Examination and care of healthy newborn babies

Daily care of infants and children ensures the healthy development of the child during learning, preventive vaccinations and early detection and treatment of diseases.

To prevent infection of the baby, it is extremely important for all personnel to follow the rules of hand washing. Active participation of both mother and father during the birth facilitates their adaptation to the role of parents.

[ 1 ], [ 2 ]

Caring for a newborn in the first hours after birth

Immediately after birth, the newborn's respiratory system, heart rate, skin color, muscle tone, and reflexes should be assessed. These are all key components of the Apgar score, which are assessed in the first and fifth minutes of a newborn's life. An Apgar score of 8-10 points indicates that the newborn is making a normal transition to extrauterine life. A score of 7 points or less at the fifth minute (especially if it persists for more than 10 minutes) is associated with a higher risk of illness and death in the newborn. Many newborns have cyanosis in the first minute of life; when assessed at the fifth minute, cyanosis usually disappears. Cyanosis that does not disappear may indicate cardiovascular abnormalities or CNS depression.

In addition to the Apgar scale, the newborn must be examined to detect any developmental defects. The examination must be performed under a radiant heat source in the presence of family members.

Antimicrobial agents are prescribed prophylactically in both eyes (for example, 2 drops of 1% silver nitrate solution, 1 cm of 0.5% erythromycin ointment, 1 cm of 1% tetracycline ointment) to prevent gonococcal and chlamydial infections; 1 mg of vitamin K is administered intramuscularly to prevent hemorrhagic disease of the newborn.

Later, the baby is bathed, swaddled, and given to the family. A cap should be placed on the head to prevent heat loss. Transfer to the ward and early breastfeeding of the newborn should be encouraged by the medical staff so that the family gets to know the baby better and can receive help from the staff while still in the maternity hospital. Breastfeeding is usually successful if the family is provided with sufficient financial support.

[ 3 ], [ 4 ], [ 5 ]

Caring for a newborn in the first days after birth

[ 6 ], [ 7 ], [ 8 ]

Physical examination

The newborn should be examined thoroughly within 24 hours of birth. Performing the examination in the presence of the mother and family members allows them to ask questions and allows the physician to communicate the examination results and provide preliminary guidance.

Basic measurements include length, weight, and head circumference. Length is measured from crown to heel; normal values are determined based on gestational age and should be prepared on standard growth charts. If the exact gestational age is unknown or the newborn appears larger or smaller than its age, morphological and functional (neuromuscular) maturity indices can be used to determine gestational age. These methods allow the gestational age to be determined with an accuracy of ±2 weeks.

Many physicians examine the heart and lungs early in the examination, while the child is calm. It is necessary to determine the location where the heart murmurs are heard loudest (to exclude dextrocardia). The normal heart rate is 100-160 beats per minute. The rhythm should be regular, although arrhythmia is possible. Heart murmurs heard during the first 24 hours are most often associated with a patent ductus arteriosus. Daily cardiac examination confirms the disappearance of this murmur, usually within three days. The femoral pulse should be sought and assessed in conjunction with the brachial pulse. A weak or deficit femoral pulse may indicate coarctation of the aorta or other arterial stenosis. Generalized cyanosis indicates congenital heart disease, lung disease.

The respiratory system is assessed by counting the respiratory rate for a full minute, as newborns have irregular breathing. The normal respiratory rate ranges from 40 to 60 breaths per minute. The chest should be symmetrical on examination, and breath sounds should be equally distributed over all lung fields. Wheezing, widening of the nasal alae, and retraction of the intercostal spaces during breathing are signs of respiratory distress syndrome.

After examining the heart and lungs, a sequential examination of the baby's organs and systems is performed from top to bottom. In cases of cephalic presentation, the bones of the skull usually overlap, and there is slight edema and ecchymosis on the skin of the head (caput succedaneum). In cases of breech presentation, the head is less deformed, and edema and ecchymosis are observed on the presenting part of the body (buttocks, genitals, feet). The size of the fontanelles can vary from a few millimeters to several centimeters. An enlarged large fontanelle can be a sign of hypothyroidism. Cephalhematomas, accumulations of blood between the periosteum and bone that look like edema, are also common. A cephalhematoma can be located in the area of one or both parietal bones, less often above the occipital bone. As a rule, cephalhematomas are not noticeable until the edema of the soft tissues of the head subsides; cephalhematomas gradually disappear over several months.

The newborn's eyes are easier to examine the day after birth, as swelling around the eyelids occurs during labor. The eyes should be examined for the pupillary reflex, which is absent in glaucoma, cataracts, and retinoblastoma. Subconjunctival hemorrhages are common after birth.

Low-set ears may indicate genetic abnormalities, including trisomy 21. The external auditory canal should be examined. Abnormalities in the structure of the outer ear should be noted, as they may be associated with deafness and kidney abnormalities.

The physician should examine and palpate the palate to detect defects of the hard palate. Some newborns are born with an epulis, a benign hamartoma of the gums. If large enough, an epulis can cause feeding difficulties and obstruct the airway. These problems can be corrected without the risk of recurrence. Newborns may also be born with teeth. Natal teeth have no roots. Such teeth must be removed because they can fall out and be aspirated by the baby. Inclusion cysts, called Ebstein's pearls, may be found on the palate.

When examining the neck, the doctor should lift the child's chin to detect such anomalies as cystic hygroma, goiter, and remnants of the gill arches. Torticollis can be caused by hemorrhage into the sternocleidomastoid muscle due to birth trauma.

The abdomen should be round and symmetrical. A scaphoid abdomen may indicate the presence of a diaphragmatic hernia, through which the intestines move into the chest cavity in utero, sometimes leading to pulmonary hypoplasia and the development of respiratory distress syndrome postnatally. An asymmetric abdomen may be a sign of an abdominal tumor. If splenomegaly is detected, congenital infection or hemolytic anemia should be assumed. The kidneys can be palpated with deep palpation, the left kidney is easier to palpate than the right. Large kidneys can be detected with obstruction, tumor, polycystic kidney disease. The edge of the liver is normally palpated 1-2 cm below the costal arch. Umbilical hernia, which occurs due to weakness of the muscles of the umbilical ring, is common, but is rarely significant.

In boys, the penis should be examined for epispadias and hypospadias. In full-term boys, the testicles should be descended into the scrotum. Swelling of the scrotum may indicate hydrocele, inguinal hernia, or, much less commonly, testicular torsion. In hydrocele, the scrotum is translucent. Testicular torsion is an urgent surgical condition, manifested by ecchymosis and compaction. In full-term girls, the labia are prominent, with the labia majora covering the labia minora. Mucous vaginal and serous-bloody discharge (false menstruation) is normal. The discharge is formed due to the fact that the fetus is exposed to maternal hormones in utero, which ceases after birth. Sometimes a small outgrowth of hymen tissue is found in the area of the posterior frenulum of the labia, which is probably associated with intrauterine stimulation by maternal hormones and disappears after a few weeks. Intersex genitalia may be a manifestation of a number of congenital diseases (congenital adrenal hyperplasia, 5a-reductase deficiency, Klinefelter, Turner, Swyersyndromes ). In such situations, consultation with an endocrinologist is indicated for evaluation and discussion with the family of immediate or delayed determination of the child's sex.

An orthopedic examination is aimed at identifying hip dysplasia. Risk factors include female gender, breech presentation, twins, and family history. The examination includes the Barlow and Ortolani maneuvers. The Ortolani maneuver is performed as follows: the newborn lies on his back, with his feet facing the examiner. The index finger is placed on the greater trochanter, and the thumb is placed on the lesser trochanter of the femur. The first movement is by fully flexing the baby's legs at the knee and hip joints, then fully abducting the legs, while simultaneously pressing the index fingers up and inward until the knees touch the surface of the table. A click of the femoral head during abduction of the legs occurs when the dislocated femoral head returns to the acetabulum and indicates the presence of hip dysplasia.

This test may be false negative in babies under 3 months due to tight hip muscles and ligaments. If the test results are questionable or if the baby is in a high-risk group (girls in breech presentation), the baby should undergo an ultrasound examination of the hip joints at 4-6 weeks.

The neurological examination includes an assessment of the newborn's muscle tone, activity, limb movements, and reflexes. Commonly elicited reflexes of newborns include the Moro, sucking, and rooting reflexes. The Moro reflex is a newborn's response to a fright, elicited by gently spreading the baby's arms and suddenly releasing them. In response, the baby spreads his arms with straightened fingers, bends his legs at the hip joints, and cries. The rooting reflex is elicited by stroking the baby's cheek at the corner of the mouth, causing the baby to turn his head toward the irritation and open his mouth. The sucking reflex can be elicited using a pacifier or a gloved fingertip. These reflexes persist for several months after birth and are signs of normal nervous system development.

The skin of the newborn is usually bright red; cyanosis of the fingers and toes is common during the first hours of life. Birth fluid does not cover the skin of most newborns after 24 weeks of gestation. Dryness and scaling often appear after a few days, especially in the folds of the wrists and knees. Petechiae may occur in areas subject to increased stress during labor, such as the face (in labors when the face is the presenting part); however, newborns with a diffuse petechial rash should be examined for thrombocytopenia. Many newborns have manifestations of erythema toxicum, a benign rash with white or yellow papules on a reddened base. This rash, which usually appears 24 hours after birth, spreads over the body and may persist for up to 2 weeks.

Screening

Recommendations for newborn screening vary depending on clinical data and country guidelines.

Blood group determination is indicated for newborns at risk for developing hemolytic disease (risk factors include the mother's blood group O or negative Rh factor, as well as the presence of minor blood antigens).

All newborns are screened for jaundice while in the hospital and before discharge. The risk of hyperbilirubinemia is assessed based on risk criteria, bilirubin measurements, and a combination of both. Bilirubin levels can be measured in capillary blood (transdermally) or in serum. Many hospitals screen all newborns and use predictive nomograms to establish the risk of high hyperbilirubinemia. Further monitoring is based on the infant's age at discharge, bilirubin levels before discharge, and the risk of jaundice.

Many states screen for specific inherited disorders, including phenylketonuria, tyrosinemia, biotinidase deficiency, maple syrup urine disease, galactosemia, congenital adrenal hyperplasia, sickle cell anemia, and hypothyroidism. Many states also screen for cystic fibrosis, fatty acid oxidation disorders, and other organic acid metabolism disorders.

Screening for HIV infection is mandatory in some states and is otherwise recommended for children born to mothers who are HIV-positive or at high social risk for HIV infection.

Toxicology testing is indicated if there is evidence of maternal drug use, unexplained placental abruption, or unexplained premature birth; if the mother was not properly cared for during pregnancy; or if the child is showing signs of withdrawal symptoms.

Screening for hearing loss varies by state; some screen only high-risk infants, while others screen all children. Initial testing often involves using a hand-held device to measure the echo produced by the healthy ear in response to a soft click (otoacoustic emissions, or OAEs); if the test results are abnormal, testing of the response of the base of the brain to an auditory stimulus (auditory evoked potentials, or AEPs) is performed. Some clinics use the OAE test as an initial screening test. Subsequent testing by an audiologist may be necessary.

Daily care and monitoring

Newborns are bathed when their body temperature has stabilized at 37°C for 2 hours. The cord clamp can be removed when the cord is dry, usually after 24 hours. The cord should be kept clean and dry to prevent infection. Some centers use isopropyl alcohol several times a day or triple dye once, a bacteriostatic agent that reduces bacterial colonization of the cord. Because the umbilical wound is a portal of entry for infection, the umbilical area should be examined daily for redness and oozing.

High Risk Factors for Hearing Impairment in Newborns

• Birth weight < 1500 g
• Apgar score at 5 minutes < 7
• Serum bilirubin level > 22 mg/dL (> 376 μmol/L) in neonates with birth weight > 2000 g or > 17 mg/dL (> 290 μmol/L) in neonates < 2000 g
• Perinatal anoxia or hypoxia
• Neonatal sepsis or meningitis
• Craniofacial anomalies
• Seizures or periods of apnea
• Congenital infections (rubella, syphilis, herpes simplex, cytomegalovirus or toxoplasmosis)
• Maternal use of aminoglycoside antibiotics
• Family history: early hearing loss in parents or close relatives

Circumcision can be safely performed - if the family so desires - under local anesthesia during the first days of life. The procedure should be postponed if the child has anomalies of the external urethral opening, hypospadias, and other anomalies of the glans penis, this is justified by the fact that the foreskin can later be used for plastic surgery; circumcision should also not be performed if the newborn is diagnosed with hemophilia or other hemostatic disorders, if there is a family history of hemorrhagic disorders, if the mother has taken anticoagulants or aspirin.

Most newborns lose 5 to 7% of their initial body weight during the first days of life, mainly due to fluid loss (through urination, minor fluid loss through breathing), as well as due to the passage of meconium, loss of vernix caseosa, and drying of the umbilical cord stump. During the first 2 days, urine may be bright orange or pink, which is due to urate crystalluria, which is normal and occurs due to urine concentration. Most newborns urinate within 24 hours of birth; the average time for the first urination is 7 to 9 hours after birth, with most newborns urinating twice during the second day of life. Urinary retention is more common in boys and may be due to physiological phimosis; failure to urinate in newborn boys indicates a posterior urethral valve. Circumcision is usually performed after the child has urinated for the first time; failure to urinate within 12 hours of the procedure may indicate a complication. If meconium has not passed within 24 hours, the neonatologist should consider examining the newborn for gastrointestinal tract anomalies such as anal atresia, Hirschsprung's disease, pancreatic cystic fibrosis, which can lead to the development of meconium ileus.

[ 9 ], [ 10 ]

Discharge from the maternity hospital

Newborns discharged from the hospital within 48 hours should be examined within 2-3 days to assess feeding (breast or formula), hydration, jaundice (in high-risk newborns). Further monitoring of newborns discharged from the hospital within 48 hours should be based on risk factors, including risk factors for jaundice and difficulties with breastfeeding.

[ 11 ], [ 12 ], [ 13 ]