2. Care of the new-born infant
Variations exist from place
to place in the care of the
newborn infant. However,
although often neglected,
their basic needs are the
same.
Infants who are unwell or
have congenital
abnormalities fall short of
the mother’s expectation of
a beautiful bundle of joy.
All mothers require urgent
and sensitive counseling.
3. Learning outcomes
After studying this module, you should be able to
Describe the routine clinical assessment of new born infants
Describe some common congenital abnormalities
Describe the essential elements of the routine management
of new-born infants including hygiene, cord care, feeding
and rooming-in
Describe what routine immunisations are required during
infancy
Discuss what information is required by mothers prior to
discharge
4. Clinical assessment
After delivery of the baby and in
the absence of any immediate
problems, essential new-born care
begins with a thorough general
clinical assessment.
This should be done on all infants
soon after birth to detect signs of
illness and congenital
abnormalities.
The following slides describe the
assessment that should be
performed routinely in all infants.
This initial assessment should
indicate where more detailed
clinical assessment is required.
Hand washing with soap and water before and after a baby
is handled goes a long way in reducing the risk of infection
A resident doctor washing her hands up to
the elbows prior to examination
7. Clinical assessment
First steps and appearance
Start by congratulating the
mother on the arrival of her
new baby and ask if she has any
concerns. The mother is usually
the first person to notice any
problems.
Ask about feeding and the
passage of urine and stools. The
infant should pass meconium
(the first black, tarry stools)
within 24 hours of birth.
General observation: inspect
colour, breathing, alertness and
spontaneous activity.
Well infants have a flexed,
posture. Partially flexed posture
is found in hypotonia or
prematurity
Well term infant showing typical well flexed
posture
Note the abduction of the hips in this
partially flexed preterm infant (“froglike”
posture)
8. Clinical assessment
Examine skin for prematurity or dismaturity
Wrinkled peeling skin of
dysmaturity in an IUGR infant
Thin,
transparent
skin in preterm
infants
Pale pink skin of a term infant (hair
shaved to site IV line)
9. Clinical assessment
Skin: some common normal findings
Vernix caseosa: a cream/white cheesy material on the skin
at birth which cleans off easily with oil.
Lanugo; fine downy hairs seen on the back and shoulders
especially in preterm infants.
Milia: pinpoint whitish papules on nose and cheeks due to
blocked sebaceous glands.
Mongolian blue spots: grey/bluish pigment patches seen in
the lumbar area, buttocks and extremities in dark skinned
babies.They usually disappear by one year.
Capillary heamangiomas (“stork bite” naevi): red flat
patches which blanch with gentle pressure. Commonly
occur on upper eyelids, forehead and nape of the neck.
Erythema toxicum: small white/yellow papules or pustules
on a red base seen on face, trunk and limbs. Develop 1 – 3
days after birth and usually disappear by one week.
10. Clinical assessment
Colour
Note pallor or plethora
Cyanosis: the baby should be
uniformly pink
Blueness of the hands and feet
(peripheral cyanosis) may be
due to cold extremities.
Blueness of the mucous
membranes and tongue is
central cyanosis and is usually
due to lung or heart problems
Bruising (ecchymosis) is
common after birth trauma.
Unlike cyanosis, bruising
does not blanch on gentle
pressure.
A Caucasian infant with marked
central cyanosis
11. Clinical assessment
Jaundice
Jaundice is common in the first week
of life and may be missed in dark
skinned babies
Blanch the tip of the nose or hold
baby up and gently tip forward
and backward to get the eyes to
open.
Teach mother to do the same at
home in the first week and report
to hospital if significant jaundice is
observed.
Blanching the tip of the nose
Two infants with jaundice; note yellow sclera
12. Clinical assessment
Head
After these general observations,
examine the infant starting with
the head and moving down the
body.
Observe the size and shape of the
head (micro- or macrocephaly;
cephalhaematoma)
Check the anterior and posterior
fontanels and that the skull
sutures feel normal
Form and position of ears (low
set ears occur in chromosomal
abnormalities, e.g. Down
syndrome)
Huge encephalocoele. Head
is disproportionately small
Cephalhaematoma limited to
the right parietal region
13. Clinical assessment
Eyes and face
Examine eyes for ocular anomalies and check for
red reflex using the ophthalmoscope (to exclude
cataract)
Examine the face for dysmorphic features and
normal movements
Examine lips and palate for clefts
Bilateral cleft lip and palate. Also
note purulent left eye discharge
Facial asymmetry due to
left facial palsy
14. Clinical assessment
Cardiovascular and respiratory
Feel femoral and radial pulses for volume, rate and
rhythm.
In aortic coarctation, femoral pulse is reduced, absent
or not synchronous with radial pulse.
If child is sick, measure blood pressure.
Locate the apex beat and listen to the heart sounds for
murmurs.
Count the respiratory rate
normal 30 – 40 breaths/min in term infants
faster in preterms.
> 60 / minute abnormal
Observe for respiratory distress: nasal flaring,
intercostal and subcostal recession.
15. Clinical assessment
Abdomen
Inspect the umbilical cord for
presence of 2 arteries and a
vein. Abnormal components
may be a pointer to the
presence of intra-abdominal
anomalies e.g. renal.
Look for umbilical
abnormalities, e.g. hernia,
omphalocoele, exompholos
Gently palpate the abdomen
the liver may be palpable
upto 2cm below the costal
margin
the lower pole of the right
kidney may also be palpable
Large omphalocoele
16. Clinical assessment
Spine and genitalia
Examine:
The spine for dimples, tuft of
hair (spina bifida occulta) or
cystic swellings (spina bifida
cystica)
Remove the diaper to examine
the genitalia. In boys, confirm
that both testicles have
descended into the scrotum.
Designate the infant’s sex
Inspect the perineum and
check anus for position and
patency (can be done by gently
checking rectal temperature)
Spine bifida cystic
17. Clinical assessment
Dimorphic features
Examine hands. Note single
palmar crease in
chromosome abnormalities.
Inspect the feet. Note effects
of foetal posture should be
noted.
Check hips for dislocation
Limitation of limb
movements occurs in
fractures and nerve injury
Tulips affecting the left leg
Short stubby fingers and single
palmar crease of Down syndrome
23. Routine care of the well newborn
Any problems identified during the initial assessment will need
specific management. However, new-born infants are a highly
susceptible group and high-quality routine care prevents a multitude
of problems. The major elements of routine care include:
Cord care
Thermal control
24 hour rooming in
Feeding
Immunization
Maternal education on hygiene and every other aspect of routine
care
Hand washing with soap and water every time a baby is
handled goes a long way in reducing the risk of infection!
24. Normal term Newborn Infant
Average weight of normal newborn infant, born after 40
weeks of gestation is around 2800-3000gm.
Length are approximately 50cm
The Head Circumference (OFC) 35cm
The Chest Circumference is usually 3cm less than OFC.
US: LS Ratio :: 1.7 and 1.9 to 1
The Skull may show moldings. The parietal bones may
slightly over-ride the occipital and frontal bone.
A full-term infant has got physiological photophobia
His sclera appears slightly bluish
The ear cartilage is firm having good elastic recoil.
25. The breast nodule is palpable ,usually >5mm in
diameter. Breast hypertrophy is common. Milk may
be present (should not be expressed)
Heart rate may vary from 120 to 160 per minutes.
There may be transitory murmur.
Congenital heart disease may not initially produce
murmurs that will be present later. Only a 1:2 chance
exist that a murmur heard at birth represent CHD.
The respiratory rate stabilizes 40 to <60
breaths/minutes.
26. In the Abdomen, Liver is usually palpable ,sometimes as
much as 2 cm below the rib margin. Less commonly, the
Spleen tip may be felt. KIDNEY can usually be
determined on deep palpation.
Testes are usually in the scrotum or palpable in the
inguinal canal, at least one testis is descended. The
scrotum appears deeply pigmented and adequate rugae.
The labia minora is covered by labia majora.
The anterior two-third or more of the soles shows deep
creases.
Peripheral cyanosis(acra0cyanosis) may be present for a
short while after birth, especially when the limbs are
cool.
27. The skin is pink and is covered with vernix caseosa.
This vernix caseosa is not evident after 40wks of
gestation.
Lungo hair is usually been lost and replaced by
vellus hair in term infant.
28.
29. Quiz: Concerning care of the new-born
Write “T” or “F” on the answer sheet. When you have completed all 5 questions, click on each box and mark
your answers.
a. Nursing a new-born with the mother
rather than in the nursery predisposes
the child to infections
b. Hand washing with soap and water
before handling a new-born
significantly reduces the risk of
infection in the baby
c. Fortified infant formula is superior to
mother’s breast milk in a sick term
new-born
d. New-born babies cannot be kept
warm without the use of incubators
e. Jaundice cannot be detected early in
dark skinned babies
a
d
e
c
b
Click to reveal
correct answers
30. back
Cord care
The umbilical stump needs particular
attention as there are risks of bleeding
and infection.
Good cord care includes:
• Cutting cord with sterile equipment or
a new razor blade depending on the
setting
• Ligation with a sterile plastic clamp or
clean thread
• Keeping cord stump exposed, clean
(with 70% alcohol, 4% chlorhexidine
or simple soap and water) and dry
A sterile clamp applied to the
umbilical cord
Binding, use of powders and traditional practices like
application of cow dung, broken glass or herbs are harmful and
should be discouraged!
31. back
Thermal control
Regulation of body temperature is immature
in newborn infants. Also, energy reserves
are low which may compromise the ability
to cope with thermal stress.
Even in tropical countries, infants may
become hypothermic especially when
temperature drops at night.
Measures to prevent hypothermia
include:
• Delivery in a warm environment
• Immediate drying of the infant to minimize
heat loss by evaporation
• Keep out of drafts
• Skin to skin contact with mother
• Proper clothing and wrapping up with
linen including use of booties and
bonnets
• Regular feeds
A well dressed baby
32. back
Rooming in
Rooming in refers to the practice of
nursing babies with their mothers
rather than keeping them in a
separate nursery.
Advantages:
Promotes bonding
Makes exclusive breastfeeding easy
Early exposure of baby to maternal
bacterial flora
Reduces risk of nosocomial
infections
Mother is able to keep a close watch
on her infant. She should be
encouraged to report any concerns
that she has to the health care staff.
A postnatal ward showing
mothers with their babies
33. back
Feeding
Breast feeding remains the
best method of feeding the
new-born and has the
following advantages:
Breast milk is nutritionally
balanced
It reduces the risk of
infection especially in
unhygienic situations
Protects against diarrhoea
and other infections in
infancy
Promotes mother-child
bonding
It is readily available
It helps in child spacing
Breast feeding a low
birth weight infant
When breast feeding is not feasible (e.g. an HIV positive mother who
chooses not to breastfeed, an infant whose mother dies) infant formula is
the most suitable alternative. It should be prepared with clean boiled
water under hygienic conditions. Cup and spoon feeding is safer than
bottle feeding in settings with limited resources.
34. back
Routine immunization
Immunization: should be commenced soon
after birth irrespective of gestational age
according to national immunization schedules
Example of an immunisation schedule
At birth BCG, Oral polio & HBV1
6 weeks DPT1, Oral polio & HBV2
10 weeks DPT2, Oral polio
14 weeks DPT3, Oral polio & HBV3
9 months Measles, yellow fever
18 months DPT4
DPT- diphtheria, pertussis, tetanus; HBV – hepatitis B
vaccine
35. Sources of information
Pocket book of Hospital care for children;
guidelines for the management of common
illnesses with limited resources. WHO
http://www.who.int/child-adolescent-
health/publications/CHILD_HEALTH/PB.h
tm
Essential newborn care
http://www.who.int/reproductive -
health/publications/
Nelson Textbook of Pediatrics: 21st Edition.
Richard E. Behrman Robert Klieg man, Hal
B. Jenson (Editors),
36. Answer to question 1a
The statement is False.
Nursing a new-born with the mother exposes baby
to mother’s normal flora early and this helps to
prevent colonization by pathogenic bacteria.
Nursery care delays this and exposes the infant to
nosocomial infections.
Back
37. Answer to question 1b
The statement is True.
Hand washing with soap is the single,
most important factor in the
prevention of infections in the new-born!!
Back
38. Answer to question 1c
The statement is False.
Mother’s milk is the most suitable in composition
for adequate growth of a term infant. In sick term
new-borns, it has added advantage of protecting
against necrotizing enteritis because it does not
favour bacterial proliferation and has less solute
load than infant formula.
Back
39. Answer to question 1d
The statement is False.
Well babies including preterm can be kept
warm by proper clothing or direct skin to skin
care with mothers or other care givers even in
the absence of incubators
Back
40. Answer to question 1e
The statement is False.
Though jaundice is difficult to detect in dark
skinned babies, it is possible to detect early jaundice
in them by blanching the skin of the tip of the nose
to elicit yellowness. This must be performed before
discharge and mothers should be taught to do same
at home
Back
