Growth and development of neonate (1)


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Growth and development of neonate (1)

  2. 2. Growth and development of neonate Introduction The arrival of the newborn is a highly vulnerable period during which many psychological, physiological adjustments to the extrauterine life must be made. When a baby is born an orderly change occurs from foetal life to extra uterine life. It includes physical,psychological and psychosexual and cognitive changes. These changes are most prominent from one year of age, even though it starts from neonatal period itself. Calendar of fetal development Conception-4weeks Rapid growth Formation of embryonic plate Formation of primitive nervous system Development & beating of heart Formation of limb buds 4-8 weeks Rapid cell division Head and face develop All major organs are present in primitive form External genitalia present but not distinguishable Early fetal movement present,visible on usg 8-12 weeks Eyelids fused Kidneys begin to function Urine formation occurs by 10 weeks Fetal circulation well established Sucking and swaloowing well established Sex apparent Moves freely
  3. 3. Some primitive reflexes present 12-16 weeks Rapid development of skeleton Presence of meconium in gut Appearance of lanugo Nasal septum and palate fuse 16-20 weeks Quickening Fhs audible Appearance of vernix caseosa Finger nails seen Renewal of shed skin cells 20-24 weeks Most organs capable of independent functioning Alternating periods of sleep and activity Fetus respond to sound-startle response Skin brick red and wrinkled 24-28 weeks Survival expected if born Eyelids open Resp movements present 28-32 weeks Begins to store fat and iron Testes descend into scrotum Lanugo disappear Skin pale and wrinkled diminish 32-36 weeks
  4. 4. Increased fat deposition Scalp hair lengthen Nails reach tip of fingers Ear cartilage soft Plantar creases visible 36-40 Term reached Skull firm labor due Principles of Growth and Development  Growth is an orderly process, occurring in systematic fashion.  Rates and patterns of growth are specific to certain parts of the body.  Wide individual differences exist in growth rates.  Growth and development are influences by are influences by a multiple factors  Development proceeds from the simple to the complex and from the general to the specific.  Development occurs in a cephalocaudal and a proximodistal progression.  There are critical periods for growth and development.  Rates in development vary.  Development continues throughout the individual's life span. Growth Pattern
  5. 5.  The child’s pattern of growth is in a head-to-toe direction, or cephalocaudal, and in an inward to outward pattern called proximodistal. Stages of Growth and Development Neonate Birth to 1 month Infancy 1 month to 1 year Early Childhood Toddler 1-3 years Middle Childhood School age 6 to 12 years Late Childhood Adolescent 13 years to approximately 18 years Preschool
  6. 6. 3-6 years Terminologies Neonate –it refers to the baby ages from birth to four weeks .the first week of age is known as early neonatal period, late neonatal period ranges from 7-28days of life. Vernix caseosa- a layer of greasy material which covers the skin of a fetus or newborn. Mangolian spot- blue black areas seen on the back and buttock of babies which usually disappear by first year. Milia-white pinpoint pimples caused by obstruction of sebaceous gland. Stork bites-flat red areas on the nape of the neck and eyelids. Adjustment to extra uterine life of all systems Immediate adjustments 1, Respiratory System The most critical and immediate physiologic change required of the newborn is the onset of breathing. The stimuli that help to initiate respiration are primary. a) Chemical stimuli-chemical factor in the blood (low oxygen,high carbondioxide and low ph ), which initiate impulses that excite the respiratory centre in the medulla. b) Thermal stimuli-it is the sudden chilling of the infant who leaves warm environment and enters a relatively cooler atmosphere. This abrupt change in temperature excites sensory impulses in the skin that are transmitted to the respiratory centre. The initial entry of air into the lungs is opposed by the surface tension of the fluid that filled the fetal lungs and alveoli. However fetal lung fluids that filled the fetal lungs and alveoli is removed by the pulmonary capillary and lymphatic vessels. Some fluid is also removed during the normal forces of labour and delivery. As the chest emerges from the birth canal, fluid is squeezed from the lungs through the nose and the mouth. Following emergence of the newborn’s chest brisk recoil of the thorax occurs. Air enters the upper airway to replace the lost fluid. In the alveoli the surface tension of the fluid is reduced by a surfactant. This surfactant reduces the surface tension of the fluid that lines the alveoli and respiratory passages resulting in uniform expansion and maintenance of lung expansion at low intra alveolar pressure. Deficient surfactant production causes unequal inflation of alveoli on and expiration. 2, Circulatory System
  7. 7. Equally important as the initiation of respiration are the circulatory changes that allow blood to flow through lungs.this change occurs more gradually and is the result of pressure changes in the lungs, heart and other major blood vessels.the transition from fetal circulation ensures that the most vital organs and tissue reciewve the maximum concentration of oxygenated blood.fetal brain requires the highest concentration og oxygenated blood .the lungs are essentially non-functional and the liver is partially functional. Therefore less blood is needed to these organs. Blood carrying oxygen and nutritive materials from the placenta enters the fetal systems through the umbilicus via the large umbilical vein ,the blood then travels to the liver where it divides part of the blood enters the portal and hepatic circulation, of the liver and the remained travels directly to the inferior venacava through the ductus venosus.because of the higher pressure of the blood entering the right atrium from the inferior venacava it is directed posteriorly in a straight pathway across right atrium and through the foramen ovale to the left this way the better oxygenated blood enters the left atrium and left ventricle to be through the aorta to the head and upper extremities .blood from the head and upper extrimities entering the right atrium from the superior venacava is directed downward through the tricuspid valve into the right ventricle,from where it is pumped through pulmonary artery. When the major portion is shunted to the descending aorta via the ductus arteriosis.a small amount flows to and from the non functioning lung. Blood is returned to the placenta from the descending aorta through the two umbilical arteries. Structure Before Birth After Birth Umbilical Vein Brings arterial blood to the heart Obliterated; becomes round ligament of the liver
  8. 8. Once the lungs are expanded the inspired oxygen dilates the [pulmonary vessel which decreases the pulmonary vascular resistance and consequently increases the pulmonary blood flow. As the lungs receive blood ,the pressure in the right atrium ,right ventricle and pulmonary artery decreases .at the same time there is progressive rise in systemic vascular resistance from the increased volume of blood through the placenta at cord clamping. This increases the pressure in the left side of the heart .since blood flows from an area of high pressure to that of low pressure ,the circulation of blood through fetal shunts is reversed. Changes in fetal circulation at birth Umbilical Arteries Bring arteriovenous blood to placenta Obliterated; becomes vesical ligame on anterior abdominal wall Ductus venousus Shunts arterial blood into inferior vena cava Obliterated; becomes ligamentum venosum Ductus Arteriosus Shunts arterial and some venous blood from the pulmonary artery to aorta Obliterated; becomes ligamentum arteriosum Foramen Ovale Connects right and left auricles Obliterated usually; at all tim Lungs Contain no air and very little blood; filled with fluid Filled with air and well supplied with blood Pulmonary arteries Bring little blood to lungs Bring much blood to lungs
  9. 9. Physiologic status of other systems 1, Thermoregulation Heat regulation is the most critical to the newborns survival. Although the newborns capacity for heat production is adequate several factors predispose the newborn to excessive heat loss .they are:- a) Newborns large surface area facilitates heat loss to the environment. Newborn produces only two third as much as heat per unit area .however the large body surface is partially compensated for by the newborns usual position of flexion ,which decreases the amount of surface area exposed o the environment. b) Radiation of conservation of body heat due to a thin layer of subcutaneous fat. Since core body temperature is approximately 100F higher than the surface body temperature ,this temperature gradient causes a heat transfer from a higher to lower temperature. c) Newborn mechanism for producing heat .unlike adult ,who can increases heat production through shivering ,a chilled neonate cannot shiver but produces heat through non shivering thermogenesis ( NST ).it is produced by stimulating cellular respiration the resulting oxygen consumption can be three times of any other body tissue. A unique thermogenic source to a full term newborn is brown adipose tissue (BAT)or brown fat. It has greater capacity for heat production through intensified metabolic activity than does ordinary adipose tissue. heat generated in the bat is distributed to other parts of the body through blood. Superficial deposition of BAT is located between the scapulae, around the neck,in the axillae and behind the sternum. Deeper layers surround the kidneys,trachea,esophagus ,some major arteries and adrenals. An important responsibility of the nurse is to maintain the body temperature of the neonate by achieving a balance between head production and heat loss. At birth the major cause of heat loss is through evaporation, the heat loss through moisture. The amniotic fluid that bathes the infant skin favours evaporation, especially when combined with the cool atmosphere of the labor room the other sources of heat loss are Aorta Receive blood from both ventricles Receive blood only from left ventricle Inferior vena cava Brings venous blood from body and arterial blood from placenta Brings blood only to right auricle
  10. 10. Radiation-the loss of heat to cooler solid objects not in direct contact with the neonate. Heat loss increases as the surrounding areas become cooler. Conduction-this involves heat loss through the direct contact of the neonate skin with acooler object. Can be minimized by keeping the baby close to mother or well padded, covered surface rather than an uncovered hard surface. Convection-similar to conduction except that heat loss is aided through surrounding air current. Infant should not be placed under a direct air current source like fan or cooler. 2, Hemopoetic Systems The blood volume of the newborn depends upon the amount of placental transfer of blood. The blood volume of the full term infant is about 80-85 ml/kg of boody weight. Immediately after birth the total blood volume averages 300ml,but depending on how long the newborn is attached to the placenta ,as much as 100 ml can be added to the blood volume. 3, Fluid And Electrolytes Changes occur in total body .water volume,ECF volume and ICF volume during transition from fetal to postnatal life. At term the fetus is composed of 73% fluid as compared to 58% in adults. The infant has a proportionately higher ratio of ECF than the adult, and consequently has a higher level of total body sodium ,chloride and a lower level of potassium, magnesium and phosphate. the rate of fluid exchange is 7times higher than in adult and the metabolism is twice as great in relation to body weight. As a result twice as much acid is formed leading to more rapid development of acidosis. In addition immature kidneys cannot sufficiently concentrate urine to conserve body water. These factors make the newborn more prone to dehydration,acidosis and over hydration. 4,Gastrointestinal System The ability of the newborn to digest, absorb and metabolize food stuff is adequate but limited to certain functions. Enzymes are available to catalyse proteins and simple carbohydrates but deficient production of pancreatic amylase impairs utilization of complex carbohydrates. A deficiency of pancreatic lipase limits the absorption of fats ,especially with ingestion of food that has high saturated fatty acids content such as cow’s milk. Liver is the most immature organ of the digestive system.the activity of glucoronic treansferase is reduced to conjugation of bilirubin with glucoronic acid., which contribute to physiologic jaundice of the newborn. Some salivary gland is functioning at birth but majority do not begin to secreate saliva until 2-3 months, when drooling is common,the stomach capacity is limited to 90ml,thus newborn require small and frequent small feeds. The infants intestine is longer in relation to body size than in adults. So there are larger number of secreatory glands and a larger surface area for absorption as compared with adult.these waves combined with an immature ,relaxed cardiac sphincter,makes regurgitation
  11. 11. a common changes in the stooling pattern indicating functioning of GI tract, which includes the following- Meconium-infants first stool. Composed of amniotic fluid and its constitutes,intestinal secreations,shed mucosal cells and possibly blood.the passage of meconuim should occur within the first 24-48 hours although it may be delayed upto 7days in a very LBW baby. Transitional stools-usually appear by third day day after initiation of feeding,greenish brown to yellowish brown,thin and less sticky than meconium,may contain some milk curds. Milk stool-usually appears by fourth feeding newborn stools are yellow to golden,is pasty in consistency and ha an odor similar to that of sour milk. In formula feeds the stools are pale yellow to light brown ,are firmer in consistency and has an offensive odour. 5, Genito-Urinary System All structural components are present in the renal systems, but there i s a functional deficiency in the kidneys ability to concentrate urine and to cope with conditions and to cope with conditions of fluid and electrolyte fluctuations, such as dehydration or a concentrated solute load. The total urinary output per 24 hours is about 200-300ml by the end of first week. The bladder involuntarily empties when stretched by a volume of 15ml resulting in as many as 20voiding per day. The first voiding occurs within 24hours.the urine is colourless and odourless and has a specific gravity of 1.020. Male genitalia develop at birth, although their maturation varies. The testes of male descend into the scrotum before birth.occasionaly they remain in the abdomen or inguinal canal called undescended testes or cryptorchidism.non retractability of the foreskin and glans penis is normal in newborn (phimosis). Foreskin and glans separate ,beginning in prenatal period. This process gradually completed in 3-5 years. Female genitalia maybe slightly swollen .blood tinged mucus maybe discharged from the vagina.this is due to hormonal withdrawl from the mother at birth. 6, Integumentary System Newborn have all the structures within the skin present but many of their functions are immature. Epidermis and dermis are loosely bound to each other and are very thin. Slight friction across the epidermis such as the removal of the tape ,can cause separation of the layers or blister formation or loss of epidermis. The sebaceous glands are very effective late in fetal life and in early infancy because of high levels of maternal androgens. They are most densely located on scalp,face and genitalia.plugging of the sebaceous gland cause milia. Vernix caseosa A cheese like substance that covers the skin of the newborn ,is made of cells and glandular secreations ,is thought to protect the skin from irritations and the effects of watery
  12. 12. environment.milia may be seen on nose and chin. And will be disappearing within a few weeks. Stroke bite is seen on the nape of neck and on the eyelids. The eccrine glands are functional at birth and palmar sweating on crying reaches levels equivalent to those of anxious adults by 3 weeks of age.observing palmar sweating is helpful in the assessment of pain.the eccrine glands produces sweat in response to higher temperature as compared to adults and retention can cause miliaria.the apocrine gland remain small and non-functional till puberty. The growth phases of hair follicles usually occur simultaneously at birth. During first few month they synchronize between hair loss and growth is disrupted and there maybe overgrowth of hair or temporary alopecia. Boys hair grows faster than girls hairs and in both sexes scalp hair grows is slower than at the crown. Because the amount of melanin is low at birth newborns are lighter skinned than they will be as children. Consequently the newborns are more susceptible to the harmful effects of the skin. Birthmarks Hemangiomas - Are vascular tumors of the skin. Three types of hemangiomas occur: 1. Nevus Flammeus - Is a macular purple or dark-red lesion that is present at birth - Sometimes called a port-wine stain - These lesion typically appear on the face, although they often found on the face; it is less likely to fade. - Can be covered by a cosmetic preparation later in life or removed by laser therapy, although lesions may reappear after treatment. 2. Strawberry Hemangioma - Are elevated areas formed by immature capillaries and endothelial cells. - Most are present at birth in term neonates, although may appear up to 2 weeks after birth. - Application of hydrocortisone ointment may speed the disappearance of the lesions by interfering with the binding of estrogen to its receptor site. 3. Cavernous Hemangioma
  13. 13. - Are dilated vascular spaces, they are usually raised and resemble a strawberry hemangioma in appearance. However they do not disappear with time as the strawberry hemangioma. - Subcutaneous infusions of interferon-alfa-2a can be used to reduce these lesions in size, or they can be removed surgically. - Usually their hematocrit levels assed at health maintenance to evaluate for possible internal blood loss Mongolian Spot - Are collections of pigment cells that appears as slate-gray patches across the sacrum or buttocks and possibly on the arms and legs. - They disappear by school age without treatment. Lanugo - Is the fine hair, downy hair that covers a newborn’s shoulder, back and upper arm. It maybe found also on the forehead and ears. - A baby born after 37 to 39 weeks of gestation has more lanugo than a newborn of 40 weeks. - Is rubbed away by the friction of bedding and clothes against the newborn’s skin. - By 2 weeks of age it disappear Desquamation - Within 24 hours after birth, the skin of most newborns has become extremely dry. The dryness is particularly evident on the palms of the hands and soles of the feet. - This results in areas of peeling similar to those caused by sunburn. Milia - all newborn sebaceous glanda are immature. - At least one pinpoint white papule can be found on the cheek or across the bridge of the nose of every newborn. - Disappear by 2 to 4 weeks of age, as sebaceous glands mature and drain. Erythema Toxicum - In most normal mature infants, a newborn rash - This usually appears in the first to fourth day of life, but may appear up to 2 weeks of age.
  14. 14. - It begins with papule, increases in severity to become erythema by the second day, and then disappears by the third day - Sometimes called flea-bite rash - Caused by a newborn’s eosinophils reacting to the environment as the immune system matures. Epstein’s Pearls - One or two small round, glistening, well circumscribed cysts are present on the palate, as a result of the extra load of calcium that was deposited in utero. 7, Musculoskeletal System At birth skeletal system contains large amount of cartilage than ossified bone, although the process of ossification is fairly rapid during the first year. The nose for example is predominantly cartilage at birth and is frequently flattened by the force of delivery. The six skull bones are relatively soft and not yet joined. The sinuses are incompletely formed at birth. Growth in size of the muscular tissue is caused by hypertrophy, rather than hyperplasia of cells. 8, Immune Systems The neonate is born with several defences against infection. The first line of defence is the skin and mucus membranes which protect the body from invading organisms. The second line of defence is the cellular elements of the immunologic system,which produces several types of cells capable of attacking a pathogen.the neutrophills and monocytes and phagocytes,cells that engulf ,ingest and destroy foreign agents.eosinophills also probably have a phagocytic proprety ,since in the presence of foreign protein they increase number. The lymphocytes are capable of converted to other cell types such as monocytes and antibodies. Although the blood has phagocytic properties in it, the inflammatory response of the tissues to localize an infection is immature. The third line of defence is the formation of specific antibodies to an antigen. This process requires exposure to various agents for antibody production to occur. Infants are not capable of producing their own immunoglobulins until the beginning of the second month of life but receive considerable passive immunity in the form of immunoglobulin from the maternal circulation and from human milk. They are protected against most childhood diseases including diphtheria,measles,polio and rubella for about three months provided that the mother has developed antibodies to these illnesses. 9, endocrine system Generally the endocrine system of the newborn is adequately developed, but their functions are immature. For eg-the posterior lobe of pituitary gland produces limited quantities of ADH or vasopressin which inhibit diuresis. This renders the newborn highly susceptible to
  15. 15. dehydration. The effect of maternal sex hormone is particularly evident in the newborn. The labia are hypertypical and the breast in both sexes may be engorged and secrete milk (witches milk),during the first few days of life to as long as 2month of age. Female may have pseudo menstruation due to sudden drop in progesterone and estrogen levels. 10, Neurologic System At birth the nervous system is incompletely integrated but sufficiently developed to extrauterine life. The autonomic nervous system is crucial during transition because it stimulates initial respirations helps maintain acid base balance and partially regulate temperature control. Myelination of the nervous system follows the cephalocaudal-proximodistal laws of development and is closely related to the mastery of fine and gross motor skills. Tracts that develop myelin earliest are the sensory,cerebellar and extrapyramidal. This accounts for the acute senses of taste, smell, hearing as well as the perception of pain,in the newborn. All cranial nerve are myelinated except the optic and olfactory nerves. 11, Sensory Functions Are well developed and have a significant effect on growth and development including the attachment process. Vision at birth the eyes are structurally incomplete. The cornea centralism is not yet completely differentiated from the macula. The ciliary muscles are immature limiting the ability of the eyes to accommodate and fixate on an object for any length of time. The pupils reflect to light, the blink reflex is responsible to a minimal stimulus, and the corneal reflex is activated by a light touch.tear glands do not begin to function until 2-4 weeks of age. The newborn has the ability to momentarily fix on bright or moving objects that is within 20cm and in midline of the visual field. In fact infant ability to fixate on coordinate movement is greater during the first hour of life than in succeeding several days. Visual acuity is between 20/100 and 20/400 depending upon the visual preference.:-medium colors (red, orange , blue),black, and white contrasting patterns, especially geometric shapes checker-large objects with medium complexity rather than small complex objects, and reflecting objects over dull ones. Hearing Ones the amniotic fluid has drained from the ears, the infants probably has auditory acuity similar to that of adult. The newborn able to detect a loud sound of about 90 decibels, and reacts with a startle reflex. Newborns response too low frequency differs from that of higher frequency. Former tends to decrease an infant’s most activities and crying whereas the later elicits an altering reaction.
  16. 16. There is an early sensitivity to human voices and sounds. For eg:- newborn less than 3days of age can differentiate the mothers voice from that of other woman’s. As early as 5days newborns can differentiate between stories repeated to them during the last trimester of their pregnancy by their mother and the same stories recited after birth by different women. The internal and middle ear structure is large at birth but the external canals have not yet developed. Consequently tympanic membrane and facial nerve are very close to the surface and can be easily damaged. Smell Newborns react to strong odours by turning their head away. Breast fed newborn are able to smell breast milk. Also they are able to differentiate the smell between the breast milk of their mother from other women. Maternal doctors are believed to influence attachment process and successful breast feeding. Tastes The newborn can differentiate taste difference between different types of solution and elicit different facial reflexes. A tasteless solution elicits no facial expression. A sweet elicits an eager suck and a look of satisfaction sour solution elicits a usual puckering of lips and bitter produces upset expressions. They prefer glucose water to sterile water. The newborn perceives tactile sensation in any part of the body although face , hands and soles of the feet seem to be most sensitive. There is increasing documentation that touches and motion are essential for normal growth and development.however painful stimuli, pinprick is upsetting. Most neurologic reflexes are primitive reflexes. Neurologic reflexes can be observed from week to week. Certain reflexes are absolutely essential. Successful use of reflex mechanism is evidence of normal functioning of the nervous system. If reflex is absent or impaired possibly the CNS has sustained injury. Although it may not be able to correct the condition, the care of the infant must be adapted to disability. Psychosexual development of newborn At the time of conception, the gender of the fetus is biologically determined. However the primitive gonads that develop by the 5th or 6th week of gestation are bio potential, containing both ovarian and testicular components. Psychosexual development containment after birth as the newborn finds satisfaction from oral stimuli from physical contact with the caregiver and from being held and cuddled. Cognitive development
  17. 17. It refers to the thinking and to the gaining and using of knowledge. The newborn has the ability to interact with the environment and signal needs and gratitude when those needs are met. The newborn as young as 12days of age are able to imitate facial and manual gestures of adult and prefers sharply contrasting colours , large squares, medium –bright objects with eyes and mouth. The newborn also has the ability to respond to auditory stimuli, by turning the head and looking to the source of stimuli. The frequency and intensity of auditory response however affect the response. High frequency stimuli are more likely to produce a response but it may be a distress response whereas low intensity signals inhibit distress. Newborn is sensitive to touch and handling. If a newborn is quiet, intrusive touch will initiate an alert state. When the newborn is upset and crying, a soft slow touch will be calming. If some form of CNS irritation exists, there is increasing irritability with stimuli and further evaluation is required. The newborns response to various stimuli affects the caregiver infant bond. Since nonverbal communication between the caregiver and baby are the initial stages of attachment, caregivers should provide the newborn with stimuli that evoke a taught to look for cues that the infant maybe over stimulates and becoming habituated. Psychosocial development Child psychoanalyst Erik Erikson, has divided the human lifespan into eight the infant first stage , including newborn is trust versus mistrust. Here the newborn relies on others to meet the needs and develops basic trust when the caregivers meet these needs. Through a supporting, nurturing and loving environment, the newborns forms an attachment to the caregivers and develops positive relationships. However the development between the newborn and caregiver requires more than just being fed and meeting the biological needs met. Attachment depends upon emotional response as well. Anticipatory guidance should given through nutrition, thermoregulation, sleep, diaper care, newborn care, newborn screening. Temperament It is the way child interacts with the surrounding environment.children are thought to be genetically endowed with specific temperamental characterestics which when combined with the caregivers personality produce a characterstic pattern of social interaction between the child and environment. Temperamental characteristic are behavioural tendencies , not implication of a good or bad child,and can be categorized into nine attributes. 1, activity-intensity and duration of physical activity 2, rhythimicity-regularity of repetitive physiological cycle, eating patterns, elimination patterns. 3, approach-withdrawal-initial reaction to a given
  18. 18. 4, adaptability-ease or difficult with which the child reacts or adapts to a given stimulus. 5, intensity of response-degree of energy used by the child to react to the stimulus 6, threshold of responsiveness-amount of stimulation needed to evoke a childs response 7, mood - amount of happiness versus unhappiness, or pleasant/friendly behaviour versus unpleasant/unfriendly behaviour elicited in various situations. 8, distractability-effectiveness of the stimulus to alter the direction of ongoing behaviour 9,Attention span and persistence-length of time the child pursues an activity and continuation of an activity, despite the obstacles. Personality type1: easy (about 40%of children) It is characterised by regularity of biologic functions (consistent, predictable times for eating, sleeping and elimination). A positive approach to new stimuli High adaptability to change Mild or moderate intensity in response A positive mood Easy going and adapts rapidly to stimuli Likes to be around people Sleeps and eats well, has regular and predictable behaviours Personality type2: difficult child (about 10% of children) It is characterised by irregularity of biologic functions negative withdrawal from new stimuli, poor adaptability and intense response and a negative mood. Adapts slowly to stimuli Has an overall negative mood Requires a structured environment Likes people but can do well alone Seems to be in constant motion Has an irregular pattern of behaviour Personality type3: slow to warm up child (about 15% of children) It is characterized by a low activity level, withdrawal from new stimuli, slow adaptability, mild intensity in response, somewhat negative mood. Adapts slowly to stimuli but is watchful
  19. 19. Quietly withdraws and is usually moody Primarily a loner and usually shy Oversensitive and slow to mature Primarily inactive Reacts passively to changes in routine NURSING CARE OF THE NORMAL NEWBORN GENERAL The practical nurse has a unique opportunity of closely observing and providing care for the newborn infant after delivery (see figure 8-1). Because of the newborn infant's helplessness, his needs must be met initially by nursing personnel. Many nursing assessments and evaluations are conducted for the well-being of the infant. Nursing care does not stop with the newborn infant. Interaction with the parents is also important in the development of a family unit.
  20. 20. . The newborn infant. CARE OF THE NEWBORN IN THE DELIVERY ROOM There are several needs of a newborn infant that require close attention. Establishing and maintaining respirations are the two needs that must be met immediately. a. Establishing and Maintaining the Newborn's Airway. The physician suctions the infant before it is completely born with a bulb syringe or a DeLee trap. A DeLee trap is used if meconium was present in the amniotic fluid. The infant's mouth is suctioned first and then his nose. Once the infant is delivered, his head is held slightly downward to promote drainage of mucus and fluid. The infant's face is wiped thoroughly clean. If the infant doesn't breathe spontaneously, he should be stimulated to cry by slapping his heels, lightly tapping the buttocks, and/or rubbing his back gently. The infant is then positioned with his head slightly down when placed in the radiant warmer. The bulb syringe is used to remove mucus from his mouth and nose (see figure 8-2).
  21. 21. Removing mucus from infant's nose. (1) Common characteristics of newborn respirations. (a) Nose breathers. Sleeps with mouth closed, does not have to interrupt feedings to breathe. (b) Irregular rate. (c) Usually abdominal or diaphragmatic in character. (d) Ranges from 40 to 60 breathers per minute. (e) Breathing is quiet and shallow. (f) Easily altered by external stimuli. (g) Periods of apnea less than 15 seconds is normal. (h) Acrocyanosis may occur during periods of crying. Acrocyanosis refers to cyanotic look of the baby's hands and feet when he is crying. When the baby stops crying, his hands and feet get pink again. (2) Signs and symptoms of newborn respiratory distress. (a) Increased rate or difficulty breathing-growing and seesaw breathing. In normal respirations, the infant's chest and abdomen rise. With seesaw respirations, the infant's chest wall retracts and his abdomen rises with inspirations. (b) Sternal or subcostal retractions. (c) Nasal flaring. (d) Excessive mucus, drooling. (e) Cyanosis.
  22. 22. See-saw respirations. b. Maintaining Body Temperature. (1) Dry the infant thoroughly immediately after delivery. The infant is extremely vulnerable to heat loss because his body surface area is great in relation to his weight and he has relatively little subcutaneous weight. Heat loss after delivery is increased by the cool delivery room and the infant's wet skin. (2) Place the infant in a radiant heat warmer. (3) Place a stockinette cap on the infant's head to prevent heat loss through the head. (4) Wrap the infant snugly in a warm blanket. (5) Place the infant closely to the mother's skin. Skin-to-skin contact with the mother will help prevent heat loss. c. Identify the Infant After Delivery. (1) The infant must be properly identified before leaving the delivery room. An identification (ID) band is placed on the infant's wrist and leg. An identical band matching the infant's band is placed on the mother's wrist. (2) The infant's footprints or palm prints placed next to the mother's thumb print is rarely done in most facilities. Each facility has its own instant identification method. d. Establish Parent-Infant Bonding Process. (1) Parent-infant bonding is the initial step in the process of attraction and response between the newborn and the parents. This paves the way for development of love and affiliation that forms a strong family unit. (2) This process should begin as soon after delivery as possible. In the delivery room as soon as the infant is dry and identified, he should be given to the parents. The infant is more alert during the first hours (approximately four) after birth than in the immediate subsequent hours. VIRGINIA APGAR SCORING OF THE NEWBORN
  23. 23. The initial APGAR scoring is performed in the delivery room by the physician. APGAR scoring is a method of evaluating the condition of the newborn at one minute and at five minutes after delivery. APGAR scoring chart. a. Purpose. The APGAR scoring chart is used to evaluate the conditions of the baby at birth, determine the need for resuscitation, evaluate the effectiveness of resuscitative efforts, and to identify neonates at risk for morbidity and mortality. b. Objective Signs Used for Evaluation. (1) Heart rate. (2) Respiratory effort. (3) Muscle tone. (4) Reflex irritability. (5) Color. c. Scoring. (1) Evaluations at each of the five categories are initially done at one minute after birth. (2) Each item has a maximum score of two and a minimum score of zero. (3) The final APGAR score is the sum total of the five items, with a maximum score of ten. The higher the final APGAR score, the better condition of the infant.
  24. 24. (4) Evaluations at one minute quickly indicate the neonate's initial adaptation to extrauterine life and whether or not resuscitation is necessary. (5) The five-minute score gives a more accurate picture of the neonate's overall status, including obvious neurologic impairment or impending death. Ballard Scoring • Is a commonly used technique of gestational age assessment. It assigns a score to various criteria, the sum of all of which is then extrapolated to the gestational age of the baby. These criteria are divided into Physical and Neurological criteria. This scoring allows for the estimation of age in the range of 26 weeks-44 weeks. The New Ballard Score is an extension of the above to include extremely pre-term babies i.e. up to 20 weeks. PROCEDURE FOR ADMISSION TO THE NURSERY
  25. 25. a. Carry out the hospital policy for gowning and the three-minute scrub. If you are already wearing scrubs, it is not necessary to gown. If the initial scrub has already been completed when coming on duty, a one-minute scrub is acceptable. b. Receive the infant from the transporter. Take the infant from the transporter or the transporter's arms. Verify the ID bracelet on the infant's arm and leg with the delivery room personnel. Make sure the information is accurate (i.e., mother's name, sex of the infant, date and time of birth, and doctor's name). Take the report from the delivery room person. The report concerns pertinent information of the mother's labor and of the newborn's birth. c. Remove the delivery room blanket from the infant. d. Weigh the infant. Place a protective paper cover over the scale first and make sure the scale is balanced. Place the infant on the scale. Document the infant's weight on the: (1) Nursing Notes. (2) Delivery room record. (3) Instant data card. e. Place the infant in an open warmer for the remainder of the admission procedures to maintain adequate temperature. (1) Measure the infant (a) Length (from top of head to the heel with the leg fully extended). (b) Head circumference - repeat after molding and caput succedaneum are resolved. (c) Chest circumference (at the nipple line). (d) Abdominal circumference.
  26. 26. Measuring infant. (2) Record measurements in inches and centimeters. (3) Document the information in the appropriate areas on Nursing Notes, the delivery room record, and the instant data card. (4) Take infant's vital signs and document on Nursing Notes and the delivery room record. (a) Temperature-only the first one is done rectally, the remainder are axillary. (b) Heart rate and respirations-count a full minute because of the irregularities in rhythm. NOTE: See figure for taking the infant's temperature for normal neonatal vital signs. Taking infant's temperature.
  27. 27. Normal neonatal vital signs. f. Aspirate fluids. (1) Aspirate the infant's mouth and nose gently with a bulb syringe. (2) Insert a number 5 French catheter into the baby's nares to check for patency. (3) Insert a number 8 French catheter in the baby's mouth down into the stomach and gently aspirate stomach contents. (4) Record the color and amount of aspirate on Nursing Notes and on the delivery record sheet. g. Evaluate the infant's physical condition. (1) Note the infant's cry, color, and activity for signs of respiratory distress throughout the assessment. (2) Do a complete head-to-toe assessment, looking for any gross abnormalities on his hands, feet, palate, spine, and so forth. (3) Document if the infant voids or passes meconium. (4) Document presence of reflexes (dealt with more extensively in the typical newborn). (a) Moro. (b) Sucking.
  28. 28. (c) Grasping. (5) Count the number of vessels in the cord and document. (6) Assess head for molding, caput succedaneum, or cephalhematoma and document in appropriate records. (7) Observe and record any birthmarks. h. Place the infant on his side to promote drainage of mucus. Note that he is supported by a pillow to his backside. Infant placed on his side. i. Provide for infant's safety while in open warmer. j. Place the infant in an isolette if his temperature is below 98°F rectally. If the infant's temperature is above 98ºF rectally, place him in an open crib. NOTE: Step "j" is done after the initial assessment and procedures are completed. ADMINISTRATION OF VITAMIN K Vitamin K is given as a prophylaxis for hemorrhagic disease. It is administered intramuscular (IM) in the vastus lateralis muscle
  29. 29. Intramuscular injection. The vastus lateralis muscle lies lateral to the midline of the thigh and wraps about 1/4 the distance around the thigh...from 12 o'clock to 3 o'clock EYE PROPHYLAXIS FOR THE NEWBORN This procedure is required by law in all states as prophylaxis against gonorrhea. The medications used are as follows: a. Erythromycin Ophthalmic Ointment. This has become the drug of choice and is received in a sterile syringe from the pharmacy. It is injected into each eye from the inner to outer canthus immediately after birth . It does not appear to cause much eye irritation. b. 1% Silver Nitrate Solution. Two drops are applied in each eye in the conjunctival sac, not the cornea. The infant eyes may or may not be irrigated after instillation, depending on local policy. The infant may get profuse discharge and chemical conjunctivitis for a few days with no residual damage. One percent silver nitrate solution is no longer recommended for use. Administration of erythromycin ophthalmic ointment.
  30. 30. INITIAL BATH a. The amount of time required for the initial bath is determined by local policy. If the infant's temperature is greater than 98ºF rectally, the bath may be done after all admission procedures are done. Otherwise, wait until the infant's temperature has stabilized above 98ºF. b. The procedure for actually completing the bath is also determined by local policy. Allow the parent to participate if possible. Remove as much of the vernix as possible. Some may not come off during the first bath because it is so "sticky." CORD CARE FOR THE NEWBORN INFANT a. Inspect the cord frequently for signs of bleeding immediately after it has been cut. b. Apply triple dye (refer to local policy) to the cord after the infant has had his bath and has been determined to be stable. The dye prevents infection and helps the cord to dry. c. Swab the cord with alcohol at least three times per day (refer to local policy). The alcohol aids in drying. d. Observe for cord detachment. The cord detaches in ten to fourteen days. The cord dries faster when left uncovered. Have the parents roll the infant's diaper down some in front initially so the cord is not covered. e. Observe for signs of infection and report findings immediately. The signs of infection are purulent drainage, redness, and possible swelling (more than usual). BONDING PROCESS a. Bonding should be initiated in the delivery room. b. The significant other should be allowed to participate in as much of the care as possible during the admission process to develop the bond between him and the infant. c. Transport the infant back to the mother as soon as local policy allows to take advantage of the alert state newborns have during those first few hours after birth. (1) This is considered a critical time for both individuals to interact and get to know one another. (2) It is an excellent time to establish breast-feeding while the infant is awake. (3) Approximately the first four hours after delivery, the infant returns to a sleep state or less alert state. INFANT BAPTISM a. Baptism is performed for infants who are in imminent danger of death and whose parents are Roman Catholic or certain other Christian denominations.
  31. 31. b. The nurse may perform the baptism by pouring a small amount of warmed water on the infant's head and saying, "I baptize thee in the name of the Father, and of the Son, and of the Holy Spirit." A record of the baptism is made in Nursing Notes. The parents are notified about the baptism. COMPLETE INSPECTION OF THE NEWBORN A complete inspection of the newborn infant is performed within 24 hours after delivery. The goal is to compile a complete record of the newborn that will act as a database for subsequent assessment and care. a. Assemble necessary equipment. (1) Pediatric stethoscope. (2) Penlight. (3) Tape measure. (4) Rectal thermometer. (5) Infant scale. b. Wash hands for a full three minutes. c. Approach and identify the infant. d. Provide for a warm, well-lighted, draft-free area, keeping the infant undressed for as short a time as possible. e. Place the infant on a flat, protected surface. f. Take the infant's temperature. The infant's temperature is taken rectally only on admission. Subsequent temperatures are to be taken by the axillary method. g. Determine the infant's apical heart rate. Count for a full minute. h. Determine the infant's respiratory rate. Count for a full minute. Note any signs of respiratory distress (retractions, grunting, nasal flaring) rate over 60 bpm, or periods of apnea. Auscultate the infant's lungs. i. Balance the scale. j. Weigh the naked infant. Most newborns weigh between six to nine pounds (2,700 and 4,000 grams). Record the weight in pounds and ounces, as well as in grams. k. Measure the infant's length from top of the head to the heel with the leg fully extended and record measurements.
  32. 32. l. Measure the infant's head circumference and record measurements. The normal head circumference is 13 to 14 inches (33 to 35 cm). Cranial molding from a vaginal delivery may affect this measurement. The measurement should be repeated on the second and third day after delivery. m. Measure the infant's chest circumference at the nipple line and record the measurement. n. Observe the general contour of the infant's head. Gently palpate the sutures and fontanelles. The anterior fontanelle is approximately two inches long and is gem/diamond shaped. The posterior fontanelle is smaller than the anterior fontanelle. Normally, the fontanelle feels soft and is either flat or slightly indented. The anterior fontanelle usually bulges when the infant cries, coughs, or vomits. o. Observe the general appearance of the infant's neck. The infant's neck is usually short, thick, and covered with folds of tissue. The infant should be able to move his neck from side to side, from flexion to extension, and can hold his head in the midline position. p. Observe the infant's eyes for symmetry of size and shape. Note the infant's eye movements. Strabismus caused by poor neuromuscular control is normal. An infant older than ten days should look in the direction in which you turn. Note the color of the infant's eyes. q. Inspect the infant's ears for structure, shape, and position. The ears should be firm with wee-formed cartilage. Tops of the auricles should be parallel to the outer canthus of the eye r. Inspect the infant's nose for patency. s. Inspect the infant's mouth for cleft palate by gently depressing his tongue when he cries. Check the mucous membranes. Observe the soft and hard palate. Make sure they are in tact. t. Inspect the infant's skin and nails. Observe for jaundice, birthmarks, milia, petechiae, and lanugo. Observe the infant's hands and feet for normal creases. Observe the color of the infant's nail beds; they should be pink. Acrocyanosis may be present up to 24 degrees, especially when the infant is crying. u. Inspect the size, shape, and symmetry of the infant's chest. Normally, an infant's chest is circular or barrel-shaped. The breast tissue of both male and female infants may be slightly engorged during the first few days of life. v. Palpate the infant's peripheral pulses (femoral, brachial, and radial). w. Inspect the size and shape of the infant's abdomen. The abdomen should be cylindrical in shape. Sunken or distended abdomen should be reported. Check the umbilical cord for the number of vessels. x. Auscultate the infant's abdomen for bowel sounds. Bowel sounds should be present within one to two hours after birth. y. Observe for excessive drooling, coughing, gagging, or cyanosis during feeding.
  33. 33. z. Place the infant on his abdomen and observe his spine for curves, masses, or abnormal openings. aa. Inspect the male infant's genitalia. The penis should be checked for location of the urinary meatus. The scrotum may appear edematous and proportionately large. bb. Inspect the female infant's genitalia. The labia majora may appear edematous and cover the clitoris and the labia minora. cc. Observe the infant's spontaneous or involuntary movements for symmetry, spasticity, or rigidity. Gently straighten his arm or leg. Release it and observe whether it returns to its normal position. If the extremity remains limp, the infant may be hypotonic. If the extremity is difficult to straighten and rapidly flexes when released, he may be hypertonic. dd. Dress the infant carefully and return him to his bassinet. ee. Record all significant nursing observations in the infants' health record. Report your observations to the Charge Nurse. PHENYLKETONURIA TEST A phenylketonuria (PKU) test is done to check for rising levels of phenylalanine. Phenylalanine is a naturally occurring amino acid essential to growth. After milk or formula (both contain phenylalanine) feedings begin, levels rise due to a deficiency of the liver enzyme that converts phenylalanine to tyrosine. Due to this metabolic deficiency, poisons build up in the bloodstream and cause mental retardation. If the infant is found to have rising levels of phenylalanine, many protein foods can be withheld from the diet and synthetic foods substituted. The following steps are performed to collect a blood specimen for a PKU test on the newborn infant. . Puncture site (X) on sole of infant's foot for heelstick sample. a. Ensure that the infant has been on milk or formula feeding for three full days. Four days are preferred. b. Explain to the parents the purpose of the test
  34. 34. c. Perform a heel stick to obtain needed specimen d. Place one drop of blood on each of the three circles on the filter paper or in accordance with local policy. e. Label and transport the specimen to the laboratory. f. Notify the parents of follow-up care of the infant, if the infant is discharged prior to his third or fourth day of life. This test must be done. GOALS OF NEWBORN NURSING CARE a. To continue appraisal of the newborn throughout his hospital stay. (1) Observe and record the infant's vital signs. (2) Monitor weight loss or gain (daily by some local policy). (3) Monitor bowel and bladder function. (4) Monitor activity and sleep patterns. (5) Monitor interactions and bonding with parents. b. To provide safeguards against infection (that is, handwashing). c. To initiate feedings. d. To provide guidance and health instruction to parents. DISCHARGE CONSIDERATION FOR THE NEWBORN AND FAMILY a. Planning for discharge should begin at time of admission. An infant in normal health is discharged from the hospital at the same time as the mother. b. Instructions for parents (teaching should be continuous). (1) Feeding schedule. (2) Bathing routine. (3) Home care needs. (4) Umbilical cord stump care. (5) Infant safety in the car. c. Prior to discharge, a follow-up appointment date should be arranged for the newborn (local policy determines the date-two, four, or six weeks).
  35. 35. d. A final identification check of the mother and the infant must be performed before the infant can be allowed to leave the hospital. Nursing Diagnosis  Risk for ineffective thermoregulation related to newborn’s transition to extrauterine environment  Risk for ineffective airway clearance related to presence of mucus in mouth and nose at birth  Risk for infection related to newly clamped umbilical cord and exposure of eyes to vaginal secretions Newborn Screening NNF Clinical Practice Guidelines Introduction Newborn Screening refers to the process where babies are subjected to simple blood test a few days after birth to see if they have a genetic or metabolic disorder. The conditions screened for in Newborn Screening (NBS) may be life threatening and/or cause intellectual disability or physical disability.1 These conditions are often referred to as Inborn Errors of Metabolism (IEM). The aim of NBS is to detect the conditions before the onset of symptoms so treatment can be started early to reduce the effect of the condition. This form of testing is known as screening because it involves testing a whole population - in this case, newborn babies. All babies are tested even if they do not have any obvious signs of a condition that affects their metabolism. The neonatal screening tests are not diagnostic. They separate a population of newborn infants into two groups: one made up of those who may have a given disease, the other by those who probably do not have it. Why is NBS needed? As per recent data 140 million children are born every year around the world, out of which 4 million children are born with some congenital problem of which thousands die of definable and non-definable reasons , referred to as Sudden Infant Death Syndrome, out of which at least 25-30% babies are expected to have Inborn Error of Metabolism. Recent data suggest that the overall incidence of metabolic disorder around the world is a good,1:1350 .Universal screening for metabolic disorders is mandatory in US, Europe and many other countries across the world. Though screening is a cost-intensive exercise, the benefits far exceed the costs as it helps in reducing the morbidity & morbidity of the disease. Screening is a process of filtration. Today, neonatal screening is the best
  36. 36. known and most widely used genetics-related preventative pediatric public health initiative in the world.1About 5 to 15 % of all sick neonates in NICU are expected to have some Inborn Error of Metabolism, which may be transient or permanent. Should routine Newborn Screening be done mandatorily for all babies born in India? Evidence: The success of the blood spot newborn screening in the USA led to early screening efforts in parts of the Asia Pacific Region from the mid-1960s onward. Though the exact incidence and prevalence of most of the disorders is not known as we do not have large population based studies, some information is available to have an idea about the disease burden in India. A pilot newborn screening project was carried out on 1,25,000 newborns. Homocysteneimia, hyperglycinemia, MSUD, PKU, hypothyroidism and G6PD deficiency were found to be the common errors. Another pilot expanded newborn screening was started in 2000 at Hyderabad to screen amino acid disorders, CH, congenital adrenal hyperplasia (CAH), G6PD deficiency, biotinidase deficiency, galactosemia and cystic fibrosis. Testing a total of eighteen thousand three hundred babies, the results revealed a high prevalence of CH (1 in 1700). The next common disorder was congenital adrenal hyperplasia followed by G6PD deficiency. Aminoacidopathies as a group constituted the next most common disorder. Interestingly, a very high prevalence of inborn errors of metabolism to the extent of 1 in every thousand newborn was observed. The authors stressed the importance of screening in India, necessitating nation-wide large-scale screening11. All this data suggest that collectively inborn errors of metabolism do have significant incidence in India which may lead to significant morbidity and mortality. All major Inborn Errors of Metabolism have been reported in the Indian literature. Recent data from Kerala has suggested congenital hypothyroidism to be about 2.1 per 1000 live inborn babies.12. Newborn Screening Summary of Recommendations • Universal newborn screening should be introduced in phases in our country. • Screening should be done after 2 days and before 7 days of age . Infants screened before 24 hours of life should be re-screened by 2 weeks of age to detect possible missed cases. Sick and premature babies should also have metabolic screening performed by 7 days of life. • The disorders to be screened our country have been classified into three groups, depending on availability of resources.
  37. 37. • A positive screening test should always be followed with parental counseling, confirmatory test, genetic counseling and early dietary or other interventions. • There is a need for comprehensive planning for NBS at state and national levels . What disorders does the Newborn Screening test for? • Congenital Hypothyroidism - A lack or absence of thyroid hormone, which is necessary for growth of the brain and the body. Treatment is required within the first four weeks to prevent stunted physical growth and mental retardation. • Congenital Adrenal Hyperplasia - An endocrine disorder that causes severe salt loss, dehydration, and abnormally high levels of male sex hormones. Left undetected and untreated, a baby may die within seven to 14 days. • Galactosemia - A condition in which babies are unable to process galactose. or the sugar present in milk. Increased galactose levels in the body lead to liver and brain damage, and to the development of cataracts. • Phenylketonuria - The inability to properly utilize the enzyme phenylalanine, which may lead to brain damage. • Glucose-6-Phosphate Dehydrogenase (G6PD) Deficiency - A condition where the body lacks the enzyme called G6PD, which may cause hemolytic anemia resulting from exposure to oxidative substances present in certain drugs, foods and chemicals. Parents of G6PD- positive babies are given a list of these substances. How is Newborn Screening administered? • Your baby will be pricked at the heel and three drops of blood are taken. This process is ideally done during the 48th to 72nd hour of life. A negative screen means that results are normal. A positive screen will require the newborn to be brought back to her pediatrician for further testing. Recent Research Study Neonatal Blue Light Phototherapy and Melanocytic Nevi: A Twin Study conducted by: 1. Zsanett Csoma, MD, PhDa , 2. Edit Tóth-Molnár, MD, PhDb , 3. Klára Balogh, MDa , 4. Hilda Polyánka, MScc , 5. Hajnalka Orvos, MD, PhDd , 6. Henriette Ócsai, MDa ,
  38. 38. 7. Lajos Kemény, MD, DSca ,c , 8. Márta Széll, DScc , 9. Judit Oláh, MD, PhDa + Author Affiliations 1. a Department of Dermatology and Allergology, 2. c Dermatological Research Group of the Hungarian Academy of Sciences, and 3. d Department of Obstetrics and Gynecology, University of Szeged, Szeged, Hungary; and 4. b Novotalex Ltd, Szeged, Hungary Abstract BACKGROUND: Neonatal blue light phototherapy (NBLP) has been widely and successfully used for the treatment of neonatal jaundice to reduce the plasma concentration of bilirubin and, hence, to prevent kernicterus. Only a few and controversial data are available in the literature as to how NBLP influences melanocytic nevus development. {A melanocytic nevus (also known as "Nevocytic nevus") is a type of lesion that contains nevus cells (a type of melanocyte). Some sources equate the term mole with "melanocytic nevus".Other sources reserve the term "mole" for other purposes. The majority of moles appear during the first two decades of a person’s life, while about one in every 100 babies is born with moles. Acquired moles are a form of benign neoplasm, while congenital moles, or congenital nevi, are considered a minor malformation or hamartoma and may be at a higher risk for melanoma. A mole can be either subdermal (under the skin) or a pigmented growth on the skin, formed mostly of a type of cell known as a melanocyte. The high concentration of the body’s pigmenting agent, melanin, is responsible for their dark color. Moles are a member of the family of skin lesions known as nevi.} OBJECTIVE: Our goal was to conduct a twin study with the aim of better understanding the role of NBLP in melanocytic nevus development. We also investigated the roles of other environmental and constitutional factors in nevus formation. METHODS: Fifty-nine monozygotic and dizygotic twins were included in this cross- sectional study. One of the twin members received NBLP, and the other did not. A whole- body skin examination was performed to determine the density of melanocytic skin lesions. The prevalence of benign pigmented uveal lesions was evaluated during a detailed ophthalmologic examination. A standardized questionnaire was used to assess data relating to constitutional, sun-exposure, and other variables. To search for possible gene-environmental interactions involved in the appearance of pigmented lesions, the melanocortin 1 receptor variants and the I439V polymorphism of histidine ammonia-lyase genes were also determined in the enrolled twins. RESULTS: NBLP was associated with a significantly higher prevalence of both cutaneous and uveal melanocytic lesions. No association was found between the examined gene polymorphisms and the number of pigmented alterations in the examined study group. CONCLUSIONS: Our data suggest that NBLP could well be a risk factor for melanocytic nevus development. Phototherapy with blue-light lamps is a standard and essential
  39. 39. therapeutic modality in neonatal care; therefore, additional in vivo and in vitro studies are necessary to establish its potential long-term adverse effects. CONCLUSION The growth and development of the newborn is starting from the mothers womb itself.if the parents do not realise this fact, it may affect the child’s physical,psychological and cognitive development. The parents especially mother has an important role in identifying the changes in her baby. The early identification and detection will be helpful in preventing many diseases and behavioural problems. References: 1,Burns, C.E., Barber, N., Brady, M.A., Dunn, A.M., (1996) Pediatric Primary Care: A Handbook for Nurse Practitioners, Philadelphia, W.B. Saunders Company. 2,Gorrie, Trula Myers, McKinney, Emily Stone, and Murray, Sharon Smith. (1994). Foundations of maternal newborn nursing,Philadelphia; W. B. Saunders Company. 3,Wong, Donna L. (l995). Whaley & Wong's nursing care of infants and children; contributing editor, David Wilson. 5th edition. St. Louis: Mosby. 4,Variations and minor departures in infants (1994), Mead Johnson & Company: Evansville, Indiana. 5,research article Published online September 19, 2011PEDIATRICS Vol. 128 No. 4 October 1, 2011 pp. e856 -e864 (doi: 10.1542/peds.2011-0292)