Newborn Physiological Adaptations

Physiological and Behavioral Adaptations of the Newborn

• At birth the adaptation to extrauterine life is orderly and continuous.

Fetal Lung Development

• Surfactant helps prevent the alveoli of newborn lungs from sticking together during first breaths.
• Surfactant production begins at 24 weeks.
• Sufficient concentrations occur between 34-35 weeks to prevent complications.

Maintaining Warmth

• The newborn heat regulating system is unstable.
• Newborns burn brown fat to keep warm.
• Shivering develops from an immature neuro system, its not a real way to keep warm
• Sweat glands don't work effectively: newborns can get overheated if overdressed or in too warm environments.
• Cold stress should be prevented, as it increases O₂ need, decreases surfactant, and increases the metabolism.

Heat Loss

• Evaporation occurs when vapor carries away heat, such as from a dry baby.
• Conduction occurs from direct contact with cold objects, such as cold surfaces; skin-to-skin contact is advisable.
• Convection occurs when heat blows away in air (avoid drafts).
• Radiation occurs as cold radiates from nearby surfaces (don't put baby near cold surfaces).

Respiratory System

• Stimulate and support newborn breathing.
• The first breath opens collapsed lungs.
• Breathing takes on the function of oxygenation.
• Clear the mouth and then the nose to clear the airway and stimulate breathing (bulb suction is optional).
• Signs of respiratory distress include cyanosis, retractions, nasal flaring, and grunting; require priority intervention.

Circulatory System

• Circulatory changes occur at birth, including the closing of shunts and blood flow to lungs.
• The Ductus Venosus stops blood flow when the cord is clamped and closes by day three, then forms a ligament.
• Foramen Ovale functionally closes at birth when increased pressure in the left atrium and decreased pressure in the right.

Renal System

• Newborn kidneys don't concentrate urine well.
• Newborn urine is odorless and pale straw-colored.
• Newborns should void within the first 24 hours.
• Urine volume increases with PO intake.
• Newborns have 1 wet diaper per age in days, and up to 6-8/day at about 1 week.

GI System

• The GI tract is sterile at birth.
• Stools change over the first week.
• Meconium stool first appears within 24-48 hours.
• Stools transition to greenish-yellow.
• Baby stool depends on diet: 3-6 yellow, soft stools if breast fed and 1-4 brown & more solid stools if bottle fed.
• Rapid peristalsis causes the stomach to empty in 2-3 hours.
• The gastrocolic reflex means feeding stimulates stool.
• Regurgitation is caused by an immature cardiac sphincter, so newborns should be placed on their R side after feeding.
• Newborns lack pancreatic enzyme lipase, which digests fat in cow's milk, so cow's milk should not be given to infants; lipase is present in breast milk.

Hepatic System

• Newborns have poor clotting ability because no Vitamin K is produced in their sterile gut.
• Vitamin K injections are offered to newborns at birth.
• Newborns have extra blood cells no longer needed.
• Bilirubin is the waste product of RBC destruction.
• Too much bilirubin causes Jaundice.

Jaundice

• A build up of bilirubin causes jaundice, a yellow discoloration of the skin caused by rapid RBC destruction.
• Normal bilirubin level should be < 5.8 mg/dl.
• Higher bilirubin levels can cause neurologic damage and death, such as from Rh disease.
• Kernicterus is the deposit of bilirubin in the brain causing neurologic damage.
• Management includes prevention, phototherapy, and transfusion.

Immune System

• Newborns receive passive antibodies from their mom.
• The response to infection is slow due to an immature immune system.
• Overwhelming infection can develop rapidly.
• Nursery standards protect the baby.
• Strict handwashing is important.
• Screen personnel and visitors for infection.
• Immunizations should begin as scheduled.

Nervous System - Behavior

• Newborns communicate by crying.
• Newborns calm down when wrapped and held.
• Newborns can focus eyes and track.
• Newborns move but can't control all 4 extremities.
• Many neonatal (primitive) reflexes are present.
• Newborns are alert for 30-60 minutes after birth, then sleep for 2-4 hours.

Nursing Care of the Newborn

• Initial assessments take place in the delivery room but is brief.
• A more thorough assessment should happen within 2 hours.
• Assess Aparent gestational age as well as any injuries or anomalies
• Check the umbilical cord for 3 vessels.
• Note elimination
• Note VS, weight, length, head & chest
• The newborn should be kept warm during assessment.
• Vital signs (respiration, pulse) should be done first, before disturbing the baby.
• A full physical assessment should be done while keeping the baby warm and examining the baby in the presence of the parent(s).
• Compare weight and measurements to expected size for gestational age which can be LGA, AGA, or SGA.

Nervous System - Reflexes

• The newborn has many neonatal (primitive) reflexes.
• These reflexes disappear at predictable times.
• Absence or persistence can indicate abnormality.
• Moro (startle), rooting, and grasp are key newborn reflexes.

Vital Signs

• Respirations: Irregular, 30-60
• Pulse: Irregular, 120-160 bpm; 100 while asleep, 180 while crying
• Temperature: Unstable temperature regulation, 36.5 – 37.4°C, 97.7 – 99.3°F, axillary
• Blood pressure is not routinely monitored in well newborns.

Size

• Average term infant measures 19-21 inches (48-53cm) long and weighs ~6-9 lbs (2500-4000 gms).
• Average term infants loses 5-10% of birth weight in the first 3-4 days.
• Head circumference is 33 – 35.5 cm.
• Chest & abdomen are slightly less.

Integumentary System (Skin)

• Normal findings include pink skin; pigmentation faint, Acrocyanosis - blue limbs, pink centrally (Central cyanosis is abnormal), Lanugo - fine hair, Vernix - protective coating, in skin folds
• Nevi and “birthmarks" appear during the inital assessment
• Other normal integumentary findings may fade or grow, and include Milia (white pinpoint “pimples”), and a Mongolian spot which is a bluish discoloration and stable, make sure to document findings

The Head

• The head is large in proportion to body.
• Molding facilitates the pass through the birth canal.
• Soft tissue swelling is common.
• Cephalhematoma occurs when bleeding happens under the periosteum, doesn't cross the sutures, whereas Caput succedaneum id fluid filled swelling under the skin and crosses the sutures.
• Fontanels are un-ossified spaces in skull.
• Fontanels Close in 2 months (p) and 18 months (a).

Eyes

• Outside corner level with top of ear
• newborns Can see & follow objects and prefers human face and responds to visual stimulation
• Newborns appear cross-eyed but will develop permenant eye color by 6-12 months from an intital blue or grey
• If the Newborn has small conjunctival hemorrhage the will resolve with no specific care

Ears

• Term infant's ears need to be firm.
• A newborn's hearing is well developed at birth, although Preterm or amniotic fluid in ear may interfere
• Newborn responds to sudden sound by ↑ pulse & resp, startle (Moro)
• Must note ear placement and form as well a performing hearing screen shortly after birth.
• Only clean the external ear and avoid sensory overload

Face

• The newborn is a nose breather and should be treated as such
• A slight clear nasal discharge is normal but flaring nostrils are abnormal
• A newborns mouth should be symmetrical ,moist, pink and checked for palate intactness
• the newborns suck reflex should be present and note any Epstein's pearls ( little cysts)

Respiratory & Cardiovascular Assessment

• Use small/pediatric stethoscope head
• Easy movements, irregular rate, and lusty cry denote a healthy newborn
• Signs of distress include retractions, nasal flaring, grunting, and cyanosis, especially central
• Listen for murmur (shhshh)

Renal - Genitourinary System

• If the newborn is a Male with a Urethral opening at tip do Don't retract foreskin to clean (until it goes back easily - about age 3-5)

• In the newborn Male Testes descend sometime before birth Check for Circumcision ( surgical removal of foreskin after 12 hrs of age ) but should be skipped if anomaly is present

• If the newborn is a Female expect Labia swollen and White or blood tinged vaginal discharge, due to withdrawal of maternal hormones

• When cleaning female Newborns Clean only from front to back: Urethra to anus

Nervous System

• The newbown is Immmature and therfore Jerking and twitching is normal, however note tremors or high-pitched cry as that can be abnoraml
• https://www.youtube.com/watch?v=_JVINnp7NZ0 for table 15-2 with full reflex explanation

NIPS Assessment

• Observe newborn for 1 minutes for facial expression, type of Cry, Breathing Pattern, Arms, and Legs
• Score >3 indicates pain

Musculoskeletal System

• Bones are naturally soft and affected by the newborn's intrauterine position
• Newborn's Movement is random & uncoordinated, with the All extremities moving in such a way. Extremities Should not feel limp
• You must Check for intact spinal column & skin ( including any dimples or openings), count fingers and toes as well as for hip
• Freedom of movement must be provided

Newborn Care

• Be sure to initiate: Rooming-in and couplet care, a Vitamin K injection (1 mg, IM)
• Injections assist in blood clotting but note that newborns Gut bacteria will produce vitamin K itself in time
• Eye care should include erythromycin eye ointment to prevent ophthalmia neonatorum from exposure to gonorrhea or chlamydia
• You must attend to the newborn Umbilical cord by insuring clean and dry conditions kept below the cord. This will Promote drying & prevent infection

Bathing

• Until first bath, baby is often contaminated with amniotic fluid, vaginal secretions & blood
• Take Standard precautions (gloves, gown...) or use a tub bath after cord off if the newborn already passed the cordon.
• Don't use harsh soaps or lotions, use Special attention to creases and the diaper area. the bath is also an Excellent time to observe, play, and clean

Gestational Age Assessment

• https://www.youtube.com/watch?v=vH4WiqUhQSM&t=13s - Newborn maturity rating scale - follow along (no subtitles but actual baby)
• Newborn Screening Tests

Newborn Screening Tests

• Newborn tests often Detect congenital problems in newborns, that are not obvious at birth. However early detection is key to preventing morbidity
• Test newborn for PKU (phenylketonuria and do it Best done 24-72 hours after 1st feeding.
• You must also test for Galactosemia ( can't break it down), Hypothyroid, and Hemoglobinopathy such as Sickle Cell
• Daily Care

Daily Care

• Make sure to attend to all Vital signs: Continue to monitor q4 - q8
• With constant Assessment head to toe fromq8 - q12'
• Feeding schedules must be adhered to as new baby is to feed often. Ensure to:be sure baby is feeding well
• Elimintation: Establish GI & GU function
• All with an the constant Use opportunity to teach the parents

Discharge Teaching

• Ensuire basic care is taken such as:Bathing & cord care, Feeding - breast or bottle, Diapering, wrapping, which you caN See in text pages 263-266
• You must touch on Satefly measure: Crib, car, pets with immuniation as it's Important to prevent many illnesses

Descharge Referals

• Provide and speak about Referrals to SW, WIC, low cost car seats, La Leche League
• Return appointments usually happen within 1 week and can adjust prn
• Provide Contacts and Danger signs with "What to do" advice
• always Reinforce with written materials

Newborn Nutrition

• Newborn nutrition is a Fundamental concept in newborn care due to the fact that newborns have the Highest caloric needs per kg than any other time in life
• Nutrition Supports the growth and brain development in newborns and is why CDC & WHO encourage breastfeeding, exclusively for 6 months

Breast Feeding: Adoption Considerations

• Breast feeding possenes advantages such as having Exact nutrients, Easily digested factors, as well as is Allergy,immunuity and constpation preventative. Breast feeding is also convenienant, economical and promotes mother's recovery while enhancing bonding for the growing newborn.
• breast feeding also possesses Advantages: Maternal medications can sometimes pass into breast milk, It is difficult to do for working mothers, could passm aternal diseases and it's, Not for drug & alcohol abuser, and it Requires commitment

“Baby Friendly Hospital”

• The main key for "Baby Friendly Hospital is to Promote breastfeeding trough Policies and education
• The best practices include initiating: Initate breastfeeding in the delivery room, keep Newborn fed only breastmilk and provide 24 hour rooming-in with No formula samples at discharge. Education and support from nurses and a lactation specialist can help facilitate this goal

Physiology of Lactation: Hormones

• Prolactin hormone causes the manufacture of milk.
• Oxytocin causes milk to be delivered thru ducts to nipple (“let-down").
• Feeding stimulates prolactin & oxytocin

Phases of Milk Production

• Colostrum: first 2-3 days, yellowish, rich in antibodies, and has a Laxative effect
• Transition: 3-10 days from colostrum to a mature milk
• Mature milk: contains 20 cal/oz, bluish, and thin

Assisting Breastfeeding

• Initiate a relaxed & supportive environment for the new mom
• Breast feeding positions: sitting or lying down, football or cradle hold. make sure Baby's entire body & head is facing mother while being comfortable & supported
• Position mother's hand in a “C” shape where you Place Thumb above nipple & fingers below, Avoid "scissors hold" and ensure No need to create a breathing space

Assisting Breastfeeding: Latching

• To assist with: Latch on follow these directions
• Brush baby's lip with nipple: When baby opens mouth wide bring the baby close so nipple and areola are in baby's mouth
• Swallowing - hear "ka” or “ah” sound
• When its To remove infant from breast: Break suction before pulling baby away or you can cause and lead to Proper technique will prevent trauma

Special Circumstances

• In Multiple birth with newborns it is best to Feed one or both but you May need helper to latch 2nd baby. This approach helps ensure that the Body will supply milk to meet demand
• In Premature infants; when a baby is unable to nurse directly, express milk and feed by gavage which will ensure baby gets the Human milk that will has immunological advantages

Nursing: Nutrition

• When Nursing a newborn mother Needs 500 calories more than non- pregnant diet and May continue PNV as long as she is nursing
• Always Avoid foods that bother the baby
• For non-nursing mother you must Continue PNV until 6 week check-up
• Formula Feeding

Formula Feeding

• In casea where a mother is unable to breast feed you must Follow a pediatrician's recommendationa abd Prepare formula exactly as stated on label
• Use tap water if dilution is required, never use Cow's milk as its NOT nutritionally adequate. The Cradle baby during feeding ( never prop a bottle) and always make sure to Dispose of leftover formula