Care of the newborn infant

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Care of the newborn infant
Variations exist from place to place in the care
of the newborn infant. However, although often
neglected, their basic needs are the
same. Infants who are unwell or have congenital
abnormalities fall short of the mothers
expectation of a beautiful bundle of joy. All
mothers require urgent and sensitive counselling.
For more information about the authors and
reviewers of this module, click here
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How should I study this module?

• This self-directed learning (SDL) module has been
  designed primarily for medical students but may
  also be of use to healthcare providers especially
  at the primary care level.
• We suggest that you first read the learning
  outcomes and try to keep these in mind as you go
  through the module slide by slide and at your own
  pace.
• Answer the MCQ at the end to assess your
  learning.
• You should research any issues that you are
  unsure about. Look in your textbooks, access the
  on-line resources indicated at the end of the
  module and discuss with your peers and teachers.
• Finally, enjoy your learning! We hope that this
  module will be easy to study and complement your
  learning about newborn care from other sources.

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Learning outcomes

• After studying this module, you should be able to
• Describe the routine clinical assessment of
  newborn infants
• Describe some common congenital abnormalities
• Describe the essential elements of the routine
  management of newborn infants including hygiene,
  cord care, feeding and rooming-in
• Describe what routine immunisations are required
  during infancy
• Discuss what information is required by mothers
  prior to discharge

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Clinical assessment

• After delivery of the baby and in the absence of
  any immediate problems, essential newborn care
  begins with a thorough general clinical
  assessment.
• This should be done on all infants soon after
  birth to detect signs of illness and congenital
  abnormalities.
• The following slides describe the assessment that
  should be performed routinely in all infants.
  This initial assessment should indicate where
  more detailed clinical assessment is required.

A resident doctor washing her hands up to the
elbows prior to examination
Hand washing with soap and water before and after
a baby is handled goes a long way in reducing the
risk of infection
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Clinical assessmentFirst steps and appearance

• Start by congratulating the mother on the arrival
  of her new baby and ask if she has any concerns.
  The mother is usually the first person to notice
  any problems.
• Ask about feeding and the passage of urine and
  stools. The infant should pass meconium (the
  first black, tarry stools) within 24 hours of
  birth.
• General observation inspect colour, breathing,
  alertness and spontaneous activity.
• Well infants have a flexed, posture. Partially
  flexed posture is found in hypotonia or
  prematurity

Well term infant showing typical well flexed
posture
Note the abduction of the hips in this partially
flexed preterm infant (froglike posture)
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Clinical assessmentExamine skin for prematurity
or dismaturity
Thin, transparent skin in preterm infants
Pale pink skin of a term infant (hair shaved to
site IV line)
Wrinkled peeling skin of dysmaturity in an IUGR
infant
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Clinical assessmentSkin some common normal
findings

• Vernix caseosa a cream/white cheesy material on
  the skin at birth which cleans off easily with
  oil.
• Lanugo fine downy hairs seen on the back and
  shoulders especially in preterm infants.
• Milia pinpoint whitish papules on nose and
  cheeks due to blocked sebaceous glands.
• Mongolian blue spots grey/bluish pigment patches
  seen in the lumbar area, buttocks and extremities
  in dark skinned babies.They usually disappear by
  one year.
• Capillary heamangiomas (stork bite naevi) red
  flat patches which blanch with gentle pressure.
  Commonly occur on upper eyelids, forehead and
  nape of the neck.
• Erythema toxicum small white/yellow papules or
  pustules on a red base seen on face, trunk and
  limbs. Develop 1 3 days after birth and usually
  disappear by one week.

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Clinical assessmentColour

• Note palor or plethora
• Cyanosis the baby should be uniformly pink
• Blueness of the hands and feet (peripheral
  cyanosis) may be due to cold extremeties.
• Blueness of the mucous membranes and tongue is
  central cyanosis and is usually due to lung or
  heart problems
• Bruising (ecchymosis) is common after birth
  trauma. Unlike cyanosis, bruising does not blanch
  on gentle pressure.

A Caucasian infant with marked central cyanosis
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Clinical assessmentJaundice

• Jaundice is common in the first week of life and
  may be missed in dark skinned babies
• Blanch the tip of the nose or hold baby up and
  gently tip forward and backward to get the eyes
  to open.
• Teach mother to do the same at home in the first
  week and report to hospital if significant
  jaundice is observed.

Blanching the tip of the nose
Two infants with jaundice note yellow sclerae
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Clinical assessmentHead

• After these general observations, examine the
  infant starting with the head and moving down the
  body.
• Observe the size and shape of the head (micro- or
  macrocephaly cephalhaematoma)
• Check the anterior and posterior fontanelles and
  that the skull sutures feel normal
• Form and position of ears (low set ears occur in
  chromosomal abnormalities, e.g. Down syndrome)

Cephalhaematoma limited to the right parietal
region
Huge encephalocoele. Head is disproportionately
small
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Clinical assessmentEyes and face

• Examine eyes for ocular anomalies and check for
  red reflex using the ophthalmoscope (to exclude
  cataract)
• Examine the face for dysmorphic features and
  normal movements
• Examine lips and palate for clefts

Bilateral cleft lip and palate. Also note
purulent left eye discharge
Facial asymmetry due to left facial palsy
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Clinical assessmentCardiovascular and respiratory

• Feel femoral and radial pulses for volume, rate
  and rhythm.
• In aortic coarctation, femoral pulse is reduced,
  absent or not synchronous with radial pulse.
• If child is sick, measure blood pressure.
• Locate the apex beat and listen to the heart
  sounds for murmurs.
• Count the respiratory rate
• normal 30 40 breaths/min in term infants
• faster in preterms.
• gt 60 / minute abnormal
• Observe for respiratory distress nasal flaring,
  intercostal and subcostal recession.

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Clinical assessmentAbdomen

• Inspect the umbilical cord for presence of 2
  arteries and a vein. Abnormal components may be a
  pointer to the presence of intra-abdominal
  anomalies e.g. renal.
• Look for umbilical abnormalities, e.g. hernia,
  omphalocoele, exompholos
• Gently palpate the abdomen
• the liver may be palpable upto 2cm below the
  costal margin
• the lower pole of the right kidney may also be
  palpable

Large omphalocoele. Surounding erythema indicates
cellulitis.
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Clinical assessmentSpine and genitalia

• Examine
• The spine for dimples, tuft of hair (spina bifida
  occulta) or cystic swellings (spina bifida
  cystica)
• Remove the diaper to examine the genitalia. In
  boys, confirm that both testicles have descended
  into the scrotum.
• Designate the infants sex
• Inspect the perineum and check anus for position
  and patency (can be done by gently checking
  rectal temperature)

Spina bifida cystica
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Clinical assessmentDysmorphic features

• Examine hands. Note single palmar crease in
  chromosome abnormalities.
• Inspect the feet. Note effects of foetal posture
  should be noted.
• Check hips for dislocation
• Limitation of limb movements occurs in fractures
  and nerve injury

Short stuby fingers and single palmar crease of
Down syndrome
Talipes affecting the left leg
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Clinical assessmentRoutine measurements

• Measure
• Weight
• normal 2.5 3.99kg
• Length
• normal 48 52cm
• Occipitofrontal circumference (OFC)
• normal 33 37cm

Measurement of OFC using a non-stretchable tape
measure
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Routine care of the well newborn

• Any problems identified during the initial
  assessment will need specific management.
  However, newborn infants are a highly susceptible
  group and high-quality routine care prevents a
  multitude of problems. The major elements of
  routine care include
• Cord care
• Thermal control
• 24 hour rooming in
• Feeding
• Immunization
• Maternal education on hygiene and every other
  aspect of routine care

Click on the links for more information on these
important elements of routine care
Hand washing with soap and water every time a
baby is handled goes a long way in reducing the
risk of infection!
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Quiz Concerning care of the newbornWrite T or
F on the answer sheet. When you have completed
all 5 questions, click on each box and mark your
answers.
Click to reveal correct answers

1. Nursing a newborn with the mother rather than in
   the nursery predisposes the child to infections
2. Hand washing with soap and water before handling
   a newborn significantly reduces the risk of
   infection in the baby
3. Fortified infant formula is superior to mothers
   breast milk in a sick term newborn
4. Newborn babies cannot be kept warm without the
   use of incubators
5. Jaundice cannot be detected early in dark skinned
   babies

a
b
c
d
e
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Cord care

• The umbilical stump needs particular attention as
  there are risks of bleeding and infection.
• Good cord care includes
• Cutting cord with sterile equipment or a new
  razor blade depending on the setting
• Ligation with a sterile plastic clamp or clean
  thread
• Keeping cord stump exposed, clean (with 70
  alcohol, 4 chlorhexidine or simple soap and
  water) and dry

A sterile clamp applied to the umbilical cord
Binding, use of powders and traditional practices
like application of cow dung, broken glass or
herbs are harmful and should be discouraged!
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Thermal control

• Regulation of body temperature is immature in
  newborn infants. Also, energy reserves are low
  which may compromise the ability to cope with
  thermal stress.
• Even in tropical countries, infants may become
  hypothermic especially when temperature drops at
  night.
• Measures to prevent hypothermia include
• Delivery in a warm environment
• Immediate drying of the infant to minimize heat
  loss by evaporation
• Keep out of drafts
• Skin to skin contact with mother
• Proper clothing and wrapping up with linen
  including use of booties and bonnets
• Regular feeds

A well dressed baby
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Rooming in

• Rooming in refers to the practice of nursing
  babies with their mothers rather than keeping
  them in a separate nursery.
• Advantages
• Promotes bonding
• Makes exclusive breastfeeding easy
• Early exposure of baby to maternal bacterial
  flora
• Reduces risk of nosocomial infections
• Mother is able to keep a close watch on her
  infant. She should be encouraged to report any
  concerns that she has to the health care staff.

A postnatal ward showing mothers with their babies
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Feeding

• Breast feeding remains the best method of feeding
  the newborn and has the following advantages
• Breastmilk is nutritionally balanced
• It reduces the risk of infection especially in
  unhygienic situations
• Protects against diarrhoea and other infections
  in infancy
• Promotes mother-child bonding
• It is readily available
• It helps in child spacing

Breast feeding a low birthweight infant
When breast feeding is not feasible (e.g. an HIV
positive mother who chooses not to breastfeed, an
infant whose mother dies) infant formula is the
most suitable alternative. It should be prepared
with clean boiled water under hygienic
conditions. Cup and spoon feeding is safer than
bottle feeding in settings with limited resources.
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Routine immunization

• Immunization should be commenced soon after
  birth irrespective of gestational age according
  to national immunization schedules
• Example of an immunisation schedule
• At birth BCG, Oral polio HBV1
• 6 weeks DPT1, Oral polio HBV2
• 10 weeks DPT2, Oral polio
• 14 weeks DPT3, Oral polio HBV3
• 9 months Measles, yellow fever
• 18 months DPT4
• DPT- diptheria, pertussis, tetanus HBV
  hepatitis B vaccine

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Sources of information

• Pocket book of Hospital care for children
  guidelines for the management of common illnesses
  with limited resources. WHO http//www.who.int/chi
  ld-adolescent-health/publications/CHILD_HEALTH/PB.
  htm
• Essential newborn care http//www.who.int/reproduc
  tive - health/publications/
• Nelson Textbook of Pediatrics 16th Edition.
  Richard E. Behrman Robert Kliegman, Hal B. Jenson
  (Editors),

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Authors and reviewers

• Authors
• Dr. O. Tongo, Lecturer and Consultant
  Paediatrician, College of Medicine, University of
  Ibadan, Ibadan, Nigeria.
• Mrs A. Alao, System analyst, College of
  Medicine, University of Ibadan, Ibadan, Nigeria.
• Dr. Stephen Allen, Reader in Paediatrics and
  Honorary Consultant Paediatrician, The School of
  Medicine, Swansea University, Swansea, UK

We would like to acknowledge the of the
Association of Commonwealth Universities, London
for awarding the Fulton Fellowship which
supported Dr. Tongo and Mrs Alao in developing
this module
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Answer to question 1a
û
The statement is False. Nursing a newborn with
the mother exposes baby to mothers normal flora
early and this helps to prevent colonization by
pathogenic bacteria. Nursery care delays this and
exposes the infant to nosocomical infections.
Back
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Answer to question 1b
The statement is True. Hand washing with soap is
the single, most important factor in the
prevention of infections in the newborn!!
ü
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Answer to question 1c
û
The statement is False. Mothers milk is the
most suitable in composition for adequate growth
of a term infant. In sick term newborns, it has
added advantage of protecting against necrotizing
enterolitis because it does not favour bacterial
proliferation and has less solute load than
infant formula.
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Answer to question 1d
û
The statement is False. Well babies including
preterms can be kept warm by proper clothing or
direct skin to skin care with mothers or other
care givers even in the absence of incubators
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Answer to question 1e
û
The statement is False. Though jaundice is
difficult to detect in dark skinned babies, it is
possible to detect early jaundice in them by
blanching the skin of the tip of the nose to
ellicit yellowness. This must be performed before
discharge and mothers should be taught to do same
at home
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