Neonatology

term newborn and introduction into the area of pathological newborn

Ivan Peychl
The speciality of neonatology
Neonatology is the speciality oriented on the newborn care. During the last 20 30 years, it
has become the independent subspeciality of pediatrics throughout the developed world.
The main reason, why this subspeciality has been set aside, was especially in the ongoing development of more and more complicated specific field of intensive care of the
premature and pathological newborns.
Nevertheless, neonatology as a whole includes the care of healthy, term newborns
(approximatelly 95% of all born babies), as well as moderately premature babies or babies
with moderate disturbances of postnatal adaptation (4%), and above mentioned intensive care
of hardly premature babies or hardly diseased babies (0,5 1%).
Of course, these groups differ much in theor demands for medical care after the delivery.
Term newborn care consists of the observation of normal postnatal adaptation, professional
treatment and some preventive measures, including support of breastfeeding, routine
screening sampling and first vaccinations.
Healthy newborn stays several days in the neonatal department of the maternity hospital, in
the Czech Republic the stay usually takes about 4 5 days. On the other hand, extremely
preterm babies can be immediatelly after the delivery in the critical status requiring extreme
intensive care measures, which can last long days or weeks. Then, it can take several months
until the baby achieves the degree of postnatal adaptation enabling his/her discharge home.
On the base of this postnatal course diversity there was created in the Czech Republic
(similarly as in some other countries) so called three-degree-system of the newborn care.
Neonatology Ist degree departments provide care for healthy term newborns, IInd degree
departments in addition to that care of newborns with moderate adaptation problems (e.g.
babies born between 32nd to 37th week of gestation and/or babies requiring short-term
ventilatory support), and, IIIrd degree departments also called perinatology centers, which
provide, except for the care typical for lesser degrees, the care of newborns with all types of
postnatal disturbances, including long-lasting intensive care of the most serious cases. There
are presently (September 2000) 122 neonatal departments in the Czech Republic, 12 of which
are perinatology centers.
This is the three-degree system what makes neonatal care more effective from professional
and financial point of view. The minority of more serious cases (about 1000 cases/per year
presently) is treated predominantly in the IIIrd degree facilities. Concentration of these more
or less rare cases in the centres make possible for doctors to gain higher erudition and better
skills and for hospitals to use the expensive medical equipment more economically.
Neonatology as a part of pediatrics influences its primary speciality: intensive care caused
progressive fall of infant mortality and improved dramatically the prospects of premature
babies for survival and good quality of life. On the other hand, the increased survival rates of
prematures causes so far the increase of absolute number of children with long-term
developmental defects.
In addition to pediatrics, neonatology is in close interrelationship with the speciality
obstetrics and gynecology. The care of premature and pathological newborns starts mostly
before delivery and so close co-operation between obstetricians and pediatricians is an
essential precondition for finding the optimal treatment, e.g. decision about maintenance or

terminating the pregnancy, about pharmacology treatment of pregnant women etc.

Interconnection between obstetric and neonatology fields in care of pathological pegnancy
cases results in calling this area perinatology or perinatology care.
Relatively new is also the term fetal medicine. It refers to the narrow specific part of obstetric
care aimed at direct treatment of the fetus in the mothers womb (e.g., intraumbilical blood
transfusions to anemic fetuses with severe Rh-isoimmunization).
Basic terms and definitions
Gestational age is the time elapsed from the conception. It represents the age of the fetus in
weeks or, more exactly, in weeks + days (e.g. formula 28 + 5 means 28
completed weeks + 5 days of gestation). Normal pregnancy lasts on average 40
weeks, presumed term of the delivery is counted usually by the last menses
period according to the following formula (TD term of delivery, DM date
of the 1st day of the last menses):
TD = DM 3 months + 1 week.
(For example: if the date of the start of the last menses is June 3rd, the presumed term of
delivery is March 10th).
Exact expression of the gestational age of the baby born just in the presumed term is 40 + 0.
Relative term postconceptional (or postmenstrual) age is used in babies after delivery: this is
the sum of the gestational age and the chronological postnatal age. (E.g., baby born at the age
of 31 weeks has 4 weeks after delivery the postconceptional age 35 weeks).
The delivery the expulsion of the fetus from the womb. Normally vital signs are present in the
fetus after the delivery and the infant is what we call live- born baby. If there are no vital
signs (heart beat, breathing, spontaneous movements) at birth, this is the case of fetal death.
We distinguish between fetal death and abortion (miscarriage). The latter term refers to the
expulsion of the fetus lacking vital signs before completion of 28 weeks of gestation or with
the birthweight lower than 1000g. If the birthweight is lower than 500g, the expulsion of the
fetus is called abortion even if the vital signs disappeare until 24 hours after delivery. These
definitions of the delivery and abortion are formal and used for statistics needs in the Czech
Republic. These definitions may vary a little in different countries and can change with the
progress of the speciality.
Developing capabilities of the medical care decrease the viability limits of the fetus, i.e. the
lowest gestational age at the delivery in which there is the chance for the long-term survival
of the newborn. Presently (2000), completed 23 gestational weeks are considered the viability
limit. Earlier in the gestation born babies are virtually all born dead or dye soon after the
delivery.
Newborn is the baby since the moment of the delivery until the finished 28 days after
delivery. This neonatal period includes early (since the delivery until the end of the 7th day)
and late neonatal period (since 8th until the completed 28th day).
Newborn classification according to the gestational age at delivery:
Term (mature) newborn is the baby born after the completion of 38 weeks and before
completion of 42 weeks of gestation. The baby born earlier, i.e. before
completion of 38 weeks of gestation, is preterm (premature) newborn, the
baby born after the completion of 42 weeks is post-term newborn.
In some countries the baby that completed 37 weeks of gestation is considered mature.

Newborn classification according to the birthweight:

The group of newborn babies with birtweight lower than 2500g is called low-birth-weight
babies (LBW). The birthweight lower than 1500g defines the group of very-low-birth-weight
infants (VLBW) and babies with birthweight lower than 1000g are extremely-low-birthweight infants (ELBW).
Newborn classification according to the relation of birthweight and gestational age at
birth:
Newborn, whose birthweight at birth is adequate to his/her gestational age, is called
normotrophic newborn. If the birthweight is inappropriatelly low for the certain gestational
week (g.w.), the newborn is hypotrofic, if the birthweight is inappropriatelly high, the
newborn is hypertrofic. The birthweight of term normotrophic newborn is approximatelly in
the range 2500g-4200g. To classify the newborn exactly in any gestational week the tables or
centile graphs are used, that vary a little accordint to the sex of the newborn. See graph 1.
Healthy, term newborn is a normotrophic term newborn with normal postnatal adaptation.
Newborns mortality statistics
Is one of the indicators of quality of the newborn care.
Following terms are used:
Neonatal mortality is the rate of newborns (infants younger than 28 days), that died, out of all
live-born.
Early neonatal mortality is the rate of newborns younger than 7 days, that died, out of all
live-born.
Late neonatal mortality, the rate of newborns, that died between the age of 8 28 days, out of
all live-born.
Fetal death rate, the rate of fetal death out of all deliveries.
Perinatal mortality is the sum of fetal deaths and early neonatal mortality.
Postneonatal mortality, the rate of infants that died after 28th day, but until the age of 1 year,
out of all live-born.
Infant mortality is designated as a rate of a infants that died between birth and 1 year of age,
out of all live-born, and is the sum of the neonatal + postneonatal mortality.
Sometimes the term in-hospital mortality is used, which means the sum of the neonatal
mortality and the rate of infants, that died after the 28 th day of age, but earlier than discharged
from the hospital, out of all live-born.
The values are expressed usually either in percent or per mile.
Instead of the term mortality sometimes the reciprocal value is used, called survival. For
instance, mortality 30% corresponds to the survival 70%.
Mortality in specific birthweight groups is called specific mortality.
See some statistical values in the tables.
Table 1: Low-birth-weight rate in the Czech Rep. in 1997 (rounded):
birthweight
rate out of all newborns
(%)
< 2500 g
< 1500g

5,7
0,9

< 1000 g

0,4

Table 2: Approximate values of infants mortality, neonatal mortality and specific neonatal
mortality in certain birthweight groups in CR, 1997-98.
% out of all live-born
infant mortality
0,52
neonatal mortality
0,32
specific neonatal mortality in the group with
22,0
birthweight
< 1500 g
< 1000 g
36,0
< 750 g
58,0

Prenatal period from the pediatricians point of view

Pediatric care starts in the moment of birth of the baby. Nevertheless, number of neonatal
diseases and postnatal complications have its origin in the prenatal period, i.e. pregnancy.
Proper obstetric follow-up is of primary importance. It includes clinical follow-up, follow-up
of the fetal growth, measuring of the growth parametres by repeated ultrsound examination
and ultrasound screening of malformations. The next part is genetic screening the
examination of biochemical markers and ultrasound. The monitoring of blood pressure during
pregnancy is routine. The aim is to diagnose the hypertension of pregnancy and/or the late
gestosis (preeklampsia) as soon as possible. This disease can cause a damage of the placenta,
the early diagnosis can lead to the decision to terminate the pregnancy thus saving the fetus.
Blood group and mothers Rh is also examined in obstetricians office. Then, pregnancies
jeopardized by immunologic colision (incompatibility) of blood groups are followed very
properly. Especially if Rh-negative mother is pregnant with Rh-positive fetus, the fetus is
endangered by so called Rh-isoimmunisation.
Especially in the prenatal period it is important to diagnose early the acute hypoxia, mainly
according to fetal bradycardia examined by auscultation or by cardiotocography (CTG)
monitoring.
In certain special cases, when genetic screening is positive, amniocentesis, chorion villi
examination or chordocentesis (fetal blood sampling via transabdominal umbilical puncture)
may be performed.
When there is serious intrauterine growth retardation (IUGR) present, looking for its cause
may be needed (small placenta, intrauterine infection etc.). Also umbilical blood flow
monitoring by Doppler ultrasound examination may be necessary. Bad blood flow threatens
the fetus and may be also the reason for pregnancy termination.
Above mentioned and some other information about pregnancy circumstances are important
for neonatologists decisions and comprises the main part of newborns medical history. See
table 3.

Table 3: Some pregnancy disorders with impact on fetus

preeclampsia
diabetes mellitus
hypertension
other diseases of heart and circulation: right-left shunt, ischemia
Rh-sensitisation
epilepsia
thyroid gland diseases thyreotoxicosis, hypothyreosis
autoimmune diseases
TORCH infections (toxoplasmosis, rubela, cytomegalovirus, herpes )
sexually transmitted diseases (gonorrhea, syfilis, AIDS)
trauma or surgery in pregnancy
drug addiction
autoimmune trombocytopenia
myastenia gravis
With regard to the above mentioned 3-degree system of newborn care it should be
emphasised, that immediate availability of equipped intensive care unit after delivery is
critically important for the prognosis of the ill newborn. If transfer from one to the other
hospital is necessary, the outcome is significantly worse. Obviously, efforts are made to
concentrate the care of high-risk pregnancies in perinatology centres, i.e. to hospitalize
pregnant women in which signs potentially endangering the fetus were found (e.g., imminent
premature labour, IUGR) preferentially in these centres before the delivery. With regard to the
fetus we speak about the in utero transfer.
Delivery
The circumstances of the labour and delivery are important for the neonatal course. The most
frequent is the spontaneous delivery in occipital position, breech delivery occurs in
approximatelly 5%. This position is more often associated with complications and may be the
reason for cesarean section.
Cesarean section for differing reasons is performed in 5-10% of deliveries, in some centres
with higher occurrence of high-risk pregnancies the frequency may be as high as 15-20%.
The forceps (or vacuumextractor) delivery because of the not-proceeding labour is also
associated with higher risk of birth trauma.
The labour and the delivery of the newborn is the natural process, which most usually
proceeds without problems even in the absence of medical care. Nevertheless, up to date
obstetric care brings a lot of possibilities of monitoring the mother and the fetus in the
antenatal period and during the labor and delivery and prompt treatment of complications.
Owing to the obstetric care the occurence of pathological conditions in the developed
countries decreased significantly and/or their consequences were alleviated: e.g., the perinatal
maternal mortality decreased dramatically, the frequency of perinatal sepsis was decreased to
the minimum, it is sometimes possible to save the fetus even in the case of acute intrauterine
hypoxia, the outcome of premature babies has improved etc. Therefore, the delivery in the
hospital under professional supervision has become standard in developed countries.
On the other pole of the universally active strategy there is a philosophy of so called natural
delivery emphasising uselessness of many of the obstetricians interventions, prefers to allow

the labor and delivery theirs free course and leads sometimes to extreme strategies such as the
delivery in the water basin or deliveries at home without professional assistence.
The reasonable balance of both attitudes is optimal from neonatologists standpoint. The
delivery in the absence of the obstetrician exposes the baby (and the mother) to serious
unnecessary risks. The presence of experienced obstetrician and midwife decreases the risks
of the labour and delivery and may occassionally save mothers and babys life. On the other
hand, it is part of obstetricians responsibility to decide judiciously which interventions to use,
and to be rigorous in using them only if indicated. Some too frequently used procedures and
methods can be reduced this way (e.g., immobilization of the mother, enemas, early
membranes dirruption, episiotomy or external pressure on the uterus which should be
definitely avoided). Unwarranted use of some of these procedures may cause inconvenience
to the mother, who may experience the postnatal period less comfortably, and/or cause some
of complications of postnatal course.
Problems of perinatal analgesia are specific. In accordance with up to date knowledge, the
intensity of experienced pain of labor can be significantly decreased by the use of noninvasive methods like allowing free motion (walking) before the delivery, looking for the
appropriate position for relief (with the aid of apecial tools soft balls, shapeable bags) or
administering warm (warm shower or bath before the delivery). Only if the pain is too
intensive and the mother wishes more potent analgesia, the use of pharmacological analgesia
is appropriate. General analgesia (parenteral administering of opioids or analgesic mixtures)
should be avoided, because it may worsen mothers coopoeration during labor and/or cause
respiratory depression in the newborn. Hence, epidural analgesia should be preferred. Even
the epidural analgesia should be used only if strictly indicated, because its use may lead to
head- or backaches in mother after delivery, thus worsening the cooperation of the mother
after delivery and interfering with the good start of lactation.
In the immediate postnatal period, the philosophy of non-separation of the mother and the
baby is critically important for the lactation commencement.
The practice of separated health-care for both mother and child used to be a big disadvantage
of in-hospital deliveries during past decades. Later, it was found that such practice causes
significantly worse and delayed start od lactation and less successful breastfeeding in the
population as a whole. Therefore, in up to date hospitals the health-care professionals aim to
enable the close mother and childs skin-to-skin contact and nursing from the very first
minutes after delivery and afterwards frequent breastfeeding and common care for both in
one room (rooming-in system) throughout their stay in the maternity hospital.
Immediate postnatal adaptation of newborn
In the fetal period lungs are collapsed and oxygen is delivered in the body by the placental
circulation. It comes via the umbilical vein into the inferior vena cava (either directly or
through the venous duct and portal vein). Only smaller part of blood from the right heart (less
than 10% of the whole blood flow) go through the lungs, although the majority aims directly
into the systemic circulation through the shunts (foramen ovale and ductus arteriosus).
Placental oxygen suply is less effective than postnatal lungs ventilation. That is why
hematocrit of the fetus is higher (45 65% before delivery) and hemoglobin saturation is
lower (about 45%).
The delivery changes the conditions in the circulation. The placental oxygen supply is
interrupted. The newborn responds by the start of regular spontaneous breathing. It is started
with the first inhalation. The latter is more vigorous than later breaths, with lower negative
pressure in the pectoral cavity, because this first breath opens the lungs. The air is inhaled
into the lungs and the transport of oxygen into the pulmonal capilaries starts. The fetal type

of circulation is becoming disadvantageous and necessary redirections occur: umbilical

vessels stop working, right-to-left shunts are closed. The close of foramen ovale and ductus
arteriosus is functional at first but later (after days to weeks) becomes anatomic.
Owing to the above mentioned changes the pulmonal and systemic circulations are connected
after one another, 100% of blood go through the lungs and effective oxygenation of blood and
fast delivery of oxygen into the organs is made. The hemoglobin saturation increases to
normal postnatal values above 95%.
These patophysiologic changes are associated by characteristic clinical manifestations.
Usually, the newborn is born with peripheral cyanosis or mild body cyanosis, which
disappears quickly after breathing was started. If the peripheral vessels are filled well, the skin
colour changes to pink (or even red, if the hematocrit is higher).
The first inspiration is usually, but not always, associated with crying. Baby, that does not
cry, can also breath regularly and adapt normally. The remnants of amnial liquor in the lungs,
that stay in the lungs and airways after lungs expansion, cause wet lung auscultation
rales, but they are absorbed during first minutes after delivery. In the period of the functional
close of shunts, small parts of blood flow can be directed through these shunts. This flow i
hemodynamically insignificant, but can lead to changeable heart murmurs.
So, the skin of the normally adapting newborn becomes pink during the first minutes
after delivery, the baby is breathing regularly, has good muscle tone, responses to
painful stimuli and is able to suck the breast.
Simultaneously, changes in the gastrointestinal and urinary tracts, termoregulation and
metabolism are under way during the first hours after delivery. These changes are parts of
complex babys adaptation to extrauterine life.
Care of the healthy term newborn
After the delivery, the umbilicus is interrupted (ligated and cut) and the newborn is usually
taken to the newborn-care room, where the process of adaptation is quickly evaluated and the
first necessary treatment is performed by midwife, pediatric nurse or pediatrician. One of
these responsible persons assess, whether the adaptation is normally progressing, with use of
clinical experience as well as objective clinical signs: for each newborn, so called Apgar score
is counted and documented (see later in the chapter about asphyxia).
The care of the normally adapting healthy newborn consists of:
1. providing thermal comfort (among others, the temperature of the environment 20 - 22C)
2. drying the skin from the amnial liquor (gentle touching of the skin with clean warm towel,
not rubbing)
3. proper check of the umbilicus ligation, to ascertain umbilicus cannot bleed
4. treatment of the umbilicus tip with aseptic solution and its wrapping with sterile soft
cloth to avoid the injury of the stem
5. weighing and measuring the length of the baby, measuring head and chest circumference
6. treating eyes with aseptic or antibiotic eye drops so called credeisation
7. administering vitamin K
8. labeling the baby such securing unambiguous later identification
To provide thermal comfort to the healthy term baby, it is enough if there is appropriate
temperature of the environment (delivery room), the skin is gently dried and the baby is put
on the abdomen of the mother, whose body affects as a warm source in that case. The back of
the baby is covered with warm towel. If abnormal adaptation is suspected and there is need of

close observation of the baby, or there is even the apparent need of resuscitation, the baby has
to be transfered to the resuscitation room, where machines serve as a source of the warm
(electric heater or incubator).
Mentioned above, skin drying diminishes temperature loss. It is good not to rub the skin and
not to clean vernix from the skin surface, because the newborns skin is very sensitive during
the first days after delivery, there in no resistant superficial layer and vernix constitutes its
natural protection. Too vigorous rubbing irritates the skin and contributes to the development
of the neonatal rash called erythema toxicum on next days benign maculous exantema,
which is itching and provokes scratching and sometimes secondary infection of the skin.
Measuring of the length of the body should be performed in the special measurign device,
where the baby is laying on his/her back and touches the margin of the device with his/her
head. The attempts to measure the length on the table just with tape measure are usually very
inaccurate. The length measuring can be postponed in those babies, whose hip joints are not
movable enough and limbs extension could be painful for them especially after deliveries in
breech position. then, the lenth is measured on the day 2 or 3. Normal length of the healthy
term newborn ranges between 47 55 cm.
Range of normal birthweight of healthy term newborn is 2500g 4200g.
Head circumference measuring is performed with tape measure in the longest occipitofrontal
circumference over the forehead just above eyes and over the most prominent part of
occiput. Normal head circumference ranges between 33 37cm. If there is apparent
subcutaneous swelling (caput succedaneum), the measuring could be also inaccurate and it is
necessary to repeat it after several days, when the swelling disappeares.
Normal chest circumference in newborn should be between 30 37cm and it is shorter than
head circumference in the first half-year of life. It is measured in lying baby at the level of
breast nipples.
The aim of credeisation is the prevention of gonoccocal and/or other bacterial coniunctivitis.
Eyes can be infected while going through the birth canal. In the Czech Republic, aseptic drops
(Opthalmo-septonex) are presently usually used. In some countries drops with erythromycin
are preferred.
Preventive administering of vitamin K decreases the risk of so called haemorrhagic disease of
the newborn. The dose 1 mg i.m. or 1 2 mg. p.o. is used.
Preferrable way to label the baby is a plastic stripe clasp on which the name is written and it
is buckled around the wrist or ankle. Instead, sometimes small circlets with the number of
delivery are used, both for the mother and the baby. Frequently too different ways of labelling
are used. In some countries, as definite way for later unequivocal identification, babys heelfootprint in the chart is used.
The appropriate moment to interrupt umbilical stem is a little controversial. The cut
immediately after the delivery is usual. It allows the prompt transfer of the baby to the
resuscitation room. Nevertheless, when there is optimal technical and personal equipment, it
is mor appropriate to put the baby on mothers abdomen and allow the umbilicus to work one
or two minutes more. This way, slowlier and more continual transition from prenatal to
postnatal type of oxygenation is allowed and early skin-to-skin contact of the mother and the
baby is ascertained, usually with the first breastfeeding. The routine first treatment is several
minutes delayed then. The obvious precondition of this approach is reliable assessment of
normal course of adaptation and no need of resuscitation, and optimal environment of the
delivery room, especially appropriate temperature.

Perinatal asphyxia
About 90% of newborns undergo normal postnatal adaptation and are cared for routinely as
described above. In smaller part (5-10%) the adaptation in the first moments after delivery is
disturbed, hypoxia occurs (perinatal asphyxia) and immediate resuscitation is necessary
instead of routine care.
Asphyxia can be caused by prenatal (placental abruption, cord compression and others) or
postnatal (immature lungs, meconium aspiration and others) reasons.
Apgar score is used to assess the progress of postnatal adaptation:

Table 4: Apgar score

heart rate
breathing

0
asystole
no

muscle tone

very hypotonic,
limbs extension

skin colour

general cyanosis
or pale
no

response to irritation

1
< 100/min
slow, irregular,
or gasping
hypotonic,
but certain limbs
flexion present
peripheral cyanosis
weak, grimace

2
> 100/min
regular,
or crying
normal tone,
limbs flexion,
active movement
pink
defensive movement,
or cry

The score assigns 0 to 2 points to 5 different parameters. The resulting score is the sum, so the
result can have values 0 to 10.
Routinely, Apgar score is assessed 1, 5 and 10 minutes after delivery. The score 8 or more is
considered normal. Typical Apgar score of healthy newborn is 9-10-10 (there is usually
distinct peripheral cyanosis present one minute after the delivery).
The score below 8 reflects usually perinatal asphyxia. The lower the score, the more serious is
the adaptation disturbance. 3 degrees of perinatal asphyxia are usually described: 1st degree
asphyxia (Apgar score 5-7), 2nd degree asphyxia (score 3-4) or 3rd degree asphyxia (score
0-2).
This is a traditional concept of perinatal asphyxia. However, it must be considered that low
Apgar score does not equal the asphyxia. Sometimes the low score can have different reasons
than perinatal hypoxia or stress of the labour. For example, the newborn with congenital
disorder of neuromuscular transmission will suffer hypotonia and/or respiratory distress and
will have low Apgar score, reason of which is not asphyxia. Similarly, premature newborn
has usually weaker muscle tone than term baby and lower Apgar score: again, hypotonia is
not caused by asphyxia, but rather by general immaturity of the baby. (On the other hand,
obviously asphyxia may also influence Apgar score of the premature newborn).
The evaluation with the use of Apgar score helpa us to document the progress of immediate
postnatal adaptation and has also prognostic significance: it was found that even very low
score values in the 1st minute are not associated with developmental disturbances (i.e.,
long-term sequelae and handicaps) if the baby is resuscitated successfully. On the
contrary, still low Apgar scores in 5 th or 10th minute after the delivery are signs of
increased risk of irreversible brain tissue damage.

Apgar score is a tool for clinical evaluation of asphyxia. It is contributing to perform also
laboratory examination umbilical blood pH. Low umbilical pH is also evidence of asphyxia.
pH 7,25 and more can be considered normal in newborn, pH 7,15 7,25 shows 1 st degree
asphyxia, pH 7,05 7,15 means 2nd degree asphyxia and pH under 7,05 is sign of serious 3 rd
degree asphyxia. Very low pH value (less than 7,0) is sign of poor long-term neurologic
outcome, especially if associated with low BE, meaning that acidosis has its significant
metabolic component, i.e. acidosis is probably already long-lasting.
Using both approaches to evaluate asphyxia, Apgar score as well as umbilical blod pH, can
contribute to finding etiology of asphyxia: if Apgar score and umbilical pH are decreased
simultaneously, the cause of asphyxia is probably prenatal (ubmilical cord complication,
placental abruption, intrauterine infection). If pH is normal, while Apgar score is low, the
cause is more likely postnatal (for example, pharmacological depression with opioids
administered to mother during the delivery, meconium aspiration or RDS).
So, assignment to those 3 degrees of asphyxia is not necessarily corresponding with both
methods.
If the baby suffering asphyxia is not promptly efficiently resuscitated, hypoxic damage of
organs occurs. The most significant consequence in surviving children is a brain damage,
(hypoxic-ischemic encephalopathy, HIE). Morphological corelate of the latter may be
cortical atrophy or brain cysts, whereas functional corelate is a disturbance of a motor
development (cerebral palsy), sensoric malfunction (vision or hearing deficits) and/or
cognitive deficit.
Resuscitation of the newborn
Data shows, that each year approximatelly 5 million of newborns die worldwide. In about
19% of them, i.e. about 1 million, the reason of death is perinatal asphyxia. These numbers
underline the importance of resuscitation techniques knowledge in all health-care givers
involved in newborn care.
The primary precondition for the successfull resuscitation is optimal thermal comfort.
Hypothermia increases tissue oxygen consumption, such decreasing the chance for succes of
the resuscitation. On the other hand, it is also imperative to avoid hyperthermia, which may
cause the respiratory depression. Ideally, newborn should be cared for in the electric heater
with the opportunity of the fine heating intensity adjustment.
(It is possible, that in the future the selective hypothermia of the brain will be used as a part of
treatment protocol for perinatal asphyxia. Some data shows potential of this treatment for
improving outcome. Nevertheless, the method is in the early stage of clinical experiments).
The first step of the resuscitation is to secure the patency of the airways. This is provided by
positioning and suctioning. The adequate position of the baby is on his/her back, head
aiming to the resuscitating person. The head must not be hyperextended (difference from
older children) nor in anteflexion, nor bowed to side. The right position is neutral or
slightly extended (sniffing position).
Suctioning is important particularly if there is content in the mouth which obturates airways
and hampers breathing (bigger amount of amnial liquor) or may cause aspiration (liquor with
solid meconium). It is necessary to suction quickly and as gently as possible, from the mouth,
upper airways and nose. If there is meconium in the liquor, it is necessary to suction
repeatedly, including stomach. One has to avoid too aggressive suctioning: rough irritation of
the palate can lead to vagal reflex with bradycardia and laryngospasm thus causing more harm
than benefit.
Next steps depend on the newborns status. If the asphyxia is mild, circulation works (heart
rate more than 100/min) and at least irregular spontaneous breathing is present, we can start
resuscitation with tactile stimulation. It means rubbing of the skin in lumbar area or on the

10

plants. This technique may contribute to physiologic reflexes triggering normal adaptation
and regular breathing. Next step may be oxygen inhalation via mask: mask is put on the
mouth and nose of the baby, which then inhales 100% oxygen and oxygenation of his/her
body is made easier. If the status of the baby improves quickly, the cyanosis is disappearing
and regular breathing begins, next resuscitation may be unnecessary.
If the asphyxia is more serious, the baby struggles for air (gasping) or does not breath at all,
the intermittent positive pressure ventilation with bag and mask is necessary. The mask is
put over the mouth and nose again, but his time the mask has to adhere tightly to the skin of
the face, encircled with fingers of one hand (the left one in right-handed persons). The gas
mixture cannot escape then. Thus the establishment of positive pressure is enabled. The other
hand compresses the bag rythmically with the rate about 40-60/min. The most important
while resuscitating this way is to maintain the right position of the body and head and the
patency of airways, and the same time to create sufficient pressure to ventilate the lungs.
Nevertheless, the pressure must not also be too high, because this could cause lung injury
including pneumothorax. For the first inspirations higher pressures are usually necessary.
Later, when the alveoli are already filled with air (oxygen), lower pressures may be enough.
The efficacy of the positive pressure ventilation is confirmed by rythmical movements of the
chest and/or lungs auscultation. (The adequate strength of bag compressions can be practiced
with the bag with affixed manometer. The right pressure is about 25 30cmH 2O, for the first
inspirations 30 40 cmH2O.
If there are no heart sounds at all or serious bradycardia is present (less than 60/min), we
perform chest compressions together with positive pressure ventilation. The chest is
compressed rythmically in the area of lower third of sternum, approximatelly to one third of
the distance sternum-backbone. 2 techniques may be used. a) hands are put under the body of
the baby and thumbs are crossed on sternum (picture 1), or b) we cross second and third
finger of both hands on sternum. Recent data seem to show that the first described technique
is more efficient and should be preffered. Also while compressing sternum the sufficient but
not too big strength is important. The right compressions rate is 120/min.
Because chest compressions and positive pressure inspirations are performing simultaneously,
the rythm is importnat. The right rate compressions : inspirations rate is 3:1, usually 120
compressions and 40 inspirations per minute. The optimal rythm looks like this: inspiration
1st compression exhalation 2nd compression 3rd compression.
If the babys status is so serious that bag and mask ventilation does not seem to be efficient
enough, we perform intubation.
We have to prepare properly for intubation. Again, the above described position of the baby is
important. The intubating person needs assistant (nurse or colleague) which holds the
appropriate, straight position even when the intubating doctor concentrates on the view of
larynx. Further, the appropriate laryngoscope has to be prepared (Miller with straight blade,
number 0) with good batteries, adequate endotracheal tubes (see table 5) and stripes of wellsticking adhesive plaster for tube fixation.
The procedure itself starts with introducing the tip of the blade of the laryngoscope into the
right mouth corner and push the blade right to the vallecula glossoepiglottica. The tip of the
blade is pressed gently against the bottom of the vallecula. Thus, the epiglottis is pushed away
and the view into the larynx is uncovered: white vocal cords aiming down and diverging
obliquely and the laryngeal entrance between them. Then, the larynx is positioned as to be in
the center of the view, with slight laryngoscope movements and/or with the slight external
pressure on the cricoidal area (with the middle finger of the other hand). After that, the tip of
the endotracheal tube is inserted into the trachea (enough, but not too deep, see table 5).

11

Table 5: Recommended diameter and deepness of introduction of endotracheal tube (ETC)

according to the weight and gestational age of the newborn baby. Valid for orotracheal
intubation.
Weight (g)
< 1000
1000 - 2000
2000 - 3000
> 3000

gestational age
(week)
< 28
28-34
34 - 38
> 38

ETC insertion deepness

diameter
(cm from upper lip)
(mm)
2,5
6,5 - 7
3,0
7-8
3,5
89
3,5 4,0
>9

Usually, the right-handed person uses his/her right hand to intubate. After finding the good
larynx view the laryngoscope is passed to the left hand and the right hand inserts the tube.
Some right-handed people use the left hand to hold the laryngoscope from the beginning of
the procedure.
Soft endotracheal tube may twist such making the insertion just between the vocal cords more
difficult. Sometimes it helps if the tubes are stored in the environment with low temperature,
where the material becomes tougher. Or, the introducer can be used sterile aid passed
through the endotracheal tube such making it stiffer. After the successful insertion teh
introducer is pulled back.
Adequate deepness of the insertion is of critical importance. Insufficient deepness can lead to
undesirable spontaneous extubation. On the other hand, if the tip of the tube is too deep, it
aims already into the right main bronchus and the baby is endangered with collaps of the left
lung and emphysema of the right lung.
After insertion of the tube its adaptor is connected with the adaptor of the ambu-bag.
The appropriate deepness of the insertion is confirmed according to the centimeter scale
marked on the tube and checked with the lung auscultation: the mechanical inspirations
should be heard symetrically on both sides. If the breathing sounds are very quiet above both
lungs and, conversely, the loudest above the stomach, it is likely that the tube has been
inserted incorrectedly into the oesophagus. Then, the breathing movements of the chest are
lacking. If the breathing sounds are heard well on the right side but clearly weakened on the
left side, the insertion is too deep and the tip of the tube aims into the right main bronchus.
After the right position of the tube is confirmed, the tube is fixed to the face with two plaster
stripes. After the fixation another check of the position is needed, because sometimes one can
shift the tubeto the incorrect position while fixing it. If we are in doubts about the right
position of the tube, it can be confirmed also by x-ray. The tip of the tube should be under the
level of the vocal cords but above the level of carina. In the x-ray picture it means the position
between the medial ends of clavicles or slightly under this level. Recently developed aid
contributing to confirmation of the correct position of the tube is the device measuring CO 2 in
the exspired air.
The intubation has it alternative in introducing of the laryngeal mask. However, this
technique is not equivalent of the intubation comes into consideration only if the equipment
for intubation is not available or the attempts to intubate were unsuccessful.
The combination of intermittent positive ventilation (with bag or via endotracheal tube) and
chest compressions, i.e. complete cardiopulmonal resuscitation, is a technique enabling

12

successful resuscitation of absolute majority of asphyctic newborns. summary of the

procedure see in the picture
Schema 1: Steps in resuscitation of the newborn

approximate time

Birth
Clear of meconium?
Breathing or crying?
Good muscle tone?
Color pink?
Term gestation?

YES
----------

ROUTINE CARE
- provide warmth
- clear airway
- dry

30s

NO

Provide warmth
Position, clear airway (as necessary)
Dry, stimulate, reposition
Give O2 (as necessary )

30s

30s

Breathing
Evaluate respirations, ----------------------
SUPPORTIVE CARE
heart rate and color
HR > 100 and pink

Apnea or HR < 100

ventilating
Provide positive pressure ventilation * --------------------- ONGOING CARE

HR > 100 and pink

HR < 60 HR > 60
Provide positive pressure ventilation*
Administer chest compressions

HR < 60
Administer epinephrine*
* ENDOTRACHEAL INTUBATION MAY BE CONSIDERED AT SEVERAL STEPS

13

Pharmacological resuscitation is of secondary importance. It is beginned, if cardiopulmonal

resuscitation is unsuccessful for longer period of time (1-3 minutes). See the table 6 for
reccomended drugs, doses and ways of administration.
Table 6: Drugs used for resuscitation:
drug
epinephrin
volumexpander
saline, Ringer-lactate
0 negat.ery koncentrate
naloxon

bicarbonate

indication
dose
asystole,bradycardia< 60/min 0,10,3ml/kg sol. 1:10 000
hypovolemia
10 ml/kg in 5 10 minutes
depression
with
opioids 0,1mg/kg
administered to the mother
during last 4 hours before
delivery
prolongated resuscitation
1 2 mmol/kg

Some aspects of pharmacological resuscitation are controversial. It is considered appropriate

to administer epinephrin in asystolic or seriously bradycardic baby and to administer naloxon
if the depression with opioids is suspected. If hypovolemia is likely, volumexpansion is
indicated. Bicarbonate does not belong to primary drugs used in resuscitation of the newborn
and should be considered only if the resuscitation is not successful for extended period of time
or if metabolic acidosis is confirmed by laboratory evaluation. Tthe use of calcium and
magnesium preparations is controversial.
The fastest way to administer the drug is the intratracheal one. It is possible in epinephrin and
naloxon. Naloxon can be administered also subcutaneously or intramuscularly, if the
peripheral perfusion is still satisfactory. To secure the vein we perform the umbilical vein
cannulation.
Also possible, but not frequently used is intraosseal way.
It is good to practice the technique of resuscitation on the mannequin.
Newborn examination
Early after the delivery the baby is usually examined by pediatrician, either in the delivery
room or during the first hours after the delivery in the neonatal department.
The examination is preceded by taking the detailed history of the family, pregnancy and
delivery.
Detailed physical examination serves to the assessment of the general status of the baby and
exclusion of congenital malformations. The newborn should be examined when naked, in
warm environment on well enlightened place, preferably in parents presence, enabling to ask
for peculiarities of the history. It is also advantageous to allow to the parents to tak part in the
examination, for example by undressing the baby, holding the baby on their knees during
certain parts of the examination etc. The examination is easier if the baby is quiet and happy.
It may be contributing to allow the baby to hold the parents or doctors hand (finger). The
firm surface of the table and the feeling of stable position are also important for the baby. It is
necessary to remember, that the muscles of the neck of the baby are not able to support the

14

head. Therefore, if we pick up the baby, we hold him/her with one hand under the back and
with the other one support the head, holding it along the body axis. See picture 2.
The correct evaluation of all findings in newborn examination is a matter of clinical skills and
experience and cannot be fully explained by words. It is true for instance for assessment of the
maturity of the baby, normal findings in lungs auscultation, assessment of the muscle tone etc.
From this pint of view, the following text is the instruction which can lead to the knowledge
of newborn examination only together with clinical practice.
The examination begins with observation of the baby. We observe the behaviour does the
baby sleep or is alert, is he/she crying, is the anomalous irritability present or, conversely, is
the baby lethargic and generally hypotonic? We evaluate, how regular the breathing is and
exclude rspiratory distress jugulum, intercostal spaces and/or hypgastrium retractions,
grunting. We observe spontaneous movements of extremities and head. The intensity and the
tone of cry should be noticed healthy newborn has a strong and clear voice, congenital
anomaly of larynx may cause stridor, CNS damage may lead to high-pitched voice. We
evaluate the proportions of body parts, face features, presence of apparent congenital
malformations, deformations or deformits. If we suspect anomalous facies, firstly we compare
the face features of the baby with features of the parents. Seemingly unusual features of the
face could be rather familial variation than pathological findings. However, sometimes real
signs of hereditary syndrome can be found, e.g. anomalous size or shape of the head, low
position of external ears, eyes anomalies, Gothic palate etc.
Also babies with congenital palsy of n. facialis have characteristic facies, which is most
apparent in crying baby: on the side of palsy the mouth corner is not raising and the nasolabial
crease is wiped out.
See the most frequent visible syndromes and malformations in the tables 7 and 8.

Table 7: The most frequent hereditary syndromes which can be diagnosed by the first
newborn examination with their signs.
Syndrome
M. Down, 21 trisomy

most usual phenotypical signs in newborn

mongoloid shape of eyes, epicanthal folds, flat occiput, transversal
palmar creases, bigger distance between the 1st and 2nd toes,
sometimes heart murmur
M. Edwards, 18 trisomy hypotrophy, crossed 2nd and 3rd fingers and 5th and 4th toes,
microcephaly, micrognathia
M. Patau, 13 trisomy
cleft of the palate, low position of external ears, microphtalmia
Turner syndrome, XO
hypotrophy, shorter length, lymphedema of the backs of hands and
feet insteps

Table 8: Some more frequent isolated malformations

which can be diagnosed in the first newborns examination
cleft of the lip and palate
polydactylia, syndactylia
reduction deformities of extremities
15

microcephaly, macrocephaly, hydrocephalus

choanal atresia
omphalocele, gastroschisis, urinary bladder exstrophy
spina bifida, meningomyelocele, encephalomyelocele
hypospadia, epispadia
pes equinovarus, pes calcaneovalgus
Assessment of the maturity (gestational age in delivery) is a part of newborns examination.
This is a clinical estimate which can be used as a correction of inaccurate prenatal evaluation
according to the last menstrual period of the mother. Several body signs are used for
approximate estimate. The external ear of the mature newborn is fully shaped and has a stiff
and elastic cartilage. The cartilage of premature baby is soft and lacks flexibility. Mature
infant has fully developed breast nipple prominating over the level of the skin and palpable
gland with diameter about 5 mm under the areola. The more premature the delivery, the less
developed the nipple and the gland are and so in very premature babies born before the 28 th
week the nipple is flat and the gland not palpable. The skin of the mature newborn on plants
is richly creased. Premature babies have shallow creases, in very premature ones the plant is
flat and free of drawing. Genitalia of the mature boy is developed to the stage of fully
descnded testicles, the scrotum is pendulating and the skin is creased. In premature boys the
incomplete descensus of testicles is more usual, scrotum is smaller with flat skin. Labia
majora of mature girls are clearly bigger than labia minora and cover the latter, while in
premature girls the difference is not so clear. Except of these basal signs there are complex
scoring systems (Dubowitz, Brazelton) based on examination of many physical and
neurological signs of maturity. These systm are time-consuming and not widely used.
The nutritional status is evaluated according to the layer of the subcutaneous fat (thinner in
hypotrophic babies, where the skin is folded on thighs, face is of old man appearance) and
classification according to exact growth parameters in centile graphs. The most informative is
the relation of birthweight and gestational age.
We observe the skin colour and peripheral perfusion quality. Newborns epidermis is covered
with slimy and whitish layer of vernix caseosa. Vernix protects the skin of the fetus in the
intrauterine life where the skin is exposed to the action of amnial liquor, and goes on to
protect the skin during the first hours after the delivery, when the skin of the newborn is very
sensitive. The skin of the healthy newborn is pink and without peripheral cyanosis severeal
tens of minutes after the delivery. In some babies the skin is rather red than pink, because the
hematocrit is high. (Due to the increased hemolysis during the first days of life hematocrit
decreases quickly so that after 7 10 days the skin is much paler.) Persistent significatn
peripheral cyanosis and especially central cyanosis is anomalous. The term central cyanosis
refers to the blue colour of circumoral skin, body and mucous membranes of the mouth. This
is the evidence of circulatory maladaptation (e.g. as a consequence of congenital heart defect
or pneumopathy). Erythema or angiomatosis on the skin of the forehead, face or the eyelids
are very frequen and usually disappears during the first days. Even more frequent are so
called milia, whitish or yellowish dots visible usually on the nose or cheeks. They are also
benign. Harlequins skin is the skin divided sharply in 2 halves with different colours: one
half is white and the other one is red. It is a striking transient sign with no specific underlying
pathology and probably no prognostic value.
There is no jaundice on the skin of healthy newborn during the first 24 hours. Normally, the
jaundice appears not earlier than on the day 2. If it appears sooner or even is present at
delivery, it is early jaundice caused most usually by Rh or ABO isoimmunization.

16

Peripheral perfusion can be basically assessed by performign short pressure with a finger on
the small skin area: after relieving the skin we observe the speed of blood refill, which should
last not more than 2 seconds. If the peripheral perfusion is worsened, the peripheral parts of
extremities use to be colde, too.
Sometimes the hemangioma of the skin can be found, usually planar, and most frequently
benign, sometimes with tendency to involute spontaneously. However, bigger hemangiomas
neccessitate proper follow-up in next months and prospective dermatologic treatment.
Exceptional is Sturge-Weber disease with a large planar hemangioma of one half of the face
and head: this can be associated with intracranial and intraocular hemangiomas,
developmental disorder, seizures and vision disturbance.
Brown nevi can be also found on the skin, usually benign. It is good to describe the size of the
nevus properly for later compartion. Also petechie can be revealed. The most probable reason
is an increased venous pressure during the labour and delivery. Then, petechie are located on
the face or head, sometimes very rich, with appearance of continual blue areas. If petechie are
generalised, trombocytopenia must be considered (caused by intrauterine viral infection,
action of antitrombocytic antibodies etc.). Hematomas can be found on the head,
extremities,in the pelvic area or in other locations. Sometimes they are becoming to be
apparent only several hours after delivery. Large sufusions lead to suspicion of coagulation
disorder. Frequent finding during the first week is erythema toxicum. It can begin as several
small red spots, sometimes confluencing and covering bigger surfaces, and not rarely
generalised. This is a response of the sensitive skin to first postnatal contacts with
extrauterine environment (touches of napkins, hands etc.) It s evolvement is less likely if the
skin is cared for gently during the first hours, without rough rubbing, and if vernix is left on
the skin at least several hours. This is an itching exantema but disappears spontaneously until
the end of the first week. It is good to avoid scratching of the skin which could support the
secondary infection. 1- 2 chamomile bathes per day seems to relieve itching. So called
mongolian spot, red-violet area of the skin in lumbosacral location, is insignificant finding,
more usual in asian races.
The order of examination uses to be described craniocaudally. However, if the baby is quiet, it
is advantegeous to begin the examination with heart and lungs auscultation. Later, baby
usually start to cry and the auscultation may be more difficult.
Lung auscultation gives information about normal postnatal expansion of the lungs: one
should hear symmetrical alveolar breathing. We assess regularity and rate. Normal rate of
breathing in newborn is about 40/min, with range about 30 60/min. The brathing of a
healthy newborn is not necessarily absolutely regular, but time intervals between breathes
should not exceed 10 seconds. Longer interval is called apnea. One-sided weakening of
breathing sounds may be caused by atelectasis, emphysema or pneumothorax. Breathing is
weakened bilaterally in RDS or pneumonia. Grunting is a specific expiratory sound which
may be listened in respiratory distress. Inspiratory stridor may be caused by inborn
feebleness of ligamentous laryngeal structures (stridor laryngis congenitum), usually transient,
but it may also have its origin in vascular ring compressing trachea or in tracheomalacia.
While auscultating heart, the heart rate is counted (normal range in quiet baby 100160/min) and the regularity of heart beat has to be assessed. Respiratory arrhytmia is not
present in newborn but mild undulations of the rate is normal. If the irregularities are more
pronounced, the ecg examination and/or ecg monitoring is indicated to rule out serious
ventricular dysrythmias. We are looking for murmur. The heart sounds are distinct in healthy
newborn, but sometimes quiet changeable murmur associating physiologic postnatal
adaptation of circulation may be present transiently. Rough or unusually loud murmur may
lead to suspicion of congenital heart defect and indication of echocardiography.

17

The shape of the head should be noticed: mesocephalic shape is usual in babies born by
cesarean section or in breech position. After the head-position delivery the shape may be
modified during the first hours, sometimes quite a lot usual elongation of the scull to the
vertex is caused by the compression of the head in the birth canal and the flexibility of the
sutures. The shape changes to normal in several hours. The anterior fontanelle should be
palpated. It is open in healthy newborn, the most usual diameter is 2-3cm. However, the
diameter of only several mm orconversely, 4-5cm can be also physiological. Open sagittal
suture and open posterior fontanelle may be signs of delayed scull ossification. If the anterior
fontanell is extraordinarily large and/or the head circumference is increased, the ultrasound
examination of the brain is appropriate to rule out hydrocephalus. Whole scull should be
palpated thoroughly. The finding of fractures is rare, but possible, especially after the forceps
delivery. Caput succedaneum is usual finding: it is a soft doughy edematous subcutaneous
infiltration, most often in the occipital or parietal area. This is caused by the lower pressure in
the vessels of just delivered head of the newborn (before the delivery of the rest of the body)
and is transient, disappears after several days. Sometimes one can find kefalhaematoma,
subperiostal bleeding, which is tough, fluctuant and located usually in parietal areas, often
bilaterally. Its consistence is different from caput succedaneum and it does not cross the
borders of the sutures. It resorbs longer time, goes through the period of partail calcification
and may persist to the second month of age.
We examine the external ears. Soft and inflexible cartilage suggests immaturity of the baby,
anomalous shape or low position of external ears may be sign of genetic disease. These
findings should lead to looking for other morphological anomalies. There can be found skin
outgrowths in front of the ears, usually benign, but occassionally also as a part of genetical
syndromes. It is usually possible to remove the outgrowths by simple strangulation with
sterile thread. However, it is probably preferable to refer the patient to plastic surgeon.
The eyelids use to be swollen after birth. It is better, then, not to open the eyes violently, but to
postpone the eye examination one or two days. Also next time the baby may have closed eyes
while examined. Vestibular reflex may be helpful: we hold the baby vertically and perform
several rotational movements around the vertical axis of the body, in the angle about 90, back
and forth several times. The baby usually opens the eyes during this maneuvre. Newborn is
able to recognize main features of the face of the examining physician and to follow the face
again approximately in the angle 90. But, the accommodative ability is limited in the
newborn, and so the face has to be in optimal distance , approximately in adults arms
distance. If the baby follows our face with movements of his/her eyes, the amaurosis can be
practically ruled out.
Very frequent finding is a bleeding under corneal conjunctiva (subconiunctival suffusion or
episcleral hemorrhage), which may be apparent on one or both eyes as very conspicious red
spots on sclera. It is also caused by increased pressure when the head goes through birth canal
and it is harmless. Usually it disappeares spontaneously after one or two weeks. The
congestion of conjunctiva can occur in the first days or even infectious conjunctivitis. From
the half of the first week the scleral jaundice can be found. Chorioidal koloboma, enlarged
bulbus in congenital glaucoma or dim whitish pupils in congenital cataract are rare findings.
The size of bulbi should be noticed. They should be symmetrical, comparation with adults
eyes may be helpful. We ask the mother to hold the baby on her arm, with her own cheek next
to the cheek of the baby. The increased bulbus of the infant may seem bigger than adults eye.
It is possible to examine newborns red reflex using opthalmoscope or retinoscope, thus
confirming the translucency of eye media.
We can find cleft of the lips, more usually paramedial, either unilateral or bilateral and more
often associated with a cleft of the palate than isolated. We observe the mouth where the
isolated cleft of the palate can be sometimes found. The palate should be palpated with a clean

18

finger to rule out the hidden submucous cleft. If the cleft was found, it is important to be
careful with feeding in the beginning. Some babies are able to suck and to be breastfed, but
sometimes the bottle feeding is necessary. We have to prevent milk aspiration. Parents are
usually terrified by the finding and it is important to reassure them and to offer the
information about the possibilities of successful surgery. It is advantegeous to be prepared to
show the parents the pictures of older children who underwent such surgery. See picture 3.
When the baby has a cleft, we are looking for the associated anomalies. If teh cleft is isolated
finding, we refer the baby to plastic surgeon. The surgery is performed in several steps during
the first years of life. The lip is usually operated during the first months.
Short sublingual frenulum is usually variation of physiology and should not be operated in
newborn it is likely, that it will improve to normal function. The finding of neonatal tooth is
rare. It is necessary to extract the tooth gently to avodi the aspiration. Mild salivation is quite
usual, especially during the first days, when thegastrointestinal peristalsis only begins and the
baby spits up the remnants of amnial liquor. Enormous salivation, however, should not be
omitted. It can be sign of swallowing difficulties in neuromuscular disorder, for exaomple in
congenital myotonia, or esophageal atresia. If atresia of esophagus is present, the salivation
is often associated with episodes of cyanosis. The suspicion of esophageal atresia leads to
sondage of the esophagus, which confirms whether the esophagus is clear to the stomach. If
the atresia is confirmed the permanent tube should be put into the blind stump of the
esophagus, the saliva should be suctioned continually and on the stable infant surgery should
be performed. We examine the nose of the baby, confirm patency of both nostrils: with mouth
closed, we press externally one and then the other half of the nose. If atresia is suspected,
patency is confirmed by pulling tube through nostrils. Atresia is indicated to immediate
surgery. Especially bilateral choanal atresia can lead to acute respiratory distress and
cyanosis and may necessitate the use of plastic airway aid until the operation is done.
We observe the shape of chest , assess the maturity of breast nipples and mammal glands
and examine properly clavicles. Fractured clavicle belongs to the most frequent birth injuries,
especially of big fetuses, after complicated deliveries associated with anomalous position or
forceps deliveries. The lateral third of the clavicle is mostly involved. During the first hours
and days one can palpate crepitation above the place of fracture. The palpation may be painful
for the baby. The fracture may be associated with brachial pseudoparalysis situation, when
active movement of the extremity is possible but the baby avoids movement because of pain.
It can resemble real brachial palsy, but pseudoparalysis is transient and resolves
spontaneously after several days. After the fracture is found, it is important to reassure the
parents. The fracture is almost always benign. It is recommendable to spare the extremity for
one or two weeks, not to palpate the place again and again uselessly nor to move the
extremity qithout purpose. The fracture is usually healed without treatment in several weeks.
After several days crepitation disappeares, then palpable lump (calus) occurs and afterwards,
until the 2nd month of age, the bone is fully reconstructed. Mammal glands may be increased
sometimes and even mild milk production may be apparent. Maternal hormones cause this
hormonal reaction. No treatment is necessary, spontaneous resolution is a rule.
It is easier to palpate abdomen in a baby who, lying on his/her back, is a little bended
forward. The abdominal wall is softer then. Margin of newborns liver may normally be 1 2cm below the costal arch, spleen is either not palpable or one can feel the lower pole. Both
kidneys may be palpable, especially in smaller babies. tumor must be ruled out (increased
multicystic kidney, ovarian tumor etc.). Good intestinal peristalsis may be confirmed by
auscultation. Umbilicus is always examined, bleeding and inflammation must be ruled out.
After the umbilicus is cut, umbilical vessels should be checked. Usually one vein and two
arteries are seen. If one artery is missing, one should suspect increased risk of associated

19

congenital organ anomalies, especially of urinary tract, which should be examined by

ultrasound.
Omphalocele is one of congenital anomalies visible by a first view. This is abdominal organs
herniation through the enlarged umbilical orifice, sometimes large and not easily treatable by
operation. Similar malformation is gastroschisis herniation through the paramedial orifice
besides the umbilicus, usually smaller than omphalocele and with better prognosis. The other
malformation involving abdominal wall is urinary bladder exstrophy.
The examination of femoral arteries is a part of examination. It is screening for coarctation
of aorta weak or absent pulse should lead to indication of echocardiography. Palpation is
always possible, but sometimes difficult when the baby is restless or crying. One has to be
patient and, if uncertain, to repeat the examination later. The examination should be
performed not sooner than on day 3 or 4. Until then, the prenatal physiological shunts may be
still open and the femoral pusle may be palpable even in patients with coarctation.
In the lumbal area of the back impaired skin surface can be found when herniation of menings
is present (meningocele, meningomyelocele). Or, the spinal cord dysraphism may be limited
to dorsal parts of vertebrae, without herniation. This split (spina bifida) may be palpable under
the intact skin. The finding of pilonidal sinus is not rare. this is a dimple in sacral area. If the
bottom of the dimple consists of intact skin, the finding is usually benign and no other
examination is needed. The dimple sometimes disappeares after several months. In rare cases,
where the sinus communicates into the deeper layers and the bottom is not covered with skin,
next investigation is necessary. The dimple may be part of fistula and of more complex spinal
cord malformation.
The examination of hips is important. It is performed by pediatrician (neonatologist) or by
specialist pediatric orthopedist. The examination is reliable only if the baby is quiet. The
newborn is laid on firm surface on his/her back. Thighs are flexed to vertical position and the
lenth of both thighs is checked under gentle vertical pressure. Then we take the thighs in our
hands: thumb touches the inner part of the thigh in its upper third while middle finger
touches the area of trochanter major. We perform maneuvre of reposition (Ortolani) by gentle
rotation with adduction and pressure of the middle finger on trochanter. Then maneuvre of
luxation (Barlow) follows with rotation in opposite direction and pressure of the thumb in
lateral direction. In healthy newborn, both fenomena are negative, articulations are firm in
rotations and the adduction is free at least to 45 from the table. If dysplasia is present,
reposition fenomena is positive as a clunk with a shift of thefemoral head back to the
articulation and luxational fenomena head jump out the articulation. In milder degree of
dysplasia, the head does not luxate spontaneously, but luxation by luxational maneuvre is
possible luxable hip. On the contrary, in more pronounced asymmetrical dysplasia, also
some other findings may be present: limited adduction, length of thighs asymmetry (Bettman
s sign: exarticulated femur is shifted higher and shortened) and skin folds asymmetry on
thighs and buttocks. Every pathological finding is and indication to refer the baby to pediatric
orthopedist for ultrasound examination and early treatment, enabling normal development of
the articulations. Missed diagnosis may lead to fixed articulations damage and delayed
development of walking.
While examining extremities we observe the shape and motion, articulations, number and
shape of fingers. Syndactylia may be found, sometimes as isolated and benign sign (most
frequently patial adhesion of 2nd ad 3rd finger on feet) but some other time associated with
other morphological organ malformations as a part of genetic disease. Also redundant
fingers, partial or total finger aplasia or reduction deformities of the whole extremities are
possible findings.
The examination of genitalia is also important. In boys, glans should be fully covered by
praeputium (which cannot be totally pulled back and neither examining doctor nor parents

20

should not be trying that). Scrotum and testicles findings were partially described above as a
part of maturity assessment. Diameter of testicles may be 1-2cm, mild asymmetry is
common. Among anomalous findings hydrocele is not rare, usually without need of any
treatment. It is recommendable for the community pediatrician to follow the baby during the
following months hydrocele usually resolves spontaneously. Only if hydrocele is very large,
filling major part of the relevant half of scrotum, covered with tense skin, it can threaten the
nutrition of the testicle and be indicated for surgery. To examine glans, pulling back
praeputium a little is needed, to make clear that outer end of uretra is normally positioned and
shaped it should be slit and in the apex of glans. If possible, it is contributing to see the
baby urinating and to assess the quality of the stream: very thin or oblique stream may
suggest uretral anomaly. Anomalous position of uretral ostium is also not rare. Hypospadia is
more often found, i.e. ostium located on dorsum of glans or penis or even on perineum. It
may be difficult to find the exact position of uretra visually and again observation of urination
may be of help. Epispadia is less frequent. If epispadia or hypospadia has been found, an
ultrasound examination of urogenital systm is indicated to rule out associated anomalies and
the baby should be referred to pediatric urologist and/or plastic surgeon. Fining of
undescended testicles is significant as well. More commonly it is partial, sometimes onesided. If at least one testicle can be palpated, in scrotum or in inguinal duct, the baby should
be only followed by community pediatrician. (If the descensus of testicles is not finished until
1 year of age, irreversible damage of testicles may occur and hormonal treatment or surgery
may be warranted to avoid it.) If we are unable to palpate even a single testicle (total
cryptorchism), one must take possible intersex into consideration, especially if other
morphological anomalies of genitalia are present. It is critically important to rule out
congenital adrenal hyperplasia, because the baby could be endangered by mineral
inbalance, hyperkalemia and sudden death! Also history of unexplained sudden deaths in
older siblings in neonatal period may support the diagnosis. Mature genitalia of newborn girls
was also described above. The finding of yellowish skin tails, partially covering the introitus
of vagina is not rare and is benign. Also mild whitish or haemorrhagic vaginal discharge may
be seen quite often and is result of maternal hormones influence. Newborn girls clitoris may
seem diproportionatelly large, especially in premature ones, but it should not resemble fallic
appearance. Also in girls anomalous position of uretral ostium on perineum etc. is possible.
Hernias may be apparent in newborn. Inguinal and umbilical hernia are most commonly
involved. In inguinal hernia, especially in boy, it must be checked, whether it is reponible. If
the herniation is large surgery is sometimes necessary. If the hernia cannot be given back
(strangulated hernia), the immediate surgery is indicated. Umbilical hernias usually do no
need surgery, but rarely, for example in prematures, even umbilical hernia may have potential
to strangulate and operation may become necessary.
Anal ostium is always examined. We observe the position and outer appearance, the patency
is confirmed by the first temperature measuring and the first passage of meconium. Manual
rectal examination is almost never perfomed as a part of pediatric examination of newborn.
Basic neurological examination should be performed. It consists of assessment of muscle
tone, usually with repeated passive flexion and extension of upper extremities, or according to
lower extremities and general posture while picking up the trunk. In mature baby the palmar
grasp reflex may be elicited by pressing on the palm the baby grasps the pressing fingers,
usually firmly enough that it is possible to pick up the baby partially above the table. Sucking
reflex is also present: it can be elicited if one puts his/her finger in the mouth of the baby.
Also startling reflexes are easy to examine, mostly Moro reflex: in a quiet baby lying on its
back the napkin baby is lying on is quickly shifted. The normal reflex has 2 phases. In phase
one the baby stretches out his/her arms, in phase 2 he/she put hands to the chest and legs to
the abdomen and starts crying. We evaluate especially the symmetry of Moro reflex. Also

21

walking reflex can be elicited in newborn: a baby holded vertically above a table, whose
heels touches gently the table, starts to change feet as if walking.
More detailed examination of neonatal reflexes, if indicated, should be performed by
specialist.

Postnatal adaptation in general

Except of the pediatric physical examination, continual observation of the behaviour of the
baby throughout the whole time of stay in maternity hospital is useful. Healthy newborn uses
to sleep major part of the day, 18 20 hours on average. During the first days or weeks he
usually does not distinguish between day- and nighttime, sleeps and falls asleep irregularly
and for different periods of time. The phase immediately after his waking up is the most
active one, with active movement, interest for the environment and breastfeeding. It is
preferable not to try to rule newborns activities according to watch and not to wake him up
actively. For instance, if we decide to wake the baby up each 3 hours because of
breastfeeding, it leads often to interrupting his/her deep sleep, after which the baby is not
necessarily in the best mood for eating. Bad temper and restlessnes may complicate
breastfeeding then. If we allow natural course (the baby is breastfed anytime he/she wakes up
spontaneously), the baby will at first wake up rather irregularly and the intervals between
feedings may be once 1 hour while next time, for example, 5 hours. If the interval is not
extraordinarily long (e.g. more than 6 hours), we do not wake up the baby actively. The fact,
that newborn wakes up for breastfeeding at night the same way as during the day is tiring for
mother but it must be taken into consideration. The rhythm of sleeping at night and vigil
during a day develops gradually and the process may last weeks or months. Thus, mother has
to sleep with a baby part of a day. The period of activity immediately after awakening may
last different piece of time, sometimes 5 minutes, other time one hour or more. Therefore, it
is important, especially during the first weeks, to allow the baby to breastfeed early after
awakening so that he/she can use the most active time for sucking the breast. This way,
good cooperation of the mother and the baby is formed and good advancement of
lactation is supported.
The cry of the baby may become important psychological problem of some parents. Although
the cry can be considered, to certain extent, natural way of communication in small infants
and staff of neonatal wards is used and resistible to it, for newborns mother the
inconsolable crying can represent months lasting ordeal. For parents, who are worried by
frequent crying, reassurance from nurse or doctor (after babys examination), that the reason
of crying is not serious one. It is necessary to make sure, that no apparent discomfort causes
the reason for crying (pain, heat or cold, beeing wrapped too firmly, not allowing to move,
feeling unstable etc). If we are unable to find any pathological finding or discomfort, crying
should not be reason for everlasting anxiety. Usually working approach to appease the baby
is: crying baby wants to suck the breast! The vast majority of babies quiet down after
breastfeeding is allowed. Also for this reason it is not reasonable to delay breastfeeding just
because short time elapsed from the last breastfeeding. If the baby does not want to suck, is
leaving the breast and turning away from it and goes on crying, bad technique of
breastfeeding or, rarely, anomalous shape of the nipple can be a reason. We have to accept the
fact, that in some cases the reason of cry will not be found and it will not be easy to appease
the baby. Then, it is imporatant to explain to the parents, that frequency and intensity of
crying is to certain extent associated with high spirits of the baby and a right approach is to do
their best to comfort him/her, to try to find the most comfortable position etc. (In older

22

infants, the problems evolves into the problem of infant colics, when baby is crying with
his/her legs pulled to abdomen. Not in this case the underlying problem must be usually
blamed abdominal pains and gassy stomach. Attacks of cry and colics begin usually
disappear at latest in the second half of the first year and they do not interfere in any way with
normal development of the infant.)
Jitternis is frequent associating sign of neonatal period. These are irregular movements of
extremities or the whole body either in vigil or in sleep state. They may alarm parents as well
as to become a diagnostic problem for a physician. to diiffer jitterness from real seizures is
sometimes difficult, especially because seizures in newborn may be nonspecific for
example, look like singel movements, face grimaces or apneas. To differ jitterness from
seizures several features can be used. Jitterness is usually symmetric, not one-sided. On the
other hand, only one half of the body may be involved in seizures. Jitterness is not associated
with abnormal eye movements. And, simple maneuvre can be performed: we try to hold the
extremity with suspected movements in our hand and try to stop the movements. If jitterness
is the problem, it is possible to stop it. On the contrary, the extremity involved in seizure
attack, the movements go on in spite of our effort to stop it.
Weight development
A newborn decreases his/her weight during the first days after birth. This decrease is
temporary and under normal circumstances lasts not more than 3-4 days and is not bigger than
10 15% of the birthweight. In premature babies the decrease may be deeper and may last
longer. The underlying process corresponding to the postnatal weight decrease is the transition
of circulation from fetal into postnatal type. It is associated with contraction of intravascular
compartment and temporary over-abundance of body fluids. A newborn excrete this part of
his fluids and his weight decreases.
The initiation of lactation is related to the weight decrease. The baby is nurse during the first
hours after birth several times for zero (no milk is drunk), first small doses of milk are
drunk optimally about 24 hours after delivery. The body undergoes short transient catabolic
period. Gradually, the milk production begins, the drunk doses increase, anabolism
predominate, the infant start to increase his weight (from day 3 4) and in the 2nd week drinks
already 100 cc per dose or more.
Normal speed of weight gain throughout the first year of life is approximately 100-250g per
week. See graph 2.
Postnatal weight decrease is a natural phenomenon and it is useful to alert parents in before
and then to reassure them when decrease occurs, that the weight is evolving normally. The
efforts to avoid weight decrease by early offer of bottle with water or milk should be
discouraged. The decrease will occur anyway and the bottle feeding may interfere with
breastfeeding. That is why in healthy and mature newborn no fluids are offered during the
first 24 hours after birth. If the lactation initiation is delayed and it is necessary to offer some
fluids, water or tea should be preferred (not milk) given from a cup, a spoon or a syringe.
After lactation begins (usually not later than on day 2 4) we stop offering these fluids
immediately and allow exclusive breastfeeding.
Gastrointestinal system adaptation
Gradual initiation of lactation and breastfeeding were described above. In accordance with
them, functional adaptation of gastrointestinal system is under way. Intestines of the fetus are
filled with a black content, meconium, consisting from intestinal epithelium and swallowed
amnial liquor. An intestinal peristalsis is slow before delivery and there is normally no
passage of meconium. (finding of meconium in amnial liquor is abnormal and suggests
intrauterine hypoxia. The hypoxia itself as well as meconium aspiration bring risk to the fetus,

23

then.) After birth, peristalsis strengthens, the first passage of meconium occurs usually during
the 1st day, at latest until 48 hours after birth. The lack to pass meconium may suggest
congenital gastrointestinal tract (GIT) obstruction. Under normal circumstances, black
meconium changes into normal stools of breastfed baby of yellow colour and mushy
consistence.
Natural strat of breastfeeding enables to increase step by step the load of milk. On the first
day GIT is not prepared to accept milk: peristalisis is only beginning, meconium is beginning
to pass and the upper parts of GIT are cleaned from remnants of amnial liquor, process often
associated with mild spitting-up.
Bottle-feeding the baby with formula from the very first hours may bring problems. The baby,
fully capable of sucking reflex, drinks eagerly from the bottle, is able to drink 30-40 cc or
more, but this success is often folowed by vomiting and risk of milk aspiration. GIT is not
ready and does not tolerate too early feeding with tto large doses.
Also other signs then delayed meconium passage may alert anomalies of GIT. Finding of
intestinal dilatation on prenatal ultrasound examination of the fetus may lead to intestinal
atresia suspicion. After birth, atresia may manifest by vomiting (the earlier the vomiting, the
more orally the obstruction uses to be in esophageal atresia the baby is vomiting from birth,
in atresia of ileum or rectum the vomiting may occur only after several days). The warning
sign is abdomen overdistension or general sepsis symptoms (from peritonitis after
perforation).
Meconium ileus is a specific case, where GIT obstruction is caused by increased viscosity of
meconium. It may suggest cystic fibrosis.
Urinary tract adaptation
The urine is formed in small amounts in kidneys before birth and is passed into amnial liquor.
After birth the first urination should be observed. This is an evidence of patency of urinary
tract and should occur not later than 24 hours after birth. If the first voiding have not
occured, the urinary bladder should be examined (with palpation and ultrasound) and the
reason of the delay should be searched.
The amount of urine may be very small initially, about 5 cc for one voiding and the urine is
usually transparent, almost without yellowish coloration. Therefore, the napkin mut be
observed thoroughly, because otherwise the first voiding could be missed and this mistake
could lead to useless investigation of the baby. during the next days, with increasing doses of
milk, also diuresis increases. We do not measure exact amount of urine in healthy newborns,
but i should be at least about 1-2cc/kg/hour.
Hemopoiesis adaptation, neonatal jaundice
Normal hematocirt of healthy newborn is higher than normal hematocrit anytime later in life,
0,55 0,65 on average. (A newborn with hematocrit less than 0,40 on day 1 after birth should
be considered anemic.) The increased rate of reticulocytes (up to 60 per mile) is an evidence
of increased stimulation of erythropoiesis.
At birth, the way of oxygenation changes: oxygenation by gas exchange in the lungs is more
efective than oxygenation via placental circulation and the baby will need less erythrocytes
for successful oxygen tissue supply in its extrauterine life. Therefore, the activity of
erythropoiesis attenuates soon after birth (reticulocytes decreases to 1-5 per mile). this process
is associated with an increased hemolysis.
The balance between erythrocytes production and degradation is shifted to the side of
degradation (lower need of erythrocytes, and their shorter survival) and hematocrit decreases.
This decrease is quite quick during the first days and hematocirt may fall to 0,40 0,45.

24

(Later, the decrease gets slower, but the period of erythropoiesis depression and hematocrit
fall continues until the 2nd 3rd month. Then usually the development turns, erythropoiesis
intensifies and hematocrit gradually increases to the level usual in older children.) See graph
3.
The development of neonatal jaundice is related to hemopoiesis adaptation. Yellow coloration
of the newborns skin, usually appearing during the first week of life, is a normal
physiological associating feature of the above described accelerated hemolysis. While normal
plasma bilirubin level of older child is less than 20 mol/l, bilirubinemia in newborn on its
peak (usually on the day 3 or 4) is often 200-300 mol/l, occasionally even more than 300.
Nevertheless, it is important for the level not to increase to extreme values. Levels above
400mol/l are associated with a risk of brain damage. This can happen most probably when
isoimmunization is an underlying problem, i.e. immunologic colision between Rh or ABO
blood groups of the maother and the baby. One of the substantial tasks of pediatrician is to
follow neonatal jaundice properly and to diagnose non-physiological course as soon as
possible.
Normal physiological jaundice has several important features:
1. It is not present at birth and it appears not sooner then after 24 hours.
2. Its intensity does not exceed common limit.
3. It peaks on day 3-4 and spontaneously disappears afterwards.
The said common limit is estimated firstly visually by the pediatrician with use of his/her
clinical experience. There is an optical tool capable to partly objectify this visual estimate,
called transcutaneous icterometer (or bilirubinometer). This aid uses arbitrary units for rough
quantification of intensity of yellow skin colour and its trend. Nevertheless, the reliability is
rather dependent on natural coloration of the skin; it is very inaccurate in babies with dark
skin. In caucasians, if measured with the only available machine Minolta, findings of 20 and
more arb. units usually require further investigation.
If pathological jaundice is suspected, the objective method to evaluate its intensity is only
measuring bilirubinemia from blood sample, repeated as needed. Not only absolute bilirubin
level is important, but also a factor of time the age of the baby in hours. During the first 4
days, the earlier the bilirubin level increases and the steeper is the increase, the more likely is
an achievement of dangerous levels. In other words, the same level (for example, 220 mol/l)
may be absolutely normal on the 4 th day after birth, but at the age of incomplete 24 hours it
may be the reason for intensive treatment. Also, the increased level must be considered as
more serious in babies with evidenced isoimmunisation, especially Rh, where higher
dynamics of increase must be assumed. The assessment is also different in premature babies,
in which phototherapy is usually started sooner, with lower levels. To evaluate how serious
jaundice is and for indication of phototherapy special graphs or tables are used (in the Czech
Republic, for instance, graph Hodr-Polacek). See graph 3 and table 9.
Table. 9: Indication of
jaundice and bilirubinemia monitoring and indication of
hyperbilirubinemia treatment according to the zone in Hodr-Polacek graph. Valid in term
newborns without Rh or ABO isoimmunisation and in term newborns with Rhisoimmunisation. (PT phototherapy, ET exchange transfusion, bili sampling for
bilirubinemia, TCI transcutaneous icterometry)
zone
without Rh or ABO
Rh
V
PT, if no success, ET
ET
IV
PT
PT, if no success, ET
III
bili, TCI repeatedly
PT
II
TCI 2 times a day
bili

25

TCI once a day

bili

For better evaluation of the dynamics of bilirubinemia it is useful to know the bilirubin level
of umbilical blood, i.e. in the moment of birth. Normal value is less than 40 mol/l, 40-50 is
borderline. Umbilical blood bilirubin above 50 is an clearly increased starting value
suggesting pathological hemolysis in fetus and predicting abnormal speed of increase of
bilirubinemia during the first hours after birth. Except of assigning in graph also evaluation of
speed of increase of bilirubinemia is helpful. In healthy baby, the speed is not higher than 5
mol/l per hour, while serious isoimmunisation leads to the speed exceeding 10 mol/l per
hour.
The strongest reaction of this type is Rh-isoimmunisation originating from constelation of
Rh-negative mother and Rh-positive fetus. Rh-antigen on erythrocytes of the fetus penetrates
into the circulation of the mother (during pregnancy, labour and delivery), stimulates
production of anti-Rh (anti-D) antibodies, which after their penetrance back to the circulation
of the baby hemolyse his/her erythrocytes. Similar reaction may be caused when conflict in
other blood groups exists (ABO or some rare blood groups) but hemolysis is usually not so
serious
Rh-isoimmunisation used to be the most frequent reason of extreme hyperbilirubinemia in
newborn, which jeopardised the baby seriously. In extreme levels, bilirubin may transfer
hematencephalic barrier and form deposites in brain tissue, mainly in basal ganglia
(kernicterus). This process causes irreversible brain damage and may lead even to death. In
surviving babies, permanent neurological and developmental handicap called bilirubin
encephalopathy evolves.
With up to date knowledge and prevention and treatment possibilities kernicterus can be
always prevented. Rh-isoimmunisation prevention involves passive immunisation of Rhnegative mothers immediatelly after delivery of Rh-positive baby (administration of anti-D
antibodies attenuates the immunological reaction and endogenous antibodies production, thus
attenuating reaction in possible next pregnancy). Also, it is important to assess the blood
groups in all pregnant women in an early stage of their pregnancy and to follow closely all
Rh-negative ones. Evaluation of anti-D antibodies plasma level should be part of this followup. If these antibodies are found, the development of the fetus has to be closely monitored and
if serous intrauterine course is revealed, the early intervention is necessary. In the past,
evaluation of bilirubinoids in amnial liquor used to be performed, nowadays early
percutaneous umbilical blood sampling (chordocentesis) for evaluation of fetal blood count
and bilirubinemia, and intrauterine transfusion if indicated. Serious anaemia adn fetal hydrops
can be avoided this way.
Treatment of pathological jaundice
Normal physiological jaundice in healthy newborn does not require treatment. In pathological
cases early intervention is required. The most frequently used treatment is phototherapy,
method based on interference of electromagnetic waves of specific wave-length (420-470nm)
comprised in violet and green part of light spectrum with bilirubin molecules stricken by the
light in the blood of superficial skin capillaries. The efficacy of the method depends on the
body surface on which the light falls and on the intensity of the light. As a source of light
special lamps are used which provide concentrated light af desired wave-length. Treated baby
must be naked in and incubator or an electric heater. In accordance with how serious the
hyperbilirubinemia is intensive phototherapy may be used, i.e. use of several lamps together.
Also combination with bili-blanket enabling underneath exposure is useful.
Bilirubinemia increase is influenced also by the degree of hydration. Therefore adequate
fluids offer is needed. In many cases breastfeeding itself is enough, sometimes we can add the

26

offer of tea or water from spoon or syringe, not from bottle), in serious cases of
isoimmunisation fluids are given intravenously.
If the treatment with phototherapy is not successful in maintaining bilirubinemia in normal
physiologic range of values, exchange transfusion is a next step. To perform the latter, we
have to insert catether in umbilical vein and then, during several hours lasting procedure to
take up from circulation part of babys own blood and to replace it with a blood of the same
group and Rh-negative (recommended volume is 180-200 cc/kg). This way part of bilirubin as
well as antibodies is removed and bilirubin level increase slow down sharply. Rarely, it may
be necessary to repeat the procedure twice or even three times with intervals of several hours.
Other treatments are only auxiliary: administration of albumin binding bilirubin in the blood
such decreasing itsability to cross hematencephalic barriere. Some other treaments were used
in the past, as administration of phenobarbital; however, this treatment does not influence
progress of hyperbilirubinemia significantly and may be even complicating factor because of
its sedative effect. It should not be recommended anymore.
In future, management of neonatal hyperbilirubinemia might include administration of
mesoporphyrin, drug decreasing bilirubin production.
Other forms of pathological jaundice
Occasionally some other form of pathological jaundice may be found in newborn. Increased
hemolysis in newborn may be associated with benign hyperbilirubinemia (Gilbert disease) or,
rarely, with serious hereditary disorder of bilirubin metabolism (e.g.,Criggler-Najjar disease).
Common feature of all hemolytic forms of hyperbilirubinemia in newborn is that increased
level of unconjugated bilirubin is an underlying problem.
Conjugated bilirubin level may be normally slightly increased in newborn, but it should not
exceed approximately 25mol/l. If the level is significantly higher, congenital hepatopathy
should be considered (e.g., from intrauterine viral infection, cholestasis in biliary atresia etc.).
If significant part of bilirubin is its conjugated component, phototherapy is not indicated (it
is not effective and leads to produciton of bilirubin metabolite discolorating the skin in so
called bronze icterus).
Postnatal adaptation of metabolism, hypoglycemia
Metabolic changes are complex. Problems of glycemia should be noticed. Normal glucose
level is in intrauterine life maintained by supply from mother. Permanent overload of glucose
maintains the fetus in the state of relative hyperinsulinemia. In the moment of umbilicus
interruption the external supply of glucose is stopped. Remaining hyperinsulinemia causes fall
of glycemia during approximately 1 hour after birth to borderline values about 3,0 mmol/l.
This glycemia fall stimulates adaptive mechanisms, insulin level falls, glycogenolysis and
gluconeogenesis begins and glycema begins to increase again. during the second hour after
birth metabolic circumstances changes to permanent normoglycemia.
Postnatal fall of glycemia may be faster and deeper and may lead to serious symptomatic
hypoglycemia under certain pathological conditions. For example, in an infant of diabetic
mother. Especially if mothers diabetes mellitus is not adequately compensated during her
pregnancy, the fetus undergoes repeated hyperglycemias, compensated by pathological
hyperinsulinemia. Remaining increased level of insulin during the first tens of minutes after
birth may cause serious hypoglycemia (even less than 0,5 mmol/l!) with seizures or
apnea. Thats why obstetrician has to notify pediatrician before delivery about mothers
diabetes and the baby has to be monitored after birth. During the first hours glycemia is
evaluated each 30-60 minutes and, if necessary, parenteral supply of glucose is ascertained
early enough.

27

Also premature and hypotrophic babies are prone to postnatal hypoglycemia, as well as
asphyctic babies or babies with congenital bacterial sepsis.
Adaptation of thermoregulation
When in a womb, fetus need not to maintain its body temperature by its own
thermoregulatory mechanisms, because it is under influence of mothers thermoregulation. In
the moment of birth, the body temperature tends to fall till the moment, when this fall is
counteracted by initiation of babys own adaptive mechanisms. In healthy term newborn the
temperature falls to borderline values about 36,0 C during the first hour after birth and then
increases to normal values. Risk of hypothermia is bigger, for example, if the temperature of
environment in the delivery room is low or, if the skin surface is not dried or in some
pathological situations like asphyxia, congenital sepsis, prematurity, intrauterine growth
retardation etc.
Breastfeeding
Problems of breastfeeding are everyday destiny of neonatologist. In an environment with
well-established system of breastfeeding support there is not a lot of work for physician left
and a practical education of mothers is more pediatric nursesand midwives concern (or, in
some countries, concern of lactation consultants). However, it requires a lot of hard work of
doctors to create such environment.
The period, when formula feeding got overestimated (1950 1970) are already the past.
Multiple scientific evidence was published about advantages of breatfeeding for baby and
mother and it is difficult to disprove. Every pediatrician and obstetrician should be aware of
this knowledge. See table 10.

Table 10.: Advantages of breastfeeding for baby and mother

Advantages for baby
evidenced:
decreased risk of infant diarrhea
decreased risk of respiratory and other infections in infant period
including sepsis, meningitis and UTI
decreased risk of SIDS
decreased risk of necrotising enterocolitis in prematures
decreased risk of food allergy in childhood
decreased risk of Crohns disease and ulcerose colitis
decreased risk of dental caries in childhood
decreased risk of obesity in childhood
b) likely or possible
decreased risk of hypertension and atherosclerosis in childhood and adult
age
more favourable cognitive development (higher IQ)
decreased risk of some malignancies, e.g. lymphoma
decreased risk of diabetes mellitus type I

28

Advantages for mother

evidenced:
shortened period of postpartum bleeding, quicker postpartum uterus
involution
decreased blood loss during lactational amenorrhea
improvement of postnatal bone remineralisation
decreased risk of malignant breast and ovarian tumours
General advantages
psychologically significant for mother-infant bonding
practical convenience of breastfeeding
economic advantage for the family
As the table shows, breastfeeding represents an important preventive factor not only for
infancy but really for whole life. Most of world significant health-care authorities (for
instance, WHO or American Academy of Pediatrics) recommends exclusive breastfeeding
until 6 months of age and then partial breastfeeding until different age with a step by step
introduction of other food. Exclusive breastfeding refers to the offering of food exclusively by
nursing, without any combination with formula or other feeding. Even single doses of
formula fed unnecessarily in the period of lactation initiation may lead to lifelong
sensitization. Furthermore, premature introduction of bottle feeding complicates
establishment of good cooperation between mother and baby and may be reason of
unsuccessful breastfeeding efforts. The younger the infant, the more significant are
advantages of breastfeeding. So, breastfeeding is most important during the first months. The
specific age of weaning is not so much important and depends on mother, family and babys
preferences. The optimal age in weaning is perhaps between 12 a 24 months.
Success of breastfeeding as measured by percentage of infants breastfed exclusively until 6
months of age is presently the highest in scandinavian countries (80% and more). The exact
information about the smae value in the Czech Republic is lacking but it seems to be about
30% and increasing.
Several factors support success of breastfeeding:
1. a family should have enough information about advantages of breastfeeding before
delivery (prenatal classes, prenatal visit to pediatrician)
2. a philosophy of non-separation of mother and child after birth cannot be
overemphasised mother and child should be in a skin-to-skin contact from the
moment of birth and the first nursing should take place not later than 30 minutes after
birth (early initiation)
3. a baby should be breastfed anytime when wakes up, independently on time, and
allowed to suck as long as he/she is sucking
4. if the progress of lactation is normal (baby drinks the first doses of breastmilk
approximately 24 hours after birth) and the baby is healthy, offering other fluids is not
needed, we wait for breastfeeding
5. if the lactation is delayed (baby drinks the first doses of breastmilk on day 2-4), we
offer after nursing fluid supplement (tea or water) as the baby wishes, from syringe, cup
or spoon (never from bottle), we do not offer formula, we wait for breastfeeding
6. offering formula should come into consideration only in rare special occassions, when
lactation does not progress in spite of all efforts, and not sooner then on day 5. If only
temporary formula feeding is presumed, hypoallergenic formula should be used
29

7. unnecessary use of plastic nipple-shields should be avoided. It may be necessary only

rarely if nipples are much excavated such making sucking impossible. It s unnecessary
use leads to the short-term feeling of success but from a long-term view it usually causes
insuficient progress of lactation and breastfeeding termination.
8. it is useful, if mother is taught in the maternity, how to express milk, most efficiently
with her own fingers. Especially women during the first 2 weeks after delivery, who feel
pressure or pain in breasts even after breastfeeding, should express their milk.
Under special circumstances, breastfeeding may be contraindicated. See table 11.
Table 11: Contraindication of breastfeeding
drug-abused mother
HIV-positive mother (only in developed countries)
mother on cytostatic treatment
mother with untreated active tbc
child with galactosemia
Probably more than in healthy newborns, breastfeeding is important in premature babies. For
example, ofthe lethal complication necrotising enterocolitis is up to 6 times more frequent in
formula-fed than in breastfed prematures. To achieve exclusive breastfeeding may be much
more difficult in premature babies and requires a lot of efforts from mother and pediatric
nurses. If cooperative staff is able to support mother, the achievement of high rate of success
in exclusive breastfeeding is possible even in premature babies.
Other practical aspects of newborn care in neonatal ward
During the first day after birth blood sampling for screening of certain diseaes is performed.
Presently, congenital hypothyreosis and phenylketonuria is screened. Both are congenital
diseases which can be diagnosed soon after birth and due to early diagnosis and treatment the
baby avoids permanent developmental deficit.
Several drops of capillary blood are took up from babys heel, on special suctorial paper.
Afterwards, dry drops of blood are sent to the central screening laboratory for evaluation.
Optimal age for sampling is a little controversial. While hypothyreosis could be diagnosed
immediately after birth, the sensitivity of phenylketonuria screening increases until about 6
days of age. Most usually, samples are drawn on day 4, or, if milk-feeding has been delayed,
one or two days later.
In future the spectrum of dieseases screened in neonatal period may widen.
Every baby in the Czech Republic, except of babies with significantly lower birthweight, is
vaccinated against tuberculosis (BCG vaccination) before discharge from maternity. The
vaccination is performed intradermally, on left shoulder, dose 0,3 BM.
Umbilicus must be kept clean after birth (wrapped in sterile gauze) and is usually cut on day 3
4. After this procedure, umbilicus should be closely observed for possible bleeding and
later cleaned with desinfection until complete healing. Inflamation of umbilicus, omphalitis,
manifests with reddening and swelling and may be dangerous. Central circulation is
anatomically near to umbilicus and spread of the infection and sepsis is possible. Therefore, if
above mentioned signs are found, early laboratory examination is necessary and systemic
antibiotic treatment may come into consideration. Umbilicus is usually completely healed

30

until the age of 2 weeks. In the Czech Republic, umbilicus is cut usually. Nevertheless, it is
not necessary to perform this procedure. The alternative way is to discharge the baby with dry
umbilicus left in place. It will fall away spontaneously after several days.
Statistics on national numbers of births and postnatal course and itcomplications is important
for physicians. In the Czech Republic, unified protocol called Zprva o novorozenci
(Newborn report) is used. It serves as both discharge report and information for center for
health-care statistics, institution held as a part of Ministry of health, which receives one copy.
It depends on a helath status of the mother and baby, how long they stay in neonatal ward. In
the Czech Republic, a discharge on about day is most usual. 4 days after delivery are usually
enough to assess adequately normal postnatal adaptation, to be sure that lactation and
breastfeeding initiates normally and umbilicus heals well. Also the baby is old enough for
screenings and physician is usually sure, whether the intensity of jaundice does not progress
in abnormal way. In some countries, newborns are discharged earlier, for instance 48 hours
after birth, or even sooner. This approach is usually welcomed by families but is more
demanding for pediatric care in the community and leads to increased rate of
rehospitalizations.
Introduction into the area of pathological newborn
Although all organ functions of healthy newborn are fully developed and ready for
extrauterine life, the development has not bee finished and thats why newborn is more
vulnerable to unfavourable influences.
In the following text, some of more frequent pathological circumstances possibly associating
neonatal period are discussed.
Perinatal asphyxia was discussed above. Its course and consequences may vary. Milder
degrees of asphyxia, when a newborn resolves spontaneously or after short resuscitation, are
more common. More rarely, serious asphyxia requiring several minutes of resuscitation and
occassionally also following ventilatory support lasting hours or days until achievement of
full cardiopulmonary adaptation occurs. Lethal course is possible in extremely serious cases.
Birth trauma may occur under certain circumstances. Less serious are kefalhaematoma and
fracture of clavicle. More serious may be brachial plexus palsy, caused by mechanical
damage of nerve roots. There are two types, upper and lower. Upper type (Erb-Duchenne)
involves motor activity of upper extremity apart from hand, lower type (Klumpke) involves
fine hand motor activity. Upper type is more frequent. Characteristic feature is a flaccid
extremity which stays in addcution to the body and prone position, without motion. Grasp and
Moro reflexes cannot be elicited on involved side. The course uses to be favourable with
gradual (weeks lasting) resolution of motor function. However, permanent palsy is also
possible. Treatment consists of physical therapy and rehabilitation.
Birth trauma may occur during and after delivery. Kefalhaematoma and fractrue of the
clavicle are among less serious ones. Brachial plexus palsy may be more serious. It is causes
by mechanical damage of nerve roots. Upper and lower type are known. Upper type (ErbDuchenne) deteriorates motor function of the upper extremity except of the hand, lower type
(Klumpke) involves fine motor function of the hand. Upper type is more frequent: typicla
manifestation is lack of motor function of the whole arm and forearm the extremity stays in
adduction to the trunk and prone position. Moro and grasp reflex cannot be elicited on the
involved side. The course uses to be favourable with gradual (weeks) resolution. However,
permanent damage is also possible. Treatment consists of physical therapy and rehabilitation.
Long bone fracture (femur or humerus) may occur occassionally, requiring orthopedic
treatment, but usually with good outcome. Infraction of skull may be caused by forceps

31

delivery. During operative delivery (caesarean section) may occur skalpel skin incisions,
occassionally requiring suture. Extraordinary (in term newborn) is intracranial haemorrhage
cuased by birth injury, subarachnoidal, subdural or intraventricular, subcapsular liver
haematoma or, in boys, contusion of genitalia or even torsion os testicle.
Problems of postmature newborn (postmaturity, dysmaturity), i.e. baby born after completed
42 weeks of gestation, are specific. It is not necessarily different from term baby, but
sometimes, characteristic signs are present, as poor vernix covering of the skin, dry and
peeling skin, increased birthweight. Nevertheless, postmaturity may also lead to fetal hypoxia:
then, the fetus may become relatively hypotrofic and/or meconium may be found in amniotic
fluid. Green coloration of the umbilicus is characteristic, too. Postmature babies are in higher
risk of neonatal mortality, caused by hypoxia or meconium aspiration.
Congenital developmental anomalies (malformations) may lead to various pathological
states. In summary, congenital heart defects may cause serious symptoms during the first
hours after birth (cyanosis, respiratory distress, heart failure), lungs or airways malformations
may underlie disturbed adaptation of breathing, large congenital diphragmatic hernia may
lead to serious adaptation disturbance. Also CNS malformations or congenital
neuromuscular disorders may be reason for need of intensive care. The spectrum of
congenital anomalies is wide and out of scope of this text.
Neonatal jaundice exceeding above said features of normal physiological course, i.e.
hyperbilirubinemia, is treated with phototherapy, or exceptionally with exchange transfusion.
Congenital infection is dreaded complication of neonatal period. In nurseries with good
standard of hygiene and aseptic measures group B Streptococcus (GBS) is presently the most
prevalent etiologic factor of bacterial infections in term babies, while in premature ones the
most common are Staphyloccoccus epidermidis. Also intestinal gramnegatives or other
bacteria may be involved. Due to immature immunity, neonatal infection is usually not local
one but generalised, i.e. progressing with clinical pattern of neonatal sepsis. Except of
bacterial infections, the fetus may become infected by microorganisms of so called TORCH
group (toxoplasmosis, rubeola, cytomegalovirus, herpes simplex), which may induce varying
symptoms in newborn.
Problems of infants of diabetic mothers were discussed above.
Meconium aspiration is a serious complication. Preconditions are intrauterine or perinatal
hypoxia causing preterm passage of meconium into the amniotic fluid. Then, risk of aspiration
into the airways is significant during the first inspirations after birth. It leads to respiratory
distress or even suffocation and respiratory failure. Postmature or hypotrophic babies are most
commonly involved. It may be extremely difficult to stabilize the baby. Risk can be decreased
with proper obstetric follow-up (early recognition of hypoxia and pregnancy termination) and
readiness of the neonatologist to resuscitate. If solid pieces of black meconium are present
in amniotic fluid during delivery, or if the fluid is dark and thick, it is necessary to start
intensive suctioning of upper airways and stomach immediately after delivery of the
head to avoid aspiration of the meconium. If aspiration occurs, one has to start
resuscitation with suctioning as much of meconium as possible from upper airways and,
if needed, also from trachea (after intubation), before positive pressure ventilation is
commenced.
Hypotrophia (small-for-date baby), refers to the birthweight under 3rd centile in specific
gestational age. It is proportionate (head circumference is decreased proportionately to body
weight) or disproportionate (head circumference is on higher centile than body weight).
Hypotrophia of proportionate type is a result of long-lasting chronic hypoxia (insufficient
nutrition) of the fetus in the womb and it is associated with a worse developmental outcome,
because damage of brain development is more likely under these circumstances. On the other

32

hand, hypotrophia of disproportionate type results from worsened nutrition of the fetus during
the last weeks before delivery (the fetus slims), when there is a bigger chance that CNS has
been saved.
Small-for-date babys adaptation is usually better than adaptation of normotrophic baby of
the same birthweight, because its gestational age is higher, i.e. the baby is more mature.
Furthermore, lung maturity is favourably influenced by intrauterine stress (maturation of
adaptive mechanisms is accelerated. Also in these cases monitoring of glycemia is necessary,
because the baby is more in risk of hypoglycemia, and to provide optimal thermal comfort.
Persistent pulmonary hypertension of newborn (PPHN) is a specific circulatory disease
out of the range of congenital heart defects. It is a functional problem resulting from
intrauterine stress or perinatal asphyxia, or, sometimes occuring withou any apparent reason.
It can be seen mostly in term or near-term babies. Underlying problem is a functional spasm
or a morphological contraction (hypertrophy) of pulmonary vessels. As a consequence,
resistance in pulmonary circulation does not decrease after delivery and does not allow
normal lungs perfusion. With increased ventilation/perfusion rate part of blood continues to be
shunted fromt the right to the left through foramen ovale, ductus arteriosus and intrapulmonal
shunts and goes to the systemic circulation. Cyanosis, respiratory distress and possible serious
or even lethal state may develop. Management consists of mechanical ventilation, oxygen
administration and inhalation of NO (nitric oxide), which has capability of selective
pulmonary arteries dilatation. Exceptionally, ECMO (extracorporeal membrane oxygenation)
is used.
Premature newborn
Mild degree of prematurity (33 37th gestational week) is associated with no or mild
problems of adaptation, for example periodic breathing, sometimes with apneas (apneic
intervals longer than 20 seconds) or transient tachypnea of newborn (TTN, wet lung), i.e.
temporary postnatal tachypnoe and/or mild dyspnea, disappearing during the first hours after
birth, sometimes requiring short-term treatment with oxygen. Sometimes, commencement of
feeding may be more difficult in prematures and achievement of exclusive breastfeeding may
last several days longer and it may be preceded by period of partly feeding with expressed
mother milk or parenteral nutrition. The weight fall may be deeper and last longer, peak of
bilirubin level may be postponed and jaundice may persist until higher age (1-2 months). The
full postnatal adaptation, allowing discharge to home, is usually achieved at latest about 36 th
postconceptional age.
Last 3 decades brought radical changes in diagnostic and treatment possibilities of very
prematurely born babies ( 32 completed gestational weeks or less).
Fundamental pathophysiological problem of premature newborns adaptation with a lot of
consequences is lung immaturity. The reasons of the latter are complex, but lack of lung
surfactant is substantial. Surfactant is a substance which, under normal circumstances, equals
surface tension of alveoli and its deficiency leads to RDS (respiratory distress syndrome,
hyaline membranes disease,HMD). It is characterised by development of multiple small
atelectasis, i.e. patial lung collaps and decreased aeration. Clinically, the disease manifests by
dyspnea (jugulum, intercostal spaces and epigastrium retractions), grunting (typical sound
originating when exspired air passes the narrowed place under partially closed epiglottis),
increased oxygen demand and gradual development of respiratory failure. X-ray pattern is
typical. See picture 4. Management of RDS consists of oxygen administration and, if needed,
ventilatory support, together with parenteral fluids and nutrition. Ventilatory support is either
continuous positive pressure (CPAP) or artificial ventilation with respirator. Intratracheal
instillation of comercially produced surfactant, repeated as needed, is used routinely as a
causative treatment of RDS, which can bridge the period until sufficient production of

33

endogenous surfactant (usually not more than several days). Mechanical ventilation may be
required for several hours to several weeks.
A lot of complications may be associated with RDS, which are also more or less specific for
premature babies. They include persistent ductus arteriosus, intraventricular and
periventricular haemorrhage into the brain, retinopathy of prematurity, acute necrosis of
part of intestinal wall called necrotising enterocolitis, and, regarding pulmonary
pathogenesis, RDS may be followed by long-term pulmonary changes called
bronchopulmonary dysplasia BPD).
Problems of RDS and its complications and other diseases asociated with premature delivery,
as well as problems of term ill newborn, are objects of subspecialty neonatal intensive care.
Long-term development of premature babies
Enormous increase of survival of very- and extremely-low-birth-weight infants raises the
question about their chances for good quality of life. Therefore, recently the quality of
newborn care is not only appraised along the survival statistics. More crucial are data on longterm development of premature babies. So, every hospital providing high-degree newborn
care should have its own programme of long-term follow-up. There are efforts in developed
countries to collect these data on national basis.
Premature or ill newborn is exposed to increased risk of CNS and other organs damage in
postnatal period. Thats why especially among premature children higher rate of those
with long-term handicaps is found. The defects include motor (cerebral palsy), cognitive
(lower developmental quotient or IQ) or sensoric ones (deficit of hearing or vision).
Risk of long-term handicap is the higher, the lower is the birthweight and gestational week. In
the group of babies with birthweight under 1500g the risk of serious handicap is about 5
7%, in the group under 1000g the risk is about 20%. The probability of serious long-term
handicap in relation to gestational age at birth see in talbe 12:
Table 12: Schema, how to remember risk of serious developmental deficit in premature babies
along with gestational age at birth.

g.w.
survive
at
(% of all
birth
born alive)
23
30
24
40
25
50
26
60
27
70
28
80
29
90
30 and
> 95
more
(g.t. = gestan tden)

without severe handicap

(% of all surviving)
30
40
50
60
70
80
90
> 95

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Sudden infant death syndrome

Sudden infant death syndrome ( SIDS, cot death) affects infants during the first year of life,
but usually (95%) during the first 6 months, mostly at home. Thus, this is not primarily
neonatal problem. However, parents of all babies should be informed about SIDS and
possibilities of its prevention at latest after birth of a baby and knowledge of the problem is
important for all neonatologists as well as community pediatricians.
SIDS is a situation, when until then absolutely healthy infant is found dead in his/her bed in
the reason is not enlightened even with autopsy. Thera are lots of theories about possible
reasons (peracute infection, inborn dysrhytmia, unrecognizde inborn metabolic error with
hypoglycemia and others). Prevalence of the syndrom in developed countries is about 1 : 1000
of all born alive.
Aboslutely reliable prevention is not known. Nevertheless, several risk factors were
identified, which increase the risk of SIDS. They include smoking of the mother during
pregnancy and smoking in the family generally, early introducing of formula instead of
breastfeeding, sleeping in the other room than where parents are sleeping, sleeping in the
same bed with parents and sleeping in the prone position. Campaigns providing families with
need to avoid these risk factors the decreased incidence of SIDS was achieved in some
countries.
So, parents should be provided by pediatrician with these advises:
avoid smoking in the environment, where the baby lives
do your best to breastfeed your baby exclusively until 6 months of age
when the baby is sleeping unattended, put him to his/her own bed close to your bed, and
positioned on his/her back

Some used and recommended sources:

Pediatric Clinical Skills.
Schaffer, Avery: Diseases of the Newborn.( Saunders)
Fanaroff, Martin: Neonatal-Perinatal Medicine.(Mosby)
Sinclair, Bracken: Effective care of the newborn infant.(Oxford University Press)
Royal College of Midwives: Succesfull Breastfeeding. (Churchill Livingstone)
Nelson: Textbook of pediatrics. (Saunders)
American Academy of Pediatrics, Work Group on Breastfeeding: Breastfeeding and the
use of human milk. (Pediatrics 6/97, str. 1035-1039)
International Guidelines for Neonatal Resuscitation: An Excerpt From the Guidelines
2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care:
International Consensus on Science. (Pediatrics 3/2000, str. e29)
Postup resuscitace na videokazet Pe o novorozence I. (vyd. Centrum podpory
zdrav, k dispozici ve videopjovn Sttnho zdravotnho stavu, Praha 10, robrova 48,
tel. 02 6708 2986).
Avery, Fletcher: Neonatology. (Lippincott comp.)

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