INTRODUCTION TO

NEONATOLOGY.
PETER G.M
2ND YEAR
An introduction to the neonatology.
Medical care for the newborns in a maternity
hospital.

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“The most dangerous time in an infant’s life is the
neonatal period, the 28 days after birth. For those
babies who survive, over seven decades of life
may be anticipated.”

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Neonatology is a
branch of
pediatrics that
studies the care,
development, and
diseases of
newborn infants.

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Gestational age is measured from the first
day of the mother's last normal
menstruation. The average gestational
age is 40 weeks (280 days). The majority
of infants are born between 37 weeks (259
days) and 42 weeks (294 days) and is
referred to as term infants. Preterm
infants are those born before 37 weeks
while post-term infants are born on or
after 42 weeks.

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 Intrauterine periods of development

Embrional development Placental development

begins from the zygote formation, begins in the 8 weeks of gestations.
lasts up to the 8-th week of gestation. Continue up to the end of pregnancy.

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Intranatal period
begins from the first signs of pregnancy,
extends until the birth of the baby.

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Perinatal period
begins from 28 weeks of gestation, extends
until the 7 days after delivery, and
includes:
a) late antenatal period (from 28 weeks of
gestation to 40 weeks of gestation);
b) intranatal period (from the first signs of the
delivery until the baby will born);
c) early neonatal period (from the birth of the
baby until 7 days after birth)

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Neonatal period
begins from the birth of the baby, extends
until 28 days after birth. Neonatal period
divides on:
1.Early neonatal period – from the birth
until 7 days after birth.
2.Late neonatal period - from 7 days until 28
days after birth.

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 The functional status and grade of
maturity of the newborn are
evaluated with:
Ability to maintain the stable
temperature.
Presence of the newborns reflexes.
Apgar score.
Sufficient levels of movement activity
and emotional reactions.
Newborns maturity signs according
clinical features and special tables.

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Care for newborn immediately after birth.
Clearing the airway.
Assessment by Apgar score.

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Care of Newborn in Delivery Room:

 Adequate breathing pattern established

 Mouth suctioned 1st
 Nurse wraps infant in warm blanket & places under
radiant warmer
 Drying motion usually stimulates 1st cry. Drying
helps prevent heat loss
 Note time of 1st cry & success at breathing
attempts.
 May need resuscitative attempts.
 infant kept unwrapped on clean/dry radiant warmer
to promote thermoregulation
APGAR SCORE
Is the very first test given to a newborn in the delivery
room to ascertain the health status of the newborn
A-Appearance (skin color)
P-Pulse (heart rate)
G-Grimace response (reflexes)
A-Activity (muscle tone)
R-Respiration (breathing rate and effort)
Apgar Score

 Apgar score - assessment scale since 1958

to assess newborn well-being at 1 & 5 min.
 Newborn observed & rated on 5 components
.
 Heart rate
 Respiratory effort
 Muscle tone
 Reflex irritability
 Color
Apgar score
 Score of 0, 1, or 2 - each component
 Five scores added & final number @ 1 & 5 min
 9/9 common - 2 on HR, Resp, reflexes, muscle
tone & 1 on color d/t acrocyanosis.
 Heavy sedation of mother may lower respiratory effort
or reflex irritability score.
 Score of 4 or less indication that infant most likely
needs resuscitative efforts
 Score of 4-6 may indicate suctioning and oxygen
therapy.
 Apgar Scoring
Sign 0 1 2
Heart rate Absent Slow-below 100 Above 100

Respiratory effort Absent Slow- irregular Good Crying

Apgar Scoring

Muscle tone Flaccid Some flexion of Active motion

extremities

Reflex irritability None Grimace Vigorous cry

Color Pale blue Body pink, blue Completely

extremities pink
scoring
Feature 1min 5min
Heart rate 1 2
Respiratory effort 2 2
Muscle tone 0 1
Reflex irritability 1 2
Color 1 1
Total 5 8
Umbilical Cord

 Umbilical Cord: After delivery, 2 clamps placed

 Cord clamped again 1- 2 inches from umbilicus

Vessels counted [2 arteries; 1 vein - AVA].

 Bleeding may occur if clamp not tight

 umbilical stump; falls off by 7th - 10th day

?Teach: do not bathe infant until site completely healed

?Sponge bath
Identification of Newborn
 Done immediately > delivery by same person
assisting mother
 Prevent giving wrong infant to wrong mom.
Identification is 1 band on mom, one on
significant other & 2 on baby.
 Footprints of infant & mother’s thumb print on
footprint sheet.
Health providers Responsibilities
in Delivery Room
Eye Care: erythromycin ointment > delivery
 Eliminates gonorrhea/chlamydia.
Vitamin K Injection: produced in intestinal tract and
used by body for coagulation.
 Newborn @ risk for bleeding disorders during 1st wk
of life. injection given IM within 1st hour [Dose = 0.5
mg. to 1.0 mg.] Site: vastus lateralis

 In the DR, infant given to mom to begin bonding

process & breast feeding started.
Health providers Responsibilities
in Newborn Nursery
 Admission to Nursery
 Infant transferred to Newborn Nursery.
 Report given by L&D nurse to NBN nurse.
 Routine newborn care.
 Infant under radiant warmer, VS, measurements,
head to toe assessment, bath [98.0 R].
 To mom in 4 hrs. if WNL. [98.0]
 Universal security system on maternity units -
ensure safety of all newborns on unit.
 Alarm placed on infant ankle or umbilical cord
stump. All doors in unit are alarmed & locked.
Newborn Adaptation
 Newborn’s ability to adapt successfully depends
upon conditions in utero, care it receives during
intrapartum period, & newborn period aka neonatal
period = 1st 28 days of life.
 2/3rds of all deaths that occur in 1st year of life occur
during neonatal period [1st 28 days of life].
Head to Toe Assessment of Newborn

Head: General appearance

 NOTE: Size: ¼ of body size [33-35 cm., 13-14 in.
circumference]
 Molding: Asymmetry of skull
 Cephalohematoma: collection of blood bet. skull
bone & periosteum
 Caput succedaneum: swelling over presenting part
Fontanels: “soft spot”
 Anterior fontanel – diamond shaped, measures 2-3
cm. wide & 3-4 cm. long. Closes @ 12-18 months. @
juncture of frontal & parietal bones. Overriding sutures
w. NSVD(normal spontaneous vertex delivery). Level
C/S
cont
 Posterior fontanel - triangular shaped; small [~0.5 cm.]
hard to feel; juncture of occipital & parietal bones.
Closes 2 mos.
 *Depression indicates dehydration
 *Bulging > hydrocephalus
 Hair gestational marker; preterm sparse
Eyes
 Eyes: usually blue or gray
 Permanent color develops 3 - 12 mos of age. Iris does not
develop color til 3-6 mos.
 Lacrimal [tear] glands- not fully mature
 Subconjunctival hemorrhage: from stress of vaginal delivery
 First 6 wks; transient strabismus; not able to focus.
 Constant strabismus < 6 weeks, further assessment needed.
Strabismus > 6 weeks, referral needed.
 Scant purulent discharge > erythromycin ointment
 Pupils round & equal; should constrict - normal response to light
 “PERL” =pupils equal & reactive to light
Nose

 Nose: Infants obligatory “nose

breathers”.
 Note size & shape, & presence of nasal
discharge or stuffiness.
 Clean nose with bulb syringe; saline
drops.
 Observe for nasal flaring
Mouth
 Mouth: Examine palate with index finger
 Cleft lip and/or cleft palate

 Epstein’s pearls [small, round, white cysts]

 Note size & shape of tongue and length of frenulum membrane

 Supranumery teeth aka natal teeth

 Sucking reflex- evaluate

 Rooting reflex
Ears/Neck
 Ears: Note position of ears in relation to eyes

Pinna should be fully formed and firm.

 Term infant: pinna recoils easily
 Preterm infant, < 36 wks - relatively shapeless and flat; little
cartilage. Slow recoil.
 Skin tag – harmless; may be associated w. kidney disease.
Hearing test done before newborn D/C home; If fails 2nd time,
hearing eval.done as outpt.
 Neck: Normal newborn neck short, chubby w.creased skin folds.
Head support necessary. Inspect masses, limitation of movement
& webbing.

Clavicles: straight, palpate each clavicle for intactness; “crepitus”

Common in larger infants delivered vaginally
Chest
 Chest: Inspect shape, symmetry, position,
development of nipples; breast tissue.
 Chest 12-13 in. [30 –33 cm.].
 Breast engorgement – maternal hormones.
 Normal respirations 40 – 60 breaths/minute.
Retractions abnormal; indicates respiratory distress.
RR can be in 30’s [sleep].
 After 4 hr. transition period, RR 40’s.
Grunting [hoarse sound - expiration]
 transient d/t mucous in lungs. Suction.
 If retractions/grunting not clear by 4-6 hrs, may
indicate respiratory distress
 TTN; transient tachypnea of NB. RR = 70-80’s for
several hrs. [transition period] if more > 4 hrs., NICU.
Abdomen/Kidneys
 Abdomen: palpate for masses/organs
 Umbilical Cord: Inspect 3 vessels (“AVA”); falls off in
7 – 10 days. Let dry.
 If only 2 vessels present, artery and vein, observe
infant closely d/t association with heart or kidney
anomalies.
 Kidneys may be felt on right & left side of abdomen by
deep palpation.
 S/S infection
Genitalia - Male
 Genitalia: Male: Assess for gestational maturity &
sexual ambiguity.
 Scrotum in full term infant swollen; + rugae; both R & L
testes descended into scrotal sac.
 Testes may be in process of descending. If one or
both testes are undescended = “cryptorchidism”,
 Agenesis [no testes] or closed scrotal sac
 Normal length of newborn’s penis = ~ 2cm long.
Assess for urethral opening “aka” urinary meatus
Abnormal placement on dorsal surface *epispadias*;
ventral surface *hypospadias
Genitalia - Female

 Female: Vulva typically swollen. Labia minora

& clitoris large with labia majora covering both

 Female infants have “pseudomenstruation”

 “Hymenal tag” or small piece of pink tissue

protrudes between labia
Extremities
 Extremities: Assess for muscle tone
 Note length of arms/legs; should be
symmetrical
 Limp arm may have nerve damage [birth
injury] “aka” brachial plexus palsy.
 Observe palm: simean crease [single
 Assess: syndactyly: webbing of fingers/toes &
polydactyly: > than 10 fingers or toes.
 Assess sole creases; mature infant: 2/3rds or
full sole w.creases
Skin
 Reddish pinkish in color; smooth and puffy
 At 24 - 36 hours of age, skin flaky, dry and pink in color. Edema
around eyes, feet, genitals.
 Acrocyanosis: Bluish discoloration of hands and feet. Lasts for
24-48 hrs. Mucous obstruction may cause central cyanosis
 Milia: Pinpoint white papules; Disappear 2-4 wks
 Neck: Normal newborn neck short, chubby w. creased skin folds.
Support is necessary. Inspect for masses, limitation of movement
& webbing

Clavicles: straight, palpate for intactness; feel for “crepitus”

Commonly found in larger infants delivered vaginally.
Skin
 Lanugo: fine hair covering newborn’s upper arms, shoulders, &
back that decreases as gestational age increases
 Vernix caseosa: white, cream cheese like substance; skin
lubricant.
 Erythema neonatorum [toxicum]: NB rash; red rash with flea-
biten appearance.
 Stork Bites - a.k.a. telangiectasia - pink spots found on nape of
neck, nose, upper eyelids, upper lip. Disappear in 1-2 yrs.
 Mottling: Generalized red and white discoloration of skin of
exposed infants with fair complexion.
 Mongolian Spots: Collections of pigment cells [melanocytes]
that appear as patches across infant’s sacral area and buttocks.
Tend to occur in newborn’s of Asian, African, or Southern
European descent
Skin
 Capillary Hemangiomas: 3 types, all are vascular

 Nevus flammeus: macular (flat), purple or dark red

lesions, present @ birth. Aka “port wine stain

 Strawberry hemangiomas: raised areas formed by

immature capillaries & endothelial cells. Occurs
typically in term infant.

 Cavernous hemangiomas: Raised; resembles

strawberry hemangioma Can be surgically removed
Back/Anus/Rectum
 Spine:
 Assess for intact spine without masses or
openings. Small indentation @ base of spine
may suggest “pilonidal dimple”. May be
pilonidal sinus [opening]; represents possible
spina bifida occulta.
 Tuft of hair present @ base of spine = Nevus
pilosus.
 Anus & Rectum: Assess rectal patency [NBN]
with 1st temp; lubricated thermometer. If
rectum not patent, called imperforate anus
Routine Exam of Newborn – Vital
Signs
 Vital Signs: admission NBN & q shift.
 Temperature ( 35.5-37.5ºC) Initial rectal.
 Heart Rate: 110 –160 bpm.
 Femoral, radial, brachial pulses can be
palpated;. Apical pulse used for HR;
auscultate 1 min
 Respiratory Rate: 40-60 min. Initial rate 80
/min.
 BP ~ 80/46 mmHg @ birth. By 10th day,
100/50.
Cont..
Daily:
 Weight: 2,500-4,000 gm; compare with previous
day. 5-10 % weight loss acceptable
 Assess feedings daily. # voids/stools in 24 hrs.
Done once on admission to nursery:
 Length: 45-55 cm = 18-22 in
 Head: slightly larger than chest; 13-14 in.= 33-35
cm
 Chest: 12-13 in. = 31- 33 cm
SENSORY BEHAVIORS OF THE
NEWBORN

Tactile

Olfactory

Vision (see black & white best)

Auditory

Taste
REFLEXES

 Sucking – place finger in mouth; infant sucks right

away.
 Moro – [“startle reflex”] elicit by loud noise; infant
extends arms & legs suddenly.
 Rooting – touch cheek; turns head in direction of touch.
 Babinski – stroke sole of foot from top to
bottom; toes fan out.
 Grasping – place finger in newborn’s hand;
grabs & hold.
 Stepping – hold infant upright w. feet on
surface; stepping movements
Behaviors – Sleep/Awake
Predictable Behaviors:
1st 4 hours > delivery:
 1st period of reactivity: alert, active state; awake, crying,
sucking.
 Then Sleep phase 4-6 hrs.
 2nd period of reactivity 2-3 hrs. Sleep/awake during day.
Sleep States
 1. Deep Sleep
 2. Light Sleep
Awake States
 Drowsy; Quiet Alert – best time for breast feeding/bonding
 Active Alert; Crying
Behaviors
 Brazelton Neonatal Behavioral Assessment Scale:
Scale developed in 1970’s to evaluate newborn’s behavior to stimuli
Assesses motor maturity & social behavior. Takes ~ 30 min to do

 Ballard Assessment scale: developed 1970’s to assess

gestational maturity; takes 2-3 minutes to do.
 Assesses physical & neuromuscular maturity. Useful in
differentiating between SGA infant & miscalculated due date
 SGA infant is mature gestationally.
 Full term infant gets score of ~ 3.3 in each category. Compare
infants in NICU(NEONATAL INTENSIVE CARE UNIT) to those in
NBN( NEWBORN NURSERY).
 See nelsons for detailed ballard score
Nutrition in Newborn
 Bonding process reinforced during feeding – w.
breast & bottle.
 Approx. 64% of women breast feed in early post
partum period
 29 % still nursing @ 6 months; 16% still nursing @ 1
year.
 Growth & caloric requirements during neonatal
period & early infancy are faster than any other period
of life.
 Newborns can lose up to 5-10% of birth weight while
waiting for breast milk to come in. Colostrum rich in
antibodies but has less calories than breast milk.
Breast milk has no allergies.
Education
 Teach mom: ^ calories by 500/day
 ^ fluids by 8 glasses/day
 Well balanced diet; omit caffeine/alcohol.
 Breast feed q2-3 hrs./day; Bottle feed q 3-4
hrs./day
 Avoid fish containing mercury.
 Teach positions for breast feeding; football
hold for C/S.
 Any position OK as long as baby has nipple &
areola; infant can breathe. Find comfortable
position; Use pillows - free up hands.
Nutrition in Newborn
Daily Requirements:
Calories: body maintenance & growth.
Birth to 2 months of age: require 110-
120 calories/kg/24 hrs.
Up to 6 months, require 108 cal/kg/24
hrs.
6 mos. to 1 yr. require 98 cal//kg/24 hrs.
 Protein: needed to form new cells;
important for rapid growth.
 Up to 2 months, 2.2 g/kg/24hrs required.
 6mos.-1yr. 1.6g/kg req.
 Fluid: 150-200 mL/kg/24 hrs
 75% of NB body composed of water
 Fluids: Need 65 ml/kg [30 ml/lb] daily 1st 2
days of life then 100-150 ml/kg [45-68
ml/lb/day] afterwards.
 Voids: 1st few days 2-6 voids/day; > 2-3 days:
6 or more voids.
Nutrition in Newborn
 Fat: [Linoleic acid] found in both breast milk & formulas

 Carbohydrates: Lactose most easily digested of carbohydrate

group. Helps to reduce GI illness in newborns by producing
stool with gram + bacteria instead of gram negative bacteria.
Rare to have infant with lactose intolerance

 Iron: Found in breast milk & added to commercial formulas

 Flouride: Not found in breast milk or formula; need

supplement starting @ 6 mos. if not found in drinking water

 Calcium: needed for bone growth

 Vitamins: Start supplement @ 6 months of age

ADVANTAGES OF BREAST FEEDING

 Helps with uterine involution.

 May help prevent breast cancer.
 Empowering effect on mother; ↑ self esteem.
Provides more frequent close contact
 Inexpensive. Complete nutrition for baby.
Provides extension of immunity for up to 6
mos. Colostrum IgA [immunoglobulin] which
binds to bacteria & viruses; proteins/enzymes
destroy bacteria. Macrophages produce
interferon - interfere with virus growth.
Disadvantages of Breast
Feeding:
Father feels left out.
Sore nipples. Painful engorgement.

More frequent feeding required so less time with

other children.
Embarrassment related to feeding in public.
Mastitis.
Infections: Hepatitis B & HIV can pass thru milk.
ADVANTAGES OF BOTTLE FEEDING

 ^^ freedom due to less frequent feedings;

infant sleeps longer periods.
 No sore nipples.
 No worry over breast feeding in public or
pumping at work.
 Father can feed infant frequently.
 Frees up mom with older children.
Disadvantages of Bottle Feeding

 More expensive; infant may not tolerate

formula
 May have to try different formulas before
finding right one
 More prep time; more shopping time.
 ^ waste: discard unused portion > 1 hr.
 [^bacteria]. No transfer of passive immunity.
General Care of Infant
Bathing day; Teach parents: sponge bathe
daily before
cord falls off and tub bath > cord falls off &
healed. Mild soap
Positioning & holding – lay infant on back
to sleep;
Hold upright to feed formula & burp. Teach
breast feeding
positions: cradle hold, side lying, &
football hold.
Vaseline to buttocks w. diapering. Record
stools/voids.
Teach parents to take temp.
CONT
Stools:
 Meconium : very dark. green/almost black,

sticky.
 Transitional stool: yellow/green [>

meconium]
 Breast fed stool: yellow seedy w. sweet odor.

 Formula fed stool: green/yellow.

Adaptation to Extrauterine Life

Adaptation to Extrauterine Life

Cardiovascular: NB must initiate

respirations & sustain extrauterine
oxygenation
 When born, infant forced to take in
oxygen thru lungs.
 Shunts close & vessels clot off & regress
cont
Respiratory: First breath also in response to
temperature & pressure changes, light & noise.
 1st breath requires great amt.of pressure;

40-70 cm H2O. Small amt of fluid present

in lungs.
 1/3 rd of this fluid forced out by pressure of

vaginal birth; rest absorbed by lung tissue.

C/S infants may need more suctioning &
oxygen therapy.
Adaptation to Extrauterine Life

Renal: Renal function does not fully mature until > 1st yr. 1st void
occurs within 1st 24 hrs.
 No urine for 36 hrs. needs further evaluation for obstruction or
absent kidneys.
 1st voiding may be dark.pink/red due to uric acid crystals.
Disappears 1st few days as kidneys mature. Alarming to parents;
harmless finding.
cont
Gastrointestinal: GI tract sterile @ birth; bacteria
enters GI tract thru mouth within 24 hrs.of life.
Bacteria needed for prod. Vit.K

 Infant: limited ability to digest fats & starches

 Meconium passed 1st 24-48 hrs. of life
 By 2nd - 3rd day, transitional stool passed
Thermogenesis

Brown fat : helps conserve body heat; produces

heat.
Found in upper chest, back of neck, around
abdomen.
Is deposited in 2nd trimester; Helps regulate
body temp>delivery.
Radiant warmer - helps regulates body temp. by
conserving heat.
Newborns can produce sufficient heat in optimal
thermal
Environment if warm enough.
cont
Rapid heat loss occurs in suboptimal environment
[cooler].
Infants do not shiver; can go into cold stress
quickly.
Uses up extra glucose & oxygen to thermoregulate.
Leads to:
 metabolic acidosis; respiratory distress
 Hypoglycemia; Jaundice; decreased surfactant
production
Thermogenesis
Infants Lose heat in 4 ways:
 Convection
 Evaporation
 Conduction
 Radiation
immunologic
 Newborn still prone to infection,
handwashing important!
 IgG: Infant born with passive immunity
from mom. Fetus makes own starting @ 20
wks
 IgM too large to cross; makes own after
delivery.
 IgA do not cross placenta. Produced by
infant > birth @ 6-12 wks. Found in breast
milk.
Labs
 Hemoglobin: 15-20 g/dl.; Hct: 43-61%
 Blood volume: 80-110 ml/kg. or 300 ml.
 WBC: 10-30,000 mm
 Glucose 45-60 mg/dl - heel stick < 45 &
feed with ½ oz formula. Repeat within
hour. Send serum blood glucose as per
protocol.
jaundice
 Breast Fed Jaundice: 1 out of 3 breast feeding
infants. Most common cause: insufficient intake -
1st week of life. Bili can reach 12mg/dl. Theory:
Enzymes in breast milk thought to interfere with
conjugation process.
 Feed @ least 8-10 feedings in 24 hrs.
 Teach moms: ^^ their own po fluids
 Kernicterus rare with breast fed jaundice
Contraindications to “early” discharge (<
30 hours):
1. Birth asphyxia
2. Diagnostic work-up in progress
3. Presence of significant congenital
anomalies (i.e.cleft lip/palate, heart
disease, chromosomal abnormalities,
hydrocephalus, meningomyelocele...)
4. Medical/surgical problems requiring
further care (i.e. congenital infections,
apnea episodes, drug withdrawal, poor
feeding, anemia, paralysis, blindness,
abnormal neurological function)
65
5. Multiple birth
6. Parental history of significant
medical/psycho-social problem (i.e. substance
abuse, uncontrolled epilepsy, mental
retardation, psychiatric problem)
7. Maternal age 16 or younger
8. Maternal death
9. High risk for child abuse (i.e. previous child
abuse family, poor social conditions, unwanted
pregnancy, poor parental problems)
10. Severe family economic problems (i.e.
inadequate housing)

66