CONCEPT, ASSESSMENT, GOALS, OBJECTIVES OF

HIGH RISK NEWBORN

INTRODUCTION

A n ew b o rn s ho u ld ha v e a th o ro ug h ev a lua tio n pe rfo rm e d w ith in 2 4 h o u rs o f

b irth to id en tify a ny ab n o rm ality t ha t w o uld a lter th e n o rm al n ew b o rn c o u rs e o r

id en tify a m ed ic al c o nd itio n th at s h o uld b e a d d res s e d ( e.g ., a n o m a lies , b irt h in ju ries ,

ja u nd ic e , o r c ard io pu lm o n ary d is o rd ers ) . T h is a s s es s m en t in c lu d es rev ie w o f th e

m ate rna l, f a m ily, an d p r en ata l h is to ry a nd a c o m p lete e xa m ina tio n. D ep en d ing upon

th e le ng th o f s tay , a no th er ex am in atio n s ho u ld b e p erf o rm ed w ith in 2 4 ho u rs b ef o re

d is c h arg e f ro m the h o s pita l.

T h e h ig h-r is k p erio d b eg in s at th e tim e o f v ia b ilit y (t he g es ta tio na l ag e at w hic h

s urv iv a l o u ts id e th e u te rus is b eliev ed t o b e p o s s ib le , o r a s e ar ly as 2 3 w e ek s o f

g es ta tio n) u p to 28 d ays a fte r birt h a nd inc lu d es th rea ts to L if e a nd hea lth tha t o c c u r

d ur in g T h e p re na ta l, p erin a tal, and p os t na ta l p erio d s .

1
 CONCEPT OF HIGH RISK NEWBORN

MEANING OF NEONATE

 F ro m b irth t o un d er fo u r w eek s o f a ge ( < 2 8 d ay s ), th e inf an t is c alled

n eo na te o r ne w bo r n. Firs t w eek o f lif e ( < 7 d ay s o r < 1 6 8 h o ur s is k n ow n a s ea rly

n eo na ta l p erio d . L ate ne on a ta l p er io d ex te nd s fro m 7 th to < 2 8 th d ay.

 DEFINITION OF HIGH RISK NEWBORN

o A n ew b o rn re g ard les s o f g e s tat io n a l ag e o r b irth w e ig ht, w h o h as a g rea ter
– tha n a v era g e c h a nc e o f m o rb id ity o r m o rta lity b ec au s e o f c o nd itio n s o r

c irc u m s ta nc es s u pe rim po s e d on the n o rm a l c o u rs e of ev en ts

a s s o c iat ed w ith b irth an d th e a d ju s tm en t to ex tra u terin e exis ten c e.

o E n c o m p as s e s h um a n g ro w th an d d e ve lo p m en t f ro m th e tim e o f v iab ility

±2 8 da ys f o llo w in g b ir th a n d in c lu d es th rea t to lif e an d h ea lt h th a t o c c u r
d u ring the p re na ta l, p er in a tal, an d p o s tna ta l pe rio d s .

2
CLASIFICATION Of HIGH RISK NEWBORN

H igh -ris k in fa nt s a re m o s t o fte n c las s ifie d ac c o rd in g to b irth w e ig ht, g es ta tio na l

ag e , and p red o m in an t p a th o p hy s io lo g ic p ro b lem s . T he m o re co m m o n p ro b lem s

rela ted to ph ys io lo g ic s tatu s a re c lo s ely a s s o c iat ed w ith th e inf an t’ s s t ate of

m atu rity a nd us u a lly in vo lv e c he m ic a l d is tu rb an c e s ( e.g ., hy p o g ly c em ia , h yp o c a lc em ia )

an d c o ns eq u en c e s of im m a tu re o rg an s a nd s ys te m s (e .g ., h yp er biliru b ine m ia ,

res p ira to ry d is tres s , hy po th erm ia ).

CLASSIFICATION ACCORDING TO SIZE

— A n in fa n t w h o s e b irth w eig h t is les s tha n 2 5 0 0 g

(5 .5 lb ), reg a rd les s o f g es ta tio na l a ge

— A n in fa n t w ho s e b irth w eig ht is les s

than

1 5 0 0 g ( 3.3 lb )

— A n inf a nt w h o s e b irth w eig ht is

les s t ha n 1 0 0 0 g (2 .2 lb)

— A n inf an t w ho s e w e igh t f alls

b etw e en

th e 1 0t h a nd 9 0 th p er c en tiles o n intr au terin e g ro w th c urv es .

— A n inf an t w ho s e
ra te o f intra u terin e g ro w th w a s s lo w e d an d w h o s e b irth w e ig ht f alls b elo w

th e 1 0th p erc en tile o n in tra u terin e g ro w th c u rve s.

— F o u nd in in fa n ts w h o s e in tra ut erine g ro w th
is r eta rd ed (s o m etim es u s ed as a m o re d es c r ip t iv e te rm f o r the S G A in fa nt)

— A n inf an t w h o s e b irth w eig h t f alls ab o v e

the 9 0 th p erc e ntile o n in tra u terin e g ro w th c ha rts

3
CLASSIFICATION ACCORDING TO GESTATIONAL AGE

— A n in fa n t b o rn b efo r e c o m p letio n o f 3 7 w ee k s o f
g es ta tio n , re g ard les s o f b irt h w eig ht

— A n in fa nt b o rn b et w e en th e b eg in nin g o f 3 8 w e ek s a nd
the c o m p letio n o f 4 2 w ee k s o f ge s ta tion , reg a rd les s o f b irth w eig ht

— A n in fa n t b o rn a ft er 4 2 w eek s o f g es ta tio n al
a ge, reg a rd les s o f b irth w eig h t

4
 — A n inf an t b o rn b e tw een 3 4 an d 3 6 w eek s o f g e s tat io n ,
reg a rd les s o f b irth w eig h t

CLASSIFICATION ACCORDING TO MORTALITY

— B irth in w h ic h th e n eo n a te m a nif es ts a ny he art b ea t, b rea th es , o r

d is pla ys vo lu nta ry m o ve m en t, re g ard les s o f g es ta tio n al ag e

— D ea th o f th e f etu s a ft er 2 0 w e ek s of g es ta tio n a nd b ef o re d elive ry,

w ith a b s en c e o f a n y s ig ns o f life a f ter b irth

— D ea th th a t o c c u rs in th e f irs t 2 7 da ys o f lif e; ea rly n eo n a tal

d ea th o c c urs in th e f irs t w e ek o f lif e; late ne o na ta l d e ath o c c u rs at 7 to 2 7 d ays

— D es c rib es t he to t al nu m b er o f feta l an d ear ly n eo n a tal

d e ath s per 1 0 0 0 live birth s

— D e at h tha t o c c urs a t 2 8 d ay s to 1 ye ar a f ter b irth

CLASSIFICATION ACCORDING TO BIRTH WEIGHT

- B irth w e ig h t les s th an 2 5 0 0 g re ga rd les s o f g es ta tio n al

ag e

- b irth w eig ht is b etw ee n 1 5 0 1 g to 2 5 00 g .

-b irth w eig ht is les s t ha n 1 5 0 0 g.

- b irth w e ig ht les s th an 1 00 0 g .

CLASSIFICATION ACCORDING TO SIZE

) - b irth w e ig h t fa lls b e tw een th e 1 0 a n d

9 0 p erc en tile

- b irth w eig h t fa lls b elo w the 1 0 pe rc entile

- b irth w eig h t fa lls a b o ve the 9 0 p erc entile

5
MEDICALLY HIGH RISK NEWBORN (MHRN) ELIGIBILITY CRITERIA

(les s th an 3 2 w e ek s ge sta tion )

( les s tha n 1 5 0 0 gra m s)

( s m all fo r g e s tatio n al a g e) f ailu re to thr iv e, IU G R (intra uterin e

g ro w th re tard a tio n ) le s s t ha n 5 th p erc en tile.

h yp o x em ia, a c id e m ia , rep e titive a p ne a, req u ired a s s is ted v en tilatio n x

40 h o urs .

, i.e h yp o g lyc em ia, hyp o c a lc em ia

(c o n s id ered w hen p ers iste nt an d un trea ted

hy p erb ilirub in em ia re q uire s ex c h a ng e tran s f us io n s an d /o r is a s s o c ia ted w ith

c o ng en ita l a no m alies ).

o r s e iz u res b eyo n d the neo n a tal p erio d.

i.e. C N S b lee d s , RD S (re s p ir ato ry dis tres s

s yn d ro m e ) c o n firm ed inf ec tio n , c h ro nic lu ng d ise as e.

r eq u irin g s p ec ia l s er vic e s , b ut w ith

p res u m e d p o te ntia l f o r n o rm a l d ev elo p m en ta l o utc om e.

6
 a nd / o r s ub s ta n c e a b u s e i.e .

a lc o h o l h yd a nt oin , w a rf arin a n d c oc aine .

e vid en c e o f d e la y in o ne o r m o r e d ev elo p m e nt al a re as a n d p o o r

p a rent- inf a nt a ttac h m ent.

IDENTIFICATION OF HIGH RISK NEWBORNS

M a tern a l d iab etes

M a tern a l n arc o tic s d u rin g lab o r M a ter na l s u b s tan c e a bu se

F eta l as p hy xia

D if fic u lt/p ro lo n g ed la b o r c a us in g b irth trau m a M u ltip le g es tatio n

P re term o r p os t term d eliv ery

C on g en ita l a no m alies M a tern a l o r n eo n ata l inf ec tio n S G A o r LG A

A pg a r s c o re < 6 a t 1 m in o r < 7 at 5 m in

7
 PRETERM INFANTS

MEANING - A n in fa n t b o rn b efo r e term (< = 3 6 w ee k s ); A lo w b irth w eig h t in f an t:

< /= 1 3 00 - 2 0 0 0 g ( P hilip p ine S ta nd a rd s ) (,2 .5 k g)

A n ew b o rn b o rn b ef o re c o m p lete m a turity ; b o rn b efo re b od y an d o r ga n s y s tem

h ave c o m p lete ly m a ture d is c a lle d pre m a turity.

INCIDENCE:

H ig h es t a m on g lo w s o c io ec o n o m ic c la ss La rg es t

- o f a d m is s io n to N IC U

1 2 % o f all p reg na nc ies

CAUSES

§ M aln utritio n
§ P re ec la m ps ia (to x em ia o f p reg na nc y)
§ C hro n ic M e d ic a l illne s s ( C a rd ia c / k id ne y
d is eas e/ D M )

§ In f ec tio n ( U T I , v ag in a l inf ec tion )

§ D rug U s e ( c o c c ain e, to b ac c o , alc o ho l)

8
 § A bn o rm a l s tru c tu re o f th e u terus
§ P re vio u s P re term B irth s

§ H y pe rtens io n
§ In c o m p et ent C ervix
§ P la c en ta l P re via / A b ru p tio P la c en ta
§ P P R O M , po ly/o ligo h yd ram nio s

§ C hro m o s o m al ab n o rm a lities
§ In tra u terin e Inf ec tio n
§ A na to m ic A b no rm alities
§ IU G R
§ M u ltip le g es ta tio n s

DIAGNOSTIC EVALUATION

A p pr ais a l is m a d e a s s o o n as p o s s ible a ft er ad m is s io n to th e nu rs ery.

H e ad c irc u m f ere nc e is la rg e in c o m p a ris o n w ith c h es t (r eflec ts c ep h a lo c au d a l

d ire c tio n o f gro w th)

T he fo n ta ne ls a re s m all a nd b o n es a re s o ft - S o ft c ra niu m s u bjec t to

c ha ra c ter is tic no n- inte ntio n al d ef orm a tio n .

B o n es o f s k ull a nd rib s - s o ft V er y s m a ll an d ap p ea r s c ra w n y,

A bs e nt eye bro w s E yes c lo s ed

E a rs are p o or ly s up p o rte d b y c ar tila g e ( s o ft a nd p lia ble)

9
B rig h t p in k (o f ten t ran s luc en t) w ith s m a ll b lo o d v es s els

S m o o th a nd s hin y ( m a y b e ed em a to u s ) w ith s m a ll b lo o d c lea rly v is ib le

v es s els u n d ern ea th th in ep id erm is

F ine la n ug o h air a b un d an t o v er b o d y, s p a rs e, fin e & fu zz y o n head

L es s s ub c uta n eo u s f at ( s k in is w rink led )

M in im a l c re as es

S k in c o lo r c h an g es w he n p ret erm inf an t is m o ved ;

U pp e r ha lf o r o ne s id e o f th e b o d y is p a le o r o ne s id e o f th e b o d y is red .

S m a ll b re as t b u d s iz e w ith un d erd e ve lo pe d n ipp les

M a le Inf a nts - fe w s c ro t al ru g ae , u nd e s c en d ed tes tes Fe m a le inf an ts - La b ia a nd

c lito ris a re p ro m in en t in fem a les

C om p lete rela xa tio n w ith m ark e d flex io n a nd a b d uc tio n c o m p le te re lax a tio n w ith

m ark ed fle xio n a n d a b d uc tio n o f th e th igh s ;

R a nd o m m o v em en ts are c o m m o n w ith s lig h tes t stim ulus

In a c tiv e an d lis tles s

10
E xt rem ities m a in ta in an a ttitu d e o f e xte ns io n a nd rem a in in a n y p o s itio n in

w hic h they are p la c ed .

p ar tia lly d eve lo p ed

S u c k in g a b s en t, w e ak o r in ef fe c tu al; s w a llo w , g ag , c o u g h re flex es - A B S E N T

H ea t re g ula tio n p o o rly d ev elo p ed in t he p re term inf a nt b e c a us e o f p o o r

d ev elo p m en t of C N S

In c rea s ed s us c ep tib ility to inf ec tio n

Re s p iratio n s a re n o t eff ic ien t b ec a us e of m u s c u lar w ea k ne s s o f lu ng s a nd rib

c a g e and lim ited s u rfa c ta nt p ro d uc tio n;

Re tra c tio n a t xip h o id is ev id e nc e o f air h un g er I nf an ts s ho u ld b e s t im u late d if a p n ea

o c c u rs

H M D /R D S , c h ro n ic lun g d is e as e , B P D , a p ne a o f p rem atu rity

G rea ter ten d en c y to w a rd c ap illa ry fra g ility in the p r eterm in fa nt

Re d an d w hite b lo o d c ell c o un ts a re lo w w ith res u lting a ne m ia d urin g firs t f ew

m o nth s of lif e.

N eu ro - H ig he r in c id en c e o f in tra c ra n ia l he m o rr ha g e in th e p re term in fa nt

M us c le tw itc hin g , c o n v uls io n s , c ya no s is , a b n o rm al res p ira tio ns , an d a s ho rt s h rill

c ry C e reb ra l p a ls y, vis u al -m o to r d e fic its , alte red inte lle c tu al fu nc tio ns

11
 N u tritio n is d if fic u lt to m ain ta in b ec a u s e o f w ea k s u c k in g a nd s w a llo w in g r eflex es ,

s m all c ap a c ity o f s t o m a c h , a n d s lo w em p tyin g tim e o f the sto m ac h

R ed u c ed g lo m eru lar f iltrat io n ra te res u lts in d e c rea s ed ab ility to c o n c e ntr ate

u rin e and c o n s erv e fluid .

H ig h er E C F , vu lne rab le to f lu id a n d e le c tro lyt e im b ala nc e

PREVENTION

G o o d n utritio n an d e du c a tio n Id e nt if ic a tio n o f m o th ers at risk E d uc ate o n

s y m p to m s o f P T la bo r

A vo id he av y/ rep et itiv e w o rk o r s tan d ing lo ng p e rio d s o f tim e

TREATMENT

O x yg en

U m b ilic a l c a thete riz atio n

In tra v en o us F lu id M ed ic atio ns

B lo o d In trav en o u s F luid ex trac tio n X -ray

S p ec ia l f eed in g s o f b r ea s t m ilk /fo rm ula K a ng a ro o c are

NURSING CARE

M a inta in airw ay

C hec k res p ira to r f u nc tio n if em p lo yed P o s it io n to p ro m o te ven tila tio n

12
 S uc tion w he n n ec es s ary

M a inta in tem p era tu re o f en viro nm en t A d m in is ter o x yg en o nly if n ec e ss a ry

O b s er ve f o r c h an g es in res p ira tio n s , c o lo r, an d v ita l s ig n s

C he c k eff ic a c y o f Is o lette

M a inta in h ea t, h um id ity, an d o xy g en c on c e nt ratio n ; m o n ito r o xy g en c a ref ully to

p rev en t re tro len tal fib ro p la s ia s

M a inta in as e p tic tec h n iq ue to p rev en t infe c tio n

M o n ito r f o r hy po g ly c em ia ,h yp er b iliru b ine m ia & h em o rrha ge C a re fu l s k in c ar e &

p o s itio n in g to p re ve nt bre ak d o w n

A d her e to the t ec h niq u es o f g a va g es fe ed in g f o r s af ety o f the in fan t O b s erv e

w eig h t -g a in p attern s

D eterm in e b loo d g a s es freq u en tly to p rev en t ac id o s is

P ro v id e fle xib le a nd lib e ral v is it in g ho u rs f o r p ar ent s a s s oo n as p o s s ib le

A llo w p are nts to d o as m uc h a s p o s s ib le fo r th e in fa n t a ft er a p p ro p riate te ac h ing

A rran g e f o llo w -u p b e fo re a n d a ft er d is c ha rg e .

POSTMATURE INFANTS

MEANING

B ab y b o rn a fter 4 2 w ee k s A O G / 2 9 4 da ys p as t 1 st d a y o f m o th er ’ s LM P ;

reg a rd les s o f b irt h w eig h t is ref erre d t o a s p o s tm a tu re infa nts .

OTHER NAMES - P o s t term , p o s t m a tur it y, p r o lo n g ed p reg n a nc y , p o s t da tism

13
INCIDENCE

7 % (3 .5 -1 5 % ) o f a ll p reg n an c ie s

CAUSES

o f > /= 1 p re vio u s p o s t ter m p reg na nc ie s d u e d ate (n o t s u re o f

LM P)

§ P ro g re s s iv e p la c en ta l d y s fu nc tio n ±p la c e nta ( s up p lies nu trien t & o xy g en) ag e s

to w a rd th e e nd o f p reg n a nc y ---m a y no t f un c tio n eff ic ien tly

§ A m n io tic flu id v o lu m e d ec rea s es , f etu s m a y s to p g a in in g w eig h t/ w eig h t lo s s

§ D e c re as e d am n io tic flu id m a y lea d to c o r d c o m p res s io n d u ring lab o r
§ In c re as e d r is k o f M A S a n d h yp o g ly c em ia
§ In c re as in g s iz e ( m a in ly len g th ) & h a rd en in g o f s k ull m a y c o n trib u te to C PD
§ G R E A T E S T R IS K : d u ring s tres s e s o f lab o r & d eliv ery es p ec ia lly in in fa n ts
o f p rim ig ra vid as .

CHARACTERISTICS OF POST MATURE INFANTS

■ A b s e nt lan ug o ,

14
 ■ L it tle if an y v ern ix c a s eo sa ,
■ A bu n d an t s c a lp h air,
■ O v erg ro w n n ails
■ D ry, p eeling s k in ( c ra c k e d, p a rc h m e nt lik e & d es q ua m ating )
■ W a s ted p h ys ic a l a p p ea ran c e (ref lec t s in tra ute rine d e priv atio n)
■ M in im a l f at d ep o s it (d e p le ted s ub c uta n eo u s f at) th in , elo ng a ted
a p pe ara nc e

■ M ec o niu m s ta inin g - s een in s k in fo ld s w / ve rnix c a se o sa

■ V is ib le c rea s es p alm s / s o le s

DIAGNOSIS:

P h ys ic a l Ex am ina tio n U ltras o u n d S c an ning N o n -s t res s tes tin g

E s tim a te am n io tic f luid vo lum e

MANAGEMENT

C hec k res p ira to ry p ro b lem s r elate d to m ec o niu m S u c tion ing

B lo o d tes t f or h yp o g ly c em ia

PREVENTION

A c c u ra te d ue d a te a nd U ltr as o u nd S c a nn ing C es a re an s ec tio n /

in d uc tio n o f la bo r - rec o m m en d ed .

HIGH RISK RELATED TO PHYSIOLOGIC FACTORS

HYPERBILIRUBINEMIA

MEANING- H yp e rb iliru b in em ia ref ers to ex c e s s ive lev el o f a c c u m ula ted B iliru b in in th e

b lo o d

15
JAUNDICE or ICTERUS - yello w is h d is c o lo ra tio n o f s k in, s c lera , na ils . R ela tive ly be nig n

b ut it c an a ls o b e p a tho log ic

PATHOPHYSIOLOGY

R B C D es truc tio n

16
 G lo bin H em
e

P ro te in (u s ed b y th e U nc on jug a ted
b o d y) B iliru b in

L iv er

B iliru bin d eta c h ed fro m a lb u m in t hro u g h en z ym e g luc o ro ny l tra n s fera s e o r

g lu c o ro n ic ac id

C o njug a ted
B iliru b in

E x c re ted into B ile (f ec e s a n d

u rine)

R es u lt f ro m in c re as e d u n c o nju g ate d / c o n ju g at ed biliru b in

- o ne o f th e b r ea k do w n p ro d u c ts o f o ne o f th e b re ak d o w n p ro d u c ts o f h g b f ro m

R BC de stru c tio n

- in s o lu ble , b o u nd to in s olu b le, b o un d to a lb u m in

- re d uc es c o nju g ate d b iliru b in

- p ig m e nt tha t g ive s s to o l its c h ara c t eris tic o d or.

COMPARISON OF MAJOR TYPES OF UNCONJUGATED HYPERBILIRUBINEMIA

PHYSIOLOGIC BREAST-FEEDING BREAST MILK HEMOLYTIC

JAUNDICE ASSOCIATED JAUNDICE (LATE DISEASE

JAUNDICE ONSET)

17
 (EARLY ONSET)

Im m a ture h ep atic D ec re as e d m ilk P o s sib le f ac to rs is B lo o d an tige n

i k
fu n c tio n o r re la ted to few er b rea s t m ilk th at inc om p a tib ility
i d
b ilirub in lo ad fro m c alo ries c o ns u m ed p rev ent b iliru b in he m o ly s is o f la rg e

RB C h em o ly sis in fa n t b e fo re c o n ju ga tion les s o f RB C s . Live r un ab le

h ’
m ilk is w ell f req u en t s too ling to c o njug a te and

e sta b lis he d exc rete e xc es s

e ntero h ep atic b ilirub in fo rm

s h un tin g hem o lys is .

A fter 24 h o urs 2 nd - 4 th d ay 5 th – 7 th da y D u ring 1 st 24

(p reterm in fa nts , hrs ( le ve ls in c re as e

p ro lo n ge d) fa ste r th a n 5 m g /d ay)

7 5 - 9 0 ho urs 3 rd – 5 th d ay 1 0 th – 1 5 th da y V ariab le

D ec lin es o n 5 th – V a ria b le M a y re m a in D ep e nd en t o n

7 th d ay jau nd ic ed x 3 -1 2 s eve rity a nd

In c rea s e f req u en c y F req u en t (1 0 In c re as e fre qu en c y M o n ito r

–
of fe ed in g s a nd o f b re as t fe ed ing ; T c B /T S B leve l.
1 2 x /d ay) bre as t
a vo id u se n o P erfo rm ris k
f eed in g , a v o id
s u pp le m e nts . s u pp lem enta tion s as s es s m ent
g luc os e w ate r, w ater
E va lu ate s to o lin g (g luc os e w ater) : P OS T N A T A L-
s u p plem en ts or
p attern . c e ss a tio n of p ho to thera p y;
f o rm ula . Ev a lu ate
M o n itor b rea s tf eed ing no t ad m in is t er IV IG p er
s to o lin g p attern ;
tran s c uta ne ou s rec o m m end ed . p roto c o l; if s ev ere,
s tim u late a s need ed

18
(T S B ) a s se ss m en t. tran s fus io n.

P erfo rm risk U s e p ho to th era p y C o n sid er p erf o rm ing P RE N A T A L

if
as s es s m ent. Use b iliru b in lev el a dd itio na l tran s fus io n (f etus )

p ho to the rap y if in c re as e s ev alu atio ns : G 6 PD , p reven t

b ilirub in level ( 17 -2 2 m g /d l) or d irec t an d in d irec t (Rh inc o m pa tib ility)

inc rea s es s ig n ific a nt s erum b iliru b in , of Rh - ne ga tive

(> 5 m g /d l/ d ay) or is p res ent. fa m ily h is to ry an d m o th er w ith Rh ig

s ig nif ic an t o th ers a s n ec e ss a ry. (R ho g am )

h l i
is p res en t

BREAST – FEEDING . BREAST MILK HEMOLYTIC DISEASE

ASSOCIATED JAUNDICE JAUNDICE (LATE

(EARLY ONSET) ONSET)

If p ho t ot he rap y is M ay inc lu d e ho m e P RE N A T A L – if m o the r Is

ins tituted , ev alu a te b e nef its p ho to th er ap y w ith a b rea s tfe ed ing , a s s is t

a nd h a rm of tem p o ra rily tem p o ra ry (1 0 -1 2 hr) w ith m a int ena n c e and

d is c o n tin uin g b reas tf eed in g ; d is c o nt in u atio n of a s to rag e o f m ilk ; m ay

a d d itio na l b rea s tfe ed ing , a b o ttle-feed e xp re s s ed m ilk

a s s es s m en ts m ay b e s ub s eq uen t T SB m ay b e as a pp ro p ria te to

req uired . A s s is t m o ther d raw n to eva lua te a d ro p in the rap y . M in im ize

w ith m a inta inin g s eru m lev els . m a ter na l- in fa nt

m ilk s u p p ly, fe ed e xp re s s ed A s s is t m o ther w ith se pa ratio n a n d en c o u rag e

m ilk as a p p rop riate . A fte r m a in ten an c e of m ilk c o n tac t as ap p ro pria te.

d is c h arg e , f o llo w up s up p ly and rea s s u ran c e

a c c o rd in g to ho u r reg a rd ing her m ilk s u p p ly

f di h

CAUSES

P h ys io lo g ic ( d ev elo p m ent al) f ac t o rs

( pre m a turity):
19
 E x c es s p ro d uc tio n o f b iliru b in - H e m oly tic d is e as e , b io c h em ic a l d e fec ts , b ru is es

H em o lytic d is ea s e - blo o d an tig en inc o m p a tib ility b lo o d an tig en

inc o m p atib ility, h em o lys is o f R BC ; liv er u na b le to c o n ju g ate & ex c r ete ex c es s b ilirub in

fro m h em o lys is

PHASES OF PHYSIOLOGIC JAUNDICE

2 P H A S E S : T E RM IN FA N T S

- B ilir ub in : 6 m g /d l o n 3 rd da y

D a te O f La b o u r : d ec rea s ed to 2 --3 m g /d l by 5 th d ay

- S tea d y p late au w ith o u t inc r ea s e/d e c rea s e le vel

1 2 th -1 4 th d ay : lev els d ec rea s ed to no rm a l ( 1 m g /d l) P atte rn v a rie s

a c c o rd in g to ra c ia l g ro u p , m eth o d o f fe ed ing , g es ta tio na l ag e P R E T E RM : B iliru b in -

1 0 -1 2 m g /d l at 4 -5 d a ys s lo w ly d e c rea s e b y 2 -4 w eek s . CLINICAL MANIFESTATIONS

J au nd ic e m o s t o b v io us s ig n

Y ellow is h d is c o lo ra tio n : s c lera , n a ils , s kin

If it a p p ea rs w ithin 1 st 2 4 h ou rs : h em o lytic d is ea s e of N e w b o rn, s ep s is ,

m atern ally- d eriv ed dis e as e s ( D M , inf ec tio ns )

A p p ea rs o n 2 nd o r 3 rd d a y, p e ak s o n 3 rd ±4 th d ay , d ec lin es o n 5 th ±7 th d a y:
p hys io log ic ja u nd ic e ( va ries a c c o rd in g to eth nic ity)

In ten s ity o f jau nd ic e is n o t alw a ys rela ted t o th e d e g ree o f h yp erb ilirub in em ia

BREASTFEEDING JAUNDICE (Early onset)

E arly o n s et B e g in s at 2 - -4 d ay s o f a g e; 1 2 -1 3 % o f Br ea s tfee d ing infa nts

Re late d to p ro c es s o f b rea s tfee d ing , re s ults f ro m d e c rea s ed c a lo ric & flu id

inta k e by B r eas t fee d in g in fa n ts b ef o re m ilk s u p p ly is w ell-es ta b lis he d ( fa s ting is

as s o c iate d w ith d ec rea s e es ta b lis h ed ( fa s tin g is as s o c ia ted w ith d ec r ea s e hep a tic

c lea ra nc e o f b ilirub in)

20
 F eed in g ( o r) p eris ta ls is m o re r ap id p a s s a g e o f m ec o n ium m o re ra p id

p a s s ag e o f m e c o n iu m d ec re as e d a m o u n t o f rea b s o rp tio n o f u n c o n ju g ate d b ilirub in

F eed in g in tro d u c es b ac teria to a id in red u c tio n o f biliru b in t o u ro bilino g en

C o lo s tru m s , n atu ra l c ath a rtic , fa c ilit ate s m ec o niu m e va c ua tion

BREAST MILK JAUNDICE (late onset)

La te o n s et : 4 th -7 th d ay of a g e; 1 2 -1 3 % o f B rea s tfe ed ing in fan ts

R is in g lev els p ea k at 2 nd w e ek g ra d u ally d im in is h . M ay rem a in jau n d ic ed x 3- 1 2

w eek s o r m o re 1 2 w ee k s o r m o re in fa nt s a re w ell

M ay b e c a us e d b y f a c to rs in B rea s t M ilk ( p reg n an ed io l, fa tty a c id s , B - g lu c o r in id as e )

tha t eith er inh ib it c o njug a tio n o r d ec rea s e ex c ret io n o f b ilirub in

Le s s fre q ue nt s to o lin g b y B rea s tf eed in g inf an ts m a y a llow fo r e xt en d ed tim e

fo r rea b s o rp tio n o f b iliru b in fro m s to o ls

E x c es s p ro d uc tio n o f b iliru b in - H e m oly tic d is ea s e, b io c h em ic a l d e fe c ts , b ru ise s

DIAGNOSTIC EVALUATION

S e rum B ilir ub in (B 1 : 0 .2 -1.4 m g /d l) J a un d ic e a p p ea rs a t > 5 m g/ d l E v alu at io n b as e d

o n:

§ T im ing o f a p pe ar an c e o f c linic a l jau nd ic e

§ G es ta tio n al ag e a t birth
§ A g e in d ay s s in c e b irth
§ F am ily his to ry in c lud in g m a tern a l R h f ac to r
§ E v id e nc e o f h em o lys is
§ In fa n t ¶s p hy s io lo g ic s ta tus
§ P ro g res s io n o f s eru m b iliru b in lev els
P ers is te nt jau nd ic e o ve r 2 w ee k s in fu ll-t erm , f o rm ula fed ter m , fo r m u la f ed in fan t

T o ta l s eru m b iliru b in lev els 1 2 .9 m g/ d l (te rm inf an t) o r o ve r 1 5 m g /d l (p r eterm ) ;

up p er lim it fo r b re as tf eed in g in fa n t ± 1 5 m g /d l

In c rea s e s e rum b ilir ub in > 5m g /d l/d ay

D irec t biliru b in (B 2 ) 1 .5 -2 m g /d l

21
 T o ta l s e ru m B iliru b in ±o v er 9 5 th p erc en tile fo r a g e ( in h o u rs )o n ho u r--s p e c ific
ris k n om o g ram

T ra ns c uta n eo u s B iliru b ino m etr y , n o nin va s iv e m o nito rin g o f b iliru b in v ia

c uta neo u s r eflec ta nc e m ec ha n is m s ; a llow fo r rep e titive e s tim atio n s o f b iliru b in

H o ur – s p ec ific S e rum B iliru b in Le ve ls ±p r ed ic t ne w b o rn a t r is k fo r ra p id ly ris in g

lev els Rec o m m e nd ed b y A A P f or m o n ito ring h ea lth y N e w b o rn > 3 5 w k s A O G b efo re

dis c h arg e fro m h os p ital

C ar b o n m o no x id e ind ic e s in ex ha led b rea th ± C O is p ro d u c ed w he n R B C is b ro k e n

do w n

TREATMENT:

● P ho to th era p y - m ain fo rm
● E xc ha ng e tra n s fu s io n - red u c e h ig h b ilirub in le ve ls th at o c c ur w ith h em o lytic d is eas e

● T ra ns f us io n (fetu s )
● P hen o b a rb ital ±he m o ly tic d is ea s e; e ff ec tiv e w h en g iv en to m o th er s ev er al d a ys
be fo re de liv ery

COMPLICATIONS

B iliru b in E n c ep h a lo p a th y/ K ern ic terus - u n c o n ju g ate d b iliru b in hig h ly to x ic to

th e n euro n s

o S yn d ro m e o f s ev er e b rain d am a g e d ue to d ep o s itio n o f u nc o njug a ted

b iliru b in in b r ain c ells ( ex trem e ly h ig h B 1 le ve l in c re as e c ro s s es the b lo o d

-b ra in b arrier)

K ern ic teru s - ye llo w s ta in in g o f b rain c ells tha t m a y re s ult in b ilir ub in

enc e ph a lo p ath y b ra in injury

M e tab o lic a c id o s is

Lo w s e rum a lb u m in level

Int rac ran ial inf ec tio n s (m en in g itis ) A b ru p t inc rea s e in B P

22
 C o nd itio n s th at inc rea s e m e tab o lic d em a nd s fo r o xy g en a nd g lu c o s e - fet al

d is tres s , h yp o x ia, h yp o th erm ia, hy p og lyc em ia

PROBLEMS RELATED TO BIRTH TRAUMA

FACIAL PARALYSIS

Fr om p res s u re o n fa c ia l n erv e d u ring d elivery A ff ec te d s id e u nr es p o ns iv e w he n

c rying R es o lve s in ho u rs / da ys

ERB’ S PALSY (ERB- DUCHENNE PARALYSIS)

A s s o c ia ted w ith s tre tc h ing o r p ulling h ea d a w ay f ro m s h o uld er d u ring d eliv ery

: F la c c id arm , e lbo w ex ten d ed , ha n d ro ta te d inw a rd , M o ro & g ras p re flex es

ab s en t o n af fe c ted s ide

Re q uire s im m ob iliz atio n & re p o s it io n fo r 2 to 3 h rs

FRACTURED CLAVICLE

B o ne m o s t fre q ue ntly f ra c tu red d ur in g d eliv ery A s s o c ia ted w ith C PD

lim ited R OM ( ran g e o f m o tio n) , c re p itus , a b s en t M o ro ref lex on a ffe c ted s ide

H ea ls q u ic k ly, ha n d le g e ntly , im m o biliz e arm

ASPHYXIA

In ad eq u a te tis s u e pe rfus io n

: ac id ot ic s c a lp o r c o rd p H Lo w A p g a r s c o re (< 4 at 1 m in) B eg in res u s c ita tio n

im m ed ia tely

23
NEONATAL RESPIRATORY DISTRESS

C om m o n c au se s

o P re term inf an ts (P rim a rily a s s o c ia ted w ith in fa n ts < 3 7 w ks )

o M ec o niu m a s p iratio n s yn dr o m e ( M A S ):
o T ran s ien t ta c h yp n ea o f th e ne w bo r n (T T N ) : d e la ye d flu id a b s o rp tio n in lun g s .

o T a c h yp nea
o In ter c o s ta l retra c tio ns
o N a s a l f la rin g
o E x p irat o ry g run tin g , d im inis h ed b rea th s o un d s
o P a O 2 < 5 0 , P C O 2 > 60
o C e nt ral c ya n o s is ( la te f in d ing )

o R a d ia n t w a rm er o r is o le tte to m ain ta in n eu tra l th erm a l en v ir o nm en t &

p rev en t c o ld s tre s s ; o xy g en d e m a n d s in c re as e if n eo n ate is c o ld .

o W a rm ed , hu m id if ied ox yg en
o W ith h o ld f eed in g s if R R > 6 0 b rea ths /m in
o P o s itio n s id e lyin g o r s u p ine w ith n ec k s lig ht ly ex tend ed
o S uc t io n the b ab y to m ain ta in a p a ten t airw ay
o M o n it o r o x yg e n s a tura tio n a n d /o r A B G s a s ord ere d

24
 MECONIUM ASPIRATION SYNDROME (MAS)

Pr en ata l a s p h yx ia c a us e s re la x atio n o f an a l s p h inc ter & p as s a g e o f m ec o niu m in to

a m nio tic flu id F etu s /in fa nt inh a le s m ec o niu m in to a irw a y

F o rm s m ec ha n ic al o b s tru c tio n ; a ir c a n b e in ha led b ut c an ’ t b e ex ha led

Lu ng s b ec o m e h yp e r in flate d

Irrita tin g to a irw a y C au s in g c h em ic a l p n eum o nitis

o F eta l dis tres s

o A p g ar s c o re < 6 a t 1 & 5 m in,
o D is t en d ed ab d o m en
o B a rre l- s ha p ed c he st,
o D im in is he d b re ath so u nd s ,
o Y ello w s t ain ing o f s k in, n ails & c o rd

o S uc tio n o ro p ha ryn x & na s o p h ary nx af ter he ad is bo r n & s h o u ld e rs a n d

c he s t s till in b irth c a na l

o E n d o tra c h ea l s u c tio nin g ind ic a ted b e fo re s tim ula ting re s p iratio n s un les s
in fan t

c ryin g & v ig oro u s

o A d m in is ter O 2 a n d a n tic ip ate n ee d f o r ven tila tio n

o P e rfo rm c h es t p hy s io the rap y rou tinely

25
TRANSIENT TACHYPNEA OF THE NEWBORN (TTNB)

F a ilu re to c lea r airw a y o f ex c e s s f luid at d elive ry

P rim a rily te rm inf an ts , es p ec ially if C /S ( m is s m ec ha n ic al s q u eez e o f v ag in a l

d elivery )

o G run ting
o F la ring
o M ild c yan o sis
o T ac h yp n ea , - res p ira tio ns c a n b e a s hig h a s 1 0 0 to 1 4 0 b rea ths /m in

o O 2 as n eed e d to m a inta in P O2
o U s u a lly res o lve s w ith in 7 2 ho u rs

COLD STRESS

A ll n ew b o rns a t ris k f o r hy po th erm ia K e ep tem p 9 7 .6 -9 9 .2 b y

o D e lay b a th u n til te m p e ratu re s ta ble

o D r y im m ed ia tely a fte r b ath
o U n d er w a rm er o r s k in to s k in a fte r de liv ery
o W ra p w ith w a rm b lan k ets
o C h ec k O2 s a t a nd b lo o d g lu c o se
o C h ro n ic hy p o the rm ia c a n b e ea rly s ig n o f s ep s is

HYPOGLYCEMIA

B lo o d g lu c o s e < 4 0 m g /d l in term new b o rn

o ID M (I nf an t o f a D iab e tes M e llitus )

o S G A ( S m all fo r G es ta tio na l A ge)
o P rem atu re
o In fa n ts w ith c o ld s tres s

26
 o H y po th erm ia
o D elay ed feed ing s

o T re m o rs
o J itte rin es s
o Le tha rgy
o D ec re as e d m us c le ton e
o A p n ea
o A n o rexia

o C he c k b lo o d g lu c o s e o f a t-ris k in fa n ts , ( 3 0 m in if ID M ) & o n a ny
s ym p to m a tic n ew b orn .

o F ee d ( b rea s t o r b ottle)
o R ea s s es s g luc o s e b efo re n ex t fe ed in g

INFANT OF A DIABETIC MOTHER (IDM)

M a tern a l g luc o s e c ro s s es p la c en ta

Fet al p an c re as s ec rete s m o re ins u lin to m eta b o liz e g luc o s e

In c re as e d in s ulin d e c rea s es s u rfa c ta n t p ro d uc tio n .

o L G A ( La rg e fo r G es ta tio n al A ge)
o H y po g lyc em ia
o R D S (R es p ira to ry D is tre s s S y nd ro m e )
o F a ls e p o s itiv e L/S ratio ,
o In c re as e d r is k f o r c o ng e nita l a no m a lie s (es p e c ia lly c ard ia c a nd
s p ina l)

27
 o A s s e s s f o r b ir th tra um a
o M o n it o r B lo o d g luc o s e at 3 0 m in a nd 1 , 2 , 4 , 6 , 9 1 2 a nd 2 4
h o urs

o T rea t hy po g lyc em ia

NEWBORN SEPSIS

G ro u p B s tr ep to c o c c u s m o s t c o m m o n c aus e

C om p lic a ted b y im m a tur e im m un e s y s tem & la c k o f Ig M A s s o c ia ted

w ith P RO M

P ro lo n g ed la b o r

M a tern a l infe c tion .

o Le tha rgy
o S eizu re a c tivity
o P a llo r
o H y po th erm ia
o P o o r fee din g
o R es p ira to ry d is tres s
o A p n ea
o T a c h yc a rdia
o B ra dy c ard ia
o H y pe rbiliru b inem ia

o O b ta in c u ltu res (b lo o d , urin e, C S F)

o S tart a n tib io tic s s ta r. A f ter 7 2 hrs ,
o T rea tm e nt s to p p e d if c ultu re n eg a tive & as ym p to m a tic .
o C o n tin ue a n tib io t ic s fo r 1 0 -1 4 da ys if c u ltu re rep o rts p o s itiv e

28
FETAL ALCOHOL SYNDROME (FAS)

A lc o ho l c ro s s es p lac e nta

In terf eres w it h p ro tein s ynth es is In c re as in g ris k o f c o ng e nita l

a no m alies , M en ta l d ef ic ien c y & IU G R

o SG A
o S m a ll eyes
o F lat m idf ac e
o L o ng , th in u p p er lip
o F lat u p p er lip g ro o ve
o Irritab le
o H y pe rac tive
o H ig h p itc h ed c ry

o R ed u c e en v iro nm en ta l s tim u li
o S w a d d le to in c r eas e fee lin g s o f se c urity
o S ed at iv es fo r w ith dr aw a l s id e ef fec ts

NEONATAL ABSTINENCE SYNDROME (NAS)

o R ep e ate d in tra ut erin e d ru gs e xp o s u re c au s es feta l d ru g de p en d en c y,

d e g ree o f w ith d ra w al d ep en d s o n ty pe & d u ra tion o f ad d ic tion

29
 o H y p era c tiv ity, jitter in es s & s h rill, p ers is te nt c ry
o F req u en t ya w nin g & s n eez ing , n as a l stu ff in es s
o S w ea ting
o A bs e nc e o f “ s tep ” & “ h ead - rig htin g ” reflex
o D ev elo p m e nta l de la ys
o F ee d in g d iffic ulties (v o m iting , reg u rg ita tio n, d ia rrh ea ) in c r ea s ed ne ed fo r
n on - n u tritive s uc kin g

o P o s itio n in fa nt o n s id e to fa c ilita te d rain a ge of m u c us

o S uc tio n P RN to m a in tain p a ten t airw ay
o D ec re as e en v ir o nm en ta l s tim u li, s w ad d le fo r c o m fo rt
o In ta k e & o utp u t, d aily w eigh t
o O b ta in m ec on iu m a nd / or u rin e fo r d ru g sc reenin g
o M ed s m a y in c lud e p a reg o ric elix ir, th o ra zin e & V a liu m , m eth a d o ne ,
p h eno b arb ital

o P a c ifie r f o r no n -n utritiv e s uc kin g

o D on ’ t g ive N ar c a n to inf an t b o rn t o n a rc o tic a dd ic t

INTENSIVE CARE FACILITIES FOR HIGH RISK NEWBORN

Ra p id a d v an c e s in o u r u nd e rs tan d ing o f t he p a th o p hy s io lo g y o f th e ne o na te a n d

inc rea s ed c ap a c ity to ap p ly th is k n o w le d g e h av e em p ha s iz ed t he n eed fo r a p pr o p ria te

s ettin g s in w h ic h to c a re f or the s erio u s ly ill in fa n t. A d v an c e m e nts in elec tr o nic s a n d

b io c h em is t ry, ne w m eth o d s f or m o nito rin g c a rd io r es p irat o ry f u nc t io n , m ic ro tec hn iq ue s

fo r b io c h em ic a l d et erm ina tio n fro m m inu te q u a ntitie s of b lo o d , no n inv a s ive

m o nito rin g , a n d n ew m eth o d s fo r a s s is ted v entilatio n an d c o n s erv at io n o f b o d y he at

ha v e m ad e it p o s s ib le to ef fec tive ly m an ag e the n ew b o rn w ith s erio u s illn es s .

In ten s iv e c a re o f the ill a n d im m a tu re n ew b o rn req u ires s p ec ia lize d k no w led g e

an d sk ill in a n u m be r o f are as . M u c h o f the eq uip m en t u s ed in the c ar e o f the c ritic ally ill

ad u lt is un s uited

30
to th e s in gu la r n eed s o f th e ve ry s m a ll in fa n t; t her efo re eq u ip m e nt h as b een m o d ifie d

to m eet th es e n ee d s . E xa m p les o f m o d if ic at io n s inc lud e ve ntila to rs th at d e liv er s m a ll

vo lu m es o f o x yg en in th e p ro p er c o nc en tra tion a n d p res s u re, in f us io n pu m p s th at

ac c u rate ly d e liv er ve ry s m all am o u nts , a nd r ad ia nt he at w a rm ers th a t p ro v id e a

c o n s tan t s o u rc e o f w arm th an d allo w m a xim um a c c es s to th e in fa nt . M o s t im p o rt an t,

ad v a nc es in in ten s ive c a re h a ve c re ate d a n eed f or h ig hly s k illed p ers o n n el train ed in th e

art o f ne o na ta l in ten s ive c are.

T h e d ive rs ity o f s p ec ia l c a re n ee d s req u ir es th at t he un it b e a rra ng e d fo r g ra d u ate d

c a re of the in fa nt p o p u la tio n . T he re s ho u ld b e ad e q ua te fa c ilities an d s k illed p e rs o nn el t o

p ro vid e o n e-to - on e nu rs in g c a re f or ea c h s e rio us ly ill inf a nt, as w e ll a s a m ea n s fo r

g rad u a tio n to o n e-t o -thr ee o r on e- to -fo u r nu rs in g c are in a q u ieter a rea w h ere in fa nt s

req u ire le s s in ten s ive c a re un til th ey a re rea d y to be d is c h a rg ed to ho m e.

Fa m ily-c e nte red c a re a nd a re lativ ely q u iet en viro n m en t are o f ten d if fic u lt to p ro vid e in

a b u s y n eo n at al in ten s iv e c are u n it ( N IC U ); the ref or e s o m e un its ha v e d e ve lo p e d

s tep -d o w n u n it s a nd s in g le ro o m u n it s w h ere h igh -ris k inf an ts m ay b e o b s erve d b y

s k ille d s taf f. S u c h a rea s a re d e s ig n ed fo r fa m ily-c e nte red c are alo n g w ith a p pr o p ria te

neu ro d e ve lop m e nta l c a re.

ORGANIZATION OF SERVICES

T he m o s t e ff ic ien t o rg a n iz a tio n o f s erv ic es is a reg io n aliz ed s y s tem o f f ac ilities

w ith in a

d e s ig n a ted g eo g ra p hic a rea . N eo n a tal in ten s ive c are fa c ilit ie s m a y p ro vid e th re e

p re s c rib ed leve ls o f c are w it h s p ec ial eq u ip m e nt, s k illed p ers o n ne l, a n d a nc illa ry

s e rvic es c o n c en tra ted in a

31
c en tra lize d ins t it utio n ( A m eric a n A c a d em y o f P e d ia tric s an d A m e ric a n C o lleg e o f

O bs tetric ia ns an d G y ne c o lo g is ts , 2 0 0 7 ):

— P ro v id es m an a g em en t o f no r m a l m a ter na l a n d new b o rn c a re.

— P ro v id es a fu ll ra ng e o f m a tern ity an d n ew b o rn c are a n d c a n
p rov ide c a re to in fa nts b o rn a t m o r e th a n 3 2 w ee k s o f g es ta tio n a n d w eig hin g

m or e th an 1 5 0 0 g (3 .3 lb ) w h o a re m o d era tely ill w ith p ro b lem s tha t are

ex p ec te d t o re s olv e ra p idly a nd w h o are no t a nt ic ip ate d to ne ed s ub s p e c ialty c a re;

o r w h o a re c o n va les c in g af ter inten s ive c a re.

— In ad d itio n to th e a bo v e, c a n p r ov id e m ec h a nic a l v en tilat io n f o r

up to 2 4 h o urs a nd c a n p ro v id e c o n tin uo u s p o s itiv e a ir w a y p re s s ure (C P A P ).

— N e o na ta l inte ns iv e c are
o u nits p ro v id e c ar e f o r inf an ts w ith b irth w eig ht o f m o re tha n

1 0 0 0 g (2 .2 lb ) a n d g es ta tio na l a g e o f m o re th a n 2 8 w eek s . Lif e s u p p o rt

is lim ite d to c o n v en tio n a l m ec ha n ic al ve ntila tion .

o u nits c a n p ro vid e c are fo r ex tre m e ly lo w – birt h w eig ht (E LB W )

infa nts

w ith te c h no lo g y in c lud in g h ig h fre q ue nc y ve ntila tio n a nd in ha led nitr ic o xid e,

on - s ite a cce ss to p e d iatric m ed ic a l s u b s p ec ia lis ts , a nd ad v an c e d

d iag n o s tic im a gin g a nd p ed ia tric s u rg ery a va ila b le.

o u nits ha v e th e c a p ab ilities o f a lev el IIIB N IC U a nd , in a dd itio n ,

o ffer

ex tra c o rp o rea l m em b ra ne ox y ge na tio n (E C M O ) an d s u rg ic al re p air o f

s eriou s c o ng e nita l c a rd ia c m alfo rm atio ns .

TRANSPORTING HIGH-RISK NEWBORNS

W he n a n at- ris k inf a nt is id en tified o r a n tic ip ate d , a rra ng e m e nts a re m a d e f o r c a re

in the in ten s ive c a re f ac ility . T h e ut eru s is th e id ea l tr an s p o rt u nit fo r th e in fa nt w ith

an tic ip a ted d if fic u lties ; the refo r e, w he ne ve r p o s s ib le, tak e th e m o th er w her e s p ec ia l c are

is av a ila b le f o r her d elivery.

S o m e in fa nt s d ev elo p d iffic ulties a fte r a s e em ing ly no rm a l p reg n an c y a n d

un c o m p lic ate d la b o r. B ec a u s e it is im p o s s ib le to a lw a ys p re d ic t w he n in fa nts w ill

req u ire in ten s ive c are , a c o o rd ina ted S ys t em is n ee d ed t o en s ur e t he m a n o p tim u m

32
o p p o rtu nity fo r s u rv iva l. E ac h h o sp ita l
th at d elive rs in fa nts s ho u ld b e a b le t o p ro v id e f o r ap p ro p ria te n eo na ta l s ta b iliz a tio n a n d

arra ng e fo r t ran s p o rt to a te rtiar y c ar e fa c ility.

Th e inf an t m us t be ke pt w a rm , be a d eq u at ely o xy g en ate d ( inc lu d in g

intu b a tio n if in d ic at ed ), h av e v it al s ig ns an d o xy g en s a tur atio n m o n ito red , a nd , w h en

ind ic a te d, rec eive an in tra v en o us (I V ) in fu s io n . T he inf an t is tra n s p o rted in a s p e c ially

d es ig n ed inc ub a to r u n it that c o nta in s a c om p lete lif e-s u p p o rt s y s tem an d o th er

em erg e nc y e q uip m en t th at c a n b e c ar rie d by a m b u lan c e , v a n, p lan e, o r he lic o p ter.

T h e tran s p o rt tea m m a y c o ns is t o f o ne o r m o re o f th e h ig h ly tr ain ed pe rs o n s

fro m the

N IC U : a ne o na to lo g is t ( o r a fe llo w in n eo n ato lo g y) , a ne o na ta l n ur s e p rac titio ne r, a

res p ira to ry th era p is t, a n d o n e o r m o re n u rs es . T h e p ro fe s s io na l as s ig n ed to a c c o m p a ny

th e inf an t m u s t b e c o n s tan tly a lert to e ve ry c h an g e in the inf a nt’ s c o nd itio n an d a b le t o

inte rv en e ap p ro pria tely.

T h e n eo n ate w ho m u s t b e m o v ed fro m o n e p la c e t o a n o the r w ith in th e ho s p ita l

(e .g ., to

s ur g ery, o r f ro m d e liv er y ro o m to nu rs ery ) is tra n s p o rted in a n in c ub a to r o r rad ia nt

w arm e r an d a c c o m p an ied b y th e ne c es s a ry p e rs o nn el an d eq uip m e nt.

33
NURSING MANAGEMENT

Im p a ired G as E x c ha ng e

R is k f o r Flu id V o lu m e D efic it

R is k f o r im p a ired N u tritio n R is k f o r

In fec tio n

R is k f o r A ltere d Pa ren tin g

D iv ers io n a l A c tivity D ef ic it

R is k f o r D is o rg an iz ed Inf a nt
B eh av ior

34
P H Y S IC A L A S S E S S M E N T

T H E RM O R E G U LA T IO N - ne ed ne utra l t her m a l e nv iro nm e nt, u s e b ro w n fat

 CO N SEQ UEN CES OF C OLD STR ESS- h yp o xia, a c id os i

s,
m eta bo lic h yp o g ly c em ia

G L U C O S E & C A LC IU M

P R O T E C T F RO M IN FE C T IO N

H Y D R A T I O N - IV F fo r c alo ries , elec tro lytes & H 2O

N U T R IT IO N - n o c o o rd in atio n o f s uc k ing un til 3 2- 3 4 w ee k s ; n o t s y nc hr o niz ed un til

3 6 - 3 7 w e ek s ; g ag ref lex n o t d ev elo p ed u ntil 3 6 w eek s

E A RLY FE E D I N G - w ith in 3 -6 h ou rs B R E A S T F E ED IN G

G A V A G E F E E D IN G - < 3 2 w k s . o r < 1 5 00 g

S K IN C A R E O F P R E M A T U R E - inc rea s ed s en s itivity & frag ile M E D IC A T ION

D E C RE A S E S T RE S S

35
 § B E F O RE 3 3 W E E K S - m in im um s tim ula tio n

§ 3 4 -3 6 W E E K S - s tim u la te s e ns e s b u t d o n’ t
tire ou t

ASSESSMENT OF NEWBORN

INTRODUCTION

At b irth th e new b o rn is g iv e n a c u rs o ry yet th o ro u g h as s e s s m e nt to

d ete rm in e an y a p p ar en t p ro b lem s an d id en tify tho s e th at d em a nd im m ed ia te a tten tio n.

T his ex a m in at io n is p rim a rily c o n c e rne d w ith th e ev alu a tio n o f c ar dio p u lm o n a ry an d

n eu ro lo g ic f un c tio n s . T he a s s es s m en t in c lu d es the a s s ig nm en t o f an A p g ar s c o re

a nd an ev a lu a tio n f o r an y o b vio us c o ng e nita l a no m a lie s o r e vid e nc e o f n eo n ata l

d is tres s . T h e inf a nt is s ta biliz ed a n d ev alua ted b ef o re b eing t ran s p o rted to the N I C U f o r

th era p y a nd m o re ex ten s ive a s s es s m en t.

A th o ro ug h , s ys te m a tic p h ys ic al a s s es s m en t is an es s e ntia l c o m p on en t in the

c a re o f the h ig h -ris k in fa nt . S u b tle c ha n g es in fe ed ing b e ha v ior , ac tivity , c o lo r, o xy g en

s a tura tio n ( S p o 2) , or v ital s ig ns o fte n in d ic at e an un d erly ing p ro b le m . T h e p ret erm

inf a nt, es p e c ially the E LBW in f an t, is n o t ab le to w ith s ta nd p ro lo ng e d p h ys io lo g ic

s tre s s a n d m ay d ie w ithin m in u tes o f e xh ib iting a b no rm a l s y m pt o m s if the u n d erlyin g

p a tho lo g ic p ro c es s is no t c o rrec t ed . T h e a lert nu rs e is a w are o f s u b tle c h a ng e s an d

rea c ts pr o m p tly to im p lem en t int erv en tio ns th a t p ro m o te o p t im u m fu n c tio n in the

hig h- ris k n eo na te.

Th e nu rs e no te s c h an g es in th e in fa nt ’ s s tat us thro u g h o ng o in g
o b s erv a tio ns o f the

inf a nt’ s a d a p tat io n to th e ex tra ut erine en viro n m en t. O b s erv a tio na l as s e s s m e nts o f the

h ig h -risk in fa n t a re m a d e a c c o rd in g t o th e in fa nt ’ s a c u ity (s e riou s n es s o f c o n d itio n) ; the

c ritic ally ill in fan t re q uire s c lo s e o b s e rva tio n an d as s e s s m e nt o f res p ira to ry f un c tio n ,

inc lud in g c o nt in u o us p uls e o x im etry, ele c tro lyte s , an d b loo d g a s es . A c c u rate

d o c u m en tatio n o f the inf an t’ s s ta tu s is an int eg ra l c o m p o ne nt o f n ur s in g c are . W ith

th e aid o f c o n tin u o us , s o p h is tic ate d c ard iop u lm o na ry m o n ito ring , nu rs ing a s s es s m en ts

a nd d a ily c are ca n b e c o or d in a ted to allo w fo r m inim um ha n d lin g o f th e in fa n t

36
(e s p ec ia lly t he v ery lo w – b irth- w e ig ht [V L B W ] o r E LB W in fa n t) to d ec rea s e t he ef fec ts

o f en v iro nm en ta l s tres s .
 T he ne w b o r n re q uire s th o ro ug h s k illed o b s erv a tio n t o en s ur e a s a tis fa c to ry

a d ju s tm en t to th e e xtr au terin e life. P h ys ic a l a s s es s m en t fo llo w in g d elive ry c a n b e d ivid e d

in to 4 p h as es :

1 . T he in it ia l as s e s s m e nt u s in g an A p g ar s c o rin g s ys tem .

1 . T ran s itio na l a s s es s m e nts d urin g th e p erio d s o f rea c tiv ity.

1 . A s s es s m en t o f g es t atio n al ag e.

1 . S ys tem a tic p hy s ic al ex am ina tio n .

INITIAL ASSESSMENT: APGAR SCORING

O ne s ig n ific a n t as s e s s m e nt of the n eo n a te is ‘ APG A R S C O R IN G ’ as

d es c r ib e d b y D R V ir g in ia A p g ar. D es p ite its lim ita tio ns , it is a u s efu l q ua n titat iv e

as s e s s m en t of ne on ate ’ s c o nd itio n at b irth e s p ec ia lly fo r th e res p ira to ry,

c irc u la to ry a n d n eu ro lo g ic a l s ta tus . F iv e o b jec tive c riter ia ’ s a re e va lu ate d at o n e

m in u te a nd fiv e m inu tes , af ter th e n eo n ate s b o d y is

37
 SIGN 0 1 2
HEART RATE ab s en t S lo w < 10 0 > 1 00

RESPIRATORY ab s en t Irre g ula r s lo w w ea k c ry G o o d s tro ng c ry

EFFORT

MUSCLE TONE lim p S o m e f le xio n of W e ll flex ed

ex trem ities

REFLEX N o re sp o n se G rim a c e C ry. S nee ze

IRRITABILITY

COLOR B lu e, pa le B o d y p ink ex trem ities C o m ple tely p in k

blue
c o m p letely b o rn . T h e c riteria ’ s a re res p ira tion , h ea rt rate /m inu te, m us c le to n e, ref lex

irrita b ility an d s k in c o lo r. E ac h o f th es e c rite ria is a n in d ex o f n eo n ate s d ep re s s io n o r lac k

o f it a t b irth an d is g iv en s c o re o f 0 ,1 o r 2 . T he s c o re s fr o m ea c h o f t he c riter ia a re

ad d e d to d e term ine t he to ta l s c o re . T h e ne o na te is th e b e s t p o s s ib le c on d itio n if t he

s c o re is 1 0. S c o re s o f 7 -1 0 in d ic a te n o d if fic u lty in a dju s tm ent in e xtr au terin e life.

S c o r es o f 4 -6 s ig n if y m o d era te d if fic u lty a nd if the s c o re is 3 o r b elo w , t he n eo n at e is in

s ev ere d is tre s s w h ic h m u s t b e t rea ted im m e dia tely.

Total score =
10
● N o d ep res s ion : 7 -1 0

● M ild d ep res s io n : 4 -6

● S ev ere : 0 -3
d ep res s io n

TRANSITIONAL ASSESSMENT: PERIOD OF REACTIVITY-

D u ring the in itial 2 4 h o urs , c h a ng es in h ea rt r ate re s p iratio n , m o to r ac tivity , c o lo r,

m u c u s p ro d u c tio n a n d b o w e l ac tivity o c c u rs in a n o rd e rly, p red ic ta b le s e q uen c e tha t

is n o rm a l an d ind ic a te s la c k o f s tres s .

38
 D u ring th e 1 st 3 0 m in ute s th e in fa nt is v er y a c t iv e, a le rt, c rie s v ig o ro us ly , s u c k s

th e fist g ree d ily , a n d a p p ea rs v ery in tere s ted in the en viro n m en t. N eo n a te’ s ey es a re

w ide op e n th u s , is a n ex c e lle nt o p p o rtu n it y fo r m o the r, fa the r a n d c hild t o s e e ea c h oth er.

B e c a us e th e n ew b o rn h a s a vig o ro u s s uc k th is is th e b es t tim e to b e g in
b rea s tfeed ing .

H e ar t rate = 1 8 0 /m t R es p ira tio n= 8 0 /m t B o w e l s o u n d s a re a c tive.

Second stage of first reactive period:

L as ts fo r 2 - 4 h o urs .

H e ar t r ate , re s p iratio n d ec rea se s.

T em p era tur e c o nt in u es to d e c rea s e. U nd re s s in g an d b at hin g is av o id ed d u rin g

th is tim e.

39
 M u c u s p ro d u c tio n d ec rea s es .

U rine a n d s to o l g en era lly no t

p a s se d. B a b y in a s tate o f s leep

a n d is c alm .

La s ts fo r n ex t 2 -5 ho urs .

H ea rt ra te an d res p ira tio ns inc re as es . A lert a n d re sp o n siv e.

G as tr ic , re s p ir ato ry s ec re tio ns inc rea s ed .

P as s a g e o f m ec o n iu m fre qu en tly .

A ft er this s ta ge is a s ta g e o f s ta b iliz a tio n o f p h ys io lo g ic sy ste m s .

ASSESSMENT OF GESTATIONAL AGE

O ne o f the m o s t s a tis f a c to ry m eth o d f o r p red ic tin g m o rta lity ris k s an d p ro vid in g

g uid elin es f o r th e m a n ag em e nt o f n ew b o rn is th e c la s s ific atio n o f in fa n ts a t b irth b y

b o th b irth w e ig h t and t he g es t atio n al ag e.

▶ A p p ro p ria te fo r g es ta tio n al age

▶ La rg e fo r g es t atio n al ag e
▶ S m all fo r g es ta tio na l ag e

A s s es s m en t of g es t atio n al ag e is m an d at or y for a ll ne on a tes for f urth er

m an a ge m en t. Las t m e ns tru a l p erio d is im p o rt an t c lu e fo r c a lc u lat io n o f g es ta tio na l ag e ,

b ut it m a y n o t b e r eliab le in

40
m en s tru a l irr eg u la rities o r m o th er m a y no t rem em b er th e ex a c t d a te . T h e c linic al
a s s es sm en t
Physical Preterm Transitional Term

Characteristics

m o re p ra c tic ally s ig nif ic an t. P h ys ic a l an d n eu ro lo g ic a l e xa m ina tio ns a re d o n e t o

d e tec t the g es ta tio n al m a turity.

41
 Hair texture W o o ly fu z zy a n d very Fin e w o o ly , f uz zy S ilk y , b la c k c o ars e
a nd
and distribution fine
in d iv id u al s tran ds
on

scalp

Skin texture S h in y oily p leth oric , Les s s h iny, pe rip h eral P in k , s c a n ty lan u go
a nd
and opacity p len ty o f la nu g o , c ya n o s is , les s la nu g o
ed em a and o nly la rg e veins are

w ith v is ib le v eins an d ve ins a re o n ly fo u nd s e en. G o o d elas tic it y

v en ules o n ab d o m en on a b do m en o r tu rgo r
Breast nodule B rea s t tis s ue les s tha n B rea s t t is s u e 5 -1 0 m m M ore tha n 1 0m m
5
and nipple N ipp le p res ent bu t no t d iam eter
m m o n o ne o r b o t h
formulation rais ed B re as t tis s u e an d
s ide s. N o n ipp le pre se nt
n ip p le rais e d a b o ve s k in

Ear cartilage P inn a fee ls s o f t w ith S om e c a rtila g e p res en t P inn a is firm w ith
no
an d s o m e rec o il d ef in ite c artilag e and
c a rtilag e a n d no rec o il
in s tan t rec o il

Planter creases Fa int red m ark s ov er C rea s es s ee n o v er E n tire s o le c o ve red

an terior w ith
a nte rio r pa rt o f s o le
1/

or m a y b e a b s ent 3 to ½ o f s ole d ee p c reas e s

Genitalia S c ro tum s m a ll w ith no S c ro t um w ith s o m e A tlea s t on e tes tis

or rug a e
[male] d es c en d s in th e
fe w r ug a e a nd an d t es tis in th e s c ro tu m .
lig h t
in g uina l c an al P ro m in ent rug ae and
p ig m e nt atio n .
d ee p p ig m enta tion
T es tis u s ua lly not
Genitalia La bia m a jo ra w id ely Lab ia m ajora p a rtia lly L ab ia m ajo ra
c o m p le tely
[female] s ep a ra ted w ith c o ver o v er the
c ov er th e la b ia
p ro m ine nt lab ia m in o ra la b ia m in o ra
m ino ra a nd c lito ris

A s s es s m en t o f m atu rity o f the n eo n at es is f a irly relia b le o n t he b a s is o f

p h ys ic al c h ara c te ris tic s . B ut th ey a re o f lim it ed va lue to a s s es s th e g es ta tio na l ag e in les s

th a n 3 6 w eek s o f

42
m a tur it y. Th e ne ur olo g ic a l c ha ra c teris tic s are m o re reliab le fo r the p re c is e

a s s es s m en t of m atu rity .

T he n eu ro lo g ic al a s s es s m en t is p e rfo rm ed b a s ed on f o ur f un d a m e nt al

o b s e rva tio n s , i.e. m u s c le to n e, jo in t m o b ility, c ert ain a uto m a tic ref lex es an d fu nd u s

ex a m ina tion .

T he m us c le to n e o f t he n ew b o rn b a b y is as s e s s ed b y th ree p a ram e ters , i.e . p o s tu re o r

a ttitu d e, p as s iv e to n e [p o p litea l an g le]a nd s c arf s ig n a nd ac tive to ne [tra c tio n res p o n s e

a n d rec oil]

T he join t m o b ility is le s s in p ret erm b a b ies . A te rm b a b y ha s m o re flex ib le a n d re la x ed

join t. T h e d e g ree o f fle xio n a t a nk le an d w ris t [s q u are -w in d o w ] is lim ite d d ue to s tif fn es s

o f jo ints in e ar ly g es tatio n.

C erta in a uto 9 m a tic ref lex es lik e m o ro ref le x, p a p illa ry res p o n s e to lig h t, b lin k

re s p o ns e to g la b ella r ta p , g ra s p res p o n s e, n ec k f le xo rs , ro o ting ref lex w ith c o o r din a ted

s u c k lin g eff o rts are as s e s s ed to d ete c t the s p e c ific a g e of g e s ta tio n a l m atu rity b a s ed o n

a p p ea ra nc e o f the s e reflex es .

T he fu n d am en ta l ex am in atio n f o r d is ap p e ara n c e o f a n terio r v a s c u la r c ap s u le o f len s

is d o ne to a s s es s t he g es ta tio na l a g e. In in fa nt s les s th an 2 8 w ee k s , th e a n terio r

c ap s u le is c o m p letely v as c ula rize d an d a fter 34 w eek s of g es ta tio n al lif e, th e

v es s e ls a re a lm o s t a tro p h ied . T his e xa m in a tio n is d iff ic u lt d u e to no n -c o -o p e rat io n an d

p h o to p h ob ia o f the neo n ate.

W ith th e s c o rin g s ys te m o f th e n eu ro lo g ic a l as s e s s m e nt th e ac c ur ate es tim atio n o f

g es ta tio n al a g e c an b e d o n e. N ew B a lla rd s c o re is w ide ly u s ed . N eu ro m us c ula r m a tu rity

is as s es s e d b y the te s t lik e p o s tur e, s q u a re w ind o w [w ris t], arm re c o il, p o p litea l an g le,

s c arf s ig n a n d h eel to e ar, u s in g t he n ew B a llard s c o ring s ys te m . P hy s ic a l m at urity is

a s s es s e d w ith th is s ys te m b y th e c ha ra c teris tic s lik e s k in , la n ug o , p lan ter s u rfa c e , b re as t,

ey e/e ar a nd g enita ls .

43
TESTS USED IN ASSESSMENT OF GESTATIONAL AGE:

POSTURE:

W ith in fa n t q uite a n d in s u p ine p o s itio n , o b s erv e d eg re e o f f lex io n in a rm s an d

le gs .

M us c le t o ne a n d d e g ree o f f le xio n in c r ea s e w ith m atu rity. F ull flex io n o f t he a rm s a nd

leg s= 4

SQUARE WINDOW:

W ith th u m b s u p p o rting b a c k o f a rm b elo w w ris t, a p p ly g en tle p res s u re w ith ind ex

fing er a nd third f ing e rs o n d o rs u m o f h an d w ith o ut ro ta ting in fa n t’ s w ris t. M ea s u re

an g le b e tw een b as e o f thu m b an d fo rea rm . Fu ll flex io n ( ha nd lies fla t o n v en tra l s u rfa c e of

fo rea rm ) =4

ARM RECOIL:

W ith in fa n t s u p in e, f ully f lex b o th f o rea rm s o n up p e r ar m s , h o ld f o r 5 s ec o nd s ; p ull

d ow n o n ha n d s to f ully ex ten d an d ra p id ly re leas e a rm s . O b s erv e rap id ity an d in ten s ity

o f re c o il to a s ta te o f f lex ion . A b ris k retu rn t o f ull flex io n =4

POPLITEAL ANGLE:

W ith in fa nt s up in e a nd p elv is f lat o n a firm s u rf ac e, f lex lo w er le g o n th ig h a nd

th en f lex th ig h o n a b d o m en . W hile h o ld ing k n ee w ith th u m b a n d in d ex fing e r, ex ten d lo w er

leg w ith ind ex fin g er o f o the r h an d . M ea s u re d e g ree o f an g le b e hin d k ne e ( p o p lite al

an g le) . A n an g le o f les s t ha n 9 0 d eg rees = 5

SCARF SIGN:

W ith in fa nt s u p ine , s up p o rt h ea d in m id lin e w ith o n e ha n d ; u s e o th er h a nd to p ull

infa nt’ s arm a c r o s s the s h o u ld e r s o th a t in fa nt’ s ha n d to u c h es s ho u 7 ld er. D eter m in e

lo c a tio n of e lbo w in rela tio n to m id lin e. E lb o w d o es n o t rea c h m id line= 4

HEEL TO EAR:

W ith in fa nt s u p ine an d p elvis fla t o n a firm s urf ac e, p ull fo o t a s f a r a s p o s s ib le up

to w a rd e ar o n s a m e s id e. M ea s ure d is tan c e o f fo o t fro m ea r an d d eg r ee o f k ne e

44
flex io n (s a m e as p o p lit eal an g le). K n ees flex ed w ith a p o p litea l a ng le o f les s th an 1 0

d eg re es = 4
NEW BALLARD SCORING SYSTEM

N eur o m u s c u lar m a turity is as s e s s ed

b y:

• P o s ture

• S q ua re w in d o w

• A rm rec oil

• P o p litea l a ng le

• S c a rf s ig n

• H e el to ear

SUBSEQUENT OR FOLLOW-UP ASSESSMENT IN THE NEONATAL PERIOD

45
S ub s eq u en t a s s es s m en t is us u ally d o n e, in ins titu tio na l d eliv ery, o n th e firs t d a y o f b irth ,

i.e. w ith in 2 4 h o u rs an d w ithin the tim e of d is c h arg e . D a ily c lin ic a l ev alu a tion s h o uld b e
d o n e,

b etw ee n firs t d ay ex a m in a tio n an d th e d a y of d is c h a rg e. D a ily c lin ic al ev alu at io n s h o u ld

b e d o n e, b etw ee n f ir s t d ay ex am in atio n an d the d ay o f d is c h a rg e. B u t d aily de ta ile d

ex am in atio n is not ne c es s a ry b ec au s e it m ay int ro d uc e in fec tio n s .

First day examinations should include the followings:

Fo r f ull term inf an t av era g e h ea d c irc u m fere nc e = 3 3 a nd 3 3 .5c m . C h es t

c irc u m fe ren c e= 3 0 .5 -3 3c m .

H ea d to he el le ng th = 4 8 -5 3 c m B o d y w e ig h t= 2 7 0 0 -4 00 0 g .

A x illa ry te m p e ratu re : 3 6 .5 to 3 7 .6 C ( 9 7 .7 - 9 9 .7F ) P u ls e : 1 2 0 -1 4 0 /m t

Re s p ir atio n s : 3 0 - 60 /m t

B loo d p re s s ure : 6 5 / 4 1 m m o f H g

46
 P o s tur e- c o m p le te flex io n

B eh av io ur - d e g ree o f a lertn es s , d ro w s ines s o r irrita b ility to b e n ote d.

PHYSICAL ASSESSMENT:

V elv ett y, s m o o th a n d p u ff y, c o lo r d ep en d ing o n t he ra c ia l an d f a m ily b ac k gro u nd .

C he c k th e c o nto u r. P a lp at e fo n ta ne lle s an d s u tur es n ot in g s iz e , s h ap e ,

m o ld in g , or a b n or m a l c lo s u re.c he c k f o r an y c ep h al h em a to m a an d c a p u t s uc c ed a n eu m .

A s s es s th e d eg ree o f he ad c o n trol

: E d em at o us lid s , pu ru len t d is c h a rg e fro m e yes s ho r tly a ft er b irth is ab n o rm a l. S c le ra

s ho u ld b e w hite an d c lea r.

N o te th e p o s itio n , s tr uc ture a nd a u d it o ry f un c tio n . T o p o f th e p in n a s h o u ld

lie in h o riz on ta l p la ne to th e o u ter c a nt hu s o f eye . O b s e rve s t artle re flex.

S n ee zin g a n d th in w h ite m uc us c o m m o n.

47
 :

▶ S iz e : s m all m o u th fo u nd in t ris om y 1 8 a nd 2 1 ; c o rn ers o f m o u th turn d o w n ( fis h

m o ut h) in fe tal alc o ho l s ynd ro m e.

▶ M uc o us m em b ra ne s s h o u ld b e p ink .

▶ P a la te ex a m in a tio n (h a rd a n d s o f t p ala te ) fo r c lo s ure.

▶ S iz e o f t o ng u e: in re latio n to m o u th no rm a lly d o es no t ex ten d m u c h p as t t he

m ar g in o f

g u m s . E xc es s iv ely la rg e to ng u e s e en in c o ng e nita l a no m a lie s , s uc h as

c r etinis m a nd tris o m y 2 1.

▶ T e eth : p re-d ec id u o u s tee th ar e f ou n d o n ra re o c c a s io ns ; if th ey inte rfe re w ith

fe ed in g , they m ay b e rem o v ed .

▶ E p s tein 's p ea rls : s m a ll w h ite n o du les fo u n d o n s id e s o f h a rd pa la te (c o m m o n ly

m is ta k en fo r te eth ); re g res s in a few w eek s .

▶ F ren ulu m lin g ua e: thin rid g e o f tis s ue run n in g fro m b as e o f t o ng u e a lo n g

u nd e rs urf a c e to tip of to n g ue , f o rm erly b eliev ed to c au s e to n g u e-tie; no

tre atm en t ne c es s a ry . T ru e c on g en ita l a n k ylo g lo s s ia ( ton g ue-t ie ) is rare.

▶ In fe c tio ns : thr us h , c a u s ed b y C an d id a alb ic a ns , m a y a p p ea r a s w hite p a tc h es o n

to ng u e

a nd /o r ins id es of

c h ee k s th a t do n o t w a s h a w a y w it h flu id s ; tr ea ted w ith ny s ta tin s us p en s io n .

E x a m in e th e fo llo w ing :

▶ M o b ilit y : inf an t c an m o v e h ea d fr o m s id e to s id e; p a lp at e f o r ly m ph no d e s ;

p a lp a te c lav ic le fo r f rac tur es , e s p ec ia lly af ter a d iff ic u lt d elivery .

▶ T o rtic o llis : ap p e ars a s a s p as m o d ic , o ne -s id ed c o n tra c tio n o f n ec k m u s c les ;

g en erally fro m he m ato m a o f s t ern o c leid o m as to id m u s c le; u s u ally n o tre at m e nt

req u ire d.

▶ E x c e s s iv e s k in f o lds m ay be a s s o c ia ted w it h c o n g en ital ab n o rm alities s u c h a s

tr is o m y 2 1.

▶ S tiffn es s a nd h yp ere xte ns io n m a y b e c au s ed b y tra um a o r in fec tio n .

▶ C la v ic le fo r inta c tn es s.
48
▶ O b s er ve f o r m a s s es s u c h a s c ys t ic hy g ro m a w hic h is s o f t a n d u s u ally s ee n

la tera lly or o ve r the c lav ic le.

▶ C irc um f eren c e an d s ym m etry : a v era g e c irc u m fe ren c e is 1 2 to 1 3 inc he s ( 3 0 to

3 3 c m ), a p pr o xim at ely 2 c m s m aller t ha n h ea d c irc um feren c e.

▶ B rea s t.

● E n g o rg em en t m a y o c c u r at d ay 3 b ec a u s e o f w ith d ra w al of m a tern al

h o rm o n es , es p e c ia lly e s tro g en ; no trea tm en t r eq u ire d . R eg re s s es in 2 w eek s .

● N ip p les a nd a reo la les s fo r m e d a n d p ro n o u nc ed in p rete rm in fan ts .

▶ R a te n o rm ally b etw ee n 4 0 to 6 0 b rea th s /m inu te; inf lue nc ed b y s leep -w a k e s ta tu s ,

w hen la s t fed , d ru g s ta k en b y m ot he r, a n d ro o m tem p era ture .

▶ R h yth m re s pira tio n s m a y b e s h allo w w ith irre g ula r rhyth m .

▶ B re ath s o un d s ,d ete rm in ed b y au s c ulta tio n .

▶ R a te: n o rm al b etw ee n 1 1 0 to 1 6 0 b p m ( 8 0 to 1 1 0 n o rm al w ith d eep s leep ) ;

in flu en c ed b y b e ha v ior al s tate , e nv iro nm en ta l te m p e ratu re , m ed ic a tio n; ta k e ap ic a l

c o un t fo r 1 m inu te.

▶ R h yth m :c o m m o n to fin d p erio d s o f d ec ele rat io n fo llo w ed b y p erio d s o f a c c elera tio n .

▶ H e ar t s ou n d s ,s ec o n d s o un d hig h er in p itc h a n d s h a rp er tha n firs t; th ird an d fo u rth

s o un d s ra re ly h ea rd ; m urm u rs c o m m o n , m a jo rity a re t ran s ito ry a nd b en ig n .

▶ P u ls es ,ex a m in e e q ua lit y a n d s tren g th o f b rac hia l, ra d ia l, p ed a l, a nd fem o ra l

p u ls es ; lac k o f f em o ra l p u ls es in d ic a tive o f ina d eq u ate a o rtic b lo o d f lo w .

▶ C ya no s is ,ex am in e f or c ya n o s is . A c ro c ya no s is o f d is ta l ex tre m ities is c om m o n ;

rec ord lo c a tio n o f a ny c ya n o s is , c o lo r c h an g es w ith tim e, an d w he n c ryin g .

▶ B lo o d p res s u re ,n eo n a tes w h o w eig h m o r e th an 3 k g ha v e s y s to lic b lo o d p re s s ure

b etw een 6 0 to 8 0 m m H g ; d ias t o lic , b etw e en 3 5 a n d 5 5 m m H g . B lo o d p res s u re is

u s u ally hig he r in the lo w er e xtr em it ie s tha n in t he u p p er ex trem ities . B lo o d p res s u re

a s s es s m en t m ay n ot b e c o n d u c ted ro u tine ly o n h ea lth y ne o na tes . M ea s u rem en t

o f b lo o d p re s s ure is es se ntial
49
 f o r in fa n ts w h o s ho w s ig ns o f d is tre s s , a re p re m atu re, o r a re s u s p ec te d o f ha v in g a

c a rd ia c an o m a ly.

▶ S ha p e,c y lin d ric a l, p ro tru d es s lig htly, m o v es s yn c h ro n o us ly w ith c he s t in res pira tio n .

▶ D is te ns io n m a y b e c a us e d b y b ow e l o b s tru c tio n , or g an e nla rg em en t, o r in fec tio n.

▶ P a lp ate ab d o m en f o r m a s s es ; g ap b e tw een re c tu s m u s c les is c o m m o n ; p a lp ate

liv er a nd s p le en.

▶ A us c u lta te ab d o m en in all fo u r q u a dr an ts fo r b o w el s o u n d s ; us u a lly b o w el

s o u n ds o c c u r

a n h o u r af ter d elivery .

▶ K id n eys p a lp a te k id n eys f or s iz e a nd s h ap e.

▶ U m b ilic a l c o rd

● N or m a lly c o n ta in s tw o a rterie s , o ne ve in; s in g le a rtery s o m etim es

a s s o c ia ted w ith re na l an d o the r c o ng e nita l a b no rm alities .

● S ig n s o f inf ec tio n a ro u nd in s ertio n in to a b d o m ina l w a ll-red n es s , d is c h arg e.

● M ec o niu m s ta inin g ,as s o c ia ted w ith in tra ute rine c o m p ro m is e o r po s tm atu rity .

● B y 2 4 ho u rs , b ec o m es y ello w is h b ro w n ; d ries a nd f alls o ff in a p p ro x im a tely

1 0 to 1 4 d ays .

● U m b ilic a l h ern ia,d ef ec t in a b d o m in a l w all.

 Female

■ La b ia m ajo ra c o ve r la b ia m in o ra a nd c lito ris in fu ll- term fe m a le inf an ts.

■ H y m e na l t ag (tis s u e) m a y p ro tru d e fro m va g in a,reg r es s es w it hin s e ve ral w eek s .

■ V a g in a l d is c h ar ge ,w hite m uc o us d is c h arg e c o m m o n ; p in k -tin g ed m u co u s

d isc ha rge

( ps e ud o m en s tru a tio n) m a y b e p re s en t b ec a u s e o f th e d ro p in m a tern a l

h o rm o nes ; no t rea tm en t nec es sa ry.

50
  Male

■ Fu ll-te rm ,te s tes in s c ro t al s ac ; s c ro ta l s a c a pp e ar s m a rk ed ly w rink le d d u e to rug ae .

■ E d em a m a y b e p re s en t in s c ro ta l s a c if th e inf an t w a s b o rn in b ree c h p res e nta tio n ;

a fra nk c o llec tio n o f fluid in th e s c ro ta l s a c is a h yd ro c e le ,reg re s s es in a p p ro x im a tely a

m o n th.

■ E xa m ine g la ns p en is fo r ur eth ral o p en ing ,n o rm ally c en tra l; o p enin g v en tra l

(hy p os p a dia s) ; op e nin g d o r s ally (e p is p a d ias ) ; ab n o rm a lly a d he ren t f o res k in ( p him o s is ).

o C h ec k fo r p ate nt a nu s ,inf an t s ho u ld p a s s s to o l w ithin 2 4 ho u rs a fte r

d eliv ery. If p a s s ed m ec o n ium in u tero , p at en t a nu s ha s b een es tab lis h ed .

E xa m ine s p ina l c o lu m n f or n o rm a l c ur va tu re, c lo s u re, a nd p ilo n id a l d im p le o r s inu s ;

als o fo r tu fts o f h air o r s k in d is ru p tio n s tha t w o uld ind ic ate p o s s ib le s p ina b if id a .

E xa m ine a n al are a f o r a n al o p en ing , res p o n s e o f an a l s p h inc ter, fis s ures .

■ E xa m ine e xt rem ities f o r fra c tu res , p ar alys is , ra ng e o f m o tio n , irreg u la r p o s itio n .

■ E xa m ine f ing e rs a n d to e s f o r nu m b er an d s ep ar atio n : e xt ra d ig its , p o ly d ac t yly;

fu s ed d ig its , sy nd ac tyly.

■ E xa m ine hip s fo r d is lo c a tio n,w ith th e in fa n t in s up in e p o s itio n, fle x k n ees a nd

ab d u c t h ip s t o s id e and dow n t o ta b le s u rfa c e; c lic k in g s o un d ind ic a tes

d is lo c at io n (O rto la ni's s ign ).

■ A s ym m etr ic al g lu tea l fo ld s a ls o in d ic a te c o ng e nita l h ip dis loc atio n.

■ E xa m ine fe et f o r s tru c tu ra l an d p o s itio na l d ef or m ities , ie , c lub fo o t ( talip es

eq uin ov aru s ) o r m e ta tars u s ad d u c tu s (in w ard tu rn in g o f th e fo o t).

▶ N eu ro lo g ic m ec ha n is m s a re im m a tu re an at o m ic a lly a n d p h ys io lo g ic ally; as a

res ult, u n c o o rd ina te d m ov em e nts , la b ile t em p era tur e re g ula tio n, an d lac k o f

c o n tro l o ver m us c u la ture a re c ha ra c teris tic o f t he inf an t.

51
 ▶ E x a m in e m us c le to ne , h ea d c o ntro l, an d reflex es .

▶ T w o ty p es o f ref le xe s are p r es en t in the neo n ate:

✓ P ro tec tive in na tu re (b lin k , c o ug h , s n ee ze , g a g ),rem a in th ro ug h o u t life.

✓ P rim itiv e in na tu re ( ro o tin g/ s u c k ing , m o ro , s tar tle, to nic ne c k , s tep p in g , a n d

p alm ar/p la nta r

g ra s p ),eith er d is ap p e ar w it hin m o nt hs o r b ec o m e h ig hly d ev elo p ed a n d v o lun ta ry

(s u c k ing an d g ras p in g )

BEHAVIORAL ASSESSMENT

N e o na tes ex hib it p red ic ta b le, d ire c ted res p o n s es in s o c ia l inte ra c tio ns w ith

n urtu rin g a d u lts o r in res p o n s e to a ttra c tiv e au d ito ry o r vis u a l s tim u li.

 L en g th o f s lee p c y c les ( R EM , a c t iv e a n d q u iet s lee p ) c ha n g es w ith m a tura tio n

o f the c en tra l n erv o u s s y s tem (C N S ) .

 Q u iet s leep s h o uld in c re as e w ith tim e in re latio n to R E M s leep .

 N e o na tes u s ua lly s leep 2 0 h ou rs p er d ay.

52
▶ M o s t n eo n ate s fe ed s 6 to 8 tim es p e r d ay w ith 2 to 4 ho u rs b etw e en fee d ing s ;

es ta b lis h f airly re gu la r f ee d in g p att ern s in a p p ro x im a tely 2 w eek s .

▶ C alo ric req u irem en ts are hig h ,1 10 to 1 3 0 c a lo ries / k g o f b o d y w e ig h t d aily.

▶ M o s t d ig es tive en zy m e s a re p res e nt a t birth .

▶ Im p er fec t c o ntro l o f c a rd ia c an d p ylo ric s p hin c te rs ; im m at urity re s ults in

reg u rg ita tio n .

Stool

o M ec o niu m is us u a lly p as s ed in 2 4 h ou rs .

o P a s s a ge o f m ec o n ium (ta rry g r een -b lac k s to o ls ) c o ntin ue s f o r 4 8 h o ur s ,

f ollo w e d

b y tra ns itio n al s to o ls ( c o m b ina tio n o f m ec o n iu m a n d yello w o r m ilk s to o ls ).

M ilk s to o ls (y ello w ) are pa s s ed b y d a y 5 .

o N eo na te h a s u p to s ix s to o ls p e r da y in th e firs t w ee k s a ft er b irth .

Voiding

o N eo na te v o id s w ith in firs t 2 4 ho u rs .

o A fter f irs t few d a ys , in f an t vo id s fro m 1 0 t o 1 5 tim es p er d ay.

▶ In f an t's b o d y res p o n d s rea d ily to c ha n g es in en viro n m en tal tem p eratu re.

▶ H e at lo s s at b irth m a y o c c ur th ro ug h ev ap o ra tio n , c o nv ec tio n , c o n d uc tio n , a n d

ra d ia tio n .

▶ P h ys io lo g ic m e c h an is m s to av o id h ea t lo s s inc lu d e:

o V a so c on s tric tio n .

o N on s h ive ring th er m o g e ne s is elic ited b y s ym p ath et ic ne rv o us s y s tem in

re sp o n se to d ec rea s ed tem p eratu re.

53
REFLEXES OF NEWBORN

PRIMITIVE REFLEX

Primitive reflexes a re ref lex a c tio n s o rig in atin g in t he c en tra l n erv o us

s ys te m th at are ex h ib it ed b y n o rm a l in fa nts b ut n o t n eu ro lo g ic ally in ta c t a d u lts , in

res p o n s e to p a rtic ular s tim uli. T h es e re flex es d is a pp e ar o r a re inh ib ited b y th e fro n ta l

lo b es as a c h ild m o v es thro u g h n o rm al c h ild d ev elo p m e nt . T he s e p rim itiv e ref le xe s a re

als o c alled infantile , infant o r newborn reflexes.

ADAPTIVE VALUE OF REFLEXES

Re flex es va ry in utility. S o m e h a ve a s u rv iva l v a lu e. A p e rfe c t e xa m p le w o u ld

b e the ro o tin g refle x, w hic h h elp s a b re as tf ed inf a nt f in d th e m o the r's n ip p le . B ab ies

d is p la y it o nly w he n hu n g ry a n d to uc he d b y an o th er p e rs o n, no t w hen th ey to uc h

th em s elv es . T he re a re a few ref le xe s th a t p ro b ab ly h elp ed b ab ie s s u rv iv e d u ring

hu m a n e vo lu tio na ry p as t lik e th e M o ro reflex .

O the r r efle xe s s u c h a s s u c k in g a n d g ra b b ing h elp es ta b lis h gr atif ying

intera c tion b e tw een p are nts a nd inf a nts . T h ey c a n en c o u ra g e a p a ren t to r es p o nd

lo vin g ly an d fe ed m o re
54
c o m p ete ntly . T he y c an als o help p are nts c o m fo rt t heir inf an t b e c a us e th ey allo w th e

b ab y to c o n tro l d is t res s an d the a m o un t o f s tim ula tio n th ey re c eive.

Th e ro o ting ref lex is p res en t at b irth : it a s s is t s in b rea s tf eed in g ,

d is ap p e arin g a t a ro un d fo u r m o n th s of ag e a s it g rad u a lly c o m e s u n d er v olu n tary c on tro l.

A n ew b o rn in fa nt w ill turn h is h ea d to w ard a n yth ing t ha t s t ro k es h is

c h eek o r m o uth , s ea rc h ing f o r the o b jec t b y m o v ing h is he ad in s te ad ily d ec rea s ing a rc s

un til th e o b jec t is f o u nd . A f ter b e c o m ing u s ed to res p o n d ing in th is w a y (if b rea s tfe d ,

ap p r ox im at ely th ree w eek s af ter b irth ), t he in fa n t w ill m o ve d irec t ly to th e o b je c t w ith o ut

s earc hing .

Rooting reflex

T h e s u c k in g ref le x is c o m m o n to a ll m am m a ls an d is p res e nt a t b irth . It is

lin k ed w ith th e ro o tin g r efle x a nd b rea s tfe ed ing , an d c a us e s th e c h ild t o ins t in c tiv ely

s uc k a t an ythin g tha t to u c h es t he ro o f o f the ir m o ut h a n d s u d d en ly s t arts to s uc k

s im u la ting th e w ay the y n atu rally e at . T he re are tw o s ta g es to th e ac tio n:

Expression : ac tiva ted w h en th e nip p le is p la c e d b e tw een a c h ild 's lip s a nd to u c h es the ir

p alate . T he y w ill in s tin c tiv ely p res s it be tw een t he ir to n g u e a n d pa la te to d raw o ut th e m ilk .

55
Milking: T h e to ng u e m o ve s fr o m a reo la to n ip p le , c o ax ing m ilk fro m th e m o th er

to b e s w a llo w ed b y the c hild .

T h is refle x is s h o w n b y p lac in g fin g er o r a n o b je c t in to b ab y 's o p e n p a lm , w h ic h

w ill c a u s e a refle x g ra s p o r g rip . If it is tried to p u ll aw a y, th e g rip w ill g e t ev en s tro ng .

T h e p alm ar a nd p lan ta r g ra s p us u a lly d is a p p ea rs b y 5 -6 m o n ths a nd 9 -1 2 m o n th s

res p ec tive ly.

A p la nt ar ref lex is a n o rm a l ref lex th at inv o lve s p la nta r flex io n o f the f o o t ( to es

m o ve a w ay f ro m t he s h in, a nd c u rl do w n.

A n in fa nt d em o n s tra ting the B a b in s k i re flex : he o p en s h is m o u th w he n

p res s u re is a p p lie d to b o th pa lm s ( ).

Th e B ab in s k i ref le x oc c u rs in n ew b o rn b a b ies , an d d e s c rib es v ary ing

res p o n s es to th e a p p lic a tio n o f p re s s ure to b o th p alm s . I nf an ts m a y d is p la y he ad

flex io n , h ea d ro ta tio n o r o p enin g o f th e m o u th , o r a c o m b ina tio n o f t he s e res p o n s es .

S m a lle r, p rem a tu re in fa n ts a re m o re s us c ep tib le to t he re flex.

A ls o c alled th e s ta rtle ref lex , th e M o ro is u s ua lly trig g ered if b a b y is s ta rtled

b y a lo ud n o is e o r if his he ad f alls b ac k w ard o r q u ic k ly c ha n g es p o s ition . B ab y 's

res p o n s e t o the m o r o w ill in c lu d e s p rea d in g h is a rm s a nd leg s o u t w id ely an d ex ten d ing

his n ec k . H e w ill then

56
q u ic k ly b rin g h is arm s b a c k to g eth er a nd c r y. T h e m o ro ref le x is us u a lly p re s en t at

b irth and d is a p p ea rs b y 3 -6 m on ths .

STARTLE REFLEX

T h e M o ro ref lex in a fo u r-d a y-o ld in fa nt: 1 ) the ref lex is in itiate d b y p u llin g th e

inf an t up fr o m t he flo o r a nd th en relea s ing h im ; 2 ) h e s p rea d s h is ar m s 3 ) h e p u lls h is

ar m s in; 4 ) h e c ries ( )

MORO REFLEX

57
 T h e w alk in g o r s te p pin g ref le x is p res en t a t b irt h; th o u g h inf an ts th is yo u n g

c a n not s u p p o rt the ir o w n w e ig ht, w he n th e s o les o f th eir fee t to uc h a f la t s u rfa c e th ey

w ill a ttem p t to 'w a lk ' b y p la c ing o n e fo o t in f ro nt o f t he o th er. T his ref le x d is a pp e ar s a t 6

w eek s as an au tom a tic res p o n s e a n d rea p p ea rs a s a v o lu n tar y b eh a vio r at aro u n d eig h t

m o nth s to a yea r o ld

WALKING/STEPPING REFLEX

T h e to nic n ec k re flex , a ls o k n o w n a s a s ym m etric to n ic n ec k re flex o r 'fe nc in g

p os tu re' is p res e nt at o n e m o n th o f a g e an d d is a p p ea rs a t a ro u nd fo u r m o n th s . W h en

th e c hild 's he ad is t urn ed to th e s id e , the a rm o n th a t s id e w ill s traig h ten an d th e o p p o s ite

ar m w ill b e nd (s o m etim es th e m o tio n w ill b e v er y s u b tle o r s lig ht) . A c c o rd in g to

res e arc he rs , t he to n ic n ec k ref lex is a p rec u rs o r to th e h an d /e ye c o o rd ina tio n o f th e

inf an t. I t als o p r ep ar es th e in fa n t f o r v olu nta ry reac h ing .

58
 TONIC NECK REFLEX

Opposite reaction Tonic Neck Reflex

A p o s tu ra l rea c tio n , th e a s ym m etric to nic ne c k re flex , o r f en c er res p o n s e, is

p res e nt a t birt h. T o e lic it th is re flex , w hile yo u r b ab y is ly in g o n his b a c k , tu rn h is h ea d t o

o ne s id e, w hic h s h o uld c a u s e th e a rm an d leg o n th e s id e th a t he is lo o k in g to w ard t o

ex ten d o r s traig h ten , w hile his o th er ar m a nd leg w ill f le x. T his ref lex u s ua lly d is ap p e ars b y

4 -9 m o n ths .

If yo u r b a b y is o n h is s t o m a c h a n d yo u s tro k e n ec k to th e s p ina l c or d

(p ara v erteb ral a rea ) o n his m id d le to low e r b a c k , it w ill c a us e h is b a c k to c urv e to w ar d s

th e s id e t ha t y o u a re s tro k in g . T h is refle x is p re s en t at b ir th a n d d is ap p ea rs b y 3 - 6

m o nth s . If th e refle x p ers is ts pa st s ix m o nth s o f a g e, it is a s ign o f p ath o lo g y. T he

ref lex is n am ed af ter the R u s s ia n n euro lo gis t Jo h a nn S us m a n G a la nt.

59
 A n inf a nt p lac e d f ac e d o w n in a p o o l o f w a ter w ill b eg in to p ad d le a nd k ic k

in a s w im m in g m o tio n . T he re flex d is a p p ea rs be tw een 4 – 6 m o nt hs . Its s u rv iv a l f un c tio n

is to h elp the c hild s tay a live if it is d ro w n in g s o a c ar eg ive r h a s m o re tim e to s av e it.

E yes o p e n o n c o m ing to s ittin g ( Lik e a D o ll's ) H ea d initia lly lag s B ab y us e s

s ho u ld ers to rig ht h ea d po s ition

1 . S o f t c lo th is p la c e d o v er th e b a b ie s e yes a nd no s e

1 . B ab y arc he s h ea d an d turn s he ad s id e to s id e

1 . B ring s b o th h a nd s to fa c e t o s w ip e c lo th a w a y

N ew b o rn p la c e d on ab d o m e n

B ab y f lex es leg s un d er h im a nd s ta rts to c raw

T h is is a p ro te c tiv e res p o n s e t ha t p ro te c ts inf a nt if h e f a lls . B e g in n ing a t

ab o u t 5 - 6 m o nt hs , if an inf an t fa lls , h e w ill ex te nd his a rm s to try a n d 'c a tc h ' him s elf.

B eg in nin g at d if fe ren t a g es , th e p ro p p in g re s po n s es he lp c hild lea rn to s it. T he

firs t is th e an terio r p ro p p in g re s p o ns e , w hic h b e g in s a t 4- 5 m o n th s , a nd in vo lv es in fa n t

ex ten d ing his a rm s w h en he is h eld in a s ittin g p o s itio n , allo w in g h im to a s s um e a trip o d

p os itio n.

N ex t, la tera l p ro p p in g , ap p e arin g a t 6 -7 m o n th s , c a us e s h im to ex ten d h is a rm to

th e s ide if h e is tilted .
60
 La s tly, p os t erio r p ro p p in g , c au s ing h im to e xte nd h is a rm s b a c k w a rd s if h e is

titled b ac k w a rd.

DAILY OBSERVATION OF NEONATES:

N eo n a tes s ho u ld b e o b s er ve d d a ily d u ring h o s p ital s ta y. D eta ile d e xa m ina tio n

is n ot ne c es s a ry b u t m o th er a nd b a b y s ho u ld b e ap p ro a c h ed tw o tim es d aily a nd

inf o rm atio n s s ho u ld b e c o lle c te d fro m th e m o th er (o r c a reta k er) ab o u t t he fe ed ing

b eh av io r, v o m itin g , pa s s a g e o f s to o l a n d urin e, s le ep an d p res e nc e o f a ny p ro b le m s .

Th e ne o na tes s ho u ld als o be a s s es s ed fo r h yp o th erm ia , res p ira to ry d is tre s s ,

ja u nd ic e a nd s u p erf ic ial in fe c tio n s lik e c o n jun c tivitis , u m b ilic a l s e p s is , o ra l th ru s h

an d s k in infe c tion .

T h e n eo n ate s s h o u ld b e m o nito re d f o r th e d a ng e r s ig n s . P re s en c e o f th es e

fea ture s in d ic ate s s p ec ial atte nt io n , reev a lu a tio n a nd ea rly interv en tio n s.

The danger signs are:

● P o o r f ee din g , s uc k in g an d s w a llo w in g reflex .

● C o ld to t o uc h o r ha v ing ris e in b o d y tem p era ture
● P o o r ac t iv ity a nd p o o r res p o n s e to s tim u la tion
● E xc es s iv e c ryin g an d irritab ility
● Ra p id r es p irat io n , m o re tha n 6 0 p er m inu tes a nd p res e nc e o f c h es t retra c tio ns
● B lue d is c o lo ra tio n o f lip s o r to n g ue ( c e ntra l c ya no s is )
● D ro o ling o f s a liva o r c ho c k in g d ur in g fee d ing o r fro th in es s
● La b o red res p ira tio n o r a bs e nc e o f res p iratio n
● Ja u nd ic e a p p ea rs w ith in 2 4 h o urs o n e ex ten d ing to p alm s o r s o les
● N o urin e w ithin 4 8 h o u rs a n d no m ec o n ium w ithin 2 4 h o urs
● C o n vu ls io ns o r ab n o rm a l m ov em en ts
● B leed in g f ro m a n y s ite
● U m b ilic al dis c h arg e
● S u p erf ic ial inf ec tio n s ( p yo d er m a , a b s c e s s , o ra l t hru s h , c o n ju nc tiv itis )
● D iar rhe a, v om itin g a nd a b d o m in al d iste ns ion .

61
 NEONATAL INTENSIVE CARE UNIT GOALS AND OBJECTIVES

GOAL 1: U n d ers ta n d the p ed ia tric ia n’ s ro le in re d uc in g m o rb id ity in h ig h ris k

p re g na n c ies a nd c o m p lic a tio ns o f c h ild b irth.

OBJECTIVES

D es c rib e g en era l pr in c ip les ab o u t:

o B a s ic v ita l s ta tis tic s th at ap p ly to ne w b o rns (n eo n at al, p erina ta l

m o rtality,etc .)

o T es ts c o m m o n ly us e d b y o bs t etric ia ns t o m ea s ure f eta l w e ll- be in g .

o P re na ta l s e rvic es av a ila b le in o n e’ s reg ion .
o P re na ta l v is it in t he p e d ia tric ia n ’ s o ff ic e.
o N e o na ta l tra n s p o rt s ys tem s
o E f fec tive in ter ve ntio n p ro g r am s fo r tee ns an d o th er hig h ris k m o thers

F o r ea c h o f th e f o llo w in g p re na ta l a n d p er in a tal c o m plic a tio n s

o D e s c rib e th e p ed ia tric ian ’ s ro le in as s e s s m e nt a n d m an ag em en t.

o R ec o g n iz e p o ten tial ad v ers e o utc o m e s f or th e fetu s /n eo na te

62
L is t o f c o m p lic atio ns :

o M a tern al in fe c tio n s /ex p o s u re to inf ec tion s d urin g pre gn an c y

o F eta l e xp o s u re to ha rm fu l s u bs t an c e s (E T O H , T OB , s tree t d ru g s ,
m ed ic atio ns , en viro n m en t tox ins )

o M a tern a l in s ulin -d ep end en t d ia b etes an d p re g na nc y-in d uc ed into

g luc os c e
leran
e
o P re m a tu re lab o r, p rem a tur e ru p tur ed m em b ran es
o C o m p lic a tio ns o f an es th es ia an d c o m m o n d elive ry p ra c tic es ( C es a ere an
s ec tio n , v ac uu m , f o rc ep s , ep id u ra l, in d uc t io n o f la b o r)

o F eta l d is tr es s d u rin g d elivery

o P o s tp a rtu m m a tern al fe ver/ in fec tio n
o H is to r y o f m ate rna l G B S c olo n iz atio n/ treatm en t
o M u ltip le g es ta tio n
o P la c en ta l a b no rm alities
o P re-e c lam p s ia , ec la m p s ia l. C h o rio a m n io n itis

o P o lyhy dra m n io s
o O lig o h yd ram nio s

D is c us s th e p ed ia tric ia n’ s ro le in red u c in g fet al a nd n eo n ata l m o rb id ity /m o rta lity

ihis /h er o w n c o m m u nity.

GOAL 2: U n de rs ta nd h o w to res u s c ita te an d s tab iliz e a c ritic a lly ill n eo na te.

OBJECTIVES

D es c rib e th e s tep s in res u s c ita tio n a nd s t ab iliza tio n , inc lu d ing eq u ip m ent n eed ed .

D em o ns tra te ef fic ie nt a nd e ffe c tiv e re s us c it atio n in m o c k c o d es a nd u nd e r s tres s

o f ac tu al c o d es .

F o rm ula te a d if fe ren tial d iag n o s is fo r s erio u s s ym p to m s p re s ent in g d u rin g

tr an s fe r to the N IC U o r in th e N I C U im m ed ia tely a fte r res us c ita tio n .

63
GOAL 3: U n d er s tan d h o w to e va lua te a nd m an ag e c o m m o n s ig n s a nd s ym p to m s o f

d is ea s e in h ig h ris k n ew b o rn s.

OBJECTIVES

F o r ea c h o f the s ig n s an d s ym p to m s b elo w :

1 . P e rfo rm an ap p ro p ria te a s s es s m en t ( H & P , I nitia l d ia g no s tic s tu dies ).

1 . F o rm ula te a d iff eren tia l d ia g no s is w ith ap p ro p ria te p rio ritiza tio n

1 . D es c rib e in dic atio n s f o r ad m is s io n o r ref erra l to Lev els I, II, a n d III

n urs eries .

1 . D es c rib e s ta b iliz a tio n p ro c e d ure s to p rep a re f o r tran s fer

1 . F o rm ula te an d c a rry o u t a p la n fo r c o n tin uin g as s e s s m e nt a n d

m an ag em en t.

L is t o f S ig ns a nd S y m p to m s (N IC U )

● In tra u terin e g ro w th fa ilu re

● L arg e f o r g es ta tio na l ag e
● H y po th erm ia
● H y pe rtherm ia,
● P rem atu rity
● F ee d in g p rob lem s
● P o o r p o s tna ta l w e ig h t g ain
● Le tha rgy /irrita b ility/jitte rin es s ,
● H is to r y o f m a te rna l in fe c tio n o r ex p os u re,
● D e hyd ra tio n .

§ R es p ira to ry d is tres s
§ C y an os is
§ A p n ea
§ B ra dy c ard ia 64
§ H e ar t m u rm u r
§ H y po ten s io n
§ H y po ten s io n
§ H y po v o lem ia
§ P o o r p uls es
§ Sh o ck.

■ C om m o n s k in ras he s /c o nd ition s ,
■ B irthm ark s
■ H y p er a nd h yp o p ig m e nt ed les io ns
■ D is c ha rg e a nd / o r in fla m m a tio n o f th e
u m b ilic us

■ P ro p e r s k in c a re fo r p re m a tu re inf an ts
■ V es ic les .

■ F ee d in g in to leran c e
■ V o m iting ,
■ B lo o d y s to o ls
■ D is te nd e d a b d om en ,
■ H e pa to s plen o m eg a ly
■ A bd o m in al m a ss
■ F a ilu re to p a s s s to o l
■ D ia rrhea .

 M eta b o lic d eran g em e nts ,

 H y po g lyc em ia
 H y pe rc alc em ia
 H y po c a lc em ia ,
 H y po k a lem ia
65
 H y pe rka lem ia
 A pp a re nt c o n g en ital d ef ec t o r d ys m o rp h ic
s yn d ro m e.

✓ J a un d ic e in a p r em atu re, te rm o r s e rio us ly ill

n eo na te,

✓ P etec hiae
✓ A n em ia ,
✓ P o lyc yth em ia
✓ A bn o rm a l b leed ing ,
✓ T h ro m b o c yto p en ia
✓ N e utro p enia .

▶ B irth trau m a re late d f ra c tu res a nd s o ft tis s u e

injuries

▶ D is loc atio ns
▶ B irth d ef ec ts a nd d efo rm ities .
▶ N e uro log ic
▶ H y po to n ia
▶ H y pe rton ia
▶ S e iz ure s,
▶ Le tha rgy
▶ E a rly s ig ns o f n eu ro lo g ic im p airm ent,
▶ M ic ro c ep h aly, m ac ro c e ph aly
▶ S p in a b ifid a
▶ B irth tra um a r elat ed n erv e d am a ge .

P o o r atta c h m en t,

P o s tp a rtu m d ep res s ion A nx iety dis o rd ers T een

p a rent

66
 S ub s ta n c e ab us e C h ild ab u s e an d N eg lec t.

■ E d em a
■ D ec re as e d u rine o utp ut
■ A bn o rm a l g en italia
■ R en al m as s
■ H e m a turia,
■ U rin a ry reten tion
■ In g u ina l hern ia .

✓ A bn o rm a l re d reflex
✓ E y e an o m a ly

GOAL 4: U n d ers ta n d ho w to m a na g e, un d er the s u p erv is io n o f a ne o na to lo g is t,

c om m on d ia g n o s es in inf an ts in a Lev el II o r III n urs ery .

OBJECTIVES

F o r ea c h o f t he f o llo w in g c o m m o n d ia g no s e s in th e lis t b elo w ; b e

a b le to

o D e s c rib e th e p at ho p h ys io lo g ic ba s is of th e d is ea se .
o D e s c rib e th e initia l a s s es s m en t p lan s .
o D is c us s k ey p rin c ip les o f th e N IC U m a na g em en t p lan .
o E x p lain w h en to u s e c on s ultan ts .
o E x p lain th e ro le o f th e p rim a ry c a re p ro vid er.

67
Lis t o f C o m m o n D ia g no s e s in t his S ett in g ( N IC U )

: H ya line m em b ran e d is ea s e, tr an s ien t ta c h yp ne a o f th e

ne w b o rn,

m ec o n ium a s p irat io n , a m n io tic flu id o r b lo o d a s p ir atio n , p ers is te nt p u lm o na ry

hy pe rtens io n, p ne um o n ia , p n eu m o tho ra x , b ro n c h o p ulm o n ary d ys p las ia , a telec ta s is .

C o n g en ita l he ar t d is ea s e (c y an o tic a nd a c ya n ot ic , o b s t ruc tive

les io n s , s ing le v en tric le) , p a ten t d uc tus a rter io s u s , c o ng e s tive h ea rt fa ilure , S VT , c om p lete

he ar t b lo c k .

: In f an t o f d ia b etic m o the r, c o m m o n c hr om o s o m a l

an o m a lies , c o n g en it al ad re na l hy p erp las ia , hy p o a n d h yp erth yro id is m .

: F ee d in g p la ns a n d n ut rit io n a l m an a g em en t o f h ig h ris k ne o na tes o r

th o s e w ith s p ec ia l ne ed s , b re as t fe ed in g s u pp o r t for m o th ers an d in fa n ts w ith

s p ec ia l n eed s , h ep atitis , g a s tro in tes tin al ref lux , m e c o n iu m p lug , m alro ta tio n ,

H irs c h p ru ng s , ne c ro tiz in g entero c o litis , s ho rt g u t s yn d ro m e, g a s tro e s o ph a g ea l re flux .

In d ic at io n s f or p h ot o the rap y , an em ia , p oly c yth em ia ,

tra ns f us io n of b lo o d p ro d uc ts , e xc ha ng e tra ns f us io n s in th e p rem a ture /te rm o r ill

ne o na te, eryth rob las to s is fe ta lis / hy d ro p s fet alis , c o ag u lo p ath y, he m o p h ilia, V ita m in K

p rop h ylax is/ de fic ienc y .

: In tra ute rine v iral in fe c tio n s , G ro u p B S tr ep to c o c c al in fe c tio n s ,

ne on ata l s ep s is a nd m en ing itis , h erp e s s im p lex ; in fa nt of H IV inf ec te d m ot he rs ,

ne o na ta l h ep atitis , s yp h ilis ; no s o c o m ia l inf ec t io n s in th e N IC U , c en tra l line

inf ec t io n s , im m u n iz a tio n o f the p rem a tur e ne on a te, is o la tio n p ro c ed u res fo r c o nt ag io u s

d is ea s es in m o the r/in fa nt, ind ic atio n s fo r R S V p ro p hy la xis .

H y p o xic - is c he m ic e nc ep ha lo p a thy , int rav en tric u lar h em o rrh ag e ,

he aring lo s s in hig h ris k n ew b o rn s , d r ug w ith d raw a l, s eiz u res , hy d ro c ep h alu s , s p in a

b ifid a , CN S an o m a lies .

68
 (a s s es s a nd p a rtic ip a te in m a n ag em e nt un d er s u p erv is io n of or

c o llab o ra tio n w ith p ed ia tric s urg e o n) N ec ro tizin g e nte ro c o litis , s h o rt g ut s yn d ro m e ,

inte s tina l p e rfo ra tio n, in tes tin al o b s truc tio n, d ia p hra g m atic he rnia , m alro ta tio n ,

es o p h ag e al a tres ia a nd tra c h eo e s o p ha g ea l f is tu la, in tes tin a l a tre s ia , m ec o n ium ileu s ,

m ec o n ium p lu g s yn d ro m e , g as t ro s c h is is , o m p h alo c ele, im p er fo ra te a nu s , p re-o p a n d

p os t-o p c a re.

retin o p at hy o f p re m a tu rity, c ata ra c ts an d eye a no m alies

c o m p lic a tio n s o f um b ilic a l c ath eteriza tio n

GOAL 5: U nd e rs ta nd ho w to us e an d in terp r et la bo r ato ry a n d im ag in g s t ud ies un iq ue

to th e N I C U s ettin g.

OBJECTIVES

O rd er an d inte rp ret lab o ra to ry a n d im a gin g s tu d ies ap p ro p ria te fo r N I C U p atients .

E xp la in in d ic atio n s , lim ita tio ns , a nd g es tatio na l-ag e no rm s f or t he fo llo w in g w h ic h

m a y h av e s p ec ific ap p lic a tio n to n eo n ata l c are:

o S ero lo g ic a nd o th er s tu d ies f o r tra ns p la c en ta l in fec tio ns

o D irec t a n d in d irec t C o o m b ’ s test
o N eo n a tal d ru g sc reenin g
o N eu ro ultras o u nd
o A b d o m ina l x- ray s fo r p la c em e nt of u m b ilic a l c a th eter, b o w e l g as
p attern , e vid en c e of N EC

o C h es t x -ra ys fo r en d o tra c h ea l tu b e p la c e m e nt , h ea rt s ize a n d va s c u larity ,

d eep lin e

p la c em en t

69
GOAL 6: U n d ers ta n d th e a p p lic a tio n o f th e p hy s io lo g ic m o nito r in g a n d s p ec ial

tec h no lo gy a p p lied to th e c a re o f the fet us a nd ne w b o rn

OBJECTIVES

Fo r ea c h o f t he fo llo w ing , w h ic h are c o m m o nly us e d b y p e d ia tric ia n s , d is c us s

in d ic atio ns an d lim ita tio ns a nd d em o ns t rate p ro p er u s e/in s tru c tio n in h o w t o u se:

o P hy s iolo g ic m o nito rin g of tem p era tu re, p uls e , re s pira tio n , b lo o d p res s u re
o P ho to thera p y
o P uls e o xim etry
o U m b ilic al ar teria l a nd v eno u s c ath eteriz atio n
o E nd o tr ac h ea l in tub a tio n
o T ho ra c en tes is
o C h es t tu b e p la c em en t
o E lec tric a nd m an u al b rea s t p um p s
Fr om ea c h o f the f o llo w in g tec hn iq ue s a n d p ro c ed u res u s ed by

o bs tetric ia ns , p erin at alo lo g is ts , an d ne o na to lo g is ts , d es c rib e k ey in d ic a tio ns ,

lim ita tio ns , n o rm al an d f req u en tly en c o u nte red a b no rm a l fin d in g s , a nd

co m m o n c o m p lic a tio ns for th e fe tus /inf an t:

o Fe tal u lt ras o u n d f o r s iz e a nd a na tom y

o Fe tal h ear t rate m o nito rs
o S c a lp an d c o rd b lo o d s a m p ling
o S u rfa c ta n t th era py
o E C M O /N itric o x id e th era py
o A m n io c ente sis
o B iop h ys ic al pr o file/s t res s te stin g
o In trau te rin e tra ns fu s ion s /P U B S
o C h o rio nic v illu s sa m pling
o E xc ha n g e tran s fus io n
o C en tra l hyp era lim en tatio n
D is c u s s in g en era l term s , ho m e m ed ic a l eq u ip m e nt a nd s erv ic e s n eed e d f o r

o xyg en d ep en d en t a n d te c h no lo g y d e pe nd e nt g ra d u ate s o f th e N IC U

70
GOAL 7: D ev elo p a lo g ic a l an d e ffe c tiv e a p p ro a c h to th e a s s es s m en t an d d a ily

m an a ge m en t of s erio u s ly ill n eo n a tes a nd th eir fa m ilies , u nd e r the g uid a n c e o f a

ne o na to lo g is t, u s in g d ec is ion - m a k in g a n d p ro b lem s o lvin g sk ills .

OBJECTIVES

A p p ly p rinc ip le s o f d ec isio n -m a k ing a nd p ro b lem s o lvin g t o c are in th e N IC U .

S ee k in fo rm a tio n a s ne ed ed an d a p ply th is k n o w led g e a p p ro p riat ely u s in g

ev id en c e b as e p ro b lem so lv in g .

Re c o g n iz e th e lim its o f o n e’ s o w n k n o w le d g e, s k ill, a nd to lera n c e o f s tr es s ;

k no w w h en to a f or h elp , ho w to c o nta c t c o n s u lt an ts an d w her e to fin d b as ic

in fo rm atio n.

D ev elo p a c o m p reh en s ive p ro b lem lis t w ith ap p ro p ria te a n d ac c u rate

p rio ritiza tio n for ac tio n.

GOAL 8: U n d ers ta n d h o w to fu n c tio n ef fe c tiv ely as p a rt o f a n inte rd is c ip lin a ry tea m

m em b er in th e N IC U .

OBJECTIVES

C o m m u n ic a te an d w o rk ef fec tive ly w ith a ll m em b ers o f th e h ea lth c ar e tea m

(res id ents ,

at ten d in g , c o ns u lta nts , n urs e s , n ur s e s p e c ia lis ts , la c ta tio n c o n s ulta n ts ,

nu tritio nis t, p h arm a c is ts , re s p irato r y th era p is t, s o c ia l w o rk er s , d is c h arg e

c o o rd in ato rs , ref erring p hy s ic ian s a n d a n c illa ry S taf f).

C o m m u n ic a te ef fec tive ly w ith p a re nts of c ritic ally ill p atie nts a nd h ig h ly

s tres s ed f am ilies .

D is c u s s ro le o f p r im a ry c a re p h ys ic ia n in the lo ng term m an a g em en t o f in fa n ts
ad m itte d

to the N IC U .

D is c u s s th e ro le o f m a na g ed c are c a s e m a n ag er , w o rk w ith th es e in d iv id u a ls to

o ptim iz e h ealth c a re o utc om es .

71
GOAL 9: U nd e rs tan d ho w to p ro v id e c o m p reh en s ive an d s up p o rtiv e c a re to t he N IC U

infa nt a nd th eir fa m ily.

OBJECTIVES

S erv e e ffe c tiv ely a s a n a d vo c ate an d c as e m an ag e r f o r p atie nts w ith m ultip le

p ro b lem s or c h ro nic illnes s es .

W o rk w ith d is c ha rg e c o o rd ina to r t o d ev elo p d is c h a rg e p la ns w h ic h fa c ilita te th e

fa m ily’ s tra ns itio n to h o m e c are , in c lu din g a d eq u ate f o llo w -u p a n d ap p ro p ria te

us e o f c o m m u nity s erv ic es .

D em o n s tra te s e ns itiv ity an d s k ills in d ea ling w ith d ea th an d d y in g in th e N IC U

s etting .

C o n s is t en tly lis ten c a refu lly to c o nc e rn s o f fa m ilies a nd p ro v id e ap p ro p ria te

in fo rm atio n a nd s up p o rt.

P ro vid e c o un s elin g a n d s u p p o rt f o r b r eas t fee d in g o f p rem a tu re a nd c r itic ally ill

in fa nts , in c lu d ing m a in ten an c e o f m o th er’ s m ilk s u p p ly w h en th e in fa nt c an n o t

s uc k le.

P ro vid e res p o n s ib le c o m m un ic a tio n w ith the n eo n ate ’ s p rim ary c a re p h ys ic ia n

d urin g the ho s p ita l s t ay a nd in d is c h a rg e p la nn ing

Id en tify p ro b lem s a nd ris k fa c to rs in th e inf an t o r f am ily an d m a k e

ap p ro p ria te in te rve ntio n s an d /o r ref errals .

GOAL 10: B e c o m e fa m ilia r w ith eth ic a l a nd m ed ic a l-leg a l c o n s id e ra tio n in th e c a re o f

c ritic ally ill ne w b o rns .

OBJECTIVES

D is c u s s c o nc ep ts of fu tility , w ith d ra w a l a n d w ith h o ld in g c are . D es c rib e h o s p it al

p o lic y o n “ A llo w N a tu ra l D ea th” o rd ers .

Id en tify s itu atio n s w a rra nt in g c o ns u lta tio n w ith th e ho s p ita l eth ic s c om m ittee .

C o m p lete a d e ath c ertif ic at e a p p rop riate ly .

72
GOAL 11: U nd e rs tan d k ey a s p ec ts o f c o s t c o ntr ol a n d m ec h an is m s fo r p a ym en t in the

N IC U s ettin g

OBJECTIVES

B e s e ns itiv e to t he b u rd en o f c o s ts o n f am ilies a nd re fer f o r s oc ial s erv ic es a s

ind ic a ted . U s e c o ns u ltan ts an d o th er res o u rc e s a p p ro p riat ely d u rin g N IC U s ta y

a n d in d isc ha rge p lan nin g.

D em o ns tra te a w a ren es s o f c o s t s a nd c o s t c o n tro l in N IC U c a re.

E x p lain p rin c ip les o f typ ic a l c o ve rag e b y lo c a l in s u ran c e p lan , M ed ic a l, a nd o th er

s ta te an d f ed er al s ub s id ies fo r th e c a re o f h ig h ris k n eo na tes .

GOAL 12: U n d ers ta n d h o w to m a inta in a c c ura te, tim ely a nd leg a lly a p p ro p ria te

m ed ic al rec o rd s in t he c r it ic al c a re s et ting o f th e N IC U .

OBJECTIVES

E n s u re th a t initia l his to ry an d p h ys ic a l e xa m ina tio n r ec o rd s in c lud e ap p ro p r ia te

h is to ry,

e xa m a p p ro p ria te fo r th e in fa n t’ s c o n d it io n , r ec o rd o f p ro c e du re s in d eliv ery

ro o m and s in c e a d m is s io n ; p ro b lem lis t a s s es s m en t a n d p lan.

M a inta in d a ily tim ed no te s , w ith u p d ate s a s n ec es s a ry, c lea rly d oc um e ntin g th e

p a tien t’ s p ro g re s s a n d d e tails o f th e o n- g o in g ev alu at io n a nd p lan .

E n s u re d is c h arg e s u m m ary is tim e ly a n d c o n c is e, w ith c lea r d o c um e nta tio n o f

d is c ha rg e p la n s a n d fo llo w u p ap p o in tm e nts .

73
RESEARCH ARTICLE

1. HEARING SCREENING IN HIGH RISK NEWBORNS AND RESEARCH OF HIGH

RISK FACTORS OF HEARING LOSS IN NEWBORNS.

Abstract

T o id en tify th e n ew b o rn s w h o s h o u ld re c eiv e h ea ring ev a lua tio n b y h ea ring

s c re en in g in

hig h ris k n ew b o rn s ; to find a nd c o nf irm th e h ig h ris k f ac to rs o f he arin g d is o rd er s in

hig h risk new b o rns .

T h e firs t s c reen in g w as p erf o rm ed b y D P O A E . N ew b o rns d id n o t p a s s ed the

firs t

s c re en in g un d ert o ok s e c o nd s c reen ing u s ing D P O A E + A B R . a nd n ew b o rns d id no t

p as s e d the s e c o nd s c reen ing re c eiv ed h ea ring ev alu a tio n. H ig h ris k fa c to rs o f h ea ring

lo s s w ere f o un d b y Lo g is tic reg res s io n a na lys is.

T h ree hu n d red a nd tw e nty -s ev en c a s es w ere s c re en ed . T h e p o s it iv e rat io in firs t

s c reen in g w a s 3 7 .0 % . T h e p o s itive ra tio in s e c o n d s c ree nin g w a s 1 1 .0 % . T en c a s es

w ere d ia g n o s ed a s h ea ring lo s s an d th e inc id e nc e o f h ea ring lo s s w a s 3 .3 9 % . H igh r is k

fa c to rs o f he ar in g lo s s w ere a s p hy xia tio n, v ery lo w b o r n w eig h t (< 1 ,5 0 0 g ) a n d he ad a nd

ne c k ab no rm ality.

74
(1 ) D PO A E c o m b in ed w ith A B R is c red ib le a nd fe as ib le in h ea ring s c re en in g o f h ig h

ris k ne w bo r ns . (2 ) H ig h ris k fa c to rs of h ea rin g lo s s w ere a s p h yx ia tio n , v ery lo w b o rn

w eig ht (< 1 ,5 0 0 g ) an d he ad a nd n ec k a b no rm a lit y in th is s tud y.

2. LONG TERM NEUROLOGICAL OUTCOME OF HIGH RISK INFANTS

1 . S elz er, S C

1 . Lin d gr en , S D

1 . B lac k m a n , J A

E va lu ate d lo n g -term n eu ro p s yc h o lo g ic al o u tc o m e o f 2 0 h ig h ris k in fa n ts w ith

intra c ran ia l

he m o rrha g e (IC H ) du rin g th e n eo n at al p e rio d w ho ap p ea re d fre e of s ig n ific a nt

im p a irm en t t hro u g h 3 0 m o nth s o f ag e . T h is g ro u p w as c o m p a red w ith a m atc he d

s am p le o f 2 0 h ig h ris k inf an ts w ith o ut in tra c ra n ial h em o rrh a ge a nd a g ro up o f 7 0

c h ild r en w it h n o h is to ry o f p erina ta l o r c hro n ic h ea lth p ro b le m s . A c o m p reh en s ive

ne ur o ps y c h o lo g ic al ev a lua tio n a t a g e 5 re ve ale d that th e tw o hig h ris k g ro u p s t en de d t o

p erf o rm at a lo w er le ve l th an th e c o n tro l g ro u p ac ro s s m o s t m ea s u res . H o w ev er, t he

IC H g ro up p erf o rm ed a t a s ig n ific a n tly lo w er lev el t ha n th e c on tro l g ro u p o n m ea s ur es

o f p e rc ep tu a l-m o t o r s k ills a nd in term o d a l m e m o r y ab ilities w h ile th e hig h ris k g ro u p

w itho u t IC H d id n o t. Th e im p lic at io n s of d iff eren c e s in le ve l a nd pa tte rn of

p erf o rm an c e a re d is c us s e d a lo ng w it h th e im p lic a tio ns o f the c urr en t f in d in g s fo r

lo ng -term f un c tio n ing o f h ig h ris k in f an ts w ith IC H .

SUMMARY

H igh -ris k n eo n ate s m ay b e d efin ed a s n ew b o rns , reg a rd les s o f g e s tatio n a l a g e

o r b irth w e ig h t, w ho h a ve a g rea te r tha n a ve rag e c h a nc e o f m o rb id ity o r m o rt ality

b ec a u s e o f c o n d itio ns o r c irc u m s t an c e s s u p erim p o s ed on th e n o rm al c o u rs e of

ev en ts a s s o c ia ted w ith b irth a nd a d ju s tm en t to ex tra u terin e ex is ten c e. Id e ntif ic at io n of

hig h -ris k ne w b o rn s m a y o c c ur d ur in g any o f th e fo llo w ing s ta g es : p ren at al, na ta l, o r

p os tn ata l.
75
H igh -ris k in fa nt s m ay b e c la s s if ied a c c o rd ing to b irth w eig h t, g es ta tio na l a g e, a n d

m o rb id ity f a c to rs . M eet in g th e h ig h -ris k inf an t’ s n utritio n a l n ee d s re q uire s

s p ec if ic k n o w le d ge of p h ys io log ic c h ar ac teris tic s , th e inf an t’ s p a rtic u la r n ee d s ,

an d m e tho d s o f f eed in g . D ela yed d e ve lo p m en t in hig h-ris k ne o na tes is a c o n c e rn;

d ev elo p m en tal in terv en tio ns a re ind ivid ua liz ed t o a m e lio ra te th e eff ec ts a nd in c re as e

inf an t w ell-b eing .

P are nt al inv o lve m ent in th e c a re o f h igh -ris k inf an ts is im p o rtan t, a nd n u rs es

s ho u ld en c o u rag e pa ren t-in f an t rela tio ns h ip s fro m b irth to dis c h arg e.

P rem a turity ac c o u nts fo r t he larg e s t n um b er o f a d m is s io ns to a n N IC U . N u rs es

p lay an

im p o rt an t ro le in en d -o f-life c a re o f th e fa m ily o f the d ying inf an t.

CONCLUSION

S o m e n ew b o rn s a re c o ns id ere d hig h ris k . T his m ea ns th a t a n ew b o rn ha s a g r ea ter

c h an c e of c o m p lic a tio n s b e c a us e of c o n d it io n s th at o c c ur d u rin g f eta l

d ev elo p m en t, pre gn an c y c o nd itio n s o f the m o th er, o r p ro b lem s th at m ay o c c ur d urin g

lab o r a nd b irth.

S o m e c o m p lic a tio ns a re u n ex p ec te d an d m a y o c c u r w ith o u t w arn in g . O the r tim e s ,

there a re c e rta in ris k fa c to rs th at m ak e p r ob le m s m o r e lik ely.

76
 Fo rtu n ate ly, a d v an c es in te c h no lo g y h a ve h elp e d im p ro v e the c are o f s ic k

new b o rns . U nd e r th e c ar e o f s p ec ia lize d p hy s ic ian s a nd o the r h ea lthc are p ro v id ers ,

b ab ies h a ve m uc h g rea te r c ha nc es fo r s u rviv ing a nd g et ting b etter to d a y th an ev er b efo re.

BIBLIOGRAPHY

● M eh a rb an S in g h, C a re o f N ew b o rn . 6 th ed . J a yp ee b ro the rs m e d ic al
p u b lis her ,p v t ltd

,N e w D elh i.

● D .K .G uh a , B o o k o f n eo n ato lo g y p r in c ip les a n d pr ac tic e ,2 nd ed itio n,J a yp ee

b ro the rs m ed ic a l pu b lis he r,p vt ltd ,N ew D elh i,p a g e n o -3 0 -37 .

● H o c k en b erry J M , W ils o n D W on g ’ s nu rs in g c are o f in fa n t’ s an d c hild ren .

8 th ed . M is s o uri: E ls ev ie r; 2 0 0 7 . p .2 7 1 -80
77
 ● M a rlo w R D T e xtb o o k o f p a ed ia tric n urs in g . 6 th e d . P en ns y lv a nia : E ls e vie r;
2 0 0 7 .p .25 0 -8 .

● P illiteri A C h ild h ea lt h n urs in g . 1 st e d . Ph ilad e lp hia : Lip p in c o tt;1 9 9 9 .p .4 3 2 -8 .

● P a rth a s ara th y A IA P te xtb o o k o f p ae d ia tric s . 3 rd ed . N ew D e lh i: Ja yp ee;2 0 0 6 .p. 44 2 -6 .

● D utt a A K , S a c h d ev a A A d va n c es in p ae dia tric s . 1 st e d . N ew D elh i:

J ay p ee;2 0 07 .p .8 9 -96 .

● G h a i O P , G u p ta P , P a ul V K G h a i es s e nt ia l p ae d ia tric s . 6 th ed . N ew D elh i:
C B S ; 2 0 05 . p .1 6 6 -9.

RESEARCH ARTICLE

S elz er, S C , Lin d g ren , B lac k m an . ‘ Lo ng T erm N eu ro lo g ic a l O u tc o m e O f H ig h

Ris k In fa n ts ’ . In s titu te f or C lin ic a l and T ran s lat io n a l S c ien c e: E ls ev ier

pu b lic a tion s .

http://www.icts.uiowa.edu/Loki/publications/browsePublication.jsp?id=1527677 , Se p 2,

20 1 1 .

78