2.1 THE EXTRAORDINARY ADAPTATION OF THE BABY 
2.2 THE FIRST MEDICAL CARE FOR THE BABY 
2.3 THE FIRST PEDIATRIC EXAMINATION
2.4 THE NEUROLOGICAL EXAMINATION 
2.5 MEDICAL FOLLOW UP AT THE HOSPITAL 
2.6 THE FIRST DAYS AFTER THE BIRTH

Until the moment he is born the baby has lived thanks to the blood of his mother that has supplied nourishment and oxygen. The placenta is the filter that has ensured the exchange of oxygen that reaches the baby through the umbilical cord for the carbon dioxide it collects to expel it.

Just after the stage of expelling, in less than five minutes, the respiratory system and the blood circulation of the baby must adapt to an autonomous life in the open air.

The baby's first breathing is difficult because of the mucous and amniotic fluid that still prevents the air from circulating normally. The baby inhales for the first time and the muscles of the thorax send the air to the lung alveolus that expelled the amniotic fluid while the baby was being born.

The heart of the baby begins to pump blood to the lung vessels so that they can collect the oxygen. At the time of birth, the lung artery opens up, closing the ways that maintained the blood circulation of the baby without the blood going through the lungs. This way, the circulation between the heart and the lungs is established once the umbilical cord is cut.

Both the respiratory system and blood circulation need some training time and this is why the breathing process may be slightly irregular and the heart beat may be somewhat fast at first.

The skin of the newborn may be somewhat wrinkled, slightly purplish and covered by a white substance, vernix caseosa or some blood.

The head may be slightly deformed from the pressure while going through the birth canal and may seem large but in a few hours or days everything will be normal.

The neonatologist and the pediatric nurse will give the baby his first medical care to ensure his wellbeing.

•  They will take out of the respiratory ways any mucous and amniotic fluid remains.

•  They will verify that there are no malformations.

•  They will verify that the esophagus and the digestive tube are normal.

•  They will conduct the first Apgar test.

•  They will definitely clamp the umbilical cord.

•  They will take a blood sample.

•  They will administer eyewash to disinfect the baby's eyes.

•  They will administer vitamin K to avoid the risks of hemorrhages.

•  They will weight and measure the baby and also measure his cranial perimeter.

The Apgar test

In the 50's, the North American anesthetist, Virginia Apgar designed a method to examine the vitality and adaptation to the new setting of the newborn.

The Apgar test is done three times: one minute after birth, 5 minutes and 10 minutes later.

With this test five parameters are measured (0, 1 or 2 points):

•  The heart frequency, that is to say, the number of beats per minute.

•  The regularity of the breathing.

•  The muscular tone or activity.

•  The coloration of the skin.

•  The reflexes or reaction to stimuli.

When the baby is well, he usually scores a sum of the 5 parameters equal to or above 8 points in the first test. His adaptation to the environment is progressive and he usually reaches an ideal score in the second test that is carried out 5 minutes after being born.

A result between 8 and 10 points indicates that the new born is well and he doesn't require reanimation, but a score that doesn't reach 4 points means that the baby needs intensive cares that reestablish effective breathing and proper blood circulation immediately, to avoiding an oxygen shortage in different parts of the body and especially in the brain. These measures of urgency allow the new born with a low Apgar score to recover and to become a healthy baby. A low score doesn't necessarily imply that the baby will have neurological problems in the future, but just the type of reanimation type that is necessary to avoid possible neurological problems if the baby responds favorably.

After the test, the midwife usually places the baby on the mother's belly so that he recovers the sense of security when he feels the heat, the noises of the heart and the maternal voice that are familiar sounds for him.

The midwife then makes the definitive clipping of the umbilical cord and takes a small sample of blood to determine the blood group, the RH factor and other information that could be necessary.

Beginning of the nursing

If the mother has decided to breastfeed the baby, this is the best moment to begin. It is possible that he takes only some millimeters of colostrum. This substance precedes the milk, it is denser, has a yellowish color and it is extremely nutritious, besides providing the baby with defenses against many infectious diseases. It is possible that the ascent of milk takes a little, but while, the breasts produce colostrum that contains all the nutrients that the baby needs.

There are more possibilities of success in the nursing if it begins in the first hour of the baby's life. Also, breastfeeding accelerates the mother's recovery because the production of oxitocyn is stimulated and, as we have already seen, this is the hormone that makes the uterus contract.

These first moments in the delivery room are intense and valuable to begin establishing strong affective bonds with the baby, for that reason it is important that the father is there and that he can hold in his arms the newly born baby.

A little bit later, the baby is taken to the nest where they control the weight, the size, the cranial perimeter, they give him some drops of eyewash to disinfect the eyes and they also give him some vitamin K.

The weight

The average weight of a baby boy born in term is between 2.700 and 3.800 kilograms , and in the case of a girl between 2.500 and 3.600 kilograms . When the weight is below these values the baby is considered under weight for his age. The reasons that can provoke the low weight are many, the most habitual are genetic conditionings, the mother's habits such as smoking or the faulty functioning of the placenta.

The underweight newborns usually reach a normal weight in a few months if their feeding is adequate.

After being born, the baby loses some weight. This loss of weight that is less than 10% of the total, is due to the fact that the newborn eliminates the intestinal content (meconium) and that of the bladder, also because at the beginning, through the maternal nursing, the baby takes the colostrum that is rich in nourishment and immunologic elements but is poor in calories. The baby usually recovers his weight around the tenth day of life.

The size

In many cases this fact is not precise because to measure the baby it is necessary to fully stretch his legs and this bothers him very much because during the nine months that he has remained in the uterus he has folded them.

The average size of a newborn is of 50 centimeters for the boys and of 49 centimeters for the girls, although there can be differences of 3 or 4 centimeters between babies.

The cranial perimeter

This data is important because it offers information on the development of the baby's brain. Just after being born the cranial perimeter is conditioned by the circumstances of the childbirth and this first measure is not completely reliable, but it can alert on possible problems that are not frequent. A rather big perimeter can be an indication that there is an excess of cerebrospinal fluid, if the perimeter is small it is necessary to check that the brain development is not below normal and to rule out any type of malformation.

The average size of the cranial perimeter at birth is of 35 or 36 centimeters and in the first years of life it experiences a great increase in size due to the growth of the cerebrum and to the maturation of the nervous central system.

The eyewash

In the first hour of life and after the washing, the baby is administered some antiseptic eyewash, in ointment or drops, to prevent infections from germs coming from the mother's genital apparatus that could cause problems of vision to the baby.

Vitamin K

The baby is also given some vitamin k, in drops or in an injection, to decrease the risk of hemorrhages because, until after a few days go by, the baby's body is not able to produce this vitamin that regulates the clotting factors.

In the first 24 hours of the baby's life, the pediatrician conducts an exhaustive revision. This pediatric exam should be done in the most pleasant possible environment for the little one: the temperature and the lighting have to be adequate, offering a calm atmosphere and should be done while he is awake, for example, after a feeding, so that he responds to the stimuli.

Mainly, the pediatrician verifies the following:

The skin

When born, the baby's skin is covered by the vernix caseosa, specially in the skin folds. This whitish substance disappears when washing the baby and if this is not done, it dries off and disappears in 24 or 30 hours.

At times, the body (mainly the shoulders, the back, the extremities and part of the face) is covered by the lanugos hair that is a very fine hair lining of dark color that disappears in the first weeks. It is also possible that the newborn has red skin and the hands and the feet dry, a little wrinkled and somewhat purplish. A couple of days later the color is rosy, the skin flakes and comes off.

Eruptions of the baby's skin

The baby's skin can have different dermatological affections, most of them benign; the most frequent are the following ones:

•  MILIUM. Around 40% of newly born have an eruption of small white pimples, mainly in the cheeks, the forehead, the nose and the area around the lids. They are very small and they receive the name of milium because they have the form of a grain of millet. They are formed of sebaceous accumulations and they disappear spontaneously in a few weeks.

ANGIOMAS. In 10% of the babies, but more frequently in premature borns, there can be one or several stains denominated reddish angioma that are formed by an accumulation of blood vessels.

The angioma are flat when the superficial blood vessels of the skin dilate and, if they appear in the lid, the nose, in the nape or in the middle of the face, it is very possible that they will disappear after a few months. Those located in other areas of the face can persist in the future.

The angioma in relief are of intense red color and although they usually increase in size in the first months, they end up disappearing in the first three years. In any case if one observes that they grow too quick or they bleed easily, it is necessary to consult with the dermatologist.

•  TOXIC ERYTHEMA. It is very common in new borns between 24 and 48 hours of life. They are small papules that evolve to white vesicles on a red base that appear mainly on the thorax and their duration varies from some hours up to six months. This is a benign affection that the pediatrician distinguishes easily from other eruptions of infectious origin.

•  MONGOLIC STAIN. It is an angioma of blue slate color. They usually show up in the lower part of the back and in some cases are quite extensive. Although it is highly noticeable, it is benign and it disappears spontaneously in some months.

•  MILIARY OR HIDROA. It affects babies when they sweat a lot due to high temperatures, for that reason it is frequent in the summer months. This cutaneous eruption appears when perspiration is retained in the sweat glands that enlarge and form small clear vesicles. In intense eruptions small papules appear and the skin around them turns red and, in some cases, they can end up forming pocks. The eruption is more frequently found in the folds of the skin of the articulations and it is advisable to maintain the baby's skin clean and dry.

The head

When the baby is born by means of a Caesarean operation, the head has a round and symmetrical form, and when the childbirth was by natural means with cephalic presentation, the head is more lengthened. Any possible asymmetries disappear in a few days.

The pediatrician checks, besides the size, the presence of cephalic hematomas that are originated by small hemorrhages that arise when the fine blood vessels break under the periosteum that is a membrane that recovers the cranial bones. These hematomas are habitual when the head goes through the childbirth channel and are not important and disappear in 15 or 20 days, although it is advisable that the pediatrician follows up on them.

The exam of the head also includes the fontanelles that are two cartilaginous membranes, one in the back side and another in the top part of the skull. These membranes separate the bones that are not welded until they have grown sufficiently. The back fontanelle is sometimes not as easily observed as the top one that is shaped as a diamond and is easily observed when it beats or when it tenses up when the baby cries. The fontanelles ossify progressively and they close around the two years of life.

The face

The pediatrician carefully checks the eyes and their reaction to light, also the ears and the reaction of the baby to the sounds to check that there are no auditory deficits. The exam extends to the gums, the palate, the throat and the nose.

The neck

Some babies during the childbirth press their neck and they are born with torticollis. In these cases the pediatrician informs the parents of the steps to follow so that the affected muscle returns to normal.

The clavicles

Although it is not habitual, there are cases in which the clavicle can fracture when going through the childbirth channel. When this happens, at once the bony callus is formed to weld the fracture, nevertheless, it is necessary to try not to put the baby on that side in his bed.

The torso

The pediatrician auscultates the heart and the lungs controlling the frequency and the characteristics of the breathing and the heart beats. In the exploration of the breasts he checks if they are red or swollen, this is quite frequent both in boys as in girls and it is due to the sudden lack of the mother's sexual hormones. This inflammation disappears in some days and it should only be a concern when an infection or fever is observed.

The abdomen

Through careful touching, the pediatrician checks the size and development of the liver, the spleen and the bowels. He verifies the condition of the umbilical cord which should be white and jellied, and he should be able to see the hole of the three umbilical vessels.

The genitals and the anus

Usually, the external genital organs are big with regard to the size of the body.

The males have inflamed sacks and the skin that covers the penis can be closed, but everything returns progressively to normal. Another important aspect in the case of the males is the verification that the testicles have descended to the scrotal sacks.

The girls have the labia minora and the clitoris swollen for first days after being born and the big lips don't cover the vulva because they still have not fully developed.

As we saw in the exam of the thorax, the newly born (boys or girls) usually have the breasts swollen and they can even segregate “witches milk” that it is a milky substance. The sudden privation of the mother's sexual hormones is also the cause that the boys have erections and the girls experience some whitish loss, or some drops of blood, through the vagina.

The extremities

In the upper members the doctor checks the state of the clavicle and the articulations.

In the lower extremities the doctor evaluates that there are no deformations caused by the position of the legs before and during the childbirth. He checks that the pelvis and the femur are correctly inserted and that they are articulated in an effective way. Through some maneuvers (Ortolani and Barlow) he also verifies that there is no dislocation of the hip. This defect that is more frequent in girls and childbirths of buttocks, is corrected easily if it is detected early, for this it is necessary to maintain the baby with the legs spread apart, so that the head of the femur is placed correctly in the articulation of the hip. In most of the cases it is enough to put a double diaper on the baby and that the pediatrician follows up the evolution through revisions and ecographies.

There can be other small deformations, such as the varus foot that a physiotherapist can correct easily if they are detected early.

SELF CHECK QUIZ
SECTION 2 - BLOCK 2	CHAPTER 3	Date:
1. In the first exam, the pediatrician checks the size of the head, the state of the fontanelles and of any possible hematomas. T r F r
2. In this examination he also checks the state of the skin, face, neck, clavicles, the torso, the abdomen, the genitals, the extremities and the sensory development. T r F r
3. All the babies have hip problems due to their positioning when they were born. This problem corrects itself. T r F r
4. The external genital organs, both of the newly born boys and girls, are big with regards to the size of the body. T r F r

Evolutionary neurology studies the development of the nervous system in the first years of life. The neurologist, neonatologist or pediatrician that carries out the neurological exam, compares the results with the pattern of normal evolution outlined by trimesters of the baby's age.

When carrying out this check up it is necessary to keep in mind the moment in when the childbirth took place and the hours or days that have lapsed from that moment.

In the newly born at least 70 neurological signs can be explored, this progressive exam will increase with the data contributed by the follow up exams. This exploration, besides other aspects such as the motor and sensory development, basically assesses:

the active and passive muscle tone.

the reflexes and/or postural reactions.

The tone

The active muscle tone is the one that refers to the development of the motor acquisitions: control of the head, to remain sited, to walk independently, etc.

Placing the new born standing up, held from under the armpits or allowing him to lean on slightly on feet soles, if he straightens out with vigor on the legs lifting the neck and the head, he demonstrates that he maintains a good, active muscular tone. This is also proven when sitting down from laying down, the baby maintains the head up for some seconds.

The passive muscular tone is examined based on the extensibility of the corporal segments and, in a supplementary way, in the flexion of the members, some with regard to the others (angle of abductors, heel-ear, posture of thighs in hyperextension, popliteus angle, angle of dorsal flexion of the foot, maneuver of the scarf, etc.).

The fluctuations in the muscular tone are very marked during the first year of life. In the first trimester the level of tonicity is very high. The baby remains with the arms and legs flexed, the hands closed with the thumb outside of the fist and the head rotated towards one side.

During the second trimester this attitude in tension diminishes and is substituted by another in which the baby appears much more flexible and calm in his movements. The hands frequently open up, the head remains long periods in the half line and it is easy for him to extend his arms and legs.

During the third and fourth trimester these characteristics are even more evident because the muscular flexibility increases to such an extent that the boy or girl is able to take the feet to the mouth with easiness.

Between the 12 and 16 months, the flexibility is stabilized, providing the appropriate tone for the motor acquisitions of this period and of the coming stages.

The muscular tone varies in diverse circumstances, for example when the baby sleeps, the tone diminishes to the maximum, however when he is exalted and cries or when he feels intense emotions there will be variations.

The observation of the baby's muscular tone is very important, not only for its diagnostic contribution, but because starting from these observations we can do some exercises to get patterns of passivity or extensibility next to normality, it can also contribute data with regard to possible deviations that, with neurological treatment and stimulation could correct abnormalities.

The reflexes.

When the baby is born, he has automatic answers for certain stimuli that favor the adaptation to his new setting. We call these answers reflexes. We can distinguish the primary or archaic reflexes and the secondary or postural responses.

The primary or archaic reflections are present during the first months of life. The date in which they disappear can be variable, although their persistence after five months should be a reason for a deeper exploration by the neurologist. These are some of the primary reflexes that are usually checked:

•  Suction reflex . When placing any object touching the lips, the baby sucks repeatedly.

•  Swallowing reflex . It completes the previous one and it allows the boy's correct feeding.

•  The rooting reflex . It is related with the two previous reflexes and it persists until the second month of life. When touching the cheek, the newborn turns his mouth toward the touched side. In the same way, he flexes his head when we touch him on the chin or the forehead.

•  Step reflex . With the baby in vertical position, held by the armpits, with the feet in contact with a hard surface, when he is slightly leaned forward, the baby advances the feet alternating, as if he was walking.

Some researchers maintain that the walking unchained by this reflex has a very sophisticated grade of adaptation, since if while walking the baby finds a small obstacle, he adapts his step and avoids it. He is also able to take some steps on an upward slope.

This reflex usually disappears between two or three months of age.

Grasp reflex . When placing any small object in the hand, a strong grasping reaction is provoked in the fingers. This reflex usually disappears between two and four months.

Answer reflex to traction . When one obtains the grasping of the fingers of both hands, as we have described, on the index fingers of the adult, or on a bar of similar thickness, the baby is capable of staying suspended with all or part of his weight.

In the second trimester, this grasping reflex is replaced by voluntary grasping so that when the adult places his fingers, the baby will take them as a support to try to sit down.

•  Tonic neck or fencing reflex . With the baby tossed on his back, he rotates the head towards one side and maintains his arms in the posture of a “swordsman”, that is, the arm of the side towards which he rotates his head is extended and the other is flexed at the height of the shoulder. The legs are usually crossed.

•  Moro reflex . It consists of a flexion of the trunk, shoulders, hips, hands and feet, at the same time that he extends his elbows, knees and fingers; everything followed by a cry. This reaction is obtained when faking a fall back of the baby.

During the first trimester, the reflex is complete and during the second trimester, the response is limited to opening his hands and crying. It later disappears.

•  Toe curl reflex . When a fine object, for example a pencil, touches the back side of big toe, it provokes that the toes flex, even ending up retaining the object.

This reflex disappears at a later point, approximately at about the ninth months.

•  Eye reflexes , mainly:

•  Eyelid reflex. The baby closes his eyelids if there is a sudden strong light or loud noise nearby.

•  Dolls eyes . It is present during the first month. When the baby moves his head towards one side, the eyes appear to move to the opposite side. The reflex disappears when the baby establishes his visual fixation.

•  Secondary reflexes or postural responses. They appear after the primary reflexes. They are important in the follow up of the baby's neurological evolution and they are included as automatic in the behavior of the human being throughout his life. Among them we have:

•  Lateral or backward propulsion. When the baby is sitting down without any help and he is pushed on one of his sides, at the height of the shoulder, he extends his arm on the opposite side to prevent the fall.

The same way, when the baby is pushed backwards, he uses his hands to try to keep his balance.

•  Parachute reflex . When the baby is suspended on his belly and he is suddenly leaned forward, he makes a motion to protect himself from the fall, extending his arms and spreading his hands.

This reflex appears between six and nine months and, as some of the others, its absence can be a sign of a neurological injury. This is why it is important to verify it.

Throughout the days that the mother and the baby stay in the hospital the follow up of the evolution of both helps them to overcome the inconveniences of the childbirth and to guarantee their well-being.

In these days it is necessary to watch for variations of the baby's weight and of the faeces, to take some blood tests to verify the state of their health and, when necessary, to diagnose possible congenital illnesses, and to practice all the controls that may be necessary.

The skin

Between 20% and 30% of the babies born to term and between 70% and 90% of the premature babies develop benign jaundice during the first two or three days of life.

The physiologic jaundice of the newborn is due to the increase of the biliary pigments in the blood, and it is characterized by a yellowish coloration of the skin and of the conjunctivas of the baby. Starting from the 4th or 5th day, the jaundice diminishes as the baby's organism matures and it has the enzyme that is necessary to transform the bilirubin into a disposable substance. When the liver produces normally this enzyme, the jaundice disappears, this usually happens in one or two weeks.

The medical team of the hospital watches over the bilirubin index and if it comes close to the critical value they apply a phototherapy treatment exposing the baby to the blue light of an ultraviolet lamp to facilitate the elimination of bilirubin. The physiologic jaundice of the newborn is completely different to the one provoked by the incompatibility of the blood group that requires other specific care.

The weight

As we saw in the previous chapter, in the first days the baby usually loses up to 10% of his weight when he is born. This loss is due mainly to the elimination of the excess of water, to the expulsion of the meconium and because the calorie contribution of the colostrum is insufficient. By the 6th or 7th day he begins to recover an average of 30 grams per day and around the 10th or 12th day he has already recovered his weight at birth.

The faeces

The faeces of the first days are almost blackish, somewhat greenish and sticky, they are made up of mucosity and bile and they are denominated meconium. As the days go by, the faeces begin to clear up, taking a yellowish color and a clotted texture and, in occasions, somewhat liquid.

When the baby takes maternal milk he usually defecates after each taking and if he takes a baby formula, he will defecate two or three times per day.

Glucemy

To avoid the cases of hypoglycemia, some hours after the childbirth, a drop of blood from the baby's heel is taken and placed on test slip to control the level of sugar in the blood. In the babies with risk of suffering Glucemy (premature and very thin or very big babies with a diabetic mother) this control is kept systematically.

The Guthrie test

The Guthrie test, or test of the heel is done by obtaining a few drops of blood from the heel. This is done 48 hours after the birth and between the 5th and 7th day of life. The blood is used to smear the circles of a card that is sent to the Diagnosis Center of Molecular Diseases. The results of these tests allow to detect any metabolic illnesses (hypothyroidism or phenylketonuria) that if not treated properly can provoke irreversible damages and mental delay.

Phenylketonuria affects one out of 10,000 babies and is genetically transmitted. It is characterized by the lack of an enzyme that provokes the abnormal accumulation of an amino acid, the phenylalanine in the blood. The excess of this amino acid in the body is toxic, especially for the brain and it can even generate mental delays, deterioration of the brain and physical problems.

To treat this problem it is indispensable to follow a special diet to suppress the contribution of the amino acid and a control to achieve the baby's normal development. The girls with this problem, once they are adults, will require a special follow up during pregnancies.

•  Hypothyroidism comes about when there is an inadequacy of the thyroid gland that doesn't produce the necessary hormones. When there is a malfunction of this gland there can appear an increase of weight, weakness, dryness of the skin or constipation. If it is not diagnosed and treated on time, the baby can suffer continuous jaundice, increase in the size of the tongue, umbilical hernia, general delays in his growth and intellectual delays.

The diagnosis after the birth allows for an early treatment that consists of administering the hormones as drops to achieve the normal physical and intellectual development of the baby.

Other controls that can be done to detect congenital illnesses are that of the cystic fibrosis provoked by the malfunction of the exocrine glands or hereditary problems in the production of hemoglobin.

SELF CHECK QUIZ
SECTION 2 - BLOCK 2	CHAPTER 5	Date:
1. Between 20% and 30% of the babies born to term develop physiologic jaundice of the newborn. T r F r
2. The baby usually loses 20% of his weight at birth during the first 10 days of life. T r F r
3. Babies are given the heel test to prevent cases of hypoglycemia. T r F r
4. Phenylketonuria affects one out of 1,000 babies. T r F r
5. When hypothyroidism is detected, the baby is given hormones so that he can achieve normal physical and intellectual development. T r F r

After nine months of wait, the baby is at your side. The birth has supposed a great effort for the mother and for the newly born, for that reason, besides the medical controls, both need a calm environment to get acquainted and to rest.

The visits are pleasant but they can also end up burdening, for which reason it is advisable that only the closer relatives go to the hospital. It is very probable that the mother, after the initial euphoria, will feel exhausted and concerned, as she has gone through some difficult moments and is now living a completely new situation with big responsibilities. There is also a considerable and quick decrease of the level of estrogens and progesterone and this hormonal change influences in her state of spirit.

If the childbirth has been natural and both the mother and the baby evolve well, they will remain hospitalized two or three days. In the event of a Caesarean operation, the stay can be extended to 8 or 10 days. The father and the mother can take advantage of this period to become acquainted with the baby and to learn how to take care and to tend his needs appropriately, while the medical team carries out the mother's and the baby's follow up.

The control of the mother's evolution extends to her general state. Her temperature will be taken to rule out the existence of some type of infection, her tension and the state of the blood circulation will also be checked. The gynecologist checks the episiotomy and the uterus verifying that there are not lesions or infections in the vagina, the cervix or the perineum. He also examines the breasts to prevent problems that could hinder the nursing.

The documents

Before the mother and the baby are released, the hospital gives the parents the Birth certificate and the Report of the newborn. In many hospitals they will also give the mother the Maternity certificate that she should take to her work, within the five following days to the childbirth and to the office of the National Institute of the Social Security to request her Maternity Benefits. When the hospital doesn't provide the Maternity certificate, it will be issued by the family doctor when he is shown the baby's birth certificate.