New born care

1. ADAMA HOSPITAL MEDICAL
COLLEGE
DEPARTMENT OF PEDIATRIC
CLASSIFICATION OF THE NEWBORN AND
CARE OF LBW/PRETERM
BY
Nasir Mohammed
Natnael Kidanu
Negash Begashaw
1
10/3/2023

2. Presentation Outline
Introduction
Classification of newborn by
 gestational age
 birth weight
 other classification
Essential newborn care
2
10/3/2023

3. Objectives
At the end of this presentation students will able to:
 Describe the classification of newborn
 Explain the essential elements of early newborn care
 describe the principles of each elements of newborn care
3
10/3/2023

4. Introduction
A live born child is a fetus that shows
– at least one sign of life after birth & weighs at least 500 g or,
– in case of lower birth weight, survives 24 hours after birth.
Signs of life are breathing, beating of the heart, umbilical
cord pulsation or definite movement of voluntary muscles.
4
10/3/2023

5. A fetus that shows none of these signs of life and weighs
1000 g or more is classified as still born child.
If fetus shows no sign of life and weighs less than 1000 g,
the termination of pregnancy is classified as abortion.
Immediately following birth, infant survival depends on a
prompt and orderly conversion to air breathing.
5
10/3/2023

6. Cont…
Fluid-filled alveoli expand with air, perfusion must be
established, and oxygen and carbon dioxide exchanged
Perinatal mortality is influenced by
 prenatal, maternal, and fetal conditions
 circumstances surrounding delivery.
 Perinatal deaths are associated with IUGR;
conditions that predispose the fetus to asphyxia,
such as
 placental insufficiency; severe congenital malformations;
and overwhelming early-onset neonatal infections
6

7. Cont…
• The major causes of neonatal mortality are prematurity/low birthweight
(LBW) and congenital anomalies
• Mortality is highest during the 1st 24 hr after birth.
• Neonatal mortality (4.04/1,000 in 2011) accounts for about two thirds
of all infant deaths.
• Factors related to the decline in mortality include improved obstetric
and neonatal intensive care management with a significant reduction
in birth weight-specific neonatal mortality
• Further reduction in neonatal mortality will depend on prevention
of preterm delivery and LBW, prenatal diagnosis and early management
of congenital anomalies, and effective diagnosis and treatment of
diseases that result from adverse factors during pregnancy, labor,
and/or delivery
7

8. Cont…
• Infant mortality rates (deaths occurring from birth to 12 mo per
• 1,000 live births) vary by country; in 2010, rates were lowest in Hong
• Kong (1.7/1,000 births), moderate in the United States (6.1/1,000),
• and highest in developing, resource-poor countries (30-150/1,000).
• Medical, socioeconomic, and cultural factors influence perinatal and
• neonatal mortality. Preventive variables such as health education,
prenatal care, nutrition, social support, risk identification, and obstetric
• care can effectively reduce perinatal, neonatal, and infant mortality.
8

9. Classification of newborn by gestational age
Preterm: less than 37 weeks gestation
Term : completed 37 weeks gestation till 42 weeks
Post-term: born after completed 42 weeks' gestation or
more
9
10/3/2023

10. Classification of Newborn based on birth weight
 Irrespective of the cause & without regard to the duration of the
gestation, newborn can be classified as
• Normal birth weight (NBW) is b/n 2500-4500g
• Low birth weight (LBW) < 2500 g
• Very low birth weight (VLBW) < 1500 g
• Extremely low birth weight (ELBW) < 1000 g
10
10/3/2023

11. Other Classification
Newborn classification based on birth weight and gestation
is valuable in predicting the outcome.
At any gestation the poorest outcome is seen in infants with
marked IUGR.
• Small for gestational age (SGA) <10th percentile
• Large for gestational age (LGA) >90th percentile
• Average for gestational age (AGA) = 10-90th percentile
11
10/3/2023

12. 10/3/2023 12

13. Epidemiology
20 million LBW births /year
20% of 4 million neonatal deaths /year
33% are SGA and 67% are AGA and Preterm
Low birth weight

14. Factors associated with LBW
Pregnancy in women who:
 Are less than 20 or older than 35
 Have births that are less than 3 years apart
Women who:
 Had a LBW baby before
 Do hard physical work for many hours with no rest
 Are very poor
 Are underweight and have poor nutrition

15. cont..
Women who have pregnancy problems such as:
 Severe anemia
 Pre-eclampsia or hypertension
 Multiple pregnancy
 Infections during pregnancy (bladder and kidney infections,
hepatitis, STIs, HIV/AIDS, malaria)
Babies who have:
 Congenital or genetic abnormalities
 Infection while in the uterus

16. What Problems Do Low Birth Weight Babies Have?
1. Breathing problems at birth and later like apnea and HMD
2. Low body temperature because there is little fat on the
body and the newborn’s temperature regulating system is
immature.
3. Low blood sugar because there is very little stored energy
in the LBW baby’s body.
4. Feeding problems because of their small size, lack of
energy, small stomach and inability to suck.

17. 10/3/2023 1:16 PM 17
5. Infections because the infection fighting system is
not mature.
6. Jaundice (high bilirubin) because the liver is not
mature.
 Premature LBW babies become yellow earlier and it
lasts longer than in term babies.
7. Bleeding problems due to immature clotting
ability at birth.
8. Perinatal asphyxia due to compromized oxygen delivery
in utero

18. Preterm birth
Definition: PTB refers to a birth that occurs before 37 weeks
of gestation.
Subtypes of preterm birth are variably defined.
1. By gestational age:
– Moderate preterm: 32 to <37 weeks
– Late preterm: 34 to 36 weeks
– Very preterm: 28 to <32 weeks
18

19. Cont…
2. BY birth weight (BW):
Low birth weight (LBW): less than 2500 g
Very low birth weight (VLBW): less than 1500
Extremely low birth weight (ELBW): less than 1000 g
19

20. Significance
PTB is the leading direct cause of neonatal death (death in the
first 28 days of life).
It is responsible for 27 % of neonatal deaths worldwide,
comprising over one million deaths annually.
The risk of neonatal mortality decreases as gestational age at
birth increases, but the relationship is nonlinear .
20

21. Cont…
The burden of PTB includes neonatal morbidity and long-term
sequelae, including neurodevelopmental deficits & an
increased risk of chronic disease in adulthood
The percentage of newborns delivered at VLBW has declined
only minimally from 1.46 % in 2008 to 1.45 % in 2010
PTB is the 2nd most common cause of-death (after pneumonia)
in children younger than 5 years.
21

22. Prevalence
 Worldwide, the PTB rate is estimated to be about 11%
 range 5 % in parts of Europe to 18 % in parts of Africa,
 On average about 15 million children are born preterm each yr
 Of these PTBs, 84 % occurred at 32 to 36 weeks, 10 % occurred at 28
to <32 weeks
 A study done by Bekele T. et al, in Debremarkos Town Health
Institutions showed that 11.6% from the total 422 mothers gave a PTB.
22

23. Pathogenesis
 Clinical & laboratory evidence suggest that a number of pathogenic processes
can lead to a final common pathway that results in preterm labor and delivery.
 The four primary processes are:
– Activation of the maternal or fetal hypothalamic-pituitary-adrenal axis
– Infection
– Decidual hemorrhage (placental abruption)
– Pathological uterine distention
23

24. Approximately 70 % of preterm deliveries occur
spontaneously as a result of
– preterm labor (45 %) or PPROM (25 %);
– intervention for maternal or fetal problems account for the
remaining 30 %
24

25. RISK FACTORS
Non modifiable
• Prior preterm birth
• African-American race
• Age <18 or >40 years
• Uterine malformation
• Over distended uterus like in case
of multiple gestation
25
Modifiable
• Substance abuse
• Absent prenatal care
• Short interpregnancy intervals
• Anemia
• urinary tract infection
• High personal stress
• Occupational issues
• STI

26. Identifiable causes of PTB
FETAL
 Fetal distress
Multiple gestation
Congenital anomalies
PLACENTAL
 Placental dysfunction
 Placenta previa
 Abruptio placentae
MATERNAL
Preeclampsia, Chronic medical illness
Infection
Drug abuse (cocaine)
Uterine associated like
 Bicornuate uterus
 Incompetent cervix (premature dilatation)
OTHERs:-
 PROM
 Polyhydramnios
 Trauma
26

27. CLINICAL MANIFESTATIONS
 Four or more uterine contractions in one hour.
 vaginal bleeding in the third trimester.
 Heavy pressure in the pelvis, or abdominal or back pain could be
indicators that a PTB is about to occur.
 A watery discharge from the vagina may indicate PROM that
surround the baby. While the rupture of the membranes may not be
followed by labor.
 In some cases the cervix dilates prematurely without pain or
perceived contractions. 27

28. Complications
The shorter the term of pregnancy, the greater the risks of
mortality and morbidity for the baby
cognitive dysfunction
Cardiovascular complications may arise from the failure of
the ductus arteriosus to close after birth
Respiratory distress syndrome
 Hypoglycemia ,feeding difficulties, hypocalcemia,
inguinal hernia, and necrotizing enterocolitis (NEC).
Anemia of prematurity, thrombocytopenia, and
hyperbilirubinemia (jaundice) that can lead to kernicterus.
28

29. Diagnosis
• Continuous evaluation of Maternal vital signs and fetal
heart rate and contraction frequency/duration/intensity.
• Evaluation for signs and symptoms of preterm labor and
presence of risk factors for PTB
• Examination of the uterus to assess firmness, tenderness,
fetal size, and fetal position.
• Speculum examination using a wet non-lubricated speculum
• The presence and amount of uterine bleeding should be
assessed.
29

30. Cont…
• The status of the fetal membranes, intact or ruptured, should be
determined. PPROM often precedes or occurs during preterm labor
• Send swab to lab for fFN determination if the cervical length is 20 to
30 mm
• A rectovaginal GBS culture should be performed if not done within
the previous five weeks; antibiotic prophylaxis depends on the
results.
• STI Screening
30

31. Cont…
Triage based upon cervical length
• Cervical length >30 mm — women are at low risk of PTB,
– no need of sending their swabs for fFN testing to the lab.
• Cervical length 20 to 30 mm — Women are at increased risk of PTB
– send the swab for fFN testing.
– If the test is positive, fFN level >50 ng/mL, we actively manage the pregnancy
in an attempt to prevent morbidity associated with preterm birth.
• Cervical length <20 mm — women are at high risk of PTB regardless
of the fFN result.
– do not send swabs for fFN testing to the lab and we actively manage the patient
in an attempt to prevent morbidity associated with PTB.
31

32. Cont..
• Fetal fibronectin
– The most important biomarker, indicates that the border
between the chorion and deciduas has been disrupted.
• Ultra sonography of the cervix
– A cervical length of less than 25 mm at or before 24 weeks of
GA is the most common definition of cervical incompetence.
32

33. Management
Glucocorticosteroids
Fluids and nutrition through intravenous catheters.
Oxygen supplementation and medications.
Kangaroo care (skin to skin warming).
Encouraging breastfeeding.
Prophylactic Rx are also used to care for preterm infants.
– indomethacin is commonly used to help with the closure of a
PDA
33

34. Post-term (PT)
• PT infants are born at a GA > 42 weeks or 294 days from
the 1st day of the LMP.
• PT infants have higher rates of morbidity and mortality
than term infants
• The etiology of most PT pregnancies is unknown.
34

35. RISK FACTORS
Primigravidity
Prior PT pregnancy
Genetic predisposition as concordance for PT pregnancy is
higher in monozygotic than dizygotic twin mothers
Maternal obesity & older age
Male fetal gender
Specific conditions in the offspring associated with prolonged
gestation include
– adrenal gland hypoplasia & congenital adrenal hyperplasia
due to 21-hydroxylase deficiency.
35

36. CLINICAL MANIFESTATIONS
 Based primarily on fetal growth.
 Usually continued fetal growth results in higher birth weights in the
PT than term infant with an increased likelihood of macrosomia.
 However, FGR occurs in some PT infants, most likely caused by a
poorly functioning placenta that is unable to provide adequate
nutrition
 results in the birth of a SGA infant, who usually appears malnourished.
 Macrosomia ( >4000g) — Infant size and birth weight are affected
by extended gestational length.
 PT macrosomic infants are at risk for birth injury due to prolonged
labor, cephalopelvic disproportion, and shoulder dystocia.
36

37. SMALL FOR GESTETIONALAGE(SGA)
Definition :
 SGA refers to a weight below the 10th percentile for gestational age
 Moderate SGA is defined as birth weight in the 3rd to 10th
percentile
 Sever SGA is defined as birth weight less than 3rd percentile
 Normal term infants typically weigh more than 2500 g by 37
weeks gestation
37

38. 38

39. Interautrine Growth Restriction
 IUGR is defined as a rate of fetal growth that is less than normal for
the population and for the growth potential of a specific infant or
 It is the term used to designate a fetus that has not reached its growth
potential because of genetic or environmental factors.
 FGR results in the birth of an infant who is SGA
 Mortality and morbidity are increased in SGA infants compared to
those who are AGA
39

40. CLASSIFICATION
SGA infants have either symmetric or asymmetric fetal
growth restriction (FGR).
1. Symmetric FGR
Have reductions in both body and head growth .
Begins early in gestation
Usually caused by intrinsic factors such as congenital
infections or chromosomal abnormalities.
However, decreased nutrient supply early in development
can restrict growth of all organs .
40

41. 2. Asymmetric FGR
Have reduced body weight and relatively normal length
and head growth.
Begins in the late 2nd or 3rd trimesters .
Results from reductions in fetal nutrients that limit glycogen
and fat storage yet allow continued brain growth .
41

42. Fig. 1. Causes of FGR 42
Maternal
 Infections
 Nutrition
 Medical conditions
 Substance abuse
 Pregnancy
pathology
 Ethnic background
Placental
• Insufficiency
• Abruption
• Structural
abnormalities
Fetal
• Genetic
abnormalities
• Down syndrome
• Congenital
malformations
• Metabolic problems
• Multiple gestations
ETIOLOGY OF FGR

43. CLINICAL FEATURES
 SGA infants appear thin with loose, peeling skin and decreased
skeletal muscle mass and subcutaneous fat tissue.
 The face has a typical shrunken or "wizened" appearance, and
the umbilical cord often is thin.
 Meconium staining may be present .
 In newborns with asymmetric FGR, the head appears relatively
large compared to the size of the trunk and extremities
43

44. Fig. 2. The infant has the typical shrunken or "wizened"
appearance of an SGA infant. 44

45. 45
Fig. 3. The infant has the characteristic appearance of an SGA infant. Note
the loose, peeling skin, decreased subcutaneous tissue and muscle mass,
and meconium staining.

46. COMPLICATIONS
• Deprived of oxygen and nutrients .
• Perinatal asphyxia.
• Meconium aspiration.
• Persistent pulmonary hypertension .
• Poor thermoregulation.
• Hypoglycemia.
• Polycythemia .
• Impaired immune function.
• Impaired growth and neurodevelopment(late complication.
46

47. DIAGNOSIS
• Maternal history
• Maternal examination
• Soft tissue measurements
• Doppler velocimetry
• Amniotic fluid volume
47

48. MANAGEMENT
Heat loss should be avoided by immediate drying and
placement under a radiant warmer
Prompt resuscitation, including clearing the airway of
meconium if needed, should be instituted.
Appropriate therapy is begun for disorders of transition,
including
 meconium aspiration pneumonia, myocardial dysfunction, or
persistent pulmonary hypertension, that develop.
48

49. Essential Newborn care

50. NEWBORN CARE
• Newborn care is important because major causes of newborn
death are birth asphyxia and infection.
• A skilled attendant at childbirth who can assess the newborn
correctly, perform essential interventions and does not delay
resuscitation if indicated, is crucial.
• The attendant should also be able to care for or transport a
sick newborn if needed.
50
10/3/2023

51. NEWBORN CARE
After birth, most newborn infants require only routine care to
make a successful transition to extrauterine life.
The major components of routine care for neonate are:
• Delivery room and transitional care, including early bonding
• Newborn assessment (maternal HX and neonates PE)
• Prophylaxis care to prevent serious disorders
• Family education
• Discharge evaluation

52. Delivery room care
Six cleans during delivery (WHO)
1. Clean attendant's hands
(washed with soap).
2. Clean delivery surface.
3. Clean cord- cutting instrument
(e.g. scissors).
4. Clean string to tie cord.
5. Clean cloth to dry the baby.
6. Clean cloth to wrap the baby with
the mother.

53. Delivery room care …..
After delivery, immediate neonatal care includes;
• drying the infant,
• clearing the airway secretion
• providing warmth.
Delivery room care

54. clinical status is quickly performed by addressing these
questions
• Is the infant full-term?
• Is the infant breathing or crying?
• Does the infant have good muscle tone?
Delivery room care

55. Delivery room care …..
If yes is the answer to all the questions,
• infant does not require further
intervention and should be given to
the mother.
• Healthy term or late preterm infants
should remain with the mother to
promote infant-maternal bonding by
»skin-to-skin contact and
»early initiation of breastfeeding.
Delivery room care

56. Delivery room care …..
If the answer to any of the questions
is no,
• Infant requires further evaluation
and intervention.
»Oxygen administration
»Positive pressure ventilation
»Chest compressions
»Use of resuscitative medications
(eg, epinephrine)
Delivery room care

57. Delivery room care …..
Apgar score
• is a practical method of systematically assessing
newborn infants immediately after birth
– Evaluation at one and five minutes of age.
– The following signs are given values of 0, 1, or 2 and added to
compute the Apgar score.
• Heart rate
• Respiratory effort
• Muscle tone
• Reflex irritability
• Color
Delivery room care

58. Delivery room care …..
Delivery room care

59. Resuscitation
5-10% newborn require active intervention to establish
normal cardiorespiratory function.
The elements of resuscitation include :
• 1. Initial steps:
• thermal management,
• clearing the airway,
• tactile stimulation
• 2. Establishment of ventilation
• 3. Chest compression
• 4. Medication

60. Thermal Protection
• To minimize heat loss,
– placed in a warmed towel or blanket
– under a pre-warmed radiant heat
source,
– dried with other warmed towel or
blanket.
• If infant is placed on the warmer
(radiant heat) should be regulated
at 36.5ºC to avoid hyperthermia.

61. Factors leading to heat loss
1.Thin skin and proximity of blood vessels to surface increase
heat loss.
2. Little subcutaneous fat to protect against heat loss
3. High proportion of surface area to body mass.
4 .Preterm infants at risk for cold stress
61
T.U

62. Four mechanisms of heat loss and corresponding interventions
• Evaporation
– Dry infant immediately
• Conduction
– Place on mothers body skin
to skin
• Convection
– Cover with a blanket, wear a
cap , close door
• Radiation
– Keep away from cold
windows and cold objects

63. resuscitation …..
• Evaluating breathing;
– Check if the baby is crying.
– If the baby does not cry, see if the baby is
breathing properly. The baby should not
have any chest in-drawing or grunting.
– The infant is positioned with the neck in a
neutral to slightly extended position.

64. resuscitation …..
• Tactile stimulation
– stimulation include briefly
slapping or flicking the soles of
the feet, and rubbing the
infant's back. More vigorous
stimulation is not helpful and
may cause injury.
– If the infant still remains apneic,
PPV should be initiated.
NB The time elapsed from the baby's birth to
placing the baby under the warmer, positioning,
suctioning, and providing additional stimulation
should be no more than 30 seconds

65. Resuscitation …..
• Positive pressure ventilation
Usually can be provided quickly by
bag and mask.
• Endotrachial intubation should be
performed in any infant who does not
respond to initial bag and mask
ventilation,
• If after 30 seconds heart rate remains
low, chest compression may be
needed

66. Delivery room and transitional care …..
• Chest compression is
recommended if:
– The chest should be compressed
between 100-120 times per minute
with ventilation occurring 40 to 60
times per minute.
– If chest compressions and ventilation
do not raise the heart rate above 80
within 30 seconds, support for the
cardiovascular system with
medications is needed.

67. Resuscitation …..
• Medications are rarely required but
should be administered when the heart
rate is <60 beats/min after 30 sec of
combined ventilation and chest
compressions.
• Epinephrine , (0.1- 0.3 ml/kg )
stimulates the heart and increases non-
cerebral peripheral vascular resistance.

68. Delivery room and transitional care …..
• normal saline, ringers lactate or blood
– should be given for hypovolemia, history of blood loss,
hypotension or poor response to resuscitation.
• Sodium bicarbonate , should be given slowly if there is a
documented metabolic acidosis or if there is no adequate
response to proper ventilation.
• Dopamine and dobutamine and volume expanders should
be started.

70. Transitional period
• is during the first four to six hours of life after delivery.
• Physiological changes that occur during the transitional
period include
– decreased pulmonary vascular resistance
– increased blood flow to the lungs,
– lung expansion with clearance of alveolar fluid and improved
oxygenation, and
– closure of the ductus arteriosus.

71. • the clinical status of the infant should be assessed every 30 to 60 minutes
– Temperature — normal 36.5 to 37.5ºC (axillary)
– Respiratory rate — normal is 40 to 60 b/min
– Heart rate — normal heart rate is 120 to 160 beats per minute but may
decrease to 85 to 90 per minute in some term infants during sleep.
– Color — Central cyanosis (lips, tongue, and central trunk) may be
indicative of respiratory or cardiac disease.
– Tone — Hypotonia may be secondary to exposure to maternal
medications or fever, sepsis, or neurologic impairment.

72. Routine care
The following are routine procedures performed
after birth to prevent serious disorders.
Umbilical cord care
Prophylactic eye care
Administration of vitamin k
Early initiation of Breast feeding
Immunization
 Monitoring for hyperbilirubinemia and hypoglycemia
T.U 72

73. Umbilical cord care
• Optimal cord care consists of the following:
• Clamping /tying the cord: wait for cord
pulsations to cease or approximately 1-3
minutes after birth,
 Cutting the cord: Cut the cord with sterile
scissors or surgical blade, under a piece of
gauze in order to avoid splashing of blood.
 Omphalitis is a neonatal infection resulting
from inadequate care of the umbilical cord.
T.U 73

74. Prophylactic eye care
• To Prevent or Manage Ophthalmia Neonatorum
• Ophthalmia neonatorum
- Is aform of conjunctivitis
- occurring < 4 wk of age
- Is the most common eye disease of newborn.
- Neisseria gonorrhoeae can cause corneal perforation,
blindness, and death.
74
T.U

75. 75
T.U
 Prevention…Clean eyes
immediately after birth then
apply one of:-
– 0.5% erythromycin drop
– 1% Tetracycline ointment
– Silver nitrates

76. Administration of vitamin K
Prophylactic vitamin K1 is given
to newborns shortly after birth
to prevent vitamin K deficient
bleeding (VKDB), previously
referred to as hemorrhagic
disease of the newborn.
American Academy of Pediatrics
recommends a single dose of
0.5 to 1 mg IM.
76

77. Early and Exclusive Breastfeeding
• Early contact between mother and
newborn.
– Enables immediate initiation of breastfeeding.
– prevents nosocomial infection.
• Best practices
– No prelacteal feeds or other supplement.
– Giving first breastfeed within one
hr/immediately after birth.
– Positioning the infant and determining
adequate latch-on.
– EBF with frequency of 8 -12 times/24 hrs.
– No frequent change of breast
– Psycho-social support to breastfeeding mother.
77
T.U

78. Immunization
 Give bacille Calmette-Guerin( BCG), OPVo
and Hepatitis B vaccination at birth. BCG
0.01 ml intradermal on right arm.
 Single dose ( 2 drops po) of OPV 0 ( zero) at
birth or in the two weeks after birth.
 HBV vaccination( 0.5 ml given IM) at as
soon as possible where perinatal infections
are common.
78
T.U

79. Monitoring for hyperbilirubinemia & hypoglycemia
• Hyperbilirubinemia with a total serum bilirubin level > 25
mg/L is associated with an increased risk for bilirubin-
induced neurologic dysfunction (BIND).
• during the birth, infants should be routinely assessed every
8 to 12 hours and at discharge check for the presence of
jaundice.
• .
T.U 79

80. Assess serum glucose level for hypoglycemia
before discharge.
treatment or further evaluation is considered if
• Less than 40 mg/dL during the first 24 hours of life for
asymptomatic infants and
• 45 mg/dL for symptomatic infants
• Less than 50 mg/dL after 24 hours of age
T.U 80

81. Family Education
• Importance and benefits of breastfeeding.
• Positioning the infant and determining adequate latch-on
and swallowing.
• Appropriate frequency of urination, and defecation and
appearance of urine and stool.
• Cord, skin, and genital care.
• Recognition of the signs of common neonatal illnesses,
particularly hyperbilirubinemia and sepsis.
• Proper infant safety, including supine sleeping position.
T.U 81

82. Discharge evaluation
made jointly with the family, and the obstetric and
neonatal care providers.
• No neonatal abnormality
• vital signs are within normal ranges
• has urinated and passed at least one stool
spontaneously.
• successful feedings and is able to coordinate sucking,
swallowing, and breathing while feeding.
T.U 82

83. Reference
1. Kliegman M, et al. Nelson text book of pediatrics. In: Carlo
A. The Newborn Infant. Elsevier; 2015. 20th ed. p794-812
2. Upto date 21.2
3. Hospital care for children WHO 2013.
4. Bekele T, Amanon A, Gebreslasie KZ (2015) Preterm Birth
and Associated Factors among Mothers Who gave Birth in
Debremarkos Town Health Institutions, 2013 Institutional
Based Cross Sectional Study.
83
T.U

84. Thank you
84