CARE OF THE NEWBORN NFP

Define key terms relating to newborns Describe the ongoing assessment and care of newborn Describe methods to protect newborns by proper identification Describe prevention of infection in newborns Discuss important considerations in parent teaching Describe thermo-regulation in the newborn Describe neonatal jaundice and its treatment

LEARNING OBJECTIVES

RECAP
Immediate Care of Newborn Prevention of heat loss Clearing the airway Cutting the cord Skin to skin initiation Breastfeeding Identification Assessment of baby s condition

Measurements Crown heel length (average 50cm) Head circumference ( average 35cm) Chest ( average 35cm) Weight ( average 2.5kg 4.5kg) Hepatitis B Immunoglobulin given to infants of HBV+ve mothers in LW

Proper identification
Name band applied securely to the infant before he leaves the mother s side. ID band indicates: - mother s name - Sex of infant - Date of birth - Time of birth * Removed only upon discharge

 Advisable for mother to accompany her baby at all times Mums should be able to identify staffs who are involved in the care of her baby Staff must be alert to the movement of babies and mothers in their care

Ongoing care Vitamin K administration Initial toilet Maintenance of body temperature Breastfeeding Taking vital signs Identify deviations and refer accordingly

 Thermoregulation is critical to neonatal survival Neutral thermal environment is defined as the ambient air temperature at which oxygen consumption or heat production is minimal with the body temperature in the normal range of 36.7 to 37.3 C

Thermoregulatory crisis @ birth

Immediately after birth, body temperature of a neonate falls rapidly Rate of fall is greatest in the first few minutes Maintaining temperature @ time of birth is one of the primary goals of NB care

Heat Loss
Evaporation- from skin, each ml that evaporates removes 560 calories of heat Conduction- in contact with cold surfaces e.g.linen, surfaces Convection cool air currents passing over baby Radiation transfer of heat to cold objects in the vicinity eg. Trolleys, cannisters

Thermoregulation
Non-shivering thermogenesis Brown fat assists with heat generation Adopt flexed body position to minimise heat loss Ability to constrict subcutaneous and skin vessels

Prevention of infections
Meticulous hand washing Mothers should be allowed to give necessary care to their infant Care of the umbilicus Nappies & excreta carefully disposed Nappy area cleaned and dried appropriately Care givers with minor infections not to handle babies

 Encouraging & assisting mothers with breastfeeding immune system Avoiding trauma/irritation to baby s skin Early diagnosis & treatment of infection Adequate spacing of cots Individual equipment for each baby Isolating infected babies Ongoing education on infection control

Parent teaching
Teaching parents necessary skills to enable them to : - Prevent avoidable illness - Provide proper nutrition - Provide appropriate development stimulations - Provide love that evolves and grows

Identifying illnesses in neonates Poor feeding or unable to feed Hypo/hyperthermia Cord sepsis Fits/convulsions Breathing fast/difficulty in breathing Change in skin color Skin pustules

Newborn screening tests

Blood tests cord blood for Group O+ve mothers Unbooked mothers Reflexes Head scan/eye check for premature infants

Basic care for Baby

Skin care Bath time & grooming Keeping warm Breastfeeding Burping Care of crying baby Gaseous baby Colic Shaken baby syndrome

CRYING BABIES!!!!!!!!!!!!!!

Why babies cry?

Need food Comfort Too hot/too cold Need to be held Needs rest Something to make me feel better

Taking vital signs

TPR - Count respiration first- periodic breathing, immature respiratory system - Take temperature and count heart rate - Check color of baby - Check cord - Check for PU and BO - Check for lactation & breastfeeding

Initial toilet
Can be delayed if hypothermic Vital signs rectal temperature to exclude imperforate anus. Oiled Vitamin K administration- 1mg IMI Equipment basin with warm water, swabs,soap Dry and dress up quickly Taken to mom for bonding Avoid separation for more than one hour

Ballard Score
The New Ballard Score is a set of procedures developed by Dr. Jeanne L Ballard, MD to determine Gestational Age through neuromuscular and physical assessment of a newborn baby. Neurological criteria muscle tone Physical criteria anatomical changes

Physical maturity

Neurological maturity

Maturity Rating
Total score (neuromuscular + physical) -10 -5 0 5 10 15 20 25 30 35 40 45 50 weeks 20 22 24 26 28 30 32 34 36 38 40 42 44

Neonatal jaundice
Is the yellow discoloration of the skin, sclera and mucosa due to hyper-bilirubinaemia. Unconjugated bilirubin common for NNJ - Able to pass through blood-brain barrier and cause kernicterus - Permanent brain damage with chronic disability. - Can cause death

Conjugation of bilirubin
What is bilirubin? - waste product of red blood cells - haemoglobin broken down into haem, globin and iron - haem converted to biliverdin unconjugated bilirubin - globin amino acids protein - iron stored/used for new RBC

NORMAL CONJUGATION OF BILIRUBIN

Step 1: Red blood cells are broken down by the reticuloendothelial system and unconjugated bilirubin in the bloodstream is carried by albumin to the liver. This is known as "prehepatic," "free," "unconjugated," or"indirect bilirubin"

 Step 2: The liver converts or conjugates bilirubin and makes it water-soluble. This is known as "posthepatic", "conjugated" or "direct" bilirubin (normal value = 0.0 - 0.4 mg/dl)

 Step 3: Conjugated bilirubin is excreted via bile salts to intestine. Bacteria in the intestine break down bilirubin to urobilinogen for excretion in the feces

 Bilirubin is the pigment that gives bile its characteristic bright greenish yellow color. When the bile salts reach the intestine via the common bile duct, the bilirubin is acted on by bacteria to form chemical compounds called urobilinogens. Most of the urobilinogen is excreted in the feces; some is reabsorbed and goes through the liver again and a small amount is excreted in the urine. Urobilinogen gives feces their dark color. An absence of bilirubin in the intestine, such as may occur with bile duct obstruction, blocks the conversion of bilirubin to urobilinogen, resulting in clay-colored stools.

Forms of Bilirubin
Unconjugated fat soluble cannot be excreted easily in bile or urine Conjugated water soluble excreted in faeces or urine 3 stages of bilirubin conjugation process are: - transport - conjugation - excretion

Types of Jaundice
1. Physiological Jaundice - appears after 24 hrs and fades by 1 wk of age - a normal transitional state, affects about 50% of term babies - progressive rise in unconjugated bilirubin

2. Pathological jaundice - appears within 24 hrs of birth - rapid increase in total serum bilirubin (5mg/dl per day)

Causes of jaundice
Blood type/group incompatibility Enzyme deficiencies Spherocytosis Extravasated blood Polycythemia Sepsis Hypothermia, hypoxia, acidosis

KRAMER S SCALE 1. 2. 3 4. 5. 100umol/l 150umol/l 200umol/l 250umol/l 250umol/l

Treatment
Phototherapy use of fluorescent lights which photo- chemically converts fat-soluble unconjugated bilirubin water-soluble conjugated bilirubin excreted in bile and urine.

Preparation for Phototherapy

Baby fully undressed Cot/incubator Phototherapy light Eye pads Expressed breast milk (EBM) Feeding cups Explain and reassure mom

Monitoring during phototherapy

Temperature Eyes Skin Hydration Neurobehavioural status Calcium levels Bilirubin levels Parent support

Side effects of phototherapy

Hyperthermia Retinal damage Lethargy/ irritability, loose stools, eagerness to feed Skin rashes/skin burns Isolation & lack of usual sensory experience including visual deprivation Bronze baby syndrome

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