Newborn infant and clinical exam Flashcards
Visit Priorities of a prenatal interview
- Maternal/Paternal medical & genetic hx:
- Social circumstances
- Health of mother & father
- including allergies or meds
- Genetic problems in the family
- Alcohol & smoking habits
- Past maternal obstetric history
Newborn exam step 1
Review Delivery Record
Delivery record data
- Length
- Membrane rupture timing
- Delivery type & reasoning
- Medications used
If membrane rupture >24 hours =
↑ risk of infection
* Subtle S/S of infection in newborn
warrant greater attention
* Consider sepsis workup on the baby,
EVEN IF APPEARING WELL!
Significant peripartum events
- Fetal distress
- Meconium-stained amniotic fluid
- Anesthesia & analgesia used
- Infant status at birth
- Maternal fever (T.O.R.C.H. infections)
Review Delivery Record: Condition of infant
- APGAR Score = Resuscitation needed
- Weight & length (absolute & %)
- Vital Signs
- Blood type, & Rh factor of infant
- Gestational age
- Fetal Distress
Future (mostly counseling) priorities during prenatal interview:
- Feeding plan: Breast feeding vs. bottle feeding
- Safety & general care concerns
- Car seat usage
- Exposure to cigarette smoke
- Crib safety
- Work plans/childcare plans
- Social Support
If baby suspected to be born + for HIV
- PCR testing for infant
- Initiation of antiviral HIV treatment within 8-12
hours following birth - Consult pediatric HIV specialist
Normal infant pulse =
100-160 bpm
Normal infant respiratory rate =
40-60 rpm
Newborn transition problems
- Respiratory distress
- Cyanosis
- Hypoglycemia
- Poor feeding
- Temperature instability
- Jittery or lethargic
- Risk of withdrawal from maternal substance use
No meconium by 24 hours OR (+) abdominal distention = Workup for
Anal patency, Hirschsprung disease
* Other causes of intestinal obstruction:
* Cystic fibrosis, electrolyte abnormalities, hypothyroidism, & neuromuscular
disease
Color of baby meanings
- Normal Hgb = 16-17g/dl: Ruddy appearance (healthy & red)
- Plethoric (excessively red) in polycythemia, suspect maternal diabetes
- Pallor (pale): with anemia or poor perfusion
- Cyanosis (blue): typically manifests in the
extremities when the newborn is cold, ALWAYS requires immediately evaluation
What do you call the baby on the right’s color?
Plethoric
What do you call the color of the baby on the left?
Anemic, abnormally pallid
Jaundice in the newborn
- Yellow staining of the body tissues & fluids
- Excessive levels of bilirubin in the bloodstream
- Timing
- > 24 hours
- Physiologic jaundice of the newborn = Normal
- < 24 hours
Pathologic jaundice = Abnormal
Acute Bilirubin Encephalopathy
Neurological dysfunction in first postnatal weeks from bilirubin toxicity
Acute Bilirubin Encephalopathy clinical phases
- Early (1-2 days) - Poor feeding, high-pitched cry, stupor, hypotonia
- Middle (1st postnatal week)
* Hypertonia of extensor muscles
* Opisthotonos (severe arching of the neck & spine)
* Retrocollis (tightening of the muscle of the neck & shoulder girdle) - Late (after 1st postnatal week) - generalized hypotonia
Chronic bilirubin encephalopathy (Kernicterus)
Slower evolution of S/S over the first years of life
1. (1st year) - hypotonia, hyperreflexia, & delayed
motor development
2. (>1 year)
* Extrapyramidal dysfunction
* Dental enamel hypoplasia
* Visual
* Auditory
* Minor intellectual deficits possible
Kernicterus Risk Factors: Think J.A.U.N.D.I.C.E.
Jaundice within first 24 hours
A sibling who was jaundiced as a neonate
Unrecognized hemolysis such as ABO blood type
incompatibility or Rh incompatibility
Nonoptimal sucking/nursing
Deficiency in glucose-6-phosphate dehydrogenase
Infection
Cephalohematomas/bruising
East Asian or Mediterranean descent
Vernix Caseosa
(varnish cheesy)
* White, lipid-rich, moisturizer
* Fetal sebum, lanugo, & corneocytes
* Found in creases & flexor surfaces
* Lysosomes & lactoferrin are
antibacterial/fungal
* Helps retain heat
* Facilitates stratum corneum growth
Vernix retention after birth leads to
↑ skin hydration & ↓ skin surface
pH 24 hours after birth
* WHO recommends
Lanugo
- Downy hair covering the body
- More common with prematurity
Sebaceous gland hyperplasia
- Small, yellow papules over nose & cheek
- Disappear spontaneously
Acne Neonatorum
- Acne appearance
- Maternal hormonal influence
- Spontaneous resolution in 2-3 months
What is this?
Cutis Marmorata
* Newborn’s skin is thin & blood vessels can be seen
* Bluish, mottled, lacey, reticular appearance
* Disappears with rewarming (if not consider sepsis, esp in an ill-appearing infant)
What is this?
Erythema Toxicum
* Benign, common rash (50%)
* Erythematous papules & pustules (eosinophils)
* Predominates on face & chest
* 1 - 2 days after birth
* Resolves within 5 - 7 days
What is this?
Transient Neonatal Pustular Melanosis
* Idiopathic pustular eruption of the newborn
* Resolves with hyperpigmented macules
* Less common than erythema toxicum
* More prevalent with darkly pigmented skin
* Present at birth, may appear up to 3 weeks after
What is this?
Dermal melanocytosis (Mongolian spots) - essentially a birth mark that goes away
* Bluish/black macular lesions
* Usually over lumbosacral area
* Native American, Asian infants (99-100%)
* Ectopic melanocytes, incomplete migration from
the neural crest to the epidermis
* Tend to disappear within one year
* Always document! (NOT a bruise!)
What are birthmarks called & when do they present?
Congenital Melanocytic Nevi
* Present at birth or appear in the first few months
* Tend to grow with children (esp puberty)
* ↑ risk of melanoma
* 2+ medium lesions → ↑ risk for neurocutaneous melanocytosis
What is this?
Cafe au lait spots
* Light-brown, oval macule
* dark brown on brown/black skin, possible
halos
* Found anywhere on the body
* 1.5 cm or larger
One of the MAJOR diagnostic criterion for
Neurofibromatosis Type 1
Café Au Lait
What is this?
Nevus Flammeus
(Nevus Simplex, Macular Hemangiomas, Vascular Nevi)
* “Stork bites” → back of neck
* “Crow’s nests” → above the eyes
* Benign, flat, red skin patches
* May disappear within 1st year
* Can persist & darken
What is this?
Port-Wine Stain
* Nevus flammeus family
* Permanent skin discoloration
* May be associated with other
arteriovenous malformations
What is this?
Strawberry or capillary hemangioma
* Elevated collections of capillaries
* Variable appearance
* Grow for 3-7 months, stabilize, then involute ~1
year old → resolved by 5 yo
* Usually, no scar or blemish
* Observation only, unless on the eyelid - Ophthalmology consult required
What is this?
Cavernous Hemangioma
* Less common than strawberry hemangiomas
* Less predictable course
* Collection of larger blood vessels
* Larger than strawberry hemangiomas & bluer in color
* May be associated with thrombocytopenia
* Often, they mature & then disappear
* May treat with steroids or radiation
What is this?
Milia
* Subepidermal keratin cysts
* Pilosebaceous units or
eccrine sweat ducts
* Disappear spontaneously
Craniotabies
Thin, soft skull bones
* Caused by rickets or syphilis
* Common in babies born prematurely
Caput Succedānēum
Cone-head
* Common
* Boggy swelling of subcutaneous
tissues of the presenting part
* Crosses suture lines*
* Head compression against cervix
impedes venous return
* Reabsorbs in 1–3 days
What is Cephalohematoma?
- Blood pooling subperiosteum
- Confined to a single bone
- CANNOT cross suture lines**
- Apparent 2 hrs – 2 days after birth
- Almost always parietal bone
- From fracture*
- Lasts >4 weeks
What is this head shape called?
Caput succedānēum
What is this head shape called?
Cephalohematoma
Fontanelles
- Anterior fontanelle (junction of two frontal & two parietal bones)
- Larger
- Closes ~18-24 months
- Posterior fontanelle (junction of parietal & occipital bones)
- Smaller
- < 1 cm
- Closes ~6 weeks
Craniosynostosis
- Abnormal, premature closure of skull sutures
- Most common = Sagittal suture - Anterior/posterior lengthening of the head
- Fusion of coronal sutures - Lateral widening of the head
- Palpate sutures: Should move up & down independently
Normal Head circumference of neonate, what would micro and macrocephaly be?
~34-35 cm
* Compare with normative data
* Microcephaly - ↓ head circumference
* <2 SDs of the mean for the gestational age
- Macrocephaly - ↑ head circumference
- > 2 SDs of the mean for the gestational age
- May indicate Hydrocephalus
Hydrocephalus
↑ volume of CSF
* Obstruction in the subarachnoid space
* Need pediatric neuro consult
* Treatment usually consists of
ventriculoperitoneal shunting
Clinical features of Hydrocephalus
- Macrocephaly
- ↑ rate of head growth
- Irritability
- Vomiting
- Voss of appetite
- Impaired extraocular movements, Esp. upward gaze
- Hypertonia
- Hyperreflexia
Facial appearance in neonates with downs syndrome
- Eyes slanting up
- sloping forehead
- low-set ears with small canals
- Glaucoma
- Eye(s) appear larger than normal
Facial appearance in neonates with fetal alcohol syndrome
- Eyes appear too small
- wide, flat nasal bridge
- Lacking a groove between lip &
nose (philtrum) - Small jaw (micrognathia)
Facial appearance in neonates with Pierre Robin syndrome
- Small chin (micrognathia): May predispose infant to respiratory obstruction
Asymmetry of neonatal face while crying might be associated with
aortic valve abnormalities
* Also consider Facial nerve palsy
Eyesight at birth
Visual acuity is poor (20/400)
* Lens is immobile
* Acuity improves the first 6 months
* Able to fixate & track by 2 months
Nose exam on a neonate
- Asymmetry of nares
- Possible septal deviation
- Birth trauma
T/F Infants are obligate nose breathers
T
Choanal atresia
narrow or blocked nasal airway (tissue)
Torticollis
Head persistently turned to one side
T/F It is NOT significant to hear fluid
during the Newborn exam
T
2 MOST COMMON signs of heart disease in the newborn infant
- Cyanosis
- Diminished pulses
Diminished pulses pathologies
i. Hypoplastic left heart + critical aortic stenosis
* Diminished pulses at all sites
ii. Aortic coarctation + interrupted aortic arch
* Diminished pulses in the lower extremities
Polyhydramnios
excessive amniotic fluid
Umbilical cord
- 2 umbilical arteries & 1 umbilical vein
- Only 1 umbilical artery may be
associated with renal, CV, & MSK
malformations
Hypospadias
Urethral meatus displaced proximally on ventral penis
* Do NOT circumcise!
Unpalpable testes may indicate
_____
Cryptorchidism
Clinodactyly
In turning of a finger, usually 5th
* Trisomy 21 Feature
* Short broad hand, single palmar crease
Intrauterine crowding causes an increased
risk for _____
Developmental Dysplasia of Hip
Examine hips via these tests
- Barlow test (dislocating the hip)
- Ortolani (relocating the hip)
Talipēs Ēquīnōvārus
Clubfoot
1. Metatarsus adductus
2. Varus heel deformity
3. Shortening of the Achilles tendon
* Treatment should begin while newborn
is in the nursery
* Serial casting
Asymmetry with hemihypertrophy
May be associated with a Wilms tumor of the
kidney
Brachial plexus palsies (Erb’s palsy)
- One of the upper extremities flaccid
- 2° difficult delivery with brachial plexus injury
- Most common = C5, C6
- Absent Moro reflex on the affected side
- Consult pediatric neurology
- Good prognosis
Subdural Hematoma
- Related to birth trauma
- Tear(s) in the venous blood supply of the
subdural space - Vomiting, irritability, lethargy, & seizures
within 2-3 days of birth - May be asymptomatic
- Neurological consult
Most common neonatal intracranial hemorrhage
Primary Subarachnoid Hemorrhage
Babinski reflex
is “POSITIVE”
* Toes splay
* Normal in infants < 6 months of age
Moro (startle) reflex
- 28 weeks gest. to ~3 months
- Supporting head/neck, quickly lower baby down
- Symmetric abduction & extension
Rooting reflex
- 28 weeks gestation
- Stroking the cheek
- Infant turns head towards stimulus & opens mouth
Sucking reflex
- 14 weeks gestation
- Sucks in response to a nipple in the mouth
Palmar Grasp reflex
- 28 weeks gest. to ~ 4 months
- Placing index finger in palm of hand will elicit grasp
Tonic neck reflex
- Disappears by age 8 months
- Turn Infant’s head to one side
- Ipsilateral arm & leg will extend
- Contralateral arm & leg will flex
- ”Fencing position”
