THE NEONATE

‘Neonate’ is the term used to refer to the newborn baby in the first month of life. This
period is crucial for survival of the baby. In our country, at this stage, a large proportion of
infants die. One reason why this period is crucial for survival is because the newborn
experiences a sudden change in her environment from the womb to the outside world. If the
caregivers do not give her adequate protection, she becomes vulnerable to (open to; exposed
to; at risk of) illness which can lead to death. Let us see how the environment is different
after birth compared to what it was in the womb.
The Changed Environment
The newborn child has to adjust to an environment which is very different from the one in the
mother’s womb. In the womb the foetus had a comfortable and protected existence — the
temperature was controlled and so the foetus did not experience ‘hot’ or ‘cold’; it was
cushioned from physical shocks by the amniotic fluid; and received nutrition from the
mother. From this comfortable existence the baby is pushed out into an atmosphere of relative
discomfort. She is surrounded by air which may be cold or hot, dry or humid. She has to cry
to call attention and to indicate that she is hungry, wet or uncomfortable.
Thus, after birth, the newborn has to make efforts to satisfy her needs and has to
depend wholly on adults, usually the mother. But as you will read further, you will see
that the newborn has many capabilities which help her to adjust to the new
surroundings.
The First Day
A full-term Indian baby, on an average, weighs about 2.5 to 3.5 kilograms at birth. The
skin of the newborn is usually covered with a white wax-like coating. Soon after birth, this
coating dries and begins to peel off. The skin is greyish or pink in colour and may be covered
with fine hair, which disappears during the first month. The newborn’s head is large in
proportion to the rest of the body. It may be slightly elongated due to the birth process and
regains shape in the first few weeks after birth. Genitals in both boys and girls appear to be
enlarged.
Birth Cry — As soon as the baby is born, she gasps for air to breathe and this causes the
baby to cry. Thus, the baby’s cry indicates to us that she has begun to breathe and that there is
adequate supply of oxygen to the brain. Remember, the baby does not breathe in the womb.
Her oxygen needs are met through the umbilical cord. The birth attendants are fully aware of
the significance of the birth cry. If the cry does not come naturally, the baby is patted on the
back to facilitate the cry. If the child does not breathe at birth, the lack of oxygen to the brain
can cause brain damage resulting in serious disorders like cerebral palsy or other mental
disorders.
After the birth cry, the baby may have some difficulty in breathing due to the presence of
‘amniotic fluid’ in the lungs. The baby’s breathing during this period is irregular and strained
which may worry a new mother. But it clears out soon. Coughing, sneezing and yawning help
in clearing the air passage which enables the infant to breathe.
 The Neonate Three days old

APGAR Scale — In the hospitals, as soon as the baby is born, her condition is evaluated on
the APGAR scale. This Scale is administered twice by the hospital staff — at one minute
after delivery and then at five minutes after the delivery. This scale, named APGAR helps us
to remember the five signs which are evaluated through this scale to judge the baby’s
condition at birth. These signs are — A-Activity, P-Pulse, G-Grimace, A-Appearance, and
R Respiration. (APGAR- Dr. Virginia Apgar, 1952)
The baby is given 0, 1 or 2 points for each sign (i.e., activity, pulse, grimace, appearance
and respiration) depending upon her condition. Hence, APGAR is a 10-point scale with
maximum score of 2 points for each sign. Table 1 below explains the scale:
Table 1: The Apgar Scale
Sign 0 Point 1 Point 2 Point
A Activity (Muscle Completely limp Weak Strong movements
Tone) body movements of of arms and legs
arms and legs
P Pulse No Heart beat Below 100 beats 100-140 beats per
per minute minute
G Grimace (Reflex No response Weak reflexive Strong reflexive
Irritability) response response
(sneezing, coughing,
expressions on face
due to pain, disgust
etc.)
A Appearance (Skin Blue body, arms and Body pink with Body, arms and legs
Colour) legs blue arms and completely pink
legs
R Respiration No breathing Slow, irregular Strong breathing and
breathing crying
A score of 7-10 on the APGAR Scale is considered normal, while a score of 4-7 indicates that
the child needs medical attention to maintain her breathing and blood circulation in the body.
A baby with an APGAR score of 3 and below is in a serious condition and in need of urgent
immediate medical attention to help her to survive.
When the baby scores low on APGAR scale, additional scorings are done at 10 minutes, 15
minutes and 20 minutes after birth along with providing the required medical services. If the
score remains between 0-3 in these additional scores also, it may indicate possibility of
neurological or other damage in the newborn.
However, a low Apgar score does not always mean that the child may have brain damage or
may not survive. The baby’s activity level and responsiveness may be low because of the
following:
• Because of sedatives and pain killers received by the mother during delivery.
• Due to physiological immaturity as in case of Premature/Pre-term babies
Hence, if the baby scores low on the APGAR scale, the doctor checks for all the factors
which may cause it and acts accordingly.
APGAR scale is easy to administer, quick and inexpensive, causes no harm to the newborn
and helps doctors evaluate the child’s condition and act accordingly in time. It is the first
test conducted on the babies soon after their birth in hospitals all around the world.

Capacities of Neonate
Until a few decades ago, the newborn babies were considered as helpless beings who
could do very little on their own. But now research has shown that babies have several
capabilities right from the time of their birth, which are crucial for their survival and for
attracting care and attention of the parents/caregivers. These capabilities help the babies to
perceive, understand and adjust to the new environment around them. Babies are active from
birth and they actively relate to the people and environment around them. We shall now read
in detail about the capabilities of the newborn:
Motor Capabilities of the Newborn — Reflexes
All babies are born with a range of reflexes necessary for their survival. Reflexes
are automatic physical movements in response to a particular event or stimulus. In other
words, they are involuntary physical actions. For example, if you stroke the corner of the
newborn’s mouth, her head turns towards the corner you are stroking, she opens her lips, puts
out her tongue and tries to take the object in her mouth to suck it. This reflex is referred to as
the rooting reflex. It can be seen before birth and disappears in three months after birth. The
reflex is necessary for survival since it allows the newborn to reach for the breast or bottle.
The second reflex associated with feeding, and thus important for the baby’s health, is the
sucking reflex. When something is placed in her mouth, she sucks at it. This reflex
disappears sometime after birth. In sleep, however, it can be seen till seven months after birth.
When we say that the rooting and sucking reflexes disappear after some time, it does not
mean that the infant does not suck anymore. It means that sucking comes under voluntary
control instead of being reflexive (involuntary).
 When the baby sucks, she forms a seal around the nipple with her lips and creates a
vacuum in her mouth by moving the jaws, which helps to draw the milk from the nipple. At
the same time the infant uses the tongue to draw milk from the nipple towards the back of her
mouth. Infants can suck and inhale (breathe in air) simultaneously, swallowing between the
breaths at a very fast rate, three times faster than adults. The synchronized activities of
sucking, swallowing and breathing are mastered by infants in the first one or two weeks of
birth.
In the newborn some twenty reflexes have been identified. All the reflexes help the
neonate to adjust to her environment and to survive. Specific reflexes are present at specific
times and disappear after a particular age. The appearance of these reflexes indicates healthy
development of the nervous system. Some reflexes are present only for a short period — they
disappear after a given period. Others remain throughout the lifespan such as the automatic
blinking of our eyes when something comes close to them or the automatic moving away of
one’s hand when it touches a hot object.
lists some reflexes that all healthy newborns have. When assessing the health status of
the infant the doctor looks for the presence of the reflexes at the given ages. Absence of any
of the reflexes in the ages when they should be seen or their persistence after the age
when they should have disappeared or abnormal responses indicate problems of the
nervous system. Medical attention is needed in such cases.
Table 2: - Some Newborn Reflexes
Reflex Stimulation Response Age of Function
Disappearance
Eye Blink Shine bright Infants quickly Permanent Protects infants
light at eyes or close eyelids from strong
clap hand near stimulation
head
Withdrawal Prick sole of foot Foot withdraws, Weakness after Process infants
with pin with flexion of 10 days from unpleasant
knee and hip tactile stimulation
Rooting Stroke cheek Head turns 3 weeks Helps infant find
near corner of towards source (becomes the nipple
mouth of stimulation voluntary head
turning at this
time)
Sucking Place finger in Infant sucks Replaced by Permits feeding
infant’s mouth finger voluntary
rhythmically sucking after 4
months
Swimming Place infant face Baby paddles 4-6 months Helps infant
down in pool of and kicks in survive if dropped
water swimming into water
motion
Moro Hold infant Infant makes an 6 months In human
horizontally on “embracing” evolutionary past,
back and let motion by may have
head drop arching back,
 slightly, or extending legs, developed infant
produce a throwing arms cling to mother
sudden loud outward, and
sound against then bringing
surface arms in towards
supporting infant the body
Palmer Place finger in Spontaneous 3-4 months Prepares infant for
grasp infant’s hand and grasp of finger voluntary grasping
press against
palm
Tonic neck Turn baby’s head Infant lies in a 4 months May prepare infant
to one side while “fencing for voluntary
lying awake on position.” One reaching
back arm is extended
in front of eyes
on side to which
head is turned,
other arm is
flexed
Stepping Hold infant Infants lifts ne
2 months in Prepares infant for
under arms and foot after another
infants who voluntary walking
permit bare feet in stepping
gain weight
to touch a flat response
quickly;
surface. sustained in
lighter infants
Babinski Stroke sole of Toes fan out and 8-12 months Unknown
foot from toe curl as foot
toward heel twists in
Sources: Knobloch & Pasamanick, 1974; Prechtl & Beintema, 1965; Thelen, Fisher, & Johnson, 1984

Sensory Capabilities of the Neonate

The neonate has various sensory capabilities which help her to adjust to the outside world. On
the basis of many research studies, it is now known that the eyes, ears and other sense organs
function in a remarkable manner from birth onwards. Neonates react to touch, heat and cold
and can distinguish certain sounds, tastes and smells. Let us read about these in detail.
a) Vision: The infant’s visual system matures over the first two years. Due to this visual
immaturity, the newborn baby cannot focus on objects as well as adults. Also, unlike
adults, who can see nearby objects clearly, the newborn babies see nearby and far off
objects similarly. The vision of the newborn is quite immature and the infant cannot
see as clearly as adults. It has also been found that although newborns prefer to look
at bright objects, their colour vision is immature and they are not able to discriminate
between different colours. It takes about a month or two for their colour vision to
develop.

But most of us when we hold a baby in our arms do not get the feeling that the baby is
not able to focus – in fact, we often feel that the infant is looking quite intensely at us.
 Studies indicate that the neonate can see objects and people clearly when they are at a
distance of eight to ten inches from her face. This is usually the distance between the
adult’s and the baby’s face when the adult holds the baby in the arms! Thus, during
these interactions, the baby can clearly see the caregiver’s face and gets an
opportunity to examine it. This is the way in which the baby learns to recognize the
people around her. This mutual gazing also helps to establish an emotional bond
between the child and the caregivers.

Though the infant finds it difficult to focus, she has many visual abilities. The
newborn’s eyes are sensitive to light. If placed in a dark room, her eyes search
actively for light and if she finds a source of light, she continues to look at it. The
light, however, should be bright. This means that she can differentiate between light
and dark.

Immediately after birth, the baby can follow a moving object with her eyes. The
object should be moderately bright and should move slowly. The newborn is attracted
by things that move, produce sound and those which have a light and dark contrast.
The human face has all these characteristics and it greatly attracts the newborn. When
the caregivers interact with the child, their eyes and mouth move frequently. The eyes,
in addition, have a light and dark contrast.

In fact, the newborn baby continuously scans her surroundings and when she sees an
object, she gives it a good deal of attention. The child thus seems predisposed to look
around and examine the world. She may not understand all that she sees, but she is
building up a store of experience which will help her in learning later.

b) Hearing: From the time of birth babies respond to sound. This is evident from the
fact that they turn their head towards the direction of the sound source. However, they
cannot hear as well as, for example, a one-year-old child. They can hear only
moderately loud sounds. Different levels of sounds have different effects on the child.
Loud noises distress the babies and they get startled and begin to cry. Soft sounds
soothe them. They are most responsive to human voice as compared to any other
sound. The newborn’s preference for human speech is reflected in the fact that they
move their arms, legs and body in rhythm to the caregiver’s speech as early as twelve
hours after birth. If the pace of the adult’s speech is fast, the movements of the
neonate become fast. If the rhythm of the speech slows down, so do the infant’s
movements.

While it will take the infant another three months to distinguish the mother’s face
from other people’s faces, she can discriminate the mother’s voice from other female
voices in the very first week of birth. This is probably because the baby has been
hearing the mother’s voice while in the womb and is already familiar with it.

c) Taste and Smell: The senses of taste and smell are also well developed in the
newborn. Neonates can distinguish the four basic tastes: sweet, sour, salt and bitter.
Research indicates that when newborns are given sweet liquid instead of plain water,
they suck more. However, if they are given salty water, they reduce sucking or do not
suck at all. These reactions are essential for survival as the ideal food for the newborn
is the sweet tasting milk from the mother’s breast. The infant responds positively to
other tastes by the age of 4 months, when she is ready to eat solid foods.

As regards the sense of smell, the baby turns her head away from any unpleasant
odours as early as the first day after birth. Babies who are breast-fed appear to be able
to recognize the smell of breastmilk as early as in the first week.

d) Touch: Sensitivity to touch is well developed at birth. Newborns respond when

touched on any part of the body. They are especially sensitive to touch on the mouth,
face, soles of the feet and the palms. Newborn babies also react to stimuli that are
colder or warmer than their body temperature. Babies are sensitive to pain as well and
react with intense and high-pitched crying to pain.