Neonatal



Neonatal





Neonatal flow algorithm




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Medications for neonatal resuscitation

The American Heart Association and the American Academy of Pediatrics recommend you refer to this chart before giving medications for resuscitating neonates.

















Medication Concentration to administer Dosage and route Rate and precautions
Epinephrine

  • 1:10,000 (0.1 mg/ml) for I.V. or ET route

  • 0.01 to 0.03 mg/ kg (0.1 up to 0.3 ml/kg)
  • I.V. route is preferred

  • Give rapidly
  • Up to 0.1 mg/kg through ET tube may be given but only while I.V. access is being obtained.
Volume expanders

  • Lactated Ringer’s solution (isotonic crystalloid)

  • 10 ml/kg
  • I.V.

  • Avoid giving too rapidly to a preterm neonate (may be associated with intraventricular hemorrhage)



Physiology of the neonate









































Body system Physiology after birth
Cardiovascular

  • Functional closure of fetal shunts occurs.
  • Transition from fetal to postnatal circulation occurs.
Respiratory

  • Onset of breathing occurs as air replaces the fluid that filled the lungs before birth.
Renal

  • System doesn’t mature fully until after the first year of life; fluid imbalances may occur.
GI

  • System continues to develop.
  • Uncoordinated peristalsis of the esophagus occurs.
  • The neonate has a limited ability to digest fats.
Thermogenic

  • The neonate is susceptible to rapid heat loss because of acute change in environment and thin layer of subcutaneous fat.
  • Nonshivering thermogenesis occurs.
  • The presence of brown fat (more in mature neonate; less in preterm neonate) warms the neonate by increasing heat production.
Immune

  • The inflammatory response of the tissues to localize infection is immature.
Hematopoietic

  • Coagulation time is prolonged.
Neurologic

  • Presence of primitive reflexes and time in which they appear and disappear indicate the maturity of the developing nervous system.
Hepatic

  • The neonate may demonstrate jaundice.
Integumentary

  • The epidermis and dermis are thin and bound loosely to each other.
  • Sebaceous glands are active.
Musculoskeletal

  • More cartilage is present than ossified bone.
Reproductive

  • Females may have a mucoid vaginal discharge and pseudomenstruation due to maternal estrogen levels.
  • Small, white, firm cysts called epithelial pearls may be visible at the tip of the prepuce.
  • The scrotum may be edematous if the neonate is presented in the breech position.



Neonatal assessment


Initial neonatal assessment



  • Ensure a proper airway via suctioning.


  • Administer oxygen as needed.


  • Dry the neonate under the warmer.


  • Keep the neonate’s head lower than his trunk to promote drainage of secretions.


  • Help determine the Apgar score.


  • Apply a cord clamp and monitor the neonate for abnormal bleeding from the cord.


  • Analyze the umbilical cord. (Two arteries and one vein should be apparent.)


  • Observe the neonate for voiding and meconium.


  • Assess the neonate for gross abnormalities and signs of suspected abnormalities.


  • Continue to assess the neonate by using the Apgar score criteria, even after the 5-minute score is received.


  • Obtain clear footprints and fingerprints.


  • Apply identification bands with matching numbers to the mother (one band) and neonate (two bands) before they leave the delivery room.


  • Promote bonding between the mother and neonate.


  • Review maternal prenatal and intrapartal data to determine factors that might impact neonatal well-being.


Ongoing assessment



  • Assess the neonate’s vital signs.


  • Measure and record blood pressure.


  • Measure and record the neonate’s size and weight.


  • Complete a gestational age assessment, if indicated.


Categorizing gestational age



  • Preterm neonate—Less than 37 weeks’ gestation


  • Term neonate—37 to 42 weeks’ gestation


  • Postterm neonate—Greater than or equal to 42 weeks’ gestation



Recording the Apgar score

Use this chart to determine the neonatal Apgar score after birth. For each category listed, assign a score of 0 to 2, as shown. A total score of 7 or higher indicates that the neonate is in good condition; 4 to 6, fair condition (the neonate may have moderate central nervous system depression, muscle flaccidity, cyanosis, and poor respirations); 0 to 3, danger (the neonate needs immediate resuscitation, as ordered). Each component should be assessed at 1, 5, 10, 15, and 20 minutes after delivery, as necessary.





































Sign     Apgar score
  0 1 2
Heart rate Absent Less than 100 beats/minute More than 100 beats/minute
Respiratory effort Absent Slow, irregular Good crying
Muscle tone Flaccid Some flexion and resistance to extension of extremities Active motion
Reflex irritability No response Grimace or weak cry Vigorous cry
Color Pallor, cyanosis Pink body, blue extremities Completely pink


Normal neonatal vital signs


Respiration



  • 30 to 50 breaths/minute


Temperature



  • Rectal: 96° to 99.5° F (35.6° to 37.5° C)


  • Axillary: 97.5° to 99° F (36.4° to 37.2° C)


Heart rate (apical)



  • 110 to 160 beats/minute


Blood pressure



  • Systolic: 60 to 80 mm Hg


  • Diastolic: 40 to 50 mm Hg


Counting neonatal respirations



  • Observe abdominal excursions rather than chest excursions.


  • Auscultate the chest.


  • Place the stethoscope in front of the mouth and nares.



Average neonatal size and weight


Size

Average initial anthropometric ranges are:



  • head circumference—13″ to 14″ (33 to 35.5 cm)


  • chest circumference—12″ to 13″ (30.5 to 33 cm)


  • head to heel—18″ to 21″ (46 to 53 cm)


  • weight—2,500 to 4,000 g (5 lb, 8 oz to 8 lb, 13 oz).


Birth weight



  • Normal birth weight: 2,500 g (5 lb, 8 oz) or greater


  • Low birth weight: Between 1,500 g (3 lb, 5 oz) and 2,499 g


  • Very low birth weight: Between 1,000 g (2 lb, 3 oz) and 1,499 g


  • Extremely low birth weight: Less than 1,000 g


Preventing heat loss

Follow these steps to prevent heat loss in the neonate.


Conduction



  • Preheat the radiant warmer bed and linen.


  • Warm stethoscopes and other instruments before use.


  • Before weighing the neonate, pad the scale with a paper towel or a preweighed, warmed sheet.


Convection



  • Place the neonate’s bed out of a direct line with an open window, fan, or air-conditioning vent.


Evaporation



  • Dry the neonate immediately after delivery.


  • When bathing, expose only one body part at a time; wash each part thoroughly, and then dry it immediately.


Radiation



  • Keep the neonate and examining tables away from outside windows and air conditioners.



Neurologic assessment

Normal neonates display various reflexes. Abnormalities are indicated by absence, asymmetry, persistence, or weakness in these reflexes:



  • sucking—begins when a nipple is placed in the neonate’s mouth


  • Moro’s reflex—when the neo-nate is lifted above the bassinet and suddenly lowered, his arms and legs symmetrically extend and then abduct while his thumb and forefinger spread to form a “C”


  • rooting—when the neonate’s cheek is stroked, he turns his head in the direction of the stroke


  • tonic neck (fencing position)— when the neonate’s head is turned while he’s lying in a su-pine position, his extremities on the same side straighten and those on the opposite side flex


  • Babinski’s reflex—when the sole on the side of the neonate’s small toe is stroked, toes fan upward


  • grasping—when a finger is placed in each of the neonate’s hands, his fingers grasp tightly enough that he can be pulled to a sitting position


  • stepping—when the neonate is held upright with his feet touching a flat surface, he responds with dancing or stepping movements.


Common skin findings

The term neonate has beefy red skin for a few hours after birth before it turns its normal color. Other findings include:

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Jul 26, 2016 | Posted by in PEDIATRICS | Comments Off on Neonatal

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