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The Normal Newborn


									   Care of the Normal Newborn

   Laedwig Chapters 23, 24, 25, 26

   Mary Jane Hopkins, ARNP

   The Newborn Assessment

   General appearance—flexed position

   Weight and measurements

           Average birth weight—3405 g= 7 lb, 8 oz

                     2500-400G= 5 lb. 8 oz- 8 lb. 13 oz

                     Can lose 5-10 % of weight in first 3-4 days due to small fluid intake, and fluid loss
                      (meconium loss& urine)

                     Will regain 1 oz/ day after loss over

                     Usually regains in second week

           Average length is 50 cm=20 in

                     range 48 to 52 cm =18 to 22 in

           Head circumference—32 to 37 cm =12. 5 to 14.5 in

           Chest circumference—32 cm =12. 5 in

                     range 30 to 35 cm =12 to 14 in

   Vital Signs

   Heart rate, 120 to 160 beats per minute

           Count AP for 1 full minute

           AP may increase to 180 when crying or go as low as 80 when resting

   Respirations, 30 to 60 respirations per minute

   Count for 1 full minute

           May be irregular with short periods of apnea

           May be slightly elevated with crying

           >60 tachypnea and < 30 bradypnea
           Blood pressure at birth, 80–60/45–40 mm Hg

                   Should be measure when infant is resting


   Signs of Respiratory Distress

           SeeSaw breathing

           Sternal retractions

           Xiphoid retractions

           Nasal Flaring

           Expiratory Grunt

   Temp  100 or  97

   Apical Pulse  160 or 120

   Respirations 60 or  30

   B/P cuff can be applied to the upper arm or thigh.

   Thermoregulation

   Thermoregulation in newborn is closely related to rate of metabolism and oxygen consumption

   Neutral thermal environment (NTE) zone exists when rates of oxygen consumption and
    metabolism are minimal.

   Characteristics affecting thermoregulation

           Newborn has decreased subcutaneous fat and thin epidermis

           Blood vessels closer to skin than adult

           Flexed posture of term newborn decreases surface area exposed to environment,
            reducing heat loss

           preterm or small-for-gestational-age (SGA) newborn has less adipose tissue and is
            hypoflexed requiring higher environmental temperatures to achieve an NTE

   Heat Production

   Thermogenesis—Physiologic mechanisms that increase heat production. Include

           increased basal metabolic rate
           muscular activity

           chemical thermogenesis or Nonshivering thermogenesis (NST) stimulates sympathetic
            nervous system to metabolize newborn's stores of brown adipose tissue (BAT) or brown
            fat to provide heat.

   Oxygen consumption and metabolic rate increase in response to cold environment. If prolonged
    glycogen stores will be depleted and acidosis can occur

                   Methods of heat loss

   Characteristics of Newborn

   Head—newborn's head is disproportionately large for its body

   Approximately one fourth of body size

   Molding-overriding of cranial bones

   Fontanelles ="soft spots"

                   Palpated on newborn’s head

                   Should be flat and smooth may bulge when crying

                   Depressed may indicate dehydration

                   Bulging may indicate Increase ICP

           Anterior fontanelle= diamond shaped

                   Between Frontal and parietal bones

           Posterior fontanelle= triangular

                   Between the occipital and pariental bones

           Caput succedaneum

           swelling of soft tissue under the scalp

           Usually from Birth Trauma

           Will resolve 1 week

   Hair—term newborn's hair is smooth with texture variations depending on ethnic background.

           Lanugo- fine downy hairy seen on body between 20 weeks and birth

   Face
           Should be symmetrical

   Eyes

           Color established at 3 months, may change any time up to 1 year

           Small subconjunctival hemorrhages may appear on sclera.

           Transient strabismus caused by poor neuromuscular control of eye muscles.

           Absence of red reflex occurs with cataracts.

           No tears until 2 months

   Nose

           Nose breathers for first few months of life

           Remove obstructions by sneezing

   Mouth

           Lips of newborn should be pink.

           Touch on lips should produce sucking motions.

           Palate intact

           Epstein's pearls

                   On hard palate and gum margins

                   Small glistening white specks (keratin-containing cysts)

                   Will disappear 2-3 months

           Ears

           Soft and pliable

           Recoil readily when folded and released

           Low-set ears may indicate chromosomal abnormalities.

                   Trisomies 13 and 18

                   Mental retardation

                   Internal organ abnormalities
                     Neck

             A short neck, creased with skin folds

             Evaluate clavicles for evidence of fractures

                     Chest

             Lung sounds clear

             Engorged breasts occur frequently in both males and females.

                     Result of maternal hormonal influence

                     last up to 2 weeks

             Supernumeray= extra nipple

   Cry

             Should be strong, lusty, and of medium pitch

             A high-pitched, shrill cry may indicate neurological disorders or hypoglycemia.

                     Abdomen

             Cylindrical and protrude slightly

             Bowel sounds present

             Laxness of the abdominal muscles is normal.

             Umbilical cord

                     White and gelatinous in appearance

                     Two umbilical arteries and one umbilical vein

                     Umbilical hernia

   Term Newborns Usually Pass Meconium within 8 to 24 Hours

   Formed in utero from amniotic fluid and its constituents, intestinal secretions, and shed mucosal

   Thick, tarry black or dark green appearance.

   Physiologic Factors of Newborn Kidney function
   Term newborn's kidneys have full complement of functioning nephrons by 34 to 36 weeks'

   Glomerular filtration rate of newborn's kidney is low compared with adult rate; newborn's
    kidney unable to dispose of water rapidly when necessary.

   Full-term newborns less able than adults to concentrate urine because tubules are short and

   Reduced ability to concentrate urine caused by limited tubular reabsorption of water and
    limited excretion of solutes (principally sodium, potassium, chloride, bicarbonate, urea, and
    phosphate) in growing newborn

   Decreased ability to excrete drugs

   Urinary elimination

   First 2 days newborn voids two to six times daily, with urine output of 15 mL/day

   Newborn subsequently voids 5 to 25 times every 24 hours, with volume of 25 mL/kg per day

   Record # of wet diapers

   Rule of thumb

           day 1 of life= 1 wet diaper

           day 2 of life =2 wet diapers……

           after day 6= 6 or more wet diapers daily

   Genitals-Female

           Vaginal discharge of thick, whitish mucus

           Can become tinged with blood, called pseudomenstruation, caused by withdrawal of
            maternal hormones

           Vernix caseosa, a white substance, is often present between labia.

   Genitals-Male

           Scrotum is inspected for size and symmetry and presence of both testes.

           Hypospadias—urinary meatus located on ventral surface of penis

           Phimosis—opening of foreskin (prepuce) is small and foreskin cannot be pulled back
            over glans; may interfere with urination
   Extremities

           Gross deformities, extra digits, webbing, clubfoot, and range of motion

           Arms and hands

                     Brachial palsy, paralysis of portions of arm

                     Erb-Duchenne paralysis (Erb's palsy)

                             damage to upper arm (fifth and sixth cervical nerves)

                             Unable to move arms or they may be assymetical

           Assymetry of the gluteal folds may indicate hip dysplasia

           Legs and feet

                     Ortolani's maneuver

           Barlow's maneuver

           Talipes deformity (clubfoot)

   The asymmetry of gluteal and thigh fat folds seen in infant with left developmental dysplasia of
    the hip

   Barlow’s (dislocation) maneuver. Baby’s thigh is grasped and adducted (placed together) with
    gentle downward pressure.

   Ortolani’s maneuver puts downward pressure on the hip and then inward rotation. If the hip is
    dislocated, this maneuver will force the femoral head back into the acetabular rim with a
    noticeable “clunk.”

   The nurse moves the foot to the midline. Resistance indicates true clubfoot.

   Back

           Spine should appear straight and flat.

           Lumbar and sacral curves not developed until the newborn begins to sit

           Anus

           Should be patent

           Well placed

           Meconium stool
           Skin Characteristics

           Skin color varies with genetic background, pink tinge

   Acrocyanosis

           bluish discoloration of hands and feet may be present in first 2 to 6 hours after birth.

   Mottling

           lacy pattern of dilated blood vessels under the skin occurs as result of general
            circulation fluctuations.

   Harlequin sign (clown)

           transient—deep red color develops over one side of body while other side remains pale,
            color change results from vasomotor disturbance in which blood vessels on one side
            dilate while vessels on other side constrict

   Acrocyanosis= bluish discoloration of hands and feet

   Skin turgor

           Assessed to determine hydration status

   Vernix caseosa

           Whitish, cheeselike substance

           Covers fetus while in utero

           Lubricates skin of the newborn

           Post-term newborn has less vernix.

   Milia

           Exposed sebaceous glands

           Appear as raised white spots on the face, especially across the nose

           Clear spontaneously within the first month

   Forceps marks—present after a difficult forceps birth

   Facial milia.

   Birthmarks

           Telangiectatic nevi (stork bites)
           Mongolian spots

                    Seen on Asian, African , and hispanic babies

           Nevus flammeus (port-wine stain)

           Nevus vasculosus (strawberry mark)

   Erythema toxicum on leg.

   Jaundice—first detectable on face

           First appears where skin overlies cartilage= bridge of nose, mucous membranes of
            mouth and has head-to-toe progression.

                    Pathologic Jaundice

                             noted before newborn is 24 hours of age, it should be reported to

                             Serious blood incompatability

                    Physiologic Jaundice

                                      Begins after the first 24 hours

                                      Normal complication caused by

                                      Accelerated destruction of fetal RBCs

                                      Impaired conjugation of bilirubin

                                      Increased bilirubin reabsorption from intestinal tract

                                      Bilirubin peaks in 3-5 days

                                      Bilirubin levels should not excede 13 mg./ dl.

   Breast Milk Jaundice

   Bilirubin level begins to rise after first week of life.

   Level peaks at 5 to 10 mg/dL at 2 to 3 weeks of age

   Level declines over first several months of life

   Related to milk composition

   Associated with poor feeding practices
   If bilirubin becomes too high may need to D/C breastfeeding

   Prevention of early breastfeeding jaundice:

           Encourage frequent breastfeeding,

           Avoid supplementation

           Access maternal lactation counseling

   Conjugation of Bilirubin

   Definition: Conversion of yellow lipid soluble pigment into water-soluble pigment

   Unconjugated (indirect) bilirubin is breakdown product

           Derived from hemoglobin

           Released primarily from destroyed RBCs

           Unconjugated bilirubin not in excretable form

   Total serum bilirubin is sum of conjugated (direct) and unconjugated (indirect) bilirubin.

   Fetal unconjugated bilirubin crosses placenta to be excreted, so fetus does not need to
    conjugate bilirubin

   Total bilirubin at birth usually less than 3 mg/dL unless abnormal hemolytic process has been
    present in utero

           After birth newborn's liver must begin to conjugate bilirubin by itself.

           Produces normal rise in serum bilirubin levels in first few days of life

           Bilirubin formed after RBCs are destroyed

   Direct bilirubin excreted into tiny bile ducts, then into common duct and duodenum.

           In the intestinals bacteria transform it into urobilinogen (urine bilirubin) and
            stercobilinogen and excreted.

           Stercobilinogen is not reabsorbed but is excreted as yellow-brown pigment in stools.

   About 50% of full-term and 80% of preterm newborns exhibit physiologic jaundice on about
    second or third day after birth.

           Yellow color results from increased levels of unconjugated (indirect) bilirubin,

           Normal product of RBC breakdown
               Reflect body's temporary inability to eliminate bilirubin

      Serum levels of bilirubin about 4 to 6 mg/dL before yellow coloration of skin and sclera appear.

      Newborn Care Procedures to Decrease Probability of High Bilirubin Levels

      Maintain newborn's skin temperature at 36.5°C (97.8°F) or above

      Monitor stool for amount and characteristics

      Encourage early feedings

      Clinical Gestational Age Assessment Tools

      Gestational Age can be determine by

               maternal menstrual dates

               Ultrasound

               External physical characteristics

      Ballard and Dubowitz Assessment tools

               Measure:

               Neurological or neuromuscular development

               Physical Characteristics

      Gestational age testing done soon after birth

      Helps to determine possible neonatal complications arising from pre or post term maturity

Neuromuscular Evaluation

      Square window sign

      Recoil

      Popliteal angle

      Scarf sign

      Heel-to-ear extension

      Ankle dorsiflexion

      Head lag
       Ventral suspension

Physical Characteristics

       Skin

       Sole creases

       Amount of breast tissue

       Amount of lanugo/ Vernix

       Cartilaginous development of the ear

       Testicular descent and scrotal rugae or labial development

       Correlation of Gestational Age and Birth Weight

       Gestational age score, birth weight, length, head circumference are marked on a graph to
        determine maturity and Intrauterine growth

       Appropriate for gestational age (AGA)= when the newborn is between the 10th and 90th

       Small for gestational age (SGA)= Below the 10th percentile,

       Large for gestational age (LGA)= Above the 90th percentile

       Neurological Adaptations
        Major Reflexes Present at Birth

       Sucking

                 elicited when object placed in newborn's mouth or anything touches lips

                 Disappears by 12 months

       Rooting

                 Elicited when side of newborn's mouth or cheek is touched.

                 In response, newborn turns toward that side and opens lips to suck (if not fed recently).

                 Disappears 4-7 months

       Palmar grasp.
        Elicited by stimulating newborn's palm with a finger or object
        Newborn grasps and holds object or finger firmly enough to be lifted momentarily from crib.
        Disappears 3-4 months
   Moro or Startle reflex. Elicited when newborn startled by loud noise or lifted slightly above crib
    and then suddenly lowered
    In response, newborn straightens arms and hands outward while knees flex, slowly arms return
    to chest, as in embrace. Fingers spread, forming C, and newborn may cry. Disappears by 6

   The Babinski reflex (response) Fanning of toes occurs when lateral aspect of sole is stroked from
    heel upward across the ball of foot.
    Disappears by 12 months

   The stepping reflex disappears after about 4 to 8 weeks.

           Tonic neck “Fencer position”

                    Elicited when newborn is supine and head is turned to one side

                    In response, extremities on same side straighten, whereas on opposite side they

                    Disappears by 3-4 months

                    Trunk incurvation—stroking spine when newborn is prone causes pelvis to turn
                     to stimulated side.

   Prone crawl—When placed on stomachs, they push up and try to crawl.

   Newborns can blink, yawn, cough, sneeze, and draw back from pain (protective reflexes).

                    Behavior during first hours Periods of Reactivity/ inactivity

   First period of reactivity

           Lasts approximately 30 minutes after birth

           Awake and active

           Strong sucking reflex

           Initiate breastfeeding

           Bursts of random, diffuse movements alternating with relative immobility

           Respirations are rapid, may be retraction of the chest, transient flaring of nares, and

           Heart rate is rapid and rhythm may be irregular.

           Bowel sounds are usually absent.
           Period of inactivity to sleep phase

           After approximately half an hour

           Activity gradually diminishes

           Heart rate and respirations decrease as newborn

           May last from a few minutes to 2 to 4 hours

           Difficult to awaken

           Show no interest in sucking

           Bowel sounds become audible

           Cardiac and respiratory rates return to baseline values

   Second period of reactivity

           Awake and alert

           Lasts 4 to 6 hours

           Physiologic responses are variable.

           Heart and respiratory rates increase.

           Production of respiratory and gastric mucus increases, and newborn responds by
            gagging, choking, and regurgitating.

           Gastrointestinal tract becomes more active; first meconium stool is frequently passed
            and initial voiding may also occur.

   Interventions during second period of reactivity

           Nurse must be alert for apneic periods, may cause a drop in heart rate.

           Newborn is stimulated to continue breathing during such times.

           Newborn may develop rapid color changes and become mildly cyanotic or mottled
            during these fluctuations.

           Continued close observation and intervention may be required to maintain clear airway.

           Newborn will indicate readiness for feeding by such behaviors as sucking, rooting, and
            swallowing. If feeding was not initiated in first period of reactivity, it is done at this time.

   Newborn Behaviors
       Sleep state

                  Characterized by closed eyes with no eye movements

                  Regular, even breathing

                  Jerky motions or startles at regular intervals

                  Behavioral responses to external stimuli delayed

                  Startles rapidly suppressed

                  Changes in state not likely to occur

                  Heart rate may range from 100 to 120 beats per minute

       Any disturbance of sleep-wake cycle can result in irregular spikes of growth hormone.

       REM sleep stimulates highest peaks of growth hormone and growth of neural system.

Alert States

       Drowsy or semi-dozing

       Wide awake

                  Alert and follows

                  Fixates on attractive objects, faces, or auditory stimuli

       Active awake

                  Eyes are open

                  Motor activity is intense

                  Thrusting movements of extremities

                  Environmental stimuli increase startles or motor activity

       Crying

                  May be distraction from disturbing stimuli such as hunger and pain

                  Fussiness allows discharge of energy and behavior reorganization

                  Elicits an appropriate response of help from parents

       Behavioral-Sensory Capacities of Newborn
   Self-quieting ability

           Hand to mouth movements

           Sucking on fist

   Habituation

           The ability of the newborn to ignore repetitive disturbing stimuli

   Visual Capacity-Orientation

   Ability to be alert to, follow, and fixate on complex visual stimuli

   Optimum state for interaction between baby and parents

   Newborn prefers human face and eyes and bright shiny objects

   Becomes familiar with family, friends, and surroundings

   Auditory Capacity

           Responds with definite, organized behavior repertoire

           Cardiac rate rises

           Minimal startle reflex observed

           All birthing centers in Florida Screen Newborn hearing

           Olfactory Capacity

           Select people by smell

           Distinguish mother

           Taste and Sucking

           Sugar increases sucking

           Sucking pattern variations

            rubber nipple and breast

           Rooting reflex

           Tactile Capacity

           Sensitive to being touched, cuddled, and held
           Settled newborn is able to interact with environment.

   Neonatal Transition

   Definition: The first few hours of life when the newborn stabilizes respiratory and circulatory

   Fetal lung development

           Surfactant mixture of surface-active phospholipids (lecithin and sphingomyelin)

           Fetal breathing movements

           Initiation of breathing

                   Pulmonary ventilation must be established through lung expansion following

                   Marked increase in pulmonary circulation must occur

                   Chemical stimuli = elevated CO2

                   Thermal stimuli=Change in temperature at birth

                   Sensory stimuli= light, sounds, drying and wrapping

   Cardiopulmonary Changes

           Greater blood volume to lungs contributes to conversion of fetal circulation to newborn

           Shunting of blood is common in early newborn period

   Oxygen saturation in newborn's blood is greater than adult's

   Amount of oxygen available to tissues is less

   Airway resistance is increased in newborn as compared to adult

   Cardiovascular Adaptations

   Onset of respiration triggers increased blood flow to lungs after birth

   Major areas of change occur in cardiopulmonary adaptation

           Increased aortic pressure and decreased venous pressure

           Increased systemic pressure and decreased pulmonary artery pressure

           Closure of foramen ovale ( R to L atria)
                     Closes in 1-2 hours. Blood now flows from aorta to Pul. artey

             Closure of ductus arteriosus

             Closure of ductus venosus

                     Closure forces perusion to the liver

   90% of all murmurs in newborns are transient.

             Lab values

   CBC

   Hematocrit may rise 1 to 2 g/dL above fetal levels

              due to placental transfusion, low oral fluid intake, and diminished extracellular fluid

   Hemoglobin level declines progressively over first 2 months of life.

             Due to decrease in red cell production and increase in loss.

   Leukocytosis is normal finding, because stress of birth stimulates increased production of
    neutrophils during first few days of life.

   Blood Coagulation

   Coagulation factors II, VII, IX, and X are synthesized in liver and activated under influence of
    vitamin K

   Absence of normal flora needed to synthesize vitamin K in newborn gut results in low levels of
    vitamin K

             Creates transient blood coagulation alteration between second and fifth day of life

             Coagulation factors rise slowly.

   Vitamin K =Aquamephyton 0.5- 1mg. given IM prophylactically at birth to combat potential
    clinical bleeding problems

             Vastus lateralis

             25 gauge ½ inch needle

             Other Lab Tests on the Newborn

   Blood type and Rh
   Presence of antibodies(direct Coombs)

   May have blood glucose if mom had DM

                   Metabolic Screening ( In Florida)

                           Done after 24 hours of protein feedings

                           For multiple disorders including

                   PKU phenylketonuria

                   Galactosemia

                   Congenital Hypothyroidism

                   Hemoglobinopathies- sickle cell, thallasemia

                   Congenital Adrenal Hyperplasis

                   Cystic Fibrosis

                   Biotidase deficiency

                   Homcystinuria

                   GI adaptations

   Proteins well digested and absorbed from newborn intestine

   Air enters stomach immediately after birth.

   Newborn's stomach has capacity of about 50 to 60 mL

   Bowel sounds present within first 30 to 60 minutes of birth and newborn can successfully feed
    during this time.

   Immature Cardiac Sphincter

           Regurgitation may be noted

           Avoiding overfeeding

   Term newborn requires 120 cal/kg/day to gain weight

   Immune Function in Newborn

   Limitations in newborn's inflammatory response result in failure to recognize, localize, and
    destroy invasive bacteria
There is a poor hypothalamic response to pyrogens

              fever is not reliable indicator of infection

      Active Acquired Immunity

      IgG crosses placenta

      Pregnant woman forms antibodies in response to illness or immunization

      Passive Acquired Immunity

      IgG antibodies are transferred to fetus in utero

      Fetus does not produce antibodies itself

      Period of resistance varies:

              Immunity against common viral infections such as measles may last 4 to 8 months.

              Immunity to certain bacteria may disappear within 4 to 8 weeks.

      Normal newborn produces antibodies in response to antigen.

      Immunize at 2 months of age to develop active acquired immunity.

      Nutritional Needs

              Newborns need

                      105-108 kcal/ kg./day

                      50-55 kcal. /lb/ day

                      140-160 ml/kg/day of fluid

                               Increase fluid need in hot weather and during illness

              Formula fed babies tend to regain their weight faster- 10 days. Breast fed babies by day

              Formulas are made to meet these requirements =20cal/oz.

              First feeding is usually 15-30 ml. of water to assure swallow ability.

                      May regurgitate mucous first few feedings

              Stomach capacity= 50-60 ml.

              Emptying time about 2-3 hours
           Bottle feeding should be at least 1 oz. Q 2-4 hrs

           Instruct mother to notify nurse if <30ml/ feeding

           Burp at frequent intervals- every 1/2- 1 oz. or between breasts

                     Prevents distension

                       helps hiccups

                       allows baby to eat more

           Breast feeding meets all the nutritional and fluid requirements and should be done q 1-3

           Hunger is usually manifested by crying, restlessness, sucking

           Parents need to be taught to use bulb syringe to clear nasal/oral secretions

           Need to clear nares before feeding ( nose breathers)

   Breastfeeding

   Breast Milk

   Colostrum

           Yellowish or creamy-appearing fluid

           Thicker than mature milk

           Contains more protein, fat-soluble vitamins, and minerals

           Contains high levels of immunoglobulins or antibodies

           Source of passive immunity for the newborn

   Transitional milk

           2 to 4 days after birth until approximately 2 weeks postpartum

           Contains lactose, water-soluble vitamins, elevated levels of fat

           More calories than colostrum

   Mature Milk

           10% solids (carbohydrates, proteins, fats)

           Water—vital for maintaining hydration
           Composition of mature milk varies according to time during feeding

           Foremilk

                   Obtained at beginning of the feeding

                   High in water content

                   Contains vitamins and protein

           Hindmilk

                   Released after initial letdown of milk

                   Higher fat concentration

                   Maure Breast Milk and formulas provide 20kcal/ oz

           Nutritional Advantages of Breast Milk

   Composed of lactose, lipids, polyunsaturated fatty acids, amino acids

   Whey-to-casein protein ratio that facilitates digestion, absorption

   High concentration of cholesterol and polyunsaturated fatty acids

   Balance of amino acids best for myelination and neurologic develops

   Provides minerals in more appropriate doses than formulas

   Concentration of iron in breast milk

           Lower than that in prepared formulas

           Much more readily and fully absorbed

           Sufficient to meet iron needs for the first 6 months

   Component delivered to the infant in an unchanged form

   Vitamins not lost through processing and heating

   Protein metabolism produces less nitrogen waste—positive effect on the infant's immature
    renal system

   Immunologic Advantages of Breastfeeding

           Protection from respiratory and gastrointestinal infections, otitis media, meningitis,
            sepsis, and allergies
           Secretory IgA has antiviral, antibacterial effect

   Psychosocial Advantages of Breastfeeding

           Maternal-infant attachment

           Oxytocin increases with breastfeeding

                   Even mood responses

                   Increased feelings of maternal well-being

   Other Advantages to Breastfeeding

           Convenience

           Cost

           Milk always perfect temperature

           No preparation time needed

           Contraindications and Disadvantages of Breastfeeding

   Diagnosis of breast cancer

   Maternal Human Immunodeficiency Virus (HIV)/ AIDS

   Maternal medications may or may not be contraindication

   Newborn jaundice may include a brief suspension of breastfeeding.

   9 to 12 feedings every day may be considered inconvenient and stressful.

   Exclusion of the father from nurturing involved in feeding infant

   Maternal smoking – nicotine in breast milk

   Breastfeeding after returning to work may be difficult.

   Commercial Formulas

   Cow's milk proteins

           Enriched with tyrosine, phenylalanine, iron, vitamins

   Soy protein-based formulas

           Isomil, Prosobee, Gerber So
          Substitute soy protein supplemented with methionine protein

          Used for primary lactase deficiency or galactosemia

   Specialized or therapeutic formulas

          Casein-hydrolysated or whey-hydrolysated formulas

          Allergy or intolerance to cow's milk protein

   Use iron-fortified formulas or supplements to prevent iron deficiency anemia

   Formula-Feeding Advantages

          Parents can share equally in the nurturing, caring experience.

          Positive parent-infant interaction

          Father or anyone can feed baby.

          Formula-fed babies gain weight faster because of higher protein.

   Disadvantages

          Potential allergies to formula

          Expense

          Risk for infection in preparation

          Need for refrigeration

          Preparation time

          Establishing a Feeding Pattern

   Breast-fed newborns

          "On-demand" feeding program

          Facilitate each baby's rhythm

          Assists mother in establishing lactation

          Nurse 8 to 10 times in a 24–hour period

   Formula-fed newborns

          Awaken for feedings every 2 to 5 hours
          Satisfied with feedings every 3 to 4 hours

          Digest more slowly, go longer between feedings

   After Feeding

          Observe newborn closely

          Positioned on right side to aid drainage and facilitate gastric emptying

          Social Cultural Influence and Infant Care

   Mothers identify modesty and embarrassment as reasons why they may not breastfeed

   North American

          Consider it indecent to expose breast

          Believe that too much handling spoils children

          Regard weaning as sign of infant development

   Mexican American, Navajo, Filipino, and Vietnamese

          Colostrum is not offered to newborn.

          Breastfeeding begins after milk flow is established.

   Muslim mothers

          Breastfeed because Koran encourages it

          Breastfeed until child is 2 years old

   Japanese women—breastfeed for baby's first year

   African American culture

          Emphasize plentiful feeding

          Solid foods introduced early and added to infant's formula

          Frequent feeding—positive behavioral characteristic

   Traditional Mexican women

          A fat baby is considered healthy.

          Infants fed on demand
                "Spoiling" encouraged

      To Facilitate Successful Breastfeeding

      Privacy

      Comfortable position

      Position baby comfortably close to mother

      Position baby so nose is at level of the nipple

      Nose is at level of the nipple

      Gums are on areola

      both breasts offered at each

Feeding to stimulate supply demand

                Stimulate early feedings supply

      Burp between feedings on each breast

       and at end of feeding

      Encourage a Sleepy Baby to Breastfeed

      Unwrap baby

      Provide skin-to-skin contact between mom and baby

      Have mom rest with baby near her breast

      Encourage mom to watch for feeding cues

                Hand-to-mouth activity

                Fluttering eyelids

                Vocalization but not necessarily crying

                Mouthing activities

      Mother should be taught the signs of milk transfer to infant

                Audible swallowing

                Milk appearing in baby's mouth
           Breast feeling soft after feeding

           Milk leaking from opposite breast

   Newborn gains weight

   Has six or more wet diapers per day.

   Storing Breast Milk

   Breast milk can be pumped and stored

           Refrigerated milk used within 3 days

           Store in clean plastic containers

           Can be frozen for up to 2 weeks

   External Supports

   The father or other partner is the most important support person.

   Baby provides support in form of positive feedback

   La Leche League International

           Provide education about breastfeeding

           Assistance to women who are breastfeeding

           Provides printed materials

           Offers one-to-one counseling

   Local lactation consultants

   Drugs and Breastfeeding

   Observe infant for

           Signs of drug reaction

           Rash

           Fussiness

           Lethargy

           Changes in sleeping habits or feeding patterns
   Most drugs cross into breast milk.

           < 1% of maternal dose

   Tell physician who may prescribe medications that client is breastfeeding.

   Foods can also affect newborn

           Caffeine, chocolate can stimulate

           Gaseous foods can cause gas

   Infant's Nutritional Status Assessed at Each Well-Baby Visit

   Weight gain since the last visit

           Formula-fed infant—30 g (1oz)/ day for first 6 months of life

           Breastfed infant—0. 5 oz/day for first 6 months

           Breastfed infant—15 g (0. 5 oz) per day for the second 6 months

   Growth chart percentiles

           Height

           Weight

           Head circumference

   Physical examination

           Identify any nutritional disorders

           Newborn Care

   Bathing the newborn and teaching parents

           1st Bath after VS and temperature are stabilized

           Recheck temp after bath

           Sponge bath initially while under warmer

           Wear gloves

           Mild or no soap

           Girls clean peri area front to back
           Boys be sure foreskin is not left retracted

   Cord Care

           Triple dye initially, avoid getting wet

           alcohol to cord with each diaper change

           Will fall off within 10 days- then tub bath OK

           Monitor for S & S of infection

   Circumscision- surgical removal of foreskin

           Religious, parents preference, controversial?

           Use of anesthetic or analgesic recommended

           Requires parents consent, separate cost

           Keep clean, apply petroleum ointment

           Observe for bleeding

                   apply pressure if bleeding occurs

           Do not remove yellow exudate or crust

           Observe for S&S of infection, decreased urination

           Position baby on back to sleep to prevent SIDS

   Parents need to have a thermometer and know how to take baby’s axillary temperature &

   Call MD for sudden fever, rash, excessive vomiting, abdominal distension,

   Car Seat Law all children under 4

           Will not be discharged from hospital without seat

   Parents should know CPR/ airway clearing

   Prevention of Eye infections

   Erythromycin opthalmic ointment

   Tetracycline opthalmic solution

           Prophylaxis for Opthalmia Neonatorum
                  possible exposure to gonorrhea or chlamydia

          May cause irritation or imflammation

                  Will resolve in 24-48 hours

   Hepatitis B Immunization

          Administered at birth if Hep B Positive mom or if Hep B status is unknown.

          If Mom negative dose can be delayed

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