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Pediatrics Exam 1 > Lecture 1 - Assessment and Care of the Newborn > Flashcards

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
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2
Q

What is normal temperature of a newborn?

A

36.5 - 37.5 (97.7 - 99.5)

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3
Q

What are normal responses to cold stress?

A

Vasoconstriction
Increased muscle flexion
Metabolism of brown fat, glucose

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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

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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)

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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

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7
Q

How to newborns with hypoglycemia present?

A 
Lethargy
Poor feeding
Tachypnea
Jitteriness
Hypothermia
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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
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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

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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)
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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

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12
Q

Apgar Score

A

LOOK AT CHART

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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

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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

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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

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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

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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

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18
Q

Early term

A

37 weeks to 38 6/7 weeks gestation

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19
Q

Late pre-term

A

32 weeks to 36 6/7 weeks

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20
Q

Very premature

A

28 weeks to 31 6/7 weeks

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21
Q

Extremely premature

A

28 weeks or less

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22
Q

Gestational age

A

Elapsed time between last menstrual period and delivery

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23
Q

Chronological (post-natal) age

A

Time since birth

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24
Q

Post-menstrual age

A

Gestational plus chronologic

basically time since conception

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25
Q

Corrected age

A

Chronological age minus number of weeks premature

12 month old born at 28 weeks gestation has a corrected age of 9 months

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26
Q

Low birth weight

A

BW < 2500 gm

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27
Q

Very low birth weight

A

VLBW

BW <1500gm

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28
Q

Extremely low birth weight

A

ELBQ

< 1000g

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29
Q

Small for gestational age

A

<10th percentile for GA

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30
Q

Large for gestational age

A

> 90th percentile for GA

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31
Q

How common are birth injuries?

A

Incidence: 1-2%

Possibly lower for cesarean section

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32
Q

What are risk factors for birth injuries?

A

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

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33
Q

Caput succedaneum

A

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

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34
Q

Cephalohematoma

A

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

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35
Q

Subgaleal hemorrhage

A

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

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36
Q

What can cause caput succedaneum?

A

Prolonged fetal engagement or vacuum

Can cross suture lines since it affects the scalp
Often unilateral

Benign -resolves within days

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37
Q

What is the treatment for caput succedaneum?

A

Benign condition

Resolves within days

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38
Q

What causes cephalohematoma?

A

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

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39
Q

Subgaleal Bleed

A

Most concerning head injury of infants

Triad:
Tachycardia
Decrease in HCT
Increase in head size

Support their fluids, check coagulation factors

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40
Q

Shoulder Dystocia

A

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%)
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41
Q

Complications of shoulder dystocia

A

Complications:

  • brachial plexus injury
  • clavicular fx
  • humerus fx
  • hypoxic-ischemic encephalopathy
  • death (5-15%)
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42
Q

Brachial Plexus injury

A

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%

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43
Q

What is the minimum criteria for discharge of well term newborn?

A

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

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44
Q

Meconium

A

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

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45
Q

Delayed passage of meconium

A

Prompt consideration of

  • hirschuprung disease
  • imperforate anus or other obstruction
  • meconium ileus = cystic fibrosis until proven otherwise f
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46
Q

What must be done if there is a delay in conversion to transitional stools?

A

Evaluation of feed adequacy

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47
Q

When does the first urination occur?

A

Should occur within the first 24 hours

Can be difficult to detect in presence of frequent meconium

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48
Q

What is the first thing you do for a pt that isn’t urinating?

A

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

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49
Q

What are other normal diaper findings?

A

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

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50
Q

Weight loss in infants

A

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

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51
Q

Hyperbilirubinemia

A

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
Q

What is the concern of hyperbilirubinemia?

A

Can be normal in about 60% of infants

Bilirubin-induced neurologic dysfunction (BIND)
-acute bilirubin encephalopahty, kernicterus

53
Q

Jaundice within the first 24 hours of life is ______

A

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
Q

How does jaundice first appear in the infant?

A

Cephalocaudal progression

Starts at the head and progresses to the trunk

55
Q

How do you screen for hyperbilirubinemia?

A

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
Q

Universal assessment for hyperbilirubinemia risk

A

Pre-discharge measurement of bilirubin in all infants
Assessment of risk factors
Follow up within 3 days, depending on timing/risk

57
Q

What are risk factors of hyperbilirubinmeia?

A

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
Q

Bilirubin Management

A

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
Q

Bilirubin >25

A

Emergency

Tx: exchange transfusion

60
Q

Breast Feeding Jaundice vs Breast Milk Jaundice

A

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
Q

Newborn screening

A

Components:

  • Heel stick blood sample
  • Pulse ox
  • hearing screen

RUSP (Recommended universal screening panel)

Mandatory other than religious exemptions

62
Q

What are the most common disorders identified with screening?

A

Hearing loss
Congenital hypothyroidism
Hemoglobinopathies (sickle cell disease)
CF
Medium chain acyl-CoA dehydrogenase deficiency

63
Q

When is the blood spot screening done?

A

Obtained within 24-48 hours after birth - AFTER FIRST FEEDING

Heel stick

64
Q

CCHD

A

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
Q

Positive CCHD screening

A

NOT DONE HERE

66
Q

Most neonatal hearing loss is _________

A

Sensorineural

67
Q

Umbilical Cord Care

A

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
Q

Skin care

A

Sponge baths until cord detaches

No need for frequent bathing

Avoid powders

Fragrance free soaps/lotions

Avoid direct sunlight

69
Q

What are the breast feeding recommendations?

A

Exclusive breastfeeding during first 4-6 months on demand every 2-3 hours

70
Q

Why avoid water or sugar water?

A

Hyponatremia and electrolyte disturbances that could cause seizures

71
Q

Safe sleeping

A

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
Q

PURPLE Crying

A

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
Q

Appropriate car seat

A

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
Q

When does discharge typically happen?

A

Typically not met until 48 hours after birth

75
Q

What are the 3 main principles of newborn care?

A

assure smooth transition to extra-uterine environment
screening
parental education and anticipatory guidance

76
Q

What happens in the first 4-6 hours of life for a newborn?

A

decreased pulmonary vascular resistance

increased blood flow to the lungs

lung expansion with clearance of alveolar fluid

closure of ductus arteriosus

77
Q

What are mechanisms of heat loss and what can we do as providers to prevent heat loss in a newborn?

A

conduction, convection, evaporation, and radiation

remove wet liners
skin to skin contact
hat
swaddling

78
Q

Which newborns are at risk of hypoglycemia?

A

late pre term
small for gestational age
large for gestational age
birth asphyxia (or other birth stressor)

79
Q

For infants at risk for hypoglycemia, what are the screening recommendations?

A

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
Q

What is normal HR for a sleeping newborn?

A

85 to 90 bpm

81
Q

If a newborn has tachycardia or bradycardia, what might that mean?

A

underlying cardiac disease, anemia, or sepsis

82
Q

What causes apnea if a newborn?

A
  • neurological impairment
  • sepsis
  • secondary to exposure to maternal medications (mag sulfate, anesthesia)
83
Q

Acrocyanosis is considered normal until when?

A

normal in the first 48 hours of life

84
Q

What can cause decrease in tone of the newborn?

A

exposure to maternal medications or fever
underly syndrome
sepsis
neurologic impairment

85
Q

What are the 5 categories in Apgar?

A 
Appearance 
Pulse 
Grimace 
Activity 
Respiration
86
Q

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?

A

Subgaleal bleed

this is because an infant can bleed 40% into this space

12-14% mortality

87
Q

What is the management for brachial plexus injury?

A

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
Q

What is the management for clavicle fracture in newborn?

A

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
Q

What does normal meconium stool look like?

A

dark color, sticky consistency, odorless

90
Q

When is the normal passage of meconium?

A

at least 1 stool in the first 48 hours of life

onset of transitional stools by 4th day of life

91
Q

What might be a reason for delayed passage of meconium?

A

Hirschprung disease
imperforate anus or other obstruction
meconium ileus = Cystic Fibrosis until proven otherwise

92
Q

What are some indications that a newborn might have Cystic Fibrosis, or at least that you need to explore the possibility of CF?

A

delayed passage of meconium (48 hours have gone by without the passage of meconium)

could be meconium ileus –Cystic Fibrosis until proven otherwise

93
Q

What color is normal infant stool?

A

yellow (typically seen by 4th day of life)

94
Q

When should you expect to see an infants first urination?

A

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
Q

What are some reasons why a newborn would have anuria and what should you to do evaluate?

A

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
Q

Besides meconium and transition stools, what are other normal findings seen on diapers?

A

urate crystals

vaginal discharge

97
Q

Is weight loss in newborns normal?

A

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
Q

When is weight loss in a newborn concerning?

A

> 10-12% in the first week of life

99
Q

What percentage of newborns have jaundice?

A

60%

100
Q

Why do newborns have hyperbilirubinemia?

A 
increased production 
higher HCT 
shorter RBC half life 
decreased conjugation d/t lower UGT activity in the liver 
decreased clearance
101
Q

When do we expect hyperbilirubinemia to resolve?

A

resolves by 1 - 2 weeks

peaks at day 3 or 4

102
Q

BIND

A

bilirubin induced neurologic dysfunction

acute bilirubin encephalopathy
kernicterus

103
Q

When is newborn jaundice considered pathologic?

A

within the first 24 hours of life

104
Q

What should you be thinking about if a newborn has jaundice that starts at the head and progresses down to the trunk?

A

Cephalohematoma

105
Q

What are possible reasons for newborn jaundice within the first 24 hours?

A

hemolysis

  • immune mediated (ABO, Rh)
  • membrane defect
  • enzyme defects
  • sepsis

polycythemia
cephalohematoma

106
Q

What lab work up do we do for infant with Rh - mothers?

A

group/type and DAT

107
Q

What is the universal assessment for hyperbilirubinemia risk?

A

pre-discharge measurement of bilirubin in ALL infants
assessment of risk factors
follow up within 3 days depending on timing/risk

108
Q

Why do we use phototherpay for bilirubin treatment?

A

breaks bilirubin down into water soluble byproducts that can be excreted

109
Q

How do you treat a newborn with hyperbilirubinemia?

A

phototherpay
hydration
IVIG
exchange transfusion

110
Q

What is breastfeeding jaundice?

A

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
Q

What are the 3 components of the newborn screen?

A

heel stick blood sample
pulse ox
hearing screen

112
Q

RUSP

A

recommended universal screening panel set forth by the HHS advisory committee on hereditary disorders in newborns and children

currently 34 core conditions

113
Q

What criteria do disease have to have in order to be put on the newborn screen?

A

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
Q

What are the most common disorders found on newborn screening?

A 
hearing loss 
congenital hypothyroidism 
hemoglobinopathies (sickle cell) 
cystic fibrosis 
medium chain acyl-CoA dehydrogenase deficiency
115
Q

When is the blood spot screening test obtained?

A

24-48 hours after birth

after the first feeding

116
Q

CCHD

A

critical congenital heart disease

CCHD is about 25% of CHD

requires intervention within 1st year of life
cyanotic lesions or ductal dependent lesions

117
Q

What are the screening guidelines for CCHD?

A

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
Q

What determines a positive screen for CCHD and what must be done?

A

O2 <90% at any time
90-94% in both extremities on 3 scan
>3% difference between extremities on 3 scans

119
Q

How are newborn hearing tests done?

A

auditory brainstem responses (ARB or BAER) or otoacoustic emissions (OAE)

120
Q

If a family has chosen to use formula instead of breast feed, how much and how often should they be feeding?

A

2 oz every 2-3 hours

121
Q

Why do you want to avoid water or sugar water in infants?

A 
hyponatremia 
electrolyte disturbances (seizures)
122
Q

How do you want to wake an infant for feeding?

A

start by changing them or patting them

123
Q

What are the appropriate slit measurements for an infant crib?

A

< 2 3/8 inches apart

124
Q

What are soothing techniques for a crying baby?

A

repositioning
repeating/rhythms
white noise
closeness

125
Q

When are discharge criteria normally met?

A

typically not until after 48 hours after birth

Pediatrics Exam 1 (6 decks)

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