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Educational - methodical book

Is recommended by the Ministry of Health of Ukraine as educational - methodical book for the students of higher educational institutions of III-IV accreditation levels

Sumy State University


UDК 616-053.31

BBК 57.31

Н 52


О.P.Volosovets (professor), V.Е.Мarkevich (professor), І.V.Tarasova (associate professor), А.М.Loboda (associate professor)


E.E.Shunko – doctor of medical sciences, professor

(P.L.Shupik National Medical Academy of Post-Graduate education);

V.V.Berezhnoy – doctor of medical sciences, professor

(P.L.Shupik National Medical Academy of Post-Graduate education)

О.І.Smiyan – doctor of medical sciences, professor

(Sumy State University)

Н 52 Neonatology: educational - methodical book for the students of higher educational institutions of III-IV accreditation levels / О.P. Volosovets, V.Е.Мarkevich, І.V.Tarasova, А.М.Loboda. – Sumy: Sumy State University, 2011. - 214 p.

ISBN 978-966-657-345-5

The manual covers issues of diagnosis and treatment of main physiological and pathological conditions in infants during the neonatal period. It is necessary for students of higher educational institutions of III-IV accreditation levels who learn the academic discipline in English.

Посібник висвітлює питання діагностики та лікування основних фізіологічних та патологічних станів у немовлят протягом неонатального періоду.

Для студентів вищих медичних навчальних закладів ІІІ-IV рівнів акредитації, які опановують навчальну дисципліну англійською мовою.

UDК 616-053.31

BBК 57.31

 О.P. Volosovets, V.Е.Мarkevich, І.V.Tarasova, А.М.Loboda, 2011

ISBN 978-966-657-345-5  Sumy State University, 2011




Introduction to neonatology


General care of healthy newborns


Transitory conditions




Neonatal and fetal hypoxia


Birth trauma


Overview and principles of resuscitation


Premature infants


Intrauterine growth retardation


Intrauterine infections


Local festering infection of newborns


Pneumonia of newborns


Neonatal sepsis


Neonatal meningitis


Antibiotic therapy of newborns


Hemolytic disease of newborns


Syndrome of respiratory disorders


Haemorrhagic disease of newborns


Post-course test




^ Preface

The book “Neonatology” is intended to be a practical bedside reference – not a comprehensive textbook – for problems likely to be encountered in the Newborn Nursery or Newborn Intensive Care Unit by residents, Neonatal-Perinatal Medicine Fellows, family physicians, pediatricians, and neonatologists.

This book aims to provide the reader with a very up-to-date summary of the current concepts and practices in neonatal medicine. The book presents easily read topics set in a unique format which encourages the adoption of a problem-based approach ideal for day-to-day clinical practice.

The readers will find in this manual post-course questions and other helpful information.

We hope you find our book useful in your day-to-day encounters with sick newborn infants and their families.

^ Introduction to neonatology

Neonatology is a young subspecialty of pediatrics that was formed at the beginning of 70s of the XX century.

The main task of neonatology is ensuring life and health of children during neonatal period of 28 days from the moment of birth.

Periods of antenatal and perinatal development:

  • Blastogenesis (І critical period) – from the moment of impregnation to the 15th day of pregnancy (impregnation and implantation).

  • Embrio - and organogenesis (ІІ critical period) – 16-76th day of pregnancy; formation of internals, systems and placenta.

  • Fetogenesis (ІІІ critical period) – 76-280th day of pregnancy, growth and fetation.

- Early fetal period – 76-180th day of pregnancy

- Late fetal period – 181-280th day of pregnancy

  • Perinatal period includes late fetal period since 28th week. (since 181th day of pregnancy till birth), intranatal (period of birth) and early neonatal period (1st week of life).

Gestational age is veritable age of child since the moment of conception.
Subject to gestational age of newborn is divided to:
Full term infant - gestational term - 37-41 weeks.
Premature infant – gestational term is <37 weeks.
Postmature infant – gestational term is >41 weeks.

Basic requirements of caring newborn:

  • Providing accurate care in birth;

  • Control of adequate respiration;

  • Control of adequate feeding;

  • Support of thermal balance;

  • Preventing contact with infection.

Signs of life-born (1 sign is enough):

  • Independent breathing

  • Palpitation

  • Pulsation of umbilical cord

  • Autokinesias of muscles

GENERAL care of healthy newborns

Modern methods of perinatal care are based on the conception of WHO related to physiological pregnancy management, labor management and physiological care of a baby with limitation of medical interference without clear indications.

100% of newborns are to be primarily estimated.

The main task of primary estimation of newborn infant in the delivery room is to get answers to the following questions:

  • What is the term of gestation?

  • Is amniotic fluid clear?

  • Is newborn breathing / crying?

  • Is his muscle tone good?


Routine care:

  • Contact “skin to skin” with mother

  • Warming (following 10 steps of heat chain)

  • Clearance of the airways (if it’s necessary)

  • Estimation of skin color


If at least one answer is “No”, go to Chapter “RESUSCITATION OF NEWBORN”

If the amniotic fluid and/or skin of a newborn are colored with meconium and the newborn is not active, right after the birth intubation of trachea and sanation of the tracheobronchial tracts are conducted. If the child is active (breathing or crying, muscle tonus is satisfactory, heart rate is faster than 100 per minute), the child is put on the stomach of the mother and then medical staff take care of him for the next 15 minutes. If the respiratory disorders are absent, routine medical care is provided.

^ The mode of providing medical care to healthy newborn in the delivery room

  1. As soon as the umbilical cord pulsation discontinues (not later than 1 minute after birth), midwife changes the gloves, ligates and cuts the umbilical cord with sterile scissors.

  2. The baby is put on the stomach of the mother; his head and body are dried with preliminarily warmed sterile napkin.

  3. If searching and sucking reflexes are noticed, midwife assists the mother with the first feeding.

  4. 30 minutes later midwife measures the temperature of the body in axillary area with electronic thermometer and records it in the child’s development card.

  5. After the contact “eyes-to-eyes” between mother and a baby (during the first hour of life), midwife having washed her hands, carries out preventive ophthalmia of newborn with 0,5% of erythromycin or 1% tetracycline ointment once. She also measures height, circumference of the head and chest and weighs the baby.

  6. The contact ”skin-to-skin” lasts for at least 2 hours in the delivery room, after that midwife puts the baby on the warmed table for swaddling, prepares and ligates the umbilical cord (sterile disposable clam is put 0,3-0,5cm near umbilicus).

The main principles of ligation the umbilical cord:

    • Wash the hands thoroughly;

    • Use sterile instruments and gloves;

    • Put on clean clothes on the baby;

    • Do not cover umbilical rest with a diaper.

  1. Neonatologist examines a newborn and fills in a newborn’s development card.

  2. A baby and mother are covered with the blanket and transported to the ward of rooming-in; the rules of heat chain are followed.

Heat chain

Even non-fulfilment of one step of heat chain leads to its rupture, overcooling of newborn with the risk of hypoglycemia, metabolic acidosis, infection, respiratory disorders, haemorrhages, convulsions.

Ten steps of heat chain

  1. Warming the delivery room (optimal temperature is 25-280C).

  2. Immediate drying of the baby (right after the birth, before ligation of the umbilical cord, midwife has to dry the head and the body of newborn with sterile, dry, preliminarily warmed napkins).

  3. Contact “skin-to-skin” (on the chest of the mother the baby is covered with preliminarily warmed diaper and is left there for at least 2 hours till he is transported to rooming-in).

  4. Early breast feeding (within the 1st hour after birth).

  5. Delayed weighing and bathing (the 1st bathing is reasonable at home, weighing and anthropometry are performed before referral to rooming-in).

  6. Putting on clothes and swaddle correctly.

  7. Round-the-clock staying of the baby with mother.

  8. Transportation in warm conditions (to the ward of joint stay a baby should be transported with mother).

  9. Reanimation in warm conditions.

  10. Improvement of practical and theoretical skills of the medical staff as for the principles of heat chain).

Routine medical interference

The majority of newborns don’t need routine medical interference. Medical interference has to be well grounded and be performed only in agreement with mother. Before discharge from the hospital the weighing of the baby is obligatory.

Medical care of newborns

  • Primary estimation of newborn condition is performed by neonatologist right after birth.

  • Primary medical inspection of newborn is performed by neonatologist before transportation to rooming-in. Consequently doctor examines the baby every day.

  • Inspection of the baby is performed according to the systems of organs; overcooling is not acceptable.

  • Before inspection the doctor washes the hands and disinfects the phonendoscope.

  • Inspection is compulsory on the day of discharge from the hospital.

The plan of medical examination of newborn infant

If the baby is healthy, the skin is pale pink, smoothy, elastic, on attempt to fold it it’s straightened up in a moment, slightly dry. Pathological changes of the skin are cyanosis, paleness, grey, yellowish color and mottled skin.

On examination the skin of newborn some clinical signs that aren’t considered to be pathologic ones can be observed.

  1. Milia – white-yellowish spots that arise above the surface of the skin, localized in the area of the nasolabial triangle, nosetip, correspond to retentional cysts of fat glands.

  2. Nonabundant petechial hemorrhages on the skin of the resented part of body.

  3. Telangiectasia (red-bluish vascular spots). They don’t arise above the surface of the skin, disappear after being pressed - it is differential diagnostic sign of haemangioma.

  4. Lanugo – hair, heavy growth is seen in premature infants.

  5. Mongolian spots.

  6. Birthmarks.

Postmature newborns have dry skin that can be exfoliated, and they don’t need medical care. The presence of edema and palpable lymphatic nodes has to be noted. The symptom of white spot is checked: if the child is healthy, the spot disappears 3 seconds after pressing. Inspection of the umbilical wound and umbilical ring includes estimation of its size, condition of the skin around it, character of the rate of healing.

^ Head and scull: the shape of the head can be brachycephalic, dolichocephalic. Circumference of the head of full term infant goes to 32-38cm (see figure 1).

It is necessary to estimate the size, borders, consistency for the presence of birth tumor or cephalohematoma (see figure 2).

Fig.1 Fig.2

Examine the sutures and fontanelles carefully (see figure 3). The bones of the skull are separated from one another by membranous tissue spaces called sutures. The area where the major sutures intersect in the anterior and posterior portions of the skull is known as fontanelle.

On palpation, the sutures are felt like ridges and the fontanelles like soft concavities. The anterior fontanelle at birth measures 2cm to 3cm in diameter and usually closes to the end of the 1st year of life. The posterior fontanelle measures 0,5cm to 1cm at birth and usually closes up to 2 months. In full-term newborn posterior fontanelle is usually closed at birth.


^ Face: location of the eyes, nose, and signs of dismorphy are examined.

Oral cavity: the color of the mucous membrane, symmetry of the angle of mouth, integrity of the palate and the upper lip are estimated.

Eyes: presence or absence of the anomaly of the development and haemorrhages into the sclerae, their color, symmetry and size of pupils.

^ External organs of hearing: external aucustic meatus, the shape and location of the auricules are inspected.

Nose: examine the shape of the nose.

Neck: the presence or absence of torticollis has to be determined.

Chest: normally has cylindrical shape, the low aperture is extended; the location of the ribs is symmetric, coming to horizontal. Palpate along the clavicle of the newborn noting any lumps, tenderness, or crepitus; these may indicate a fracture. A fracture of the clavicle can occur at complicated delivery.

Lungs: the presence or absence of the retractions of the jugular fossa, intercostal spaces, and xiphoid process during inspiration are taken into consideration. At auscultation there is puerile type of breathing above the total surface of the lungs. The average rate of breathing is 40-50 per minute.

Heart: auscultation of the heart is performed, determining the presence of the tones and extra murmurs. Heart rate is variable; the average is 110-140 per minute.

Stomach: of round shape, participates in breathing, soft, accessible to deep palpation. The low edge of the liver and spleen is detected by palpation. The liver can outcome below the edge of the costal margin for 1-2cm. The edge of the spleen is not palpable normally or palpable under the costal arch.

^ Genitals and anus: they must be formed according to feminizing or virilizing type. Phimosis is a physiological sign of boys. Testicles are in scrotum in full-term boys. In full-term girls the large lips of pudendum cover the small lips of pudendum. The presence of anus is detected.

^ Inguinal region: the pulse on the femoral artery is palpated.

Fig.4 Fig.5

^ Limbs, the spinal cord, joints: the shape of the limbs, the number of fingers on the hands and the number of toes on the feet are examined. Check the absence of displasia of the femoral bones in the coxofemoral joint: during swinging in the coxofemoral joints it is full, the symptom of the “clunk” is absent.

The following photos demonstrate the two major techniques, the first - to check the presence of a posteriorly dislocated hip (see fig.4), and the second - to check for the ability to sublux or dislocate an intact but unstable hip (see fig.5). With a hip dysplasia, you feel a “clunk” as the femoral head which lies posterior to the acetabulum, enters the acetabulum.

The back of newborn is examined for the presence of myelocele and dermal sinus.

Typical signs of full-term newborn: quiet face, original expression of the face. The beginning of the inspection is signed by emotional noisy cry. The motions are redundant and uncoordinated. Physiological hypertonus of the muscles-flexors is characteristic to stipulate the flexor position. The head is easily inclined to the chest, the hands are flexed in the elbow joint and adducted to the lateral surfaces of the chest and the hand is tight into the fist. The legs are flexed in the knee and coxofemoral joints.

Neurological inspection of a newborn requires the following criteria:

  • Expression of the face;

  • Cry: strength, duration, modulation

  • Motor activity: weakness is possible at CNS and somatic disorders; hyperactivity testifies the symptom of Ilpo (starting or reflex of Moro during percussion with the finger on the chest), tremor, spontaneous reflex of Moro, spontaneous starting, convulsions.

Fig.6 Fig.7 Fig.8 Fig.9

Fig.10 Fig.11 Fig.12 Fig.13

  • Reflexes of neonatal period that should be checked: rooting reflex (fig.6), palmar reflex (fig.7), plantar reflex (fig.8), Moro reflex (fig.9), support reflex (fig.10), placing & stepping reflex (fig.11), trunk incurvation (Galant’s) reflex (fig.12), tendon reflexes (fig.13).

- A muscle tone (resistance of muscles to the tension at passive bending and unbending of extremities) can be increased or decreased. Changes of muscle tone cause pathological positions of a newborn.


Pathological positions of newborns:

The position of the “frog” – the hands are inertly streched along the body, the legs are widely moved apart in the coxofemoral joints and easily flexed in the knee joints. For deeply premature infants this position is physiological. In full term children it appears at intracranial hemorrhages, damages of the upper segments of the cervical part of the spinal cord, severe somatic diseases.

Opisthotonus - the head is thrown back, hands are in fists stretched along the body, the legs are straightened in the knee joints, crossed in the low third part of the shin. This position is typical for the purulent meningitis, subarachnoidal hemorrhage and bilirubinic encephalopathy.

At purulent meningitis the head is easily thrown back, the legs are flexed in the knee joints and adducted to the abdomen closely. On attempt to straighten the legs the cry and nervousness appear.

^ Asymmetric positions

Hemitype: the hand and the leg on one side are in the physiological position, on the other side the limbs are straightened, their muscle tonus is reduced. Paraplegia - reduction of the muscle tonus of the upper or lower limbs is possible. Monotype - decrease of the motion activity and muscle tonus of one limb alongside with physiological position of the healthy limbs.

^ Pathological position of the hands: the symptom of the griffin claw, wristdrop, monkey hand (adduction of the first finger to the palmary surface of the hand with flexor position of the rest fingers).

Pathological position of the feet: bow position (deflection of the foot from the axis of the limb to the medial direction), valgus position (deflection of the foot from the axis of the limb to the lateral direction), calcaneal position, drop foot.

^ Rooming-in of mother and newborn

Rooming-in is the staying of mother with her baby in the same room for 24 hours a day since the birth till the discharge from the hospital.

Rooming-in includes:

- contact “skin-to-skin” in the delivery room

- transportation of the mother with her baby to the ward

  • breast feeding on request

  • taking care of the child by mother together with the other members of the family

  • well grounded minimization of the medical staff intervention

- all the administrations and manipulations should be performed only at presence and in agreement with mother.

Daily care of newborn includes:

Care of the umbilical wound, care of the skin, measuring of the body temperature (2 times a day).

Principles of early breast feeding

  • Measures are directed to support breast feeding, regular informing of the whole medical staff, pregnant women and their families.

  • Medical staff is taught systematically as for the support of breast feeding.

  • Practical application of modern methods of preparing the family for the birth of the baby. Pregnant women, mothers and members of their families are informed and taught as for the advantages of breast feeding.

  • Help mothers begin early breast feeding successfully.

  • Pregnant women, mothers and members of their families are taught how to feed a baby and keep on lactation in difficult situations, including situations when they are temporarily separated from the children.

  • Support of breast feeding till the 6th month age of the child, except medical or social contraindications. Introduction of breast feeding till the age of one year and more alongside proper introduction of supplementory feeding.

  • Round-the-clock rooming-in of the mother with her baby and participation of the mother (members of the family) in caregiving.

  • Encourage mothers to breast feeding on request of the baby if there are no medical contraindications.

  • Refusal to use the pacifier and other mediators that imitate the mother’s breast.

  • Organization of the groups of breast feeding support, sending mothers there.

  • Observation of the international summary of the rules of realization breast milk substitutes.
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