Peds: Prenatal/Newborn Assessment/Screening

Question 1

Assessment of Prenatal History

Answer 1

• *course of prenatal care;
• *xenobiotic used during gestational period;
• *health problems during pregnancy;
• • intrauterine fetal health problems;
• *mother’s perception of pregancy

Question 2

Assessment of Perinatal History

Answer 2

• *delivery process (vaginal vs c-section, planned vs emergent, induced, analgesia/anesthesia);
• *complications during delivery (meconium, placenta previa/abruption, forceps/vacuum);
• *birth size/wt (low < 2,500 g, very low < 1,500 g, extremely low < 1,000 g);
• *assessment of wt for gestational (average 10th - 90th percentile, large > 90th percentile, small < 10th percentile);
• *APGAR socres (5 areas= appearance, pulse, grimace, activity, & respiration = 0, 1, 2 pts possible with max score noted at 1 min & 5 min after birth = total max 10 pts)

Question 3

Assessment of Postnatal History

Answer 3

• *hospital course;
• *maternal problems (bleeding, infection, dehydration, breastfeeding, anesthesia response, fever, depression);
• *infant problems (ABO/RH incompatibilities, hyperbilirubinemia, Hip dysplasia, murmurs, Talipes equinovarus congenita (club feet), & genetic syndromes

Question 4

Newborn Physical Examination:

• average weight, length, head circumference
• gestational age

Answer 4

• *weight, length, head circumference:
• —average length 20-21 inches;
• —average wt 7 lbs (3.1 kg);
• —average head circumference 13-14 in (33-35 cm);
• – note ethnic differences in height;
• *assessment of gestational age:
• –37-41 weeks full term - best outcomes;
• –prior to 37 weeks premature;
• –after 41 weeks post term

Question 5

Newborn Physical Examination
IUGR = Intrauterine Growth Retardation:
- Small Gestational Age (SGA)

Answer 5

• SGA = small gestational age**
• **33% of SGA infants = SYMMETRIC
• – head circumference, weight, & length are < 10th percentile;
• *due to long term compromise to fetus as in genetic disorders, intrauterine infection, inborn metabolism errors, & environment- drugs, smoking, or radiation;
• **55% of SGA infants = ASYMMETRIC
• — head circumference & length are normal but weight is < 10th percentile;
• *due to extra fetal compromise occurring > 24 weeks; from chronic HTN, pre-eclampsia, renal disease, cyanotic heart disease, hemoglobinopathies, abruptio placentae, high altitudes (mountains), multiple gestation

Question 6

Newborn Physical Examination:

LGA or Large Gestational Age

Answer 6

• *weight > 90th percentile; may be due to-
• *Beckwith-Wiedemann syndrome: congenital growth disorder which causes hemihypertrophy, large organs, & other symptoms;
• *Hydrops Fetalis: fatal condition of which abnormal accumulation of fluid is noted in 2 or more fetal body areas;
• *maternal diabetes;
• *large mother

Question 7

Newborn Physical Examination:
Dubowitz/Ballard Exam for Gestational Age
- part 1: physical maturity assessment

Answer 7

• *physical maturity assessment–
• *2 hours of birth with pts (-2 to +5) given for six criteria:
• *skin texture (sticky, smooth, peeling);
• *lanugo (soft, downy hair- absent on immature infants, present on mature infants, and disappears with post maturity);
• *plantar creases (sole of feet ranging from absent to covering entire feet);
• *breasts (thickness & size of breast tissue);
• *eyes/ears, & genitals (male- presence/appearance of smooth to wrinkled scrotum; female- size/appearance of clitoris/labia)

Question 8

Newborn Physical Examination:
Dubowitz/Ballard Exam for Gestational Age
- part 2: neuromuscular maturity assessment

Answer 8

• *neuromuscular maturity assessment–
• *24 hrs of birth with pts given for six criteria:
• *posture- how arms/legs held (good tones/flex);
• *square window- how baby’s hand flexes toward wrist (90 degree angle flex- premies, flex to forearm- term);
• *arm recoil- how far arm’s spring back to flex position;
• *popliteal angle;- how far knees extend;
• *scarf’s sign- how far elbows cross chest (no cross midline- term; line of elbow cross midline- premie);
• *heel to ear- how close feet move to ears;

Question 9

Newborn Physical Examination:
Dubowitz/Ballard Exam for Gestational Age
- part 3: gestational age determination based upon sum of scores

Answer 9

• *low scores indicate immaturity;

* *high scores indicate mature or post mature infant

Question 10

The Dubowitz/Ballard Exam for Gestational Age has ____ parts.

Answer 10

**physical maturity, neuromuscular maturity, & gestational age determination

Question 11

Newborn Vital Signs

Answer 11

• *FEVER = temperature > 100.4 degrees F (38 deg. C);
• *PULSE 120-180 bpm;
• *RESP 30-80 bpm;
• *BLOOD PRESSURE < 112/74 mmHg

Question 12

Newborn Skin: Common Variations

Answer 12

• *typical skin changes - pallor, cyanosis, plethora (blotchy skin- polycythemia), jaundice, grey;
• *milia- pinpoint white papules to face, disappears 3-4 wks (widespread distribution = genetic syndrome);
• *miliaria- (R for red aka “prickly heat”)- obstructed sweat or eccrine gland ducts;
• *erythema toxicum- most common, appears 2-5 days after birth, blotchy red spots with overlying white/yellow papules/pustules; disappears 14th day;
• *Cafe au lait spots- subtle shade discoloration on either flank, may not present @ birth, size increase with age, more than 6 in child > 5 yrs suspect neurofibromatosis;
• *Mongolian spots- benign, flat, congenital birthmark with wavy borders/irregular shape, commonly blue, last 3-5 days after birth, disappear @ puberty;
• **Port wine stains- vascular birthmark of superficial deep dilated capillaries in skin, produce reddish/purplish discoloration, permament, associated to neuro (seizures) & ocular (glaucoma) disorders;
• *Strawberry mark- “hemangiomas”- 2% babies, raised soft red lumps, common in prematurity, hypo/per-pigmented, shrink/fade after 6 mos of age

Question 13

Newborn Neurological Exam:

Reflexes, LOC, Tones, & Posture

Answer 13

• *LOC- alert;
• *Posture- hips abducted/partially flexed, knees flexed, arms adducted, elbows flexed, fist clenched;
• *Tone- head inline at least 3 sec;
• *Reflexes- symmetrical;
• *Primitive Newborn Reflexes- pacing/stepping (disappears 1-2 mos), rooting, sucking, moro, plantar grasp, tonic neck (disappear 3-4 mos); palmar grasp (disappear 3-6 mos), Babinski “toes fan”- (disappears 12 mos or walking)

Question 14

Newborn Assessment of Head/Neck:

Head Variations

Answer 14

• *Caput Succedaneum- fluid under skin, simple swelling, crosses suture lines, result of birth trauma, disappears 2-3 days; no tx required;
• *Cephalohematoma- blood under periosteum (skull bone), does not cross midline, develops 24-48 hrs after birth, needs further evaluation;
• *Bossing- protruding of various skull bones- noted in Rickets, , beta-thalessema (late), acromegaly, congenital syphillis, prematurity;
• *Microcephaly- head circum smaller than 2 stand. dev, -small brain, fetal alcohol syndrome, chromo. abn, PKU
• *Macrocephaly- head circum larger than 2 stand. dev, hydrocephalus;

Question 15

Newborn Assessment of Head/Neck:

Eyes

Answer 15

• *sclera is normally white and may appear bluish in premies;
• *deep blue sclera- rule out osteogenesis imperfecta- prone to fxs;
• *red reflex- normally ranges from pink, orange, & red in color on exam;
• *red reflex- replaced by black spots (means no clear pathway from lens to retina);
• *red reflex- replaced by whitish color (means retinoblastoma or congenital cataracts);
• *Colobomas- (familial or spontaneous embryonic fissure defect- normally closes 5th wk gest)- mild forms affect iris, severe forms-choroid/optic nerve involved- suspect CNS defect ex. optic nerve hypoplasia;
• *Heterochromia- mix/diff colors of the iris;
• *Cloudy corner- sclerocornea, Peters anomaly, trauma, infection, dermoid tumor
• *Salt/Pepper speckling (Brushfield spots of the iris)- assoc to Down syndrome

Question 16

Newborn Assessment of

Cardiovascular, Pulmonary, Gastrointestinal, & Genitourinary system

Answer 16

• *Pulmonary/Chest- assess resp rate/pattern (normally abdominal breathers); retractions, stridor, grunting, breast enlargement;
• *CV- assess cap refill, radio-femoral pulse delay- diff noted in upper/lower extremities (consider coarctation of aorta), pulse character, location/size of PMI (point of max impulse)- 3rd-4th intercostal space/lfet midclavicular line, murmurs- present in 85% newborns;
• *Abdomen- flat abdomen is abnormal (should be slightly protruding), umb. cord (2 arteries/1 vein), color of umb cord, hernias, anal patency (noted by meconium passage);
• *genitourinary- males -penis for urethral meatus (hypospadias- ventral side & epispadias- dorsal side); ability to retract foreskin, tests- 97% descended @ birth (occurs in 3rd trimester); females- discharge/small amount of bleeding may be noted (hormones)

Question 17

Newborn Assessment: Screening Principles

Answer 17

• *screen for disorders of which symptoms may not present until irreversible damage occurred;
• *disorders without cure;
• *prevalence of disease in population;
• *use simple screening method;
• *use screening which has low false +/false - results;
• *high benefit-to-cost ration (most cost effective);
• *mechanism present for follow-up after dx;
• *tests available for over 50 conditions;
• *early identification of metabolic disorders is a goal;
• *all 50 states require testing of: PKU, GALACTOSEMIA, SICKLE CELL, CONGENITAL HYPOTHYROIDISM

Question 18

Newborn Assessment: Screening Considerations

Answer 18

• *re-screen is mandatory if newborn tested < 24 hrs of birth;
• • re-screen infants who appear asymptomatic;
• *identify disease risk factors-
• *vision screening- congenital cyanotic disease or structural anomalies;
• *hearing screening-absent startle (moro) reflex, BSAER (brain stem auditory evoked response) test- no later than 3 mos and tx by 6 mos of age;

Question 19

Newborn Assessment of Head/Neck:

Hair Patterns & Growth

Answer 19

• *color should match/uniform;
• *distribution- uniform;
• *white forelocks iwth other anomalies- assoc. to deafness & retardation (Waardenburg syndrome- group of familial conditions);
• *more than 1 whorl (patch of hair growing in oppos direction of rest of hair)- possible poor brain growth;
• *unruly hair with unusual facies, SGA, & microcephaly- assoc to Down syndrome

Question 20

Newborn Assessment of Head/Neck:

Fontanels

Answer 20

• *anterior fontanel- largest (2-5 cm), closes by 18 mos;
• *posterior fontanel- may not be palpable at birth, closes by 2-3 mos;
• *Overriding sutures- normal and disappears as brain/head grows;
• *wide fontanels- prematurity, IUGR, Down, hydrocephalus, & hypothyroidism

Question 21

Newborn Assessment of Head/Neck:

Ears, Nose, & Throat

Answer 21

• *assess for symmetry, placement, pits, skin tags;
• *Choanal atresia (narrowing/blockage of nasla airway by tissue at birth);
• *Mouth/plalate- assess size/shape-
• *Microstomia (small mouth)- trisomy 18 “Edwards” (high pitch cry, posturing, mult. defects, high mortality) and 21 “Down”;
• *Macrostomia (large mouth)- mucopolysaccharidoses (lysosomal disorder- cannot break down sugar) and fetal alcohol syndrome;
• *Cleft lip/palate- assess feeding/aspiration, freq. URI; teach- feeding position, may need sx repair;
• *Tongue- macroglossia- hypothyroidism, Down (hypotonia), mucopolysaccharidoses;
• *Teeth- Epstein pears- collect in gums over time (assoc with Miliria); Natal teeth

Question 22

Newborn Assessment of Musculoskeletal system

Answer 22

• *scoliosis- lateral curvature of spine;
• *kyphosis- curvature of thoracic spine;
• *lordosis- curvature of lumbar spine;
• *spinal defects- ex. meningomyeloceles (spina bifida);
• *clavicle fx;
• *fingers/creases;
• *hip dsyplasia- hips flexed 90 degrees/knees together (check knee ht)- abduct and adduct while fingers @ greater trochanter-
• **ORTOLANI click- heard/felt as dislocation reduced;
• **BARLOW’S MANEUVER- feeling of slip as femoral head slps from acetabulum causing dislocation; also note fat pads (skin fold thickness @ hip)

Question 23

A newborn is considered ____ months of age.

Answer 23

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