CARE OF NORMAL NEWBORN
Care of a normal newborn in delivery room has already been discussed earlier. This chapter deals with care in postnatal wards/home.
• ‘Rooming in', i.e. keeping the baby with mother is best option for normal newborns to facilitate—(a) emotional infant-mother bonding, (b) successful lactation, (c) maternal involvement in baby care and (d) prevention of nosocomial infections.
• Thermoregulation: Hypothermia is a leading cause of morbidity in normal newborns, which may be prevented by—(a) proper room temperature
(~ 28-30°C), (b) avoidance of direct wind movements, e.g. fans, (c) proper cloths* and wrapping of baby in clean sheets and caps, (d) delayed bath till next day, and (e) oil application without vigorous massage to provide protective insulation against insensible heat loss and stimulation to baby (touch therapy).
*Two layers (inner vest and outer frock, to trap the warmth) of soft, loose, easy to wear cotton clothes are advised with additional layers of soft woolen including cap and socks in winter season. Synthetic clothes and diapers must be avoided. A square piece of cotton may be used as diaper.
Kangaroo care is an excellent method to prevent hypothermia, specially in preterms/low birth weights, which involves placement of baby inside mother's clothing with close skin-to skin contact (see Fig. 12.12). It also stimulates lactation and emotional bonding between mother and baby.
• Feeding: Breastfeeding should be initiated as early as possible, preferably in the labor room itself. Successful lactation requires—(a) early initiation, (b) constant motivation, (c) conductive atmosphere, e.g. privacy, (d) demand feeding, (e) no pre-lacteal feeds, (e) proper technique, (g) management of breast/nipple problems, and (h) adequate maternal nutrition (extra 400-500 calories).
• Care of the skin: At birth, baby is covered with vernix caseosa and amniotic fluid, which should be gently wiped-off in delivery room, though vigorously scrubbing should be avoided.
The need for first-day bath is controversial and should be avoided during winter season. Subsequently, baby may be bathed or sponged next day with lukewarm water and unmedicated soap. Medicated, e.g. chlorhexidine soap are not advisable, which may be irritant to tender skin and prevent colonization with normal flora. Dip-baths should be avoided till cord has fallen.Pre-bath gentle oil massage with a non-irritating oil, e.g. olive or coconut oil, is claimed to comfort the baby, improve muscle tone, and strengthen maternal bonding (touch therapy). However, due care is necessary to prevent trauma and hypothermia. Practice of instilling a few drops of oil in nose and ears, prevalent in some communities, may lead to aspiration and should be strongly discouraged.
• Care of umbilical stump: Umbilical sepsis is the commonest source of infection in normal newborns. It should be kept dry, clean and unsoiled from urine/ stool. No topical antibiotic or antiseptic application is required. Cord stump usually falls off on 7-10th day, unless infected. Cord should be regularly examined for signs of umbilical sepsis, e.g. foul smelling pus discharge and peri-umbilical induration.
• Care of eyes: Sticky eyes are common in newborns and not necessarily indicate infection. Excessive watering or stickyness may be due to nasolacrimal duct blockage, which opens up spontaneously after 3-6 months. Eyes say be cleaned at birth and then periodically with a sterile cotton-swab soaked in normal saline.
• Medications are rarely needed, except:
- Single dose of vitamin K (0.5-1.0 mg, PO/IM) to all normal newborns at birth. Low birth weight or sick newborns should receive it by IM route only.
- BCG, OPV and HBV vaccine is indicated to all newborns before discharge.
- IV tetanus immunoglobulin 250-750 IU, only if mother had not received TT in antenatal period and delivered by untrained dai/cord cut by unsterile blade.
• Clinical monitoring for—(a) weight changes, (b) warning signals (see Table 12.17) and (c) adequacy/ problems related to breastfeeding.
Cases with warning signals need transfer to intensive care.• Maternal/family counseling regarding essential aspects of child care, e.g. prevention of hypothermia, breastfeeding, maintenance of hygiene, etc. should be reinforced on daily rounds and on discharge.
When to discharge: A normal newborn may be discharged after 24 hours, if—(a) accepting feeds properly,
(b) has passed urine and stools, (c) has no warning signs as in Table 12.17; (d) has received at-birth immunizations, and (e) mother has been counselled about routine newborn care and recognition of warning signs. Follow-up is indicated at 6 weeks.
Follow-up care: Indian Academy of Pediatrics (IAP) recommends periodic growth assessment of newborns and infants at—(a) birth, (b) during each immunization visits at 6,10,14 weeks and 6, 9 and 15 months, (c) every 6 months from 18 months to 8 years of age and then, (d) annually during 9-18 years.
During each of these visits, baby should be assessed for—(a) growth, (b) immunization status, (c) common health problems, (d) specific health concerns reported by parents. In addition, mother should also be counseled about infant feeding practices, immunization needs, importance of growth monitoring and watch for red-flags signs.
12.5