Newborn. Assessment and care of the normal newborn
LEARNING OBJECTIVES
• Describe the changes in the biologic system of the neonate during the transition to extrauterine life.
• Compare and contrast the four types of heat loss in a neonate and describe how to prevent heat loss.
• Describe the behavioral adaptations of the newborn, including periods of reactivity and sleep-wake states.
• Describe the sensory and perceptual functioning of the neonate.
• Identify the purpose and components of the Apgar score.
• Estimate the gestational age of newborns.
• Identify the sequence to follow in assessment of the newborn.
• Recognize deviations from normal physiologic findings during examination of the newborn.
• Explain what is meant by a safe environment.
• Discuss phototherapy and the guidelines for teaching parents about this treatment.
• Explain purposes and methods of circumcision, the postoperative care of the circumcised infant, and parent teaching information regarding circumcision.
• Review procedures for a heel stick, collecting urine specimens, assisting with venipuncture, and restraining the newborn.
• Evaluate pain in the newborn based on physiologic changes and behavioral observations.
• Review anticipatory guidance nurses provide parents before discharge.
• Describe current recommendations for feeding infants.
• Describe nutritional needs of infants.
• List newborn feeding-readiness cues.
• Discuss benefits of breastfeeding for infants, mothers, families, and society.
• Describe the anatomy and physiology of breastfeeding.
• Identify nursing interventions to facilitate and promote successful breastfeeding.
• Recognize signs of adequate intake in the breastfed infant.
• Identify common problems associated with breastfeeding and nursing interventions to help resolve them.
• Develop a patient teaching plan for the formula-feeding family.
KEY TERMS AND DEFINITIONS
acrocyanosis Peripheral cyanosis; blue color of hands and feet in most infants at birth that may persist for 7 to 10 days
brown fat Source of heat unique to neonates that is capable of greater thermogenic activity than ordinary fat; deposits are found around the adrenals, kidneys, and neck, between the scapulae, and behind the sternum for several weeks after birth
caput succedaneum Swelling of the tissue over the presenting part of the fetal head caused by pressure during labor
cephalhematoma Extravasation of blood from ruptured vessels between a skull bone and its external covering, the periosteum; swelling is limited by the margins of the cranial bone affected (usually parietals)
cold stress Excessive loss of heat that results in increased respirations and nonshivering thermogenesis to maintain core body temperature
erythema toxicum Innocuous pink papular neonatal rash of unknown cause, with superimposed vesicles appearing within 24 to 48 hours after birth and resolving spontaneously within a few days
habituation An acquired tolerance from repeated exposure to a particular stimulus
hyperbilirubinemia Elevation of unconjugated serum bilirubin concentrations
milia Small, white sebaceous glands, appearing as tiny, white, pinpoint papules on the forehead, nose, cheeks, and chin of the neonate
mongolian spots Bluish gray or dark nonelevated pigmented areas usually found over the lower back and buttocks present at birth in some infants, primarily nonwhite; usually fade by school age
physiologic jaundice Yellow tinge to skin and mucous membranes in response to increased serum levels of unconjugated bilirubin; not usually apparent until after 24 hours; also called neonatal jaundice, physiologic hyperbilirubinemia
sleep-wake states Variation in states of newborn consciousness surfactant Phosphoproteiecessary for normal respiratory function that prevents alveolar collapse (atelectasis)
thermogenesis Creation or production of heat, especially in the body
thermoregulation Control of temperature
transition period Period from birth to 4 to 6 hours later; infant passes through period of reactivity, sleep, and second period of reactivity
vernix caseosa Protective gray-white fatty substance of cheesy consistency covering the fetal skin
Apgar score Numeric expression of the condition of a newborn obtained by rapid assessment at 1 and 5 minutes of age; developed by Dr.
circumcision Excision of the prepuce (foreskin) of the penis, exposing the glans
hypothermia Temperature that falls below normal range, that is, below 35° C, usually caused by exposure to cold
ophthalmia neonatorum Infection in the neonate’s eyes usually resulting from gonorrheal, chlamydial, or other infection contracted when the fetus passes through the birth canal (vagina)
phototherapy Use of lights to reduce serum bilirubin levels by oxidation of bilirubin into watersoluble compounds that are processed in the liver and excreted in bile and urine
colostrum The fluid in the breast from pregnancy into the early postpartal period; rich in antibodies, which provide protection from many diseases; high in protein, which binds bilirubin; and laxative acting, which speeds the elimination of meconium and helps loosen mucus
demand feeding Feeding a newborn every third hour or when the baby cries to be fed, whichever comes first
engorgement Swelling of breast tissue brought about by an increase in blood and lymph supply to the breast, which precedes true lactation; lasts approximately 48 hours and usually reaches a peak between the third and fifth postbirth days
feeding-readiness cues Infant responses (mouthing motions, sucking fist, awakening, and crying) that indicate optimal times to begin a feeding
growth spurts Times of increased neonatal growth that usually occur at approximately 6 to 10 days, 6 weeks, 3 months, and 4 to 5 months; increased caloric needs necessitate more frequent feedings to increase the amount of milk needed
inverted nipples Nipples invert rather than evert when stimulated; interferes with latch-on
lactation consultant Health care professional who has specialized training in breastfeeding
lactogenesis Beginning of milk production
latch-on Attachment of the infant to the breast for feeding
let-down reflex Release of milk caused by the contraction of the myoepithelial cells within the milk glands in response to oxytocin; also called milk ejection reflex (MER)
mastitis Infection in a breast, usually confined to a milk duct, characterized by influenza-like symptoms and redness and tenderness in the affected breast
milk ejection reflex (MER) Release of milk caused by the contraction of the myoepithelial cells within the milk glands in response to oxytocin; also called let-down reflex
nipple confusion Difficulty experienced by some infants in mastering breastfeeding after having been given a pacifier or bottle
nipple erection reflex The nipple becomes erect when stimulated (infant cries, suckles, or rubs against the breast)
plugged milk ducts Milk ducts blocked by small curds of dried milk
rooting reflex
supply-meets-demand system Physiologic basis for determining milk production; the volume of milk produced equals the amount removed from the breast
The neonatal period includes the time from birth through the twenty-eighth day of life. By term gestation the various anatomic and physiologic systems in the fetus have reached a level of development and functioning that permits a separate existence from the mother. At birth the newborn infant manifests behavioral competencies and a readiness for social interaction. These adaptations set the stage for future growth and development.
TRANSITION TO EXTRAUTERINE LIFE
Infants undergo phases of instability during the first 6 to 8 hours after birth. These phases collectively are termed the transition period between intrauterine and extrauterine existence. The first phase of the transition period lasts up to 30 minutes after birth and is termed the. first period of reactivity. The newborn’s heart rate increases rapidly to 160 to 180 beats per minute (beats/min) but gradually falls by 30 minutes to a baseline rate between 100 to 120 beats/ min. Respirations are irregular, with a rate between 60 and 80 breaths per minute. Crackles may be present on auscultation; audible grunting, nasal flaring, and retractions of the chest may also be noted. Brief periods of apnea may occur; the body temperature may decrease. The infant is alert and may have spontaneous startles, tremors, crying, and movement of the head from side to side. Bowels sounds become audible and meconium may be passed.
After the first period of reactivity, the newborn either sleeps or has a marked decrease in motor activity. This period of unresponsiveness, often accompanied by sleep, lasts from 60 to 100 minutes and is followed by a second period of reactivity.
The second period of reactivity occurs roughly between the fourth and eighth hours after birth and lasts from 10 minutes to several hours. Periods of tachycardia and tachypnea occur, associated with increased muscle tone, skin color, and mucus production. Meconium is commonly passed at this time. All newborns experience this transition, regardless of gestational age or type of birth.
PHYSIOLOGIC ADJUSTMENTS
RESPIRATORY SYSTEM
With the cutting of the umbilical cord, the infant must undergo rapid and complex changes. The most critical and immediate adjustment a newborn must make at birth is the establishment of respirations. During normal vaginal birth some lung fluid is squeezed or drained from the newborn’s trachea and lungs. With the first breath of air, the newborn begins a sequence of cardiopulmonary changes.
Initial breathing is probably the result of a reflex triggered by pressure changes, chilling, noise, light, and other sensations related to the birth process. In addition, the chemoreceptors in the aorta and carotid bodies initiate neurologic reflexes when arterial oxygen pressure (Po2) falls, arterial carbon dioxide pressure (Pco2) rises, and arterial pH falls. In most cases an exaggerated respiratory reaction follows within 1 minute of birth, and the infant takes the first gasping breath and cries.
After respirations are established, respirations are shallow and irregular, ranging from 30 to 60 breaths per minute, with short periods of apnea (less than 15 seconds). These short periods of apnea occur most often during the active (rapid eye movement [REM]) sleep cycle and decrease in frequency and duration with age. Apneic periods longer than 15 seconds in duration should be evaluated.
Signs of respiratory distress
Most term infants breathe spontaneously and continue to have normal respirations. Signs of respiratory distress may include nasal flaring, retractions (i.e., indrawing of tissue between the ribs, below the rib cage, or above the sternum and clavicles), or grunting with respirations. Any increased use of intercostal muscles may be a sign of distress. Seesaw respirations instead of normal abdominal respirations are not normal and should be reported (Fig. 1). A respiratory rate less than 30 or greater than 60 breaths per minute with the infant at rest must be reported to the physician. The respiratory rate can be negatively influenced (slowed or depressed) by analgesics or anesthetics administered to the mother during birth. Apneic episodes can be related to rapid warming or cooling of the infant; tachypnea may result from aspiration or a diaphragmatic hernia.
Fig. 1 Comparison of normal and seesaw respirations. A,
Maintaining adequate oxygen supply
During the first hour of life the pulmonary lymphatics continue to remove large amounts of fluid. Removal of fluid is also a result of the pressure gradient from alveoli to interstitial tissue to blood capillary. Reduced vascular resistance accommodates this flow of lung fluid. Retention of fluid interferes with the infant’s ability to maintain adequate oxygenation.
The chest circumference is approximately 30 to 33 cm at birth. Auscultation of the chest of a newborn infant reveals loud, clear breath sounds that seem very near because little chest tissue intervenes. The ribs of the infant articulate with the spine at a horizontal rather than a downward slope; consequently the rib cage cannot expand with inspiration as readily as an adult’s. Neonatal respiratory function is largely a matter of diaphragmatic contraction. The newborn infant’s chest and abdomen rise simultaneously with inspiration.
The alveoli of the infant’s lungs are lined with surfactant. Lung expansion augments surfactant secretion. Surfactant lowers surface tension, thereby requiring less pressure to keep the alveolus open, and maintains alveolar stability by changing surface tension as the size of the alveolus changes.
CARDIOVASCULAR SYSTEM
The cardiovascular system changes markedly after birth. The infant’s first breath inflates the lungs and reduces pulmonary vascular resistance to pulmonary blood flow. The pulmonary artery pressure drops. This sequence is the major mechanism by which pressure in the right atrium declines. The increased pulmonary blood flow returned to the left side of the heart increases the pressure in the left atrium. This change in pressures causes a functional closure of the foramen ovale. During the first few days of life, crying may reverse the flow through the foramen ovale temporarily and lead to mild cyanosis.
In utero, fetal Po2 is 27 mm Hg. After birth, when the Po2 level in the arterial blood approximates 50 mm Hg, the ductus arteriosus constricts. Later, the ductus arteriosus occludes and becomes a ligament. With the clamping and severing of the cord, the umbilical arteries, umbilical vein, and ductus venosus close immediately and are converted into ligaments. The hypogastric arteries also occlude and become ligaments.
Heart rate and sounds
The heart rate averages 140 beats/min at birth, with variations noted during sleeping and waking states. Shortly after the first cry the infant’s heart rate may be as high as 175 to 180 beats/min. The range of the heart rate in the term infant is 80 to 100 beats/min during sleep and 120 to 160 beats/min while awake. It is not unusual to find a heart rate of 160 to 180 beats/min when the infant cries. A heart rate that is either high (greater than 160 beats/min) or low (less than 120 beats/min) should be reevaluated within an hour or when the activity of the infant changes.
The apical impulse (point of maximal impulse [PMI]) in the newborn is at the fourth intercostal space and to the left of the midclavicular line. The PMI is often visible.
Apical pulse rates should be obtained on all infants. Auscultation should be for a full minute, preferably when the infant is asleep. Sinus arrhythmia (irregular heart rate) may be considered a physiologic phenomenon in infancy and an indication of good heart function.
Heart sounds during the neonatal period are of higher pitch, shorter duration, and greater intensity than during adult life. The first sound is typically louder and duller than the second sound, which is sharp. Most heart murmurs heard during the neonatal period have no pathologic significance, and more than half of the murmurs disappear within 6 months.
Blood pressure
The newborn infant’s average systolic blood pressure (BP) is 60 to 80 mm Hg, and the average diastolic pressure is 40 to 50 mm Hg. The blood pressure varies from day to day during the first month of life. A drop in systolic blood pressure (approximately 15 mm Hg) in the first hour of life is common. Crying and movement usually cause increases in the systolic blood pressure. The measurement of BP is best accomplished with a Doppler device and while the infant is at rest. The correct size cuff must be used for accurate measurement of an infant’s BP. Unless there is a specific indication, blood pressure is not usually measured in the newborn.
Blood volume
Blood volume in the newborn is approximately 80 to 85 ml/kg of body weight. Immediately after birth the total blood volume averages 300 ml, but this volume can increase by as much as 100 ml, depending on the length of time the infant is attached to the placenta (Wong, 1999). The infant born prematurely has a relatively greater blood volume than the term newborn. This occurs because the preterm infant has a proportionately greater plasma volume, not a greater red blood cell (RBC) mass.
Early or late clamping of the cord changes circulatory dynamics of the newborn. Late clamping expands the blood volume from the so-called placental transfusion. This, in turn, causes an increase in heart size, higher systolic blood pressure, and increased respiratory rate.
HEMATOPOIETIC SYSTEM
The hematopoietic system of the newborn exhibits certain variations from that of the adult. Levels of RBCs and leukocytes differ, but platelet levels are relatively the same.
Reef blood cells and hemoglobin
At birth the average levels of RBCs and hemoglobin are higher than those in the adult. Cord blood of the term newborn may have a hemoglobin concentration from 14 to 24 g/dl (mean 17 g/dl). The hematocrit ranges from 44% to 64% (mean 55%). The RBC count is correspondingly elevated, ranging from 4.8/mm3 to 7.I/mm3. These values fall and reach the average levels of 11 to 17 g/dl and 4.2/mm3 to 5.2/mm3, respectively, by the end of the first month. The blood values may be affected by delayed clamping of the cord, which results in a rise in hemoglobin, RBCs, and hematocrit. The source of the sample is another significant factor because capillary blood will yield higher values than venous blood. The time after birth when the blood sample is obtained is significant; the slight rise in RBCs after birth is followed by a substantial drop. At birth the infant’s blood contains approximately 80% fetal hemoglobin, but because of the shorter life span of the cells containing fetal hemoglobin, the percentage falls to 55% by 5 weeks and to 5% by 20 weeks. Iron stores generally are sufficient to sustaiormal RBC production for 5 months in the term infant; thus mild, brief anemia is not serious.
Leukocytes
Leukocytosis, with a white blood cell (WBC) count of approximately 18,000/mm3 (range 9000 to 30,000/mm3), is normal at birth. The number of WBCs increases to 23,000 to 24,000/mm3 during the first day after birth. The initial high WBC count of the newborn decreases rapidly, and a resting level of 11,500/mm3 is normally maintained during the neonatal period. Serious infection is not well tolerated by the newborn, and marked increase in the WBC count is unlikely, even in critical sepsis (infection). In most instances, sepsis is accompanied by a decline in WBCs, particularly ieutrophils. The activity of the bone marrow is accurately reflected by the number of circulating cells—both erythrocytes and leukocytes.
Platelets
Platelet count ranges between 150,000 and 300,000/mm3 and is essentially the same in newborns as in adults. The level of factors II, VII, IX, and X, found in the liver, is decreased during the first few days of life because the newborn cannot synthesize vitamin K. However, bleeding tendencies in the newborn are rare, and unless the vitamin K deficiency is great, clotting is sufficient to prevent hemorrhage.
Blood groups
The infant’s blood group is genetically determined and established early in fetal life. However, during the neonatal period there is a gradual increase in the strength of the agglutinogens present in the RBC membrane. Cord blood samples may be used to identify the infant’s blood type and Rh status.
THERMOGENIC SYSTEM
Next to establishing respirations, heat regulation is most critical to the newborn’s survival. Thermoregulation is the maintenance of balance between heat loss and heat production. Newborns attempt to stabilize their internal body temperatures within a narrow range. Hypothermia from excessive heat loss is a common and dangerous problem ieonates. The newborn’s ability to produce heat (thermogenesis) often approaches that of the adult; however, the tendency toward rapid heat loss in a cold environment is increased in the newborn and poses a hazard.
Thermogenesis
The shivering mechanism of heat production is rarely operable in the newborn. Nonshivering thermogenesis is accomplished primarily by brown fat, which is unique to the newborn, and secondarily by increased metabolic activity in the brain, heart, and liver. Brown fat is located in superficial deposits in the interscapular region and axillae, as well as in deep deposits at the thoracic inlet, along the vertebral column, and around the kidneys. Brown fat has a richer vascular and nerve supply than ordinary fat. Heat produced by intense lipid metabolic activity in brown fat can warm the neonate by increasing heat production as much as 100%. Reserves of brown fat, usually present for several weeks after birth, are rapidly depleted with cold stress. The less mature the infant, the less reserve of this essential fat is available at birth.
Heat loss
Heat loss in the newborn occurs by four modes:
• Convection is the flow of heat from the body surface to cooler ambient air. Because of heat loss by convection, the ambient temperature in the nursery is kept at 24° C and newborns are wrapped to protect them from the cold.
• Radiation is the loss of heat from the body surface to a cooler solid surface not in direct contact but in relative proximity. To prevent this type of loss, cribs and examining tables are placed away from outside windows.
• Evaporation is the loss of heat that occurs when a liquid is converted to a vapor. In the newborn, heat loss by evaporation occurs as a result of vaporization of moisture from the skin. The process is invisible and is known as insensible water loss. This heat loss is intensified by failure to dry the newborn directly after birth or by drying the infant too slowly after a bath (see Research box).
• Conduction is the loss of heat from the body surface to cooler surfaces in direct contact. When admitted to the nursery, the newborn is placed in a warmed crib to minimize heat loss.
Loss of heat must be controlled to protect the infant. Control of such modes of heat loss is the basis of caregiving policies and techniques.
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RESEARCH. Timing of Newborn Newborns are vulnerable to thermal stress, as a result of immature thermoregulation and large surface-to-mass ratio, which leads to heat loss. Based on this principle, hospital staff have delayed initial bath for up to 4 hours.This exposes staff and other patients to blood and body fluids, which could transmit human immunodeficiency virus, herpes simplex virus, and hepatitis. Earlier bathing would decrease this risk and decrease patient and staff exposure to latex, which staff are required to wear whenever they could contact body fluids. This study compared temperatures of 80 healthy newborns randomly assigned to baths at 1 hour or 2 hours of age. Axillary temperatures were taken before bathing and at 10, 20, and 60 minutes after bathing. All babies were bathed in a warmer and left in a warmer for at least 10 minutes, then swaddled. Results showed no statistical differences between the 1-hour and 2-hour groups in temperature recovery. At 10 minutes, close to 90% of the babies were below their prebath temperature. The average drop was 0.4° C. At 20 minutes, close to two thirds were still below baseline an average of 0.2° C. At 60 minutes, nearly half were recovered to either baseline or 36.7° C. IMPLICATIONS FOR PRACTICE This research suggests that infants can have baths as early as 1 hour after birth, providing the newborn’s condition is stable and appropriate care is given. The bath can be given anywhere the mother is recovering or in the nursery. If the bath is given in the presence of the family, this is an ideal time for the nurse to teach the parents about bathing safety, infant characteristics, and how to keep the baby warm. |
Temperature regulation
Anatomic and physiologic differences among the newborn, child, and adult are notable. The newborn’s thermal insulation is less than that of an adult; the blood vessels are closer to the surface of the skin. Newborns have larger body surface to body weight (mass) ratios than children and adults. The flexed position of the newborn helps guard against heat loss because it diminishes the amount of body surface exposed to the environment. Infants can also reduce the loss of internal heat through the body surface by constricting peripheral blood vessels.
Cold stress imposes metabolic and physiologic problems on all infants, regardless of gestational age and condition. The respiratory rate increases in response to the increased need for oxygen. In the cold-stressed infant, oxygen consumption and energy are diverted from maintaining normal brain cell and cardiac function and growth to thermogenesis for survival. If the infant cannot maintain an adequate oxygen tension, vasoconstriction follows and jeopardizes pulmonary perfusion. As a consequence, the partial pressure of arterial oxygen (PaO2) is decreased, and the blood pH drops. These changes aggravate existing respiratory distress syndrome. Moreover, decreased pulmonary perfusion and oxygen tension may maintain or reopen the right-to-left shunt across the patent ductus arteriosus.
The basal metabolic rate increases with cold stress (Fig. 2). If cold stress is protracted, anaerobic glycolysis occurs, resulting in increased production of acids. Metabolic acidosis develops, and if a defect in respiratory function is present, respiratory acidosis also develops. Excessive fatty acids displace the bilirubin from the albuminbinding sites. The resulting increased level of circulating unbound bilirubin heightens the risk of kernicterus even at serum bilirubin levels of 10 mg/dl or less.
Fig. 2 Effects of cold stress. When an infant is stressed by cold, oxygen consumption increases and pulmonary and peripheral vasoconstriction occur, thereby decreasing oxygen uptake by the lungs and oxygen to the tissues; anaerobic glycolysis increases; and there is a decrease in Po2 and pH, leading to metabolic acidosis.
Hyperthermia develops more rapidly in the newborn than in the adult because of decreased ability to increase evaporative skin water losses. Although newborn infants have six times as many sweat glands per unit area as adults,these glands do not function sufficiently to allow the infant to sweat. Serious overheating of the newborn can cause cerebral damage from dehydration or heat stroke and death.
RENAL SYSTEM
At term the kidneys occupy a large portion of the posterior abdominal wall. The bladder lies close to the anterior abdominal wall and is an abdominal as well as a pelvic organ. In the newborn almost all palpable masses in the abdomen are renal in origin.
A small quantity (approximately 40 ml) of urine is usually present at birth in the bladder of a term infant. The frequency of voiding varies from two to six times during the first and second days of life and from 5 to 25 times during the subsequent 24 hours. Approximately six to eight voidings per day of pale straw-colored urine indicates adequate fluid intake. Generally, term infants void 24 to 72 ml of urine per kilogram per day (Fanaroff & Martin, 1997).
Term infants have limited capacity to concentrate urine; therefore the specific gravity ranges from 1.001 to 1.018 (Pagana & Pagana, 2001). The ability to concentrate urine fully is attained by approximately 3 months of age. After the first voiding the infant’s urine may appear cloudy (because of mucus content) and have a much higher specific gravity. This decreases as fluid intake increases. Normal urine during early infancy is usually straw colored and almost odorless. Sometimes pink-tinged uric crystal stains appear on the diaper; these stains are normal.
Loss of fluid through urine, feces, lungs, increased metabolic rate, and limited fluid intake results in a 5°/o to 10% loss of the birth weight. This usually occurs over the first 3 to 5 days of life. If the mother is breastfeeding and her milk supply has not come in yet (which occurs by the third or fourth day after birth), the neonate is protected from dehydration by its increased extracellular fluid volume. The neonate should regain the birth weight within 10 days.
Because renal thresholds are low in the infant, bicarbonate concentration and buffering capacity are decreased. This may lead to acidosis and electrolyte imbalance.
Fluid and electrolyte balance
Approximately 40% of the body weight of the newborn is extracellular fluid. Each day the newborn takes in and excretes roughly 600 to 700 ml of water, which is 20% of the total body fluid or 50% of the extracellular fluid. The glomerular filtration rate of a newborn is approximately 30% to 50% that of the adult. This results in a decreased ability to remove nitrogenous and other waste products from the blood.
Sodium reabsorption is decreased as a result of a lowered sodium- or potassium-activated adenosine triphosphatase (ATPase) activity. The decreased ability to excrete excessive sodium results in hypotonic urine compared with plasma. There is a higher concentration of sodium, phosphates, chloride, and organic acids and a lower concentration of bicarbonate ions. The infant has a higher renal threshold for glucose.
GASTROINTESTINAL SYSTEM
The term newborn is capable of swallowing, digesting, metabolizing, absorbing proteins and simple carbohydrates, and emulsifying fats. With the exception of pancreatic amylase, the characteristic enzymes and digestive juices are present even in low-birth-weight neonates.
In the adequately hydrated infant, the mucous membrane of the mouth is moist and pink; the hard and soft palates are intact. Drooling of mucus is common in the first few hours after birth. Small whitish areas (Epstein pearls) may be found on the gum margins and at the juncture of the hard and soft palate. The cheeks are full because of well-developed sucking pads. These, like the labial tubercles (sucking calluses) on the upper lip, disappear around 12 months of age, when the sucking period is over.
Even though in utero sucking motions have been recorded by ultrasound, these motions are not coordinated in any infant who is less than 1500 g at birth or born before 32 weeks of gestation. Sucking behavior is influenced by neuromuscular maturity, maternal medications received during labor and birth, and the type of initial feeding.
A special mechanism present in healthy term newborns coordinates the breathing, sucking, and swallowing reflexes necessary for oral feeding. Sucking in the newborn takes place in small bursts of three or four sucks at a time. The infant is unable to move food from the lips to the pharynx; therefore placing the nipple (breast or bottle) well inside the baby’s mouth is necessary. Peristaltic activity in the esophagus is uncoordinated in the first few days of life. It quickly becomes a coordinated pattern iormal infants, and they swallow easily.
Teeth begin developing in utero, and enamel formation continues until approximately 10 years of age. Tooth development is influenced by neonatal or infant illness and medication, as well as maternal illness or medication taken by the mother during pregnancy. The fluoride level in the water supply also influences tooth development. Occasionally, an infant may be born with one or more teeth. Native American infants are commonly born with teeth.
Bacteria are not present in the infant’s gastrointestinal tract at birth. Soon after birth, oral and anal orifices permit entrance of bacteria and air. Generally, the highest bacterial concentration is found in the lower portion of the intestine, particularly in the large intestine.
Stomach capacity varies from 30 to 90 ml, depending on the size of the infant. Emptying time for the stomach is highly variable. Several factors, such as time and volume of feedings or type and temperature of food, may affect the emptying time. The cardiac sphincter and nervous control of the stomach are immature, so some regurgitation may occur. Regurgitation during the first day or two of life can be decreased by avoiding overfeeding, by burping the infant, and by positioning the infant with the head slightly elevated.
Digestion
The infant’s ability to digest carbohydrates, fats, and proteins is regulated by the presence of certain enzymes. Most of these are functional at birth. One exception is amylase, produced by the salivary glands after approximately 3 months and by the pancreas at approximately 6 months of age. This enzyme is necessary to convert starch into maltose. The other exception is lipase, also secreted by the pancreas; it is necessary for the digestion of fat. Thus the normal newborn is capable of digesting simple carbohydrates and proteins but has a limited ability to digest fats.
Further digestion and absorption of nutrients occur in the small intestine in the presence of pancreatic secretions, secretions from the liver through the common bile duct, and secretions from the duodenal portion of the small intestine.
Stools
At birth the lower intestine is filled with meconium. Meconium is formed during fetal life from the amniotic fluid and its constituents, intestinal secretions (including bilirubin), and cells (shed from the mucosa). Meconium is greenish black and viscous and contains occult blood. The first meconium passed is usually sterile, but within hours all meconium passed contains bacteria. The majority of normal term infants pass meconium within 12 hours of life and almost all do so by 24 hours. The number of stools passed varies during the first week, being most numerous between the third and sixth days. Newborns fed early pass stools sooner. Progressive changes in the stooling pattern indicate a properly functioning gastrointestinal tract (Box 1).
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Changs in Stooling Patterns of Newborns MECONIUM Infant’s first stool; composed of amniotic fluid and its constituents, intestinal secretions, shed mucosal cells, and possibly blood (ingested maternal blood or minor bleeding of alimentary tract vessels). Passage of meconium should occur within the first 24 to 48 hours, although it may be delayed up to 7 days in very low-birth-weight infants. TRANSITIONAL STOOLS Usually appear by third day after initiation of feeding; greenish brown to yellowish brown, thin, and less sticky than meconium; may contain some milk curds. MILK STOOL Usually appears by fourth day. In breastfed infants, stools are yellow to golden, are pasty in consistency, and have an odor similar to that of sour milk. In formula-fed infants, stools are pale yellow to light brown, are firmer in consistency, and have a more offensive odor. |
HEPATIC SYSTEM
The liver and gallbladder are formed by the fourth week of gestation. In the newborn the liver can be palpated approximately 1 cm below the right costal margin because it is enlarged and occupies approximately 40% of the abdominal cavity. The infant’s liver plays an important role in iron storage, carbohydrate metabolism, conjugation of bilirubin, and coagulation.
Iron storage
The fetal liver (which serves as the site for production of hemoglobin after birth) begins storing iron in utero. The infant’s iron store is proportional to total body hemoglobin content and length of gestation. At birth the term neonate has iron stores sufficient to last 4 to 6 months; the preterm infant’s iron stores will be depleted sooner.
Carbohydrate metabolism
At birth the newborn is cut off from its maternal glucose supply and as a result experiences an initial decrease in serum glucose levels. The newborn’s increased energy needs, decreased hepatic release of glucose from glycogen stores, increased RBC volume, and increased brain size may initially contribute to the rapid depletion of stored glycogen within the first 24 hours after birth. In most healthy term newborns, blood glucose levels stabilize at 40 to 60 mg/dl during the first several hours after birth; by the third day of life, the blood glucose levels should be approximately 60 to 70 mg/dl. The initiation of feedings assists in the stabilization of the newborn’s blood glucose levels.
Conjugation of bilirubin
Bilirubin is a yellow pigment derived from the hemoglobin released with the breakdown of RBCs and the myoglobin in muscle cells. The hemoglobin is phagocytized by the reticuloendothelial cells, converted to bilirubin, and released in an unconjugated form. Unconjugated (indirect bilirubin) is relatively insoluble and almost entirely bound to circulating albumin, a plasma protein. The unbound bilirubin can leave the vascular system and permeate other extravascular tissues (e.g., the skin, sclera, oral mucous membranes). The resulting yellow coloring is termed jaundice.
In the liver the unbound bilirubin is conjugated with glucuronide in the presence of the enzyme glucuronyl transferase. The conjugated form of bilirubin (direct bilirubin) is soluble and is excreted from liver cells as a constituent of bile. Along with other components of bile, direct bilirubin is excreted into the biliary tract system that carries the bile into the duodenum. Bilirubin is converted to urobilinogen and stercobilinogen within the duodenum through the action of the bacterial flora. Urobilinogen is excreted in urine and feces; stercobilinogen is excreted in the feces (Fig. 3). The total serum bilirubin level is the sum of the levels of both conjugated and unconjugated bilirubin.
Fig. 3 Formation and excretion of bilirubin. (From Wong, D. [1999]. Whaley & Wong’s nursing care of infants and children [6th ed.[.
Adequate serum albumin-binding site are available unless the infant experiences asphyxia neonatorum (respiratory failure in the newborn), cold stress, or hypoglycemia. A mother’s prebirth ingestion of medications such as sulfa drugs and aspirin can reduce the amount of serum albuminbinding sites in the newborn. Although the neonate has the functional capacity to convert bilirubin, physiologic hyperbilirubinemia commonly occurs in infants.
Physiologic jaundice
Physiologic jaundice or neonatal hyperbilirabinemia occurs in 50% of term and 80% of preterm newborns. The incidence and severity of physiologic jaundice is increased in Asian, Native American, and Eskimo infants (Merenstein & Gardner, 1998). Although neonatal jaundice is considered benign, bilirubin may accumulate to hazardous levels and lead to a pathologic condition. Neonatal jaundice occurs because the newborn has a higher rate of bilirubin production, and the reabsorption of bilirubin from the neonatal small intestine is considerable (Guyton & Hall, 1995).
Physiologic jaundice fulfills the following specific criteria (Korones, 1995):
• The infant is otherwise well.
• In term infants, jaundice first appears after 24 hours and disappears by the end of the seventh day.
• In preterm infants, jaundice is first evident after 48 hours and disappears by the ninth or tenth day.
• The serum concentration of unconjugated bilirubin usually does not exceed 12 mg/dl in term and 15 mg/dl in preterm infants.
• Hyperbilirubinemia is almost exclusively of the unconjugated variety, and conjugated (direct) bilirubin does not exceed 1 to 1.5 mg/dl.
• Daily increments of bilirubin concentration should not surpass 5 mg/dl. Bilirubin levels in excess of 12 mg/dl may indicate either an exaggeration of the physiologic handicap or the presence of disease.
NURSE ALERT At any serum bilirubin level the appearance of jaundice during the first day of life or persistence beyond the ages previously delineated usually indicates a pathologic process.
Jaundice is generally first noticed in the head, especially the sclera and mucous membranes, and then progresses gradually to the thorax, abdomen, and extremities.
Feeding practices may influence the appearance and degree of physiologic jaundice. Early feeding (within the first hour) tends to keep the serum bilirubin level low by stimulating intestinal activity (the gastrocolic reflex) and the passage of meconium.
Cold stress of the newborn may result in acidosis and raise the level of free fatty acids. In the presence of acidosis, albumin binding of bilirubin is weakened and a higher concentration of unconjugated bilirubin results.
Kernicterus, the most serious complication of neonatal hyperbilirubinemia, is caused by the precipitation of bilirubin ieuronal cells, resulting in their destruction. Cerebral palsy, epilepsy, and mental retardation may occur if the infant survives kernicterus.
Jaundice associated with breastfeeding
Breastfeeding-associated jaundice (early-onset jaundice) is associated with the breastfeeding pattern and occurs 2 to 4 days after birth. Breast milk jaundice (late-onset jaundice) is a progressive indirect hyperbilirubinemia beyond the first week of life. (See Chapter 20 for a discussion of these conditions.)
Coagulation
Coagulation factors, which are synthesized in the liver, are activated by vitamin K. The lack of intestinal bacteria needed to synthesize vitamin K results in transient blood coagulation deficiency between the second and fifth days of life. An injection of vitamin K on the day of birth helps prevent clotting problems.
IMMUNE SYSTEM
The cells that provide the infant with immunity are developed early in fetal life; however, they are not activated for several months. For the first 3 months of life, the infant is protected by passive immunity received from the mother. Natural barriers such as the acidity of the stomach and the production of pepsin and trypsin, which maintain sterility of the small intestine, are not fully developed until 3 to 4 weeks of age (Guyton & Hall, 1995). The membrane-protective IgA is missing from the respiratory and urinary tracts and, unless the newborn is breastfed, is also absent from the gastrointestinal tract. The infant begins to synthesize IgG, and levels reach approximately 40% of adult levels by 1 year of age (Guyton & Hall, 1995). Significant amounts of IgM are produced at birth, and adult levels are reached by 9 months of age. The production of IgA, IgD, and IgE is much more gradual, and maximum levels are not attained until early childhood. The infant who is breastfed continues to receive passive immunity through breast milk as long as the mother continues to breastfeed (
INTEGUMENTARY SYSTEM
All skin structures are present at birth. The epidermis and dermis are bound loosely and are very thin. Vernix caseosa is fused with the epidermis and serves as a protective covering. The infant’s skin is sensitive and can be easily damaged. The term infant has an erythematous (red) skin for a few hours after birth, after which it fades to its normal color. The skin often appears blotchy or mottled, especially over the extremities. The hands and feet appear slightly cyanotic (acrocyanosis); this is caused by vasomotor instability, capillary stasis, and a high hemoglobin level. Acrocyanosis is normal and appears intermittently over the first 7 to 10 days, especially with exposure to cold.
The healthy term infant is plump. Subcutaneous fat accumulated during the last trimester acts as insulation. The newborn’s skin may be slightly tight, suggesting fluid retention. Fine lanugo hair may be noted over the face, shoulders, and back. Actual edema of the face and ecchymosis (bruising) may be noted as a result of face presentation or forceps-assisted birth.
Creases can be found on the palms of the hands. The simian line, a single palmar crease, is often found in Asian infants or in infants with Down syndrome. The soles of the feet should be inspected for the number of creases. Premature newborns have few if any creases. Increasing numbers of creases correlate with a greater maturity rating.
Caput succedaneum
Caput succedaneum is a generalized, easily identifiable edematous area of the scalp, most commonly found on the occiput (Fig. 4, A). The sustained pressure of the presenting vertex against the cervix results in compression of local vessels, thereby slowing venous return. The slower venous return causes an increase in tissue fluids within the skin of the scalp, and an edematous swelling develops. This boggy edematous swelling, present at birth, extends across the suture lines of the skull and disappears spontaneously within 3 to 4 days. Infants who are born with the assistance of vacuum extraction usually have a caput in the area where the cup was applied.
Fig. 4 Differences between caput succedaneum and cephalhematoma. A, Caput succedaneum: edema of scalp is noted at birth and crosses suture lines. B, Cephalhematoma: bleeding between periosteum and skull bone appears within first 2 days and does not cross suture lines.
Cephalhematoma
Cephalhematoma is a collection of blood between a skull bone and its periosteum. Therefore a cephalhematoma does not cross a cranial suture line (Fig. 4, B). Often caput succedaneum and cephalhematoma occur simultaneously.
Bleeding may occur with spontaneous birth from pressure against the maternal bony pelvis. Low forceps birth and difficult forceps rotation and extraction may also cause bleeding. This soft, fluctuating, irreducible fullness does not pulsate or bulge when the infant cries. It appears several hours or the day after birth and may not become apparent until a caput succedaneum is absorbed. A cephalhematoma is usually largest on the second or third day, by which time the bleeding stops. The fullness of a cephalhematoma spontaneously resolves in 3 to 6 weeks. It is not aspirated because infection may develop if the skin is punctured. As the hematoma resolves, hemolysis of RBCs occurs and jaundice may result. Hyperbilirubinemia may occur after the newborn is home.
Desquamation
Desquamation (peeling) of the skin of the term infant does not occur until a few days after birth. Its presence at birth is an indication of postmaturity.
Sweat and oil glands
Sweat glands are present at birth but do not respond to increases in ambient or body temperature. Some fetal sebaceous (oil) gland hyperplasia and secretion of sebum results from the hormonal influences of pregnancy. Vernix caseosa is a product of the sebaceous glands. Removal of the vernix is followed by desquamation of the epidermis in most infants. Distended, small, white sebaceous glands, noticeable on the newborn face, are termed milia.
Mongolian spots
Mongolian spots, bluish black areas of pigmentation, may appear over any part of the exterior surface of the body, including the extremities. They are more commonly noted on the back and buttocks (Fig. 5). These pigmented areas are most commonly noted in babies whose ethnic origins are in the Mediterranean area, Latin America, Asia, or
Fig. 5 Mongolian spot. (From Wong, D. [1999]. Whaley & Wong’s nursing care of infants and children [6th ed.]. St. Louis: Mosby.)
Nevi
Known as “stork bites,” telangiectatic nevi are pink and easily blanched (Fig. 18-6, A). They appear on the upper eyelids, nose, upper lip, lower occipital area, and nape of the neck. They have no clinical significance and fade between the first and second year of life.
Fig, 6 A, Telangiectatic nevus (“stork bite”). B, Erythema toxicum. (Courtesy Mead Johnson & Co.,
The strawberry mark, or nevus vasculosus, is a common type of capillary hemangioma. It consists of dilated, newly formed capillaries occupying the entire dermal and subdermal layers with associated connective tissue hypertrophy. The typical lesion is a raised, sharply demarcated, bright or dark red, rough-surfaced swelling that resembles a strawberry. Lesions are usually single but may be multiple, with 75% occurring on the head. These lesions can remain until the child is of school age or sometimes even longer.
A port-wine stain, or nevus flammeus, is usually observed at birth and is composed of a plexus of newly formed capillaries in the papillary layer of the corium. It is red to purple; varies in size, shape, and location; and is not elevated. True port-wine stains do not blanch on pressure or disappear. They are most frequently found on the face.
Erythema toxicum
A transient rash, erythema toxicum (also called erythema neonatorum, newborn rash, or flea bite dermatitis) is found in term neonates during the first 3 weeks of age. It has lesions in different stages: erythematous macules, papules, and small vesicles (Fig. 6, B). The lesions may appear suddenly anywhere on the body. The rash is thought to be an inflammatory response. Eosinophils, which help decrease inflammation, are found in the vesicles. Although the appearance is alarming, the rash has no clinical significance and requires no treatment.
REPRODUCTIVE SYSTEM
Female
At birth the ovaries contain thousands of primitive germ cells. These represent the full complement of potential ova; no oogonia form after birth in term infants. The ovarian cortex, which is made up primarily of primordial follicles, occupies a larger portion of the ovary in the female newborn than in the adult. From birth to sexual maturity, the number of ova decreases by approximately 90%.
An increase in estrogen during pregnancy followed by a drop after birth results in a mucoid vaginal discharge and even some slight bloody spotting (pseudomenstruation). External genitals (i.e., labia majora and minora) are usually edematous with increased pigmentation. In term neonates, the labia majora and minora cover the vestibule (Fig. 7, A). In preterm infants the clitoris is prominent and the labia majora are small and widely separated. Vaginal or hymenal tags are common findings and have no clinical significance. Vernix caseosa may be present between the labia. If the female was born in the breech position, the labia may be edematous and bruised. The edema and bruising resolve in a few days; no treatment is necessary.
Male
The testes descend into the scrotum by birth in 90% of newborn boys. Although this percentage drops with premature birth, by 1 year of age the incidence of undescended testes in all males is less than 1%.
A tight prepuce (foreskin) is common iewborns. The urethral opening may be completely covered by the prepuce, which may not be retractable for 3 to 4 years. Smegma, a white cheesy substance, is commonly found under the foreskin. Small, white, firm cysts called epithelial pearls may be seen at the tip of the prepuce. In the preterm male who is less than 28 weeks of gestation the testes remain within the abdominal cavity and the scrotum appears high and close to the body. By 28 to 36 weeks of gestation, the testes can be palpated in the inguinal canal and a few rugae appear on the scrotum. At 36 to 40 weeks of gestation, the testes are palpable in the upper scrotum and rugae appear on the anterior portion. After 40 weeks the testes can be palpated in the scrotum and rugae cover the scrotal sac. The postterm neonate has deep rugae and a pendulous scrotum. The scrotum is usually more deeply pigmented than the rest of the skin (Fig. 7, B) and is especially apparent in darker-skinned infants. This pigmentation is a response to maternal estrogen. Hydroceles, caused by an accumulation of fluid around the testes, may be found. They can be transilluminated with a light and usually decrease in size without treatment.
If the male infant is born in a breech presentation, the scrotum is edematous and may be bruised. The swelling and discoloration subside within a few days.
Fig. 7 External genitalia. A, Genitals in female term infant. B, Genitalia in male infant (uncircumcised penis). Rugae cover scrotum, indicating term gestation. Cord has been swabbed with ethylene blue to prevent infection. (Courtesy Marjorie Pyle, RNC, Lifecircle,
Swelling of breast tissue
Swelling of the breast tissue in term infants of both sexes is caused by the hyperestrogenism of pregnancy. In a few infants a thin discharge (witch’s milk) can be seen. This finding has no clinical significance, requires no treatment, and subsides within a few days as the maternal hormones are eliminated from the infant’s body.
The nipples should be symmetric on the chest. Breast tissue and areola size increase with gestation. The areola appears slightly elevated at 34 weeks of gestation. By 36 weeks a breast bud of 1 to 2 mm is palpable and increases to 12 mm by 42 weeks.
SKELETAL SYSTEM
The infant’s skeletal system undergoes rapid development during the first year of life. At birth, more cartilage is present than ossified bone. Because of cephalocaudal (head-to-rump) development, the newborn looks somewhat out of proportion.
The head at term is one fourth of the total body length. The arms are slightly longer than the legs. In the newborn the legs are one third of the total body length but only 15% of the total body weight. As growth proceeds, the midpoint in head-to-toe measurements gradually descends from the level of the umbilicus at birth to the level of the symphysis pubis at maturity.
The face appears small in relation to the skull. The skull appears large and heavy. Cranial size and shape can be distorted by molding (the shaping of the fetal head by overlapping of the cranial bones to facilitate movement through the birth canal during labor) (Fig. 8).
Fig. 8 Molding. A, Significant molding after vaginal birth. B, Schematic of bones of skull when molding is present. (A, Courtesy Kim Molloy,
The bones in the vertebral column of the newborn form two primary curvatures, one in the thoracic region and one in the sacral region (Fig. 9, A). Both are forward, concave curvatures. As the infant gains head control, at approximately 3 months of age, a secondary curvature appears in the cervical region (Fig. 9, B).
In some newborn infants, there is a significant separation of the knees when the ankles are held together, resulting in an appearance of bowlegs. At birth, there is no apparent arch to the foot (Fig. 10). The extremities should be symmetric and of equal length. Skin folds should be equal and symmetric. The hips should be checked for dysplasia using the Ortolani maneuver (Fig. 11). Fingers and toes should be equal in count and have nails. Extra digits (polydactyly) are sometimes found on the hands and feet. Fingers or toes may be fused (syndactyly). If the infant’s presentation was breech, the knees may remain extended and the infant will maintain the in utero position for several weeks.
Fig. 10 Extremities. A, Bowed appearance of legs. B, Normal absence of arch iewborn’s foot. (Courtesy Marjorie Pyle, RNC, Lifecircle,
The newborn’s spine appears straight and can be flexed easily. The vertebrae should appear straight and flat. The base of the spine should be free from a dimple. If a dimple is noted, further inspection is required to determine whether a sinus is present. A pilonidal dimple, especially with a sinus along with a nevus pilosis (hairy nevus), may be associated with spina bifida.
NEUROMUSCULAR SYSTEM
The neuromuscular system is almost completely developed at birth. The term newborn is a vital, responsive, and reactive being with a remarkable capacity for social interaction and self-organization (Fanaroff & Martin, 1997).
Growth of the brain after birth follows a predictable pattern of rapid growth during infancy and early childhood; growth becomes more gradual during the remainder of the first decade and minimal during adolescence. The cerebellum ends its growth spurt, which began at approximately 30 gestational weeks, by the end of the first year. This may be the reason the brain is vulnerable to nutritional deficiencies and trauma in early infancy.
The brain requires glucose as a source of energy and a relatively large supply of oxygen for adequate metabolism. Such requirements signal a need for careful assessment of the infant’s respiratory status. The necessity for glucose requires attentiveness to those neonates who may have hypoglycemic episodes.
Spontaneous motor activity may be seen as transient tremors of the mouth and chin, especially during crying episodes, and of the extremities, notably the arms and hands. Transient tremors are normal and can be observed iearly every newborn. These tremors should not be present when the infant is quiet and should not persist beyond 1 month of age. Persistent tremors or tremors involving the entire body may indicate pathologic conditions. Marked tonicity, clonicity, and twitching of facial muscles are signs of convulsions. Normal tremors, tremors of hypoglycemia, and central nervous system (CNS) disorders must be differentiated so corrective care can be instituted as necessary.
Neuromuscular control in the newborn, although limited, can be noted. If newborns are placed face down on a firm surface, they will turn their heads to the side to maintain an airway. They attempt to hold their heads in line with their bodies if they are raised by their arms. Various reflexes serve to promote safety and adequate food intake.
Newborn reflexes
The newborn infant has many primitive reflexes. The times at which these reflexes appear and disappear reflect the maturity and intactness of the developing nervous system. The most common reflexes found in the normal newborn are described in Table 1.
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Table 1 Assessment of Newborn’s Reflexes |
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REFLEX |
ELICITING THE REFLEX |
CHARACTERISTIC RESPONSE |
COMMENTS |
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Sucking and rooting |
Touch infant’s lip, cheek, or corner of mouth with nipple |
Infant turns head toward stimulus, opens mouth, takes hold, and sucks |
Response is difficult if not impossible to elicit after infant has been fed; if response weak or absent, consider prematurity or neurological defect Parental guidance: Avoid trying to turn head toward breast or nipple, allow infant to root; response disappears after 3 to 4* mo but may persist up to 1 yr |
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Swallowing |
Feed infant; swallowing usually follows sucking and obtaining fluids |
Swallowing is usually coordinated with sucking and usually occurs without gagging, coughing, or vomiting |
If response is weak or absent, this may indicate prematurity or neurologic defect Sucking and swallowing are often uncoordinated in preterm infant |
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Grasp Palmar
Plantar |
Place finger in palm of hand Place finger at base of toes |
Infant’s fingers curl around examiner’s fingers, toes curl downward |
Palmar response lessens by 3 to 4 mo, parents enjoy this contact with infant, plantar response lessens by 8 mo |
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Extrusion |
Touch or depress tip of tongue |
Newborn forces tongue outward |
Response disappears about fourth month of life |
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Glabellar (Myerson) |
Tap over forehead, bridge of nose, or maxilla of newborn whose eyes are open |
Newborn blinks for first four or five taps |
Continued blinking with repeated taps is consistent with extrapyramidal disorder |
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Tonic neck or “fencing” |
With infant falling asleep or sleeping, turn head quickly to one side |
With infant facing left side, arm and leg on that side extend; opposite arm and leg flex (turn head to right, and extremities assume opposite postures) |
Responses in leg are more consistent Complete response disappears by 3 to 4 mo, incomplete response may be seen until third or fourth year After 6 wk, persistent response is sign of possible cerebral palsy |
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Classic pose in spontaneous tonic neck reflex. (Courtesy Marjorie Pyle, RNC, Lifecircle, Costa Mesa, CA.) |
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Moro |
Hold infant in semi-sitting position, allow head and trunk to fall backward to an angle of at least 30 degrees Place infant on flat surface, strike surface to startle infant |
Symmetric abduction and extension of arms are seen; fingers fan out and form a C with thumb and forefinger; slight tremor may be noted; arms are adducted in embracing motion and return to relaxed flexion and movement Legs may follow similar pattern of response Preterm infant does not complete “embrace”; instead, arms fall backward because of weakness |
Response is present at birth; complete response may be seen until 8 wk; body jerk only is seen between 8 and 18 wk; response is absent by 6 mo if neurologic maturation is not delayed; response may be incomplete if infant is deeply asleep; give parental guidance about normal response Asymmetric response may connote injury to brachial plexus, clavicle, or humerus Persistent response after 6 mo indicates possible brain damage |
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Moro reflex. |
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Stepping o “walking” |
Hold infant vertically, allowing one foot to touch table surface |
Infant will simulate walking, alternating flexion and extension of feet; term infants walk on soles of their feet, and pre-term infants walk on their toes |
Response is normally present for 3 to 4 wk |
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Stepping reflex. (From Dickason, E., Silverman, B., & Kaplan, J. [1998]. Maternal-infant nursing care [3rd ed.]. St. Louis: Mosby.) |
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Crawling |
Place newborn on abdomen |
Newborn makes crawling movements with arms and legs |
Response should disappear about 6 wk of age |
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Deep tendon |
Use finger instead of percussion hammer to elicit patellar, or knee jerk, reflex; newborn must be relaxed |
Reflex jerk is present; even with newborn relaxed, nonselective overall reaction may occur |
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Crossed extension |
Infant should be supine; extend one leg, press knee downward, stimulate bottom of foot; observe opposite leg |
Opposite leg flexes, adducts, and then extends |
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Crossed extension reflex. With the infant in supine position, examiner extends one leg of the infant and presses the knee down. Stimulation of sole of foot of fixated limb should cause free leg to flex, adduct, and extend as if attempting to push away stimulating agent. This reflex should be present during newborn period. (Courtesy Marjorie Pyle, RNC, Lifecircle, |
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Startle |
Perform sharp hand clap; best elicited if newborn is 24 to 36 hr old or older |
Arms abduct with flexion of elbows, hands stay clenched |
Response should disappear by 4 mo of age Response is elicited more readily in preterm newborn (inform parents of this characteristic) |
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Babinski sign (plantar) |
On sole of foot, beginning at heel, stroke upward along lateral aspect of sole, then move finger across ball of foot |
All toes hyperextend, with dorsiflexion of big toe – recorded as a positive sign |
Absence requires neurological evaluation, should disappear after 1 yr of age |
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Babinski reflex. A, Direction of stroke. B, Dorsiflexion of big toe. C, Fanning of toes. (From Wong, D. [1999]. Whaley & Wong’s nursing care of infants and children [6th ed.]. |
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Pull-to-sit (traction) |
Pull infant up by wrists from supine position with head in midline |
Head will lag until infant is in upright position, then head will be held in same plane with chest and shoulder momentarily before falling forward; infant will attempt to right head |
Response depends on general muscle tone and maturity and condition of infant |
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Trunk incurvation (Galant) |
Place infant prone on flat surface, run finger down back about 4 to 5 cm lateral to spine, first on one side and then down other |
Trunk is flexed and pelvis is swung toward stimulated side |
Response disappears by fourth week Absence suggests general depression of nervous system |
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Trunk incurvation reflex. In prone position, infant responds to linear skin stimulus (blunt end of pin or finger) along paravertebral area by flexing the trunk and swinging the pelvis toward stimulus. With transverse lesions of cord, no response below the level of the lesion is present. Response may vary but should be obtainable in all infants, including preterm ones. If not seen in the first few days, it is usually apparent by 5 to 6 days. (Courtesy Marjorie Pyle, RNC, Lifecircle, |
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Magnet |
Place infant in supine position, partially flex both lower extremities and apply pressure to soles of feet |
Both lower limbs should extend against examiner’s pressure |
Absence suggests damage to spinal cord or malformation Reflex may be weak or exaggerated after breech birth |
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Magnet reflex. A, With child in supine position and lower limbs semiflexed, light pressure is applied with fingers to both feet. B, Normally, while the examiner’s fingers maintain contact with the soles of the feet, the lower limbs extend. Weak reflex may be seen after breech presentation without extended legs or may indicate sciatic nerve stretch syndrome. Breech presentation with extended legs may evoke exaggerated response. (Courtesy Michael S. Clement, MD, Mesa.AZ.) |
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Additional newborn responses Yawn, stretch, burp, hiccup, sneeze |
These are spontaneous behaviors |
May be slightly depressed temporarily because of maternal analgesia or anesthesia, fetal hypoxia, or infection |
Parental guidance: most of these behaviors are pleasurable to parents Parents need to be assured that behaviors are normal Sneeze is usually response to lint, etc., in nose and not an indicator of a cold No treatment is needed for hiccups, sucking may help |
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BEHAVIORAL CHARACTERISTICS
The healthy infant must achieve behavioral and biologic tasks to develop normally. Behavioral characteristics form the basis of the social capabilities of the infant.
Behavioral responses, as well as physical characteristics, change during the period of transition. The Brazelton Neonatal Behavioral Assessment Scale (BNBAS) can be used to systematically assess the infant’s behavior (Brazelton & Nugent, 1996). The BNBAS is an interactive examination that assesses the infant’s response to 28 areas organized according to the clusters in
. It is generally used as a research or diagnostic tool and requires special training.
In addition to their use as initial and ongoing tools to assess neurologic and behavioral responses, the scale can be used to assess initial parent-infant relationships and as a guide for parents to help them focus on their infant’s individuality and to develop a deeper attachment to their child.
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Clusters of Neonatal Behaviors in BNBAS Habituation—ability to respond to and then inhibit responding to discrete stimulus (light, rattle, bell, pinprick) while asleep. Orientation —quality of alert states and ability to attend to visual and auditory stimuli while alert Motor performance—quality of movement and tone Range of state—measure of general arousal level or arousability of infant Regulation of state—how infant responds when aroused Autonomic stability—signs of stress (tremors, startles, skin color) related to homeostatic (self-regulator) adjustment of the nervous system Reflexes—assessment of several neonatal reflexes |
PLAN OF CARE Immediate Care of the Newborn
NURSING DIAGNOSIS: Risk for aspiration related to neonate’s immature cough or gag reflex as evidenced by need for oropharyngeal suctioning.
EXPECTED OUTCOME: Neonate exhibits no signs and symptoms of aspiration.
Nursing Interventions/Rationales
Assess neonate’s respiratory status at regular intervals until stable to evaluate transition to extrauterine life.
Monitor vital signs and report changes to determine adjustment to the extrauterine environment.
Suction mouth and nasopharynx as needed to keep upper and lower airways clear.
During initial feeding, observe for adequate suck and swallow reflexes to detect difficulties, prevent aspiration, and promote adaptation.
NURSING DIAGNOSIS: Risk for imbalanced body temperature related to cool environment in birthing room as evidenced by acrocyanosis and cool skin temperature.
EXPECTED OUTCOME: Neonate will stabilize temperature within normal range of 36.5″ to 37.2″ C.
Nursing Interventions/Rationales
Dry infant thoroughly and double wrap in warmed blankets; cover infant’s head with hat to prevent further heat loss.
Alternatively, may place infant in skin-to-skin contact with mother; cover infant’s head and body with a warmed blanket to warm infant by conduction through contact with mother; or place unclothed infant under overbed warmer to warm infant by radiation.
Assess and record axillary temperature every 1 to 4 hours to monitor increase or decrease of temperature and make necessary adjustments.
NURSING DIAGNOSIS: Readiness for enhanced organized infant behavior related to responsiveness to visual and auditory stimuli as evidenced by alert and wide-awake appearance.
EXPECTED OUTCOME: Parents express positive feelings about their infant’s behavior and their understanding of the infant’s behavioral development.
Nursing Interventions/Rationales
Demonstrate capabilities of infant to encourage parents to engage in sensory experiences that enhance development.
Demonstrate appropriate ways to interact with infant to decrease parental feelings of incompetence and anxiety.
Praise parents for their interactions with the infant to provide positive reinforcement.
Provide parents with information about infant behavior and capabilities and resources specific to infant development to encourage them to foster their infant’s development.
NURSING DIAGNOSIS: Deficient knowledge related to caput succedaneum or cephalhematoma as evidenced by parent’s statements.
EXPECTED OUTCOME: Parents will verbalize correct information regarding neonate’s condition at time of discharge.
Nursing Interventions/Rationales
Provide information to parents regarding alterations in appearance of head and scalp to alleviate anxiety.
Instruct parents to observe for evidence of jaundice or increase in jaundice to provide early interventions if necessary.
Teach parents to report any evidence of infant pain or discomfort to care provider to give information that may require further assessment.
Provide parents with contact number for health care provider to ensure that parents have opportunity to have questions answered and concerns addressed.
SLEEP-WAKE STATES
Variations in the state of consciousness of infants are called sleep-wake states (Brazelton & Nugent, 1996). The six states form a continuum from deep sleep to extreme irritability (Fig. 12). There are two sleep states (deep sleep and light sleep) and four wake states (drowsy, quiet alert, active alert, and crying). Each state has specific characteristics and state-related behaviors. The optimum state of arousal is the quiet alert state. During this state infants smile, vocalize, move in synchrony with speech, watch their parents’ faces, and respond to people talking to them. The infants’ reaction to internal and external stimuli and ability to control their responses while in these sleep-wake states reflect their ability to organize behavior.
Fig. 12 Sleep-wake states. State of consciousness: A, Deep sleep. B, Light sleep. C, Drowsy. D, Quiet alert. E, Active alert. F, Crying. (Courtesy Marjorie Pyle, RNC, Lifecircle,
Infants use purposeful behavior to maintain the optimum arousal state: (1) actively withdrawing by increasing physical distance, (2) rejecting by pushing away with hands and feet, (3) decreasing sensitivity by falling asleep or breaking eye contact by turning head, or (4) using signaling behaviors, such as fussing and crying. These behaviors permit infants to quiet themselves and reinstate readiness to interact.
The first 6 weeks of life involve a steady decrease in the proportion of active REM sleep to total sleep. A steady increase in the proportion of quiet sleep to total sleep also occurs. Periods of wakefulness increase. For the first few weeks the wakeful periods seem dictated by hunger, but soon a need for socializing appears as well. The newborn sleeps approximately 17 hours a day, with periods of wakefulness gradually increasing. By the fourth week of life, some infants stay awake from one feeding to the next.
OTHER FACTORS INFLUENCING BEHAVIOR OF NEWBORNS
Gestational age
The gestational age of the infant and level of CNS maturity affect the observed behavior. In an infant with an immature CNS the entire body responds to a pinprick of the foot; the mature infant withdraws only the foot. CNS immaturity is reflected in reflex development and sleepwake cycles. Preterm infants have brief periods of alertness but have difficulty maintaining this state. Premature or sick infants show fatigue or stress sooner than term healthy infants do.
Time
The time elapsed since labor and birth affects the behavior of infants as they attempt to become organized initially. Time elapsed since the previous feeding and time of day may also influence infants’ responses.
Stimuli
Environmental events and stimuli affect the behavioral responses of infants. The newborn responds to animate and inanimate stimuli. Nurses in intensive care nurseries observe that infants respond to loud noises, bright lights, monitor alarms, and tension in the unit. If a mother is tense and has a rapid heart rate while feeding her infant, the infant will have an increase in heart rate that is similar to the mother’s.
Medication
Controversy surrounds the effects on infant behavior of maternal medication (e.g., analgesia, anesthesia) during labor. Infants of mothers given medications may continue to demonstrate poor state organization after the fifth day; medication effects have beeoted as long as 30 days after birth. Some researchers maintain that the effect of maternal medication can be beneficial or nonexistent.
SENSORY BEHAVIORS
From birth, infants possess sensory capabilities that indicate a state of readiness for social interaction. Infants effectively use behavioral responses in establishing their first dialogues. These responses, coupled with the newborn’s “baby appearance” (e.g., facial proportions of forehead and eyes larger than the lower portion of the face) and their small size and helplessness, rouse feelings of wanting to hold, protect, and interact with them.
Vision
At birth the eye is structurally incomplete and the muscles are immature. The pupils react to light, the blink reflex is easily stimulated, and the corneal reflex is activated by light touch. The clearest visual distance is 17 to 20 cm, which is approximately the distance the infant’s face is from the mother’s face as she breastfeeds or cuddles. Infants are sensitive to light; they will frown if a bright light is flashed in their eyes, and will turn toward a soft, red light. If the room is darkened, they will open their eyes wide and look about. By 2 months of age, they can detect color, but at 5 days of age and younger, they seem more attracted by blackand-white patterns (Kenner, Lott, & Flandermeyer, 1997).
Response to movement is noticeable. If a bright light is shown to newborns (even at 15 minutes of age), they will follow it visually; some will even turn their heads to do so. Because human eyes are bright, shiny objects, newborns will track their parents’ eyes. Parents often comment on how exciting this behavior is. The development of eye-to-eye contact is important for parent-infant attachment. Children of blind parents, and parents who have blind children, must circumvent this obstacle for the formation of a relationship.
Visual acuity is surprising; even at 2 weeks of age, infants can distinguish patterns with stripes 3 mm apart. By 6 months their vision is as acute as that of an adult. They prefer to look at patterns rather than plain surfaces, even if the latter are brightly colored. They prefer more complex patterns to simple ones. They prefer novelty (changes in pattern) by 2 months of age. The infant of a few weeks of age is therefore capable of responding actively to an enriched environment.
Hearing
As soon as the amniotic fluid drains from the ears, the infant’s hearing is similar to that of an adult. Loud sounds of approximately 90 decibels cause the infant to react with a startle reflex. The newborn responds to low-frequency sounds such as a heartbeat or lullaby by decreasing motor activity or stopping crying. High-frequency sound elicits an alerting response.
The infant responds readily to the mother’s voice. Studies indicate a selective listening to maternal voice sounds and rhythms during intrauterine life that prepares newborns for recognition and interaction with their primary caregivers—their mothers. Newborns are accustomed to hearing the regular rhythm of the mother’s heartbeat. As a result, they respond by relaxing and ceasing to fuss and cry if a regular heartbeat simulator is placed in their cribs.
Hearing loss is a common major abnormality at birth; 1 to 3 of every 1000 well-born infants has bilateral hearing loss (
Fig. 13 Hearing screening in the newborursery. (Courtesy Dee Lowdermilk,
Smell
Newborns react to strong odors such as alcohol or vinegar by turning their heads away. Breastfed infants are able to smell breast milk and can differentiate their mother from other lactating women by the smell (
Taste
The newborn can distinguish between tastes, and various types of solutions elicit differing facial expressions. A tasteless solution produces no response; a sweet solution elicits eager sucking. A sour solution causes puckering of the lips, and a bitter liquid produces a grimace. Newborns prefer glucose water over plain water (
Young infants are particularly oriented toward the use of their mouths, both for meeting their nutritional needs for rapid growth and for releasing tension through sucking. The early development of circumoral sensation, muscle activity, and taste would seem to be preparation for survival in the extrauterine environment.
Touch
The newborn is responsive to touch on all parts of the body. The face (especially the mouth), hands, and soles of the feet seem to be the most sensitive. Reflexes can be elicited by stroking the infant. The newborn’s responses to touch suggest this sensory system is well prepared to receive and process tactile messages. Touch and motion are essential to normal growth and development. However, each infant is unique, and variations can be seen iewborns’ responses to touch. Birth trauma or stress and depressant drugs taken by the mother decrease the infant’s sensitivity to touch or painful stimuli.
RESPONSE TO ENVIRONMENTAL STIMULI
Temp&rarrient
Classic studies have identified individual variations in the primary reaction pattern of newborns and described them as temperament. Their style of behavioral response to stimuli is guided by the temperament affecting the newborn’s sensory threshold, ability to habituate, and response to maternal behaviors. The newborn possesses individual characteristics that affect selective responses to various stimuli present in the internal and external environment.
Habituation
Habituation is a protective mechanism that allows the infant to become accustomed to environmental stimuli. Habituation is a psychologic and physiologic phenomenon in which the response to a constant or repetitive stimulus is decreased. In the term newborn, this can be demonstrated in several ways. Shining a bright light into a newborn’s eyes will cause a startle or squinting the first two or three times. The third or fourth flash will elicit a diminished response, and by the fifth or sixth flash, the infant ceases to respond (Brazelton & Nugent, 1996). The same response pattern holds true for the sounds of a rattle or a pinprick to the heel.
The ability to habituate allows the newborn to select stimuli that promote continued learning about the social world, thus avoiding overload. The intrauterine environment seems to have programmed the newborn to be especially responsive to human voices, soft lights, soft sounds, and sweet tastes.
The newborn quickly learns the sounds in a newborursery and the home and is able to sleep in their midst. The selective responses of the newborn indicate cerebral organization capable of memory and making choices. The ability to habituate depends on the state of consciousness, hunger, fatigue, and temperament. These factors also affect consolability, cuddliness, irritability, and crying.
Consolability
Newborns vary in their ability to console themselves or to be consoled. In the crying state, most newborns initiate one of several ways to reduce their distress. Hand-to-mouth movements are common, with or without sucking, as well as alerting to voices, noises, or visual stimuli.
Cuddliness
Cuddliness is especially important to parents because they often gauge their ability to care for the child by the child’s responses to their actions. The degree to which newborns mold into the contours of the person holding them varies. Babies are soothed and become alert with the vestibular stimulation of being picked up and moved.
Irritability
Some newborns cry longer and harder than others. For some, the sensory threshold seems low. They are readily upset by unusual noises, hunger, wetness, or new experiences, and thus respond intensely. Others, with a high sensory threshold, require a great deal more stimulation and variation to reach the active, alert state.
Crying
Crying in an infant may signal hunger, pain, desire for attention, or fussiness. Most mothers learn to distinguish among the cries. The duration of crying is highly variable in each infant; newborns may cry for as little as 5 minutes or as much as 2 hours or more per day. The amount of crying peaks in the second month and then decreases. There is a diurnal rhythm of crying, with more crying occurring in the evening hours. Crying does not seem to differ with different caregivers.
ASSESSMENT AND CARE OF THE NEWBORN
The numerous biologic changes the neonate makes during the transition to extrauterine life are discussed in the preceding chapter. The first 24 hours of life
are critical because respiratory distress and circulatory failure can occur rapidly and with little warning. Although most infants make the necessary biopsychosocial adjustment to extrauterine existence without undue difficulty, their wellbeing depends on the care they receive from others. This chapter describes the assessment and care of the infant from immediately after birth until discharge. A discussion of pain in the neonate and its management is included.
BIRTH THROUGH THE FIRST 2 HOURS CARE MANAGEMENT
Care begins immediately after the birth and focuses on assessing and stabilizing the condition of the newborn. The nurse has primary responsibility for the infant during this period, because the physician or nurse-midwife is involved with delivery of the placenta and care of the mother. The nurse must be alert for any signs of distress and initiate appropriate interventions.
Assessment and Nursing Diagnoses
The first assessment of the newborn is done immediately after birth by using the Apgar score (Table 1) and a brief physical examination (
). A gestational age assessment is done within 2 hours of birth (Fig. 1). A more comprehensive physical examination is completed within 24 hours of birth (Table 2).
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TABLE 1 Apgar Score |
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SIGN |
0 |
1 |
2 |
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Heart rate |
Absent |
Slow(<100) |
Over 100 |
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Respiratory rate |
Absent |
Slow, weak cry |
Good cry |
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Muscle tone |
Flaccid |
Some flexion of extremities |
Well flexed |
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Reflex irritability |
No response |
Grimace |
Cry |
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Color |
Blue, pale |
Body pink, extremities blue |
Completely pink |
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Initial Physical Assessment by Body System CNS [ ] Moves extremities, muscle tone good [ ] Symmetric features, movement [ ] Suck, rooting, Moro response, grasp reflexes good [ ] Anterior fontanel soft and flat CV [ ] Heart auscultation, strong and regular [ ] No murmurs heard [ ] Pulses strong/equal bilaterally RESP [ ] Lungs auscultated, clear bilaterally [ ]Respiratory rate <60 breaths/min [ ] Chest expansion symmetric [ ] No upper airway congestion GU [ ] Male: urethral opening at tip of penis; testes descended bilaterally Female: vaginal opening apparent GI [ ] Abdomen soft, no distention [ ] Cord attached and clamped [ ] Anus appears patent ENT [ ] Eyes clear [ ] Palates intact [ ] Nares patent SKIN Color [ ] pink [ ] acrocyanotic [ ] No lesions or abrasions [ ] No peeling [ ] Birthmarks [ ] Caput/molding [ ] Vacuum “cap” [ ] Forceps marks [ ] Other Comments: ___________________________________________________
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Fig. 1 Estimation of gestational age. A, New Ballard Score for newborn maturity rating. Expanded scale includes extremely premature infants and has been refined to improve accuracy in more mature infants. (A, From Ballard, J. et al. [1991]. New Ballard Score, expanded to include extremely premature infants. J Pediatr, 7 79[3], 417.). Estimation of gestationai age. B, Newborn classification based on maturity and intrauterine growth. (B, Modified from Lubchenco, L., Hansman, C, & Boyd, E. [1966].
Intrauterine growth in length and head circumference as estimated from live births at gestational ages from 26 to 42 weeks. J Pediatr, 37[3], 403; and Battaglia, F., & Lubchenko, L. [1967]. A practical classification of newborn infants by weight and gestationai age. J Pediatr, 77[2], 159.)
TABLE 2 Physical Assessment of Newborn
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AREA ASSESSED AND APPRAISAL PROCEDURE |
NORMAL FINDINGS |
DEVIATIONS FROM |
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AVERAGE FINDINGS |
NORMAL VARIATONS |
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POSTURE Inspect newborn before disturbing for assessment Refer to maternal chart for fetal presentation, position, and type of birth (vaginal, surgical), since newborn readily assumes prenatal position |
Vertex: arms, legs in moderate flexion; fists clenched Resistance to having extremities extended for examination or measurement, crying possible when attempted Cessation of crying when allowed to resume curled-up fetal position |
Frank breech: legs straighter and stiff, newborn assuming intrauterine position in repose for a few days Prenatal pressure on limb or shoulder possibly causing temporary facial asymmetry or resistance to extension of extremities |
Hypotonia, relaxed posture while awake (prematurity or hypoxia in utero, maternal medications) Hypertonia (drug dependence, central nervous system [CNS] disorder) Opisthotonos (CNS disturbance) Limitation of motion in any of extremities |
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VITAL SIGNS Check heart rate and pulses: Thorax (chest) Inspection Palpation Auscultation Apex: mitral valve Second interspace, left of sternum: pulmonic valve Second interspace, right of sternum: aortic valve Junction of xiphoid process and sternum: tricuspid valve
For femoral pulse palpation, place fingers along inguinal ligament about midway between symphysis pubis and iliac crest; feel bilaterally simultaneously
Attain temperature: Axillary: method of choice until 6 yr of age
Electronic: thermistor probe (avoid taping over bony area)
Check respiratory rate and effort: Observe respirations when infant is at rest Count respirations for full minute Check apnea monitor Listen for sounds audible without stethoscope Observe respiratory effort
Attain blood pressure (BP) (usually assessed only if a problem is suspected) Check electronic monitor BP cuff: BP cuff width affects readings, use cuff 2.5 cm wide and palpate radial pulse |
Visible pulsations in left mid-clavicular line, fifth intercostal space Apical pulse, fourth intercostals space 120-160 beats/min Quality: first sound (closure of mitral and tricuspid valves) and second sound (closure of aortic and pulmonic valves) sharp and clear
Femoral pulses equal and strong
Axillary: 37° C Temperature stabilized by 8-10 hr of age Undeveloped shivering mechanism
40/min Tendency to be shallow and irregular in rate. rhythm, and depth when infant is awake No sounds audible on inspiration or expiration Breath sounds: bronchial; loud, clear, near
78/42 (approximately) At birth Systolic: 60-80 mm Hg Diastolic: 40-50 mm Hg At 10 days Systolic: 95-100 mm Hg Diastolic: slight increase |
100 beats/min (sleeping) to 180 beats/min (crying); possibly irregular for brief periods, especially after crying Murmurs, especially over base or at left sternal border in interspace 3 or 4 (foramen ovale anatomically closing at about 1 yr)
36.5°-37.2° C Heat loss: 200 kcal/kg/min from evaporation, conduction, convection, radiation
30-60/min Possibly appearing to be Cheyne-Stokes with short periods of apnea and no evidence of respiratory distress First period (reactivity): 50-60/min Second period: 50-70/min Stabilization (1-2 days): 30-40/min
Variation with change in activity level: awake, crying, sleeping |
Tachycardia: persistent, >160 beats/min (respiratory distress syndrome [RDS]) Bradycardia: persistent, s120 beats/min (congenital heart block) Murmurs (possibly functional) Arrhythmias: irregular rate Sounds Distant (pneumomediastinum) Poor quality Extra Heart on right side of chest: Dextrocardia, often accompanied by reversal of intestines
Weak or absent femoral pulses (hip dysplasia. coarctation of aorta, thrombophlebitis)
Subnormal (prematurity, infection, low environmental temperature, inadequate clothing, dehydration) Increased (infection, high environmental temperature, excessive clothing, proximity to heating unit or in direct sunshine, drug addiction, diarrhea and dehydration) Temperature not stabilized by 10 hr after birth if mother received magnesium sulfate. newborn less able to conserve heat by vasoconstriction; maternal analgesics possibly reducing thermal stability in newborn)
Apneic episodes: >15 sec (preterm infant: “periodic breathing,” rapid warming or cooling of infant) Bradypnea: <25/min (maternal narcosis from analgesics or anesthetics, birth trauma) Tachypnea: >60/min (RDS, aspiration syndrome, diaphragmatic hernia) Sounds Crackles, rhonchi, wheezes (fluid in lungs) Expiratory grunt (narrowing of bronchi) Distress evidenced by nasal flaring, retractions, chin tug, labored breathing (RDS, fluid in lungs)
Difference between upper and lower extremity pressures (coarctation of aorta) Hypotension (sepsis, hypovolemia) Hypertension (coarctation of aorta) |
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WEIGHT* Put protective liner cloth or paper in place and adjust scale to 0 Weigh at same time each day Protect newborn from heat loss |
Female 3400 g Male 3500 g Regaining of birth weight within first 2 weeks |
2500-4000 g Acceptable weight loss: 10% or less Second baby weighing more than first |
Weight £2500 g (prematurity, small for gestational age, rubella syndrome) Weight >4000 g (large for gestational age, maternal diabetes, heredity—normal for these parents) Weight loss over 10% (dehydration) |
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LENGTH Measure length from top of head to heel, measuring is difficult in term infant because of presence of molding, incomplete extension of knees |
50 cm |
45-55 cm |
<45 cm or >55 cm (chromosomal aberration, hereditynormal for these parents) |
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Weighing the infant. Note that a hand is held over infant as a safety measure. The scale is covered to protect against cross infection. (Courtesy Kim Molloy, |
Length, crown to rump. To determine total length, include length of legs. If measurements are taken before the infant’s initial bath, the nurse must wear gloves. (Courtesy Marjorie Pyle, RNC, Lifecircle, |
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HEAD CIRCUMFERENCE Measure head at greatest diameter: occipitofrontal circumference May need to remeasure on second or third day after resolution of molding and caput succedaneum |
33-35 cm Circumference of head and chest approximately the same for first 1 or 2 days after birth |
32-36.8 cm |
Small head <32 cm: microcephaly (rubella, toxoplasmosis, cytomegalic inclusion disease) Hydrocephaly: sutures widely separated, circumference >4 cm more than chest circumference Increased intracranial pressure (hemorrhage, spaceoccupying lesion) |
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CHEST CIRCUMFERENCE Measure at nipple line |
2-3 cm less than head circumference, averages between 30 and 33 cm |
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£30 cm (prematurity) |
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Circumference of head. (Courtesy Marjorie Pyle, RNC, Lifecircle, |
Circumference of chest. (Courtesy Marjorie Pyle, RNC, Lifecircle, |
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ABDOMINAL CIRCUMFERENCE Measure below umbilicus (not usually measured unless specific indication) |
Abdomen enlargement after feeding because of lax abdominal muscles Same size as chest |
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Enlarging abdomen between feedings (abdominal mass or blockage in intestinal tract) |
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Abdominal circumference. (Courtesy Marjorie Pyle, RNC, Lifecircle, Costa Mesa, CA.) |
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SKIN Check color: Inspect and palpate Inspect naked newborn in well-lit, warm area without drafts; natural daylight provides best lighting Inspect newborn when quiet and when active
Check for jaundice
Check birthmarks: Inspect and palpate for location, size, distribution, characteristics, color
Check condition: Inspect and palpate for intactness, smoothness, texture, edema
Assess hydration and consistency Weigh infant routinely Inspect and palpate Gently pinch skin between thumb and forefinger over abdomen and inner thigh to check for turgor Check subcutaneous fat deposits (adipose pads) over cheeks, buttocks
Check voiding
Check vernix caseosa: Observe amount
Observe its color and odor before bath or wiping
Assess lanugo: Inspect for this fine, downy hair, including its amount. distribution |
Generally pink Varying with ethnic origin, skin pigmentation beginning to deepen right after birth in basal layer of epidermis Acrocyanosis, especially if chilled
None at birth Transient hyperpigmentation Areolae Genitals
Linea nigra
No skin edema Opacity: few large blood vessels visible indistinctly over abdomen
Dehydration: loss of weight best indicator After pinch released, skin returning to original state immediately
Voiding within 24 hours of birth Voiding 6 to 10 times per day after first day of life
Whitish, cheesy, odorless
Over shoulders, pinnas of ears, forehead |
Mottling Harlequin sign Plethora Telangiectases (“stork bites” or capillary hemangiomas) (see Figure 6, A) Erythema toxicum/neonatorum (“newborn rash”) (see Fig. 6, B) Milia
Petechiae over presenting part
Ecchymoses from forceps in vertex births or over buttocks, genitalia, and legs in breech births
Physiologic jaundice in 50% of term infants after first 24 hr
Mongolian spotting (see Fig. 18-5) Infants of African- American, Asian, and Native American origin: 70% Infants of Caucasian origin: 9%
Slightly thick; superficial cracking, peeling, especially of hands, feet No visible blood vessels, a few large vessels clearly visible over abdomen Some fingernail scratches
Normal weight loss after birth: up to 10% of birth weight Possibly puffy Variation in amount of subcutaneous Fat
Variation in amount; usually more found in creases, folds
Variation in amount |
Dark red (prematurity. polycythemia) Pallor (cardiovascular problem, CNS damage, blood dyscrasia, blood loss, twin-to-twin transfusion, nosocomial infection) Cyanosis (hypothermia, infection, hypoglycemia, cardiopulmonary diseases, cardiac, neurologic, or respiratory malformations) Petechiae over any other area (clotting factor deficiency, infection) Ecchymoses in any other area (hemorrhagic disease, traumatic birth)
Gray (hypotension, poor perfusion) Jaundice within first 24 hr (Rh isoimmunization)
Hemangiomas Nevus flammeus: portwine stain Nevus vasculosus: strawberry mark Cavernous hemangiomas
Edema on hands, feet; pitting over tibia Texture thin, smooth, or of medium thickness; rash or superficial peeling visible Numerous vessels very visible over abdomen (prematurity) Texture thick, parchmentlike; cracking, peeling (postmaturity) Skin tags, webbing Papules, pustules, vesicles, ulcers, maceration (impetigo, candidiasis, herpes, diaper rash)
Loose, wrinkled skin (prematurity, postmaturity, dehydration: fold of skin persisting after release of pinch) Tense, tight, shiny skin (edema, extreme cold, shock, infection) Lack of subcutaneous fat, prominence of clavicle or ribs (prematurity. malnutrition)
Absent or minimal (postmaturity) Excessive (prematurity) Yellow color (possible fetal anoxia more than 36 hr before birth, Rh or ABO incompatibility) Green color (possible in utero release of meconium or presence of bilirubin) Odor (possible intrauterine infection)
Absent (postmaturity) Excessive (prematurity, especially if lanugo abundant and long and thick over back) |
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HEAD Palpate skin
Inspect shape, size
Palpate, inspect, measure fontanels
Palpate sutures
Inspect pattern, distribution, amount of hair; feel texture |
See Skin
Making up one fourth of body length Molding (see Fig. 8)
Anterior fontanel 5 cm diamond, increasing as molding resolves Posterior fontanel triangle, smaller than anterior
Palpable and unjoined sutures
Silky, single strands lying flat; growth pattern toward face and neck |
Caput succedaneum, possibly showing some ecchymosis (see Fig. 4, A)
Slight asymmetry from intrauterine position Lack of molding (prematurity, breech presentation, cesarean birth)
Variation in fontanel size with degree of molding Difficulty in feeling fontanels possible because of molding
Possible overlap of sutures with molding
Variation in amount |
Cephalhematoma (see Fig. 4, B)
Molding Severe molding (birth trauma) Indentation (fracture from trauma) (see Fig. 6)
Fontanels Full, bulging (tumor, hemorrhage, infection) Large, flat, soft (malnutrition, hydrocephaly, retarded bone age, hypothyroidism) Depressed (dehydration)
Sutures Widely spaced (hydrocephaly)
Premature closure Fine, woolly (prematurity) Unusual swirls, patterns, hairline or coarse, brittle (endocrineor genetic disorders) |
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EYES Check placement on face
Check for symmetry in size, Shape
Check eyelids for size, movements, blink
Assess for discharge
Evaluate eyeballs for presence, size, shape
Check pupils
Evaluate eyeball movement
Assess eyebrows: amount of hair, pattern |
Eyes and space between eyes each one third the distance from outer-to-outer canthus
Symmetric in size, shape
Blink reflex
None
No tears Both present and of equal size, both round, firm
Present, equal in size, reactive to light
Random, jerky, uneven, focus possible briefly, following to midline
Distinct (not connected in midline) |
Epicanthal folds: normal racial characteristic
Edema if silver nitrate instilled; also may occur with instillation of erythromycin and tetracycline
Some discharge if silver nitrate used
Occasional presence of some tears Subconjunctival hemorrhage
Transient strabismus or nystagmus until third or fourth month |
Epicanthal folds when present with other signs (chromosomal disorders such as Down, cri-du-chat syndromes)
Discharge: purulent (infection)
Agenesis or absence of one or both eyeballs Small eyeball size (rubella syndrome) Lens opacity or absence of red reflex (congenital cataracts, possibly from rubella) Lesions: coloboma, absence of part of iris (congenital) Pink color of iris (albinism) Jaundiced sclera (hyperbilirubinemia)
Pupils: unequal, constricted, dilated, fixed (intracranial pressure, medications, tumors)
Persistent strabismus Doll’s eyes (increased intracranial pressure) Sunset (increased intracranial pressure)
Connection in midline (Cornelia de Lange syndrome) |
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Eyes. In pseudostrabismus inner epicanthal folds cause the eyes to appear misaligned; however, corneal light reflexes are perfectly symmetric. Eyes are symmetric in size and shape and are well placed. |
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NOSE Observe shape, placement, patency, configuration of bridge of nose |
Midline Apparent lack of bridge, flat, broad Some mucus but no drainage Preferential nose breather Sneezing to clear nose |
Slight deformity from passage through birth canal |
Copious drainage, with or without regular periods of cyanosis at rest and return of pink color with crying (choanal atresia, congenital syphilis) Malformed (congenital syphilis, chromosomal disorder) Flaring of nares (respiratory distress) |
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EARS Observe size, placement on head, amount of cartilage, open auditory canal
Assess hearing |
Correct placement: line drawn through inner and outer canthi of eyes reaching to top notch of ears (at junction with scalp) Well-formed, firm cartilage
Responses to voice and other sounds |
Size: small, large, floppy
State (e.g., alert, asleep) influencing response |
Agenesis Lack of cartilage (prematurity) Low placement (chromosomal disorder, mental retardation, kidney disorder) Preauricular tags Size: possibly overly prominent or protruding ears
Deaf: no response to sound |
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Placement of the ear on the head in relation to a line drawn from the inner to the outer canthus of the eye. A, |
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FACIES Observe overall appearance of face |
“Normal” appearance, well-placed, proportionate, symmetric features |
Positional deformities |
Infant appearance “odd” or “funny” Usually accompanied by other features such as lowest ears, other structural disorders (hereditary, chromosomal aberration) |
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MOUTH Inspect and palpate Check placement on face Assess lips for color, configuration, movement
Check gums
Assess tongue for attachment, mobility, movement, size
Evaluate cheeks
Assess palate (soft, hard): Arch Uvula
Assess chin
Evaluate saliva for amount, character
Check reflexes: Rooting Sucking Extrusion |
Symmetry of lip movement
Pink gums
Tongue not protruding, freely movable, symmetric in shape, movement Sucking pads inside cheeks
Soft and hard palates intact Uvula in midline
Distinct chin
Mouth moist
Reflexes present |
Transient circumoral cyanosis
Inclusion cysts (Epstein pearls—Bohodules, whitish, hard nodules on gums or roof of mouth)
Short frenulum
Anatomic groove in palate to accommodate nipple, disappearance by 3 to 4 yr of age Epstein pearls
Reflex response dependent on state of wakefulness and hunger |
Gross anomalies in placement, size, shape (cleft lip and/or palate, gums) Cyanosis, circumoral pallor (respiratory distress, hypothermia) Asymmetry in movement of lips (seventh cranial nerve paralysis)
Teeth: predeciduous or deciduous (hereditary)
Macroglossia (prematurity. chromosomal disorder)
Thrush: white plaques on cheeks or tongue that bleed if touched (Candida albicans)
Cleft hard or soft palate
Micrognathia (Pierre Robin or other syndrome) Excessive saliva (esophageal atresia, tracheoesophageal fistula)
Absent (prematurity) |
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NECK Inspect and palpate length
Check sternocleidomastoid muscles, movement and position of head
Assess trachea for position and thyroid gland |
Short, thick, surrounded by skin folds; no webbing
Head held in midline (sternocleidomastoid muscles equal), no masses Freedom of movement from side to side and flexion and extension, no movement of chin past shoulder
Thyroid not palpable |
Transient positional deformity apparent wheewborn is at rest: passive movement of head possible |
Webbing (Turner syndrome)
Restricted movement, holding of head at angle (torticollis [wryneck], opisthotonos) Absence of head control (prematurity, Down syndrome)
Masses (enlarged thyroid) Distended veins (cardiopulmonary disorder) |
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CHEST Inspect and palpate Shape
Check respiratory Movements
Evaluate clavicles
Assess ribs
Assess nipples for size, placement, number
Check breast tissue
Auscultate: Heart sounds and rate and breath sounds (see Vital signs). |
Almost circular, barrel shaped
Symmetric chest movements, chest and abdominal movements synchronized during respirations
Clavicles intact
Rib cage symmetric, intact; moves with respirations
Nipples prominent, well formed; symmetrically placed
Breast nodule: approxi- mately 6 mm in term infan |
Tip of sternum possibly prominent
Occasional retractions, especially when crying
Breast nodule: 3-10 mm Secretion of witch’s milk |
Bulging of chest, unequal movement (pneumothorax, pneumomediastinum) Malformation (funnel chest—pectus excavatum)
Retractions with or without respiratory distress (prematurity, RDS)
Fracture of clavicle (trauma); crepitus (see Fig. 9)
Poor development of rib cage and musculature (prematurity)
Nipples Supernumerary, along nipple line Malpositioned or widely spaced
Lack of breast tissue (prematurity)
Sounds: bowel sounds (see Abdomen, below) |
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ABDOMEN Inspect, palpate, and smell umbilical cord
Inspect size of abdomen and palpate contour
Auscultate bowel sounds and note number, amount, and character of stools; note behavior—crying, fussiness —before or during elimination
Assess color
Check movement with respiration |
Two arteries, one vein Whitish gray Definite demarcation between cord and skin, no intestinal structures within cord Dry around base, drying Odorless Cord clamp in place for 24 hr
Rounded, prominent, shaped because abdominal musculature not fully developed Liver possibly palpable 1-2 cm below right costal margin No other masses palpable No distention
Sounds present within 1-2 hr after birth Meconium stool passing within 24-48 hr after Birth
Respirations primarily diaphragmatic, abdominal and chest movement synchronous |
Reducible umbilical herniation
Some diastasis of abdomidome nal musculature
Linea nigra possibly apparent and caused by hormone influence during pregnancy |
One artery (renal anomalies) Meconium stained (intrauterine distress) Bleeding or oozing around cord (hemorrhagic disease) Redness or drainage around cord (infection, possible persistence of urachus) Hernia: herniation of abdominal contents into area of cord (e.g., omphalocele); defect covered with thin, friable membrane, possibly extensive
Gastroschisis: fissure of abdominal cavity Distention at birth (ruptured viscus, genitourinary masses or malformations: hydronephrosis, teratomas, abdominal tumors) Mild (overfeeding, high gastrointestinal tract obstruction) Marked (lower gastrointestinal tract obstruction, imperforate anus) Intermittent or transient (overfeeding) Partial intestinal obstruction (stenosis of bowel) Visible peristalsis (obstruction) Malrotation of bowel or adhesions Sepsis (infection)
Scaphoid, with bowel sounds in chest and respiratory distress (diaphragmatic hernia)
Decreased abdominal breathing (intrathoracic disease, diaphragmatic hernia) “Seesaw” (respiratory distress) |
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GENITALIA Female (see Fig. 7) Inspect and palpate General appearance Clitoris Labia majora
Labia minora
Discharge Vagina
Urinary meatus
Male (see Fig. 7) Inspect and palpate General appearance Penis Urinary meatus as slit
Prepuce
Scrotum Rugae (wrinkles)
Testes
Check urination
Check reflexes: Erection Cremasteric |
Female genitals Usually edematous Usually edematous, covering labia minora in term newborns
Possible protrusion over labia majora
Smegma Open orifice Mucoid discharge Hymenal/vaginal tag
Beneath clitoris, difficult to see—to watch for voiding
Male genitals Meatus at tip of penis
Prepuce (foreskin) covering glans penis and not retractable
Large, edematous, pendulous in term infant; covered with rugae
Palpable on each side
Voiding within 24 hr, stream adequate, amount adequate
Erection possibly occurring spontaneously and when genitals touched Testes retracted, especially wheewborn is chilled |
Increased pigmentation caused by pregnancy hormones Edema and ecchymosis after breech birth
Blood-tinged discharge from pseudomenstruation caused by pregnancy hormones
Some vernix caseosa between labia possible
Rust-stained urine (uric acid crystals)*
Increased size and pigmentation caused by pregnancy hormones
Prepuce removed if circumcised Wide variation in size of genitals
Scrotal edema and ecchymosis if breech birth Hydrocele, small, noncommunicating
Bulge palpable in inguinal canal
Rust-stained urine (uric acid crystals)* |
Ambiguous genitalsenlarged clitoris with urinary meatus on tip, fused labia (chromosomal disorder, maternal drug ingestion)
Stenosed meatus
Labia majora widely separated and labia minora prominent (prematurity) Absence of vaginal orifice or imperforate hymen Fecal discharge (fistula)
Ambiguous genitals Urinary meatus not on tip of glans penis (hypospadias, epispadias) Round meatal opening
Scrotum smooth and testes undescended (prematurity, cryptorchidism) Hydrocele Inguinal hernia
Undescended (prematurity) |
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EXTREMITIES Make a general check: Inspect and palpate Degree of flexion Range of motion Symmetry of motion Muscle tone
Check arms and hands: Inspect and palpate Color Intactness Appropriate placement
Check number of fingers
Palpate humerus Evaluate joints Shoulder Elbow Wrist Fingers Check reflex: grasp Check legs and feet: Inspect and palpate Color Intactness Length in relation to arms and body and to each other
Number of toes
Femur Head of femur as legs are flexed and abducted, placement in acetabulum (see Fig. 11)
Major gluteal folds Soles of feet
Evaluate joints Hip Knee Ankle Toes
Check reflexes (see Table 1) |
Assuming of position maintained in utero Attitude of general flexion Full range of motion, spontaneous movements
Longer than legs iewborn period Contours and movement symmetric
Five on each hand Fist often clenched with thumb under fingers
Intact Full range of motion, symmetric contour
Appearance of bowing because lateral muscles more developed than medial muscles
Five on each foot
Intact femur No click heard, femoral head not overriding acetabulum
Major gluteal folds even Soles well lined (or wrinkled) over two thirds of foot in term infants Plantar fat pad giving flatfooted effect
Full range of motion, symmetric contour |
Transient (positional) deformities
Slight tremors sometimes apparent Some acrocyanosis, especially when chilled
Feet appearing to turn in but can be easily rotated externally, positional defects tending to correct while infant is crying
Acrocyanosis |
Limited motion (malformations) Poor muscle tone (prematurity, maternal medications, CNS anomalies)
Positive scarf sign Asymmetry of movement (fracture/crepitus, brachial nerve trauma, malformations) Asymmetry of contour (malformations, fracture) Amelia or phocomelia (teratogens) Palmar creases Simian line with short, incurved little fingers (Down syndrome)
Webbing of fingers: syndactyly Absence or excess of fingers Strong, rigid flexion; persistent fists; positioning of fists in front of mouth constantly (CNS disorder)
Fractured humerus Increased tonicity, clonicity. prolonged tremors (CNS disorder)
Amelia, phocomelia (chromosomal defect, teratogenic effect)
Webbing, syndactyly (chromosomal defect) Absence or excess of digits (chromosomal defect, familial trait)
Femoral fracture (difficult breech birth) Congenital hip dysplasia/dislocation
Soles of feet Few lines (prematurity) Covered with lines (postmaturity) Congenital clubfoot Hypermobility of joints (Down syndrome)
Yellowed nail beds (meconium staining) Temperature of one leg differing from that of the other (circulatory deficiency,CNS disorder)
Asymmetric movement (trauma, CNS disorder) |
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BACK Assess anatomy: Inspect and palpate Spine Shoulders Scapulae Iliac crests Base of spine —pilonidal area
Check reflexes (spinal related) Test trunk incurvation reflex
Test magnet reflex |
Spine straight and easily flexed Infant able to raise and support head momentarily when prone Shoulders, scapulae, and iliac crests lining up in same plane
Trunk flexed and pelvis swings to stimulated side
Lower limbs extend as pressure applied to feet with legs in semiflexed position |
Temporary minor positional deformities, correction with passive manipulation
May not be apparent in first few days but is usually present in 5-6 days
Weak or exaggerated response with breech presentation |
Limitation of movement (fusion or deformity of vertebra) Pigmented nevus with tuft of hair, location anywhere along the spine, often associated with spina bifida occulta Spina bifida cystica (meningocele, myelomeningocele)
If transverse lesion is present, no response below lesion; absence of response: nervous system abnormality or general depression
Absence: suggestive of spinal cord damage or malformation |
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ANUS Inspect and palpate Placement Number Patency
Test for sphincter response (active “wink” reflex) Observe for following: Abdominal distention Passage of meconium Passage of fecal drainage from surrounding orifice; |
One anus with good sphincter tone Passage of meconium within 24 hr after birth
Good “wink” reflex of anal sphincter |
Passage of meconium within 48 hr of birth |
Low obstruction: anal membrane High obstruction: anal or rectal atresia
Drainage of fecal material from vagina in female or urinary meatus in male (rectal fistula) |
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STOOLS Observe frequency, color, consistency |
Meconium followed by transitional and soft yellow stools |
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No stool (obstruction) Frequent watery stools (infection, phototherapy) |
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Apgar score
The Apgar score permits a rapid assessment of the need for resuscitation based on five signs that indicate the physiologic state of the newborn: (1) heart rate based on auscultation with a stethoscope; (2) respiratory rate based on observed movement of the chest wall; (3) muscle tone based on degree of flexion and movement of the extremities; (4) reflex irritability based on response to gentle slaps on the soles of the feet; and (5) color described as pallid, cyanotic, or pink (see Table 1). Evaluations are made at 1 and 5 minutes after birth and can be done by the nurse or birth attendant. Scores of 0 to 3 indicate severe distress, scores of 4 to 6 indicate moderate difficulty, and scores of 7 to 10 indicate that the infant should have no difficulty adjusting to extrauterine life. Apgar scores do not predict future neurologic outcome, but the 5-minute score does correlate with the degree of risk for neonatal morbidity and mortality (Juretschke, 2000).
Initial physical assessment
The initial physical assessment includes a brief review of systems (see
1. External: Notes skin color, staining, peeling, or wasting (dysmaturity); notes length of nails and development of creases on soles of feet; checks for presence of breast tissue; assesses nasal patency by closing one nostril at a time while observing respirations and color; notes meconium staining of cord, skin, fingernails, or amniotic fluid (staining may indicate fetal hypoxia; offensive odor may indicate intrauterine infection)
2. Chest: Palpates for point of maximal impulse and auscultates for rate and quality of heart tones and murmurs; notes character of respirations and presence of crackles; notes equality of breath sounds on each side of chest by holding stethoscope in each axilla
3. Abdomen: Verifies presence of a rounded abdomen and absence of anomalies; notes number of vessels in cord
4. Neurologic: Checks muscle tone and reflex reaction and assesses Moro reflex; palpates anterior fontanel for fullness or bulge; notes by palpation the presence and size of the fontanels and sutures
5. Other observations: Notes gross structural malformations obvious at birth
The nurse responsible for the care of the newborn immediately after birth verifies that respirations have been established, dries the infant, assesses temperature, and places identical identification bracelets on the infant and the mother. In some settings, the father or partner also wears an identification bracelet. The infant may be wrapped in a warm blanket and placed in the arms of the mother, given to the partner to hold, or kept undressed under a radiant warmer. In some settings, immediately after birth the infant is placed on the mother’s abdomen to allow skin-to-skin contact. This contributes to maintenance of the infant’s optimum temperature and parental bonding. The infant may be admitted to a nursery or remain with the parents throughout the hospital stay.
The initial examination of the newborn can occur while the nurse is drying and wrapping the infant, or observations can be made while the infant is lying on the mother’s abdomen or in her arms immediately after birth. Efforts should be directed toward minimizing interference in the initial parent-infant acquaintance process. If the infant is breathing easily, has good color, and is normal in appearance, further examination can be delayed until after the parents have had an opportunity to interact with the infant.
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Routine Admission Orders Vital signs: on admission and q30min x 2, qh x 2, then q8h Weight, length, and head and chest circumference on admission; then weigh daily Tetracycline or erythromycin ophthalmic ointment 5 mg/g V/i to 2 cm line in lower conjunctiva of each eye (ou) Vitamin K 1 mg IM Hematocrit by warm heel stick within 3 to 8 hours of age; call health care provider if <44 or >72 Dextrostix prn; notify health care provider if <40 mg/dl; offer early D5W Feedings: sterile water x 1 by nurse within first 4 hr of life; if tolerated, begin formula q3-4h on demand (Breastfeeding on demand may be initiated immediately after birth without initial sterile water feeding.) Rooming-in as desired and infant’s condition permits Newborn screen for phenylketonuria (PKU), thyroxine (T4), and galactosemia or other screening tests as ordered at least 24 hr after first feeding |
Routine procedures and the admission process can be carried out in the mother’s room or in a separate nursery.
shows an example of newborn routine orders.
Nursing diagnoses are established after analysis of the findings of the physical assessment and include the following:
• Ineffective airway clearance related to
-airway obstruction with mucus
• Impaired gas exchange related to
-hypothermia
• Ineffective tbermoregulation related to
-heat loss to the environment
• Risk for infection related to
-umbilical cord stump
-fetal scalp electrode sites
Expected Outcomes of Care
Expected outcomes can apply both to the infant and the parents. Expected outcomes for the newborn during the immediate recovery period include that the infant will achieve the following:
• Maintain effective breathing patterns
• Maintain effective thermoregulation
• Remain free from infection
• Receive necessary nutrition for growth
Expected outcomes for the parents include that they will do the following:
• Attain knowledge, skill, and confidence relevant to infant care activities
• State understanding of biologic and behavioral characteristics of the newborn
• Begin to integrate the infant into the family
Plan of Care and Interventions
Changes can occur rapidly iewborns immediately after birth. Assessment must be followed quickly by implementation of appropriate care.
Stabilization and resuscitation
Generally, the normal term infant born vaginally has little difficulty clearing the air passages. Most secretions are moved by gravity and brought to the oropharynx by the cough reflex to be drained or swallowed.
If the infant has excess mucus in the respiratory tract, the mouth and nasal passages may be suctioned with a bulb syringe (Fig. 2); routine suctioning is not necessary (Waltman, 2000). The nurse may perform gentle percussion over the chest wall using a soft circular mask or a percussion cup to aid in loosening secretions before suctioning (Fig. 3). The infant who is coughing and choking on the secretions should be supported with its head to the side. The mouth is suctioned first to prevent the infant from inhaling pharyngeal secretions by gasping as the nares are touched. The bulb is compressed and inserted into one side of the mouth. The center of the infant’s mouth is avoided because this could stimulate the gag reflex. The nasal passages are suctioned one nostril at a time. When the infant’s cry does not sound as though it is through mucus or a bubble, suctioning can be stopped. The bulb syringe should always be kept in the infant’s crib. The parents should be given a demonstration of how to use the bulb syringe and asked to perform a return demonstration.
Fig. 19-2 Bulb syringe. Bulb must be compressed before insertion.
Fig. 3 Chest percussion. Nurse performs gentle percussion over the chest wall using a percussion cup to aid in loosening secretions before suctioning.
Use of nasopharyngeal catheter with mechanical suction apparatus. Deeper suctioning may be necessary to remove excessive or tenacious mucus from the infant’s nasopharynx. Proper tube insertion and suctioning for 5 seconds or less per tube insertion help prevent laryngospasms and oxygen depletion. If wall suction is used, the pressure should be adjusted to less than 80 mm Hg. The catheter is lubricated with sterile water and then inserted either orally along the base of the tongue or up and back into the nares. After the catheter is properly placed, suction is created by placing one’s thumb over the control as the catheter is carefully rotated and gently withdrawn. This procedure may need to be repeated until the infant’s cry sounds clear and air entry into the lungs is heard by stethoscope.
Relieving airway obstruction. A choking infant needs immediate attention. Often, simply repositioning of the infant and suctioning the mouth and nose with the bulb syringe eliminates the problem. The infant should be positioned to facilitate gravity drainage. The nurse should also listen to the infant’s respirations and lung sounds with a stethoscope to determine whether there are crackles and wheezes. If the lungs are clear, the bulb syringe is used to clear the mouth and nose. If the bulb syringe does not provide relief, mechanical suction can be used.
If these measures do not relieve the obstruction, the nurse gives the infant back blows and chest thrusts (Fig. 4) (see Emergency box). All personnel working with infants must have current infant cardiopulmonary resuscitation (CPR) certification. Many institutions offer infant CPR courses to new parents before discharge. Because cardiac and respiratory arrest can occur in infants, careful monitoring is necessary so that rapid treatment can be initiated (see Emergency box).
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EMERGENCY Relieving Airway Obstruction Back blow and chest thrusts are used to clear an airway obstructed by a foreign body. BACK BLOWS (Fig. 4, A) Position the infant prone over forearm with the head down and the infant’s jaw firmly supported. Rest the supporting arm on the thigh. Deliver four back blows forcefully between the infant’s shoulder blades with the heel of the free hand. TURN INFANT Place the free hand on the infant’s back to sandwich the baby between both hands; one hand supports the neck, jaw, and chest while the other supports the back. Turn the infant over and place the head lower than the chest, supporting the head and neck. Alternative position: Place the infant face down on your lap with the head lower than the trunk; firmly support the head. Apply back blows and then turn the infant as a unit. CHEST THRUSTS (Fig. 4, B) Provide four downward chest thrusts on the lower third of the sternum. Remove foreign body, if it is visible. OPEN AIRWAY Open airway with the head tilt-chin lift maneuver and attempt to ventilate. Repeat the sequence of back blows, turning, and chest thrusts. Continue these emergency procedures until signs of recovery occur: Palpable peripheral pulses return. The pupils become normal in size and are responsive to light. Mottling and cyanosis disappear. Record the time and duration of the procedure and the effects of this intervention. |
Fig. 13-4 Back blows and chest thrust in infant to clear airway obstruction. A, Back blow. B, Chest thrust.
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EMERGENCY Cardiovascular resistucion Wash hands before and after touching infant and equipment. Wear gloves, if possible. ASSESS RESPONSIVENESS Observe color; tap or gently shake shoulders. Yell for help; if alone, perform CPR for 1 min before calling for help again. POSITION INFANT Turn the infant onto back, supporting the head and neck. Place the infant on firm, flat surface. AIRWAY Open the airway with the head tilt-chin lift method. Place one hand on the infant’s forehead and tilt the head back. Place the fingers of other hand under the bone of the lower jaw at the chin. BREATHING Assess for evidence of breathing: Observe for chest movement. Listen for exhaled air. Feel for exhaled air flow. To breathe for infant: Take a breath. Place mouth over the infant’s nose and mouth to create a seal. NOTE: When available, a mask with a one-way valve should be used. Give two slow breaths (1 to 1.5 sec/breath), pausing to inhale between breaths. NOTE: Gently puff the volume of air in your cheeks into infant. Do not force air. The infant’s chest should rise slightly with each puff; keep fingers on the chest wall to sense air entry. CIRCULATION Assess circulation: Check pulse of the brachial artery while maintaining the head tilt. If the pulse is present, initiate rescue breathing. Continue doing once every 3 sec or 20 times/min until spontaneous breathing resumes. If the pulse is absent, initiate chest compressions and coordinate them with breathing. Chest compression. There are two systems of chest compression. Nurses should know both methods. Maintain the head tilt and: 1. Place thumbs side-by-side in the middle third of the sternum with fingers around the chest and supporting the back. —Compress the sternum 1.25 to 2 cm. 2. Place index finger of hand just under an imaginary line drawn between the nipples. Place the middle and ring fingers on the sternum adjacent to the index finger. — Using the middle and ring fingers, compress the sternum approximately 1.25 to 2.5 cm. Avoid compressing the xiphoid process. Release the pressure without moving the thumbs/fingers from the chest. Repeat at least 100 times/min, doing five compressions in 3 sec or less. Perform 10 cycles of five compressions and one ventilation. After the cycles, check the brachial artery to determine whether there is a pulse. Discontinue compressions when the infant’s spontaneous heart rate reaches or exceeds 80 beats/min. Record the time and duration of the procedure and the effects of intervention.
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Maintaining an adequate oxygen supply. Four conditions are essential for maintaining an adequate oxygen supply:
• A clear airway
• Respiratory efforts
• A functioning cardiopulmonary system
• Heat support (exposure to cold stress increases oxygeeeds)
Signs of potential complications related to abnormal newborn breathing are shown in the Signs of Potential Complications box.
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signs of POTENTIAL COMPLICATIONS Abnormal Newborn Breathing Bradypnea: respirations (s25/min) Tachypnea: respirations (a60/min) Abnormal breath sounds: crackles, rhonchi, wheezes, expiratory grunt Respiratory distress: nasal flaring, retractions, chin tug, labored breathing |
Maintenance of body temperature
Effective neonatal care includes maintenance of an optimal thermal environment. Cold stress increases the need for oxygen and can upset the acid-base balance. The infant may react by increasing the respiratory rate and may become cyanotic. Ways to stabilize the newborn’s body temperature include placing the infant directly on the mother’s abdomen and covering with a warm blanket, drying and wrapping the newborn in warmed blankets immediately after birth, keeping the head well covered, and keeping the ambient temperature of the nursery at 24° C.
If the infant does not remain with the mother during the first 1 to 2 hours after birth, the nurse places the thoroughly dried, unclothed baby under a radiant heat panel or warmer until the body temperature stabilizes. The infant’s skin temperature is used as the point of control when using a warmer with a servocontrolled mechanism. The control panel usually is maintained between 36° and 37° C. This setting should maintain the healthy term infant’s skin temperature at approximately 36.5° C. A thermistor probe (automatic sensor) is taped to the right upper quadrant of the abdomen immediately below the right costal margin (never over a bone). This will ensure detection of minor temperature changes resulting from peripheral vasoconstriction, vasodilation, or increased metabolism long before a change in core body temperature develops. The other end of the probe cord is attached to the control panel. The sensor must be checked periodically to make sure it is securely attached to the infant’s skin. The axillary temperature of the newborn is checked every hour until the newborn’s temperature stabilizes. By the twelfth hour, the newborn’s temperature should stabilize within the normal range.
During all procedures, heat loss must be avoided or minimized for the newborn; examinations and activities are performed with the newborn under a heat panel. The initial bath is postponed until the newborn’s skin temperature reaches 36.5° C.
Even a normal term infant in good health can become hypothermic. Birth in a car on the way to the hospital, a cold birthing room, or inadequate drying and wrapping immediately after birth may cause hypothermia. Warming the hypothermic baby is accomplished with care. Rapid warming may cause apneic spells and acidosis in an infant. The warming process is therefore monitored to progress slowly over a period of 2 to 4 hours.
Immediate interventions
It is the nurse’s responsibility to perform certain interventions immediately after birth to provide for the safety of the newborn.
Eye prophylaxis. The instillation of a prophylactic agent in the eyes of all neonates (Fig. 5) is mandatory in the
Fig. 5 Instillation of medication into eye of newborn. Thumb and forefinger are used to open the eye; medication is placed in the lower conjunctiva from the inner to the outer canthus. (Courtesy Marjorie Pyle, RNC, Lifecircle,
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Medication Guide Eye Prophylaxis: Erythromycin Ophthalmic Ointment 0.5% and Tetracycline Ophthalmic Ointment 1% ACTION These antibiotic ointments are both bacteriostatic and bactericidal. They provide prophylaxis against Neisseria gonorrhoeae and Chlamydia trachomatis. INDICATION These medications are for the prevention of ophthalmia neonatorum iewborns of mothers who are infected with gonorrhea and conjunctivitis iewborns of mothers infected with chlamydia. NEONATAL DOSAGE Apply a 1 to 2 cm ribbon of ointment to the lower conjunctival sac of each eye; may also be used in drop form. ADVERSE REACTIONS May cause chemical conjunctivitis that lasts 24 to 48 hours; vision may be blurred temporarily. NURSING CONSIDERATIONS Administer within 1 to 2 hours of birth. Wear gloves. Cleanse eyes if necessary before administration. Open eyes by putting a thumb and finger at the corner of each lid and gently pressing on the periorbital ridges. Squeeze the tube and spread the ointment from the inner canthus of the eye to the outer canthus. Do not touch the tube to the eye. After 1 minute, excess ointment may be wiped off. Observe eyes for irritation. Explain treatment to parents. Eye prophylaxis for ophthalmia neonatorum is required by law in all states of the |
Vitamin K prophylaxis. Administering vitamin K intramuscularly is routine in the newborn period. A single injection of 0.5 to 1 mg of vitamin K is given soon after birth to prevent hemorrhagic disorders. Vitamin K is produced in the gastrointestinal tract by bacteria starting soon after microorganisms are introduced. By day 8, normal newborns are able to produce their own vitamin K (see Medication Guide).
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Medication Guide Vitamin K: Phytonadione (AquaMEPHYTON, Konakion) ACTION This intervention provides vitamin K because the newborn does not have the intestinal flora to produce this vitamin in the first week after birth. It also promotes formation of clotting factors (II, VII, IX, X) in the liver. INDICATION Vitamin K is used for prevention and treatment of hemorrhagic disease in the newborn. NEONATAL DOSAGE Administer a 0.5- to 1-mg (0.25- to 0.5-ml) dose intramuscularly within 2 hours of birth; may be repeated if newborn shows bleeding tendencies. ADVERSE REACTIONS Edema, erythema, and pain at injection site may occur rarely; hemolysis, jaundice, and hyperbilirubinemia have been reported, particularly in preterm infants. NURSING CONSIDERATIONS Wear gloves. Administer in the middle third of the vastus lateralis muscle using a 25-gauge, %-inch needle. Inject into skin that has been cleaned, or allow alcohol to dry on puncture site for 1 minute to remove organisms and prevent infection. Stabilize leg firmly and grasp muscle between the thumb and fingers. Insert the needle at a 90-degree angle; aspirate and inject medication slowly if there is no blood return. Massage the site with a dry gauze square after removing needle to increase absorption. Observe for signs of bleeding from the site. |
Umbilical cord care. The care of the umbilical cord is the same as that for any surgical wound (Krebs, 1998). The goal of care is prevention and early detection of hemorrhage or infection. The umbilical cord stump is an excellent medium for bacterial growth and can easily become infected.
NURSE ALERT If bleeding from the blood vessels of the cord is noted, the nurse checks the clamp (or tie) and applies a second clamp next to the first one. If bleeding is not stopped immediately, the nurse calls for assistance.
Hospital protocol directs the time and technique for routine cord care. The stump and base of the cord should be assessed for edema, redness, and purulent drainage with each diaper change. The cord clamp is removed after 24 hours when the cord is dry (Fig. 6).
Fig. 6 Using special scissors, remove clamp after cord dries (approximately 24 hours). (Courtesy Marjorie Pyle, RNC, Lifecircle, Costa Mesa, CA.)
Promote parent-infant bonding
Today’s childbirth practices strive to promote the family as the focus of care. Parents generally desire to share in the birth process and to have early contact with their infants. Early contact between mother and newborn can be important in developing future relationships. It also has a positive effect on the duration of breastfeeding. There are physiologic benefits of early mother-infant contact. Oxytocin and prolactin levels rise in the mother, and sucking reflexes are activated in the infant. The infant can be put to breast soon after birth. The process of developing active immunity begins as the infant ingests flora from the mother’s skin.
Evaluation
Evaluation of the effectiveness of care of the newborn is based on the previously stated outcomes.
FROM 2 HOURS AFTER BIRTH UNTIL DISCHARGE
CARE MANAGEMENT
The infant’s admission to the nursery may be delayed or it may never actually occur. Depending on the routine of the hospital, the infant often remains in the labor area and is transferred to the nursery/postpartum unit with the mother. Many hospitals have adopted variations of singleroom maternity care (SRMC). One nurse provides care for both the mother and the newborn. SRMC allows the infant to remain with the parents after the birth. Many of the procedures, such as assessment of weight and measurement (i.e., circumference of head and chest; length), instillation of eye medications, intramuscular administration of vitamin K, and physical assessment, may be carried out in the labor and birth unit. Nurses who work in an SRMC unit; a labor, delivery, recovery (LDR) room; or a labor, delivery, recovery, postpartum (LDRP) room need to be educated in intrapartal, neonatal, and postpartum nursing care and competent in providing it. If the infant is transferred to the nursery, the infant’s identification is verified by the nurse receiving the infant, who places the baby in a warm environment and begins the admission process.
Regardless of the physical organization for care, many hospitals have a small holding nursery, which is available for procedures or on request by the mother who wishes her infant to be placed there. This arrangement promotes parent-infant bonding while still allowing the new parents some time to be alone.
Assessment
Assessment of gestational age
The assessment of physical and neurologic findings to determine gestational age should optimally be done between 2 and 12 hours after birth. If the tests are done earlier, while the infant is recovering from the stress of birth, muscle movements may reflect fatigue; for example, the arm recoil is slower. After 48 hours, there are some significant changes. The plantar creases on the soles of the feet appear to be more numerous and visible as the skin loses fluid and dries.
Assessment of gestational age is important because perinatal morbidity and mortality are related to gestational age and birth weight. The simplified Assessment of Gestational Age (Ballard, Novak, & Driver, 1979) is commonly used to assess gestational age of infants between 35 and 42 weeks. It assesses six external physical and six neuromuscular signs. Each sign has a number score, and the cumulative score correlates with a maturity rating of 26 to 42 weeks. The score is accurate to plus or minus 2 weeks and is accurate for infants of all races.
The New Ballard Score, a revision of the original score, can be used with newborns as young as 20 weeks of gestation. The tool has the same physical and neuromuscular sections but includes — 1 to —2 scores that reflect signs of extremely premature infants, such as fused eyelids; imperceptible breast tissue; sticky, friable, transparent skin; no lanugo; and square window (flexion of wrist) angle greater than 90 degrees (see Fig. 1, A). The score overestimates gestational age by 2 to 4 days in infants younger than 37 weeks of gestation, especially at gestational ages of 32 to 37 weeks (Ballard et al, 1991).
Classification of newborns by gestational age and birth weight
There is a normal range of birth weights for each gestational week (see Fig. 1, B), but the birth weights of preterm, term, postdate, or postmature newborns may also be outside these normal ranges. Birth weights are classified in the following ways:
• Large for gestational age (LGA)-Weight is above the 90th percentile (or 2 standard deviations or more above the norm) at any week.
• Appropriate for gestational age (A GA)–-Weight falls between the 10th and the 90th percentile for the infant’s age.
• Small for gestational age (SGA)—Weight is below the 10th percentile (or 2 standard deviations or more below the norm) at any week.
• Low birth weight (LBW)–Weight of 2500 g or less at birth. These newborns have had either less than the expected rate of intrauterine growth or a shortened gestation period. Preterm birth and LBW commonly occur together (e.g., less than 32 weeks of gestation and birth weight of less than 1200 g).
• Very low birth weight (VLB)-Weight of 1500 g or less at birth.
• Intrauterine growth restriction (IUGR)–Term applied to the fetus whose rate of growth does not meet expected norms. Newborns are classified according to their gestational ages in the following ways:
• Preterm or premature--Born before completion of 37 weeks of gestation, regardless of birth weight.
• Term—Born between the beginning of week 38 and the end of week 42 of gestation.
• Postterm (postdate)—Bom after completion of week 42 of gestation.
• Postmature—Born after completion of week 42 of gestation and showing the effects of progressive placental insufficiency.
Maternal effects on gestational age assessment
Some maternal conditions can affect the results of the gestational assessment. For example, any infant who has experienced oxygen deprivation during labor will have poor muscle tone. Infants in respiratory distress tend to be flaccid and assume a “frog-leg” posture. Even though an infant may appear large, such as an infant of a diabetic mother, it may respond in the same way as a premature infant. The infant of a mother who has been on magnesium sulfate will tend to be somewhat lethargic.
PHYSICAL ASSESSMENT
A complete physical examination should be done within 24 hours after birth, after the newborn’s temperature stabilizes or under a radiant warmer. The parents’ presence during this examination encourages discussion of parental concerns and actively involves the parents in the health care of their infant from birth. It also affords the nurse an opportunity to observe parental interactions with the infant.
The area used for examination should be well lighted, warm, and free from drafts. The infant is undressed as needed and placed on a firm, warmed, flat surface. The physical assessment should begin with a review of the maternal history and prenatal and intrapartal records. This provides a background for the recognition of any potential problems. This assessment also includes general appearance, behavior, vital signs measurements, and parent-infant interactions. Descriptions of any variations from normal findings, and all abnormal findings, are included. After birth, ongoing assessments of the newborn are made and an evaluation is performed before discharge.
The assessment of the newborn should progress systematically from head to toe, with evaluation and assessment of each system, that is, respiratory, cardiovascular, and so on. Descriptions of any variations from normal findings, and all abnormal findings, are included. The findings provide a database for implementing the nursing process with newborns and for providing anticipatory guidance for the parents. (Table 2 summarizes the newborn assessment.)
NURSING CONSIDERATIONS IN ASSESSMENT
The neonate’s maturity level can be gauged by assessment of general appearance. Features to assess in the general survey include posture, head size, lanugo, vernix caseosa, breast tissue, sole creases, cry, and state of alertness. The normal resting position of the neonate is one of general flexion. The umbilicus is the center of the newborn’s body, the neck is short, and the abdomen is prominent.
The temperature, heart rate, and respiratory rate are always obtained. Blood pressure (BP) is not routinely assessed unless cardiac problems are suspected. An irregular, very slow, or very fast heart rate may indicate a need for BP measurement.
The axillary temperature is a safe, accurate substitute for the rectal temperature (Fallis & Christiani, 1999). Electronic thermometers have expedited this task and provide a reading within 1 minute. Taking an infant’s temperature may cause the infant to cry and struggle against the placement of the thermometer in the axilla. Tympanic thermometers may be used after the newborn’s ear canals are free of vernix and fluid. Before taking the temperature, the examiner may determine the apical heart rate and respiratory rate while the infant is quiet and at rest.
The respiratory rate varies with the state of alertness after birth. Respirations are abdominal and can be counted by observing or by lightly feeling the rise and fall of the abdomen or by listening with a stethoscope. Neonatal respirations are shallow and irregular. It is important to count the respirations for a full minute to obtain an accurate count because of normal short periods of apnea. The examiner should also observe for symmetry of chest movement.
Apical pulse rates should be obtained on all infants. Auscultation should be for a full minute, preferably when the infant is asleep. The infant may need to be held and comforted during assessment. Auscultation of the heart sounds is difficult because of the rapid rate and effective transmission of respiratory sounds. However, the first (S1) and second (S2) sounds should be clear and well defined; the second sound is somewhat higher in pitch and sharper than the first. Murmurs are often heard in the newborn, especially over the base of the heart or at the left sternal border in the third or fourth interspace. These are usually functional murmurs due to incomplete closure of fetal shunts. Any murmur or other unusual sounds should be recorded and reported.
If blood pressure is measured, a Doppler (electronic) monitor facilitates this procedure. It is important to use the correct size BP cuff. Neonatal BP usually is highest immediately after birth and falls to a minimum by 3 hours after birth. It then begins to rise steadily and reaches a plateau between 4 and 6 days after birth. This measurement is usually equal to that of the immediate postbirth BP.
BP may be measured in both arms and legs to detect any discrepancy between the two sides or between the upper and lower body. A discrepancy of 10 mm Hg or more between the arms and legs may signal a cardiac defect such as coarctation of the aorta.
Molding may give the neonate’s head an asymmetric appearance (see Fig. 8). Parents should be reassured that this will go away and that nothing need be done to the head. Facial asymmetry may occur from in utero pressure. The hard and soft palate is assessed with the little finger of the examiner; gloves should be worn for this examination. At the same time, the suck reflex can be assessed.
A gross assessment of hearing can be done by watching the neonate respond to voices or other sounds; a loud noise should elicit a startle reflex. Formal hearing screening of all infants is conducted in the newborursery (see Fig. 13).
The nose is examined for size, shape, mucous membrane integrity, and discharge. The nares are checked for patency by occluding one nostril at a time and observing for respirations.
If a mass or lump is detected when palpating the clavicles, the examiner tries to move the neonate’s arm gently while palpating with the other hand. A grating sensation and uneven movement of two juxtaposed bone fragments indicate a fracture.
Breast tissue is assessed through observation and palpation. Breast tissue can be measured by palpating the nipple gently with one finger, or by placing the second and third fingers on either side of the nipple and measuring the distance between the fingers.
Movement of the arms should be assessed. Trauma to the brachial plexus during a difficult delivery may result in brachial palsy. The most common type, Duchenne-Erb paralysis, involves the fifth and sixth cervical nerve roots. The affected arm is held in a position of tight adduction and internal rotation at the shoulder. The grasp reflex on the affected side may be intact; however, the Moro reflex is absent on that side. With treatment, most neonates have complete recovery; surgery may be necessary in some instances (Grossman, 2000).
A neurologic assessment of the newborn’s reflexes provides useful information about the infant’s nervous system and state of neurologic maturation. Many reflex behaviors (e.g., sucking, rooting) are important for survival. Other reflexes, such as gagging, coughing, and sneezing, act as safety mechanisms. The assessment must be carried out as early as possible because abnormal signs present in the early neonatal period may disappear. They may reappear months or years later as abnormal functions.
ASSESSMENT OF COMMON PROBLEMS IN THE NEWBORN
TRANSIENT MECHANICAL BIRTH TRAUMA
Birth trauma includes any physical injury sustained by a newborn during labor and birth. Many injuries are minor and readily resolve in the neonatal period without treatment. Other types of trauma require some form of intervention. A few are serious enough to be fatal. Several factors predispose an infant to birth trauma (Pressler & Hepworth, 2000). Maternal factors include uterine dysfunction that leads to prolonged or precipitous labor, preterm or postterm labor, and cephalopelvic disproportion. Injury may result from dystocia caused by fetal macrosomia, multifetal gestation, abnormal or difficult presentation, and congenital anomalies. Intrapartum events that can result in scalp injury include the use of intrapartum monitoring of the fetal heart rate and fetal scalp sampling. Obstetric birth techniques can also cause injury. These include forceps birth, vacuum extraction, external version and extraction, and cesarean birth.
Soft tissue injuries
Subconjunctival and retinal hemorrhages result from rupture of capillaries caused by increased pressure during birth. The hemorrhages clear within 5 days after birth and usually present no further problems. Parents need explanation and reassurance that these injuries are harmless.
Erythema, ecchymoses, petechiae, abrasions, lacerations, or edema of buttocks and extremities may be present. Localized discoloration may appear over presenting parts and may result from application of forceps or the vacuum extractor. Ecchymoses and edema may appear anywhere on the body.
Bruises over the face may be the result of face presentation (Fig. 7). In a breech presentation, bruising and swelling may be seen over the buttocks or genitalia (Fig. 8). The skin over the entire head may be ecchymotic and covered with petechiae caused by a tight nuchal cord. Petechiae (pinpoint hemorrhagic areas) acquired during birth may extend over the upper trunk and face. These lesions are benign if they disappear within 2 or 3 days of birth and no new lesions appear. Ecchymoses and petechiae may be signs of a more serious disorder, such as thrombocytopenic purpura. To differentiate hemorrhagic areas from skin rashes and discolorations, try to blanch the skin with two fingers. Petechiae and ecchymoses do not blanch because extravasated blood remains within the tissues, whereas skin rashes and discolorations do.
Fig. 7 Marked bruising on the entire face of an infant born vaginally after face presentation. Less severe ecchymoses were present on the extremities. Phototherapy was required for treatment of jaundice resulting from the breakdown of accumulated blood. (From O’Doherty, N. [1986]. Neonatology: Micro atlas of the newborn. Nutley, NJ: Hoffmann-La Roche.)
Fig. 8 Swelling of the genitals and bruising of the buttocks after a breech delivery. (From O’Doherty, N. [1986]. Neonatology: Micro atlas of the newborn.
Trauma secondary to dystocia occurs to the presenting fetal part. Forceps injury and bruising from the vacuum cup occur at the site of application of the instruments. In a forceps injury there is commonly a linear mark across both sides of the face that is in the shape of the blades of the forceps. The affected areas are kept clean to minimize risk of infection. With the increased use of the vacuum extractor and use of padded forceps blades, the incidence of these lesions may be significantly reduced (Fanaroff & Martin, 1997).
Accidental lacerations may be inflicted with a scalpel during cesarean birth. These cuts may occur on any part of the body but are most often found on the scalp, buttocks, and thighs. Usually they are superficial and only need to be kept clean. Butterfly adhesive strips will hold together the edges of more serious lacerations. Sutures are rarely needed.
Skeletal injuries
Fracture of the clavicle (collarbone) is the most common fracture during birth; the break usually occurs in the middle third of the bone (Fig. 9). It is often associated with difficult vertex or breech birth of infants of greater than average size. Limitation of the motion of the arm, crepitus of the bone, and an absent Moro reflex on the affected side are diagnostic findings. Except for the use of gentle rather than rigorous handling of the infant, there is no accepted treatment for a fractured clavicle. The infant may be positioned in bed with the fractured side up. The figure-of-eight bandage, which is appropriate for the older child with a fractured clavicle, is not used for the newborn. The prognosis is good.
Fig, 9 Fractured clavicle after shoulder dystocia. (From O’Doherty, N. [1986]. Neonatology: Micro atlas of the newborn. Nutley, NJ: Hoffmann-La Roche.)
Fracture of the humerus and femur may occur during a difficult birth, but such fractures iewborns generally heal rapidly. Immobilization is accomplished with slings, splints, swaddling, and other devices.
The infant’s immature, flexible skull can withstand a great deal of molding before fracture results. Unless a blood vessel is involved, linear fractures heal without special treatment. These fractures account for 70% of all fractures in this age group. Depressed skull fractures may occur without laceration of either the skin or the dural membrane (Fig. 10). These fractures may occur during difficult births from pressure of the head on the bony pelvis or from injudicious application of forceps. Spontaneous or nonsurgical elevation of the indentation using a hand breast pump or vacuum extractor has been reported (Fanaroff & Martin, 1997).
Fig. 10 Depressed skull fracture in a term male after rapid (1-hour) labor. The infant was delivered by occiputanterior position after rotation from occiput-posterior position. (From Fanaroff, A., & Martin, R. [1997]. Neonatal-perinatal medicine: Diseases of the fetus and infant [6th ed.].
Congenital dislocation of the hip (congenital hip dysplasia) is often a hereditary disorder and occurs more commonly in girls because of the structure of the female pelvis. In this condition, the acetabulum is abnormally shallow; this allows the head of the femur to become dislocated upward and backward so that it lies on the dorsal aspect of the ilium. The pressure of the displaced femoral head may then form a false acetabulum on the ilium. A stretched joint capsule results, and ossification of the femoral head is delayed.
Reduced movement, splinting of the affected hip, limited abduction, and asymmetry of the hip may be noted before dislocation occurs. After dislocation, all of these signs are present, together with external rotation and shortening of the leg. A clicking sound may be heard on gentle forced abduction of the leg (Ortolani sign; see Fig. 11), and a bulge of the femoral head is felt or seen.
Treatment involves pressing the femoral head into the acetabulum to form an adequate socket before ossification is complete. Thick diapers may be applied to abduct and externally rotate the leg and flex the hip; the anterior flaps of the diapers are pinned under the posterior flaps. Alternatively, a Frejka pillow may be applied over a diaper and plastic pants. A Pavlik harness is also used frequently in treatment of congenital hip dislocation. Later a spica cast may be applied to maintain abduction, extension, and internal rotation, usually with the infant in a frog-leg position.
Parents need support in handling an infant with skeletal injuries because they are often fearful of hurting their newborn. Parents are encouraged to practice handling, changing, and feeding the injured newborn under the guidance of the nursing staff. This increases the parents’ knowledge and confidence, in addition to facilitating attachment. A plan for follow-up therapy is developed with the parents so that the times and arrangements for therapy are convenient for them.
PHYSIOLOGIC PROBLEMS
Physiologic jaundice
Approximately 50% to 80% of all term newborns are visibly jaundiced (yellowish) during the first 3 days of life. Serum bilirubin levels less than 5 mg/dl usually are not reflected in visible skin jaundice. Physiologic jaundice is characterized by a progressive increase in serum levels of unconjugated bilirubin from 2 mg/dl in cord blood to a mean peak of 6 mg/dl by 72 hours of age, followed by a decline to 5 mg/dl by day 5, and not exceeding 12 mg/dl. These serum values are considered to be the normal physiologic limits for the healthy term newborn who has not been exposed to perinatal complications such as hypoxia. No bilirubin toxicity develops under these conditions. For the normal term newborn, a serum bilirubin level of 12 to 15 mg/dl is usually the cutoff point for the use of phototherapy, and 20 mg/dl is the cutoff point for exchange transfusion.
Every newborn is assessed for jaundice. The blanch test helps differentiate cutaneous jaundice from skin color. To do the test, pressure is applied with a finger over a bony area (e.g., nose, forehead, sternum) for several seconds to empty all the capillaries in that spot. If jaundice is present, the blanched area will look yellow before the capillaries refill. The conjunctiva and buccal mucosa are also assessed, especially in darker-skinned infants. It is better to assess for jaundice in natural light because artificial lighting and the reflection from nursery walls can distort the actual skin color.
Jaundice is noticeable first in the head and then progresses gradually toward the abdomen and extremities because of the newborn infant’s circulatory pattern (i.e., cephalocaudal developmental progression).
Hypoglycemia
Hypoglycemia during the early newborn period of a term infant is defined as a blood glucose concentration of less than 35 mg/dl or as a plasma concentration of less than 40 mg/dl. It occurs because the newborn abruptly loses its glucose supply when the cord is cut. Because hypoglycemia may be asymptomatic, a blood glucose test is often done soon after birth and repeated at 4 hours of age. More frequent testing is required if the newborn is in an at-risk group (i.e., LGA, SGA, or LBW) or has been exposed to stressors such as cold, perinatal asphyxia, or tocolysis to inhibit preterm labor.
Signs of hypoglycemia include jitteriness; irregular respiratory effort; cyanosis; apnea; weak, high-pitched cry; feeding difficulty; lethargy; twitching; eye rolling; and seizures. The signs may be transient but recurrent.
Hypoglycemia in the low risk term infant is usually eliminated by feeding the infant. Occasionally the intravenous administration of glucose is required.
Hypocalcemia
Hypocalcemia (blood calcium levels of less than 7 mg/dl) may occur iewborns of diabetic mothers or in those who experienced perinatal asphyxia or trauma, and in LBW and preterm infants. Early-onset hypocalcemia occurs within the first 72 hours after birth. Signs of hypocalcemia include jitteriness, edema, apnea, intermittent cyanosis, and abdominal distention.
In most instances, early-onset hypocalcemia is selflimiting and resolves within 1 to 3 days. Treatment includes early feeding and, occasionally, administration of calcium supplements.
Jitteriness is a symptom of both hypoglycemia and hypocalcemia. Therefore hypocalcemia must be considered if therapy for hypoglycemia is ineffective. In many newborns, jitteriness remains despite therapy and cannot be explained by either hypoglycemia or hypocalcemia (Fanaroff& Martin, 1997).
LABORATORY AND DIAGNOSTIC TESTS
Blood glucose levels are measured and urinalysis is performed commonly iewborns. Other tests may be performed as needed, including measurement of bilirubin levels, newborn screening tests (e.g., phenylketonuria [PKU], thyroid [T4], galactosemia; Table 19-3), hematocrits, and drug tests. See
for standard laboratory values in the neonatal period.
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Table 3 Newborn Screening Summary |
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DISORDER/EVIDENCE |
SYMPTOMS |
SCREENING INCIDENCE |
TREATMENT |
|
PKU (classic) Elevated phenylalanine |
Severe mental retardation, eczema, seizures, behavior disorders, decreased pigmentation, distinctive “mousey” odor |
1:10,000 to 1:15,000 More common in Caucasians |
Lifelong dietary management with low-phenylalanine diet; possible tyrosine supplementation |
|
Congenital hypothyroidism (primary) Low T4, elevated TSH |
Mental and motor retardation, short stature, coarse, dry skin and hair, hoarse cry, constipation |
Overall 1:4000 with ethnic variation 1:12,000 African-American 1:1000 Native American |
Maintain L-thyroxine levels in upper half of normal range; periodic bone age to monitor growth |
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Galactosemia (transferase deficiency) Elevated galactose; low or absent fluorescence |
Neonatal death from severe dehydration, sepsis, or liver pathology; mental retardation, jaundice, blindness, cataracts |
1:10,000 to 1:90,000 |
Eliminate galactose and lactose from the diet; soy formulas in infancy; lactose-free solid foods |
|
Maple syrup urine disease (MSUD) levated leucine |
Acidosis; hypertonicity and seizures, vomiting, drowsiness, apnea, coma; infant death or severe mental retardation and neurological impairment; behavioral disorders |
1:90,000 to 1:200,000 |
Diet low in leucine, isoleucine, and valine; thiamine supplement if responsive |
|
Homocystinuria Elevated methionine |
Mental retardation, seizures, behavioral disorders, earlyonset thromboses, dislocated lenses, tall lanky body habitus |
1:200,000 |
Methionine-restricted diet; cystine supplement; vitamin B6 supplement if responsive |
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Congenital adrenal hyperplasia (CAH) Elevated 17-hydroxyprogesterone; abnormal electrolyte |
Hyponatremia, hypokalemia, hypoglycemia, dehydration, and early death; ambiguous genitalia in females; progressive virilization in both sexes |
1:15,000 to 1:30,000 Native Eskimos |
Replace corticosteroids; plastic surgery to correct ambiguous genitalia |
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Biotinidase deficiency Deficient or absent activity of biotinidase on colorimetric assay |
Mental retardation, seizures, ataxia, skin rash, hearing loss, alopecia, optic nerve atrophy, coma, and death |
1:60,000 to 1:100,000 |
10 mg biotin daily |
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Standard Laboratory Values in the Neonatal Period |
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1. HEMATOLOGIC VALUES Clotting factors Activated clotting time (ACT) Bleeding time (Ivy) Clot retraction Fibrinogen |
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NEONATAL
2 min
2 to 7 min Complete 1 to 4 hr 125to300mg/dl* |
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Hemoglobin (g/dl) Hematocrit (%) Reticulocytes (%) Fetal hemoglobin (% of total) Red blood cells (RBCs)//Jt Platelet count//xl White blood cells (WBCsl/l Neutrophils (%) Eosinophils and basophils (%) Lymphocytes (%) Monocytes (%) Immature WBC (%) |
TERM 14 to 24 44 to 64 0.4 to 6
40 to 70
4.8 X 106to 7.1 X 106 150,000 to 300,000
9000 to 30,000 54 to 62
1 to 3 25 to 33 3 to 7 10 |
PRETERM 15 to 17 45 to 55 Up to 10
80 to 90
120,000 to 180,000 10,000 to 20,000
47
33 4 16 |
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2. BIOCHEMICAL VALUES Bilirubin, direct Bilirubin, total
Blood gases
Serum glucose |
Cord: Peripheral blood:
|
0 to 1 day 1 to 2 days 3 to 5 days Arterial:
Venous: |
NEONATAL
0 to 1 mg/dl <2 mg/dl 6 mg/dl 8 mg/dl 12 mg/dl pH 7.31 to 7.45 Pco2 33 to 48 mm Hg Po2 50 to 70 mm Hg pH 7.28 to 7.42 Pco2 38 to 52 mm Hg Po2 20 to 49 mm Hg 40 to 60 mg/dl |
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3. URINALYSIS Color Specific gravity pH Protein Glucose Ketones RBCs WBCs Casts |
NEONATAL Clear, straw 1.001 to 1.018 5 to 7 Negative Negative Negative 0to2 0 to 4 None |
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Some states require newborns to be tested for up to nine disorders. Information about which tests are required in a state can be obtained from state health departments. Approximately 30 states require testing for sickle cell anemia, and some states now require testing for cystic fibrosis and human immunodeficiency virus (Frank, Esch, & Margeson, 1998).
COLLECTION OF SPECIMENS
Ongoing evaluation of a newborn often requires obtaining blood by heel stick or venipuncture or the collection of urine specimens.
Heel stick
Most blood specimens are drawn by laboratory technicians. However, nurses may be required to perform heel sticks to obtain blood for glucose monitoring and to measure hematocrit levels. The same technique is needed to complete the PKU form or to test for galactosemia and hypothyroidism or other inborn errors of metabolism.
It may be helpful to warm the heel before the sample is taken; application of heat for 5 to 10 minutes helps dilate the vessels in the area. A cloth soaked with warm water and wrapped loosely around the foot provides effective warming (Fig. 11, A). Disposable heel warmers are available from a variety of companies; they should be used with care to prevent burns. Nurses should wear gloves when collecting any specimen. The nurse cleanses the area with alcohol, restrains the infant’s foot with her free hand, and then punctures the site. A spring-loaded automatic puncture device causes less pain and requires fewer punctures than a manual lance blade.
Fig. 11 Heel stick. A, Newborn with foot wrapped for warmth to increase blood flow to extremity before heel stick. B, Heel-stick sites (shaded areas) on infant’s foot for obtaining samples of capillary blood. (A, Courtesy Marjorie Pyle, RNC, Lifecircle,
The most serious complication of infant heel stick is necrotizing osteochondritis from lancet penetration of the bone (Meehan, 1998). To prevent this, the penetration should be made at the outer aspect of the heel and should penetrate no deeper than 2.4 mm (Wong, 1999). To identify the appropriate puncture site, the nurse should draw an imaginary line from between the fourth and fifth toes that runs parallel to the lateral aspect of the heel where the stick should be made; a line can also be drawn running from the great toe that runs parallel to the medial aspect of the heel (Fig. 11, B). Repeated trauma to the walking surface of the heel can cause fibrosis and scarring that may lead to problems with walking later in life.
After the specimen has been collected, pressure is applied with a dry gauze square. No further alcohol should be applied because this will cause the site to continue to bleed. The site is then covered with an adhesive bandage. The nurse ensures proper disposal of equipment used, reviews the laboratory slip for correct identification, and checks the specimen for adequate labeling and routing.
A heel stick is traumatic for the infant and causes pain. After several heel sticks, infants have been observed to withdraw their feet when they are touched. To reassure the infant and promote feelings of safety, the neonate should be cuddled and comforted when the procedure is complete. Skin-to-skin contact with the mother reduces pain reactions during heel stick (Gibbons, 2000). A venipuncture is less painful than a heel stick for blood sampling (Shah & Ohlsson, 2001).
Venipuncture
Venous blood samples can be drawn from antecubital, saphenous, superficial wrist, and, rarely, scalp veins. If an intravenous site is used to obtain a blood specimen, it is important to consider the type of infusion fluid; contamination of the blood with the fluid can alter results.
When venipuncture is required, positioning of the needle is extremely important. Although regular venipuncture needles may be used, some individuals prefer butterfly needles. It is necessary to be very patient during the procedure because the blood return from small veins is slow, and consequently the small needle must remain in place longer. The mummy restraint commonly is used to help secure the infant (Fig. 12).
Fig. 12 Application of mummy restraint. A, Infant is placed on folded corner of blanket. B, One corner is brought across body and secured beneath the body. C, Second corner is brought across body and secured, and lower corner is folded and tucked or pinned in place. D, Modified mummy restraint with chest uncovered. (From Wong, D. [1999]. Whaley & Wong’s nursing care of infants and children [6th ed.].
If venipuncture or arterial puncture is being performed for blood gas studies, crying, fear, and agitation will affect the values. Therefore every effort must be made to keep the infant quiet during the procedure. For blood gas studies the blood sample tubes are packed in ice (to reduce blood cell metabolism) and are taken immediately to the laboratory for analysis.
Pressure must be maintained over an arterial or femoral puncture with a dry gauze square for at least 3 to 5 minutes to prevent bleeding from the site. The nurse should observe the infant frequently for evidence of bleeding or hematoma at the puncture site for an hour after any venipuncture. The infant’s tolerance of the procedure should be noted and recorded. The infant should be cuddled and comforted (e.g., rocked, given a pacifier) when the procedure is completed.
Obtaining a urine specimen
Examination of urine is a valuable laboratory tool for infant assessment; the way in which the specimen is collected may influence the results. The urine sample should be fresh and examined within 1 hour of collection. A variety of urine collection bags are available, including the Hollister U-Bag (Fig. 13). These are clear plastic, single-use bags with adhesive material around the opening at the point of attachment.
Fig. 19-13 Collection of urine specimen. A, Protective paper is removed from the adhesive surface. B, Applied to females. C, Applied to males. D, Cut to drain urine. E, Collection tube. (Permission to use and/or reproduce this copyrighted material has been granted by the owner, Hollister, Inc.,
To prepare the infant, the nurse removes the diaper and places the infant in a supine position. The genitalia, perineum, and surrounding skin are washed and thoroughly dried because the adhesive of the bag will not stick to moist, powdered, or oily skin surfaces. The protective paper is removed to expose the adhesive (see Fig. 13, A). In female infants, the perineum is stretched to flatten skin folds, and then the adhesive area is pressed firmly to the skin all around the urinary meatus and vagina. (NOTE: Start with the narrow portion of the butterfly-shaped adhesive patch.) Starting the application at the bridge of skin separating the rectum from the vagina and work upward is most effective (see Fig. 13, B). In male infants the penis and scrotum are tucked through the opening of the collector before the nurse removes the protective paper from the adhesive; then the protective paper is removed, and the flaps are pressed firmly to the perineum, making sure the entire adhesive coating is firmly attached to skin and the edges of the opening do not pucker (see Fig. 13, C). This helps ensure a leakproof seal and decreases the chance of contamination from stool. Cutting a slit in the diaper and pulling the bag through the slit may also help prevent leaking.
The diaper is carefully replaced and the bag is checked frequently. When a sufficient amount of urine (this amount varies according to the test done) has been obtained, the bag is removed. The infant’s skin is observed for signs of irritation while the bag is in place. The specimen can be aspirated with a syringe or drained directly from the bag. For draining, the bag is held in one hand and tilted to keep urine away from the tab. The tab is then removed and the urine is drained into a clean receptacle (see Fig. 13, D).
Collection of a 24-hour specimen can be a challenge; the infant may need to be restrained. The 24-hour urine bag is applied in the manner just described, and the urine is drained into a receptacle. The collection tube can be shortened or capped (see Fig. 13, E). The infant’s skin is watched closely for signs of irritation and for lack of a proper seal.
For some types of urine testing, urine can be aspirated directly from the diaper by means of a syringe without a needle. If the diaper has absorbent gelling material that traps urine, a small gauze pad or cotton balls can be placed inside the diaper and the urine aspirated from them (Wong, 1999).
Restraining the infant
The infant may need to be restrained to (1) protect the infant from injury; (2) facilitate examinations; and (3) limit discomfort during tests, procedures, and specimen collections. The following special considerations must be kept in mind when restraining an infant:
• Apply restraints and check them to make sure they are not irritating the skin or impairing circulation.
• Maintain proper body alignment.
• Apply restraints without using knots or pins if possible. If knots are used, make the kind that can be released quickly. Use pins with care so that there is no danger of their puncturing or pressing against the infant’s skin.
• Check the infant hourly or more frequently if indicated. The mummy restraint may be used during examinations, treatments, or specimen collections that involve the head and neck (see Fig. 2).
Although the blanket support is not a true restraint, it controls the infant’s position and movement. The blanket may be rolled or folded and placed at the infant’s sides.
Restraint without appliance. The infant may be restrained with the nurse’s own hands and body. Fig. 14, B, illustrates restraint of the infant in position for lumbar puncture.
Fig. 19-14 A, Restraining infant for femoral vein puncture. B, Modified side-lying position for lumbar puncture. (From Wong, D. [1999]. Whaley & Wong’s nursing care of infants and children [6th ed.].
Nursing Diagnoses
Possible nursing diagnoses for the newborn include the following:
• Ineffective breathing pattern related to
-obstructed airway
• Impaired gas exchange related to
-hypothermia (cold stress)
• Ineffective thermoregulation related to
-heat loss to environment
• Acute pain related to
-circumcision
-heel sticks, venipuncture
Possible nursing diagnoses for the parents are as follows:
• Readiness for enhanced family coping related to
-knowledge of newborn’s social capabilities
-knowledge of newborn’s dependency needs
-knowledge of biologic characteristics of the newborn
• Situational low self-esteem related to
-misinterpretation of newborn’s behavioral cues
Examples of nursing diagnoses derived from specific assessment findings are listed in the Plan of Care.
Expected Outcomes of Care
The expected outcomes for newborn care relate to the infant and the parents. The expected outcomes for the infant include that the infant will do the following:
• Maintain an effective breathing pattern
• Maintain effective thermoregulation
• Remain free from infection
• Establish adequate elimination patterns
• Receive measures to relieve pain
Expected outcomes for the parents include that they will do the following:
• Attain knowledge, skill, and confidence relevant to infant care activities
• State understanding of biologic and behavioral characteristics of the newborn
• Have opportunities to intensify their relationship with the newborn
• Continue to integrate the infant into the family
Plan of Care and Interventions
In the inpatient setting, priorities of care must be established and a systematic teaching plan for infant care devised. One way to achieve this is to use critical path case management. A care path may be developed that covers the changes expected in the infant during the first several days of life (see Care Path). When variations from the care path occur, further assessment and intervention may be necessary.
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CARE PATH Neonatal Adaptation to Extrauterine Life |
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DAY 1 |
DAY 2 |
DAY 3 |
DAY 4 |
DAY 7 |
DAY 14 |
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WEIGHT |
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Loss of 5%-10% of birth weight |
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Gain of 150-300 g per day |
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Birth weightregained |
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TEMPERATURE |
Stabilized at 37° C |
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FEEDINGS Volume
Formula Breast
Frequency Formula Breast |
15-60 ml
6-10 times/24 hr 8-12 times/ 24 hr
|
60-90 ml |
60-90 ml |
60-90 ml |
60-90 ml |
60-90 ml |
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Softening of at least one breast at each feeding |
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VOIDING |
At least 1 time in first 24 hr |
2-6 times/ 24 hr |
6-10 times/ 24 hr |
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6-10 times/ 24 hr |
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STOOLS |
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Meconium; at least 1 time in first 48 hr |
Transitional stool: 1-5/day |
Yellow stool 1-5/day |
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Yellow stool: 1-2/day |
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SLEEP |
16-20 hr/24hr |
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16-20 hr/24hr |
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UMBILICAL CORD |
Moist; clamped |
Dry; clamp Removed |
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Cord off |
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CIRCUMCISION |
Red; sore |
Yellow exudate covers glans |
Healing |
Healing |
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Healed |
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COLOR |
Pink; acrocyanotic |
Pink; slight jaundice |
Peak of jaundice |
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Pink
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BILIRUBIN LEVEL |
0-6 mg/dl |
<8 mg/dl |
<12 mg/dl |
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<2 mg/dl |
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LABORATORY TESTS |
Glucose when required; HCT |
PKU, T4, galactose |
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Repeat PKU, if needed |
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MEDICATIONS |
Eye prophylaxis and vitamin K within 2 hr of birth; HBIG within 12 hr of birth (if needed) |
HBV before discharge |
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Protective environment
The provision of a protective environment is basic to the care of the newborn. The construction, maintenance, and operation of nurseries in accredited hospitals are monitored by national professional organizations such as the
• Environmental factors—provision of adequate lighting, elimination of potential fire hazards, safety of electric appliances, adequate ventilation, controlled temperature (i.e., warm and free of drafts), and humidity (i.e., lower than 50%)
• Measures to control infection—adequate floor space to permit positioning bassinets at least 60 cm apart, handwashing facilities, and areas for cleaning and storing equipment and supplies
Only those personnel directly involved in the care of mothers and infants are allowed in this area, thereby reducing opportunities for the introduction of pathogenic organisms.
NURSE ALERT Personnel are instructed to use good hand washing techniques. The most important single measure in the prevention of neonatal infection is hand washing between handling different infants.
Health care workers must wear gloves during the following: when handling the infant until blood and amniotic fluid have been removed from the infant’s skin, when drawing blood (e.g., heel stick), when caring for a fresh wound (e.g., circumcision), and during diaper changes.
Visitors and health care providers such as nurses, physicians, parents, grandparents and siblings, department supervisors, electricians, and housekeepers are expected to wash their hands before having contact with infants or equipment. Cover gowns are not necessary.
Individuals with infectious conditions are excluded from contact with newborns or must take special precautions when working with infants. This includes persons with upper respiratory tract infections, gastrointestinal tract infections, and infectious skin conditions. Most agencies have now coupled this day-to-day self-screening of personnel with yearly health examinations.
• Safety factors. Many agencies have implemented security measures in response to infant abductions from nurseries. These incidents have been occurring with greater frequency. Examples of measures taken include placing identification bracelets on infants and their parents, and footprinting or taking identification pictures immediately after birth, before the infant leaves the mother’s side.
Personnel wear picture identification badges or other badges that identify them as newborn personnel. Mother-baby units may have infant tracking systems that will set off an alarm if a baby is left alone or with unauthorized personnel. Mothers are instructed to be certain they know the identity of anyone who cares for the infant and never to release the infant to anyone who is not wearing appropriate identification.
SUPPORTING PARENTS IN THE CARE OF THEIR INFANT
The sensitivity of the caregiver to the social responses of the infant is basic to the development of a mutually satisfying parent-child relationship (Leitch, 1999). Sensitivity increases over time as parents become more aware of their infant’s social capabilities (see Cultural Considerations box).
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CULTURAL CONSIDERATIONS Cultural Beliefs and Practices Nurses working with childbearing families from other cultures and ethnic groups must be aware of cultural beliefs and practices that are important to individual families. People with a strong sense of heritage may hold on to traditional health beliefs long after adopting other American lifestyle practices. These health beliefs may involve practices regarding the newborn. For example, some Asians, Hispanics, Eastern Europeans, and Native Americans delay breastfeeding because they believe that colostrum is “bad.” Some Hispanics and African-Americans place a belly band over the infant’s navel. The birth of a male child is generally preferred by Asians and Indians, and some Asians and Haitians delay naming their infant (Geissler, 1999). |
SOCIAL INTERACTIONS
The activities of daily care during the neonatal period present the best times for infant-family interactions. While caring for their baby, the mother and father can talk to the infant, play baby games, and caress and cuddle the child, and they may use infant massage. In Fig. 15, a mother, father, and infant are shown engaging in arousal, imitation of facial expression, and smiling. Too much stimulation should be avoided after feeding and before a sleep period. Older children’s contact with a newborn must be supervised in terms of strength of hugs, the exploring of eyes and nose, and attempts to feed the baby. Parents often keep baby books that record their infant’s progress.
Fig. 15 Mother-father-baby interaction. (Courtesy Ellen Lewis, Irvine, CA.)
INFANT FEEDING
The infant may be put to breast shortly after birth or at least within 4 hours of birth. If the infant is to be bottle-fed, a nurse may offer it a few sips of sterile water to be certain that the infant’s sucking and swallowing reflexes are intact and that there are no anomalies such as a tracheoesophageal fistula. Most infants are on demand feeding schedules and are allowed to feed when they awaken. Ordinarily mothers are encouraged to feed their infants every 3 to 4 hours during the day and only when the infant awakens during the night in the first few days after birth. Breastfed babies nurse more often than bottle-fed babies because breast milk is digested faster than formulas made from cow’s milk and the stomach empties sooner as a result. Water supplements are usually not recommended. For a thorough discussion of infant feeding, see Chapter 20.
THERAPEUTIC AND SURGICAL PROCEDURES
INTRAMUSCULAR INJECTION
As discussed previously, it is routine to administer a single dose of 0.5 to 1 mg of vitamin K intramuscularly (see Medication Guide).
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Medication Guide. Hepatitis B Vaccine (Recombivax HB, Engerix-B) ACTION. Hepatitis B vaccine induces protective anti-hepatitis B antibodies in 95% to 99% of healthy infants who receive the recommended three doses. The duration of protection of the vaccine is unknown. INDICATION HBV is for immunization against infection caused by all known subtypes of hepatitis B virus. NEONATAL DOSAGE The usual dosage is Recombivax HB 5 fj,g/0.5 ml or Engerix-B 10 fig/0.5 ml at 0, 1, and 6 months. An alternative dosing schedule is 0, 1, 2, and 12 months and is usually for newborns whose mothers were HBsAg positive. ADVERSE REACTIONS Common adverse reactions are rash, fever, erythema, swelling, and pain at injection site. NURSING CONSIDERATIONS Parental consent must be obtained before administration. Wear gloves. Administer in the middle third of the vastus lateralis muscle using a 25-gauge, 5/8-mch needle. Inject into skin that has been cleaned, or allow alcohol to dry on puncture site for 1 minute to remove organisms and prevent infection. Stabilize leg firmly and grasp muscle between the thumb and fingers. Insert the needle at a 90-degree angle; aspirate and inject medication slowly if there is no blood return. Massage the site with a dry gauze square after removing needle to increase absorption. If the infant was born to HBsAg-positive mother, hepatitis B immune globulin (HBIG) should be given within 12 hours of birth in addition to the HB vaccine. Separate sites must be used. |
Hepatitis B (Hep B) vaccination is recommended for all infants. Infants at highest risk of contracting hepatitis B are those born to women who come from Asia,
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Medication Guide. Hepatitis B Immune Globulin (HBIG) ACTION HBIG provides a high titer of antibody to hepatitis B surface antigen (HBsAg). INDICATION The HBIG vaccine provides prophylaxis against infection in infants born of HBsAg-positive mothers. NEONATAL DOSAGE Administer one 0.5-ml dose intramuscularly within 12 hours of birth. ADVERSE REACTIONS Hypersensitivity may occur. NURSING CONSIDERATIONS Must be given within 12 hours of birth. Wear gloves. Administer in the middle third of the vastus lateralis muscle using a 25-gauge, 5/8-inch needle. Inject into skin that has been cleaned, or allow alcohol to dry on puncture site for 1 minute to remove organisms and prevent infection. Stabilize leg firmly and grasp muscle between the thumb and fingers. Insert the needle at a 90-degree angle; aspirate and inject medication slowly if there is no blood return. Massage the site with a dry gauze square after removing needle to increase absorption. May be given at same time as hepatitis B vaccine, but at a different site. |
In most cases a 25-gauge, V8-inch needle should be used for the vitamin K and hepatitis vaccine injections. A 22-gauge needle may be necessary if thicker medications such as some penicillins are to be given.
Selection of the site for injection is important. Injections must be given in muscles large enough to accommodate the medication, and major nerves and blood vessels must be avoided. The muscles of newborns may not tolerate more than 0.5 ml per intramuscular injection. The injection site for newborns is the vastus lateralis (Fig. 16). The dorsogluteal muscle is very small, poorly developed, and dangerously close to the sciatic nerve, which occupies a larger proportion of space in infants than in older children. Therefore it is not recommended as an injection site until the child has been walking for at least 1 year.
Fig. 16 Intramuscular injection. A, Acceptable intramuscular injection site for newborn infant. X, Injection site. B, Infant’s leg stabilized for intramuscular injection. Nurse is wearing gloves to give injection. (B, Courtesy Marjorie Pyle, RNC, Lifecircle,
Newborn infants offer little, if any, resistance to injections. Although they squirm and may be difficult to hold in position if they are awake, they can usually be restrained without the need for assistance from a second person if the nurse is experienced.
The neonate’s leg should be stabilized. Gloves are worn for the injection. The nurse cleanses the injection site with alcohol and then pinches up the infant’s muscle with the thumb and forefinger. The needle is inserted into the vastus lateralis at a 90-degree angle. The muscle is released and the plunger of the syringe is gently withdrawn. If no blood is aspirated, the medication is injected. If blood is aspirated, the needle is withdrawn and the injection is given in another site. The needle is withdrawn quickly and the site massaged with a gauze square to hasten absorption unless contraindicated. It is not uncommon for blood to ooze from the injection site, but it is not necessary to cover the site with an adhesive bandage. Pressure should be applied until oozing stops.
The nurse should always remember to comfort the infant after an injection and to properly discard equipment. It is important to record medication, date and time, amount, route, and site of injection.
THERAPY FOR HYPERBILIRUBINEMIA
The best therapy for hyperbilirubinemia is prevention. Because bilirubin is excreted in meconium, prevention can be facilitated by early feeding, which stimulates passage of meconium. However, despite early passage of meconium, the term infant may have trouble conjugating the increased amount of bilirubin derived from disintegrating fetal red blood cells. As a result, the serum levels of unconjugated bilirubin may rise beyond normal limits, causing hyperbilirubinemia. The goal of treatment of hyperbilirubinemia is to help reduce the newborn’s serum levels of unconjugated bilirubin. There are two principal ways of doing this: phototherapy and exchange blood transfusion. Exchange transfusion is used to treat those infants whose raised levels of bilirubin cannot be controlled by phototherapy.
Phototherapy
During phototherapy the infant is placed, unclothed, approximately 45 to 50 cm under a bank of lights. The distance may vary based on unit protocol and type of light used. The infant is turned every 2 hours to expose all body surfaces to the light. This is done for several hours or days until the infant’s serum bilirubin level decreases to within acceptable range. The decision to discontinue therapy is based on a definite downward trend in the bilirubin values. After therapy has been terminated, the infant may have a rebound of bilirubin level, which is usually harmless.
Several precautions must be taken while the infant is un dergoing phototherapy. The lamp energy output should be monitored routinely during treatment with a photometer (Fanaroff & Martin, 1997). The infant’s eyes must be protected by an opaque mask to prevent overexposure to the light; the eye shield should cover the eyes completely but not occlude the nares. Before the mask is applied, the infant’s eyes should be closed gently to prevent excoriation of the corneas. The mask should be removed during infant feedings so that the eyes can be checked and the parents can have visual contact with the infant (Fig. 17, A and B).
Often, a “string bikini” made from a disposable face mask is used instead of a diaper. This allows optimal skin exposure, yet sufficient protection to the genitals and bedding.
Fig. 17 Eye patches for newborns receiving phototherapy. A, Small Velcro patch stuck to both sides of head. B, Eye cover sticks to Velcro patch, which reduces movement of eye cover and facilitates removal for feedings. C, A mother can breastfeed her baby without interrupting phototherapy. (C, Courtesy Respironics, Inc.,
NURSE ALERT Before its application, the metal strip must be removed from the mask to prevent burning the infant. Lotions and ointments should not be used because they absorb heat and this can cause burns.
Phototherapy may cause the infant to sleep for longer than the usual 4-hour periods, but the infant needs to be kept on a regular feeding schedule to maintain hydration. The number and consistency of stools are monitored. Bilirubin breakdown increases gastric motility, which results in loose stools that can cause skin excoriation and breakdown; the infant’s buttocks must be cleaned after each stool to help maintain skin integrity.
During phototherapy, the infant’s temperature may become elevated; this requires monitoring at least every 4 hours. The lights increase the rate of insensible water loss, making it possible for fluid loss and dehydration to occur. Therefore it is important that the infant be adequately hydrated. All aspects of the phototherapy rendered should be accurately recorded in the infant’s chart.
An alternative device for phototherapy that is as safe and effective as traditional phototherapy is a fiberoptic panel attached to an illuminator. This fiberoptic blanket, which wraps light around the newborn’s torso, delivers continuous phototherapy. The newborn can remain in the mother’s room in an open crib or in her arms during treatment; follow unit protocol for the use of eye patches (Fig. 17, C). The blanket may also be used for home phototherapy.
Parent education
Serum levels of bilirubin in the newborn continue to rise until the fifth day of life. Many parents leave the hospital within 24 hours, and some as early as 6 hours after birth. Therefore parents must be able to assess the newborn’s degree of jaundice. They should have written instructions for assessing the infant’s condition and the name of the contact person to whom they should report their findings. Some hospitals have a nurse make a home visit to evaluate the infant’s condition. If it proves necessary to measure bilirubin levels after discharge from the hospital, the home care nurse may draw the blood for the specimen, or the parents may take the baby to a laboratory for the determination (see Teaching Guidelines box).
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TEACHING GUIDELINES. Hyperbilirubinemia DEFINITIONS Hyperbilirubinemia: higher levels of bilirubin than normal Bilirubin: end product of RBCs when they mature and break down RBCs: red blood cells Jaundice: yellow skin, sclerae, and mucous membranes caused by circulating bilirubin Phototherapy: the use of fluorescent light to break down the bilirubin in the skin into substances that can be excreted in the feces (stool) and urine Bililites: fluorescent lights used for phototherapy HOW JAUNDICE HAPPENS When RBCs break down, they release bilirubin, which then circulates in the blood. The bilirubin combines with another substance in the liver. This combined substance moves through the blood to the kidneys and the intestines, where it is eliminated in the urine and the stool. The bilirubin gives the yellow color to urine and the brown color to the stool. Before birth, babies have more RBCs in each ounce of blood than adults have. The RBCs of the unborn infant also have a shorter life span (70 to 90 days) than RBCs formed after birth (120 days). When the RBCs of a fetus break down, the bilirubin produced by this is carried by the fetus’s blood, through the placenta, and to the mother’s liver to be excreted. After birth, the infant’s liver must get rid of the bilirubin. Even though a baby’s liver functions well, it may not be able to get rid of all the bilirubin produced by breakdown of RBCs. Bilirubin then seeps out of the blood and into the tissues, coloring them yellow (jaundice). The blood level of bilirubin rises quickly up to the fifth day and then it declines; the jaundice usually clears up by the end of the week. THE DANGER OF EXCESS BILIRUBIN Some newborns seem to have extra bilirubin to excrete. High levels of bilirubin may cause damage to the brain. According to the CARING FOR THE INFANT The newborn is placed in an incubator under phototherapy lights so that it can be kept warm and the nurse can observe it. The infant wears an eye mask to keep the light out of the eyes. The infant is undressed so that as much light as possible can reach the skin. The newborn may wear a “string bikini” as a small diaper, which is made out of a paper diaper or a face mask. The infant’s temperature is taken often so that any changes in temperature can be noted and the infant is not allowed to become too hot or too cold. The infant may be given extra water to drink or extra breastfeedings because infants have watery, green stools resulting from excretion of the extra bilirubin, and this can lead to dehydration. The newborn is taken out from under the lights for feedings and cuddling unless a bili blanket is being used. There is no need to remove the bili blanket for feeding. Blood is taken from the heel to check the amount of bilirubin still in the newborn’s blood, and the nurse updates the parents about the results. AFTER THE NEWBORN GOES HOME The parents should be encouraged to ask any questions that they might have. The nurse gives them a telephone number to call at any hour with their questions. If therapy is continued at home, referral is made to home care. |
CIRCUMCISION
Circumcision of male infants is commonly performed in the
Circumcision is a matter of personal parental choice. Parents usually decide to have their newborn circumcised for one or more of the following factors: hygiene, religious conviction, tradition, culture, or social norms. Regardless of the reason for the decision, parents should be given unbiased information and the opportunity to discuss the benefits and risks (Van Ryzin, 2000).
Expectant parents need to begin learning about circumcision during the prenatal period, but circumcision often is not discussed with the parents before labor. In many instances, it is only when the mother is being admitted to the hospital or birth unit that she is first confronted with the decision regarding circumcision. Because the stress of the intrapartal period makes this a difficult time for parental decision making, this is not an ideal time to broach the topic of circumcision and expect a well thought-out decision.
Procedure
Circumcision involves removing the prepuce (foreskin) of the glans. The procedure is not usually done immediately after birth because of the danger of cold stress but is performed in the hospital before the infant’s discharge. The circumcision of a Jewish male is performed on the eighth day after birth and is done at home in a ceremony called a bris, unless the infant is unwell. This is logical from a physiologic standpoint because clotting factors drop somewhat immediately after birth and do not return to prebirth levels until the end of the first week.
Feedings are usually withheld up to 4 hours before the circumcision to prevent vomiting and aspiration. To prepare the infant for the circumcision, he is positioned on a plastic restraint form (Fig. 18) and his penis is cleansed with soap and water or other prep solution such as povidone-iodine. The infant is draped to provide warmth and a sterile field, and the sterile equipment is readied for use.
Fig. 18 “Circ board” restrains infant during circumcision. (Courtesy Marjorie Pyle, RNC, Lifecircle,
Although some circumcision procedures require no special equipment or appliances (Fig. 19), numerous instruments have been designed for this purpose. Use of the Yellen or Mogen clamp (Fig. 20) may make this an almost bloodless operation. The procedure itself takes only a few minutes to perform. After it is completed, a small petrolatum gauze dressing or a generous amount of petrolatum or A and D emollient ointment may be applied to the penis for the first day to prevent the diaper from adhering to the site. A PlastiBell may also be used for the circumcision. The advantages to its use are that it applies constant direct pressure to prevent hemorrhage during the procedure and afterward protects against infection, keeps the site from sticking to the diaper, and prevents pain with urination. When using the bell for circumcision, it is first fitted over the glans, the suture is tied around the rim of the bell, and excess prepuce is cut away. The plastic rim remains in place for approximately 1 week until it falls off, after healing has taken place (Fig. 21). Petrolatum is not needed when the bell is used.
Fig. 19 Technique of circumcision. A to D, Prepuce is stripped and slit to facilitate its retraction behind glans penis. E, Prepuce is now clamped and excessive prepuce cut off. F and G, A very small needle and plain 2-0 or 3-0 catgut are used for suture material; some physicians prefer silk.
Fig. 20 Circumcision with Yellen clamp. A, Prepuce drawn over cone. B, Yellen clamp is applied, hemostasis occurs, and then prepuce (over cone) is cut away.
Fig. 21 Circumcision using Hollister PlastiBell. A, Suture around rim of PlastiBell controls bleeding. B, Plastic rim and suture drop off in 7 to 10 days. (Permission to use and/or reproduce this copyrighted material has been granted by the owner, Hollister, Inc.,
Discomfort
Circumcision is painful; the pain is manifested by both physiologic and behavioral changes in the infant (see discussion that follows). Three types of anesthesia/analgesia are used iewborns who undergo circumcisions. These are (from most effective to less effective) ring block, dorsal penile nerve block (DPNB), and topical anesthetic (Williamson, 1997).
A ring block is the injection of buffered lidocaine administered subcutaneously on each side of the penile shaft. DPNB includes subcutaneous injections of buffered lidocaine at the 2 o’clock and 10 o’clock positions at the base of the penis. The circumcision should not be done for at least 5 minutes after these injections.
A topical cream containing prilocaine-lidocaine such as EMLA (eutectic mixture of local anesthetics) can be applied to the base of the penis at least 1 hour before the circumcision (Taddio, Ohlsson, & Ohlsson, 2001). The area where the prepuce attaches to the glans is well coated with the cream and then covered with a transparent occlusive dressing or finger cot. After the procedure, the cream is removed. Blanching or redness of the skin may occur.
Oral acetaminophen and comfort measures such as the infant sucking on a pacifier and talking to the infant in a soothing voice have not proved to be effective in pain reduction (Williamson, 1997); however, pacifiers dipped in a concentrated glucose solution have been used during the procedure with varying levels of effectiveness.
After the circumcision, the infant is comforted until he is quieted. If the parents were not present during the procedure, the infant is returned to them. The infant may be fussy for several hours and may refuse a feeding.
Care of the newly circumcised infant
The nurse checks the infant hourly for the next 12 hours to make sure that no bleeding is occurring and voiding is normal. If bleeding is noted from the circumcision, the nurse applies gentle pressure to the site of bleeding with a folded sterile gauze pad or sprinkles powdered Gelfoam on it. If bleeding is not easily controlled, a blood vessel may need to be ligated. In this event, one nurse notifies the physician and prepares the necessary equipment (i.e., circumcision tray and suture materials) while another nurse maintains intermittent pressure until the physician arrives. If the parents take the baby home before the end of the 12-hour observation period, they have to be taught the proper home care (see Teaching Guidelines box). Before the infant is discharged, the nurse checks to see that the parents have the physician’s telephone number.
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TEACHING GUIDELINES. Circumcision • Wash hands before touching the newly circumcised penis. CHECK FOR BLEEDING • Check circumcision for bleeding every hour for the first 12 hours after the procedure. • If bleeding occurs, apply gentle pressure with a folded sterile gauze square. If bleeding does not stop with pressure, notify primary health care provider. OBSERVE FOR URINATION • Check to see that the infant urinates after being circumcised. • Infant should have a wet diaper 6 to 10 times per 24 hours. KEEP AREA CLEAN • Change diaper and inspect circumcision at least every 4 hours. • Wash penis gently with warm water to remove urine and feces. Apply petrolatum to the glans with each diaper change (omit petrolatum if PlastiBell was used). • Use soap only after circumcision is healed. • Fanfold diaper to prevent pressure on the circumcised area. CHECK FOR INFECTION • Glans penis is dark red after circumcision, then becomes covered with yellow exudate in 24 hours. This is normal and will persist for 2 to 3 days. Do not attempt to remove it. • Redness, swelling, or discharge indicate infection. Notify primary health care provider if you think the circumcision area is infected. PROVIDE COMFORT • Circumcision is painful. Handle the area gently. • Provide extra holding, feeding, and opportunities for nonnutritive sucking for a day or two |
Nursing actions are planned and implemented to prevent infection. Prepackaged wipes for cleaning the diaper area should not be used because they contain alcohol, which delays healing and causes discomfort. Instead, the nurse washes the penis gently with water to remove urine and feces and, if necessary, applies fresh petrolatum around the glans after each diaper change. The glans penis, normally dark red during healing, becomes covered with a yellow exudate in 24 hours. This is part of normal healing, not an infective process; no attempt should be made to remove the exudate, which persists for 2 to 3 days. Parents should be taught to fan-fold the diaper so that it does not press on the circumcised area. They should be encouraged to change the diaper at least every 4 hours to prevent it from sticking to the penis.
PAIN IN NEONATES
Pain has physiologic and psychologic components. The psychologic component of pain and the diffuse total body response to pain exhibited by the neonate led many health care providers to believe that infants, especially preterm infants, do not experience pain. However, the central nervous system is well developed as early as 24 weeks of gestation. The peripheral and spinal structures that transmits pain information are present and functional between the first and second trimester. The pituitary-adrenal axis is also well developed at this time, and a fight-or-flight reaction is observed in response to the catecholamines released in response to stress (
The physiologic response to pain in the neonate can be life threatening. Pain response can decrease tidal volume, increase demands on the cardiovascular system, increase metabolism, and cause neuroendocrine imbalance. The hormonal-metabolic response to pain in a term infant has a greater magnitude and shorter duration than in adults. The newborn’s sympathetic response to pain is less mature and thus less predictable than an adult’s (Franck & Gregory, 1993).
ASSESSMENT
Pain can be assessed in behavioral, physiologic/autonomic, and metabolic categories (Franck & Gregory, 1993).
Behavioral responses
The most common behavioral sign of pain is a vocalization or cry. The pain cry is distinctive: high pitched and shrill. A cry face is characteristic for an infant experiencing pain. Other facial features exhibited during a pain stimulus include eye squeeze, brow contraction, deepened nasolabial furrows, taut and quivering tongue, and open mouth. The infant will flex and adduct the upper body and lower limbs in an attempt to withdraw from the painful stimulus (Anand, Gruneau, & Oberlander, 1997; Hadjistavropoulos et al., 1997). The preterm infant has a lower threshold for initiation of this flex response. An infant who receives a muscle-paralyzing agent such as vecuronium will be unable to mount a behavioral or visible pain response.
Physiologic/autonomic responses
Significant changes in heart rate, blood pressure (increased or decreased), intracranial pressure, vagal tone, respiratory rate, and oxygen saturation occur during noxious stimulation (Franck & Gregory, 1993; Lynam, 1995).
Metabolic responses
Infants release epinephrine, norepinephrine, glucagon, corticosterone, cortisol, 11-deoxycorticosterone, lactate, pyruvate, and glucose in response to pain (Franck & Gregory, 1993; Lynam, 1995).
Several pain assessment tools have been developed for the assessment of pain in the neonate. One pain assessment tool used by nurses in the neonatal intensive care unit is the CRIES (Table 4). This tool was developed for use by nurses who work with preterm and term infants. CRIES is an acronym for the physiologic and behavioral indicators of pain used in the tool: crying, requiring increased oxygen, increased vital signs, expression, and sleeplessness. Each indicator is scored from 0 to 2. The total possible pain score, which represents the worst pain, is 10. A pain score greater than 4 should be considered significant. This tool can be used on infants between ages 32 weeks of gestation and 20 weeks after birth (Bildner & Krechel, 1996; Krechel & Bildner, 1995).
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TABLE 4. CRIES Neonatal Postoperative Pain Scale |
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0 |
1 |
2 |
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Crying Requires 02 for saturation >95% Increased vital signs
Expression Sleepless |
No
No Heart rate and blood pressure equal or less than preoperative state None No |
High pitched
<30% Heart rate and blood pressure <20% of preoperative state Grimace Wakes at frequent intervals |
Inconsolable
>30% Heart rate and blood pressure >20% of preoperative state Grimace/grunt Constantly awake |
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CODING TIPS FOR USING CRIES |
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Crying |
The characteristic cry of pain is high pitched. If no cry or cry that is not high pitched, score 0 If cry high pitched but infant is easily consoled, score 1 If cry is high pitched and infant is inconsolable, score 2 |
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Requires 02 for saturation >95% |
Look for changes in oxygenation. Infants experiencing pain manifest decreases in oxygenation as measured by tCO2 or oxygen saturation. (Consider other causes of changes in oxygenation, such as atelectasis, pneumothorax, oversedation.) If no oxygen is required, score 0. If <30% O2 is required, score 1. If >30% O2 is required, score 2. |
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Increased vital signs |
Note: measure blood pressure last because this may wake child, causing difficulty with other assessments. Use baseline preoperative parameters from a nonstressed period. Multiply baseline HR x 0.2, then add this to baseline HR to determine the HR that is 20% over baseline. Do likewise for BR Use mean BP. If HR and BP are both unchanged or less than baseline, score 0. If HR or BP is increased but increase is <20% of baseline, score 1. If either one is increased >20% over baseline, score 2. |
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Expression |
The facial expression most often associated with pain is a grimace. This may be characterized by brow lowering, eyes squeezed shut, deepening of, the nasolabial furrow, open lips and mouth. If no grimace is present, score 0. If grimace alone is present, score 1. If grimace and noncry vocalization grunt is present, score 2. |
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Sleepless |
This parameter is scored based on the infant’s state during the hour preceding this recorded score. If the child has been continuously asleep, score 0. If he/she has awakened at frequent intervals, score 1. If he/she has been awake constantly, score 2. |
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MANAGEMENT OF NEONATAL PAIN
The goals of management of neonatal pain are to (1) minimize intensity, duration, and physiologic cost of the pain and (2) maximize the neonate’s ability to cope and recover from the pain (Franck & Gregory, 1993). Nonpharmacologic and pharmacologic strategies are used.
Nonpharmacologic management
Containment, also known as swaddling, is effective in reducing excessive, immature motor responses. This may provide comfort through other senses such as thermal, tactile, and proprioceptive senses (Franck & Gregory, 1993; Lynam, 1995). Nonnutritive sucking (NNS) is the most common comfort measure used. However, the effectiveness of NNS on the pain response is limited and confined to the pain caused by certain procedures (Lynam, 1995; Mohan et al., 1998). Sucrose is effective in reducing response to procedural pain (Stevens & Ohlsson, 2001). Distraction with visual, oral, auditory, or tactile stimulation may be helpful in term or older infants (Franck & Gregory, 1993). Skin-to-skin contact with the mother during painful procedures reduces the pain reaction (Gibbins, 2000).
Pharmacologic management
Pharmacologic agents are routinely used for adults during painful procedures. These same agents are now being routinely used for neonates to alleviate pain with procedures. Local anesthesia has become routine during certain invasive procedures such as chest tube insertion and may be used for circumcision. Topical anesthesia has been used for circumcision, lumbar puncture, venipuncture, and heel sticks (Franck, 1998; Mohan et al., 1998). Opioids have been used as preprocedural analgesia. If the infant is not ventilated, the use of opioids is of concern because of the potential for these agents to cause respiratory depression (Franck, 1998; Franck & Gregory, 1993).
DISCHARGE PLANNING AND TEACHING
Infant care activities can cause much anxiety for the new parent (see Plan of Care). Support from nursing staff members can be an important factor in determining whether new mothers seek and accept help in the future.
Whether this is the woman’s or couple’s first baby or an adolescent whose mother will be the primary caregiver, or whether they attended parenthood preparation classes, parents appreciate anticipatory guidance in the care of their infant. The nurse should not try to cover all the content at one time because the parents can be overwhelmed by too much information and become anxious. However, because of the early discharge of new mothers that is currently common practice, it may be a problem for the nurse to teach all the content that is necessary. As a result, many institutions have developed home visitation programs that take the necessary teaching to the new parents, although the hospital or birth center nurse still provides most of the essential information for newborn care.
To set priorities for teaching, the nurse follows parental cues. Knowledge deficits should be identified before beginning to teach. Normal growth and development and the changing needs of the infant (e.g., for stimulation, exercise, social contacts), as well as the following topics, should be included during discharge planning with parents.
PLAN OF CARE The
NURSING DIAGNOSIS Risk for ineffective airway clearance related to excess mucus production/Improper positioning
Expected Outcome Neonate’s airway remains patent; breath sounds are clear and no respiratory distress is evident.
Nursing Interventions/Rat/ona/es
Suction mouth and nasopharynx with bulb syringe as needed; cleaares of crusted secretions to clear airway and prevent aspiration and airway obstruction.
Position neonate on right side after feeding to prevent aspiration and on back or side when sleeping to prevent suffocation.
Teach parents that gagging, coughing, and sneezing are normal neonatal responses that assist the neonate in clearing airways.
Teach parents how to hold, suction, feed, and position the neonate with return demonstration to ensure parental skill at airway clearance and maintenance.
NURSING DIAGNOSIS Risk for imbalanced body temperature related to larger body surface in relationship to mass
Expected Outcome Neonate temperature remains in range of 36.5° C to 37.2° C.
Nursing Interventions/Rat/ona/es
Maintain neutral thermal environment to identify any changes ieonate’s temperature that may be related to other causes.
Monitor neonate’s temperature often to identify any changes promptly and ensure early interventions.
Bathe neonate efficiently when temperature is stable, using warm water, drying carefully, and avoiding exposing neonate to drafts to avoid losses from evaporation and convection.
Report any alterations in temperature findings promptly to assess and treat for possible infection.
NURSING DIAGNOSIS Risk for infection related to immature immunologic defenses/environmental exposure
Expected Outcome The neonate will be free from signs of infection.
Nursing Interventions/Rationales
Review maternal record for evidence of any risk factors to ascertain whether the neonate may be predisposed to infection.
Monitor vital signs to identify early possible evidence of infection, especially temperature instability.
Have all care providers, including parents, practice good handwashing techniques before handling newborn to prevent spread of infection.
Monitor and instruct parents to monitor visitors and personnel for evidence of infection and limit contact as needed to prevent spread of infection.
Keep genital area clean and dry using proper cleansing techniques to prevent skin irritation, cross-contamination, and infection.
Keep umbilical stump clean and dry and keep exposed to air to allow to dry and minimize chance of infection.
If circumcised, keep site clean and dressed with prescribed ointment and diaper applied loosely to prevent trauma and infection and to promote healing.
Teach parents to keep neonate away from crowds and environmental irritants to reduce potential sources of infection.
NURSING DIAGNOSIS Risk for injury related to sole dependence on caregiver
Expected Outcome Neonate remains free of injury.
Nursing Interventions/ Rationales
Monitor environment for hazards such as sharp objects, long fingernails of caretaker and neonate, and jewelry of caretaker that may be sharp to prevent injury.
Handle neonate gently and support head, transport only in crib, ensure use of car seat by parents, teach parents never to place neonate on high surface unsupervised, and to supervise pet and sibling interactions to prevent injury.
Assess neonate often for any evidence of jaundice to identify rising bilirubin levels, treat promptly, and prevent kernicterus.
NURSING DIAGNOSIS Readiness for enhanced family coping related to anticipatory guidance regarding responses to neonate’s crying
Expected Outcome Parents will verbalize understanding of methods of coping with neonate’s crying and describe increased success in interpreting neonate’s cries.
Nursing Interventions/ Rationales
Alert parents to crying as neonate’s form of communication and that cries can be differentiated to indicate hunger, wetness, pain, and loneliness to provide reassurance that crying is not indicative of neonate’s rejection of parents and that parents will learn to interpret different cries.
Differentiate self-consoling behaviors from fussing/crying to give parents concrete examples of interventions.
Discuss methods of consoling a neonate such as changing diapers; showing parent’s face to neonate; talking softly to neonate; swaddling; rocking; using a pacifier, feeding, or burping; or going for a car ride to provide anticipatory guidanceю
TEMPERATURE
The following topics should be reviewed:
• The causes of elevation in body temperature (e.g., overwrapping, cold stress with resultant vasoconstriction, or minimum response to infection) and the body’s response to extremes in environmental temperature
• Signs to be reported, such as high or low temperatures with accompanying fussiness, stuffy nose, lethargy, irritability, poor feeding, and crying
• Ways to promote normal body temperature, such as giving a tepid tub bath, dressing the infant appropriately for the air temperature, and protecting the infant from long exposure to sunlight
• Use of warm wraps or extra blankets in cold weather
• Technique for taking the baby’s axillary temperature
RESPIRATIONS
Review the following points:
• Normal variations in the rate and rhythm.
• Reflexes such as sneezing to clear the air passage.
• Need to protect the infant from the following:
-People with upper respiratory tract infections
-Pollution from a smoke-filled environment (secondhand smoke)
-Suffocation from loose bedding, water beds, and beanbag chairs; drowning (in bath water); entrapment under excessive bedding; anything tied around the infant’s neck; poorly constructed playpens, bassinets, or cribs
• Sleep position—on side or back when put to sleep.
• Aspiration pneumonia. A commonly aspirated substance is baby powder, which usually is a mixture of talc (hydrous magnesium silicate) and other silicates. Parents are advised that, if they prefer to use a powder, a cornstarch preparation can be substituted. Whenever a powder is used, it should be placed in the caregiver’s hand and then applied to the skin, never sprinkled directly onto the skin.
• Symptoms of the common cold: nasal congestion, coughing, sneezing, difficulty in swallowing or breathing, low-grade fever. Advise the parents on measures to help the infant:
-Feeding smaller amounts more frequently to prevent overtiring the infant
-Holding the baby in an upright position to feed
-For sleeping, raising the infant’s head and chest by raising the mattress 30 degrees (do not use pillow)
-Avoiding drafts; not overdressing the baby
-Using only medications prescribed by a physician
-Covering the upper lip with a light film of petrolatum to minimize excoriation from nasal secretions
FEEDING SCHEDULES
Feeding practices and schedules for newborns are discussed in Chapter 20.
ELIMINATION
A review includes the following reminders:
• Changes to be expected in the color of the stool (meconium to transitional to soft yellow/golden yellow) and the number of bowel evacuations, plus the odor of stools for breastfed or bottle-fed infants
• Color of normal urine and number of voidings (6 to 10) to expect each day
POSITIONING AND HOLDING
Positioning the infant on the right side after feeding promotes gastric emptying into the small intestine (see Fig. 2). Placing the infant in the crib in a side-lying position also promotes drainage of mucus from the mouth and applies no pressure to the cord or the sensitive circumcised penis. The
Anatomically, the infant’s shape—a barrel chest and flat, curveless spine—makes it easy for the child to roll and startle. The placement of a folded or rolled blanket against the infant’s spine will prevent rolling to the supine position and promote a feeling of security. Care must be taken to prevent the infant from rolling off flat, unguarded surfaces. When an infant is on such a surface, the parent or nurse who must turn away from the infant even for a moment should always keep one hand placed securely on the infant.
The infant is always held securely with its head supported because newborns are unable to maintain an erect head posture for more than a few moments. Fig. 22 illustrates various positions for holding an infant with adequate support.
Fig. 22 Holding baby securely with support for head. A, Holding infant while moving infant from one place to another. Baby is undressed to show posture. B, Holding baby upright in “burping” position. C, “Football” hold. D, Cradling hold. (A, Courtesy Kim Molloy,
RASHES
Diaper rash
The warm, moist atmosphere created in the diaper area provides an optimal environment for candidal growth; dermatitis appears in the perianal area, inguinal folds, and lower abdomen. The affected area is intensely erythematous with a sharply demarcated, scalloped edge, often with numerous satellite lesions that extend beyond the larger legion. The usual source of infection is through the gastrointestinal tract when organisms are swallowed from the birth canal during delivery. It may also appear 2 to 3 days after an oral infection.
Therapy consists of applications of an anticandidal ointment, such as nystatin or clotrimazole, with each diaper change. Sometimes the infant also is given an oral antifungal preparation to eliminate any gastrointestinal source of infection.
Washing and drying the wet and soiled area and changing the diaper immediately after voiding or stooling will prevent and help treat diaper rash. Parents can be taught that placing the infant in a warm room with the buttocks exposed to air or even filtered sunlight can help dry up diaper rash. Warmth can also be achieved with a 25-watt bulb placed 45 cm from the affected area for brief periods (15 minutes) several times a day. Disposable diapers and plastic pants should be avoided until healing occurs.
Other rashes
A rash on the face may result from the infant’s scratching (excoriation) or from rubbing the face against the sheets, particularly if regurgitated stomach contents are not washed off promptly. Newborn rash, erythema toxicum, is a common finding.
CLOTHING
Parents commonly ask how warmly they should dress their infant. A simple rule of thumb is to dress the child as they dress themselves, adding or subtracting clothes and wraps for the child as necessary. A shirt or diaper may be sufficient clothing for the young infant. A cap or bonnet is needed to protect the scalp and minimize heat loss if the weather is cool or to protect against sunburn and shade the eyes if it is sunny and hot. Wrapping the infant snugly in a blanket maintains body temperature and promotes a feeling of security. Overdressing in warm temperatures can cause discomfort, as can underdressing in cold weather.
SAFETY: USE OF CAR SEAT
Infants should travel only in federally approved rear-facing safety seats secured in the rear seat (Fig. 23). The safest area of the car is in the back seat. A car seat that faces the rear gives the best protection for the disproportionately weak neck and heavy head of an infant. In this position, the force of a frontal crash is spread over the head, neck, and back; the back of the car seat supports the spine.
Fig. 23 Rear-facing infant seat in rear seat of car. Infant is placed in seat when going home from hospital. (Courtesy Marjorie Pyle, RNC, Lifecircle,
NURSE ALERT Infants should use a rear-facing car seat from birth to 20 pounds and to 7 year of age
The car seat is secured using the vehicle seat belt; the infant is secured using the harness system in the car seat. If the infant must ride in the front seat, the air bag must be turned off to prevent injury from the air bag.
NURSE ALERT In cars equipped with air bags, rea facing infant seats must not be placed in the front seat. Serious injury can occur if the air bag inflates because these types of infant seats fit closer to the dashboard (Fig. 24).
Fig. 24 An air bag could strike a child safety seat, causing serious injury to the child. (Redrawn from Health Alert. [1994]. AAP News, 10[4], 22.)
Infants less than 37 weeks of gestation should be observed in a car seat for a period of time before discharge. The infant is monitored for apnea, bradycardia, and a decrease in SaO2. It may be necessary to place blanket rolls on either side of the infant for support of the head and trunk. To prevent slumping, the back-tocrotch strap distance should be 14 cm. If necessary, a rolled blanket can be placed between the infant and the crotch strap.
NONNUTRITIVE SUCKING
Sucking is the infant’s chief pleasure. However, sucking needs may not be satisfied by breastfeeding or bottle-feeding alone. Sucking is such a strong need that infants who are deprived of sucking, such as those with a cleft lip, will suck on their tongues. Some newborns are born with sucking pads on their fingers that developed during in utero sucking. Several benefits of nonnutritive sucking have been demonstrated, such as an increased weight gain in premature infants, decreased crying, and decreased length of hospital stay (Pinelli & Symington, 2001).
Problems arise when parents are concerned about the sucking of fingers, thumb, or pacifier and try to restrain this natural tendency. Before giving advice, nurses should investigate the parents’ feelings and base the guidance they give on the information elicited. For example, some parents may see no problem with the use of a finger but may find the use of a pacifier objectionable. In general, there is no need to restrain either practice, unless thumb sucking persists past 4 years of age or past the time when the permanent teeth erupt. Parents are advised to consult with their pediatrician and pediatric nurse practitioner about this topic.
To decrease an infant’s dependence oonnutritive sucking, the feeding time can be prolonged. One way of doing this is to use a small-holed, firm nipple because this necessitates stronger sucking and slows the feeding. A parent’s excessive use of the pacifier to calm the child should also be explored, however. It is not unusual for parents to place a pacifier in their infant’s mouth as soon as the infant begins to cry, thus reinforcing a distressrelief pattern.
If parents choose to let their child use a pacifier, they need to be aware of certain safety considerations before purchasing one. A homemade or poorly designed pacifier can be dangerous because the entire object may be aspirated if it is small or a portion may become lodged in the pharynx. Improvised pacifiers, such as those commonly made in hospitals from a padded nipple, also pose dangers because the nipple may separate from the plastic collar and be aspirated. Safe pacifiers are made of one piece that includes a shield or flange that is large enough to prevent entry into the mouth and a handle that can be grasped (Fig. 25).
Fig. 25 Design of safe pacifier. (From Wong, D. [1999]. Whaley & Wong’s nursing care of infants and children [6th ed.].
SPONGE BATHING, CORD CARE, AND SKIN CARE
Bathing serves a number of purposes. It provides opportunities for (1) completely cleansing the infant (see Research box), (2) observing the infant’s condition, (3) promoting comfort, and (4) parent-child-family socializing. Although the sponging technique is generally used (Fig. 26), bathing the newborn by immersion has been found to allow less heat loss and provoke less crying but is not advised until the umbilical cord falls off.
Fig. 26
The umbilical cord begins to dry, shrivel, and blacken by the second or third day of life. The umbilicus should be inspected frequently for signs of infection (e.g., foul odor, redness, purulent discharge), granuloma (i.e., small, red, raw-appearing polyp where the umbilical cord separates), bleeding, and discharge. The cord clamp is removed when the cord is dry, in approximately 24 hours (see Fig. 6). The cord normally falls off approximately 10 to 14 days after birth.
In the hospital the umbilicus may be cleansed with alcohol or other designated solution with each assessment and with diaper changes if the cord is moist. However, natural drying is as effective, with no increase in infection rate (Dore et al., 1998).
The Teaching Guidelines box contains information regarding sponge bathing, skin care, cord care, cutting nails, and dressing the infant.
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TEACHING GUIDELINES. Sponge Bathing FITTING BATHS INTO FAMILY’S SCHEDULE Give a bath at any time convenient to you but not immediately after a feeding period because the increased handling may cause regurgitation. PREVENTING HEAT LOSS The temperature of the room should be 24° C (75° F), and the bathing area should be free of drafts. Control heat loss during the bath to conserve the infant’s energy. Bathing the infant quickly, exposing only a portion of the body at a time, and thorough drying are all parts of the bathing technique. GATHERING SUPPLIES AND CLOTHING BEFORE STARTING Clothing suitable for wearing indoors: diaper, shirt; stretch suit or nightgown optional Unscented, mild soap Pins, if needed for diaper, closed and placed well out of baby’s reach Cotton balls Towels for drying infant and a clean washcloth Receiving blanket Tub for water or use a sink BATHING THE BABY Bring infant to bathing area when all supplies are ready. Never leave the infant alone on bath table or in bath water, not even for a second! If you have to leave, take the infant with you or put back into crib. Test temperature of the water. It should feel pleasantly warm to the inner wrist, 36.6° to 37.2° C (98° to 99° F). Do not hold infant under running water—water temperature may change, and infant may be scalded or chilled rapidly. Wash infant’s head before unwrapping and undressing to prevent heat loss. Cleanse the eyes from the inner canthus outward, using separate parts of a clean washcloth for each eye. For the first 2 to 3 days there may be a discharge resulting from the reaction of the conjunctiva to the substance (erythromycin) used as a prophylactic measure against infection. Any discharge should be considered abnormal and reported to the health care provider. Wash the scalp with water and mild soap; rinse well and dry thoroughly (Fig. 19-26). Scalp desquamation, called cradle cap, often can be prevented by removing any scales with a fine-toothed comb or brush after washing. If condition persists, the health care provider may prescribe an ointment to massage into the scalp. Creases under the chin and arms and in the groin may need daily cleansing. The crease under the chin may be exposed by elevating the infant’s shoulders 5 cm and letting the head drop back. Cleanse ears and nose with twists of moistened cotton or a corner of the washcloth. Do not use cotton-tipped swabs because they may cause injury. Undress baby and wash body and arms and legs. Pat dry gently. Baby may be tub bathed after the cord drops off and umbilicus and circumcised penis are completely healed. PREVENTING SKIN TRAUMA The fragile skin can be injured by too vigorous cleansing. If stool or other debris has dried and caked on the skin, soak the area to remove it. Do not attempt to rub it off, because abrasion may result. Gentleness, patting dry rather than rubbing, and use of a mild soap without perfumes or coloring are recommended. Chemicals in the coloring and perfume can cause rashes on sensitive skin. CARE OF THE CORD Use a cotton swab. Dip swab in solution the health care provider has ordered and cleanse around base of the cord where it joins the skin. Notify the health care provider of any odor, discharge, or skin inflammation around the cord. The clamp is removed when the cord is dry (approximately 24 hours). The diaper should not cover the cord because a wet or soiled diaper will slow or prevent drying of the cord and foster infection. When the cord drops off after a week to 10 days, small drops of blood may be seen when the baby cries. This will heal by itself. It is not dangerous. CARE OF HANDS AND FEET Wash and dry between the fingers and toes. Do not cut fingernails and toenails immediately after birth. The nails have to grow out far enough from the skin so that the skin is not cut by mistake. If the baby scratches himself or herself, apply loosely fitted mitts over each of the baby’s hands. Do so as a last resort, however, because it interferes with the baby’s ability for self-consolation sucking on thumb or finger. When the nails have grown, the fingernails and toenails can be cut more easily with manicure scissors (preferably scissors with rounded tips) when the infant is asleep. Nails should be kept short. CLEANSING GENITALS Cleanse the genitals of infants daily and after voiding or defecating. For girls, the genitals may be cleansed by separating the labia and gently washing from the pubic area to the anus. For uncircumcised boys, gently pull back (retract) the foreskin. Stop when resistance is felt. Wash and rinse the tip (glans) with soap and warm water and replace the foreskin. The foreskin must be returned to its original position to prevent constriction and swelling. In most newborns the inner layer of the foreskin adheres to the glans and the foreskin cannot be retracted. By the age of 3 years in 90% of boys, the foreskin can be retracted easily without causing pain or trauma. For others, the foreskin is not retractable until adolescence. As soon as the foreskin is partly retractable and the child is old enough, he can be taught self-care. Once healed, the circumcised penis does not require any special care other than cleansing with diaper changes. |
INFANT FOLLOW-UP CARE
With shorter hospital stays, the focus and site of infant care is changing. Home care may be provided either by a nurse as part of the follow-up of patients, or through a visiting nurse or community health nurse referral service. For infants discharged early, newborn home care is essential (see Teaching Guidelines box). Parents should plan for their infant’s health follow-up care at the following ages: 2 to 4 weeks of age, then every 2 months until 6 to 7 months of age, then every 3 months until 18 months, at 2 years, at 3 years, at preschool, and every 2 years thereafter.
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TEACHING GUIDELINES. Newborn Home Care Following Early Discharge Wet diapers: 6 to 10 per day Breastfeeding: Successful latch-on and feeding every 1V2 to 3 hr daily Formula feeding: Successfully, voiding as noted above, taking 3 to 4 oz every 3 to 4 hr daily Circumcision: Stools: At least one every 48 hr (bottle-feeding) or two to three per day (breastfeeding) Color: Pink to ruddy when crying; pink centrally when at rest or asleep Activity: Has four to five wakeful periods per day and alerts to environmental sounds and voices. Jaundice: Physiologic jaundice (not appearing in first 24 hr), feeding, voiding, and stooling as noted above or practitioner notification for suspicion of pathologic jaundice (appears within 24 hr of birth, ABO/Rh problem suspected); decreased activity; poor feeding; dark orange skin color persisting beyond fifth day in lightskinned newborn Cord: Kept above diaper line; nonodorous; drying Vital signs: Heart rate 120 to 140 beats/min at rest; respiratory rate 30 to 55 at rest without evidence of sternal retractions, grunting, or nasal flaring; temperature 36.5° to 37.2° C (97.3° to 98.6° F) axillary Position of sleep: Back |
Immunizations
The schedule for immunizations should be reviewed with the parents. Hepatitis B vaccine is currently administered to newborns before hospital discharge with parental permission. An infant’s ability to protect himself or herself against antigens by the formation of antibodies develops sequentially; therefore the infant must be developmentally capable of responding to these antibodies. This is the reason for planning sequential immunizations for infants.
A form of passive immunity is already present in colostrum and breast milk. However, these antibodies are specific for microbes present in the mother’s gastrointestinal tract and protect against overgrowth as fresh colonization occurs in the newborn.
The active ingredients in immunizations for diphtheria-pertussis-tetanus, hepatitis B, rubella, measles, and mumps, as well as the oral poliovirus vaccine, do not appear to be altered by breast milk and should be given according to the regular recommended schedule (
Recognizing signs of illness
As well as explaining the need for well-baby follow-up visits, the nurse should discuss with parents the signs of illness iewborns. Parents should be advised to call their nurse practitioner or pediatrician immediately if they notice such signs and to ask about over-the-counter medications, such as Tylenol for infants, to keep at home (see Plan of Care).
EVALUATION
The nurse can be reasonably assured that care was effective to the extent that the expected outcomes for care have been achieved.
NEWBORN NUTRITION AND FEEDING
Good nutrition in infancy fosters optimal growth and development. Infant feeding is more than the provision of nutrition; it represents opportunity for social and psychologic interactions between parent and infant. It can also establish a basis for developing good eating habits that last a lifetime. Health supervision of infants requires knowledge of their nutritional needs. This chapter focuses on meeting nutritional needs for normal growth and development from birth to 6 months of age, with emphasis on the neonatal period when feeding practices and patterns are being established. Both breastfeeding and formula feeding are addressed.
RECOMMENDED INFANT NUTRITION
The
NUTRIENT NEEDS
ENERGY (CALORIES OR KCAL)
Infants require adequate caloric intake to provide energy for growth, digestion, physical activity, and maintenance of the metabolic function of organs. For the first 3 months, the infant needs 110 kcal/kg/day. From 3 months to 6 months, the requirement is 100 kcal/kg/day. This decreases slightly to 95 kcal/kg/day from 6 to 9 months and increases to 100 kcal/kg/day from 9 months to 1 year (AAP, 1998).
Human milk provides approximately 67 kcal/100 ml or 20 kcal/oz; the greatest amount of energy is provided by the fat content of breast milk. Infant formulas are made to simulate the caloric content of human milk; standard formulas contain 20 kcal/oz, and differences in composition vary among brands (Darby & Loughead, 1996).
CARBOHYDRATE
Because newborns have only small hepatic glycogen stores, carbohydrates should provide at least 40% to 45% of the total calories in the diet. Moreover, newborns may have limited ability for gluconeogenesis (formation of glucose from amino acids and other substrates) and ketogenesis (formation of ketone bodies from fat), which are mechanisms that provide alternative energy sources.
As the primary carbohydrate in human milk, lactose is the most abundant carbohydrate in the diet of infants up to 6 months of age. Lactose provides calories in an easily available form; its slow breakdown and absorption probably also increase calcium absorption. Corn syrup solids or glucose polymers are added to infant formulas to supplement the lactose in the cow’s milk and provide sufficient carbohydrates.
PROTEIN
The protein requirement per unit of body weight is greater in the newborn than at any other time of life. The recommended daily allowance for protein during the first 6 months is 2.2 g/kg.
The protein content of human milk, lower than that of unmodified cow’s milk, is ideal for the newborn. Human milk contains far more lactalbumin in relation to casein than does cow’s milk, and lactalbumin is more easily digested than casein. In addition, the amino acid composition of human milk is suited to the newborn’s metabolic capabilities. For example, phenylalanine and methionine levels are low, and cystine and taurine levels are high. The protein in some commercial formulas is modified to increase the amount of lactalbumin (i.e., whey protein) and to decrease the relative proportion of casein to more closely approximate human milk.
FAT
For infants to acquire adequate calories from the limited amount of human milk or formula they are able to consume, at least 15% of the calories provided must come from fat (triglycerides). The fat must be easily digestible. Fat in human milk is easier to digest and absorb than that in cow’s milk because of the arrangement of the fatty acids on the glycerol molecule and because of the presence of the enzyme lipase.
Cow’s milk is used in most infant formulas, but the milk fat is removed and replaced by another fat source, such as corn oil, that can be digested and absorbed by the infant. If whole milk or evaporated milk without added carbohydrate is fed to infants, the resulting fecal loss of fat (and therefore loss of energy) may be excessive because the milk moves through the infant’s intestines too quickly for adequate absorption to take place. This can lead to poor weight gain.
In addition to its energy contributions, fat also furnishes essential fatty acids (EFAs), which are required for growth and tissue maintenance. EFAs are components of cell membranes and precursors of some hormones. Inadequate intake of EFAs results in eczema and growth failure. The lack of EFAs in skim and low-fat milk is another reason infants should not be fed these products.
FLUIDS
The fluid requirement for normal infants is approximately 80 to 100 ml of water per kilogram of body weight per 24 hours (Behrman, Kliegman, & Arvin, 1996). In general, neither breastfed nor formula-fed infants need to be fed water, not even those living in very hot climates. Breast milk contains 87% water, which easily meets fluid requirements. Feeding water to infants may only decrease caloric consumption at a time when infants are growing rapidly.
Infants have room for little fluctuation in fluid balance and should be monitored closely for fluid intake and water loss. Infants lose water through excretion of urine and through insensible losses such as respiration. Under normal circumstances, infants are born with some fluid reserve, and some of the weight loss during the first few days is related to loss of this fluid.
VITAMINS
Human milk contains all the vitamins required for infant nutrition, with individual variations based on maternal diet and genetic differences. Vitamins are added to cow’s milk formulas to approximate the levels in breast milk. Although cow’s milk contains adequate amounts of vitamin A and vitamin B complex, vitamin C (ascorbic acid) and vitamin E must be added.
Vitamin D is also added to commercial infant formulas. Although human milk may be somewhat deficient in vitamin D, supplementation may not be necessary provided that the infant is exposed to sunlight for 30 minutes per week wearing only a diaper, or for 2 hours per week fully clothed but without a hat. To prevent rickets, supplementation may be recommended for preterm infants and darkskinned infants with limited exposure to the sun, as well as infants whose mothers eat vegetarian diets that exclude meat, fish, and dairy products.
Vitamin K, required for blood coagulation, is produced by intestinal bacteria. However, the gut is sterile at birth, and a few days are needed for intestinal flora to become established and produce vitamin K. To prevent hemorrhagic problems in the newborn, an injection of vitamin K is routinely given at birth.
MINERALS
The mineral content of commercial infant formula is designed to reflect that of breast milk. Unmodified cow’s milk is much higher in mineral content than human milk, which makes it unsuitable for infants in the first year of life. Minerals are typically highest in human milk during the first few days after birth and decrease slightly throughout lactation.
The ratio of calcium to phosphorus in human milk is 2:1, a proportion optimal for bone mineralization. Although cow’s milk is high in calcium, the calcium-to-phosphorus ratio is low, resulting in decreased absorption. Consequently, young infants fed unmodified cow’s milk are at risk for hypocalcemia, tetany, and seizures. The calcium-to-phosphorus ratio in commercial infant formulas is between that of human and cow’s milk.
Milk of all types is low in iron; however, iron from human milk is better absorbed than that from cow’s milk, iron-fortified formula, or infant cereals. Breastfed infants benefit from the high lactose and vitamin C levels in human milk, which facilitate iron absorption. The infant who is totally breastfed normally maintains adequate hemoglobin levels for the first 6 months of life. After that time, iron-fortified cereals and other iron-rich foods are added to the diet. Infants weaned from the breast before 6 months of age and all formula-fed infants should receive an iron-fortified commercial infant formula until 12 months of age.
The fluoride levels in human milk and commercial formulas are low. This mineral, which is important in the prevention of dental caries, may cause spotting of the permanent teeth (fluorosis) in excess amounts. It is recommended that a fluoride supplement be given only to those infants not receiving fluoridated water after 6 months of age (
FEEDING READINESS
Term neonates are born with reflexes that facilitate feeding: the rooting reflex, sucking, and swallowing. Healthy newborns have experience with sucking on fingers and swallowing amniotic fluid for several weeks in utero but have made no connection between sucking and satiation. Although the majority of newborns do not experience hunger or thirst in the first hours after birth, they will suckle when given the opportunity.
Signs that the newborn is physiologically ready to begin feeding include the following:
• Vital signs withiormal limits
• Unlabored respirations; nares patent; no cyanosis
• Active bowel sounds
• No abdominal distention
When newborns experience hunger, they usually cry vigorously until their needs are met. Some infants, however, will withdraw into sleep because of discomfort associated with hunger. Babies exhibit feeding-readiness cues that can be recognized by a knowledgeable caregiver. Instead of waiting to feed until the infant is crying distraughtly or withdraws into sleep, it is better to begin a feeding when the baby exhibits some of these cues (even during light sleep):
• Hand-to-mouth or hand-to-hand movements
• Sucking motions
• Rooting
• Mouthing
Babies normally consume small amounts of milk during the first 3 days of life. The breastfed infant receives colostrum, which is concentrated and high in protein. Similarly, bottle-fed infants initially require small feedings. However, as the infant adjusts to extrauterine life and the digestive tract is cleared of meconium, milk intake increases.
At birth and for several months thereafter, all of the secretions of the infant’s digestive tract contain enzymes especially suited to the digestion of human milk. The ability to digest foods other than milk depends on the physiologic development of the infant. The capacities for salivary, gastric, pancreatic, and intestinal digestion increase with age, indicating that the natural time to introduce solid foods may be around 6 months of age.
Babies are born with a tongue extrusion reflex that causes them to push out of the mouth anything placed on the tongue. This reflex disappears by 6 months-another indication of physiologic readiness for solids.
Early introduction of solids may make the infant more prone to food allergies. Regular feeding of solids can lead to decreased intake of breast milk or formula and may be associated with early cessation of breastfeeding.
CHOOSING AN INFANT FEEDING METHOD
Women who elect to breastfeed usually do so because they are aware of the benefits to the infant. Many are seeking the unique bonding experience between mother and infant that is characteristic of breastfeeding. The support of her partner and family is a major factor in the mother’s decision to breastfeed and in her ability to do so successfully. Prenatal preparation ideally includes the father of the baby, providing information about the benefits of breastfeeding and how he can participate in infant care and nurturing (Bar-Yam & Darby, 1997).
Prenatal breastfeeding classes are an excellent vehicle to relay important information to expectant parents. Each encounter with an expectant mother is an opportunity to dispel myths, clarify misinformation, and address personal concerns. Connecting expectant mothers with women who are breastfeeding or who have successfully breastfed and are from similar backgrounds may be helpful. Peer counseling programs, such as those instituted by the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), are beneficial, particularly in low socioeconomic groups where bottle-feeding is common (Arlotti et al., 1998). To provide effective support for the mother, health care professionals must be knowledgeable about the benefits of breastfeeding, the basic process of breastfeeding, breastfeeding management, and interventions for common problems (
; see Research box) (International Lactation Consultant Association, 1999).
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Guidelines for Breastfeeding Support During pregnancy a breast assessment is performed that includes a breastfeeding history, a breast examination, and a medication use history. A prenatal plan of care is developed to prepare the woman for lactation. Immediately after birth, the newborn is kept with the mother when possible so that breastfeeding can be initiated when the newborn is most receptive. After birth: -Assistance with latch-on and positioning are given as needed. -Encouragement of frequent feedings is reinforced. -Discharge instructions for knowing criteria for successful breastfeeding are given. -Information about community resources for breastfeeding is given. Especially for premature and low-birth-weight infants, breastfeeding is encouraged. |
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RESEARCH Prenatal Formula Advertising and Breastfeeding Patterns Infant formula companies widely distribute to obstetric offices advertising, samples, and education materials for feeding. Although the materials clearly state that breastfeeding is preferable, the packs contain free offers and coupons and show use of formula in situations idealizing artificial feeding. The distribution of such materials and formula samples in hospitals has been shown to decrease breastfeeding duration. This study examined the effect on breastfeeding initiation and duration of distribution of such materials and samples in obstetrician offices. Five hundred forty-seven pregnant women were randomly assigned to receive either formula company or specially designed educational materials about infant feeding at their first prenatal visit. At delivery, feeding method was determined. The duration of breastfeeding was determined for the women who chose to breastfeed [n = 294) at 2, 6, 12, and 24 weeks after birth. The researchers found that initiation of breastfeeding and duration longer than 2 weeks were not affected. However, women who received the commercial materials were more likely to quit breastfeeding before discharge and before 2 weeks after the birth. IMPLICATIONS FOR PRACTICE Nurses need to ensure that educational materials in prenatal settings unequivocally support breastfeeding. Products that promote formula should be removed from prenatal settings. These actions would support the World Health Organization’s international code for marketing, which prohibits the promotion of formula and distribution of samples in health care settings and using pictures that idealize artificial feeding. |
CULTURAL INFLUENCES ON INFANT FEEDING
Cultural beliefs and practices are significant influences on infant feeding methods. As many as 50 of 120 cultures studied typically do not give colostrum to newborns and only begin breastfeeding after the milk has “come in” (Morse, Jehle, & Gamble, 1990). Some Filipinos, Mexican-Americans, Vietnamese, Hmong, Koreans, and Nigerians are among these groups. When breastfeeding is delayed until the milk is in, babies are given prelacteal food (Lefeber & Voorhoeve, 1999) (Table 20-1). In
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Table 1. The Advised First Food for Newborn Babies in Countries of Africa, Asia and |
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Yoruba, Pedi, Zulu, Sotho
Lozi, Mbunda |
Gin, rum, lime-juice palm Palm wine Watery porridge, cow’s milk/water dextrose/water mixture Light beer [‘mahel’] |
To clear the infant’s throat
To clear the infant’s throat
To clear the infant’s bowel of meconium |
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Lowland
Highland |
Karen
Minangkabau |
Mustard oil Honey, sugar Cgur’ or ‘talmisri’) Sugar-water
Honey, water Castor oil: herbs
Rice
Honey, coconut water Rice water
Sago, sago-porridge Taro (yam), pork fat |
To clean intestine of meconium For ritual and/or medicinal purpose
To clean and purify the body To remove the fluids of the womb ingested by the newborn during birth
To learn the taste
To learn the taste
To learn the taste To learn the taste
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Jamaica
Haiti
Guatemala
Bolivia |
Maya, Ladinos
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Mint tea, castor oil Castor oil
Tea, boiled with anise, sugar, onion stalk, garlic, salt, tea of ‘chicoria’ Wine, cow’s milk, water with herbs or salt, coffee |
To cough up mucus
To get the meconium out |
BENEFITS OF BREASTFEEDING
Human milk is designed specifically for human infants and is nutritionally superior to any alternative. Breast milk is considered a living tissue because it contains almost as many live cells as blood. It is bacteriologically safe and is always fresh. The nutrients in breast milk are more easily absorbed than those in formula.
Benefits of breastfeeding for the infant include the following:
• Breast milk enhances maturation of the gastrointestinal (GI) tract and contains immune factors that contribute to a lower incidence of diarrheal illness, necrotizing enterocolitis, Crohn’s disease, and celiac disease (Barnard, 1997; Lopez-Alarcon, Villalpando, & Fajardo, 1997; Scariati, Grummer-Strawn, & Fein, 1997).
• Breastfed infants receive specific antibodies and cellmediated immunologic factors that help protect against otitis media, respiratory illnesses such as respiratory syncytial virus and pneumonia, urinary tract infections, bacteremia, and bacterial meningitis (Cushing et al., 1998; Lopez-Alarcon et al., 1997).
• There is a lower incidence of allergies among infants from families at high risk. Allergic manifestations occur at a greater rate and are more severe in formula-fed infants (Halken & Host, 1996).
• Breastfed infants are less likely to die from sudden infant death syndrome (McVea, Turner, & Peppier, 2000).
• Breast milk may have a protective effect against childhood lymphoma and insulin-dependent diabetes (Davis, 1998; Hypponen et al, 1999).
• Breast milk may enhance cognitive development (Horwood & Fergusson, 1998).
Maternal benefits include the following:
• Women who have breastfed have a decreased risk of ovarian, uterine, and breast cancer (Enger et al., 1998; Rosenblatt & Thomas, 1995).
• Breastfeeding promotes uterine involution and is associated with a decreased risk of postpartum hemorrhage (
• Mothers who are breastfeeding tend to return to their prepregnancy weight more quickly (King, 2000).
• Breastfeeding may provide some protection against the development of osteoporosis (Eisman, 1998).
• Breastfeeding provides a unique bonding experience and increases maternal role attainment (
Benefits to families and society include the following:
• Breastfeeding is convenient; there are no bottles or other equipment to purchase or clean. Breastfed babies are portable; when traveling, there are fewer supplies to take along.
• Breastfeeding saves money. The cost of formula far exceeds the cost of extra food for the lactating mother. Breastfeeding families who are eligible for WIC represent a cost savings to the government. Because breastfed babies have a lower incidence of illness and infection, health care costs are lower for families and for federal, state, and local governments. Less time is lost from work by parents who must stay home with sick infants, which is a benefit to employers (Riordan, 1997)
OVERVIEW OF LACTATION
MILK PRODUCTION
Each female breast is composed of 15 to 20 segments (lobes) embedded in fat and connective tissue and well supplied with blood vessels, lymphatic tissue, and nerves (Fig. 1). Within each lobe are alveoli (the milk-producing cells), surrounded by myoepithelial cells, which contract to send the milk forward into the ductules. Each ductile enlarges into lactiferous ducts and sinuses where milk collects just behind the nipple. Each nipple has 15 to 20 pores through which milk is transferred to the suckling infant.
Fig. 1 Detailed structural features of the human breast.
Although nearly every woman can lactate, some mothers have insufficient glandular development to exclusively breastfeed their infants. Typically, these women experienced few breast changes during either puberty or early pregnancy. In some cases, women may still be able to breastfeed and offer supplemental nutrition to support optimal infant growth. There are devices available to allow mothers to offer supplements while the baby is at the breast (Fig. 2).
Fig. 2 Supplemental nursing system. (Courtesy Medela, Inc.,
After the mother gives birth, there is a precipitous fall in her estrogen and progesterone levels, which triggers release of prolactin from the anterior pituitary. During pregnancy, prolactin prepares the breasts to secrete milk and, during lactation, to synthesize and secrete milk. Prolactin levels are highest during the first 10 days after birth; they gradually decline over time, but remain above baseline levels for the duration of lactation. Prolactin is produced in response to infant suckling and emptying of the breasts (lactating breasts are never completely empty; milk is constantly being produced by the alveoli as the infant feeds) (Fig. 3, A). Milk production is a supply-meets-demand system; that is, as milk is removed from the breast, more is produced. Incomplete emptying of the breasts with feedings can lead to a decrease in milk production.
Fig. 3 Maternal breastfeeding reflexes. A, Milk production. B, Let-down.
Oxytocin is the other hormone essential to lactation. As the nipple is stimulated by the suckling infant, the posterior pituitary is prompted by the hypothalamus to produce oxytocin. This hormone is responsible for the milk ejection reflex (MER), or let–down reflex (Fig. 3, B). The myoepithelial cells surrounding the alveoli respond to oxytocin by contracting and sending the milk forward through the ducts to the nipple. Many “let-downs” can occur with each feeding session. The MER can be triggered by thoughts, sights, sounds, or odors that the mother associates with her baby (or other babies), such as hearing the baby cry. Many women report a tingling “pins and needles” sensation in the breasts as let-down occurs, although some mothers can detect milk ejection only by observing the sucking and swallowing of the infant. Let-down may also occur during sexual activity, because oxytocin is released during orgasm.
Oxytocin is the same hormone that stimulates uterine contractions during labor. Oxytocin contracts the mother’s uterus after birth to control postpartum bleeding and promote uterine involution. Thus mothers who breastfeed are at decreased risk for postpartum hemorrhage. These uterine contractions that occur with breastfeeding can be painful during and after the feeding, particularly in multiparas, for 3 to 5 days after giving birth.
Prolactin and oxytocin have been referred to as the “mothering hormones” because they are known to affect the postpartum woman’s emotions, as well as her physical state. Many women report feeling thirsty or very relaxed during breastfeeding, probably as a result of these hormones.
The nipple erection reflex is an integral part of lactation. When the infant cries, suckles, or rubs against the breast, the nipple becomes erect. This assists in the propulsion of milk through the lactiferous sinuses to the nipple pores. Nipple sizes, shapes, and their ability to become erect vary with individuals. Some women have flat nipples or inverted nipples that do not become erect with stimulation; however, they are usually able to learn to breastfeed successfully. It is important that these infants are not offered bottles or pacifiers until breastfeeding is well established.
UNIQUENESS OF HUMAN MILK
Human milk is a highly complex, species-specific fluid uniquely designed to meet the needs of the human infant. It is specific to the needs of each newborn; for example, the milk of the mothers of preterm infants differs in composition from that of mothers who give birth at term.
Human milk contains antibodies that provide some protection against a broad spectrum of bacterial, viral, and protozoan infections. Secretory IgA is the major antibody in human milk. There are antiinflammatory agents, growth factors, hormones, and enzymes in human milk, many of which contribute to the maturation of the infant’s intestine (Table 2).
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Table 2 Summary of Immun Properties of Brsast Milk |
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COMPONENT |
ACTION |
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WHITE BLOOD CELLS |
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B lymphocytes
Macrophages
Neutrophils
T lymphocytes |
Give rise to antibodies targeted against specific microbes. Kill microbes outright in baby’s gut, produce lysozyme, and activate other components of the immune system. May act as phagocytes, ingesting bacteria in baby’s digestive system. Kill infected cells directly or send out chemical messages to mobilize other defenses. They proliferate in the presence of organisms that cause serious illness in infants. They also manufacture compounds that can strengthen an infant’s own immune response. |
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MOLECULES |
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Antibodies of secretory IgA class
B12-binding protein
Bifidus factor
Fatty acids
Fibronectin
Gamma-interferon Hormones and growth factors
Lactoferrin
Lysozyme Mucins
Oligosaccharides |
Bind to microbes in infant’s digestive tract and thereby prevent them from passing through walls of the gut into body’s tissues. Reduces amount of vitamin B,2, which bacteria need in order to grow. Promotes growth of Lactobacillus bifidus, a harmless bacterium, in infant’s gut. Growth of such nonpathogenic bacteria helps crowd out dangerous varieties. Disrupt membranes surrounding certain viruses and destroy them. Increases antimicrobial activity of macrophages; helps to repair tissues that have been damaged by immune reactions in infant’s gut. Enhances antimicrobial activity of immune cells. Stimulate infant’s digestive tract to mature more quickly. Once the initially “leaky” membranes lining the gut mature, infants become less vulnerable to microorganisms. Binds to iron, a mineral many bacteria need to survive. By reducing the available amount of iron, lactoferrin thwarts growth of pathogenic bacteria. Kills bacteria by disrupting their cell walls. Adhere to bacteria and viruses, thus keeping such microorganisms from attaching to mucosal surfaces. Bind to microorganisms and bar them from attaching to mucosal surfaces. |
Human milk composition and volumes vary according to the stage of lactation. In lactogenesis stage I, beginning in pregnancy, the breasts are preparing for milk production. Colostrum, a clear yellowish fluid, is present in the breasts at this time. Colostrum is more concentrated than mature milk and is extremely rich in immunoglobulins. It has higher concentrations of protein and minerals but less fat than mature milk. The high protein level of colostrums facilitates binding of bilirubin, and the laxative action of colostrum promotes early passage of meconium. Colostrum gradually changes to mature milk; this is referred to as the “milk coming in” or lactogenesis stage II. By the third to fifth day after birth, most women have experienced this onset of copious milk secretion. Breast milk continues to change in composition for approximately 10 days, when the mature milk is established in stage III of lactogenesis (
Composition of mature milk changes during each feeding. As the infant nurses, the fat content of breast milk increases. There is initially a release of bluish white foremilk that is part skim milk (approximately 60% of the volume) and part whole milk (approximately 35% of the volume). It provides primarily lactose, protein, and water-soluble vitamins. The hindmilk, or cream (approximately 5%), is usually let down 10 to 20 minutes into the feeding, although it may occur sooner. It contains the denser calories from fat necessary for optimal growth and contentment between feedings. Because of this changing composition of human milk during each feeding, it is important to breastfeed the infant long enough to supply a balanced feeding.
Milk production gradually increases, and by the time her infant is 2 weeks old, the mother produces 720 to 900 ml of milk every 24 hours. Babies experience fairly predictable growth spurts (i.e., at approximately 10 days, 3 weeks, 6 weeks, 3 months, and 4 to 6 months), when more frequent feedings stimulate increased milk production. These more frequent feedings usually last 24 to 48 hours, and then the infants resume their usual feeding pattern.
CARE MANAGEMENT: THE BREASTFEEDING MOTHER AND INFANT
Assessment and Nursing Diagnoses
Infant
Before the initiation of breastfeeding, the nurse needs to consider several factors to effectively assist the breastfeeding infant. Maturity level, experience during labor and birth, any birth trauma or maternal risk factors, congenital defects or physical instability, and state of alertness all affect the readiness and ability of the infant to breastfeed.
During feeding, the infant is assessed by direct observation for latch-on, position and alignment, and sucking and swallowing. After the feeding, the infant is observed for behavior such as contentment or sleepiness. Elimination patterns are noted: within 24 hours after birth, at least one wet diaper and one stool; by day 3, three to four wet diapers and one or two stools that are beginning to change from meconium to yellowish; after day 4 (and mother’s milk has “come in”), 6 to 10 wet diapers and at least three stools per 24 hours. Other factors to assess include the presence of jaundice, weight loss less than 10% of birth weight, and a regain of birth weight by 10 to 14 days of age (
).
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Signs of Adequate Intake in the Breastfeeding Infant The mother’s milk transitions from colostrum to mature milk. Milk “comes in” by 3 to 5 days after birth. The infant feeds at least eight times per day: approximately every 2 to 3 hours in the day and every 4 hours at night. After correctly latching on to the breast, the baby feeds for 15 to 20 minutes (per breast) with gliding jaw movements and audible swallowing. At least one breast is softened completely at each feeding. The infant appears relaxed and satisfied after feeding and is likely to fall asleep. By 24 hours after the milk has “come in,” the infant urinates at least six to eight times (pale urine) and has at least two bowel movements per day. The stools transition from meconium to bright yellow, somewhat loose stools with a cottage cheese consistency by the fifth day. The infant gains 15 to 30 g per day after the fourth or fifth day and surpasses the birth weight by 10 to 14 days of age. The mother reports a “tugging” sensation at the nipple with feeding and feels warm and relaxed during feeding. |
Mother
Before breastfeeding is begun, the nurse should carefully assess the mother’s knowledge of breastfeeding and her physical and psychologic readiness to breastfeed. Factors to include are her previous experience with breastfeeding, knowledge about breastfeeding, cultural factors, physical features of the breasts or nipples or other physical limitations, psychologic readiness (time since birth, mood and energy level), and support of the baby’s father or the family.
During the time in the hospital, the nurse can help the mother view each breastfeeding session as a “feeding lesson” or “practice session” that will foster maternal confidence and a satisfying breastfeeding experience for mother and infant. Assessment includes condition of nipples, transition to mature milk, breasts feeling lighter or softer after feeding, mother feeling relaxed or sleepy after feeding, uterine cramping or increased lochia flow during and after a feeding, and mother’s appearance of comfort with breastfeeding techniques.
Nursing diagnoses for the breastfeeding woman include the following:
• Effective breastfeeding related to
-mother’s knowledge of breastfeeding techniques
-mother’s appropriate response to infant’s feedingreadiness cues
-mother’s ability to facilitate efficient breastfeeding
• Ineffective breastfeeding related to
-insufficient knowledge regarding newborn’s reflexes and breastfeeding techniques
-lack of support by father of baby, family, friends
-lack of maternal self-confidence; anxiety, fear of failure
-poor infant sucking reflex
-difficulty waking sleepy baby
• Imbalanced nutrition: less than body requirements related to
-increased caloric and nutrient needs for breastfeeding (mother)
-incorrect latch-on and inability to transfer milk (infant)
• Risk for deficient fluid volume related to
-ineffective sucking (infant)
Expected Outcomes of Care
The expected outcomes include that the infant will do the following:
• Latch on and feed effectively at least eight times per day
• Gain weight appropriately
• Remain well hydra ted (have 6 to 10 wet diapers and at least three bowel movements every 24 hours after day 4)
• Sleep or seem contented between feedings
Examples of expected outcomes for the mother include that she will do the following:
• Verbalize/demonstrate understanding of breastfeeding techniques, including positioning and latch-on, signs of adequate feeding, self-care
• Report no nipple discomfort with breastfeeding
• Express satisfaction with the breastfeeding experience
• Consume a nutritionally balanced diet with appropriate caloric and fluid intake to support breastfeeding
Plan of Care and Interventions
In the early days after birth, interventions focus on helping the mother and the newborn initiate breastfeeding and achieve some degree of success and satisfaction before discharge from the hospital or birthing center. Interventions to promote breastfeeding progress from basics such as latch-on and positioning to signs of adequate feeding and self-care measures such as prevention of engorgement.
The ideal time to begin breastfeeding is within 1 hour after birth (
Positioning
There are four basic positions for breastfeeding: football hold, cradle, modified cradle or across-the-lap, and side-lying position (Fig. 4). Initially, it is best to use the position that most easily facilitates latch-on while allowing maximum comfort for the mother. The football hold is usually preferred by mothers who gave birth by cesarean. The modified cradle or across-the-lap hold also works well for early feedings. The side-lying position allows the mother to rest while breastfeeding and is often preferred by women experiencing perineal pain and swelling. Cradling is the most common breastfeeding position for infants who have learned to latch on easily and feed effectively. Before discharge from the hospital, the mother should be assisted to try all of the positions so that she will feel confident in her ability to vary positions at home.
Fig. 4 Breastfeeding positions. A, Football hold. B, Cradling. C, Lying down. (B and C, Courtesy Marjorie Pyle, RNC, Lifecircle,
Whichever position is used, the mother should be comfortable, with pillows used as needed to provide support for her back and arms. The infant is placed at the level of the breast, supported by pillows or folded blankets, turned completely on his or her side, and facing the mother so that the infant is “belly to belly,” with the arms “hugging” the breast. The baby’s mouth is directly in front of the nipple. It is important that the mother support the baby’s neck and shoulders with her hand and not push on the occiput. The baby’s body is held in correct alignment (i.e., ears, shoulders, and hips are in a straight line) during latch-on and feeding (Fig. 5) (see Guidelines/Guias box).
Fig. 5 Latching on. A, Tickle baby’s lower lip with your nipple until he or she opens wide. B, Once baby’s mouth is opened wide, quickly pull baby onto breast. C, Baby should have as much areola (dark area around nipple) in his or her mouth as possible, not just the nipple. (Courtesy Medela, Inc., McHenry, IL.)
Latch-on
In preparation for latch-on, it may be helpful for the mother to manually express a few drops of colostrum or milk and spread it over the nipple. This lubricates the nipple and may entice the baby to open the mouth as the milk is tasted.
To facilitate latch-on, the mother supports her breast in one hand with the thumb on top and the ringers underneath at the back edge of the areola. The breast is compressed slightly so that an adequate amount of breast tissue is taken into the mouth with latch-on (Weissinger, 1998). Most mothers need to support the breast during feeding for at least the first few weeks until the baby can stay latched on easily.
The mother lightly touches the baby’s lower lip with her nipple, stimulating the mouth to open. When the mouth is open wide and the tongue is down, the mother quickly pulls the baby onto the nipple. She brings the baby to the breast, not the breast to the baby. If the breast is pushed into the baby’s mouth, the baby often closes the mouth too soon and does not latch on correctly.
The amount of the areola in the baby’s mouth with correct latch-on depends on the size of the baby’s mouth and the size of the areola and nipple. In general, the baby’s mouth should cover the nipple and an areolar radius of approximately 2 to 3 cm all around the nipple.
When the baby is latched on correctly, the nose, cheeks, and chin should all be touching the breast (Fig. 6). The mother should not pull the nipple out of the mouth when trying to create a breathing space for the baby’s nose. If the mother is worried about the baby’s breathing, she can raise the baby’s hips slightly to change the angle of the baby’s head at the breast. Depressing the breast tissue around the baby’s nose is not necessary. If the baby cannot breathe, reflexes will prompt the baby to move the head and pull back to breathe.
Fig. 6 Correct attachment (latch-on) of infant at breast.
Sucking creates a vacuum in the intraoral cavity as the breast is compressed between the tongue and the palate. If the mother experiences pinching or pain after the first few sucks, or does not feel a firm tugging on the nipple, the latch-on and positioning should be evaluated.
If each suck is painful, the baby may be having difficulty keeping the tongue out over the lower gum ridge. Clicking or smacking may be audible when this occurs. The nurse can place a finger on the side of the baby’s lower jaw, pulling down gently but firmly as the baby sucks, to help stabilize the jaw so that the tongue stays in place.
Any time the signs of adequate latch-on and sucking are not present, the baby should be taken off the breast and latch-on attempted again. To prevent nipple trauma as the baby is taken off the breast, the mother is instructed to break the suction by inserting her finger in the side of the baby’s mouth between the gums and keeping it there until the nipple is completely out of the baby’s mouth (Fig. 7).
Fig. 7 Removing infant from the breast. (Courtesy Marjorie Pyle, RNC, Lifecircle,
When the baby is latched on correctly and sucking appropriately, (1) the mother reports a firm tug on her nipple, but no pinching or pain; (2) the baby sucks with cheeks rounded, not dimpled; (3) the baby’s jaw glides smoothly with sucking; and (4) swallowing is audible.
Milk ejection or let-down
As the baby begins sucking on the nipple, the let-down, or milk ejection, reflex is stimulated. The hormone oxytocin causes milk to be sent forward from the milk ducts to the nipple. The following signs indicate that let-down has occurred:
• The mother may feel a tingling sensation in the nipples, although many women do not feel their milk let down.
• The baby’s suck changes from quick, shallow sucks to a slower, more drawing, sucking pattern.
• Swallowing is heard as the baby sucks.
• The mother feels relaxed, even sleepy, during feedings.
• The mother experiences uterine cramping and increased lochia flow during or after the feeding.
• The opposite breast may leak.
Frequency of feedings
Newborns need 8 to 12 feedings in a 24-hour period (
Parents should be cautioned about attempting to place newborn infants on the strict feeding schedules that are recommended by some contemporary child-rearing proponents. There have been incidences of dehydration, poor weight gain, and failure to thrive in infants whose parents adhered to a strict feeding schedule.
Babies should be fed whenever they exhibit feeding cues such as hand-to-mouth movements and mouth and tongue movements. Crying is a late sign of hunger, and babies may become frantic when they have to wait too long to feed. Some infants will shut down or go into a deep sleep when their needs are not met. Keeping the baby close is the best way to observe and respond to infant feeding cues.
Duration of feedings
The duration of breastfeeding sessions is highly variable, because the timing of milk transfer differs for each mother-baby pair. Some infants may complete a feeding in 5 or 10 minutes; others may require 45 minutes or longer. The average time for feeding is 30 minutes, or approximately 15 minutes per breast. Instructing mothers to feed for a set number of minutes in inappropriate. It is better to teach mothers how to determine when a baby has finished a feeding: the baby’s suck/swallow pattern has slowed, the breast is softened, and the baby appears content and may fall asleep or release the nipple.
If a baby seems to be feeding effectively and is having adequate urine output but not gaining weight well, the mother may be switching to the second breast too soon. The high lactose content in foremilk may cause the baby to have explosive stools, gas pains, and inconsolable crying. Keeping the baby on the first breast until it is soft ensures that the baby receives the more calorie-dense, high-fat hindmilk, which usually results in increased weight gain.
Supplements, bottles, and pacifiers
The
Situations related to the infant that may necessitate supplemental feedings include low birth weight, hypoglycemia, dehydration, and inborn errors of metabolism. Mothers may be unable to feed because of severe illness, or they may be taking medications incompatible with breastfeeding.
Offering a bottle after breastfeeding “just to make sure the baby is getting enough” is normally unnecessary and should be avoided. This can contribute to nipple confusion (i.e., difficulty knowing how to latch on to the breast) and to low milk supply because the baby becomes overly full and does not breastfeed often enough. Supplementation interferes with the supply-meets-demand cycle of milk production. The parents may interpret the baby’s willingness to take a bottle to mean that the mother’s milk supply is inadequate. They need to know that a baby will automatically suck from a bottle as the nipple triggers the suck/swallow reflex.
Babies can become confused going from breast to bottle or bottle to breast. Breastfeeding and bottle-feeding require different skills. The way babies use their tongues, cheeks, and lips, as well as the swallowing patterns, are very different. Some babies can transition easily between breast and bottle, but some experience considerable difficulty. It is impossible to predict which babies will adapt well and which ones will not. Therefore it is best to avoid bottles until breastfeeding is well established, usually after 3 to 4 weeks. If supplementation is needed, there are mechanisms such as supplemental nursing systems that allow the infant to breastfeed while being supplemented (see Fig. 2). Although some parents combine breastfeeding and bottlefeeding, many babies never take a bottle and go directly from the breast to a cup as they grow.
Pacifiers are not recommended until breastfeeding is well established. Their use has been associated with early termination of breastfeeding (Aarts et al., 1999; Howard et al., 1999). Newborns need to learn the association between sucking and satiation. Although some infants have nonnutritive sucking needs between feedings, it is best to wait to introduce a pacifier until the infant is proficient at breastfeeding.
Special considerations
Sleepy baby. During the first few days of life, some babies need to be awakened for feedings. If the infant is awakened from a sound sleep, attempts at feeding are more likely to be unsuccessful. Unwrapping the baby, changing the diaper, sitting the baby upright, talking to the baby with variable pitch, gently massaging the baby’s chest or back, and stroking the palms or soles may bring the baby to an alert state.
Fussy baby. Babies sometimes awaken from sleep crying frantically. Although they may be hungry, they cannot focus on feeding until they are calmed. Calming techniques include swaddling the baby, holding the baby close, talking soothingly, and allowing the baby to suck on a clean finger.
Some infants cry as soon as they are positioned for feeding. This may be due to a bruised head or previously undetected fractured clavicle. Changing the feeding position may solve the problem.
If an infant required extensive suctioning at birth, there may be an aversion to oral stimulation and the baby may scream and stiffen if anything approaches the mouth. Parents may need to spend time holding and cuddling the baby before attempting to breastfeed.
Fussiness may be related to GI distress (i.e., cramping and gas pains). This may occur in response to an occasional feeding of infant formula, or it may be related to something the mother has ingested. Although most mothers can consume their normal diet without affecting the baby, foods such as cabbage, broccoli, or onions may aggravate some babies. Others may react to cow’s milk products ingested by the mother. There are no standard foods that all mothers should avoid when breastfeeding; each mother-baby couple responds individually. If gas is a problem, giving the baby liquid simethicone drops before a feeding may be helpful.
Persistent crying or refusing to breastfeed can indicate illness, and the health care provider should be notified. Ear infections, sore throat, or oral thrush may cause the infant to be fussy and not breastfeed well.
Slow weight gain. Newborns commonly lose 8% to 10% of their birth weight during the first 3 to 5 days after birth as they eliminate amniotic fluid and meconium. Thereafter, they should begin to gain weight at the rate of 110 to 200 g per week or 20 to 28 g per day. The infant who continues to lose weight after 5 days, who does not regain birth weight by 2 weeks, or whose weight is below the 10th percentile by 1 month should be evaluated and closely monitored by a health care provider.
Most often, slow weight gain is related to inadequate breastfeeding. Feedings may be short or infrequent, or the infant may be latching on incorrectly or sucking ineffectively or inefficiently. Other causes are illness, infection, malabsorption, or circumstances that increase the baby’s energy needs such as congenital heart disease, cystic fibrosis, or being small for gestational age.
Maternal factors may contribute to slow weight gain. There may be inadequate emptying of the breasts, pain with feeding, or inappropriate timing of feedings. Inadequate glandular breast tissue or previous breast surgery may affect milk supply. Severe intrapartum or postpartum hemorrhage, illness, or medications may decrease milk supply. Stress and fatigue may also negatively affect milk production.
Usually the solution to slow weight gain is to improve the feeding technique. Positioning and latch-on are evaluated and adjustments made. It may help to add a feeding or two in a 24-hour period. Massaging alternate breasts during feedings may help increase the amount of milk going to the infant. With this technique, the mother massages her breast from the chest wall to the nipple whenever the baby has sucking pauses. Some think this technique may also increase the fat content of the milk, which aids in weight gain.
When babies are calorie deprived and need supplementation, the extra breast milk or formula can be given with a spoon or cup, a nursing supplementer, or a bottle. If there are latch-on problems, it is best to avoid bottles. In most cases, supplementation is needed only for a short time until the baby gains weight and is feeding adequately.
Jaundice. Jaundice (hyperbilirubinemia) in the newborn is discussed in detail in Chapter 18. Physiologic jaundice usually occurs after 24 hours of age and peaks by the third day. This is referred to as early-onset jaundice, which in the breastfed infant may be associated with insufficient feeding and infrequent stooling. Colostrum has a natural laxative effect (and promotes early passage of meconium). Bilirubin is excreted from the body primarily (98%) through the intestines. Infrequent stooling allows bilirubin in the stool to be reabsorbed into the infant’s system, thus promoting hyperbilirubinemia. Infants who receive water or glucose water supplements are more likely to have hyperbilirubinemia, because only 2% of bilirubin is excreted through the kidneys. Decreased caloric intake (less milk) is associated with decreased stooling and increased jaundice.
To prevent early-onset breastfeeding jaundice from occurring, babies should be breastfed early and often during the first several days of life. More frequent feedings are associated with lower bilirubin levels.
If the infant’s intake of milk needs to be increased, a supplemental feeding device may be used to deliver additional breast milk or formula while the infant is nursing. Hyperbilirubinemia may reach levels that require treatment with phototherapy administered with a light or a fiberoptic blanket.
Late-onset jaundice affects few breastfed infants; it develops in the second week of life, peaking at approximately 10 days of age. These infants are typically thriving, gaining weight, and stooling normally, and all pathologic causes of jaundice have been ruled out. It was once postulated that an enzyme in the milk of some mothers caused the bilirubin level to increase. It now appears that a factor in human milk increases the intestinal absorption of bilirubin. In most cases no intervention is necessary, although some experts recommend temporary interruption of breastfeeding for 12 to 24 hours to allow bilirubin levels to decrease. During this time, the mother pumps her breasts and the baby is offered alternative nutrition, usually formula (
Preterm infants. Human milk is the ideal food for preterm infants, with benefits that are unique and in addition to those received by term, healthy infants. Breast milk enhances retinal maturation in preterm infants and improves neurologic outcome. There is also greater physiologic stability with breastfeeding as compared with bottlefeeding (Brown et al, 1996; Meier & Brown, 1996).
Mothers of preterm infants should begin pumping their breasts as soon as possible after birth with a hospital-grade electric pump. To establish an optimal milk supply, the mother should use a dual collection kit and pump 8 to 10 times daily for 10 to 15 minutes or until the milk flow has ceased for a few minutes (Meier, 1997). These women are taught proper handling and storage of breast milk to minimize bacterial contamination and growth.
Breastfeeding twins. Caring for twins takes some planning, but breastfeeding means that feedings are always ready instantly; no one has to wash bottles and fix formula; and, for some mothers, both babies can be fed at once. The mother with twins will need extra nourishment (200 to 500 kcal/day for each baby).
Each baby feeds from one breast per feeding, usually for approximately 20 to 30 minutes. Some mothers assign each baby a breast; others switch babies from one breast to the other, either on a schedule or randomly. The mother may find it easiest to use a modified demand feeding schedule; that is, feeding the first baby who wakes up and then waking the second baby for feeding.
During the early weeks, parents may find it helpful to keep a record of feeding times and which breast was used first by which baby. If one twiurses more vigorously than the other, that baby should be alternated between breasts to equalize breast stimulation.
If the mother wants to feed the babies simultaneously, she may wish to experiment with positions. For example, one baby can be held in the football hold and the other in the cradle hold, or the babies can each be held in a cradling position. Each baby can be supported on firm pillows while in the football hold. At first, some mothers using this position may require assistance to get the babies off the breasts (Fig. 8).
Fig. 8 Breastfeeding twins. (Courtesy Marjorie Pyle, RNC, Lifecircle,
Expressing and storing breast milk
There are situations when expression of breast milk is necessary or desirable, such as when engorgement occurs, the mother and baby are separated (e.g., preterm or sick infant is ieonatal intensive care), the mother is employed outside the home and wants to maintain her milk supply, the nipples are severely sore or cracked, or the mother leaves the infant with a caregiver and will not be present for feeding.
Because pumping and hand expression are rarely as effective as a baby in removing milk from the breast, the milk supply should never be judged based on the volume expressed.
Hand expression. To manually express milk, after thoroughly washing her hands, the mother places one hand on her breast at the edge of the areola. With her thumb above and fingers below, she presses in toward her chest wall and gently compresses the breast while rolling her thumb and fingers forward. These motions are repeated rhythmically until the milk begins to flow. While the milk is flowing easily, the mother maintains a steady, light pressure. The thumb and fingers should not pinch the breast or slip down to the nipple. The hand should be rotated to reach all sections of each breast. After expressing milk from the second breast, she should return to the first breast and then repeat until all readily available milk is expressed.
Pumping. There are numerous ways to approach pumping. Some women pump when they first wake up in the morning or when the baby has fed but did not completely empty the breast. Others prefer to pump just before going to sleep. Some pump one breast while the baby is feeding from the other. Double pumping (pumping both breasts at the same time) saves time (Fig. 9).
Fig. 9 Bilateral breast pumping. (Courtesy Medela, Inc.,
The amount of milk obtained when pumping depends on the type of pump being used, the time of day, how long it has been since the baby breastfed, the mother’s milk supply, how practiced she is at pumping, and her comfort level (pumping is uncomfortable for some women). Breast milk may vary in color and consistency, depending on the time of day, the age of the baby, and foods the mother has eaten (e.g., the milk may appear green after the mother eats spinach).
Types of pumps. Many types of breast pumps are available (Biancuzzo, 1999) (Fig. 10). Some are more effective than others, and they vary in price. Manual pumps are the least expensive and may be the most appropriate where portability and quietness of operation are critical, or when a mother is pumping only for an occasional bottle (see Fig. 10, B).
Fig. 10 A, Hospital-grade electric breast pump. B, Manual breast pumps. (B, Courtesy Marjorie Pyle, RNC, Lifecircle,
Full-service electric pumps, or hospital-grade pumps, are similar to the sucking action and pressure of the breastfeeding infant. These are expensive and therefore are usually rented. When breastfeeding is delayed after birth (e.g., the infant is preterm or ill), or when mother and baby are separated for lengthy periods, these pumps are most appropriate (see Fig. 10, A). Electric, self-cycling double pumps are efficient and easy to use. Some of these pumps come with carry bags containing coolers in which to store pumped milk (see Fig. 10).
Smaller battery-operated or electric pumps are also available. Some have automatic suck/release cycling and others require use of a finger to regulate strength and speed of suction. These are typically used when pumping is done occasionally, but some models are satisfactory for working mothers or others who pump on a regular basis.
Storage of breast milk. Breast milk can be stored safely in any clean glass or plastic container. Disposable bottle liners are easy and inexpensive to use when storing milk. When using bottle liners, double bagging is recommended, to protect the milk most effectively.
Breast milk can be refrigerated safely for 48 hours after it is expressed. If it is not used within that time, it can be frozen (at 0° C) for up to 6 months; it should be kept in the middle or toward the back of the freezer to avoid variations in temperature. Milk can be stored for 1 year in a freezer at —20° C. When storing breast milk, the container should be dated and the oldest milk used first.
Frozen milk is thawed by placing the container in warm water or in the refrigerator. It cannot be refrozen, and should be used within 24 hours. After thawing, the container should be shaken gently to mix the layers that have separated.
NURSE ALERT Frozen milk is never thawed or heated in a microwave oven. Microwaving does not heat evenly and can cause encapsulated boiling bubbles to form in the center of the liquid. This may not be detected when checking drops of milk for temperature. Babies have sustained severe burns to the mouth, throat, and upper Gl tract as a result of microwaved milk {
Being away from the baby
Many women successfully combine breastfeeding with employment, attending school, or other commitments. If feedings are missed, the milk supply may be affected. Some women’s bodies adjust the milk supply to the times she is with the baby for feedings. Other mothers must pump while away or their supply diminishes rapidly. Businesses are increasingly making available rooms where mothers caurse their infants or use breast pumps (Fig. 11).
Fig. 11 Room on a university campus dedicated to parents and infants. The room contains comfortable furniture, a breast pump, a refrigerator, a baby changing table, and a television and VCR for instructional purposes. The room is available to students, faculty, and staff. (Courtesy Shannon Perry,
Weaning
Typically, weaning is initiated at a time chosen by the mother or the infant. Weaning can be accomplished with little effort and no discomfort when it is done gradually. Abrupt weaning is likely to be distressing for both mother and baby, as well as physically uncomfortable for the mother.
Infant-led weaning means that the baby moves at his or her own pace in omitting feedings. Drinking from a cup and increasing the amount of solid foods substitute for breastfeeding.
Mother-led weaning means that the mother decides which feedings to drop. This is most easily done by omitting the feeding of least interest to the baby or the one the infant is most likely to sleep through. It can also be the feeding most convenient for the mother to omit. After a week or more, another feeding is dropped, and so on, until the infant is weaned from the breast. Allowing time for the milk supply to adjust before omitting another feeding prevents discomfort for the mother as her supply gradually decreases.
Infants can be weaned directly from the breast to a cup. Bottles are usually offered to infants less than 6 months of age. If the infant is weaned before 1 year of age, formula should be offered instead of cow’s milk.
If abrupt weaning is necessary, breast engorgement often occurs. The mother is instructed to take mild analgesics, wear a supportive bra, apply ice packs or cabbage leaves to the breasts, and pump if needed to increase comfort. The pump should not be used to empty the breasts, because they should remain full enough to promote a decrease in milk production.
Milk banking
For infants who cannot be breastfed but also cannot survive except on human milk, banked donor milk is critically important. Because of the antiinfective and growth promoting properties of human milk—as well as its superior nutrition—donor milk is used in many neonatal intensive care units for preterm or sick infants when the mother’s own milk is not available. Donor milk is also used therapeutically for medical purposes, such as in transplant recipients who are immunocompromised.
The Human Milk Banking Association of
Care of the mother
Diet. The composition of human milk varies slightly among women, regardless of their diets. The mother’s milk automatically contains everything the baby needs, except in rare cases of maternal nutrient deficiencies. For most women, only 200 to 500 extra calories per day must be added to the diet to provide adequate nutrients for the infant while also protecting the mother’s body stores.
There are no specific foods or drinks that all breastfeeding mothers must either consume or avoid. Lactating mother should ideally consume a balanced diet of nutrient dense foods. Adequate amounts of calcium, minerals, and fat-soluble vitamins are important.
If the breastfeeding mother is drinking enough fluids to quench her thirst, she is likely drinking enough to support lactation. Typically, women find that they are drinking as much as 2 to 3 quarts of fluid each day, with the choice of fluid depending on the mother’s preference. Because of her increased need for fluids, the breastfeeding mother may wish to keep a drink within reach during breastfeeding. An indicator of adequate fluid intake is the color of the mother’s urine. If she is drinking enough fluids, her urine should be clear to light yellow throughout the day.
Weight loss. Because it takes energy to produce milk, many mothers experience a gradual weight loss while breastfeeding as fat stores deposited during pregnancy are used. For the mother who is overweight, this fact can present an added incentive for breastfeeding. However, the mother who wants to diet while lactating should avoid losing large amounts of weight quickly because fat-soluble environmental contaminants to which she has been exposed are stored in her body’s fat reserves and these may be released into her milk. In addition, some mothers find that their milk supply decreases when caloric intake is severely restricted. Most mothers find that they can lose approximately 1 kg per week without affecting their milk supply (King, 2000).
Exercise. There is no reason for a breastfeeding woman to restrict her physical activity. Women continue activities such as hiking, jogging, swimming, and aerobics with no detrimental effect on milk supply or composition. Women often find they are more comfortable if they engage in exercise soon after breastfeeding when their breasts are as empty as possible. Wearing a well-designed, supportive bra may also be helpful.
Rest. It is important for the breastfeeding mother to rest as much as possible, especially in the first 1 or 2 weeks after birth. Fatigue, stress, and worry can interfere with milk production and let-down. The nurse can encourage the mother to sleep when the baby sleeps. Breastfeeding in a side-lying position promotes rest for the mother. Assistance with household chores and caring for other children can be done by the father, grandparents or other relatives, and friends.
Breast care. The breastfeeding mother’s normal routine bathing is all that is required to keep her breasts clean. Soap can have a drying effect oipples, so she should be instructed to avoid washing the nipples with soap. The small amount of soap that runs down her breasts while washing her face and neck or shampooing her hair is of no concern.
Breast creams should not be used routinely because they may block the natural oil secreted by the
Modified lanolin with reduced allergens can be used safely on dry or sore nipples. Lanolin is beneficial in moist wound healing of sore nipples (Brent et al., 1998; Huml, 1995). Because lanolin is made from sheep’s wool, the nurse should ask the mother if she is allergic to wool before applying the ointment. Lanolin is not recommended if it is suspected that nipple soreness may be due to a monilial infection. Antifungal creams are used to treat yeast infections oipples.
The mother with flat or inverted nipples will likely benefit from wearing breast shells in her bra. These hard plastic devices exert mild pressure around the base of the nipple to encourage nipple eversion. They are also useful for sore nipples to keep the mother’s bra or clothing from touching the nipples (Fig. 12).
Fig. 12 Breast shells.
If a mother needs breast support, she will be uncomfortable unless she wears a bra, because the ligament that supports the breast (Cooper’s ligament) will otherwise stretch and be painful. If she is comfortable without a bra, there is no reason for her to wear one. If a woman prefers to wear a bra, it should fit well, offer nonbinding support, and feel comfortable. Underwire bras or improperly fitting bras may contribute to clogged milk ducts. Mothers should be encouraged to breastfeed at least once daily without a bra on so that all milk ducts can empty well.
Leakage of milk between feedings is a problem for some women. Using breast pads (washable or disposable) inside a bra and wearing layered or printed tops can help camouflage the leakage. Plastic-lined pads are not recommended because they trap moisture and may lead to sore nipples. To stop leakage, the mother can be alert to any sensation, such as tingling, that her milk is letting down. If this happens, she can usually stop the let-down by pressing straight back on her nipples. In public the mother can fold her arms across her chest to apply pressure unobtrusively.
Breast self-examination. Although only 1% to 2°/o of cases of breast cancer are diagnosed during pregnancy or lactation, the breastfeeding woman should perform breast self-examination (BSE). The woman who is not menstruating should choose a convenient date on which to do her BSE every month. She needs to become familiar with the normal nodularity of her lactating breasts so that she can detect anything unusual on examination. Nodules that match in location in both breasts are almost always breast tissue. Nodules that increase and decrease in size are probably milk glands or ducts. Because lactating breasts are very dense, mammography is of limited diagnostic value. Should a suspicious nodule be discovered, a biopsy can usually be done without interrupting breastfeeding.
Effect of menstruation. The return of menstrual periods varies among lactating women. The majority will resume menstruation by 6 months postpartum. Menstruation has no effect on breastfeeding. There are no hormonal effects on the infant, although some babies may seem fussy for the first day. The quality of milk is not affected (
Sexual sensations. Some women experience rhythmic uterine contractions during breastfeeding. Such sensations are not unusual because uterine contractions and milk ejection are both triggered by oxytocin; however, they may be disturbing to some mothers who perceive them to be similar to orgasm.
Breastfeeding and contraception. Although breastfeeding confers a period of infertility, it is not considered an effective method of contraception. Breastfeeding delays the return of ovulation and menstruation; however, ovulation may occur before the first menstrual period after birth. Thus the breastfeeding woman who is relying on the lactational amenorrhea method of birth control needs to be knowledgeable about ways to determine when ovulation occurs (i.e., basal body temperature, presence of cervical mucus, and cervical position). Hormonal contraceptives, including pills, injectables, and implants, may cause a decrease in the milk supply and are best avoided during the first 6 weeks postpartum. Oral contraceptives containing estrogen are not recommended for breastfeeding mothers. Progestin-only birth control pills are less likely to interfere with the milk supply. Some mothers find that the progestin-only injection (Depo-Provera) or the implantable Norplant interferes with milk production, although others notice no alteration in the milk supply. Nonhormonal contraceptive methods (e.g., foam, condoms, nonhormonal intrauterine device, natural family planning, sterilization) are less likely to have a detrimental effect on breastfeeding (Kelsey, 1996).
Breastfeeding during pregnancy. It is possible for a breastfeeding woman to conceive and continue breastfeeding throughout the subsequent pregnancy if there are no medical contraindications (e.g., risk of preterm labor). When the baby is born, colostrum is produced. The practice of breastfeeding a newborn and an older child is termed tandem nursing. The nurse should remind the mother to always feed the newborn first to ensure that the newborn is receiving adequate nutrition. The supply meets demand principle works just as with breastfeeding multiple babies.
Diabetic mother. The diabetic mother is encouraged to breastfeed. In addition to benefits for the infant and maternal satisfaction, breastfeeding has an antidiabetogenic effect. Blood glucose levels and insulin requirements are lower because of the carbohydrate used in milk production. During lactation, the diabetic woman may be able to eat more food and still take less insulin. However, insulin dosage must be adjusted as the baby is weaned. Some diabetic women are at increased risk for sore nipples caused by monilial infections and may have an increased risk for mastitis (
Drugs and breastfeeding. Although there is much concern about the compatibility of drugs and breastfeeding, there are in fact few drugs that are contraindicated during lactation. Considerations in evaluating the safety of a specific medication during breastfeeding include the pharmacokinetics of the drug in the maternal system, as well as the absorption, metabolism, distribution, storage, and excretion in the infant. The gestational and chronologic age of the infant, body weight, and breastfeeding pattern are also considered (
). In certain instances (e.g., radioactive diagnostic agents), the mother is instructed to pump her breasts and discard the pumped milk until the drug has cleared her body.
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Medications Excreted in Breast Milk That Are Usually Compatible with Breastfeeding ANALGESICS AND ANTIINFLAMMATORY DRUGS (NONNARCOTIC) Acetaminophen (Datril, Tylenol) Aspirin (e.g., Bayer, Anacin, Bufferin, Excedrin) Ibuprofen (e.g., Advil, Nuprin, Motrin) Indomethacin (Indocin) Mefenamic acid (Ponstel) Naproxen (Naproxyn, Anaprox, Naprosyn, Aleve) Propoxyphene (Darvon) ANTIINFECTIVES (may change intestinal flora of infant and sensitize for later allergic reaction) Acyclovir (Zovirax) Ampicillin (Polycillin, Amcill, Omnipen, Penbritin) Carbenicillin (Pyopen, Geopen) Cefazolin (Ancef, Kefzol) Cephalexin (Keflex) Cephalothin (Keflin) Chloramphenicol* (Chloromycetin) Colistin (Colymycin) Demeclocycline (Declomycin) Erythromycin (llosone, E-Mycin, Erythrocin) Gentamicin Isoniazid (Nydrazid) Kanamycin (Kantrex) Metronidazole (Flagyl)* Nitrofurantoin (Furadantin, Macrodantin) Novobiocin (Albamycin, Cathomycin) Penicillin G, benzathine (Bicillin) Penicillin G, potassium Streptomycin Sulfisoxazole (Gantrisin) Tetracycline HCI (Achromycin, Panmycin, Sumycin) ANTICOAGULANTS Coumarin derivatives Dicumarol (bishydroxycoumarin), warfarin (Panwarfin) ANTICONVULSANTS AND SEDATIVES (barbiturates may pass into milk but do not sedate infant) Magnesium sulfate Pentobarbital (Nembutal) Phenytoin (Dilantin) Phenobarbital (Luminal) Sodium bromide (Bromo-Seltzer and OTC sleeping aids) ANTIHISTAMINES (may suppress lactation; administer after breastfeeding; all pass into breast milk) Brompheniramine (Dimetane) Diphenhydramine (Benadryl) Promethazine (Phenergan) CARDIOVASCULAR DRUGS Diazoxide (Hyperstat) Digoxin Hydralazine (Apresoline) Methyldopa (Aldomet) Propranolol (Inderal) Quinidine DIURETICS Furosemide (sulfamoylanthranilic acid) (Lasix) Spironolactone (Aldactone) Thiazides (Diuril, Enduron, Esidrix, HydroDiuril, Oretic, Thiuretic tablets) HORMONES AND CONTRACEPTIVES Contraceptives (oral) Ethinyl estradiol, mestranol, 19-nortestosterone, norethindrone (Norlutin) Corticotropin Cortisone Epinephrine (Adrenalin) Estrogen Medroxyprogesterone acetate (Provera) Prednisone Tolbutamide (Orinase) NARCOTICS Cocainet Codeine Heroint Marijuana (Cannabis sativa L ) t Meperidine (Demerol) Methadone Morphine Percodan (oxycodone [derived from opiate thebaine], aspirin, phenacetin, caffeine) PSYCHOTROPIC AND MOOD-CHANGING DRUGS Alcohol (Ethanol) Amphetamine* Benzodiazepines (alcohol enhances the effects of these drugs) Chlordiazepoxide (Librium)* Diazepam (Valium)* Haloperidol (Haldol)* Lithium carbonate (Eskalith, Lithane, Lithonatejt Milk That Usually Are Compatible Meprobamate (Miltown, Equanil)* Phencyclidine (PCP)t Phenothiazines* Chlorpromazine (Thorazine) Thioridazine (Mellaril) Trifluoperazine (Stelazine) Tricyclic antidepressants Amitriptyline (Elavil)* Desipramine (Norpramin, Pertofrane)* Imipramine (Tofranil)* STIMULANTS Caffeine Theobromine Theophylline THYROID AND ANTITHYROID MEDICATIONS Thiouracil Thyroid and thyroxine MISCELLANEOUS DPT* Methotrexatet Nicotinet Rh antibodies* Rubella virus vaccine* |
Smoking may impair milk production; it also exposes the infant to the risks of secondhand smoke. Mothers who continue to smoke tobacco when lactating should be advised not to smoke within 2 hours before breastfeeding and to never smoke in the same room with the infant (
If a mother chooses to consume alcohol, she should be advised to minimize its effects by having only one drink and consuming it immediately after a feeding. The mother who is pumping for a preterm or sick infant should avoid alcohol until her baby is healthy.
Coffee intake may lead to a reduced iron concentration in milk, and consequently contribute to the development of anemia in the infant. The infant’s immature system limits the ability to excrete the caffeine. Caffeine accumulates in the infant’s system and can cause irritability and poor sleeping patterns. Some infants are sensitive to even small amounts of caffeine; mothers of such infants should limit caffeine intake. Caffeine is found in coffee, tea, chocolate, and many soft drinks.
Herbs and herbal teas are becoming more widely used during lactation. Although some are considered safe, others contain pharmacologically active compounds that may have detrimental effects. A thorough history should include the composition of any herbal remedies. Each remedy should then be evaluated for its compatibility with breastfeeding. A regional poison control center may provide information on the active properties of herbs (
Environmental contaminants. Except under unusual circumstances, breastfeeding is not contraindicated because of exposure to environmental contaminants such as DDT (an insecticide) and tetrachloroethylene (used in dry cleaning) (
Special considerations
The breastfeeding mother may experience some common problems. In the majority of cases, these complications are preventable if the mother receives appropriate education about breastfeeding (see Teaching Guidelines box).
Early recognition and resolution of these problems is important to prevent interruption of breastfeeding and to promote the mother’s comfort and sense of well-being. Emotional support provided by the nurse or lactation consultant is essential to help allay the mother’s frustration and anxiety and to prevent early cessation of breastfeeding.
Engorgement. Engorgement is a common response of the breasts to the sudden change in hormones and the presence of increased volume of milk. It usually occurs on the third to fifth day postpartum when the “milk comes in” and lasts approximately 24 hours. Blood supply to the breasts increases and causes swelling of tissues surrounding the milk ducts. The duct may be pinched shut, preventing the milk from flowing. The breasts are firm, tender, swollen, hot, and may appear shiny and red. The tenderness and swelling extend into the axilla. The areolae are firm and the nipples may flatten, making it difficult for the baby to latch on. Because back pressure on full milk glands inhibits milk production, if milk is not removed from the breasts, the milk supply may diminish.
When engorgement occurs, the nurse should assure the mother that this is a temporary condition usually resolved within 24 hours. The mother is instructed to feed every 2 hours, softening at least one breast, and pumping the other breast to soften. Pumping during engorgement will not cause a problematic increase in milk supply.
Because of the swelling of breast tissue surrounding the milk glands’ ducts, ice packs are recommended in a 15 to 20 minutes on, 45 minutes off rotation between feedings. The ice packs should cover both breasts. Large bags of frozen peas or corn make easy packs and can be refrozen between uses.
Raw cabbage leaves placed over the breasts between feedings may help reduce the swelling (Roberts, 1995). The mother washes the cabbage leaves and places them in her freezer until they are cold, and then places them over her breasts. The leaves are replaced when they begin to wilt. Although the exact mechanism of action of cabbage leaves in treatment of engorgement is not understood, it is thought that continuous application might decrease milk supply. They are often effective for formula-feeding mothers who want their milk to “dry up.”
Antiinflammatory medications such as ibuprofen may help reduce pain and swelling associated with engorgement. Mothers often have an elevated temperature and experience achiness in their breasts; ibuprofen can help remedy this.
Because heat increases blood flow, application of heat to an already congested breast is usually counterproductive. Occasionally, however, standing in a warm shower will start the milk leaking, or the mother may be able to manually express enough milk to soften the areola enough for the baby to be able to latch on and feed.
Sore nipples. Mild nipple discomfort at the beginning of feedings or mild nipple tenderness during the first few days of breastfeeding is common. Severe soreness and abraded, cracked, or bleeding nipples are not normal and most often result from poor positioning, incorrect latchon, improper suck, or a monilial infection. Many women expect breastfeeding to be painful based on stories they have heard from family and friends; however, breastfeeding is not supposed to be painful. Limiting the time at the breast will not prevent sore nipples; the key to preventing sore nipples is correct breastfeeding technique.
For the first few days after birth, the mother may experience some tenderness with the infant’s initial sucks. This should quickly dissipate as the milk begins to flow and acts as a lubricant. To make the initial sucks less painful, the mother can express a few drops of milk to moisten the nipple and areola before latch-on. The mother should ensure that the baby is well supported, is in straight body alignment, and has no pressure on the back of her or his head. The baby’s nose, cheeks, and chin should be touching the breast, and the mother should be supporting the breast with her hand during the early feedings. The nurse helps to reposition as necessary to try to resolve the nipple discomfort.
If the mother reports a pinching sensation of the nipple as the baby sucks, it may be helpful to gently pull down on the side of the baby’s jaw while he or she is sucking to increase the amount of breast tissue in the baby’s mouth. If the nipple pain continues, the mother needs to remove the baby from the breast, breaking suction with her finger in the baby’s mouth. She then attempts latch-on again, making sure the baby’s mouth is open wide before the baby is pulled quickly to the breast (see Fig. 5).
The infant’s suck can be assessed by the nurse or lactation consultant by inserting a clean gloved finger in the baby’s mouth and stimulating the baby to suck. If the baby is not extruding his or her tongue over the lower gum and the mother reports pain or pinching with sucking, the baby may have a short frenulum (commonly referred to as being “tongue-tied”) (Messner et al., 2000). Sometimes this is corrected surgically to free the tongue for less painful, more effective breastfeeding.
The treatment for sore nipples is first to correct the cause. Once the problem is identified and corrected, sore nipples should heal within a few days, even though the baby continues to breastfeed regularly.
When sore nipples occur, it is more comfortable to start the feeding on the least sore nipple. Applying ice to the nipple for 2 to 3 minutes provides a numbing effect that increases comfort with latch-on. After feeding, the nipples are wiped with water to remove the baby’s saliva. A few drops of milk can be expressed, rubbed into the sore area, and allowed to air dry. It is usually soothing to apply a cooled, steeped caffeinated tea bag to sore nipples (tannic acid may help promote healing). The tea bag is “dabbed” on the nipples and should not be left in place for longer than 1 to 2 minutes. Warm water compresses may also be comforting (Lavergne, 1997).
If nipples are extremely sore or damaged and the mother cannot tolerate breastfeeding, she may be advised to use an electric breast pump for 24 to 48 hours to allow the nipples to begin healing before resuming breastfeeding. It is important that the mother use a pump that will effectively empty the breasts.
Sore nipples should be open to air as much as possible. Breast shells worn inside the bra allow for air to circulate, while keeping clothing off sore nipples.
Flexible nipple shields have been marketed as a treatment for sore nipples; however, they do not protect the nipples and can actually chafe the nipple as the infant sucks. There is also danger of the baby not receiving adequate milk flow through the shield because it is difficult for most infants to get far enough back on the breast to adequately compress the lactiferous sinuses and get the milk to flow. There are special situations in which nipple shields are useful; however, they should be used only by trained lactation consultants who closely monitor the infant’s intake of milk and growth.
Monilial infections. Sore nipples that occur after the newborn period are often due to a monilial (yeast) infection. The mother usually reports severe nipple pain and tenderness, burning or stinging, and may have sharp, shooting, burning pains in the breasts during and after feedings. The nipples appear somewhat pink and shiny or may be scaly or flaky; there may be a visible rash, small blisters, or thrush. Most often, the pain is out of proportion to the appearance of the nipple. Yeast infections of the nipples and breast can be excruciatingly painful and can lead to early cessation of breastfeeding if not recognized and treated promptly.
Babies may or may not exhibit symptoms of monilial infection. Oral thrush and a red, raised diaper rash are common indications of a yeast infection. An affected infant is often very fussy and gassy. When feeding, the baby is likely to pull off the breast soon after starting to feed, crying with apparent pain. The infant may be biting or gumming at the breast.
The most common predisposing factors for yeast infections of the breast include previous antibiotic use, vaginal yeast infections, and nipple damage.
Mothers and babies must be treated simultaneously, even if the infant has no visible signs of infection. Treatment for the mother is typically an antifungal cream applied to the nipples after feedings. Most pediatricians prescribe an oral antifungal medication, such as nystatin, for infants. Treatment should continue for at least 7 days after symptoms begin to improve. Careful handwashing is essential to prevent the spread of yeast.
Plugged milk ducts. A milk duct may become plugged or clogged, causing an area of the breast to become swollen and tender. This area typically does not empty or soften with feeding or pumping. There may also be a small white pearl on the tip of the nipple; this is the curd of milk blocking the flow. The mother is afebrile and has no generalized symptoms.
Plugged milk ducts are most often the result of inadequate emptying of the breast. This may be due to clothing that is too tight, a poorly fitting or underwire bra, or always using the same position for feeding.
Application of warm compresses to the affected area and to the nipple before feeding helps promote emptying of the breast and release of the plug. (A disposable diaper filled with warm water makes an easy compress.)
Frequent feeding is recommended, with the baby beginning the feeding on the affected side to foster more complete emptying. The mother is advised to massage the affected area while the baby nurses or while she is pumping. Varying feeding positions and feeding without wearing a bra may be useful in resolving a plugged duct.
If the mother develops fever or flulike symptoms, she may have developed mastitis and should notify her health care provider. Plugged milk ducts do not necessarily cause mastitis, but milk stasis may increase the susceptibility to a breast infection.
Mastitis. A breast infection, or mastitis, is characterized by the sudden onset of flulike symptoms, including fever, chills, body aches, and headache. (Flulike symptoms in a breastfeeding mother should be considered indicative of mastitis, until proven otherwise.) There is localized breast pain and tenderness and a hot, reddened area on the breast, often resembling the shape of a pie wedge (see Fig. 4). Mastitis most commonly occurs in the upper outer quadrant of the breast; it may affect one or both breasts.
Certain factors may predispose a woman to mastitis. Inadequate emptying of the breasts is common, related to engorgement, plugged ducts, a sudden decrease in the number of feedings, abrupt weaning, or wearing underwire bras. Sore, cracked nipples may lead to mastitis by providing a portal of entry for causative organisms (Staphylococcus, Streptococcus, and Escherichia coli are most common) (Osterman & Rahm, 2000). Stress and fatigue, ill family members, breast trauma, and poor maternal nutrition are also predisposing factors for mastitis (Featherston, 1998).
Breastfeeding mothers should be taught the signs of mastitis before they are discharged from the hospital or birth center, and they need to know to call the health care provider promptly if the symptoms occur. Treatment includes antibiotics such as cephalexin or dicloxacillin and analgesics/antipyretic medications such as ibuprofen. Rest is extremely important; the mother is advised to sleep whenever the baby sleeps. The mother should feed the baby or pump frequently, striving to adequately empty the affected side. Warm compresses to the breast before feeding or pumping may be useful. Adequate fluid intake and a balanced diet are important for the mother with mastitis.
Complications of mastitis include breast abscess, chronic mastitis, or fungal infections of the breast. Most complications can be prevented by early recognition and treatment. Mastitis is the cause of cessation of breastfeeding for a number of women (Osterman & Rahm, 2000).
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TEACHING GUIDELINES Common Breastfeeding Problems ENGORGED BREASTS Engorgement usually occurs 3 to 5 days after birth and lasts 12 to 24 hours. It is the result of sudden hormonal changes and increased milk volume. Blood supply to the breasts increases and causes swelling of tissues surrounding the milk ducts. The ducts may be pinched shut, so that the milk does not flow. The breasts are firm, tender, hot, and may appear shiny and taut. The tenderness extends into the axilla. The unyielding areola makes it difficult for the infant to latch on. If milk is not removed from the breasts, milk production will decrease and the milk supply may suffer. Prevention 1. Breastfeed frequently as milk is “coming in”—at least every 2 to 3 hours during the day, with only one longer interval at night of 4 to 5 hours. 2. Encourage baby to feed at least 15 to 20 minutes on each breast or until at least one breast softens per feeding. Treatment 1. Feed every 2 hours, softening at least one breast per feeding, and pump as needed to soften second breast. Pumping during engorgement will not cause a problematic increase in milk supply. 2. Apply ice packs to breasts for 15 to 20 minutes in between feedings to reduce swelling. 3. Place raw cabbage leaves on breasts in between feedings; replace when wilting (Roberts, 1995). CAUTION: Continuous application may decrease milk supply. 4. It may be helpful to apply warm compresses or stand in warm shower just before feeding to foster relaxation and let-down. Use heat cautiously, since it may increase swelling. 5. Take an antiinflammatory analgesic (ibuprofen) to help decrease swelling and pain. 6. Gently massage breasts during nursing to help empty firmer areas. 7. To soften areola for easier latch-on, a manual or electric pump can be used if manual expression is not effective. If the baby is not effective in softening the breast, a pump can be used to remove residual milk. Milk can be fed to the baby or frozen for future use. SORE NIPPLES Mild nipple discomfort at the beginning of feedings or mild nipple tenderness during the first few days is not abnormal. Severe soreness and abraded, cracked, or bleeding nipples are not normal and most often result from poor positioning or incorrect latch-on. Monilial infection of the nipples causes severe soreness, stinging, or burning, and nipples appear shiny pink. Prevention 1. Position baby at level of breast with baby’s mouth directly in front of nipple. 2. Express milk to moisteipple. Latch baby on only when mouth is open wide. Hold baby in close while nursing, with infant’s nose, cheeks, and chin touching the breast. If sucking is painful after first 1 to 2 minutes, break suction and repeat latch-on. Treatment 1. Assess positioning and latch-on. Position baby at level of breast with body in straight alignment and mouth directly in front of nipple. Support breast with C-hold: four fingers below areola and thumb on top. Express milk to lubricate nipple. Tickle baby’s lower lip with nipple until mouth opens widely. Pull baby quickly onto breast so that mouth covers nipple and at least 2-cm diameter of areola. If nipple pain persists after first few sucks, break suction and latch on again; repeat until pain is eliminated and a “tugging” sensation is felt. 2. Evaluate baby’s sucking during feeding, noting position of tongue. 3. Begin feedings on least sore nipple. Apply ice to nipple 2 to 3 minutes before latch-on for numbing effect. 4. After feeding, wipe nipple with water to remove baby’s saliva. 5. Express a few drops of milk and rub into nipples. Allow to air dry 6. It may be helpful to blot a steeped, cooled caffeinated tea bag oipples (tannic acid may help promote healing). Warm water compresses may also be comforting (Lavergne, 1997). 7. Modified lanolin can be applied to the nipples and areola. Do not use if allergic to wool or if a monilial infection on the nipples is suspected (Huml, 1995). 8. Breast shells may increase comfort by keeping clothing off nipples. Leave nipples open to air as much as possible. PLUGGED MILK DUCT A milk duct may become plugged, causing an area of the breast to be swollen and tender. There may be a small white pearl on the nipple; this is the curd of milk blocking the milk flow. Plugged ducts are caused by inadequate emptying of the breasts, poor positioning for feeding, always using the same position for feeding, or wearing a bra (underwire) or clothing that is too tight. Treatment 1. Apply warm compresses to affected area of breast and to nipple before feeding. 2. Offer the sore breast first to foster more complete emptying. 3. Breastfeed more frequently and for longer periods. Massage swollen area while feeding. 4. Vary positions with every feeding MASTITIS Mastitis, or breast infection, is commonly caused by bacteria normally present in the baby’s mouth (Staphylococcus aureus). Predisposing factors are cracked nipples, plugged ducts, breast trauma (poor latch-on, infant teething), and maternal exhaustion. Flulike symptoms, such as fever, chills, body aches, and headache, may occur, along with breast pain and redness. Treatment 1. Notify the health care provider when symptoms occur. Antibiotic treatment for 10 days is often ordered. 2. Rest; increase fluid intake; take over-the-counter (OTC) analgesic/antipyretic. 3. Breastfeed more often. Apply warm compresses to breast before feedings. 4. If breastfeeding is too painful or ineffective in relieving fullness, use electric breast pump. INSUFFICIENT MILK SUPPLY (OR SLOW WEIGHT GAIN IN INFANT) Insufficient milk supply is often associated with slow weight gain or weight loss in the breastfed infant. Causes may include infrequent (fewer than eight feedings per day) or inadequate emptying of the breasts, poor positioning and/or latch-on, sleepy baby, abnormal sucking, unrelieved engorgement, sore nipples, maternal stress or exhaustion, pregnancy, use of oral contraceptives, or previous breast surgery. In addition to weight loss or poor weight gain, the infant may have fewer than six to eight wet diapers and fewer than two stools per day and may not seem satisfied after feedings. Treatment 1. Increase number and length of feedings. 2. Awaken sleepy baby for feedings. 3. Examine positioning and latch-on techniques, and infant sucking. 4. Increase maternal fluid intake and nutrition, as well as rest. 5. Use imagery, relaxation, and breast massage to promote let-down reflex. 6. Use “alternate breast massage” during feedings (when baby stops sucking, massage breast from periphery toward nipple; continue throughout feeding). 7. If supplementation is needed, use nursing supplementer device to provide extra nutrition while nursing or offer supplement in cup, spoon, or bottle (use bottle only if no problems with latch-on and sucking). 8. Consult health care provider about maternal food supplements or medications that may help to increase milk supply. |
ROLE OF THE NURSE IN PROMOTING SUCCESSFUL LACTATION
Providing a birthing environment where breastfeeding is initiated and supported is an important nursing responsibility. “Baby Friendly” status for a hospital is one means to promote a family-centered approach that facilitates breastfeeding. The Baby Friendly Hospital Initiative, sponsored by the World Health Organization and UNICEF, was founded to encourage institutions to offer optimal levels of care for lactating mothers. When a hospital achieves the “Ten Steps to Successful Breastfeeding for Hospitals,” it is recognized as a
Nurses play a major role in breastfeeding education and support for new parents (see Research box). Nurses often work with lactation consultants in hospitals, physicians’ offices, or community settings. Although the vast majority are registered nurses, lactation consultants come from a variety of educational backgrounds such as nutrition, physical and occupational therapy, home economics, psychology, social work, education, or the basic sciences. Lactation consultants have had specialized postbaccalaureate education, training, and clinical experience working with breastfeeding mothers and have passed a certifying examination that requires meeting defined academic and clinical experience criteria.
Nurses in prenatal settings can educate the mother and her partner about the advantages of breastfeeding and explore reasons why they may prefer bottle-feeding. They can provide expectant parents with current reading materials and information about prenatal classes. At each encounter, the nurse can answer questions and provide additional information as needed.
Assessment of the mother’s breasts and nipples during pregnancy is important. Flat or inverted nipples are identified.
The nurse should determine whether the woman has had any breast surgery. Breast reduction or augmentation may interfere with the ability to produce milk and transfer it successfully to the baby.
In the immediate postpartum period, the nurse is instrumental in helping the mother initiate breastfeeding as soon as possible after birth. Encouraging parents to keep the baby in the mother’s room (rooming in) provides the opportunity for the mother to learn to recognize feeding cues and to feed the baby when these cues are present. The nurse provides help with positioning and latch-on until the mother can accomplish this independently. Explanations are given early regarding frequency and duration of feedings, how to wake a sleepy baby, and how to determine if the baby is getting enough milk. Information about the transition to mature milk (milk coming in) and how to prevent or deal with engorgement is needed. The mother is informed about the prevention and treatment of sore nipples and about signs of mastitis.
Parents often expect that because breastfeeding is “natural,” it will come naturally for both mother and baby. This misconception must be clarified early so that parents may view breastfeeding as a learning process and not have unrealistic expectations. All health care providers who are knowledgeable about breastfeeding can offer needed support and encouragement to parents, helping to instill a sense of confidence (Fig. 13).
Fig. 13 Mother and infant enjoying breastfeeding. (Courtesy Marjorie Pyle, RNC, Lifecircle,
FOLLOW-UP AFTER HOSPITAL DISCHARGE
Problems with sore nipples, engorgement, mastitis, and neonatal jaundice are likely to occur after discharge. Thus it is the role of the nurse to educate and prepare the mother for problems she may encounter once she is home. Objective data should be used to assess breastfeeding; tools are available for this purpose (Johnson, Brennan, & Flynn-Tymkow, 1999). It is critical that the mother be given a list of resources for help with breastfeeding concerns and that she understands when to call for assistance. Community resources for breastfeeding mothers include lactation consultants in hospitals or birth centers, physicians’ offices, or in private practice; nurses in pediatric or obstetric offices; support groups such as La Leche League; and peer counseling programs (such as those offered through WIC) (see Resources at end of chapter).
Telephone follow-up by hospital, birth center, or office nurses within the first day or two after discharge can provide a means to identify any problems and offer needed advice and support. The AAP recommends that infants discharged before 48 hours of age be seen by a health care provider within 48 hours and have an office visit within 7 days after discharge. In some settings and circumstances, home care follow-up is available for mothers after hospital discharge. The readmission rate of infants who are breastfed is lower for those who receive a home visit than for those who do not receive a home visit (Johnson et al., 1999).
Evaluation
Evaluation is based on the expected outcomes, and the plan of care is revised as needed based on the evaluation (see Plan of Care).
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PLAN OF CARE Breastfeeding and Infant Nutrition NURSING DIAGNOSIS ineffective breastfeeding related to knowledge deficit of mother as evidenced by ongoing incorrect latch-on technique Expected Outcome Patient will express increased satisfaction with breastfeeding, and neonate will exhibit satisfaction of hunger and sucking needs. Nursing Interventions/Rationales Assess patient’s knowledge and motivation for breastfeeding to acknowledge patient’s desire for effective outcome and provide starting point for teaching. Observe a breastfeeding session to provide database for positive reinforcement and problem identification. Describe and demonstrate ways to stimulate the sucking reflex, various positions for breastfeeding, and the use of pillows during a session to promote patient and neonatal comfort and effective latch-on. Monitor neonatal position of mouth on areola and position of head and body to give positive reinforcement for correct latch-on position or to correct poor latch-on position. Teach patient ways to stimulate neonate to maintain an awake state by diapering, unwrapping, massaging, or burping to complete a breastfeeding thoroughly and satisfactorily. Give patient information regarding lactation diet, expression of milk by hand or pump, and storage of expressed breast milk to provide basic information. Make sure patient has written information on all aspects of breastfeeding to reinforce verbal instructions and demonstrations. Refer to support groups and lactation consultant if needed to provide further information and group support. |
FORMULA FEEDING
REASONS FOR FORMULA FEEDING
The decision to feed a baby infant formula may be the result of the mother’s or partner’s personal preference, the influence of other significant family members, or simply a lack of familiarity with breastfeeding. Occasionally, there is no other option: the mother may have extensive breast scarring or may have had a bilateral mastectomy; the mother may be taking medications that preclude breastfeeding; or the baby may be adopted. Some mothers are able to induce lactation for an adopted baby. Rarely, an infant may have galactosemia and must be fed a lactose-free formula.
Infant formula may be used to supplement breastfeeding if the mother’s milk supply is inadequate. It may also be fed to the baby if the mother will be away and wishes to leave a bottle of formula instead of expressed breast milk.
Formula feeding is also recommended for mothers who are infected with the human immunodeficiency virus.
PARENT EDUCATION
Inexperienced mothers and fathers who are formula feeding their infants usually need teaching, counseling, and support. They may need assistance with the feeding process and with any problems they may experience. Some parents who are formula feeding express concern that the baby will suffer as a result of their decision. Emphasis on the beneficial use of feeding times for close contact and socializing with the infant can help relieve some of this concern.
Readiness for feeding
The first feeding of formula is ideally given after the initial transition to extrauterine life is made. Feeding-readiness cues include such things as stability of vital signs, presence of bowel sounds, an active sucking reflex, and those described earlier for breastfed babies.
Before the first formula feeding, some institutions have a policy of offering sips of sterile water to the newborn to assess patency of the GI tract and absence of tracheoesophageal fistula. If the infant sucks and swallows the water without difficulty, formula is then offered.
Feeding patterns
Typically, a newborn at first will drink 10 to 15 ml of formula at a feeding. Intake gradually increases during the first week of life. Most babies are drinking 90 to 150 ml at a feeding by the end of the second week, or sooner. Generally, a baby who weighs less than 4.5 kg takes in approximately 840 ml of formula every 24 hours after the newborn period. A baby who weighs more than 4.5 kg ingests approximately 960 ml in 24 hours.
The newborn infant should be fed at least every 3 to 4 hours, even if that requires waking the baby for the feedings. The infant showing an adequate weight gain can be allowed to sleep at night and fed only on awakening. Most newborns need 6 to 8 feedings in 24 hours, and the number of feedings decreases as the infant matures. Usually, by 3 to 4 weeks after birth a fairly predictable feeding pattern has developed. Scheduling feedings arbitrarily at predetermined intervals may not meet a baby’s needs, but initiating feedings at convenient times often moves the baby’s feedings to times that work for the family.
Mothers will usually notice increases in the infant’s appetite at 7 to 10 days, 3 weeks, 6 weeks, 3 months, and 6 months. These appetite spurts correspond to growth spurts. The amount of formula per feeding should be increased by approximately 30 ml to meet the baby’s needs at these times.
Feeding techniques
Parents who choose formula feeding ofteeed education regarding feeding techniques. Formula can be fed at room temperature or warmed. Formula should never be heated in a microwave oven. Microwaving does not heat evenly and can cause encapsulated boiling bubbles to form in the center of the liquid. This may not be detected when checking drops of milk for temperature. Babies have sustained severe burns to the mouth, throat, and upper GI tract as a result of microwaved milk (
During feedings parents should be encouraged to sit comfortably, holding the infant closely in a semi-upright position. Feedings provide opportunities to bond with the baby through touching, talking, singing, or reading to the infant. Parents should consider feedings as a time of peaceful relaxation with the baby.
A bottle should never be propped with a pillow or other inanimate object and left with the infant. This practice may result in choking, and it deprives the infant of important interaction during feeding. Moreover, propping the bottle has been implicated in causing nursing bottle caries, or decay of the first teeth resulting from continuous bathing of the teeth with carbohydrate-containing fluid as the infant sporadically sucks the nipple.
The bottle should be held so that fluid fills the nipple and none of the air in the bottle is allowed to enter the nipple (Fig. 14). After the newborn period the infant who falls asleep, turns aside the head, or ceases to suck usually is signaling that enough formula has been taken. Parents should be taught to look for these cues and avoid overfeeding, which could contribute to obesity.
Most infants swallow air when fed from a bottle and should be given a chance to burp several times during a feeding (Fig. 15).
Fig. 14 Grandfather feeding infant granddaughter. Note angle of bottle that ensures milk covers nipple area. (Courtesy Kim Molloy,
Fig. 15 Positions for burping an infant. A, Sitting. B, On the shoulder. C, Across the lap.
Bottles and nipples
Various brands and styles of bottles and nipples are available to parents. Most babies will feed well with any bottle and nipple. It is important that the bottles and nipples be washed in warm soapy water, using a bottle and nipple brush to facilitate thorough cleansing. Careful rinsing is necessary. Boiling of bottles and nipples is not needed unless there is some question about the safety of the water supply.
Infant formulas
Commercial formulas. Because human milk is species specific to meet the needs of the human infant, it is used as the standard for all infant formulas. Commercial infant formulas are designed to resemble human milk as closely as possible, although none has ever duplicated it.
Infants who are not breastfed should be given commercial formulas. If this is too expensive, the family would likely be eligible for services through the WIC program, which provides iron-fortified infant formula. Cow’s milk is the basis for most infant formulas, although soy-based and other specialized formulas are available for the infant who cannot tolerate cow’s milk.
Commercial formulas are available in three forms: powder, concentrate, and ready-to-feed. All are equivalent iutritional content, but they vary considerably in price. Powdered formulas are least expensive and are convenient because they are lightweight and require no refrigeration before mixing with water. Concentrated liquid formula is more expensive than powder. It is diluted with water and can be stored in the refrigerator for 24 hours after opening. Ready-to-feed formula is most expensive but easiest to use. The desired amount is poured into the bottle. The opened can is safely refrigerated for 24 hours. This type of formula can also be purchased in individual disposable bottles for the most convenient feeding.
Special formulas. Some infants have an allergic reaction to cow’s milk formula. They may experience diarrhea, rash, colic, vomiting, and, in extreme cases, failure to thrive. Some of these infants may be able to tolerate a soy milk formula; however, some are allergic to soy protein. If hypersensitivity to cow’s milk protein is suspected, a hydrolyzed casein formula may be effective. However, these special formulas are expensive. Some women may be able to begin breastfeeding or, in life-threatening cases, obtain human milk through a milk bank, at least temporarily.
Formula preparation. The commercial infant formula must include label directions for preparation and use of the formula with pictures and symbols for the benefit of individuals who cannot read. Some manufacturers translate the directions into various languages, such as Spanish, French, Vietnamese, Chinese, and Arabic, to prevent misunderstanding and errors in formula preparation. It is important to impress on families that the proportions must not be altered—that is, neither diluted to extend the amount of formula nor concentrated to provide more calories.
Although manufacturers of commercial formulas include directions for preparing their products, the nurse should review formula preparation with the mother. It is especially important that formula be mixed properly. The newborn’s kidneys are immature; giving the infant overly concentrated formula may provide protein and minerals in amounts that exceed the kidneys’ excretory ability. In contrast, if the formula is diluted too much (sometimes done to save money), the infant does not consume sufficient calories and does not grow well.
Sterilization of formula rarely is recommended when families have access to a safe public water supply. Instead, formula is prepared with attention to cleanliness. When water from a private well is used, parents should be advised to contact the health department to have a chemical and bacteriologic analysis of the water done before using the water in formula preparation. The presence of nitrates, excess fluoride, or bacteria may be harmful to the infant.
If the sanitary conditions in the home appear unsafe, it would be better to recommend the use of ready-to-feed formula or to teach the mother to sterilize the formula. The two traditional methods for sterilization are terminal heating and the aseptic method. In the terminal heating method, the prepared formula is placed in the bottles, which are topped with the nipples placed upside down and covered with the caps, and then sealed loosely with the rings. The bottles are then boiled together in a water bath for 25 minutes. In the aseptic method, the bottles, rings, caps, nipples, and any other necessary equipment, such as a funnel, are boiled separately, after which the formula is poured into the bottles. Any formula left in the bottle after the feeding should be discarded because the baby’s saliva has mixed with it. (Instructions for formula preparation and feeding are provided in the Teaching Guidelines box.)
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TEACHING GUIDELINES Formula Preparation and Feeding Your newborn baby will be hungry about every 2V2 to 3 hours but sometimes may go 3 to 4 hours between feedings. The newborn should not go longer than 4 hours between feedings until a weight gain pattern is established —usually in about 2 weeks. Your baby needs to be awake before being fed. If your baby is sleepy, massage the baby’s back and chest and talk to him or her. Your baby’s feedings will change a lot in the first week after birth. The first day, most babies only drink 7.5 to 15 ml of formula at a feeding. By the time they are a week old, most babies drink 30 to 60 ml at a feeding and then gradually increase their intake as they grow. If you do not use all of the formula at a feeding, throw away what is left, because it spoils once it has mixed with the baby’s saliva. You may want to write down how many milliliters your baby drinks each day. When you take the baby in for a checkup, the physician or nurse will ask you about how much formula the baby drinks. By 1 week of age, most babies who weigh 7 to 10 Ib are drinking about 840 ml in 24 hours. Smaller babies drink a little less. Babies weighing more than 10 Ib drink about 960 ml each day. To feed your baby, place the nipple in the baby’s mouth on the tongue. It should touch the roof of the mouth to stimulate the baby’s sucking reflex. Hold the bottle like a pencil. Keep the bottle tipped so that the nipple stays filled with milk and the baby does not suck in air. Hold your baby close for feedings. This should be a pleasant time for social interaction and cuddling. Some newborns take longer to feed than others. Be patient. It may be necessary to keep the baby awake and encourage continued sucking. Moving the nipple gently in the baby’s mouth may stimulate more sucking. Some newborns swallow air when sucking. Give your baby a chance to burp several times during early feedings. As your baby gets older and you get more experienced, you will know when to stop for burping. If your baby fusses or cries in between feedings, check the diaper to see if he or she needs to be changed and see if the baby needs to be picked up and cuddled. If the baby continues to cry and acts hungry, then he or she needs to be fed. Babies do not get hungry on a schedule. Place your baby on the right side after feedings so that air bubbles can come up easily. A rolled-up receiving blanket or small towel against the baby’s back will keep him or her in the side-lying position. Some babies sleep better on their backs. To decrease the risk of sudden infant death syndrome, however, it is important not to put your baby to sleep stomach down. The stools (bowel movements) of a formula-fed newborn are yellow and soft but formed. The baby will probably have a stool during or after each feeding in the first 2 weeks, but this will then gradually decrease to one to two stools each day. SAFETY TIPS • Babies should be held and never left alone while feeding. Do not prop the bottle. The baby could inhale formula or choke on any that was spit up. • Know how to use the bulb syringe in case your baby should choke. • Babies who are put to bed with a propped bottle of formula or juice are at a high risk for dental caries when their first teeth come in (see p. 539 for rationale). FORMULA PREPARATION • Wash your hands and clean the bottle, nipple, and can opener carefully before preparing formula. • If new nipples seem too hard, they can be softened by boiling them in water for 5 minutes before use. • Read the label on the container of formula and mix it exactly according to the directions. • Use tap water to mix concentrated or powdered formula unless directed otherwise by your baby’s physician or nurse. • Test the size of the nipple hole by holding a prepared bottle upside down. The formula should drip from the nipple. If it runs in a stream, the hole is too big and should not be used. If it has to be shaken for the formula to come out, the hole is too small. You can either buy a new nipple or enlarge the hole by boiling the nipple for 5 minutes with a sewing needle inserted in the hole. • If a nipple collapses when your baby sucks, loosen the nipple ring a little to let in air. • Opened cans of ready-to-feed or concentrated formula should be covered and refrigerated. Any unused portions must be discarded after 48 hours. • Bottles or cans of unopened formula can be stored at room temperature. • If the formula is refrigerated, warm it by placing the bottle in a pan of hot water. Never use a microwave to warm any food to be given to a baby. Test the temperature of the formula by letting a few drops fall on the inside of your wrist. If the formula feels comfortably warm to you, it is the correct temperature. |
Vitamin and minуral supplemуntation
Commercial iron-fortified formula contains all the nutrients needed by the infant for the first 6 months of life. After 6 months the only mineral supplementation required is 0.25 mg of fluoride per day if the local water supply is not fluoridated (
Weening
The bottle-fed baby will gradually learn to use a cup, and the parents will find that they are preparing fewer bottles. Commonly, the feeding before bedtime is the last one to remain. Babies have a strong need to suck, and the baby who has had the bottle taken away too early or abruptly will compensate with nonnutritive sucking on his or her fingers or thumb, a pacifier, or even his or her own tongue. Weaning from a bottle should therefore be done gradually because the baby has learned to rely on the comfort that sucking provides.
