Newborn Eval -- first 28d of life

newborn phase

first 28d of life

newborn history

- review of current preg, L&D

- review of past pregnancy outcomes

- review of mothers and father's medical and genetic hx

- delivery of infant

most important review of moms hx

- maternal age, gravida, parity, blood type

- illnesses

- any pertinent positives (alcohol, substance abuse)

- moms GBS status

what happens to baby in delivery room

- placed on warmer, oropharynx and nose are suctioned, skin is dried

- brief exam (resp distress, cyanosis, cardiac exam, gestational age, med significant congenital abnorms)

- APGAR score

apgar scoring

- at 1m and 5m

- if <7, continue scoring every 5m until >7

most reliable way to determine gestational age

knowing with certainty the LMP date

fetal u/s <22 wks also reliable

if neither u/s or LMP is reliable, how will you know gestational age

ballard score (postnatal)

physical indicators on the ballard score

Skin

Plantar creases

Breast appearance

Eyelids and Ear cartilage

Genitalia appearance

neuromuscular indicators on the ballard score

Posture

Active and Passive tone

Reflexes

___________ to eyes for prophylaxis to gonorrhea and chlamydia

erythromycin

___________to prevent hemorrhagic disease (due to deficiency of Vit K dependent factors: 2, 7, 9 and 10)

Vitamin K 1 mg IM

normal HR newborn

102 - 162 (50%ile is 120), HR may decrease in some infants to 85-90 during sleep

normal respirations in NB

35 - 60 (counted over 1 min)

avg temp of NB

97.7 to 99.5°F (axillary)

avg length of NB

average 20 inches (18 - 21.5) from top of head to bottom of feet with legs extended using a length board or measuring tape.

head circumference NB

ideal time to measure is 48 hrs after birth.

Measured from above the eyes and over the occipital bone prominence, may change in the first few days as molding and scalp edema resolve

avg weight NB

7.5 lbs (5.5 - 9.5, 5 - 95 %) without diaper or clothes

gestational age

# of weeks from 1st day of LMP

small for GA

- <10%ile for weight for their GA

cause of small baby

Can be caused by Congenital infection, maternal hypertension, maternal substance abuse, genetic syndrome

short term complication small baby

hypothermia and hypoglycemia

how long to most SGA infants catch up growth

by 2-4y

when are SGA infants more likely to remain small

when one or both parents are also small

large for GA (LGA)

>90th %ile for weight for their GA

associated maternal factors for LGA

-obesity, gestational diabetes, excessive gestational weight gain, certain genetic syndromes, AMA, post-term parity, multiparity

short term complications of LGA

hypoglycemia (should all be screened shortly after birth), birth injury (brachial plexus injury, clavicle fx), perinatal asphyxia, respiratory distress (TTN from C-section, meconium aspiration), polycythemia, , congenital anomalies

when does comprehensive exam of NB occur

on the day of delivery or the next morning.

what is reviewed at the NB comprehensive exam

baby's assigned sex, measurements (with percentiles) and VS should be reviewed .

general appearance of baby

Observation of the baby in the resting state should be observed before the exam.

acrocyanosis

blue hands and feet -- is common in first few days

indicates hypoxia and warrants immediate eval

Central cyanosis, bluish color to tongue, lips and mucous membranes

why might baby have facial bruise and pink lips

delivery

pallor in NB

anemia

ruddy color NB

polycythemia

jaundice

yellow baby

when is jaundice def abnormal

first 24 hr

respiratory disease in infant

rapid RR, nasal flaring, grunting or retractions suggest respiratory disease

how to note adequate intrauterine nutrition

subQ fat in NB

movement and position in NB baby

all extremities should move symmetrically. Abnormal movements and position may be from injury or deformation.

milia

white papules from retained keratin and sebum in follicles on nose and cheeks, may last 2 weeks

normal

Transient Pustular Melanosis

-superficial pustules overlying darker macules, usually in dark skinned babies

Erythema Toxicum

1-2mm white papules on erythematous base, filled with eosinophils, on body

Congenital Dermal Melanosis (Mongolian spots)

blue-grey or brown macules, usually over spine and buttocks. More typical in babies of African or Asian decent

Nevus Simplex (Salmon patches or Stork bite)

pink-red macule on upper eyelids, upper eyelid, forehead or nape of neck

Nevus Flammeus (Port Wine Stain)

low flow capillary malformation that can occur anywhere on the body

lanugo

a fine, soft hair that covers a fetus while developing in the womb, often appearing on newborns, especially premature babies

general inspection head and scalp

inspection for head shape and size, protuberances, lacerations and abrasions, swelling, lesions.

avg head size

Average is 35cm, Range 33-37cm

macrocephaly

HC>97%ile for GA , hydrocephalus or any enlargement of brain structure st

microcephaly

HC < 3%ile for GA, genetic, metabolic, toxic or infectious causes

fontanelles

usually flat

In an infant at rest, a bulging fontanelle can indicate hydrocephalus or meningitis

anterior vs posterior fontanelle

Anterior- variable size, usually closes by 9-18m

Posterior usually < 1 cm, usually closes by 2-4m

suture lines and molding/overlapping -- what happens?

Molding or overlapping skull bones from passage through the birth canal, a temporary asymmetry of the head.

If the asymmetry persists >2-3w, may be craniosynostosis --> refer

craniotabes

-soft area of the skull (usu parietal) that feels like a ping-pong ball when depressed.

benign: May be intrauterine position.

If doesn’t resolve, it may be pathologic --> refer

caput succedaneum

area of edema of the scalp which crosses the suture lines, occurs at presenting part of skull.

cephalohematoma

Subperiosteal bleeding which forms a fluctuant mass that does not crosses the midline. Takes weeks-months to resolve.

what might cause facial palsies in NB

from forceps deliveries or prolonged labor

what might cause facial dysmorphology in the NB

genetic syndromes or Fetal Alcohol

Syndrome, unusual shape of the nose or ears, wide spaced

eyes, long philtrum

why might exam of baby's eyes be hard after birth

edema of eyes

eyes & genetic syndromes or Fetal Alcohol Syndrome

wide spaced eyes

why might baby have asymmetry of eyes

due to prominent epicanthal folds (Down's), size of globes or ptosis.

palpebral fissures in baby eyes

when slanted indicate a genetic syndrome. Up (Downs) or Down (Treacher's Collins)

eye movement test in baby -- what is important to note

eye movement can be tested by holding infant upright and moving them from side to side. Asymmetrical eye movement is common in first month of life

sclera of NB

normally white/clear

conjunctiva in baby

examine for inflammation or drainage. Hemorrhage may occur spontaneously during birth or from a traumatic delivery.

pupils and baby -- what is abnormal

shape and constriction reflex to light,

Leukocoria, a white pupil may be retinoblastoma

red reflex in baby -- what is abnormal and what does that indicate

elicited with an ophthalmoscope light from 18" away, in darkened room. A diminished or white reflex can be congenital cataracts

position of baby ears

Low set if top of ear is lower than an imaginary line drawn posteriorly from the outer canthus of the eye. Posterior position. Genetic syndromes

malformed ears associated w...

dysplasia, associated hearing loss

preauricular pits and tags are associated w...

when found in isolation (no facial dysmorphology or ear dysplasia) are unlikely to be associated with hearing loss

ear canal in NB

examined for patency. Small size and occlusion with vernix prohibits an otoscopic ear exam

nose shape in baby

- what might thin/wide nose suggest

appearance may be flattened or asymmetrical from intrauterine positioning.

A very thin nose or extra wide nose may be consistent with a genetic syndrome.

nares in baby

- what might cause obstruction

patency is very important as neonates are primarily nose breathers.

Obstruction may be from suctioning at birth or Choanal atresia (tested by attempting to pass a feeding tube through the nose.

a recessed jaw (micrognathia)

part of Pierre Robin Syndrome which also includes glossoptosis (falling backwards of the tongue) and a Cleft palate.

complications of recessed jaw

There can be feeding and breathing issues.

treatment of severe recessed jaw

surgery

epstein pearls

benign inclusion cysts in the midline between the hard and soft palate

mucous retention cysts

benign cysts on gums, inside of lips or floor of the mouth

frenulum lingae / complication of this

unusually short band of tissue from the floor of the mouth to the tongue.

May extend to the time of the tongue and interfere with latching during breastfeeding

natal teeth

- how to manage?

- what is this associated w/?

Primary mandibular incisors often just a single tooth.

Consider extraction, if not well secured and may result in aspiration. Can be associated with Genetic syndromes.

cleft of hard or soft palate

Require surgical correction. A bifid uvula may be associated with a submucosal cleft palate

cystic hygromas

microcystic malformation of the lymphatic system, usually a painless, transilluminated cyst located about the clavicles

brachial cleft cyst

located anterior margin of SCM

thyroglossal duct cyst/enlarged thyroid

midline

cervical lymph nodes

may be normal or be from congenital infections

torticollis

head tipped to one side, chin points to the other side.

Usually caused by injury to SCM during delivery or from intrauterine positioning/

excess skin in NB

webbing in Turners syndrome and redundant folds in Downs

clavicle fx in NB / presentation

caused from birth trauma. Presents with irritability and decreased mobility of arm

Exam shows tenderness, swelling and crepitus of the clavicle and asymmetrical Moro reflex.

small chest / malformed thorax indicates...

pulmonary hypoplasia or a neuromuscular disorder

pectus excavatum (funnel chest)

Depression of the sternum

pectus carinatum

chest wall movement with breathing

On inspiration rib cage moves inward while abdomen moves outward

breasts in NB baby

In both males and females, breast may be hypertrophied and asymmetrical, due to maternal hormones,

wide nipples in baby indicates what

possible turners

supernumerary nipples, where are they normal

along milk line

respiratory distress in baby

nasal flaring, grunting, tachypnea and accessory muscle use, stridor

normal breath sounds in baby

equal on both sides. Rales can be normal for a few hours after birth

normal RR baby

40-60 w/ variations in rate/rhythm

PMI of baby

PMI is felt best a left lower sternal border. RV is dominant.

pulses in baby -- which are best

femoral pulses are the most easily detected when the infant is quiet.