V.N.

Karazin Kharkiv National University

Department of Pediatrics #2

INTRODUCTION TO NEONATOLOGY
ORGANIZATION OF NEWBORN HEALTH CARE

Associate prof. Tetyana Holovko

“The most dangerous time in an infant’s life
is the neonatal period, the 28 days after
birth. For those babies who survived over
seven decades of their lives may be
anticipated.”
H.E. Evans
The state (reaction), reflecting the process of
adaptation after the delivery, to the new
conditions of life is called transitional or
physiological states of newborn.
 They are characterized by the fact that they
appear while the delivery process or after birth,
and then disappear. They often do not require
treatment. They are also called borderline state
because they occur at the border of two periods
(intrauterine and extrauterine) and under certain
conditions may take pathologic features.
 Intranatal period: is starting from the first signs of
the delivery and extends until the birth of the baby.

Neonatal period : the period of adaptation to

extrauterine life, and it finishes with the
disappearance of transient states.
By the definition of the World Health Organization it
lasts for the first 4 weeks or 28 days.

Perinatal period: is the period since the 28th

completed week of gestation till the 7th day after
birth.
Perinatal period
begins since the 28th week of gestation and lasts
till the 7 days after delivery and includes:

a) late antenatal period (since the 28th week of

gestation till the 40th week of gestation);

b) intranatal period (since the first signs of the

delivery till the baby born);

c) early neonatal period (since the birth of the

baby till the 7th day after birth)
Neonatal period
begins since the birth of the baby lasts till the
28th day after birth. Neonatal period is divided
on:
1. Early neonatal period – since the birth till the
7th day after birth.
2. Late neonatal period – since the 7th day till
the 28th day after birth.
 The causes of neonatal transitory
(temporary, physiological) states:

 the environment becomes totally different

 change of barometric pressure

 unstable temperature of surroundings

 other tactile irritants

 microbic environment
 Syndrome of the "just born child"
is associated with the large hormones emission
in the body of the child while delivery process
and an abundance of internal and external
stimuli, shouting and assumes the
characteristic flexion posture. During the 5-10
minutes after birth it is active, is looking for a
thele and vigorously sucks if it is latched on.
Some time later the baby calms down
and falls asleep.
The process of birth can be called the term of
Aristotle catharsis - (Katharsis – old-Greek
soul cleanup). According to Aristotle anger,
fear leads to the purification of the soul and
emotions. Within the first seconds of life the
child is immobilized, does not react to any
stimuli and do not invoke any reflexes.
 Transitory hyperventilation

is observed during the first 2-3 days of life.

After the transition to spontaneous breathing
(first inspiration deploy lungs) appear
periodically irregular respiratory movements
with a deep breath and the complicated
expiration which are directed on the
compensation acidosis at the birth.
The first respiratory movement is called gasp -
the breathing with a deep breath and the
complicated expiration. Observed in healthy
term infants during the first 3 hours of life, and
in average takes 4-8% out of all respiratory
movements.
 Respiratory Adaptations
• Established within 1 minute of birth
• Respirations should be quiet
• Diaphragmatic and abdominal muscles are used
• Nasal breathing
• Normal rate 30-60 inspirations per/minute
• Acrocyanosis and circumoral cyanosis may take
place during 1-2 hrs
• Abnormal, is if respiratory distress nasal flaring,
grunting, costal retractions and a rate less than
30 or greater than 60 inspirations/ minute
 Transitory circulation
There is a significant restructuring circulation.
Circulation of the fetus and newborn differ
fundamentally. Intrauterine circulation has three
shunt to facilitate venous return to the uterine cake
- venous flow and the two right-left shunt, reducing
blood flow through the lungs (patent foramen ovale
and patent ductus arteriosus). Fetus’s blood is
oxygenizing in the uterine cake and comes back to
the fetus through the umbilical vein, which empties
into the portal vein of the liver. Approximately
40% of cardiac output passes through the uterine
cake.
As soon as the pulmonary circulation is
established, venous return towards lungs
increases and pressure in the left atrium rises.
When air breathing begins, paries of umbilical
arteries are decrease and in 45 sec umbilical
arteries are listed as closed up. There is the
decrease in pressure in the right auricle, while
it increases in the left one, what leads to the
closing of oval window.
Anatomic hole obliteration occurs later, a few
months or years later. Soon after a birth
resistance to a circulation in the big circle of
blood circulation becomes higher than in
lungs.
Fig. 4 Bloodstream in heart after birth
Fig. 5 Bloodstream through Botallo 's Fig. 6 Bloodstream through ductus
foramen . arteriosus .
 Neonatal Circulation
• Apical pulse should be counted for a full minute
• Point of maximum impulse (PMI) is at the 4th
intercostal space to the left of the midclavicular line
• Heart rate at birth is120-160 strikes per/minute
• Tachycardia is when it is higher than 160 strikes
per/minute
• Bradycardia is when it is less than 100 strikes
per/minute. Capillary are refilled less than in 3 sec.
• Femoral/Brachial pulses are palpated
symmetrically, strength and rate will provide
information about the change to adult circulation
pattern
• Average systolic pressure is 60-80 mm Hg,
diastolic is 40-50 mm Hg
 Transitory polycythemia
Near 2-5% of healthy newborn have
policithemia. This is the condition when
haematocrit is 0,65 and even higher or
hemoglobin is 220 g/l and even higher in the
first hours of life (peak is the 4th-6th hour).
In this case happens the haemoconcentration:
the level of hemoglobin, erythrocytes and
leukocytes and haematocrit increase.
Clinical signs are not specific: cherry cyanosis,
edema, cyanosis of extremities, oliguria,
tachycardia, muffled heart tones, adynamia,
weakness, increased intracranial pressure,
underlying risk for icterus.
 Transitory hypervolemia
In the airways of fetal lung there is some liquid
(which is different from the composition of
amniotic fluid) in an amount of about 30 ml/kg of
body weight of the child. Fetal lung fluid is
absorbed into the blood and lymph at once after
birth. This is one of the factors which determines
the increase in volume of blood circulation after
birth.
Other reason for the volume blood circulation
increase at this time is very active secretion of
the antidiuretic hormone at once after birth.
Volume of blood circulation for term infants at
birth ranges from 65 to 80 ml/kg of body
weight, rising during 30 minutes -60 minutes
on 20-30 ml/kg of body weight. Transitory
hypervolemia disappears during the second
part of the first day of life.
 Sexual (hormonal) crisis
In some newborn boys or girls on the 3 (third)-4th
day of life it can appear symmetrical breast
engorgement, nipple discharge (white transparent
fluid). It disappear at the postnatal age within 2 or
3 weeks. It does not require management.
 Sexual (hormonal) crisis

Desquamative vulvovaginitis (mucous vaginal

discharge during first 3 days of life) also can
take place in 60-70 % of girls.
In 5-10% of girls on the 5th-8th day of life
can be observed pseudomenstruation which
lasts for 1 day.
It does not require any management.
 Milia
- all newborn sebaceous
glands are immature.
- White papule can be found
on the cheek or across the
bridge of the nose, on the
chin and on the forehead can
be observed at about 40% of
newborns.
- It disappears within 2 - 4
weeks of life, as sebaceous
glands mature and drain.
 Transitory peculiarities
of the renal function
In all newborns during first 3 days of life there
are early neonatal oliguria, transient
albuminuria. During the first week of life 25-
30% of term newborn can have uric acid
infarct.
The clinical features of it are rick-red or dark
orange spots on the draw-sheet or on the
newborns’ clothes after urination. The causes
of uric acid infarct is breaking large numbers of
cells and catabolic orientation of metabolism.
The transitory stool of the newborn is
meconium (Gr.: mekonion, from mekon -
poppy, poppy juice) - a sticky greenish
substance that is excreted during the first few
days after birth. The structure of meconium
consists of residues absorbed amniotic fluid,
bile pigments, desquamated epithelium, thicken
mucus. During the first 3-5 hours meconium is
sterile, later it can contain microorganisms.
The acidity of meconium –
about 6 pH.
 Transitory dysbacteriosis

Frequent watery greenish stool is a clinical

manifestation typical for transitory
dysbacteriosis. All newborns have this change.
The causes of this disorder are bacterial
contamination of sterile intestine and new milk
food.
 Gastrointestinal System

• Audible bowel sounds within 1 hour

• Stomach capacity 30-90 ml.
• Dyscoordinated peristaltic activity in the
esophagus for a few days
• Immature cardiac sphincter
• Enzymes able to digest carbohydrates (CHO),
protein and fats
 Hepatic Adaptation
• Iron is accumulated intrauterine for the
hemoglobin production after birth. If adequacy
will last till 5th month without needing any
supplement.
• Glucose is stored as glycogen for neonatal
metabolic demands
• Due to the rapid depletion of glycogen during the
first 24 hours the glucose level must be between
50 to 60 mg/ml
• Feedings will help stabilize the glucose levels,
which will be between 60-70 mg/ml after 3 days
 Immune System Adaptation

• Neonate depends on three immunoglobulins: IgA,

IgG, and IgM
• IgG crosses the uterine cake and is found in the
fetus by the 3rd trimester. It protects the newborn
against bacterial and viral infections.
• Mother has developed antibodies for tetanus,
measles, mumps
 Immune System Adaptation

• IgM is found in the blood and lymph and is the

first immunoglobulin to respond to infection.
Production starts at birth. If it is increased at
birth it may indicate exposure to intrauterine
infection
• IgA is found in colostrum and can contribute to
passive immunity. It restricts bacterial growth
in the GI tract and is produced gradually.
 Transitory weight loss

Up to 10 % of birth weight loss may occur

during the first 3 to 5 days of life.
The cause of weight loss is depends on food
(deficit of milk and water). Birth weight is
usually regained by the seventh day.
More than 10% of weight loss is indicate of
diseases or badly attendance.
Transitory changes of heat balance:

- transitory hypothermia

- transitory hyperthermia
 Thermoregulation
Newborn physiology
•Normal temperature: 36.5–37.5°C
•Hypothermia: lower than < 36.5°C - significant
contribution to deaths in low birth weight infants and
preterm newborns
•Stabilization period: 1st 6–12 hours after birth
The body temperature is likely to be influenced by the
environmental temperature.
Neutral environmental temperature: the
environmental temperature at which the core temperature
of the infant at rest is between 36.7 and 37.3°C and oxygen
consumption and caloric utilization are lower
 Temperature Regulation
• Newborn’s temperature may drop several degrees after
delivery because the external environment is cooler
than the intrauterine environment
• Rapid heat loss in a cool environment occurs by
conduction, convection, radiation and evaporation;

• Cold stress in the newborn → an increase in

the metabolic rate → increased oxygen
demands and caloric consumption, metabolic
acidosis.
 Signs of Cold Stress / Hypothermia

• cool skin while touching

• Mottling (spots on skin different size) of the
skin
• Central cyanosis
• Decreased responsiveness
• Restless
• Tachypnea
 Transitory hyperthermia

may occur during the first 3 - 5 days of life.

Infant is restless, laps up, has dry mucous. The
causes of hyperthermia is heat stroke or poor
water drinking.
 Transitory erythema
usually appears in all
newborns during first 3-7
days of life because of
capillary reaction of skin
receptors stimulates with
different external
irritants.
After erythema there is a
slight desquamation on
the skin.
 Toxic erythema of newborns
can appear on the 2nd -5th day of life like allergic
reaction. This disorder has 20-30% of term
newborns. It looks like red blotchy rash, associated
with whitish papules (which may look like firm
erythematous macules 1-3 mm, yellow or white
papules or pustules contain eosinophiles and are
sterile). It can be located on the trunk, extremities,
and the face. They are never on the palms, foot and
mucouses. It usually disappears during 2-3 days.
No treatment is indicated.
41
Acrocyanosis is a result
of sluggish peripheral
circulation.
 Transitory hyperbilirubinemia
(physiological jaundice)
Neonatal hyperbilirubinemia is often seen in all
infants around the second day after birth, lasting
until day 8 in term births, or to around day 14 in
premature births.
 Transitory hyperbilirubinemia
Normal level of bilirubin in term newborn is
103-137 mcmol/l. About 30% of term newborns
may have level of bilirubin near 171 mcmol/l.
Level of bilirubin increases by unconjugated
(indirect) fraction. Icterus of skin appears when
level of bilirubin amount increases up to 51-60
mcmol/l in the term newborn and 85-103
mcmol/l in the preterm newborns.
No treatment is indicated.
 Lanugo

- Is the fine hair, downy hair that

covers a newborn’s shoulders,
back and upper arm.
- It also may be found on the
forehead and ears.
- A baby born within 37 - 39
weeks of gestation has more
lanugo than a newborn of 40
weeks.
- By the age of 2 weeks it
disappears
 Mongolian spots
Are collections of pigment cells

 90% of African infants, 81% of Asian, and

9.6% of Caucasian infants
 From slate-gray to blue-black lesions
 Usually over lumbosacral area and buttocks
 The accumulation of melanocytes within the
dermis
 They disappear by school age without
treatment