Chapter 12: The Newborn – Feeding, High‑Risk, Birth Trauma, Asphyxia & HIE

Feeding full‑term newborn · High‑risk newborn · Birth trauma (cephalhematoma, brachial plexus, facial palsy) · Perinatal asphyxia · Hypoxic–ischemic encephalopathy (HIE) · Therapeutic hypothermia
📌 Core principles: Breastfeeding initiation within 1 hour. High‑risk newborns (preterm, SGA, asphyxia, trauma) need intensive monitoring. HIE staging (Sarnat) guides neuroprotection. Therapeutic hypothermia within 6 hours improves outcomes in moderate‑severe HIE.

📖 Core summary: feeding, high‑risk, trauma, asphyxia, HIE

🤱 Feeding full‑term newborn
Breastfeeding within 1 hour, colostrum rich in IgA. Latch assessment: wide mouth, lower lip flanged, audible swallowing. Cue‑based feeding (rooting, hand‑to‑mouth). Weight loss <10% acceptable first days, regain by day 10‑14.
⚠️ High‑risk newborn
Factors: preterm, SGA, LGA, asphyxia, maternal diabetes, infection, meconium aspiration, birth trauma. Need thermoregulation, glucose monitoring, respiratory support, sepsis evaluation.
💢 Birth trauma
Cephalhematoma (subperiosteal, crosses sutures), caput succedaneum (subgaleal, crosses sutures). Brachial plexus injury (Erb – C5‑6, Klumpke – C8‑T1). Facial palsy (forceps). Clavicle fracture. Management: observation, physiotherapy, prognosis good.
😵 Perinatal asphyxia
Insufficient gas exchange → hypoxemia, hypercapnia, metabolic acidosis (cord pH <7.0, base deficit ≥12). Multi‑organ injury (CNS, heart, kidney, liver, GI). Apgar ≤3 at 5 minutes.
🧠 Hypoxic–ischemic encephalopathy (HIE)
Staging (Sarnat): mild (irritability, hyperalert), moderate (lethargy, seizures), severe (coma, brainstem dysfunction). Therapeutic hypothermia (33‑34°C × 72h) within 6 hours reduces death/disability in moderate‑severe HIE.
📋 HIE management
Cooling protocol, EEG monitoring, seizure control (phenobarbital), avoid hyperthermia, maintain normotension, treat hypoglycemia, MRI predictive of outcome.
📊 Key HIE outcomes: Moderate HIE with cooling: 40‑50% death/disability → reduced to 25‑30%. Severe HIE still poor prognosis (50% mortality).

🔍 Approach to high‑risk newborn & HIE

1
Birth trauma evaluation – Palpate skull for swelling (caput/cephalhematoma). Assess brachial plexus: Erb (waiter’s tip – adducted, internally rotated, pronated); Klumpke (hand weakness, Horner syndrome). Facial asymmetry → exclude central vs peripheral palsy.
2
Identify asphyxia risk factors – Cord prolapse, placental abruption, tight nuchal cord, shoulder dystocia, prolonged labor, meconium, maternal hypotension.
3
HIE staging (Sarnat) – Mild: hyperalert, irritability, normal feeding. Moderate: lethargy, hypotonia, seizures (focal or multifocal). Severe: coma, flaccid, no seizures, brainstem (pupil, apnea, bradycardia).
4
Eligibility for therapeutic hypothermia – ≥36 weeks, within 6 hours of birth, moderate‑severe HIE (Sarnat stage II/III) or abnormal aEEG (seizures, burst suppression, flat trace).
5
Supportive care in HIE – Maintain normotension, normoglycemia, treat seizures (phenobarbital, levetiracetam), avoid hyperthermia (fever worsens injury). MRI at 5‑10 days predicts outcome.

📋 Stepwise management of HIE & birth trauma

1
Immediate resuscitation (delivery room) – NRP: warm, dry, stimulate, PPV if apnea or HR <100. Intubate if meconium with poor respiratory effort. Establish IV access, correct acidosis.
2
Initiate therapeutic hypothermia (within 6h) – Whole‑body or head cooling to 33.5°C (core esophageal/rectal). Maintain 72 hours, then rewarm 0.5°C/h. Contraindications: major congenital anomalies, severe coagulopathy.
3
Seizure management – Phenobarbital 20 mg/kg IV (loading), additional 10 mg/kg if needed. Levetiracetam or fosphenytoin second‑line. Continuous aEEG/EEG monitoring.
4
Systemic support – Maintain mean BP >40 mmHg (dopamine if needed). Treat hypoglycemia (D10W 2 mL/kg). Monitor urine output, liver enzymes, coagulopathy.
5
Birth trauma management – Cephalhematoma: observe, phototherapy if hyperbilirubinemia. Brachial plexus: immobilization, gentle ROM, early physiotherapy. Clavicle fracture: no splint needed, prognosis excellent.
6
Follow‑up & neurodevelopmental surveillance – MRI (T2, DWI, spectroscopy). Early intervention (PT, OT). Risk of cerebral palsy, cognitive impairment, epilepsy.
⚡ Key reminder: Therapeutic hypothermia reduces death/disability in moderate HIE (number needed to treat = 6‑7). Contraindicated if >6 hours old, severe coagulopathy, or major congenital anomalies.

🧠 Reflex prompts – feeding, trauma, asphyxia, HIE

🤱 Signs of effective breastfeeding latch:
Wide mouth, lower lip everted, chin touches breast, audible swallowing, no pain.
💥 Erb’s palsy (C5‑C6) – typical posture:
“Waiter’s tip”: adducted, internally rotated shoulder, extended elbow, pronated forearm, wrist flexion.
🧠 Sarnat stage II (moderate HIE) features:
Lethargy, hypotonia, seizures (often focal), poor feeding, autonomic instability.
❄️ Inclusion criteria for therapeutic hypothermia:
GA ≥36 weeks, age ≤6 hours, moderate‑severe HIE (Sarnat II/III) or abnormal aEEG (seizures, burst suppression).
🩺 Cephalhematoma vs caput succedaneum:
Cephalhematoma: subperiosteal, does not cross sutures, appears after hours. Caput: subcutaneous, crosses sutures, present at birth.
📉 Cord blood gas indicating asphyxia:
pH <7.0, base deficit ≥12 mmol/L. Low Apgar (≤3 at 5 min) supports diagnosis.