Gestational Age & Newborn Assessment

Gestational Age

• Physical signs & neurologic characteristics assessed

  • Determined using a tool such as the Ballard Scale

  • Determines a NB’s gestational age

  • Between 20 & 44 weeks

  • Higher scores = More mature

New Ballard Score

• Physical Maturity

• Neuromuscular Maturity

• More to the left = Pre-term

• More to the right = Post-term

Physical Maturity (Gestational Age Assessment)(New Ballard Score)

• Performed within the first 2 hrs of birth or ASAP

• Examines physical characteristics

• Skin

• Lanugo

• Plantar surface

• Breasts

• Eyes & ears

• Genitals

Neuromuscular Maturity (Gestational Age Assessment)(New Ballard Score)

• Usually completed within 24 hrs of birth

• Activities or maneuvers that the NB performs with various body parts determine the NB’s degree of maturity

  • Can be affected by sedation, illness, or hypoxia

• Posture

• Square window

• Arm recoil

• Popliteal angle

• Scarf sign

• Heel to ear

Newborn Physical Examination (General)

• Perinatal Hx

• Newborn physical examination

• Least invasive first

  • Auscultate before palpate

• Assess heart & respiratory rates when quiet

• Calm/ comfort baby

• VS

Newborn Physical Examination

• Skin

• Head

• Face:

  • Nose, mouth, eyes, ears

• Neck, chest

• Abdomen

• Hips, extremities, & back

• Neurologic status:

  • Alertness, posture, & muscle tone

  • Reflexes

Newborn Physical Examination (Skin Variations)

• Acrocyanosis:

  • Cyanosis of hands &/ or feet

• Vernix Caseosa:

  • Thick white substance that protects skin

• Milia:

  • Unopened sebaceous glands on nose

  • Disappears about 2-4 weeks

• Epstein pearls:

  • Milia on the gums

  • NOT teeth

• Mottling

• Lanugo:

  • Hairy

• Bruising

• Cafe au lait spots:

  • Light brown birth mark

  • More than 6 =

• Nevus Simplex (Stork bites/ Salmon patches)

  • Superficial vascular areas

  • On Nape of neck, eyelids, or between eyes

  • Fade by 1 year

• Erythema Toxicum:

  • Benign palpular-pustular rash

• Mongolian Spots (Congenital Dermal Melanocytosis)

  • Bluish spots

  • On Lower back, buttock

• Harlequin Sign (Clown suit)

  • Dilation of blood vessels on one side of the body

• Nevus Vasculosus

  • Strawberry mark/ hemangioma

  • Benign

  • May darken

  • Disappear by age 3

• Nevus Flammeus (Port-wine stain)

  • Usually on face or head area

  • PERMANENT

  • Tests to see if anything below it (Possible cancer)

Acrocyanosis (Skin Variations)

• Cyanosis of hands &/or feet

Vernix Caseosa (Skin Variations)

• Thick white substance that protects the skin

Milia (Skin Variations)

• Unopened sebaceous glands on the nose

• Disappears about 2-4 weeks

Epstein Pearls (Skin Variations)

• Milia on the gums

• NOT teeth

Mottling (Skin Variations)

• Irregular patchy pattern of discoloration of the skin

• Red, purple, or bluish marks

Lanugo (Skin Variations)

• Soft, fine unpigmented hair

• Falls off naturally

Bruising (Skin Variations)

• From vaginal delivery or use of devices to help with delivery

Cafe au lait spots (Skin Variations)

• Light brown birth mark

• More than 6 = Possible neural fibromatosis

Nevus Simplex (Stork Bites/ Salmon Patches) (Skin Variations)

• Superficial vascular areas

• On the Nape of the neck, eyelids, or between the eyes

• Fade by 1 year

Erythema Toxicum (Skin Variations)

• Benign palpular-pustular rash

Mongolian Spots (Congenital Dermal Melanocytosis) (Skin Variations)

• Bluish spots

• On the lower back, buttocks

Harlequin Sign (Clown Suit)

• Dilation of the blood vessels on ONE side of the body

Nevus Vasculosus (Strawberry mark/ hemangioma) (Skin Variations)

• May darken

• DISAPPEARS by age 3

• Benign

Nevus Flammeus (Port-Wine Stain) (Skin Variations)

• Usually on face or head area

• Permanent

• Tests to see if anything below it = Possible cancer

Newborn Physical Examination (Head Variations)

• Fontanelles

• Sutures

• Molding

• Cephalohematoma

• Caput Succedaneum

Fontanelles (Head Variations)

• Soft membranous gaps BETWEEN skull bones

Sutures (Head Variations)

• Fibrous joints occurring only in the skull

Molding (Head Variations)

• Elongated head shape to accommodate birth canal

• Cone head head ahh boy, Crystal skull head ahh boy

Cephalohematoma (Head Variations)

• Bleeding between the periosteum & the skull

• Does NOT cross suture lines

• Takes weeks to months to go away

  • Absorbs back

• REPORT

• MORE critical

Caput Succedaneum (Head Variations)

• Localized serous, soft tissue swelling

• CROSSES suture lines

• Goes away in 2-3 days

Head & Face (Newborn Physical Examination)

• Low set ear

  • Ear deviation

• Cleft palate

• Cleft lip

• Cleft lip & cleft palate

• Bruising

Neck & Chest (Newborn Physical Examination)

• Inspect for ability to move head

• Palpate clavicles

• Inspect chest for size, shape, & symmetry

  • Nipples

  • Xiphoid process

Cardiovascular (Newborn Physical Examination)

• Apical rhythm & rate

  • Normal: 110-160 bpm

  • Full 60 seconds

  • Hard to count!

• Murmurs

• Pulses

  • Brachial

  • Femoral

• Perfusion

  • Cyanosis

Respiratory (Newborn Physical Examination)

• Breath sounds

• 30-60 rpm

• Listen for full minute

• Work of breathing

  • Tachypnea

  • Nasal flaring

  • Retractions (Chest sinking in when breathing)

  • Grunting = Trying to open alveoli

• Choanal atresia

  • Congenital condition

  • Back of their nasal passage blocked by bone &/or soft tissue

  • EMERGENCY

GI System (Newborn Physical Examination)

• Abdomen

  • Shape

  • Bowel sounds

  • Umbilical cord

• Anus

  • Can be imperforate (NO opening of anus)

  • Check for patent anus

• Stools

  • MUST pass at least 1 in the first 24 hrs

• Void

  • At least once in the first 12-24 hrs

Male Genitalia (Newborn Physical Examination)

• Penis:

  • Hypospadias

  • Epispadias

• Testicles

  • Descended

  • Cryptorchidism

  • Scrotal edema

  • Hydrocele

• Circumcision

Female Genitalia (Newborn Physical Examination)

• Labial edema

• Vaginal discharge

• Vaginal tag

• Pseudomenstruation

Back Exam (Newborn Physical Examination)

• Sacral dimple

  • Small shallow pit near the base of the tailbone

  • No medical Tx needed

Extremities

• Polydactyly

• Clubfoot

• Syndactyly

• Simian Crease

• Breech Legs

Polydactyly (Extremities)

• Birth defect

• Born w/ an extra finger or toe

Clubfoot (Extremities)

• Birth defect

• Born with the foot turned inward & downward

  • Could be one or both

Syndactyly (Extremities)

• Congenital condition

• When 2 or more fingers or toes are fused or webbed together

Simian Crease (Extremities)

• Single palmar crease

• Literally me

Breech Legs (Extremities)

• After birth

• Baby may still be in Breech position

• Usually temporary

Hip Exam

• Barlow

  • Cannonball

• Ortolani

  • Make an “O”

• Clicks & clunks = Hip dysplasia

• Gluteal creases

Reflexes

• Sucking

• Rooting

• Moro (startle)

• Truncal Incurvation reflex (Galant reflex)

• Palmar grasp

• Plantar grasp

• Babinski

• Tonic neck

• Stepping

Sucking Reflex

• Place nipple or gloved hand in mouth & rub against palate

Rooting Reflex

• Touch or stroke from side of mouth toward cheek

• Infant should turn their head to the side being touched

Moro (Startle) Reflex

• Let infant’s head drop back approximately 30 degrees

• Sharp extension & abduction of arms followed by flexion & adduction to “embrace” position

Truncal Incurvation Reflex (Galant Reflex)

• With infant prone, lightly stroke along the side of the vertebral column

• Entire trunk flexes toward the stimulated side

Palmar Grasp Reflex

• Press finger against base of infant’s fingers

• Fingers curl tightly

Plantar Grasp Reflex

• Press finger against base of infant’s toes

• Toes curl forward

Babinski Reflex

• Stroke lateral sole of foot from heel to across the base of the toes

  • Tickle tickle

• Toes flare w/ dorsiflexion of the big toe

Tonic Neck Reflex

• Gently turn head to one side while infant is supine

• Infant extends extremities on side to which head is turned

  • With flexion on opposite side

• Fencing position

Stepping Reflex

• Hold infant so feet touch solid surface

• Infant lifts alternate feet as if walking

Newborn Care

• Swaddling techniques

• Sleep sack

• Diapers

• Circumcision care

  • Lots of petroleum jelly

• Newborn bath

• Cord care

Newborn Bath

• Often delayed

  • 12-24 hrs after birth

• Check axillary temp. BEFORE bathing

• Plain warm water on face & eyes

  • NO soap on face & eyes!!!

• Mild soap to cleanse the remainder of body

• Cleanse diaper area

• Wash hair using mild shampoo

• Dry baby off

• Put new diaper on

• Skin to skin w/ mom or radiant warmer

• Recheck axillary temp.

Newborn Safety

• Prevent newborn falls!

  • NO sleeping in bed w/ baby

• Prevent infant abduction

• Car safety

  • Car seat test

• Infection prevention

Newborn Care

• Promoting sleep

• Enhancing bonding

• Promoting nutrition

  • Breastfeeding

  • Formula feeding

Newborn Immunizations

Hep. B Vaccine (IM)

• Recommended that all neonates be vaccinated w/ Hep. B within 12 hrs after birth

  • Can be given ANY time before discharge or at first pediatrician appointment

  • Many hospitals giving it w/ Vit. K & Erythromycin

• If mother is Hep. B positive:

  • Baby will need BOTH Hep. B vaccine & HBIG (Hep. B Immunoglobulin) within 12 hrs of birth

State Infant Screening, Newborn Screening, “PKU Test” (Newborn Screening Tests)

• Tests vary by state

  • Florida requires screening for 60 disorders

• Tests for inborn errors of metabolism & other genetic conditions

• Common tests:

  • PKU, congenital hypothyroidism, galactosemia, sickle cell anemia, cystic fibrosis

• Done at least 24 hrs after birth

• Heel stick

  • Blood in 5 circle paper thingy

Congenital Heart Screen (Newborn Screening Tests)

• Done at least 24 hrs of age

• Pulse Ox. on R hand & either foot

• > 95% in both upper & lower extremities

  • < 3% difference between the 2

• If newborn fails the test, it is repeated

• If newborn fails AGAIN, workup for congenital heart disease is done

Hearing Screening (Newborn Screening Tests)

• Hearing loss is the most common birth disorder in the U.S.

• ALL babies are screened before discharge

• Screening Tests:

  • Otoacoustic Emissions (OAE)

  • Acoustic Brainstem Response (ABR)

  • Either or is used

• If failed hearing test:

  • Repeat in hospital before discharge

• If SECOND failed hearing test:

  • Audiologic evaluation within 3 months

• May order Cytomegalovirus (CMV) test if failed hearing test

Education (Discharge Education)

• Follow up in 1-2 days w/ pediatrician

• Breastfeeding/ formula feeding instructions

• Change diapers frequently to prevent diaper rash

• Circumcision/ cord/ bathing techniques

• Safe sleep environment

• NO OTC meds. UNLESS OKAY w/ pediatrician

• NO NAIL CLIPPING

  • You can nail file

• Resources:

  • Breastfeeding

  • Support groups

  • WIC

  • Healthy Start

When to Call the Pediatrician (Discharge Education)

• Temperature < 97.7 or > 100.4 degrees F or higher

• Yellowing of the skin or eyes

• Changes in eating habits, refusing feedings, or vomiting 2 full feedings in a 24 hr timeframe

• No wet diapers for 12 hrs

• No stool for 48 hrs

• Low energy or hard to wake up

• Changes in typical behavior

• An unusual or high-pitched cry

• Redness, drainage, or foul odor from the umbilical cord

• Circumcision concerns

  • Bleeding or infection

• Signs of dehydration

Call 911 if you baby has:

• Blue lip color

• Difficulty breathing or turning blue