Lecture 02 Neonatal Care Flashcards
1
Q
Where is Wharton’s Jelly and what does it do?
A
It is gelatinous substance within the umbilical cord.
It protects and insulates the two arteries in umbilical cord.
2
Q
What process beings in utero to prepare the baby to transition to extrauterine independence? (3)
A
In utero
- Fetal breathing
- Production of surfactant after 34 weeks
- Deposit of brown fat to help thermoregulate
3
Q
What does the umblical cord consist of? What are the func of each vessel?
A
AVA. Two arteries that removes waste from the baby
One Vein that delivers oxygen and nutrients to the baby.
4
Q
What are the chemical stimuli to intiate respiration? (3)
A
- Decrease pH
- Decrease PaO2
- Increase PaCO2
5
Q
What are the sensory stimuli to intiate respiration? (5)
A
- Cold
- Gravity
- Pain
- Light
- Noise
6
Q
What are the mechanical stimuli to intiate respiration? (1)
A
- Thoracic squeeze with vaginal delivery, helps squeeze out amniotic fluid.
In C Section they dont’ get this and will need suctioning.
Note that there’s dif adaptations done by the baby depending on what delivery method was used.
7
Q
What is the First Period of Reactivity?
How long does it last for?
What is occuring at this time?
What helps baby to organize HR and RR?
What vital signs are elevated?
What are the normal vital signs and what are the new figures after Period of Reactivity?
A
First Period of Reactivity lasts 60 ~90 min
The newborn is awake, active, appears hungry and has strong suck. The motehr should attempt to intiate breastfeeding.
Skin to skin contact is important as it helps baby organize HR and RR
Normal Signs: HR 100~160 mmHg, RR 30~60 breathes/min
HR increases to 160 ~180 bpm
RR is irregular 60~80 breathes/min, may hear crackles
onset of bowel sounds
8
Q
When does Period of Inactivity occur?
What happens during this time?
A
It occurs 3~4 hours after birth.
The newborn is difficult to awaken, and may last few min to several hours.
Vital signs return to normal and can do assessment now.
9
Q
When does Second Period of Reactivity occur?
How long does it last?
What occurs during this time?
What should you observe for?
A
It occurs 4~8 hours after birth.
Lasts 4~6 hours after period of inactivity
The vital signs are variable, so observe newborn closely for apnea, gagging and regugitation
Tachycardia and tachypnea may occur.
Increased muscle tone, skin color changes, meconium may be passed.
10
Q
What is the mnemonic for APGAR?
A
A: Appearance (color)
P: Pulse (Heart rate)
G: Grimace (response to stimulation)
A: Activity (muscle tone)
R: Respiration
11
Q
How does the APGAR score work?
A
Each category has 2 points possible.
They total up to ten.
7~10: good, continue to asess for changes
4~6 fair, needs air passages cleared, oxygen
0~3 poor, needs resucitation
12
Q
What kind of assessment is the APGAR scale?
A
It’s a transitional assessment
13
Q
What are 4 problems that may occur during transition?
A
- Respiratory
- Circulatory
- Thermoregulation
- Neurologic
14
Q
What is the normal newborn respiratory rate?
What do you expect when you auscultate RR for one full min?
A
Normal rate is 30~60 breathes/min
Auscultation: normally shallow and irregular
15
Q
Common Newborn Problems: Hyperbilirubemia
How often does Physiologic Jaundice occur in term newborns?
What’s the increase in uncongulated bilirubin?
The peak may be higher in breast fed infants, what’s the level?
A
- Occurs in 50% of all newborns, arises >24 hours after birth
- Increase in unconjugated bilirubin is no more than 12 mg/dl by 3 days of age
- Peak may be higher in breast fed infants at range of 15~17 mg/dl
16
Q
Describe the following respiratory problem: Tachypnea
A
RR >60 breathes/minute
17
Q
Describe the following respiratory problem: Grunting
A
Infant closes glottis during expiration, in an attempt to increase intra thracic pressure
18
Q
Describe the following respiratory problem: Retractions
A
Accessory muscles used to breath, noted by observing the chest
19
Q
Describe the following respiratory problem: Nasal flaring
A
Nares expand to allow fuller inspiration
20
Q
Describe the following respiratory problem: Unequal Breath Sounds
A
Air entry not equal bilaterally
21
Q
Describe the following respiratory problem: Apnea
A
Absence of breathing >15 seconds
22
Q
Describe the following respiratory problem: Oxygen Requirements
A
Signs that supplementary O 2 needed to maintain central pink color
23
Q
What is the normal newborn heart rate?
A
120-160 bpm for NCLEX
24
Q
Where could you palpate HR of infant?
A
After birth, can do it at the base of umblical cord
PMI in newborn: 4th intercostal space to the left of the midcalvicular line
Sometimes eprson taking bpm can count with their finger
25
What are 5 symptoms of circulatory problems during the transition phase?
1. Unequal/weak pulses: brachial, femoral
2. BP instability: monitoring is done only when they're not transitioning well
3. Pallor/ Mottled appearance: decreased perfusion
4. Central Cyanosis
5. Bradycardia: HR \<80 beats/min
26
***What is the normal axiallary temperature?***
36.5~37.4 C
27
***When are the risks of hypothermia, for an infant, the greatest?***
In the first 8~12 hours of life
28
When does a newborn's temp stabilize?
72 hours after birth. If not, they'll be using up their energy to shiver and keep warm. This will make them hypoglycemic.
29
What are risk factors (7) for hypothermia?
1. Decrease SQ fat and thin epidermis
2. Blood vessels closer to skin compared to an adult
3. Head larger than body
4. Large body surface area compared to volume
5. Prematurity or small for gestational age
6. Prolonged resuscitation efforts
7. Sepsis
30
What are the 3 newborn's defense against the cold?
1. Flexed posture: Decreases SA
2. Brown fat: Appear at 26~30 weeks of gestation.
Richer vascular and nerve supply than ordinary fat.
Present for several weeks after birth, depleted by cold stress
Warms neonate by increasing production up to 100%
3. Peripheral vasoconstriction: acrocyanosis
31
***Types of Heat Loss: Conduction***
Loss of heat in direct contact with cool surfaces
32
Types of Heat Loss: Evaporation
Loss of heat as water evaporates from infants body
33
***Types of Heat Loss: Convection***
Loss of heat due to cool air
34
***Types of Heat Loss: Radiation***
loss of heat to cool surfaces not in contact wih the body
35
List heat loss in order from greatest to least
TIE: Radiation and convection
Evaporation
Conduction
36
What are the best ways to reduce risk for heat loss? **Must know the 3 bolded ones**
1. **Dry immediately,** remove wet towels after drying
2. **Place skin to skin with mother**, can place warm blankets over mother and child
3. **Hat & wrap** the baby and promote flexion
4. Do not place infant directly on to cold surfaces like scale
5. Infant may be placed on radiant warmer if mother can't do skin to skin
37
What are initial signs of an infant trying to compensate for heat loss? (4)
1. Increased movement
2. Flexed position
3. Burn up glucose
4. Increased RR, HR
38
What are some last symptoms as infant is unable to compensate for the cold stress anymore
1. ***Mottled*** pale skin
2. Lethargy due to low blood sugar, poor suck feeding
3. ***Hypoglycemia***
4. Cry becomes weaker
39
What's the Moro reflex?
What is it caused by?
What does it indicate?
The startle reflex
Best indicator of neurological integrity, and elicited by loud noise or change of position.
Infant flexes legs, embrace position of arm, thumb and index finger forms a C
should be symmetric
disappears by 3 months
40
What is the rooting reflex?
Reflex that helps with feeding. The baby will turn and open their mouth in direction to look for breast.
41
***What is the sucking reflex and how is it tested?***
Test by putting finger in mouth and rub the roof of their mouth.
When you try to pull your finger out, they will not let your finger go.
42
***What is the tongue extrusion reflex?***
Baby pushes out their tongue whenever something touches the tip of their tongue.
This is reflex lasts from 4 to 6 months. That's why there shouldn't be any solid fluids until the reflex is gone.
43
***What is the plantar grasp reflex?***
***Toes grasp around the finger as well***
44
***What is the Babinski reflex?***
Toes splay in response to stimuli
disappears 1 year
45
***What tonic (fencing) reflex?***
Baby will extend head in the direction that you turn their head. This makes dressing the baby easier.
This disappears 2~4 months. If the reflex persists, then it may indicate neurological issue.
46
What does NIPs stand for?
Neonatal Infant Pain Scale
47
What NIPs intervention is done at each level?
0-2
3-4
5-7
?\< = pain
0-2: non pharmacologic measures
3-4: consider non narcotic analgesia, non pharmacologic measures
5~7: treat with narcotic analgesia, non pharmacologic measures. This level is when something is wrong with the baby.
48
***Initial Newborn Assessment***
## Footnote
Immediately after birth, how often should vital signs and assessments be done?
Every 15 min within the first hour
49
***Initial Newborn Assessment***
Within 1~4 hours of birth:
Gestational age evaluation
***Why is erythromycin ointment given?***
***Why is Vitamin K given?***
Wt, length, head/cheste circumference is taken
ID: maternal thumbprint, infant footprints, banding
**Hep B Vaccine may be given but you need:**
Erythromycin ointment given to prevent bacterial infection: Chlamydia and Gonorrhea
Vitamin K injection is given: because babies can't make this yet since their gut is sterile. Vitamin K helps with clotting factors. So you can also do a circumcision after baby is born compared to waiting till the 8th day.
Hep B Vaccine needs maternal consent
50
***Gestational Age Assessment***
How long is this performed for?
Up to 96 hours of age and done twice by two dif examiners
51
Gestational Age Assessment
## Footnote
***What are the 6 neuromuscular assessments?***
***SHAPPS***
1. Posture: Assess degree of flexion of the extremities. At term the newborn's legs and arms are moderately flexed at rest. Less degree of flexion=younger the GA
2. Square Window: Grasp baby's forearm and gently flex wrist towards inner arm. Don't allow wrist rotation. At term, baby's hand should touch the wrist. Younger the baby=less flexion
3. Arm recoil: Flex and hold forearms for 5 seconds, then exten arms and hands fully at the side. Release, and allow arms to revoil. Term babies does full recoil. Preterms do less.
4. Popliteal angle: Have newborn's thigh pressed against abs. Move foot gently to the head until resistance. Measure angle. Term babies has less flexibility compared to preterms.
5. Scarf Sign: Assess by grasping newborn's hand and attempt to cross arm over body at neck. The arms of term babise will meet resistance before crossing midline. Preterm babies cross the elbow past the midline
6. Heel to ear: Assess by raining newborn's heel toward the head in attempt to bring foot to ear. Do not raise buttocks off surface. When met with resistance, measure degree of extension of the elgg. With preterms, heel will be close to ear, while you'll meet resistance almost immediately with newborns.
52
Gestational Age Assessment
## Footnote
***What are 6 physical criterias of GA***
***GPLEBS***
1. Genitals:
Males: testes usually descended near term and has ridges visible on scotum. Premies' scrotum is very flat and smooth.
Females: Labia majora ? clitoris + labia minora.
Premies have prominent clitoris and small labie minora
2. Plantar: Inspect for creases. Term babies have creases over entire plantar surface. Creases of preterm range from absent to faint red marking.
3. Lanugo: fine body hair. Extreme premies don't have any. Middle of 3rd trimester has a lot of lanugo. Closer to term the hair begins to thin.
4. Eye/ear: Pinna is less curved in premies. Determine ear recoil by folding pinna down and assess how quickly it retuns to previous condition. Premies may have infused eyelids.
5. Breast buds: Inspect breast to see size of bud in mm and development of areola. Premies lack developed tissue. Term has raised full areola with buds 3~10 mm in diameter.
6. Skin: Assess for transparency, cracks, veins, peeling or wrinkles. Premies: translucent and friable. Post term is leathery and cracked.
53
Gestational Age Assessment
How accurate should this be?
When should you overestimate GA?
Accurate within 2 weeks of GA
Overestimate GA by 2~4 days if infants are between 32 to 37 weeks
54
***GA Terms:***
***Preterm***
Born before 37 weeks, regardless of birth weight
55
***GA Terms:***
***Term***
Borned between week 38 and end of week 42
56
***GA Terms:***
***Post term***
Born after 42 weeks
57
***GA Terms:***
***Postmature***
Born after week 42 and signs of placental insufficiency .
58
***GA Weight Assessment:***
***What's the normal weight range for babies?***
2500 g ~ 4200 g
59
***GA Weight Assessment***
***What's AGA and what is it defined as?***
Defined as weight between 10th and 90th percentile weight for age
60
***GA Weight Assessment***
***SGA is defined as:***
***More problems with?***
Small Gestational Age: weight below 10 percentile at any week of gestation
More problems with: hypoglycemia, polycythemia, thermoregulation difficulties, impaired immune system
61
***GA Weight Assessment***
***LGA def***
***Problems with?***
Large for gestational age: weight above the 90th percentile at any week
Problems: birth, hypoglycemia, increase incidence of birth defects, respiratory difficulty, jaundice
62
***Birth Weight Classification:***
***LBW defined as***
Low Birth Weight (LBW)
\<2500 grams
63
***Birth Weight Classification:***
***VLBW***
VLBW: Very Low Birth Weight
\<1500 grams (3lb 4 oz)
64
***Birth Weight Classification:***
***ELBW***
***What is this often related to?***
ELBW: Extremely Low Birth Weight
\<1000 g (2lb 3oz)
***often related to intrauterine growth restriction factors:***
***multiple births, HTN, smoker, African American mother, pre exclampsia, malnutrition, substance abuse***
64
***Birth Weight Classification:***
***What are intrauterine growth restriction risk ractors? (IUGR)***
•multiple births, smoker, AA (African American) mother, HTN pre-eclampsia, malnutrition, substance abuse
65
***Newborn Measurements:***
***What's the average weight?***
3405 grams (7lb, 8 oz)
66
***Newborn Measurements:***
***Average length***
50 cm (20 inches)
67
***Newborn Measurements:***
***Head and chest circumference***
Head 32~37 cm (usually 2 cm \>than chest)
Chest 30~35 cm
68
***Newborn Modified Ballard Assessment***
***Involves NIPS (make sure you know it)***
***How do you assess Heart, Lungs and Axillary temp?***
1. Heart: Apical pulse rate, rhythm, murmur, brachial and femoral pulses
2. Lungs: rates (RR), effort, sounds grunting, rales (Crackly sounds)
3. Axillary temp should be taken up in the arm pit. Should be done last
69
***Newborn Modified Ballard Assessment***
***How do you assess for head and face?***
Head and Face: symmetry, fontanels, molding, cephlohematoma, caput succuduem, vacuum extractor marks, forcep marks, you want to feel for lumps and pumps
70
***Newborn Modified Ballard Assessment:***
***What assessments do you do for Eyes, Ears and Nose?***
1. Eyes: shape, subconjunctival hemorrhage, edema
2. Ears: development of cartilage, ear canal, position
3. Nose: Flaring, patency (since babies are obligatory nose breather)
71
***Newborn Modified Ballard Assessment***
***What are assessments for Mouth and tongue?***
1. Mouth: Lip color to deteect central cyanosis, cleft (there's a dif between cleft lip and cleft palate), sometimes will have to suck or feel for it, Epstein's pearls (whitish-yellow cysts that form on the gums and roof of the mouth in a newborn baby), natal teeth, palate
2. Tongue: Movement, frenulum of tongue, suck
72
***Modified Ballard Assessment***
***What are the assessments for Neck, Clavicles and Chest?***
1. Neck: nodes, swelling, ROM
2. Clavicles: assess for symmetry, fracture
3. Chest: Symmetry, shape of sternum, breast buds, retractions
73
***Modified Ballard Assessment***
***What are assessments for the umbilicus, extremities and hips?***
1. Umbilicus: AVA, cord clamp
2. Extremities: posture, ROM, symmetry, skin folds, number of digits, capillary refill, pulses, reflexes
3. Hips: Ortolani's sign: to make sure balland socket joint are fit well, this checks for hip dysplasia
74
***Modified Ballard Assessment***
***What are the assessments for Male Genitalia, Female Genitalia, Anus & Rectum, Trunk and Spine***
1. Male genitalia:
Penis: prepuse is not easily retractable, check for opening of urethral meatus (there may be hypospadius, where urethra is on the penis' underside)
Scrotum: Testes: descended in 90% of term infants
2. Female genitalia:
Labia majora covers labia minora in term infants
White discharge is normal. Pseudomenstruation may occur
3. Anus and Rectum: anal wink reflex, voids, stools
4. Trunk and spine: palpate spine fully, gluteal folds even, tufts of hair, pilonida dimple (condition), cleft
75
Skin Variations
What is perioral cyanosis?
Cyanosis between nose and mouth
76
***Head Shape Variation***
***What is caput succedaneum?***
Fluid is over the suture line. between skin and periosteum
77
***Head Shape Variation***
What is Cephalhematoma?
This has fluid and blood in it, between skull and skin. It looks like horns.
78
Skin Variation
What is erythema toxicum?
This is a normal hormonal response. You can see some whiteness, and it looks rash like. It's normal and will go away.
79
Skin Variation
What is milia?
White bumps on the nose, upper lips and eye areas. Just pus subacious glands.
80
Birth Marks
What are the differences between Stroke Bites and Angel kisses?
Both are superficial capillaries. They'll fade over time.
Stroke bites occur on the back of the head, angel kisses are on the forehead.
81
Birth Marks
What are Cafe Au Lait?
Flat macule. If there are too many of them, then babies may have to be assessed for neurlogical issues.
82
Vascular Birth Marks
What are hemangioma?
Typically a red dot at birth and over time becomes more palatable.
83
Vascular Birth Marks
What are Port Wine Stains
Looks like spilled wine on skin, won't fade over time
84
Birth Marks
What are Blue and Black spots?
What ethnicity typically has it?
It's a dense collection of melanocytes that are close to the surface and looks deep brown.
Native Ameircan, African, Asian or Hispanic Descent
They are present in 1/10 of fair skinned infants.
Most fade by 2~5
85
***Common Newborn Problems: Hypoglycemia***
***What's the normal range for neonatal bg?***
***How is it obtained?***
***What's considered hypoglycemia?***
Normal range is 40~100 mg/dl
Obtained through heelstick, lateral or medial aspect of heel
**Hypoglycemia is BG\< 45 mg/dl**
86
***Common Newborn Problems: Hypoglycemia***
***What are risk factors? 6***
Cold stress
IDM (Infant of diabetic mother)
Pallor
Jitteriness
Temperature instability
Cyanosis
87
***Common Newborn Problems: Hyperbilirubemia***
***How often does breastmilk jaundice occur?***
***How does milk affect the absoprtion of bilirubin?***
1. Breastmilk jaundice is rare, and develops in 2nd week of life, peaks at 10 days
2. Breastmilk may increase the absoprtion of bilirubin. In most cases, intervention isn't necessary.
May need to temporarily interrupt breastfeeding.
88
Common Newborn Problems: Hypoglycemia
How do you treat for this?
1. Feed
2. warm infant by **skin to skin**
3. Recheck bg after feeding
4. IV dextrose may be necessary for **severe or persistent bf instability**
89
***What occurs in Direct bilirubin metabolism?***
Conjugates in liver, conjugated bilirubin excreted from liver cells as part of bile, then from body is extreted through feces or urine
90
***what occurs in Indirect bilirubin metabolism?***
•unconjugated bilirubin binds to circulating albumin then sent to liver can leave vascular system and bind with tissues, causing yellowish hue to skin
Total serum bilirubin (TSB) is sum of unconjugated and conjugated Coombs’ test
•determines if there are antibodies in bloodstream, causing immune system to attack and destroy red blood cells
91
***What are Normal Bilirubin Levels in Premature babies?***
***For less than 24 hours***
***Less than 48 hours***
***3~5 days***
***7 days and older***
1. Less than 24 hours: Below 8.0 mg/dl
2. Less than 48 hours: Below 12.0 mg/dl
3. 3~5 days: Below 15.0 mg/dl
4. 7 days and older: Below 15.0 mg/dl
92
***What are Normal Bilirubin Levels in Full term babies***
***Less than 1 day old?***
***Less than 2 days old?***
***3~5 days old?***
***7 days and older?***
1. Less than day old: \< 6.0 mg/dl
2. Less than 2 day old: \<10.0 mg/dl
3. 3~5 days: \<12.0 mg/dl
4. 7 days + : \<10.0 mg/dl
93
***What are major risk factors for physiologic jaundice? (5)***
1. Gestational age 35~36 week
2. Previous sibling had phototherapy
3. cephalohematoma/sig bruising
4. Exclusive breast feeding, esp if nursing isn't going well and weight loss is excessive
5. east Asian Race
94
The level of jaundice may correlate with bili level.
Visibility of jaundice indicates what level of bili?
Above nipple line predicts bili at?
Head and neck?
Trunk to umbilicus?
Trunk to knees?
Wrist and ankles?
Hands and feet?
Visibility indicates bili\> 4 mg/dl
Above nipple \>12 mg/dl
head and neck 6mg/dl
Turank to umbilicus 9 mg/dl
Trunk to knees 12 mg/dl
Wrists and ankles 15 mg/dl
Hands and feet \>15 mg/dl
95
***How would you treat jaundice? (5)***
1. Wake baby up frequently for feeding
2. Monitor stooling, amount, color and consistency
3. Follow up visit with doc, 1~2 days after discharge
4. No longer recommend placing baby near window for indirect sunlight exposure
5. Phototherapy
96
***Pathologic Jaundice***
***When is it observed?***
***What are some causes? (4)***
***If untreated, what would happen?***
Pathologic jaundice typically occur in first day
Caused by:
1. Rh incompatability: isoimmunization
2. Blood group incompatability: Mother O, fetus A,B or AB
3. Metabolism and excretion disorders
4. Serum bilirubin \>4 mg/dl in cord blood
Increases more than 5 mg/dl in a day or
\> .5mg/dl over 4~8 hours
If untreated: reslts in kernicterus unconjugated bilirubin deposits in brain that can lead to hearing loss, mental retardation, cerebral palsy, death
97
How does Phototherapy work?
What are precautions for baby?
Phototherapy exposes newborn to blue light spectrum. facilitates biliary exretion of unconjugated bilirubin.
Precautions: eye protectors, out for 30 min for feedings, monitor I/Os in case of dehydration
98
What are somethings that may be included in the newborn care teaching plan? (list 5)
* Feeding
* Bath, cord care, temperature
* Newborn states
* Swaddling
* Jaundice
* Circumcision care
* Newborn screening
* Newborn protection and Safety- bulb syringe, back to sleep, tummy time, shaken-baby syndrome, car seat-positioning
* Infant abilities/development
* When to call the doctor
99
**How long does a baby have to have sponge baths?**
Until cord stump falls off or circumcision heals
100
What are some tips of giving a baby bath?(7)
1. Clean to dirty – face, body, genitals, buttocks
2. Wash face and diaper area daily
3. Baths two to three times a week
4. Room temperature 70-72F
5. Bath water temperature 90-95F
6. No Q tip use or baby powder
7. Massage scalp over soft spots and rinse well to prevent cradle cap
101
***What are precautions in Umblical Cord (3)***
1. No alcohol to clean stump
2. Expose tump to air, by folding shirt above and diaper below stump
3. No tub bath until stump falls off, typically 7~10 days
102
***Circumcision Care.
What's the difference between Plastibell and Gomco/Mogen?***
Plastibell uses clear water to clean until plastic ring falls off (5~7 days)
Gomco/Mogen: Has what looks like a bread clip. Petrolatum gauze or vaseline in front of diaper for 12~24 hours, then clear water to clean the area. It may have yellow film over glans as it heals.
103
What's the leading cause of death in infants between 1 month and 1 year?
SIDS
104
When does most SIDS deaths occur?
Between 2 and 4months
AA babies 2x more than white babies
Native Americans 3x more
105
What are ways to prevent SIDS? (6)
1. •No co-sleeping
2. •Always place baby on the back to sleep, even for naps
3. •Place baby in a safety-approved crib with a firm mattress
4. •Remove soft, fluffy bedding and stuffed toys
5. •Place baby to sleep in light clothing to avoid overheating, use a sleep sack, or a wearable blanket
6. •Use a pacifier (breastfeed infant after 1 mo)
106
When should the doctor be contacted, about the baby? (8)
1. •No urine in first 24 hrs or stool in first 48 hrs at home
2. •Rapid or noisy breathing, wheezing, grunting, or whistling sounds
3. •Temperature above 100.4°F
4. •Yellowish colored skin or eyes or pale, mottled skin
5. •Vomiting or diarrhea
6. •Refuses several feedings or eats poorly
7. •Hard to waken or unusually sleepy, lethargic
8. •Crying more than usual, very hard to console, jittery
107
What are 4 precautions to car seat safety
1. •Rear-facing car seats, best in center of back seat
2. •Need to adjust straps and secure base in car
3. •Premie babies need car seat trial
4. •No blankets, sacks or snowsuits without legs
This is the nubmer 1 overall cause of death for kids under 14
