Newborn Screening Tests For Disorders That, If Left Untreated, May

Newborn Screening tests for disorders that, if left untreated, may lead to mental retardation, health complications, or even death. An affected baby looks healthy at birth because symptoms do not begin to show until a much later age. Once the signs and symptoms set in, the ill effects are often already permanent. Early detection of these disorders is crucial. Diagnosed children can continue to live normal and healthy lives as long as they are given treatment on time and consistently follow up with a specialist. The Philippine Newborn Screening Project says that 33,000 children out of the 2 million Filipino babies born yearly are at risk from the disorders that NBS addresses. Currently, NBS tests for five disorders: • Congenital Hypothyroidism - A lack or absence of thyroid hormone, which is necessary for growth of the brain and the body. Treatment is required within the first four weeks to prevent stunted physical growth and mental retardation. One out of 3,369 babies are at risk. • Congenital Adrenal Hyperplasia - An endocrine disorder that causes severe salt loss, dehydration, and abnormally high levels of male sex hormones. Left undetected and untreated, a baby may die within seven to 14 days. One in 7,960 newborns are at risk. • Galactosemia - A condition in which babies are unable to process galactose, which is the sugar present in milk. Increased galactose levels in the body lead to liver and brain damage, and to the development of cataracts. One in 82,250 may be affected. • Phenylketonuria - The inability to properly utilize the enzyme phenylalanine, which may lead to brain damage. One in 109,666 may be at risk. • Glucose-6-Phosphate Dehydrogenase Deficiency (G6PD) - A condition where the body lacks the enzyme called G6PD, which may cause hemolytic anemia resulting from exposure to oxidative substances present in certain drugs, foods and chemicals. Parents of G6PD-positive babies are given a list of these substances. While this is the mildest disorder that is covered in NBS, one out of 55 babies may be affected.

APGAR Score Introduction Your baby?s first exam in life that she needs to pass with flying colours is the Apgar Test. Developed by Virginia Apgar, an anesthesiologist, it is performed one minute after birth and then repeated after five minutes. Dr. Apgar has identified certain critical signs that are measured and rated immediately after birth. The results reflect the baby?s general condition and help the doctors to determine the nature of the baby?s post-delivery care.

The rating scale The baby is rated on a scale of zero to two on the following five signs: • • • • •

Appearance or colour Pulse or heart rate Grimace or reflex irritability Activity or muscle tone Respiration

The babies are rated in the following manner:

Appearance: If the baby is pink all over, she will get the maximum score of 2. If the body is pink with the exception of the arms and legs, which are blue, the baby will score 1. She will get a minimum score of 0, if her body is blue all over. Pulse: The baby scores 2 if her pulse rate is above 100 beats a minute. If her pulse rate is below 100, she will score 1 and if it not detectable, she will score 0. Reflex irritability: The doctor will slap the baby on the soles of her feet. If she cries lustily in response, she will score 2. A grimace or slight cry will get her a score of 1. If she does not respond at all, she will score 0. Activity: A baby that flails its arms and legs or otherwise displays a lot of activity at birth scores a two in this category. If the baby moves her limbs slightly, she will receive a score of 1. If the baby is limp and flaccid, and shows no activity, she will score 0. Breathing: Strong efforts to breathe, accompanied by crying are a sign that the baby?s lungs are in good working order. She will receive a score of 2. Slow, irregular breathing rates a 1. No respiration gets the lowest score of 0.

What the scores mean The baby?s scores in these five categories are added up to give the Apgar score. (The maximum score is 10). It has been observed that most babies score between 7 and 10 points one minute after birth, indicating that the baby is generally in good health and will require only routine post-deliver care. Babies who score between 4 and 6 are in fair condition, though they may require help to breathe. They may be put on oxygen or if there is mucus in the throat it will have to be removed to prevent any obstruction in the baby? breathing. Those babies that have a total score below 4 are normally pale, limp and unresponsive. They will require immediate life-saving efforts. The baby?s lungs will have to be externally inflated and the throat will have to be suctioned to clear the air passage. Such babies will have to be closely monitored in the intensive care until their bodies take over and they can wing it on their own.

The five minute score The Apgar test is repeated after five minutes. While the one-minute score is an indication to doctors as to the nature of the immediate care required postdelivery, the five minute score was thought to be a good predictor of the baby?s survival and development in early infancy.

Newborn - Reflexes What reflexes should be present in a newborn?

Reflexes are involuntary movements or actions. Some movements are spontaneous, occurring as part of the baby's usual activity. Others are responses to certain actions. Reflexes help identify normal brain and nerve activity. Some reflexes occur only in specific periods of development. The following are some of the normal reflexes seen in newborn babies:

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root reflex This reflex begins when the corner of the baby's mouth is stroked or touched. The baby will turn his/her head and open his/her mouth to follow and "root" in the direction of the stroking. This helps the baby find the breast or bottle to begin feeding.

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suck reflex Rooting helps the baby become ready to suck. When the roof of the baby's mouth is touched, the baby will begin to suck. This reflex does not begin until about the 32nd week of pregnancy and is not fully developed until about 36 weeks. Premature babies may have a weak or immature sucking ability because of this. Babies also have a hand-to-mouth reflex that goes with rooting and sucking and may suck on fingers or hands.

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Moro reflex The Moro reflex is often called a startle reflex because it usually occurs when a baby is startled by a loud sound or movement. In response to the sound, the baby throws back his/her head, extends out the arms and legs, cries, then pulls the arms and legs back in. A baby's own cry can startle him/her and begin this reflex. This reflex lasts about five to six months.

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tonic neck reflex When a baby's head is turned to one side, the arm on that side stretches out and the opposite arm bends up at the elbow. This is often called the "fencing" position. The tonic neck reflex lasts about six to seven months.

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grasp reflex Stroking the palm of a baby's hand causes the baby to close his/her fingers in a grasp. The grasp reflex lasts only a couple of months and is stronger in premature babies.

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Babinski reflex When the sole of the foot is firmly stroked, the big toe bends back toward the top of the foot and the other toes fan out. This is a normal reflex up to about 2 years of age.

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step reflex This reflex is also called the walking or dance reflex because a baby appears to take steps or dance when held upright with his/her feet touching a solid surface.

Newborn - Sleep Patterns What are the sleep patterns of a newborn?

The average newborn sleeps much of the day and night, waking only for feedings every few hours. It is often hard for new parents to know how long and how often a newborn should sleep. Unfortunately, there is no set schedule at first and many newborns have their days and nights confused - they think they are supposed to be awake at night and sleep in the daytime. Generally, newborns sleep about eight to nine hours in the daytime and about eight hours at night. Most babies do not begin sleeping through the night (six to eight hours) without waking until about three months of age, or until they weigh 12 to 13 pounds. Newborns and young infants have a small stomach and must wake every few hours to eat. In most cases, your baby will awaken and be ready to eat about every three to four hours. It is not necessary to wake a baby for feedings unless you have been advised to do so by your baby's physician. However, do not let a newborn sleep longer than five hours at a time in the first five to six weeks. Some premature babies need more frequent feedings and must be awakened to eat. Watch for changes in your baby's sleep pattern. If your baby has been sleeping consistently, and suddenly is waking, there may be a problem such as an ear infection. Some sleep disturbances are simply due to changes in development or because of overstimulation. Never put a baby to bed with a bottle propped for feeding. This is a dangerous practice that can lead to ear infections and choking. What are the sleep states of a newborn?

Babies, like adults, have various stages and depths of sleep. Depending on the stage, the baby may actively move or lie very still. Infant sleep patterns begin forming

during the last months of pregnancy - active sleep first, then quiet sleep by about the eighth month. There are two types of sleep:

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REM (rapid eye movement sleep) This is a light sleep when dreams occur and the eyes move rapidly back and forth. Although babies spend about 16 hours each day sleeping, about half of this is in REM sleep. Older children and adults sleep fewer hours and spend much less time in REM sleep.

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Non-REM sleep: Non-REM has 4 stages:

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Stage 1 - drowsiness - eyes droop, may open and close, dozing

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Stage 2 - light sleep - the baby moves and may startle or jump with sounds

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Stage 3 - deep sleep - the baby is quiet and does not move

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Stage 4 - very deep sleep - the baby is quiet and does not move

A baby enters stage 1 at the beginning of the sleep cycle, then moves into stage 2, then 3, then 4, then back to 3, then 2, then to REM. These cycles may occur several times during sleep. Babies may awaken as they pass from deep sleep to light sleep and may have difficulty going back to sleep in the first few months. What are the different alert phases of a newborn?

Babies also have differences in how alert they are during the time they are awake. When a newborn awakens at the end of the sleep cycles, there is typically a quiet alert phase. This is a time when the baby is very still, but awake and taking in the environment. During the quiet alert time, babies may look or stare at objects, and respond to sounds and motion. This phase usually progresses to the active alert phase in which the baby is attentive to sounds and sights, but moves actively. After this phase is a crying phase. The baby's body moves erratically, and he/she may cry loudly. Babies can easily be overstimulated during the crying phase. It is usually best to find a way of calming the baby and the environment. Holding a baby close or swaddling (wrapping snugly in a blanket) may help calm a crying baby. It is usually best to feed babies before they reach the crying phase. During the crying phase, they can be so upset that they may refuse the breast or bottle. In newborns, crying is a late sign of hunger. Helping your baby sleep:

Babies may not be able to establish their own sleeping and waking patterns, especially in going to sleep. You can help your baby sleep by recognizing signs of sleep readiness, teaching him/her to fall asleep on his/her own, and providing the right environment for comfortable and safe sleep. What are the signs of sleep readiness?

Your baby may show signs of being ready for sleep when you see the following signs:

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rubbing eyes yawning looking away fussing

How can you help your baby fall asleep?

Although it is surprising, not all babies know how to put themselves to sleep. When it is time for bed, many parents want to rock or breastfeed a baby to help him/her fall asleep. Establishing a routine like this at bedtime is a good idea. However, be sure that the baby does not fall asleep in your arms. This may become a pattern and the baby may begin to expect to be in your arms in order to fall asleep. When the baby briefly awakens during a sleep cycle, he/she may not be able to go back to sleep on his own. Most experts recommend allowing a baby to become sleepy in your arms, then placing him/her in the bed while still awake. This way the baby learns how to go to sleep on his own. Playing soft music while your baby is getting sleepy is also a good way to help establish a bedtime routine. What sleeping positions are best for a newborn?

For many years in the United States, babies have been put to bed on their stomachs. In most other countries, babies sleep on their backs. Research has found a link between sudden infant death syndrome (SIDS) and babies who sleep on their stomachs (in the prone position). Experts now agree that putting a baby to sleep on his/her back is the safest position. Side-sleeping may also be used, but this also has a higher risk than back sleeping. Other reports have found soft surfaces, loose bedding, and overheating with too many blankets also increase the risk for SIDS. When infants are put to sleep on their stomachs and they also sleep on soft bedding, the risk for SIDS is even higher. Smoking by the mother is also a major risk for SIDS, as are poor prenatal care and prematurity. Since the American Academy of Pediatrics (AAP) made the "back-tosleep" recommendation in 1992, the SIDS rate has dropped more than 40 percent. Back sleeping also appears to be safer for other reasons. There is no evidence that babies are more likely to vomit or spit up while sleeping on their back. In fact, choking may be more likely in the prone position. A task force of The US Consumer Product Safety Commission (CPSC), the American Academy of Pediatrics (AAP), and the National Institute of Child Health and Human Development (NICHD), offer the following recommendations for infant bedding:

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Place your baby on his/her back on a firm, tight-fitting mattress in a crib that meets current safety standards.

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Remove pillows, quilts, comforters, sheepskins, stuffed toys, and other soft products from the crib.

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Consider using a sleeper as an alternative to blankets with no other covering.

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If using a blanket, put your baby with his/her feet at the foot of the crib. Tuck a thin blanket around the crib mattress, only as far as the baby's chest.

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Make sure your baby's head remains uncovered during sleep.

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Do not place your baby on a waterbed, sofa, soft mattress, pillow, or other soft surface to sleep.

According to the task force report, bed sharing or co-sleeping may be hazardous for babies in certain conditions. The report advises the following:

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Parents should consider placing the infant's crib near their bed for more convenient breastfeeding and parent contact.

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If a mother chooses to have her infant sleep in her bed to breastfeed, care should be taken that the baby sleeps in a non-prone position, soft surfaces or loose covers are avoided, and the bed is moved away from the wall and other furniture to avoid the baby becoming entrapped between them.

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Adults other than the parents, children, or other siblings should not share a bed with an infant.

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Parents who choose to bed share with their infant should not smoke or use substances such as drugs or alcohol that may impair their ability to awaken.

To prevent overheating, the report recommends that the infant should be lightly clothed for sleep and the room temperature kept comfortable for a lightly clothed adult. Avoid over bundling and check the baby's skin to make sure it is not hot to the touch. Additional research has found that infants should not be put to sleep on a sofa, alone or with another person, as this practice increases the risk for SIDS. While babies should sleep on their backs, other positions can be used during the time babies are awake. Babies can be placed on their stomachs while awake to help develop muscles and eyes and to help prevent flattened areas on the back of the head.

Newborn - Senses The senses of a newborn:

Babies are born fully equipped with all the necessary senses of sight, hearing, smell, taste, and touch. However, some of these senses are less precise than others. Below are some of the ways newborn babies express their senses:

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vision A newborn's eyes are a little more than half the size of an adult's eyes. They grow the most in the first year, then slowly grow until puberty. Most Caucasian babies have light gray or blue eye color, but this often changes by 6 months of age. Over the first few months, babies may have uncoordinated eye movements and may even appear cross-eyed. Babies are born with the ability to focus only at close range - about 8 to 10 inches or the distance between a mother's face to the baby in her arms. Babies are able to follow or track an object in the first few weeks. Focus improves over the first two to three years of life to a normal 20/20 vision. Newborns can detect light and dark but cannot see all colors. This is why many baby books and infant stimulation toys have distinct black and white patterns.

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hearing During pregnancy many mothers find that the baby may kick or jump in response to loud noises and quiet with soft, soothing music. Hearing is fully developed in newborns. Babies with normal hearing should startle in response to loud sounds, pay quiet attention to the mother's voice, and briefly stop moving when sound at a conversational level is begun. Newborns seem to prefer a higher-pitched voice (the mother's) to a low sounding voice (males). They also have an ability to tune out loud noises after hearing them several times.

It is estimated that serious hearing loss occurs in about one to three of every 1,000 healthy newborns. Without screening or testing, hearing loss may not be noticed until the baby is more than 1 year old. If hearing loss is not detected until later years, there will not be stimulation of the brain's hearing centers. This can affect the maturation and development of hearing, and can delay speech and language. Social and emotional development and success in school may also be affected. It is now recommended that all newborns be screened for hearing loss before leaving the hospital.

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taste Taste buds begin forming early in fetal development. It is known that babies prefer sweet tastes over sour or bitter tastes. Babies also show a strong preference for breast milk and breastfeeding, especially after the first few months.

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smell The brain's olfactory (smell) center forms very early in fetal development. Studies have found that newborns have a keen sense of smell. Within the first few days they will show a preference for the smell of their own mother, especially to her breast milk.

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touch Throughout the last months of pregnancy, a baby is snugly cocooned in the uterus, with arms and legs tucked. At birth, babies are suddenly thrust into a bright, cold world, where their arms and legs can suddenly move freely. This new freedom can make babies frantic and they may flail and thrash about. Placing a hand on the baby's abdomen, or cuddling close can help a baby feel more secure. Swaddling (wrapping snugly in a blanket) is another technique for babies who need to feel tucked and secure. Some mothers find their babies respond and calm when they are "worn" in a sling or carrier. This may be helpful for colicky or high-need babies. Holding a baby for feedings is also important. Breastfeeding ensures that a baby spends several hours in mother's arms.

Newborn - Crying What are the crying patterns of a newborn?

The first cries of a newborn baby are often music to the ears of parents. However, over the next weeks and months this "music" can become grating and painful. This is especially true when all attempts fail to stop the crying. Surprisingly, crying does not produce tears until after the first month or two. Crying is the way babies communicate. They cry because of hunger, discomfort, frustration, fatigue, and even loneliness. Sometimes, cries can easily be answered with food, or a diaper change. Other times, it can be a mystery and crying stops as quickly as it begins. You will soon learn differences in cries, from a cry of "I'm hungry" to "I've been overstimulated." It is important to respond to your baby's cries. Contrary to old wives' tales, young babies cannot be spoiled by being picked up when crying. Being held is reassuring and comforting when a baby cannot express him/herself any other way. Some techniques to help console a crying baby include the following:

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Take care of physical problems first - hunger, diaper change, need to burp. Walk with baby in a sling or in a stroller. Rock your baby in a rhythmic, gentle motion.

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Try a baby swing or rocking cradle. Gently pat or stroke on the back or chest. Try swaddling the baby. Go for a ride in the car. Turn on some white noise (such as a washing machine or vacuum cleaner).

No matter how frustrated you may become, NEVER SHAKE A BABY. This can cause severe injury to the baby's fragile brain. If you become angry or frustrated, allow someone else to take over for a while. If you are alone, put the baby down in a safe place, such as the crib, and go to another room for a few moments. This will give you time to collect yourself. Then you can return to your baby and try a different tactic to comfort your baby.

Newborn Immunizations According to the Centers for Disease Control and Prevention (CDC), vaccinepreventable childhood diseases in the United States are near an all-time low. But, some viruses and bacteria are still active and can cause serious illness. It is important that all children, especially infants and young children, receive recommended immunizations on time. In other countries, many vaccine-preventable diseases are relatively common. Because of travel, these diseases could return to the US, resulting in increased, and unnecessary, illness, disability, and death among children. What is hepatitis B vaccine?

Immunizations start at birth. The first immunization given is the hepatitis B vaccine. Listed below are some facts about hepatitis B:

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Hepatitis B is a disease of the liver caused by hepatitis B virus.

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Potentially, there may not be any symptoms present when first infected (the likelihood of early symptoms decreases with the person's age); if present: yellow skin or eyes, tiredness, stomach ache, loss of appetite, nausea, or joint pain may occur.

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The younger the person is when infected with hepatitis B, the greater the likelihood of staying infected and having life-long liver problems, such as scarring of the liver and liver cancer.

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The disease is spread through contact with the blood of an infected person or by having sex with an infected person.

Hepatitis B vaccine will prevent this disease. This vaccine is given to nearly all newborns. Additional doses are given before the age of 18 months. If newborns are exposed to hepatitis B before, during, or after birth, both the vaccine and a special hepatitis B immune globulin dose are given within 12 hours of birth. The other two doses of the vaccine are also given before the age of 18 months.

Summary of the neurologic examination with respect to gestational age

Respiratory and Cardiovascular Systems Respiratory System Baby’s respiration organs begin their work right after the moment of arrival together with his first cry. Breath frequency and intensity changes under the influence of different exogenous and endogenous irritators. Baby’s organism needs much of oxygen, and high frequency of respiration covers this necessity. Lungs of a newborn baby are rich in blood vessels and poor in the elastic tissue. The newborn baby’s nose is little, his nostrils are extremely narrow, the mucous membrane is tender with a big number of blood vessels that is why even the least inflammation may cause difficulties with breathing. Because of the horizontal ribs position and week intercostal muscles a baby breathes often and not deeply. Because of this respiration peculiarity his lungs do not get filled with oxygen completely, which leads to oxygen dearth. If your baby spends much time in a badly aired room, it may grow progressively worse and it may even cause flatulence. While a baby is crying, his bungs get ventilated better, so a weak baby’s cry may even be useful sometimes. Cardiovascular System Before the moment of birth baby’s respiration is placental. After the first breath his lungs open and get filled with blood. Heart mass of a newborn baby is relatively big. It weights 0,8 % of his body mass. The heart is of a roundish form and it is situated in the middle of the chest. The correlation of atriums and ventricles of a newborn baby is different than adult people have: babies’ atriums are of a bigger size.

Newborn baby’s pulse is relatively often: up to 120-140 beats per minute. It is quite uneven. The frequency of baby’s heartbeats depends on his cry, movements, raised temperature, and other reasons. While your little one is crying, his pulse may be up to 180-200 beats per minute. But the pulse frequency decreases, as a baby gets older. So, at the age of 6 months, baby’s pulse is about 125-130 beats per minute, and it is 115-120 beats per one minute, when your child is 12 months old.

Assessments for Newborn Babies Each newborn baby is carefully checked at birth for signs of problems or complications. A complete physical assessment will be performed that includes every body system. Throughout the hospital stay, physicians, nurses, and other healthcare providers continually assess a baby for changes in health and for signs of problems or illness. Assessment may include: Apgar scoring: The Apgar score is one of the first checks of your new baby's health. The Apgar score is assigned in the first few minutes after birth to help identify babies that have difficulty breathing or have a problem that needs further care. The baby is checked at one minute and five minutes after birth for heart and respiratory rates, muscle tone, reflexes and color. Each area can have a score of zero, one or two, with 10 points as the maximum. A total score of 10 means a baby is in the best possible condition. Nearly all babies score between eight and 10, with one or two points taken off for blue hands and feet because of immature circulation. If a baby has a difficult time during delivery, this can lower the oxygen levels in the blood, which can lower the Apgar score. Apgar scores of three or less often mean a baby needs immediate attention and care. However, only 1.4 percent of babies have Apgar scores less than seven at five minutes after birth.

Birthweight and measurements: A baby's birthweight is an important indicator of health. The average weight for term babies (born between 37 and 41 weeks gestation) is about 7 lbs. (3.2 kg). In general, small babies and very large babies are at greater risk for problems. Babies are weighed daily in the nursery to assess growth, fluid, and nutrition needs. Newborn babies may lose as much as 10 percent of their birthweight. This means that a baby weighing 7 pounds 3 ounces at birth might lose as much as 10 ounces in the first few days. Premature and sick babies may not begin to gain weight right away. Most hospitals use the metric system for weighing babies. This chart will help you convert grams to pounds: Converting grams to pounds and ounces: 1 lb. = 453.59237 grams; 1 oz. = 28.349523 grams; 1000 grams = 1 Kg.

Measurements: Other measurements are also taken of each baby. These include the following:

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head circumference - the distance around the baby's head (normally about one-half the baby's body length plus 10 cm)

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abdominal circumference - the distance around the abdomen

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length - the measurement from crown of head to the heel

Physical examination: A complete physical examination is an important part of newborn care. Each body system is carefully examined for signs of health and normal function. The physician also looks for any signs of illness or birth defects. Physical examination of a newborn often includes assessment of:

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vital signs:

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temperature - able to maintain stable body temperature 98.60 F (370 C) in normal room environment

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pulse - normally 120 to 160 beats per minute

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breathing rate - normally 30 to 60 breaths per minute

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general appearance - physical activity, tone, posture, and level of consciousness

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skin - color, texture, nails, presence of rashes

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head and neck

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appearance, shape, presence of molding (shaping of the head from passage through the birth canal)

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fontanels (the open "soft spots" between the bones of the baby's skull)

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clavicles (bones across the upper chest)

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face - eyes, ears, nose, cheeks

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mouth - palate, tongue, throat

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lungs - breath sounds, breathing pattern

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heart sounds and femoral (in the groin) pulses

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abdomen - presence of masses or hernias

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genitals and anus - for open passage of urine and stool

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arms and legs - movement and development

Gestational assessment: Assessing a baby's physical maturity is an important part of care. Maturity assessment is helpful in meeting a baby's needs if the dates of a pregnancy are uncertain. For example, a very small baby may actually be more mature than it appears by size, and may need different care than a premature baby. An examination called The Dubowitz/Ballard Exam for Gestational Age is often used. A baby's gestational age often can be closely estimated using this exam. The Dubowitz/Ballard Exam evaluates a baby's appearance, skin texture, motor function, and reflexes. The physical maturity part of the exam is done in the first two hours of birth. The neuromuscular maturity examination is completed within 24 hours after delivery. Information often used to help estimate babies' physical and neuromuscular maturity are shown below.

Physical maturity: The physical assessment part of the Dubowitz/Ballard Exam looks at physical characteristics that look different at different stages of a baby's gestational maturity. Babies who are physically mature usually have higher scores than premature babies. Points are given for each area of assessment, with a low of -1 or -2 for extreme immaturity to as much as 4 or 5 for postmaturity.

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skin - ranges from sticky and red to smooth to cracking or peeling lanugo (the soft downy hair on a baby's body) is absent in immature babies then appears with maturity and then disappears again with postmaturity

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plantar creases - these creases on the sole of the feet range from absent to covering the entire foot depending on the maturity

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breast - the thickness and size of breast tissue and areola (the darkened nipple area) are assessed

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eyes and ears - eyes fused or open and amount of cartilage and stiffness of the ear tissue are assessed

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genitals, male - presence of testes and appearance of scrotum, from smooth to wrinkled

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genitals, female - appearance and size of the clitoris and the labia

Neuromuscular maturity: Six evaluations of the baby's neuromuscular system are performed. These include:

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posture - how does the baby hold his/her arms and legs.

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square window - how much the baby's hand can be flexed toward the wrist.

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arm recoil - how much the baby's arms "spring back" to a flexed position.

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popliteal angle - how much the baby's knee extends.

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scarf sign - how far the elbow can be moved across the baby's chest.

• heel to ear - how close the baby's foot can be moved to the ear. A score is assigned to each assessment area. Typically, the more neurologically mature the baby, the higher the score. When the physical assessment score and the neuromuscular score are added together, the gestational age can be estimated. Scores range from very low for immature babies (less than 26 to 28 weeks) to very high scores for mature and postmature babies. All of these examinations are important ways to learn about your baby's well-being at birth. By identifying any problems, your baby's physician can plan the best possible care.

Changes in the newborn at birth At birth, an infant's body undergoes a number of changes that allow it to survive outside the womb and adapt to life in a new environment. Information LUNGS AND CIRCULATORY SYSTEM While the fetus is in the womb, it "breathes" by exchanging oxygen and carbon dioxide through the mother's circulation via the placenta. Most of the blood does not go through the developing baby's lungs. Instead, it travels through the heart and flows throughout the baby's body. At birth, the baby's lungs are filled with amniotic fluid and are not inflated. The baby takes the first breath within about 10 seconds after delivery. It sounds like a gasp, as the newborn's central nervous system reacts to the sudden change in temperature and environment. Once the umbilical cord is cut and the baby takes the first breath, a number of changes occur in the infant's lungs and circulatory system:

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Increased oxygen in the lungs causes a decrease in blood flow resistance to the lungs. Blood flow resistance of the baby's blood vessels also increases. Amniotic fluid drains or is absorbed from the respiratory system. The lungs inflate and begin working on their own, moving oxygen into the bloodstream and removing carbon dioxide through exhalation.

TEMPERATURE REGULATION A developing baby produces about twice as much heat as an adult. That heat dissipates as blood flows into the mother's circulation via the placenta and is cooled. A small amount of heat is removed through the developing baby's skin, the amniotic fluid, and the uterine wall. After delivery, the newborn begins to lose heat. Receptors on the baby's skin send messages to the brain that the baby's body is cold. The baby's body then creates heat by shivering and by burning stores of brown fat , a type of fat found only in fetuses and newborns. LIVER In the fetus, the liver acts as a storage site for sugar (glycogen) and iron. When the baby is born, the liver has various functions: • • •

It produces substances that help the blood to clot. It begins breaking down waste products such as excess red blood cells. It produces a protein that helps break down bilirubin. If the baby's body does not properly break down bilirubin, it can lead to newborn jaundice.

GASTROINTESTINAL TRACT A baby's gastrointestinal system doesn't fully function until after birth. However, in the womb, it does allows the baby to absorb nutrients from the placenta. In late pregnancy, the fetus produces a tarry green or black waste substance called meconium. Meconium is the medical term for the newborn infant's first stools. Meconium is composed of amniotic fluid, mucous, lanugo (the fine hair that covers the baby's body), bile, and cells that have been shed from the skin and the intestinal tract. In some cases, the baby passes stools (meconium) while still inside the uterus. URINARY SYSTEM The developing baby's kidneys begin producing urine by 9 - 12 weeks into the pregnancy. After birth, the newborn will usually urinate within the first 24 hours of life. The kidneys become able to maintain the body's fluid and electrolyte balance.

The rate at which blood filters through the kidneys (glomerular filtration rate) increases sharply after birth and in the first 2 weeks of life. Still, it takes some time for the kidneys to get up to speed. Newborns have less ability to remove excess salt (sodium) or to concentrate or dilute the urine compared to adults. This ability improves over time. IMMUNE SYSTEM The immune system begins to develop in the fetus, and continues to mature through the child's first few years of life. The womb is a relatively sterile environment. But as soon as the baby is born, he or she is exposed to a variety of bacteria and other potential disease-causing substances. Although newborn infants are more vulnerable to infection, their immune system can respond to infectious organisms. Newborns do carry some antibodies from their mother, which provide protection against infection. Breastfeeding also helps improve a newborn's immunity. SKIN Newborn skin will vary depending on the length of the pregnancy. Premature infants have thin, transparent skin. The skin of a full-term infant is thicker. Characteristics of newborn skin: •

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A fine hair called lanugo might cover the newborn's skin, especially preterm babies. The hair should disappear within the first few weeks of the baby's life. A thick, waxy substance called vernix may cover the skin. This substance protects the fetus from constant exposure to amniotic fluid in the womb. Vernix should wash off during the baby's first bath. The skin might be cracking, peeling, or blotchy, but this should improve over time.

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Acne may be seen from birth, but it should go away within a few months. Milia are small white spots on the cheeks and nose. They are filled with a waxy protein called keratin. They should disappear within the first few weeks. Mongolian spots are blue-gray or brown spots can emerge on the skin of the buttocks or back, mainly in dark-skinned babies. They should fade within a year. Stork bites are small red patches on the baby's forehead, eyelids, back of the neck, or upper lip are caused by stretching of the blood vessels. They often go away within 18 months.