Lecture 1 - Assessment and Care of the Newborn Flashcards
1
Q
Transition Period
A
First 4-6 hours of life
Normal physiologic changes in the newborn:
- decreased pulmonary vascular resistance
- increased blood flow to the lungs
- lung expansion with clearance of alveolar fluid
- closure of the ductus arteriosus
2
Q
What is normal temperature of a newborn?
A
36.5 - 37.5 (97.7 - 99.5)
3
Q
What are normal responses to cold stress?
A
Vasoconstriction
Increased muscle flexion
Metabolism of brown fat, glucose
4
Q
During which trimester is glycogen storage increased?
A
3rd trimester
This helps them with body temperature regulation at birth
This is why full term babies do better with body temp regulation d/t having more glyogen
5
Q
What factors impact blood glucose after birth?
A
Inadequate glycogen stores
Hyperinsulinemia (baby born to a DM mother)
Increased glucose utilization (stressed, sick infants)
6
Q
What happens to an infant whose mother has DM?
A
during pregnancy the mother will have intermittent hyperglycemia causing her fetus to have hyperglycemia
the fetus responds by upregulating the pancreas which leads to hyperinsulinemia and thus hypoglycemia post birth
7
Q
How to newborns with hypoglycemia present?
A
Lethargy Poor feeding Tachypnea Jitteriness Hypothermia
8
Q
What are the recommendations for newborn glucose screening?
A
Asymptomatic infants at risk for hypoglycemia should be screened
- glucose level drawn within first 30 minutes to first hour of life (after 1st feed ideally)
- begin frequent feeding
- measure pre-feeding glucose every 3-6 hours for 24-48 hours
9
Q
What is the heart rate for a newborn?
A
120 - 160 bpm
Sleeping: 85 to 90 bpm
Tachy or bradycardia may indicate underlying cardiac disease, anemia, sepsis
10
Q
What is the normal RR of newborn?
A
40-60 breaths/min
Tachypnea may be sign of respiratory or cardiac disease
Apnea
- neurological impairment
- sepsis
- secondary to exposure to maternal medications (mag sulfate, anesthesia)
11
Q
Acryocyanosis vs central cyanosis
A
Central cyanosis is NOT normal
Acrocyanosis is normal in first 48 hours —little blueness in hands/feet with pink limbs
No blue lips, blue trunk —-thats cyanosis and that’s bad
12
Q
Apgar Score
A
LOOK AT CHART
13
Q
Limitations to APGAR
A
Doesn’t predict neurological outcome
Doesn’t account for other variables such as maturity of the infant, congenital abnormalities, etc
14
Q
All neonates are born with low levels of vitamin _____
A
K
They don’t have liver stores and this doesn’t cross the placenta well
15
Q
What does vitamin K deficient bleeding (hemorrhagic disease of the newborn) at birth put the baby at risk for?
A
Bruising, mucosal bleeding
Bleeding in umbilicus, circumcision
Intracranial hemorrhage
16
Q
What do we do for the vitamin K deficiency in newborns?
A
IM Vitamin K (0.5 to 1 mg) given within the first hours after birth
17
Q
Erythromycin ophthalmic
A
28% of newborns delivered to women with gonorrheal infection develop gonococcal ophthalmia neonatorum
Given to EVERY BABY —placed over the eyes
Erythromycin 0.5% ointment
18
Q
Early term
A
37 weeks to 38 6/7 weeks gestation
19
Q
Late pre-term
A
32 weeks to 36 6/7 weeks
20
Q
Very premature
A
28 weeks to 31 6/7 weeks
21
Q
Extremely premature
A
28 weeks or less
22
Q
Gestational age
A
Elapsed time between last menstrual period and delivery
23
Q
Chronological (post-natal) age
A
Time since birth
24
Q
Post-menstrual age
A
Gestational plus chronologic
basically time since conception
25
Corrected age
Chronological age minus number of weeks premature
12 month old born at 28 weeks gestation has a corrected age of 9 months
26
Low birth weight
BW < 2500 gm
27
Very low birth weight
VLBW
| BW <1500gm
28
Extremely low birth weight
ELBQ
| < 1000g
29
Small for gestational age
<10th percentile for GA
30
Large for gestational age
>90th percentile for GA
31
How common are birth injuries?
Incidence: 1-2%
| Possibly lower for cesarean section
32
What are risk factors for birth injuries?
Macrosomia (>4000gm)
Maternal obesity
Abnormal presentation (breech)
Operative vaginal delivery with forceps or vacuum
Small material stature, maternal pelvic anomalies
Precipitous delivery
Very fast delivery
33
Caput succedaneum
Edema above periosteum, after prolonged fetal head engagement or vacuum
soft swelling that extends across suture lines
benign, largest at birth, resolves within few days
complications:
- skin necrosis, infection, occasionally hemorrhagic
34
Cephalohematoma
Doesnt cross suture lines
Subperiosteum hemorrhage, much more common with forceps of vacuum
firm then fluctuant, not discolored, distinct margins, does not cross suture lines
Can increased for 12 - 24 hours, resolves over 2-3 weeks
complications:
- fracture
- infection
- hyperbilirubinemia
35
Subgaleal hemorrhage
Below aponeurosis, above periosteum, shearing of veins,
More common after vacuum
diffuse, fluctuant, fluid waves, unconfined, can extend from orbital ridges to upper neck
can increase steadily after birth, resolves over 2-3 weeks
complications:
- blood loss
- coagulopathy
- shock
- 12-14% mortality
tx: blood products, volume
36
What can cause caput succedaneum?
Prolonged fetal engagement or vacuum
Can cross suture lines since it affects the scalp
Often unilateral
Benign -resolves within days
37
What is the treatment for caput succedaneum?
Benign condition
| Resolves within days
38
What causes cephalohematoma?
forceps of vacuum
Collection of blood under the periosteum
Does NOT cross suture lines
If more than one bone affected, will have separation between the two areas at suture line
Evolves over 24 hours or more d/t slow bleed
Will resolve within 2-4 weeks
39
Subgaleal Bleed
Most concerning head injury of infants
Triad:
Tachycardia
Decrease in HCT
Increase in head size
Support their fluids, check coagulation factors
40
Shoulder Dystocia
Birth injury
After delivery of the head, the anterior shoulder cannot pass below, or requires significant manipulation to pass below the pubic symphysis
Complications:
- brachial plexus injury
- clavicular fx
- humerus fx
- hypoxic-ischemic encephalopathy
- death (5-15%)
41
Complications of shoulder dystocia
Complications:
- brachial plexus injury
- clavicular fx
- humerus fx
- hypoxic-ischemic encephalopathy
- death (5-15%)
42
Brachial Plexus injury
Birth injury secondary to should dystocia
Almost always from stretching/traction of the nerves
Most cases unilateral
Management: PT after several days, continued weekly for 3 months
Prognosis: recovery over 1-3 months
Persistent impairment in 20-50%
43
What is the minimum criteria for discharge of well term newborn?
Stable VS at least 12 hours, including temp
Regular urine output, at least one spontaneous stool
At least 2 successful feedings
No excessive circumcision bleeding for >2 hours
Appropriate screening for hyperbilirubienmia
Appropriate evaluation and monitoring for sepsis risk
Hepatitis B vaccine, review of maternal vaccinations
Newborn screening (Blood spot, hearing, CCHD)
Appropriate care seat available
Follow up care identified
Maternal and family education provided
Risk factors for safe home environment assessed
44
Meconium
Stool
Dark color, sticky consistency, odorless
Normal passage of meconium - at least 1 stool in first 48 hours of life
Onset of transitional stools by day of life 4
45
Delayed passage of meconium
Prompt consideration of
- hirschuprung disease
- imperforate anus or other obstruction
- meconium ileus = cystic fibrosis until proven otherwise f
46
What must be done if there is a delay in conversion to transitional stools?
Evaluation of feed adequacy
47
When does the first urination occur?
Should occur within the first 24 hours
Can be difficult to detect in presence of frequent meconium
48
What is the first thing you do for a pt that isn’t urinating?
Take a detailed pregnancy history
Decreased amniotic fluid (oligohydramnios)
Pre-natal US findings suggestive of renal/urinary disorders
Then
Assess feeding adequacy
PE - GU, abdomen, spine
Catheterization, hydration, bladder and renal US
49
What are other normal diaper findings?
Urate crystals - orange - sit on the surface of the diaper
Vaginal discharge —might occur on the 3rd day of life and resolves in a few days —-unless there is A LOT of blood this is normal —-check Vitamin K if large blood loss
50
Weight loss in infants
Normal as long as the pt is feeding well
Weight loss >10-12% in the first post natal week is cause for concern and should be evaluated
Emphasis should be on establishing a feeding relationship between infant and mother and promotion of breastfeeding
Rule of thumb: most infants will be back to birth weight by 2 weeks of age
51
Hyperbilirubinemia
Physiological unconjugated hyperbilirubinemia (all newborns)
- increased production (higher HCT, shorter RBC half life)
- decreased concentrations of bilirubin binding proteins
- decreased conjugation (lower UGT activity in liver)
- decreased clearance
Peaks around day 3 or 4 of life, resolved by 1-2 weeks
52
What is the concern of hyperbilirubinemia?
Can be normal in about 60% of infants
Bilirubin-induced neurologic dysfunction (BIND)
-acute bilirubin encephalopahty, kernicterus
53
Jaundice within the first 24 hours of life is ______
Considered pathologic and requires investigation
Increased production:
- hemolysis: immune mediated (ABO, Rh), membrane defects, enzyme defects, sepsis
- polycythemia, cephalohematoma
Decreased clearance or excretion:
- Crigler-Nijjar, Gilbert, hypothyroidism, galactosemia
- intestinal obstruction
54
How does jaundice first appear in the infant?
Cephalocaudal progression
Starts at the head and progresses to the trunk
55
How do you screen for hyperbilirubinemia?
Screen for moms ABO/Rh
Group/Type and DAT on infants of Rh- mothers (+/- if O+)
If DAT is positive or excessive jaundice —-early bilirubin monitoring if antibody positive
56
Universal assessment for hyperbilirubinemia risk
Pre-discharge measurement of bilirubin in all infants
Assessment of risk factors
Follow up within 3 days, depending on timing/risk
57
What are risk factors of hyperbilirubinmeia?
Major:
Early jaundice, positive antibody screen, GA 35-36 weeks, sibling needing phototherapy, bruising, exclusive breastfeeding, east asian descent
Minor:
GA 37-38 weeks, jaundice prior to hospital discharge, sibling with jaundice, macrosomia/IDM, maternal age >25, male gender
58
Bilirubin Management
Parental support
- frequent feedings and breast feeding support
- follow up care post discharge
Treatment:
- phototherapy
- hydration
- IVIG
- exchange transfusion (for pts who don’t respond to phototherapy, or if bilirubin is >25)
59
Bilirubin >25
Emergency
Tx: exchange transfusion
60
Breast Feeding Jaundice vs Breast Milk Jaundice
Feeding:
- onset 2-4 days of life
- related to poor enteral intake
- self limiting and improves as milk supply increases
- prevention: lactation support, education, follow up
Milk:
NOT DONE HERE
61
Newborn screening
Components:
- Heel stick blood sample
- Pulse ox
- hearing screen
RUSP (Recommended universal screening panel)
Mandatory other than religious exemptions
62
What are the most common disorders identified with screening?
Hearing loss
Congenital hypothyroidism
Hemoglobinopathies (sickle cell disease)
CF
Medium chain acyl-CoA dehydrogenase deficiency
63
When is the blood spot screening done?
Obtained within 24-48 hours after birth - AFTER FIRST FEEDING
Heel stick
64
CCHD
Critical congenital heart disease
CHD effects 1% of new borns
CCHD effects 25% of those 1%
Requires intervention within 1st year of life
Cyanotic lesions or ductal-dependent lesions
Detected via pulse ox on both upper and lower extremities
65
Positive CCHD screening
NOT DONE HERE
66
Most neonatal hearing loss is _________
Sensorineural
67
Umbilical Cord Care
Keep the stump dry
Don’t put in anything on it
It will fall off naturally typically within 10-14 days
We ask about when the stump has fallen off because this is the first healing process the baby has to do and if they fail this might show some abnormality
68
Skin care
Sponge baths until cord detaches
No need for frequent bathing
Avoid powders
Fragrance free soaps/lotions
Avoid direct sunlight
69
What are the breast feeding recommendations?
Exclusive breastfeeding during first 4-6 months on demand every 2-3 hours
70
Why avoid water or sugar water?
Hyponatremia and electrolyte disturbances that could cause seizures
71
Safe sleeping
Requires 16 - 20 hours of sleep
Supine position
Firm surface and avoid soft bedding and soft objects
Co-sleeping —associated with SIDS
Crib slats <2 3/8 inches apart
72
PURPLE Crying
Resources for parents to know whats normal crying
```
P - peak of crying
U - unexpected
R - resists soothing
P - pain like face
L - long lasting
E - evening
```
73
Appropriate car seat
Rear facing until 2 years of age or max weight or height allowed by their car seat’s manufacturer
Certified car seat safety inspectors
74
When does discharge typically happen?
Typically not met until 48 hours after birth
75
What are the 3 main principles of newborn care?
assure smooth transition to extra-uterine environment
screening
parental education and anticipatory guidance
76
What happens in the first 4-6 hours of life for a newborn?
decreased pulmonary vascular resistance
increased blood flow to the lungs
lung expansion with clearance of alveolar fluid
closure of ductus arteriosus
77
What are mechanisms of heat loss and what can we do as providers to prevent heat loss in a newborn?
conduction, convection, evaporation, and radiation
remove wet liners
skin to skin contact
hat
swaddling
78
Which newborns are at risk of hypoglycemia?
late pre term
small for gestational age
large for gestational age
birth asphyxia (or other birth stressor)
79
For infants at risk for hypoglycemia, what are the screening recommendations?
draw glucose within the first 30 minutes - 1 hours of life (ideally after the 1st feed)
begin frequent feeding
measure PRE-feeding glucose every 3-6 hours for 24-48 hours
80
What is normal HR for a sleeping newborn?
85 to 90 bpm
81
If a newborn has tachycardia or bradycardia, what might that mean?
underlying cardiac disease, anemia, or sepsis
82
What causes apnea if a newborn?
- neurological impairment
- sepsis
- secondary to exposure to maternal medications (mag sulfate, anesthesia)
83
Acrocyanosis is considered normal until when?
normal in the first 48 hours of life
84
What can cause decrease in tone of the newborn?
exposure to maternal medications or fever
underly syndrome
sepsis
neurologic impairment
85
What are the 5 categories in Apgar?
```
Appearance
Pulse
Grimace
Activity
Respiration
```
86
What dx should you be on the look out for if you have an infant with tachycardia, decrease in HCT, and an increase head size?
Subgaleal bleed
this is because an infant can bleed 40% into this space
12-14% mortality
87
What is the management for brachial plexus injury?
PT after several days --continued weekly for at least 3 months
prognosis: recovery over 1-3 months in most
persistent impairment in 20-50%
88
What is the management for clavicle fracture in newborn?
no splinting
basically do nothing expect give tylenol
advise the parents that there might be a bump present once the new bone starts to form
89
What does normal meconium stool look like?
dark color, sticky consistency, odorless
90
When is the normal passage of meconium?
at least 1 stool in the first 48 hours of life
onset of transitional stools by 4th day of life
91
What might be a reason for delayed passage of meconium?
Hirschprung disease
imperforate anus or other obstruction
meconium ileus = Cystic Fibrosis until proven otherwise
92
What are some indications that a newborn might have Cystic Fibrosis, or at least that you need to explore the possibility of CF?
delayed passage of meconium (48 hours have gone by without the passage of meconium)
could be meconium ileus --Cystic Fibrosis until proven otherwise
93
What color is normal infant stool?
yellow (typically seen by 4th day of life)
94
When should you expect to see an infants first urination?
within the first 24 hours of life
can be difficult to detect in presence of frequent meconium stools
you COULD but a cotton ball between the labia or use a U bag to differentiate --remember that part of the discharge criteria is regular urine output -- so you need to monitor this
95
What are some reasons why a newborn would have anuria and what should you to do evaluate?
Pregnancy hx
-decreased amniotic fluid (oligohydramnios)
-prenatal US findings suggestive or renal/urinary disorder
Assess feeding adequacy
PE - GU, abdomen, spine
catheterization, hydration
bladder and renal US
96
Besides meconium and transition stools, what are other normal findings seen on diapers?
urate crystals
| vaginal discharge
97
Is weight loss in newborns normal?
considered normal AS LONG AS THE INFANT IS FEEDING WELL
weight loss <10%
most infants will be back to birth weight by 2 weeks of age
98
When is weight loss in a newborn concerning?
>10-12% in the first week of life
99
What percentage of newborns have jaundice?
60%
100
Why do newborns have hyperbilirubinemia?
```
increased production
higher HCT
shorter RBC half life
decreased conjugation d/t lower UGT activity in the liver
decreased clearance
```
101
When do we expect hyperbilirubinemia to resolve?
resolves by 1 - 2 weeks
peaks at day 3 or 4
102
BIND
bilirubin induced neurologic dysfunction
acute bilirubin encephalopathy
kernicterus
103
When is newborn jaundice considered pathologic?
within the first 24 hours of life
104
What should you be thinking about if a newborn has jaundice that starts at the head and progresses down to the trunk?
Cephalohematoma
105
What are possible reasons for newborn jaundice within the first 24 hours?
hemolysis
- immune mediated (ABO, Rh)
- membrane defect
- enzyme defects
- sepsis
polycythemia
cephalohematoma
106
What lab work up do we do for infant with Rh - mothers?
group/type and DAT
107
What is the universal assessment for hyperbilirubinemia risk?
pre-discharge measurement of bilirubin in ALL infants
assessment of risk factors
follow up within 3 days depending on timing/risk
108
Why do we use phototherpay for bilirubin treatment?
breaks bilirubin down into water soluble byproducts that can be excreted
109
How do you treat a newborn with hyperbilirubinemia?
phototherpay
hydration
IVIG
exchange transfusion
110
What is breastfeeding jaundice?
onset 2-4 days of life
related to poor enteral intake
self limiting and improves as milk supply increases
prevention: lactation support, education, follow-up
111
What are the 3 components of the newborn screen?
heel stick blood sample
pulse ox
hearing screen
112
RUSP
recommended universal screening panel set forth by the HHS advisory committee on hereditary disorders in newborns and children
currently 34 core conditions
113
What criteria do disease have to have in order to be put on the newborn screen?
it has to be a serious disorder than can lead to long term morbidity
there must be a treatment of intervention available
must be shown that early treatment is better
it must be sensitive, cheap, and timely to screen for it
definitive specific follow-up test available
114
What are the most common disorders found on newborn screening?
```
hearing loss
congenital hypothyroidism
hemoglobinopathies (sickle cell)
cystic fibrosis
medium chain acyl-CoA dehydrogenase deficiency
```
115
When is the blood spot screening test obtained?
24-48 hours after birth
after the first feeding
116
CCHD
critical congenital heart disease
CCHD is about 25% of CHD
requires intervention within 1st year of life
cyanotic lesions or ductal dependent lesions
117
What are the screening guidelines for CCHD?
must be after first 24 hours of life
pulse ox on right hand and food (to get both pre and post ductal)
can repeat 3 times, each separated by an hour
118
What determines a positive screen for CCHD and what must be done?
O2 <90% at any time
90-94% in both extremities on 3 scan
>3% difference between extremities on 3 scans
119
How are newborn hearing tests done?
auditory brainstem responses (ARB or BAER) or otoacoustic emissions (OAE)
120
If a family has chosen to use formula instead of breast feed, how much and how often should they be feeding?
2 oz every 2-3 hours
121
Why do you want to avoid water or sugar water in infants?
```
hyponatremia
electrolyte disturbances (seizures)
```
122
How do you want to wake an infant for feeding?
start by changing them or patting them
123
What are the appropriate slit measurements for an infant crib?
< 2 3/8 inches apart
124
What are soothing techniques for a crying baby?
repositioning
repeating/rhythms
white noise
closeness
125
When are discharge criteria normally met?
typically not until after 48 hours after birth
