Documentos de Académico
Documentos de Profesional
Documentos de Cultura
Los primeros minutos de vida presentan retos biolgicos al recin nacido, que podran influir
radicalmente el resto de su existencia en caso de no ser superados en forma adecuada.
Hay numerosas condiciones maternas, placentarias y fetales pueden comprometer al feto e
interferir con la transicin fisiolgica a la vida extrauterina, a veces ocurren dificultades
luego de una gestacin, trabajo de parto y parto sin complicaciones aparentes. De hecho,
una cuarta parte de los pacientes que ingresan a las Unidades de Cuidado Intensivo
Neonatal son hijos de madres que fueron clasificadas como de bajo riesgo durante el control
prenatal. Por esta razn todos los neonatos deberan ser considerados pacientes de
recuperacin, como si hubiesen salido de una intervencin, y deben ser vigilados hasta estar
seguros que la adaptacin neonatal se ha llevado a cabo en forma exitosa.
Cambios fisiolgicos en adaptacin neonatal:
1. Respiratorios
El trabajo de parto y el nacimiento producen una asfixia fetal transitoria que estimula
quimiorreceptores perifricos y centrales; la estimulacin tctil y trmica; y el
incremento de la presin arterial sistmica como resultado del pinzamiento del
cordn umbilical, son estmulos suficientes como para iniciar y mantener la
respiracin en forma vigorosa.
2. Circulacin fetal
El retorno venoso de la placenta entra a la aurcula derecha proveniente del ductus venoso y
la vena cava inferior para unirse con el retorno venoso de la parte inferior del cuerpo. La
sangre en la aurcula derecha es dirigida a travs del foramen oval fluye hacia el ventrculo
derecho. Los patrones de flujo dentro de la aurcula derecha, se hacen de manera que el 50%
de la sangre oxigenada que retorna de la placenta sea desviado hacia la aurcula izquierda,
mientras que la sangre desaturada de la vena cava superior es dirigida preferencialmente es
dirigida preferencialmente hacia el ventrculo derecho.
La sangre de la aurcula izquierda luego entra al ventrculo izquierdo para ser bombeada
predominantemente hacia la cabeza y las extremidades superiores. As, el g.asto ventricular
izquierdo tiene un contenido ms alto de oxgeno que el gasto ventricular derecho, lo cual
origina mayor entrega de oxgeno al cerebro. Esto provee el oxgeno suficiente para llenar las
demandas metablicas del cerebro en desarrollo.
El ventrculo derecho es responsable de la perfusin de la parte inferior del cuerpo y,
principalmente, de la placenta. Aunque la presin ventricular derecha est a niveles
sistmicos, la postcarga ventricular derecha permanece ms baja que la del ventrculo
izquierdo debido a la presencia de la baja impedancia de la placenta.
Finalmente, el ductus arterioso provee una comunicacin directa entre la arteria pulmonar y
la aorta, que permite el paso libre de sangre de la arteria pulmonar principal hacia la aorta
descendente.
3. Cambios hemodinmicos
|
19000000000000000000000000000000000000000000000000000000000000
00000000000000000000000000000000000000000000000000000000000000
00999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
99999999999999999999999999999999999999999999999999999999999999
999iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii
Al nacimiento, ocurren grandes cambios en la hemodinmica como consecuencia de
la transicin de la vida intrauterina a la extrauterina. Dichos cambios incluyen: (1)
aireacin pulmonar con aumento del flujo sanguneo pulmonar y disminucin de la
impedancia vascular, (2) aumento de la PO2 y del contenido sanguneo de oxgeno, y
(3) remocin de la placenta de baja impedancia y alta capacitancia del circuito
cardiovascular.
Con el nacimiento de la cabeza, el lquido de la orofaringe y vas areas superiores es
desplazado, comienza la aireacin de las vas respiratorias, la expansin de los
pulmones y la la ventilacin. Muchos de los cambios en la hemodinmica
cardiovascular notados al nacimiento son el efecto directo de la expansin pulmonar,
con en incremento del flujo sanguneo pulmonar y de la PaO2. La aireacin pulmonar
crea una interfase gas-lquido dentro de los alvolos que disminuye
significativamente la presin sobre los capilares pulmonares, y permite an ms la
expansin pulmonar y disminuye la impedancia vascular pulmonar. El inflamiento
estimula los receptores de estiramiento pulmonar, y produce vasodilatacin refleja de
los lechos vasculares perifricos.
A medida que el oxgeno entra a los alvolos e incrementa el pH y la PO2 de la sangre
y subsecuentemente de los tejidos endotelial y perivascular pulmonares, disminuye el
tono vasomotor pulmonar.
Con los eventos relacionados con el nacimiento (ventilacin, oxigenacin y
pinzamiento del cordn) ocurre una disminucin progresiva en el gasto ventricular
derecho, un aumento progresivo en el gasto ventricular izquierdo, una disminucin en
el flujo de la aurcula derecha hacia la izquierda a travs del foramen ovale, un
incremento del flujo sanguneo pulmonar y un cambio en el flujo sanguneo a travs
del ductus arterioso; con la expansin pulmonar y el incremento en el flujo sanguneo
pulmonar, el flujo ductal de la arteria pulmonar a la aorta disminuye pero todava
persiste un flujo neto de derecha a izquierda. Con la oxigenacin subsiguiente el flujo
se torna de izquierda a derecha. El aumento del flujo sanguneo pulmonar es seguido
por un incremento en el flujo venoso pulmonar con una elevacin en la presin de la
aurcula izquierda, y cierre del foramen ovale.
4. Cambios trmicos
Figura
1.
trmico al nacimiento.
Respuestas al estrs
no es lo suficiente como para interferir con este proceso. Sin embargo, la transicin puede
ser alterada significativamente por una variedad de eventos ante e intraparto resultando en
depresin cardiorrespiratoria, asfixia o ambos.
Caractersticas clnicas del perodo de transicin
Para detectar desrdenes en la adaptacin neonatal deben conocerse las caractersticas
normales del perodo transicional. Durante el trabajo de parto y el nacimiento hay una serie
de estmulos sensoriales al feto que influyen su adaptacin al ambiente extrauterino. Dichos
eventos resultan en una descarga simptica que se refleja en cambios en la frecuencia
cardiaca, color, respiracin, actividad motora, funcin gastrointestinal y temperatura del
beb.
Se describen tres fases consecutivas en el perodo de transicin: primer perodo de
reactividad, intervalo de reposo segundo perodo de reactividad.
Dura de 10 minutos a varias horas, usualmente durante las primeras 6 horas de vida.
Se caracteriza por la presencia de los fenmenos descritos en el primer perodo de
reactividad pero ms llamativos. Se observa taquicardia, taquipnea, cambios en el
tono muscular, color, produccin de moco, tendencia a nuseas y vmito, y aparicin
de respuestas a estmulos exgenos o endgenos. Con frecuencia se expulsa
meconio. A medida que concluye este perodo, el recin nacido aparenta una mayor
estabilidad.
Patrones de frecuencia
cardiaca fetal anormales
Anestesia general
Narcticos 4 horas antes del
parto
Prolapso del cordn
Abruptio de placenta
Placenta previa
Parto instrumentado
Trauma obsttrico
3. Limpieza de las vas areas La boca y las fosas nasales del recin nacido: solo se
realiza si hay secreciones que obstruyan la va area, ya sea manualmente (pera de
goma) o por aspiracin utilizando una sonda de calibre 8 o 10 F. la aspiracin debe
ser suave y que la presin del aspirador no exceda los 100 mmHg, en decbito
lateral. Esta no debe durar mas de 10 segundos.
4. Estimular al recin nacido: Tanto el secado como la succin estimulan al recin
nacido. Los mtodos seguros y apropiados para proporcionar estimulacin tctil
incluyen: Palmotear o dar golpecitos en las plantas de los pies y Frotar suavemente la
espalda, tronco o extremidades.
5. Pinzamiento del cordn umbilical: hacerlo inmediatamente, si hay
una indicacin
especifica. Se debe realizar al 2 - 3 minuto. Verificar aspecto del cordn, insercin y
numero de vasos (2 arterias y 1 vena). la banda de caucho y o la pinza de ligadura
debe quedar a 1 cm de la piel del abdomen para evitar granulomas umbilicales.
6. Cuidados con el cordn umbilical: Mantener la zona limpia y seca, paal hacia abajo,
destapando el muon, aplicar un antisptico para el mun umbilical, debe quedar
expuesto al aire. Los mas recomendados son:
Alcohol 70%
Clorhexidina alcohlica 0.5%
Clorhexidina acuosa 1%.
Colocar solucin una vez al da con aplicador o copito y limpiar toda la zona de
alrededor del mun del cordn umbilical del beb, debe sanar y caerse para cuando
el beb tenga 5 -8 das.
7. Muestra de sangre del cordn umbilical: Se toma una muestra de sangre del extremo
placentario del cordn. Estas muestras se realizan para el tamizaje de hipotiroidismo
congnito, TSH neonatal y hemoclasificacin y otros.
8. Profilaxis ocular: evita las infecciones oculares gonoccicas o por clamidias en el
recin nacido El recin nacido adquiere esta infeccin al pasar por el canal de parto y
tener contacto con secreciones maternas infectadas . El tratamiento precoz consiste
en administrar antibioticoterapia en la primera hora post parto: Eritromicina al 0.5%:
1 gota en cada ojo.
9. Profilaxis de enfermedad hemorrgica: El recin nacido no puede sintetizar la
vitamina K, ya que para su sntesis interfiere la flora intestinal y el intestino del recin
nacido esta estril y aun no ha desarrollado su propia flora intestinal. Se administra 1
mg de vitamina K, IM APLICAR EN LA CARA ANTERO LATERAL DEL MUSLO DERECHO.
10. Medidas antropomtricas Se debe tomar y registrar (en la historia clnica del recin
nacido), las mediciones basales para ayudar a valorar el progreso del neonato. Esta
evaluacin antropomtrica se usa para determinar los patrones de crecimiento,
deteccin de riesgos de morbi-mortalidad y deterioro del estado nutricional. Permite
la toma de decisiones oportunas y convenientes de acuerdo a lo encontrado. Peso y
talla y Circunferencias.
11. En la HC deben quedar registrados: Huellas plantares , Sexo del recin nacido, Huella
del pulgar derecho materno Diligenciar las manillas de identificacin materna y el
recin nacido (letra clara, legible y todos los datos que exige) Colocarla en el
Valorar las caractersticas de las deposiciones: las primeras deposiciones son verdes
(meconio), luego se vuelven amarillas grumosas y son frecuentes. Cada vez que
comen hacen deposicin.
22. Visitas Recomendar a la madre que las personas que vayan a visitar al bebe se laven
las manos con agua y jabn, Evitar contacto con personas resfriadas o con
enfermedades infectocontagiosas Evitar que besen al bebe en los labios Si la madre
esta resfriada recomendar protegerse con tapabocas.
23. Reposo y sueo Se aconseja para dormir la posicin decbito lateral y cabeza elevada
a 30 Informarle que el bebe duerme la mayor parte del tiempo y se despierta cuando
tiene hambre o alguna molestia Brindar un amiente agradable para dormir con poco
ruido, adecuada temperatura y poca luz Despertar al recin nacido cada 3 horas para
alimentarlo
24. Extraccin de gases: Para reducir regurgitacin se recomienda hacer eructar al bebe
durante y despus de la alimentacin. Llanto: Revisar las posibles causas ya que es
su nico medio de comunicacin: Hambre Calor o fri Gases Cansancio Cambio de
paal
BIBLIOGRAFA:
American Heart Association/American Academy of Pediatrics: Textbook of Neonatal
Resuscitation. Dallas, 2000.
Arango F. Tpicos recientes en termorregulacin neonatal. Revista UCIN Sociedad
Colombiana de Neonatologa 2001;1:23-32.
Baumgart S. Thermal regulation in the fetus and newborn. In Spitzer AR (ed): Intensive Care
of the Fetus and Neonate. Mosby Year Book, 1996:401-16.
Baumgart S. Temperature regulation of the premature infant. In Schaffer and Avery (eds):
Diseases of the Newborn. Sixth edition. W. B. Saunders, 1991:255-9
Bland RD. Formation of fetal lung liquid and its removal near birth. In Polin RA, Fox WW (eds):
Fetal and Neonatal Physiology. W.B. Sauders, 1992:782-9.
DHarlingue AE, Durand DJ. Recognition, stabilization and transport of the high-risk newborn.
In Klaus MH, Fanaroff AA (eds): Care of the High-Risk Neonate. Fourth edition. WB Saunders,
1993:62-85.
Kalhan SC, Saker F. Disorders of carbohydrate metabolism. In Fanaroff AA, Martin RJ (eds):
Neonatal-Perinatal Medicine. Sixth edition. Mosby Year Book, 1997:1439-63.
Klaus MH, Martin RJ, Fanaroff AA. The physical environment. In Klaus MH, Fanaroff AA (eds):
Care of the High-Risk Neonate. Fourth edition. WB Saunders, 1993:114-29.
McGowan JE. Neonatal hypoglycemia. NeoReviews 1999;e6-e15.
Mercer JS, Skovgaard RL. Neonatal transitional physiology: A new paradigm. J Perinat Neonat
Nurs 2002;15:56-75.
Nedergaard J, Cannon B. Brown adipose tissue: development and function. In Polin RA, Fox
WW (eds): Fetal and Neonatal Physiology. W.B. Sauders, 1992:314-25.
Perlstein PH. Physical environment. In Fanaroff AA, Martin RJ (eds): Neonatal-Perinatal
Medicine. Sixth edition. Mosby Year Book, 1997:481-501.
Power GG. Fetal thermoregulation: animal and human. In Polin RA, Fox WW (eds): Fetal and
Neonatal Physiology. W.B. Sauders, 1992:477-83.
Rigatto H. Control of breathing in fetal life and onset and control of breathing in the neonate.
In Polin RA, Fox WW (eds): Fetal and Neonatal Physiology. W.B. Sauders, 1992:790-801.
Serwer GA. Postnatal circulatory adjustments. In Polin RA, Fox WW (eds): Fetal and Neonatal
Physiology. W.B. Sauders, 1992:710-21.
http://www.minproteccionsocial.gov.co/Norma Tcnica para la Atencin del Recin Nacido
http://www.nlm.nih.gov/medlineplus/framing.html
ESTRATEGIA AIEPI.