Newborn & Pediatric Care

Assessment of the newborn
is essential to ensure a
successful transition

1. Immediately after birth
2. Within the 1st
4 hours after
birth
3. Prior to discharge

A ctivity/ Muscle Tone
P ulse/ Heart Rate
G rimace/ Reflex Irritability/ Responsiveness
A ppearance/ Skin Color
RR espiration/ Breathing

INDICATORS 2 1 0
Appearance Completely pink Acrocyanosis
(Body pink,
Extremities blue)
Pale or blue all
over
Pulse More than 100
bpm
Less than 100
bpm
Absent
Grimace Pulls away when
stimulated
sneezes, coughs,
good, strong cry
Facial grimace,
feeble cry when
stimulated
No response with
stimulation
Activity Active movement,
well-flexed
extremities
Some flexion
of extremities
No movement
(flaccid, limp)
Respiration Good, strong cry Slow, irregular
Weak cry
Absent

Score Interpretation Nursing Interventions
7 to 10 Good Adjustment Rarely needs resuscitation
4 to 6 Moderately
Depressed Infant
Airway clearance:
Suction
Dry immediately
Ventilate until stable
Careful observation
0 to 3 Severely Depressed
Infant
Intensive resuscitation:
CPR
Intubation
Ventilate with 100% O2
Maintain body temperature
Parental support

General Guidelines
•Keep warm during examination
•From general to specific
•Least disturbing first
•Document ALL abnormal findings &
provide nursing care

GENERALGENERAL
APPEARANCEAPPEARANCE

•Symmetric
• Flexion of head and extremities
•Hands tightly fisted with thumb covered
by the fingers

• Asymmetric
• Fractured clavicle or humerus
• Nerve injuries (Erb-Duchenne’s Paralysis)
• Breech Presentation
• Extended leg, thighs fully rotated and
abducted, flattened occiput and extended
neck

• Site: Axillary NOT Rectal
• Duration: 3 mins
• Normal Range: 36.5 – 37 °C (97.9 °F-
98°F)

• 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 con;
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

• Keep dry and well-wrapped
• Keep away from cold objects or outside
walls
• Perform procedures in warm, padded
surface
• Keep room temperature warm
Nursing Considerations

PULSE
• Site: Apical (considered the most accurate)
• Duration: 1 full minute, not crying
• Awake: 120-140 bpm
• Asleep: 90-110 bpm
• Crying: 180 bpm

• Keep warm
• Take heart rate for 1 full minute
• Listen for murmurs
• Palpate peripheral pulses
• Assess for cyanosis
• Observe for cardiopulmonary
distress

Respiration
• Characteristics:
Nose breathers, gentle, quiet, rapid BUT
shallow; may have short periods of apnea
(<15 secs)
• Rate: 30-60 cpm
• Duration: 1 full minute
• No sound should be audible on inspiration or
expiration.

• Position on side
• Suction as needed
• Observe for respiratory distress
• Administer oxygen as prescribed

• NOT routinely measured UNLESS
in distress or CHD is suspected
• Oscillometric: 65/41 mmHg in arm and calf
Blood Pressure
• A drop in systolic BP of about 15 mm Hg
the first hour after birth is common.
• BP may be taken with a Doppler blood
pressure device (greatly improves
accuracy).

• Weight:
–5.5 to 9.5 lbs (2,500-4,300 gms)
• Caucasian: 7 lbs
• Filipinos: 6.5 lbs
–70-75% of total body weight is water
–Low birth weight = below 2500 gms;
regardless of Age of gestation

• Length:
–45 to 55 cm (18-22 inches)
–Average: 50 cm
–Techniques: using tape
measure
• Supine with legs extended
–Crown to rump
–Head to heel

• Head Circumference (HC):
–33 to 35 cm (13-14 inches) about 2-3 cm
larger than chest circumference
–Technique: using tape measure
• From the most prominent part of the
Occiput to just above the Eyebrows
–1/3 the size of an adult’s head
–Disproportionately LARGE for its body

• Chest Circumference (CC):
–30 to 33 cm (12-13 inches)
–Technique: using tape
measure
• From the lower edge of the
scapulas to directly over the
nipple line anteriorly
–Should be = or < 2 cm than
Head circumference

SKIN
• Under natural light
• Assess for:
–Color
–Hair distribution
–Turgor/Texture
–Pigmentation/Birthmarks
–Other skin marks

• At birth: bright red, puffy,
smooth
• 2nd
– 3rd
day: pink, flaky, dry
• Ruddy complexion due to
increased RBC concentration
and decreased
subcutaneous fat.
Skin Color

Acrocyanosis
• Bluish discoloration of palms of hands &
soles of feet
• Due to immature peripheral circulation
• Exacerbated by cold temperatures
• Normal within 1st
24 hrs
Skin Color

Jaundice
• yellow discoloration that may be seen
in the infant's skin or in the sclera of
the eye.
• caused by excessive amounts of free
bilirubin in the blood and tissue.
• Physiologic Jaundice- after the 1st
24
hours
• Pathologic Jaundice- within 24 hours
of life
Skin Color

 Lanugo
• fine downy hair that
covers the newborn's
shoulders, back, and
upper arms
• Immature newborns
have more lanugo than
mature infant
• may disappear within 2
weeks

 Vernix Caseosa
• white cream-cheese like that serves as a
skin lubricant
• It offers protection from the watery
environment of the uterus and serves as a
natural moisturizer
• Nursing Considerations:
- Use baby oil
- DO NOT attempt to remove vigorously

• Multiple, tiny white
papules approx. 1 mm
wide
• Due to enlarged or
clogged sebaceous
gland
• Usually found on the
nose, chin, cheeks,
eyebrows and
forehead
MiliaMilia

Mongolian Spots
• Irregular areas blue-black colorations
on the infant's lower back, buttocks, and
anterior trunk.
• The spots are not bruises nor are they
associated with mental retardation.
• They disappear in early childhood.

Stork Bites
• Telangiectatic nevi
• Flat deep pink
localized area on
back of the neck
• Disappears at 2
years of age.

 Strawberry marks
• Nevus Vasculosus or
Capillary Hemangioma
• Elevated areas formed by
immature capillaries and
endothelial cells.
• Head, neck trunk &
extremities
• Disappears after 7 to 9 years
of age

 Port wine stain
• Nevus Flammeus
• Large red purple lesion
• Generally appear on the
face or neck
• Does not blanch with
pressure
• Not raised above the skin
and does not
spontaneously disappear

 Mottling
• Cutis marmorata
• Transient mottling of
skin when exposed to
decrease temperature

 Erythema toxicum
• Newborn rash
• Small pink papular rash
• Thorax, back, buttocks
and abdomen
• Appears in 24 to 48
hours and subsides after
several days

 Petechiae
• Pinpoint hemorrhages
on skin
• Due to increased
vascular pressure,
infection or
thrombocytopenia
• Within 48 hrs

 Ecchymoses
• Bruises
• As a result of rupture of
blood vessels
• May appear at the
presenting part as a result of
trauma during delivery
• May also indicate infection
or bleeding problems

Harlequin Sign
• Outlined color change as
infant lies on side, dependent
side turns red and the other
turns pale
• Due to gravity and vasomotor
instability or immature
circulation

Café-au-lait spots
• Tan or light brown
macules or patches
• No pathologic
significance, if < 3 cm in
length and < 6 in number
• If > 3 cm or 6 in number
it may indicate Cutaneous
Neurofibromatosis

• The infant’s head represents ¼ of
total body length.
• Head circumference: 33 to 35 cm (13-
14 inches) about 2-3 cm larger than
chest circumference.
• The head is shaped or molded as it is
forced through the birth canal.

 Fontanelles
• The space where more than two bones
come together
• Should be flat, soft and firm
• Anterior Fontanel: diamond shape (2.5- 4
cm); closes at 12 to 18 months
• Posterior Fontanel: triangular shape (0.5- 1
cm); closes at 2 months
• Bulging fontanel due to crying & coughing

Caput Succedaneum
• Edema of the soft scalp tissue at the
presenting part of the head.
• Due to pressure on the presenting
part of the fetal head.
• Crosses the suture lines
• 2- 3 days after birth

• Is a collection of blood between the
periosteum of the skull bone and the
bone
• Caused by pressure of the fetal head
against the maternal pelvis during a
prolonged or difficult labor
• Does not cross suture lines.
• Within several weeks

• Localized softening of the cranial bones
• Caused by pressure of the fetal skull
against the mother’s pelvic bone in utero
• Can be indented by pressure of fingers
Craniosynostosis
• Premature closure of the fontanelles.

 Color:
 White sclera
 Slate gray, dark blue or brown
 Final eye color: 3- 6 months or may take
a year
 Pupils equal, round, reactive to light
 (+) Blink reflex

 Lids usually edematous
 Able to move and fixate
momentarily
 May cross (strabismus) or twitch
(nystagmus)
 Absence of tears until one to three
months of age

 Small and narrow
 Flattened, midline
 Nasal breathers
 (+) Periodic sneezing
 (+) Nasal flaring= respiratory distress
 (+) Low nasal bridge= Down’s syndrome

 Folded and creased
 Pinna in line with outer canthus of the eye,
flexible and cartilage present
 Startle reflex is elicited by loud, sudden
noise
 (+) Low set ears= chromosomal defect &
kidney anomaly

 Pink, moist
 Intact soft and hard palate
• Epstein’s pearls- small, white epithelial
cysts (midline of hard palate)
 Uvula in midline
 Tongue smooth and symmetrical, moves
freely with short frenulum

 Sucking reflex (strong and coordinated)
 Other reflexes: Rooting, Gag and Extrusion
 Small mouth or large, protruding tongue=
chromosomal problems
 (+) White patches on tongue or side of the
cheek= Candidiasis (oral thrush)

 Short, creased with skin folds
 Head rotate freely but cannot support
the full weight of head
 Trachea midline
 Thyroid gland not palpable
 Intact clavicle

 Chest circumference- should be = or
< 2 cm than Head circumference
 Antero-posterior & lateral diameters
equal
 Symmetrical
 Cylindrical thorax and flexible ribs
 (+) Breast engorgement subsides
after 2 wks.

 (+) Witch’s milk
 Respirations appear diaphragmatic
 Bilateral equal bronchial breath sounds
 Cough reflex: absent at birth; present
by 1- 2 days
 Periodic apnea- common in preterm
infants

 Heart rate: 120- 140 bpm (apical)
 Apex: 4TH
to 5th
ICS, lateral to left
sternal border
 S2 slightly sharper and higher pitch
than S1
 Transient cyanosis when crying

 Potential signs of distress:
• Dextrocardia- heart on right side
• Displacement of apex
• Murmurs and thrills
- ASD, VSD, PDA
• Persistent cyanosis

 Umbilical Cord:
- 2 arteries and 1 vein
- Bluish white at birth
- Begins to dry between 1-2 hrs. following
birth
- Gradually falls off by 7 days
 Daily Cord Care:
- Keep cord dry and clean & clamp secured

- Cleanse cord with 70% isopropyl alcohol
with each diaper change and at least 2- 3
times a day
- Keep the newborn’s diaper below the cord
- Note for any signs of infection (redness,
drainage, swelling, odor)
- Avoid using creams, lotions or oils near
the cord

 Newborn’s abdomen is shaped like a
dome and cylindrical
 Liver- palpable 2- 3 cm below right
costal margin
 Kidneys- about 1-2 cm above
umbilicus
 Spleen- tip palpable at end of first
week of age

 GITGIT
- Capacity: 90 ml, with rapid intestinal
peristalsis ( 2 ½ to 3 hrs)
- Bowels sounds; (+) within 1-2 hrs after
birth
- (+) Scaphoid = diaphragmatic hernia
- (+) Distended = LGIT obstruction/ mass
- (+) Visible peristalsis= Hirschprung’s
disease

 AnusAnus
- Check patency
- First stool (Meconium) – usually
passed within 12-24 hrs. after birth
• Sticky, tarlike, blackish-green,
odorless

Meconium Transitiona
l Stool
Milk Stool
(Breastfed)
Milk Stool
(Bottlefed)
Within 48 hours
after birth
From 2- 3
days
4- 5 days
onwards
4- 5 days
onwards
Thick, sticky,
black – tarry
Yellow brown
to greenish
brown stools
Golden yellow
and pasty,
sour smelling
Pale yellow to
light brown,
more formed
with foul odor

 Female:Female:
- Edematous labia and clitoris
- Urethral meatus behind clitoris
- First voiding should occur within 24 hours
- Pseudomenstruation- blood- tinged
mucus from the vagina at 1st
week after
birth
- Hymental tag may be present but
disappear in a few weeks.

 Male:Male:
- Prepuce covers glans penis
• Small opening in the foreskin = Phimosis
- Scrotum: edematous
• Excessive amount of fluid= Hydrocele
- Meatus: central
• (+) ventral/ dorsal = Hypo/epispadias
- Testes: descended
• (+) undescended = Cryptorchidism
- First voiding should occur within 24 hrs

 Spine:
- Intact, straight and flat
- No openings, masses or prominent
curves
- Trunk incurvation reflex- disappears by 4
weeks
- (+) Small tuft of hair or dimpling at the
base= Spina Bifida

 Symmetrical and full range of motion
 Even gluteal folds
 Complete fingers and toes
- Polydactyly- extra digits on either fingers or
toes
- Syndactyly- fusion of 2 or more digits
 Legs- equal in length w/ symmetric skin
fold

 Check for hip fractures or dysplasia
- (+) Ortolani’s click & uneven gluteal folds =
Hip dysplasia
 Creases on soles of feet, usually flat
- (-) crease= prematurity
- Simian crease- single palmar crease
(Down’s syndrome)
 (+) inward turning of the foot = club foot
or talipes equinovarus

Polydactyly
Club foot
Syndactyly

Blinking or
Corneal
Pupillary Doll’s Eye
 Infant blinks with
sudden appearance of
bright light or approach
of an object towards
the cornea.
 Persists throughout
life.
 Pupils constrict
when bright light
shines toward it.
 Persists
throughout life.
 As the head is
moved slowly (right or
left), the eyes lag
behind & do not adjust
to new position of the
head.
 Disappears as
fixation develops.
If it persists it may
indicate neurologic
damage.
Sneeze Glabellar
 Spontaneous response of nasal
passages to irritation or
obstruction
 Persists throughout life.
 Tapping briskly on the bridge of
the nose (glabella)
 Eyes close tightly

Sucking Gag Rooting
 Strong sucking
movements of the
circumoral area
(response to
stimulation).
infancy (even without
stimulation.
 Stimulation of
posterior pharynx
causes the infant to
gag.
life.
 Touching or stroking
the cheek along the side
of the infant’s mouth
causes the head to turn
towards that side.
 Should disappear at
about 3-4 months.
 Persists up to 12
months.
Extrusion Yawn Cough
 Tongue is touched
or depressed and the
infant responds by
forcing it outward.
 Disappears by age 4
months.
 Spontaneous
response to decreased
oxygenation by
increasing the amount
of inspired air.
life.
 Irritation of the
mucus membrane of the
larynx or
tracheobronchial tree
causes coughing.
life (usually present
st

CARE OF THECARE OF THE
NEWBORNNEWBORN

ESSENTIALNEWBORN CAREESSENTIALNEWBORN CARE
PROTOCOLPROTOCOL
 On December 7, 2009 the Department
of Health, in cooperation with WHO
launched the Unang Yakap Camapaign
which aims to cut down infant
mortality in the Philippines by at least
half.
 The campaign employs Essential
Newborn Care (ENC) Protocol a series
of time bound, chronologically-ordered,
standard procedures that a baby
receives at birth.

ESSENTIALNEWBORN CAREESSENTIALNEWBORN CARE
PROTOCOLPROTOCOL
 Provides an evidence-based, low cost,
low technology package of
interventions that will save
thousands of lives.
 Also supports the Philippine
Government commitment to the
United Nations Millenium
Development Goals (MDG) 4 and 5 by
year 2015.

Time- Bound ProceduresTime- Bound Procedures
 Should be routinely performed first
 Immediate drying, skin-to-skin contact
 Clamping of the cord after one to three
minutes or until pulsations have stopped
 Non-separation of the newborn from the
month
 Breastfeeding initiation.

 Should only be done after the first full
breastfeed.
 Immunizations
 Eye care
 Vitamin K administration and weighing.
 Washing must be postponed by at least 6
hours as this will hinder the crawling
reflex.

 Routine suctioning
 Routine separation of newborns for
observations
 Administration of pre lacteals like
glucose, water formula
 Footprinting.

I. Immediate Newborn CareI. Immediate Newborn Care
(The First 90 Minutes)
Time Band: Within the 1st 30 secs
-Call out the time of birth
Intervention: Dry and provide warmth.
Action:
- Use a clean, dry cloth to thoroughly dry
the baby by wiping the eyes, face, head,
front and back, arms and legs.

Action:Action:
- Remove the wet cloth.
- Do a quick check of newborn’s
breathing while drying.
Notes:
- During the first 30 seconds:
– Do not ventilate unless the baby is
floppy/limp and not breathing.
– Do not suction unless the
mouth/nose are blocked with
secretions or other material.

Time Band: After 30 secs of thorough
drying
Intervention: Do skin-to-skin contact
Action:
- If a baby is crying and breathing
normally, avoid any manipulation, such as
routine suctioning, that may cause trauma
or introduce infection.
- Place the newborn prone on the mother’s
abdomen or chest skin-to-skin.

Action:Action:
- Cover newborn’s back with a blanket
and head with a bonnet.
- Place identification band on ankle.
Notes:
- Do not separate the newborn from
mother, as long as the newborn does
not exhibit severe chest in-drawing,
gasping or apnea.

Notes:Notes:
- Do not wipe off vernix if present.
- Do not bathe the newborn earlier
than 6 hours of life.
- Do not do footprinting.
- If the newborn must be separated
from his/her mother, put him/her on
a warm surface, in a safe place close
to the mother.

Time Band: 1 - 3 minutes
Intervention: Do delayed or non-
immediate cord clamping
Action:
- Remove the first set of gloves
immediately prior to cord clamping.
- Clamp and cut the cord after cord
pulsations have stopped (typically at 1
to 3 minutes)

Action:Action:
- Put ties tightly around the cord at 2 cm
and 5 cm from the newborn’s abdomen.
– Cut between ties with sterile instrument.
– Observe for oozing blood.
Notes:
- Do not milk the cord towards the
newborn.
- After cord clamping, ensure Oxytocin 10
IU IM is given to the mother.

Time Band: Within 90 min of age
Intervention: Provide support for initiation
of breastfeeding.
Action:
- Remove the first set of gloves
immediately prior to cord clamping.
- Leave the newborn on mother’s chest in
skin-to-skin contact.
- Observe the newborn. When the newborn
shows feeding cues (e.g. opening of mouth,
rooting), make verbal suggestions to the
mother to encourage her newborn to move
toward the breast e.g. nudging.

Action:Action:
- Counsel on positioning and attachment. When
the baby is ready, advise the mother to:
• Make sure the newborn’s neck is not flexed
or twisted.
• Make sure the newborn is facing the breast,
with the newborn’s nose opposite her nipple
and chin touching the breast.
• Hold the newborn’s body close to her body.
- Support the newborn’s whole body, not just
the neck and shoulders.
– Wait until her newborn’s mouth is opened
wide.

- Look for signs of good attachment and
suckling:
• Mouth wide open
• Lower lip turned outwards
• Baby’s chin touching breast
• Suckling is slow, deep with some pauses.
- Do not give sugar water, formula or other
prelacteals.
– Do not give bottles or pacifiers.
– Do not throw away colostrum.
Adapted fro: Newborn Care until the First Week Of Life: Clinical


Cord careCord care
Nursing Responsibilities:
- Put nothing on the stump.
– Fold diaper below stump. Keep cord
stump loosely covered with clean clothes.
– If stump is soiled, wash it with clean
water and soap. Dry it thoroughly with
clean cloth.
- Explain to the mother that she should
seek care if the umbilicus is red or
draining pus.

 Cord careCord care
Notes:
– Do not bandage the stump or
abdomen.
– Do not apply any substances or
medicine on the stump.
– Avoid touching the stump
unnecessarily.

NEWBORN SCREENINGNEWBORN SCREENING
• R.A. 9288
• Disorder Screened:
-Congenital Hypothyroidism (CH)
- Congenital Adrenal Hyperplasia (CAH)
- Galactosemia
- Phenylketonuria
- G6PD Deficiency
• Done 48th
to 72nd
hour of life or 24 hours
from birth.
• Uses the heel prick method.

BreastfeedingBreastfeeding
 The traditional and ideal form of infant
feeding, meeting an infant’s nutritional
needs for his first 4-6 mos. of life.
 Is one of the most effective ways to
ensure child health and survival.
 The WHO actively promotes breastfeeding
as the best source of nourishment for
infants and young children.

Exclusive BreastfeedingExclusive Breastfeeding
 Giving the infant only breastmilk
with no additional foods or liquids,
not even water.
 Recommended up to 6 months of
age, with continued breastfeeding
along with appropriate
complementary foods up to two
years of age or beyond.

 The Rooming- in and Breastfeeding Act of
1992 (R.A 7600)
 Milk Code (E.O. 51)
 Rooming- inRooming- in- the practice of placing the
newborn in the same room as the mother
right after delivery up to discharge to
facilitate mother-infant bonding and to
initiate breastfeeding.

Advantages of BreastfeedingAdvantages of Breastfeeding
1. Breastmilk is the best natural food for
babies. It contains the right amount of
proteins, fats, sugars, vitamins & minerals
needed by a growing baby.
2. Breastmilk is easily digested. Protein is in
the form of lactalbumin which is superior to
casein and is readily digested by the
infant’s enzymes because it forms small
amounts of curds.

4. Colostrum, the first yellowish milk
secretion has immune bodies that gives
the baby immunity against some gastro-
intestinal infections and common illness
during the first six months of life.
5. Breastfeeding is beneficial to the health of
the mother. It hastens the return of her
uterus to normal size. Because she does
not menstruate she conserves her iron
stores.

6. Breastfeeding is economical and convenient
because it is available 24 hours and needs no
special preparation.
7. It offers an excellent opportunity for the mother
to develop a stable and close bond with her
child.
8. Breastfeeding promote birth spacing through
LAM method (Lactational amenorrhea method).
9. Human milk contains Bifidus Factor that
promotes growth of desirable bacteria in the
GUT.

Protection against infectionProtection against infection
> Breastmilk contains white blood cells, and a
number of anti- infective factors, which help
protect a baby against many infections.
> Protects babies against diarrheal and
respiratory illness and also ear infections,
meningitis and urinary tract infections.
> A baby should not be separated from his
mother when she has an infection, because
breast milk protects him against the
infection.

Variations in Composition of BreastVariations in Composition of Breast
MilkMilk
 ColostrumColostrum
 The breast milk that women produce in the
first few days after delivery. It is thick and
yellowish or clear in color.
 Recommended by WHO as the perfect
food for the newborn, and feeding should
be initiated within the first hour after birth.

 ColostrumColostrum
PropertyProperty
- Antibody rich
- Many white cells
- Purgative
- Growth factors
- Rich in Vitamin A
ImportanceImportance
- Protects against allergy &
infection
- Protects against infection
- Clears meconium
- Helps to prevent jaundice
- Prevents allergy, intolerance
- Reduces severity of infection

 Mature MilkMature Milk
 The breast milk that is produced after few
days. The quantity becomes larger, and the
breasts feel full, hard and heavy. Some
people call this the breast milk ‘coming in’.
 Contains proteins, vitamins and minerals,
lactose (sugar), fatty acids, antibodies and
enzymes that aid in digestion and
absorption.

 ForemilkForemilk
 The milk that is produced early in a feed.
 Looks bluer than Hindmilk
 Produced in larger amounts & it provides
plenty of protein, lactose & other nutrients.
 HindmilkHindmilk
 Is the milk that is produced later in a feed.
 Looks whiter than foremilk, because it
contains more fat which provides much of the
energy of a breastfeed.

Summary of Differences Between MilkSummary of Differences Between Milk
Human Milk Animal Milk Formula
Milk
Protein Correct amount,
Easy to digest
Too much,
difficult to
digest
Partly
corrected
Fat Enough
essential fatty
acids, lipase to
digest
Lacks
essential
fatty acids,
no lipase
No lipase
Adapted from: Breastfeeding counselling: A training course. Geneva,
World Health Organization, 1993

Human Milk Animal Milk Formula
Milk
Water Enough Extra
needed
May need
extra
Anti-
infective
properties
Present Absent Absent
Adapted from: Breastfeeding counselling: A training course. Geneva,
World Health Organization, 1993

Nutrients in Human MilkNutrients in Human Milk
 Human milk contains essential fatty acids
that are needed for a baby’s growing brain
and eyes, and other healthy blood vessels.
 Human milk contains more whey proteins that
contain anti- infective proteins which help to
protect a baby against infection.
 Human milk is better absorbed. Totally
breastfed infants triple their birth weight,
maintain normal iron status without iron
supplements.

 Occurrence of Rickets in breastfed infants is
minimal because of water soluble Vitamin D
sulfate.
 Human milk has softer, smaller and sweeter-
smelling curd.
 Human milk has 2 times more of readily
absorbed Olein; a better source of Linoleic
acid (supplies 4- 5 %); has dienoic fat, which
is necessary to prevent growth failure &
production of dry, thick and scaly skin.

ProlactinProlactin
 Secreted after a feed to produce next
feed.
 The pituitary gland at the base of the
brain secretes prolactin.
 Prolactin makes the milk secreting cells
produce milk.
 Most of the prolactin is in the blood
about 30 minutes after the feed so it
makes the breast produce milk for the
next feed.

OxytocinOxytocin
 Works before or during feed to make milk flow.
 Is produced more quickly than prolactin.
 Makes a mother’s uterus contract after delivery.
 Oxytocin reflex- easily affected by a mother’s
thoughts and feelings. Sensations such as
touching or seeing her baby, or hearing him cry,
can also help the reflex. But bad feelings, such as
pain or worry or doubt that she has enough milk,
can hinder the reflex and stop her milk from
flowing.

ABC’s of BreastfeedingABC’s of Breastfeeding
AAwarenesswareness- Watch for the baby's signs of hunger,
and breastfeed whenever your baby is hungry.
BBeing patient-eing patient- Breastfeed as long as the baby
wants to nurse each time. Infants typically
breastfeed for 10 to 20 minutes on each
breast.
CComfortomfort- Get comfortable with pillows to support
arms, head, and neck and a footrest to support
feet and legs before beginning to breastfeed.

““Latching On”Latching On”
 Position the baby facing the mother.
 With one hand, cup breast and gently stroke
the baby's lower lip with the nipple.
 With the mother’s hand supporting the baby's
neck, bring the baby's mouth closer around the
nipple, trying to center the nipple in the baby's
mouth above the tongue.
 The baby is "latched on" correctly when both
lips are pursed outward around the mother’s
nipple.

Complementary FeedingComplementary Feeding
• Given to infants at age 6 months in order to
meet their evolving nutritional requirements.
• Appropriate complementary feeding means:
a. Timely- introduced when the need for energy &
nutrients exceeds what can be provided
through breastfeeding.
b. Adequate- provide sufficient energy, protein
and micronutrients to meet a growing child’s
nutritional needs.

c. Safe- hygienically stored and prepared, and fed
with clean hands using clean utensils and not
bottles and teats or artificial nipples.
d. Properly fed- given consistent with a child’s
signals of appetite and satiety, and meal
frequency and feeding method.
• Frequent feeding (4–5 times a day) with
appropriate foods ensures that young children
get sufficient energy and nutrients to grow
normally and stay healthy.

• Good first complementary foods
include soft meat, vegetables and
fruits, mashed to a thin consistency.
• Foods should be prepared without
added salt.
• New foods should be introduced to the
child one at a time, allowing the child
to get used to the food before another
new food is introduced in their diet.

• By 5- 6 months, the infant is ready to eat
scraped banana, papaya, rice gruel or
commercial cereal food can e given.
• When teething begins, chewy foods such as
crackers are given.
• Between 7th
and 8th
months, foods are chopped
finely such as soft cooked rice with boiled fish
and leafy vegetables.
• From 9th
to the 12th
month, depending on the
child’s dental development, whole tender foods
or food chopped coarsely are given.

Nutrition in LactationNutrition in Lactation
• A mother who is breastfeeding needs to eat
300 more calories to provide the extra energy
the body needs.
• Choose foods with a lot of fiber- fruits,
vegetables, dry beans, whole grain breads
and cereals, and other whole grain products.
• Eat food containing vitamin B9 (folic acid).
• Consume 1,200 milligrams of calcium/day
can be partly met by from dairy products and
raw vegetables.

• Iron Supplementation in Lactating Women
- 60 mg elemental iron with 400 mcg Folic
acid 1 tablet once a day.
• Avoid smoking and consumption of alcohol.

MOTHER BABYMOTHER BABY
FRIENDLY HOSPITALFRIENDLY HOSPITAL
INITIATIVEINITIATIVE

- BFHI was launched by WHO and UNICEF in
1991.
- The initiative is a global effort to implement
practices that protect, promote and
support breastfeeding.
- The goal is to encourage optimal
breastfeeding practices through prolonged,
exclusive and early initiated breastfeeding.

- The MBFHI, the name for the Filipino version of
the initiative, was launched by the Department
of Health in 1992 in line with the Rooming-in
and Breastfeeding Act of 1992 (RA 7600).
- All private & government hospitals offering
maternity and newborn care may be
accredited as Mother-Baby Friendly if they
implement the 10 Steps to Successful
Breastfeeding adopted from UNICEF/WHO
criteria of BFI.

 The revised BFHI package includes:
• Section 1: Background and Implementation
• Section 2: Strengthening and sustaining the
Baby-friendly Hospital Initiative
• Section 3: Breastfeeding Promotion and
Support in a Baby-Friendly Hospital
• Section 4: Hospital Self-Appraisal and
Monitoring
• Section 5: External Assessment and
Reassessment

 The 10 Steps to Successful BreastfeedingThe 10 Steps to Successful Breastfeeding
1. Baby-friendly hospitals have a written
breastfeeding policy that is routinely
communicated to all health care staff.
2. Baby-friendly hospitals train all health care
staff in skills necessary to implement this
policy.
3. Baby-friendly hospitals inform all pregnant
women about the benefits and management of
breastfeeding.
4. Baby-friendly hospitals help mothers initiate
breastfeeding within one half-hour of birth.

5. Baby-friendly hospitals show mothers how
to breastfeed and maintain lactation, even
if they should be separated from their
infants.
6. Baby-friendly hospitals give newborn
infants no food or drink other than
breastmilk, not even sips of water, unless
medically indicated.
7. Baby-friendly hospitals practice rooming- in
that is, allow mothers and infants to remain
together 24 hours a day.

8. Baby-friendly hospitals encourage
breastfeeding on demand.
9. Baby-friendly hospitals give no artificial
teats or pacifiers to breastfeeding infants.
10. Baby-friendly hospitals foster the
establishment of breastfeeding support
groups and refer mothers to them on
discharge from the hospital or clinic.
Source: Baby-Friendly Hospital Initiative. World Health
Organization. January 2009.

Accreditation Process of MBFHIAccreditation Process of MBFHI
FacilitiesFacilities
Self- Assessment by the facility using the Global
Criteria on MBFHI Self- Appraisal
Submission of self- assessment of the health
facility for validation by the CHD MBFHI Assessors/
Coordinators
Issuance of Certificate of Commitment by the CHD
Director for validated compliance.

Accreditation Process of MBFHI FacilitiesAccreditation Process of MBFHI Facilities
Re- assessment of the CHD MBFHI Assessor/
Coordinator after 2 years of sustained
implementation by the health facility
Issuance of Plaque of Accreditation by the Secretary
of Health for sustained implementation on MBFHI
and integration of Mother Friendly indicators
Annual MBFHI Implementation Report (Using the Self-
Assessment Tool) for submission by the health
facility to the CHD

Accreditation Process of MBFHIAccreditation Process of MBFHI
FacilitiesFacilities
Re- Assessment every three (3) years by the CHD
Team of Assessors for MBFHI sustainability
Best Practices/ Innovations for sustaining
MBFHI status
Hall of Fame Award based on guidelines set by
the IYCF National Management Committee and

 Hospital Self- Appraisal and Monitoring
• Specific purposes of monitoring and
reassessment:
- To support and motivate facility staff to maintain
baby-friendly practices.
- To verify whether mothers experiences at the
facility are helping them to breastfeed.
- To identify if the facility is doing poorly on any of
the Ten Steps and thus whether needs to do
further work to make needed improvements.

Monitoring-Monitoring- a dynamic system for data
collection & review that can provide
information on implementation of the Ten
Steps to assist with on-going management of
the initiative.
Reassessment-Reassessment- “re-evaluation” of already
designated baby-friendly hospitals to
determine if they continue to adhere to the
Ten Steps and other baby-friendly criteria.

 Most common treatment for reducing high
bilirubin levels/ hyperbilirubinemia that
cause jaundice in a newborn.
 Goal: Decrease the serum unconjugated
bilirubin level because a high level may lead
to bilirubin encephalopathy (kernicterus).
 Safe, effective, non- invasive and easy to
use.

> Normal unconjugated bilirubin are 0.2 to 1.4 mg/dl.
In newborns level must exceed 5 mg/dl before
jaundice (icterus) is observable.
 The ff: are the indicators of pathologic jaundice
> Persistent jaundice over 2 weeks in a full- term
formula- fed infant
> Total serum bilirubin level over 12.9 mg/dl (term
infant) or over 15 mg/dl (preterm infant); the upper
limit for breastfed infant is 15 mg/dl.
> Increase in serum bilirubin by 5 mg/dl/day
> Direct bilirubin exceeding 1.5 to 2mg/dl

 Possible causes of hyperbilirubinemia inPossible causes of hyperbilirubinemia in
newborns:newborns:
> Prematurity
> Excess production of bilirubin (hemolytic
disease)
> Disturbed capacity of the liver to secrete
conjugated bilirubin (e.g., enzyme deficiency,
bile duct obstruction)
> Sepsis
> Some disease states (e.g., hypothyroidism,
galactosemia, infant of a diabetic mother)

Devices Used forDevices Used for
PhototherapyPhototherapy
 Fluorescent tubes
- Classified as: “daylight” (white), blue & special
blue
- Narrow- spectrum blue lamps work best while
white fluorescent tubes are less efficient.
 Halogen lamps
- Most heat producing
- Use a commercially available tungsten- halogen
light bulb and direct a strong beam of

Devices Used for PhototherapyDevices Used for Phototherapy
 Fiberoptic systems
- Deliver high energy levels but, but to a limited
surface area.
- Low risk of overheating the infant.
 LED lights
- Low power consumption
- Low heat production
- Longer life span of the light- emitting unit

Factors Affecting the Dose ofFactors Affecting the Dose of
PhototherapyPhototherapy
1. Type of light used
2. Light intensity
3. Surface area of skin exposed to light
 The optimum distance of the light source
from the baby is 30- 50 cm in conventional
lights.

LED System Halogen Lamp
Fiberoptic Fluorescent tube

Nursing Care and ProcedureNursing Care and Procedure
 Expose as much of the newborn’s skin as
possible.
 Cover the genital area, and monitor genital area
for skin irritation or breakdown.
 Cover the newborn’s eyes with eye shields or
patches; make sure eyelids are closed when
shields or patches are applied and should be
properly sized & correctly positioned.
 Remove the shields or patches at least once
per shift.

 Measure the quantity of light every 8 hours.
 Monitor skin temperature closely.
 Increase fluids to compensate for water loss.
 Monitor the newborn’s skin color with the
fluorescent light turned off, every 4 to 8 hours.
 Monitor the skin for the bronze baby syndrome,
a grayish brown discoloration of the skin.
 Reposition newborn every 2 hours.

 During breastfeeding switch off the phototherapy
unit. Provide frequent breastfeeding.
 Keep baby at a distance of 45 cm from the
source.
 Monitor temperature every 2 to 4 hours.
 Maintain baby in a flexed position with rolled
blankets along the sides of the body.
 Weight is taken at least once a day.

 Ensure that serum bilirubin levels are obtained
as prescribed.
 Discontinue phototherapy when serum bilirubin
returns to a safe value as per unit protocol.
 Accurate documentationdocumentation is another important
nursing responsibility:
• time that phototherapy is started & stopped
• proper shielding of the eyes & covering of the
genitals

• type of fluorescent
lamp (by manufacture)
• no. of lamps
• distance between
lamps & infant (should
not be less than 45
cms.)
• use of phototherapy in
combination with an
incubator or open
bassinet
• occurrence of side
effect.
• length of time the bulbs
have been used
• record VS every 2 hrs.
• maintain feeding and
weight chart regularly
• serum bilirubin is
monitored every 12 hrs.

Side Effects of PhototherapySide Effects of Phototherapy
• Bronze- baby syndrome
• Loose, greenish stools
• Transient skin rashes
• Hyperthermia
• Increased metabolic rate
• Dehydration
• Electrolyte disturbance

Umbilical CannulationUmbilical Cannulation

 Indications for Catheterization
• For frequent measurement of arterial blood
gases / other blood tests
• For continuous arterial blood pressure
monitoring.
• For exchange transfusion.
• For administration of IV fluids
 Contraindications
• Gastroschisis Peritonitis
• Omphalocele Necrotizing enterocolitis
• Omphalitis

 Before initiating the procedure, a radiant
warmer should be obtained, and the patient
should be connected to a cardiac monitor.
 Make sure that the baby’s condition & vital
signs are stable.
 Babies with umbilical lines can be safely
nursed prone, provided that the lines have
been correctly secured.

Equipment :Equipment :
• Personal protective equipment (i.e., sterile
gown, gloves, mask)
• Sterile drapes
• #3.5 or #5 Fr. Single or double lumen umbilical
catheter
• Iris forceps without teeth
• Small clamps
• Scalpel
• Scissors

• Tape measure
• Limb restraints
• Needle holder
• Silk suture (3-0) or umbilical tape
• Intravenous tubing and 3-way stopcock
• Infusion solution (dextrose 5% in water or 0.9%
sodium chloride NaCl with heparin 1 U/mL
solution)

Procedure:Procedure:
• Perform the shoulder to umbilicus measurement.
a. Measure in a straight line parallel to the neonate’s
body and record in cm’s the distance from the
infant’s distal end of the clavicle to the umbilicus.
b. Take the SU measurement and multiply x 0.66 for
UAC placement plus stump length.
c. Multiply x 0.5 for UVC placement plus stump
length. This length is needed to place the tip of the
catheter between the diaphragm and
the right atrium.

• Restrain infant’s arms and legs. Observe
buttocks, legs and feet for baseline
color/perfusion prior to and following
catheterization.
• Assemble equipment for UAC/UVC placement.
• Hold the umbilical cord clamp upward while the
provider cleans the cord and surrounding skin
with betadine swabs. The provider will drape
the patient and place the umbilical tie around
the stump of the cord.

• Using the scalpel, the cord is cut
horizontally, approximately 1.5-2 cm from
the abdominal wall.
• Hemostasis is achieved through tightening
the umbilical tape or suture. The arteries
do not usually bleed secondary to
vasospasm.
• Forceps are then used to clear any thrombi
and dilate the vein.

• A 3.5F catheter is used for preterm newborns,
and a 5F catheter is used for full-term newborns.
• The catheter should be flushed with pre-
heparinized solution and attached to a closed
stopcock.
• The catheter is then grasped 1 cm from its distal
tip with the iris forceps and gently inserted,
aiming the tip toward the right shoulder. Advance
the catheter only 1-2 cm beyond the point at
which good blood return is obtained.

• Do not force the advancement.
• Secure the catheter with a suture through the
cord, marker tape, and a tape bridge.
• The position of the catheter must be
confirmed radiographically.
• In an emergency resuscitation, the catheter is
best advanced only 1-2 cm beyond the point at
which good blood return is obtained.

• To ensure an air-free catheter, fill the lumen with
infusion solution and close the stopcock until the
catheter is in the vein/artery.

 Removal of UAC/UVCRemoval of UAC/UVC
• Identify patient per nursery procedure.
• Restrain extremities.
• Assemble equipment at bedside.
• Wash hands and don clean gloves.
• Remove the UAC/UVC tape from the catheter.
• Using the knife blade or scissors cut and
remove the sutures securing the UAC/UVC.
Always cut away from the catheter.
• Turn the stopcock off toward the patient.
Discontinue infusion.

• Withdraw the catheter gradually with steady
continuous pulling action until all but approx. 2
cm of the catheter has been removed. Retape
the UAC/UVC to the abdomen to prevent
accidental dislodgment or tighten umbilical tie.
• Open the stopcock to air & observe for
pulsation’s or blood return in the catheter. If
pulsation’s or blood return is noted, return the
stopcock to the off position and wait an
additional 5-10 minutes before opening the
stopcock to air again.

• If no blood return or pulsations are noted, the
catheter may be slowly withdrawn.
• If bleeding occurs after removal of the catheter,
tighten umbilical tie and apply continuous
pressure with 4x4 sterile gauze for 3-5 minutes.
• Observe the umbilicus for bleeding after
catheter removal.
• Document: Time UAC/UVC removed, amount of
bleeding noted upon removal, patient’s tolerance
of procedure

Nursing ManagementNursing Management
• Ensure that the baby is comfortably positioned,
is normothermic and is stable before the
procedure starts.
• Connections are checked at beginning of each
shift to ensure they are secure and there are no
kinks in the lines.
• The toes, feet and legs are checked frequently
for changes in color and circulation. Cyanosis or
pallor of toes/feet/buttock discoloration is
reported to doctor immediately.

• Ensure there is no blood or bubbles present in
the blood pressure line causing damping of the
reading.
• Check umbilicus for oozing of blood regularly.
• UAC and UVC infusions are changed daily or as
prescribed.
• Cleaning outer surface and umbilical stump with
alcohol as needed.
• Positioning infant on back.
• Securing connections and stabilizing catheter
with tape.

ComplicationsComplications
• Infection
• Hemorrhage
• Vessel perforation
• Air embolism
• Catheter tip embolism
• Portal venous thrombosis
• Dysrhythmia and pericardial tamponade
or perforation (if the catheter is
advanced to the heart).

PEDIATRIC/ NEONATALPEDIATRIC/ NEONATAL
INTUBATIONINTUBATION

 Indications
• Ventilation – Apgar score 0-3, ventilatory
failure (or resuscitation), bag and mask
unsuccessful or undesirable (diaphragmatic
hernia, meconium aspiration)
• Obstruction - upper airway
• Protection - from aspiration

 Anatomic Considerations for InfantAnatomic Considerations for Infant
IntubationIntubation
• Larynx more anterior and cephalad
• Tongue relatively large
• Short neck
• Epiglottis is longer, stiffer and protrudes at 45o
angle
• Trachea is short (easy for bronchial intubation)
• Elevation of hyoid bone may precipitate apnea
 Cautions: Do not overextend neck in infants.
• Never attempt procedure for more than 30

 Preparing for Intubation (Endotracheal)
1. Recognize the need for intubation.
2. Notify physician and respiratory therapist.
Ensure consent obtained if not emergency.
3. Gather all necessary equipment:
• Laryngoscope (with extra batteries and bulbs)
• Blades
- Straight blade (infants and young children)
- Curved blade (older children and adolescents)
• Uncuffed tubes (infants to 8 years)
• Cuffed tubes (8 years and older)

• Stylet
• Suction device
• Suction catheters (all sizes), Yankauer
• ETCO2 detector (Pediatrics Only)
• Magill forceps (if necessary)
• Sterile water or lubricant
• Fixation device (Neobar), scissors, tape, etc.
• Syringe
• Sedation medications as ordered by the
physician.

Tube Sizes for PediatricTube Sizes for Pediatric
IntubationIntubationAge Endotracheal Tube
(mm)
Suction Catheter
Premature 2.5 6F
Newborn 3.0 6F
6 month 3.5 8F
18 month 4.0 8F
3 years 4.5 8F
5 years 5.0 10F
6 years 5.5 10F
8 years 6.0 10F
12 years 6.5 10F

Blade Sizes For PediatricBlade Sizes For Pediatric
IntubationIntubation
Age Blade Size
Premature No. 0 straight
Miller
Term newborn to
3- year old
No. 1 straight
Miller
3- year old to
adolescent
No. 2 straight
Miller or curved
Macintosh
Adolescent No. 3 curved
Macintosh

Nursing ResponsibilitiesNursing Responsibilities
• Obtain the necessary equipment and ensure its
working order. Explain to the child and the
family the need for the procedure, as time
permits.
• Don gloves, goggles and mask.
• Select the correct size of the laryngoscope
blade and two Endotracheal tubes. Ensure that
the distal end of the stylet is at least 2cm
proximal from the tip of the endotracheal tube.
• Obtain and administer paralyzation and
sedation medications.

• Place the child in the head-tilt position.
• Hyperventilate the child a100 percent oxygen using a
bag-valve-mask device for several minutes prior to the
intubation attempt.
• Place the laryngoscope in your left hand and open
the child’s mouth with your right hand.
• Introduce the laryngoscope into the right side of the
mouth, & sweep the tongue over to the left side; have
suction readily available.
• If a curved blade is used, advance it gently until the
tip is in the vallecula; if a straight blade is being used,
tip should be placed just under the epiglottis.

• Once the vocal cords are visualized, the
endotracheal tube is inserted until the black
marker is at the level of the vocal cords. If the
vocal cords are not easily visualized, slight
external cricoid pressure may be helpful.
• Confirm correct tube placement:
- Observe symmetrical chest wall movement.
- Attach an end-tidal CO2 detector between the
bag-valve- mask device and endotracheal
tube.

• Tape or tie the tube where the upper central
incisors touch the endotracheal tube.
• Obtain a chest x- ray to confirm the tube’s
placement. (when time permits.)
• Reevaluate the tube placement at frequent
intervals and observe for complications.
• Explain to the family and the child why the tube
is in place, how it works, why the child cannot
speak and so forth.

DocumentationDocumentation
• time of intubation
• the size of the endotracheal tube
• confirmation of the placement
• medications administered
• how the child tolerated the procedure
• changes in the child’s condition.

CardiopulmonaryCardiopulmonary
ResuscitationResuscitation
(Hospital Setting)(Hospital Setting)

The 2010 AHA GuidelinesThe 2010 AHA Guidelines
• Change in CPR Sequence (C-A-B Rather
Than A-B-C)
• Continued emphasis on provision of
high-quality CPR.
• AED Use in Children Now Includes
Infants
• Removal of “look, listen, and feel for
breathing” from the sequence.

Prepared by: Julie Ann E. Cordovez, RNPrepared by: Julie Ann E. Cordovez, RN
Nursing Service- Ospital ng MakatiNursing Service- Ospital ng Makati

Newborn & Pediatric Care

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