1

Module 3
 2

Introduction

Module 3 is all about newborn. It discusses the immediate newborn care, its principle, normal
characteristics, physical and neuromuscular assessment, nutrition with emphasis on breast feeding,
adaptation to extrauterine life, senses, newborn screening, and immunization.

Objectives

At the end of the discussion, you should be able to:

1. Discuss the principle of newborn care.

2. Describe the normal characteristics of a newborn.
3. Identify normal growth, development and behaviour of newborn.
4. Perform physical and neuromuscular assessment.
5. Explain newborn nutrition with emphasis on breast feeding.
6. Determine the newborn adaptation to extrauterine life.
7. Explain the newborn senses.
8. Recognize the importance of immunization to infant.

THE NEWBORN
- The birth of the baby.

NEONATE: The first28 days of life

Four (4) time-bound interventions involved in Essential Newborn Care (ENC)

1) Immediate and thorough drying - Immediate and thorough drying of the newborn prevents
hypothermia which is extremely important to newborn survival

2) Early skin-to-skin contact, keeping the mother and baby in uninterrupted skin-to-skin contact
prevents hypothermia, hypoglycemia and sepsis, increases colonization with protective bacterial flora
and improved breastfeeding initiation and exclusivity

3) Properly-timed clamping and cutting of the cord after 1 to 3 minutes. Properly timed cord
clamping and cutting until the umbilical cord pulsation stops decreases anemia in one out of every
seven term babies and one out of every three preterm babies. It also prevents brain (intraventricular)
hemorrhage in one of two preterm babies.

4) Non-separation of the newborn from the mother for early breastfeeding initiation and rooming-in.
Breastfeeding initiation within the first hour of life prevents an estimated 19.1% of all neonatal deaths.

The following practices should never be done anymore to the newborn:

 Manipulation such as routine suctioning of secretions if the baby is crying and breathing
normally. Doing so may cause trauma or introduce infection.
 Putting the newborn on a cold or wet surface.
 Wiping or removal of vernix caseosa if present
 Foot printing
 Bathing earlier than 6 hours of life
 3

 Unnecessary separation of the newborn primarily for weighing, anthropometric measurements,

intramuscular administration of vitamin K, Hepatitis B vaccine and BCG vaccine
 Transferring of the newborn to the nursery or neonatal intensive care unit without any indication

The newborn care practices in health facilities, both government and private, and also the proper
sequence or order of newborn care services was standardized based on current evidences that show
reduction in neonatal mortality and morbidity. This is to achieve the United Nations Millennium
Development Goal 4 of Reducing Under 5 Child Mortality (through reduction of neonatal deaths).

PRINCIPLES OF NEWBORN CARE

I. Established and maintain patent airway

 Never stimulate a baby to cry unless secretions have been drained out.

 A newborn must be suctioned first by a bulb syringe as soon as the head is delivered.

 As soon as the infant is born, he or she should be held for a few seconds with head slightly
lowered than the rest of the body for further drainage of secretions.

EXCEPT WHEN THERE ARE SIGNS OF INCREASED ICP:

1. Vomiting

2. Bulging tense fontanels

 4

3. Abnormally large head

4. Increase BP,RR and PR

5. Widening pulse pressure

6. Shrill, high pitched cry

Mucus must be removed from the mouth and pharynx before the first breath to prevent aspiration of the
secretions. Reminder that a crying infant is a breathing infant.

 In ENC newborn suctioning is not a routine procedure unless there is difficulty in breathing and
ordered by pediatrician.

Suction the newborn properly: 1. Turn the baby’s head to one side; 2. Suction gently and quickly

 Prolonged and deep suctioning of the nasopharynx during the first 5-10 minutes of life will
stimulate the vagus nerve (located in the esophagus) and cause bradycardia

3. in suctioning, mouth first before the nose

When suctioning the nose, the stimulation of the nasal mucosa will cause reflex inhalation to
pharyngeal material into the trachea and bronchi causing aspiration.

. And to test the patency of the airway, occlude one nostril at a time

REMEMBER: Newborn are nasal breathers.

If the newborn struggles, when the nostril has been occluded, additional suctioning is indicated.

II. Maintain appropriate temperature

 There is a tendency of the body to seek increase temperature. The newborn suffers
large losses of heat (cold stress) because he is wet at birth, the DR is cold, and he
does not have enough adipose tissue and does not know how to shiver.

 Chilling will increase body’s need for oxygen.

Effects of cold stress:

1. Metabolic acidosis- one of the ways by which heat is produced in the newborn is by increasing
metabolism. When this occurs, fatty acids accumulate because of the breakdown of brown fat
(seen only in newborn)
 5

Chilling increase BMR increase oxygen demand - release of norepinephrine increase -

utilization of Brown fats - breakdown of triglycerides - accumulation of fatty acids

Metabolic acidosis

2. Hypoglycemia- due to the use of glucose stored as glycogen

Management:

a. Dry the newborn immediately

b. Wrap him warmly
c. Put him under droplight
d. Placed him under radiant warmer

Major cause of heat loss:

1. Evaporation – the loss of heat through moisture or when liquid is converted to a vapor. Amniotic
fluid that bathes the infant skin favors evaporation especially when combined with cool
atmosphere of the DR. Minimized by rapidly drying skin and hair with a warmed towel and
placing the infant in a heated environment.

2. Radiation- loss of heat to cooler solid objects in the environment that are not in direct contact with the
infant. Ex. Airconditioning unit

To prevent loss of heat from radiation placed infant to radiant warmer.

III. Immediate assessment of the newborn

APGAR SCORE- standardized evaluation of the newborn’s condition. Done at one minute after birth to
determine the general condition and then at five minutes to determine how well the newborn is adjusting
to the extra uterine life.
 6

Obtaining an Apgar score

 Observe skin color, esp. at the extremities (if the neonate is dark skinned, inspect the oral
mucosa, conjunctiva, lips, palms, and soles).

 Assess the neonate’s heart rate. Using stethoscope, listen to the heart beat for 60 seconds and
then record the rate.

 Assess reflex irritability by observing the neonate’s response to nasal suctioning or to flicking
the sole.

 Determine muscle tone by evaluating the degree of flexion and resistance to extension in the
extremities (extend the limbs and observe their rapid return to flexion).

 Assess respiration by noting the volume and vigor of the neonate’s cry. Then using
stethoscope, assess the dept and rate of respiration. Begin neonatal resuscitation if you detect
abnormal respiration.

SIGN 0 1 2

Heart rate Absent <100 >100

Respiratory effort Absent Weak cry Good strong cry

Muscle tone Limp flaccid Some flexion Well flexed

extremities extremities

Reflex irritability No response Grimace, weak cry Sneeze, good

strong cry

Color Pale, blue Extremities blue, Pink all over

body pink
 7

Heart rate is the most important indicator

Flexion is the general attitude of the baby at birth

Interpretation of Results

a. 0-3 The baby is in serious danger and needs immediate resuscitation.

b. 4-6 Condition is guarded and need more extensive clearing of the airway.

c. 7-10 Baby is in the best possible health

IV. Proper identification

a. Bracelet- less accurate

b. Footprints- more accurate, the best way to identify NB (no longer practice in ENC)

 Proper identification of the NB must be done in the DR before bringing to the nursery
 8

V. Nursery Care

a) Check identification band

b) Take anthropometric measurements.

Length- average 50 cm (20 inches)

47.5-59.75 cm (9-21.5 inches)

Head circumference: 33-35cm

Chest circumference: 31-33cm

Abdominal circumference: 31-33 cm

c) Take the temperature

Passage of meconium- most important indicator for patency of the anal opening.
 9

 At birth the temperature of newborn is about 37.2 centigrade or 99 degree farenheight, because
they had been confined in an internal organ but because evaporation from the moist skin and
the cool DR will stabilize in 8 hours and must be maintained at 35.5 degree Celsius – 36.5
degree Celsius so as to prevent hypoglycemia and acidosis due to hypothermia

 Axillary and rectal temperatures are approximately the same, immediately following birth, but
the rectal route is preferred in order to check patency of the anus.

d) Specific Nursing Actions:

1. Give initial warm bath to cleanse the baby of blood mucus and vernix

 Dress the umbilical cord

 Inspect for the presence of 2 arteries and 1 vein

2. Suspect for congenital anomaly if blood vessels are not complete

3. Credes prophylaxis is a prophylaxis treatment of the NB’s eyes against gonorrheal conjunctivitis
ophthalmia neonatorum which the baby acquires as he passes through the birth canal of his mother
who has untreated gonorrhea
 10

a) Wipe the face dry

b) Shade the eyes from light and open one eye at a
time by exerting gentle pressure on the upper
and lower lids.
c) Two drops of 1% silver nitrate are instilled one at
a time into the lower conjunctival sac (be careful
not to drop on the cheeks because parents may
worry about the stain).
d) Wash silver nitrates away with sterile NSS after
1 minute to prevent chemical conjunctivitis
(inflammation, edema, purulent discharge).
e) Penicillin/Chloromycetin/ Terramycin ophthalmic
ointment may be used since it does not irritate
the eyes ( although the sensitivity at an early
age.
f) Apply from the inner to the outer canthus of the eyes

4. Vitamin K administration

Administered prophylactically to prevent a transient deficiency of coagulation factors II, VII, IX, and X.

a) Rationale: Vit. K facilitates production of the clotting factor, thus preventing bleeding.
Vit.K is synthesized in the presence of normal bacterial flora in the intestines since the
NB’s intestine are relatively sterile, therefore they will not be able to synthesized Vit. K,
that is why synthetic Vit. K is given to prev ent hemorrhage.

b) Method:1 mg, 0.1 cc Aquamephyton ( generic name is Phytonadione is injected

Intramuscular into the lateral anterior thigh vastus [Link] children below 12 months
of age who have not yet learned how to walk. This is the preferred site of injection,
because gluteal muscle are not yet fully developed.
 11

The major function of vit. K is to catalyze the synthesis of prothrombin in the liver which is needed for
blood clotting coagulation.

5) Weight taking

Weight: -1(6.5 lb) +1

3 to 3.4 kg=3000 gm

Procedure:

1) Weigh the clothes first

2) Put on the baby’s clothes

3) Weight the baby with his clothes on

4) Subtract the weight of the clothes from the total weight of the baby and his clothes

 The neonates loses 5-10% of birth weight (6-10oz) during the first few days after the birth. This
physiologic weight loss occurs because the NB: 1. is no longer under the influence of maternal
hormones; 2. voids and passes out stools; 3. has limited intake; and 4. has beginning difficulty
establishing sucking
 12

6) Feeding

Before

a. Initial feeding is a test feeding consisting of an ounce of water, glucose water is irritating to the lungs
if aspirated

b. Subsequent feedings is preferably given by demands

Term infant: feed 4-6 hours after birth start with 15-20 cc increasingly by 5 ml/ feeding.

In Essential Newborn Care (Unang Yakap)

Early breast feeding or immediate latching on/ latch on is done.

Rationale:

- To promote early feeding

- To promote immediate bonding between mother and child

- Observe for feeding reflexes, rooting, sucking, swallowing, gagging, and extrusion.

PHYSICAL ASSESSMENT

1. Temperature

1. 37.2 degree Celsius at birth

2. 35.5 degree Celsius (stabilized)

2. PR = 120 – 150 beats/min

Apical pulse (found below the nipple line) is recommended since radial pulses are not ordinarily
palpable (if prominent, in fact, may be a sign of congenital heart anomaly – PDA patent ductus
arteriosus wherein there is an opening between the pulmonary artery and the aorta

3. RR = 30 – 60 breaths/min

It is gentle, rapid but shallow, quiet, largely diaphragmatic and abdominal.

4. BP = at birth I s 80/46 mmHg ; after 10 days: 100/50 mmHg

BP is not routinely measured in NB unless certain cardiac anomalies are suspected.

 13

The size of cuff in children: not more 2/3 the length of the extremity (will result in false low BP) nor less
than ½ the length of the extremity (will result in false high BP)

Flush Method/Doppler Method may be used to take BP of the newborn.

Procedure:
Cuff is applied to an extremity

Extremity is elevated and an elastic bandage is wrapped around the distal part

Inflate cuff, remove the elastic bandage (extremity is expectedly pale)

Slowly deflate the cuff, while watching the pale extremity

As soon as the extremity turns pink (flushes), read the manometer

Only one reading can obtained. The average between the diastolic and systolic pressure is called flush
pressure

Complete gestational age assessment (Ballard gestational-age assessment tool)

The clinical assessment of gestational age is used to determine if an

Infant should be categorized as:

Preterm – less than 37 weeks’ gestation

Term – 37 to 42 weeks’ gestation

Post term – greater than or equal to 42 weeks’ gestation

The Ballard scoring system uses physical and neurologic findings to estimate gestational age

This system enables estimates of gestational age to within 1 week, even in extremely preterm neonates

This evaluation can be done anytime between birth and 42 hours of age, but the greatest reliability is at
30 and 42 hours.
 14

Scarf sign. A, No resistance is noted until after 30 weeks’

gestation. The elbow moves readily past the midline. Score
1. B, The elbow is at midline at 36 to 40 weeks’ gestation.
Score 2. C, Beyond 40 weeks’ gestation, the elbow will not
reach the midline. Score 4.

Heel-to-ear. No resistance. Leg

fully extended. Score 0.

Ankle dorsiflexion. A, A 45-degree angle

indicates 32 to 36 weeks’ gestation. A 20-
degree angle indicates 36 to 40 weeks’
gestation. Score 2-3. B, A 15- to 0-degree
 15

Ankle dorsiflexion. A, A 45-degree angle

indicates 32 to 36 weeks’ gestation. A 20-degree
angle indicates 36 to 40 weeks’ gestation. Score
2-3. B, A 15- to 0-degree angle is common at 40
weeks’ or more gestational age. Score 4.
 16

SKIN

Color: normally ruddy in color because of the increase concentration of RBC and the decreased amount
of subcutaneous fat

1. Ruddy is reddish in color

2. Acrocyanosis refers to body pink, extremities blue. Normal during the first 24-48 hours of life

3. Mottling refers to turning red and white color. Common due to an immature circulatory system. The
other term is “Cutis Marmorata”.

4. Pallor color is due to anemia which results from excessive blood loss when the umbilical cord is cut,
inadequate blood loss from cord to infant at birth, inadequate iron stores because of poor maternal
nutrition. May also be due to blood incompatibility.

5. Gray color may indicates infection

6. Green color occurs on meconium-stained babies

7. Blue color is common to babies with congenital heart anomalies

 17

7. Jaundice is the yellowish discoloration of the skin and sclera.

The two types of jaundice are :
a. Physiologic jaundice is normal from 2nd – 7th day of life.
b. Pathologic jaundice is abnormal, baby has turned yellowish before 24 hours.

Breatfed babies, however, have longer physiologic jaundice because human milk has pregnanediol
which depresses the action of glucoronyl transferase (the enzyme responsible for converting indirect
bilirubin to direct bilirubin)

Cause: inability of the NB to conjugate bilirubin

 18

Normal values:

Total serum bilirubin=1.5 mg%

Direct bilirubin=1.7

Indirect bilirubin=13.3

The most accurate method of assessing presence of jaundice: use natural light and blanch skin on the
chest or tip of the nose

9. Harlequin sign – because of immaturity of

circulation, on an infant who has been lying on his
side will appear red on the dependent side and pale
on the upper side

10. Mongolian spots – accumulation of melanin

pigments. These all slate-gray patches seen across the
sacrum/buttocks and consist of collection of pigment
cells (melanocytes). Disappear by school age. Seen only
among Southern European, Asian and African children

MARKS:

[Link] – fine, downy hair that covers the shoulders, back and upper arms. Will disappear in 2
weeks time

[Link] – drying of NB skin

[Link] – on face and neck, due to increased intravascular pressure during delivery

[Link] – unopened sebaceous glands found on the nose, skin and cheeks, disappear spontaneously
by 2-4 weeks
 19

[Link] toxicum – pink popular rash in which vesicles maybe superimposed. Appearing 1-2 days
after birth and disappearing several days later

[Link] caseosa – cheeselike, greasy yellowish white substance sometimes likened to cream
cheese or cold cream which covers the NB’s skin.

16. Nevus vasculosus ‘’ strawberry mark or strawberry hemangioma – benigh capillary

hemangioma in the dermal and subdermal [Link] is raised , rough, dark red and sharply dermarcated
found in the head region within few weeks after birth, common in premature infants.
 20

17. Nevus flammeus “port wine” – commonly appears on the newborn’s face or other areas. It is
capillary angioma located directly below the dermis. Sharp dermarcation, purple-red in color. The skin
lession is made up of mature capillaries that are congested and dilated

18. Telangiectatic nevi or “stork bites’’ superficial vascular layers, flat, deep pink localized areas
seen in back, nape, eyelid, between eyes and upper lip cause by immature blood vessels.

HEAD

• Largest part of the infant’s body

• ¼ of his total length

• Elongated

• Fontanels are neither sunken (a sign of DHN) nor bulging (a sign of increase ICP)the end of
between 2-3 months in infant

Fontanels – membrane covered spaces at the junction of the main suture lines. Opening at the
points of union of the skull bones
 21

a. Anterior fontanel – larger, diamond-shaped fontanel located at the juncture of 2

parietal and 2 frontal bones. Closes between 12-18 months in an infant, measures 4 to
6 cm.

b. Posterior fontanel – smaller, triangular-shaped fontanel, located between the occipital

and parietal bones. Closed by the end or between2-3 months in infants.

- Both fontanels should be soft, flat and open

Overlapped cranial bones produce a visible ridge

in a small, premature newborn. Easily visible
overlapping does not occur often in term infants.

Craniosynostosis – abnormal/premature closure of fontanels leads to mental retardation

Craniotabes – localized softening of the cranial bones. More common among first born(s) because of
early lightening. Probably caused by pressure of the fetal skull against the mother’s pelvic bone in the
utero.

Molding – refers to asymmetry of the cranial sutures due to difficulties during vaginal delivery. There
are 2 types of cranial abnormalities:

Caput succedaneum

Definition: edema of the scalp at

the presenting part of the head
Extent of involvement: both
hemispheres
Cause: pressure as in prolonged
labor
Period of absorption: the most
significant difference between
caput and cephalhematoma; the
edema will gradually be
absorbed and disappear about the 3rd day of life
Treatment: it needs no treatment

Cephalhematoma

Definition: a collection of blood

between the periosteum of the
skull bone and the bone itself
Extent of involvement: confined
to an individual bone; does not
cross suture lines
Cause: rupture of a periosteum
capillary due to the pressure of
birth
 22

Period of absorption: takes several week

Treatment: none; support the anxious parent.

EYES

In assessing infant’s eyes, put him in a supine position and lift the head (upright position). This will
cause the baby to open the eyes. Observe the lids for edema, normally present for the first few days.

Assess for symmetry in size and shape.

Neonates tend to keep their eyes tightly shut.

The eyes should appear clear without redness or purulent discharge

 Lacrimation is an outflow or weeping of tears. Lacrimal glands are immature at birth, resulting
in tearless crying for up to 2 months.
The neonate’s eyes usually gray or blue because of scleral thinness. Permanent eye color is
established within 3 to 12 months.
The neonate may demonstrate transient strabismus.

 Purulent discharge may cause by administration of ophthalmic ointment which is applied at

birth to prevent ophthalmia neonatorum (gonorrheal conjunctivitis).

The doll’s eye reflex may persist for up to 10 days.

When the head is rotated laterally, the eyes deviate in the opposite direction.

The pupillary reflex is present.

Puffy eyelids is usually normal

Cornea should be round and proportionate in size to that of an adult eye
Pupil should be dark, a white pupil suggests congenital cataract. Pupil should be round not key-
holed (coloboma)
 Pressure during birth will cause rupture of a conjunctival capillary in a small amount. This is
termed; Subconjunctival hemorrhage – red spot on the sclera usually at the inner aspect of
the eye or red ring around the cornea. Bleeding is slight and needs no treatment.
 23

Infant at term shows well-defined incurving of

the entire pinna.

 Small tags of skin found in front of ear can be

removed by ligation immediately or when the child
is a week old.

NOSE

May appear large for the face. There should be no septal deviation.
Should have a midline placement, patent nares and an intact septum
Milia are usually present on the tip or bridge of the nose

MOUTH

NB’s mouth should open evenly when crying, if no suspect for cranial nerve injury.

The neonate’s mouth has scanty saliva and pink lips.

Inspect the mouth for its existing structures.

Palate should be intact

Tongue appears large and prominent in the mouth; because the tongue is short, the frenulum
membrane is attached close to the tip of the tongue, creating the impression that the infant is “tongue
tied”

 If the infant appears tongue tied it needs a surgical correction because the baby cannot suck.

 Eipstein’s Pearls – one or two small round, glistering cysts present on the palate, a result of
the extraload of calcium that is deposited in utero. There are no significance and need no
treatment because they disappear spontaneously in weeks’ time. This should not be mistaken
for oral thrush.
 Oral Thrush – white or gray patches on the tongue and sides of the cheeks due to candida
albicans acquired during passage of the baby on the birth canal of the mother with untreated
moniliasis also known as oral moniliasis.
 It is unusual for the NB to have teeth but sometimes one or two called natal teeth will have
erupted. If loose should be extracted to prevent aspiration when feeding

NECK
Short and thick often chubby usually surrounded by and skin folds.
 24

The head should rotate freely.

 Wryneck torticolis is the rigidity of the neck

caused by damage to the sternocleidomastoid
muscle during birth.

Brudzinki’s Sign is the nuchal rigidity which suggest

infection of the CNS (meningitis).

CHEST
Barrel-shaped, cylindrical thorax and flexible
ribs. As large or as smaller than the head.
Breast maybe engorged in both male and female infants due to influence of maternal
hormones.

Witch’s Milk is a thin watery fluid secreted by the breast of NB babies also due to maternal
hormones.
Should never be expressed because it will disappear naturally. Manipulation may introduce
bacteria and may lead to mastitis
Chest should be symmetrical
Respiratory movement is normally rapid but not distressed.
Retraction should not be present
 25

Breast tissue. A, Newborn has a visible

raised area > 0.75 cm diameter. Score 3.
The gestational age is 38 weeks

Newborn has 10 mm breast tissue area.

Score 4. The gestational age is 40 to 44 weeks.

Gently compress the tissue between the

middle and index fingers and measure the
tissue in centimeters or millimeters. Absence
of or decreased breast tissue often indicates
premature or small-for-gestational-age
newborn

ABDOMEN

The contour is slightly protuberant (prominent striking out). Dome-shape or large hemispherical
roof.

If scaphoid or sunken appearance suspect missing abdominal contents

Liver, spleen and kidneys are palpable at birth. Liver is about 1-2 cm below the right costal
margin. Kidney is 1-2 cm above the umbilicus.

Inspect the umbilical cord for 2 arteries and 1 vein; a single artery is associated with congenital
anomaly and it needs close observation of the infant.
 26

Cord-off: 7-10 days

Umbilical cord at first hour after birth appears white, gelatinous structure marked with the red
and blue streaks of the umbilical vein and arteries. Base of cord should appear dry-moist or
odorous cord suggests infection.

Cullen’s sign – bluish discoloration of the

umbilicus

Wharton’s jelly – unusually thick

umbilical cord
 27

Omphalocele – congenital protrusion of

the abdominal viscera into the weakend
portion of the navel also called umbilical
hernia

Omphalitis is the inflammation or infection of the umbilical cord.

Omphalangia is the bleeding of the cord.

ANOGENITAL AREA

Anus should be patent and not covered by a membrane. Determine patency of the anus by
inserting a rectal thermometer into the rectum for the length of the bulb or by inserting the tip of
a lubricated gloved little finger

 Imperforate anus a new born does

not have patent anus or there is no outlet to
release stool after birth. The intestine ends in a
blind pouch.
 28

REMINDER: Take note of the time meconium is first passed. It should be within 24 hour of life.
REMEMBER: Passage of meconium is the most important indicator for the patency of the anus
Diastasis recti is the separation of rectum muscle common in NB.

FEMALE GENITALIA
The vulva may be swollen because of the action of the maternal hormones

The term newborn has well-developed, Newborn has a prominent clitoris. The labia
large labia majora that cover both clitoris majora are widely separated, and the labia
and labia minora. minora, viewed laterally, would protrude
beyond the labia majora. The gestational age
is 30 to 35 weeks.

 A mucous vaginal secretion may be present which is sometimes blood tinged which is due to
maternal estrogen and progesterone pseudomenstration
The discharge should not be mistaken for an infection or taken as an indicator that a trauma
has occurred and the discharges will disappear as soon as the infant’s system has cleared the
hormones, 2-4 weeks
 Hermaphrodites – ambiguous genitalia

MALE GENITALIA

Scrotum is edematous, pendulous and rugae, deeply pigmented in black or dark-skinned

neonates

Palpate the presence of testes

Penis appears small

 29

 Cryptorchidism is the undescended testicles.

Management: Orchidopexy, the repair of the scrotum

The prepuce (foreskin) of the penis should be retractable

 Phymosis the tight foreskin, prepuce not retractable “supot”

 30

Treatment: circumcision

Maybe done prior to discharge from the nursery, preferably by the first week

 It should be inspected to see the urethral opening at the tip of the penis

Epispadias – urethral opening on the dorsal surface

Hypospadias – urethral opening on the ventral surface

Chordee the ventral curvature of penis

Hydrocele the presence of fluid in the scrotum.

 31

CIRCUMCISION:

NURSING CARE:

 Check for bleeding (most common complication)

 Apply gentle pressure to the area with a sterile gauze pad in small amount if bright red blood is
observed
 Do not attempt to remove exudates which persist for 2-3 days. Just wash with warm water
 Diaper must be pinned loosely during first 2-3 days when the base of the penis is tender

BACK
On prone, appears flat; the curved seen in the adult appears only when a child is able to sit and
walk

EXTREMITIES
Arms and legs are short
Hands are plumb and clenched into fists
Should move symmetrically
Check for the numbers of fingers

ABNORMALITIES:

 Adactyl refers to absence of fingers or toes

 32

 Macrodactyl is the over development of one or more fingers or toes.

 Syndactyl the fingers are fused or webbing of fingers.

 Polydactyl refers to numerous finger or extra toes or fingers; sole of foot appears to be flat.
 33

 sole of the foot appears to be flat

 Hemimelia – absence of distal part of extremity

 34

 Phocomelia – hands or feet attached close to trunk

To evaluate the child with knock–knees, have the child stand on a firm surface. Measure the distance
between the ankles when the child stands with the knees together. The normal distance is not more
than 2 in. (5 cm) between the ankles.

Adaptation to Extrauterine life

a. Physiologic function
I. CARDIOVASCULAR SYSTEM

Exchange of oxygen and carbon dioxide takes place in the placenta not in the fetal lungs because the
cord is not yet ligated or clamped. When the cord is clamped, a neonate is forced to take in oxygen
through the lungs, increases systemic vascular resistance and left atrial pressure. As soon as breathing
has initiated, oxygenation has taken place in the NB’s lungs.

FETAL CIRCULATION

Oxygenated blood from the placenta enters to fetus through umbilical vein. A small amount of blood
pass to the liver but most of it pass to the inferior vena cava via ductus venosus. Then the blood enters
 35

to the right atrium, then the foramen ovale and left atrium, and from here blood moves to left ventricle
and pump out by ascending aorta and brought to upper extremities.

Blood coming from the upper part of the body enters to the right atrium via superior vena cava then
flows to the right ventricle and eventually pushed into the pulmonary artery then to a short duct called
ductus arteriosus.
Descending aorta pumps blood out to the lower extremities then return to placenta for oxygenation of
blood via umbilical artery.
Because little blood goes to the fetal lungs, pressure in the left side of the fetal heart is less than the
pressure in the right side of the fetal heart.
Inspiration of air and expansion of the lungs allow for an increase in tidal volume (amount of air brought
inside into the lungs). Surfactant lining the alveoli enhances lungs, thus reducing surface tension and
lowering pressure aeration of gas
When oxygenation takes place, this causes the lungs to expand. As the lungs are expanded this will
cause pressure on the left side of the heart to become higher.

A. Increased pressure on the left side of the NB’s heart results in:
1. Closure of the foramen ovale
2. Change of the ductus arteriosus to ligamentum arteriosum

B. Decrease pressure on the right side of the NB’s hearts causes:

1. Ductus venosus to ligamentum venosum

C. Because the remaining fetal circulatory structures are no longer receiving blood these blood vessels
atrophy and degenerate.
1. Umbilical vein – becomes ligamentumteres
2. Umbilical arteries – umbilical ligaments

.
 36

Initiation of respiration in the newborn

Transitional circulation: conversion from fetal to neonatal circulation.

Response of blood pressure (BP) to neonatal changes in blood volume

Left umbilical vein

- Receives oxygenated blood from the placenta carries the most amount of oxygenated blood
 37

- Shunts blood to the ductus venosus and a small amount of blood to the liver to nourish the liver

Right and Left umbilical arteries Left umbilical vein

- Receives O2 blood from the hypogastric arteries and coarse it back to the placenta for O2
Ductus Venosus
- Shunts blood from the umbilical vein to the inferior vena cava by passing the liver

Foramen Ovale
- Shunts blood from the right to left auricle. Functionally closes immediately at birth, permanent closure
may take several months or maybe as early as 2-3 months or as late as about a year

Ductus Arteriosus
- Shunts blood from the pulmonary artery to the aorta
- By passes the lungs
- Functionally closes at birth
- Permanent closure takes several months

Blood Values – are all high in the NB period as a response to the pulmonary circulation
Blood volume 80-85 ml/KBW
RBC – 6 million/ml3 or 17-20 g/dl
- Fetal RBC are large but few in number after birth the RBC count gradually increases as the cell size
decreases because they live in an environment with high PO2
Hgb – 17-18 g/100 ml
Hct – 45-50%
WBC – 15,000-45,000/ml3
Platelet – 100,000- 300,000

A high WBC count during NB period, therefore is not a sign of infection, with or without infection all NB
has high WBC count.
As RBC are destroyed after birth, the iron is released and is stored by the liver until new RBC need to
be produced.
NB iron stores are determined by total body hemoglobin content and length of gestation at birth.
NB iron stores is sufficient to last 4-6 months.

II. GASTROINTESTINAL SYSTEM

GIT’s usually sterile at birth, but bacteria may enter the tract via the NB’s mouth (some mouth bacteria
are airborne)
1. vaginal secretions as the baby passes through the birth canal of his mother
2. from contact at breasts
Accumulation of bacteria is necessary for digestion, e.g. synthesis of Vit. K is necessary for blood
coagulation.
Neonate’s stomach holds about 60-90 ml; emptying time is 2-4 hours.
It has limited ability to digest fat and starch because some enzymes (lipase and amylase) are deficient
for the first few months of life.
The cardiac sphincter and nervous control of the stomach is immature which may lead to uncoordinated
peristaltic activity and frequent regurgitation.
 38

Immaturity of the pharyngeal sphincter and absence of lower esophageal peristaltic waves also
contribute to the reflex of gastric content.
Audible bowel sounds can be hear 1 hour after birth.

Differences in stool

a. MECONiUM
The first stool of the neonate, should be passed within 24 hours after birth, if not suspect abnormality in
the anus (imperfoccrate anus, meconium ileus or bowel obstruction). Meconium is sticky, tar-like,
blackish green, odorless material formed from mucus, vernix, lanugo, hormones and carbohydrates that
accumulated during intrauterine life.

b. TRANSITIONAL
On the second or third day of life, the neonate’s stool changes in color and consistency in response to
the feeding pattern. Transitional stools are shiny green and loose resembling diarrhea to the untrained
eye

c. BREASTFED STOOL
This stool is golden yellow, mushy, more frequent (3-4 times a day) and sweet smelling because breast
milk is high in lactic acid which reduces the amount of putrefactive organisms in the stool.

d. BOTTLE FEED STOOL

This stool is pale yellow in color, firm, less frequent (2-3 times a day) and with more noticeable odor.
The neonate placed under phototherapy lights treated for jaundice will have bright green stool because
of increased bilirubin secretions
Obstruction of the bile ducts will have clay- colored (gray) stools because the bile pigments do not enter
the intestinal tract
Stool which remains black or tarry, intestinal bleeding should be suspected

Newborn stool samples. A, Meconium stool. B, Breast milk stool. C, Cow’s milk stool.

III. URINARY SYSTEM

Renal function does not fully mature after the first year of life, the neonate has a minimal range of
chemical balance and safety. NB should void within the first 24 hours of life.
 39

Low ability to excrete drugs and excessive fluid loss can rapidly lead to acidosis and fluid imbalances.
Newborn should void within the first 24 hours of life.
1. Female NB formed a strong stream when voiding

2. Male NB formed a small projected arch when voiding. If not, suspect a defect in the urethral
meatus

a. HYPOSPADIAS refers urethral opening located in the ventral (under) surface of the penis
b. EPISPADIAS refers urethral opening located in the dorsal (above) surface of the penis

Renal cortex is relatively underdeveloped at birth and does not reach maturity until 12-18 months of
age. Glomerular filtration rate (GFR ) is 30% of normal adult values.

The urine is usually light in color and odorless because kidneys do not concentrate urine well.
A single voiding is about 15 ml. The daily urine output for the first 1 or 2 days is about 30-60 ml total. By
week 1, total volume has risen to about 300 ml.
A small amount of protein may be normally present in voiding for the first few days of life until kidney’s
glomeruli are fully mature.
The first voiding may be pink or dusty because of uric acid crystals that were formed in the bladder in
the utero, (this is an innocent finding).

IV. AUTOIMMUNE SYSTEM

Neonate has difficulty forming antibodies against invading antigens up to 2 months of age
The neonatal immune system depends largely on 3 immunoglobulins (Igs): IgG, IgM, and IgA

Immunoglobulin G (IgG), a placentally transferred immunoglobulin, provides the neonate with

antibodies to bacterial and viral agent. Present in the fetus at the third month of gestation.
The infant first synthesizes its own IgG during the first 3 months of life thus compensating for
catabolism of maternal antibodies antibodies against poliomyelitis, measles, diptheria, pertusis, rubella
and tetanus.

Immunoglobulin m (IgM), the fetus synthesizes IgM by the 20th week of gestation. IgM does not cross
the placenta. High levels of IgM in the neonate indicate a nonspecific intrauterine infection
Secretory immunoglobulin A (IgA), found in the colostrum of breast milk. This limits bacterial growth
in the GI tract.

Neonate has fragile defences against infection. Their skin is fragile, thin, and easily broken allowing
for easy entry of microorganisms.

The neonate’s immune response is limited to localized infections, thus spread of microorganism is
rapid. And, little immunity is transmitted against varicella (chicken pox), or herpes simplex. That is why
chicken pox is fatal in the NB.

V. NEUROMUSCULAR ASSESSMENT

Different reflexes may be tested to assess muscular responses

 40

1. Glabellar or Blink reflex – rapid eyelid closure and may be elicited by shining, a strong light

such as flashlight on the eye. It is always present or does not disappear.

2. Rooting Reflex – if a neonate’s cheek is brushed or stoked near the corner of the mouth, the
infant will turn the head in that direction. This reflex serves to help the baby find food. As the
mother holds the child and allows her breasts to brush the baby’s cheek the baby will turn to-
wards the breast. The reflex disappears about the 6th week of life. At about this time, the eyes
focus steadily and a food source can be seen, the reflex is no longer needed.

3. Sucking reflex – anything placed between the lips will be sucked; disappears by 6th month

IMPORTANT: sucking reflex disappears immediately if not stimulated regularly.

IMPLICATION: any infant who will be put on NPO should be given a pacifier not only for psychological
(emotional) reasons but also to prevent premature disappearance of the sucking reflex.
 41

4. Extrusion reflex – “spitting out reflex”, anything placed on the anterior portion of the tongue will be
spit-out; disappears by 4 months of age. This is protected thing placed in the mouth

REMINDER: mother should wait for sucking and extrusion reflex to disappear before they start to give
semi or solid foods.

5. Swallowing reflex – anything placed on the posterior portion of the tongue will automatically be
swallowed. It will never disappear.
 42

6. Palmar grasp reflex – neonates will grasp an object placed in their palm by closing their fingers on
it. The reflex disappears at about age 6 weeks

7. Step (Walk) –in-place Reflex – NB who are held in a vertical position with their feet touching a hard
surface will take a few quick, alternating steps. This reflex disappears by 3 months of age.

1. Placing reflex – similar to step-in-place reflex, except it is elicited by touching the anterior sur-
face of a NB’s leg against the edge of a bassinet or a table. A NB will make a few quick lifting
motions as if to step on a table.
 43

9. Plantar grasp reflex – when an object touches the sole of a NB’s foot at the base of the toes. The
toe grasps in the same manner as the fingers do. The reflex disappears at about 8-9 months of age in
preparation of walking; although it may be present in sleep for a longer period of time. To assess the
plantar reflex, stroke the bottom of the infant’s or child’s foot in the direction of the arrow. Watch the
toes for plantar flexion or the Babinski response, fanning and dorsiflexion of the big toe. The Babinski
response is normal in children under two years of age. Plantar flexion of the toes is the normal
response in older children. A Babinski response in children over 2 years of age can indicate neurologic
disease.

9. Tonic neck reflex/ boxer or fencing reflex – when NB lie on their back, their heads usually
turn to one side or the other. The arm of the leg on the side to which his head turns extend and
the opposite arms and leg contracts or flex.
 44

11. Moro reflex – “startle reflex”, single most important reflex indicative of neurological status. Can
be initiated by startling the NB by a loud noise or by jarring the bassinet.
The most accurate method of eliciting this reflex is to hold the NB in a supine position and allow
their heads to draw backward. They abduct and extend their arms and legs. Their fingers
assume a typical “C” position. They then bring their arms into an embracing position and pull up
their legs against their abdomen (adduction). It starts to disappear at 4-5 months. Subsides by
7 months.

12. Babinski reflex – when side of the sole is stroke with a “J” from heel upward the infant will fan
out his toes (+ Babinski sign). It starts to disappear by 3 months of age. Subside by 1 year old.
This reaction occurs to NB because of the immaturity of nervous system.

NOTE: if the adults sole is stroked the adult will

curved in his toes. It is normal for an infant until 1
year of age. But abnormal for adults if still present.

(+) Babinski sign – abnormal

(-) Babinski sign – normal
 45

13. Magnet reflex – if pressure is applied to their soles of the feet of a NB lying in a supine position,
she pushes back against the pressure. This reflex and the two following reflexes are tests of spinal cord
integrity.

14. Crossed extension reflex – one leg of a neonate lying supine is extended and the sole of that
foot is irritated by being rubbed by a sharp object, such as a thumb nail. This causes the NB to
raise the other leg and extend it as if trying to push away the hand irritating the first leg.

15. Trunk incurvation reflex/ gallant reflex – when NB lie in a prone position and are touch along
the paravertebral area by a probing finger, they will flex their trunk and swing their pelvis toward
the touch; subsides by 4 weeks.
 46

16. Landau reflex –head raises, legs and spine straighten when suspended prone, the NB should
demonstrate some muscle tone; a test of spinal cord integrity. Subsides by 4-6 months.

17. Deep tendon reflex

a. Patellar reflex – can be elicited in a NB by tapping the patellar tendon with the tip of the
finger; in older children and adults a percussion hammer is needed to demonstrate this reflex. Test for
spinal nerve L2 thru L4.

b. Biceps reflex - place the thumb of your left hand on the tendon of the biceps muscle on the
inner surface of the elbow. Tap the thumb as it rests on the tendon. Test for spinal nerves C5 and C6.

18. Postural reflex/Parachute – the last of the postural reflex to develop, appears at 8-9 months of
age. When the baby is turned face down towards the mat, the arms will extend as if the baby will
 47

actually bring the arms back to the plane of the body and away from the mat a protective response
which protects the infant if he falls. The infant is suspended by the trunk. The trunk is suddenly lowered
as if the child will fall for an instant. The child will spontaneously throws out then arms as protective
mechanism. Elicited by holding the child upright then noting the body quickly face forward with arms are
reflexively extend.

THE SENSES

1. HEARING. The fetus is able to hear in utero. As soon as amniotic fluid drain or is absorbed from the
middle ear by way of the Eustachian tube – within hour after birth – the newborn can already hear.

2. VISION. All newborn can see at birth as demonstrated by blinking at strong light (blink reflex) or
following a bright light or toy, a short distance with their eyes. They cannot see objects past the visual
midline (not until 6 to 8 weeks). They focus best on black and white objects at a distance of 9 to 12
inches (20 to 22cm). A papillary reflex is present at birth.

3. TOUCH. The most developed of all senses. Newborn demonstrated this by quieting at a soothing
touch and by the presence of sucking and rooting reflexes, which are elicited by touch. They react to
painful stimuli. Lips are hypersensitive. Skin on thighs, forearms, and trunk is hyposensitive.

4. TASTE. As soon as secretions have been suctioned, NB can already taste. A NB turns away from a
bitter taste such as salt but readily accepts the sweet taste of milk or glucose water.

5. SMELL. The sense of smell is present in NB as soon as the nose is clear of mucus and amniotic
fluid.
 48

How will you determine if NB’s are in pain?

According to research, the indications that reveal pain in NBs are the following: fussiness,
restless activity, crying, and grimacing.

NEWBORN SCREENING

A screening test to determine congenital metabolic disorders that cause mental retardation,
physical handicaps or even death if left untreated. This is the screening test for diseases: PKU
(Phenylketonuria), GAL (Galactosemia), CH (Congenital Hypothyroidism), CAH (Congenital
Adrenal Hyperplasia), G6PD Glucose-6-PD Glucose-6-Phosphate Dehydrogenase
Deficiency.

Universal NB Screenings

 When is NB screening done?

NBS is ideally on the 48th – 72nd hour of life. May also be done 24 hours from birth

 How is newborn screening done?

A few drops of blood are taken from the baby’s heel, bottled on a special absorbent filter
card and then sent to Newborn Screening Center

 RA 9288 Newborn Screening Law in the Philippines

 49

DISHARGE INSTRUCTIONS

1.) BATHING
Maybe given anytime as long as the baby is not sick. Do not bath the baby when
newly fed. Thirty (30) minutes after feeding you may give bath because the increased
handling during bathing can cause regurgitation.

Do not give tub bath until the cord has fallen off; sponge bathe are done until cord falls
off (7-14 days).

Bath water should be around 98 to 100 degree Fahrenheit (37 to 38 degree Celsius) a
temperature that feels pleasantly warm to the elbow or wrist.

If soap is used, it should be mild and without a hexachlorophene base.

In giving a bath, it should proceed from the cleanest to the most soiled areas of the
body, that is from the eyes and face, trunk and extremities and last to the diaper area.

2.) CORD CARE

Dab 70% of isopropyl alcohol once a day or twice a day. Use of antiseptic prolonged
drying and separation.

3.) NUTRITION

Proper nutrition is essential, especially in the early months, to fulfill the physiologic
needs because the neonate is growing at such high rate. Rapid brain growth is
occurring. Providing nutrition also fills psychological needs, helping to establish the
parent-neonate relationship.

Breast milk is the ideal nutrition for neonate and ideal food source for the first 12
months of life.

Infants typically gain 1 oz (28 g) /day in the first 6 months. Let the baby suck as often
as he likes (when the baby demands)

EXECUTIVE ORDER 51 (E.O 51) Breastfeeding law in the Philippines

Mothers should exclusively breast fed their infants from birth to 4 to 6 months of age.
Exclusive breastfeeding means giving no other liquid or food to babies from birth to 4-
6months, except breast milk. Breast milk alone is the best possible food and drink before a
baby in their 4 to 6 months of life. Giving other foods or drinks like milk powder, water or
“am” can be dangerous and harmful. Breast milk helps to protect the baby against diarrhea,
cough and colds.
 50

ADVANTAGES OF BREASTFEEDING

The advantages of breast feeding to the mother are: economical, readily available, aids in
uterine involution, less preparation, reduces incidence of maternal breast cancer. In a way
promotes family planning because breastfeeding may delay ovulation but should not be
considered a reliable form of contraception.

The advantages of breast feeding for the baby are: nutritionally superior to all other
options, it enhances maternal-neonatal bonding, ppromotes transfer of maternal antibodies
and reduces risk of infections, breast milk contains secretory IgA which interferes with GI
absorption of viruses and bacteria.

Lactoferrin, a component of breast milk, as an iron-binding protein that interfere with

bacterial growth, leukocyte in WBC found in breast milk provides protection for the neonate
from common respiratory tract infection, macrophages cells that produce interferon, offer
protection from viral invasion. Lactobacillus bifidus, a bacteria found in breast milk, aids in
preventing episodes of diarrhea through its interference with growth of pathogenic bacteria
in the GI tract. Breast milk is more easily digestible because of the greater abundance of
lactalbumin, the higher percentage of amino acids, and softer curd formation. It has a higher
calcium-phosphorus ratio, reducing risk of tetany in the neonate.

It reduces incidence of allergies, colic, and spitting up, dental-arch malformations

secondary to the sucking mechanism used when breastfeeding. Provides adequate electrolyte
and mineral composition for the neonate’s needs without overloading his renal system. Breast
milk promotes rapid brain growth because it contains large amount of lactose, which easily
digested and can be rapidly converted to glucose. Breast milk’s protein and nitrogen contents
provide foundations for neurologic cell building.

COMPARISON BETWEEN HUMAN MILK AND COW’s MILK

HUMAN COW’s
MILK MILK

Protein below 3% above 20%

(CHON)

Carbohydrate above 42% above 32%

 51

(CHO) 6.8g/dl (4.9g/dl)

FATS above 50% above 50%

MINERALS below above

IRON below below

CALORIES 20 20
calories/oz calories/oz

Oligosaccharides in human milk stimulates growth. Human milk contains less

protein. Cow/s milk contains more patients more proteins but the NBs kidneys become
overwhelmed with the higher protein content of cow’s milk that is why cow’s milk need
to be diluted.
The main protein in human milk is lactalbumin and the main protein in cow’s milk
is casein. The curd tension in milk is related to the amount of casein and the curds in
cow’s milk are large, tough and difficult to digest.
Histidine, an amino acid essential for normal growth is found in breast milk. The
ratio of cysteine to methionine (2:2) amino in breast milk favor rapid brain growth in
early months of life.
Human milk and cow’s milk have similar fat content but linoleic acid, an essential
fatty acids necessary for growth and skin integrity is three times higher in human milk
than in cow’s milk.
Human milk contain more carbohydrates (CHO). Lactose in human milk is the
most digestible of all the sugars, it also improves calcium absorption and aids in
nitrogen retention.

MINERALS

HUMAN COW’s
MILK MILK

SODIUM 7 mEq/L 25m

Eq/L

POTASSIU 14mEq/ 36m

M Eq/L

PHOSPHO 12mEq/L 53m

ROUS Eq/L

CHLORIDE 9mEq/L 34m

Eq/L
 52

There are more major minerals in cow’s milk than in human milk but NB’s kidneys
overwhelmed.

BOTTLE-FEEDING

These formulas are classified as:

Milk based formulas, examples are Enfamil and Similac. This is usually
prescribed by pediatrician for the average infant, some may be lactose free to use for
baby with lactose intolerance.
Soy-based formula, such as Isomil and Nursoy, are used for infants who have
protein allergic to cow’s milk.
Elemental formulas are commonly prescribed for infants who have protein
allergies or fat malnutrition.
Formulas are available in several forms: powder which is combined with water
(least expensive); condensed liquid that must diluted, ready to feed, and individually
prepackaged prepared bottles (most expensive).

The advantages of formula feeding are permits the father and other member to
feed the infant; poses fewer restriction on the mother than breast-feeding; allows more
accurate measurement of intake; enables the mother to take medications without risk;
requires fewer feeding than breast-feeding; and enables the mother to feed the infant
in public without embarrassment.

The disadvantages of formula feeding are, cost more than breast-feeding;

requires greater preparation time and effort; requires cleanliness of hands, water and
equipment, and requires adequate refrigeration and storage.

4.) CLOTTING. Rule of thumb: is applied, if the mother feels warm, keep the baby cool if
the mother feels cold, keep the baby warm.
5.) SLEEP PATTERN- babies sleep 16-20 of the 24 hours of the day

Immunity is the ability of an organism to resist a particular infection or toxin by the

action of specific antibodies or sensitized white blood cells.

TYPES OF IMMUNITY
A. Vaccines. It is composed of weakened or dead microorganisms that cause
antibody formation. Vaccines are given to prevent some infectious diseases
transferred by animal bites and injuries.
B. Toxoid. It is a bacterial vaccine that has reduced toxicity but can cause antibody
formation.

Immunity is the ability of the body to fight or conquer infection. There are types of
immunity:

Natural Immunity exist from birth and is a basic form of resistance to disease
 53

Acquired immunity occurs at birth. Can be active or passive. Involves the

manufacture of antibodies against antigens in the body. Takes time to develop and
considered to be permanent. Acquired by the person having a specific disease or by
inoculation with toxoid or vaccine

Passive immunity involves the individual receiving antibodies against antigens

that have been formed someplace other than within the person. Is immediate but effects
are short lived. Is acquired through injection of serum containing antibodies.

If immunosuppressed, receiving corticosteroid therapy, or has an active

infection, should not be inoculated

A. SPECIFIC VACCINES AND TOXOIDS

1.) (Diphtheria, Tetanus toxoid and Pertussis Vaccine)
It produces active immunity by forming antibodies.
 DPT (Diphtheria and Tetanus toxoid) are available for children with
contraindications to pertussis vaccine. Three doses are given at 2-month
intervals starting at 2 months of age followed by a booster 6 to 12 months
after the 3rd dose. Booster is giver at age of 4 to 6 years when starting school.
 Vaccines are contraindicated in children with nervous system disorders and
neurological reaction. Pertussis vaccine is not given to children above age 7.
2.) MMR (Mumps, Measles and Rubella) contains live attenuated virus. Made from
chick embryos. Should not be given to persons allergic to eggs. Given at 15 months.
 DPT and OPV can be given with MMR.
3.) OPV (Oral Polio Vaccine) trivalent contains live attenuated virus that causes three
types of polio. Given at age 2 to 4 months. Third dose is not indicated, in U.S booster
is given between 12-24 months and again at the age of 4 to 6.
4.) Bacillus calmette-guerin vaccine (BCG) produces active immunity to tuberculosis.
Given to infants in countries were TB is endemic. Persons who have had BCG will
have a positive purified protein derivative test (PPD). Also used to stimulate the
immune system in treating cancer. Should not be given to persons taking anti-
tuberculosis drugs.
5.) Hepatitis (Heptavax-B) effective against all types of hepatitis B and recommended
for individuals at risk to contact hepatitis B. It does not prevent an unrecognized
infection already present. Two IM doses are given 1 month apart and a third dose is
given six months after the first dose.

B. Special considerations concerning immunization:

1. If the immunization schedule is interrupted it is not necessary to reinstitute the entire

series. Immunization should occur on the next visit as if the usual interval has
relapsed
2. Immunization status is unknown, children should be considered susceptible and
appropriate immunizations administered
3. For children not immunized during the first year of life and who are less than 7 years
old the same immunization are given but following different time schedule.
4. For children 7 years old and older who are not immunized, Td rather than DPT is
administered
5. Immunizations should not be given during a febrile illness.
 54

6. Live virus vaccines are contraindicated for children with congenital disorder of the
immune system.
7. Live virus vaccines are usually contraindicated for children receiving
immunosuppressive therapy.
8. Hemophilus influenza is the leading cause of meningitis and septic arthritis in infants;
the most recent vaccines offer greater protection.
9. The recommended HIB vaccine should be schedule may vary depending on the type
of vaccine used.

Tubercullin Testing

This is not an immunization, but part of normal screening program for children; included
in immunization schedule. Testing recommended at 12 to 15 months of age, before school
entry (4 to 6 years of age), and in adolescence (14 to 16 years of age). Skin testing is always
indicated for individuals with known contact with a person with tuberculosis disease.

Positive reaction means that child has been exposed and has circulating antibodies to
tuberculosis but does not necessarily have the disease.

References

Flagg. J & Pillitteri Maternal and Child Health Nursing (2020), Lippincott Williams & Wilkins 9 th
Edition

Flagg. J., Maternal and Child Health Nursing (2023), Wolters Kluwer 9th Edition
Perry, Cashion, Alden, Dishansky, Lowdermilk, Hockenberry Maternal Child Nursing Care
(2023), Mosby 7th Edition
DOH Health Manual