NEW BORN CHILD. PECULIARITIES OF THE NEWBORN  PERIOD.

NEW BORN CHILD. PECULIARITIES OF THE NEWBORN  PERIOD. MAIN COMPONENTS OF NEUROLOGICAL AND PSYCHOLOGICAL DEVELOPMENT IN CHILDREN OF EARLY AGE. TRANSITORY STATES IN A NEWBORN PERIOD

 

Neonatal period

INTRODUCTION At the time of birth, the newborn must quickly make changes in

the respiratory system to allow gas exchange to take place in the lungs and also make changes in the circulatory system to support the change to respiratory gas exchange. These profound, vital changes are critical to maintaining extrauterine life. The first few hours after birth wherein the newborn makes these changes and stabilizes respiratory and circulatory functions is called the neonatal transition period. Other body systems also make changes in their functioning over a longer period, although

they are not crucial to the immediate survival of the infant. Nurses are instrumental in assisting the newborn and mother through the neonatal transition period.

The neonatal period extends from birth to somewhere between 2 weeks and 1 month.

Immediately after the baby is born, uterine contractions force blood, fluid, and the placenta from the mother’s body. The umbilical cord—the baby’s lifeline to it’s mother—is now severed. Without the placenta to remove waste, carbon dioxide builds up in the baby’s blood. This fact, along with the actions of medical personnel, stimulates the control center in the brain, which in turn responds by triggering inhalation. Thus the newborn takes its first breath. As the newborn’s lungs begin to function, the bypass vessels of fetal circulation begin to close. The bypass connecting the atria of the heart, known as the foramen ovale, normally closes slowly during the first year.

During this period the body goes through drastic physiological changes. The most critical need is for the body to get enough oxygen as well as an adequate supply of blood. (The respiratory and heart rate of a newborn is much faster than that of an adult.)

 

IMMEDIATE NEEDS OF THE NEWBORN

 

The immediate needs of the newborn are airway, breathing, circulation, and warmth.

Airway A clear airway is necessary for adequate gas exchange.

Breathing In utero, the fetus relied on the placenta and the mother’s respirations for gas exchange; however, fetal breathing movements, from approximately 11 weeks’ gestation, help develop the chest wall muscles and the diaphragm (Ladewig, Moberly, Olds, & London, 2005). By approximately 35 weeks’ gestation,

the surfactant produced by the alveoli is sufficient in amount (L/S ratio 2:1) to allow the alveoli to remain partially expanded when the newborn begins to breathe at birth.

For the lungs to function, two changes must happen:

• Pulmonary ventilation must be established with lung expansion at the first breath.

• Pulmonary circulation must greatly increase.

The initiation of breathing is influenced by four factors—physical, chemical, thermal, and sensory—which work together.

Physical Factors

The physical (sometimes called mechanical) factors include the compression of the fetal chest as it moves through the birth canal, which squeezes fluid from the lungs and increases intrathoracic pressure; and the chest wall recoil, which occurs as the newborn’s trunk emerges. The chest recoil creates negative intrathoracic pressure, which causes a small amount of air to replace the fluid that was squeezed out of the lungs and some of the lung fluid to move across the alveolar membranes into the interstitial tissue of the lungs. Each breath allows more air into the alveoli and more fluid into the interstitial tissue.

Because the protein concentration is higher in the capillaries, the interstitial fluid is drawn into them. All of the alveolar fluid is absorbed within the first day after birth.

Chemical Factors

When the cord is clamped, placental gas exchange ceases, causing an increase in PaCO2 and a decrease in PaO2 and pH (a transitory asphyxia). These changes stimulate the carotid and aortic chemoreceptors, which send impulses to the respiratory center in the medulla, which in turn stimulates respirations. A brief period

of asphyxia stimulates respirations, whereas prolonged asphyxia is a central nervous system (CNS) respiratory depressant.

Thermal Factors

The change in temperature from the intrauterine environment to the extrauterine environment, a decrease of more than 20°F, is also a stimulus to breathing. The colder temperature stimulates the skierve endings and the newborn breathes as

a response. Cold stress and respiratory depression result from excessive cooling of the newborn.

Sensory Factors

The comfortable, relatively quiet uterine environment is left behind for an environment full of sensory stimuli. The auditory and visual stimuli associated with birth, along with the tactile stimulation of being handled, assist in the initiation of

respirations.

Circulation

Several circulatory changes are necessary for the successful change from fetal circulation to neonatal circulation. These changes involve the pulmonary blood vessels, ductus arteriosus,foramen ovale, and ductus venosus.

Pulmonary Blood Vessels

The dilation of these blood vessels begins with the first breath taken by the newborn. This results in lower pulmonary resistance, which allows the blood to freely circulate through the lungs to be oxygenated.

Ductus Arteriosus

Within minutes after birth, the ductus arteriosus has a reversal of blood flow caused by the increased pressure in the aorta and the increase of oxygen in the blood. This results in more blood flowing through the pulmonary arteries for oxygenation.

Closure of the ductus arteriosus is complete within 24 hours and is permanent in 3 to 4 weeks.

Foramen Ovale

The foramen ovale closes within minutes after birth because of the higher pressure in the left atrium than in the right atrium. The increased blood flow in the lungs decreases pressure in the right atrium, and the return of blood from the lungs

increases the pressure in the left atrium. Closure of the foramen ovale is permanent in approximately 3 months.

Ductus Venosus

When the cord is clamped, the blood ceases flowing through the umbilical vein to the ductus venosus and into the inferior vena cava. Blood now flows through the liver and is filtered as in adult circulation.

Heat Loss

The newborn has thin skin with blood vessels close to the surface and little subcutaneous fat to prevent heat loss. Heat moves from the warm internal areas to the cooler skin surface and then to the surrounding environment. Excessive heat loss

is called cold stress. An increase in metabolism leads to a significant increase in the need for oxygen. When oxygen is used for metabolism (heat production), the infant may experience hypoxia. There may not be enough oxygen for the metabolic

rate to increase, and the newborn will not be able to maintain body temperature. Prolonged cold stress causes respiratory difficulties and a decrease in surfactant production. Less surfactant hinders lung expansion, which in turn leads to more

respiratory distress. Decreased blood oxygen may cause vasoconstriction of the pulmonary vessels with a return to fetal circulation patterns, which further increases respiratory distress.

The glucose necessary for increased metabolism is made available when glycogen stores are converted to glucose. If the glycogen is depleted, hypoglycemia results.

Brown fat metabolism results in the release of fatty acids.

Continuous brown fat metabolism, when the newborn is in a cold stress situation for a considerable time, results in metabolic acidosis, which can be life-threatening. Excess fatty acids in the blood interfere with bilirubin transportation to the liver, which

increases the risk of jaundice.

There are four methods by which the newborn loses heat: conduction, convection, evaporation, and radiation.

Conduction is the loss of heat by direct contact with a cooler object. When a newborn is touched by cold hands or a cold stethoscope or is placed on a cold surface such as a scale, heat is lost. Heat loss can be prevented by warming

objects touching the newborn. If a newborn is wrapped in a warmed blanket or placed against the mother’s warm skin, heat will be lost by the blanket or mother’s skin to the cooler newborn and the newborn is warmed.

Convection is the loss of heat by the movement of air. When air moves (air currents), heat is transferred to the air. Air currents from an open door or window, air conditioning, or from people moving around increase heat loss.

A radiant warmer is often used for the newborn immediately after birth to prevent heat loss by convection.

 

Heat loss in the newborn can be prevented by wrapping the infant in a blanket and placing a stocking cap on the head and by keeping the newborn out of any drafts.

Evaporation is the loss of heat when water is changed to a vapor. When a wet body dries, heat is lost, such as a newborn wet with amniotic fluid or during a bath.

The insensible water loss from the skin and respiratory tract also results in heat loss. Heat loss can be prevented by immediately drying the newborn at birth and after

receiving a bath, and by changing wet clothing and diapers promptly.

Radiation Radiation is the loss of heat by transfer to cooler objects nearby, but not through direct contact. An infant placed near a cold window loses heat by radiation to the sides of the crib and the window. If the walls of an incubator are cold, the infant loses heat. Heat loss can be prevented by keeping cribs and incubators away from cold windows.

 

THE NEWBORN’S APPEARANCE

A newborn’s skin is oftentimes grayish to dusky blue in color. As soon as the newborn begins to breathe, usually within a minute or two of birth, the skin’s color returns to normal tones. Newborns are wet, covered in streaks of blood, and coated with a white substance known as vernix caseosa, which is believed to act as an antibacterial barrier. The newborn may also have Mongolian spots, various other birthmarks, or peeling skin, particularly at the wrists, hands, ankles, and feet.

A newborn’s shoulders and hips are narrow, the abdomen protrudes slightly, and the arms and legs are relatively short. The average weight of a full-term newborn is approximately 7 ½ pounds (3.2kg), but can be anywhere from 5.5–10 pounds (2.7–4.6kg). The average total body length is 14–20 inches (35.6–50.8cm), although premature newborns may be much smaller. The Apgar score is a measure of a newborn’s transition from the womb during the first ten minutes of life.

A newborn’s head is very large in proportion to the rest of the body, and the cranium is enormous relative to his or her face. While the adult human skull is about 1/8 of the total body length, the newborn’s is twice that. At birth, many regions of the newborn’s skull have not yet been converted to bone. These “soft spots” are known as fontanels; the two largest are the diamond-shaped anterior fontanel, located at the top front portion of the head, and the smaller triangular-shaped posterior fontanel, which lies at the back of the head.

During labor and birth, the infant’s skull changes shape to fit through the birth canal, sometimes causing the child to be born with a misshapen or elongated head. This will usually return to normal on its own within a few days or weeks. Special exercises sometimes advised by physicians may assist the process.

Some newborns have a fine, downy body hair called lanugo. It may be particularly noticeable on the back, shoulders, forehead, ears and face of premature infants. Lanugo disappears within a few weeks. Likewise, not all infants are born with lush heads of hair. Some may be nearly bald while others may have very fine, almost invisible hair. Some babies are even born with a full head of hair. Amongst fair-skinned parents, this fine hair may be blond, even if the parents are not. The scalp may also be temporarily bruised or swollen, especially in hairless newborns, and the area around the eyes may be puffy.

A newborn’s genitals are enlarged and reddened, with male infants having an unusually large scrotum. The breasts may also be enlarged, even in male infants. This is caused by naturally-occurring maternal hormones and is a temporary condition. Females (and even males) may actually discharge milk from their nipples, and/or a bloody or milky-like substance from the vagina. In either case, this is considered normal and will disappear in time.

The umbilical cord of a newborn is bluish-white in color. After birth, the umbilical cord is normally cut, leaving a 1–2 inch stub. The umbilical stub will dry out, shrivel, darken, and spontaneously fall off within about 3 weeks. Occasionally, hospitals may apply triple dye to the umbilical stub to prevent infection, which may temporarily color the stub and surrounding skin purple.

Newborns lose many of the above physical characteristics quickly. Thus prototypical older babies look very different. While older babies are considered “cute”, newborns can be “unattractive” by the same criteria and first time parents may need to be educated in this regard.

Neonatal jaundice

Neonatal jaundice is usually harmless: this condition is often seen in infants around the second day after birth, lasting until day 8 iormal births, or to around day 14 in premature births. Serum Bilirubin initially increase because a newborn does not need as many red blood cells as it did as a fetus (since there is a higher concentration of oxygen in the air than what was available through the umbilical vein). The newborn’s liver processes the breakdown of the extra red blood cells, but some bilirubin does build up in the blood. Normally bilirubin levels drop to a low level without any intervention required. In babies where the bilirubin levels are a concern (particularly in pre-term infants), a common treatment is to use UV lights (“bili lights”) on the newborn baby.

Changes in body Size and Muscle fat makeup

By the end of the first year an infant’s height is increased by 50% and by the age of 2 the baby will have grown 75% greater.

By 5 months a baby will have doubled its weight, and tripled its weight by the first year. By the age of 2, a baby’s weight will have quadrupled.

Infants and toddlers grow in little spurts over the first 21 months of life. A baby can go through periods of 7 to 63 days with no growth but they can add as much as an inch in one 24 hour period. During the day before a growth spurt, parents describe their babies as irritable and very hungry.

The best way to estimate a child’s physical maturity is to use skeletal age, a measure of bone development. This is done by having a x-ray of the long bones of the body to see the extent to which soft, pliable cartilage has hardened into bone.

Changes in body Proportions

Cephalocaudal trend means that growth occurs from head to tail. The head develops more rapidly than the lower part of the body. At birth the head takes up to one fourth of the total body length and legs only one third. The lower body catches up by age 2 and the head accounts for only one fifth and legs for nearly one half of the body length.

Proximodistal trend means that head growth proceeds literally form near to far or from center of the body outward.

At birth the brain is nearer its adult shape and size than any other physical structure. The brain continues to develop at an astounding pace throughout infancy and toddlerhood.

The Brain Development

The neurons of infants and adults differ in 2 significant ways: Growth of neural fibers and synapses increases connective structures. When synapses are formed, many surrounding neurons die. This occurs in 20 to 80 percent of the brain region.

Dendrites synapses: Synapses are tiny gaps betweeeurons where fiber from different neurons come close together but do not touch. Neurons release chemicals that cross the synapses sending messages to one another. During the prenatal period the neural tube produces far more neurons than the brain will ever need. Myelinization: The coating of neural fibers with a fatty sheath called myelin that improves the efficiency of message transfer. Multi-layered lipid cholesterol and protein covering produced by neuralgia cause a rapid gain in overall size of brain due to neural fibers and myelination.

Synaptic pruning: Neurons seldom stimulated soon loose their synapses. Neurons not needed at the moment return to an uncommitted state so they can support future development. However, if synaptic pruning occurs in old age neurons will lose their synapses. If neurons are stimulated at a young age, even though neurons were pruned, they will be stimulated again.

Cerebral Cortex: Surrounding the brain, it is the largest most complex brain structure. The cortex is divided into four major lobes: occipital lobe, parietal lobe, temporal lobe, and frontal lobe which is the last to develop.

Brain plasticity: The brain is highly plastic. Many areas are not yet committed to specific functions. If a part of the brain is damaged, other parts can take over tasks that they would not normally have handled.

 

BORDERLINE (IN-BETWEEN) STATE

Till birth, the child is in the mother’s uterus, and after birth he/she gets into an environment which is completely new to him/her. Conditions considerably differ from intra-uterine: the temperature of air, various flora of the environment, extensive sound, tactile irritations etc. Simultaneously to it, in a child’s organism there are expressive internal changes: the pulmonary circulation of blood is included in action, some sites of blood-flow are closed, the child starts to breathe, the gastrointestinal tract becomes more active, etc. A newborn child has to get used to new conditions of his/her life.

Conditions of adaptation of a newborn to the external environment refer to borderline state. They appear during and after birth. There are no standard rules of their occurrence in all newborns: not every chili has all borderline state, some of them develop only in premature babes. Besides, on the basis of scientific research in the last years, it is found out, that many physiological conditions are shown only by the change in the laboratory data and have no clinical manifestations.

Normally transitory conditions disappear rather quickly. However in some cases the manifestation of physiological conditions can turn into pathological violations which becomes the reason for occurrence of diseases in the child and sometimes can leave traces for the whole life.

 

The basic borderline states are:

•   The first breath and transitory hyperventilation.

•   Physiological erythema.

•   Toxic erythema.

•   Physiological jaundice.

•   Transitory hyperthermia.

•   Physiological loss of primary weight of the body.

•   Transitory features of the kidneys.

•   Transitory polycythemia.

•   Sexual crisis.

•   Physiological dyspepsia.

 

The first breath and transitory hyperventilation: Right after birth under the influence of metabolic changes arising during delivery (hypoxia, hypercapnia, acidosis, etc.) the activation of the respiratory center occurs, and the child does the first breath.

During the first 2-3 days in every newborn the borderline state—transitory hyperventilation is observed, its structure includes the following processes:

·       High frequency of breath (up to 60 per minute).

·       Periodic breath of’ gasping’ type — a deep inspiration and troublesome expiration — is marked in 4-8% of all respiratory movements during the first 3 hours of life; further on the frequency of breathing of ‘gasping’ type decreases.

·       The lungs are filled with air and released from liquid.

·       The shunts between lesser and greater circulations, which the fetus had before, are closed (see “Cardiovascular system”), arteries extend and vascular resistance in the lungs is reduced, and as a result the pulmonary blood-flow increases.

 

Transitory hyperventilation provides intensive expansion of the lung tissue with more and more active participation of the lungs in the act of breathing and, as a result of this, large amount of air enters during inspiration. This borderline state will be manifested by the fact, that in 30 minutes after delivery (it is an acute phase of adaptation to extrauterine life) during the first 2-3 days the pulmonary ventilation during a minute in the child is 1.5-2 times more than during the next days. The existed hypercapnia in blood of the child during delivery is replaced into necessary hypocapnia.

 

Physiological erythema

For toxic erythema, arising on the 2^nd-5^th day of the life in 20-30% of newborns, the following manifestations are characteristic:

•   Localization of erythema — around joints of extremities, on the extensor surface of thigh, buttocks, chest, abdomen, face of the child. It nevtl happens on the palms, feet and mucous membranes.

•   Characteristic signs — red spots a little thick at palpation, in the center of which papules of grey-yellow color or blisters can be seen.

•   The quantity of spots — can be single, or all over the body.

•   Duration — Sometimes after the first spots the new ones arise, but In 2-3 days they all disappear.

 

The physiological jaundice

Transitory hyperthermia — on the 3^rd-5^th day of life the temperature of it newborn child sometimes rises up to 38.5-39.5°C.

Etiology:

·          Overheating (the temperature of the air in a chamber is higher than 24°l the arrangement of the bed near a heating radiator, under direct solar rays).

·          If the newborn dosen’t get the necessary amount of liquid.

 

The physiological loss of body weight

At birth, for a full-term newborn, the body weight at an average is 3.500 g for the male child and 3.350 g for the girl child. Permissible normal fluctuations of body weight are from 2.700 g till 4.000g. If the body weight at birth exceeds 4000 g. then the child is considered large.

In the first days after the birth the child’s weight decreases a little. This is called physiological loss of body weight. A reduction of weight up to 6-8% from weight of the body at birth is considered as a maximum limit. This process continues for up to the third day of life and by the 7′^h-8′^h day the weight of the newborn is restored — such ideal type of changes are noticed in 1/5 of all newborn. In the rest cases the necessary increase in body weight till the initial value is delayed till the second week of a life — the slow type- In rare cases the restoration of body weight occurs in the third week of the life of the child.

Physiological loss of body weight is due to the following factors: in the first day of life, the child receives a small amount of mother’s milk at the loss of a great amount of energy because right after the birth all organs and systems of the newborn starts functioning. Three quarters of the lost body weight are due to the “perspiratio insensibilis” that is due to excretion of liquids without the sensation of this process through skin. The liquid is lost through the functional respiratory system after birth also. Excretion of urine, meconium, falling off of the umbilical cord and drying of umbilical wound are the other reasons of reduction of body weight of a newborn.

The length of the body of a newborn is of special importance as a parameter of maturity of the organism. Normally to is equal to 50 cm (50.7 cm and 50.2 cm for boys and girls respectively). Permissible fluctuations are 46-56 cm.

The head circumference of the child at birth is 34-36 cm (agreeable size — 32-38 cm: according to Carol Copper’s The Baby & Child Question & Answer Book’ M., 2006. — 240 pgs, [pg. 61) — 31-39 cm) and the chest circumference is 32-34 cm

 

Transitory features of the function of kidneys

The basic kinds of borderline states of kidneys are: anuria, oliguria, albuminuria and uric acid infarct.

The signs of anuria — the absence of urinations — within 12 hours after the birth is shown in most children (and 10% of newborns for the first time urinate only in 24 hours).

Oliguria — the reduction in the amount of urine — takes place iil newborns in the first 3 days of life.

For calculating the necessary daily volume of urine which is excreted by rate mature infant during the first week, such formula is used:6-8 ml x day of life x body weight (kg)

Albuminuria is the excretion by every newborn a considerable amount of protein in urine during the first days of life. Albuminuria is caused by the Increased permeability of the epithelium of glomeruli and canals of the kidneys.

The basis of uric acid infarct is the increased destruction of the cells basically of leukocytes, caused by the catabolic character of metabolism

in  newborn. During the final stage of disintegration of the nucleus of cells, uric acid is formed. Newborns have 5-10 mg/kg of nitrogen of uric acid in the daily amount of urine that is 2-3 times more, than in adults.

Uric acid infarct is shown by deposition of uric acid in the form of crystals in the lumen of collective tubules and in ductus pappilaris of kidneys. The crystals look like thin strips of yellow-orange color in the form of rays from renal pelvis. II does not render any pathological influence on the epithelium of canals.

Uric acid infarct is developed in 1/3 of children by the end of the first week of life.

Approximately 50% of children during their first week have infarct-urine — turbid, of yellow-brick color. At microscopic research, leukocytes, epithelium, hyaline and granular cylinders can be found in increased quantity in urine. Normally, by the end of the first week these changes disappear.

Transitory polycythemia (erythrocytosis) is the increase in quantity of hemoglobin (Hb) in blood above 220 g/L (normally — 180-220 g/L) or hematocrit (Ht) — higher than 0.65 (normally — 0.55-0.65). Such polycythemia develops in 2-5% of the term newborns and up to 15% of preterm born children.

 

The sexual crisis (hormonal crisis) takes place in 70% of newborns. The most widespread signs of the sexual crisis, mostly observed in girls, are:

Desguamative vulvovaginitis (arises on the 1^st-3^rd day of life in 2/3 of newborn girls) is a significant gray-white color secretion from the vagina which gradually disappears in 2-3 days.

 

Physiological mastopathy (the induration of mammary glands): Mastopathy is caused by sexual hormones of the mother’s placenta which are included into intra-uterine blood circulation at the end of pregnancy. This signs arises on the 3^rd-4^h day of life: its maximal increase is marked on the 5^h-10^th day. Then mammary glands gradually decrease and reach the normal sizes by the end of the neonatal period. The characteristic signs of physiological mastopathy are:

•   Skin usually has natural color or with little hyperemia.

•   The process is symmetric.

•   Increase in diameter is not more than 1.5-2 cm.

•   Often on squeezing the glands, excretion of contents which are at first greyish, and then — milk color), it is similar In structure to colostrum secreted from mother’s mammary glands during last days of pregnancy.

 

Metrorrhagia is the secretion from the vagina of approximately 1 ml of blood during 1-3 days on the 5^th-8′^h day of life in 5-10% of girls.

 

Milia. Sweat glands are underdeveloped at birth. Sometimes miliaria are seen on the skin of a child they are occluded excretory channels of sweat glands which look like drops of water. Their formation comes to an end on the forehead and head first, later — on the skin of thorax and back. The most active sweating presents within the first two months of life. An adequate sweating response to the environment temperature is marked only in children of 7 years of age.

 

Physiological dyspepsia is stool disorder in a newborn on the 3^rd-4′^h day of life.

Meconium is passed during the 1^st, 2^nd, sometimes the 3^rd day of life. On the 3^rd-4^lh day meconium is replaced by transitional stool. The frequency of excretions at this time is increased, and the stool is characterized by the following signs of physiological dyspepsia:

 

•   Consistence — the stool is liquid, watery (there is a stain around feces) with lumps and mucous.

•   Color — different sites of stool have different color (white, yellow, bright and dark green).

These two signs specify non-homogeneity (i.e. heterogeneity) of stool,

• The microscopic structure — in stool there are plenty of leukocytes (25-30 in r/v), fatty acids and mucous.

The transitional stool is passed during 2-4 days, then it becomes homogeneous in consistence (porridge-like) and yellow in color. The amount of leukocytes in it decreases to 20-10 in r/v, there are no fatty acids.

 

REFLEXES OF THE NEWBORN

          There are three groups of reflexes in the newborn. The first group includes the unconditioned reflexes that persist throughout life. They are divided into swallowing reflex, papillary reflex, sneeze reflex, blinking or corneal reflex, glabellar reflex, yawn reflex, cough reflex, gag reflex, and tendon reflexes.

The second group includes the ttransitional reflexes or reflexes of neonate and infancy. These reflexes disappear during infancy. The transitional reflexes are divided into:

1. The reflexes of oral automatism.

2. Spinal automatism.

3. Myelocephalic reflex.

          The third group includes the righting reflexes that reflexes are absent in the newborn and appear during infancy. The examples of the righting reflexes are upper Landau’s reflex, low Landau’s reflex and a parachute reflex.

Upper Landau’s reflex appears at 4 month. When an infant is placed on the abdomen, he can lift the head and the front portion of the chest about 90 degrees above the table, bearing his weight on the forearms.

Low Landau’s reflex appears at 5-6 month. When an infant prones he extends and holds (lifts) his legs.

Parachute reflex elicits a protective response to falling, and appears at 7 months.

 

Assessment of the reflexes in the normal neonate

 

Gross motor behavior

Gross motor behavior includes developmental maturation in posture, head balance, sitting, creeping, standing, and walking. The full-term neonate is born with some ability to hold the head erect and reflexly assumes the postural tonic neck position when supine. Several of the primitive reflexes have significance in terms of development of later gross motor skills. The righting reflexes are those reflexes that elicit certain postural responses, particularly of flexion or extension. They are responsible for certain motor activities, such as rolling over, assuming a crawl position, and maintaining normal head-trunk-limb alignment during all activities. The neck-righting reflex, which turns the body to the same side as the head, enables the child to roll over from supine to prone. Other reflexes, such as the otolith-righting and labyrinth-righting reflexes, enable the infant to raise the head.

The asymmetric tonic neck reflex, which persists from birth to 3 months, prevents the infant from rolling over. The symmetric tonic neck reflex, which is evoked by flexing or extending the neck, helps the infant to assume the crawl position. When the head and neck are extended, the extensor tone of the upper extremities and the flexor tone of the lower extremities increase. The child extends the arms and bends the knees. Because of the strong flexor tone of the lower extremities, the infant may initially crawl backward before forward. This reflex disappears wheeurologic maturity allows actual crawling to occur because independent limb movement is required.

 

 

Initial assessment of new born

The newborn requires thorough, skilled observation ensure a satisfactory adjustment to extra uterine life. Physical assessment following delivery can be divided into four phases

In additional nurse must be aware of those behaviors that signal successful attachment between the infant and parents.

The most frequently using methods to assess the newborn’s immediate adjustment to extra uterine life are the Apgar score system. The score is base on the observation of heart rate, respiratory effort, muscle tone, reflex irritability, and color. 

 

APGAR SCORING

 

 

Each item is given a score of 0, 1, or 2.Evaluation of all the categories are made 1 and 5 minutes after birth and are repeated until the infant’s condition stabilizes. Total scores of 0 to 3 represent sever distress , scores of 4 to 6 signify moderate difficulty, and score 7 to 19 indicate the absence of difficulty in adjusting to extra uterine life. Many newborn don’t achieve a score of 10 because the body is not completely pink. The  score is affected by the degree of

physiologic immaturity, infection, congenital malformation, maternal sedation or analgesia and neurological disorderthe apgar score reflect the general condition of the infant at 1 and 5 minutes based  on the five parameters given above.

 

Transitional Assessment: Periods of Reactivity

The newborn exhibits behavioral and physiologic characteristic that can at first appear to be signs of stress. However, during the initial 24 hours changes in heart, respiration, motor activity, color, mucus production, and bowel activity occur in an orderly, predictable sequence, which is normal and indicate lack of stress, distress infants also progress through these stages but at a slower Rate.

The first period of reactivity is from 6 to 8 hours after birth the newborn in. during the first 30 minutes the infant is very active, cries vigorously, may suck a fist greedily, and appears very interested in the environment. At this time the neonate’s eyes are usually open suggesting that this is an excellent opportunity for mother, father and the child to see each other. The newborn has a vigorous suck reflex; this is an opportunity time for the mother to begin breast feeding.

The new born usually grasp the nipple quickly, satisfying both mother and child. After this highly active state the infant be quite sleepy and uninterested in sucking. Physiologically the respiratory rate be high as 80 breath /min, crackle may heard, heart rate  may reach 180beats/min, bowel sound are active, mucus secretion  are increase, and temperature may decrease slightly.The second stage of first period of reactivity, after the initial stage of alertness and activity, the infant enters the second stage of period of reactivity. This period is last for 2 to 4 hours. Heart rate and respiratory rates decrease, temperature continues to fall, mucus production decrease and urine or stool is usually not passed. The infant is in a state of sleep and relative calm. Any attempt at stimulation usually elicits a minimal response .because of the decrease in the body temperature. Avoid undressing or bathing the infant during this time.

The second period of the reactivity: begins when the infant awakes from this deep sleep; its last about 2 to 5 hours and provides another excellent opportunity for child and parents to interact .the infant is again alert and responsive, heart and respiratory rates increase, the gag reflex is active, gastric and respiratory secretion are increased, and passage of meconium commonly occur. This period is usually over when the amount of the respiratory mucus has decreased. Following this period is the period of stabilization of physiologic system and a vacillating pattern of sleep and activity.

 

Pattern of sleep and activity:

The infant’s sleep and wakefulness comprise five distinct states; state refers to an interaction between the infant and the environment in which the infant’s behavior form a continuum from arousal to consciousness. The cycle of these states highly variable and is based on the number of hours an infant sleeps per day, which may range anywhere from 16 to 18 hours (Ferber) and Kryger, 1995).Approximately 50% of total sleep time is spent in irregular or rapid eye movement (REM) sleep. Sleep period last 20 min to 6 hours with little day night differentiation, which begins to develop during the first month of life. Period of sleep and period of activity are highly influence by environment stimuli.

 

 

Cry: The new born should begin extra terrine life a strong cry. The duration of crying is as highly variable in each infant as is the duration of sleep pattern. Some newborn may cry for as little as 5 min or as much as 2 hours or more per day.

Absent, weak, or constant sever respiratory disturbance. Absent, weak, or constant crying may suggest brain damage.

A high pitched shrill cry may be a sign on increase intracranial pressure.

Assessment of attachment behaviors;

One of the most important areas of assessment is careful observation of those behavior that are thought to indicate the formation of emotional bonds between the new born and family, especially the mother. Bonding representing the development of emotional ties from parent to infant and attachment represent the emotional ties from infant to parent, term are used interchangeably to denote both processes. Assessment of attachment requires much skilled observation

and interview.

 

Clinical Assessment of Gestational Age:

 Assessment of gestational age is an important criterion because perinatal morbidity and mortality are related to gestational age and birth weight. A frequent used method of determining gestational age is the simplified assessment of gestational age by the Ballard scale. An abbreviation version of the Dudowitz scale can be used to measure gestational ages of infant between 35 and 42 weeks.It assesses sis external physical and six neuromuscular signs. Each sign has a number score, and the cumulative score

correlates with a maturity rating of 26 to 44 week of gestation. The new Ballard scale a revision of the original scale, can be used with newborn as young as 20 weeks of gestation. The tool has the same physical and neuromuscular

section includes -1 and -2 scores that reflect signs of extremely premature infant, such as fused eye lids, imperceptible

breast tissue, sticky ,friable, transparent skin, no lanugo;and squares window(flexion of wrist)angle greater than 90 degree. The examination of infant with a gestational age of 26 weeks or less should be performed a postnatal age less than 12 hours. For infants with a gestational age of at least 26 week, the examination can be performed up to 96 hours after birth. To ensure accuracy, it is recommended that the initial examination be performed within the first 48 hours of life. neuromuscular adjustment following birth in extremely immature neonates require that follow up examination be performed to further validate neuromuscular criteria.The scale over estimation age by 2 to 4 days in infants younger than 37 weeks of gestation , especially at gestational ages of 32 to 37 week

Weight related to gestational Age; The weight of the infant at birth also correlates with the incidence of  perinatal morbidity and mortality. Birth weight alone, however is a poor indicator of gestational age and fetal maturity. Maturity implies functional capacity- the degree o which the neonate’s organ systems are able to adapt to the requirement of extra uterine life. Therefore gestational age is more closely related to fetal maturity than is birth weight. Because heriditary influence size at birth, it is important to note the size of other family members at birth, it is important to note the size of other family member as part of the assessment process.

The infant birth weight, length ,and head circumference are plotted on standardized graphs that identify normal values for gestational age the infant whose weight is appropriate for gestational age (AGA)(between the 10th and

90thpercentiles)can be presumed to have grown at normal rate regardless of the length of gestational –preterm,term,or post term.

Large for gestational age (LGA) (above 90th percentile) can be presumed to have grown at an accelerated rate during fetal life.

 

Small-for –gestational age (SGA) infant (below 10th percentile) can be presumed to have grown at a retarded rate during intrauterine life.

When gestational age is determine according to the Ballard scale , the new born will fall into one of the following nine

possible categoriesfor birth weight and gestational age;

AGA-term , preterm, post term

SGA-term, preterm, post term

LGA-term, preterm postterm.

 

PHYSICAL ASSESSMENT:

Vital sign-

Temperature range from 36-37C

Crying may increase body temperature

Slightly radiant warmer will falsely increase the temperature,

Heart rate

Apical 120 -140 beats/min

Common variation

Crying will increase heart rate, sleeping will decrease heart rate,

During the period of reactivity (6 to 8hrs) heart rate can reach 180 beats/min

Respiration

 30-60 breath

Common variation

     Crying will increase, sleep will decrease respiratory rate

     Blood pressure

     During the first period of reactivity (6 to8 hours), rate can reach 80 breaths/min

Blood pressure

Oscillometric -65/41mmhg in arm and calf

Common variation

Crying will increase b.p

Thigh BP may be higher than arm or calf BP by 4-8mmhg

(Oscillometric systolic pressure in calf 6-9mmhg in upper extremities then it is a sign of coarctation of aorta)

      General measurement:

Head circumference-33-33.5(13-14inch), about 2-3cm (1inch larger than chest cm):

Chest circumference- 30.5-33cm (12-13inch)

Crown to rump length- 31-35(12.5-14inch) approximately equal to head circumference.

Head to heel- 48-53cm (19-21inch)

   

General appearance:

Posture –flexion of head and extremities, which rest on chest and abdomen.

Common variation

Frank breech –extended legs, abducted and fully rotated thigh, fatten occiput, extended neck.

Skin:

1.      Skin reddish in color, smooth and puffy at birth

2.      At 24 – 36 hours of age, skin flaky, dry and pink in color

3.      Edema around eyes, feet, and genitals

4.      Vernix caseosa

5.      Laungo

6.      Turgor good with quick recoil

7.      Hair silky and soft with individual strands

8.       Nipples present and in expected locations

9.       Cord with one vein and two arteries

10.    Cord clamp tight and cord drying

11.    Nails to end of fingers and often extend slightly beyond

 

 

Head: Anterior fontanel diamond shaped 2-3 – 3-4 cms

Posterior fontanel triangular 0.5 – 1 cm

Fontanels soft, firm and flat

Sutures palpable with small separation between each

 

 

Eyes

Slate gray or blue eye color

Fixation at times – with ability to follow objects to midline

Red reflex

Distinct eyebrows, Cornea bright and shiny,Pupils equal and reactive to light

 

 

Ears

Pinna top on horizontal line with outer canthus of eye.Loud noise elicits Startle Reflex. Flexible pinna with cartilage present

 

 

Nose:Nostrils patent bilaterallyNo nasal discharge

 

 

Mouth and Throat: Mucosa moist. Shortly after birth may visualize sucking calluses on central portions of lips.Palate

high arched. Uvula midline. Minimal or absent salivation. Tongue moves freely and does not protrude. Well developed

fat pads bilateral cheeks. Presence ofSucking reflex,Rooting reflex,Gag reflex,Extrusion reflex

 

 

Neck

Short and thick,Turns easily side to side,Clavicles intact,Tonic neck reflex present,Neck-righting reflex present.Some head control present.

Signs of potential distress or deviations from expected findings

Torticollis-stiff neck drawing head to one side and chin pointing to opposite side Resistance to flexion

Webbing of neckLarge fat pad on back of neck

Palpable crepitus, movement with palpation of clavicle

 

Chest: Evident xiphoid process

Equal anteroposterior and lateral diameter

bilateral synchronous chest movement

Symmetrical nipples

 

 

 

Lungs

Respiration chiefly abdomen Cough reflex absent, present by 1-2 days bilateral equal bronchial breath sound

 

 

Heart: Apex –fourth to fifth intercostals space, lateral to left sternal borders.S2 slightly shaper and higher than S1.

 

 

Abdomen

Dome-shaped abdomen

Abdominal respirations

Soft to palpation

Well formed umbilical cord

Three vessels in cord

Cord dry at base

Liver papable 2 – 3 cms below right costal margin

Bilaterally equal femoral pulses

Bowel sounds auscultated within two hours of birth

Voiding within 24 hours of birth

Meconium within 24 – 48 hours of birth

 

Common variations

Small umbilical hernia

Signs of potential distress or deviations from expected findings

Bowel sounds absent

Peristaltic waves visible

Abdominal distention

Palpable masses

Scaphoid-shaped abdomen

Omphalocele

Base of cord with redness or drainage

Cord with two vessels

 

Female Genitalia

Edematous labia and clitoris

Labia majora are larger and surrounding labia minora

Vernix between labia

 

Common variations  Hymenal tag, Pseudomenstruation.Increased pigmentation. Ecchymosis and edema after breech birth. “Red brick” pink-stained urine due to uric acid crystals

Signs of potential distress or deviations from expected findings Labia fused Fecal discharge from vaginal opening Imperforate hymen Ambiguous genitalia Widely separated labia

 

Male Genitalia

Urinary meatus at tip of glans penis

Palpable testes in scrotum

Large, edematous, pendulous scrotum, with rugae

Stream adequate on voiding

 

Common variations Prepuce covering urinary meatus Erections Increased pigmentation Edema and ecchymosis after breech delivery

Signs of potential distress or deviations from expected findings Non palpable testes Hypospadius Epispadius Scrotum smooth Ambiguous genitalia

 

Back and Rectum

Intact spine without masses or openings

Trunk incurvature reflex

Patent anal opening

“Wink reflex” present

Signs of potential distress or deviations from expected findings

Limitation of movement

Fusion of vertebrae

Spina bifida

Tuft of hair

Imperforate anus

Anal fissures

Pilonidal cyst

 

Extremities

Maintains posture of flexion

Equal and bilateral movement and tone

Full range of motion all joints

Ten fingers and ten toes

Legs appear bowed

Feet appear flat

Palmar creases present

Sole creases present

Negative hip click

Grasp reflex present    

 

Signs of potential distress or deviations from expected findings

Unequal tone

Asymmetrical movement of extremities

Polydactyly

Syndactyly

Unequal leg length

Asymmetrical skin creases posterior thigh

Dislocation of hip

Persistent cyanosis of nail beds

Marked metatarus varus

 

Neuromuscular System:

Maintains position of flexion

when prone, turns head side to side

Holds head and back in horizontal plane when held prone

Ability to hold head momentarily erect

 

Signs of potential distress or deviations from expected findings

Hypotonia

Quivering

Limp extremities or straightening of extremities

Clonic jerking

Paralysis

 

 

References

а) Basic

 

1. Manual of Propaedeutic Pediatrics / S.O. Nykytyuk, N.I. Balatska, N.B. Galyash, N.O. Lishchenko, O.Y. Nykytyuk – Ternopil: TSMU, 2005. – 468 pp.

2. Kapitan T. Propaedeutics of children’s diseases and nursing of the child : [Textbook for students of higher medical educational institutions] ; Fourth edition, updated and translated in English / T. Kapitan – Vinnitsa: The State Cartographical Factory, 2010. – 808 pp.

3. Nelson Textbook of Pediatrics /edited by Richard E. Behrman, Robert M. Kliegman; senior editor, Waldo E. Nelson – 19^th ed. – W.B.Saunders Company, 2011. – 2680 p.