NURSING CARE OF THE NEONATE

Physiology of the Neonate

The first 24 hours of life constitute a highly vulnerable time, during which the infant must make major
physiologic adjustments to extrauterine life.

Transitional Stages
During the period of postnatal transition, six overlapping stages have been identified:
Stage 1. Receives stimulation (during labor) from the pressure of the uterine contractions and from changes in
pressure when the membranes rupture.
Stage 2. Encounters various foreign stimuli such as light, cold, gravity, and sound.
Stage 3. Initiates breathing.
Stage 4. Changes from fetal circulation to neonatal circulation.
Stage 5. Undergoes alteration in metabolic processes, with activation of liver and GI tract for passage of
meconium.
Stage 6. Achieves a steady level of equilibrium in metabolic processes (production of enzymes, increased blood
oxygen saturation, decrease in acidosis associated with birth, and recovery of the neurologic tissues from the
trauma of labor and delivery).

1. Respiratory Changes

A. Factors Initiating Respiration
Mechanical pressure changes from intrauterine life to extrauterine life produce stimulation to initiate
respirations.
Chemical changes in the blood, as a result of transitory asphyxia, include:
Lowered oxygen level.
Increased carbon dioxide level.
Lowered pH if asphyxia is prolonged, depression of the respiratory center (rather than stimulation)
occurs, and resuscitation is necessary.
Sensory light (visual), sound (auditory), olfactory, and tactile stimulation, beginning in utero with uterine
contraction and when the infant is touched and dried, contribute to the initiation of respiration.
Thermal a drop in environmental temperature from 98.6 F (37 C) to 70F to 75 F (21C to 23.9 C).
First breath maximum effort is required to expand the lungs and to fill the collapsed alveoli.
Surface tension in the respiratory tract and resistance in lung tissue, thorax, diaphragm, and respiratory
muscles must be overcome.
First active inspiration comes from a strong contraction of the diaphragm, which creates a high negative
intrathoracic pressure, causing a marked retraction of the ribs and distention of the alveolar space. (Any
remaining fluid is reabsorbed rapidly if the pulmonary capillary blood flow is adequate because the fluid
is hypotonic and passes easily into the capillaries.)

B. Character of Normal Respirations
First period of reactivity occurs immediately after birth. Vigorous, diffuse, purposeless movements alternate
with periods of relative immobility/inactivity.
Respirations are rapid, as frequent as 80 breaths/minute, accompanied by tachycardia, 140 to 180
breaths/minute.
Relaxation occurs and the infant usually sleeps; he or she then awakes to a second period of activity. Oral mucus
may be a major problem during this period.
Respirations are reduced to 35 to 50 breaths/minute and become quiet and shallow; respiration is carried out by
the diaphragm and abdominal muscles.
Period of dyspnea and cyanosis may occur suddenly in an infant who is breathing normally; this may indicate an
anomaly or a pathologic condition.
Apnea is normal in the neonatal period and lasts 10 to 15 seconds.

2. Circulatory Changes
A. Blood Volume
Blood volume is 85 to 100 mL/kg at birth. Factors that influence blood volume:
Maternal blood volume (affected by maternal diseases and iron intake).
Placental function.
Uterine contractions during labor.
Amount of blood loss associated with delivery.
Placental transfusion at birth increase in blood volume of 60% if cord is clamped and cut after pulsation
ceases.


B. Peripheral Circulation
Residual cyanosis in hands and feet (acrocyanosis) for 1 to 2 hours after birth because of sluggish circulation.
Pulse Rate
Generally follows pattern similar to that of respiration.
Apical pulse rate is more accurate.
Normal rate 80 to 160 bpm.
May rise to 180 bpm when the infant is crying or drop to 70 bpm during deep sleep.
Blood Pressure
Blood pressure is 70/45 mm Hg at birth; 100/50 mm Hg by 10th day.
Blood pressure rises with crying.
Blood pressure in the leg will be slightly higher.
Blood pressure measurement is best accomplished with a Doppler device while the infant is at rest.
Pulse pressure is 25 to 30 mm Hg at term.
A systolic blood pressure in the upper extremities that is 20 mm Hg greater than in the lower
extremities strongly suggests coarctation of the aorta.
Blood Coagulation
Coagulability is temporarily diminished because of lack of bacteria in the intestinal tract that
contributes to the synthesis of vitamin K.
Coagulation time is 3 to 4 minutes.
Bleeding time is 2 to 4 minutes.
Prothrombin 50%, decreasing to 20% to 30%.
Blood Elements
Values for blood components in the neonate:
Hemoglobin, 16 to 22 g.
Reticulocytes, 2.5 to 6.5%.
Leukocytes, 15,000 to 20,000/l.
3. Temperature Regulation
Mechanism not fully developed; heat production low.
Infant responds readily to environmental heat and cold stimuli.
Heat loss of 35.6 to 37.4 F (2 to 3 C) may occur at birth by evaporation, convection, conduction, and
radiation.
Radiation = transfer of heat from neonate to cooler object not in direct contact with the infant.
Convection = transfer of heat when flow of cool air passes over infant's skin.
Evaporation = loss of heat when water on infant's skin is converted to vapor.
Conduction = transfer of heat when neonate comes into direct contact with cooler surface/object.
Decreased adipose tissue, thinner skin, blood vessels closer to the skin results in increased heat loss.
Infant develops mechanisms to counterbalance heat loss.
Vasoconstriction = blood directed away from skin surfaces.
Insulation = from subcutaneous adipose tissue.
Heat production = by nonshivering thermogenesis (brown fat metabolism) elicited by the sympathetic
nervous system's response to decreased temperatures; activated by adrenaline.
Fetal position = by assuming a flexed position.

4. Basal Metabolism
Surface area of infant, especially the head, is large in comparison to weight.
Basal metabolism per kilogram of body weight is higher than that of an adult.
Calorie requirements are high; 117 Kcal of body weight per day.

5. Renal Function
Low arterial blood pressure and increased renal vascular resistance lead to the following effects:
Decreased ability to concentrate urine because of low tubular resorption rate and low levels of antidiuretic
hormone.
Limited ability to maintain water balance by excretion of excess water or retention of needed water.
Decreased ability to maintain acid-base mechanism; slower excretion of electrolytes, especially sodium and the
hydrogen ions, results in accumulation of these substances, which predisposes the infant to dehydration,
acidosis, and hyperkalemia.
Excretion of large amount of uric acid during neonatal periodappears as brick dust stain on diaper.

6. Hepatic Function
Function limited because of lack of GI tract activity and limited blood supply; consequences include the following:
Decreased ability to conjugate bilirubin (rationale for physiologic jaundice).
Decreased ability to regulate blood glucose concentration (rationale for neonatal hypoglycemia).


Deficient production of prothrombin and other coagulation factors that depend on vitamin K for synthesis
(rationale for neonate's predisposition to hemorrhage).

7. Endocrine Function
Endocrine glands are better organized than other systems: disturbances are most commonly related to maternally
provided hormones. This can cause the following:
Vaginal discharge (or bleeding [pseudomenstruation]) in female infants.
Enlargement of mammary glands (breast engorgement) in both sexes is related to increased estrogen, luteal,
and prolactin activity. Milky secretions may be present (witch's milk).
Disturbances related to maternal endocrine pathology (eg, mother with diabetes or mother with inadequate
iodine intake).

8. GI Changes
The neonate's intestinal tract is proportionately longer than the adult's; however, elastic tissue and musculature are
not fully developed, and neurologic control is variable and inadequate.
Most digestive enzymes are present, with the exception of pancreatic amylase and lipase. Protein and
carbohydrates are easily absorbed, but fat absorption is poor.
Limitations relate primarily to anatomic structures and neutrality of the gastric contents.
Imperfect control of the cardiac and pyloric sphincters and immaturity of neurologic control cause mild
regurgitation or slight vomiting.
Irregularities in peristaltic motility slow stomach emptying.
Peristalsis increases in the lower ileum, resulting in stool frequencyone to six stools per day. No stool within
48 hours after birth is indicative of intestinal obstruction.

9. Neurologic Changes
Neurologic mechanisms are immature; they are not fully developed anatomically or physiologically ---
uncoordinated movements, labile temperature regulation, and poor control over musculature are
characteristic of the infant.
Reflexes are important indicators of infant neural development.

NURSING ASSESSMENT

Delivery of effective neonatal care is enhanced by communication of pertinent information about the mother and her
infant to the pediatrician or other health care provider. It is important that the obstetric staff record the following
information on the medical record that accompanies the neonate during any transfer of care.

Pertinent Maternal History
Mother's age, socioeconomic status, ethnic or cultural group, educational level, marital status.
Mother's/family's past medical history.
Mother's past obstetric history.
Mother's prenatal history with this pregnancy includes rubella status, hepatitis B testing, history of psychiatric
disease, domestic violence, or history of previous child abuse or neglect. Also includes other maternal test
results relevant to neonatal care (ie, human immunodeficiency virus test results and colonization with group B-
hemolytic streptococci).
Labor and delivery. (Includes intrapartum maternal antibiotic therapy, along with type and dosage of
antibiotics.)
Physical Assessment Findings and Physiologic Functioning

Posture
Full-term neonate assumes symmetric posture; face turned to side; flexed extremities; hands tightly fisted with
thumb covered by fingers.
Asymmetric posture may be caused by fractures of clavicle or humerus or by nerve injuries commonly of the
brachial plexus.
Infants born in breech position may keep knees and legs straightened or in frog position, depending on the type
of breech birth.
Length
Average length of full-term neonate is 20 inches (51 cm); range, 18 to 22 inches (46 to 56 cm).
Weight
AGA: Weight range of 80% of full-term neonates is 5 lb 5 oz to 9 lb (2,500 to 4,000 g)


Average weight of male neonates is 7 lb (3,400 g)
female neonates, 7 lb (3,200 g)
SGA : small for gestational age; weight is less than 5 lb 5 oz (2,500 g)
is the infant who has not achieved his genetic growth potential
Dysmaturity; fetal growth retardation (FGR);intrauterine growth restrictions (IUGR)
High-risk for: stillbirth,perinatal morbidity,adverse effect in adulthood, and disruption of parent-infant
bonding
LGA : Large for gestational age; weight more than 9 lb (4,000 g)
Skin
Hair distribution
Term infant will have some lanugo over back; most of the lanugo will have disappeared on extremities and
other areas of the body.
Turgor
Term infant should have good skin turgor; ie, after gently pinching small portion of skin and releasing it, the
skin should return to its original position.
Color
Cyanosis bluish discoloration of the skin and mucuous membranes because of inadequate oxygenation.
Acrocyanosis - bluish color in palms of hands and soles of feet, is common because of immature peripheral
circulation. This condition is exacerbated by cold temperatures.
Pallor may indicate cold, stress, anemia, or cardiac failure.
Plethora reddish (ruddy) coloration may be caused by a high level of red blood cells to total blood volume
from intrauterine intravascular transfusion (twins), cardiac disease, or diabetes in the mother.
Jaundice physiologic jaundice caused by immaturity of liver is common beginning on day 2, peaking at 1
week and disappearing by the 2nd week. It first appears in skin over the face or upper body, then progresses
over a larger area; it can also be seen in conjunctivae of eyes.
Meconium staining staining of skin, fingernails, and umbilical cord indicates passage of meconium in utero
(possibly caused by fetal hypoxia in utero).
Dryness/peeling
Marked scaling and desquamation are signs of postmaturity.
Vernix
In full-term infants, most vernix is found in skin folds under the arms and in the groin under the scrotum (in
males) and in the labia (in females).
Nails
Should reach end of fingertips and be well developed in the full-term infant. There should be no evidence of
pits, ridges, aplasia, or hypertrophy.
Edema
Some edema may occur over buttocks, back, and occiput if the infant has been supine; pitting edema may
be caused by erythroblastosis, heart failure, and electrolyte imbalance.
Ecchymosis
May appear over the presenting part in a difficult delivery; may also indicate infection or a bleeding
problem.
Petechiae
Pinpoint hemorrhages on skin caused by increased intravascular pressure, infection, or thrombocytopenia;
regresses within 48 hours.
Erythema toxicum (newborn rash)
Small white, yellow, or pink to red papular rash that appears on trunk, face, and extremities; regresses
within 48 hours.
Hemangiomas vascular lesions present at birth; some may fade, but others may be permanent.
Strawberry brigh t red, raised, lobulated tumor that occurs on the head, neck, trunk, or extremities; soft,
palpable, with sharp demarcated margins; increases in size for approximately 6 months, then regresses after
several years.
Cavernous larger, more mature vascular elements; involves dermis and subcutaneous tissues; soft,
palpable, with poorly defined margins; increases in size the first 6 to 12 months, then involutes
spontaneously.
Telangiectatic nevi (stork bites)
Flat red or purple lesions most commonly found on the back of the neck, lower occiput, upper eyelid, and
bridge of the nose
Regress by 2 years of age, although the ones on the neck may persist through adulthood.
Milia
Enlarged sebaceous glands found on nose, chin, cheeks, brow, and forehead; regress in several days to a few
weeks.


They appear as multiple yellow or pearly white papules, approximately 1 mm in diameter.
When found in the mouth, they are referred to as Epstein pearls.
Mongolian spots
Blue-green or gray pigmentation on the lower back, sacrum, and buttocks
Common in Blacks (90%), Asians, and infants of southern European heritage
Regress by 4 years of age
May be mistaken for signs of child abuse.
Caf-au-lait spots
Tan or light brown macules or patches.
When less than 1 inches (3 cm) in length and less than six in number, there is no pathologic significance
If greater than 1 inches or more than six in number, may indicate cutaneous neurofibromatosis.
Harlequin color change
When on side, dependent half turns red, upper half pale
Caused by gravity and vasomotor instability.
Abrasions or lacerations can result from internal monitoring and instruments used at birth.
Cutis marmorata
Bluish mottling or marbling of skin in response to chilling, stress, or overstimulation.
Port wine nevus (nevus flammeus)
Flat pink or reddish purple lesion consisting of dilated, congested capillaries directly beneath theepidermis;
does not blanch.
Head
Examine head and face for symmetry, paralysis, shape, swelling, movement.
Caput succedaneum swelling of soft tissues of the scalp because of pressure; swelling crosses suture
lines. Associated with vacuum-assisted birth.
Cephalohematoma subperiosteal hemorrhage with collection of blood between periosteum and bone;
swelling does not cross suture lines. May result from vacuum-assisted birth (use of the vacuum extractor).
Molding overlapping of skull bones, caused by compression during labor and delivery (disappears in a few
days).
Examine symmetry of facial movements.
Forceps marks U-shaped bruising usually on cheeks following forceps delivery.
Measure head circumference 13 to 14 inches (33 to 35 cm), approximately inch (2 cm) larger than chest.
Measure just above the eyebrows and over the occiput.
Fontanelle area where more than two skull bones meet; covered with strong band of connective tissue; also
called the soft spot.
Enlarged or bulging may indicate increased intracranial pressure (ICP).
Sunken commonly indicates dehydration.
Size posterior; triangle shaped may be obliterated because of molding; generally closes in 2 to 3 months.
Anterior is palpable; diamond shaped; generally closes in 12 to 18 months.
Sutures junctions of adjoining skull bones.
Overriding caused by molding during labor and delivery.
Separation extensive separation may be found in malnourished infants and with increased ICP.
Face
Eyes
Color sclera in most full-term infants are white; blue sclera is indicative of osteogenesis imperfecta. Eye
color usually slate-gray, brown, or dark blue; final eye color is evident by 6 to 12 months.
Hemorrhagic areas subconjunctival hemorrhages may appear as a red band from pressure during delivery;
regress within 2 weeks.
Edema edema of the eyelids may be caused by pressure on the head and face during labor and delivery.
Conjunctivitis or discharge may be caused by instillation of silver nitrate (if still used) or infections from
organisms, such as staphylococcus, chlamydia trachomatis, or gonococcus. Tear formation does not usually
begin until age 2 to 3 months.
Jaundice may be seen in sclera because of physiologic jaundice or, if severe, blood group incompatibility.
Pupils equal in size and should constrict equally in bright light.
Infant can see and discriminate patterns; limited by imperfect oculomotor coordination and inability to
accommodate for varying distances.
Red reflex red-orange color seen when light from an ophthalmoscope is reflected from the retina. No red
reflex indicates cataracts.
Brushfield's spots white or yellow pinpoint areas on iris that may indicate trisomy 21 or even a normal
variant.


Abnormal placement of eyes or small eye openings can signify a syndrome or chromosomal anomaly.
Strabismus cross-eyed appearance that is common; nystagmus (constant, rapid, involuntary movement of
the eye) is also common and disappears by age 4 months.
Nose
Patency necessary because infants breathe through the nose, not the mouth.
Nasal flaring abnormal and may indicate respiratory distress. Check for appropriate size and shape of the
nose; should be placed vertically midline in face.
Discharge stuffiness is normal unless chronic nasal discharge is present; may be caused by possible
infection.
Sense of smell infants will turn toward familiar odors and away from noxious odors.
Septum should be midline; low nasal bridge with broad base may be associated with Down syndrome.
Periodic sneezing is common.

Ears
Formation large, flabby ears that slant forward may indicate abnormalities of the kidney or other parts of
the urinary tract.
Position in relation to the eye helix (top of ear) on the same plane as eye; low-set ears may indicate
chromosomal or renal abnormalities.
Cartilage full-term infant has sufficient cartilage to make the ear feel firm.
Hearing auditory canals may be congested for a day or two after birth; the infant should hear well in a few
days.
Observe for skin tags; preauricular sinus located in front of the ear may be normal or may be associated with
genetic disorders.

Mouth
Size small mouth found in trisomy 18 and 21; corners of mouth turn down (fish mouth) in fetal alcohol
syndrome. Mucous membranes should be pink.
Palate examine hard and soft palate for closure.
Size of tongue in relation to mouth normally does not extend much past the margin of gums. Excessively
large tongue seen in congenital anomalies, such as cretinism and trisomy 21.
Teeth predeciduous teeth are found on rare occasions; if they interfere with feeding, they may be
removed.
Epstein's pearls small white nodules found on sides of hard palate (commonly mistaken for teeth); regress
in a few weeks.
Frenulum linguae thin ridge of tissue running from base of tongue along undersurface to tip of tongue,
formerly believed to cause tongue-tie; no treatment necessary. True congenital ankyloglossia (tongue-tie) is
rare.
Sucking blisters (labial taberales) thickened areas on midline of upper lip that may be filled with fluid or
callous; no treatment necessary.
Infections thrush, caused by Candida albicans, may appear as white patches on tongue and/or insides of
cheeks that do not wash away with fluids; treated with nystatin suspension.
Neck
Mobility infant can move head from side to side; palpate for lymph nodes; palpate clavicle for fractures,
especially after a difficult delivery.
Torticollis appears as a spasmodic, one-sided contraction of neck muscles; generally from hematoma of
sternocleidomastoid muscle; usually no treatment required.
Excessive skin folds may be associated with congenital abnormalities such as trisomy 21.
Stiffness and hyperextension may be caused by trauma or infection.
Clavicle for intactness.
Observe for masses such as cystic hygromasoft and usually seen laterally or over the clavicle.
Chest
Circumference and symmetry - average circumference is 12 to 13 inches (30 to 33 cm), approximately inch (2
cm) smaller than head circumference.
Breast.
Engorgement may occur at day 3 because of withdrawal of maternal hormones, especially estrogen; no
treatment required. Regresses in 2 weeks.
Nipples and areolae less formed and pronounced in preterm infants



Respiratory System
Rate normally between 40 to 60 breaths/minute; influenced by sleep-wake status, when last fed, drugs taken
by mother, and room temperature.
Rhythm - respirations may be shallow with irregular rhythm.
Respiratory movements are symmetric and mainly diaphragmatic because of weak thoracic muscles. For
example, the lower thorax pulls in and the abdomen bulges with each respiration.
Periodic breathing - resumption of respiration after 5- to 15-second period without respiration; decreases
with time; more common in preterm infants. Substernal retractions if accompanied by gasps or stridor are
indicative of upper airway obstruction.
Observe for abnormal respiratory signs.
Breath sounds determined by auscultation.
Bronchial sounds are heard over most of the chest.
Rales may be heard immediately after birth.
Expiratory grunting is indicative of respiratory distress syndrome (RDS).

Cardiovascular System
Rate normal between 110 to 160 bpm (80 to 110 normal with deep sleep); influenced by behavioral state,
environmental temperature, medication; take apical count for 1 minute.
Rhythm common to find periods of deceleration followed by periods of acceleration.
Heart sounds second sound higher in pitch and sharper than first; third and fourth sounds rarely heard;
murmurs common, majority are transitory and benign.
Pulses examine equality and strength of brachial, radial, pedal, and femoral pulses; lack of femoral pulses
indicative of inadequate aortic blood flow.
Cyanosis examine for cyanosis. Acrocyanosis of distal extremities is common; record location of any cyanosis,
color changes with time, and when crying.
Blood pressure neonates who weigh more than 3 kg have systolic blood pressure between 60 to 80 mm Hg;
diastolic, between 35 and 55 mm Hg. Blood pressure is usually higher in the lower extremities than in the upper
extremities. Blood pressure assessment may not be conducted routinely on healthy neonates. Measurement of
blood pressure is essential for infants who show signs of distress, are premature, or are suspected of having a
cardiac anomaly.
Abdomen
Shape cylindrical, protrudes slightly, moves synchronously with chest in respiration.
Distention may be caused by bowel obstruction, organ enlargement, or infection.
Palpate abdomen for masses; gap between rectus muscles is common; palpate liver and spleen.
Liver has decreased ability to conjugate bilirubin (rationale for physiologic jaundice).
Liver has decreased production of prothrombin and factors that depend on vitamin K for synthesis
(rationale for neonate's predisposition to hemorrhage).
Auscultate abdomen in all four quadrants for bowel sounds; usually bowel sounds occur an hour after delivery.
Kidneys palpate kidneys for size and shape.
Infant has decreased ability of kidney to concentrate urine, excrete a solute load, maintain water and
electrolyte balance.
Urine may contain uric acid crystals, which appear on diaper as reddish blotches; uric acid crystals may
yield false-positive result when the infant's urine is tested for protein.
Umbilical cord
Normally contains two arteries, one vein; single artery sometimes associated with renal and other
congenital abnormalities.
Signs of infection around insertion into abdominal wall-redness discharge.
Meconium staining - associated with intrauterine compromise or postmaturity.
By 24 hours, becomes yellowish brown; dries and falls off in approximately 10 to 14 days.
Umbilical hernia - defect in abdominal wall.
Genitalia
Female
Labia majora cover labia minora and clitoris in full-term female infants.
Hymenal tag (tissue) may protrude from vagina; regresses within several weeks.
Vaginal discharge white mucous discharge common; pink-tinged mucous discharge
(pseudomenstruation) may be present because of the drop in maternal hormones; no treatment
necessary.



Male
Full-term testes in scrotal sac; scrotal sac appears markedly wrinkled due to rugae.
Edema may be present in scrotal sac if the infant was born in breech presentation; a frank
collection of fluid in the scrotal sac is a hydrocele; regresses in approximately a month.
Examine glans penis for urethral opening; normally central; opening ventral (hypospadias); opening
dorsally (epispadias); abnormally adherent foreskin (phimosis).
Check for patent anus - infant should stool within 24 hours after delivery. If passed meconium in utero,
patent anus has been established.
Back
Examine spinal column for normal curvature, closure, and pilonidal dimple or sinus; also for tufts of hair or skin
disruptions that would indicate possible spina bifida.
Examine anal area for anal opening, response of anal sphincter, fissures.
Musculoskeletal System
Examine extremities for fractures, paralysis, range of motion, irregular position.
Examine fingers and toes for number and separation: extra digits, polydactyly; fused digits, syndactyly.
Examine hips for dislocation - with the infant in supine position, flex knees and abduct hips to side and down to
table surface; clicking sound indicates dislocation (Ortolani's sign).
Asymmetrical gluteal folds also indicate congenital hip dislocation.
Examine feet for structural and positional deformities, ie, club foot (talipes equinovarus) or metatarsus adductus
(inward turning of the foot).
Neurologic System
Neurologic mechanisms are immature anatomically and physiologically; as a result, uncoordinated movements,
labile temperature regulation, and lack of control over musculature are characteristic of the infant.
Examine muscle tone, head control, and reflexes.
Reflexes are natural physical responses a baby has that helps him or her to survive outside of the
womb
Two types of reflexes are present in the neonate:
Protective in nature; remain throughout life
a. Blink
b. Cough
c. Sneeze
d. Gag
Primitive in nature;
a. Rooting Reflex: The rooting reflex is most evident when an infant's cheek is stroked. The baby
responds by turning his or her head in the direction of the touch and opening their mouth for
feeding.
b. Gripping/palmar Reflex: Babies will grasp anything that is placed in their palm. The strength of this
grip is strong, and most babies can support their entire weight in their grip.
c. Toe Curling/Plantar/ Babinski Reflex: When the inner sole of a babys foot is stroked, the infant will
respond by curling his or her toes. When the outer sole of a babys foot is stroked, the infant will
respond by spreading out their toes.
d. Stepping Reflex: When an infant is held upright with his or her feet placed on a surface, he or she will
lift their legs as if they are marching or stepping.
e. Sucking Reflex: The sucking reflex is initiated when something touches the roof of an infants mouth.
Infants have a strong sucking reflex which helps to ensure they can latch onto a bottle or breast. The
sucking reflex is very strong in some infants and they may need to suck on a pacifier for comfort.
f. Startle/Moro Reflex: Infants will respond to sudden sounds or movements by throwing their arms
and legs out, and throwing their heads back. Most infants will usually cry when startled and proceed
to pull their limbs back into their bodies.
g. Galant Reflex: The galant reflex is shown when an infants middle or lower back is stroked next to the
spinal cord. The baby will respond by curving his or her body toward the side which is being stroked.
h. Tonic Neck Reflex: The tonic neck reflex is demonstrated in infants who are placed on their
abdomens. Whichever side the childs head is facing, the limbs on that side will straighten, while the
opposite limbs will curl.


i. Swimming Reflex. An infant placed face down in a pool of water will begin to paddle and kick in a
swimming motion. The reflex disappears between 46 months. Its survival function is to help the
child stay alive if it is drowning so a caregiver has more time to save it.
j. Babkin Reflex. This occurs in newborn babies, and describes varying responses to the application of
pressure to both palms. Infants may display head flexion, head rotation or opening of the mouth, or a
combination of these responses. Smaller, premature infants are more susceptible to the reflex, with
an observed occurrence in a child of 26 weeks gestation
Behavioral Assessment
Response to Stimulation
Neonates exhibit predictable, directed responses in social interactions with nurturing adults or in response to
attractive auditory or visual stimuli.
Neonate responses are influenced by states of consciousness, such as:
Quiet, deep sleep (sleep state)
No spontaneous activity, eyes closed, respirations regular, with delayed response to external stimuli.
Light, active sleep (sleep state)
Random startles, eyes closed, Rapid eye movement (REMs), frequent change of state with response to
stimulation.
Drowsy awake (transitional state)
Eyes open or closed, appearing dull and heavy lidded, eyelids flutter, variable activity level, mild
startles periodically, delayed response to stimulation.
Quiet alert (awake state)
Eyes open, little motor activity, focuses on source of stimulation. Interacts most with environment;
respirations regular.
Alert active (awake state)
Eyes open, less bright and attentive, much motor activity, increase in startles in response to
stimulation.
Crying (awake state)
Intense crying that is difficult to interrupt with stimulation; increased motor activity and color
changes.

Sleeping Pattern
Length of sleep cycles (REM, active and quiet sleep) changes with maturation of the central nervous system
(CNS).
Quiet sleep should increase with time in relation to REM sleep.
Neonates usually sleep 20 hours per day.
Feeding Pattern
Most neonates eat 6 to 8 times per day with 2 to 4 hours between feedings; establish fairly regular feeding
patterns in approximately 2 weeks.
Caloric requirements are high = 110 to 130 calories/kg of body weight daily.
Most digestive enzymes are present at birth.
Imperfect control of cardiac and pyloric sphincters; immaturity results in regurgitation.

Pattern of Elimination
Stool
Neonate has up to six stools per day in the first weeks after birth.
Meconium transitional stools Milk stools (breasts) Milk stools (cows milk)
Within 48 hours From 48 hours to 3
rd
days 4 -5 days onwards 4 5 days onwards
Thick; tarry green-black
stools
Yellow brown to greenish
brown stools
Golden yellow and pasty,
sour smelling stools
Pale yellow to light brown,
more formed with foul odor
stools
Voiding
Neonate voids within first 24 hours.
After first few days, infant voids from 10 to 15 times per day.


Temperature Regulation
Infant's body responds readily to changes in environmental temperature.
Heat loss at birth may occur through evaporation, convection, conduction, and radiation.
Physiologic mechanisms to avoid heat loss include:
Vasoconstriction.
Nonshivering thermogenesis elicited by sympathetic nervous system in response to decreased
temperature.
Adipose tissue and brown fat; the latter contains many small blood vessels, fat vacuoles, and mitochondria
and is a site of heat production. Brown fat is found between scapulae, around neck and thorax, behind
sternum, and around kidneys and adrenals.
Flexed position of full-term neonate.
Metabolic Screening Tests
Phenylketonuria - inability of the infant to metabolize phenylalanine; scheduled after 48 hours of protein
feedings.
Galactosemia - inborn error of carbohydrate metabolism, in which galactose and lactose cannot be converted to
glucose.
Hypothyroidism - thyroid hormone deficiency.
Maple sugar urine disease - inability to metabolize leucine, isoleucine, and valine.
Homocystinuria - inborn error of sulfur amino acid metabolism.
Sickle cell anemia - abnormally shaped RBCs with lower oxygen solubility.
Newborn Screening
Newborn Screening (NBS) is a simple procedure to find out if your baby has a congenital metabolic disorder that may
lead to mental retardation and even death if left untreated.
Newborn Screening means the process of collecting a few drops of blood from the newborn onto an appropriate
collection card and performing biochemical testing for determining if the newborn has a heritable condition.
Legal Basis
Republic Act No. 9288: "Newborn Screening Act of 2004."
1. It is the policy of the State to protect and promote the right to health of the people, including the rights of
children to survival and full and healthy development as normal individuals.
2. To provide comprehensive, integrative and sustainable national newborn screening system, to ensure that every
baby born in the Philippines is offered the opportunity to undergo newborn screening and thus be spared from
heritable conditions that can lead to mental retardation and death if undetected and untreated.
The objectives of the National Newborn Screening System are:
1. To ensure that every newborn has access to newborn screening for certain heritable conditions that can result in
mental retardation, serious health complications or death if left undetected and untreated;
2. To establish and integrate a sustainable newborn screening system within the public health delivery system;
3. To ensure that all health practitioners are aware of the advantages of newborn screening and of their respective
responsibilities in offering newborns the opportunity to undergo newborn screening; and
4. To ensure that parents recognize their responsibility in promoting their child's right to health and full
development, within the context of responsible parenthood, by protecting their child from preventable causes
of disability and death through newborn screening.
Components of Comprehensive Newborn Screening System
1. Collection and biochemical screening of blood samples taken from newborns
2. Tracking and confirmatory testing to ensure the accuracy of screening results
3. Clinical evaluation and biochemical/medical confirmation of test results
4. Drugs and medical/surgical management and dietary supplementation to address the heritable conditions
5. Evaluation activities to assess long term outcome, patient compliance and quality assurance.
Heritable conditions
1. Congenital Hypothyroidism (CH)
CH results from lack or absence of thyroid hormone, which is essential to growth of the brain and the body. If the
disorder is not detected and hormone replacement is not initiated within (4) weeks, the baby's physical growth will be
stunted and she/he may suffer from mental retardation.



2. Congenital Adrenal Hyperplasia (CAH)
CAH is an endocrine disorder that causes severe salt loses, dehydration and abnormally high levels of male sex
hormones in both boys and girls. If not detected and treated early, babies may die within 7-14 days.

3. Galactosemia (GAL)
GAL is a condition in which the body is unable to process galactose, the sugar present in milk. Accumulation of excessive
galactose in the body can cause many problems, including liver damage, brain damage and cataracts.

4. Phenylketonuria (PKU)
PKU is a metabolic disorder in which the body cannot properly use one of the building blocks of protein called
phenylalanine. Excessive accumulation of phenylalanine in the body causes brain damage.

5. Glucose-6-Phosphate Dehydrogenase Deficiency (G6PD Def)
G6PD deficiency is a condition where the body lacks the enzyme called G6PD. Babies with this deficiency may have
hemolytic anemia resulting from exposure to certain drugs, foods and chemicals.
Importance of Newborn Screening
Most babies with metabolic disorders look normal at birth. One will never know that the baby has the disorder until the
onset of signs and symptoms and more often ill effects are already irreversible.
Performance of Newborn Screening
Newborn screening shall be performed after twenty-four (24) hours of life but not later than three (3) days from
complete delivery of the newborn.
A newborn that must be placed in intensive care in order to ensure survival may be exempted from the 3-day
requirement but must be tested by seven (7) days of age.

Procedure of Newborn Screening
Explain procedure to couple
Done by a physician, a nurse, a midwife or medical technologist
Using the hell prick method, a few drops are taken from the baby's heel and blotted on a special absorbent filter
card.
The blood is dried for 4 hours and sent to the Newborn Screening Laboratory. (NBS Lab).

Availability
Newborn screening is available in practicing health institutions (hospitals, lying-ins, Rural Health Units and
Health Centers).
If babies are delivered at home, babies may be brought to the nearest institution offering newborn screening.
Newborn Screening results
Newborn screening results are available within three weeks after the NBS Lab receives and tests the samples sent
by the institutions.
Results are released by NBS Lab to the institutions and are released to your attending birth attendants or
physicians.
Parents may seek the results from the institutions where samples are collected.
A negative screen means that the result of the test is normal and the baby is not suffering from any of the
disorders being screened.
In case of a positive screen, the NBS nurse coordinator will immediately inform the coordinator of the institution
where the sample was collected for recall of patients for confirmatory testing.
Action for positive newborn screening result
Should be referred at once to the nearest hospital or specialist for confirmatory test and further management.
Should there be no specialist in the area; the NBS secretariat office will assist its attending physician.

Disorder
Screened
Effect
SCREENED
Effect if SCREENED and treated
CH (Congenital Hypothyroidism) Severe Mental Retardation Normal
CAH (Congenital Adrenal Hyperplasia) Death Alilve and Normal
GAL (Galactosemia) Death or Cataracts Alive and Normal
PKU (Phenylketonuria) Severe Mental Retardation Normal
G6PD Deficiency Severe Anemia, Kernicterus Normal