Nursing Care Management 101

1. Republic of the Philippines
Laguna State Polytechnic University
College of Nursing and Allied Health
Santa Cruz, Laguna
BIRADOR, ROXANNE MAE E. BS NURSING II-A
ELIZABETH VIVIAN A. MOZO RN, MAN
Clinical Instructor

2. 1. BREASTFEEDING is the feeding of an infant or young child with breast milk directly from
female human breasts (lactation) rather than using infant formula. It is considered the healthiest form
of milk for babies. Breastfeeding promotes the health of both mother and infant and helps to prevent
disease, it is the normal way of providing young infants with the nutrients they need for healthy growth
and development. Virtually all mothers can breastfeed, provided they have accurate information, and
the support of their family, the health care system and society at large.
1.1 STAGES OF HUMAN MILK
COLOSTRUM— the yellowish, sticky breast milk produced at the end of pregnancy, is
recommended by WHO as the perfect food for the newborn, and feeding should be initiated within the
first hour after birth. Exclusive breastfeeding is recommended up to 6 months of age, with continued
breastfeeding along with appropriate complementary foods up to two years of age or beyond. It
contains proteins, carbohydrates, fats, vitamins, minerals, and proteins (antibodies) that fight disease-
causing agents such as bacteria and viruses. Antibody levels in colostrums can be 100 times higher
than levels in regular cow’s milk. Colostrum is also used for boosting the immune system, healing
injuries, repairing nervous system damage, improving mood and sense of well being, slowing and
reversing aging, and as an agent for killing bacteria and fungus.
TRANSITION MILK— the breast milk will evolve to transmission milk a few days after the
birth of your baby. Transition milk is a mixture of colostrum and mature milk. It will be produced for
about 1-2 weeks, even longer if your baby is premature. In the case of a premature baby, transition
milk could be produced up to 6 months. A premature baby will longer need the benefits of the
colostrums contained in the transition milk and also she will benefit from all the components that the
semi-mature breast milk contains to ensure the steady growth.
Transition Milk Composition
It contains high levels of lipids (fats) and lactose. It also contains proteins, minerals and water-soluble
vitamins. Transition breast milk is a perfectly designed formula that ensures your baby’s steady
weight gain. Its components ensure your baby has a regulated blood sugar level, an optimum brain
development, a normal retina function and a constant high level of energy from calories ingested from
your transition milk.
Your child instinctively knows how long to suckle to get what they need. They will suck
lighter if they are thirsty and harder when they are hungry.

3. MATURE MILK— it is usually produced around the second or third week after the birth of
your baby. The composition of mature milk will change during the whole lactation period but it will
always be adequate to the baby as they grow through the stages of infancy, baby and toddler.
Foremilk has a thinner consistency.
The foremilk is the milk that, when nursing, a
baby will draw first; it has lower fat content and
higher lactose content.
Hindmilk has a thicker, creamier
consistency. The hindmilk is the milk behind
the foremilk. The baby will receive the hindmilk
after drawing the foremilk.
Your baby will receive the foremilk first, and this will quench their thirst; the hindmilk will come next
and will relieve your child's hunger because it is richer and fattier than the foremilk.
Mature Milk Composition
Researchers have found more than 200 components in mature milk of which the major elements are;
water, lipids, proteins, lactose, vitamins and minerals, hormones, enzymes and antibodies.
INVOLUTIONAL MILK—it is so called when the baby or toddler starts to gradually wean.
The composition of the breast milk will then slowly change and the quantity produced will decrease as
there is less demand and stimulation on the mammary glands. Involutional milk is very interesting in
the way that it prepares your baby or toddlers for the final wean. Indeed the amount of lactose will
progressively get lower but proteins, lipids sodium and especially antibodies will increase in
concentration. It will provide her immune system one last phenomenal immunological boost.
1.2 MATERNAL POSITION DURING BREASTFEEDING
1.2.1. Description
Getting Comfortable: If you're a first-time parent, breastfeeding your newborn may seem
complicated until you've had some practice. But a little preparation can help you feel more
comfortable. Before you begin nursing, take a look at your surroundings. Many mothers like to sit in a
glider or in a cozy chair with armrests. Footstools and pillows can provide extra support (try donut-
type nursing pillows or "husband" back pillows with arms on each side for nursing in bed).
1.2.2. Procedure
THE CRADLE HOLDS—this is the first hold many mothers will try,
often soon after their babies are born. To start, cradle your baby's head in the
crook of your arm with your baby's nose opposite your nipple. Use that hand to
support your baby's bottom. Turn your baby on his or her side, so that your
baby is belly to belly to you. Then, raise your baby to your breast. You can
support your breast with your other hand.

4. THE CROSS-CRADLE OR CROSSOVER HOLD—this hold
is similar to the cradle hold, but your arms are positioned differently. Instead
of supporting your baby's head in the crook of your arm, use the hand of that
arm to support your breast. Your opposite arm should come around the back
of your baby. Support your baby's head, neck, and shoulder by placing your
hand at the base of your baby's head with your thumb and index finger at your
baby's ear level. Like the cradle hold, your baby will be belly to belly to you.
You may need to use a pillow on your lap to raise your baby to nipple level.
The cross-cradle position allows you to have more control over how your
baby latches on. Many moms find that they're able to get their babies latched
on more deeply with this hold.
THE SIDE-LYING POSITION—this position is comfortable for
mothers who've had a cesarean section (C-section) because the baby
doesn't put pressure on the mother's abdomen. This is also a great way
for you to get some rest while nursing your baby, but return your baby to
the crib or bassinet before falling asleep.
Start by lying on your side with your baby on his or her side, facing
you. Your baby should be positioned so his or her nose is opposite your
nipple. Use your lower arm to cradle your baby's back, or you can tuck a
rolled-up receiving blanket behind your baby to help nestle your little one
close to you while you use your arm to support your own head. You can
support your breast with your other hand.
THE CLUTCH OR FOOTBALL HOLD—this is also a good
position for the mom who's had a C-section and also for mothers with large
breasts or small babies. Mothers with twins who want to feed the babies at
the same time may also choose this position. The football hold allows babies
to take milk more easily — which is also good for mothers with a forceful
milk ejection reflex (or let down).To achieve the clutch (or football) hold,
place a pillow next to you. Cradle your baby — facing upward — in your
arm. Use the palm of your hand on that same arm to support his or her neck,
and nestle your baby's side closely against your side. Your baby's feet
and legs should be tucked under your arm. Then lift your baby to your breast.

5. 1.4 BREASTFEEDING TECHNIQUES
LATCHING ON—after your baby is positioned correctly, make sure he or she latches on (takes
the breast into his or her mouth) properly:
1. Make sure your baby's mouth is opened wide and his or her tongue
is down when latching on.
2. Support your breast with your hand, positioning your thumb on top
and your fingers at the bottom, keeping your thumb and fingers back far
enough so that your baby has enough of the nipple and areola (the circle of
skin around the nipple) to latch onto.
3. Gently glide your nipple from the middle of your baby's bottom lip
down to his or her chin to help prompt your baby to open his or her mouth.
4. When your baby opens his or her mouth wide and the tongue comes
down, quickly bring your baby to your breast (not your breast to your baby).
Your baby should take as much of the areola into his or her mouth as possible,
with more areola showing at the top lip than at the bottom.
5. Make sure your baby's nose is almost touching your breast
(not pressed against it), his or her lips are turned out (or flanged), and you
see and hear your baby swallowing. (You should be able to tell by seeing
movement along your baby's lower jaw and even in your baby's ear and temple.)
When properly latched on, you may have 30 to 60 seconds
of latch-on pain (this is caused by the nipple and areola being pulled into
your baby's mouth), then the pain should subside. It will then feel like a tug
when your baby is sucking. If you continue to feel pain, stop feeding
momentarily and reposition your baby on your breast. Your baby should give
four to five sucks, followed by a 5- to 10-second pause. Your baby's sucks
will increase in number as the quantity of your milk increases. As the milk
flow slows, your baby's pattern will probably change to three or four sucks
and pauses that last longer than 10 seconds.

6. SUCKING FOR COMFORT
If your baby seems to be getting enough milk, but continues to suck for an hour or more, your
little one might be nursing for comfort rather than for nourishment. So, how do you know? Once your
baby has fed well, he or she may stay on your breast but:
 seem satisfied
 stop sucking and swallowing
 play with your nipple
If your baby is showing these signs of non-nutritive sucking (or pacifying), you may want to
offer your infant his or her thumb or hand to suck on. You could also consider giving your little one a
pacifier. However, because early use of a pacifier makes it less likely that a mother and baby will
continue breastfeeding, you should only do this after breastfeeding is well established (usually after 1
month).
After that point, a bottle and pacifier may be introduced — with the realization that even then it
may cause your baby to have "nipple confusion," undermining your breastfeeding efforts. The other
concern about using a pacifier is that your child might still be hungry and actually needs to feed.
1.3 The Health Benefits of Breastfeeding for Both Baby and Mother
Breastfeeding has many great health benefits for both baby and mother. Here's why most
moms should try to breastfeed for at least six months or longer.
a) Immediate benefits for breastfed babies:
 Fewer infections and increased resistance to infectious diseases, including:
 Bacterial meningitis, which can occur when bacteria migrate into the brain and spinal cord
causing infection (Mayo Clinic Staff, 2013)
 Bacteraemia - particularly community-acquired bacteraemia in less advantaged children which
may be caused by a variety of pathogens, but mainly Salmonella species
 Diarrhoea, which is extremely prevalent in Africa and can have life-threatening consequences
 Otitis media or ear infections
 Infections of the respiratory tract (colds, pneumonia, bronchitis, croup)
 Urinary tract infections (bladder and kidney infections)

7. b) Long-term benefits for breastfed babies:
Reduction in disease in later life. Children who were breastfed:
 Have less asthma
 Have a reduced tendency to develop food allergies possibly because children are exposed to
allergens in mother’s milk so that they produce their own antibodies at an early stage and/or also
benefit from the mother’s antibodies
 Are less likely to develop Hodgkin disease (a type of cancer) and lymphoma
 Tend to have less high blood cholesterol in adulthood
 Develop leukemia less frequently
 Are less susceptible to sudden infant death syndrome (SIDS)
 Are less prone to overweight and obesity
 Are less likely to suffer from types 1 and 2 diabetes
 Are likely to have better cognitive skills and fewer learning problems
If mothers breastfeed their babies, they are indeed doing their children a great deal of good.
For example if a breastfed infant is less likely to become overweight and obese in later life, this will
also reduce his or her risk of developing all the diseases that are linked to obesity, such as type 2
diabetes, metabolic syndrome, joint problems and gout, sleep apnoea, gallbladder problems and
infertility (PCOS).
Benefits for breastfeeding mothers
Infants are not the only ones who benefit from breastfeeding. Mothers who take the time
and effort to breastfeed also gain advantages:
 Immediate reduction in bleeding after childbirth, which is why newborns are put to the mother’s
breast just after birth
 Promotes the fast return of the uterus to its pre pregnancy shape and size
 Reduction in the amount of blood lost through menstruation during lactation. Some women stop
menstruating during the breastfeeding period, but they should keep in mind that they may still
conceive despite the general belief that women cannot conceive another baby while
breastfeeding.
 Women who breastfeed have less of a risk of developing the so-called ‘hormonal’ cancers (breast
and ovarian cancers)
 May improve loss of the weight gained during pregnancy (see below)
 Spacing of children which gives every child a chance to develop to its fullest potential and allows
mothers to recover their health, strength and nutritional reserves before they have the next child
 Despite increased demands on body calcium stores during lactation, breastfeeding is associated
with a decreased risk of hip fractures and osteoporosis after the menopause

8. 2. NEWBORN SCREENING
2.1 INDICATION
Newborn screening tests look for developmental, genetic, and metabolic disorders in the
newborn baby. This allows steps to be taken before symptoms develop. Most of these illnesses are
very rare, but can be treated if caught early. The types of newborn screening tests that are done vary
from state to state. Most states require three to eight tests. Some organizations such as the March of
Dimes and the American College of Medical Genetics suggest more than two dozen additional tests.
The most thorough screening panel checks for about 40 disorders. All 50 states screen
for congenital hypothyroidism, galactosemia, and phenylketonuria (PKU).In addition to the newborn
screening blood test, a hearing screen is recommended for all newborns.
CONGENITAL ADRENAL HYPERPLASIA
Congenital adrenal hyperplasia is an endocrine disorder that causes severe salt loss,
dehydration of high levels of male sex hormones in both boys and girls. If not treated, babies may die
within 7-14 days. Congenital adrenal hyperplasia can affect both boys and girls. People with
congenital adrenal hyperplasia lack an enzyme needed by the adrenal gland to make the hormones
cortisol and aldosterone. Without these hormones, the body produces more androgen, a type of male
sex hormone. This causes male characteristics to appear early (or inappropriately). About 1 in 10,000
to 18,000 children are born with congenital adrenal hyperplasia. Girls will usually have normal female
reproductive organs (ovaries, uterus, and fallopian tubes). They may also have the following changes
such as abnormal menstrual periods, deep voice, early appearance of pubic and armpit
hair, excessive hair growth and facial hair, failure to menstruate and Genitals that look both male and
female (ambiguous genitalia), often appearing more male than female. Boys won't have any obvious
problems at birth. However, they may appear to enter puberty as early as 2 - 3 years of age. Changes
may include deep voice, early appearance of pubic and armpit hair, early development of male
characteristics, enlarged penis, small testes and well-developed muscles. Both boys and girls will be
tall as children but much shorter than normal as adults. Some forms of congenital adrenal hyperplasia
are more severe and cause adrenal crisis in the newborn due to a loss of salt. Newborns with these
forms develop severe symptoms shortly after birth, including
cardiac arrhythmias, dehydration, electrolyte changes and vomiting. The goal of treatment is to return
hormone levels to normal. This is done by taking a form of cortisol (dexamethasone, fludrocortisone,
or hydrocortisone) every day. People may need additional doses of medicine during times of stress,
such as severe illness or surgery. People with this condition usually have good health. However, they
may be shorter than normal, even with treatment. Males have normal fertility. Females may have a

9. smaller opening of the vagina and lower fertility. People with this disorder must take medication their
entire lives.
PHENYLKETONURIA
Phenylketonuria is a rare condition in which the body cannot properly use one of the
building blocks of protein called phenylalanine that with excessive accumulation may lead to brain
damage. At least 1 baby in 25,000 is born with PKU in the United States. Amino acids are the
building blocks for protein, but too much phenylalanine can cause a variety of health problems.
People with phenylketonuria (PKU) — babies, children and adults — need to follow a diet that limits
phenylalanine, which is found mostly in high-protein foods. Newborns with phenylketonuria initially
don't have any symptoms. Without treatment, though, babies usually develop signs of PKU within a
few months. Phenylketonuria symptoms can be mild or severe and may include mental retardation,
behavioral or social problems, seizures, tremors or jerking movements in the arms and legs,
hyperactivity, stunted growth, skin rashes (eczema), small head size (microcephaly), musty odor in
the child's breath, skin or urine, caused by too much phenylalanine in the body, fair skin and blue
eyes, because phenylalanine cannot transform into melanin — the pigment responsible for hair and
skin tone. A woman who has PKU and becomes pregnant is at risk of another form of the condition
called maternal PKU. Many people with PKU used to stop following a low-phenylalanine diet during
their teen years, as was directed by doctors at the time. But, doctors now know that if a woman
doesn't follow the diet during pregnancy, blood phenylalanine levels can become very high and harm
the developing fetus. Because of this, and other reasons, doctors recommend that anyone with PKU
follow the low-phenylalanine diet for life.
GLUCOSE 6- PHOSPHATE DEHYDROGENASE DEFICIENCY
Glucose 6-phosphate dehydrogenase deficiency the most prevalent illness recorded by
the Department of Health (DOH) is a deficiency where the body lacks the enzyme G6PD. Babies with
this deficiency may have haemolytic anemia resulting from exposure to oxidative substances found in
drugs, foods and chemicals. G6PD deficiency is the most common known enzyme deficiency in
humans. An estimated 400 million people around the world are affected. In the Philippines, around 1
in 50 children are G6PD deficient. G6PD deficiency is more common in boys than in girls. There is no
known cure for G6PD deficiency. It is a lifelong condition that cannot be outgrown. However, a child
with G6PD deficiency can live an active, healthy and normal life as long as he is able to avoid the
substances that can trigger G6PD deficiency symptoms. If your child is G6PD deficient, he will have
no symptoms unless he is exposed to one of the harmful substances that can trigger the breakdown
of red blood cells. Your child's symptoms will depend on what the harmful substance was and how
much of it he was exposed to. In milder cases, your child may not even show any symptoms. In more
serious cases, hemolysis (or hemolytic anemia) the accelerated destruction of red blood cells may
happen. If so, he may have these symptoms such as pale skin (among darker skinned children,
check the lips and tongue for paleness), fatigue, shortness of breath, rapid heart
rate, jaundice(yellowing of skin and eyes) especially among newborns and dark, tea-colored urine. If
your child is showing these symptoms, take him to the nearest hospital Emergency Room
immediately. He may need hospitalization and medical care. When the trigger has been removed or
treated, the symptoms usually resolve themselves within a few weeks.

10. CONGENITAL HYPOTHYROIDISM
Congenital hypothyroidism results from the lack or absence of thyroid hormones
essential for the physical and mental development of a child. If not treated at an early stage or within
two weeks, the baby may suffer from growth and mental retardation. From June 1996 to June 1998, a
total of 62,841 newborn infants were screened for congenital hypothyroidism with thyroid stimulating
hormone assay as a primary test. The method used was an immune fluorescent assay using the
DELFIA TSH Kit on dried blood specimens collected by heel prick on filter paper. All infants with TSH
values greater than 20microU/ml were retested. If the results remained abnormally high, confirmatory
testing was done by radioimmunoassay. All infants who were confirmed to be hypothyroid were
referred to pediatric endocrinologists for initial management. The overall weighted incidence of
congenital hypothyroidism obtained in this study was 0.000277 (95% CI; 0.000122 - 0.000432) or
1:3,610 which may be higher than that reported by most screening programs worldwide. The recall
rate was 0.16%. The higher recall rate may be explained by early testing in a number of cases and by
the possibility of iodine deficiency in some of the mothers.
GALACTOSEMIA
Galactosemia is a condition in which babies are unable to process galactose, the sugar
present in milk. If not treated, accumulation of excessive galactose in the body can cause problems
such as liver and brain damage and cataract.To determine the incidence of galactosemia (GAL) in the
Philippines and to determine whether newborn screening for GAL is cost-beneficial from a societal
perspective, cost-benefit analysis was performed. Newborn screening for GAL was done after the
24th hour of life using the Beutler test however it is ideally done on the 48-72 hours after birth to
detect all the metabolic conditions/disorders such as Congenital Hypothyroidism, Congenital Adrenal
Hyperplasia, Galactosemia, Phenylketonuria and Glucose 6-Phosphate Dehydrogenase Deficiency.
Patients screened positive were recalled for confirmatory testing. Using incidence rates obtained from
the different participating hospitals of the Philippine Newborn Screening Program (PNSP), the costs
for the detection and treatment of GAL were compared to the expected benefits by preventing mental
retardation, cataracts and other physical disabilities caused by the disorder that would lead to a loss
of productivity for the individual. Sensitivity analyses for incidence and discount rates were also
included. Of the 157,186 newborns screened by the PNSP since its inception in 1996, 8 screened
positive results. Confirmatory testing of these patients showed that 2 had galactosemia. The
incidence of galactosemia in this population therefore, is 1 in 106,006 (95% CI= 1:44,218 -
1:266,796). Projecting the figures to the actual birth rate (1.5M newborns/year), the total costs of the
screening program amounted to $1.1M, while the total benefits amounted only to $0.2M, yielding net
cost of $0.9M. A cost-benefit analysis of the screening program for galactosemia using the incidence
1 in 106,006 demonstrated that the costs of the program outweigh the benefits. The true incidence of
galactosemia in the Philippine population may yield an incidence rate that will result in greater net
benefits for the program.

11. 2.2 NEWBORN SCREENING PROCEDURE
Blood Test:
First, a physician, nurse, midwife, or other trained member of the hospital staff will fill
out a newborn screening card. One part of this card is the filter paper to collect the baby’s blood
sample. The other part is for important information for the lab performing the screen, such as the
baby’s name, sex, weight, date/time of birth, date/time of heel stick collection, and date/time of first
feeding. It will also include the contact information of the parents and the baby’s primary care
provider for the follow-up results.
During the blood test, which is sometimes called a heel stick, the baby’s heel will be
pricked to collect a small sample of blood. Parents are welcome to be a part of this process by
holding their baby while the heel stick is performed. Studies show that when mothers or health
professionals comfort babies during this process, the babies are less likely to cry. The health
professional will put drops of blood onto the filter paper card to create several “dried blood spots.” The
newborn screening card is then sent to the state laboratory for analysis.
Families can make requests for additional screening, also known as supplemental
screening. Additional screening refers to extra testing that can be performed after participating in your
state’s newborn screening program. This is sometimes done if there is family history of certain
conditions or other health concerns. While each state screens for many conditions, there are more
conditions that can be detected at birth. We recommend discussing additional screening and any
concerns you might have with a health care professional. Make sure to ask what conditions are
covered in your state and what information additional screening could provide. It is also important to
contact your insurance company to determine their policy regarding additional screening coverage,
since state programs do not pay for additional screening or the follow-up treatment.
Hearing Screen:
Two different tests can be used to screen for hearing loss in babies. Both tests are
quick (5-10 minutes), safe and comfortable with no activity required from your child. In fact, these
tests are often performed while a baby is asleep. One or both tests may be used.
Otoacoustic Emissions (OAE) Test: This test is used to determine if certain parts of the
baby’s ear respond to sound. During the test, a miniature earphone and microphone are placed in the
ear and sounds are played. When a baby has normal hearing, an echo is reflected back into the ear
canal, which can be measured by the microphone. If no echo is detected, it can indicate hearing loss.
Auditory Brain Stem Response (ABR) Test: This test is used to evaluate the auditory brain
stem (the part of the nerve that carries sound from the ear to the brain) and the brain’s response to
sound. During this test, miniature earphones are placed in the ear and sounds are played. Band-Aid-
like electrodes are placed along the baby’s head to detect the brain’s response to the sounds. If the
baby’s brain does not respond consistently to the sounds, there may be a hearing problem.

12. Pulse Oximetry Testing:
Pulse oximetry, or pulse ox, is a non-invasive test that measures how much oxygen is in
the blood. Infants with heart problems may have low blood oxygen levels, and therefore, the pulse ox
test can help identify babies that may have Critical Congenital Heart Disease (CCHD). The test is
done using a machine called a pulse oximeter, using a painless sensor placed on the baby’s skin.
The pulse ox test only takes a couple of minutes and is performed after the baby is 24 hours old and
before he or she leaves the newborn nursery.
Why are all babies screened at birth?
Most babies are born healthy. However, some infants have a serious medical condition
even though they look and act like all newborns. These babies generally come from families with no
previous history of a condition. Newborn screening allows health professionals to identify and treat
certain conditions before they make a baby sick. Most babies with these conditions who are identified
at birth and treated early are able to grow up healthy with normal development.
Do parents have to ask for screening?
No – it is normal hospital procedure to screen every baby regardless of whether the
parent asks for it and whether the parents have health insurance. The screening test is normally
included in the forms for standard medical procedures that the newborn may need after birth. Parents
sign this form upon arrival at the hospital for the birth of their baby. All states require screening to be
performed on newborns, but most will allow parents to refuse for religious purposes. Any decision to
decline or refuse testing should first be discussed with a health professional, since newborn
screening is designed to protect the health of the baby.
When does the screen happen?
The blood test is generally performed when a baby is 24 to 48 hours old. This timing is
important because certain conditions may go undetected if the blood sample is drawn before 24
hours of age. If the blood is drawn after 48 hours of age, there could be a life-threatening delay in
providing care to an infant that has the condition. Some states require babies to undergo a second
newborn screen when they are two weeks old. This precaution ensures that parents and health
professionals have the most accurate results. Ideally, the newborn hearing screen should be
performed before the baby leaves the hospital.
How will parents find out the results?
Parents will learn if their baby’s newborn screening result is out of the normal range
from their baby’s health care provider and/or the state newborn screening program. An abnormal
newborn screen result does not necessarily mean your baby is ill. It may occur because the blood
sample was collected too soon after birth, not enough blood was obtained, or your infant did not have
enough breast or bottle feedings prior to the testing. However, sometimes an out-of-range
result indicates a serious, but treatable, health problem. It is important for parents to follow up with the
baby’s primary healthcare provider immediately to learn the cause of the out-of-range result.

13. Republic of the Philippines
Department of Health
OFFICE OF THE SECRETARY
01 December 2009
ADMINISTRATIVEORDER
No.2009-0025
SUBJECT: Adopting New Policies and Protocol on Essential Newborn Care
Profile/Rationale of the Health Program
The Child Survival Strategy published by the Department of Health has emphasized the need to
strengthen health services of children throughout the stages. The neonatal period has been identified as one
of the most crucial phases in the survival and development of the child. The United Nations Millennium
Development Goal Number 4 of reducing under five child mortality can be achieved by the
Philippines however if the neonatal mortality rates are not addressed from its non-moving trend of decline,
MDG 4 might not be achieved.
I. Objectives
This policy aims to ensure the provision of globally accepted evidence-based essential newborn care
focusing on the first week of life.
Specifically, aims to:
(1.) Guide health workers and medical practitioners in providing evidence-based essential newborn care.
(2.) Define the roles and the responsibilities of the different DOH offices and other agencies in the
implementation of the Newborn Protocol.
II. Scope of the Application
This order shall apply to the whole hierarchy of the DOH and its attached agencies, other public and
private providers of health care and development partners implementing Maternal, Newborn and Child Health
and Nutrition (MNCHN) strategy and to all health practitioners involved in maternal and newborn care.

14. III. Definition of Terms
1. Attachment— is the mode of contact between the baby’s mouth and the mother’s breast during the act of
breastfeeding.
2. Kangaroo Mother Care— a universally available and biologically sound method of care for all newborns, but
in particular for premature babies, with three components:
a. Skin-to-skin Contact
b. Exclusive breastfeeding
c. Support to the mother-infant dyad
3. Newborn Resuscitation— a series of action taken to establish normal breathing in a newborn with
depressed vital signs.
4. Positioning— means how the mother holds her baby to ensure proper attachment to each other.
5. Positive Pressure Ventilation— the most important aspect of Newborn resuscitation for ensuring adequate
ventilation of the lungs, oxygenation of the vital organs such as heart and brain, and initiation of spontaneous
breathing.
6. Pregnancy, Childbirth, Postpartum and Newborn Care (PCPNC): A Guide for Essential Practice in Philippine
Setting— an Essential Care Practice Guideline adapted from the World Health Organization by the
Department of Health. It provides evidence-based recommendations to guide healthcare professionals in the
management of women during pregnancy, childbirth and postpartum, post-abortion, and newborns during
their first week of life.
7. Skin-to-skin contact— is placing the naked newborn prone on the mother’s bare chest. It is considered a
critical component for successful breastfeeding initiation.
8. Small baby – a newborn weighing from between 1,500g to 2,499g.
IV. Specific Guidelines
Standard essential newborn care practices guidelines are organized by time, beginning at the time of
perineal bulging until one week of life. However for this Administrative Order, emphasis is given to care
interventions that should be provided to the newborn from birth until the first 6 hours of life. The care for the
newborn after the 6 hours till the first week of life is mentioned briefly.

15. A. ENSURE QUALITY PROVISION OF TIME-BOUND INTERVENTIONS— this is the aspect of
newborn care in the Philippines that have not met international standards, and should therefore, be re-taught
and re-learned by all health care providers.
1. Within the first 30 seconds
1.1 OBJECTIVE: Dry and provide warmth to the newborn and prevent hypothermia
 Put on double gloves just before delivery.
 Use a clean, dry cloth to thoroughly dry the newborn by wiping the eyes, face, head, front and back,
arms and legs.
 Remove the wet cloth.
 Do a quick check of newborn’s breathing while drying
 Do not put the newborn on a cold or wet surface.
 Do not bathe the newborn earlier than 6 hours of life.
 If the newborn must be separated from his/her mother, put him /her on a warm surface, in a safe
place close to the mother.
2. After thorough drying
2.1 OBJECTIVE: Facilitate bonding between the mother and her newborn through skin-to-skin contact to
reduce likelihood of infection and hypoglycemia
 Place the newborn prone on the mother’s abdomen or chest, skin-to skin.
 Cover the newborn’s back with a blanket and head with a bonnet.
 Place the identification band on the ankle.
 Do not separate the newborn from the mother, as long as the newborn does not exhibit severe chest
in-drawing, gasping or apnea and the mother does not need urgent medical/ surgical stabilization e.g.
hysterectomy.
 Do not wipe off the vernix if present.
Check for multiple births as soon as newborn is securely positioned on the mother. Palpate the
mother’s abdomen to check for a second baby or multiple births. If there is a second baby or more, get
help. Deliver the second newborn, manage like the first baby.
3. While on skin-to-skin contact (up to 3 minutes post delivery)
3.1 OBJECTIVE: Reduce the incidence of anemia in term newborns and intra ventricular hemorrhage in pre-
term newborns by delaying or non-immediate cord clamping
 Remove the first set of gloves immediately prior to cord clamping.
 Clamp and cut the cord after the cord pulsations have stopped (typically at 1-3 minutes).

16. a. Put ties tightly around the cord at 2-5 cm from the newborn’s abdomen.
b. Cut between ties with sterile instrument.
c. Observe for oozing blood.
 After cord clamping, ensure 10 IU Oxytocin IM is given to the mother. Then, follow other protocols per
PCPNC.
4. Within 90 minutes
4.1 OBJECTIVE: Facilitate the newborn’s the early initiation to breastfeeding and transfer of colostrum through
support and initiation of breastfeeding
 Leave the newborn on the mother’s chest in skin-to-skin contact. Health workers should not touch the
newborn unless there is medical indication.
 Observe the newborn. Advise the mother to start feeding the newborn once the newborn shows
feeding cues ( e.g. opening of mouth, tonguing, licking, rooting).
 Counsel on positioning and attachment.
 Advise the mother not to throw away the colostrum.
 A small amount of breast milk may be expressed before starting breastfeeding to soften the nipple
area so that it is easier for the newborn to attach.
4.2 OBJECTIVE: to prevent opthalmia neonatorum through proper eye care
 Administer erythromycin or tetracycline ointment or 2.5 % povidone-iodine drops to both eyes after
the newborn has located the breast.
 Do not wash away the eye antimicrobial.
B. NON-INTERMMEDIATEINTERVENTIONS—these interventions are usually given within 6 hours after
birth, and should never be made to complete with the time-bound interventions.
1. Give Vitamin K prophylaxis.
Inject a single dose of Vitamin K 1 mg IM (if parents decline intramuscular injection, offer oral vitamin K as a
2nd line).
2. Inject Hepatitis B and BCG vaccination.
Inject Hepatitis B vaccine IM and BCG intradermally.
3. Examine the newborn. Check for birth injuries, malformation or birth defects.
 Weigh the newborn and record.
 Look for possible birth injuries or malformations.
 Refer for special treatment or evaluation if available.
 If the newborn has feeding difficulties because of the injury/ malformation, help the mother to
breastfeed. If not successful, teach her alternative feeding methods.
4. Cord care.

17.  Wash hands.
 Fold diaper below stump. Keep cord stump loosely covered with clean clothes.
 If stump is soiled, wash it with clean water and soap. Dry it thoroughly with clean cloth.
 Explain to the mother that she should seek care if the umbilicus is red or draining pus.
 Teach the mother to treat local umbilical infection three times day.
C. NEWBORN RESUSCITATON—
1. Start resuscitation if the newborn is not breathing or gasping after 30 seconds of drying or before 30
seconds of drying if the newborn is completely floppy and not breathing.
2. Clamp and cut the cord immediately.
3. Call for help.
4. Transfer the newborn to a dry, clean and warm surface. Keep the newborn wrapped or under the heat
source if available.
5. Inform the mother that the newborn needs helps to breathe.
6. Refer to the Department Circular for the step-by-step newborn resuscitation guideline.
D. UNNESSECARY PROCEDURES— the following are procedures that were observed to have been
routinely given in the Philippines hospitals but, in fact, are not recommended for all neonates.
1. Routine Suctioning
2. Early bathing or washing
3. Foot printing
4. Giving sugar water, formula or other prelacteals and the use of bottles or pacifiers.
5. Application of alcohol, medicines and other substances on the cord stump and bandaging the cord stump or
abdomen.

18. http://www.natural-childbirth-and-gentle-parenting.com/breast-milk.html#sthash.DUTeaUH2.dpbs
(Breastfeeding)
http://kidshealth.org/parent/pregnancy_newborn/breastfeed/nursing_positions.html#
(Maternal Position During Breastfeeding)
http://www.health24.com/Parenting/Child/Baby-centre/The-health-benefits-of-breastfeeding-20130813
(Benefits of Breastfeeding)
http://www.babysfirsttest.org/newborn-screening/screening-procedures#WhatAre
(Newborn Screening indication & procedures)
http://unangyakap.doh.gov.ph/ao20090025.pdf
(Outcome of DOH Administrative Order .NO.2009-0025: “Adopting New Policies & Protocol on
Essential Newborn Care)