6.4: Contemporary Figurative
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In the 20 th century, figurative images were frequently ignored, the focus on the ever-changing abstract movements like Cubism or the Minimalists. As the 21 st century began, figurative work resurged and expanded through multiple forms and expressions. Although the old masters set the standards, today’s figurative artists use the concepts of the past and earlier abstract movements to depict their own unique identities for the figure.
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Name |
Native Country |
|---|---|
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Njideka Akunyili Crosby |
Nigeria |
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Marlene Dumas |
South Africa |
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Zhang Xiaogang |
China |
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Kerry James Marshall |
United States |
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Jylian Gustlin |
United States |
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Jenny Saville |
England |
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Eric Fischl |
United States |
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Kehinde Wiley |
United States |
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Pablita Velarde |
United States |
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Faith Ringgold |
United States |
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Fang Lijun |
China |
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Chantal Joffe |
England |
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Amy Sherald |
United States |
Njideka Akunyili Crosby (born 1983) is from Nigeria before moving to the United States and attending the university to study medicine following the footsteps of her parents before changing directions to become an artist. In her work, she uses multi-media materials of paint, photos, fabric, and pencils. Crosby depicted scenes of everyday life in different rooms of the house, the kitchen, the table and chairs in the dining room, all adorned with images, pictures and things as part of the small details of one's life. Many patterns on the clothing, walls, or part of the furnishings reflect the colors and styles of her native Nigeria. Each painting is a story of life's events as one travels from room to room. A painting (15.73) from the series Portals, appears to be a young woman pondering the future, bringing the viewer into her room. Crosby’s work (Before Now After (Mama, Mummy, and Mamma) (15.74) depicts her relationship with her family, including images of her mother, grandmother, and sister, a table set with familiar family items and pictures.
Marlene Dumas (born 1953) was born in Cape Town, South Africa, where she studied art before moving to the Netherlands to study psychology. Dumas depicts her figures in dramatic concepts of love, death, or sexuality, sometimes intimate and controversial. Her brushstrokes are broad and loose and along with dark, brooding colors enhancing a distorted feeling to create the psychological and emotional images seen in Intimate Relations (15.75). Stern (15.76) portrays a woman who may be sleeping or perhaps deceased, an image giving the viewers choices, as does Losing (Her Meaning) (15.77), is the figure swimming or perhaps deceased.
Zhang Xiaogang (born 1958) was born in China and said his parents taught him how to draw early in his life to give him something to do and stay out of trouble, a skill he continued as an adult. His parents were removed from their home and placed in a re-education camp during the Cultural Revolution in China, an experience influencing his artwork today. He was able to attend the university, although he suffered from alcoholism at the time, another life-altering problem changing his life. He became part of a group of artists who were considered avant-garde, setting up their exhibitions until the events at Tiananmen Square ended liberal ideas. Much of his work today is based on families and the influence of past events as he created the stoic, flat, compliant characters, adding contrast with splotches of color. My Ideal (15.78) depicts a family, controlled by soldiers, with oversized heads and long noses. In his close-ups of individuals, Untitled (15.79), he used shadows, making the image slightly clouded, their oversized eyes staring outward, the black and gray image only highlighted by a splash of yellow.
Kerry James Marshall (born 1955) was born in Alabama but raised in Los Angeles. He received his BFA at Otis Art Institute and became a professor of art at the University of Illinois. The events of the time influenced Marshall, the Black Panthers, the Watts riots, the civil rights movements, and experiences of African Americans. His work reflects his study of history and the effects on the African American community, which he emphasizes by exaggerating the body with a deep black, a recognition of the usual recessed images of darker skin, bringing the color to the forefront. Untitled (15.80) depicts a female artist with an overly broad palette, facing the viewer with her painting behind her, a twist with the paint by number image. The Actor Hezekiah Washington as Julian Carlton Taliesen Murderer of Frank Lloyd Wright Family (15.81), is the image of an actor portraying a man who committed murder. The actor gazes out at the viewer, who is left with little knowledge of the person he pretends to be.
Jylian Gustlin (born 1960), born in California, lives in the San Francisco Bay Area, where she majored in art and mathematics before receiving her BFA. Although she includes mathematical expressions in her art, as seen in her Fibonacci series, her passion is the human figure and the fluidity and emotions of the figure. Sirens 3 (15.82) leaves the viewer guessing about the feelings exhibited between the three figures, all painted on a background of multiple layers of mixed media. Icarus (15.83) and Aphrodite 3 (15.84) both demonstrate the emotions of the figures, clouded in the background, faces turned from the viewer.
Jenny Saville (born 1970), one of the Young British Artists, received her degree from Glasgow School of Art. She spent some time studying in the United States, developing her views of women based on the numbers of large women she saw and how physically interesting she found their body shapes. Saville took the concepts of the body further based on how deformities could be corrected or what liposuction meant or how diseases affect the body, all taking her paintings to unusual proportions. She used patches of color and brushstrokes on large-sized canvases to create sensual skin and fleshy bodies. Strategy (15.85) displays the ample female forms demonstrating how many women appear, disparaging the myth of the runway model.
Eric Fischl (born 1948) lived in several parts of the United States after he graduated from college, eventually even teaching art for a while. Fischl often painted subjects set in suburbia, seeming to be performing everyday actions; however, many images were based on voyeurism by adolescents, or alcoholism in the country club life, displaying the contradictions found in the suburbs. In the Haircut (15.86), the viewer seems to be looking through the window at the young lady cutting her hair while sitting provocatively on her bed. Saigon, Minnesota (15.87) is a set of four panels depicting several people in the backyard that appears to be near a pool. Some of the people have a bathing suit; others are nude, lying, or sitting daringly, leaving the viewer to wonder what each of the groups is doing. Oddly, the people are relatively static while the dog seems to be running through the yard.
Pablita Velarde (1918-2006) belonged to the Santa Clara Pueblos and was sent with her sisters at an early age to a boarding school. As a teenager, she was able to attend an art school, one of the few female students. Velarde learned to paint in a flat style and used her skills to paint images to document and preserve the history of her people. At first, she used watercolors and later used natural pigments found in her area to grind and mix her paints, making earth paintings and is considered one of the outstanding female artists of the southwest. Basketmaking (15.88) portrays a man making a basket from yucca leaves as the man behind weaves a twilled basket. The woman is seated and preparing the materials the two men in the background have collected.
Kehinde Wiley (born 1977) was born in Los Angeles along with his twin brother, although early in their life, his father returned to Nigeria, leaving his mother to raise the children. Wiley was interested in art as a child and received a BFA from the Art Institute in San Francisco and an MFA from Yale. He was influenced by paintings from the old masters and incorporated their styles in combination with his interest in African and Islamic designs. Coming to Richmond (15.89) is an example of an African rider, sword in hand with horse rearing, very similar to paintings of Napoleon in the Alps. Wiley likes to use ordinary people as his models and often found people in the neighborhood to pose for him, then removing the person from the ordinary and placing the image in a composed environment with ornate backgrounds.
Mary Comforter of the Afflicted (15.90) is from a series of paintings Wiley created based on historical figures from old masters.  Wiley was chosen to paint the official portrait for President Barack Obama, the first African American president. Wiley did not use the usual presidential poses, instead of placing the president in an ordinary chair nestled into a background of flowers. The colorful flowers had specific meanings to the president; chrysanthemums were the flower of Chicago; jasmine represents his birthplace of Hawaii and blue lilies for his father, who was from Kenya.
Faith Ringgold (born 1930) was born in Harlem, New York City, living in an area filled with artists, poets, writers, and musicians; her mother was a fashion designer. She learned to work with fabric from her mother, a medium she used extensively in her later artwork. After receiving her master's degree, Ringgold traveled to Europe, especially Paris, where she found the inspiration for the series, French Collection , her quilt paintings. She also visited West Africa, which motivated her construction of sculptures and masks. Her early works were based on some of the political unrest of the 1960s, and she created several series about the issues and problems of black Americans. Ringgold became well-known for her quilt and fabric paintings, sculptures, and masks.
Fang Lijun (born 1963) was born in China, his family comfortable with its well-placed social status. As a child, he was trained in art and graduated from the Central Academy of Fine Arts. He became a member of the group Cynical Realism, artists who incorporated political issues into their art, especially human rights and suppression. Lijun used the bald head of people, focusing on faces to bring his message and develop the emotions and stories of each person as they may feel somewhat helpless in the overall society. Both of his images (15.92, 15.93), portray different emotions open for interpretation by the viewer.
Chantal Joffe (born 1969) studied at colleges in Scotland and England and currently paints women and children in large-scale works. She was inspired by the body positions and clothing of women and presented them in a form seemingly simplistic with unsettling characteristics, hinting at unseen and unsaid conflicts. She paints on oversized canvases with large brushstrokes, leaving drips of paints or outlines, the heads of her figures oddly shaped with piercing eyes. The woman in Green Dress, Black Knickers (15.94), appears to be looking into a mirror, or is there someone else in the room she sees.  The feelings of the child are masked, a blanket held tightly. In the background, the green pillow anchors the two figures.
Amy Sherald (born 1973), who lives in Maryland, received her M.F.A. in painting, now focusing on documenting African Americans and their experiences in everyday life. She uses a form of grayscale or grisaille for the different skin tones of her images to defy the concept of color equals race. Grand Dame Queenie (15.96) depicts a woman holding a cup and saucer while she gazes at the viewer, her bright clothing symbolic of Sherald’s color palette. The Boy with No Past (15.97) displays a young man standing stiffly in his colorful clothing against a muted background. Both images depict individuals as important in their own right, challenging the viewers to recognize them. Sherald was selected to paint the official portrait, First Lady Michelle Obama (15.98).  Obama's white dress is a foil for patches of color, some of the squares similar to the quilts of Gee's Bend.


24.3: Care of Common Problems in the Newborn
By the end of this section, you will be able to:
- Describe the pathophysiology and signs and symptoms of hyperbilirubinemia and the care of the newborn with hyperbilirubinemia
- Describe the pathophysiology and signs and symptoms of hypoglycemia and the care of the newborn with hypoglycemia
- List the common newborn infections and describe the care of the newborn with an infection
- List common newborn dermatologic issues including the pathophysiology of both expected and pathophysiologic findings along with their care and management
This section provides a comprehensive understanding of significant issues that commonly arise during the early stages of a newborn’s life: hyperbilirubinemia, hypoglycemia, dermatologic problems, viruses, and bacterial infections. By understanding the pathophysiology, signs and symptoms, risk factors, and preventive measures, as well as the appropriate care and management, for each condition, nurses can effectively address these challenges. They can also differentiate between normal variations and abnormal conditions and can educate parents about both. In providing adept and knowledgeable care of newborns with these problems and educating their caregivers, nurses can help ensure the health and well-being of this vulnerable population.
Hyperbilirubinemia
One common problem in newborns is hyperbilirubinemia, characterized by elevated levels of bilirubin in the blood. Understanding the underlying pathophysiology, including the breakdown of red blood cells, helps identify infants at risk. Recognizing the signs and symptoms associated with hyperbilirubinemia enables prompt intervention and appropriate care to manage this condition effectively.
Care of the Newborn with Hyperbilirubinemia
Many normal and healthy babies develop jaundice , or hyperbilirubinemia , which is an increase in the concentration of bilirubin in the serum , the amber-colored, protein-rich liquid that separates out when blood coagulates. With jaundice, the skin and sclera of the eyes of the newborn may appear noticeably yellow due to the breakdown of fetal red blood cells. Mild jaundice is harmless. However, if the bilirubin level continues to rise and is not treated, it can lead to kernicterus , a type of brain injury . Jaundice tends to be more common in breast-feeding infants, particularly in those that are not feeding well. Therefore, breast-feeding parents should nurse their newborns at least 8 to 12 times per day (or every 2 to 3 hours), which will help produce enough milk and keep bilirubin levels low.
Nurse’s Response When Asked about the Preferred Way to Feed a Baby: Breast versus Bottle
Each birthing parent has the autonomy to choose how they would like to feed their newborn. Each way of feeding a newborn has advantages and disadvantages. Human milk is recommended as the optimal source of nutrition for newborns due to the health benefits it provides for both the newborn and the lactating parent. Consequences of insufficient oral intake in the newborn and psychologic distress in the lactating parent may result when the plan does not work. When discussing the topic of feeding with the parent, the nurse must determine what the parent’s goals are and what would work best for their newborn and themselves. Nurses have an ethical obligation to provide infant feeding support in a way that is sensitive, individualized, objective, and supportive to the person while avoiding harm.
Pathophysiology of Neonatal Jaundice
The primary source of bilirubin is the breakdown of hemoglobin, leading to the formation of unconjugated bilirubin and related substances. Unconjugated bilirubin then binds to albumin in the bloodstream to facilitate its journey to the liver. Once in the liver, hepatocytes take up bilirubin and, through the action of the enzyme uridine diphosphogluconurate glucuronosyltransferase (UGT) , conjugate it with glucuronic acid , making it water-soluble.
Due to the common occurrence of temporary jaundice in healthy infants, hyperbilirubinemia can be classified as either physiologic or pathologic. It can also be classified based on whether the hyperbilirubinemia is unconjugated, conjugated, or a combination. Additionally, classification by the underlying mechanism is another method. Most cases of neonatal jaundice involve unconjugated hyperbilirubinemia. Among the most common factors contributing to neonatal jaundice are physiologic hyperbilirubinemia, breast-feeding–related jaundice, breast milk–induced jaundice, and pathologic hyperbilirubinemia associated with hemolytic diseases. Dysfunction or disease of the liver may result in conjugated or mixed hyperbilirubinemia (e.g., parenteral alimentation causing cholestasis, neonatal sepsis, neonatal hepatitis) (Dysart, 2022).
Jaundice first appears on the face, then the chest and abdomen, and finally the arms and legs in some instances. The whites of the infant’s eyes may also turn yellow. At the present time, most newborns are routinely screened for jaundice in the skin 24 hours before leaving the hospital, using a painless handheld light meter called a transcutaneous bilirubin (TCB) monitor . If jaundice is suspected in the newborn based on skin color, age, and other factors, the pediatrician may order a blood test to make an accurate diagnosis. If parents notice a sudden increase in jaundice once they are home, they should call their health-care provider. The specific blood tests that may be ordered are as follows: (Cedars Sinai, 2023)
- Direct and indirect bilirubin levels —This test will show if bilirubin is bound with other substances by the infant’s liver. The level of indirect bilirubin is increased in normal physiologic jaundice. High levels of either type of bilirubin are seen with jaundice caused by more serious problems.
- Red blood cell counts —This test is important because jaundice occurs as a result of the breakdown of fetal RBCs.
- Blood type and testing for Rh incompatibility (the Coombs test or direct antiglobulin test [DAT])
One major differentiating factor between the four types of newborn jaundice is the timing of when the jaundice first starts. Treatment will depend on the degree of jaundice, the bilirubin level, and the age and weight of the infant (Cedars Sinai, 2023; Kemper et al., 2022).
- Jaundice that develops after the first 24 hours of life in term infants is called developmental jaundice or physiologic jaundice . It is considered normal. The bilirubin peaks between the 2nd and 4th days of life and falls to normal levels by 57 days. Jaundice becomes visible when the bilirubin level is greater than 5 mg/dL (Cedars Sinai, 2023).
- Jaundice that develops in the first 24 hours of life is called pathologic jaundice or nonphysiologic jaundice . When bilirubin rises higher than expected or remains elevated longer than expected, earlier treatment is needed to prevent severe hyperbilirubinemia. Abnormalities that cause excessive destruction of RBCs or problems in bilirubin conjugation result in nonphysiologic jaundice (Cedars Sinai, 2023; Kemper et al., 2022). These can include incompatibilities between the birthing parent’s and infant’s blood types, metabolic disorders, and infections. Phototherapy is often the treatment for nonphysiologic jaundice (Figure 24.11.)
- Jaundice that develops in breast-fed infants within the first week after birth is called breast-feeding jaundice or early-onset jaundice . It involves bilirubin levels of >12 mg/dL and develops in 13 percent of breast-fed infants by 1 week of life (Kemper et al., 2022). The most common cause of jaundice this early in breast-fed infants is insufficient milk intake, dehydration , or low caloric intake. Serum bilirubin may reach dangerous levels if intake is not increased. An increase in enterohepatic circulation may also result from reduced bacteria in the intestine that act to convert bilirubin to nonresorbed metabolites (Dysart, 2022). Babies who are sleepy, have a poor suck, or nurse infrequently do not get sufficient colostrum . Colostrum has a normal laxative effect in eliminating bilirubin-rich meconium. When meconium is not eliminated, bilirubin may be deconjugated in the intestine, absorbed, and recirculated to the liver for conjugation again. Lack of suckling decreases production of breast milk and further increases the problem.
- Jaundice that occurs after the first 5 to 7 days of life and lasts 3 weeks to as long as 3 months, peaking at about 2 weeks of age for some infants is considered true breast milk jaundice or late-onset breast milk jaundice. Bilirubin usually peaks at levels of 5 to 10 mg/dL and gradually decreases over several months, but for some infants, levels get as high as 20 to 30 mg/dL. Although the exact cause is unknown, true breast milk jaundice is thought to be caused by an increased concentration of beta-glucuronidase in the breast milk, which causes an increase in the deconjugation and reabsorption of bilirubin (Dysart, 2022). Infants show no signs of illness. Treatment consists of 8 to 12 feedings per 24 hours. If levels of bilirubin become too high, phototherapy may begin while the nursing parent continues to breast-feed. Interruption of breast-feeding is not usually recommended (Cedars Sinai, 2023; Kemper et al., 2022). This type of jaundice generally resolves without further morbidity concerns.
Take Action: Setting a Newborn Patient under the Phototherapy Light
The nurse is caring for a 4-day-old who has been showing signs of hyperbilirubinemia with jaundice on the face down to the chest. The breast-fed infant had an elevated level when checked with the noninvasive bili tool (BiliTool) in the nursery.
The nurse knows that to start phototherapy the newborn will need to be uncovered but will require eye protection and groin coverage before being placed under the phototherapy light.
The nurse is successful in ordering goggles and groin coverage from hospital services, and phototherapy is initiated. A follow-up bilirubin level will be checked in 6 hours.
Nursing Care Plan for the Jaundiced Newborn
Subjective data may come from the parents who may report or the nurse who may observe that the newborn is having difficulty with breast-feeding or is not taking the bottle well. The problem may be infant fussiness related to feedings or lethargy and difficulty in waking to feed. The problem could be an issue with latch or positioning or with suck and swallow. To accurately assess what is happening, the nurse must become more involved with feedings in general. A loss of color in the stool also warrants investigation.
When assessing the infant in daylight, the nurse will most likely observe yellowing of the skin all over the body and in the sclera of the eyes. In newborns with dark skin, yellowing may not be visible, so jaundice should be confirmed with TCB (Ansong-Assoku, et al., 2023). Weight loss will be greater than expected (>10 percent). The infant will be difficult to awaken and, when awake, will be very fussy with a high-pitched cry.
The nurse assesses the infant’s skin for abnormalities, noting the color (yellowing) of skin or eyes. When determining yellowing of the skin, the nurse lightly presses on the skin of the baby’s forehead. If the skin looks yellow where pressed, the baby is likely jaundiced.
When assessing the infant for neurologic involvement, the nurse should keep in mind expected infant development. Infants experiencing hyperbilirubinemia are likely to be very fussy when awake and difficult to arouse when asleep. Consequently, many parents inadvertently delay waking their babies to feed them. More advanced stages of neurologic sequelae include hyperreflexia (twitching, overexcitability, sensitive reflexes, and convulsions). Symptoms can also include a high-pitched cry. An infant’s change in feeding pattern s is neurologically significant as well.
Obtaining a good history, including a review of the pregnancy and delivery, may show a stressful delivery. When assistive devices such as vacuum or forceps have been used, they can increase infant trauma and, therefore, the risk of neonatal jaundice. The nurse is aware of high-risk disorders or diseases that may affect the infant (i.e., spleen or liver disease or hypothyroidism). As part of the physical assessment of the newborn, the nurse should obtain serum or transcutaneous bilirubin (TCB) values. TCB is preferred because of the noninvasive nature of the test. Any level greater than 12 mg/dL usually requires treatment, and the nurse should follow the provider’s orders and hospital policy and protocol. If a serum bilirubin level is required, it is usually obtained by heel stick , per facility protocol. If the newborn is breast-feeding, the nurse should observe and offer assistance to improve latch, suck, and swallow. The nurse will encourage frequent feedings, every 2 hours, and may suggest that the parent supplement with formula as appropriate/or needed.
Jaundice may be present if infants are having difficulty with breast-feeding, are dehydrated, or are taking in insufficient calories. Frequent feedings promote good hydration of the infant and help to boost the milk supply in the nursing parent. If breast milk is insufficient, even temporarily, infants may require additional calories and nutrients from formula.
The nurse initiates phototherapy per facility protocol and health-care provider order. The newborn is placed under the bili light s in an incubator or thermoregulated environment or in an open crib wrapped in a bili blanket . Phototherapy helps improve the solubility of bilirubin for faster secretion through the stool and urine. This is a noninvasive treatment.  The nurse assesses the skin and eyes every 2 hours when the infant comes out from under the lights for feeding. The nurse also monitors the infant’s temperature for elevations or fever every 2 hours while phototherapy continues. Phototherapy can elevate an infant’s body temperature to dangerous levels. Therefore, close monitoring of temperature is necessary during treatment. Additionally, the nurse notes any signs of infection or sepsis.
Hyperbilirubinemia related to Rh incompatibility with the birthing person or severe anemia may require a blood transfusion. As for medication, the infant may require the administration of acetaminophen for fever or may be given phenobarbital , which acts to stimulate the liver to metabolize bilirubin more quickly (Dysart, 2022)
Because much of this treatment and phototherapy itself can be done at home, particularly if parents use a bili blanket, it is essential that the newborn’s caregivers receive thorough education about monitoring the infant’s skin, the need for skin surfaces to be exposed, monitoring temperature, and encouraging feedings every 2 hours. It is also very important that they keep scheduled appointments with their care provider because the infant’s blood will need to be monitored closely and frequently for bilirubin levels if it is not done by a visiting nurse. Infants who are receiving phototherapy, whether at home or in the hospital, can have brief periods outside the phototherapy lights. Ideally, this could be timed to occur every 2 hours when assessments and feedings occur. This is necessary so that the infants can be cuddled and held and so that they can bond with their parents and breast-feed if that is desired. Eye covers can be removed for parent-baby interaction and eye contact but must be replaced when the baby is returned to phototherapy . Also, the nurse must ensure that phototherapy is turned off during the collection of blood for serum bilirubin levels because both conjugated and unconjugated bilirubin are photo-oxidized when exposed to white or ultraviolet light (Wang et al., 2021).
Hypoglycemia
Hypoglycemia, another frequently encountered issue, refers to low blood glucose levels. Identifying infants at risk is an important step in newborn care. Early recognition of signs and symptoms is crucial because it allows nurses to implement appropriate care and management strategies. These include monitoring glucose levels and timely feeding or administering glucose water or intravenous glucose in severe cases.
Care of the Newborn with Hypoglycemia
In the term newborn, hypoglycemia refers to a blood glucose level below 40 mg/dL. It is a common transient occurrence in the immediate postpartum period; therefore, it is not necessary to routinely monitor the blood glucose of all term newborns. Most hospitals and birthing centers have policies and procedures that require monitoring of at-risk newborns rather than waiting for them to become symptomatic. The most common cause of hypoglycemia in infants is hyperinsulinism, typically occurring right after birth. Newborns at risk include the following:
- small for gestational age (SGA)
- large for gestational age (LGA)
- fetal growth–restricted (FGR) infants
- infants of a diabetic mother (IDM) (Stanford Medicine, 2023b)
See Chapter 23 Newborn Assessment for a full discussion of gestational age.
Other causes of hypoglycemia in the newborn are poor nutrition of the pregnant parent, incompatible blood types between birthing parent and baby (Rh incompatibility), neonatal pancreatic tumor, birth asphyxia or stressful birth, cold stress, liver disease, preterm birth, being born to a birthing parent treated with terbutaline, and infection (Stanford Medicine, 2023b).
Hospitals, birthing centers, and nurses can help prevent or significantly reduce hypoglycemia in infants by:
- encouraging breast-feeding initiation within the first 30 to 60 minutes after birth
- promoting skin-to-skin contact between birthing parent and baby to prevent cold stress, which depletes the infant’s glucose stores
- encouraging breast-feeding 8 to 12 times a day
- encouraging breast-feeding in response to infant feeding cues rather than a set schedule
- teaching that crying is a late cue for hunger; instructing parents not to let the newborn cry for prolonged periods because crying rapidly depletes glycogen stores and can contribute to rapid drops in blood sugar levels
- promoting continuous parent-baby rooming-in.
Pathophysiology of Neonatal Hypoglycemia
Neonatal hypoglycemia may present as transient or persistent. The developing fetus relies on maternal metabolism and placental circulation to obtain vital energy sources like glucose, ketones, free fatty acids, and amino acids to meet their energy demands. The placenta serves as a direct supplier of glucose to the fetal circulation. However, when the umbilical cord is clamped immediately after birth, it abruptly interrupts this continuous glucose supply, resulting in a rapid drop in the infant’s blood glucose levels during the first 2 to 3 hours of life (Abramowski et al., 2023).
Low blood glucose levels trigger the release of insulin and other hormones, including catecholamines, glucagon, and corticosteroids. These hormones stimulate the production of glucose through processes like glucogenesis and glycogenolysis while also enhancing the oxidation of fatty acids. This creates an internal source of glucose and other necessary energy substrates for the infant’s metabolic requirements. As a result, blood glucose levels gradually increase over the next several hours to days. Disrupting the established sequence of these physiologic changes can pose a heightened risk of more severe or extended periods of low glucose in the infant. The highest likelihood of hypoglycemia occurs within the initial hours after birth (Abramowski et al., 2023). Persistent hypoglycemia may arise due to overproduction of insulin, insufficient cortisol or growth hormone, or inherent metabolic disorders (Abramowski et al., 2023).
The signs of hypoglycemia are not always noticeable in the newborn, but those infants who are at risk should be tested per protocol regardless of the presence of symptoms. The diagnosis is made with a simple test on blood obtained by a heel stick . The most common symptoms of hypoglycemia in the newborn include shakiness or jitteriness, hypothermia (low body temperature), poor muscle tone (floppy muscles), lethargy (lack of movement and energy, out-of-the-ordinary sleepiness), seizure s, and possibly cyanosis (blue tint to skin and lips) and apnea (stopping breathing) (Stanford Medicine, 2023b).
Treatment of neonatal hypoglycemia depends on the baby’s age and overall health and well-being. Depending on the facility’s protocol, treatment usually includes giving the baby a fast-acting source of glucose. This may be as simple as an oral glucose gel (“Standard-Dose Oral Dextrose Gel for Neonatal Hypoglycemia,” 2022), a glucose and water mixture, formula as an early feeding, or putting the baby to the breast if the infant nurses well. The baby’s glucose level is checked after the treatment to see if the hypoglycemia has improved. The baby may need glucose given through an IV as further treatment (Stanford Medicine, 2023b). Because the brain needs glucose to function, severe hypoglycemia, or not enough glucose for a prolonged period, can impair the function of the infant’s brain, causing seizures and brain injury . Thus, identifying and treating hypoglycemia as early as possible after birth. with the goal of stabilizing and maintaining a normal blood glucose level in the newborn, is optimal.
Umbilical Cord Conditions
After birth, the umbilical cord is cut, and the newborn is left with an umbilical cord stump that will fall off over time. The nurse educates the newborn's caregiver on caring for the stump at home and the signs or symptoms that would warrant a call to the primary care provider. Some common issues that arise from the stump include granulomas, hernia, and infection.
Umbilical Cord Granuloma
An umbilical cord granuloma is a small nodule of tissue, which can measure up to 1 cm, that may become evident after the separation of the umbilical cord (Poenaru, 2001). For some infants, after the cord has fallen off, a small granuloma will form. It will stay on the umbilicus and drain a light yellowish fluid. This condition will usually go away on its own in about a week, but if it does not, the pediatrician may choose to cauterize the area to burn off the granulomatous tissue (AAP, 2021a). Another treatment option for small granulomas may be an application of topical silver nitrate . These procedures are commonly treated in the pediatrician’s office. For larger granulomas or those unresponsive to silver nitrate, surgical resection may be indicated (Poenaru, 2001).
Umbilical Hernia
An umbilical hernia is present when the baby’s umbilical cord area appears to push outward when the baby cries. It is caused by a small hole in the muscular part of the abdominal wall that allows the tissue to bulge out when there is increased abdominal pressure (e.g., crying) (see Figure 23.9). It is not a serious condition and will usually heal itself in the first 12 to 18 months of life (AAP, 2021a). The healing process may take longer in infants of color for unknown reasons (AAP, 2021a). If the hole does not heal by the age of 3 to 5 years, it may require surgery.
Care of the Newborn
Culture has a strong influence on behaviors and practices during pregnancy, childbirth, and infancy. The challenges arising from this exciting, yet demanding period of transition often prompt new parents to turn to traditional and cultural practices. Some examples of cultural practices in the early newborn period include the following:
- In Zambia, the care of a baby’s umbilical stump involves three main methods: drying (using coal or powder on the cord), moisturizing (using engine oil on the cord), and protection (using breast milk, manure, or chicken feces on the cord).
- Among Jordanian women and in several other cultures, it is a well-known practice to place a coin on the infant’s umbilical stump, which is believed to be beneficial in preventing umbilical hernias.
- In India, cultural practices include the application of cow’s urine on the mother and refraining from breast-feeding the newborn for the initial 3 days of life.
- In Bulgarian culture, safeguarding infants from malevolent magic is achieved through the wearing of amulets and protective “evil eye” beads (Kuşlu & Koçak, 2023).
Umbilical Cord Infection
After birth and until the umbilical cord naturally separates, bacteria can invade the umbilical stump and cause infection called omphalitis . While caring for the infant, the nurse’s main priority in preventing umbilical cord infection is to keep the cord clean and dry and to teach the parents to do so as well. No dressing is necessary. When changing diapers, the diaper is folded below the umbilical area to avoid urine-induced infection. As part of the discharge instructions, the nurse instructs the parents that once the umbilical cord has separated, they should maintain clean and dry precautions until the base of the umbilicus is dry without secretions. If the area still presents with a large amount of discharge after more than 1 week, they should consult the baby’s health-care provider.
The umbilical cord of the newborn is a direct line into the circulatory system. Therefore, if it becomes infected, the infection can quickly spread systemically and become very serious. When an infection enters the bloodstream, it is called sepsis, and it can damage the body’s organs and tissues. For up to 15 percent of newborns who get an umbilical cord infection, it is fatal, so it is considered a medical emergency (Healthline, 2019). A culture of the infected area will be taken to determine which antibiotic is best, which will largely depend on the extent of the infection.
If the cord infection is minor, the health-care provider may recommend application of an antibiotic cream to the area a few times daily to fight the infection (Healthline, 2019). If it is more serious, the baby will most likely need to be hospitalized to receive IV antibiotics for a course of 10 days (Healthline, 2019). This may be followed by oral antibiotics. How long the baby is hospitalized is up to the health-care provider, but usually it is for the duration of the IV antibiotic treatment. In some severe cases, the infection may need surgical intervention. Frequently, the infection causes cells to die at the base of the umbilicus, and these dead cells may need to be removed surgically (Healthline, 2019).
Common Dermatologic Conditions of the Newborn
Newborn dermatologic conditions can be a source of great concern for parents, but most of these issues are benign and temporary. While they can be initially frightening, these conditions often resolve with time. From common rashes like baby acne, milia, and cradle cap to mild skin discolorations, most newborn skin problems pose no long-term harm. Pediatricians can provide guidance and reassurance to parents, helping them navigate these early challenges and ensuring the baby's skin health. Understanding that these conditions are a normal part of infancy can ease parental anxiety and promote a sense of confidence in caring for their newborn's delicate skin.
Milia
Tiny white bumps or cysts on the newborn’s skin, usually on the face around the cheek, nose, or chin area are called milia (Mount Sinai, 2021) (see Table 23.2). Occasionally, there may be a narrow red halo around the base of the milia. Milia form when dead skin cells get trapped in small pockets near the surface of the skin. The protein in those cells, called keratin, hardens into tiny cysts that present as small raised white bumps on the skin (Mount Sinai, 2021). No treatment is needed for milia because they will disappear on their own in the first few weeks of life.
Baby Acne
The common short-term skin condition that causes acne breakouts (papules and pustules) on a baby’s face, chest, or scalp is called baby acne (Cleveland Clinic, 2022e) (Figure 24.12). It occurs on average at about 2 weeks of age, although some babies are born with it. It resolves within weeks. Infantile acne occurs after 2 months of age and is different from baby acne, lasting up to a year. If an infant develops acne after 2 months of age, parents should see their pediatrician for intervention. Baby acne can develop slowly or suddenly. The cause is varied and may be related to clogged pores, oily skin, maternal or placental hormones, or other causes. The acne starts as red dots and turns into raised pustules, but not blackheads, disappearing in a few days to a couple of weeks. Generally, this acne resolves without treatment other than washing the area gently with mild soap and water, keeping the area clean and dry, and not using lotions or oils on the baby’s skin. An antifungal cream or low-potency topical steroid may be prescribed in serious cases (Cleveland Clinic, 2022e).
Erythema Toxicum
The skin condition in newborns that causes a red rash and small, fluid-filled bumps on the infant’s face and/or limbs is called erythema toxicum neonatorum (ETN) (Cleveland Clinic, 2022d) (see Table 23.2). ETN is not dangerous, it does not itch, and it is not uncomfortable for the baby. It does not have any long-term effects and may go away within 5 to 14 days after forming. The condition may come back and once again resolve in a week or two. Although often confused with baby acne, ETN is different. It can be differentiated by the fact that the bumps disappear and form in new areas over a few hours. Between the bumps, the skin has what appears to be a red rash or red patches. Symptoms usually show up only on parts of the body that have hair follicles, such as the arms, legs, chest, or face (Cleveland Clinic, 2022d). The bumps and rash will get paler when pressure is applied to them. No specific treatment is needed for ETN, and parents should be instructed not to squeeze or pick at pustules because that may cause infection or scarring.
Pustular melanosis
The normal and harmless skin condition that affects term newborns and presents with skin bumps, pustules, or blisters anywhere on the infant’s body is called transient neonatal pustular melanosis (TNPM) (Cleveland Clinic, 2022a). The pus-filled bumps are noticeable at birth and will rupture, causing white-encircled dark spots on the skin. The darkened skin will fade in 3 to 4 weeks (Cleveland Clinic, 2022a). Because blisters rupture easily, care must be taken to avoid infection. TNPM affects boys and girls equally and affects infants of color more than white infants. TNPM is benign, and it does not itch or cause scarring. The condition resolves without treatment.
Management of Common Newborn Skin Ailments
Most common skin ailments in the newborn are benign and require little management. It is important to understand the expected and pathophysiologic findings in the skin. Nurses can differentiate between normal variations and abnormal conditions and can educate parents about both. Appropriate care and management approaches are discussed to address issues effectively.
Diaper Rash
A common form of dermatitis , skin inflammation, in the diaper area of the buttocks, thighs, and genitals is called diaper rash (Mayo Clinic, 2022b). Diaper rashes are often uncomfortable and tender, causing fussiness and crying during diaper changes and in between. They can be caused by:
- Delay in changing wet or soiled diapers . Babies have sensitive skin. Diarrhea may also cause a rash.
- Chafing or rubbing . Rash may also occur if diapers are too tight or too small.
- Using a new product such as baby wipes, diapers, detergent, bleach, or fabric softener. Ingredients in lotions or oils might add to the problem.
- Developing a bacterial or yeast (fungal) infection . Skin creases around the diaper area are perfect breeding grounds for bacterial or yeast infections because they are moist and warm. If a yeast infection has developed, parents might notice red dots in the area, and the skin may be bright red and painful.
- Introducing new foods . As infants are introduced to new foods, their stool changes. This increases the likelihood of developing a diaper rash.
- Having sensitive skin .Infants with skin conditions such as atopic dermatitis (eczema) are more likely to develop diaper rashes (Mayo Clinic, 2022b). The skin affected by eczema is usually in areas not covered by diapers.
- Using antibiotics . Antibiotics can contribute to rashes by killing off bacteria that keep yeast growth in check, thereby allowing yeast to grow. Antibiotic use also increases the risk of diarrhea.
The best way to prevent a diaper rash is to keep the area clean and dry and to change diapers often. The nurse should teach the parents to use warm water and a mild soap to cleanse the area, or a baby wipe that does not contain alcohol, which would sting when a rash is present. Most commercial wipes do not contain alcohol. Parents or caregivers should gently pat the area dry or let it air dry. Cream, paste, or ointment should be applied regularly to the diaper area as a barrier to protect the skin. Petroleum jelly and zinc oxide are ingredients present in many proven diaper rash products. Diapers should fit securely but not too tightly, and when possible, the baby should have time without wearing a diaper. After each diaper change, it is important to maintain good handwashing to avoid the transfer of bacteria and yeast to other parts of the baby’s body, to the caregiver, or to other people.
Cradle Cap
The common, harmless skin condition on an infant’s scalp that presents as yellow scaly patches with a red rash is called cradle cap or seborrheic dermatitis (Cleveland Clinic, 2020). It is not uncomfortable for the baby, and it is not contagious. The exact cause of cradle cap is unknown, but overproduction by sebaceous glands in the baby’s scalp or a type of yeast in the oil produced by these glands may contribute to this condition (Cleveland Clinic, 2020). Infants who have family members with eczema or asthma are more likely to have cradle cap. It occurs equally in males and females and does not affect one ethnicity more often than another. Cradle cap looks like a reddened area with crusty brown or yellow scales on the scalp that resemble fish scales. The scales feel flaky, or waxy and greasy, to the touch. Cradle cap is seen in the first weeks or months of life and usually disappears completely by 12 months of age. Home treatment is all that is needed to manage most cases of cradle cap. Parents should massage petroleum jelly or mineral oil into the scalp, use a soft brush to gently remove the scales, and wash the baby’s hair daily with a mild baby shampoo. If this does not resolve the cradle cap, other over-the-counter baby products are available for this purpose. Once the cradle cap is resolved, the infant’s hair should be washed 2 to 3 times weekly with a mild baby shampoo to prevent it from returning.
Eczema
The common skin condition that causes patches of skin to become dry, itchy, and scaly is called eczema . It most commonly affects babies on their face, scalp, feet, hands, and legs. Eczema is a chronic condition that is not contagious. In the United States, baby eczema affects 15 percent to 20 percent of infants up to the age of 2 years (Cleveland Clinic, 2022b). This condition can come and go unexpectedly throughout life regardless of age. It is believed that a combination of genetics and environmental factors causes baby eczema, and these factors include:
- skin irritants and allergens, including fabrics, soaps, and certain foods
- immune system reaction
- genetics
Treating eczema can often be a frustrating experience for parents. The first step is to eliminate skin irritants and allergens. To do that, parents need to know what they are. Unfortunately, that is often a process of elimination and trial and error. If parents can identify these triggers, avoiding them will help the baby’s skin to heal and will prevent or lessen future flare-ups. Next, parents may use topical corticosteroids, which are rubbed on the baby’s skin like lotion. These are steroids prescribed by the infant’s provider, generally for no more than twice a day for 2 weeks. Longer or more frequent use may lead to discoloration or thinning of the infant’s skin. Finally, parents can apply moisturizers to the baby’s skin. By keeping the skin well hydrated, symptoms will be reduced, skin will be soothed, discomfort will be alleviated, and flare-ups will be prevented. Moisturizers without fragrance should be used and can be applied after bathing and several times a day as needed for dry skin.
Common Newborn Illnesses
Differentiating between common newborn viral illnesses and bacterial infections is not always easy and often requires a trip to the pediatrician. However, viral illnesses are more common than bacterial infections in the newborn period. Both may cause similar symptoms, such as fever, irritability, and listlessness, while the treatments for each are different. Testing may be required to determine the causative factor.
Management of Common Newborn Viral Illnesses
Some common viral agents in the newborn include herpes simplex virus es, HIV , cytomegalovirus ( CMV ), and hepatitis B . Intrapartum infection with HIV or hepatitis B can occur as the newborn passes through an infected birth canal or by ascending infection if delivery is delayed after rupture of membranes (Tesini, 2022). It is possible for these viruses to also be transmitted transplacentally, which commonly occurs. Specifically, CMV (cytomegalovirus) is commonly transmitted in this manner.
Upper Respiratory Infections
Many common newborn viruses, such as upper respiratory infections (URIs), or “common colds,” present with a runny nose, cough, low-grade fever with decreased feeding, and difficulty in sleeping. No antibiotics or antiviral medications will help the infant recover more quickly from a cold. Treatment is to keep the infant as comfortable as possible. Clear their nasal passages so that breathing and eating are easier. Advise caregivers to not overdress the infant with a fever and to medicate as directed by the infant’s care provider with acetaminophen (Tylenol) or ibuprofen (Motrin). Aspirin should not be given to newborns. Aspirin has been linked to Reye syndrome, a serious and potentially fatal condition for infants and children that causes swelling of the liver and brain after a viral infection. Acetaminophen is a safer alternative for fever or pain in babies up to 6 months of age, while both acetaminophen and ibuprofen are recommended for use in infants 6 months and older.
Caregivers should monitor the baby’s temperature, and if it gets worse, notify the pediatrician. Parents should be alert for signs of dehydration , particularly if the baby is not eating well because of a runny or stuffy nose. Infants can dehydrate very quickly due to decreased feedings and the immature nature of the neonatal kidneys, which are not as efficient in concentrating urine. For infants and children, the “common cold” can last from 10 to 14 days, and they occur an average of 6 to 8 times per year (Duke Health, 2019) and up to twice as often for infants in daycare.
Respiratory Syncytial Virus (RSV)
The contagious virus causing an illness more serious than a cold or upper respiratory infection is called respiratory syncytial virus (RSV) . Its symptoms start similarly, with fever (over 100.4° F or 38° C or higher), cough (dry or wet sounding), congestion, runny nose, sneezing, fussiness, and poor feeding. Symptoms may progress to bronchiolitis , a lower respiratory infection, which includes cold symptoms as well as rapid breathing; nasal flaring (when the nostrils flare out with each breath) and head bobbing with breathing; rhythmic grunting (occurs during breathing out, which is the infant’s way of trying to keep air in the lungs so the lungs will stay open); abdominal breathing; intercostal retraction (a sucking-in between the ribs when the infant breathes in) or an upside-down V shape under the infant’s neck when breathing in; and wheezing. These are all signs that the infant is working too hard to breathe. If their skin turns blue or purple, they are not getting enough oxygen. On darker skinned infants, look for changes in color to lips, tongue, gums, and around the eyes. Parents should be educated to notify their health-care provider if infants develop symptoms of bronchiolitis; dehydration (less than 1 diaper every 8 hours); long pauses (greater than 10 seconds between breaths) or difficulty in breathing; gray or blue color to tongue, lips, or skin; or significant decrease in activity and/or alertness (AAP, 2023b). For infants and certain toddlers, the RSV immunization nirsevimab (Beyfortus) can be administered via injection and may be integrated into their routine immunization schedule. Nirsevimab has been proven to reduce the risk of RSV-related hospitalizations and health-care visits in infants by approximately 80 percent (AAP, 2023b). This injection functions uniquely compared to traditional vaccines. It supplies antibodies that initiate immediate protection for infants, offering safeguarding throughout the standard RSV season. A single nirsevimab dose is suggested for infants under 8 months of age, to be given during or just before the RSV season. Additionally, a single dose is recommended for certain children between 8 and 19 months of age who are entering their second RSV season and face an increased risk of severe illness (AAP, 2023b).
Influenza
Another viral illness, influenza —also commonly referred to as the flu—can cause many of the same symptoms as the common cold but is accompanied by severe body aches and higher fever. If diagnosed within the first 48 hours of illness, influenza can be shortened by antiviral medication (Duke Health, 2019). A dose of flu vaccine (or two doses given a month apart in the young child receiving the flu vaccine for the first time) given at the start of each flu season can help to prevent influenza infections. The American Academy of Pediatrics (2023a) recommends annual influenza vaccination for all children without medical contraindication starting at 6 months of age (injection or intranasal). Although all children, particularly those under the age of 5 years, are considered at a higher risk for complications from the flu virus, the highest risk is for those younger than 2 years.
COVID-19
Infants and children of all ages can get COVID-19 , an infectious illness caused by the coronavirus SARS-CoV-2 that became a pandemic disease in 2020. In fact, babies can test positive from birth if the birth parent is positive, which is why it is important for pregnant persons to keep up to date with their immunizations and monitor their health. Newborns can get COVID-19 from the people who care for them. The nurse provides education on good handwashing techniques when caring for their infant. The infant’s crib can remain in the room with the parent while in the hospital, but keeping a reasonable distance from the newborn when not providing direct care or feeding is important. These precautions help to keep the risks of the infant getting COVID-19 low. If the birth parent is very sick and symptomatic, it would then be best to temporarily separate parent and baby by moving the baby out of the parent’s room (Mayo Clinic, 2023b).
Infants who have tested positive for COVID-19 but remain asymptomatic may be allowed to return home from the hospital, depending on the circumstances. To ensure protection, it is recommended that the caregivers of the baby wear face masks and maintain rigorous hand hygiene. Continuous monitoring and follow-up with the infant’s health-care provider, conducted through phone consultations, virtual check-ins, or in-person visits, are necessary for the next 14 days. Infants who test negative for COVID-19 may also be discharged from the hospital (Mayo Clinic, 2023b).
In the United States, vaccinations for COVID-19 are not available for infants under the age of 6 months. The Pfizer-BioNTech COVID-19 vaccine can be given at age 6 months if requested by the parents. It is given to children between 6 months and 4 years and consists of three doses to bring the child “up to date” with the vaccine. After the first dose, the second dose is given 3 to 5 weeks later, and the third dose is given at least 8 weeks after the second (Mayo Clinic, 2023b). The alternative is the Moderna COVID-19 vaccine, which can be given between ages 6 months and 5 years. This vaccine consists of two doses, with the second dose given 8 weeks after the first (Mayo Clinic, 2023b).
Management of Common Newborn Bacterial Infections
Bacterial infections are any illness or condition caused by bacterial growth or toxins. Harmful bacteria can attack the skin, gastrointestinal (GI) system, lungs, heart, brain, blood, or anywhere in the body. Most bacteria are not harmful, and many are helpful. Many of the vaccines that infants and children receive are meant to prevent serious bacterial infections.
Commonly seen bacterial agents affecting newborns include group B streptococci, enteric gram-negative organisms (primarily Escherichia coli or E. coli ), Listeria monocytogenes , gonococci, and chlamydia (Tesini, 2022).
With bacterial infections:
- Symptoms tend to persist longer than the 10 to 14 days that a virus usually lasts.
- Fever is usually higher than expected from a virus.
- Rather than improving, the fever and symptoms get worse a few days into the illness.
Antibiotics can treat most bacterial infections, but only a few viral infections have medications that can treat them. The primary treatment for neonatal bacterial infections is prompt empiric antimicrobial therapy with drugs such as ampicillin and gentamicin or ampicillin and cefotaxime (Tesini, 2022). Once culture results are returned, the drug, dose, and frequency will be adjusted to best fight the identified organism.
Bacteria in the blood, or sepsis , and a bacterial infection in the lining of the brain and spinal cord, or bacterial meningitis , are two serious and concerning kinds of bacterial infections. Infants have few subjective symptoms. Diagnostic tests are required to ascertain that bacterial infections are part of their current or presenting illness.
Read the current guidelines from the American College of Obstetricians and Gynecologists (ACOG) and AAP regarding prophylactic treatment of group B streptococcus (GBS) sepsis, a dangerous pathophysiology resulting from a bacterial infection.
Helping Parents Recognize and Respond to Signs of Illness in a Newborn
Having a newborn is both exciting and stressful for new parents for many reasons. One of these is concern for the baby’s health. How does a new parent know if their baby is getting sick? They may not know what their baby’s normal behavior is, and that makes it difficult to determine if their newborn’s behavior is not normal. Changes in newborn behavior can be subtle, so they are not always easy for new parents to spot. The best advice the nurse can give a new parent is to have them note any behavior that seems abnormal to them. Use the following list to teach new parents about signs of illness in newborns. New parents should watch for:
- any suspicion of illness, such as crying more than usual, irritability, coughing, diarrhea, or vomiting (if vomit is green, which means bile, notify the health-care provider immediately)
- changes in feeding pattern s, such as having to wake the baby for feedings or if the baby no longer finishes their feedings, which could indicate illness
- a fever of greater than 100.4° F (38° C), which warrants a call to the health-care provider
- low body temperature, less than 96.8° F (36° C), which warrants a call to the health-care provider
- changes in the baby’s cry—if the cry becomes weak, sounds strange, or becomes frantic or inconsolable
- weak suckling or not being able to suck for very long
- sweating while eating
- sleeping more than usual
- decreased muscle tone, floppy limbs, floppy neck when the infant previously could hold head up
- moaning or grunting noises when breathing, with or without flaring of nostrils
- decreased urination (fewer wet diapers) and dry mouth (dehydration)
- any color change, such as pale, bluish, or gray arms and legs
Any of these signs and symptoms of infant illness can occur independently or in combination. Babies do not often get sick, but when they do, they can deteriorate quickly (Kliegman et al., 2020).
When Contacting Health-Care Providers: Be Prepared
When contacting health-care providers or taking a baby to the emergency department (ED) for any problem or emergency, parents should be prepared to assist medical personnel in understanding what is happening with their baby and why they are concerned. Table 24.6 provides a summary of the helpful information parents will be asked to give health-care providers who are caring for their child. Being prepared will save both parents and their health-care provider time during a phone call, office visit, or trip to the ED, when time is of the essence. Parents need to be as objective as possible in relaying the facts of the situation. When parents can accurately and calmly describe in detail what they observed and what took place as well as any pertinent history, this allows the health-care provider to make quick and necessary assessments and decisions to provide the best care for their baby. Photos or videos of concerning symptoms can also be valuable.
| Category | Information |
|---|---|
| The baby’s symptoms | What prompted parents to contact their health-care provider or seek medical advice? |
| The baby’s medical history | Be prepared to discuss the history of the current symptoms or illness. When did it start? How has it progressed? Is the baby up to date on their immunizations? |
| Changes in the baby’s feeding or bowel movements | Is the baby feeding on a normal schedule, retaining feedings, spitting up, vomiting? Do parents need to wake the baby for feedings, is the baby refusing to eat, not interested in feeding, not taking the full feeding? Does the baby show signs of watery stools, diarrhea, change in stool volume, consistency, amount, effort? Are there any known allergies or sensitivities to food, formula? Are there any known chronic conditions? |
| Changes in the baby’s body temperature | What is the baby’s temperature, and what time was it last taken? Make sure to mention how it was taken (e.g., rectally, axillary, temporally, forehead). |
| Any home remedies or medicines | Has the infant been given any home remedies, over-the-counter, or prescription medicines? If so, what strength, what dose, and when? |
| Possible exposures | Is anyone in the household or daycare ill? Has the infant been exposed to anyone who has been ill? Has the baby or any family member recently received any immunizations (e.g., COVID-19 or flu)? |
Parents should be prepared to record any specific care instructions from their care provider, either on their phone or with paper and pen. They should also carry with them the phone number and location of their family pharmacy in case a prescription is ordered.
Parental education regarding common conditions that may occur in newborns is important to fostering parental bonding and feelings of confidence and competence as parents. The American Academy of Pediatrics (2021a) has identified a number of conditions common during the first couple of weeks of life as being of particular importance to new parents of newborns.
Abdominal Distention
Most babies have round bellies that stick out right after a feeding, but the abdomen (stomach) should feel soft between feedings. If it feels swollen or hard, there could be a problem with gas or constipation. If the baby has not had a bowel movement in more than a day or two, if the stool is like currant jelly or has blood in it, or if they are vomiting, a swollen stomach could be an indication of an intestinal problem. Parents should notify the baby’s health-care provider immediately.
Birth Injuries
Babies can be injured during birth, particularly if they are very large. While they usually recover quickly from these injuries, some symptoms may persist. Occasionally, a broken collar bone may occur. During the initial assessment, the nurse will detect a concavity (the curving in of a surface) and/or crepitus (a crackling or crunching sound made by the damaged bone) when palpating the newborn’s clavicle. After a few weeks, a small lump may form at the fracture site, a sign that new bone is forming to mend the injury.
Muscle weakness, or brachial plexus injury, is another common injury. This occurs during labor when pressure, compression, or stretching damages the nerves that send signals from the spinal cord to the shoulder, arm, and hand. Muscles are usually weakened on one side of the face or one shoulder or arm and generally return to normal after several weeks. Nurses and health-care providers can show parents how to nurse and hold the baby to promote healing of the muscles and nerves. Chapter 25 Care of the Newborn at Risk provides more information on birth injuries and their management.
“Blue Baby”
Newborns may have acrocyanosis, mildly blue or purple hands and feet, when they are cold, which is normal (Kutlubay et al., 2017). This condition is not related to the infant’s temperature and is very common in newborns in their first few hours of life as they adjust to extrauterine circulation and life. Acrocyanosis is caused by the constriction of the small blood vessels that deliver oxygen-rich blood to the extremities. An infant’s face, tongue, or lips may occasionally turn a little blue when the newborn is crying hard, but once they are calm, their color should quickly return to their typical shade. However, persistent blue coloring, or grey coloring in darker skinned infants, blue coloring circling the mouth, or blue coloring plus breathing or feeding difficulties is an emergency. It could mean that the heart or lungs are not working correctly, and the baby should be taken to the emergency department or 911 should be called immediately!.
Unusual Bowel Movements
Unusual bowel movements or stooling pattern s can include failure to pass meconium during the first 48 hours after birth. If the newborn has not passed the meconium in that time, evaluation of the lower bowel is indicated to detect potential problems.
Blood in newborn stool is not expected. Newborns may have a small amount of blood in their stool in the first few days of life. If this occurs, it usually means the infant has a fissure , or tiny crack, opening, or split, in the skin or tissues of the body, such as the anus from stooling (AAP, 2021a). Although this is generally harmless, it is suggested that parents notify their health-care provider about any signs of blood to confirm the reason because other causes require further investigation and treatment.
Coughing
Newborns may cough, gag, or sputter as they learn to feed. If breast-feeding, this may happen if the nursing parent’s milk lets down very fast or when switching from the breast to a bottle. When solely bottle-feeding, the size and shape of the nipple could be the issue. If the baby coughs or gags regularly when trying to feed and adjustments have not helped, parents should consult their care provider because these symptoms could indicate an underlying problem in the lungs or digestive tract.
Excessive Crying
All newborns cry and sometimes for no reason at all. If a newborn is crying, the parent or caregiver should “go to the basics” by making sure the baby is fed, burped, and have a clean diaper. After that, swaddle them and hold them, rock them, talk softly, sing, sway, or do whatever works to calm them down. The nurse should teach parents that they cannot “spoil” a newborn by picking them up and holding them, so they should not hesitate to do that when their baby is crying. Soon enough, parents will know their baby’s crying pattern s and be better able to tell why they are crying. If the baby’s crying sounds different, such as shrieking, or it goes on for an unusually long time, parents should call their health-care provider.
Forceps Marks
If forceps were used to assist in the delivery, they can often leave bruised, red marks or even superficial scrapes or scratches on the newborn’s face and head. These marks may not appear immediately after birth and may first appear as redness or puffiness of the face (Figure 24.13). It may take a few hours for bruising and forceps marks to become visible. These marks will generally disappear within a few days of birth. Sometimes, a firm, flat lump develops in one of these areas due to damage of the tissue under the skin and bleeding in that area. Parents could, and should, bring this to the attention of their newborn’s care provider, who will likely tell them that this will go away within 2 months (AAP, 2021a).
Lethargy and Sleepiness
Newborns sleep an average of 16 to 17 hours in a 24-hour period. Some may sleep even more. They will most likely set their own sleep-wake patterns, waking every 2 to 4 hours for feedings throughout the day and night. Parents need to expect their newborns to spend most of their time asleep.  If the baby is rarely alert, does not wake on their own for feedings, or seems too tired or uninterested to eat, those are indicators that parents should contact their health-care provider. This lethargy—particularly if it is sudden or a change in their usual behavior pattern—may be a symptom of a serious illness.
Respiratory Distress
Within a few hours after birth, the typical newborn has settled into a relaxed, comfortable, and stable breathing pattern. After this, if the newborn has trouble breathing, it is most likely because their nasal passages are blocked. Newborns are nasal obligate breathers (Hamming & Walner, 2012), meaning they breathe through their noses. The only time newborns breathe through their mouths is when they are crying. Therefore, clear nares are necessary for effortless breathing. When at home, troubled breathing is normally easy to remedy by using saline. It may become necessary to suction the infant’s mouth and nose to provide an open airway and to remove secretions or regurgitated feeding from these areas. The mouth must always be suctioned before the nose. When the nose is suctioned, the infant will often gasp, choke, or aspirate any contents in the mouth. Suctioning the mouth first reduces the risk of aspiration.
QSEN Competency: Safety: Nasal and Oral Suctioning
Definition: Minimize the risk of harm to patients and providers through both system effectiveness and individual performance.
Knowledge: Examine human factors and other basic safety design principles as well as commonly used unsafe practices.
Skill: Demonstrate effective use of technology and standardized practices that support safety and quality.

- The infant’s head is positioned to the side, as the infant is prone. This position will allow fluid to pool in the lower cheek.
- The bulb syringe is compressed prior to inserting it into the lower cheek. (Do not compress while it is in the mouth because any secretions that are in the bulb will be expelled back into the mouth and may cause choking or respiratory distress).
- Gently position the tip of the bulb syringe into the side of the infant’s mouth between the cheek and the gums. Do not insert it into the back of the throat, which could stimulate the gag reflex, causing regurgitation, or produce a vagal response that could result in bradycardia or apnea.
- Release the bulb while it is in the infant’s mouth, between the lower gums and cheek. This will cause the bulb to suction or draw secretions into the bulb. Remove the bulb syringe and empty it by compressing it several times, outside the mouth, before using it again. Emptying it prepares it for use again.
- Repeat the procedure to suction the mouth again. Suction the nose following the mouth, only if necessary. Infants may gasp when the nose is suctioned and might aspirate secretions in the mouth if it is not cleared first. Therefore, always suction the mouth before the nose.
- If suctioning the nose is necessary, do it gently. Suctioning of the nose can cause edema and trauma, which will obstruct the delicate nasal passages and cause unnecessary respiratory difficulties. It is best to suction the baby’s nose before a feeding or bedtime. Do not suction after a feeding because it may cause the baby to vomit.
- When suction is completed, clean the bulb syringe with hot soapy water, squeezing water from the bulb. Air dry. This will prepare it for future use.
Procedure for suctioning of the infant’s nose using a NoseFrida (Frida.com, 2003):
Thoroughly wash and dry hands prior to suctioning the infant’s nose.
- The disposable hygiene filter needs to be in place to prevent mucus or bacteria transfer. Be sure that the assembly is complete and secure.
- Place the large tube against the child’s nostril, not inside the nostril, creating a seal.
 Wipe the exterior if needed and repeat by creating a seal against the child’s other nostril.
- After the mucus-sucking session is completed, dispose of the filter.
- Wash the large tube with warm soap and water. Clean the tube with a few drops of rubbing alcohol.
- Firmly snap dry pieces together, inserting a new filter in place, preparing for the next use.
By following this procedure, the item is cleaned, assembled, and ready for use.
Attitude: Value the contributions of standardization/reliability to safety.


4.3: External Environments and Industries
- Identify contemporary external forces pressuring organizations.
Industry and organizational leaders monitor environments to identify, predict, and manage trends, issues, and opportunities that their organizations and industries face. Some corporations, such as Amazon, anticipate and even create trends in their environments. Most, however, must adapt. External environments, as identified in the previous section, can be understood by identifying the uncertainty of the environmental forces.Exhibit 4.4 illustrates a classic and relevant depiction of how scholars portray environment-industry-organization “fit,” that is, how well industries and organizations align with and perform in different types of environments.
The two dimensions of this figure represent “environmental complexity” (i.e., the number of elements in the environment, such a competitors, suppliers, and customers), which is characterized as either simple or complex, and “environmental change,” described as stable or unstable. How available monetary and financial resources are to support an organization’s growth is also an important element in this framework. 17 Certain industries—soft drink bottlers, beer distributors, food processors, and container manufacturers—would, hypothetically, fit and align more effectively in a stable (i.e., relative unchanging), simple, and low-uncertainty (i.e., has mostly similar elements) external environment—cell 1 in Exhibit 4.4. This is referred to when organizations are in a simple-stable environment . Of course unpredicted conditions, such as global and international turmoil, economic downturns, and so on, could affect these industries, but generally, these alignments have served as an ideal type and starting point for understanding the “fit” between environment and industries. In a stable but complex, low- to moderate-uncertainty environment, cell 2 in Exhibit 4.4, universities, appliance manufacturers, chemical companies, and insurances companies would generally prosper. This is referred to when organizations are in a complex-stable environment . When the external environment has simple but high to moderate uncertainty, cell 3 of Exhibit 4.4, e-commerce, music, and fashion clothing industries would operate effectively. This is referred to when organizations are in a simple-unstable environment . Whereas in cell 4 of Exhibit 4.4, an environment characterized by a high degree of uncertainty with complex and unstable elements, industries and firms such as computer, aerospace, airlines, and telecommunications firms would operate more effectively. This is referred to when organizations are in a complex-unstable environment .
Exhibit 4.4is a starting point for diagnosing the “fit” between types of external environments and industries. As conditions change, industries and organizations must adapt or face consequences. For example, educational institutions that traditionally have been seen to operate best in low- to moderate-uncertainty environments, cell 4 of Exhibit 4.4, have during this past decade experienced more high to moderate uncertainty (cell 2)—and even high uncertainty (cell 1). For example, for-profit educational institutions such the University of Phoenix and others—as compared to not-for-profit universities and colleges, such as public state institutions, community colleges, and private nonprofit ones—have undergone more unstable and complex forces in the external environment over the past decade. Under the Obama administration, for-profit universities faced greater scrutiny regarding questionable advertising, graduation rates, and accreditation issues; lawsuits and claims against several of these institutions went forward, and a few of the colleges had to close. The Trump administration has shown signs of alleviating aggressive governmental control and monitoring in this sector. Still, higher educational institutions in general currently face increasingly complex and unstable environments given higher tuition rates, increased competition from less-expensive and online programs, fewer student enrollments, and an overabundance of such institutions. Several private, not-for-profit higher educational institutions have merged and also ceased to exist. Adapting to increasingly rapid external change has become a rallying call for most industries and organizations as the 21st century evolves.
Organizational Complexity
It is important to point out here that external (and internal) organizational complexity is not often as simple as it may seem. It has been defined as “…the amount of complexity derived from the environment where the organisation operates, such as the country, the markets, suppliers, customers and stakeholders; while internal complexity is the amount of complexity that is internal to the organisation itself, i.e. products, technologies, human resources, processes and organisational structure. Therefore, different aspects compose internal and external complexities.” 18
The dilemma that organizational leaders and managers sometimes face is how to deal with external, and internal, complexity? Do you grow and nurture it or reduce it? Some strategies call for reducing and managing it at the local level while nurturing it at the global level—depending on the organization’s size, business model, and the nature of the environments. Without going into complicated detail, it is fair to say at the beginning of the chapter that you may want to read through the chapter first, then return here afterward.
In the meantime, here are some simple rules from organizational practitioners De Toni and De Zan to keep in mind for managing high levels of complexity from the external environment, internally, after you have diagnosed the nature of the external complexity—as we discuss throughout in this chapter: first, assemble “…a set of self-managing teams or autonomous business units,[known as modularized units] with an entrepreneurial responsibility to the larger organization.” These focused self-organizing teams use creative methods to deal with the diversity to the advantage of the organization. A second method when facing high external environmental complexity when you want to gain value from it is to find and develop “…simple rules to drive out creativity and innovation … to keep the infrastructure and processes simple, while permitting complex outputs and behaviours.” An example offered is found in the rules of the Legos company: “(1) does the proposed product have the Lego look? (2) Will children learn while having fun? (3) Will parents approve? (4) Does the product maintain high quality standards? (5) Does it stimulate creativity?” 19
A third strategy for dealing with external complexity involves companies’ building on their own capabilities manage too much complexity, which otherwise lead to chaos. Some of those strategies include creating open networks internal and outside the organization to promote cooperation and integration and to develop brand and reputation. Also, sharing “…values, vision, strategy, organizational processes and knowledge, through the development of trust and incorporation and promotion of leaders at all levels” can help internal teams exploit external complexity to the organization’s advantage. Keep these ideas in mind as you read through the chapter and think about how leaders, managers, employees, and you can learn to read external environmental clues that organizations can use to creatively and proactively use organizational resources to be more competitive, effective, and successful.
- What factors within the economic environment affect businesses?
- Why do change and shifts and technological developments create both challenges and new opportunities for business?
References
17. Felice De Toni, A. and G. De Zan. (2016), The complexity dilemma, Three tips for dealing with complexity in organizations, Practitioner , Dec. 31, journal.emergentpublications...lexitydilemma/
18. Eisenhardt, K. M., & Sull, D. N. (2001). “Strategy as simple rules”,Harvard Business Review, 79(1): 106-119
19. Ibid


2: Diplomacy
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As the previous chapter showed, war compels and focuses public attention, leaves a clear mark on human life, and is responsible for shaping our world. On the other hand, despite its importance, diplomacy rarely gains much attention. When military theorist Carl von Clausewitz remarked in the early 1800s that war was the continuation of policy by other means, he sought to normalise the idea of war in modern politics. But, his words also indicated that actions short of war are available to help states achieve their objectives. These are typically the actions of diplomats. And, their work is often far less expensive, far more effective and much more predictable a strategy than war. In fact, unlike in centuries gone by when war was common, diplomacy is what we understand today as the normal state of affairs governing international relations. And, in the modern era, diplomacy is conducted not only between nation-states, but also by a range of non-state actors such as the European Union and the United Nations.


9.1: Are teachers born or made?
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By Brittany Bowman
Learning Objectives
- Understand that some people are born with certain qualities that make them better suited for the job.
- Understand the benefits of proper training and experience.
- Understand that the teaching profession demands more than just training ensure success.
Introduction
While good teachers are essential, great teaches are invaluable. We always remember our greatest teachers. They are the ones that not only educated us, but the ones that motivated and pushed us to our greatest potential. They were driven by the passion of intellectual aspiration. They are the ones that we looked up to as role models, giving us inspiration to one day repay their dedication and teach our future students with as much passion as when they taught us. They are the individuals we go back to visit to reaffirm how great they once were and how great they still are. These are the teachers that we are so fortunate to have had in our lives. But what makes up a great teacher? Some say it is in the genetic make-up of individuals who are born with distinct, innate qualities and characteristics that makes them better equipped for working in the classroom. Others say that taking courses and reading through textbooks makes a teacher better suited for the job. But who is to say that it can not be somewhere in the middle. Taking into consideration the ideas behind both sides, maybe the answer to the question 'are teachers born or made?' is simply both?
Note
"It's easy to make a buck. It's a lot tougher to make a difference." -Tom Brokaw (Brokaw 2009)
It's in the Genes
Some believe that genetics and the structured DNA sequence that makes up an individual plays a significant role in how that individual can excel within the classroom as a teacher. A person's genetic sequence can enable them to inherit certain characteristics and qualities that enables their nurturing and teaching side to emerge. These innate characteristics and personality traits can not necessarily be taught, and by tapping into inner talents, the full potential of the teacher can be discovered.
"By nature, some people possess a combination of personality characteristics that are conducive to effective teaching" (Malikow, 2006 1). Having a caring, patient, encouraging, and joyous personality really makes a 'born' teacher stand out compared to a 'made' teacher. These innate characteristics along with many others can not be learned or acquired from reading a textbook or by taking education courses; you either have them or you don't. For a teacher from Framingham, Massachusetts, he had all these qualities and much more. Everyone always remembered Charles Sposato as a natural-born teacher, he went above and beyond expectations. Mr. Sposato was known to be full of spirit and have high amounts of energy that he brought in the classroom to ensure that his students would always be surrounded by a positive environment (Spitz 2007). He even helped a student's family buy needed clothing when money was scarce (Spitz 2007). All the little things really do add up. Based on Mr. Sposato's actions, he was more than a teacher to his students, and he didn't learn that by reading through any textbook.
Note
"Teaching is the only major occupation of man for which we have not yet developed tools that make an average person capable of competence and performance. In teaching we rely on the "naturals," the ones who somehow know how to teach." -Peter Drucker
(Drucker 2007)
Along with many other professions, teaching is primarily based on leadership and communication (Vilhanova 2008). Teachers must have the ability to lead and guide their classroom in a way that promotes controlled and free thinking. It is very important for teachers to be able to communicate effectively, not only to the students but to the parents as well. Communicating to the students is so important to the learning process. If a teacher can not get his/her point across, then it is very possible for the students to not understand the lesson being taught. Communication must be present among, both the teacher and the student. This is where the student can begin to gain trust from the teacher, and vice versa, where the teacher can gain trust from the student (Vilhanova 2008). Gaining each other's trust is very valuable because they are able to rely on each other.
All these aspects and characteristics can only be obtained if it is present in the individuals genes. They can not be taught or learned and that is why, those who possess these innate traits must use them productively or else they would just go to waste.
It's in the Books
To some individuals, an excellent education and a comprehensive training creates the best foundation in the classroom setting and that natural talent helps but it can't provide for the necessities that makes up an adequate and positive teaching environment. Being good or great at something does not always mean that there will always be passion. People who may not possess a natural talent for teaching, but are determined to still become a teacher, may have more passion that those born with the gift.
Note
"...even the most brilliant scientists may not know how to communicate their knowledge to children." -Jay Mathews (Mathews 2002)
The main point for teacher education and training programs is to inform teachers about effective instruction methods that can be very beneficial to improve and make the overall classroom experiences more desirable and more successful (Malikow, 2006 2). Once the teacher training and education is completed, the teachers become higher quality because it allowed teachers to gain more practice and experience. In essence, teachers really do 'make themselves' (Moore, 2004 6).
Teachers' work reflects on the students' work. Studies have shown that teachers, with no means of education training or certification, have a negative influence on students in the classroom. Teachers without this proper training, have a higher percentage of students in their class that scored lower on standardized tests (Mathews 2002). Other studies have revealed that the individuals who received a five-year degree from a teacher education program, tend to stay teaching longer that those who graduated with a four-year degree; also, the individuals with four-year degrees stay teaching longer than those with little or no training at all (Mathews 2002).
According to Education Secretary, Roderick P. Paige, and his teacher quality report, he states that "we now have concrete evidence that smart teachers with solid content knowledge have the greatest effect on student achievement" (Mathews 2002). Well isn't that exactly what teachers strive to accomplish? They want their students to be able to reach their greatest or maximum potential and to get the most out of their education. There is an old saying that parents want what is best for their children. Can't teachers want what is best for their students? The answer is of course, and by spending more time taking extra classes or going through additional educational training, this really underlines how the average teacher can be 'made' into a great teacher.
It's Both
To the others who fall in the middle, including myself, we believe that great teachers are a combination between the two. Having the qualities, characteristics, and drive in becoming a good teacher is one thing, but taking classes to better educate yourself on how to better your students really takes it over the edge into becoming a great teacher. Who is to say that teachers who seem to be born with this raw, natural talent, couldn't benefit from some type of educational training to reemphasize their strengths and build on their weaknesses.
Teachers are a lot like athletes and artists. All three were born with talents, and those talents will be refined because of the training and performance that comes along with each career (Malikow 1). Even the people that were born with all the traits that would make them an excellent teaching candidate, they still might be missing something. If they do not have the desire, drive, or passion to become a teacher, then these innate traits can be thrown out the window. Proper training and experience will help give advise on different techniques and methods that can be utilized. After teaching for quit some time, the teacher will be able to throw out the methods and techniques that did not work or fix the methods to better suit or accommodate the students. Practice makes perfect!
Resources
Brokaw, Tom. (2009). Tom Brokaw quotes. BrainyQuote. Retrieved February 8, 2009, from http://www.brainyquote.com/quotes/quotes/t/tombrokaw105667.html
Drucker, Peter. (2007). Quotations about teachers. The quote garden. Retrieved February 8, 2009, from http://www.quotegarden.com/teachers.html
Malikow, Max. (2006). Are teachers born or made? The necessity of teacher training. National Forum of Teacher Education Journal [Electronic],16 3E. Retrieved February 6, 2009, from www.nationalforum.com/Electronic%20Journal%20Volumes/Malikow,%20Max%20Are%20Teachers%20Born%20or%20Made
Mathews, Jay. (2002). Teacher training: too much or not enough? Washingtonpost.com. Retrieved February 8, 2009, from www.washingtonpost.com/wp-dyn/articles/A41591-2002Jul8.html
Moore, Alex. (2004). The good teacher: dominant discourses in teaching and teacher education. New York: RoutledgeFalmer.
Spitz, Julia. (2007). Charles Sposato: a natural-born teacher. The Metrowest Daily News [Electronic]. Retrieved February 8, 2009, from www.metrowestdailynews.com/homepage/x1434249505
Vilhanova, Anna. (2008). The teacher as a leader: which qualities make a teacher a leader in the classroom. Humanising Language Teaching [Electronic]. Retrieved February 8, 2009, from www.hltmag.co.uk/jan08/sart07.htm


5.8B: Clostridial and Propionic Acid Fermentation
- Discuss the process of acidogenesis and the production of propionate
Four Stages of Anaerobic Digestion
Acidogenesis is the second stage in the four stages of anaerobic digestion: hydrolysis, acidogenesis, acetogenesis, and methanogenesis. Hydrolysis is a chemical reaction wherein particulates are solubilized and large polymers are converted into simpler monomers. Acidogenesis is a biological reaction wherein simple monomers are converted into volatile fatty acids. Acetogenes is a biological reaction wherein volatile fatty acids are converted into acetic acid, carbon dioxide, and hydrogen. Finally, methanogenesis is a biological reaction wherein acetates are converted into methane and carbon dioxide, and hydrogen is consumed.
Anaerobic digestion is a complex biochemical process of mediated reactions undertaken by a consortium of microorganisms to convert organic compounds into methane and carbon dioxide. It is a stabilization process, reducing odor, pathogens, and mass reduction. Hydrolytic bacteria form a variety of reduced end-products from the fermentation of a given substrate.
One fundamental question in anaerobic digestion concerns the metabolic features that control carbon and electron flow. This flow is directed toward a reduced end-product during pure culture and mixed methanogenic cultures of hydrolytic bacteria. Thermoanaerobium brockii is a representative thermophilic, hydrolytic bacterium, which ferments glucose, via the Embden–Meyerhof Parnas Pathway.
Acidogenisis
Acidogenic activity was found in the early 20 th century, but it was not until mid-1960s that the engineering of phases separation was assumed in order to improve the stability and waste digester treatment. In this phase, complex molecules (carbohydrates, lipids, and proteins) are depolymerized into soluble compounds by hydrolytic enzymes (cellulases, hemicellulases, amylases, lipases and proteases). The hydrolyzed compounds are fermented into volatile fatty acids (acetate, propionate, butyrate, and lactate), neutral compounds (ethanol, methanol), ammonia, hydrogen and carbon dioxide. Acetogenesis is one of the main reactions of this stage. In this reaction, the intermediary metabolites produced are metabolized to acetate, hydrogen, and carbonic gas by the three main groups of bacteria—homoacetogens, syntrophes, and sulphoreductors. For the acetic acid production are considered three kind of bacteria: Clostridium aceticum, Acetobacter woodii , and Clostridium termoautotrophicum .
In 1979, Winter and Wolfe demonstrated that A. wodii in syntrophic association with Methanosarcina produce methane and carbon dioxide from fructose, instead of three molecules of acetate. C. thermoaceticum and C. formiaceticum are able to reduce the carbonic gas to acetate, but they do not have hydrogenases to inhabilite the hydrogen use, so they can produce three molecules of acetate from fructose. Acetic acid is equally a co-metabolite of the organic substrates’ fermentation (sugars, glycerol, lactic acid, etc.) by diverse groups of microorganisms, which produce different acids:
- propionic bacteria (propionate + acetate)
- Clostridium (butyrate + acetate)
- Enterobacteria (acetate + lactate)
- Hetero-fermentative bacteria (acetate, propionate, butyrate, valerate, etc.)
Key Points
- Acetogenesis is the third stage in the four stages of anaerobic digestion.
- Acetogenesis end products are acetate, hydrogen, and carbonic gas.
- Acetogenesis occurs in three main groups of bacteria: homoacetogens, syntrophes, and sulphoreductors.
Key Terms
- acetogenesis : The anaerobic production of acetic acid or acetate by bacteria.
- metabolite : Any substance produced by, or taking part in, a metabolic reaction.