Inspection and care of healthy newborn children

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

To prevent infection of the child, it is extremely important for all personnel to follow the rules for handling the hands. Active participation in the birth of both mother and future father facilitates their adaptation to the role of parents.

[1], [2]

Care for a newborn in the first hours after birth

Immediately after birth, it is necessary to evaluate the respiratory system of the newborn, the heart rate, the color of the skin, muscle tone and reflexes. All of these are key components of the Apgar scale, which are evaluated at the first and fifth minutes of a newborn's life. The Apgar score of 8-10 points indicates that the transition of a newborn to an extrauterine life is normal. Score of 7 points or less in the fifth minute (especially if it persists for more than 10 minutes) is associated with a higher risk of disease and death of the newborn. Many newborns have cyanosis in the first minute of life, when evaluated at the fifth minute, cyanosis, as a rule, disappears. Cyanosis, which has not disappeared, may indicate an abnormality of the cardiovascular system or CNS depression.

In addition to the Apgar scale, a newborn should be examined to identify developmental anomalies. Inspection should be carried out under the radiant heat source in the presence of family members.

Prophylactically prescribed antimicrobial agents in both eyes (for example, 2 drops of 1% solution of silver nitrate, 1 cm of 0.5% erythromycin ointment, 1 cm 1% tetracycline ointment) to prevent gonococcal and chlamydial infections, intramuscularly administered 1 mg of vitamin K for the prevention of hemorrhagic diseases of the newborn.

Later the child is bathed, swaddled and given to the family. On the head, you should wear a hat to prevent heat loss. Transfer to the ward and early attachment of the newborn to the breast should be encouraged by the medical staff, so that the family can get to know the child and get help from the staff while they are still in the hospital. Breastfeeding is usually successful if the family is provided with sufficient financial support.

[3], [4], [5],

Care of the newborn in the first days after birth

[6], [7], [8],

Physical examination

The newborn should be carefully examined within 24 hours after birth. Conducting a survey in the presence of the mother and family members allows them to ask questions, and the doctor - to report the results of the survey and carry out preliminary guidance.

Basic measurements include determining the length of the body, weight and circumference of the head. The length of the body is measured from the crown to the heel; the normal parameters are determined depending on the gestational age and should be prepared on standard growth tables. If the exact term of gestation is unknown or the newborn looks more or less than its age, morphological and functional (neuromuscular) maturity indicators can be used to clarify the gestational age. These methods allow you to set the gestation period to within ± 2 weeks.

Many doctors examine the heart and lungs at the very beginning of the examination, while the child is calm. It is necessary to determine the place in which the heart sounds are heard most loudly (to exclude dextracardia). The normal heart rate is 100-160 beats per minute. Rhythm should be regular, although arrhythmia is possible. Noises of the heart, audible within the first 24 hours, are most often associated with an open botulian duct. A daily heart test confirms the disappearance of this noise usually within three days. The pulse on the femoral artery must be sought and evaluated in conjunction with the pulse on the brachial artery. A weak pulse or a pulse deficit on the femoral artery may indicate coarctation of the aorta or other stenoses of the arteries. Generalized cyanosis indicates congenital heart disease, lung disease.

The respiratory system is estimated by counting the respiratory rate for the full minute, since the newborns have irregular breathing. The normal respiratory rate ranges from 40 to 60 breaths per minute. The thorax should be symmetrical at survey, respiratory noises should be carried out equally over all fields of lungs. Chryps, widening of the wings of the nose, and the entrainment of intercostal spaces during breathing are signs of respiratory distress syndrome.

After examination of the heart and lungs, a sequential examination of the organs and systems of the child is carried out from the top down. In childbirth in the headache, as a rule, the bones of the skull overlap, small swelling and ecchymosis on the skin of the head (caput succedaneum). At birth in the breech presentation, the head is less deformed, edema and ecchymosis are observed on the presenting part of the body (buttocks, genitals, feet). The fontanel size can vary from a few millimeters to several centimeters. An enlarged large fontanel can be a sign of hypothyroidism. Also often occur kefalogematomes, blood accumulation between the periosteum and bone, which look like swelling. A cephalogram may be located in the area of one or both parietal bones, less often over the occipital bone. As a rule, cephalogematomes are not noticeable until the swelling of the soft tissues of the head passes; gradually within a few months the cephalohematoma disappears.

The eyes of the newborn are easier to examine on the day after birth, since swelling around the eyelids occurs during the birth. It is necessary to examine the eyes for the presence of a pupillary reflex, its absence is noted in glaucoma, cataract and retinoblastoma. After birth, subconjunctival hemorrhages are common in a child.

Low-lying ears may indicate genetic abnormalities, including trisomy on the 21st chromosome. It is necessary to examine the external auditory canal. Pay attention to the disturbances in the structure of the external ear, as they can be combined with deafness and kidney anomalies.

The doctor must examine and palpate the palate to detect defects of the hard palate. At some newborns at birth find epulis, a benign gamart of gums. If the size is large enough, epulis can lead to difficulties in feeding the baby and cause airway obstruction. These violations can be eliminated without the risk of re-emergence. Newborns can also be born with teeth. Natal teeth do not have roots. Such teeth must be removed, as they can fall out and be aspirated by a child. Incisive cysts, the so-called pearls of Ebstein, can be found on the palate.

Examining the neck, the doctor should raise the chin of the child to detect such anomalies as the cystic hygroma, goiter, the remains of the gill arches. The torticollis may be caused by a hemorrhage in the sternocleidomastoid muscle during birth trauma.

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

In boys, the penis should be examined for epispadias and hypospadias. The full-bodied testicles should be lowered into the scrotum. Edema of the scrotum may indicate a dropsy, inguinal hernia or much less frequently a torsion of the testicle. When dropsy, the scrotum shines through. Testicular torsion is an urgent surgical condition, manifested by ecchymosis and densification. At full-grown girls labia is embossed, large labia close small. Mucous vaginal and serous-bloody secret (false menstruation) is the norm. The secret is formed due to the fact that the intra-uterine fetus is affected by the effects of maternal hormones, which terminates after the birth of the child. Occasionally, a small growth of the hymen tissue in the region of the posterior frenum of the labia is found, which is probably associated with intrauterine stimulation with maternal hormones and disappears in a few weeks. Intersexual genitalia can be a manifestation of a number of congenital diseases (congenital adrenal hyperplasia, 5a-reductase deficiency, Kleinfelter syndromes, Turner, Svayer syndromes). In such situations, an endocrinologist is consulted to assess and discuss with the family the immediate or delayed determination of the sex of the child.

Orthopedic examination is aimed at identifying hip dysplasia. Risk factors are the female sex, breech presentation, the child from twins, and also the family anamnesis. The survey includes the use of the techniques of Barlow and Ortholani. Reception Ortolani performed as follows: the newborn lies on his back, legs in the direction of the doctor, who makes the inspection. The index finger is located on a large spit, the thumb is on a small spit of the femur. The first movement of the doctor produces a full bending of the legs of the child in the knee and hip joints, then - the full breeding of the legs, while pressing the index fingers up and inward until the knees touch the surface of the table. The click of the femoral head when the legs are withdrawn arises when the dislocated femoral head is returned to the acetabulum and indicates the presence of hip dysplasia.

This technique can be false-negative in children younger than 3 months due to muscle tension and hip ligaments. If the results of the survey are questionable or if the child is at high risk (the girls in the breech presentation) at 4-6 weeks the child needs to have an ultrasound examination of the hip joints

Neurological examination includes evaluation of the muscle tone of the newborn, activity, limb movements and reflexes. Usually cause such reflexes of newborns, as Moro, sucking and search. Reflex Moro - the newborn's response to fright, is caused by a slight dilution of the child's handles and their sudden release. In response, the child spreads the handles with straightened fingers, flexes the legs in the hip joints and cries. The search reflex is caused by stroking the baby's cheek at the corner of the mouth, which causes the child to turn his head toward irritation and open his mouth. A sucking reflex can be caused by using a nipple or fingertip in the glove. These reflexes persist for several months after birth and are signs of a normal development of the nervous system.

The skin of the newborn is usually bright red; cyanosis of the fingers of the upper and lower extremities is often observed during the first hours of the child's life. A generic lubricant does not cover the skin of most newborns at the gestational age beyond 24 weeks. Dryness and peeling often appear after a few days, especially in the folds in the wrist and knee joints. Petechiae can occur in areas experiencing increased stress in childbirth, such as a person (in childbirth, when the face is the presenting part); at the same time, newborns with diffuse petechial rash should be examined to exclude thrombocytopenia. Many newborns have manifestations of toxic erythema, benign rash with white or yellow papules on the hyperemia base. This rash, which usually appears 24 hours after the birth of the baby, spreads throughout the body and can persist for up to 2 weeks.

Screening

Recommendations for screening newborns differ depending on the clinical data and recommendations adopted in the country.

The definition of a blood group is shown to newborns at risk for developing hemolytic disease (risk factors are the mother's blood group or negative Rh factor, and the presence of small blood antigens).

All newborns are examined for jaundice while in the hospital and before discharge. The risk of hyperbilirubinemia is assessed on the basis of risk criteria, measurement of bilirubin levels and their combination. The level of bilirubin can be determined in capillary blood (percutaneously) or in serum. Many clinics examine all newborns and use predictive nomograms to establish the risk of high hyperbilirubinemia. Further observation is based on the child's age at discharge, the level of bilirubin before discharge and the risk of jaundice development.

In many states, specific hereditary diseases are screened, including phenylketonuria, tyrosinemia, biotinidase deficiency, maple syrup disease, galactosemia, congenital adrenal hyperplasia, sickle cell anemia and hypothyroidism. In many states, screening for cystic fibrosis, disturbances in the oxidation of fatty acids and other metabolic disturbances of organic acids are also performed.

Screening for HIV infection is mandatory in some states and in other cases is indicated for children from HIV-positive or in high-risk social groups for HIV-infected mothers.

Toxicological examination is indicated if there is information about the use of drugs by the mother of the child, unexplained placental abruption or unexplained preterm birth; in the absence of proper care for the mother during pregnancy; if a child has symptoms of withdrawal symptoms.

Screening for hearing impairment varies in different states; in some, only newborns at high risk are examined, while in other states, all children are examined. The initial examination often involves the use of a hand-held device to determine the echo produced by a healthy ear in response to a slight click (otoacoustic emission - UAE); if the test results differ from normal, a study of the basis of the brain response to auditory stimulus (auditory evoked potentials - SVP) is conducted. In some clinics the UAE-examination is conducted as an initial screening test. In the future, you may need to check with an audiologist.

Daily care and supervision

Newborns are bathed when their body temperature stabilizes at 37 ° C for 2 hours. The clip on the umbilical residue can be removed when the residue becomes dry, usually after 24 hours. To prevent infection, the umbilical cord should be kept clean and dry. Some centers use isopropyl alcohol several times a day or once a triple dye, a bacteriostatic agent that reduces bacterial colonization of the umbilical cord. Due to the fact that the umbilical wound is the gateway to infection, the navel area should be inspected daily to detect hyperemia and wetness.

Factors of high risk of hearing loss in newborns

• Weight at birth <1500 g
• Score on the Apgar scale in the 5th minute <7
• Serum bilirubin level> 22 mg / dl (> 376 μmol / l) in newborns with a birth weight> 2000 g or> 17 mg / dL (> 290 μmol / L) in newborns <2000 g
• Perinatal anoxia or hypoxia
• Neonatal sepsis or meningitis
• Craniofacial abnormalities
• Seizures or periods of apnea
• Congenital infections (rubella, syphilis, herpes simplex, cytomegalovirus or toxoplasmosis)
• Admission of the mother of aminoglycoside antibiotics
• Family history: early hearing loss in parents or close relatives

Circumcision can be safely performed - if the family wants it - under local anesthesia during the first days of a newborn's life. The procedure should be postponed if the child has abnormalities of the external opening of the urethra, hypospadias, as well as other anomalies of the glans penis, this is justified by the fact that later flesh can be used for plastic surgery; also, circumcision should not be performed if a newborn is diagnosed with hemophilia or other haemostasis disorders, if the family history is burdened with hemorrhagic disorders if the mother took anticoagulants or aspirin.

Most newborns lose from 5 to 7% of their initial body weight during the first days of life, mainly due to loss of fluid (during urination, minor loss of fluid with respiration), and in connection with meconium, loss of original grease, drying out the umbilical cord. In the first 2 days, urine can be colored in a bright orange or pink color, which is associated with urate crystalluria, which is the norm and occurs due to the concentration of urine. Most newborns urinate within 24 hours after birth; the average period of the first urination is from 7 to 9 hours after birth, most of the newborns urinate twice during the second day of life. Delayed urination is more common in boys and may be associated with physiological phimosis; absence of urination in newborn boys indicates the valve of the posterior urethra. As a rule, circumcision is performed after the child has first urinated; absence of urination within 12 hours after the procedure may indicate a complication. If the meconium has not departed within 24 hours, the neonatologist should keep in mind the newborn's examination to identify abnormalities in the development of the gastrointestinal tract, such as atresia of the anus, Hirschsprung's disease, pancreatic cystic fibrosis, which can lead to the development of meconial ileus.

[9], [10]

Discharging from maternity hospital

Newborns discharged from the hospital for 48 hours should be inspected for 2-3 days to evaluate breastfeeding or breastfeeding, hydration, jaundice (in newborns at risk). Further monitoring of newborns discharged from the hospital within 48 hours should be based on risk factors, including risk factors for jaundice and difficulty in breastfeeding.

[11], [12], [13]