CARE OF THE NEWBORN IN THE DELIVERY ROOM

Maintain patent airway drain secretions put the baby in trendelenberg position for drainage except when signs of increased ICP id observed: bulging fontanels, high pitched cry(earliest sign), vomiting (surest sign), increased BP, decreased PR, decreased RR suction newborn suction the mouth first before the nose - to prevent aspiration suctioning should be gentle to prevent laryngospasm it should not be more than 1 minute, (otherwise, it will stimulate vagus nerve causing bradycardia ) occlude one nostril at a time to test for patency (since newborn are nasal breather for 4 months

observe for characteristics of respirations

normal: irregular for the first 5 mins of life, quite, rapid but shallow, with period of apnea without cyanosis abnormal: noisy breathing indicates airway obstruction, chest with retractions, flaring nose, irregular even after 5 mins, rapid and deep, with short periods of apnea with cyanosis>20 sec

administer oxygen as needed oxygen concentration should be <40% (to prevent retinal scarring which may lead to blindness - retrolental fibroplasias oxygen is best administered through a tent

Keep the newborn warm

The body temperature of newborn at birth is 37.2 C shortly after birth. It falls to below normal because of the immature temperature regulating mechanism and heat loss. In addition , the cold temperature of the delivery room contributes to this Newborns have difficulty conserving heat because they have very little subcutaneous fats to act as insulators. Shivering is not also present at birth. Because of this, they are prone to cold stress which may cause metabolic acidosis as fatty acids accumulate due to breakdown of fats Dry newborn immediately Wrap in a blanket Place under radiant warmer or isollette with a temperature 33-34 C Place under a droplight which should be 12 18 from the newborn

Take the Apgar score

Done

at 1 minute after birth to know the condition of the newborn Then at 5 minutes after to determine how well the newborn is adjusting to extrauterine life

Indicators Heart rate

0 absent

1 Less than 100 beats /min Slow, irregular, weak cry Minimal flexion of extremities Minimal response to suction or to gentle slap on soles

2 More than 100 beats/min Good, vigorous cry Good flexion, active motion Responds promptly with a cry or active movement

Respiratory rate Muscle tone

absent Flaccid, limp No respon se

Reflex irritability

Skin color

Pallor or Body skin normal, cyanos extremities blue is

Body and extremity skin color normal

Interpretation
10 no intervention is required except to support the infants spontaneous efforts 4 7 gently stimulate. Rub infants back. Administer oxygen to infant 0 3 infant requires resuscitation
8

INITIAL PHYSICAL EXAMINATION

General

Guidelines Keep newborn warm during examination Begin with general observations then perform assessment that are leat disturbing to the newborn first Initiate nursing interventions for abnormal findings Document all abnormal findings

Vital Statistics

Weight

average birth weight is 6.5 7.5 lbs or 3 3.4 Kgs arbitrary limit is 2.5kg or 5.5 lbs. Below this weight, the newborn is considered low birth weight infant newborn loses 5 10% of birth weight during the first few days of life (physiologic wt loss) due to:

newborn is no longer in the influence of maternal hormones newborn voids and passes stool if breast fed, they have limited intake because colostrums has low caloric content if bottle fed, sucking is not yet effective birth weight is doubled by 6 mos, tripled by 1 yr, quadrupled by 2.5 years

Length

45 to 55 cm or 18 to 22 inches

head circumference

measured with a tape measure drawn across the center of the forehead and the most prominent portion of the posterior head 34 -35 cm or 13.5 to 14 inches

Chest circumference

Normal: 31 33 cm 2 cm or 0.75 to 1 inch less than the head circumference Measured at the level of the nipples Head circumference> chest circumference until 2 yrs of age

abdominal circumference

normal: 31 33 cm measured at the level of umbilicus

VITAL SIGNS

temperature

at birth, it is 37.2 C and must be maintained at 35.5 to 36.5 C a newborn losses heat thru the following mechanism: Conduction: heat is transferred to a cooler solid object in contact with the body Convection: heat flows from the body surface to a cool surrounding air Evaporation: heat loss thru conversion of liquid to vapor Radiation: heat is transferred to a cooler solid object but not in contact with the body

Pulse

Immediately after birth PR is 100 to 180 beats/min as the neonate struggles for respiration Normal is 120 to 140 bpm Palpate femoral pulse (absence may indicate coarctation of aorta) Radial pulse not ordinarily palpable

Respiration

Immediately after birth, it may be as high as 80 per min Normal : 30 to 60 per min Observe movement of abdomen

Respiratory Evaluation
Silverman

and Andersen Index used to estimate degrees of respiratory distress in newborns newborn is observed and then scored on each of five criteria; each item is given a value of 0,1 and 2 and added 0 indicates no respiratory distress 4-6 indicates moderate distress 7-10 indicates severe distress

Blood Pressure

Not routinely taken unless cardiac anomaly is suspected At birth, BP is 80/46 mmHg After 10 days, 100/50 The cuff to be used must not be more than 2/3 of the length of the upper arm or thigh

Flush method

Apply cuff to the extremity Elevate extremity and apply elastic bandage on the distal part of the extremity Inflate cuff to 200 mmHg Slowly deflate the cuff, while watching the pale extremity As soon as the extremity turns pink, read the manometer Only 1 reading will be obtained which is the average between the diastolic and systolic pressure called flush pressure. Normal is 60 at birth and 75 after 10 days

Administer eye care

Credes prophylaxis to protect the newborn against gonorrheal conjunctivitis acquired from the mother as the infant passes thru the birth canal Dry NB face Open the eye at a time by putting pressure on upper and lower lids Instill 2 drops of 1% Silver nitrate into the lower conjunctival sac. If erythromycin ointment is used, squeeze a line of ointment along the lower conjunctival sac from the inner canthus outward. Close eye to allow ointment to spread across conjunctiva

Cord Care
Inspect

for the presence of 2 arteries and

1 vein Assess for possible bleeding Dress the cord with alcohol to hasten drying Keep the cord clean and dry

Administer Vit K
Vit

K is normally synthesized in the presence of bacterial flora in the intestines It is administered to facilitate production of clotting factor Vit K 1mg is injected into the vastus lateralis IM.

Initial feeding
If

to9 be formula fed: give 1 oz of sterile water at 4-6 hours of age. milk is given on the 4th feeding If to be breastfed: usually 30 min after normal delivery, 4 hours after CS

Circumcision

Surgical removal of penis foreskin usually done on the 1st or 2nd day of life CI: hypospadias, epispadias Nursing responsibilities: observe closely and check for bleeding wrap penis with a strip of petroleum gauze to prevent the diaper from adhering from the circumcised area dont wash away film of yellowish mucous which often covers the glans

Physical Exam

Skin

color Most newborns have ruddy complexion Acrocyanosis extremities are blue and the body is pink. This is normal during the first 2 days of life Pallor maybe due to anemia due to blood loss when cord was cut few iron stores due to poor maternal nutrition; blood incompatibility; fetal maternal transfusion Gray may indicate infection Jaundice- yellowing of the skin and sclerae due to inability of the Nb to conjugate bilirubin due to immature liver function

Physiologic Jaundice (icterus Neonatorum)

Onset:

2nd to 3rd day Duration: 5 7 days Management: - morning sunlight Phototherapy

Harlequin Sign
Transient

phenomena Due to immature circulation Neonate lying on his side will appear red on the dependent side of the body and pale on the upper side Change position of infant

Birthmarks

Hemangiomas
Vascular tumor of the skin 3 types

Nevus Flammeus are macular purple or dark red lesions which are also called portwine stain; present at birth and found on face and thighs Strawberry Hemangiomas elevated areas formed by immature capillaries and endothelial cells; associated with high estrogen levels Cavernous Hemangiomas dilated vascular spaces; raised and resemble strawberry hemangioma in appearance

Mongolian Spots
Slate

gray patches across the sacrum and buttocks and consist of a collection of pigment cells, melanocytes Usually disappears by school age

Vernix Caseosa

White cream cheese like substance noticeable on newborns skin at birth Disappear by 2 weeks Color should be noted because it takes the color of amniotic fluid if yellow, amniotic fluid is yellow from bilirubin if green, meconium is present in the amniotic fluid harsh rubbing should not be employed or vigorous attempts to remove vernix caseosa

Lanugo
fine

dowry hair that covers NBs shoulders, back, and upperarms, also on forehead and ear disappear by age of 2 weeks

Desquamation
drying

of NBs skin within 24 hours of birth which result in areas of peeling evident on palms and soles of feet the peeling is similar to sunburn normal and needs no tx

Milia
pinpoint

white papule on cheek or across the bridge of the nose disappear by 2-4 weeks caused by immaturity of the NBs sebaceous glands

Erythema Toxicum
NBs rash that usually appears in the 1st to 4th day of life Begins with papule, increases in severity to become erythema by the 2nd day and disappears in the 3rd day Sometimes called flea-bite rash because the lesions are miniscule A response to irritation to bed sheets and clothing

Forceps Marks
A

circular or linear contusion matching the rim of the blade of the forceps on the infants cheek Disappears in 2-3 days along with edema that accompanies it Result of normal forceps usage and does not denote unskilled or too vigorous application of forceps

Skin Turgor
Should

be resilient If grasped between the thumb and fingers, it should feel elastic and when released, should fall back to form a smooth surface

Head

Disproportionately large, about of the total length Forehead is large and prominent, Receding chin which quivers if the infant is startled or is crying Well- nourished NB have full bodied hair while those poorly nourished or immature NB have stringy, lifeless hair Bones of the skull are not fused

Fontannels

Unossified membranous tissue at the junction of the sutures Anterior fontanelle normally closes at 12-18 mos; is at the junction of 2 parietal bones and the 2 fused frontal bones, measures 2-3 cm width and 3-4 cm length, will be felt as soft spot and should not appear indented or bulging Posterior Fontanelle at the junction of parietal bones and the occipital bones, triangular in shape and measures about 1 cm in length, normally closes by the end of the 2nd month

Sutures

Separating lines of the skull may override at birth because of the extreme pressure exerted by the passage of the NB thru the birth canal Should never appear separated in NB because it denotes increased ICP from abnormal brain formation, abnormal accumulation of CSF in the cranium (hydrocephalus) or as accumulation of blood from birth injury such as subdural hemorrhage

Molding
Asymmetry

of head resulting from pressure in the birth canal Disappear in about 72 hours

Masses from birth trauma

Caput Succedaneum
Edema of the soft tissue over bone (cross over suture line) Involves large size of the head or maybe the size of a goose egg Will gradually be absorbed and disappear about the 3rd day of life Needs no tx

Cephalhematoma

Swelling caused by bleeding into an area between the bone and its periosteum It is usually absorbed within 6 weeks with no treatment

Craniotabes

Localized softening of the cranial bones, so soft that it can be indented by the pressure of the examining finger Due to the pressure of fetal skull against the mothers pelvic bone in utero

Eyes

Cry tearlessly Iris are slate gray till the 3rd month of life Edema is usually present around the orbit or on the eyelids which will remain for 2-3 days Should appear clear without redness ar purulent discharge Cornea should be round and adult sized Eyes cross because of weak extraocular muscles Sometimes, pressure during delivery causes rupture of capillary resulting in a small subconjunctival hemorrhage appearing as red spot on the sclera but needs no treatment Irregularly shaped pupils connote a disease and a white pupil connotes congenital cataract

Ears

Pinna tends to bend easily Low set ears associated with Down Syndrome Level of top part of the ear should be in line with the upper canthus of the eye NB should be placed in good alignment when putting them to sleep on their side as that ear may assume the position permanently

Nose

Flat, broad, in center of face Obligatory nose breathing Occasional sneezing to remove obstruction Nares are patent and should not flare May appear large for the face Test for Choanal Atresia

Mouth

Pink, moist gums Should open evenly when NB cries Palate should be intact Epsteins pearl are present Natal teeth maybe present

Neck

Short and chubby , creased with skin folds Strong enough to support the weight of the head Trachea maybe prominent in from of the neck Thyroid gland is not palpable If with rigidity, congenital torticullis from injury to the sternocleidomastoid muscle should be considered; meningitis if with + nuchal rigidity

Chest
Circular

appearance because anteroposterior and lateral diameters are about equal Diaphragmatic respiration Nipples prominent and often edematous; milky secretion common

Abdomen

Contour is slightly protuberant, globular Scaphoid or sunken appearance suggest missing abdominal contents Bowel sound should be present within an hour after birth Edge of liver is palpate at 1-2 cm below the right coastal margin For the 1st hr of birth, umbilical cord is white, gelatinous marked with red and blue streaks of umbilical vein and arteries. After the 1st hour, cord begins to shrink, dry and be disclosed; 2nd or 3rd day, turned black, breaks free by the 6th 10th day leaving a granulating arear a few cm There should be no bleeding at cord site

Anogenital area
Check

for patency of anus Note the time the infant first passed out meconium.

Male Genitalia
Scrotum

is edematous due to maternal hormones Testes should be present in the scrotum Penis appears small, inspect if urethral opening is at the tip of the glans

Female Genitalia
Vulva

maybe swollen because of action of maternal hormones Mucus and vaginal secretions are present which is sometimes blood tinged This discharge should not be mistaken for infection or trauma

Back
Spine

appears flat in the lumbar and sacral areas; curves can be seen only when child is already able to sit and walk Base of spine should be assessed if no pinpoint opening in the skin indicating Dermal Sinus

Extremities

Arms and legs appear short Hands are plump and clenched into fist Fingernails are soft and smooth and are long enough to extent over fingertips Arms and legs should move symmetrically Check the digits for webbing (Syndactyl), extra toes or fingers (polydactyl), lacking toes or fingers(oligodactyl) legs are bowed and short; sole is flat because of extra pad of fat with crisscrossed lines in soles of the feet

Body Systems Assessment

Cardiovascular System

In utero, oxygenation takes place in the placenta not in the fetal lungs ( so pressure in the left side is less than the pressure in the right side of heart) Fetal accessory structures foramen ovale opening between the right and left atria ductus arteriosus connects pulmonary artery and aorta ductus venosus bypasses the liver umbilical vein carries oxygenated blood umbilical arteries carry deoxygenated blood

As soon as the cord is clamped, the newborn is forced to take in oxygen thru the lungs. This expansion of the lungs will cause the pressure on the left side of the heart to be higher than the pressure in the right side. This in turn will cause the foramen ovale to close and turn into a ligament ; ductus arteriosus changes into a ligament ; ductus venosus changes into ligament ; umbilical vein and arteries will atrophy and degenerate since no more blood goes thru it A newborns blood volume is around 300mL

Respiratory System

A first breath requires a tremendous amount of pressure, about 40-70 cm H2O The presence of fluid in the lungs eases the surface tension on the alveolar walls and makes a first breath easier, allowing the alveoli to inflate more easily than if the lung walls were dry Infants who are immature and whose lung collapsed each time they exhale due to lack of pulmonary surfactants have trouble in establishing effective residual capacity and respirations

Gastrointestinal System

Sterile at birth Stomach can hold about 30-60 mL Has limited ability to digest fat and starch Regurgitates easily Usually has low glucose and protein serum level

Stools

Meconium 1st stool that is usually passed 24 hrs after birth; sticky, tarlike, blackish green, odorless material formed from mucus, vernix, lanugo, hormones and carbohydrates that accumulated during intrauterine life Transitional Stool 2nd or 3rd day of life which may resemble diarrhea About the 4th day, a breastfed newborn passes 3-4 light yellow stools per day. These are sweet smelling because breast milk is high in lactic acid which decreases the amount of putrefactive organisms in the stool Bottle fed babies passes 2-3 bright yellow stools per day and has slightly noticeable odor If with mucus, suspect milk allergy Gray/clay colored stool bile duct obstruction Black/tarry stool intestinal bleeding Blood flecked stools with anal fissure

Urinary System

Void within 24 hours after birth Single voiding is about 15 mL Daily urine output is 30-60 ml/ day Light in color and odorless First voiding may be pink or dusty Males with enough force producing small projected arc Female produce a steady stream

Autoimmune System

Has difficulty forming antibodies/against invading antigens, until they are about 2 mos of age Has antibodies (IgG) from the mother that crossed the placenta like the antibodies for polio, measles, diphtheria, pertussis, rubella, and tetanus and little natural immunity against varicella and herpes simplex

Neuromuscular System
Occasional

limpness or total absence of muscular response to manipulation may indicate narcosis, shock or cerebral injury Reflexes

REFLEX

NORMAL RESPONSE

ABNORMAL RESPONSE
Weak or no response occurs with prematurity, neurologic deficit or injury, or central nervous system (CNS) depression secondary to maternal drug ingestion (eg. narcotics).

Rooting and sucking

Newborns turn head in direction of stimulus, open mouth, and begin to suck when cheek, lip, or corner of mouth is touched with finger or nipple.

Extrusion

Newborn pushes tongue outward when tip of tongue is touched with finger or nipple.

Continuous extrusion of tongue or repetitive tongue thrusting occurs with CND anomalies and seizures.

Swallowing

Newborn swallows in coordination with sucking when fluid is placed on back of tongue.

Gagging, coughing, or regurgitation of fluid may occur, possibly associated with cyanosis secondary to prematurity, neurologic deficit, or injury; typically seen after laryngoscopy.

Moro

Bilateral symmetrical extension and abduction of all extremities, with thumb and forefinger forming characteristic C are followed by adduction of extremities and return to relaxed flexion when newborns position changes suddenly or when newborn is placed on back on flat

Asymmetrical response is seen with peripheral nerve injury (brachial plexus) or fracture of clavicle or long bone or arm or leg. No response occurs in cases of severe CNS injury.

Stepping Newborn will step with one foot and then the other in walking motion when one foot is touched to flat surface.

Asymmetrical response is seen with CNS or peripheral nerve injury or fracture of long bone of leg.

Prone crawl

Newborn will attempt to crawl forward with both arms and legs when placed on abdomen or flat surface.

Asymmetrical response is seen with CNS or peripheral nerve injury or fracture of long bone of leg.

Tonic neck or fencing

Extremities on side to which head is turned will extend, and opposite extremities will flex when newborns head is turned to one side while resting. Response may be absent or incomplete immediately after birth.

Persistent response after 4th month may indicate neurologic injury. Persistent absence seen in CNS injury and neurologic disorders.

Startle

Absence of Newborn abducts and flexes response may all extremities and may begin indicate to cry when exposed to sudden neurologic deficit or injury. movement or loud noise. Complete and consistent absence of response to loud noises may indicate deafness. Response may be absent or diminished during sleep.

Crossed Extension

Newborns opposite leg will flex and then extend rapidly as if trying to deflect stimulus to other foot when placed in supine position; newborn will extend one leg in response to stimulus on bottom of foot.

Weak or absent response is seen with peripheral nerve injury or fracture of long bone.

Glabellar blink

Newborn will blink with first 4 Persistent or 5 taps to bridge of nose blinking and when eyes are open. failure to habituate suggest neurologic deficit.

Palmar grasp

Newborns finger will curl around object and hold on momentarily when finger is placed in palm of newborns hand.

Response is diminished in prematurity. Asymmetry occurs with peripheral nerve damage (brachial plexus) or fracture of humerus. No response occurs with severe neurologic deficit.

Plantar Grasp

Newborns toes will curl downward when a finger is placed against the base of the toes.

Diminished response occurs with prematurity. No response occurs with severe neurologic deficit.

Babinski sign

Newborns toes will No response hyperextend and fan apart occurs with from dorsiflexion of big toe CNS deficit when one side of foot is stroked upward from heel and across ball of foot.

G. Senses
.

Hearing A fetus is able to hear in utero Appear to have difficulty locating sounds They respond with generalized activity to the sound They recognize their mothers voice

Vision
Newborn

see as soon as they are born They cannot follow objects past the midline of vision

Touch
Most

sensitive and most developed of all the senses

Taste
Taste

buds are developed and functioning before birth They turn away from bitter taste and readily accepts the sweet taste of milk or glucose water

Smell
Present

as soon as the nose is cleared of mucus and amniotic fluid

Physiologic Adjustment to Extrauterine Life Periods of Reactivity

First Period of Reactivity

Lasts about half an hour During this time, the baby is alert and exhibit exploring , searching activity, often making sucking sounds Heart beat and respiratory rate are rapid

Resting Period

Heart beat and respiratory rate slow Newborn typically sleeps for about 90 min

Second Period of Reactivity

Between 2 and 6 hours of life, when the baby wakes again, often gagging and choking on mucus that has accumulated in the mouth The newborn is again alert and responsive and interested in the surrounding

Assessment of Gestational Age

Usher

proposed 5 criteria to evaluate gestational maturity

Gestation Age in Weeks

Findings
Sole creases

0 - 36
Anterior transverse crease only 2 Fine and fuzzy Pliable;no cartilage

37 - 38
Occasional creases in anterior two thirds 4 Fine and fuzzy Some cartilage

39 and over
Sole covered with creases

Breast nodule diameter in mm Scalp hair Ear lobe Testes and scrotum

7 Course and Silky Stiffened by thick cartilage Testes pendoluos, scrotum full; extensive rugae

Testes in lower intermediate canal; scrotum small, few rugae

Ballard

Modified the Dubowitz maturity scale in the 1970 and again in the 1990 The assessment consists of two portions: physical maturity and neuromuscular maturity The first is a series of observations about skin texture, color, lanugo, foot creases, genitalia, ear and breast maturity wherein the body parts are inspected and given a score of 0-5, done as soon as possible after birth The second half of the examination, observation and positioning the baby wherein the child is given numeric scores from 0-5

The babys gestational age is obtained with the total score in both portions and compared with a rating scale Using this standard measure of rating maturity is helpful in detecting infants who are small for gestational age and differentiating them from those who are immature because of miscalculated due date An infant who is found to be less than 35 weeks gestation requires close observation in a special care nursery.

Assessment of Behavioral Capacity

Term

newborns are physically active and emotionally prepared to interact with the people around them.

Brazelton Neonatal Assessment Scale

Rating scale devised by brazelton in the early 1970s to evaluate newborns behavioral capacity or ability to respond to stimuli Infant is scored on best performance rather than on average performance An important finding from the scale is that Nb are able to quiet themselves after crying There are 6 major categories of behavior assessed namely:

Habituation a newborn is capable of diminishing stimuli , gradually shutting out and not responding to it Orientation newborn gets to be oriented like when a bell rings, a newborn turns toward it or the rooting reflex Motor Maturity a newborn has motor coordination, flexing and extending to reach a certain object Variation Newborns have variable degrees of excitement Sel-quieting Ability newborn uses interventions to console themselves when disturbed like thumb sucking Social Behaviors responds to being held closely

Newborn Identification and Registration

Identification

band A number that corresponds to the mothers hospital number, mothers full name, and sex, date and time of the infants birth are printed on the band

Birth Registration
The

physician or nurse-midwife who supervised the birth of the infant has the responsibility to see that a birth registration is filed with the Bureau of Vital Statistics. Infants name, mothers name fathers name and the birth date and place are recorded

Birth Record Documentation

Newborn chart contains the following information: Time of birth Time the infant breathed Whether respirations were spontaneous or aided Apgar score at 1 min and at 5 min of life Whether eye prophylaxis was given Whether Vit K was administered General condition of the infant Number of vessels in the umbilical cord Whether cultures were taken Whether the infant voided and whether he or she passed a stool

Nursing Care of Newborns and Family in the Post Partal Period

Bathing
Should

be done prior to, not after a feeding to prevent regurgitation, spitting up or vomiting Room should be warm to prevent chilling, and bath water should be around 37 38C Soap should be mild Should proceed from the cleanest to the most soiled areas of the body

Procedures for bathing : wash face in clean water to avoid skin irritation by soap wash infants hair soap hair with baby lying, then hold infant in one arm over the basin of water as you would a football ( Such position supports the infants head and back and leaves the mothers other hand free for assembling or using equipment) splash water from the basin against head to rinse the hair and then dry it well to prevent chilling wash each area and rinse well that no soap is left on the skin do not soak the cord in male infants, foreskin of uncircumcised penis should not be forced back or constriction of penis may result; wash female vulva by wiping from front to back

Diaper Area Care

when changing diapers, the area should be washed with clean water and be dried well so that ammonia in urine will not irritate the infants skin an ointment maybe applied the diaper when applied should be folded down so that it does not cover the drying cord

Sleeping Patterns and Position

a

newborn sleeps an average of 16 hrs/day in the first week at home and an average of 4 hrs at a time At 4 mos, the baby sleeps 15 hrs/day and 8 hrs at a time Most typical time for wakefulness 6 11:00 pm Position on the back for sleep

Metabolic Screening Test

Infant must be screened for phenyketonuria, hypothyroidism and cystic fibrosis Done by means of a simple blood test in which 3 drops of blood from the heel are dropped onto a special filter paper The baby should have received formula or breast milk for 24 hours before the test for PKU will be accurate

NEWBORN SCREENING

NUTRITIONAL ALLOWANCES FOR A NEWBORN

Calories Growth in neonatal period and in early infancy is mora rapid than any other periods of life, therefore the caloric requirements exceed those at any other ages Infant up to 2 months of age requires 110-120 cal/kg of body wt. every 24 hrs to provide an adequate amount of food for maintenance and growth. After 2 mos, the amount declines until the requirement at 1 year is 100kcal/kg per day.

Protein

Necessary for formation of new cells Has a high requirement during newborn and infancy period (to provide for rapid growth of new cells as well as maintenance of existing cells Nutritional allowance for first 2 mos of life is 2.2g per kg of body wt.

Fat

Linoleic acid ia an essential fatty acid necessary for growth and skin integrity of infants

Carbohydrate

Lactose is a dissacharide found in human milk and added to commercial formulas appears to be the most easily digested of the carbohydrates It improves calcium absorption and aids in nitrogen retention

Fluid

It is important to maintain a sufficient fluid intake in newborn because their metabolic rate is so high A newborns body surface area is large in relation to body mass Newborn needs 150 -200 mL/Kg of water intake every 24 hours

Minerals

Calcium An important mineral in the newborn period bec of its contribution to bone growth

Iron

The term infant of a mother who had an adequate iron intake during pregnancy will be born with iron store that can last for the first 3 mos of life Breast milk usually provides an adequate amount of iron An iron supplement is recommended to be added to the formula for the formula fed infants for the entire first year of life

Fluoride

Essential for building sound teeth and for preventing tooth decay formula should be prepared with fluoridated water If there is no source of fluoridated water, a fluoride supplement of 0.25mg daily may be given to the infant

Vitamins

Vitamins A.C and D are incorporated incommercial formula Vitamins are naturally included in breast milk

Breastfeeding
Provides

numerous health benefits to both the mother and infants Considered to be the superior source of nutrition for the infants thru the first year of life

Physiology of Breast milk

Breast milk is formed in the Acinar cells or the alveolar cells of the mammary glands With the delivery of placenta, the level of Progesterone in mothers body falls dramatically stimulating the production of Prolactin (an anterior pituitary hormone acting on the acinar cells of the mammary glands stimulating the production of milk When the infant sucks at a breast, nerve impulses travel from the nipple to the hypothalamus to stimulate production of prolactin-releasing factors. This factor passes through to the pituitary and stimulates further active production of prolactin

Milk flows from the alveolar cells thru small tubules to the reservoir for milk, the Lactiferous Sinuses Foremilk is the constantly forming milk produced in all women 3-4 days after delivery For the first 3-4 days following delivery, before milk is oroduced, the milk cells produce Colostrum, a thin, watery, high protein fluid composed of protein, sugar, fat, water, minerals, vitamins and maternal antibodies. As infant sucks at the breast, Oxytocin is released from the posterior pituitary, causing the collecting sinuses of the mammary glands to contract, forcing milk forward thru the nipples and making it available for the baby.This is the let down reflex, new milk called the Hind milk is also produced Oxytocin stimulates the expression of milk by causing the smooth muscles to contract stimulating the uterus to contract

Advantages of Breastfeeding

General Principles of Growth and Development

Growth
Increased

in physical size Quantitative change

Development
Increase

in skill or ability to function Measured by observing a childs ability to perform a task

Principles of growth and development

Growth and development are continuous process from conception until death Growth and development proceed in an orderly sequence Different children pass through the predictable stages at different rate All body systems do not develop the same rate Development is cephalocaudal Development proceeds from proximal to distal body parts Development proceeds from gross to refined skills There is an optimum time for initiation of experiences or learning Neonatal reflexes must be lost before development can proceed A great deal of skill and behavior is learned by practice

Infant

0 12 months of age Significant Person: mother/ caregiver Fear: stranger anxiety Body weight is doubled at 6 mos and tripled at 1 year Increase in height by 50% during the first year First baby tooth appears at 6 mos (lower central incisor) followed by a new one monthly Play: Solitary Appropriate toys:mobiles, rattles, music box, squezze toys, plastic rings, rubber ducks, teething rings, textured toys Developmental Milestones

0-1month
Largely

reflex Keep hands fisted, able to follow objects at midline Lifts head intermittently when on prone Momentarily visual fixation on human faces and objects

2 months
Makes

cooing sound Differentiates his cry Social smile Responds to familiar voices by moving the whole body Sheds tears

3 months
Follows

objects past midline Laughs aloud Can raise head but not cheat when on prone Grasp reflex fades 180 degrees visual arc

4 months
Bears

partial weight on feet when held upright No longer has head lag when pulled upright Grasps objects and bring to mouth

5 months
Rolls

over Raking grasp Moro reflex fade

6 months
Doubles

birth weight Reaches out in anticipation of being pick up Sits with support Starting stranger anxiety Eruption of first tooth Can be pulled from sitting to standing position

seven months
Plays

with feet Says dada or mama but nonspecific Transfer object from one hand to another Pivots when on prone

8 months
Sits

securely without support Peak of stranger anxiety

9 months
Can

hold bottle with good hand mouth coordination Crawls Takes some steps when held Neat pincer grasp

10 months
Pull

self to stand Responds to own name

11 months
Put

objects in container Stands with assistance Attempts to walk with help

12 months
Stands

alone Walks with help Holds cup and spoon well Triples birth weight Can say two words

Toddler
1

to 3 years of age Significant Person: parents Fear: Separation Anxiety; 3 stages: protest, despair, denial Play: Parallel Appropriate toys: push pull toys, building blocks, toys to ride on, pounding pegs, stuffed toys

Developmental Milestones Critical for language development Favorite word is NO (autonomy) Negativistic and difficult to manage Active, curious They have ritualistic behavior They go into temper tantrums ( ignore and direct them to activities that they can master) All deciduous teeth are out by 2.5 to 3 years

Toilet training is the biggest task Clues for readiness for toilet training:
can already stand alone can walk steadily can keep himself dry for intervals of at least 2 hours can demonstrate awareness of voiding or defecating is able to use words or gestures regarding toileting needs is desirous of pleasing the primary caretaker

bowel control 18 mos daytime bladder control 2.5 years nighttime bladder control: 3 years

. PreSchooler

3-6 years Significant Person: Family Fear: Castration Anxiety, Fear of the dark Play: associative play Appropriate toys: housekeeping toys, playground equipments, tricycles, watercolors, finger paints, clay, picture, coloring books, material s for cutting and pasting, simple jigsaw puzzle 3 years old: undresses self, run, climbs step one at a time, walk backwards, stands on 1 foot, vocabulary of 300-900 words

4 years old: can do simple buttons, jumps skips, uses alternate steps when climbing stairs, vocabulary of 1500 words 5 years: draws a 6part man, throws over hand, runs well, vocabulary of 2100 words They asks questions constantly Favorite word is WHY They are self centered They have active imaginations, fantasies They love to watch adults and imitate their behavior Oedipus Complex/ Electra complex Masturabtion may be seen in some Sibling Rivalry

School Age child

6-12 years of age Significant persons: Teacher and family Play: competitive Appropriate toys: dolls, trains and model kits, jigsaw puzzles, magic tricks, books, table games, video, records, bicycles, skateboards, collecting objects Fear: Fear of death, fear of replacement in school, loss of privacy By age 10 brain growth is complete They are modest and industrious Thay enjoy collecting items Stealing is a common problem

6 years old
Jumps,

skips, stumbles Talk in full sentence Play in groups First molar may erupt

Seven years old

Withdrawn

and moody Difference in sexes become apparent in play Can tell time in hours Is seldom able to complete task School phobia is common

Eight years old

Improved

coordination Loves collecting items Prefers playmate of own sex Best friends develop Onset of secondary sex characteristics

Nine years of age

More

interested in friends than on family Worry and complain great deal Always on the go Gang age

Ten years old

Coordination

improves Cooperative and affectionate Are peer oriented With secret language Interest in opposite sex is apparent Interested in rules and fairness Enjoy privacy

11 years old
Are

critical of adults Beginning hero worship Are moody More active

Adolescent
12-18

years old Significant persons: peers Fear: fear of acne, homosexuality, displacement from friends, death Are bothered by the statement WHO AM I Rebellious, reformers, idealistic, futuristic Use of status symbol Conscious of body image

DIFFERENT PRINCIPLES OF GROWTH AND DEVELOPMENT

Principle 1. Growth and Development are Orderly and sequential. As a child grows, maturation is predictable and follows a general time table. Developmental milestones give indications of the average time that the child will maintain head control, attempt to roll over, crawl walk and say his first words. The occurrence of each milestone typically follows a universal pattern.

Principle 2.Growth and development are continuous and complex. Although it is an ongoing process, there are varying rates of physical growth resulting in growth sports during infancy and adolescence. Intellectual curiosity increases markedly during the preschool years as language and motor skills advance. This continuous process of growth and development is multifaceted, influenced by biophysical, psychological and environmental factors which contribute to the whole being. Genetic potential is determined with conception and stimulated by the environment.

Principle 3. The pace of Growth and Development is specific for each individual. Although growth and development are continuous, they do not occur simultaneously. Acquisition of skills and changes in physical appearance or behavior may vary with each individual . Thus, physiologic and psychological maturation varies among people. For example as the child is learning locomotion skills, he may be exerting all of his energies on this tasks, while language skills may not be heightened during this brief period. Because of this variation most developmental assessment guide list a wide spread for norms according to age. Cultural variations can also be observed, e.g. Oriental or Asian children to be smaller than Caucasian children of the same age.

Principle 4. Psychosocial Development is influenced by Many Environment Factors. Socialization and emotional behavior are learned from family, friends church and community. Values, roles, rules and regulation and determined in different cultural or social groups. The task of clarifying ones own value system proceed throughout life.

Principle 5. There are Regular Trends in the Direction of Human Development. Some unifying directions give order to growth and development. Three rudimentary trends can be easily observed. The first trend is that the development is cephalocaudal, meaning that areas such as the brain and head develop first, followed by the trunk, legs and feet. Pictures of an embryo in utero demonstrate the large size of the head in comparison to body size. The second trend is proximodistal development which means that growth progresses from the central axis of the body toward the periphery. Gross motor movements such as learning to roll over are developed earlier than fine motor movements.

Principle 6.Growth and Development are both Quantitative and Qualitative. During the formative years, the body size of the individual increases continuously. As size increases, differentiation occurs to support refinement of quality functioning. As the nerve pathway form in the neonate, they become more and more specialized for transmitting certain impulses in the growing child. Another example of differentiation refers to the behavioral changes manifested from a painful stimulus. The newborn responds to pain with his whole body, kicking arms and legs while grimacing and crying. The older child and adult express pain in more specific mannerisms, seen predominantly in the face.

Principle 7. Growth and Development become gradually integrated. Behavior and function progress from simple to complex as the child builds all previously learned skills to achieve more difficult task. The acquisition of more complex skills proceeds into and throughout the adult years. The young toddler learning to use as spoon combines motor skills from hand-eye. Coordination, cognitive patterning to repeat the act when appropriate and of using as spoon becomes basic ,forming the foundation to learning more advanced skills requiring manual dexterity.

Principle 8. There are vulnerable periods in Development. The susceptibility of the human organism to certain effects during critical periods has been proposed. Research has verified that during the time of rapid cellular growth of the fetus in the first 3 months, the organism is more prone to insults from viruses, chemicals or drugs, leading to congenital defects.

Principle 9.The Rate and Pattern of Growth and Development can be Modified. Nutrition is one factor which can effect physiology development at any age. Both positive and negative effect are seen. The child with development at any age. Both positive and negative effects are seen. The child with malabsorption may be small for age on growth charts for height or weight. The adult with chronic ulcerative colitis may appear emaciated and dehydrated. An appropriate response occurs when the infant is able to progress from bottle or breast milk to baby foods or soft table foods and gains weight appropriately. Adult weight appropriately. Adult weight , size and tone are best maintained through regular exercise and daily meals prepared from the four basic food groups.

Principle 10. Different aspects of Growth and Development occur at Different stages and at different Rates. Muscles and bone growth both occur most rapidly during the first year of life, increasing the integration of neuro muscular function. During the toddler and preschool years, muscle fibers increase in strength and size, whereas bone growth slows.

DIFFERENT FACTORS THAT INFLUENCE GROWTH AND DEVELOPMENT

A. GENETIC INFLUENCE

1.Gender- on the average, females are born weighing less and measuring less in length. (less an inch or two). Than males. Boys tend to keep his height and weight advantage until pre puberty. 2. Race and nationality- person of the some races and nationalities. Tend to be taller or shorter than others. 3. Intelligence- children who high intelligence do not generally grow faster than other children but they do not tend to advance faster in motor skills. 4. Health- a children who is chronically ill may not grow or develop as well as the healthy child, depending on type or illness and the treatment or care available.

DIFFERENT FACTORS THAT INFLUENCE GROWTH AND DEVELOPMENT

B. ENVIRONMENTAL INFLUENCE 1. 2. Quality nutrition- the quality of nutrition during growing years has a significant inference on eventual health and status. Socioeconomic level- because health care and good nutrition require sufficient income a family of reduced socioeconomics means may not be able to provide its children with either. Parent-child relationship- parent child love is very difficult to define or measure. Children who have love thrive better than who are not. Either parent or a non parent care giver may serve as the primary care giver or form the primary child relationship. It is the quality of time spent with children not the amount of time is important. Loss of love form primary care giver occurring with the prolonged hospitalization, divorce or in adequate parent love, can interferes with the child desire to eat, improve and advance.

3.

4.

5.

Ordinal position- the position of the child in the family, whether a first born child, some are middle child, the baby can only child or one with large family, will have some bearing on his or her growth and development. Health- disease that come from the environmental sources, have as strong influence on growth and developmental as generally inherited disease infants cared for in neonatal intensive care units may have their bearing affected by the over stimulation of sound, so that their health becomes directly influence by the environment.

THEORIES OF GROWTH AND DEVELOPMENT

I. PSYCHOSEXUAL DEVELOPMENT: The theory of SIGMUND FREUD

II. PSYCHOSOCIAL DEVELOPMENT: The theory of ERIK ERIKSON

III. COGNITIVE DEVELOPMENT: The theory of JEAN PIAGET

Freuds Theory of Personality Development

STAGE
INFANT PSYCHOSEXUAL STAGE ORAL STAGE NURSING IMPLICATION Feeding produce pleasure and sense of comfort/safety, feeding should be pleasurable & provided when required

TODDLER

ANAL STAGE

Toilet training should be a pleasurable experience and appropriate phase that can result on a personality development

PRESCHOOLER

PHALLIC STAGE

The child identifies with parent of opposite sex and later takes on a love relationship outside the family

SCHOOL AGE CHILD

LATENT STAGE

Encourage child with physical and intellectual persuits.

ADOLESCENT

GENITAL STAGE

Encourage separation from parents achievements of independence and decision making.

Eriksons Theory of Personality Development

STAGE Infant

DEVELOPMENT TASK To form a sense of trust vs. Mistrust

NURSING IMPLICATION Provide a primary care giver

Toddler

To form a sense of autonomy vs. shame

Provide opportunities for decision making such as offering choice of clothes to wear or play with.

Preschooler

To form a sense of initiative vs. guilt

Provide opportunities for exploring new places of activities

School-age child

To form a sense of industry vs. inferiority

Provide opportunities such as allowing child to assemble and complete a short project so that child feels rewarded for any accomplishment. Provide opportunities for adolescent to discuss feeling about events important to him or her .Offer support and frame for which involves uniting self identity.

Adolescent

To form a sense of identity vs. confusion

Young or early adult

To form sense of intimacy vs. isolation

Provide opportunities for new choices and offer support

Middle Adult

To form a sense of generativity vs. stagnation

A time of concern for the generation and griding ones own children, friends, etc.

Older Adult

To form a sense of integrity vs. despair

Old ages allows for the terminiscence of life events with the attainment of purpose and fulfillment.

STAGE OF DEVELOPMENT
SENSORI MOTOR Neonatal reflex

AGE SPAN

NURSING IMPLICATION

1 month

Stimuli are assimilated into beginning mental images. Behavior entirely reflexive.

Primary circular reaction

1-4 mos.

Hand, mouth and ear-eye coordination develop. Infant spend much time looking objects and separating self from them. Enjoyable activities for this period a rattle or tape with parents voice.

Secondary circular reaction

4-8 months

Coordination of Secondary reactions

12-18 mos.

Infant learns to initiate, recognize and respect pleasurable experiences from environment. Memory traces are present, infant anticipate familiar events. Good toy for his period: mirror game. Recognize shapes and size with familiar objects. Because of increased sense of separateness, infant experiences separation anxiety when primary care giver leaves. Ex. Colored boxes

Tertiary circular reaction 12-18 mos.

Intervention of new means through mental combinations

18-24 mos

Child is able to experiment to discover new properties of objects and events. Capable of space perception as well as permanence object outside self are understood or cause of actions. Good for this period: throw and retrieve. Transitional means or phase to the pre operational through out period. Uses memory and imitation to act, can solve basic problems, for see maneuvers that will succeed or fail. Good toys for this period those with period those w/ several uses as books, colored plastic rings.

2-7 yrs

Concept of time and how, concept of distance is only as far as he/she can see centering on a single aspect

CONCRETE OPERATIONAL TOUGHT

7-12 yrs.

Child is aware of reversibility an opposite operations or continuation of reasoning back to a starting paint. Good activity for this period collecting and classifying natural objects such as native plants, seashells, etc. Expose child to other viewpoints by asking questions such as now do you think youre feel it were a nurse too bad to tell a boy to stay in bed.

FORMAL OPERATIONAL THOUGHT

12 yrs.

Can solve hypothetical problems with scientific resuming understands casuality and deal with the past present and future. Adult or mature thought. Good activity for this period talk time to sort through attitudes and opinions.

INTERPERSONAL MODEL (SULLIVAN)

AGE GROUP INFANCY 0-18 months CHILDHOOD 18 months- 6 years JUVENILE 6-9 years PREADOLESCENCE 9-12 years LEARNING TABLE Other will satisfy needs Learn to delay need gratification Learn to relate pears Learn to relate to friends of same sex

EARLY ADOLESCENCE 12-14 years

LATE ADOLESCENCE 14-21 years

Learn independence and how to relate to opposite sex

Develop intimate relationship with person of opposite sex

COGNITIVE THOERY(PIAGET)
A. 0-2 years B. 2-4 years sensorimotor preoperational
Reflexes, repetition of acts No cause and effect reasoning; egocentriism; use of symbols, magical thinking

C. 4-7 years D. 7-11 years

intuitive Concrete operations

Beginning of causation Uses memory to learn aware of reversibility

E. 11-15 years

Formal operations

Reality, abstract thought can deal with the past, present and futire

E. KOHLEBERGS STAGES OF MORAL DEVELOPMENT

LEVEL I. PRECONVENTIONAL
Stage 1 Age :2-3 Punishment or obedience (heteronomous morality) A chiild does the right thing because a parent tells him or her to avoid punishment

STAGE II - Age : 4-7 Individualism, Instrumentalism, and excahnge Child carries out action to satisfy own needs rather than societys.The child does something for another if that person does something for him in return

LEVEL II. CONVENTIONAL

STAGE 3 Age : 7-10 Good boy/girl Orientation to interpersonal relations of mutuality A child follows rules because of a need to be a good person on own eyes and in the eyes of others

STAGE 4 Age : 10-12 Law and order Maintenance of social order, fixed rules and authorities Child follows rules and authority figures as well as parents to keep the system working

LEVEL III:POSTCONVENTIONAL
STAGE 5 Age : older than 12 Social contract utilitarian law making perspective Child follows standards of society for the good of all people

STAGE 6 : older than 12 Principal conscience Universal ethical principle orientation Child follows internalized standards of conduct

Breastfeeding positions

Perhaps the most frequently used breastfeeding position is the cradle, or cuddle, hold. Whether you use a chair or are sitting in bed, make sure your arm is well supported so it doesn't become tired before your baby is finished nursing Place your baby across your stomach, tummy to tummy. Her face and knees should be close into, and facing, your body. Her head should be in the bend of your elbow, with her mouth directly in front of your nipple. Her body should be in a straight line from her ear to her shoulder and to her hip. You can tuck her lower arm around your waist, so it is out of the way.

If you have difficulty feeding your baby in the cradle hold, try the football, or clutch, hold. It can also work well for: Mothers who had c-sections Small babies. Mothers experiencing difficulty on one side. Mothers with large breasts Mothers with flat nipples. Babies who are having problems latching on. Lie baby beside you, you might like to put her on pillows to support her and your arm. with her head will be in the palm of your hand and her back wil lay on your inner forearm. Tuck her feet slightly behind you.

The cross-cradle, or transverse, hold is another good position to use if you are having trouble latching on, or if you are feeding a small or premature baby. Because you have more control of your baby's head and can see the latch more clearly, it may be a better position than the cradle hold. Your baby's position will be the same as in the cradle hold, but you will be holding her in the arm opposite the breast from which she will latch onto. As in the cradle hold, make sure she is at the level of your breast, with her body turned toward you. You may be able to tuck her bottom into the crook of your arm

The lying down position is very useful, especially if you sleep with your baby. Line the baby up with her tummy to yours. Your nipple should be opposite her mouth. If she is still very young, you might want to place a pillow or rolled up blanket behind her to keep her from rolling back.
Lie on one side and support your head and back with pillows so that you are comfortable. You might like one of those "body pillows" which are very long. I think they can be bought for about ten dollars. You can also bend one arm under your head and use the other hand to support your

breast.
She will nurse on the lower breast. You can support it with your upper hand if neccessary. Many mothers like to reposition themselves on their other side to feed from the other breast. You can cuddle your baby on your chest, support her head and gently roll yourselves over. Often, you can just lean further over with the upper side instead of getting up and rolling over to switch sides. Make sure she is still postioned well in relation to your breast.

 The

tailor position is great for older babies and toddlers. You can place a pillow on your lap to raise a smaller infant up to the right level.

Latching On

The best way to ensure successful breastfeeding is getting your baby to latch on well. A baby who latches on well gets milk successfully. A baby who latches on poorly has difficulty getting milk. A poor latch may also cause the mother nipple pain and trauma. If a baby is not latched well and not receiving milk well, she will often stay on the breast for long periods, thus increasing the mother's pain from the improper latch. Steps to a Successful Latch: Get comfortable, position baby at the breast, and relax. Place four fingers under breast and thumb on top, well back from nipple and areola. Lightly tickle baby's lower lip with nipple. Have patience. Wait for her to open up her mouth wide, as if yawning, then quickly pull her towards you onto the nipple. Several tries may be necessary. Remember: bring the baby to the breast, NOT the breast to the baby

Don't let her latch onto the nipple, get as much of the areola into the mouth as possible. If she is positioned correctly, her nose will be resting on top of your breast and not buried in breast tissue. Do not press down on your breast to create breathing space. Even if her nose is pressed slightly against your breast, her nostrils should flare out at the sides allowing her to breathe. If you are concerned reattach her. Check the latch. If it is correct her mouth will be open wide with flanged ("turned back") lips. Her tongue will be covering the lower gum, perhaps extending to her lower lip. Her chin will pressed into your breast with her nose resting on top. If the latch isn't right (the baby has only part of the nipple in her mouth) you are likely to experience nipple pain.

If your baby was angry, hungry or crying when put to the breast, the tongue may on top of the nipple, making the "milking movement" of the mouth impossible. Break the suction with your finger, try to calm the baby and try again. Listen for swallowing. If she is feeding well you will see a suck- swallow motion with pauses in between. The jaw movement goes past the ears, sometimes even making the ears wiggle. If she starts wiggling around during the feed she may need to burp. Take her off the breast, remembering to break the suction first, offer a burp and then latch her on again.