normal newborn assessment and care

1. NORMAL NEWBORN

2. OBJECTIVES
At the end of the unit students will be able to -
⚫define the normal newborn.
⚫Enumerate the characteristics of normal newborn.
⚫Interrelate the assessment criteria for each component
of the physical characteristics and neuromuscular
characteristics by using ballarard assessment .
⚫Enumerate the steps of immediate newborn care.

3. ⚫ discuss the essential care ( needs) of newborn.
Exclusive breast feeding
Immunization
Hygiene measures
Newborn nutrition

4. ⚫Definition:
A healthy infant born at term (between 38-42 weeks)
should have an average birth weight for the country
(usually exceed 2500 gm.), crises immediately
following birth, establishes independent rhythmic
respiration and quickly adapts to changed environment.

5. Physiology and characteristics of
newborn.

6. vital signs:
⚫Temperature : 97.7 degree Celsius i.e. 100 degree
Fahrenheit.
⚫Pulses: normal- 120-160 beats per min.
⚫Respiration: normal- 40-60breats /min.
⚫Blood pressure :normal range 60-70/31-45mmHg. BP
is directly related to gestational age and birth weight
of the infant.

7. Anthropometric measurements
⚫Height – 45- 55 cm
⚫Weight – 2.7 – 3.1 kg
⚫ Head circumference – 33- 35 cm
⚫Chest circumference - 31- 33 cm
Posture
The newborn assumes the attitude of its intrauterine life , i.e.
extremities flexed and fists clenched.

8. General examination:
The overall appearanceof newborn is must be noted ,
the following should be found in normal newborn.
⚫Bodysymmetrical and cylindrical contour.
⚫Head is large in proportion to the body.
⚫Narrow chest .
⚫Protruding abdomen .

9. ⚫skin color: the normal skin color of newborn is pink
and covers with vernix caseosa. The skin is velvet soft
and elastic texture because of subcutaneous fat.
⚫Premature baby skin is thin ,red , shiny and cover
lanugo.
⚫Post term baby will have less vernix caseosa and skin
is wrinkled and peeling.
⚫It the single most important parameter of cardio
respiratory function.

10. A. Pallor
B. Cyanosis:
⚫ Central cyanosis.
⚫Peripheral cyanosis (Acrocyanosis )

11. A c r o c y n o s i s
c e n t r a l c y n o s i s

12. C. Plethora
D. Yellow
E. Extensive bruising
F. Vascular nevi
• Stoke bite
• Strawberry marks
• Port wine stain
G. Pigmented nevi
H. Milia
I. Mongolian spots
J. Erythema toxicum
K. Trauma

13. E x t e n s i v e b r u s h i n g
E r y t h e m a t o x i c u m

14. p l e t h o r a
J a u n d i c e

15. M o n g o l i a n s p o t s
M i l i a

16. Head
⚫Anterior fontanelles
⚫Posterior fontanelles
⚫Caput succedaneum.
⚫Moulding.
⚫Cephalhaematoma.
⚫Craniosyntosis.

17. D e p r e s s e d f o n t a n e l
B u l g i n g o f f o n t a n e l

18. Craniosynostosis

19. C a p u t s u c c e d a n e u m
C e p h a l h e a m a t o m a

20. Moulding

21. ⚫Raised intra cranial pressure is diagnosed by the
following signs:
i. Bulging anterior fontanelle.
ii. Sepration of suture lines.
iii. Paralysis of upward gaze.
iv. Prominent veins of the scalp

22. ⚫Face : Face is looked for hypertelorism ( eyes widely
separated ) or low set ears (trisomy 9,18) or facial nerve
injury..
⚫Neck: It is checked for movement, goiter, thyroglossal
cysts, sternomastoid hematoma or short neck (Turner’s
syndrome) webbed neck .

23. ⚫Eyes: Are examined for congenital cataract,
brushfield’s spots in the iris (Down syndrome) or
subconjunctival hemorrhage (traumatic delivery)
⚫Nose : cartilage of nose , flaring of nostrils.
⚫Ears : cartilage of ears, hearing ability.
⚫Mouth : the gums are smooth, tongue is red.
Mouth is checked for clefts (palate, lips), deciduous
teeth, linguinal frenulum (tongue-tie), oral thrush,
Epstein pearl, pulling of saliva, circumoral cyanosis,
facial nerve paralysis

24. C l e f t l i p
C l e f t p a l a t e

25. ⚫Chest: Is examined for any asymmetry(tension
pneumothorax), tachypnea, grunting, intercostal
retractions(respiratory distress), pectus exacavatum
and the breath sounds. The newborn’s breasts may
“witch’s milk”.
⚫Heart: Is examined for rate (normal 120-160 bpm),
rhythm, the quality of heart sound and presence of any
murmur. Significance of murmur in the new born is
less. In case of doubt a chest X-ray is helpful for
further.

26. ⚫Abdomen: Is examined for any defects or e.g.
omphalocele, hepatomegaly(sepsis) splenomegaly
(CMV, rubella infection) or any other mass.
⚫Umbilicus: Is examined for omphalocel, any
discharge, redness or infection. A greenish – yellow
coloured cord suggests meconium staining (fetal
distress). Single umbilical artery (more in twin births)
indicates genetic (trisomy 18)and congenital anomalies,
and IUGR.

27. ⚫Genitalia: Should be examined carefully before
gender assignment.
⚫Male is examined for penis (normal>2cm),testes
within the scrotum, any hydrocele and hypospadias,
epispediasis. Foreskin covers the glans penis.
⚫Female is examined for any clitorial enlargement
(maternal drug),fused labia with clitorial enlargement
(adrenal hyperplasia). Blood stained vaginal discharge
may be due to maternal estrogen withdrawal. Normally
labia majora cover the labia minora and clitoris.

28. • Back: normal newborns back is smooth and firm seen for
spine congenital anomalies, spina bifida, pilonidal dimple,
tufts of hairs may indicate fistula.
⚫Anus and Rectum: Is checked to rule out
imperforation and their position. Meconium should pass
with in 48 hours of birth.
⚫Extremities : are examined for syndactyly (fusion of
digits),polydactyl, simian crease (down syndrome), hip
dislocation(ortolani and barlow maneuvers), symmetry
of both extremities.

30. ⚫Nervous system is examined for any irritability,
abnormal muscle tone , reflexes, cranial and peripheral
nerves. Neurological development is dependent on
gestational age.

31. ⚫Haematological findings – Blood volume soon after
birth is about 80ml/kg body weight, it immediate cord
clamping is carried out. RBC- 6-8 milllion /cumm, Hb%
-18-20gm%, WBC- 10,000-17,000/cumm, Platelets –
3,50,000/cumm, nucleated red cells 500/cumm,
sedimentation rate – markedly elevated. Clotting power
may be poor because of deficient vitamin K which is
necessary for production of prothrombin from the liver.

32. Physical and behavioral assessment of
newborn
⚫The American academyof pediatrics recommended
since 1967 the all newborn are classified by birth weight
and gestational age and it scored by the Ballard scoring
tool.
⚫A baby whose lies in between 10th and 90th percentile this
is described as appropriate gestational age(AGA). If the
baby weight is greater than 90 percentile this described as
large for gestational age (LGA) baby who weights bellow
10 percentile is described as small gestational age (SGA)

33. Assessment of neuromuscular maturity
⚫Posture
⚫Squarewindow
⚫Arm recoil
⚫Popliteal angle
⚫Scarf sign
⚫Heal toear

34. ⚫Posture : posture is the natural position that the
newbornassumeson its back. Itobserved with the
infantquietand in spine position.
⚫Squarewindow: wrist f lexibilityand/or resistance to
extensorstretching are responsible for the for the
resulting angleof flexion atwrist.
⚫Arm recoil: this maneuverfocuseson positive flexor
toneof biceps muscles by measuring the angle of
recoil following very brief extension of upperarm

35. Posture
Square window

36. Arm recoil

37. ⚫Popliteal angle: this is the maneuver assess
maturationof positive flexortoneabout knee joint by
testing for resistance to extension of the lower
extremities.
⚫Scarf sign : in the supine position hold the baby's
elbowand movethearm across the midlineof the
chest towards theoppositeside.
⚫Heel toear : this maneuver assesses hip flexibility in
infants.

38. Popliteal angle

39. Scarf sign

40. Heel to ear

42. REFLEX STIMULUS RESPONSE SEEN NOT
SEEN
Moro Infant lying on back,
slightly raised head
suddenly released;
infant lowered abruptly
Arms extended, head
thrown back, fingers fat
out; arms brought back
to center with hands
clenched; legs extended
Birth 4 months
Startle Loud noise Similar to Moro
response
Birth 4 months
Rooting Lightly stroke cheek
with finger
Head turns toward
stimulus
Birth 4 months
Sucking Insert finger into
infant's mouth
Rhythmic sucking Birth 7 months
Extrusion reflex Touch the tongue of
newborn with finger or
nipple
Newborn pushes the
tongue outwards
Birth 4 months
Newborn reflexes

43. swallowing Put the nipples in the
mouth of newborn
Try’s to swallow the
sucking product
Birth Life long
Blinking Light flash Eyelids close Birth -----
Glabellar reflex Tap gently on
glabella
Blink the eyes Birth 4 months
Tonic neck
(fencing)
Head turned to one
side while infant lies
on back
Arm and leg extend
on the side infant
faces. Opposite arm
and leg extend.
2 months 6 months
Ventral
suspension
Hold the baby in
prone position in
hand
Baby shortly hold his
head at the level with
his body and flexed
his limbs
Birth 3 months

44. Stepping Infant supported in an
upright position with
feet touching flat
surface.
Rhythmic stepping
movements
Birth 6 weeks
Babinski Stroke the sole of foot
from heel to toe
laterally
Toes fan out Birth 12 mo.
Palmar (grasp) Touch palm with
finger or object
Grasp object, holds
tightly
Birth 6 months
Plantar (grasp) Place one object in
between toes of baby
Baby try’s to hold that
object in the toes.
birth 12 months

45. Assessment of physical maturity
⚫Skin
⚫Lanugo
⚫Palmarsurface
⚫Breast
⚫Eyes and ears
⚫Genital

46. ⚫Skin – scoring in this category is based on the
palpation and visual inspection skin texture,
transparency, relative thickness, flacking and peeling
of epidermis is noted.
⚫Lanugo – lanugo is the fine hairs seen mostly on the
back and arms of premature infants. It is eventually
thingsout in the lumbarregion and disappears.
⚫Palmarsurface - creases on the solesof both feet's are
scored according to theextent towhich thecreases
cover the surfaceof sole.

47. ⚫Breast – breast tissue is approximated by gently
measuring the tissuespresenton the infants using the
measuring tape in millimeters.
⚫Eyes and ears – eye lids should be open easily in
mature infantsears are inspect forcurving the pinna
and palpate foranydeterminationof thickness of
cartilage.
⚫Genitalia
Male – the testesaredescended in to the scrotumdeep
creases are gradually develops on the scrotum as the
infant more mature.
Female – assessed forcovering of theclitorisand size
of labia mejora and minora , the distance between
edgeof labia mejoraand minor.

48. ⚫Formula for calculating age = (2 * score + 120)/5

51. Immediate care of newborn
1. Initial care
2. Clearing of airway
3. Clamping and cutting thecord
4. Identification
5. Evaluationof the newbornat birth
6. Restitutionof newborn
7. Prevention of heat loss
8. Initiationof breast feeding
9. Vitamin K prophylaxis
10. Newborn immunization

52. 1. Initial care:
⚫Wipe the excess mucus
⚫Handel gently
⚫Note the sex and time of birth.

53. 2.Clearing the airway:
⚫Holding the baby as that head of the baby is lower than
the body and turn some what to side for drainage.
⚫Wipe the baby’s face and fluid from mouth and nose.
⚫Suctioning of the nasal and oral passage with soft
suctioning catheter.

54. 3.Clamping and cutting the cord:
⚫Separation of the baby from the placenta is achieved by
cutting of cord between the two clams which should be
applied 8 to 10 cm from the umbilicus enough space in
between them allows easy cutting of cord.
⚫ time of cutting the cord is not crucial unless the aspexia,
prematurity, or rhesus incompatibility is present is known
as early cord cutting.
⚫The delay cord clamping until the respiration is
established and cord pulsation has stopped. It ensures the
infant receives placental transfusion of about 70ml of
blood.

55. According to leboyer (1976) advocate the delayed cord
cutting for entirely deferent reasons.
⚫The newborn baby to have two sources of oxygen
transition.
1. From the lungs
2. From the placenta through the umbilical cord.
Then when the gradually transition from the dependence
of the placenta to the dependent on the lungs completely
as evidenced by cessation of cord pulsations. This
procedure requires 4 -5 min after birth.

56. 4.Identification:
⚫Identification of the baby is very important because
the misplace the baby and stealing of baby.
⚫In the identification band the name of mother, date
and time of birth and sex should be mentioned.
⚫Midwife ensure that the id band is not so tight and not
so loose.
⚫The id band usually on baby’s wrist or an ankle.

57. 5.Evaluation of baby at birth
APGAR Score–
⚫A measure of the physical condition of newborn
infant. If is obtained by adding points (2,1,0) for heart
rate , respiratory efforts, muscle tone, response to
stimulation, and skin coloration; a score of ten
represents the best possible condition.

58. ⚫TheApgar is quick test performed on a baby at 1min
and 5 min after birth. The 1 min score determines how
well the baby tolerated the birthing process. The 5 min
score tells how well the baby is doing outside the
mother’s womb. In rare cases, the test will be done 10
min after birth.
⚫A-Appearance
⚫P- Pulse
⚫G- Grimace
⚫A-Activity
⚫R-Respiration

59. Sign 0 points 1 points 2 points
A-Activity
(muscle tone )
Absent Arms and legs
flexed
Active movement
P-pulse Absent Below 100 b/m Above 100 b/m
G-Grimace
(reflex irritability)
No response Grimace Sneeze, cough,
pulls away.
A-Appearance Blue- gray pale
all over
Normal, except
for extremities
Normal over
entire body
R-Respiration Absent Slow, irregular Good, crying

60. ⚫In a normal infant the Apgar score is about 7 to 10
But the Apgar score is below 7 the newborn need the
immediate care.

61. 6.Resuscitation of newborn:
⚫The goal of resuscitation of newborn is:
1. Establish and maintain clear airway to ensure the
circulation and to correct the acidosis and to prevent
the hypothermia hypoglycemia and hemorrhage.
⚫Need of resuscitation:
1. Prolonged period of aspexia.
2. Heart rates falls
3. Baby who didn’t cry immediately after birth.
4. Baby born with below 7Apgar score.

62. ⚫Degrees of resuscitation:
The resuscitative requirement is varies from the
condition of the baby at the one min of age.
1. Baby born withApgar score 7 to 10 has blood pH is
7.20 to 7.40
2. The baby with anApgar score of 4 to 6 has a blood
pH 7.09 to 7.19.(moderate acidosis)
3. The baby withApgar score 0 to 3 has blood pH of
7.00 or below (sever acidosis)

63. 1. Baby born with Apgar score 7 to 10 has blood pH
is 7.20 to 7.40.
This baby has the minimal depression & normal
transition period.
Suction the oropharynx and then the nose to clear the
airway to provide the tactile stimulation.
Dry the infant and provide the warmth.
Continue to observe the transition closely.

64. 2. The baby with an Apgar score of 4 to 6 has a
blood pH 7.09 to 7.19.(moderate acidosis)
This baby has moderate depression probably reflecting a
period of primary apnea.
Dry the infant
Place the infant under the radiant heat source
Suction the oropharynx and then nose to clear airway
and provide tactile stimulation; give free flow oxygen
by nasal cannula .

65. If infant is still not apneic or has heart rate bellow 100,
begins the positive pressure ventilation by face mask
attached to the self inflating bag with oxygen reservoir
both give nearly 100% oxygen.
Continue free flow oxygen after infant has established
good respiratory efforts

66. 3. The baby with Apgar score 0 to 3 has blood pH of
7.00 or below (sever acidosis)
this baby has severe depression reflecting secondary
apnea
Suction the infant to clear the airways
Dry the baby
Place in front of the work are under the radiant heat
source
Begin positive pressure ventilation

67. If the positive pressure ventilation dose not ensures the
bag and mask ,performed endotracheal intubation.
If heart rate is less than 60 after 30 seconds after adequate
ventilation begin the cardiac massage until the infant can
sustain heart rate over the 80 with ventilation alone.

68. Equipment's for resuscitation-
Need of flat surface
Two towel
Different size of mask
Laryngoscope
AMBU bag with pop of valve
Stethoscope
Different size of airway
Suction catheter no. 6,8 & 10
Clock
Oxygen with flow meter and tubing

69. Medication for resuscitation:
Epinephrine – 1:10,000 ampoules(1ml) dosage- 0.01-
0.03mg/kg give rapidly IV or ET repeated it 3 to 5
min (ET – diluted to 1-2 ml with NS)
Naloxone 0.4 mg /ml , 1.0mg/ml dosage-0.25 mg/ml
give rapidly IV or ET.
Volume expanders- Ns or RL, sodium bicarbonate
4.2% (1mEq/ml),Dextrose 10% concentration 250 ml,
sterile water 30 ml.

70. ⚫Initial steps:
1. Preventing the heat loss
2. Positioning of the baby
3. Suctioning
4. Evaluation
• Vital signs for respiration, heart rate and color.
Respiration are normal go on evaluating the heart rate , if
respiration are not normal(apneic)begins the positive pressure
ventilation. If heart rate is over the 100 beats /m go on
evaluating color, if less than 100 b/m initiate the positive
pressure ventilation. If infant is pink no action is necessary, if
there is central cyanosis ,administer the free flow of oxygen.

71. Positive pressure ventilation
Indication-
⚫Infant apneic
⚫Heart rate less than 100 b/m

72. Procedure :
⚫Receives the baby and starts the clock
⚫Dry and stimulate the baby for 30 seconds
⚫ wrapped the baby to keeping the baby warm and
make sure that chest is open in order to assess the
baby in terms of tone, color breathing and heart rate.
⚫Ensure the head in the neutral position if the head is
extended or flexed the airway will closed.
⚫Chose the appropriate mask for the baby.

74. ⚫Hold the mask as it covers the baby's nose and mouth
and deliver the five inflation breath (3 seconds
inflation breaths ).
⚫If the chest wall dose not move perform a single
person jaw thrust (make sure fingers are on the bone
not on the soft tissue)
⚫Observe the movement of chest wall if it is not
moving and you have an assistance use the two
person technique for inflation breaths.

75. ⚫If the chest wall is not moving then we need to
consider advanced airway technique such as guedel
airway, if chest wall has a movement then we must go
on and assess the baby in term of tone, color,
breathing and heart rate.

76. ⚫If the heart rate is less than 60 or not improving we
must move on for chest compression, if you are alone
you can use the single person technique delivering the
chest compressions with two fingers below the nipple
line and at the sternum at a rate of 3,2,1;
⚫if you have a assistance you can use the double person
technique to archive the rate of 30 breath of a minute
after 30 sec you must reassessed the heart rate if heart
rate are improving you must continues the ventilation
breaths at a rate of 30 per minute.

78. ⚫If the heart rate is less than 60 still not improving
must continues the CPR if there is no sign of life no
heart rate no breathing for 20 min consider to stop the
resuscitation.
Post resuscitation care
⚫Coverthe babyand prevent the heat loss.
⚫Close monitoring of baby
⚫O2 should beadminister
⚫Shift to the NICU

79. 7. Prevention of heat loss
It is important to keep the baby warm because goes in to
the hypothermia.
Skin-to-skin contact in the first hour of life
⚫Newborns without complications should be kept in
skin-to-skin contact with their mothers during the first
hour after birth to prevent hypothermia and promote
breastfeeding.

81. 8.Initiation of breastfeeding
⚫All newborns, including low-birth-weight (LBW)
babies who are able to breastfeed, should be put to the
breast as soon as possible after birth when they are
clinically stable, and the mother and baby are ready.

82. Early initiation of breast feeding

83. 9.Vitamin K prophylaxis
⚫All newborns should be given 1 mg of vitamin K
intramuscularly [IM] after birth [after the first hour
during which the infant should be in skin-to-skin
contact with the mother and breastfeeding should be
initiated].
⚫it is the prophylaxis against the bleeding disorders and
gonococcal infection with in one hr. of birth.

84. ⚫10. Newborn immunization1
⚫All infants should receive their first dose of hepatitis
B vaccine as soon as possible after birth, preferably
within 24 hours.
⚫ Oral polio vaccine, including a birth dose (known as
zero dose because it does not count towards the
primary series).
⚫ In settings where tuberculosis is highly endemic or in
settings where there is high risk of exposure to
tuberculosis a single dose of BCG vaccine should be
given to all infants.

85. Other daily care and observation of
newborn
⚫Check the Vital signs of the baby
⚫Weight is to be checked daily and evaluate according
to birth weight. Weight loss is normal in the first few
days but more than 10% of body weight is loss is
abnormal, most of the baby gain the wt. with in 7 to
10 days there after the wt. gain rate is 150 to 200
grams per week.
⚫Look for any skin color changes such as cyanosis,
jaundice.

86. ⚫Feeding status of baby have to be assessed amount of
feeding, difficulties of feeding.
⚫Head is assessed of any depression or bulging of
fontanells and resolution of caput succedaneum and
moulding
⚫Look for the umbilical cord for drying and any presence
of sepsis.

87. ⚫Observe the baby for elimination, any constipation,
and loose stool and sore buttocks, observe the color of
urine, frequency of passing urine is noted for past 24
hrs.
⚫Cleansing of the skin may be done daily or as
frequently as required.
⚫Parent infant interaction is must needed it develops
the love bond between mother and baby.

88. Exclusive Breast feeding
⚫The two vital consideration for the infants in tropical
are breast feeding and avoidance of infection .all babies
regardless of the types of delivery should be given early
and exclusive breast feeding up to 6 months of age.
Exclusive breast feeding means giving nothing orally
other than colostrum and breast milk.

89. Preparation and position of mother:
⚫Allow the comfortable and proper
positioning for the breastfeeding.
⚫Without discomfort or pain
⚫Her bladder should be empty
⚫Rested and relaxed
⚫Assured her if she required any help
⚫Her hands should be washed and
nipples cleaned with plain water

90. ⚫Position of breast
feeding:
1. Cradle hold
2. Cross cradle / transitional hold
3. Clutch or football hold
4. Side lying position

91. ⚫First feed :
In the absence of the anatomical or medical
complications, a healthy baby is put to the breast ½
- 1 hour following normal delivery. Following
caesarian delivery a period of 4-6 hours may be
sufficient for the mother to feed her baby.

92. Feeding behavior:
⚫Starting breastfeeding as early as possible after delivery
⚫Frequent feeding during the first few days using both
breasts.
⚫No missed feeding or supplementary feeding.
⚫Rotation of breast to provide complete empting both
breast .
⚫Rested and relaxed and pain free mother during feeding
times.
⚫ baby properly positioned on the breast the baby's
breast should be slightly extended and chin should be in
contact with the breast areola should be properly placed
in the mouth of the baby.

93. Composition of breast milk
⚫Water - 88.1%
⚫Fat - 3.8%
⚫Protein - 0.9 %
⚫Lactose – 7.0%
⚫Minerals – 0.7%

94. ⚫Frequency of feeding:
 Time schedule - During the first 24 hours, the mother
should feed the baby at an interval of 2-3 hours
.gradually, the regularity becomes established at 3-4
hour pattern by the end of first week. Baby should be
fed more on demand.
 Demand feeding – The baby put on breast as soon as
the baby becomes hungry. There is no restriction of
the number of feeds and duration of sucking time.

95. ⚫Duration of feed:
The initial breast feeding should last for 5-10 min at
each breast. This helps to condition the let down reflex.
Thereafter, the time spent is gradually increased. Baby
is fed from one breast compactly so that baby gets both
the foremilk and the hind milk. Then the baby is put to
the other breast if required. Hind milk is richer in the fat
and supplies more calories to the infant. The next feed
should start with the second breast.

96. ⚫Night feed:
In the initial period, a night feed is require to avoid long
interval between feeds of over 5 hours. It not only
eliminates excessive filling and hardening of the breasts
but also quietness and ensures sound sleep for the baby.
However, as the day progress, the baby becomes
satisfied by the rhythmic 3-4 hourly feeding.

97. ⚫Amount of food: The average requirement of milk
is about 100ml/kg/24 hours on the third day and is
increased to 150ml/kg/24 hours on the 10th day.
However, the baby can take as much as he wants. In
dry tropical areas, specially for the first few days,
additional fluids additional fluids may be given after
each feed to correct dehydration in form of boiled water.

98. ⚫Breaking the wind (Burping)
All babies swallow varied amount of air during
suckling. To break up the wind, the baby should be held
upright against the chest and the back is gently patted
till the baby belches out the air. It is better to break up
the wind in the middle of sucking so as to make the
stomach empty, enabling the baby to take more food.

99. ⚫Types of breast milk
Colostrum:
⚫Colostrum is the yellowish breast milk that is first
produced in the first few days after baby’s birth and
before normal lactation begins. Colostrum is
especially rich in nutrients and antibodies, and is the
perfect food for a newborn baby.

100. Foremilk:
⚫This is the milk which is drawn during a feeding. It
is generally thin and lower in fat content, satisfying
the baby’s thirst and liquid needs

101.  Hind milk:
This is the milk which follows by the foremilk during a
feeding. It is richer in fat content and is high in calories.
The high fat and calorie content of this milk is
important for baby’s health and continuing growth.
Make sure to let the baby drain one breast before
moving on to the other.

102. Benefits of breastfeeding to the mother:
⚫Breastfeeding decreases the risk of breast cancer.
⚫The risk of thrombophlebitis is decreased in lactating
mother.
⚫Involution of uterus is rapid in lactating mother.
⚫Lactation suppress the ovulation.
⚫Breast feeding build the bond of love, affection and
care between the mother and baby.

103. Benefits of breastfeeding to the baby:
⚫Breast feeding is easy to digest.
⚫Colostrum and breast milk provides
antibody protection to the baby.
⚫Breastfeeding decreases the risk of the
respiratory infection and gastroenteritis.

104. ⚫Weight gain of the breast feed baby is less than
that of bottle fed baby, obesity is less common in
breastfed baby.
⚫Breast feeding offers a psychological benefits
by establishing healthy mother baby
relationship.
⚫Breast milk is readily available for the baby at
the right temperature.

105. Difficulties in breastfeeding - to baby
⚫Low birth weight baby
⚫Temporary illness, e.g. nasal obstruction , oral thrush.
⚫Over distension of the stomach with swallowed air.
⚫Cleft lip and cleft palate.

106. Contraindications of breast feeding
⚫Breast feeding is contraindicated when mother is
taking medication forcancer, HIV
, puerperal
psychosis.
Antiepileptic, anticoagulant, antithyoridedrug.

107. Features of underfeeding:
⚫Failure of the weight gain.
⚫Dissatisfied baby evidenced by cry in between
feed and night.
⚫Constipation.
⚫Scanty, high colored urine.

108. Feature of overfeeding:
⚫Vomiting soon after feeding.
⚫Frequent, loose, bulky stool with undigested curd and
fats.
⚫Variable weight curve excess, stationary, or at time
falling .

109. Immunization
Immunization is one of the most important and
cost effective strategies and thus a basic need of
all children. The following schedule has been
recommended by the Ministry of Health , Govt.
of India and is followed by child health care
provider.

110. Immunization schedule
Sr.n
o
Vaccine prevents When to give Dose Route Site
1 BCG TB& bladder
cancer
birth 0.1ml (0.05ml)
until 1 month of
age.
intra
dermal
left upper arm
2 Hep B Hepatitis B Birth 0.5 ml IM Antero lateral
site of mid
thigh
3 OPV 0
OPV – 1,2,3
Polio mellitus Birth
6 weeks, 10
week & 14
weeks
2 drops oral oral
4 DPT- 1,2,3 Diphtheria.
pertussis &
tetanus
6 weeks, 10
week & 14
weeks
0.5 ml IM Antero lateral
site of mid
thigh
5 Hep B – 1,2,3 Infection caused
by bacteria
6 weeks, 10
week & 14
weeks
0.5 ml IM Antero lateral
site of mid
thigh

111. Sr.n
o
Vaccine Prevents When to give Dose Route Site
6 Measles Measles 9 completed
months – 12
months .gives up to
5 years if not
received at 9- 12
months
0.5 ml
Sub
cutaneous
right upper
arm
7 Vit A 9 months 1ml oral oral

112. For
childrene
8 DPT
booster
Diphtheria.
pertussis &
tetanus
16 – 24
months
0.5 ml IM Antero lateral
side of mid
thigh
9 Opv
booster
Polio mellitus 16 – 24
months
2 drops Oral oral
10 Measles Measles
16 -24
months
0,5 ml Subcutaneo
us
Right upper
arm
11 Vit. A Deficiency of
vit A
16 months
and one dose
every 6
months
One dose
after every
six months
up to 5 yersrs
2ml
Orall
oral

113. Sr.n
o
Vaccine Prevents When to give Dose Route Site
12 DT Booster 5 – 6 years 0.5 ml IM Upper arm
13 TT
Tetanus
toxoid
10 year and 16
years
0.5 ml IM
Upper
arm

114. Immunization of Newborn –
⚫ BCG, Hep B birth dose and Opv 0 dose.
Pentavalent Vaccine -
⚫The penta valent vaccine is a combination of DPT
(diphtheria, pertussis/ whooping cough and tetanus),
Hepatitis B and Hib vaccines DPT and Hepatitis B
vaccine are already a part of the immunization
programme, it consist of 0.5 ml that will be given
IM in mid –thigh region.

115. Target diseases
⚫Diphtheria
⚫Tetanus
⚫Whooping cough
⚫Hepatitis B
⚫Haemophilus influenza type B

116. Indian Academy of Pediatrics (IAP) Recommendation
⚫Indian Academyof Pediatrics, the largestprofessional or
organization of pediatricians in ourcountry.

118. Abbreviations
1. BCG- Bacillus Calmatte Guerin
2. OPV – Oral Polio vaccine
3. DTwP – diphtheria
4. DT- diphtheria, tetanus
5. TT – tetanus toxoids
6. Hep B – Hepatitis B vaccine
7. MMR – Measles ,Mumps, Rubella vaccine
8. Hib – Hemophilus influenza type b virus
9. IPV – Inadequate polio Vaccine
10. Td – tetanus , reduced dose diphtheria toxoid
11. HPV – Human Papilloma Virus
12. Pcv – Pneumococcal conjugate vaccine
13. Tdap- Tetanus and & diphtheria Toxoids and cellular
pertussis vaccine

119. Hygienic measures of newborn
⚫Cleaning baby’s face and head.
⚫Umbilical card care.
⚫ Baby’s genital care.

120. ⚫Nutritional Needs of the Newborn
1. Proper nutrition is essential for optimal growth and
development.
2. First few months of life the brain grows at a rapid
rate.
3. Adequate food and nutrition is for physiological and
psychological needs.
4. During feeding the parent is close to the infant
5. If a warm relationship does not happen the baby may
fail to thrive nutritionalAllowances for the Newborn

121. ⚫Calories:
1. Most rapid period of growth.
2. Newborn and infant up to 2 mo. require 110 to 120
calories per kilogram of body weight (50 to 55
kcal/lb) every 24 hours for maintenance and growth.
3. Caloric requirement depends on activity level and
growth rate.
4. An infant that cries frequently and squirms constantly
needs more calories.
⚫Commercial formulas simulate breast milk and
contain
9% to 12% of the calories as protein and 45% to
55%of the calories as lactose carbohydrate. The
balance is fat, of which about 10% (4% of the calories)
is linoleic acid. (Table 24-1)

122. ⚫Protein:
1. Necessary for formation of new cells.
2. 2.2 g/kilogram of body weight.
3. Unaltered cow’s milk is not recommended for
newborns because it contains 16% of its calories as
protein whereas human milk contains 8%.
4. Newborn’s kidneys could be overwhelmed
5. Cow’s milk is difficult to digest.
⚫Fat:
1. Linoleic acid, essential fatty acid necessary for
growth and skin integrity in infants is found in both
human and commercial formulas.

123. ⚫Carbohydrate:
1. Lactose, most easily digested carbohydrates
2. Allows protein to be used for building new cells
rather than for calories, encouraging normal water
balance and preventing abnormal metabolism of fat.
3. Improves calcium absorption and aids in nitrogen
retension.
4. Produces stools consisting of gram-positive rather
than gram-negative bacteria.

124. ⚫Fluid:
1. Metabolism rate is high.
2. Newborns use 45 to 50kcal/kg.
3. Requires a large amount of water.
4. Body surface area is large in relation to body mass.
Lose water by evaporation.
5. Extracellular body wt. is 30 to 35% so lose depletes
quickly.
6. Kidneys are not fully concentrating urine so newborn
cannot conserve body water easily

125. ⚫Minerals
⚫Calcium:
1. For bone growth.
2. If newborn sucks well a low level seldom occurs.
⚫Iron:
1. Term infants of a mother who had adequate iron intake
during pregnancy will be born with iron stores lasting for
3 months, until newborn begins to produce hemoglobin.
2. Most mothers do not get adequate iron in their diet a
supplement is recommended for formula fed infants for 1
year.
3. Breast fed has adequate supply.

126. ⚫Fluoride:
1. Essential for teeth.
2. Teeth grow into their primary form during pregnancy.
3. Mother needs to drink fluoridated water during and
after pregnancy to supply the baby, also use in
formula preparation.
4. Fluoride supplement 0.25 mg/day may be given at 6
month of age. (can be detrimental or stain teeth)

127. ⚫Vitamins
1.Unnecessary for bottle fed infants because
vitaminsA,C, and D are in the formula.
2. Vitamins are naturally in breast milk.
3.May need exposed to sunlight for D or mother
can take 400 U daily.
4.Not given to infants until 6 months of age.

128. Bibliography
⚫Annama jacob , “ a coprehensive textbook of midwifery and
gynecological nursing”;jaypee publications:3rd edition :445-
495.
⚫Dutta D.C, “Textbook of obstetrics”; central publictaion: 6th
edition 445-455 .
⚫Handerson cristine and jones katheleen, “Essential midwifery”
; mosby publications;250-283.
⚫Singh meherban, “Care of Newborn”;sagar publications:7th
edition 1-31.
⚫https://en.m.wikipedia.org/wiki/ballard_maturational_assessme
nt.
⚫http://googleweblight.com/i?u=http://www.indianpediatrics.net
dec2013.
⚫http://www.google.co.in/search – for images.

129. Thank you