Chapter 9 Newborn Care Newborn infants are unique in their physiology and health problems. The neonatal period is characterized by the transition to extrauterine life and rapid growth and development. Comprising just the first 28 days of life, this period carries the highest mortality risk during childhood. Despite being less than 2% of the under-5 childhood, the newborn period accounts for over half of U-5 child mortality. Therefore, optimum care improves children’s survival and lays the foundation for optimal long-term physical and neurocognitive development. ‘Newborn health is the key to child health and survival. ‘The current neonatal mortality rate (NMR) in India is 20 per thousand live births (SRS 2020). India has about five lakh neonatal deaths each year. Neonatal deaths account for 63% of U-5 and 71% of infant deaths. First-week deaths (<7 days; early neonatal deaths) at 15 per thousand live births alone account for 47% of total under-5 deaths at 32 per thousand live births (SRS 2020). Of all the neonatal deaths, about 40% occur within the first 24 hours, half within 72 hr, and three-fourths within one week of birth. Preterm birth complications account for 44% of all neonatal deaths and constitute the most important cause of neonatal mortality (Fig. 9.1). Bacterial infections (sepsis and pneumonia) contribute to 20% of neonatal deaths. Birth asphyxia (19%) and congenital malformations (11%) are other important causes of neonatal deaths. Newborns with low birth weight (LBW) constitute nearly one-third of the neonatal population but account for three-fourths of neonatal deaths. The mother’s health and care during pregnancy and childbirth profoundly influence neonatal outcomes. Competency: PE20.1 DEFINITIONS (Fig. 9.2) Neonatal period: From birth to under four weeks (0 to 27 days or 1 to 28 days, depending on whether the first day has been taken as day 0 or day 1 of life) of age. The early neonatal period is the first week of life (<7 days or © Ramesh Agarwal O Amanpreet Sethi ro ind Prematurity oy Cen Fig. 9.1: The leading causes of neonatal deaths in India (WHO 2020) (Courtesy: Dr M Jeeva Sankar) <168 hr). The late neonatal period extends from the 7 to the 28 days. Post neonatal period: Period of infancy from 28 days to +<365 days (<1 year) of life. Perinatal period: The perinatal period extends from the 22nd week of gestation (2154 days or fetus weighing 500 g or more) to less than 7 days of life. Live birth: A product of conception, irrespective of weight or gestational age, that, after separation from the mother, shows any evidence of life such as breathing, heartbeat, pulsation of the umbilical cord, or definite movement of voluntary muscles. Fetal death: A fetal death is a product of conception that does not show any evidence of life after separation from the mother. Stillbirth (WHO): Fetal death at a gestational age of 228 weeks or weight 1000 g before or during the birth 1182awecks 28wesks S2wecks S4wecks ST weeks S9wooks 41 weeks 42 weeks Fig. 9.2: Gestation-based definitions in newborns. process. Many developed nations, suchas the USA and the UK, define stillbirths at 20 weeks of gestation ‘Term neonate: neonate is born between 37 and <42 weeks (259-293 days) of gestation. Preterm neonate: A neonate born before 37 weeks (<259 days) of gestation, irrespective of the birth weight. Post-term neonate: A neonate is born at a gestation age of 42. weeks or more (294 days or more). Late preterm neonate: A neonate born between 34 and 36 weeks and 6 days of gestation. Moderate preterm neonate: A neonate born between 34 and 33 weeks and 6 days of gestation. Very preterm neonate: A neonate born between 28 and 31 weeks and 6 days of gestation. Extreme preterm neonate: A neonate born less than 28 of gestation. Low birth weight (LBW) neonate: A neonate weighs less than 2500 g at birth, irrespective of the gestational age. Very low birth weight (VLBW) neonate: A neonate weighs less than 1500 g at birth, irrespective of the gestational age. Extremely low birth weight (ELBW) neonate: A neonate weighs less than 1000 g at birth, irrespective of the gestational age. ‘Neonatal mortality rate (NMR): Deaths of infants during the first 28 days of life per 1000 live births per year. Perinatal mortality ratio (PNMR): The number of perinatal deaths (stillbirths plus neonatal deaths before 7 days of life) per 1000 live births. It is designated as a ratio since the numerator is not the part of the denominator (for a rate, like in NMR, numerator must be part of the denominator). Competency: PE2O.3 Seucn) Around 6 lakh newborns die every year in India Approximately 19% of these deaths are atiributed to birth asphy? The term birth asphyxia connotes the inability of a newly born baby to establish optimum respiration after birth Birth asphyxia leads to progressive hypoxia, @ hypercapnia, hypoperfusion and acidosis. It affects all 8 major organsystems, including CNS, heart, GIT, and lungs. Itmay lead to multiorgan dysfunction. Hypoxic ischemic § encephalopathy (HIE) resulting from asphyxia may ead to B long-term neuromotor sequelae "Approximately 85% of all neonates born at term 2 gestation do not require resuscitation. The American Heart Association (AHA) and the American Academy of Pediatrics (AAP) have recently updated the resuscitation guidelines (2020). Around 10% of neonates require initial Steps of drying and stimulation, and approximately 5% require positive pressure ventilation at birth Pathophysiology of Asphyxic When a fetus does not receive enough oxygen, a brief period of rapid breathing occurs. Ifthe asphyxia continues, the respiratory movements cease, and the infant enters a period of apnea known as primary apnea. During primary apnea, the heart rate begins to fal, the neuromuscular tone gradually diminishes, but the blood pressure is preserved. Inmostinstances, tactile stimulation during this period will tiate respiration. If the asphyxia continues, the infant develops deep gasping respiration, the heart rate continues to fall, the blood pressure also begins to fall, and the infant becomes flaccid. The breathing becomes weaker until the infant takes the last gasp and enters a period of secondary apnea. The infant is now unresponsive to stimulation and does not spontaneously resume respiratory efforts unless resuscitation in the form of positive pressure ventilation (PPV) is initiated. As a result of fetal hypoxia, the infant may go through primary and secondary apnea phases before birth. Hence, apnea at birth may be either primary or secondary apnea. These two are clinically indistinguishable; the infant is not breathing in both instances, and the heart rate may be below 100 beats per minute. Hence, when faced with an apneic infant at birth, assume that the infantis experiencing secondary apnea and, therefore, institute full resuscitation without wasting too much time in tactile stimulation.Lung inflation During intrauterine life, the lungs do not pi gas exchange, which is taken care of by the placenta. Tung alveoli in the fetus are filled with fluid secreted by type Il alveolar cells. The process of fluid removal starts with the onset of labor. The fluid gets reabsorbed from the alveoli into the perivascular space and blood and lymphatic channels. The labor process may facilitate the removal of lung fluid, whereas removal is slowed when labor is absent (as in elective cesarean section). ‘Removal of lung fluid from the alveoli is facilitated by respiration soon after birth. The first few breaths after birth effectively expand the alveoli and replace the lung fluid with air. Problems in clearing lung fluid may occur in infants whose lungs have not inflated well with the first few breaths, such as those who are apneic at birth or havea weak initial respiratory effort as with prematurity or sedation. « Pulmonary Circulation ‘Oxygenation depends not only on air reaching the alveoli ‘B butalso on pulmonary circulation. After birth, pulmonary JB vesels dilate sesulting ina fall in pulmonary vascular resistance and increased blood flow. As the pulmonary 5B vessels remain constricted, there is hardly any blood flow = in the lungs during fetal life, © — Theasphyxiated infanthas hypoxemia and acidosis (low B pb), failing pulmonary vasodilation, and closure of ductus arteriosus (persistence of fetal circulation). Due to poor pulmonary blood flow, proper oxygenation of the body’s tissues does not occur as there is inadequate oxygen uptake in the lungs, even if the infant is adequately ventilated. In mildly asphyxiated neonates, the oxygen and pH are slightly lower; it may be possible to increase pulmonary blood flow by quickly restoring ventilation. However, pulmonary perfusion in severely asphyxiated infants may not improve with ventilation alone. The combination of oxygenation and correction of metabolic acidosis would ’be necessary to improve pulmonary blood flow. Crroutation Asphyxia redistributes the blood flow from nonwital to vital organs. There is reduced blood supply to the bowel, kidney, ‘muscles, and skin, while the blood flow to the heart and brain is relatively preserved (diving-in reflex). As asphyxia is prolonged, myocardial function and cardiac output deteriorate, and the blood flow to all the organs is further reduced. This sets in the stage for progressive organ damage. Preparing for Resusciation Even with knowledge of risk factors, we can predict asphyxia only in half of the cases. In the remaining half, asphyxia and the need for resuscitation would come as a surprise. Therefore, the team must view each delivery as an emergency and be ready to provide resuscitation and ‘manage asphyxia in the neonate. Preparation for Daiivery ‘There should be at least one person available who is solely responsible for the neonate and is capable of undertaking full resuscitation. In an anticipated need for resuscitation, more than one person may be needed. A coordinated team ‘effort is required to ensure adequate resuscitation: Inquire about antepartum and intrapartum tisk factors ‘Anticipate emergencies and plan accordingly .. Assemble a team and choose a team leader ‘Team leader delegates roles and responsibilities as per the competence of the team members ce. Use effective closed-loop communication (the listener repeats what has been said to him) £. Check the equipment and supplies (Table 9.1) g- Ask for additional help, if required. pooe Role of Apgar Scores in Resuscitation ‘The Apgar score is an objective method of evaluating the newborn’s condition (Table 9.2) Itis generally performed at I minute and again at 5 minutes after birth. However, resuscitation must be initiated before the 1-minute score is assigned. Therefore, the Apgar score is not used to guide the resuscitation. While the Apgar score does not help decide the need for resuscitation, the serial scores help in knowing how well the neonate responds to resuscitative efforts. Extended Apgar scores should be obtained every 5 minutes for up to 20 minutes, ifthe 5-minute Apgar score is less than 7. TABC of Resuscitation ‘The components of neonatal resuscitation can be summarized as TABC: ‘T-Temperature: Provide warmth, dry the neonate and remove the wet linen. Table 91: Neonatal resuscitation supplies and equipmica Suction equipment Mechanical suction Suction catheters 10, 12.0 14 F Meconium aspirator Bag and mask equipment Neonatal resustation bags tifa) Face-masts or both term and preterm babies) Oxygen with flow meter and bing Intubation equipment Layngoscope with staight blades no (preterm) and no. 1 (er) Extra bulbs and batteries oc aryngoscope) Endotachea tbesinernal ameter of 2.5, 3.0, 35 and-4.0mm) Medications Epinephrine Normal saline r Ringer lactate Naloxone hydrochloride Miscellaneous Linen, shoulder rol, gauze Raclant warmer Stethoscope Syringes 1,2, 9, 10,20, 50 ml Feeding tube 6F Umbilical catheters 3.5, 5 F Three way stopcocks GlovesTale 9.2: Apgar score ‘Sign 0 Color Blue or pale Heart rate Absent Reflex irtability No response Muscle tone Limp Respiration Absent A-Airway; Position the infant; clear the airway if required (by wiping or suctioning of baby’s mouth and nose). If necessary, insert an endotracheal (ET) tube to ensure an ‘open airway. B-Breathing: Tactile stimulation to initiate breathing, positive-pressure breaths using either bag and mask or bag and ET tube as necessary. C-Circulation: Stimulate and maintain blood circulation ‘with chest compressions and medications as indicated. ‘The resuscitation team must reach the birthing room well in time and interact with the obstetric and anesthesia team to elicit relevant information. Review the risk factors that can predispose the neonate to asphyxia. Ask these four pre-birth questions: (i) What is the gestation? (ji) ithe amniotic fluid clear or stained with meconium, (ii) Ifthere are additional risk factors as discussed before, and (iv) what is the plan for umbilical cord management? Resuscitation Algorithm Figure 9.3presents the algorithm of neonatal resuscitation. ‘At the time of birth, one should ask three questions about the newborn: 1. Term gestation? 2. Good muscle tone? (Flexed posture and active movements of the neonate denotes good tone) 3. Breathing or actively crying? If the answers to all three questions are “Yes’, the infant stays with the mother and receives “routine care.” Routine care consists of four steps: i, Warmth; Provided by putting the neonate directly on the mother’s abdomen and chest in skin-to-skin contact ii. Clearing of airway if required: Position the neonate and wipe the baby’s mouth and nose using a clean cloth—no need to suction routinely. iii, Dry the neonate using a dry and warm cloth. Remove toet linen and cover the baby. iv. Ongoing evaluation for vital parameters. Helping mothers in breastfeeding will facilitate an easy transition to an extrauterine environment. Delayed Cord Clampig (00C} In all neonates, preterm and term, that do not require resuscitation, cord clamping must be delayed for 30 to 60 seconds—delayed cord clamping (DCC). There is not enough ‘evidence to recommend DCC in neonates needing resuscitation. Iisuch neonates, clamp and cut the cord immediately and initiate resuscitation without delay. freee reese te eee eeeCeve=Led EE EEeS-eEE-CH EEE tEE-UEEE=He =eCeee-- eee Score 1 2 Body pink, extremities blue Body and extremities both pink Slow (<100 beavmin) Normal (<100 beat/min) Grimace Cough or sneeze Some flexion Active movements Ircegular/gasping Good strong cry If the answer to any of the three questions is “No”, the neonate requires at least some resuscitation. After cutting the cord, perform what is known as the “Initial steps.” Initial Steps Warmth PPlace the neonate under the heat source, preferably a radiant ‘warmer. Do not cover the neonate with blankets or towels to ensure visualization and allow the radiant heat to reach the baby. Dry and stimulate Dry the neonate adequately using pre-warmed linen, to prevent heat loss. Remove the wet linen. Suctioning and drying themselves provide enough stimulation to initiate breathing. If the newborn continues to have poor breathing, additional tactile stimulation can be provided by gently rubbing the trunk, back, and extremities. However, fone should not waste too much time providing tactile stimulation. Newborn Care Postioning Place the neonate on her back or side with the neck slightly extended (sniffing position). That keeps the airway open and facilitates breathing. Avoid hyperextension or flexion of the neck since either may interfere with respiration. To help maintain the correct position, one may place a rolled blanket or towel under the shoulders of the infant, elevating her by % or Linch off the mattress. This shoulder roll is particularly helpful, ifthe infanthas a prominent occiput resulting from molding, edema, IUGR, or prematurity (Fig. 9.4). Clear Airway, if Necessary If present, remove secretion from the airway by wiping the nose and mouth with a clean cloth or suctioning with a bulb syringe or a suction catheter. Suction mouth before nose ('M’ before ‘N’) to prevent aspiration in case the infant makes a breathing effort when the nose is suctioned. If the infant has copious secretions from the mouth, turn the head to one side to allow secretions to collect in the side of the mouth, where they can be easily removed, For suctioning, the catheter size should be 12 or 14 Fr. Keep the suction pressure around 80 mm Hig (100 cm 1,0) and no more than 100 mm Fig (130 cm H,). Do not insert the catheter too deep in the mouth or noses the stimulation of the posterior pharynx can cause vagal response resulting in bradycardia or apnea.‘Antenatal counseling “Team briefing and equipment check Tern ‘Warm, dy, stimulate, position | ‘away, suction i needed t 4 minute ‘Stays with mother for infal steps, routine care, ongoing ‘evaluation a | Position airway, sucton Pulse oximeter, juneecna consider carding monitor se oxime, oxygen needed, 8 Consiser CPAP 3 No. 3 ve | Fas ‘Ensure adequate ventilation ‘Team debriefing 3 | cont Fangs ase [_ Snes = Cardiac monitor = as rae g + 2 —_ Yes [ EFT riaygeai man mae Chest compressions “min 00-65% oorinate wih eran 2 min 65-70% uve 3min 70-75% T min 75-80% - Smin 80-85% 10min 85.95% [-Wanrepnine ay 5 In | re onyenconcenation Pv | IHR remains 80 bom weeks! GA, 21% 09 + Consider hypovolemia a tea onsder peumeshorax | <25weeks' GA | 21-80%ongen Fig. 9.3: The resuscitation algorithm. CPAP contivous postive away pressure; PPV postive pressure venlation; SpOs saturation of oxygen; ETT endotracheal tube (Adapted with permission from American Academy of Pediatrics 2020) Fig, 9.4: Rolled towel under the shoulders Infant Born through Meconium-Stained Liquor (MSL) ‘A neonate born through meconium-stained liquor (MSL) ‘may aspirate the meconium into the trachea and lungs. Recent evidence has demonstrated that procedures of intrapartum suctioning of the mouth and nose before delivery of the shoulders and postnatal tracheal suctioning of non-vigorous neonates (feeble breathing ot low tone) are not beneficial. The new guideline does not recommend these procedures anymore. Evaluation After providing initial steps, the neonate should be evaluated by assessing respiration, heart rate (HR), and color (or oxygen saturation by pulse oximetry), ‘Observe chest movements for evaluation of respiration. “Auscultate the heart or palpate the umbilical cord pulsation for 6 seconds. Multiply the number of heart beats or pulsations in 6 seconds by 10 to get the HR per minute (e.g. a count of 14in6 seconds is an HR of 140 per minute). Lookat the tongue, mucous membranes, and trunk to evaluate the color. A blue hue to the lips, tongue, and central trunk indicates central cyanosis. The presence of cyanosis in extremities (acrocyanosis) does not have any significance, © Good breathing efforts, HR 100/min or more, and no cyanosis No additional intervention is needed; monitor the neonate frequently * Labored breathing or persistent central cyanosis: Provide CPAP in preterm neonates and supplemental oxygen in term neonates. Monitor oxygen saturation and titrate supplemental oxygen toachieve the targeted saturations (ig. 9.6) «Apnea, gasping breathing, or HR below 100 min: Provide positive pressure ventilation (PPV) Supplemental Oxygen Provide supplemental oxygen by an oxygen mask or ‘oxygen tube held in a cupped hand over the baby's face or by a flow-inflating bag and mask. Do not attempt giving supplemental oxygen using a self-inflating bag. The flow of oxygen should be at least 5 L/minute. Positive Pressure Ventilation (PPV) Provide PPV with a self-inflating bag and face mask (bag and mask ventilation or BMV). The self-inflating bag is easy to use as it reinflates entirely without any external compressed gas source. The resuscitation bag (Fig. 9.5)should havea capacity of 240 to 750 mL. Connect the bag to a source of oxygen and air and a blender that provides the desired concentration of supplemental oxygen. Indications of PPV PPV is indicated, if: i. The infant is apneic or gasping. ii, HR is less than 100 beats per minute. In suspected or confirmed diaphragmatic hernia, bag and mask ventilation is contraindicated. ‘Treat oxygen as a drug—too little or too much; both are bad for the baby. Even a brief exposure to a high oxygen concentration can have a detrimental effect on the baby. Studies have shown that term neonates resuscitated with room air compared to 100% oxygen have better survival Valve assembly Patient outet (Gop-off valve Fig. 9.5: Sel-nflating bag (Adapted with permission from AAP 2005) and long-term outcomes. The recent evidence indicates that most preterm neonates needed supplemental oxygen during resuscitation. In preterm neonates, less than 35 weeks of gestation, start resuscitation with 21-30% oxygen followed by up- or downward titration based upon pulse oximetry. Starting with a lower oxygen concentration prevents the harms of hyperoxia like bronchopulmonary dysplasia and retinopathy of prematurity in this vulnerable population, Use zoom air in neonates of 35 weeks or more and 21 to 30% oxygen in preterm neonates of 34 weeks or lower to initiate resuscitation. Monitor oxygen saturation using pulse oximetry and titrate oxygen concentration to maintain oxygen saturation in the targeted range (Fig. 9.3). Without pulse oximetry, room air should be substituted by 100% oxygen, if the neonate fails to improve (improvement in HR and breathing) by 90 seconds. Procedure Stand at the head end or on the side of the neonate to get, 1 clear view of the neonate’s chest and abdomen. Keep the infant’s neck neutral or slight extension, Select an appropriate size face mask that covers the mouth and nose but not the eyes of the infant (Fig. 9.6). Hold the face mask firmly on the face to obtain a good seal. Compress the bag using your fingers and not your hands, ‘The PPV is the single most effective step in neonates who fail to breathe at birth. Ensuring adequacy of PPV is, therefore, critical for the successful resuscitation of neonates not breathing at birth. Usually, neonates respond to PPV after birth with an immediate increase in their HR. If a neonate is not responding by a rapid increase in HR after 15 seconds of PPY, assess if the baby’s chest is moving with PPV and auscultate for breath sounds. If the chest is not rising and there are no audible breath sounds, take ventilation corrective steps (MR SOPA; Table 9.3). Once the effective chest rise is observed, perform PPV at, a rate of 40 to 60 breaths per minute, following a ‘squeeze, two, three’ sequence (Fig. 9.7). Ensure the chest is rising as if the neonate is taking easy breaths. Avoid giving too deep breaths (too much tidal volume). Avoid delivering PPV at, a high rate, After the infant has received 30 seconds of PPV, evaluate the HR and take follow-up action as in Fig. 9.3. Newborn CareEssential Pediatrics one (Squeeze) ia oC ~~ wo (Release...) Three Two (Release...) Fig. 9.7: Correct rhythm of providing positive pressure ventilation (Adapted with permission from American Academy of Pediatrics 2005) ‘able 9.3: Ventilation corrective steps (MR SOPA) Action Condition Inadequate seal Re-apply mask Blocked airway Reposition the infant's head Blocked airway Clear secretions by suction Blocked airway Ventilate with mouth slightly open Inadequate pressure Increase pressure slightly Consider alternate airway Blocked airway (endotracheal tube) Improving the infant's condition is judged by increasing HR, spontaneous respiration, and improving color. If the infant fails to improve, check for chest rise. If chest rise is inadequate, take ventilation corrective steps as outlined earlier. PPV may cause abdominal distension as the gas escapes into the stomach via the esophagus. Distended stomach presses on the diaphragm and compromises ventilation. ‘Therefore, if ventilation is continued for more than two minutes, an orogastric tube (feeding tube size 6-8 Fr) should bbe inserted and left open to decompress the abdomen. Endotracheal Intubation Endotracheal (ET) intubation is required only in a small proportion of asphyxiated neonates. Intubation is a relatively difficult skill to learn, and it requires consistent practice to maintain the skill. Indications ‘The indications of ET intubation during resuscitation are: (i) Ifthe neonate’s heart rate is less than 100 bpm despite 30 seconds of effective PPV, (ii) when prolonged BMV is required, (iii) when BMV is ineffective, (iv) when chest compression is needed, and (v) when a diaphragmatic hernia is suspected, or the airway isblocked with thick secretions. ET intubation may be considered for administering epinephrine. Endotracheal Tube (EN ET should be of uniform diameter throughout the tube length (not tapered near the tip) and have a vocal cord ie at the tip and centimeter markings. ET tube size Gepends on the weight or gestation of the neonate (Table 9.4). The ET tube’s insertion depth is now determined by a formula: Nasotragal length (NTL)+ I cm, as shown in Fig. 9.8. ‘Most ET currently manufactured for neonates have a black line near the tube’s tip called a vocal cord guide. Such tubes are meant to be inserted so that the vocal cord guide is placed at the level of the vocal cords. This helps position the tip of ET above the bifurcation of the trachea, ‘Aneonatal laryngoscope with straight blades of sizes 0” (for preterm neonates) and ‘I’ (or term neonates) is required for intubation. Before intubating, the appropriate blade is attached to the laryngoscope handle, and the lightis turned Procedure ‘The infant’s head should be in the midline and the slightly extended neck. The laryngoscope is held in the left hand ‘Table 9.4: Appropriate endotracheal tube size Inner diameter Weight Gestational age of tube (mm) @ (weeks) 25 <1000 <28 3.0 1000-2000 28-34 35 2000-3000 34-38 40 3000 338Fig, 9.8: Procedure to measure nasotragal length: Blue arrow indicates the bridge of the nose and red arrow indicates the ‘ragus (Courtesy: Dr Sakshi Jindal, Faridkot) Ode Incorrect Fig. 9.9: Direction of pull on the laryngoscope (Adapted with permission from AAP 2005) Contect between the thumb and the first three fingers, with the blade pointing away from oneself. Standing at the head end of the infant, the blade is introduced in the mouth and ‘advanced to just beyond the base of the tongue so that its tip rests in the vallecula. The blade is lifted as shown in Fig, 9.9, and landmarks looked for: The epiglottis and glottis should come into view. Vocal cords on the sides surround the glottic opening. Once the glottis is visible, the ET is introduced from the right side of the mouth, and its tip is inserted into the glottis until the vocal cord guide is at the glottis level. Thus, it positions it halfway between the vocal cords and the carina. ‘Chest Compressions (CC) ‘The heart circulates blood throughout the body delivering oxygen to vital organs. When an infant becomes hypoxic, the HR slows, and myocardial contractility decreases. Asa result, blood and oxygen flow to the vital organs is diminished. CC helps mechanically pump blood to vital organs of the body. CC consists of rhythmic sternum compression that compresses the heart against the spine, increases intrathoracic pressure, and circulates blood to the body’s vital organs. BMV must always accompany CC so only oxygenated blood is circulated during CC. Peer eeeeeeeeeeeeseeeeeeeeeees Cerca Cees CeCe eCeessaCCeeCeeeeeseCeeeCCeeeCceeees teeta ae CC are indicated if HR is below 60/min, even after 30 seconds of PPV. Once the HR is 60/min or more, chest compressions should be discontinued. Procedure The CC is delivered by the 2-thumb technique (Fg. 9:10) With the thumb technique, the two thumbs are used to depress the sternum, with the hands encircling the torso and the fingers supporting the back. The earlier used two,inger technique for CC is no more recommended. When CC is performed on a neonate, pressure is applied to the lower third of the sternum (Fig, 9.10). Avoid using, force on the xiphoid. To locate the area, slide the fingers on the lower edge ofthe thoracic cage to find the xiphisternum, ‘The lower third of the sternum is just above it. Thumbs should remain in contact with the chest during compression and release. Complications of CC include broken ribs, lacerations ofthe liver, and pneumothorax. Rote 8 Ventilate between CC. A positive breath should follow O every third CC: 90 CC and 30 PPV in one minute (totaling 120 events). The chest should be compressed three times cover 1% seconds, leaving out ¥4 second for ventilation in a 2-minute cycle. Check femoral or carotid pulsation periodically to determine the efficacy of CC. Evaluation ‘After 60 seconds of CC, the heart rate is checked: HR below 60; Continue CC along with PPV. In addition, ‘medications (epinephrine) may have to be administered, HR 60 or above: Discontinue CC. PPV should be continued until the HR is above 100 beats per minute and the infant breathes spontaneously. Medications Medications used in resuscitation include epinephrine and volume expanders (Table 9.5). There is no role of atropine, dexamethasone, calcium, mannitol, dextrose, and naloxone for newborn resuscitation in the delivery room. Fig. 9.1 placed side by side on the lower part of the sternum (Adapted with permission from AAP 2020) 1: Technique for chest compression using two thumbsTable 9.5: Medications to be used inthe delivery room: Indications, dosage, and effects Medication Indication | Effects (concentration) Epinephrine HR <60/min after 60, Inotropic; (1:1000) seconds of effective PPV chronotropic; and chest compressions peripheral vasoconstrictor Normal saline, Acute bleeding with Increased Ringer lactate hypovolemia (especially in intravascular the setting of antepartum volume improves, hemorrhage) perfusion Medications are preferably delivered through the umbilical vein. There is no role for intracardiac injection, For umbilical vein access, insert a 3.5 Fr or 5 Fr umbilical catheter into the umbilical vein just deep enough to get a free blood flow. In an emergency, epinephrine can be delivered through the trachea, if the newborn is intubated. Absorption is erratic in the tracheobronchial tree, and 5 this method is tobe used only if venous access cannot be obtained. The drug is injected by a syringe or a feeding tube (5 Fr) into the endotracheal tube and dispersed into © the lungs by PPV. Indications Use of adrenaline is indicated, if HR remains below 4 60 despite adequate ventilation of 30 seconds and 60 seconds of effective ventilation and chest compressions. The dose of epinephrine is 0.2 mL/kg (range 0.1 to 0.3 mL/kg) of 1:10 000 dilution (1 mg in 10 mL. of saline). Follow the IV bolus with a saline botus of 3 mL. to flush the drug into the central circulation. Volume expander in the form of normal saline or Ringer's lactate is indicated Table 9.6: Level of newborn care Concentration Dose of the administered prepared solution 1:10000 0.2 mUkg (a repeat IV; through umbilical dose can be given _ vein (endotracheal every 3-5 minutes) route, ifno IV access) 10 mUkg (over. Umbilical vein 5-10 minutes) when there is a history of blood loss or signs of shock in the neonate. Suggested Reading 1. Textbook of Neonatal Resuscitation, 8th edn. American ‘Academy of Pediatrics and American Heart Association, 2020, Em onkons ‘The newbom care has been planned at different levels to meet the needs of neonates that may be normal to extremely sick, requiring complex care. American Academy of Pediatrics specifies four levels: Normal newborn care at all ’ birthing places (level 1) to subspecialty level care to meet the needs of highly sick neonates (Table 9.6 and Fig. 9.11). ‘The National Health Mission of the Government of India specifies three levels of care: Newborn care corners at all birthing places to meet the basic needs of all neonates, newborn stabilization units at the first referral level, and special newborn care units (SNCUs) at district hospitals and medical colleges to cater to need of sick neonates. Currently, India has nearly 1000 SNCUs. ‘These units stabilize small and sick neonates and transfer them to a higher evel Neonates of 32 weeks or more of gestation or 1500 g or more at birth Level of newborn care | Target neonates/capabilities: Level 1 ‘Normal term newborns Stable newboms of 35 to 36 weeks’ gestation Level 2 Neonate with moderate sickness. CCPAP and brief ventilation Serves as step-down units fr level-3 and level-4 care. Level 3 Neonates of less than 32 weeks or ess than 1500 g Citica illnesses Offer afl range of respiratory support Level 4 National Health Mission (NHM), India Newborn care comer (NBCC) Newborn stabilization units (NBSU) ‘Special newborn care unit (SNCU) Provide a full range of advanced subspeciality care, including options of cardiac surgery, pediatric surgery, extracorporeal membrane oxygenator (ECMO) Present in all birthing facilites Identify and refer at-risk and sick neonates to higher facilities NBCC in all birthing facilities Provide sick newborn care to neonates above 1800 g Present in CHCs and first referral units {In addition to the availability of NBCC and NBSU Provides care to neonates <1800 g and limited ventilation facilitiestubing (red arrow), an arterial line (blue arrow), a pulse oximeter probe on the right foot, and a temperature probe on the abdomen. boundary around him for developmentally supportive care Family Participatory Care Family participatory care (FPC) involves family members caring for their sick and small neonates admitted to SNCU as caregivers and decision makers. The providers’ team encourages, empowers, trains, and supports the family members to assist in caring for their sick and small neonate, FPC has been shown to improve exclusive breastfeeding rates, parent-infant bonding, infant weight gain, less hospital-acquired infections, thus leading to early discharge and fewer readmission rates. It lowers stress and anxiety among parents’ workload of the nursing staff. Mother-Neonatal Intensive Care Unit (M-NICU) Mother-neonatal intensive care unit (M-NICU) is a novel concept wherein the mothers and their sick and small neonate are kept together after delivery. In M-NICU, the mother’s bed is kept side by side with the newborn’s radiant warmer. Therefore, the mother becomes an active caregiver and can provide immediate KMC to her sick and small neonates. She can easily be trained about asepsis routine, danger signs, feeding, and recognizing danger signs. Such units can provide routine postpartum care and management of common postpartum morbidities of the mothers. Care in M-NICU has improved neonatal survival, bonding, exclusive breastfeeding rates, weight gain, less hospital stay, and maternal stress. A recent multicountry study demonstrated that immediate KMC provided by the mother or other caregiver in the M-NICU setting reduces mortality by 25% in infants 1.0 to 1.79 kg that were moderately sick. For M-NICU to be successful, proper coordination and collaboration is required with obstetrics and gynecology team. ‘The abdomen of the baby appears distended. The feeding tube has a bilious discharge (yellow arrow). The baby is kept in a cloth Competencies: PE20.2; PE20.5; PE20.6 aes Care at Birth Standard precautions and asepsis at birth: The personnel attending the delivery must exercise all the universal/ standard precautions in all cases. All fluid from the baby/ mother should be treated as potentially infectious. Gloves, masks, and gowns should be worn when resuscitating the newborn. Protective eyewear or face shields should be worn during procedures likely to generate droplets of blood or other body fluids. ‘Five cleans’ to prevent sepsis at birth: i. Clean hands: Hand-hygiene and wear sterile gloves fi. Clean surface: Use a clean and sterile towel to dry and cover the neonate Clean blade: The umbilical cord is tobe cut witha clean and sterile blade/scissor iv. Clean tie: The cord should be clamped with a clean and. sterile clamp or tie v. Nothing to be applied on the cord. Keep it dry. i. Prevention and management of hypothermia: Immediately after birth, the newborn is at high risk of hypothermia. This early hypothermia may have a detrimental effect on the infant's health. Special care should be taken to prevent and ‘manage hypothermia. The temperature ofthe delivery room should be 25°C, and the space should be free from the air draft. The neonate should be received ina prewarmed sterile linen sheet at birth. The infant should be dried thoroughly, including the head and face, and any wet linen should not remain in contact with the infant. The infant may be placed on the mother’s abdomen immediately after the birth for early skin-to-skin (STS) contact (Fig. 9.12). This maintains the newborn's temperature, promotes early breastfeeding, Fig. 911: (@) A sick aby being cared forin the neonatal intensive care un (NICU). Note the ventiator (ed arow), muti intusion. © pumps (blue arrow), and multipara monitor (yellow arrow); (b) The baby: Note the endotracheal tube connected to the ventilator Newborn Caiand decreases the mother’s pain and bleeding. The neonate should be observed during the transition. 8 Early skin-to-skin contact: According tonew NavjatShishu = Suraksha Karyakram-2020 (NSSK) guidelines provided by & National Health Mission, all healthy neonates should be delivered on the mother’s abdomen, and early skin-to-skin © contact should be promoted for atleast 1 hour. This enables 3B theneonate to breast crawl and establishes early exclusive breastfeeding, This simple intervention hasalsobeen shown 2 to prevent hypothermia in newborns. Delayed clamping of the umbilical cord: Clamp the umbilical cord 2-3 cm away from the abdomen with a clamp, a clean thread, or a sterile rubber band (Fig, 9.13). Umbilical cord clamping must be delayed for at least 30 to 60 seconds (in term and preterm neonates) to allow additional blood from the placenta to the infant. The delayed cord clamping (DCC) in term neonates improves the infants’ hemoglobin and iron stores and reduces clinical anemia at 2 to 6 months. In preterm infants, DCC is associated with reduced IVH and other morbidities. However, ifthe neonate is asphyxiated at birth, the cord should be clamped immediately after birth, and resuscitation should be initiated without delay. 9.13: Correct application of the umbilical clamp. Note the clamp should leave 1.2 cm of the cord length on each side of it Fig. 9.12: Early skin-to-skin contact with mother after vaginal delivery (a) and cesarean section (b) (Courtesy: Dr Nidhi Jain) ‘The cut umbilical stump should be kept away from the genitals to avoid fecal and urine contamination. The cord should be inspected every 15-30 minutes during the initial few hours after birth for early detection of any oozing. Cleaning of the baby: The neonate should be dried and cleaned at birth with a clean and sterile cloth. The cleaning should be gentle and only wipe out the blood and the meconium and not be vigorous enough to remove the vernix caseosa (whitish greasy material on the skin). The vernix protects the skin of the infant and helps maintain temperature. This gets absorbed on its own in a few days. Placeiient of identity band: Bach infant must have an identity band containing the mother’s name, hospital registration number, gender, and birth weight, Care of Neonate in initial Few Hours after Birth Recording of weight: The neonate should be weighed after stabilization and carly skin-to-skin contact for 1 hour after birth. A sterile pre-heated sheet (or a single-use paper towel) should be placed on a weighing machine with 10g sensitivity. Electronic weighing scales are ideal. Zeroing of the device should be performed. The neonate is then gently placed on the weighing machine, and the weight is recorded. First examination: Examine the neonate thoroughly at birth from head to toe and record the findings in the neonatal sheet. Examine midline structures for malformations (e.g cleft lip, neck masses, chest abnormality, omphalocele (Fig. 9.14), meningocele, cloacal abnormality). Examine if the anal opening is patent. There is no need for routine catheter passage in the stomach, nostrils, and rectum to detect esophageal atresia, choanal atresia, and anorectal malformation, respectively. The neonate should be ‘examined for the presence of birth injuries. The axillary temperature of the neonate should be recorded before the neonate is shifted out from the birthing place. Initiation of breastfeeding: Initiate breastfeeding within one hour of birth. Assist the mother in putting the neonate to the breast, irrespective of the mode of delivery—proactive support of breastfeeding results in high rates of successful breastfeeding. Extra-help is needed in primipara mothers, small neonates, and multiple births.Fig. 9.14:Omphalocele major. Note loops ofintestne ying outside the abdomen enclosed in a sac. in contrast to omphalocele, dgastroschisis does not have an overlying sac and the intestinal loops lie outside the intestine uncovered. (Courtesy: Dr Aparna ‘Chandrasekaran, Hyderabad) Vitamin K:Give vitamin K, toall the neonates (0.5 mgin ess than 1000 g and 1 mg in those more than 1000 g). Vitamin K, can cause hemolysis in G6PD-deficient neonates. Communication with the family: Counsel the mother and the family members atbirth: (i) Gender of the baby, (i) birth ‘weight, (ii) well-being of the baby, (iv) need for initiation of breastfeeding within one hour and need for continued observation. Rooming in: A normal newborn should not be separated from the mother. In the initial few hours of life, the neonate is very active, and co-bedding the neonate with the mother facilitates early breastfeeding and bonding, Studies have shown that separation during initial hours may have a detrimental effect on successful breastfeeding. Cate of Neonate Beyond a Few Hours after Birth Care of the cord: The umbilical stump should be kept dry and devoid of any application. The nappy of the neonate should be folded well below the stump to avoid contamination. The cord falls off in 7 to 10 days in healthy- term neonates. Exclusive breastfeeding: Follow a proactive approach to initiate and maintain breastfeeding, Inform the family of the benefits of breastfeeding, Position of sleep: All healthy-term newborn should sleep in the supine position. Evidence has linked prone position to sudden infant death syndrome (SIDS). ‘Traditional practices should be discouraged: Applying kajal or surma in the eyes, putting oil in the ear, or applying cow dung on the cord must be strongly discouraged. When to discharge: A normal neonate should stay in the health facility for at least 24 hr and preferably for 48 hours. Smallerneonates or those with feeding problems or sickness should remain in the hospital as required. Discharge Criteria ® The newborn has a normal examination. lee © No breastfeeding problems and the mother can breastfeed the neonate well. The adequacy of feeds can, be determined by: ~ Passage of urine 6 to 8 times every 24-hour — Neonate sleeping well for 2-3 hours after feeds. © The newborn has received the immunization as per the schedule, © The mother is confident in taking care of the neonate, She has been counseled regarding routine newborn care + ‘No significant jaundice or other illness requiring closer observation. © ‘Danger signs’ explained (Fig: 9.15), © Advice regarding the mother’s health: The nursing ‘mother’s nutrition and health is important. She should take adequate healthy foods above the recommended dietary allowance to meet energy and protein needs ‘while breastfeeding. Mothers should also drink enough water and other liquids to remain hydrated. Iron and. folic acid supplementation should continue till three ‘months of postnatal age. The family should be able to identify signsand symptoms of postpartum hemorrhage, infection, thromboembolism, and hypertension following, the birth of a baby. Mental health issues are common in, the postpartum period, and adequate care must be taken. ‘+ Adate for follow-up has been assigned. In the presence of any high-risk factor (eg. low birth weight, prematurity, significant jaundice, or feeding not established), the neonates should be seen within 2-3 days of discharge. Anormal newborn with the adequacy of breastfeeding. and no significant jaundice by 72 hours can be seen at 6 weeks of age. Common Parental Concerns Weight loss in the first week: Term neonates lose 7 to 10% of birth weight in the first week of life and regain their birth weight by 7-10 days. Subsequently, they gain 20 to 40 g of weight per day. The initial weight loss happens due to the loss of extracellular fluid, and subsequent weight gain is due to a gain in intracellular water and solids content leading to cellular growth. Preterm neonates tend to lose more weight (10 to 15%) owing to immaturity of the tubular function of the kidneys and skin; they tend to regain + Dificulty in feeding or poor feeding + Convulsions + Lethargy (movement only when stimulated) + Fast breathing (RR >60/min) + Severe chest indrawing femperature of more than 37.5°C or below 35.5°C + Yellow soles (severe hyperbiliubinemia) Danger signs in newborns Fig. 0.4 Newborn Carebirth weight by 10 to 14 days. Small gestational-age infants have less weight loss than their appropriate counterparts, « uri vw: The sensation of a full bladder is uncomfortable to many neonates who may cry before passing urine, and they quieten as soon as the act ‘of micturition starts—crying during micturition as opposed to before the act may indicate urinary tract infection. Bathing: Only sponging is recommended during the first week until the cord falls off, which can be given after the first 24 hr of life. Later, bathing every 2-3 day’ is enough, ‘A draught-free warm room, warm water, and quick bath ensure that the neonate does not get cold during bathing, The hhead has a large surface area; therefore, it should be washed and dried immediately. Inspect the baby’s cord, eyes, and skin for any discharge, rash, or redness during bathing, Cosmetics: Neonates have sensitive skin. Minimize the use of cosmetics. Advise parents to use a mild soap that is «g non-perfumed-non-medicated. They can use any oil except 8 tustard for skin application or massage. Avoid sprinkling talcum powder, as that can be inhaled. Avoid boric acid~ 3 containing products (present in prickly heat preparations). Regurgitation (posseting):Neonates commonly regurgitate B small amounts of curdled milk soon after feeding. This is = normal, if the neonate gains weight and passes urine 6-8 times daily. © Frequent stools: During the first few days of life, the stool color in breastfed neonates changes from black-green to yellow by the end of the first week. In between, the stools appear loose (‘transitional stools’). The stool frequency ‘may increase at this time. The transition of stools from black meconium to yellow-green stools by the end of the first week is an important indicator of the adequacy of breastfeeding. A neonate may pass a small stool after feeding (gastrocolic reflex). Ifthe neonate remains hydrated, has no signs of sepsis, feeds well, passes urine 6-8 times per day, and gains weight, there is no cause for concern. Breast engorgement: The breasts in boys and girls may get hypertrophied and secrete milk-like fluid (witch milk; Fig. 9.16 because of transplacentally transmitted hormones, Fig. 9.16: Breast enlargement, Rarely, milk-lke fluid may come ‘out of these enlarged breasts (witch milk). (Photo courtesy: Dr ‘Soumya Devarapall) It resolves spontaneously in a few days. Do not squeeze or massage the engorged breasts, as it could lead to soreness and infection Erythema toxicumn: It starts on day two or three of life. These maculopapular lesions have an erythematous base distributed over the trunk and face. These are eosinophil- laden sterile lesions and resolve spontaneously (Fig 9.17) Pyoderma (boil) is pus-filled lesions due to local skin infection commonly occurring in creases where dirt accumulates, such as the thigh fold and back of the neck (Fig. 9.17b). Ifthe boils are less than ten and there are no signs of sepsis, local cleaning with an antiseptic solution and Fig, 9.17: (a) Erythema toxicum; (b) Hymenal tag and pustule; (©) Stork bite over eyelids and forehead (blue arrows) and milia ‘on the nose (circle)applying 1.0% gentian violet is sufficient. If the number is greater than 10, investigate for sepsis. Stork bite: Sometimes, benign capillary malformation with flat red patches over the forehead and upper eyelids can be present in the newborn period (stork bites; Fig. 9.176), ‘Another common benign skin condition is milia, which consists of tiny white papular cystic lesions, especially over the face and nose (Fig. 9.170) ink diapers:Sometimes, male neonates pass pink-colored urine, usually on the 2nd or 3rd day of life, which stains diapers (Fig, 9.18). This results from the passage of urate crystals and often occurs when there is feeding inadequacy causing dehydration. The other causes, like hematuria, hemoglobinuria, myoglobinuria, and porphyria, are infrequent in an otherwise normal neonate. The condition resolves spontaneously in a couple of days and does not require any treatment. Ensure breastfeeding adequacy. Skin peeling is normal, especially in post-term and IUGR neonates. Oil massaging can decrease flaking, and no other intervention is required. Fig. 9.18: Pink diaper in a neonate due to urate crystals (blue arrow) Diaper rash: The diaper area is red and inflamed, and there is an excoriation of the skin due to maceration by stools and urine (Fig. 9.19). The problem is more frequent with commercial than domestic cotton diapers. The treatment consists of keeping the area dry, avoiding skin rubbing for cleaning, and applying a soothing cream, Competency: PERO BOON Most neonates are born healthy. Some 10% are sick and small and need admission to the neonatal unit for observation or treatment. ‘Newborns may have different physical findings at other time points. Hence, do the physical examination: (i) soon after birth, (i) at 24 hr of age, (iii) before discharge, and {v) at the follow-up visit (Table 9.7) Fig. 9.19: Diaper rash Assign Apgar scores at 1 and 5 minutes (Table 9.2) If the score is less than 7, do it every 5 minutes until 20 minutes. Apgar score provides information regarding ‘cardiopulmonary status at birth and adaptation to the postnatal environment. Apgar score of f to 3 at 5 minutes correlates well with mortality. However, low Apgar scores do not predict long-term neurodevelopmental outcomes. General Observation Carefully observing a newborn provides important information at any time and should never be missed. Assess the state of alertness, behavior, response to handling, posture, spontaneous activity, color, breathing difficulty, or obvious malformation in the baby. Ideally, observe when the neonate is in light sleep or awake but quiet—typically 1 to 1.5 hour following feeding. Vital Signs Ina sick baby, assess the vital parameters at the outset to assess hemodynamic stability and find out if the neonate needs emergency treatment (Table 9.8) Assessment of Size and Growth Low birth weight (LBW) implies birth weight below 2500 g, very low birth weight (VLBW) less than 1500 g, and extremely low birth weight (ELBW) less than 1000 g, Plotting the weight against the gestational age on the intrauterine growth curve (Fig. 9.20) provides information regarding the status of intrauterine growth. ‘© Between 10th and <90th percentile—appropriate for gestational age (AGA) * Below the 10th percentile—small for gestational age (SGA) ‘+ At or above the 90th percentile—large for gestational age (LGA) ‘The SGA neonates have suboptimal growth during the intrauterine period (intrauterine growth restriction, IUGR), ‘These neonates look thin and slender, have loose folds of wrinkled skin (Fig. 9.21), and have monkey-like faces. Intrauterine growth charts are different from postnatal growth charts. The latter assesses growth after birth, Newborn CareTable 9.7: Newbom histor and examination: Format for case presentation | History General Past obstetric Antenatal ‘Obstetric or medical complications Labor Delivery Immediate care at birth Feeding Postnatal problems Family Past medical problems Personal/social Immediately ater bith Appearance Vital signs Essential Pediatrics ‘Antheopometry Gestation Classification by intrauterine growth Congenital anomalies Birth trauma Common signs Special signs Feeding Reflexes Cardiovascular system ‘Abdomen Musculoskeletal system Central nervous system Mother's name and age, parity, last menstrual period, expected date of delivery Past pregnancies: When, gestation, fetal or neonatal problems, current status of children Number of antenatal visits tests (hemoglobin; urine albumin, sugar; ultrasound; blood group, VDRL, HIV), tetanus toxoid immunization, supplements (iron, folic acid, calcium, iodine) Obstetric complications toxemia, urinary tract infections, twinstriplets, placenta previa, accidental hemorthagel; fetal problems (IUGR, hydrops, Rh isoimmunization); medical problems (diabetes, hypertension); investigations, medications, course Presentation, onset of labor (spontaneous/induced), rupture of membranes (spontaneous/arifcal), liquor (clear’meconium stained); duration of ist and second stage of labor; fetal heart rate (tachycardia, bradycardia, iregular) Place of delivery, vaginal (spontaneousforceps/vacuum), cesarean (indication, elective/emergency); localigeneral anesthesia; duration of third stage; postpartum hemorrhage Resuscitation; time of fist breath and cry; Apgar score; cord care; passage of urine/stool Breastfeeding (when initiated, frequency, adequacy); other feeds Feeding problems, jaundice, eye discharge, fever; curent problems History of perinatal lines in other siblings History of past medical problems, if any Socioeconomic status, family support Weight, gestation, congenital anomalies, sex assigning, Apgar scores, examination of umbilical vessel, and placenta ‘Overall appearance: Well or sick looking; aler/unconscious Temperature, cold stress; respiratory rat, retraction, grunvtridor; ear rat, palpable femoral arteries; blood pressure, capillary rcil ime; cry; apnee spels ‘Weight, length, head circumference, chest circumference ‘Assessment by physical criteria; more detailed assessment by expanded New Ballard examination -AppropriatesmalVAarge for gestational age; symmetric or asymmetric smal for gestational age; signs of IUGR Head to toe examination for malformations Signs of trauma; cephalohematoma Cyanosis, jaundice, pallor, bleed, pustules, edema, depressed fontanel Caput; eye discharge; umbilical stump; discharge or redness; jiteriness; eye discharge; oral thrush; development peculiarities (toxic erythema, Epstein pearls, breast engorgement, vaginal bleeding, capillary hemangioma, mongolian spot) Observe feeding on breast (check positioning and attachment) Moto, grasp, rooting Shape; respiratory rate; retractions; air entry; adventitious sounds Apical impulse, heart sounds, murmur Distension, wall edema, tenderness, palpable liver/spleen/kidneys, any other lump, ascites, hernal sites, gonads, genitalia Deformities; ests for developmental dysplasia of hip; club foot State of consciousness; vision, pupils, eye movements facial sensation; hearing; sucking and swallowing: muscle tone and posture; power; tendon reflexes JUGR intrauterine growth retardation Anthropometry Weight is measured ona weighing scale with 10 gsensitivity, calculated by multiplying the weight in grams by a hundred length by infantometer, and head circumference (HC) by _and then dividing by a cube of length in cm. asoft non-stretchable tape circling the head just above the The mean birth weight of Indian neonates at term ‘eyebrows and the occiput. Measure chest circumference gestation is approximately 2900 g. Their birth lengths and (CC) at the level of the nipples. Ponderal index (PI) is head circumferences are about 50 cm and 33 to 37 cm.Table 9.8 Normal vital parameters in neonates | Vial parameter Normal ange Remarks Heart rate(beatsminute) Term neonates: 100-160 bpm Relative bradycardia with HR as low as 80 bpm is nosmal in erm neonates during sleep Prem neonates: 20-180bpm_Tachyara sige spss ana fever, oF ongsive carta Axillary temperature 36.5°C to 37.4°C Axillary temperature isa good proxy for the core temperature of the baby; no need to measure rectal temperature Capillary refill ime (CRT) <3 seconds Prolonged CRT (>3 seconds) suggests poor circulation as in shock or hypothermia, Assess CRT on the sternum by pressing the skin with the ball of your fingerthumb for five seconds and then noting the time taken to refill Respiratory rate 40 t0 60 breaths per minute Periodic breathing with short apneic pauses of 5-10 seconds is normal ‘A borderline count nearing 60 needs to be repeated Apnea associated with cyanosis or bradycardia is abnormal. $9 20 0s nent sz att gro che Boye SD. A ali ca RS con percent ‘son peel uit 3500" Newborn Care sooo ee 3 20 a Fm ie 5 ss00 es | 1000 ‘500- 500, Ce aE a Gestational age (wks) > Gestational age (wks) Fig. 9.20; New AIIMS intrauterine growth curve: (a) Boys; (b) Girts ‘The difference between HC and CC is usually less than, 3m. An HC-CC difference of more than [Link] may indicate TUGR in a term baby. PI is usually less than 2 in IUGR neonates and two or more in AGA neonates. ‘Alarge head is known as macrocephaly. ts causes include hydrocephalus (enlarged ventricles) and overgrowth of bone or brain tissues. Assessment of Gestational Age Based on the gestation, neonates can be classified as preterm (<37 weeks), post-term (242 weeks), and term (37-41 weeks). The gestational age of a neonate can be assessed by the last menstrual period, if the periods have been regular and reliably known by first-trimester ultrasound or newborn examination. The newborn examination for assessing gestation requires an assessment of physical features and neurological ‘maturity (Fig. 9.22a to 1). Expanded New Ballard Scores (ENBS), a commonly used scoring system, can provide Fig. 9.21: An IUGR neonate showing wrinkled skin with peeling gestation with an accuracy of 1 week. Pee eee ee ee eee eee ee ee eeeEssential Pediatrics 4 Fig. 9.22: Salient difference in physical characteristics of preterm and term neonates: (a) Well-curved pinna, cartilage reaching up to periphery; (b) Flat and soft pinna, cartilage not reaching up to periphery; (c) Well pigmented and pendulous scrotal sacs, with fully descended testes; (d) Light pigmentation and not yet descended tastes; (2) Deep, transverse creases on the soles; (f) Faint marks fon the sole, no deep creases; (g) Well-formed breast bud (>5 mm); (h) Poorly developed breast bud; (i) Silky hair, where individual strands can be made out; () Fuzzy hal; (k) Labia majora covering clitoris and labia minora; (I) Prominent labia minora General Examination Skin and hair: Examine skin for its thickness, color, transparency, and presence of edema, rashes, and lesions like hemangioma. The skin may exhibit minor features that are self-limiting. Assess the presence of jaundice by pressing the skin to reveal the yellow color of subcutaneous tissue. Eechymoses or petechiae may relate to birth trauma, Examine the presence and texture of lanugo—the fine hair of the fetal period that is shed later (Fig. 9.23a). Neonates can have significant seborrheic dermatitis in the initial few months that do not require any treatment (Fig. 9.23b). Head and fontanel: Examine the size and shape of the head, sutures, and fontanels. A small head indicates microcephaly. Caput succedaneum and cephalohematoma are common findings in normal neonates ‘The ventouse application can cause the formation of chignon in the neonate (Fig. 9.24).A full and tense fontanel in a quiet neonate is abnormal and may indicate meningitis, hydrocephalus, or intracranial hemorthage Fig. 9.23: (a) Lanugo hair in a preterm neonate; (b) Seborrheic dermatitis (cradle cap). A large yellow pustule is also seen Invertex presentation, the shape of the head may change, and the skull bones may override (sutural override) during the process of vaginal birth. Large fontanels and wideDifferences between caput succedaneum and cephalohematoma Characteristic (Caput succedaneum Incidence Common Location Subcutaneous plane ‘Time of presentation Time course Softens progressively from birth Characteristic findings Diffuse; crosses suture line None Association Fig. 9.24: Chignon in a neonate following ventouse delivery (box). It resolves without treatment in a few days sutures are common in IUGR neonates. However, their presence can indicate increased intracranial pressure, trisomy 21, hypothyroidism, and osteogenesis imperfecta. Some neonates have delayed ossification of the skull bones that may feel likea ping pong ball (craniotabes). Itis benign and resolves spontaneously. Neck, face, eyes, and ears: Examine the neck for masses such as enlarged thyroid gland and sternomastoid tumor. Newborns have short necks. A birth injury can cause facial nerve paresis causing asymmetry of the face while the neonate is crying—the affected side having an open eye, absent nasolabial fold, and deviation of angle of mouth to the normal side. The absence of depressor anguli oris(DAOM) can mimic facial nerve palsy; however, in this condition, the eyes remain tightly shut while crying, and the nasolabial fold is intact (Fig. 9.25a ancl). Examine the nose for its shape, secretions, and patency. The flaring of the nostrils indicates an increase in respiratory distress. Hee eee eee eee ‘Maximum size and firmness at birth Cephalohematoma Less common (Over parietal bones, between skull and periosteum Increasing size for 12-24 hours and then stable “Takes 3-6 weeks to resolve and resolves within 2-3 days Does not cross suture line; has distinct margins Linear sku fracture (5-25%); hyperbilirubinemia Fig. 9.25: (a) Absent depressor angull oris muscle. Note the ‘asymmetry of the face on crying and the presence of nasolabial folds and closed eyes. The uptick of the lower lip is typical of the condition (box); (b) Newborn with right-sided lower motor nerve facial palsy secondary to forceps application (red arrow) and forceps marks (black arrow). The upper lids of the baby looks pity, which is often normal at birth ‘The alveolar ridge may have natal teeth. A white papule at the apex of the hard palate is a retention cyst (Epstein pearl) that disappears in a few weeks, Subconjunctival hemorrhages are common after vaginal delivery and resolve spontaneously. The cornea should be clear; pupils should be equal in size, reactive to light, and 2 5 ° € S a @ zsymmetrical. Accessory auricles and preauricular tags are Umbilicus, anus, and spine: Inspect the number of vessels in the umbilical cord (Fig. 9.26). A single umbilical artery is found in 0.7% of live births; this may be associated with renal and gastrointestinal tract anomalies. Palpate the base of the umbilical cord for a hernia (Fig. 9.27) Palpate the spine with a finger to exclude spina bifida, masses, and abnormal curvature. Check if the anal opening is intact. A sinus (Fig. 9.28a) or tuft of hair (Fig. 9.28b)in the lumbosacral area may mark an underlying neural tube defect Genitalia (male and female): Examine the genital area for the urethral opening and clitoris. The presence of a hymenal tagisan innocuous finding). Examine the size and curvature of the penis, Hypospadias implies more ventral location, of the urethra (normally, it is located on the tip) and the resence of ventral incurvation (chordee) and deficient Essential Pediatrics Fig, 9.26: The base of a freshly cut umbilical cord shows two arteries (2 black arrows) and a vein (red arrow) Fig. 9.27: Umbilical hernia, Fig. 9.28: Sinus shown by an arrow (a) or tuft of hair (b) in the lower back may signify an underlying neural tube defect foreskin (Fig. 9.29). Circumcision should be postponed in, newborns with hypospadias. Extremities: Examine if arms and limbs are fully movable with no evidence of dislocation or asymmetry of movements. Fig. 9.29:Anewbom male with hypospadias. Note the presence of ‘chordee (ventral curvature of the penis) (Courtesy: Dr Parminder Singh)Fig. 9.30: Pre-axial polydactyly Examine the fingers and toes for abnormality in the shape, size, or number: Syndactyly or polydactyly (Fig. 9.30). ‘Acalcaneovalgus deformity is usually self-correcting within the next few months, but equinovarus requires orthopedic consultation (Fig. 9.31a and b). Fig. 9.91: (@) Congenital talipes equinovarus deformity; (b) A newborn delivered by the extended breech. Note lower limbs with extended knees and flexed hips Systemic: Examination Chest: The anteroposterior diameter of the neonate’s ches is roughly equal to the transverse diameter. Nasal flare, | grunting, fast breathing, and intercostal and subcostal retractions indicate respiratory distress. Such distress may reveal the presence of underlying pneumonia, respiratory | distress syndrome (RDS), delayed reabsorption of lung fluid (transient tachypnea), or any other cardiorespiratory cause. Stridor indicates larger airway obstruction. Wheezing denotes small airway obstruction. The [Link] bowel sounds in, the chest may mean a congenital diaphragmatic hernia. Cardiovascular system: The presence of abnormal heart sounds or murmurs may indicate congenital heart disease. Such neonates can have tachypnea, cyanosis, or both. Bilateral femoral artery pulsation may be absent in the coarctation of the aorta. Abdomen: An unusual flatness or scaphoid shape may be associated with congenital diaphragmatic hernia. Visible gastric or bowel patterns may indicate ileus or intestinal obstruction (Fig, 9.32a and b). Normal neonates can have liver palpable below the costal margin, spleen tip, and left kidney lower pole may also be normally palpable. Musculoskeletal system: The common alterations are deformations caused by adverse mechanical factors in wero. ‘Most positional deformities are mild and resolve in time. 2 5 cs € 3 2 = o iz Fig. 9.32a: Abdominal distension in a term neonate suggestive ‘of intestinal obstruction, The gastric tube (arrow) shows drainage of bile (green color fluid) —_ Fig. 9.2b: A preterm newborn showing abdominal distension with visible bowel loops. The differential diagnosis includes ‘sepsis, feed intolerance, necrotizing enterocoitis, and intestinal ‘obstruction Peer eeeeeeeeeeeeseeeeeeeeees Cerra CCeeseCeCeeee Ceres eCeeeeCceeeer eCeeCCeesCceeees tert oeDevelopmental dysplasia of the hip occurs in 1 of 800 live births, more commonly in girls, those with family history, and delivered by the breech. This is examined by i, Barlow maneuver: Barlow test is done to dislocate the unstable hip joint. Test both hips separately. Stabilize the pelvis with one hand, with the thumb on the medial side of the thigh and fingers on the greater trochanter, With the other hand, flex and adduct the hip while applying posterior pressure to dislocate the hip. Ortolani sign: This sign is present, if the hip is already dislocated. The neonate is placed on its back with the knees fully flexed, and the hips flexed toa right angle. ‘Test both hips separately. Stabilize the pelvis with one hand, with the thumb on the medial side of the thigh and fingers on the greater trochanter. Abduct the thigh and push the femoral head anteriorly with your fingers, In the dislocated hip, the femoral head suddenly slips into the acetabulum with a distinctly palpable “clunk.” sing the level of @ Neurological examination consists of ass 8 ¥ alertness, cranial nerves, motor and sensory system, and B neonatal reflexes, 3 Cranial nerves: Neonates respond to cotton soaked in & peppermint by 32 weeks of gestation. By 26 weeks, the & infant consistently blinks in response to light, and by term 3 gestation, fixation and following (tested using fluffy red 2 yarn ball) are well established. By 28 weeks, the infant & startles or blinks at a loud noise. Normal sucking and swallowing denote proper functioning of the V, VIL, IX, X, and XII cranial nerves. Feeding requires the coordinated action of sucking, swallowing, and breathing. Suck-swallow coordination to accept paladai feeding is present by 32 weeks. Suck-swallow and breathing coordination for breastfeeding occurs by 34 weeks, However, perfect coordination of suck-swallow and breathing develops only by 38 weeks of gestation, Motor examination: By 28 weeks, there is minimal resistance to passive manipulation of all the limbs, and a distinct flexor tone is appreciated in the lower extremities by 32 weeks. By 36 weeks, flexor tone is palpable in both the lower and upper extremities. Primary neonatal reflexes: To elicit the Moro reflex, raise the baby’s head slightly and drop it suddenly while the hand still supports the neonate. The response consists ofthe opening of the hands and extension and abduction of the upper extremities, followed by anterior flexion (embracing) of the upper extremities with an audible cry (Fig. 9.33a and }). The hand openings present by 28 weeks, extension and abduction by 32 weeks, and anterior flexion by 37 weeks. Moro reflex disappears by 3-6 months in normal infants. ‘The most common cause of depressed or absent Moro reflex isa generalized disturbance of the central nervous system. ‘An asymmetrical Moro reflex indicates root plexus injury ig. 9.330. The palmar grasp is present at 28 weeks of gestation and is strong by 32 weeks. Palmar grasp is strong enough to allow the lifting of the neonate at 37 weeks of gestation (Fig. 9.34); it becomes less consistent and allows the appearance of a voluntary grasp at four months. The Fig. 9.93: Moro reflex: (a) Abduction and extension of arms ‘are followed by (b) Adduction and flexion; (c) Asymmetric Moro reflex in brachial plexus injury (Erb’s palsy on the right side—the Upper limb does not move) Fig, 9.94: Palmar graspasymmetric tonic neck response is an important response elicited by head rotation that causes extension of the upper extremity on the side to the face and flexion of the upper extremity on the opposite side. This reflex disappears by four months. Suggested Viewing 1. Video link for assessing respiratory distress in preterm infants btips//youtu be/HdBqh43HyVE Competencies: PE20.12; PE27.24; PE27. Pearse) ‘Newborn neonates are prone to hypothermia as they have immature heat-regulating mechanisms, The neonates have a limited capacity to generate heat, including brown fat A larger surface area to body weight, thin and permeable skin, and lower subcutaneous fat put neonates at risk of hypothermia, The head constitutes a significant portion of the newborn's body surface area and can contribute significantly to overall heat loss. The low environmental temperature also contributes to the occurrence of hypothermia. £27.26; PEDT.27 Sources of Heat Loss Heat loss in a newborn occurs in four ways: i. Radiation to the surrounding environment not in direct contact with baby ii, Convection to the air flowing in surrounding iii, Conduction to substances in direct contact with baby iv. Eoaporation of fluid and moisture from baby’s skin Sources of Heat Production When exposed to a cold environment, the neonate tries to generate heat by increasing physical activity (crying, increased body movements). Acold environment stimulates the baby’s sympathetic system causing cutaneous vasoconstriction and generation of heat by non-shivering thermogenesis in the brown fat. Brown fat, located in the axillae, groin, and nape of the neck, interscapular, and perirenal areas, hasa rich vascular supply and sympathetic innervation. The release of norepinephrine uncouples beta- oxidation in fat, resulting in heat production. Blood passing through brown fat gets heated up and keeps the neonate warm, Preterm and small for gestational age infants have scanty brown fat stores. Response to hypothermia: Hypothermia-induced peripheral ‘vasoconstriction leads to increased metabolism with excess utilization of oxygen and glucose. When body temperature drops below 32°C, hemoglobin cannot release oxygen resulting in tissue hypoxia. The consequent anaerobic metabolism results in metabolic acidosis (Fig. 9.35), resulting in pulmonary vasoconstriction and further hypoxemia. Severe hypothermia, hypoxemia, bradycardia, hypoglycemia, and metabolic acidosis increase mortality in hypothermic neonates. Hyperthermia: An immature thermoregulating mechanism and reduced ability to sweat predispose newborns to hyperthermia. Factors like over-clothing, the high environmental temperature in summer, poor feeding, and dehydration are common factors that can lead to hyperthermia Definitions : Thermoneutral environment: The thermoneutral zone (INZ) denotes a narrow environmental temperature range in which a neonate can maintain his normal body temperature with the least basal metabolic rate and oxygen utilization, The TNZ varies with gestation and postnatal age. Itis higher at lower than higher gestation, naked than clothed, and early than later postnatal ages. The disorders canbe categorized based on axillary temperature, as shown in Fig. 9.36. Newborn Care Temperature Measurement Ideally, the axillary temperature should be measured as it is safer than the rectal temperature. Currently, we use digital thermometers as mercury thermometers have been phased out. To record axillary temperature, place the bulb Of the thermometer on the roof of the dry axilla parallel to the trunk. Hold the baby’s arm close to the body until the thermometer gives a beep. aoe | Catecholamine release | | Reduced surfactant es ian EE — Ses] sean rear : eect ———r ee ‘Hypoglycemia Increased oxygen requirement cos | cae peace mathe ah Metabolic acidosis Fig. 9.35: Response to cold stress in the sick neonate“Temperature abnormalities | [Hupothermia| (perthermia) 38S ‘Mid hypothermia’| { cold stress 36.0°C-36.4°C Fig. 9.96: Classification of temperature abnormalities (based on axillary temperature). The normal body temperature is between 36.5°C and 37.5°C (One can geta reasonable idea about a baby's body temperature by touching the baby's hands and feet and the abdomen with the back ofthe examiner's hand. The baby's body temperature is normal ifthe hands, feet, and abdomen feel warm. Warm abdomen 4 but cold feet and hands indicate mild to moderate hypothermia. & Cold feet, hands, and abdomen would suggest that the neonate $ has severe hypothermia. 3 @ Frequency of Measurement G WHO guidelines recommend the following schedule for = temperature measurement: & © Once daily, preferably in the early morning hours, for © healthy-term neonates who are otherwise well + Three times daily for healthy small neonates (2 10 2.5 kg) * Four times daily for very small neonates (<2 kg) ‘Every two hours for sick neonates. ‘The mother should be encouraged to assess the neonate’s body temperature by touching the baby. Disorders of Body Temperature Hypothermia, as well as hyperthermia, can also indicate a severe underlying illness. Hypothermia may happen due to exposure to a cold environment, such as low ambient temperature, cold surface, or cold air, or if the neonate is wet or not clothed adequately. Hyperthermia may result from exposure toa warm environment, such as in summer, direct sun exposure, or overheating in the incubator or radiant warmer. Hypothermia Hypothermia correlates well with an increased risk of mortality in neonates. Hypothermia is common in neonates in hospital as well as community settings. It also occurs in the tropical environment. The conditions, such as prematurity, hypoglycemia, and asphyxia, have a higher risk of mortality when associated with hypothermia. Prevention ‘+ Keep birthing rooms’ ambient temperature at least 25°C, and they should be free from air drafts (keep windows and doors closed). ‘+ After delivery, dry the neonate immediately, putin skin- to-skin contact on the mother’s abdomen, and cover with ‘warm and dry linen. Discard the wet towel. Dress the neonate in proper clothing, including a cap and socks (Fig. 9.37a and b). Dressing the neonate in multiple layers of warm and light clothes provides better thermal protection than a single layer of heavy woolen clothing. * Kangaroo mother care (KMC) keeps LBW neonates ‘Frequent breastfeeding allows the neonate to remain in touch with the mother’s warm body and provides energy to keep the neonate warm. * Postpone bathing and weighing, Provide sponge bathing to healthy term neonates after hospital discharge during summer months. Delay bathing during winters and in sick and small neonates until the umbilical cord falls off (end of the first week). Give bathing to small neonates once they weigh two kilograms. + Keep the mother and the neonate on the same bed (co- bedding /rooming in). ‘* Warm transportation: This is the weakest link in the warm chain witha significant risk of severe hypothermia, # Training /awareness of healthcare providers Incubators and radiant warmers: Radiant warmers and incubators help sick and small neonates maintain their Fig. 9.37: (a) Well-clothed promature baby in mother’s lap; (b) A well-covered baby in radiant warmer; clothing of baby under radiant warmer Improves thermal protection and provides developmental supportive careFig. 9.38: (a) An incubator; (b) A radiant warmer. Note that the incubator has port holes on the sides to assess the baby (Courtesy: Dr Satya Prakash) normal body temperature (Fig.9.38a and b). An incubatorisa ‘transparent acrylic cabin (closed system) witha fan initsbase that keeps circulating warm air around the neonate to keep him warm (convection). Often the incubators have a double ‘wall for better thermal protection of the neonate. A radiant warmer is an open system with a radiant heater installed over a bassinet (Table 9.10). Both types of equipment have an inbuilt feedback system (servo-control) that controls the ambient temperature by altering heater output based on the baby’s temperature, thereby maintaining the baby’s temperature in the normal range (Fig. 9.39). Radiant warmer also hasa ‘manual’ mode of operation, which allows manual adjustment of the heater output. That helps in the initial ‘warming of the bed before the neonate occupies it Use radiant warmers and incubators in servo-control ‘mode with the skin temperature probe attached to the baby. Set the skin temperature at 36.5°C to 37°C, which helps maintain the baby’s temperature in the desired range. Table 9.10: Differences between a radiant warmer and an incubator Feature Design Radiant warmer ‘A radiant heater installed over a bassinet provides heat (radiation) ‘Open care system Access to the baby Easy Insensible water loss small neonates) Option to add humidification Not available Maintenance and disinfection Cost Easy Low Greater (can result in dehydration in Signs and symptoms Hypothermia affects all the body systems adversely. Peripheral vasoconstriction results in acrocyanosis, cool extremities, and delayed capillary refill time. The neonate becomes restless and lethargic. Bradycardia, hypotension, and raised pulmonary artery pressure can cause respiratory distress and hypoxemia, There may be apnea, lethargy, poot reflexes, and decreased oral acceptance. Abdomen distension and vomiting can make enteral feeding difficult. Significant ‘metabolic disturbances such as acidosis, hypoglycemia, oliguria, azotemia, and generalized bleeding can occur in severe cases. Neonates experiencing hypothermia over more extended periods may not gain adequate weight. Management “Methods for temperature maintenance include skin-to-skin contact, warm room, radiant warmers, incubators, and increasing ambient temperature using heaters. Incubator Circulation of warm air by an inbuilt heater and fan (convection) into a canopy Closed system Restricted Lesser (suitable for neonates below 1500 g) Available in advanced machines Higher humidity reduces insensible water losses from the skin. That helps in maintaining fluid balance in neonates below 1500 g Difficult to maintain and disinfect High Newborn Care @Essential Pediatrics La Fig. 9.99: The skin servo-control mode of the radiant warmer and incubator helps maintain the infant's desired temperature: (a) The infant temperature is 36.3°C as against the set temperature of 36.6°C. Accordingly, the heater output is nearly 50%; (b) The infant ‘temperature is higher than the set temperature, and the heater output is zero Cold stress or moderate hypothermia © Remove the neonate from the source, such as a cold environment, cold clothes, or wet clothing, «© Initiate skin-to-skin contact or provide warm clothing, Keep the neonate in close contact with the mother in a ‘warm room, Alternatively, nurse the neonate in a radiant ‘warmer or incubator. ‘© Monitor temperature frequently. If the neonate does not get warm, ensure adequate warmth. ‘+ Ensure frequent feeding to prevent hypoglycemia. * Monitor vitals. Rule out sepsis, if the neonate continues to remain cold. Severe hypothermia: Severe hypothermia is a life- threatening condition and requires treatment on an urgent basis. © Remove the neonate from the source, such as a cold environment, cold clothes, or wet clothing, Nurse the neonate in an incubator ora preheated radiant warmer. Alternatively, use a room heater. ‘© Monitor oxygen saturation with a pulse oximeter. Provide oxygen, if required, ‘+ The neonate requires a saline bolus, if in shock. ‘+ Give IV dextrose infusion * Give vitamin K (1 mg) + Fast rewarming until the baby’s temperature reaches 34°C. Slow the rewarming process after that. + Measure body temperature and other vital signs frequently. © Take blood culture and give empiric IV antibiotics. Suggested Reading [Link] K, Bloom DE, Jamison DT, Hamer DH. The global burden of neonatal hypothermia: a systematic review of a ‘major challenge for newborn survival. BMC Med. 2013 Jan 31/1124. 2. Thermal protection of the newborn: A practical guide. WHO/ FHW/MSM/97.2 Competencies: PE. PEr.10 Breast milk is the ideal nutrition containing all the nutrients for optimum growth and development of a neonate from birth to six months. Exclusive breastfeeding for 6 months is the most effective public health intervention that can reduce neonatal death by 20% and under-5 deaths by 13%. Exclusive breastfeeding reduces hospital admissions due to diarrhea and pneumonia by 72% and 57%, respectively. Exclusive breastfeeding means giving only breast milk, It permits vitamin drops or any medication, if indicated. Initiate breastfeeding within one hour of the birth, and continue exclusively for 6 months. After 6 months, start complementary feeding and continue breastfeeding, for 2 years or as long as the mother wants. Aspertthe latest NFHS-5 data (2019-20), the breastfeeding, initiation within one hour was41.8%, Exclusive breastfeeding for 6 months was 64%. 2; PET; PE7.4; PET.5; PET.7; PET.8; PET.9; Benefits of Breast Milk Nutritional superiority: Breast milk contains all the nutrients in the proportions that a neonate needs for ‘optimum growth and development. The neonate can digest breast milk easily. Carbohydrates: Lactose helps absorb calcium and ‘enhances the growth of lactobacilli, the good bacteria, in the intestine. Galactose is necessary for the formation of galactocerebrosides. Proteins: The breast milk has a low protein concentration (0.9-1.1 g/dL); most of it is lactalbumin and lactoglobulin (60%), which neonates can easily digest. It contains taurine and cysteine, which are necessary for brain growth. These are lacking in cow milk and formula, Fats:Breast milkisrich in polyunsaturated fatty acids (PUFA), necessary for the myelination of the neural tissue. It also contains omega-2 and omega-6 fatty acids for synthesizing prostaglandins and cholesterol for steroid hormones.Human milk oligosaccharides (HMO): HMOs, the most abundant solid in breast milk, are non-digestible carbohydrates that reach the large intestine. They act as prebiotics, support the growth of friendly bacteria, and help develop a healthy microbiome in the large intestine. A healthy microbiome helps in preventing diarrhea and diseases like necrotizing enterocolitis Vitamins and minerals: The quantity and bioavailability of vitamins and minerals are sufficient for the baby’s needs in the first 6 months. Water and electrolytes: Breast milk has a water content of 188%; hence, a breastfed neonate does not require additional ‘water in the first few months of life, even during summer. Breast milk has a low solute load and poses less burden to the kidneys. Immunological superiority: Abreastfed neonate is 14 times less likely to die of diarrhea and almost four times less likely to die of pneumonia Breast milk contains many protective elements: Secretory IgA, macrophages, lymphocytes, lactoferrin, lysozyme, Bificius factor, and interferon, Other benefits: Breast milk contains several growth factors, enzymes, and hormones. Epidermal growth factor enhances the maturation of the intestinal cells and reduces the risk of allergy in later life. Enzymes like lipases increase the digestion of fats in the milk, Other illnesses: Breastfed neonates have a lower risk of diabetes, heart disease, cancer, allergy, ear infections, and orthodontic problems in later life. Mental growth: Breastfed neonates have a better bonding with their mothers. They have a higher 1. Benefits to mother: Breastfeeding helps in uterine involution and reduces the risk of postpartum hemorrhage. Lactation amenorrhea provides effective contraception for initial 6 months. Breastfeeding is convenient and time-saving, It reduces the risk of breast cancer and helps the mother shed the extra weight gained during pregnancy. It prevents type-2 diabetes in mothers. Breast Anatomy ‘The breast contains milk glands embedded in supporting tissues and fat (Fig, 9.40), Breast glands are clusters of ‘tiny sacs that produce milk. These glands have a layer of myoepithelial cells outside of them that propel the milk into lactiferous ducts toward the nipple. Before opening at the nipple, the ducts widen to form lactiferous sinuses, which store milk. The lactiferous sinuses lie beneath the junction of the areola and the rest of the breast. Tiny oil- producing glands on the areola keep the nipple skin soft. ‘The areola and nipples have a rich nerve supply making them extremely sensitive to the baby’s suckling efforts. For efficient milk transfer, the neonate’s gumline must overlie at the junction of the areola and the rest ofthe breast. Physiology Milk production (lactogenesis) involves the interaction of many hormones and reflexes. Two hormones, in particular, play a critical role: Prolactin and oxytocin. Se wuscle cena] X00 makes usc cone econo PN it-seoreting] Prolactin makes )\ cells them secrete mik — buets get] A Nipple Areola Montgomery lands ON at \___— supporting tissue and fat Fig. 9.40: Anatomy of breast ‘are Prolactin reflex (milk secretion reflex):Prolactin acts on the O alveolar glands of the breast to produce milk: The prolactin & reflex or the milk secretion reflex. The anterior pituitary produces prolactin, which mediates milk production by the alveolar epithelial cells (Fig. 9.41). When the neonate sucks, the nerve ending in the nipple carries the impulse to theanterior pituitary, which releases prolactin. The more the neonate sucks atthe breast, the greater the milk production, Earlier the initiation, the sooner the reflex. The greater the demand more is the production, Therefore, mothers should initiate feeding early, do it frequently, and allow complete emptying of the breasts at each session. There is a higher production of prolactin during the night; therefore, night feeding helps maintain this reflex. Newbon Oxytocin reflex (milk ejection reflex): The posterior pituitary produces oxytocin, which is responsible for ejection of milk from the milk glands into the lactiferous sinuses. ‘A baby’s thought, sight, or sound stimulates this reflex (Fig, 9.41b and c). The mother’s positive emotions and relaxed and confident attitude help the milk ejection reflex. (On the contrary, tension, lack of confidence, pain, and lack of sleep hinders the milk flow. The factors reducing milk production include: © Using dummies, pacifiers, and bottles. Not only does it interfere with breastfeeding, but it also predisposes neonates to diarthea. * Giving anything additional to breastfeeding, such as sugar water, tonic, honey, breast milk substitutes, or formula, either as prelacten! (before the first initiation of breastfeeding after birth) or supplemental (alongside breastfeeding) feeds. Studies have reported that even a single such feed may reduce the chances of successful breastfeeding, * Painful conditions like sore or cracked nipples and engorged breasts. * Lack of night feeding ‘+ Inadequate emptying of the breasts (sick or small neonate and mother not expressing milk; ess frequent feeding)Prolactin Secreted after feed to produce next feed Prolactin ‘in blocd Sensory impulses from nipple 2 Prolactin: Secreted more at night; suppresses ovulation ‘Oxytocin reflex Works before or duting {eed to make milk flow oxytocin in blood Sensory impulses from nipple Essential Pediatrics ~ 5 Pain f \ Bovbt, EEO. vn Thinks tovingly of baby > “These hinder reflex ‘Sound and sight of baby See tl confidence ‘These help reflex Fig. 9.41: (a) Prolactin and (b) oxytocin reflex; (c) Factors which help and hinder oxytocin retlex Reflexes in the Baby A neonate has reflexes that help him in attachment and. breastfeeding, Table 9.11: Maturation of breastfeeding reflexes The rooting reflex: The neonate turns his head, opens his mouth, and searches the nipple when something touches his cheek or the side of the mouth. The suckling reflex: Effective suckling requires correct attachment. The neonate starts sucking when the nipple touches his palate. Using rooting and sucking reflexes, the neonate grasps the nipple and areola in the mouth and elongates them into a teat. He compresses the teat between the tongue and the palate and draws milk from the lactiferous sinuses. ‘The swallowing reflex: The neonate suckles a few times to get enough milk, which triggers the swallowing reflex. When milk isin the mouth, the neonate reflexly swallows it. Effective suckling and swallowing require coordination, with breathing. The suckle-swallow-breathe cycle lasts for about one second. Reflexes mature fully for efficient breastfeeding by term gestation (Table 9.11). ‘Advise mothers not to bottle-feed the neonates as it, interferes with successful breastfeeding. Suckling at the breast is entirely different from sucking at the bottle, Suckling on a milk-filled bottle is a passive process; the neonate has to control the free flow of milk with her tongue. While breastfeeding requires the baby’s active efforts. Bottle-fed neonates develop nipple confusion, and that interferes with successful breastfeeding. Even a bottle-feeding session considerably lessens the chances of successful breastfeeding. Also, bottle feeding is associated with severe infections and malnutrition risk. ‘Composition of Breast Milk The breast milk composition varies with time and gestation and within a feeding session to meet the baby’s requirements, i. Colostrum is secreted during the initial 3-4 days of delivery. It is small in quantity, yellow and thick, and contains large amounts of antibodies, immune- competent cells, and vitamins A, D, E, and K ii, Transitional milk is secreted from 3-4 days until two weeks. The immunoglobulin and protein content decreases while the fat and sugar content increases. ‘Mature milk follows transitional milk. It is thinner and watery but contains all the nutrients essential for ‘optimal neonates’ growth. iv. Preterm milk contains more proteins, sodium, iron, immunoglobulins, and calories to meet a preterm baby’s requirements. However, the milk may require fortification with additional nutrients to meet high calorie, protein, and mineral requirements for very preterm neonates. i = Gestation age in weeks 28 weeks 32 weeks 34 weeks 38 weeks Rooting Absent Weak and slow Present Strong Sucking Absent Weak Weak Vigorous Swallowing Absent ‘Associated with a pause in Less frequently interruption Well-coordinated with respiration of respiration respirationig, 9.42a to c: Different postures of a mother during breastfeeding. The mother can feed the baby in any position that is comfortable for her. If siting, her back should be amply supported, and she should not lean on the baby ¥. Foremilkis the milk secreted at the start ofa feed. Watery. and high in proteins, sugar, vitamins, and minerals, it quenches the baby’s thirst vi. Hindmilk comes later and is richer in fat, providing more energy and a sense of satiety. For optimum growth, the neonate needs fore- and hindmilk. Therefore, the neonate should empty the breast before switching to the other, Technique of Breastfeeding Breastfeeding is a natural and pleasurable experience for the mother. However, the mothers require assistance and support in learning the breastfeeding technique. Many mothers face breastfeeding problems that need support from health providers. A systematic approach to lactation support involving families, mothers, and providers greatly ‘enhances breastfeeding success. Postoning Position of the mother: The mother can assume any position of comfort—she can sit or lie down, Her back should be well supported, and she should not lean on her neonate (Fig. 9.42a to 0). Position of the baby i. Baby's whole body is supported, not just the neck or shoulders fi, Baby’s head and body are in one line without any twist in the neck iii Baby’s body turned towards the mother (abdomens of the neonate and the mother touching each other) iv. Baby’s nase is at the level of the nipple. Atfachment (Latching) Ensure proper positioning of the mother and the baby. ‘The mother touches the baby’s upper lip with her breast. Wait until the neonate opens his mouth widely. Bring the neonate closer to the breast and put the nipple and most of the areola into the baby’s mouth (Fig. 9.43). The mother should not lean on the baby. ‘Signs of Good Attachment i, The baby’s mouth is wide open. Re Fig. 9.43: Good attachment Fig. 9.44: The mother feeding both the twin neonates using football hold positions. Note a relative helping the mother. ‘Supporting the babies with pillow reduces the exertion by the ‘mother. Feeding of both the babies simultaneously saves time that mother can use for self-care i, Most of the nipple and areola in the mouth, only the upper areola visible, not the lower one. ili, The baby’s chin touches the breast. iv. The baby’s lower lip is everted. ‘The mother can feed twin neonates simultaneously, saving time, and she can rest adequately between feeding sessions (Fig. 9.44). Newborn CareNeonai lon suckles a couple of times and pmses to swallow (Guck, suck, suck, and swallow). One can see throat cartilage and muscles moving and hear the gulping sounds. The baby’s cheeks are full and not hollow or retracting during suckling. Problems in Breastfeeding Inverted wipples: Flat or small nipples, which become prominent on pulling out, do not pose difficulty in breastfeeding. However, genuinely inverted or retracted nipples can make latching difficult. As the neonate cannot fully take the nipple and areola in the mouth properly, the nipple becomes sore as the neonate sucks on the nipple. ‘Treatment involves pulling out the nipple and rolling it between the finger and thumb several times daily. Alternatively, a cut plasticsyringe can alsobe used (Fig. 9.45) Sore nipple: Nipples become sore when the neonate suckles & om them rather than the areola and nipple because of incorrect © attachment. Unable to get milk, the neonate gets frustrated & and sucks vigorously, and bites on the nipple, causing soreness. Nipples can also get sore due to frequent washing, = with soap or pulling the neonate off the breast while still & sucking. Treatment primarily consists of correct positioning 5 and latching. 2 "in most cases, the mother can feed, ifthe neonate is “© attached correctly. She can apply hindmilk after feeding and keep the nipple dry between feeds. Cleaning of the breast and nipples can happen when the mother takes a bath without frequent washing. No cream or ointment should bbe applied to the sore nipples. Breast engorgement: The milk production accelerates from the second to the third day of delivery. Breasts can get engorged, if feeding is delayed or infrequent or if the neonate cannot feed due to incorrect positioning and attachment. Such breast becomes hard, warm, and tender with shiny skin (Fig. 9.46). The engorged breasts are different from the full breasts, which are heavy but not warm, hard, or tender. Full breasts do not require any specific treatment. Early and frequent feeding and correct breastfeeding technique prevent engorgement of the breast: Treatment consists of hot fomentation, massage, and frequent feeding step 1 a, sep? Insert piston ‘rom cut end — ‘step 3 —— J} mother gently pulls, this piston Fig. 9.45: Syringe treatment for invertediat nipple Fig, 9.46: Engorged breast. Note tense and shiny skin; shows excoriation (arrow) ipple or expression of milk, Analgesics can be given to relieve the pain. Breast abscess: Breast abscess formation can occur, if an engorged breast, cracked nipple, blocked duct, or mastitis is not treated in the early stages. There are systemic signs such as high-grade fever and malaise and profound signs of breast inflammation. Management involves giving analgesics and if required, incision and drainage. Often mothers can continue breastfeeding, Not enough milk: First, ensure that the perception of “not enough milk” is correct. If the neonate is satisfied and sleeps for 2-3 hr after breastfeeding, passing urine at least 6-8 times in 24 hr, and gaining weight, the mother produces enough milk. There could be several reasons for insufficient milk: Incorrect method of breastfeeding, supplementary orbottle feeding, no night breastfeeding, engorgement of the breast, maternal illness, stress, or tiredness. Identify the possible cause and take appropriate action (Table 9.12). Keeping the mother and the neonate in the same bed allows on-demand and frequent breastfeeding, ‘The mother needs sufficient rest and fluids. Expressed Breast Milk (EBM) ‘A mother can express milk if she cannot feed her neonate (sick or working mother, sick or small baby). The neonate can receive expressed breast milk (EBM) or own mother’s milk (OMM) by an alternate feeding method such as a paladai or gastric tube. EBM can be stored for 6-8 hours at room temperature, 24 hours in a refrigerator, and 3 to 6 months in a freezer at -20°C, Method of Milk Expression After washing her hands thoroughly, the mother sits comfortably and massages the breast (Fig. 9.47). She squeezes the breast at the areola and collects milk in a wide-mouth container. The proper hand position involves placing the thumb 4 cm away from the nipple and the index finger on the undersurface of the breast. She must first pull the grip towards her chest and then compress it. The milk generally starts flowing after a few compress-and-release cycles. Being at the baby’s bedside or keeping the baby’s picture can help stimulate the oxytocin reflex. If there is no milk flow, change the position of the thumb, and finger closer to the nipple and express as before. ‘Compress and release all around the breast.‘Table 9: 12-Insufficient breast milk: Causes and remedial actions Causes Remedial action Delayed initiation of breastfeeding after birth Early skin-to-skin contact Cracked o sore nipple Apply hindmilk Oral analgesics Supplementary feeding Infrequent night feeding Frequent night feeding Beast engorgement Hot fomenttion Massage Start breastfeeding immediately ater vaginal delivery and within 30 minutes after cesarean section Correct positioning and attachment ‘Avoid any supplementary feeding ‘Correct positioning and attachment Frequent breastieeding of expression of milk ‘Oral analgesics Counseling Specific treatment Pain alleviation Maternal stress Maternal illness or painful condition inthe mother Less sleep Step 1 oS ce Je Fig. 9.47: Steps of breast milk expression: (1) Massage the breasts gently toward the nipples; 2) Place the thumb and index finger opposite each other just outside the areola; (3) Press back toward the chest, then gently squeeze to release milk; (4) Repeat step 3 in different positions around the areola Ensure proper sleep and rest Keep neonate and mother together A mother should express milk from both breasts 6 to 8 times in 24 hr to maintain optimum lactation. Newborn Care Human Breast Milk Banking ‘Human milk banking (HMB) involves the supply of human donor milk for feeding sick and small neonates whose mothers cannot provide their milk. The first milk bank (/Sneha”) was established in Mumbai in 1989. Following national guidelines on establishing “Lactational Management Centers”, many centersnow have human milk banks in India, The banks accept voluntary milk donations from lactation women after screening them for a penal of infections. The milks further cultured to detect bacterial contamination and pasteurized by the Holder method. However, pasteurized donor human milk (PDHM) is inferior to the fresh mother’s ownmilk (MOM); infants tolerate it better than formula milk. ‘The PDHM retains most macronutrients and micronutrients but lacks many immunocompetent substances of fresh human milk. Compared to formula milk, PDHM use reduces late-onset sepsis, necrotizing enterocolitis, feeding intolerance, retinopathy of prematurity, and length and cost ‘of hospital stay. Long-term studies have also shown benefits in better motor and behavior scores and lower metabolic syndrome risk. Competency: PE20.11 eae son sey cus Low birth weight (LBW; birth weight less than 2500 g) neonates have higher morbidity and mortality. LBW results from either preterm birth (before 37 completed weeks of gestation), intrauterine growth restriction (IUGR), oF both, TUGR is like malnutrition and may present in term and preterm infants. Neonates affected by IUGR are usually undernourished and have loose skin folds on the face and