Newborns and Infants

When is APGAR Scoring Done?

Immediately after delivery

Scoring for APGAR score

Based on 5 factors which each factor getting a score of 0,1,2. Total scores of 0-10.

When should you give APGAR scores?

1 minute and 5 minutes.

1 minute Apgar score reflects

Pre-delivery state

5 Minute Apgar score reflects

extrauterine transition

Repeat Apgar scoring when?

At 5-minute intervals up until 20 minutes or Apgar is >7 ideally stop at 8.

Does APGAR score determine resuscitation plan or long-term prognosis?

No...

1st sign testing in APGAR and scoring

Muscle tone activity:

0=falccid

1=some flexion of arms and legs

2=well-flexed, or active movements of extremities

2nd sign of APGAR and scoring

Pulse/HR:

0=absent

1=Below 100 per minute

2=Over 100 per minute

3rd sign of APGAR and scoring

Grimace/Reflex irritability:

0=No response

1=Grimace or weak cry

2=Good cry

4th sign of APGAR and scoring

Appearance/color:

0=blue all over or pale

1=body pink, hands and feet blue

2=pink all over

5th sign of APGAR and scoring

Respiratory effort:

0=absent

1=weak, irregular, gasping

2=Good, crying

Newborn

Birth-28 days of age

Infant

Birth to 12 months

Growth charts for preterm infants

Fenton Growth Chart

Growth Chart for full term Infants

WHO growth chart

LGA

weight above 90th percentile large for gestational age

SGA

small for gestational age (<10th percentile)

What causes SGA?

•Usually from a deficiency (baby not growing well)

•Rest of body is small compared to head

•Maternal infections can cause this.

AGA

Appropriate for Gestational Age, 10th-90th percentile

ELBW

extremely low birth weight

<1000 g

VLBW

very low birth weight

<1500 g

Low Birth Weight infant minimum

<2500 grams

Normal birth weight

2500 g

Gestational Age is determined by

•OB dating (best if less than 20 weeks ultrasound)

•Exam (Ballard - accurate within two weeks of gestational age)

Preterm

<34 weeks

Late preterm

34-36 weeks and 6/7 days

Early term

37-38 6/7 weeks

Term

39-40 6/7 weeks

Late term

•41 – 41 6/7 weeks

Post-term

42 weeks and beyond

What happens to infants born late?

They're big, the head can get stuck, now the baby has oxygen issues.

What does ballard exam measure?

Neuromuscular maturity and physical maturity

Tips to examine a newborn

•Examine the newborn in the presence of the parents

•Swaddle and then undress the newborn as the examination proceeds

•Dim the lights and rock the newborn to encourage the eyes to open

•Observe feeding, if possible, particularly breastfeeding

•Demonstrate calming maneuvers to parents (e.g. swaddling)

•Observe and teach parents about transitions as the newborn arouses

Vital ranges for birth to 1 month

Avg HR: 140 bpm

HR range: 90-165 bpm

RR:(40-60)-(30-68)

Temp: 36.5-37.5 C

Vital ranges for 1-6 months

avg HR: 130 bpm

HR range: 80-175 bpm

RR: (40-60)-(30-68)

Temp: 36.5-37.5 C

Vital ranges 6 months to 12 months

avg HR: 115 bpm

HR range: 90-170 npm

RR:25-60

Temp: 36.5-37.5 C

Best way to measure breathing

Measure for 60 seconds and watch to see if they're tachypneic >60 breaths/min from birth to 2 months

Why do we count breaths for a full 60 seconds?

Irregular periodic breathing, Cheyne Stokes

Best way to do a temperature check for an infant

Under the arm, but if the infant is cold do rectal

What to note about general Appearance

•Pink vs cyanotic (blue)

•Good tone vs hypotonic

•Are arms and legs close or spread out (can they hold their arms up)

•Respiratory effort

•They're trying to breath (diaphragmatic)

•Symmetric movements

What to look for before auscultating?

Central cyanosis

How do we assess for central cyanosis?

Look at the lips, tongue, and sublingual mucosa

Confirm with a pulse ox on the right hand and foot.

A baby is sweating while feeding what am I worried about 9/10 times?

Cardiac issues. Baby is diaphroretic. Babies only work out by eating so the baby is having issues on exertion...boom heart issues.

A newborn has peaceful tachypnea...good right?

NO. This means there's no increased work of breathing...a newborn should be working hard to breath they're lungs are still forming to take over.

Pulses: where to palpate?

•Lower extremity pulse is important (femoral)

•Vary pressure w/ femoral to make sure you're not occluding it.

•Babies can have coarctation of the aorta and you don't know till PDA closes (2-7 days of life)

•Make sure theyre strong

•Compare upper & lower extremities at the same time.

•If there's a difference in pressure check echo for coarctation.

What're thrills?

Palpable turbulence in heart or great vessels

Auscultation (APT M) what to note?

-S1, S2 w/ a split S2 on inspiration.

Auscultation, murmurs

Use timing, location, quality, intensity

Two benign systolic murmurs in newborns

•Closing ductus (PDA) – Harsh, ejective (crescendo), systolic murmur, LUSB

•Peripheral pulmonary flow murmur – Soft, ejectile, systolic LUSB radiating to lung fields and axillae

True or False: PVC or PAC are benign in a newborn

Yes, just send to cardiology to get a EKG to confirm...don't miss heart issues in a newborn

How to assess capillary refill time?

you can't do Allens test with the tiny wrist so use the infant's finger.

Most common dysrhythmia in a newborn

SVT

What to observe before auscultating for the lungs?

RR, color, nasal breathing, work of breaking and audible breath sounds.

Why nasal breathing?

Infants are obligate nasal breathers since they breath mostly with their diaphragm. They don't use their mouths. This is all due to a still developing respiratory system.

Grunting

Short, repeitive, expiratory sound. From closing of the vocal cords.

Wheezing

musical expiratory sound

Stridor

High pitched, inspiratory noise

Obstruction

Lack of breath sounds, from mucous or amniotic fluid in the lungs

Nasal flaring

COngenital atresia or excess movement of the nares to breath

Retractions

Chest indrawing

-Supraclavicular, intercostal, substernal, subcostal.

how do you confirm retractions

Not pretty but you push a G-tube

Definition of apnea

absence of breathing for 20 seconds or more

Fontanelles in a newborn: enlargement could mean

Cretinism, congenital hypothyroidism

Fontanelles are usually

soft and flat or slightly concave

A bulging fontanelle might indicate

ICP, bleeding, hydrocephalus

A deeply shrunken fontanelle might mean

Dehydration

Anterior fontanelle in a newborn

Large and diamond shaped.

Closes in 80% of infants by 18 months, 90% by 22 months.

Posterior fontanelle in a newborn

Triangular shaped, usually closes by 2 months but can take up to 6 months.

Positional Plagiocephaly (bilateral)

Can be from torticollis

Torticollis

head tilt due to shortening or spasm of one sternomastoid muscle

Positional Plagiocephaly (unilateral)

Baby is spending too much time in one position

Craniosynostosis

Premature closing of cranial sutures causing an abnormally shaped skull

MC Craniosynostosis

Sagittal suture synosis causing narrow head

Sagittal suture synostosis name and shape

Scaphocephaly, boat shaped

Brachycephaly

Short broad head due to premature suture fusion

Caput succedaneum

Pitting edema in the scalp

Crosses suture lines

Resolves in 1-2 days

Occipitoparietal region

Cephalohematoma

Subperiosteal hemorrhage

Collects over 24 hrs

Does not cross suture line

Resolves in around 3 weeks

At risk for Jaundice

Can be lethal.

What do we see caput succedaneum, Cephalohematoma, and subgaleal hemorrhage with?

Vacuum delivery

Subgalea hemorrhage

Fluid wave that moves immediately to dependent locations.

Venous bleeding under galea, entire area of the scalp.

Potential for significant blood loss

Admit to SCN/NICU to monitor vitals and hematocrits.

Significant jaundice risk

Difference between subgaleal hemorrhage and cephalohematoma

Both involved venous bleeding and jaundice, but a subgalea hemorrhage has blood collection in the entire scalp. Larger volume of blood loss. Greater risk for hemorrhagic shock.

Inspect the neck for?

Webbing, torticollis, clefts, pits, masses

Inspect the clavicles for?

Symmetry, fractures

Why would the clavicle fracture?

Extremely easy to do in vaginal deliveries.

A callus will develop

Do you need to fix a clavicle fracture in a newborn?

No theyll be fine. It heals on its own.

When inspecting the ears note

Position, ear pits, tags

When do we worry about ear pits?

If they're isolated its ok, but with other malformations we worry about kidney abnormalities.

Pits and tags are associated with

Hearing loss

Imaginary line is drawn from the

Inner and outer canthi of eyes and should cross the pinna or auricle

What happens if the ears are below this line?

Low set ears like in DS!!

How to do an otoscopic exam

Pull the auricle down and out.

Newborns are obligate

Nsal breathers

True or False: when assessing patency, you 100% should occlude both nares at the same time

False...one at a time

Ankyloglossia

Tongue tied!

What happens if a newborn has ankyloglossia and they're breastfed?

There's a clicking noise.

Mouth abnormalities

Cleft lip, cleft palate, bifid uvula.

How many primary teeth for natal teeth?

20

Rate of tooth development

1 tooth for each month between 6-26 months for a maximum of 20 primary teeth

There's a white coating on the newborn tongue differential

-residual milk (can wipe off)

-Thrush (cannot wipe it off)

A baby has a protruding tongue differential

Cretinism, Trisomy 21, Beckwith-Wiedemann Syndrome