Newborn Assessment Flashcards
Neonatal History: from mom and dad
Genetic History: from mom and dad
PMHx. from mom and dad
- chronic conditions
- vaccination status
- medications
- child abuse risk
- occupational hazards?
Obstetric History
- age, gravidity, bllod type, screening tests BPPs
- pregnancy induce HTN, GDM, bleeding, UTI, pre-term labor?
- previous pregnancy and complications?
High Risk Infants
what maternal/obstertic/natal hisotyr would indicate high risk infant
preterm baby
premature rupture of membrane
choriamnionitis (infection)
SGA, IUGR, LGA
TORCH infections (viral ones in pregnancy)
low APGAR score
meconium: stooling in uterus
abruption
IVF
multiple gestations
how is age calculated in the newborn
terminlogy for the baby at different ages
neonate
preterm
later preterm
early term
term
late term
post-term
Age
- determines as actual age-time since birht (3 weeks, etc.) since birth
- corrected gestational age = age based on gestation
- so if your baby was born premature: at 28 weeks: and is 4 weeks out of womb = baby is 32 weeks (not a 4 week old)
Neonate
- first 28 days of life
Preterm
- baby born < 34 weeks
Late preterm
- baby born 34-36 weeks + 6 days
early term
- baby born 37-38 weeks 6 days
Term
- 39 weeks - 40 weeks 6days ( called 40 + 6 weeks)
Late Term
- 41- 41+ 6 weeks
Post Term
- 42+ weeks
Gestational Weight
normal
low
very low
extremely low
Appropriate for gestational age (AGA) : birth weight betwee the 10th-90th percentile
Normal = 2500-4000 g
LBW = < 2500 g
VLBW = < 1500 g
ELBW = < 1000 g
Intrauterine Growth Restriction (IUGR)
what is it
how will they look
IUGR
- restricted growth in utero
can be due to
- drinking, smoking
- twin-twin transfustion
- torch infections
baby will appear as
- malnourished
- small head circum.
- dry and loose skin
- small abd.
- thin umbilical cord
SGA: small for Gestational Age
SGA
- born at term with no complications just physically small for gestational age
- they will follow normal growth curve
- defined as any weight below the 10th percentile
these babies will stay small: follow a normal curve but stay small
Breifly Define Fetal Circulation
Fetal Circulation
placenta through umbilical vein:oxygen rich blood to the liver through the ductus venosus
from liver through IVC to the right side of the heart
from here; two pathways arise: through the patent foramen ovale (PFO) which connects the RA and LA together
this allows oxygenated blood to get to the LA and out the aorta to the brain and other organs wihtin the fetus
once the blood returns from the body it enters the RA again, and this time the blood is sent to the RV and then to the pulmonary artery
instead of going into the lungs; the deoxy. blood goes through the dutuc arterious down to the lower limbs
then it exists via the umbilical arteries (through umbilicus back to placenta
at first breathe: these opening being to shut, the PFO, ductus venousus and dusctus arteriosus
- PFO closes
- ductucus venosus = becomes medial umbilical lig.
- ductus arteriosus = become ligamentum arteriosus which is behind the aorta
What happen immediately after birth in terms of pulmonary involvement: First Breath
lung expansion and increased blood flow: icnreases the spO2
Rise in O2 and fall in Co2: results in vasodilation
PVR drop: results in an increase in pulmonary blood flow
APGAR Scoring at Birth
What does it include
when is it done
APGAR
- activity
- pulse
- grimace
- appearance (skin color)
- respirations
done at 1 minute and 5 minutes
Activity (muscle tone)
- absent, flexed or active movement(normal)
Pulse (felt at umbilicus)
- absent, below 100, over 100(normal)
Grimace (reflex irratibility)
- flaccid, some flexion, active motion/sneeze,cough,etc. (norm.)
Appearance (skin color): cyanosis in hands and feet is norm
- blue/pale, body pink, extremities blue, all pink
Respirations
- absent, slow/irregular, vigourous cry (normal) want a spontaneous cry, can flick feet, etc. to initiate
severely depressed: 0-3
moderate: 4-6
good condition: 7-10
Transition to Extra-uterine life: what would be the main reason for lack of breathing
PPV v CPAP for labored breathing/apnea
think pulmonary issues with neonates: first!!!
A : airway
B: breathing
C: Circulation
T: thermoregulation: warm them up in a swaddle: large surface area is wet
D: decreased pulmonary vascualr resistance: takes a second to get that spontantous circualtion
Protocol
- NRP: neonatal resusitation program
- first minute: establish HR > 100 and unlabored breathing > 60% pO2
Algorithm for neonatal assessment of respiration
- apna, gasping, HR < 100 = PPV (positive pressure vent)
- labored breathing or cyanosis = CPAP
if HR < 100 = consider ETT or laryngeal mask (intubation)
dont want baby at 100% oxygen; risk of increase VEGF and decreased vision
keep baby at like 60-65% in first minute, then at 10mins. 85-95%
Ballard Testing: Determinig Maturity of the baby (if you dont know age or gestational age of mom)
Ballard Testing
- Neruomuscular and physical testing to determine baby age
- > 26 weeks: before 96 hours of life
- < 26 weeks: before 12 hours of life
Surival of infants depending on when born
in general, after 23 weeks, every week of gestation increases survival odds by 10%
- at 23 weeks = 50% survival rate
What are some disease states that can worsen overall outcome of infant survival
what to do
when should we aim to have them “caught up”
Infection
- CLD: chornic lung disease
- IVH: interventricualr hemorrhage
- PDA: patent ductus arteriosus
- ROP: retionpathy of pre-mature
- NEC: necrotizing enterocolitis
what to do
- send to devleopment peds
- difficult to predict outcomes for these babies
- goal: catch up to “normal” by age 2
Vital Signs of the Newborn
apnea v periodic breathing
BP
- ensure calm infant & every newborn should have BP measures in all 4 extremities
- get MAP
Temp: under axilla
- (only rectal to confirm an abnormal axillary)
HR: will be faster than ours; 95-160
Respirations: will be faster
- apena: pauses > 20 seconds OR pauses causing cyanosis/bradycardia ABNORMAL
- Perioidic breathing: short pauses in breathing (5-10 seonds) = common in newborns and premies, normal
Pulse OX
- via beams of light which detect color and percentage of oxygen
Physical Exam of the Newborn
- general tips
- cardiac and lung specifics
General
- well lit room
- undressed baby to see all skin and areas
- listen to heart and lungs in the beginning of the exam: when baby is the most quiet
- go from head to feet
Lungs
- stethescope to listen for our normal lung sounds
- rales,wheezes,rhonci,stridor
Heart
- note rate, rhythm, PMI, quality of sound
- note for murmurs: PDA murmur!!
- PDA murmur: continuous washing machine murmur; can be normal in first few days of life
then compare pulses bilaterally uppr and lower = grade them (1+ or 2+)
- femoral pulses can be weak in the first few days but; if weak after this: consider coartation of aorta
Physical Exam of the Newborn
- Derm
- Eyes
- Ears
Dermatologic
- jaundice
- Cutus marmorta baby goosepumps: looks like mottled skin
- Mongolian blue spots
- Milia : white pustules which resolve
- Erythema Toxicum: looks like herpes but not a concern
Skull
- assess Fotanelles: open, large, small, bulging
- large = hypothyroid or OI
- small = IUGR
- assess shape: plagiocephaly or oxycephaly (premature closing)
Eyes
- red reflex
- naso-lacrimal duct obstruction: yellow crusty
- subconj. hemorrhage
Ears
- eat pitts and tags
- note position of ears in relation to eyes
Physical Exam of the Newborn
mouth
clavicles
Mouth
- cleft palate
- cleft lip
- anklyglossia: tongue tied
- Epstein pearls: bengin white/yellow pearls on the tongue
- Neonatal teeth
- nasal deformities
Clavicles
- creptius, pain, lack of arm movement or hard pump = fracture
- birth trauma
Physical Exam of the Newborn
Abd. exam
Abdomen
- listen first: bowel sounds
- palpation: masses, liver, hepatosplenomegaly
- observation: firmness and distention
Abnormal Findings
- pectus excavatum
- prune belly (urinary issues)
- distended abd.
- scaphoid abdomen: congenital diaphargm (abd. contents in the thoracic cavity)
GU Exam
- assess umbilical exam: 2 arteries 1 vein
- palpate femoral arteries
- male: testes decended, hypospadius, edema
- female: discharge, edema
- ambiguous
hypospadius = ureathra opening posterior penis
epispadius= urethra opening anterior penis
Hip Dysplasia
Risk Factors
Ortolani and Barlow Testing
Hip Dysplasia
- a physiologic laxity of the hip: due to immature acetabulum
- discovered in the first few weeks of life
Risk Factors
- Breech position (feet first)
- family hisotry
- female
Prevention
- exam hip dysplagia until 2 years: first 2 weeks are most important
Barlow
- graps thigh, adduct and posterior pressure
- if clunk = + test with suxlux. of hip
Ortolani
- start adducted and abduct pushing anteriorly
- if clunk again = + test
- means dislocated hip is reducable
Treatment
- Pavlik Harness: abduction splint
- if Pavlik Harness fails: can do closed or open reduction
- if older than 6 months at dx. = surgery
Physical Exam of Newborn
MSK
Neuro & reflexes ( big 3)
MSK
- movement of extremities equally
- ROM?
- creptius
- abnormal bumps/masses
- lengths?
Neurologic Exam
- assess hypo v hypertonis
Reflexes
Moro Reflex
- develops at 28 weeks, gone at 3 months
- startled “feeling of falling” reflex when baby “dropped” slowly and controlled
Grasping Refelx
- developed at 28 weeks gone by 4 months
- palmer reflex
Rooting Reflex
- develops around 14 weeks and gone around 4-6 months
- tap corner of mouth and they will turn to suck
Additional Newborn reflexes
Sucking
Tonic Neck
Placing
Galant Reflex (Trunk Incurvation)
Sucking
- fully developed at 36 weeks
- tap root of mouth and thye will suck
Tonic Neck
- present at birth, gone at 5-7 months
- fencing position with flexed arm and straightened other
Placing Reflex
- lasts for 2 months after birth
- dancing baby
Galant (Trunk Incurvation)
- in the ventral suspension, stroke next to the spine and baby will turn head toward the stroking sign
- lasts until 6 months
Routine Newborn Procedures
newborn screen (what tests are done)
what to the eyes
what viatmin
Newborn Screening
- newborn screening (which varies by state) done & crital congential heart defet (CCHD) screen done within first 48hours of life
- before TPN or blood products are given
- CCHD: pulse ox in LE and UE
Erythromycin Ointment on eyes
- protect from ophtalmia neonatorum (gonorrhea of the eyes)
- within both eyes in 1 hours
VItamin K injections
- prevents hemorrhagic disease of the newborn
- wihtin 4 hours
what is included in the Newborn Screen (PA) : blood
- EVERY TEST INCLUDES: PKU, hypothyroid
- galctosuriia
- maple syrup urine
- homocystinuria
- biotindase deficiency
- congential adrenal hyperplasia
- hemoglobinopathies
- amino acids profile
- acycartnitne
- G6PB
- SCID (severe combined immunodef.)
NEwborn Screening
what is done
Hep B
cord blood
labs?
hearing
bilirubin
circumcision
Hep B
- the vaccine is given if mom is positive ** at birth & give them the HBIG**
- if unknown moms status of Hep B: give within 12 hours and HBIG if moms positve within 7 days
Cord Blood
- blood typing and coombs testing
- stem cell banking
Lab Work
- bedside glucose if they are at risk
- test hemocrit at 3-6 hours IF at risk
- if not at risk, test HCT after 12 hours because thats when baby is making own
Hearing
- ABR or ARE testing (brainstem and hair cells)
- do before d/c from hospital
Bilirubin
- prior to discharge get labs
- range of accepted depends on GA of baby
Circumcision
- elective procedure
- prevents UTI, decreased penile cancer and STI
Respiratory Distress Syndrome
Symptoms
Symptoms
- tacypnea: > 60 breathes/min
- retractions: intercostal/subcostal
- grunting and stridor
- nasal flaring
- central cyanosis; around lips and nose
Transient Tachypnea of the newborn
symptoms
- a delayed clearance of fluid
- resolves in 12-24 hours
- get CXR gold: see hyperinflation and fluid within teh bronchioles and edema
Aspiration: Meconium
Symptoms = wide range
CXR: coarse irregular infilterates and hyperexpansion; looks “fluffy”
use suction to remove is milkd, can be as severe as needing ecmo
Penumonia in the newborn
Chonanal atresia
- can occur at any gestaational age
- can be before or during labor that is was accquired
- Group B strep, e. coli, klebsella
- will have signs on infection
Chonanal atresia: the nose isnt fully open in both nares
- unable to pass NG tube
- need to intubate them to stabilize
- need to dilate nares or place stent
Respiratory Distress Diseases
treatment
the first breath is most important = establishes the FRC & clears fluids
Treatment
- Supplemental O2 = maintain appropriate stat % :85-92% if < 32 weeks, 94% if > 34 weeks
- maintain paCO2 45-55
- get CXR, septic workup and blood gases
Apnea in the Newborn
MC reasons for apnea is prematurity
other reasons
- infection, sepsis, thermal issures
- metabolic disorders,
- CNS issues,
- anemai, shock, PDA etc.
Treatment
- symptomatic: can do symptomatic or nonsymptomatic treatment
- caffeeine!!! : stimulates the central respiraoty center, gets better diaphragmatic contraction but can increase HR
Respiratory Distress Syndrome of Prematurity (RDS)
“hyaline membrane disease”
etiology
what can it progress to & symptoms
Etiology
- in premature babies, there is a poor surfactant production: since lungs are last to develop this gets impacted if a premie baby
Symptoms/Signs
- decreases surface tension in alveoli
- alveoli collapse with exhalation
- decreased compliance
Can progression : to atelectasis: they are collapsing because they dont have surfactant to keep them open
symptoms of atelectasis = hypoxia, pulmonary vasoconstriction and flow and pulm. HTN as a result
Symptoms of RDS
- tachypnea, falring, retractions, cyanosis, expiratory grunt
- hypoxemia: pO2 , 50
- hypercarbia/acidosis
- CXR: ground glass haxy and low lung volumes & air bronchograms
Treatment
- oxygen: to decrease PVR
- mechanical ventilation: provide with best opportunity fr gas exchange
- surfactant replacement: open alveoli
PTX in newborn
PTX: risk in respiraotry distress syndrome premies because the lack of surfactant; so the pressure inside the lungs is high
high pressure : risk of poping and causing PTX
Treatment
- giving surfactant decreases this risk
if PTX occurs
- oygen
- intubate and adjust pressures
- pneumocentesis
- chest tube
Hypoglycemia
waht should normal glucose be for baby at 3 hours
risks for baby hypoglyc.
symptoms
tesing babies glucose soon after birth: especially if high risk baby
After 3 hours of life: normal glucose level is 50-80
Risks for neonatal hypoglycemia
- premature
- infant of diabetic mom: because baby has high insulin response)
- IUGR: reduced glucose stores and lower body fat
- asphyxia perinatal stress
- hypothermia
- large for gestational age
- maternal medications
Symptoms
- poor feeding/vomiting
- apnea
- hypothermia
- jittery & termor/seizure
- blue/pale
- lethargy
best way to treat hypoglycemia in newborn: feed! bottle or breast
- if glucose < 45 = give D10W bolus and possible glucose infusion
Hyperbilirubinemia
what is it
conjugated v unconj.
Bilirubin
- a breakdown product of RBCs
- unconjugated bili goes to liver (in the ER) to be conjugated
- conjugated bili: can be absorbed by the intestines and excreted as stool
- if this cant happen: backflow occurs and there is increased unconjugated hyperbilirubinemia
Unconj.
- fat soluable (not water)
- can be more toxic
- travels as bound to albumin or free
Conj.
- water soluable
- easily excreted in urin and stool
- less toxic
- requires O2 and glucose to form
Reasons for Hyperbilirubinemia in infants
Risk Facotrs for baby to be a bili baby
Increased Bilirubin Production
- Rh, ABO incompatibile, G6PD, septicemia and polycythemia
Decreased in bilirubin excretion
- GI obstruction (can lead to an increase in enterohepatic circulation)
- heriditary issues
- hypothyroid
Combination
- infection, G6PD and premature babies have increased bili production and decreased bili excretion
Risk Factors
- jaundice in the first 24 hours
- blood group incompatibility or known hemolyic diseae
- gestational age 35-36
- exclusive breast feeding
- asian race
Assessing for Hyperbili
PE
Visual
- take a look at skin but this is not accurate
get a Total Serum Bilirubin (TsB) :
- primary test and evaultes by the infant’s age in hours old
- indeally want to get this within the first 24 hours
transcutanesous bilirubin measurement (TcB):
- non-invasive
Bilirubin Encephalopahy
Risk Factors
Risk FActors
- asphyxia
- premature
- hypoalbuminemia
- bilirubin-displacing meds
- hyoerosmolarity
- hypoxic injury
Symptoms
- mental status cahgnes: lethargy, semi-coma or seizure
- muscle tone: hypertonia, opisthotonus & retrocolis
- cry: high-pictched, shrill, inconsolable
- fever
opisthotonus: rigid, arched back
Treatment for hyperbilirubinemia
phototherapy
- noninvasive
- lave at a wavelength is absobred by bilirubin & breaks it down
- eyes are shielded
a normogram is a graph chart to see at what age in hours and amount of bili is there in labs to determine need for
Birth Injuries
Risk Factors
- small maternal stature or abnormal pelvic anomilies
- prolonged or too rapid of labor
- breech baby
- forceps or vacuum
Fetal monitoring probes
- put on baby to monitor HR and strength of moms contractions
Birth Injury: Extracranial hemorrhage
crosses suture lines
caput succedaneum
- subcutaneous extraperiosteal fluid collection (NOT BLOOD)
- usually resolves spontaneously after first few days of life
Birht Injury: Cephalomematoma
WONT CROSS SUTURE LINES: defined edges
- subperiosteal collection of blood
- due to ruputre of superfiscial veiwns between skill and periosteum
- due to forcep or vaccum assist
- can result in hyperbilirubemia or anemia
- can take 2 months to resolve
Subgaleal hematoma
- hemorrhage under aponeurosis (fiberous tissue) of the scalp
- also due to forceps or vacuum
- hemorrhage can spead across entire head
- this is bleeding between the skin and the skull
difficult to see as it just spreads and doesnt create a bump
Craniosynostosis
- due to what
- treatment
Due to What
- cranial deformity
- restrcited head growth
- increased ICP
Treament
- open surgery at 6m onths
- minimiall invasive: before 6 months
- helment for 10-montsh-1 year
Brachial Plexus Injury
“erbs pasly”
- damange to C5,6,7
- waiters ti: shoulder adducted and internally rotated, wrist flexed
Abesent: moros, biceps, radial refelxes but grasp intact
Klumpke palsy
- rare: damange to C7,8,T1
- biceps and radial reflex are present GRASP IS ABSENT
- sensory impairement
Total Brachial Plexus INjury
- entire are is flaccid and no reflexes
negative effects of cocaine and methamphatamines in pregnancy
for mom
for baby
For Mom
- HTN
- decreased uterin blood flow
- fetal hypoxemia
- uterine contractions
- placental abruption
For Baby
- strillbirth
- symmetric IUGR
- premature
- child neglet/abuse
- higher risk os SIDS
What to do if you suspect materal alcohol or drug use
get a urine tox screen: for mom and baby
meconium or cord blood: can detect cumulative drug use in the firat trimester and onwards
Social Services involved
Signs of baby being addicted to narcotincs because of mom
narcotics: opioids and opiates
NOWS or NAS: screen
symptoms: at days 1-3 of life
- feed/sleep issues
- hypertonia
- tremor
- seizures
do a newborn tox screen
conserative v medication on scores
Effects of weed and tobacco on baby
alcohol
Weed
- no foudn teratogenic effects but long term: neurodevelopmental, ADHD, etc.
Tobacco
- featl growth slowed
- IUGR
- premature
- SUDS
- tremors
Alcohol
- clear teratogenic
- most common cause of intellectual disability
- NO SAFE dose
- geentics and degress and timing of use all play a role
- results in fetal alcohol syndroem
Complications of multiparity
Neonatal
- twin-twin transfusion syndrome
- premature: inversely related to # of fetuses
Materal complications
- polyhydramnios
- THN
- PROM
- umbilical cord prolapse
Twin-Twin transfusion syndrome
Antepartum fetal testing (starts at 32 weeks
- non stress test
- biophysical profile
- amniotic fluid volume
