Newborn Exam Flashcards
Components of a prenatal visit
- Courtesy of pediatric office without charge
- Chance to meet provider and see office/ask questions
- Chance to discuss feeding options and what happens in hospital after birth ie circumcision, immunizations, hearing screen, etc
3 components to a complete newborn history
- Maternal and paternal medical history
- Maternal past obstetric history
- Current antepartum and intrapartum history
Maternal and paternal history review
- Chronic medical issues in family
- Dietary habits
- Smoking or substance abuse
- Occupational history
- Social history - abuse or neglect
- Family illnesses and congenital anomalies
Maternal OB history
- Maternal age
- How many times pregnant
- How many times given birth
- Pregnancy outcomes
- Maternal blood type
Occuring right prior to delivery
Antepartum
Occuring during labor or delivery
Intrapartum
Time after delivery up to 6 weeks
Post partum
Review of antepartum and intrapartum hx
- Mom’s history: US, amnio, screening labs
- Tests that determine fetal well being: NST, dopplers of blood flow and BPP
- Mom prenatal issues ie gestational DM, UTIs, HTN, preeclampsia, preterm labor
- Significant issues like maternal fevers, difficult delivery, meconium stained fluid, vaginal vs C/s, forceps, resuscitation
Newborn hep B history
- Maternal hep B status: newborn given hep B vaccine within 1st 12 hrs
- Babies born to Hep B mom who do not get vaccine - 40% get hep b and 25% die from chronic liver disease
- HBsAG and HBeAg vertical transmission 90%
What does the baby need to receive after birth if the mom has HBsAg
- HBIG and Hep B vaccine ASAP after birth on opposite legs then Hep B again at 1 and 6 months
- If HBsAg not tested and mom high risk, give hep B vaccine ASAP and do labs. If HBsAg +, give HBIG up to 48 hours after
no hep c vaccine yet and no prevention for newborns :(
What should you do if mom is HIV +
- Babies receive antiretrovirals within 6-12 hours
- Breastfeeding not recommended
What is APGAR?
- Helps determine condition at birth
- Recorded at 1 and 5 minutes after birth
- Serial score shows progression/improvement
- Scale 1-10 and want at least a 7
What does APGAR stand for?
- Appearance
- Pulse
- Grimace
- Activity
- Respiration
What is a 0, 1, and 2 on Appearance APGAR score?
- 0: cyanotic
- 1: some cyanosis (extremities)
- 2: all pink
What is 0,1,2 on pulse APGAR score?
- 0: absent
- 1: <100
- 2: >100
What is 0,1,2 grimace on APGAR score?
- 0: none
- 1: “some” some flexion of extremities
- 2: cries in response
What is 0,1,2 on activity APGAR score?
0: none
1: some flexion of extremities
2: active movement
What is 0,1,2 on respirations APGAR score
0 none
1 some - slow irregular
2 spontaneous cry
Dubowitz/Ballard Exam and scoring
- Evaluates both physical characteristics and neurological characteristics of a newborn
- 6 physical and 6 neurological signs of maturity scored
- total score estimates gestational age
What are gestational age predictors?
- LMP
- Fetal US
- Physical and neurologic development
What is a square window?
Wrist flexion, term baby wrist can bend all the way down
What is scarf sign?
How far arm will extend across body
Ballard postnatal assessment
- Best performed at 30-42 hours of age
- Takes about 3-4 minutes to complete even on sick infants
- New ballard can test infants from 20-44 weeks
What can be accomplished with a prenatal visit?
Meet each other, see office
What vaccine is given to a newborn within 12 hours of birth?
Hep B
What is a perfect APGAR score?
10
What time after birth are APGARs done?
1 and 5 minutes
Is there a hepatitis C vaccine?
No
Unexplained death of a healthy baby younger than one, usually during sleep
SIDS
What causes SIDS?
True cause unknown
Thought to be related to area in brain that controls breathing and waking from sleep
Risk factors for SIDS
- Certain types of brain defects (brain area that controls breathing underdeveloped)
- Low birth weight
- Respiratory infections - many who die recently had a cold
- Sleeping on their stomach or side
- Sleeping on a soft surface (fluffy blanket, soft mattress, waterbed)
- Sharing a bed - with parents, siblings, or pets
- Overheating - being too warm can increase risk
- Males > females
- Age 2-4 months
- Race - more likely in black, native american, and alaskan native
- Family history of SIDS
- Second hand smoke
- Premature birth and low birth weight
How do we reduce the risk of SIDS?
- Place baby on back to sleep, never side or stomach
- Keep crib bare with firm/flat mattress
- No pillows, blankets, or stuffed animals
- Don’t overheat baby and never cover baby’s head
- Baby should sleep in parents room for first 6 months
- Breast feed if possible
- Do not rely on commercial devices that predict SIDS. They do not prevent
- Offer pacifier
- Get vaccines on time
What is normal cry of newborn? Abnormal?
Strong
* High pitched abnormal
* Low, hoarse cry sign of hypothyroidism
* Weak, poor cry can be sick infant
What is the average size of a full term baby in America?
- 7 lbs
- 19-20 inches long
- Head circumference of 13-14 inches
Any jaundice within the first —- is abnormal
24
Bluish discoloration of infants hands and feet
Acrocyanosis
Is acrocyanosis normal or abnormal? What causes this?
Normal
Vasomotor changes that result in peripheral vasoconstriction and is benign
central blueness is not normal
skin has mottled look like cobblestone street
cutis marmorata
When is cutis marmorata more common? What causes this?
Skin is cold
Superficial blood vessels dilate and give red color then constrict and give blue color, rewarming helps color return
Cutis marmorata is a common skin finding in what condition
Down syndrome
Waxy or cheesy like appearance after birth due to substance made of water, lipids, and proteins
Vernix Caseosa
What is vernix caseosa and what is its function?
Biofilm that covers fetus during last trimester
* Protects newborn skin and provides barrier against infection
* Delayed bathing common- delaying over 12 hours may help thermoregulation, hypoglycemia, and rates of breast feeding
Light, fine hair that covers the newborn baby
Lanugo
What is the relationship between lanugo and age of baby? What is purpose of lanugo?
- Younger baby, more hair
- Thought to insulate baby and help vernix stick, disappears over time
Are males or females more likely to have SIDS?
Males
Does a family history matter with SIDS?
Yes
Does a pacifier increase or decrease the risk of SIDS?
Decrease
Is jaundice normal in the first 24 hours?
NO
Is it okay for a baby to have blue hands and feet? What is this called
Yes, acrocyanosis
What is faint thin baby hair called on a preemie?
Lanugo
Skin rashes in newborns
- erythema toxicum
- Newborn acne
- Milia
- Sebaceous gland hyperplasia
Red base, papular - vesicular rash that is common in newborns
Erythema toxicum
Re
What causes erythema toxicum? How long does it last?
Eosinophils in tiny vesicles
Appears 2-5 days after birth and resolves in weeks
What is the appearance and cause of acne neonatorium (newborn acne)?
- Closed comedones - red and inflamed, looks like real acne on cheeks, forehead, and sometimes chest and back and resolves on own
- Thought to be due to maternal hormones
Tiny, white epidermal cysts filled with keratin
Milia
What are locations of milia?
Usually on face, resolves in 2-4 weeks
If in roof of mouth, called Epstein’s pearl
What is a hemangioma?
Very common vascular birth mark located on face, scalp, or thorax, but can be anywhere consisting of small, densely packed blood vessels
Cause unknown
What is the progression of hemangiomas?
- Start several months after birth
- Grow rapidly, then remain fixed, then start to resolve
- Most gone by age of 9
When would a hemangioma require immediate treatment?
- Visual, hearing, rectal, vaginal, nasal obstruction
- Airway obstruction
- Huge hemangiomas may cause cardiac decompensation
“Stork bite” light red macules found over nape of neck, upper eyelids, and between eyebrows
Nevus simplex
Dark red macules anywhere on body consisting of thick, dilated blood vessels
Nevus flammeus/port wine stain
If port wine stain is seen on the face along the opthalmic branch of trigeminal nerve, about 25% will have —–
sturge weber syndrome
What can port wine stains be associated with?
- Vision problems
- Angiomas that grow in brain and cause seizures and develomental disabilities
Darkish blue birthmark over lower back and butt that is more common in darker skinned babies and lasts for years
Congenital dermal melanocytosis
Also known as “Mongolian spot”
Light brown oddly shaped flat macules that can be anywhere
Cafe au lait spots
How long do cafe au lait spots persist?
For life and may increase in number
If there are more than 6 macules over half a cm of cafe au lait spots, what does that mean?
Major diagnostic criteria for neurofibromatosis 1
What is normal for vaginal birth head appearance? Breech? C- section?
C-section: pretty head
Vaginal: elongated
Breech: narrow face and head
What causes hydrocephalus?
Can be present at birth due to slowly increasing ICP causing ventricles to enlarge –> head grows in circumference
* Obstruction of flow (blocked 4th ventricle, dandy walker malformation or arnold chiari malformation)
* Overproduction of CSF (choroid plexus papilloma)
What are findings in hydrocephalus?
Sunsetting eyes due to increased pressure
Increasing serial head measurements
Treatment of hydrocephalus
VP shunt to shunt fluid from brain into abdominal cavity
What fontanelles are present at birth? How do these change over time?
- Anterior and posterior
- Anterior closes from 9-24 months
- Posterior closes around 2-3 months
What does a bulging fontanelle indicate? A depressed fontanelle?
- Bulging: increased intracranial pressure
- Depressed: dehydration
Defect caused by swelling of scalp due to pressure on the head during vaginal birth, decreased blood flow –> edema
Caput succedaneum
Presentation of caput succadaneum
- Can extend across suture lines
- Localized soft tissue edema with poorly defined borders
- Resolves after 2-3 days
What is a cephalohematoma
- Subperiosteal hemorrhage
- Feels soft like cyst and usually occurs after difficult delivery or instrument associated delivery
- Well defined outline and does not cross suture lines
- Takes weeks to resolve
Abnormal thinning of parietal bones in premature babies that gives sensation of ping pong ball on pressure
Craniotabes
Where is craniotabes usually located?
Along parietal bones, sometimes occipital, running along lambdoid suture lines
How long does craniotabes last? What happens if not?
- Usually disappears in a few weeks
- If not, think rickets, osteogenesis imperfecta or hydrocephalus
What is subgaleal hematoma/hemorrhage?
- Serious but rare complication of vacuum assisted delivery
- Caused by rupture of emissary veins, which are connections between dural sinuses and scalp veins
- Blood accumulates between epicranial aponeurosis of scalp and periosteum
- Can accomodate up to one half of blood volume of neonate
- Need to monitor BP, hematocrit, bilirubin, signs of hypovolemia
Life threatening congenital anomaly with short jaw, cleft palate, and airway obstruction
Pierre Robin syndrome
What causes pierre robin syndrome?
- Failure of mandible to grow
- Tongue blocks fusion of palate so cleft forms
- Tongue obstructs airway
Treatment of Pierre Robin syndrome
- Fixing lower jaw and supporting child with feeding and breathing in meantime
What is the presentation of facial nerve palsy at birth?
- Damage during delivery, can be due to difficult/forcep assisted delivery
- Involves lower part of facial nerve that controls mouth
- Asymmetric crying face
- Eyelid may not close on affected size
- No movement on affected side
Treatment for facial nerve palsy
Observation
Collection of blood beneath conjunctiva due to trauma
Subconjunctival hemorrhage
What is prognosis of subconjunctival hemorrhage?
- Likely due to birth process and goes away on its own without treatment
How is neonatal conjunctivitis treated?
Erythromycin ointment in eyes to prevent chlamydia
all newborns given after birth
leading cause of blindness in developing countries!
What can congenital cataracts indicate?
Metabolic disease, congenital infection, or problem with thyroid
What is presentation of glaucoma?
tearing
tight eyelids
terrified of light
What happens if glaucoma is left untreated
damage to optic nerve can lead to blindness
what can an absent, blunted, or white red reflex mean?
- glaucoma
- Congenital cataract
- retinoblastoma
Treatment for white reflex
immediate referral to opthalmology
Rapidly developing eye tumor from immature cells in the retina
retinoblastoma
best cure rate of childhood cancers if caught early
presentation and treatment of retinoblastoma
- white pupillary response or leukocoria
- Immediate referral (emergency!)
Blocked tear duct at birth that is most common cause of tearing and sicharge from eye
Dacryostenosis
Presentation of dacryostenosis
- Tearing
- Discharge
- Heavy matting and debris on lashes
- Redness of conjunctiva not normal
- Spontaneous resolution in 90% of babies by 6 months
Treatment of dacryostenosis if not resolved
referral for probing
Infected tear duct
Acute dacryocytitis
Presentation of acute dacryocystitis
- Redness
- Warmth
- Swelling
- Rare complication of stenosis
- Staph aureus MC bacteria
- Can lead to orbital cellulitis
Treatment of acute dacryocystitis
- Consult opthalmology
- Probe to open area
- Systemic antibiotics
What extracranial bleed crosses suture lines?
Caput
Which extracranial bleed does not cross suture lines?
Cephalohematoma
What is the primary reason for newborn acne?
Maternal hormones
What are the tiny, white keratin filled lesions called?
Milia
When is a hemangioma a medical issue?
Obstructs orifice
What facial birthmark can have other associated medical issues?
Port Wine Stain
A cloudy eye at birth could mean what?
Congenital cataract
What is a blocked tear duct called?
Dacryostenosis
Caues of septal deviation?
Can be due to trauma at birth, will have respiratory distress if not addressed (newborns obligate nose breathers)
Treatment for septal deviation?
Surgery as child gets older
Congenital disorder where back of nose blocked due to abnormal bony tissue
Choanal atresia –> can cause feeding and breathing issues
Treatment of choanal atresia
Surgery to open area
Natal teeth
- Teeth present at birth
- Do not have strong roots and can be easy to aspirate
- Usually removed and can be associated with several syndromes
Oral thrush
White, thick coating inside the mouth and inside the cheeks. Cannot be scraped off, causes bleeding
* Painful for baby and cause trouble earing
* Yeast
Treatment for oral thrush
- Antifungal applied inside mouth (nystatin)
- If mom breast feeding, clean breast and apply same medication
- Boil all bottle nipples and pacifiers during treatment
How is a normal location of ears determines?
Drawing line from inner canthus of the eye perpendicular to verticular axis of the head
If top part of ear beneath this line associated with syndromes
Preauricular pits of ears
- Small indentions in front of ear of newborn
- Common, but can be associated with congenital anomalies
- Should have formal hearing test
- Risk of permanent hearing loss with ear pits or tags is fix times that of normal population
- Rare that needs fixed
If a patient has a ear pit/tag and any other craniofacial developmental issue, what should be performed?
Renal ultrasound
What can a delay or absence of pulse in lower extremities indicate?
Coarctation of aorta
What is a heart sign of congenital heart disease
Central cyanosis
Birth defect in which abnormal opening in diaphragm that allows abdominal content to move into chest cavity
Diaphragmatic hernia
How is diaphragmatic hernia managed
Diagnosed prenatally and surgery performed
Presentation of diaphragmatic hernia
- Tachypnea
- Tachycardia
- Cyanosis
- One side of chest larger than the other
- Concave abdomen
What is omphalitis
Cord area infection
Rectus abdominis does not close together completely over umbilical cord passage
Umbilical hernia
Which population more commonly gets umbilical hernia
African americans
Presentation of umbilical hernia
- Soft bulge at belly button
- More prominent when baby cries
- Easy to reduce
- Usually no medical issues
- Rarely complication of incarceration
- Usually resolves spontaneosly by 3-4 months
- If not resolved by about 3, can send to surgery for eval
What is umbilical granuloma
- Soft, pink, friable lesion of granulation tissue at belly button
- Forms in first few weeks of life from excess tisue that persists at base of cord
- Persistent drainage of serous fluid, sometimes green discharge or moisture around cord
Treatment of umbilical granuloma
- Silver nitrate to cauterize
- Can be treated several times with silver nitrate and may require surgery
Leukorrhea
Vaginal DC in newborn females with milky white or blood streaked vaginal discharge as a result of maternal hormone withdrawal
Labia can be swollen or even bruised after birth
Babies must —- after circumcision to be considered for DC home
void
Fusion of digits
Syndactyly
Extra digits
Polydactyly
Congenital hip dysplasia
Head of femur does not fit in hip well due to socket of hip being too shallow
Where/who is congenital hip dysplasia more common
left hip
girls
firstborn children
multiples
CHD
breech babies
What is the risk of a missed congenital hip dysplasia?
life long limp and osteoarthritis of the hip
Most common fracture in newborn
Clavicular fracture
What are risk factors for clavicular fracture
- Difficult vaginal delivery
- Shoulder dysfocia
- Post term
- Induction
- Higher birth weight
Presentation of clavicular fracture
- Crepitus
- Swelling of area
- Abnormal bone contour
- Crying with movement
At what age does big toe bending up and backward while other 4 toes fan out in Babinski become abnormal?
2
What is a normal moro reflex?
- Arms abduct at shoulder and extend at elbow
- Adduction with flexion follows
Tonic neck reflex
- Turn infants head to one side and the same side leg and arm will extend and the opposite left will flex
- Appears like fencing position
- Gone by 8 months
Traction response
- Infant pulled from lying by it’s hands to a sitting position
- First head lags
- then comes to midline
- Then flexes forward
What can cause a brachial plexus injury
- Difficult delivery
- Hard pull on neck as shoulder pass through
- Pulling on shoulders during head first delivery
- Pressure on raised arms during feet first delivery
- More common with large babies
- breech delivery
- Difficulty getting shoulder through
Treatment of brachial plexus injury
- Most babies recover by 3-6 months with observation
- Massage and ROM exercises can help
- Rarely -surgery needed if nerves ruptures or avulsed
Sacral dimple
- small hole or dimple near infants lower back in gluteal folds
- if large or has tufts of hair or a lump, needs studied
- Could be related to spina bifida occulta condition or tethered cord
- US or MRI can help with diagnosis
If nasal passages do not connect with the throat what is that called?
Choanal atresia
What is white coating on tongue that won’t wipe off?
Thrush
What is rooting reflex?
rubbing side of cheek and will look for nipple
What does the big toe do in a + babinski in a newborn?
Up
What is the most common fracture in a newborn?
Clavicle
What increases the risk of congenital hip dysplasia?
Girls, firstborn children, multiples, family history of CHD
breech babies, multiples