In Neonatology, normal newborn study is very important. In this chapter all features in relation to newborn are given.

2. Lecture-4
Prof. Dr. Sunil Natha Mhaske
Dean
Dr. Vithalrao Vikhe Patil Foundation’s Medical College and Hospital,
Ahmednagar (M.S.) India-414111
Mo- 7588024773
Mail-sunilmhaske1970@gmail.com
Normal Newborn

3. Neonatal period – From Birth to first 28 days of extra-uterine life.
• It is an important link in the chain of events from conception to
adulthood.
• Newborn undergo profound physiologic changes at the birth
because they have been released from a warm, snug, darkened,
liquid – filled environment, which has met all the basic needs; into
a chilly, glaring, gravity based, outside world.
• Neonate - from birth to under 28 days of age, the infant is called
newborn or neonate.
• Early neonate - from birth to 7 days known as early neonatal
period.
• Late neonate - Late neonatal period extends from 7th to 28th days.
• Term baby - Any neonate born between 37and 42 weeks (259-293
days) of pregnancy irrespective of the birth weight.

4. Assessment of newborn:
• It is done by evaluating newborn by a
scoring method invented by
Dr. Virginia Apgar.
• Virginia Apgar was one of Columbia
University's first female M.D.s. She
graduated in 1933.
• She was one of the first American
• women to specialize in surgery.
• She became Columbia's first-ever
full Professor of Anesthesiology in
1949.
• Apgar specialized in anesthesia and
childbirth. She invented the Newborn
Scoring System, also called the Apgar
Score, in 1949 that assessed the health of
newborns.

5. Apgar score:
Assigned at 0 min, 1 min, 5 min.
Normal score at 5 min is >7.
Sign 0 1 2
Heart rate Absent Below 100 Over 100
Respiratory effort Absent Slow, irregular Good, crying
Muscle tone Limp Some flexion of
extremities
Active motion
Response to catheter in
nostril
No response Grimace Cough or sneeze
Color Blue, Pale Body pink, extremities
blue
Completely pink

6. Based on gestational age, neonates are classified as-
•Premature: < 34 weeks gestation
•Late pre-term: 34 to < 37 weeks
•Early term: 37 0/7 weeks through 38 6/7 weeks
•Full term: 39 0/7 weeks through 40 6/7 weeks
•Late term: 41 0/7 weeks through 41 6/7 weeks
•Post-term: 42 0/7 weeks and beyond.
•Post mature: > 42 weeks

7. (1) Neuromuscular Maturity:
Assessment of newborn by- Modified Ballard Score.

8. (2) Physical maturity:

10. Transitional Assessment –
Periods of Reactivity For a Newborn :
• The newborn exhibits behavioral and physiologic characteristics
that can at first appear to be signs of stress. However, during the
initial 24 hours changes in heart rate, respiration, motor activity,
color, mucous production, and bowel activity occur in an orderly,
predictable sequence, which is normal and indicative of lack of
stress. Distressed infants also progress through these stages but at
a slower rate.
• First period:
For 15 to 30 minutes after birth the newborn is in the first period
of reactivity. At this time his eyes are usually open, suggesting
that this is an excellent opportunity for mother, father, and child
to see each other. For the reason he has a vigorous suck reflex, an
opportune time to begin breast-feeding.

11. Resting period:
• After this initial stage of alertness and activity the infant's responsiveness
diminishes. Heart and respiratory rates decrease, temperature continues to fall,
mucous production decreases, and urine or stool is usually not passed. The infant is
in a state of sleep and relative calm. Any attempt to stimulate him usually elicits a
minimal response. This second stage of the first reactive period generally lasts 30
to 120 minutes. Due to the continued decrease in body temperature, it is best to
avoid undressing of bathing the infant during this time.
• Second period:
The second period of reactivity begins when the infant awakes from the deep sleep
following the resting period. The infant is again alert and responsive, heart and
respiratory rates increase, the gag reflex is active, gastric and respiratory secretions
are increased, and passage of meconium commonly occurs. This second period of
reactivity lasts about 2 to 6 hours and provides another excellent opportunity for
child and parents to interact, This period is usually over when the amount of
respiratory mucus has decreased. Following this stage is a period of stabilization of
physiologic systems and a vacillating pattern of sleep and activity.

12. Skin:
• Colour: Most term newborns have a ruddy complexion because of
the increased concentration of red blood cells in blood vessels.
• Hyperbilirubinemia: Hyperbilirubinemia leads to jaundice, or
yellow coloration of the skin. This occurs on the second or third day
of life. About 50% of all newborns as a result of the break down of
fetal red blood cells.
• Pallor: Pallor in new born is usually the result of anemia. Anemia
may be caused by excessive blood loss during cutting of cord ,
inadequate flow of blood from cord in to the infant at birth.
• Birth marks: A number of commonly occurring birth mark can be
observed in newborn.

13. Cyanosis: The newborns lips, hands and feet are likely to appear
cyanotic from immature peripheral circulation . Acrocyanosis is
prominent in some newborns.

14. Harlequin sign: occasionally, because of immature circulation, a
newborn who has been lying on his or her side will appear red on the
dependent side of the body and pale on the upper side.

15. Haemongiomas:
These are vascular tumors of the skin.
There are three types -
a) nevus flames
b) strawberry and
c) cavernous haemangeomas.
Mongolian spots: are the collection of pigment cells they tend to
occur in children of Asian , southern European or African origin
Vernix caseousa: A white creamy cheese like substance that serves
as a skin lubricant is usually noticeable on a newborns skin folds at
birth in a term neonate.

16. Lanugo: is the fine hair that covers the newborn shoulders ,back and
upper arms. The new born of 37-39 weeks gestational age has more
lanugo than the 40 week old infant.
Milia: Newborn sebaceous glands are immature. At least one
pinpoint papule can be found on the cheek or across the bridge of the
nose. It disappears by 2-4 weeks of age as the sebaceous glands
mature and drain.
Desquamation: Within 24 hours of birth , the skin of most newborns
has become extremely dry. The dryness is particularly evident on the
palms of the hands and the sole of the feet.

17. Erythema toxicum: A newborn rash called Erythema toxicum usually
appears in the first to 4th day of life but may disappear up to 2 weeks of
age.
Forceps' marks: There may be circular or linear contusion on
matching the rim of the blade of the forceps' on the infant cheek. This
mark disappears in 1-2 days along with the edema that accompanies it.
Skin turgour: Newborn skin should feel resistant if the underlying
tissue is well hydrated. If a fold of skin is grasped between the thumb
and fingers, it should be elastic.

18. Head:
• A newborn’s head appears disproportionately large because it
is about 1/4th of the total length, in an adult it is 1/8th of the
total height.
• The forehead of the newborn is large and prominent.
• The chin appears to be receding, and it quivers easily if the
infant is crying.

19. Fontanelles:
The Fontanels are the spaces or openings
where the skull bones join.
 Anterior fontanelle is at the junction
of the two parietal bones and the two
fused frontal bones. It is diamond-
shaped and covered by a thick fibrous
layer. It measures 2-3 cm in width and
3-4 cm in length. It normally closes
with bone when the baby is between
12 and 18 months of age.
 Posterior fontanelle is at the junction
of the parietal bone and occipital
bone. It is triangular and measures
about 1cm in length. it closes by 6 to 8
weeks.

20. Sutures:
The skull sutures, the separating lines
of the skull may override at birth
because of the extreme pressure
exerted by passage through the birth
canal. These never appear widely
separated in newborn.

22. Molding: Molding refers to the long, narrow, cone-
shaped head that results from passage through a tight
birth canal. This compression of the head can
temporarily hide the fontanel. The head returns to a
normal shape in a few days.
Caput succedaneum: This refers to swelling on top of
the head or throughout the scalp due to fluid squeezed
into the scalp during the birth process. Caput is present
at birth and clears in a few days.
Cephalohematoma: This is a collection of blood on
the outer surface of the skull. It is due to friction
between the infant's skull and the mother's pelvic
bones during the birth process. The lump is usually
confined to one side of the head. It first appears on the
second day of life and may grow larger for up to 5
days. It doesn't resolve completely until the baby is 2
or 3 months of age.

23. Eyes:
Swollen eyelids: The eyes may be
puffy because of pressure on the
face during delivery. Edema is
often present around the orbit or on
the eye lids. This will remain for
the first 2-3 days until the
newborn’s kidneys are capable of
evacuating fluid efficiently.
Subconjunctival hemorrhage: A
flame-shaped hemorrhage on the
white of the eye (sclera) is not
uncommon. It's harmless and due to
birth trauma. The blood is
reabsorbed in 2 to 3 weeks.

24. Iris color:
• The iris is usually blue, green, gray, or brown.
• The permanent color of the iris is often uncertain until baby reaches
6 months of age.
• Children who will have dark irises often change eye color by 2
months of age.
• Children who will have light-colored irises usually change by 5 / 6
months of age.
Nasolacrimal duct, blocked:
• If baby's eye is continuously watery, he or she may have a blocked
tear duct.
• This means that the channel that normally carries tears from the eye
to the nose is blocked.
• It is a common condition, and more than 90% of blocked tear ducts
open up by the time the child is 12 months old.

25. Ears:
• The ears of newborns are commonly soft and floppy.
Sometimes, one of the edges is folded over.
• The outer ear will assume normal shape as the cartilage hardens
over the first few weeks.
• The level of the top part of the external ear should be on a line
drawn from the inner canthus to the outer canthus of the eye
and back across the side of the head.

26. Nose:
• The nose can become misshapen during the birth process.
• It may be flattened or pushed to one side.
• It will look normal by 1 week of age.

27. Mouth:
Tongue-tie: The normal tongue in
newborns has a short tight band that
connects it to the floor of the mouth. This
band normally stretches with time,
movement, and growth. If not, it should be
operated before true speech develops
( < 2 years).
Epstein pearls: Little white-colored cysts
can occur along the gum line or on the hard
palate. These are a result of blockage of
normal mucous glands. They disappear
after 1 to 2 months.
Teeth: The presence of a tooth at birth is
rare. Approximately 10% are extra teeth
without a root structure. The other 90% are
prematurely erupted normal teeth.

28. Neck:
• The neck of the newborn is short, often chubby and creased with
skin folds.
• The head should rotate freely on it.
• The neck is not strong enough to support the total weight of the
newborns head.
• The trachea may be prominent on the front of the neck.
• The thymus gland may be enlarged because of the rapid growth
of glandular in comparison with other body tissues.
Chest:
The chest in some infants looks small because the infant’s head
is large in proportion until the child becomes 2 years of age
when chest measurement exceed that of the head

29. Breast:
• Swollen breasts are present during the
first week of life in many female and male
babies.
• They are caused by the passage of female
hormones across the mother's placenta.
• Sometimes the breast will leak a few
drops of milk, and this is normal.
• Breasts are generally swollen for 2 to 4
weeks.
• Nipple size in normal full term neonate is
>5 mm in diameter.
• Supernumarary (accessory) nipples may
be present in few neonates along milk
line.

30. Abdomen:
• The typical findings of the term newborn’s abdomen are Contour
slightly protuberant.
• Bowel sounds present within an hour after birth.
• Edge of the liver usually palpable at 2cm below the right costal
region.
• Edge of the spleen is possibly palpable 1-2cm below the left
costal margin.
• Palpable kidneys (although right kidney is easier to palpate than
left).
• Positive abdominal reflex which can be elicited by stroking each
quadrant of abdomen, the umbilicus moves or winks in that
direction.

31. Umbilical cord:
• Normally cord has two arteries & one vein.
• For the first hour of birth , the umbilical cord appears as a
white gelatinous structure marked with red and blue streaks of
the umbilical vein and arteries.
• After this time, the cord begins to dry shrink and become
discoloured like the dead end of the vein.

32. Genitals:
GIRLS:
• Swollen labia: The labia minora can be quite swollen in newborn
girls because of the passage of female hormones across the placenta.
The swelling will resolve in 2 to 4 weeks.
• Hymenal tags: The hymen can also be swollen due to maternal
estrogen and have smooth 1/2-inch projections of pink tissue. These
normal tags occur in 10% of newborn girls and slowly shrink over 2
to 4 weeks.
• Vaginal discharge: As the maternal hormones decline in the baby's
blood, a clear or white discharge can flow from the vagina during the
latter part of the first week of life. Occasionally the discharge will
become pink or blood-tinged (false menstruation). This normal
discharge should not last more than 2 to 3 days.

33. BOYS:
Hydrocele: The newborn scrotum can be filled with clear fluid. The
fluid is squeezed into the scrotum during the birth process. It is
common in newborn males. A hydrocele may take 6 to 12 months to
clear completely.
Undescended testicle: The testicle is not in the scrotum in about 4%
of full-term newborn boys. Many of these testicles gradually descend
into the normal position during the following months. In 1-year-old
boys only 0.7% of all testicles are undescended; these need to be
brought down surgically.
Phimosis: Most infant boys have a tight foreskin that doesn't allow
to see the head of the penis. This is
normal and the foreskin should not
be retracted.

34. Bones and joints:
• Tibial torsion: The lower legs (tibia) normally curve in because of
the cross-legged posture while in the womb. If we make baby in
stand up position will also notice that the legs are bowed. Both of
these curves are normal and will straighten out after child has been
walking for 6 to 12 months.
• Feet turned up, in, or out: Feet may be turned in any direction
inside the cramped quarters of the womb. As long as child's feet are
flexible and can be easily moved to a normal position, they are
normal. The direction of the feet will become more normal between
6 and 12 months of age.
• Long second toe: The second toe is longer than the great toe as a
result of heredity in some ethnic groups that originated along the
Mediterranean, especially Egyptians.
• "Ingrown" toenails: Many newborns have soft nails that easily
bend and curve. However, they are not truly in grown because they
don't curve into the flesh.

35. Extremities:
• The arms and legs of a newborn appear short.
• The hands are plump and clenched in to fists.
• Newborn fingernails are soft and smooth and are long enough
to extend over the fingertips.
Back:
• The spine of the newborn typically appears flat in the lumbar
and sacral areas.
• Curves appear only when child is able to sit and walk.
• The base of the spine should free of any pin point openings,
dimpling, or sinus tract in the skin which would suggestive of
spina bifida occulta.

36. Newborn Profile
Vital statistics:
Weight- The newborn weight differs according to racial,
nutritional intra uterine and genetic factors. The normal term
newborn infant at birth weighs between 2.5-3.9 kgs in India.
the newborn looses 5-10% of birth weight during the first few
days after birth.
Length: Normal term newborn length is 50 cms in India.
Head circumference: 34- 35cms
Chest circumference: 2 cms less than head circumference.
Vital signs: Counted for 1 full minute
Respirations: 30 to 60 cycles per min - diaphragmatic
breathing
Pulse: 120 to 140 beats per minutes
Blood pressure: Approximately 58/44 mmHg

37. Hematological Parameters:
Hemoglobin: 14.5 – 22.5 gms/dL (1 to 3 days)
9 – 14 gms/dL ( up to 2 months)
Total Leukocyte Count: 9000 – 30,000/cmm (Birth )
9400 – 34000/cmm (24 hrs)
5000 – 19500/cmm (1 month)
Differential Leukocyte Count:
Neutrophils: 57- 67%
Lymphocytes: 25 -33%
Monocytes: 3 – 7 %
Eosinophils: 1 -3 %
Basophils: 0 – 0.75 %
Platelet Count: 84000 – 4,78,000/cmm (up to 1 week)
1,50,000 – 4,00,000/cmm (after 1 week)
ESR: 0 – 10 mm at 1 hr (Westerngren)
0 – 13 mm at 1 hr ( Wintrobe)

38. MCH: 31 – 37 pg/cell (Birth to 3 days)
28 – 40 pg/cell (up to 1 month)
MCHC: 30 – 36 % Hb/cell (Birth)
29 – 37 % Hb/cell (up to 1 month)
MCV: 95 – 121 cμm
RBC Count: 4.0 – 6.6 millions/cmm (Birth)
3.0 – 5.4 millions/cmm (up to 1 month)
Reticulocyte Count: 0.4 – 6.0 % (1 day)
BSL: 40 – 60 mg/dL
Sr. Electrolytes: Na+ - 134 – 146 mmol/L
K+ - 3 – 7 mmol/L

39. Adjustment to extra-uterine life:
Temperature Regulation (Non-Shivering thermogenesis):
• Brown fat is the primary source of heat production.
• Brown fat is broken down into glycerol & fatty acids producing
heat. Brown fat is found at the nape of the neck, axillae, around the
kidneys and in the mediastinum.
• Slightly warmer to touch than normal skin.
• An increase in the metabolic rate associated with non-shivering
thermogenesis --> increased O2 demands and caloric consumption.
• It’s important to provide a neutral thermal environment to prevent
metabolic acidosis and prevent depleted brown fat.
Kidneys and Urination:
• 92% of all healthy infants void in the first 48 hrs of birth.
• Initial urine: cloudy, scant amounts, uric acid crystals- reddish stain
• Kidneys are not fully functional until child is 2 years of age.

40. Respiratory changes:
• The most critical and immediate physiologic change required of
the neonate is the onset of breathing.
• The stimuli that help initiate the first respiration are primarily
chemical and thermal.
• The chemical changes in the blood of low oxygen, high carbon
dioxide, and low pH initiate impulses that excite the respiratory
centre in the medulla.
• The most profound physiologic change required of the neonate
is transition from fetal or placental circulation to independent
respiration.
• The loss of the placental connection means the loss of complete
metabolic support, the most important and essential function
being the supply of oxygen and the removal of carbon dioxide.

41. • The primary thermal stimulus is the sudden chilling of the infant
as he leaves a warm environment and enters a relatively cooler
atmosphere.
• The abrupt change in temperature excites sensory impulses in
the skin that are transmitted to the respiratory centre.
• The initial entry of air into the lungs is opposed by the surface
tension of the fluid that filled the fetal lungs and alveoli.
• Lung fluid is removed by the lymphatic vessels and pulmonary
capillaries, Some fluid is also removed during the normal forces
of labor and delivery.
• As the chest emerges from the birth canal, fluid is squeezed from
the lungs through the nose and mouth.
• Following complete emergence of the neonate's chest, brisk
recoil of the thorax occurs.
• Air enters the upper airway to replace the lost fluid.

42. Circulatory changes:
• Equally as important as the initiation of respiration are the circulatory changes that
allow blood to flow through the lungs.
• These changes occur more gradually and are the result of shifts in pressure in the
heart and major vessels from increased pulmonary blood flow and systemic blood
volume.
• The transition from fetal circulation to postnatal circulation involves the functional
closure of the fetal shunts; the foramen ovale, the ductus arteriosus, and eventually
the ductus venosus.
• Once the lungs are expanded, pulmonary blood flow greatly increases because the
inspired oxygen dilates the pulmonary vessels.
• As the lungs receive blood, the pressure in the right atrium, right ventricle, and
pulmonary arteries decreases.
• At the same time, there is a progressive rise in systemic vascular resistance from the
increased volume of blood through the placenta at cord clamping .
• This increases the pressure in the left side of the heart.
• Since blood flows from an area of high pressure to one of low pressure, the
circulation of blood through the fetal shunts is reversed.

43. • The most important factor controlling ductal closure is the oxygen
concentration of the blood.
• With the backward flow of blood through the fetal shunts, the high
oxygen level of the blood causes the muscular walls of the ducts to
constrict.
• The foramen ovale closes functionally at or soon after birth.
• The ductus arteriosus is closed functionally by the fourth day.
• Anatomic closure takes considerably longer.
• Failure of the ducts to close results in congenital heart defects.
• Due to the reversible flow of blood through the ducts during the
early neonatal period, functional murmurs are occasionally heard.
• In conditions such as crying or staining the increased pressure
shunts un oxygenated blood from the right side of the heart across
the ductal opening, causing transient cyanosis.

44. Gastrointestinal System:
• Sucking becomes coordinated at 32 wks.
• Bowel sounds appears after 1 hour of birth.
• Immature at birth, reaches maturity at 2-3 years of age.
• Little saliva until 3 months of age.
• Newborn have difficulty digesting complex starches and fat.
• Abdomen becomes easily distended after feeds.
• No normal flora at birth in GI system to synthesize Vit. K

45. Meconium :
• The term Meconium derives from ‘meconium-arion’, meaning
"opium-like", in reference either to its tarry appearance or to
Aristotle's belief that it induces sleep in the fetus.[2]
• Initial fecal material is meconium which is passed within 24 hrs
after birth.
• Unlike later feces, meconium is composed of materials ingested
during the time the infant spends in the uterus: intestinal epithelial
cells, lanugo, mucus, amniotic fluid, bile, and water. Meconium is
sterile, unlike later feces, & is viscous and sticky like tar, and has
no odor. It should be completely passed by the end of the first few
days of life, with the stools progressing toward yellow (digested
milk).

46. Sleep
• Deep sleep: closed eyes. Regular breathing , No movements
except occasional sudden bodily twitch, No eye movement.
• Light sleep: closed eyes; Irregular breathing; Slight muscular
twitching of body; Rapid eye movement (REM) under closed
eyelids and may smile.
• Drowsy: Eyes may be open; Irregular breathing; Active body
movement; with occasional mild startles.
• Quite alert: Eyes wide open and bright Responds to environment
by active body movements and staring at close range objects;
Minimal body activity; Regular breathing; Focuses attention on
stimuli.
• Active alert: May begin with whimpering and slight body
movement; Eyes open; Irregular breathing.
• Crying: Progress to strong, angry crying and uncoordinated
thrashing of extremities. Eyes open or tightly closed; Grimaces;
Irregular breathing.

47. Neonatal sleep : Full-term Babies will sleep 16 to 20 hours per
day. They have a 40-minute sleep cycle and cannot differentiate
between day and night. They have 3 different sleep states and
spend half their time asleep dreaming - called REM sleep (Rapid
Eye Movement Sleep) - during which they will suck, grimace,
smile and occasionally twitch their fingers and feet. Premature
babies may sleep 20-22 hours per day with only very short periods
of wakefulness.

48. Thanks a lot