The General Care of the Newborn

Newborn Statistics

• The first 28 days of life – the neonatal period – is the most vulnerable time for a child’s survival.
• The worldwide neonatal mortality rate fell by 47 per cent between 1990 and 2015 from 36 to 19 deaths per 1,000 live births.
• Over the same period, the number of newborn babies who died within the first 28 days of life declined from 5.1 million to 2.7 million.
• Nigeria, is currently still significantly outside the current global average for NNM

The first 24 hours of life is a very significant and a highly vulnerable time due to critical transition from intrauterine to extrauterine life.

The Golden Hour

1. Antenatal counseling and team briefing
2. Delayed cord clamping
3. Prevention of hypothermia/temperature maintenance
4. Support to respiratory system
5. Support to cardiovascular system
6. Early nutritional care
7. Prevention of hypoglycemia
8. Initiation of breast feeding
9. Infection prevention
10. Starting of therapeutic hypothermia for birth asphyxia
11. Laboratory investigation
12. Monitoring/record
13. Communication with family

• Care that is applied to all newborns irrespective of GA and medical condition
• This care is provided throughout the four stages of hospitalization namely:
• Delivery
• Transition
• Hospital stay and
• Discharge
• The Goal is to prevent NNM from the Golden Hour through the neonatal period
• The basic requirements of the NB are
1. The need to be PINK
2. The need to be WARM
3. The need to be SWEET
4. The need to be CLEAN
• Thereafter they are provided with other forms of care

• Being pink is a summary index of adequacy of cardiopulmonary function (oxygenation/perfusion)
• Refers to establishment of normal respiration
• Normal values: Pulse or Heart Rate
• Awake: 120 – 160 bpm (average 120 – 140 bpm)
• Asleep: 90-110 bpm
• Crying: 180 bpm
• Rhythm: irregular, due to immaturity of cardiac regulatory center in the medulla
• Respiration:
• Nasal breathers, gentle, quiet, rapid BUT shallow; may have short periods of apnea (<15 secs) and irregular without cyanosis—periodic respirations
• Rate: 30-60 cpm
• Duration: 1 full minute
• Plans to ensure adequate cardio-pulmonary function is to be instituted throughout pregnancy, labour and immediate delivery periods;
• Antepartum
• Anticipatory care of all pregnancies
• Feto-maternal surveillance. (details in the lecture on prevention of perinatal asphyxia)
• Adequate preparation for resuscitation at birth
• During labour
• Feto-maternal surveillance in labour
• At delivery
• Clear airway with the delivery of the head
• Check for establishment of normal respiration
• Check baby’s clinical state to determine need for resuscitation
• Institute neonatal resuscitation if there is evidence of cardiopulmonary difficulties.

• Maintenance of normal body temperature
• Newborns have a large body surface area relative to their size; Hence predisposition to heat loss x4
• Temperature
• Site: Axillary NOT Rectal
• Duration: 3 mins
• Normal Range: 36.5 – 37.4 C
• Stabilizes within 8-12 hrs
• Monitor q 30 mins until stable for 2 hrs then q 8 hrs
• Methods of heat loss
• Internal gradient (within the body to the surface of the skin)
• External gradient from the skin surface to the environment

Heat Loss Mechanisms

• Convection
• The flow of heat from the body surface to cooler surrounding air
• Eliminating drafts such as windows or air con, reduces convection



• Conduction
• The transfer of body heat to a cooler solid object in contact with the baby
• Covering surfaces with a warmed blanket or towel helps minimize conduction heat loss



• Radiation
• The transfer of heat to a cooler object not in contact with the baby
• Cold window surface or air-conditioning; moving as far from the cold surface, reduces heat loss



• Evaporation
• Loss of heat through conversion of a liquid to a vapor
• From amniotic fluid;
• NB should be dried immediately

• Methods of heat control in the newborn
• None-shivering thermogenesis
• Using brown fat, which is rich in mitochondrial content.
• Brown Fat is located around the nape of the neck, scapular and around the adrenals
• Methods of warming newborn babies
• Skin-to-Skin contact
• Appropriate for all babies except those with life threatening problems
• Kangaroo mother care
• Appropriate for stabilized babies weighing 1.5 to 2.5kg





• Radiant warmer
• Used to keep baby warm especially during initial assessment and to re-warm a cold baby





• Incubator
• Appropriate for continuous care babies < 1500g and those with life threatening problems





• Warm room
• Appropriate for stabilized babies who do not need frequent diagnostic and treatment procedures
• Hot water bottles
• May be used in emergency situations when other methods are not available
• The Thermo-neutral environment
• Every baby should be nursed in a neutral-thermal environment
• A set of environmental conditions (temperature and humidity) at which oxygen consumption is least
• The younger or immature the baby, the more stringent the need for thermo-neutral environment

• Refers to the provision of adequate nutrient
• Growth rates are most rapid in the first six months of human life
• Nutrient requirements on a weight basis are highest during the first six months
• Rapid organ growth and development occurs during the last trimester and first six months
• The detrimental effects of nutritional insufficiencies are magnified during periods of rapid organ growth (i.e. vulnerable periods for brain growth)

Normal fluid and caloric requirement

• Fluid:
• 150 mls/kg/day.
• Initially 65mls/kg in term and 70mls/kg in preterm babies on day one.
• Give 10% glucose water for the first 48-72hrs then change to Dextrose Saline
• Increase by 10-15mls/kg/day until the desired maintenance is attained.
• Calorie:
• 100-120kcal/kg/day.
• Start with about 40-50 kcal/kg on day one and increase by 10 kcal/kg Daily
• Note that babies require slightly lower calorie if breastfed compared to those on formula
• Differences are due to
• Increased digestibility and absorbability of breast milk
• Presence of compensatory enzymes (lipases)

Sources of calorie

• Breast milk: Always the preferred source. Complete with all nutrients needed by the newborn
• Infant formula: medically indicated if mother is unavailable, breast milk is contraindicated e.g. IEM, maternal Ca of breast, HIV +ve mothers.
• Intravenous fluid: when there is contraindication to oral feeds (short-term) e.g. respiratory distress, neuro-depression.
• Parenteral nutrition: when there is a long term contraindication to oral feed e.g. intestinal anomaly, NEC scare, prolonged ventilation.

Method of administering calorie

• Breast feeding: the first option except baby is too weak, too immature or contraindicated
• Cup and spoon: Indicated when there is no contraindication to oral feed but baby adjudged to be incapable of feeding adequately by direct breast feeding or mother is unavailable.
• N-G tube: When babies are unable to swallow or coordinate between swallowing and sucking.
• Intravenous: Indicated when oral feeding is not possible, contraindicated, or the volume that can be administered is insufficient.

Practice Question

• A four day old preterm (32 weeks) is brought to the newborn unit. His birth weight was 1400gms. On examination he was found with good cardiopulmonary function but attempt to suckle directly on the breast was adjudged “weak”
• Write out a Management order indicating
• The amount of calorie to be given in 24 hours
• The volume of fluid required in 24 hours
• The mode of administration of the calorie source

Weight changes

• Term babies loose up to 10% of their BW in the first week
• Preterms loose up to 15% of their BW in the 1st two weeks
• Average daily weight loss is < 1.5%
• Average weight gain 10-15g/kg/day

• This refers to measures taken to prevent infection or ensure early detection
• The new born is specially predisposed to infection due to:
• Their lack of prior sensitization
• Immaturity of their immune system
• Virulence of the organism.
• However note that a newborn acquires infection ONLY after adequate exposure. Therefore, avoid risk behaviour.
• Screen history to detect adverse risk factors
• Screen babies with history of an exposure to risk factors for infection
• Carry out all procedures under aseptic conditions
• HANDWASHING IN BETWEEN PATIENTS CONTACTS IS THE SINGLE MOST IMPORTANT METHOD OF PREVENTING CROSS INFECTION
• Early institution of treatment among at risk babies

Umbilical Cord

• 2 arteries; 1 vein
• White & gelatinous immediately after birth
• Begins to DRY between 1-2 hrs following birth
• Blackened or shriveled between 2-3 days
• Dried & gradually falls off by 7 days

Daily Cord Care

• Keep cord dry and clean & clamp secured
• Apply 70% isopropyl alcohol to the cord with each diaper change and at least 2-3x a day.
• DO NOT cover with diaper
• Note for any signs of bleeding or drainage from the cord and other abnormalities
• Sponge bath until cord falls off.