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common result of the pressures of labor and birth.
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5
Systole (torr)
Birth weight (kg)
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Diastole (torr)
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The size, shape, and structure of the eye should be
noted.
The pupils of the normal newborn respond to
light by constricting. Red reflex is normally present
and indicates an intact lens and unobstructed visual
path to the retina. Tears are not normally produced
until 2 months of age. The iris is usually dark blue
until 3 to 6 months of age. Doll’s eye maneuvers are
normally associated with eyes that follow movement
of the head, often with a lag and/or nystagmus.
Discharge from the eyes may represent irrita-
tion or infection. A lateral upward slope of the eyes
with an epicanthal fold may indicate syndromes of
mental, physical, or chromosomal aberrations. The
absence of red reflex may indicate tumors or con-
genital cataracts accompanying rubella, galactosemia,
or disorders of calcium metabolism. Chorioretinitis
is often found in congenital viral diseases such as
cytomegalovirus and toxoplasmosis. White speckles
on the iris known as Brushfield’s spots are associated
with Down syndrome and developmental delay or
are a normal variant. Scleral blueness is associated
with osteogenesis imperfecta and scleral yellowness with jaundice. Brain injury may be indicated
by a constricted pupil, unilaterally dilated fixed
pupil, nystagmus, or strabismus.
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60
40
20
0
80
60
40
20
FIGURE 5.13 Aortic blood pressure during first 12 hours after birth. Linear
regression (broken lines) and 95% confidence limits (solid lines) of systolic
and diastolic blood pressures on birth weight in healthy newborn infants. (From
Versmold HT, Kitterman JA, Phibbs RH, et al. Aortic blood pressure during the
first 12 hours of life in infants with birth weight 610 to 4220 grams. Pediatrics.
1981;67:607.)
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0
12
34
119
Blood Pressure. Blood pressure (BP) with nonin-
vasive Doppler devices is best determined (1)
by using the appropriate-size cuff for upper
and lower extremities (e.g., using the same
size cuff for the leg pressure that was used for
the arm pressure results in a falsely elevated
leg pressure), (2) by obtaining the measurement when the infant is asleep or before the
infant is upset, and (3) by using the mean BP
to monitor changes.61 BP increases in the first
24 hours of life, is higher in more mature infants
(e.g., BW and GA) and in newborns whose
mothers smoke,82 and increases with increasing
postnatal age.
59
The BP should be checked in all four extremities to screen for coarctation of the aorta.
Because the BP proximal to the area of obstruction is higher than the BP distal to the area of
obstruction, BP in the upper extremities is higher
(more than 15 mm Hg higher) than in the lower
extremities (Figs. 5.13 and 5.14).
The only study to evaluate the efficacy of upper
and lower extremity BP variations was conducted
on 40 healthy neonates.61 This study showed that
with the current Doppler devices, normal neonates
may have a wide variation in BPs between limbs.
The researchers concluded that a difference of 20
mm Hg is more likely caused by random variability
than coarctation and recommended that if weak/
absent pulses are present and coarctation is suspected, an echocardiogram is necessary.
Head-to-Toe Examination. The infant’s crying will
61
not affect the data to be gathered in the headto-toe examination.
Skin. As each body part is examined, the skin
is also inspected. Vernix, a white, cheeselike
material that contains quantities of α-tocopherol
and surfactant proteins that provide significant
protection from infection, normally covers the
body of the fetus and decreases with increased
GA. Discoloration of the vernix occurs with
intrauterine distress, postmaturity, hemolytic disease, and breech presentations.
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Mean (torr)
Birth weight (kg)
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60
40
20
0
80
60
40
20
FIGURE 5.14 Mean aortic and pulse pressures during the first 12 hours af-
ter birth. Linear regression (broken lines) and 95% confidence limits (solid lines)
on birth weight in healthy newborn infants. (From Versmold HT, Kitterman JA,
Phibbs RH, et al. Aortic blood pressure during the first 12 hours of life in infants
with birth weight 610 to 4220 grams. Pediatrics. 1981;67:607.)
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34
The color of the skin is normally pink.
Mongolian spots caused by the presence of pigmented
cells may cover the sacral-gluteal areas of infants of
color (e.g., black, Hispanic, Asian). The degree of
generalized pigmentation varies and is less intense
in the newborn period than later in life. Nevus
flammeus may be present at the nape of the neck or
on the eyelids.
Note the size, shape, color, and degree of
ecchymosis, erythema, petechiae, or hemangiomas. Meconium staining, which occurs in 10%
to 20% of newborns, is indicative of prior fetal
distress. Erythema toxicum appears as a generalized
red rash in the first 3 days of life. Milia caused by
retained sebum are pinpoint white spots on the
cheeks, chin, and bridge of the nose.
The normal texture of a neonate’s skin is soft.
A preterm infant’s skin is more translucent than a
term infant’s skin. Slight desquamation may occur
as skin becomes dry. Moderate to severe desqua-
mation occurs in postterm infants with IUGR.
Puffy, shiny skin is symptomatic of edema. Localized
edema of a presenting part is caused by trauma and
is only temporary. Edema should be distinguished
from increased subcutaneous fat. Lanugo coverage
decreases with increasing GA.
Tissue turgor is the sensation of fullness derived
from the presence of hydrated subcutaneous tissue
and intrauterine nutrition. Test the elasticity of the
skin by grasping a fold of skin between the thumb
and forefinger. When released, the skin should
promptly spring back to the surface of the body. A
loss of normal skin turgor resulting in peaking
of the skin is a late sign of dehydration. A gen-
eralized hardness of the skin is a sign of sclerema that
occurs in debilitated, stressed infants.
Ears. Cartilage development and ear form
progress according to GA. Observe the exter-
nal ears for size, shape, and position. The angle
of placement of the ears is almost vertical. If the
angle of placement is greater than 10 degrees
from vertical, it is abnormal. The level of placement is determined by drawing an imaginary line
from the outer canthus of the eye to the occiput.
If the ear intersects the line, it is placed normally.
Slapping hands or other sharp noises will normally elicit a twitching in the eyelid or a complete
Moro reflex.
Malformed or malpositioned (low-set or
rotated) ears are often associated with renal and
chromosomal abnormalities and other congenital anomalies. Abnormalities such as skin tags
or sinuses may be associated with renal tract
abnormalities or hearing loss. Forceps or diffi-
cult deliveries may injure the outer ear. Congenital
deafness is suspected if the infant does not respond
to noise. It is confirmed by standardized hearing
screening tests and follow-up.
Nose. Note the shape and size of the nose.
Deformities caused by intrauterine pressure may
be temporary. Neonates are obligatory nasal
breathers and must have patent nasal passages. Check the patency of the alae nasi by (1)
obstructing one nostril, closing the mouth,
and observing breathing from the open nostril;
(2) placing a stethoscope under the nostrils
that will “fog” the diaphragm and auscultate
breathing; or (3) passing a soft catheter (if
necessary).
Abnormal configuration may be associated with
congenital syndromes. Obstructions can be caused
by drugs, infections, tumors, nasal discharge, nasal
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cysts, and mucus. Choanal atresia, a membranous or
bony obstruction in the nasal passage, may be unilateral or bilateral. Choanal atresia is characterized
by the noisy breathing, cyanosis, and apnea of
the quiet infant (mouth closed) as opposed to
the pink color of the same crying infant (mouth
open).
Mouth. The mouth may be examined here or at
the end of the examination when the infant is
crying loudly with a wide-open mouth. At birth,
a normal infant can suck and swallow (this
ability develops at 32 to 34 weeks of gestation) and root and gag (this ability develops at
36 weeks of gestation). Elicit each.
Lips and mucous membranes are normally
pink. Observe the lips and mucous membranes for
pallor and cyanosis. If the infant is well hydrated,
the membranes should be moist. Open the mouth
to look for anomalies. Palpate the hard and soft
palates for a membranous cleft or submucous
cleft. Epithelial pearls are common along the gum
margins and the palate.
Natal teeth may be present and may require
removal to prevent aspiration. A large tongue (macroglossia), cleft lip or palate (including submucous
cleft), or high-arched palate may be associated with
abnormal facies or be an isolated finding. If copious
secretions or distress in feeding is present, it is often
the result of esophageal atresia or tracheoesophageal
fistula.
Thorax. Conformation of the newborn chest is
cylindric with an anteroposterior ratio of 1:1.
Note the shape, symmetry, position, and development of the thorax. Asymmetry of the chest may
be caused by diaphragmatic hernia, paralysis of
the diaphragm, pneumothorax, emphysema, pulmonary agenesis, or pneumonia. Fullness of the
thorax caused by increased anteroposterior diam-
eter occurs with an overexpansion of the lung.
Retractions, an inward pull of the soft parts
of the chest while inhaling, indicate air-entry
interference or pulmonary disease.
Clavicles. Observe and palpate the area above
each clavicle. A fracture of the clavicle is evidenced by a palpable mass, crepitation, tenderness at the fracture site, and limited arm movements on the affected side.
Genitalia. Male and female genitalia systematical-
ly develop according to GA. Ambiguous genitalia
result from incomplete or altered differentiation
and require urology consultation.
Male Genitalia. Inspect the genitalia for the pres-
ence and position of the urethral opening.
Palpate the testes either in the inguinal canal or
scrotum. The scrotum appears large and pendulous
with the presence of descended testes. A tight prepuce may be found. In dark-skinned races, darker
pigmentation of the genitalia is normal. Hypospadias
exists if the urethral opening is on the ventral surface of the penis. Epispadias exists if the opening is
on the dorsal surface. Inguinal or scrotal swelling,
discoloration, palpable masses, and pain/tenderness with palpation may indicate an inguinal
hernia, testicular torsion, trauma, tumor, or
hydrocele—a collection of fluid in the scrotal sac.
Female Genitalia. Inspect the genitalia for the pres-
ence and position of the urethral opening. The
introitus is posterior to the clitoris. A vaginal skin
tag is a visible hymenal ring.
Edema of the genitalia in both sexes is common
in breech presentation. Note the presence of a
hydrocele or hernia. Fecal urethral discharge may
indicate rectourethral fistulas.
Rectum. Visualize and check the patency of the
anal opening by waiting for meconium passage. DO NOT use rigid objects such as glass
rectal thermometers. Observe the anatomy, and
feel the muscle tone. Meconium is normally present during the first days of life.
Imperforate anus, irritation, or fissures may
be present. Meconium passage before birth sug-
gests fetal intrauterine distress. Failure to pass
meconium within 48 hours suggests obstruction.
Meconium ileus is associated with cystic fibrosis.
Breasts. Breast tissue systematically devel-
ops according to GA. Enlargement of breasts
because of maternal hormones occurs in either
sex on the second or third day. Milky secretions
may be present. Unilateral redness or firmness
indicates infection.
Back. Place the infant in the prone position,
and observe for a flat and straight vertebral
column. Separate the buttocks to observe the
coccygeal area. To check incurving reflex, stroke
one side of the vertebral column. The baby
will turn the buttocks toward the side stroked.
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Deviations from normal include curvature of
the vertebral column, pilonidal dimple, pilonidal sinus, spina bifida, or myelomeningocele.
A study of spinal congenital dermal sinuses found
an increased incidence (greater than 50%) of
neurologic deficit, intradural tumors, or tethered cords; recommendations included a prompt
radiologic evaluation and neurosurgical consultation so that timely intervention could preserve or
improve neurologic function.
Extremities
Upper Extremities. Note the size, shape, and sym-
3
metry of the arms and hands. Observe and feel
for fractures, paralysis, and dislocations. Count
and inspect the fingers. The hands are normally
clenched into fists. The infant is capable of adduction, flexion, internal rotation, extension, and symmetry of movement. Note the tone of the muscles.
Flexion develops with increasing GA.
Single transverse palmar creases may indicate chromosomal abnormalities that are frequent causes of
deformity. Polydactyly and syndactyly of the fingers
may be found. Osteogenesis imperfecta is characterized
by multiple fractures and deformities. Palsies caused
by fractures, dislocations, or injury to the brachial
plexus are recognized by limited movement of the
extremity. Fractures may also be present with edema,
palpable crepitus, or the “palpable spongy mass sign”
over the clavicle.
Lower Extremities. Note the size, shape, and sym-
metry of the feet and legs. Note the normal
position of flexion (develops according to GA) and
abduction. Note symmetry of movement, thigh
folds, and gluteal folds. A full range of motion is
possible, including the “frog position”—a rotation
of the thighs with the knees flexed. Observe and
feel for fractures, paralysis, and dislocations. Palpate
femoral pulses.
Polydactyly and syndactyly of the toes may
exist. Osteogenesis imperfecta, a rare genetic defect
of collagen production that results in brittle bones,
manifests as multiple fractures and deformities.
Paralysis of both legs is caused by severe trauma or
congenital anomaly of the spinal cord. Unilateral
or bilateral developmental dysplasia of the hip
(e.g., congenital dislocated hip),97 which is
more common in females and breech presentations, causes a hip clunk when the baby’s legs
are abducted into the frog position. Although
soft clicks are common, a sharp click indicates
dislocation. Fractures may be present and are
characterized by limited movement and edematous, crepitant areas. Chromosomal abnormalities
are frequent causes of deformity.
Recoil is a test of flexion development and
muscle tone. Recoil appears systematically as flex-
ion first develops in the lower extremities and then
in the upper extremities. Extend the legs and then
release. Both legs should return promptly to the
flexed position in accordance with the GA of the
infant. Then extend the arms alongside the body.
On release, prompt flexion should occur at the
elbows.
NEUROLOGIC EXAMINATION
6,7,66
The neurologic examination of the newborn is
an integral part of the evaluation of the newborn
infant. This evaluation often receives little attention,
and in too many instances the infant is dismissed
from the nursery as “normal” when, in fact, little
effort was expended to determine the baby’s neurologic status. The evaluation and documentation
of the development of the nervous system in
the normal newborn should be of paramount
interest to all the health care clinicians caring
for the newborn. Some portions of the neurologic examination are carried out as a component of the general physical examination of the
newborn (activity, resting posture, symmetry, head size
and morphology, rooting reflex, muscle tone, primitive
reflexes, tremors and twitching, cry, recoil). Performing a
complete and thorough physical examination of the
newly born is paramount.
Clinical, anatomic, and encephalographic
studies of full-term and premature neonates
have confirmed that the CNS of the human
fetus matures in a consistent pattern.66 However,
there are recognized limitations and challenges in
performing an accurate neurologic evaluation. First,
because a newborn is recovering from the stress of
birth, the neurologic examination is not reliable
until after the infant has successfully completed
the transition to extrauterine life. Therefore, the
neurologic examination should be performed
after the first 12 to 24 hours of life. Second,
if the infant was born by cesarean section, or is ill
and requiring NICU care, the neurologic examination may not be accurate, even after 24 hours.
Third, newborns are born at different stages of
brain development. Fourth, there are few tests that
reflect the status of the cerebrum in the newborn.
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Nevertheless, in spite of these limitations, it is still
possible, with a systematic and detailed neurologic
examination, to obtain enough information to gain
a basic understanding of many neurologic problems
in the newborn (see Chapter 26).
Assessment of Gestational Age
It is important to remember that neurologic matu-
rity and appropriate developmental milestones
correlate with GA rather than BW. As previously
discussed, for an accurate estimation of GA, most
clinicians favor systems that combine neurologic and
physical signs of maturation. Each portion of the
neurologic examination is objective and easy to
perform, relying on muscle tone, posture, reflex
movements, and degree of extremity flexion.
The most commonly used neurologic signs for GA
are posture, square window (wrist), arm/leg recoil,
popliteal angle, scarf sign, heel-to-ear maneuver,
head lag, ankle dorsiflexion, and ventral suspension.
Assessment of Neurologic Normality
and Abnormality
The neurologic examination is most helpful if
carried out systematically on an infant during
quiet wakefulness between feedings, generally 1
hour before the next meal. The examiner should
be especially observant of the general alertness, spontaneous activity, symmetry of posture
and spontaneous movements, muscle tone and
strength, head control, developmental reflexes,
and responses to manipulation and handling.
• State of alertness: Alteration in level of con-
sciousness is an extremely important sign in
determination of the neurologic status of the
newborn. A normal term infant shows a semi-
flexed posture and smooth spontaneous movements of all extremities. The hyperalert neonate
has the appearance of increased vigilance with
eyes wide open, often decreased blinking, overreaction to minimal stimulation, and reduced
sleeping. Decreased state of alertness could be
lethargy, stupor, and coma.
• Posture: Observation of posture is one of the
first steps in the neurologic examination.
Much can be predicted from the position of the
limbs at rest. Term infants should have a pre-
ponderance of flexor tone during wakefulness
and sleep with the normal semiflexed posture
of the elbows and ankles. The hand position
typically shows a partially closed fist. A tight
cortical thumb can be normal, but when
it is persistent and obligatory, it suggests a
corticospinal abnormality. In prone position,
the pelvis is elevated by hip and knee flexion.
Alterations of expected patterns of posture
suggest neurologic abnormalities, which can be
focal or generalized.
• Tone: Muscle tone is evaluated by resistance
to passive movement. Pronounced hypotonia
characterizes the premature infant below 29
weeks of gestation, and tone increases in a
caudal-rostral direction over the ensuing weeks.
There is an orderly progression from a limp “rag
doll” at 28 weeks to the flexed “frog legs” posture
at 34 weeks and the fully flexed supine posture at
term. When evaluating tone in the newborn,
the head should be in the midline position to
avoid eliciting a tonic neck response, and a
comparison should be made between the two
sides of the body and between the upper and
lower extremities.
• Neonatal hypotonia: Term infants with decreased
tone will show less flexor posture, less resistance to passive movements, and more head
lag. The infant becomes limp and floppy, with
little control. The most frequent etiology for
hypotonia is generalized depression of the
CNS. Other causes include neuromuscular dis-
orders, CNS dysfunction, sepsis, and congenital
and genetic disorders.
• Neonatal hypertonia: Although decreased tone in
the newborn is obvious, at times the determination of increased tone can be more of a problem.
Infants with increased tone will show extensor
posturing of extremities in supine and prone
positions. Extensor posturing of the legs with
arms held tightly fisted against the midline
points to hypertonicity. The most severe degrees
of hypertonia lead to opisthotonos. Pronounced
hypertonia is usually caused by many of the same
conditions that can lead to hypotonia, but usually tends to point to more chronic or subacute
conditions. Common etiologies include hypoxicischemic encephalopathy (HIE), sepsis and meningitis, congenital structural malformations of the
brain, and intraventricular hemorrhage.
• Developmental reflexes: The developmental reflexes
used to evaluate the newborn are best described
as “primitive,” because they do not require
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functional brain above the diencephalon and
probably not above the mesencephalon. Many
such reflexes have been described; however, it is
unlikely that all can be elicited in an infant at any
given time. It is better to use six to eight usu-
ally present in all newborns and to evaluate
them consistently: Moro’s reflex, tonic neck reflex,
stepping reflex, Galant reflex (truncal incurvation),
palm and plantar grasp reflex, and Babinski’s reflex.
Reflexes are complex responses to specific stimulation, probably representing integration of the
brainstem and spinal cord level. Asymmetries are
always abnormal; these reflexes should never be
mandatory or persistent, and a reduction or absence
of all developmental reflexes may represent generalized depression of all cerebral activity from any
cause such as infection, medications, hypoxemia, or
metabolic diseases.
Because the responses vary with the state
of alertness of the infant, and the newborn’s
tolerance for prolonged examination is limited,
eliciting a perfect response to each maneuver
should not be expected. When the examination is
not fully reassuring, repeating selected parts of the
examination at a later time may be more helpful
in clarifying findings than attempting an extended
examination at one time.
Assessment of Neurobehavioral
Development
In addition to neurologic examination, the assess-
ment of neurobehavioral development is an
important step in the evaluation of the newborn
infant. All newborns requiring intensive care, par-
ticularly preterm infants, are going to continue their
development in extrauterine settings at a time when
their brains are growing more rapidly than ever in
their life span. Understanding the potential role
of illnesses, therapeutic interventions, and NICU
environment on their neurobehavioral development
is paramount for the provision of quality newborn
care during this highly vulnerable phase of brain
development.
Caregivers need to become knowledgeable
of the tools available for the assessment of the
neurobehavioral development and the potential interventions. There are numerous tools for
the assessment of neurobehavioral development.
Chapter 13 offers a detailed and comprehensive
review of this subject.
9,31
THE BRAZELTON SCALE
The Neonatal Behavioral Assessment Scale
(NBAS) is a comprehensive behavioral assessment of the newborn.31 The NBAS psychological scale enables assessment of the infant’s
individual capabilities for social relationships.
Clinical application of the Brazelton scale includes
neonatal research and clinical evaluation of newborn infants after illness, prematurity, or maternal
medications.
The NBAS focuses on an interactive approach
and highly individualized parameters of newborn
functioning. Later editions of the NBAS have added
supplemental items, which further qualify the behavior of the newborn, particularly of preterm infants.
A modified version of the Brazelton examination is useful in teaching parents about
their individual infant’s patterns of behavior,
temperament, and states. By understanding the
uniqueness of their infant, parents may more
intelligently assess and interpret their baby’s
cues for interaction and distance. If the parents
know their infant’s individual strengths and weaknesses, they will react more realistically to him or
her. It is important for the provider to elicit the
parents’ assessment of their infant’s behavior and
responsiveness. Unrealistic expectations or incorrect
parental perceptions may exist. This is an excellent
opportunity for parent teaching, and possibly referral. The NBAS is distinguished from other programs
in its use as an intervention with parents and medical staff. Employed in this manner, it is intended to
improve and enhance the caregiver’s attitude to
and interaction with the infant.
The Brazelton examination is usually performed at 2 to 3 days of life, at discharge, or
on the follow-up visit at 1 to 2 weeks. This
examination assesses the infant’s best performance in response to stimulation and handling
by the examiner. For research purposes, scoring
by a certified examiner is sufficient. For clinical use,
knowledge of the specific techniques and interpretations of results is all that is required. Knowledge
of the infant’s state is necessary (see Chapter 13,
Table 13.3). Performing the examination with
the parents present provides the opportunity for
teaching, parental participation, and observation
of their infant’s response.
Maternal use of antidepressants, opioids
and smoking have been shown to alter the
newborn’s neurobehavioral examination (see
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Chapter 11). Neonates exposed to selective sero-
tonin reuptake inhibitors late in pregnancy exhibit
the following mild and spontaneously resolving behaviors: tremors/tremulousness, restlessness/
irritability, abnormal crying, rigidity, fewer state
changes, and more active sleep with startles and
75
arousal.
CARE OF THE WELL NEWBORN
INFANT
Mother-Infant Bonding and
Interventions
FREQUENCY OF ASSESSMENTS
During the transitional period, vital signs should
be recorded frequently enough to monitor the
infant’s condition and provide appropriate care:
• If the infant is distressed (elevated heart rate or
respiratory rate, retracting and/or nasal flaring),
vital signs may be required every 30 minutes.
• If the baby’s vital signs are normal on admis-
sion (heart rate 120 to 160 beats/min, respiratory
rate 30 to 60 breaths/min, and temperature 36°
to 36.5°C), vital signs may be required every
30 to 45 minutes until the infant’s condition
has remained stable for 2 to 4 hours.
• Vital signs should be recorded at least once
every 8 hours.
• Measuring the temperature rectally is contraindicated in newborns because of the risk for rectal
perforation (see Chapter 6).
Weight, length, and head circumference should
be graphed on the appropriate intrauterine growth
chart to determine at which percentile the baby
falls. Determination of the weight/length ratio
(see Fig. 5.3) normally increases with fetal age
because the fetus becomes heavier for length
as term approaches. In IUGR, the weight/length
ratio decreases because the rate of growth in weight
is affected more than length. Severe and prolonged
intrauterine malnutrition may affect head, weight,
and length ratios.
PREVENTIVE PRACTICES
Assessment of the infant’s GA provides a reference point for individualizing care. Whether
the infant is term and admitted to the normal
newborn nursery or preterm and admitted to
the intensive care nursery, attention to care
practices that support development and neurologic integrity is essential in preventing iatrogenic disruptions or injury.
In utero, the fetus depends on the mother’s
physiologic systems to automatically regulate its
own. At birth, the neonate’s basic physiologic needs
are met in new and different ways. Emerging from
physiologic dependence into a physiologically independent neonatal state introduces new variables
for both mother and baby in the development of
their extrauterine relationship. For both term and
preterm newborns, the primary developmental
task is to reestablish biorhythmic balance by (1)
establishing homeostasis through self-regulation
of states (e.g., arousal and sleep/wake cycles);
(2) processing, storing, and organizing internal and external stimuli; and (3) establishing a
reciprocal relationship with primary care providers and the environment.
Although biorhythmic balance is internally determined, caregiving interaction between newborn and
parent or caregiver either facilitates or disturbs this
transition. After birth, balance is facilitated by
contact with familiar surroundings (the mother’s
74,148,181
body).
The mother’s sensorimotor (auditory,
tactile, visual), thermal, and nutrient stimuli provide
regulatory effects on the infant’s behavior (activity
level, sucking, sleep and wake cycles, stress management, and circadian rhythms) and physiology (endocrine secretion, oxygen consumption, and cardiovascular status).
74,148
Full-term newborns placed on
the mother’s chest immediately after delivery
(within 5 minutes) and longer (more than 60
minutes) display the following stereotypic innate
sequence of prefeeding behavior
181,201
:
• Significantly lower salivary cortisol levels and
more stable cardiopulmonary function
• No sucking activity in the first 15 minutes
• Rooting and sucking activity begins and reaches
maximum intensity at 45 minutes
• First hand-to-mouth movement at 35 minutes
• Spontaneous and unassisted finding of nipple and
initiation of breastfeeding at about 55 minutes of
age
Within the first 90 minutes after birth, neo-
nates cared for in close body contact with the
mother are quiet. However, infants separated from
their mothers during this period and cared for in a
crib cry and exhibit a separation distress call (also seen
in several other mammalian species) that ceases at
reunion.
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AVOIDANCE OF CERTAIN CARE
PRACTICES
Certain care practices (e.g., separation of the mother and infant, gastric suction, noise levels in the
newborn nursery) have become “routine” in some
maternal/child care settings. These practices are
based on few scientific foundations, disrupt
maternal and infant regulation and establishment of innate behaviors, may have hidden consequences that surpass human adaptability, and
may contribute to behavioral changes that result
from violations of an innate agenda.81 For exam-
ple, gastric suction after birth evokes aversive reflexes (e.g., retching, combative movements, alterations
in arterial blood pressure and heart rate, including
bradycardia), disrupts development of early feeding
behaviors, is unpleasant, and has no advantages in a
healthy term infant following a normal pregnancy
and normal vaginal delivery.
11,81
Use of maternal
analgesia may interfere with the newborn’s spontaneous breast-seeking and breastfeeding behavior.
During transition of a term neonate, prone
position has been shown to improve oxygenation, decrease heart and respiratory rates, and
encourage more favorable behavioral states.
159
In the newborn nursery, the lack of diurnal rhythm
in noise levels and care-providing activities disrupts
reestablishment of biorhythmic balance. Significant
differences in nighttime sleep and wake patterns
exist between newborns cared for in the nursery (exposed to more light, noise, crying, and
noncontingent care) and newborns rooming
with the mother (more quiet sleep and less cry-
102
ing).
Term infants exposed to soothing music in
the newborn nursery spent less time in high arousal
states (i.e., nonalert waking and crying) and had
fewer behavioral state changes.
MINIMIZING PROCEDURAL PAIN IN
NEWBORN CARE
101
Placing full-term and preterm infants skin-to-skin
in whole-body contact with their mothers or
breastfeeding during heelstick procedures reduces heart rate, crying (by 91%), and grimacing
(by 84%)
1,43,83,100
(see Chapter 12). When possible,
breastfeeding throughout the procedure, rather than
offering pumped breast milk, offers more comfort
because of the synergism between skin-to-skin contact with the mother, sucking, and reception of breast
milk by the infant.3 Either breastfeeding/breastmilk
or glucose/sucrose should be used to alleviate a newborn’s procedural pain rather than positioning alone
or no intervention.
162,165
The proximity and caregiving of the mother provide term and preterm infants
with a barrier against outside stimulation and an
ability to increase their threshold to noxious stimuli.
One barrier to using skin-to-skin care and
breastfeeding to relieve neonatal pain during
invasive procedures such as heelstick and injections is the uncomfortable position of the
professional performing the procedure. An ergo-
nomically sound protocol using an adjustable-height
stool has been developed and tested in the clinical
setting. This approach has resulted in a more comfortable position for the professional and greater use
of skin-to-skin care and breastfeeding for neonatal
pain relief during procedures.
NURSERY CARE PRACTICES AND
ADAPTATION TO EXTRAUTERINE LIFE
57
Adaptation of full-term neonates is influenced either
positively or negatively by nursery care practices
(early care and handling). The influence of these
practices in the adaptation of preterm or sick
neonates may be even greater. Stress-reduction
techniques to prevent fluctuations in BP, vital signs,
and oxygenation often are not initiated until after
the preterm infant has been admitted and stabilized
in the NICU. Individualized developmental care
(e.g., dimmed lights, decreased noise, gentle
handling, contingent stimuli) (see Chapter 13)
may be delayed in the presence of urgent expeditious assessment, diagnosis, and life-supporting
interventions in the delivery room and on admission to the nursery. Consequently, the physiologic,
anatomic, and psychological transition to extrauterine life makes at-risk neonates extremely vulnerable
to the stress of resuscitation and initial nursery care.
MINIMIZING STRESS DURING
RESPIRATORY AND CIRCULATORY
SUPPORT
Minimizing stress and conserving energy should
accompany establishing and maintaining an airway, adequate oxygenation and ventilation, and
circulatory support. An immature preterm infant
(less than 32 weeks of gestation) (see Chapter 13)
who is physiologically unstable may deteriorate if not
handled gently and protected from overstimulation.
Rapid fluctuations in oxygenation and blood
pressure, overwhelming stimuli, too-rapid volume
expansion, suction, unrelieved pain, and hypothermia contribute to the incidence of intraventricular hemorrhage that occurs most commonly
74
CHAPTER 5 Immediate Newborn Care After Birth
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127
in the first 24 hours after birth (see Chapters 4, 6,
12, 23, and 26). In preterm infants, “routine” proce-
dures such as bathing
19,190
result in increased heart
rate and BP, motor stress behaviors, changes in stability
and reorganizational behavior, hypoxia, and increased
care after birth that decrease stress, reduce energy
consumption, improve oxygenation and respiratory
and heart rates, and prevent iatrogenic stress and
injury. Developmentally supportive care should
begin immediately after birth.
intracranial pressure (see Chapter 13). Overwhelmed
by external stimuli, a neonate’s global response to
stress may be apnea and bradycardia.
Based on the infant’s ability to tolerate an
intervention and the benefits of early assessment
and intervention, the admission process should be
prioritized to (1) provide life-supportive care, (2)
conserve energy, and (3) collect data and complete
the health care record. Table 5.8 outlines develop-
mental interventions for neonatal admissions and
TABLE
5.8
Oxygenation Apply noninvasive monitor (see Chapter 7)
Thermoregulation Maintain temperature axillary (36.5°C–37.5°C in term infants); skin (36°C–36.5°C in preterm infants) (see Chapter 6)
Nutrition Screen at-risk and symptomatic infants for hypoglycemia (see Chapter 15)
Pain Minimize painful stimuli (see Chapters 12 and 13)
DEVELOPMENTAL INTERVENTIONS DURING ADMISSION AND INITIAL NURSERY CARE
Titrate Fio2 to maintain saturation at 92%–94% (see Chapters 7 and 8)
Handle gently, minimally (see Chapters 13 and 23)
Skin-to-skin care improves gaseous exchange, especially in preterm infants <1000 g (see Chapter 13)
Position prone to maximize oxygenation (see Chapter 13 and below)
Delay or defer bathing
Skin-to-skin contact (kangaroo care) provided by mothers or fathers to preterm/term newborns warms better than incubator care
Prewarm linen, scales, radiant warmer; incubator (see Chapter 6)
Decrease heat loss with position (i.e., prone, flexion) (see Chapters 6 and 13)
Use warm water on skin before applying probe, electrodes (see Chapter 19)
Thermoregulation is the primary consideration in the timing and location of the first bath:
• Healthy term infants with axillary temperature >36.8°C can be bathed after 1 hour of age when appropriate care is taken to support
thermal stability.
even when skin-to-skin care is used after the bath,25 and (b) routine newborn care, including bathing delays thermoregulation
• First bath delayed till 2–4 hours of age, after vital signs and temperature are stable.
• First bath delayed till the next day for full-term baby
• Delay first bath and use swaddled, immersion bathing by parents instead of sponge bath
• Sponge bathing of healthy neonates (≥37 weeks of gestation) by an RN in mother’s room at 3, 6, or 9 hours of age
resulted in an initial reduction of skin and axillary temperatures that recovered after the bath.
to bathe
Provide fluids and/or calories (orally or intravenously) (see Chapters 14 to 17)
Decrease energy expenditures by decreasing internal stressors (e.g., hypothermia, hypoxia) and external stressors (e.g., noise,
light) (see Chapters 13 and 15)
Use venipuncture rather than heelstick (see Chapter 12)
Relieve pain with nonpharmacologic interventions:
• Provide comfort measures (e.g., pacifier, containment, grasping) (see Chapters 12 and 13)
• Use sucrose, skin-to-skin care, and/or breastfeeding during painful procedures.
Relieve pain with pharmacologic interventions (see Chapter 12)
35,55,118
20,190
However, two newer studies show that: (a) bathing at 1 hour of age increases the incidence of hypothermia
20,35,125
(see Chapters 6 and 13)
(see Chapters 6 and 19)
SURVEILLANCE FOR POTENTIAL
COMPLICATIONS
Complications of common morbidities (see Fig.
5.12) are prevented by classification, assessment,
and screening of all newborns at birth. These
morbidities and their complications are thoroughly
discussed in the appropriate chapters. Close monitoring and surveillance of these groups of infants,
and long-term follow-up studies, would allow us
†
14
203
35,42
(see Chapters 6, 13, and 19)
103
Offer parents the opportunity
‡
26
169
Continued
UNIT TWO Support of the Neonate128
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TABLE
5.8
Environmental stimuli Tactile (see Chapter 13):
Position Promote flexion in side-lying position with blankets, rolls (see Chapter 13)
Assess and interpret
newborn cries
DEVELOPMENTAL INTERVENTIONS DURING ADMISSION AND INITIAL NURSERY CARE—CONT’D
Handle gently and minimally
Support and contain in flexion
Provide rest periods between procedures, handling
Early (within 5 minutes of birth) and longer (>60 minutes) skin-to-skin care stabilizes cardiopulmonary systems and reduces
newborn stress after birth
Visual (see Chapter 13):
Shield from bright, direct light
Dim lights as soon as possible
Cover oxygen hood, face with washcloth
Cover incubator with blanket or cover
Auditory (see Chapter 13):
Talk quietly
Respond quickly to alarms
Parents talk softly to infant
Keep ill neonates away from crying babies
Prone (oxygenation better; less apnea; quiet, more restful sleep; decreased caloric expenditure; decreased reflux) (see Chapter 13)
Swaddle (see Chapter 13)
Avoid supine if newborn is hypoxic and has an oxygen requirement; otherwise, always position all well term newborns supine
(see Chapter 13)
Assess avoidance and approach behaviors so that care is individualized (see Chapter 13)
Support infant strengths and adaptive and coping behaviors (see Chapter 13)
Modulate environmental and caregiver stimuli based on infant cues (contingent on cues rather than noncontingent stimuli and
interaction) (see Chapter 13)
Teach parents infant cues (see Chapter 13)
181
102
*References 43, 83, 100, 161, 164.
†
References 35, 55, 93, 111, 118, 125.
‡
References 73, 93, 108, 175, 185, 197, 210.
to establish patterns of potential outcomes for each
specific subgroup. For example: Preterm SGA/
IUGR infants are at increased risk for mortality,
more gross motor and neurologic dysfunction, more
cognitive disorders needing special education, but
less cerebral palsy compared with AGA infants.
PARENT TEACHING
Transitional care, neonatal assessment, and
initial care do not necessarily take place in a
nursery in which the newborn and family are
isolated from each other. Alternative settings
for initial care include birthing rooms, recovery
rooms in which family and baby are kept together,
the mother’s postpartum room, or at a home visit.
In fact, keeping the family together not only
facilitates bonding but also provides an excellent opportunity for teaching parents about the
individuality of their newborn.
125
The assessments of GA and physical condition
are best performed with the mother and father
in attendance so that deviations from normal
such as caput, cleft lip, cleft palate, or clubfoot
can be explained. Eliciting parental cooperation is
important. For example, when the major concern
is “Will the procedure hurt?” a response such as “It
is routine” will not comfort and reassure well-informed, noninterventionist consumers. Rather, a
more physiologically oriented explanation about
the condition being screened, why their particular
infant is at increased risk, and what interventions are
available encourages parental cooperation.
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