respiratory distress, metabolic acidosis Can result in significant morbidity and mortality in newborn - Jitteriness - Tachypnea - Grunting - Hypoglycemia - Hypotonia (can exacerbate heat loss) - Pallor - Lethargy - Poor sucking reflex

Harlequin sign

One side of body is pink, other side is white R/t vasomotor instability

Metabolic System Transition/Assessment of Newborn

Plasma BG - 70-100mg/dL; heel-stick BG should be > 40mg/dL (Goal >50 for first 48 hrs, >60 after 48 hrs) Glucose = main source of energy for brain, newborn brain depends on glucose metabolism for 90% of needs Last 2 months of fetal life, glucose stored as glycogen in liver and used after birth for: - Coping w/ stress of birth - Breathing - Heat production - Muscular activity Glucose levels at birth are 80% maternal BG levels Clamping cord = decrease in level of circulating glucose --> increase epinephrine, norepinephrine, glucagon, decrease insulin Hypoglycemia = less than 40mg/dL - Most frequent prob experienced w/in 48 hrs of birth - Increased glucose utilization demands = hypothermia, hypoxia, sepsis - Decrease in glycogen stores = prematurity, SGA, IUGR, inborn errors of metabolism - Decrease in glucose post-maturation can be d/t deterioration of placenta - Decrease can also be d/t maternal intake of certain meds (ex: terbutaline) - Overproduction of insulin = LGA, infants of mom w/ diabetes, erytrhroblastosis fetalis, Beckwith-Wiedemann syndrom (after birth, mother's BG removed but insulin still high --> hypoglycemia) - Hyperglycemic state in mom w/ diabetes = beta cell hypertrophy, increased fetal oxygen consumption, inhibited surfactant and insulin production in neonate Alterations in BG can predispose infant to metabolic acidosis Monitor BG w/ evidence of: - Risk factors - Congenital metabolic conditions, birth defects, stress, jitteriness, neonatal depression Interventions: Feeding - 5mL/kg Glucose - Infants of mothers w/ diabetes = 3-5 mg/kg/min - IUGR infants = 6-8 mg/kg/min glucose if symptomatic - Term/near-term = 4-7 mg/kg/min glucose if symptomatic

Sucking Reflex

Present at birth Disappears 10-12 mos May not respond if recently fed Prematurity or neuro defects may cause weak or absent response

Erythromycin Eye Ointment

Prevents serious eye infections (ex: gonorrhea and chlamydia), should not be washed away Side effects: - Silver nitrate can cause eye irritation (goopy discharge of eyes, slight redness of eyes) Administration: - 1-cm thin ribbon administered from inner to outer canthus on lower eyelid Special considerations: - Don't delay administration beyond 1 hour following delivery - Mandated by state laws

Vernix caseosa

Protective substance secreted from sebaceous glands that covered fetus during pregnancy Looks like whitish, cheesy substance May be noted in axillary and genital areas of full-term neonates Presence and amount of vernix assist in estimating gestational age Full-term neonates usually have no vernix or only small amounts

Maple Syrup Disease

Rare autosomal recessive disorder Common in Amish and Mennonite descent Buildup of metabolic enzyme leads to severe ketoacidosis and encephalopathy Protein-free diet must be implemented for life

Erythema toxicum

Rash w/ red macules and papules (white to yellowish-white papule in center surrounded by reddened skin) that appears on different areas of body, usually trunk area Can appear w/in 24 hrs of birth and up to 2 weeks after birth Benign Disappears w/o treatment

Delayed Cord Clamping

Recommended by ACOG Delay clamping for 30-60 seconds after birth OR until pulsation stops (around 3 min); optimum delay time usually 90 sec - Increased levels of iron hemoglobin - Decreased risk for anemia - Decreased risk for intraventricular hemorrhage - Increased transfer of stem cells - No effect on bilirubin levels

Piaget

Theory of cognitive development Sensorimotor stage - infants use five senses to explore their world Includes 6 substages that describes infant's mental representation Infants learn about environments through their senses and begin to engage in goal-directed behaviors

Infant acne

Small red bumps or pimples on infant's face or body that usually appear at 1 month of age Usually benign but concerning to parents; parents should be taught to keep infant's face or skin clean; not apply creams/ointments to skin unless prescribed by pediatrician

Vygotsky

Social context of cognitive development Describes how complex mental functioning originates in infants through social interactions Cultural factors influence attainment Close correlation b/w language acquisition and development of thinking

Mahler

Social development Describes how infant develops sense of self through symbiosis and separation, or individualism

Neonatal V/S

Temp: 36.5-37.0C Pulse: 120-160 (Can increase to 180 when crying, 100 when sleeping) Respirations: 30-60 breaths/min - Irregular, diaphragmatic, and abdominal breathing are normal - Rate increase when crying, decrease when sleeping - Apneic significant if it lasts longer than 15-20 seconds - Hold oral feedings if RR > 60 BP (not routine, should be obtained on arm or leg): - Systolic 50-75 - Diastolic 30-45

Bayley Scales of Infant Development

Test cognitive, behavioral, and motor domains of infant Used to identify infants w/ developmental disabilities Highly reliable tool that uses mental, motor, and behavioral scales to rate infant's functioning Mental test - screens for such items as whether infant turns to sound or looks for fallen object Motor test - screens for gross and fine motor skill development

Gesell Developmental Schedules

Tests for fine and gross motor skills, language, eye-hand coordination, imitation, object recovery, personal-social behavior, and play response

Brazelton Neonatal Behavioral Assessment Scale

Tests infant's neuro development, behavior, and responsiveness Used only in neonatal period

Denver Developmental Screening Test

Used to identify problems or delays Measures personal/social, fine and gross motor, language, and social skills

Developmental Milestones for Birth-3 Months

Weight: - Gains 4-7 oz weekly during first month - Gains 1-2 lb/month Feeding: - Breastfed q2-3 hrs - Formula q3-4 hrs Height: - Grows 1 inch/month for first 6 months of life Head circumference: - Grows 1/2 inch/month for first 6 months Motor Skills: - Wobbly at first, soon can lift head when on abdomen - Grasps an object, kicks vigorously, turns head from side to side - Needs to have head and neck supported - Can get their hands and thumbs to their mouths - Musculoskeletal and ortho disorders occur during fetal development (most common is talipes equinovarus aka club foot, and developmental hip dysplasia) Reflexes: - Primitive reflexes remain Hearing: - Should respond to parent's voice - Respond to loud noises by blinking, startling, frowning, waking from light sleep Vision: - Most newborns focus best on objects about 8-10 inches away (distance to your face during feeding) - Acuity 20/100 - Begin to recognize mother visually - Can track objects visually w/ more accuracy Communication: - Sensitive to the way they are held, rocked, fed - By 2 months, should smile on purpose (social smile), blow bubbles, coo when spoken to - By 3 months, infant may laugh out loud and express moods

Rooting Reflex

When side of mouth is stroked/touched, infant will turn head and seek to suck Disappears 3-6 mos May not respond if recently fed Prematurity or neuro defects may cause weak or absent response

Milia

White papules on the face; more frequently seen on bridge of nose and chin Exposed sebaceous glands that resolve w/o treatment Parents might mistake for "whiteheads" Inform parents to leave them alone and let them resolve on their own

Epstein's pearls

White, pearl-like epithelial cysts on gum margins and palate Benign and usually disappear w/in a few weeks

Jaundice

Yellow coloring of the skin First appears on face and extends to trunk and eventually entire body Best assessed in natural lighting When suspected, apply gentle pressure to skin over firm surface (nose, forehead, sternum); skin blanches to yellowish hue PATHOLOGICAL: w/in first 24 hours; usually r/t immature liver PHYSIOLOGICAL: occurs after 24 hours, r/t increased amt of unconjugated bilirubin in system