<p> Preterm -Less sub-q fat layer, transparent gelatinous ,visible ********This trans is again divided into 3 parts, first part is veins from the lecture followed by inputs from Nelsons and del Post term -Those with placental dysfunction syndrome: paler, Mundo. Enjoy sa pag aaral. dry, desquamating skin Physical Examination of the Newborn from lecture *Subcutaneous fat necrosis- associated with trauma</p><p>Placenta Wt = 500g Flat, circular disc 2-3 cm thick and 15-2cm across ▪Vermix caseosa Examine placenta to detect placental infarction, infection and - Normally covers the baby calcification Cheesy like substance seen on the new born that is for Abnormatlities of placental development - protection and for insulation - Previa – placenta is at the opening of the cervical os - Disappears after a few days but some amounts may - Succenturiate lobe – accessory lobe is present remain and removed by cotton or bath - Cirmuvalate - Do not vigorously wipe that may injure the neonate Guidelines for pathologic examinations of the placenta and cause infection to portal circulation - Fetal congenital anomaly – hydrops fetalis ▪Edema - Maternal or fetal infection – congenital Rubella - Physiologic edema may occur due to extracellular fluid - Preterm delivery during birth, but wil resolve spontaneously on the 2nd rd - Maternal disease state or 3 day Acrocyanosis - Multiply gestation ▪ - Periodic episodes of cyanosis of extremities but the - Intrauterine growth restriction – placenta with lots of trunk is pink , may be due to stress or cold infarct that Harlequin color change impedes blood flow and restrict ▪ nutrition to the baby - Transient color change with sharp demarcation from the forehead to the pubis, delineating the pale and the Umbilical Cord pinkish part of the body Length – 50 cm ▪Mottling Insertion of the cord: - Due to instability of the circulation of the NB when Marginal – at the margins exposed to cold Velamentous – at the membranes ▪Pallor and Plethora Valsa previa – cross the cervical os - May be sign of anemia in newborn 3 vessels: 2 arteries and 1 vein Single umbilical artery may indicate anomalyes in the - Plethora is the beefy red appearance of newborn like a genitor-urinary or boiled lobster. gastrointestinal tracts, skeletal, cardio, o Due to high erythrocyte/vol blood CNS etc o May also be seen in polycythemia (Hct >65%) Fetal Membrane ▪N NB: Hgb=22 - Inner (amnion) ▪Ecchymoses - Outer (chorion) - Due to pressure exerted on the baby on IE or when trying to pull out Amniotic Fluid ▪Petechiae Vol = 500-2000 ml - More common on the face Polyhydramnios - > 2000ml on 3rd trimester Associated conditions: - If generalized may signify a systemic dse GIT obstruction - If localized, due to pressure effect slike the loop of CNS abnormalities (chromosomal or structural) cord Cardiac Anomalies ▪Mongolian spot Fetal Anemia - Bluish gray pigmented areas in the buttock and back Fetomaternal hemorrhage and occasionally in extremities Blood group isoimmnization Common in Filipinos and Asians Duodenal Atresia - Twin-twin transfusion ▪Milia Maternal DM - Small whitish papule on nose Constitutional macrosomia - Made up of dilated sebaceous gland Ruptures spontaneously Oligohydramnios - < 500 ml on the 3rd trimester - Associated Conditions: ▪Hemangiomas Occult or Overt PROM (premature rupture of the - Blood-filled birthmark or benign tumor (telnagiectasia) membrane) – - Consists of closely packed small blood vessels, commonly during infancy dec in amniotic fluid - Spontaneously disappears Placental insufficiency Maternal hypertensive disease - Associated with thrombocytopenia Autoimmune condition ▪Jaundice Placental crowding - Physiologic jaundice: start in the 2nd or 3rd day of life Urinary Tract anomaly and should not ba >25mg% in term babies and not Renal agenesis >15mg% in preterms; it is not found at birth and its Uteral obstruction development during the first 24hrs should alert the Uretheral obstruction physician to any hemolytic process that needs Polycyctic or multicystic immediate attention dysplastic kidneys - rule out any incompatibilities: ABO or Rh SKIN and Subcutaneous Tissue ▪Sclerama neonatorum Term infants-Pinkish smooth and elastic skin with fair sub-q - Generalized, bilateral progressive and rapidly tissue spreading and induration and hardening of the skin</p><p>Pediatrics TransCom 2012A Kay---Giselle---Ria Page 1 - Thick waxy hard and cold, seen on the 1st week of life Congenital anomaly with abnormal small head relative to the body - During Hypothermia or infection Due to underdevelopment of the brain resulting to mental - Due to enzymatic defect that inc ration or sat or unsat retardation fat Associated with TORCH - No local theraphy, treat underlying dse Treatment: do nothing ▪Pustular Melanosis - Pustules all over the body sparing the palms and soles ▪Hydocephalus Abnormal accumulation of the CSF under increased - Collarette scale and hyperpigmentation results after pressure within the rupture cranial vault and dilation of ventricles occur - Seen at birth, resolves in 5 days, hyperpigmentation Treatment: Surgery resolves in 3 wks-3mos ▪Café-au-lait ▪Aplasia cutis congenital - Associated with neurofibromatosis Failure of the skin to develop (smooth area of skin) ▪Lanugo Hair Skin has thin row of epidermal cells very thin dermis and absent - May be present at back, shoulders, and upper arm subcutaneous fat - Fine hair…more in premature RECESSIVE trait ▪Erythema toxicum Solitary, oval or round baldness 2-3mm over posterior - Small papules top with vesicles surrounded by fontanel erythema ▪Amniotic bands Face - Can cause amputation Assymetric face may be due to the position in the utero. Eg. The jaw has been held against a shoulder or extremities, the Head mandible may deviate from midline Normal circumference is 35 cm Downs Syndrome have a typical feature that is recognizable Normal at birth HC>CC by 2-3 cm in newborn (CC=32-33cm) at birth 6 bones (frontal, occipital, 2 parietal, 2 temporals) With nerve impingement due to pressure on birth canal, Sutures: coronal, metopic, lambdoid, sagittal, squamosal there could be facial *Monitor brain growth paralysis or paresis</p><p>Fontanels: only 2 are important Dysmorphic Features Anterior – DIAMOND Epicanthal folds Size: 2x2 cm Widely spaced eyes - hypertelorism Midline at jnc of saggital and coronal Assymetry in phenytoin syndrome (Dilantin) Closes at 18 mo or early 9 mos Long philtrum – associated with fetal alcohol Posterior – TRIANGLE syndrome Between occipital and parietalbones Micrognathia – no chin Closes at birth Usually closed and non palpable after 1st -6 wk of life Eyes If persisted, consider hydrocephalus orcongenital If held up, the infant spontaneously opens his or her eyes HYPOthyrodism Conjuctival and retinal hemorrhage are usually benign and common Persistently small fontanels: suggestive of microcephaly, especially if NSVD, does not require mgt. craniosynostosis, *Retinal hemorrhage resolves mostly by 2 wks and congenital HYPERthyroidsm or WORMIAN bones in all infants by 4 wks ▪Molding Pupillary reflex – present at 20-30 weeks Babies on CS and breech have ROUND heads +ROR: means clear view up to retina with Vaginal delivery babies may have varying deg of molding no abN due to Inspect iris for colobomas and heterochromia asymmetric overlap of sutures in trying to pass thru Cornea >1cm in a FT infant w/ photophobia & tearing- the canal. congenital glaucoma This should disappear in 24hrs Cataracts: + for congenital Rubella (esp. on 1st trimester) ▪Caput succedaneum Check for anomalies associated with Galactosemia Edema with or without ecchymosis or discoloration as the and Rubella head passes Cataracts take up virus for > 1 yr; persist for >2yrs thru the cervical ring Leukoria (white papillary relfex) Disappears in few days Suggests cataracts, tumor,chorioretinitis, Borders are not well defined retinopathy, persistent hyperplastic primary vitreous Purulent Conjunctivitis ▪Cephalhematoma From subperiosteal bleeding Associated w/ Staph infection (gonorrhea)- may lead Bleeding does not cross the suture line to blindness Hematoma may increase in size Subconjuctival hemorrhage Sensation of depressed fracture due to a raised outer Secondary to difficulty in labor border Corneal Opacities Sometimes result in calcification DO NOT aspirate *******NOTE! Do a fundoscopic exam before the discharge of babies with prolonged high Oxygen to detect retinopathy of prematurity ▪Craniotabes Softening of the skull Nose Palpate for the parietal bones to elicit Note the patency of the nares on initial examination and</p><p>Sign of ricket sand Osteogenesis imperfect suctioning Should be Symmetric and patent ▪Microcephaly</p><p>Pediatrics TransCom 2012A Kay---Giselle---Ria Page 2 Anatomic obstruction of nasal passages secondary to Rales – due to remnant of lung fluid but disappears unilaterial or bilateral choanal atria results in respiratory distress ▪ PERCUSS-see Pneumothorax, pneumomediastinum & Flaring and displacement of nares – respiratory distress mediastinal shift, ▪Auscultatory findings vary in position Ears Bowel sounds in chest – Diaphragmatic hernia Low set ears – assoc with chromosomal disorder and renal anomalies Heart Preauricular skin tags – not significant Localized pulsation Amniotic fluid in ear canals –neonatal infection (3-5 while HR: 140-160/min cells in gram stain) Murmurs – maybe transitory or CHD (d/t open shunts) Tympanic membrane normally is dull gray Apex bounding Short, straight external auditory canal Pulses: brachial, radial and femoral are assessed In premature babies, manual displacement of pinna does not *Coartation of aorta = UE>LE go back BP – measured by oscillometric method (in Newborn, use Immediately (remains folded) Doppler)</p><p>Mouth /Throat Abdomen Harelip (operated 2-3mos) & cleft palate (operate >1yr to Contour: Cylindric, slightly protruding, Globular but not allow time to grow) distended Precocious teeth and supernumerary are easily pulled out, *if distended – obstruction esp when with vomiting therefore in and no meconium</p><p> danger of aspiration; (if not movable DO NOT Localized bulging – rule out tumor remove) “ Prune-belly” – congenital absence of Epstein or epithelial pearls abdominal musculature Whitish shiny cyst in palate or gum margins Scaphoid – diaphragmatic hernia--- pediatric</p><p>Disappear spontaneously after few weeks birth emergency Short Frenulum – ankyloglosia Gastroschisis: Abdominal contents OUT! Neonates DO NOT have active salivation Lateral to the midline Large tongue-HYPOthryroidism & hypoplastic mandible Umbilical hernia: m/b present but closes when musculature (Pierre-Robin syn) gets stronger Short lingual frenulum (tongue tie) restricts protrusion of Omphalocele: Large defect with the intestinal contents tongue protruding and Small tonsil – cannot be detected because it is still not amnion is the only covering; Infection is very developed likely *Stridor- laryngomalasia, disappears as infant grows -Surgical intervention is needed Liver: Palpable with edge felt at 2-3cm belowright costal arch Neck Spleen: Not easily palpable Lax or webbed neck is seen in DOWN and TURNER sundrome Kidneys: Bimanual palpation Branchial cleft cysts/sinuses – vestiges that may be seen at Other palplable mass in newborn: Renal embryoma, side of the neck hydronephrosis, Thyroglossal csts at midline Goiter with exophthalmos – hyperthyroid mother (Tx: ovarian cyst or antithyroid drugs or Io) duplication of the gut Hemorrhage of SCM may become prominent in few days after Meningomylocoele and spina bifida: Spinal cord lesion difficult birth evident at the back Treatmet: OPERATE and RELEASE Dermal sinuses at the sacral area – in pilonidal dimple Congenital torticollis – head towards, face away from affected -Tiny pore surrounded by hair and may exude white side secretion -Operate and release tension Bladder distention- catheterization or tumor Fractured clavicle – palpation of the base of the neck along Diastasis recti – separation of recti muscles clavicular area Inguinal hernia – tx: OPERATION Evident unilateral Moro Reflex Genitalia:undress the baby Chest Male Asymmetry in movement - lung or diaphragmatic pathology Size of penis and scrotum varies Intercostal/subcostal retraction indicates difficulty in Testes if not fully descended, palpable at the canal respiration hypospadias Breast hypertrophy with milk (witch’s milk) m/b present d/t Severe hypospadias or epispadias – abnormal sex sudden chromosome and infant is masculinized female with withdrawal of estrogen enlarged clitoris (Androgenital syndrome) Asymmetry, erythema, and induration with tenderness – Usually large penis with urogenital sinus – Androgenital suggests mastitis or syndrome Erection of penis is common breast abscess Hydrocele – with or without hernia is present Widely spaced nipples, shield shape chest – Turner Syndrome Supernumerary nipples Female May have mucoid non-purulent, blody vaginal discharge Lungs Breathing – diaphragmatic (Inspiration: thorax in, abdomen *blood may be secondary to estrogen withdrawal out) Hymen with prominent tags Breath – bronchovesilcular Clitoris may be large and confused with penis Normal RR – 40/min (Respiratory distress - >60/min/5min) More prominent labia minora Periodic respiration – episodes of apnea with fast respiration is NORMAL *Ambiguous genitalia- adrenal problem Urine: Usually passed during or immediately after birth: a -phasic breathing…more frequent in prematures period of non Apnea – physiologic or pathologic voiding may follow Pathologic- w/ cyanosis and bradycardia; dec PO2 for Most Void by 12 hours, 95% of preterm void within 24 >20 sec hours Grunting – a whining cry at expiration (cardiopulmonary dse or sepsis) Anus If benign resolves in 30 to 60 min</p><p>Pediatrics TransCom 2012A Kay---Giselle---Ria Page 3 Some passage of meconium is at 1st 12hr after birth *to stimulate the baby: rub the back---- cry Imperforate anus not always visible require insertion of little *once you receive the baby, you should receive with a finger/rectal tube blanket in order to dry *do not feed until treated (operate) and warm the baby- first important to do Recto vaginal fistula- stool goes out thru vagina Thermoregulation Extremities Basic Knowledge Polydactyly/syndactyly 1.Relative to the body weight, the body surface of a Club feet – transient only due to uterine position newborn in approx 3 times that of an adult. Nondevelopment of portions or extremities may occur 2.The insulating subcutaneous fat is thinner (in low—birth</p><p>Hemimelia – absent distal portion extremity ends in weight infants) stump The estimated rate of heat loss is approx 4 times that of Phocomelia – absent proximal, hand or foot seems 3. to arise from trunk and adult. Hip Dislocation – r/o ORTOLANI’s maneuver(abduction of 4.At term, the fetal metabolic processes procedure thigh with click) sufficient heat to maintain body t at higher level than the Creases: Simian – Downs syndrome mother’s. *if absent (premature); if deep (post mature) 5.Heat loss through the skin to the amniotic fluid, but Fractures – clavicular and humeral at breech delivery largely the intervillous space in the placenta. Malposition 6.Posture influence the rate of heat loss. Local deformity *premature: state of extension, inc. SA Amniotic bands Full term: state of flexion, dec SA Observe movements for any paralysis or paresis -Injury to cord if both lower extremities are Heat loss weak and paralyzed Convection-flow of heat from the body surface to cooler Palpate femoral pulse for detection of coartation of aorta surrounding air e.g. transfer of heat from body to cooler ambient air in the incubator Neurologic examination Radiation-Transfer of body heat to cooler solid surface in 1.Sontaneous movements- jerky movements the environment that are not n contact with the baby 2.Spontaneous hyperirritability and exaggerated e.g. babies placed close to windows incubator walls responses to ordinary tactile or acoustic stimuli closes to the air conditioner Evaporation-conversion of liquid to vapor Assymetry in movement: Erb’s palsy has unilateral 3. e.g. evaporation of insensible water los, sweating, Moro reflex moisture from the respiratory tract mucosa, immediate 4.Muscle tone: congenital hypotonia, wrist drop bathing when still unstable Temp 5.Reflexes Conduction- direct contact to the skin with a cooler solid object Reflex Appear Disappear e.g. placement of a naked infant in a cold table or the Moro birth 3 mos cold mattress of an unprepared incubator or drying using Complete cold blanket Incomplete *use dry warm blanket to dry baby from amniotic fluid Stepping birth 6 wks Placing birth 6 wks Heat production Sucking & rooting birth 4mos 1. Voluntary increase in skeletal muscle activity Palmar grasp birth 7 mos 2. Involuntary rhythmic contraction of skeletal muscle Plantar birth 10 mos that may be grossly impercepive but can be Abductor spread & knee jerk birth 7 mos demonstrated by electromyograms Tonic neck 2 mos 6 mos 3. Involuntary rhythmic contract that are grossly Parachute 9 mos persist visible (shivering) Neck riding 4-6 mos 6 mos 4. Non-shivering thermogenesis norepinephrine as the Care of the Newborn principal mediator Birth - Chemical thermogenesis: breakdown of brown fat Immediate newborn care 5. Heat that is produced by a metabolic rate (O2) Initial physical examination-should be performed as soon consumption that is minimal in an isothermal as possible after delivery to detect abnormalities and to environment. establish baseline for subsequent examination. 1-minute APGAR score- may signal he need for immediate Nonshivering Thermogenesis resuscitation. Sympathetic nerve endings 5-minute APGAR score (to 10 min and 20 min score)-may Release of norepinephrine indicate the probability to of a successful resuscitating an 60% increase in O2 consumption infant Stimulation of fat metabolism *low score may indicate some factor including dugs given Activation by lipase to the mother during labor and immaturity: APGAR score Breakdown of intracellular fat was not designed to predict neurologic outcome. Triglycerides Hydrolysis of triglycerides Immediate Newborn Care Glycerol and nonesterified fatty acids (NEFA) Principles Oxidation of NEFA 1.Maintenance of adequate airway-the ability to tell Production of heat whether the baby will survive or not. 2.Maintenance of body heat. Routine newborn care Principles Inverted Pyramid 1.Prevention of infection Dry, warm, position 2.Provision of adequate nutrition Oxygen- seldom Bathing Establish effective ventilation - seldom 1. careful removal of blood from the skin Chest Compression - <80/min 2. Daily bathing</p><p>Medication- rare Dry – remove vernix w/ gauze and oil (for premature)</p><p>Pediatrics TransCom 2012A Kay---Giselle---Ria Page 4 Wet i. Nipple feeding a.ii. Gavage feeding-for babies with weak suck Eye Care Crede’s prophylaxis with 1% silver nitrate (AgNO3) drops – a.Transpyloric- 15-30mins, q3hrs protection b.Intermittent or continuous- drip, 30mins against gonoccocal infections; can stain rest *O2- can cause blindness a.iii. Parenteral- big vessels/veins Other medications (peripheral) Tetracyclin 1% - not used by pediatricians; stains -high caloric feedings, essential AA teeth, affects bone - for very sick NB who needs a lot of Erythromycin – 0.5% calories Povidone iodine solution 2.5% - effective as a one- time prophylaxis Breastfeeding *Quinolone- affects cartilage Human milk is uniquely adapted to the infant’s need and is the most Cord care- reduce the incidence of skin and periumbilical appropriate for the infant colonization with </p><p> pathogenic bacteria and infections (ompahlitis) Promotion of breastfeeding and bonding Use of warm water and nonmedicated soap then 1.After birth – latching on (sucking of mother’s nipple) adequate rinsing with warm water (use sterile cotton) 2.Rooming- in- well baby nurseries; immediately after delivery baby will be given to mother Thorough washing of hands before and in between handling of neonates Legislation *Colonization- precursor of infection Rooming- in and Breastfeeding Law, Republic Act No. Infection- with s / sx ▪ 7600(1992) Other measures - Rooming in units were made to babies can be given to 1.Administration of water soluble vit K (IM) – immediately mother asap after birth to prevent hemorrhagic diseases of the newborn ▪Milk Code- no formula milk for <6mos nor are any formula (NB have low levels of Vit. K dependent factors) milk in hospital </p><p>2.Newborn screening – for some genetic, pharmacies: Baby Friendly hospitals metabolic,hematologic and endocrine disease laboratory 10 Steps to Successful Breastfeeding (WHO/UNICEF) tests performed on infant to heel puncture blood samples ******Diseases that can be seen on a newborn screening ▪ Every facility providing materniry service and care for test newborn infants should accomplish the following Congenital hypothyroidsm- may cause mental 1. Written breastfeeding policy that is routinely retardation communicated to all health care staff Phenylketonuria 2. Train health care staff in the skill necessary to Galactosemia implement this policy Maple syrup urine disease 3. Inform all the pregnanct women about the Adrenal hyperplasia- cant live w/o steroids; false (+) in benefits and management of breastfeeding LBW babies G6PD deficiency 4. Help mother initiate breatfeeding within a half hour of birth 3.Hearing Screening – all infants should be screened with 5. Show mothers how to breastfeed and how to otoacoustic emission hearing morbidity that affects maintain lactation even if they should be separated speech and language development from their infants 4.Immunization with BCG and Hepatitis – if the mother is 6. Give new born infants no food or drink other than positive, the infant should be given Ig (IM)for Hep B and a breast milk unless medically indicated course to 3 injections of vaccines before discharge and at 1 7. Practice Rooming-in 24 hours a day and 6 months of age 8. Encourage breastfeeding on demand Provision of adequate nutrition 9. Give no artificial teats or pacifier (also called Water – 75-100 ml/kg/d (150ml/kg/d) – water content of dummies or soothers) to breastfeeding infants infants is relatively 10. Foster the establishment of breastfeeding higher than of adults. Need of water are related support groups and refer mothers to them on to caloric discharge from hospital or clinic consumption CHON-2-2.2g/kg/day ▪Human Rights issues Energy: CHO: 5g/kg/day -those who refuse to breastfeed, have them sign a waiver Fats: 0.5-1.0g/kg/day Advantage of Breast milk Fat: for visual and cognitive devt. - Higher content of arachidonic and docosahexanoic Long chain polyunsaturated fatty acids (LC-PUFA) are the acid in plasma and erythrocyte most - High quality and digestibility</p><p> prevalent In the CNS - Associated with fewer feeding difficulties incident to 1.Arachidonic allergy 2.Docosahexanoic acid – 40% of the FA content of the - Great absorbability of iron through with lower level retinal photoreceptor membranes - The protein concentration in preterm milk is 20% higher Feeding – initiated as soon as after birth as possible *Do not suppress milk of mother even if premature, depending on the encourage to pump milk to be given to the baby in NICU infant’s ability to tolerated enteral nutrition Physiologic Events in the Life of Newborn 1.Breast feeding 1.Weight loss – 10% weight loss is normal in the first week 2.Formula feeing due to excretion of extravascular fluid or may be due to a.Enteral feeding – via tube poor intake BUT, it should be regained on the 2nd week and</p><p>Pediatrics TransCom 2012A Kay---Giselle---Ria Page 5 should have a growing rate of 30 g/d on the first moths of  Caput succedaneum – discoloration and edema life brought about by pressure on the scalp during the *ex. 3000g- after 24-48hrs- 2850 or 2900gms – still Normal passage of the baby’s head through cervical ring.</p><p>If 3200gms-  Cranial meningocoele – pulsating mass as a result of fluid retention problem bony defects in the skull after 10 days- regain previous bW nd rd  Facial paralysis/ paralysis due to pressure on the 2.Physiologic jaundice – can be seen on the 2 or 3 day of nerve impingement against the birth canal life, which peaks on the 4th day and should be gone by 5th – Subconjunctival haemorrhages are sometimes seen. 7th day  *Causes of jaundice  Congenital cataracts are associated with rubella - Increased bilirubin production syndrome and galactosemia. - Transient limitation in the conjugation in the liver  Ear canals are filled with amniotic fluid, and predict neonatal infection. ▪2-3d- yellowish sclera 4d-peaks  Epstein /epithelial pearls – white shiny cysts seen in the palate and gum margins 2 wks – no jaundice  High palatine arch often related to small head and ▪Basically 3 problems: Defect in metabolism mental retardation. Problem in excretion Increase production  Pierre-Robin syndrome – hypoplastic mandible of a baby whose tongue may be enlarged 3.Anemia – seen on the 8th – 12th week of life and could be from 9 -11 g/dl  Tongue tie – short lingual frenulum which may restrict tongue protrusion *Cause: suppression of erythropoiesis with low erythropoietin  Craniotabes – soft areas upon palpation of parietal bones, with a sensation of a “pingpong” ball when Discharge and Follow Up pressed. Discharge-no medical problem . If the persist beyond infancy, a Feeding well sign of rickets and osteogenesis Follow up- 2 wks post discharge imperfect Whenever develops problem Neck  Frequent site of cystic hygromas, which appear as Physical Examination of the Newborn from del Mundo fluctant masses on the lateral side and reach the **Measure weight, length, circumference of the head, chest, axilla and scapular region. abdomen, cardiac respiratory rates, blood pressure and  Webbing of the neck (Laxity)- seen in Down/ temperature. Turner’s Sydnrome  Vestiges of branchial clefts are seen at the lateral Umbilical vessels and placenta side of the neck.  Detect infection, placental infarction and  Sternocleidomastoid hematomas – felt along the calcifications. muscle which becomes more prominent a few days after birth Skin  Palpation of the base of the neck will detect any  Term infant –pinkish, smooth and elastic fracture of the bone. o Preterm infant – almost transparent; Post term infant – pale, dry, desquamating Chest  Vernix caseosa – covering of skin  Note size, shape and movement of chest. o Stained yellow, protects skin of fetus from  Pressure on the mammary glands may show witch’s maceration milk. o Disappears after a few days  Difficulty in respiration will produce retraction of the  Lanugo hair may be present in back, shoulders and chest and sternum. upper arms  Respiration is diaphragmatic (40 per min at rest).  Plethora – pallor is noted for early recognition of  Percussion of the lungs may detect pneumothorax, anemia pneumomediastinum and mediastinal shifts.  Acrocyanosis – periodic episodes of cyanosis of  Bowel sounds in the chest suggests diaphragmatic fingertips and toes (due to cold stress or poor hernia. perfusion)  Position of the heart is ascertained by auscultation.  Harlequin color change – sharp line demarcation in Cardiac murmurs after birth are not clinically midline of the whole body separating a red from a  pale half significant.  Mottling of skin – body is exposed to cold due to  Sinus arrhythmia is common in preterm infants. instability of circulation  Heart rate – 120-140 per min  Mongolian spots – bluish gray pigmented areas in o Rapid rate: respiratory distress syndrome or the buttocks and back, with no clinical significance cardiac failure  Milia – small whitish papules, made up of sebaceous o Slow rate: congenital heart block, hypoxia, glands which cover the nose intracranial hemorrhage  Erythema toxicum – skin lesion represented by small Abdomen papules topped by a vesicle at the tip  Abdomen is globular, but not distended. Head  Diastases recti - separation of recti muscles in  Babies bors by CS or breech extraction have newborn rounded heads.  Small umbilical hernia may be present but closes in  Small fontanels are associated with a small head, 3 years. microcephaly or craniosynostosis.  Omphalocoele – large hernia, with protruding  A tense fontanel may be a sign of increased intestinal contents, covered only by amnion. intracranial pressure.  Liver is palpable, felt 2-3 cm below right costal arch.  Bimanual palpation of kidneys must be done.</p><p>Pediatrics TransCom 2012A Kay---Giselle---Ria Page 6  Meningomylocoele and Spina bifida – spinal cord - Performed as soon as possible after delivery to lesion evident at the back detect abnormalities and to establish baseline  Pilonidial dimple – dermal sinuses at the sacral area - Infants should have temperature, pulse, RR, color, -surrounded by hair and exudes type of respiration, tone, activity and level of whitish secretion consciousness monitored every 30 min after birth for 2 hr or until stabilized Genitalia - For high risk deliveries – exam should take place in  Female the delivery room and focused on congenital o may show a mucoid non-purulent or anomalies and pathophysiologic problems which may interfere with normal cardiopulmonary sometimes bloody discharge and metabolic adaptation o Hymen have prominent tags - After a stable delivery room course, a second and Clitoris may be large o more detailed examination should be performed o Labia minora is more prominent within 24hr of birth  Male - If infant remains longer than 48 hr, a discharge o Palpable testes, and may not have fully examination should be performed w/in 24hr of descended discharge o Hydrocoeles may be present - Final examination should be done before discharge o Large penis w/a urogenital sinus is of infant because certain abnormalities such as associated with adrenogenital syndrome heart murmurs appear and disappear in the immediate neonatal period Musculo-Skeletal o PR (normal = 120 to 160 beats per min)  Club feet – transient, and is due to the uterine o RR (normal = 30 to 60 breaths per min) position of the fetus o Temp  Hemimelia – distal portions of the extremities are o Weight absent (ends in a stump) o Length  Phocomelia – proximal portions of the extremities o HC are absent o Dimensions of nay visible or palpable  Injury to the cord is suspected when both lower structural abnormality extremities are weak. o BP determined if neonate is ill or has heart  Palpation of the femoral pulse is done to detect murmurs coarctation of the aorta. 2. Physical Examination  Moro, rooting and sucking reflexes must be elicited. GENERAL APPEARANCE  Creases of palms and soles should be examined. - Look for active and passive muscle tone and any o Simian crease – seen in Down Syndrome unusual posture  Ortolani’s maneuver o To rule out hip dislocation Findings Associated conditions o Done by abducting the thigh and hearing a Absent physical activity Relaxation of normal sleep click Decreased physical activity Effects of illness or drugs Lying w/ extremities Conserve energy for effort of Care of the Newborn motionless difficult breathing  Vit.K (Phytomenadione) – at 1 mg IM for FT, and 0.5 Vigorously crying w/ Conserve energy for effort of activity of arms and legs difficult breathing mg in PT is given to prevent prothrombin deficiency. Coarse tremulous Common and less significant High doses of synthetic Vit.K – cause o movements with ankle or in newborn infants; when hemolysis and hyperbilirubinmeia jaw myoclonus infant is active o Oral Vit.K – prevent hemorrhagic diseases Convulsive twitching Occur in quiet state  Eyes Superficial appearance of Edema o Protected with an antibiotic ophthalmic good treatment nutrition o Erythromycin Skin of fingers and toes lacks  Temperature normal fine wrinkles o Taken per rectum or axilla every 4 hours Edema of eyelids Silver Nitrate until stabilized and then every 8 hours Generalized edema Prematurity, hypoproteinemia after. 2o to erythroblastosis fetalis, o After initial rectal temperature, following nonimmune hydrops, readings must be done by axilla because of congenital nephrosis, Hurler the danger of accidental rectal perforation syndrome, unknown cause by thermometer. Localized edema Congenital malformation of  Breastfeeding lymphatic system o Started as soon as the baby can suck. Edema confined to 1 or Turner syndrome o Early feeding (3-6 hours of age) is more extremities in female infant advocated for SGA, premature and LGA infants of diabetic mothers. *note: gray area is the normal finding  Skin SKIN o Cleansed using mild soap and water and Findings Associated conditions povidine-iodine applied to the cord and Deep redness or purple Vasomotor instability & umbilical area lividity in crying infant color peripheral circulatory o Sterile cord dressing is used may darken w/ closure of sluggishness ------glottis prior to a vigorous cry ------Harmless cyanosis of hands Acrocyanosis Physical Examination of the Newborn from Nelson and feet when cool Mottling General circulatory PE of Newborn instability – serious illness or 1. Initial Examination transient fluctuation in skin </p><p>Pediatrics TransCom 2012A Kay---Giselle---Ria Page 7 temp - Suture lines, size & fullness of anterior and posterior Harlequin color change – Transient harmless condition fontanels should be determined digitally by division from forehead to palpation pubis into red & pale halves - Great variation in size of fontanels exist at birth Significant cyanosis may be Circulatory failure, anemia o Anterior fontanel tend to enlarge during 1st masked by pallor few months of life Appearance of cyanosis High Hb content of 1st few Findings Associated conditions days & thin skin Molded Infant is firstborn, head has Blanching pallor occurring Localized cyanosis been engaged for a after pressure differentiated from considerable time ecchymosis Parietal bones override Normal neonate Pallor Asphyxia, anemia, shock, occipital & frontal bones edema Rounded head Infant born by cesarean Early recognition of anemia Diagnosis of erythroblastosis section or breech fetalis, subcapsular presentation hematoma of liver or spleen, Premature fusion of sutures Cranial synostosis subdural hemorrhage, fetal- identified by hard non- maternal or twin-twin movable ridge over suture; transfusion abnormally shaped skull Paler and thicker skin Postmature infants Persistently small fontanels Microcephaly, Ruddy red appearance of Polycythemia craniosynostosis, congenital plethora hyperthyroidism, wormian Large deep blue masses Cavernous hemangiomas bones which may trap platelets Presence of 3rd fontanel Trisomy 21, found in preterm and produce DIC infants Scattered petechiae on scalp After difficult delivery Soft areas found in parietal Craniotabes or face bones at vertex near sagittal Common in premature Slate-blue well-demarcated Mongolian spots suture infants & infants exposed to areas of pigmentation on uterine compression buttocks, backs; disappear Soft areas in occipital region Irregular calcification by w/in 1st year Wormian bone formation Osteogenesis imperfecta, Vernix, skin and cord are Amniotic fluid has been cleidocranial dysostosis, stained brownish yellow colored by passage of lacunar skull, cretinism, meconium at birth Down syndrome Thin, delicate and tends to Skin of premature infants Excessively large head: Hydrocephaly, storage be deep red Megalencephaly disease, achondroplasia, Skin is almost gelatinous Skin of extremely premature cerebral gigantism, and bleeds and bruises infants neurocutaneous syndromes, easily inborn errors of metab, Fine, soft, immature hair, Premature infants familial lanugo – covers scalp and Hydrocephaly because of Skull of premature infant brow relatively larger brain growth Lanugo has been lost or Term infants compared to other organs replaced by vellus hair Depression of skull – Prenatal onset from Tufts of hair over Occult spina bifida, sinus indentation, fracture, ping- prolonged focal pressure by lumbosacral spine tract or tumor pong ball deformity bony pelvis Nails are rudimentary Premature infants Atrophic or alopecic scalp Aplasia cutis congenital can Nails protrude beyond Post-term infants areas be sporadic or autosomal fingertips dominant, assoc. w/ trisomy Peeling parchment-like skin Post-term infants 13, chromosome 4 deletion, Severe degree of peeling Ichthyosis congenital Johanson-Blizzard syndrome Small, white Normal neonates Deformational plagiocephaly D/t in utero positioning vesiculopustular papules on – asymmetric skull w/ ear forces on the skull; torticollis erythematous base w/c malalignment & vertex positioning develop 1-3 days after birth Benign rash persisting for 1 Erythema toxicum FACE wk contains eosinophils; Findings Associated conditions distributed on face, trunk Dysmorphic features – Congenital syndromes and extremities epicanthal folds, widely or Benign lesion in black Pustular melanosis narrowly spaced eyes, neonates contains, present microphthalmos, asymmetry, at birth as vesiculopustular long philtrum and low-set eruption around chin, neck, ears back, extremities, palms or Face may be asymmetric 7th nerve palsy, hypoplasia of soles; lasts 2-3 days depressor muscle at angle of Dangerous vesicular Herpes Simplex Virus, mouth, abnormal fetal eruptions Staphylococcal disease of posture skin Mandible may deviate from Jaw has been held against a Excessive skin fragility, Ehler-Danlos syndrome, midline shoulder or extremity during extensibility w/ joint Marfan syndrome, intrauterine period hypermobility congenital contractural Symmetrical palsy Absence of hypoplasia of 7th arachnodactyly or other nerve nucleus – Mobius disorders of collagen syndrome synthesis Eyes SKULL Findings Associated conditions - All infants should have their head circumference Eyes open spontaneously Patient is held up & tipped charted gently forward and backward (result of labyrinthine & neck reflexes)</p><p>Pediatrics TransCom 2012A Kay---Giselle---Ria Page 8 Conjunctival & retinal Benign Marble-sized buccal mass D/t benign idiopathic fat hemorrhages (resolve by 2-4 necrosis wks of age) Small tonsils Normal Retinal hemorrhages More common in vacuum- assisted deliveries than NECK cesarean section - Both clavicles should be palpated for fractures Pupillary reflexes present Normal newborn Findings Associated conditions after 28-30 wk of gestation Short neck Normal Iris inspected for colobomas Abnormalities: goiter, cystic D/t fixed positioning in utero & heterochromia hygroma, branchial cleft producing hematoma or Cornea > 1cm in diameter in Congenital glaucoma rests, teratoma, fibrosis term infant (w/ photophobia hemangioma, lesions of & tearing) sternocleidomastoid muscle Presence of bilateral red Absence of cataracts & Head turn toward & face turn Congenital torticollis reflexes intraocular pathology away from affected side; if Leukokoria – white papillary Cataracts, tumor, untreated may develop into reflex chorioretinitis, retinopathy of plagiocephaly, facial prematurity, persistent asymmetry and hyperplastic primary vitreous hemihypoplasia Redundant skin or webbing in Intrauterine lymphedema, Ears female infant Turner syndrome Findings Associated conditions CHEST Deformities of pinnae Occasionally seen in Findings Associated normal newborn conditions Unilateral or bilateral preauricular Occur frequently in Breast hypertrophy Common in newborn skin tags normal newborn Milk may be present Common in newborn Tympanic membrane – short, Normal newborn Asymmetry, erythema, induration & Mastitis, breast straight external auditory canal tenderness abscess appears dark gray Supernumerary nipples Common Inverted nipples Common Nose Widely-spaced nipples w/ shield- Turner syndrome Findings Associated conditions shaped chest Slightly obstructed by Normal newborn mucus accumulated in LUNGS narrow nostrils - Respiratory rate should be counted for a full minute Nares are symmetric and Normal newborn w/ infant in the resting state or asleep patent Asymmetric nares Dislocation of nasal cartilage - Usual rate for normal term infants = 30-40/min from vomerian groove Findings Associated conditions Respiratory distress D/t anatomic obstruction of nasal Variations in rate & rhythm of Fluctuate according to passages 2o to unilateral or breathing infant’s physical activity, bilateral choanal atresia state of wakefulness, presence of crying Mouth RR is higher & fluctuates more Premature infants widely - The soft and hard palate should be inspected and Rate consistently >60/min Pulmonary, cardiac, palpated for a complete or submucosal cleft during periods of regular metabolic disease (acidosis) - Contour is noted if the arch is excessively high or breathing uvula is bifid Cheyne-Stokes rhythm – Premature infant - The throat of newborn is hard to see d/t low arch of periodic respiration or with the palate complete irregularity - Look for posterior palatal or uvular clefts Irregular gasping accompanied There is serious impairment Findings Associated conditions by spasmodic movements of of respiratory centers Rare occurrence of Normal newborn mouth & chin precocious dentition w/ natal Diaphragmatic breathing – Newborn infant or neonatal teeth in lower during inspiration the soft front incisor position of thorax is drawn inward while With occurrence of Ellis-van Creveld, abdomen protrudes precocious dentition Hallermann-Streiff syndromes Labored respiration w/ Respiratory distress Unusual occurrence of Normal newborn retractions syndrome, pneumonia, premature eruption of anomalies, mechanical deciduous teeth disturbance of lungs Epstein pearls - Hard palate Weak persistent or intermittent Signify serious may have temporary groaning, whining cry or cardiopulmonary disease or accumulations of epithelial grunting upon expiration sepsis cells Grunting resolves between 30 Benign condition Clusters of small white or Normal newborn (2nd – 3rd day and 60 min after birth yellow follicles or ulcers on of life) Flaring of alae nasi, retraction Pulmonary pathology erythematous base found on of intercostals muscle and anterior tonsillar pillars sternum No active salivation Normal neonates Bronchovesicular breath Normal Tongue appears large Normal sounds Frenulum may be short Normal Diminished breath sounds, Pulmonary pathology Too short frenulum Tongue-tied, ankylogossia rales, retractions, cyanosis verified by chest radiograph Sublingual mucous Normal membrane forms prominent HEART fold - There is normal variation in the size & shape of the Cheeks are full on both Normal, accumulation of fat chest making it difficult to estimate the size of the buccal and external aspect to make up the sucking pads heart</p><p>Pediatrics TransCom 2012A Kay---Giselle---Ria Page 9 - Location of heart should be determined to detect Single umbilical Occult renal anomaly dextrocardia artery Findings Associated conditions Transitory murmurs A closing ductus GENITALS arteriousus - The genitals & mammary glands normally respond Pulse may vary from 90/min in Normal to transplacentally acquired maternal hormones relaxed sleep to 180/min during producing enlargement & secretion of the breast in activity both sexes Suprventricular tachycardia Determined better on a - Also there is prominence of female genitals w/ >220/min cardiac monitor or ECG nonpurulent discharge Resting HR of 140-150/min then Premature infant Findings Associated conditions sudden onset of sinus Lower abdominal mass, Imperforate hymen bradycardia hydrometrocolpos Pulses are palpated in the upper Detect coarctation of Large scrotum Normal at term and lower extremities aorta Size of scrotum may be D/t trauma of breech Blood pressure (taken by Diagnositc aid in ill infants increased delivery or by transitory oscillometric method) hydrocele Testes in the scrotum or Normal term infants ABDOMEN palpable in the canals Findings Associated conditions Prepuce is normally tight & Normal newborn infant Liver is palpable Common adherent 2cm below rib Severe hypospadias or Abnormal sex chromosomes margin epispadias Tip of spleen may Less common masculinized female w/ Adrenogenital syndrome be felt enlarged clitoris Approximate size & Normal Erection of penis Common & has no location of kidney significance determined by deep Urine passed during or Normal palpation immediately after birth Amount of air in GIT Normal Period w/o voiding follow Normal vary greatly Most void by 12 hr Normal Gas normally Normal Voiding w/in 24 hr Preterm and term infants present in rectum on ANUS roentgenogramby Findings Associated conditions 24 hr of age Passage of meconium Normal Abdominal wall Normal occurring w/in 1st 12-48 hrs weak after birth Diastasis recti, Common particularly among black Imperforate anus – gentle Pathologic, not always visible umbilical hernias infants insertion of little finger or a Unusual masses Investigated immediately by rectal tube ultrasonography Dimpling or irregular skinfold Normal but may be mistaken Renal pathology in the sacrococcygeal for an actual or potential Cystic abdominal Hydronephrosis, multicystic- midline neurocutaneous sinus masses dysplastic kidneys, adrenal hemorrhage, hydrometrocolpos, EXTREMITIES intestinal duplication; choledochal, Findings Associated conditions ovarian, omental or pancreatic cysts Observe extremities in For suspicion of a fracture or Solid masses Neuroblastoma, congenital spontaneous or stimulated nerve injury assoc. w/ delivery mesoblastic nephroma, activity hepatoblastoma, teratoma Hands and feet Examined for polydactyly, Solid flank mass Renal vein thrombosis which become syndactyly clinically apparent w/ hematuria, Abnormal dermatoglyphic Simian crease hypertension and thrombocytopenia patterns Also assoc w/ polycythemia, Hips of all infants Examined w/ specific dehydration, diabetic mothers, maneuvers to r/o congenital asphyxia, sepsis, nephrosis & dislocation hypercoagulable states Abdominal Obstruction or perforation of GIT NEUROLOGIC EXAMINATION distention often as a result of meconium ileus Findings Associated Later distention Lower bowel obstruction, sepsis & conditions peritonitis Limited fetal motion constellation of Utero neuromuscular Scaphoid abdomen Diaphragmatic hernia S/S independent of specific disease diseases Omphaloceles Abdominal wall defects when Severe positional deformation & Arthrogryposis occurring through umbilicus contractures Assoc w/ Beckwith-Wiedemann, Breech presentation, Neuromuscular conjoined twins,trisomy 18, polyhydramnios, failure to breathe diseases meningomyelocele, & imperforate at birth, pulmonary hypoplasia, anus dislocated hips, undescended Gastroschisis Defect occurs lateral to midline testes, thin ribs & clubfoot Acute local Omphalitis inflammation of 3. Routine Delivery Room Care periumbilical tissue Low-risk infants – initially be placed head downward after extend to abdominal delivery wall, peritoneum & umbilical vein and - Purpose of this is to clear the mouth, pharynx, and portal vessels, liver nose of fluid, mucus, blood & amniotic debris by Umbilical cord has Normal gravity two arteries & one - Gentle suction w/ bulb syringe or soft rubber vein catheter may be employed as well</p><p>Pediatrics TransCom 2012A Kay---Giselle---Ria Page 10 - The umbilical cord can be treated daily with Cesarean delivered infants – stomach may contain more fluid bactericidal or antimicrobial agents (triple dye or - Needs to be emptied by gastric tube to prevent bacitracin) to reduce colonization w/ Staphylococcus aspiration of gastric contents aureus & other pathogenic bacteria - Naso or orograstric tube placement is potentially - One application of triple dye followed by twice-daily noxious stimulus predisposing the infant to future alcohol swabbing reduces colonization, exudates, poor experiences with pain and foul odor of the umbilicus - An alternative is chlorhexidine washing or a single Healthy infants – given directly to their mothers for hexachlorophene bath immediate bonding & nursing w/o suctioning - If respiratory distress is a concern, infants placed OTHER MEASURES under warmer w/ the head dependent - The eyes of all infants must be protected against gonococcal infection by instilling 1% silver nitrate Review of APGAR SCORE drops - Practical method of systematically assessing - Erythromycin (0.5%) and tetracycline (1.0%) sterile newborn infants immediately after birth ophthalmic ointments are alternative measures that - Purpose is to help identify those requiring add coverage against chlamydia resuscitation and to predict survival in the neonatal - Povidone-iodine (2.5% sol’n) may be effective as a period one-time prophylactic agent - One (1)-min Apgar score signals the need for - Intramuscular injection of 1 mg of water soluble immediate resuscitation vitamin K1 (phytonadione) is recommended for all - Low score may be due to numerous factors including infants after birth to prevent hemorrhagic disease of drugs taken by the mother during labor the newborn - Take note: Apgar score is not designed to predict - Higher dose, repeated administration of oral vitamin neurologic outcome K may be useful - The Apgar score & umbilical artery blood pH both - Neonatal screening is available for various genetic, predict neonatal death metabolic, hematologic and endocrine diseases - Laboratory tests performed on infant heel ppuncture MAINTENANCE OF BODY HEAT blood samples include those for hypothyroidism, - The body surface area of a newborn infant is approx. phenylketonuria, galactosemia, maple syrup urine 3x that of an adult disease, homocystinuria, biotinidase deficiency, - Low birth weight infants have thinner insulating adrenal hyperplasia, hemoglobinopathy, cystic layer of subcutaneous fat fibrosis, tyrosinemia & other organinc acid defects or - The estimated rate of heat loss in a newborn is aminoacidopathies approx. 4x that of adult 4. Nursery Care - Under usual delivery room conditions, an infant’s - Non-high-risk healthy infants may be taken to the skin temp falls approx. 0.3oC/min and deep body “regular” newborn nursery or be placed in the temp decreases approx. 0.1oC/min during period mother’s room (rooming-in) immediately after delivery The bassinet preferably of clear plastic to allow for - So there is a cumulative loss of 2-3oC in deep body - easy visibility and care should be cleaned frequently temp The clothing and bedding should be minimal only - This heat loss occurs via: - that needed for infant’s comfort o Convection of heat energy to the cooler The nursery temp should be kept at approx. 24oC surrounding air - Conduction of heat to the colder materials - The infant’s temp should be taken by axillary o st on w/c the infant is resting measurement – not shorter than 4 hr during the 1 2-3 days and 8 hr thereafter Heat radiation from the infant to other o o nearby cooler solid objects - Axillary temps of 36.4 – 37 C are within normal o Evaporation from moist skin & lungs range - Weighing at birth and daily thereafter is sufficient - Metabolic acidosis hypoxemia, hypoglycemia & increased renal excretion of water and solutes may - Healthy infants should be placed supine to reduce develop in term infants exposed to cold after birth risk of sudden infant death syndrome - Heat production is augmented by increasing the - Vernix is spontaneously shed w/in 2-3 days</p><p> metabolic rate & O2 consumption by releasing NE - Diaper should be checked before and after feeding  nonshivering thermogenesis  oxidation of and when the baby cries brown fat - Diapers must be changed when wet or soiled - Muscular activity may increase - Meconium or fecees should be cleansed from the - After labor & vaginal delivery, many newborns have buttocks w/ sterile cotton moistened w/ sterile water mild to moderate metabolic acidosis for w/c they - The foreskin of male infant should not be retracted may compensate by hyperventilating - Early discharge (<48 hr) or very early discharge - Hypoglycemic or hypoxic infants cannot increase (<24 hr) may increase the risk of rehospitalization their O2 consumption when exposed to a cold for hyperbilirubinemia, sepsis, failure to thrive, environment and their central temp decreases dehydration and missed congenital anomalies - TO reduce heat loss, infants must be DRIED and - Early discharge requires careful ambulatory follow- either wrapped in blankets or placed under a up at home or in the office w/in 48 hr warmer - Skin to skin contact w/ mother is the optimal method 5. Parent-infant bonding to maintain temperature in the stable newborn - Normal infant development depends on a series of affectionate responses exchanged between a ANTSEPTIC SKIN & CORD CARE mother and her newborn infant binding them - Careful removal of blood from skin after birth together psychologically and physiologically reduces the risk of infection w/ blood-borne agents - The attachment process is initiated before birth with - Once temp is stabilized, the entire skin & cord the planning and confirmation of the pregnancy and should be cleansed w/ warm water or mild non- with the growing acceptance of the fetus as an medicated soap solution and rinsed with water individual</p><p>Pediatrics TransCom 2012A Kay---Giselle---Ria Page 11 - After delivery, sensory and physical contact between the mother & baby triggers various mutually rewarding and pleasurable interactions (i.e. mother touching infant’s extremities and face w/ fingertips) - Touching an infant’s cheek elicits responsive turning toward the mother’s face or toward the breast w/ nuzzling & licking of the nipple – stimulus for prolactin secretion - An infant’s crying elicits maternal response of touching the infant and speaking in a soft, soothing, higher-toned voice - Initial contact between the mother and infant should take place in the delivery room - Extended intimate contact should be provided within the 1st hours after birth</p><p>NURSERIES & BREASTFEEDING - The Baby Friendly Hospital Initiative is a global effort sponsored by WHO and UNICEF to promote breastfeeding (10 steps to successful breastfeeding) - Hospital practices encouraging successful breastfeeding include: o Immediate postpartum mother-infant contact w/ suckling, rooming-in, demand feeding, inclusion of fathers in prenatal breastfeeding education o Nursing at least 5 min at each breast is reasonable and allows a baby to obtain most of the available breast contents & provides effective stimulation f or increasing the milk supply o Nursing episodes such be extended according to the comfort and desire of the mother and infant o A confident relaxed mother supported by an encouraging home and hospital environment is likely to nurse well</p><p>DRUGS & BREASTFEEDING - Maternal medications may affect production and safety of breastmilk - Most commonly used medications are safe, the safety of any drug to be used while a woman is nursing must be confirmed - Maternal sedatives may result in sedation of the infant - Maternal drugs that are weak acids, composed of large molecules, plasma bound or poorly absorbed from the maternal or neonatal intestine are less likely to affect a neonate - When fresh breastmilk is fed by tube or bottle, bacteriologic evaluation of stored milk should be performed w/in 24 hr - Medical contraindications to breastfeeding include HIV, human T-cell leukemia virus types 1 and 2, CMV, active TB (until approp. Treated >2 wks and not considered contagious), and hepatitis B virus (until infant receives hepatitis B immune globulin and vaccine) </p><p>Shoutouts:  Hi sa aking ever lovable med groupmates – Seestur Joy, Pia, Tin, Manny, Ivan, Lance, Ram, Kay ann, Pau pau, Aldrin at Armin  Hello sa aking happy pedia group – Unica, Fao, Lea, Ethel, Elaine, Nice, Rvin, Kirsten, Armin, Seestur Joy at Gissle (may nakalimutan ba ako?)  Hi kina Yoj, Nizh, Gayle at Goldie (sana mabasa nyo ito!)  Nakakamiss na ang Chorva!  Good luck and God bless sa exam</p><p>Pediatrics TransCom 2012A Kay---Giselle---Ria Page 12</p>