Neonatal Teaching: Newborn Care And Newborn Examination Flashcards
Terminology
Neonatal period: First 28 days of life
Infancy: First 1 year of life
(UpToDate:
1st trimester: 0 to 13+6
2nd trimester: 14 to 27+6
3rd trimester: 28 to delivery)
Gestational age: Time elapsed between first day of LMP and day of delivery
Normal gestation: 37+0 to 41+6
Preterm: Born before 37+0
Post-term: Born after 41+6
Birth weight categories:
- <=1kg = Extremely low birth weight (ELBW)
- <=1.5kg = Very low birth weight (VLBW)
- <=2.5kg = Low birth weight (LBW)
Small-for-date (SGA): BW <10th percentile
Large-for-date (LGA): BW >90th percentile
Appropriate-for-date: BW 10-90th percentile
NB: SGA =/= Preterm!!!
Maternal-Fetal health
Maternal condition —> Fetal effect:
1. DM —> Congenital malformation, Miscarriage, Macrosomia
2. Pre-eclampsia —> IUGR, Preterm delivery
3. Rhesus isoimmunisation —> Fetal anaemia
4. Maternal SLE —> Congenital heart block
5. Maternal drug use —> Teratogenicity, Withdrawal
Fetal condition —> Maternal effect:
1. Hydrops fetalis —> Mirror syndrome / Ballantyne syndrome (Edema, Albuminuria, Pre-eclampsia)
2. Fetal esophageal atresia —> Polyhydramnios
3. Anencephaly —> Postmaturity
Normal newborn growth parameters
Boys (37-40 weeks):
- Weight: 3-3.4 kg
- Length: 49-51 cm
- Head circumference (40 week): 34.7 cm
- Stretched penile length: 2.2-2.3 cm
Girls (37-40 weeks):
- Weight: 2.9-3.2 kg
- Length: 48-50 cm
- Head circumference (40 week): 34 cm
***Failure of adaptation: Perinatal asphyxia
Lack of O2 + blood supply to organ function
—> Rapid breathing
—> Primary apnea
—> Irregular gasping
—> Secondary apnea
Primary apnea:
- Fetus will respond to stimulation + O2 therapy with spontaneous respiration
Secondary apnea:
- Irregular gasping —> enter secondary apnea period —> NOT respond to stimulation + O2 therapy —> death occur unless resuscitation immediately
NB: Cannot differentiate primary and secondary apnea immediately after delivery —> always resuscitate if suspect asphyxia
***Causes of failure of adaptation:
1. In-utero hypoxia
- Placental abruption
- Placenta previa
- Twin-twin transfusion syndrome
- Intrapartum hypoxia
- Uterine hyperstimulation
- Shoulder dystocia - Postnatal hypoxia
- Poor respiratory drive (e.g. Preterm, Drug-induced depression)
- Poor cardiopulmonary function (e.g. RDS, Meconium aspiration)
Neonatal resuscitation
- Keep warm
- Airway opening: Suction, Position neck
- Tactile stimulation
- Positive pressure ventilation (PPV)
- External chest compression
- Drug administration
Delayed cord clamping (+ Felix Lai notes)
- 30-60s / Until pulsation stops
Advantages:
- Less Fe deficiency anaemia (∵ more blood return to baby —> more haemodynamically stable, prevent anaemia)
- Less Intraventricular haemorrhage of preterm infants
- Facilitate fetal to neonatal transition
Disadvantages:
- Polycythaemia in growth-restricted neonates
- Hyperbilirubinaemia resulting in more phototherapy
- Less umbilical cord blood for harvesting stem cells
APGAR score
Scored at 1st + 5th minute of life
- >=7 normal
- <=3 abnormal
- Poor score associated with **neonatal mortality
- Poor late score associated with **poor neurological outcome
- Appearance
- Pink: 2
- Peripheral cyanosis: 1
- Pale / Central cyanosis: 0 - Pulse
- >=100: 2
- <100: 1
- 0: 0 - Grimace (Reflex irritability)
- Cry, cough: 2
- Grimace: 1
- None: 0 - Activity (Tone)
- Well flexed: 2
- Some flexion: 1
- Flaccid: 0 - Respiration
- Regular: 2
- Gasping / Irregular: 1
- 0: 0
(NB: Intubated =/= 0, ∵ still can spontaneously breath)
Routine postnatal care
- Early skin-to-skin contact
- Facilitate early breastfeeding
- Keeping warm - Temperature regulation
- Skin: 36-36.5
- Rectal: 36.5-37.5
- Newborn are prone to excessive heat loss
—> Wet at birth
—> High surface area to body mass ratio
—> Little insulating fat in preterm / IUGR
—> Little reserves
—> Hypotonic posture in preterm
- Keep ambient temp at cool to warm (Neutral thermal environment) —> least energy required to maintain metabolic rate (basal rate of heat production = rate of heat loss to environment)
- **Plastic wrap for preterm infants
- **Incubator care for first hours when baby is nursed naked under observation
Excessive heat loss:
- Hypoxia
- Hypoglycaemia
- Metabolic acidosis
- Decreased growth
- Apnea
- Pulmonary hypertension
Hypothermia:
- Clotting disorder
- Shock
- Intraventricular haemorrhage
- Severe sinus bradycardia
- Increased neonatal mortality
Fluid requirement and Body weight
- 75% BW in term infant
- 85-90% BW in preterm infants
Physiologic contraction of extracellular water after birth —> Diuresis
- 5-7% BW loss for term infants
- 10% BW loss for preterm infants
Daily fluid intake:
- Follow “normal” breast milk production
—> 30-60 ml/kg/day
—> Increase to 150-160 ml/kg/day at the end of first week
Cord care
Cleanse with cool boiled water / antiseptic solution a few times daily —> will slough off itself by 14 days
Complications:
1. True knot —> Fetal distress
2. Allantoid cyst (connection with bladder)
3. Umbilical granuloma (benign, remnant of cord, cauterise with AgNO3, need to make sure not faeces / urine coming out)
4. Omphalitis —> infection can spread via large blood vessels
***Newborn screening in HK
- Umbilical cord blood biochemical screening
- G6PD deficiency (4.4% in male, 0.5% in female)
- TSH for Congenital hypothyroidism (1:2000-3000) - Universal newborn hearing screening
- Dried blood spots for newborn screening of Inborn errors of metabolism
- 26 inherited metabolic diseases
***Newborn prophylaxis
- IMI Vit K at birth
- prophylaxis against Vit K deficiency bleeding (VKDB) of newborn (previously called Haemorrhagic disease of newborn) - Immunisations
- HBV at birth (+ HBIG if mother HBsAg carrier)
- BCG before discharge
- Routine immunisation program at MCHC / Private sector - Ophthalmia prophylaxis (NOT done now in HK ∵ low prevalence)
- Gonococcal conjunctivitis (can cause blindness)
—> Gram +ve, -ve organisms, Neisseria gonorrhoea, Chlamydia, trachomatis
—> Prophylaxis with AgNO3, Iodine, Antibiotics eye cream
***Newborn feeding
- Milk for first 6 months
- Complementary food after 6 month
- Semisolids
- Milk continue to provide adequate nutrition + Ca - Breast milk is best
- Nutritionally adequate for first 6 months for term infants
- Consider Vit D supplement (NOT done in HA)
- Feeding up to ***2 years and beyond
Newborn sleeping
- Supine preferable (Prone position associated with high chance of sudden infant death, Lateral position also slightly higher risk)
- No pillow required
- Tight bed sheet + No loose blanket
- Avoid co-sleep with parents
- Avoid smoking
Use of pacifier
Advantages:
- Sooth a fussy baby
- Temporary distraction
- Help baby fall asleep
- Ease discomfort during flights
- Reduce risk of sudden infant death syndrome (SIDS)
- Disposable
Disadvantages:
- Early use might interfere with breastfeeding
- Become dependent on pacifier
- Increase risk of middle ear infections
- Prolonged use might lead to dental problems
***P/E of Newborn (+ Paed HKU website)
Special features:
1. Small size
2. Uncooperative
3. Hypothermia on cold exposure
4. Neurological state varies with sleep, feeding etc.
5. Ongoing transitional changes in first few days of life —> affect physical signs (e.g. murmur related to congenital heart disease)
6. Impact of intrauterine pressure effect (deformation) and birth process (e.g. head molding, abnormal posture associated with breech presentation)
Aims:
1. Assess ability to adapt to extra-uterine life (esp. cardiopulmonary status)
2. Look for major congenital anomalies (esp. those requiring urgent treatment)
3. Identify at-risk babies that need postnatal monitoring + investigations based on perinatal history, stage of maturity, variation in size, presence of systemic / neurological abnormalities
4. Mother’s competence in child care
General examination:
1. Size, Body proportion
2. Maturity
3. Gross malformation, Dysmorphic features
4. Colour / Cutaneous discolouration (e.g. Plethora, Pallor, Cyanosis, Jaundice, Skin mottling (Livedo reticularis))
5. Posture (Tone: Palpation)
6. Generalised edema
7. Activity
8. Abnormal masses
Head examination:
1. Size, Head circumference, Shape
2. Anterior fontanelle (size + pressure (assessed when upright)), Posterior fontanelle, Anterior + Posterior Lateral fontanelle (closed for term baby)
3. Sagittal suture (small dimple ~ finger tip), Coronal suture, Lambdoid suture, Metopic suture
4. Caput succadaneum, Cephalhaematoma, Subaponeurotic / Subgaleal haemorrhage
Face examination:
1. Dysmorphic facies (e.g. distance between eyes, epicanthic folds, nasal bridge, ear configuration, position of mouth + neck, eyes)
2. Oral cavity / Mouth lesion (e.g. cleft palate (e.g. Patau syndrome))
3. Eyes, Red reflex, Others (e.g. sunset eyes in Down’s syndrome, corneal opacity)
Neck examination:
1. Sternomastoid tumour
2. Cystic hygroma
3. Goitre
4. Redundant skin fold
5. Web neck
6. Fractured clavicles
Limbs examination:
1. Length
2. Soft tissue
3. Nails and digits
4. Deformities
5. Developmental dysplasia of hips (Ortolani, Barlow)
6. Lymphedema of foot (potential associated syndrome: Noonan syndrome)
Cardiovascular examination:
1. Inspection
- Peripheral vs Central cyanosis
- Palpation
- Pulses (Brachial vs Femoral pulses)
- Apex beat (Left 4th ICS (infant), 5th ICS (children), MCL) (may feel prominent RV impulse at LSB) - Auscultate
- Heart sounds, Murmur
- HR (~120)
Respiratory examination:
1. Inspection
- Respiratory pattern (Periodic respiration in preterm), RR (~40-50 / min)
- Respiratory distress (Tachypnea, Stridor, Grunting, Flaring of ala nasi, Intercostal / Subcostal / Sternal insucking)
- Asymmetry
- Chest deformity
- Percussion (not helpful)
- Auscultation
- Breath sounds, Added sounds
Abdominal examination:
1. Inspection
- Shape, Size, Umbilicus (erythema, purulent / blood stained discharge), Dilated veins, Visible peristalsis
- External genitalia, Perineum
- Hernia orifice
- Anal patency
- Palpation
- Superficial for mass / tenderness
- Deep for mass / organomegaly
- Liver (normal 1-2 cm below costal margin, soft in consistency), Spleen, Kidneys (lower pole occasionally ballotable), other masses - Percussion
- Liver border - Auscultation
- Bowel sounds
- Bruits
Spine examination:
1. Spina bifida, swellings
2. Stigmata of underlying spinal defect
- Midline dimples
- Mass
- Tuft of hair
- Haemangioma
3. Deformities (e.g. scoliosis)
Hips examination:
1. DDH
- Groin skin crease asymmetry (extra groin skin fold due to lateral femur displacement causing shortening of limb, in dislocated hip, can occur in normal baby as well)
- Decrease hip abduction, limb movement
- LLD: Galeazzi’s sign
- Ortolani, Barlow
Neurological examination (consider influence of gestational age, posture in uterus, state of wakefulness):
1. Alertness
2. Posture (e.g. flaccid, spasticity, focal abnormality (e.g. Erb’s palsy))
- Tight fisting: cerebral damage
- Frog-like posture: hypotonia
3. Muscle tone, Tendon jerks
- Pull baby to sitting position (normal: flexed elbow, minimal head lag, transiently maintain upright head, also test grasp reflex)
- Prone position (normal: raise head above crouch)
- Ventral suspension (normal: hold head in line with trunk momentarily, back straight, flexed limb; abnormal: inverted U shape)
- Vertical suspension by holding axilla (hypotonic: slip through shoulder)
4. Spontaneous movements
5. Primitive reflexes (Moro, Grasp, Suckling and Rooting)
- Present in mature babies
- Disappear by 4-6 months
- Moro reflex: hold head 45o —> suddenly let head fall back —> sudden extension of neck + abduction of upper + lower limbs + embracing movement (asymmetry —> brachial plexus injury / fractured clavicle)
- Grasp reflex (Finger + Toe grasp): put finger into palm on ulnar side —> finger flexed + grasp object
6. CN (Eye movements, Facial asymmetry, Swallowing)
Specific signs
Vernix caseosum:
- Thick layer of secretion containing:
—> Skin sloughing
—> Lanugo
—> Sebum
- Good for baby, prevent eczema
Erythema toxicum:
- Benign
- Red macules with tiny white papules (Found eosinophils)
- Disappear within first week
Mongolian spot:
- Benign
- Disappear 7-8 yo
Petechiae:
- In asphyxia (e.g. shoulder presentation)
- Check for bleeding tendency if generalised
Salmon patch (Nevus simplex):
- Benign
- Capillary malformation
- Disappear within 1 year (vs Port-wine stain (Nevus flammeus): growth darker)
- No treatment needed
Cephalhaematoma (Subperiosteal haematoma):
- Common self-limiting
- Non-pitting
- Not cross midline / suture
- vs Subaponeurotic / Subgaleal haematoma (Uncommon, life-threatening, anaemia and shock, cross midline / suture)
- vs Caput succadaneum (SC edema, Pitting)
Normal Cardio-respiratory parameters
- HR: 120 (***90-160), slower when sleeping
- Pulses volume equal
- Normal apex beat at 5th ICS, MCL
- Transient innocent murmur common
- RR: ***40-50, higher in preterm infants with occasional periodic breathing
Normal Neurological signs
Normal:
1. Predominantly ***flexor tone (reduced tone in premature infants)
2. Sleeping for 18-20 hours / day, most alert mid-way between feeding, irritable when hungry
3. Best visual at 18 inches but no consistent visual fixation
4. Concomitant squint
Warning signs:
1. Frog like posture
2. Jitteriness
3. Altered conscious state
4. Bulging fontanelles
