Normal newborn and routine care of newborn

• Who is a healthy newborn?

• Aims of Early Newborn Care

• Steps in immediate care of the newborn

• Care of umbilical cord

• APGAR score

• Definition, degree and Prevention of hypothermia

• Initiating and Promoting exclusive breast feeding, Breast feeding Technique

• Baby identification

• Vitamin K

• Anthropometry

• Communication with the family

• Postnatal care and advice on discharge

• Newborn screening

• Norms of a healthy newborn

• Establohsment of respiration

• Detection of danger signs

• Provide neonatal resuscitation effectively when needed (By a skilled person)

• Prevention of hypothermia

• Prevention of hypoglycaemia

• Initiating and promoting exclusive breast feeding

• Support mother-baby bonding (Eg: Encourage early skin to skin contact)

• Prevention of infection

• Document APGAR score

• Quick examination of the newbon

• Vitamin K

• Essential anthropometry

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• Delayed cord clamping

• Clamp the umbilical cord at least 1 minute after birth provided the baby does not need to be resuscitated and the mother does not have a post-partum haemorrhage - While holding the baby at or below placenta level - If the baby does not require resuscitation If resuscitation is required, clamp and cut the cord immediately and act quickly

• Collect cord blood if needed for any investigations (Eg: blood gas, grouping and Rh)

• Umbilical cord should be clamped by a sterile cord clamp

• Cut the umbilical cord with a sterile blade, 2-3 cm (approximately 2 finger breaths) above skin level

• Inspect frequently for early detection of any bleeding / oozing from the cord

• Do not apply anything on the stump (e.g. antiseptic)

• Keep the cord dry and clean (avoid being covered by nappy

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• Grading of hypothermia

• Cold stress : 36.1 °C - 36.4°C (96.9 °F– 97.5 °F)

• Moderate hypothermia : 32.0 °C - 36.0 °C (89.6 °F – 96.8 °F)

• Severe hypothermia : <32.0°C (<89.6°F)

• Importance?

• Keep satisfactory room temperature (26 C – 28 C)

• Keep radiant warmer ready

• Immediate drying and covering of baby including removal of wet towels and covering of the head with a cap

• Appropriate clothing (cap, socks, mittens, towels, Warm blanket)

• Skin-to-skin contact between baby and the mother

• Check baby’s axillary temperature

• Mother and baby together - Rooming-in

• Assess warmth at regular intervals

• Encourage early and regular breastfeeding

• Delay bathing and weighing

• Breast feeding must be initiated as early as possible, within 1⁄2 (one) hour of birth. The time of initiation should be

• The mother and baby should be kept with skin to skin contact after initial drying, so that the

• Proper positioning and attachment are important in establishment of breastfeeding

• Supporting establishment of lactation is an important duty of attending health care personnel

• Breast milk provides the most suitable nutrition for newborn babies

• It has immunological, medical and, psychological advantages for the baby, and mother

• Baby’s head, neck and body are in a straight line

• The baby’s face is facing the breast, with the nose

• The mother is holding baby’s body close to hers

• The mother is supporting baby’s bottom, and not

• Baby’s mouth is wide open

• Lower lip is turned outwards

• Baby’s chin touches mother’s breast

• Majority of areola is inside the baby’s

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• Two discs containing the same number is used for this purpose

• One is tied on the left wrist of the mother and the other on the

• The mother should be informed of the number on the disc

• Sometimes, better to have two tags on the baby – wrist and ankle

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• Not necessary to weigh immediately – by 2 hours is adequate. The completion of the first breast feed should be given priority over weighing,

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• Vitamin K

• Dose

• Importance?

• ------------------------------------

• Birth Weight

• Length

• Occipito-frontal Circumference (OFC)

• Communicate the birth time, birth weight, gender and condition of the newborn to the mother and other family members

• Newborn should be shown to the immediate family with particular attention to the gender and the identity tag

• Explain how to provide routine care of a newborn after discharge

• Relieve common worries as much as possible

• Be professional and empathetic

• Stabilisation within the first hour of life is vital in ensuring the best possible outcome in newborn

• By the end of the first hour, the following should have been taken care of

• Respiration and cardiovascular stability - Maintenance of body temperature - Breastfeeding - Administration of Vitamin K before sending to the ward

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• Keep under observation in the postnatal ward

• Review at frequent intervals (at least thrice daily) by a medical officer and by the nurse (and midwife) in the postnatal ward

• Monitor for,

• adequacy of breast feeding

• maintenance of temperature

• jaundice

• passage of urine

• passage of meconium

• level of activity and danger signs

• Should be quick but thorough to identify any life threatening congenital anomalies and birth injuries.

• The oral cavity must be examined to exclude a cleft palate.

• Neonatal examination (birth defects)

• Pulse oximetry screening for critical congenital heart disease Hypothyroidism screening – TSH

• Hearing screening

• Preterm babies – retinopathy of prematurity (ROP) screening

• G6PD deficiency and CAH screening - for selected babies

• Other inborn errors of metabolism - as appropriate in different populations (Eg: when significant family history is present, depending on suspicious clinical features, abnormal basic investigations

• In other countries: Screening for in born errors of metabolism

• Educate regarding ways of maintaining body temperature (clothing, wrapping)

• keep the baby dry at all times

• If the climate is cold the linen and clothes of the baby

• -During warm weather, depending on the environmental

• Exposure of the baby to direct sunlight can lead to serious hyperthermia.

• The mother should be advised to feed responsively when the baby shows early
hunger cues (6-8 times or more during 24 hours)

• Assess breast feeding adequacy and technique before discharge and arrange
follow up as necessary

• Advice on Daily bath –with attention on hypothermia prevention (less than 5 mins). Keep baby clean and dry. If the weather is very cold, instead of bathing, the baby

• Advice on care of the umbilical stump. The cord must be left open without any dressing. Do not

• BCG vaccination, before leaving the hospitalBCG vaccine should be administered before leaving the

• Advice when to seek urgent medical advice (identifying danger signs). Advise on national immunisation schedule

• Whether Neonatal Examination and screening is completed

• CHDR with adequate records in the relevant sections

• AVOID giving liquids (water, kalke) other than breast milk to

• Many normal babies posset or spit out some amount of milk, or vomit soon after feeds

• Proper advice regarding feeding and burping technique must be given to all mothers before discharge

• If there is persistent vomiting, which is projectile/ bile stained/ with other features of intestinal obstruction → Need urgent medical attention

• On days 1-4 of life babies pass urine at least 1-4 times a day; Do not discharge until urine is passed

• An adequately fed baby passes urine at least 5 to 6 times by day 3 or 4

• Any baby who has not passed meconium for 48 hrs after birth needs evaluation; Do not send home until meconium is passed

• Transitional stools are passed by the 3rd to 4th day after birth; The frequency is increased and often semi-loose and greenish-yellow

• Breastfed babies pass frequent golden yellow, sticky, semisolid stools

• The increased frequency of breast milk stools is normal and should not be confused with diarrhoea.

• Many babies pass stools while being fed or soon after a feed due to exaggerated gastrocolic reflex

• Formula fed babies generally have more formed, infrequent stools

• Most healthy term babies lose weight during the first 2 to 3 days of life

• Any weight loss >5% in a 24-hour period is abnormal

• Weight loss can be up to 5% -10% of the birth weight by day 4-5

• Birth weight is regained by 7-10 days of life

• unsatisfactory feeding → excessive weight loss +/- hypernatraemia

• Average daily weight gain is around 30g/day in the 1st month in a term baby

• Next 2-3 months weight gain is 20-30g/day

• At birth, Average Length: 45cm – 55cm; Average OFC: 33cm -36cm

• Always plot and compare using ‘Growth Charts’

• Most healthy term babies lose weight during the first 2 to 3 days of life

• Any weight loss >5% in a 24-hour period is abnormal

• Weight loss can be up to 5% -10% of the birth weight by day 4-5

• Birth weight is regained by 7-10 days of life

• unsatisfactory feeding → excessive weight loss +/- hypernatraemia

• Average daily weight gain is around 30g/day in the 1st month in a term baby

• Next 2-3 months weight gain is 20-30g/day

• At birth, Average Length: 45cm – 55cm; Average OFC: 33cm -36cm

• Always plot and compare using ‘Growth Charts’

• All infants must be examined for development and severity of jaundice twice a day on the first few days of life. • Visual assessment in daylight is the preferred method of clinical examination.

• Postnatal care in Sri Lanka consists of domiciliary care and clinic care. The area public health midwife (PHM) is responsible for the postnatal home visits while hospital or field clinics manned by a qualified medical officer (MOH) is responsible for clinic care.

• Care of a normal newborn includes immediate care at birth with maintenance of normothermia, cord care, early initiation of breastfeeding, initial screening examination and administration of Vitamin K. • Ensuring correct positioning and attachment during breastfeeding, full examination of the newborn, and identifying newborns at risk are essential prior to discharge. • Mother should be advised on danger signs, whom and how to contact to get help, further follow up and immunisation at time of discharge.

• Sleeps most of the time – 23 hours / day

• Wakes up when hungry

• Cries for hunger, cold, wetness or any other discomfort

• Sleep when full

• Initially eyes closed most of the time

• Initially up at night and sleeps during the day

• This pattern will gradually reverse so that day night rhythm will get established gradually

• Most babies pass urine within the first 24 hours. SOme are passed during birth (so check notes before investigating)

• Rule of thumb - number of urine = day of life

• Stools - within 24 hours

• Initially - Black - green

• Colour changes from greenish yellow to a golden yellow in breast fed babies

• Pale yellow - white stools are of concern

• Stool consistency becomes more liquid – water and pieces

• Sometimes lot of gas with spurting of stool

• Some babies pass stool with each feed

• Wide variation in stool frequency

• Most babies will strain and pass stool

• Unless the stool is very hard no intervention is needed

• periumbilcal erythema? infection! so antibiotics!

• Erythema toxicum

• Milia

• Neonatal teeth

• Breast enlargement

• Mongolian blue spots

• Strawberry naevi

• Vaginal bleeding may occur in female newborns about three to five days after birth due to withdrawal of maternal hormones. The bleeding is mild and lasts for two to four days. • Additional vitamin K is unnecessary, but check that it was administered at birth.

• Most female babies have a thin, grayish, mucoid, vaginal secretion, which should not be mistaken for a purulent discharge

• These lesions are poorly demarcated erythematous macules, surmounted by central pale papules. It appears on the second or third day in term neonates, over the face and spreads down to the trunk and extremities in about 24 hours. The rash can be extensive. This should be differentiated from pustules which need treatment.

• Peeling skin:

• Milia:Yellow-white spots (keratin) on the nose or face due to

• Stork bite marks (Salmon patches or nevus simplex):These are discrete, pinkish- gray, sparse, capillary hemangiomata commonly seen on the nape of neck, upper eyelids, forehead and root of the nose. Those on the face disappear after a few months while the ones on the nape of the neck get covered by hair.

• Mongolian blue spots: also called congentical dermal melanocytosis

• Epstein pearls:These are white spots, usually one on

• Sucking callosities:

• Tongue tie:

• Non retractable prepuce: The prepuce is normally

• Hymenal tags: Mucosal tags at the margin of hymen are seen in two-third of female infants.

• Umbilical hernia: Umbilical hernia may manifest after

• can take upto a month or two to resolve

• unilateral vs bilateral

• collection of blood within bone and periosteum therefore limted to margins in the bone

• very large can cause exageration of physiological jaundice

• no need to do anything

• prolongued labor or vacuum extraction

• subcutaneous oedema (not limited to suture stuff?)

• within a day or two will subside

• no need treatment

• capillary heamangiomas

• not seen in time of birth but appear gradually couple of weels

• enlarge till 6m then regress gradually

• if in a position to obstruct function of organ need to treat. first line is beta blockers (prop - no avaiable solution so must crush and stuff) small dose 6m to 1y

• more deeply situated

• blush discoloration around the lesion

• small, can regress with time, but may take longer

• abnormality of capillaries, again

• distinct nly one side of face

• doesn't go away

• mostly benign

• sometimes can be associated with Sturge-Weber sydnrome - same kinf od capillaries on surface of the body so seizures in opp side of body

• may be removed at a later stage by laser surgery for cosmetic reasons

• giant congenital melanocytic nevus

• may not fade away so easily

• need to kept under close observation coz small chance to develop into melanomas

• dry, cracked, some peeling - completely normal within a few days will peel off revealing nice skin

• primary dentiiton

• if cause problems to nipple or danger of dislodge + aspiration must remove

• due to uterime positions

• originates from CNS

• disappears with time

• can remain in nerological dmaaged babies like tonic neck reflex in cerebral palsy

• Rooting reflex

• Moro reflex - neurological intact. disaapears around 3m. absent is not normal asphyxia? persistent is also not normal

• Stepping reflex

• Walking reflex

• Tonic neck reflex

• During the first few days of life babies sleep throughout

• Keep under observation in the postnatal ward

• Review at frequent intervals (at least thrice daily) by a medical officer and by the nurse (and midwife) in the postnatal ward

• Monitor for,

• adequacy of breast feeding

• maintenance of temperature

• jaundice

• passage of urine

• passage of meconium

• level of activity and danger signs

• Should be quick but thorough to identify any life threatening congenital anomalies and birth injuries.

• The oral cavity must be examined to exclude a cleft palate.

• Neonatal examination (birth defects)

• Pulse oximetry screening for critical congenital heart disease Hypothyroidism screening – TSH

• Hearing screening

• Preterm babies – retinopathy of prematurity (ROP) screening

• G6PD deficiency and CAH screening - for selected babies

• Other inborn errors of metabolism - as appropriate in different populations (Eg: when significant family history is present, depending on suspicious clinical features, abnormal basic investigations

• In other countries: Screening for in born errors of metabolism

• Educate regarding ways of maintaining body temperature (clothing, wrapping)

• keep the baby dry at all times

• If the climate is cold the linen and clothes of the baby

• -During warm weather, depending on the environmental

• Exposure of the baby to direct sunlight can lead to serious hyperthermia.

• The mother should be advised to feed responsively when the baby shows early
hunger cues (6-8 times or more during 24 hours)

• Assess breast feeding adequacy and technique before discharge and arrange
follow up as necessary

• Advice on Daily bath –with attention on hypothermia prevention (less than 5 mins). Keep baby clean and dry. If the weather is very cold, instead of bathing, the baby

• Advice on care of the umbilical stump. The cord must be left open without any dressing. Do not

• BCG vaccination, before leaving the hospitalBCG vaccine should be administered before leaving the

• Advice when to seek urgent medical advice (identifying danger signs). Advise on national immunisation schedule

• Whether Neonatal Examination and screening is completed

• CHDR with adequate records in the relevant sections

• AVOID giving liquids (water, kalke) other than breast milk to

• Many normal babies posset or spit out some amount of milk, or vomit soon after feeds

• Proper advice regarding feeding and burping technique must be given to all mothers before discharge

• If there is persistent vomiting, which is projectile/ bile stained/ with other features of intestinal obstruction → Need urgent medical attention

• On days 1-4 of life babies pass urine at least 1-4 times a day; Do not discharge until urine is passed

• An adequately fed baby passes urine at least 5 to 6 times by day 3 or 4

• Any baby who has not passed meconium for 48 hrs after birth needs evaluation; Do not send home until meconium is passed

• Transitional stools are passed by the 3rd to 4th day after birth; The frequency is increased and often semi-loose and greenish-yellow

• Breastfed babies pass frequent golden yellow, sticky, semisolid stools

• The increased frequency of breast milk stools is normal and should not be confused with diarrhoea.

• Many babies pass stools while being fed or soon after a feed due to exaggerated gastrocolic reflex

• Formula fed babies generally have more formed, infrequent stools

• Most healthy term babies lose weight during the first 2 to 3 days of life

• Any weight loss >5% in a 24-hour period is abnormal

• Weight loss can be up to 5% -10% of the birth weight by day 4-5

• Birth weight is regained by 7-10 days of life

• unsatisfactory feeding → excessive weight loss +/- hypernatraemia

• Average daily weight gain is around 30g/day in the 1st month in a term baby

• Next 2-3 months weight gain is 20-30g/day

• At birth, Average Length: 45cm – 55cm; Average OFC: 33cm -36cm

• Always plot and compare using ‘Growth Charts’

• Most healthy term babies lose weight during the first 2 to 3 days of life

• Any weight loss >5% in a 24-hour period is abnormal

• Weight loss can be up to 5% -10% of the birth weight by day 4-5

• Birth weight is regained by 7-10 days of life

• unsatisfactory feeding → excessive weight loss +/- hypernatraemia

• Average daily weight gain is around 30g/day in the 1st month in a term baby

• Next 2-3 months weight gain is 20-30g/day

• At birth, Average Length: 45cm – 55cm; Average OFC: 33cm -36cm

• Always plot and compare using ‘Growth Charts’

• All infants must be examined for development and severity of jaundice twice a day on the first few days of life. • Visual assessment in daylight is the preferred method of clinical examination.

• Postnatal care in Sri Lanka consists of domiciliary care and clinic care. The area public health midwife (PHM) is responsible for the postnatal home visits while hospital or field clinics manned by a qualified medical officer (MOH) is responsible for clinic care.

• Care of a normal newborn includes immediate care at birth with maintenance of normothermia, cord care, early initiation of breastfeeding, initial screening examination and administration of Vitamin K. • Ensuring correct positioning and attachment during breastfeeding, full examination of the newborn, and identifying newborns at risk are essential prior to discharge. • Mother should be advised on danger signs, whom and how to contact to get help, further follow up and immunisation at time of discharge.

• Intense crying that may seem more like screaming or an expression of pain

• Crying for no apparent reason, unlike crying to express hunger or the need for a diaper change

• Extreme fussiness even after crying has diminished

• Predictable timing, with episodes often occurring in the evening

• Facial discoloring, such as reddening of the face or paler skin around the mouth

• Bodily tension, such as pulled up or stiffened legs, stiffened arms, clenched fists, arched back, or tense abdomen Sometimes there is relief in symptoms after the infant passes gas or has a bowel movement. Gas is likely the result of swallowed air during prolonged crying. CAUSE IS UNKNOWN

Possible contributing factors that have been explored include:

• Digestive system that isn't fully developed

• Imbalance of healthy bacteria in the digestive tract

• Food allergies or intolerances

• Overfeeding, underfeeding or infrequent burping

• Early form of childhood migraine

• Family stress or anxietyCompications

Research has shown an association between colic and the following problems with parent well-being:

• Increased risk of postpartum depression in mothers

• Early cessation of breast-feeding

• Feelings of guilt, exhaustion, helplessness or anger

Shaken baby syndrome!!!

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Erythema toxicum neonatorum

Transient neonatal pustular melanosis

Neonatal acne

Infantile acne

Milia

Miliaria

Sucking blisters

• ------------------------------------

Cutis marmorata

• ---------------------------------------

Harlequin color change

Slate-Greay Macules (previously know as mongolian spots)

-------------------------------- Seborrheic dermatitis

• -----------------------------------

Nevus sebaceous of Jadassohn

Aplasia cutis contenita

Newborn care guidelines

Thermal control