The Neonatal Infant

Question 1

Ballard scores

Answer 1

Used to assess gestational age of newborns

Uses 6 morphological and 6 neurologic criteria

Neuromuscular maturity

• posture (more flexed the older)
• “square window”
• arm recoil
• popliteal angle (smaller the older)
• “scarf sign”
• heel - ear

Physical/morphological maturity

• skin = more leathery and wrinkled the older
• lanugo = more bald = older (bimodal curve though)
• plantar surface = more creases the older
• breast = larger areola = older
• eye/ear = more cartilage and still ear with lids open = older
• genital = more defined = older
• *most striking difference physically = quality of skin (premature = paper thin, near gestational = thickened with keratin)**
• also premature = red and term = pink

Question 2

Lanugo

Answer 2

Fine thin hair more seen in preterm and eventually becomes coarser,thicker hair at term
- starts to develop at 24 weeks and is gone before 39-40 weeks

Question 3

Transverse sole creases

Answer 3

Begin to appear on the anterior portion of the soles of the feet at 32 weeks and by 36 weeks most of the sole is covered with creases

congenital dysfunctional or pedal edema in infants can cause less creases

Question 4

Breast tissue

Answer 4

Increases in size as gestational age advances (both in boys and girls)

Infants born <28 weeks have nearly any perceptible breast tissue and difficult to discern breast and areola

With advanced gestational age = increases in size due to active glandular secretions

• this can remain palpable for 2-3 months but resolves 90% of the time by then
• **if it doesnt resolve or turns red and tender = see for mastitis and put on antibiotics

Question 5

SGA and LGA

Answer 5

Small for gestational age = <10th percentile in growth vs standard for gestational age

Large for gestational age = > 90th percentile in growth vs stand argue for gestational age

• most are from diabetic or prediabeteic mothers (often present with moon facies and hirtuism as infants also)
• most weight more than 4kg (8lbs 13 oz)
• **often have hypoglycemia and hyperinsulinemia

Question 6

Ear cartilage

Answer 6

Proceeds in an orderly manner during gestation

Normal incurving of the upper pinna begins at 33-34 weeks and is complete at term
- **however it is more reliable to assess the extent of cartilage recoil than the curving of the pinna

**<32 weeks = minimal recoil of the pinnae

**Near term = instant recoil of the pinnae

Varies in between 32-39 weeks

Question 7

Male reproductive genitalia for gestational age

Answer 7

Testes are palpable in the inguinal canal by 28-30 weeks

Testes descend starting at around week 34-35

Rugae on scrotum parallels testicular migration and appears at 36 weeks
- these cover the entire scrotum by week 40

Question 8

Female genitalia for gestational age

Answer 8

As they get older, the labia majora starts to be come the most apparent structure and covers the clitoris
- this fully occurs at around 34-36 weeks and gets more prominent to term

**premature = clitoris is larger than labia minora/majora

Question 9

Details about the neuromuscular maturity testing for Ballard scoring

Answer 9

Best is to cover range of motion, tone reflexes and posture

none are reliable if there is illness in the neonate

Best done between 12-24hrs after birth to allow for recovery from stress of delivery

the mature infant exhibits a marked flexor posture of the extremities

Question 10

Square window test

Answer 10

Tests the wrist by performing gentle flexion of the hand on the wrist and Measure the resultant angle

<32 weeks = flexed only 45-90 degrees

Term babies = undergo full flexion

Question 11

Scarf sign

Answer 11

Measures if the elbow can be drawn across the infants chest with gentile traction

• not all the way = term
• all the way across = preterm

Question 12

Heel-ear maneuver

Answer 12

Determines resting tone of the lower extremities

Baby is on back and pelvis flat
- foot is moved as near to ipsilateral ear as possible without exerting undue forces

<30 weeks = super easier to touch heels to ears

> 34 weeks = almost impossible to do

Question 13

Primitive reflexes review

Answer 13

Normal newborns should exhibit all of these, however they should resolve by a certain age

1) Moro = hold the baby supine and then act like your gonna drop them by letting the head suddenly fall back (obviously catch the head and dont let it drop all the way)
- evaluation of the vestibular maturation and tone
- (+) reflex = sudden abduction and extension of the infants arms and elbows with immediate flexion and crying
- **should resolve no later than 3 months (3-6 is the time frame though)
- unilateral absence = ipsilateral brachial plexus injury
- bilateral absence = brain injury (CN8 or vestibular region damage) or bilateral brachial plexus injuries

2) rooting reflex
- stroking the cheeks of the infant automatically induces ipsilateral head turning and opening of the mouth
- should resolve by 4th month
- unilateral absence = lower motor neuron damage to CN 7 or 5
- bilateral absence = premature infant with intracranial hemorrhage

3) suckling reflex
- touching the roof of the mouth elicits suckling motion
- should resolve by 4th month
- absence = same as rooting reflex

4) palmar grasp
- stimulation of the palm elicits a grasping motion
- should resolve by 6 months (3-6 is timeframe)
- absence = brachial plexus injuries or cerebral palsy (if bilateral)

5) plantar grasp
- stimulation for the sole elicits curling of the toes (plantar flexion)
- goes away at 3 months, then comes back at 12 months and is normal from there on in
- bilateral absence = cerebral palsy

6) plantar reflex (babinski)
- stimulation of the foot from heel -> toe elicits dorsiflexion
- goes away by month 12
- reappearance at any time or persistence = UMN lesions)

Question 14

Intrauterine growth restriction (IUGR)

Answer 14

Deviation in the expected fetal growth pattern
- usually some body sections dont grow as well as other body parts of compartments

Complicates upon to 8% of all pregnancies and is increased with perinatal morbidity

Etiology is multifactorial and can be fetal/placental and maternal factors can all palsy role

small for gestational age DOESNT equal IUGR

Question 15

Caput succedaneum

Answer 15

Edema in the skull and scalp of a baby that generally cross the suture lines of the parietal and occipital sutures

Is normal in small amounts but large amounts can occur with prolonged labor and birthing Trauma
- also with use of vacuum extractor

most often collects around occipital and parietal bones bilaterally

most of the time doesn’t require any intervention as long as it regresses within 3 days

Question 16

Cephalhematoma

Answer 16

Is a localized collection of blood beneath the periosteum of one of the calvarial bones
- usually unilateral but can be bilateral

• *can be confused with a caput except that that this hematoma DOENST cross suture lines**
• usually confined within the parietal bones

Can develop jaundice due to breakdown and resorption of a large hematoma

Question 17

Clavicle fracture

Answer 17

Common in macrosomia and breech infants

If non displaced = may be asymptomatic

should be suspected if palpation produces creptius and/or intense crying or if there is a asymmetrical Moro reflex

Treatment = immobilization of ipsilateral limb with shoulder and elbow flexed to 90 degrees for 8-10 days
- this is when a callus is palpable which means the bone has healed properly

Question 18

Supernumerary digit vs polydactyly

Answer 18

Both present as 6 fingers or toes

Supernumerary = usually no bones and has a small pedicle “stalk” coming off a digit

Supernumerary = usually asymptomatic and just need to strangulate the digit for a week and it falls off by itself

this is common in African-American infants

Question 19

Surgical correction of syndactyly

Answer 19

Usually postponed until 3 years of age unless synchondrosis is present

Question 20

Midline cleft lip/palate

Answer 20

Most common facial anomalies

Most are seen at day 35 days by ultrasound if present

if Pierre robin sequence = significant respiratory obstruction also and needs surgery earlier at brith

also often presents with Eustachian tube dysfunction and recurrent otitis media

Question 21

Congential hip dislocation

Answer 21

6x more likely in females than males and even more common breech, oligohydramnios and family history

Often shows (+) Galeazzi sign = unequal knee height and apparent shorter femur when a child is placed supine with hips and knees flexed

Requires ortolani and Barlow maneuvers to diagnose (Barlow) and and see if the dislocation is reducible (ortolani)

• Barlow = flex and adduct hip produces a “thunk” with hip dislocation
• ortolani = flex and abduct hip produces a “thunk” with hip reduction

**even with these two you still need to get hip ultrasound if less than 4 months and pelvic xray if greater than 4 months to confirm

Should consult orthopedic consultation if this is present

Treatment = Pavlov harness for infants <6 months (keeps hip at 90 degree flex with 50 degree abduction)

6-18 month or fails pavlov = closed reduction with hip spica cast

Question 22

Umbilical hernia

Answer 22

Defect of the central fascia beneath the umbilicus
- more common in African Americans, premature infants and those with congenital thyroid Deficiency

Must differentiate from omphalocele!!

• *usually don’t have to worry about it and can resolve by itself
• only need surgery if bowel gets stuck in the umbilical hernia**

Question 23

Respiratory distress syndrome

Answer 23

Usually seen in premature babies <34 weeks gestational age Due to Deficency of surfactant

Symptoms

• hypoxia, cyanosis and tachypnea
• grunting
• flaring of nares
• retracting and poor air movement
• *all are seen shortly after birth**

Imaging shows “ground glass” appearance in lungs

Supportive care is needed to keep oxygen sat 90-95%
- give exogenous surfactant after birth and give prenatal corticosteroids to mother if you know this may be coming

• *most recovery with this but <3% show bronchopulmonary dysplasia**
• also more prone to RSV and asthma in the future

Question 24

Transient tachypnea of the newborn (TTN)

Answer 24

Msot common cause of respiratory distress for term infants

Is more repeated to delayed removal of fetal lung fluids and is more common in C-section babies

Shows streaky perihilar shadows with visible fluid densities

Shows similar symptoms to respiratory distress syndrome except far less severe symptoms a newborn not cyanotic

Is temporary and goes away in 2 days (needs mild supportive care at worst)

• don’t need antibiotics and surfactant
• if they aren’t better in 2 days = work up for infections and lung issues that are worse than this

Question 25

Meconium aspiration

Answer 25

Inflammatory response caused by inhalation of the meconium - shown inflammation throughout the lungs and always appears in respiratory distress Imaging shows hyperaeration and consolidations in the lung fields (usually need a Hx of meconium being passed)

Question 26

Neonatal abstinence syndrome

Answer 26

Occurs if a pregnancy mother is addicted to opioids and takes them while pregnant Multiple different symptoms but reside in three systems 1) GI 2) neurologic 3) cardiopulmonary Common ones are - tremors, irritability high pitched cry, seizures, hyperactive reflexes - sneezing, tachypnea and tachycardia - poor feeding, uncoordinated or constant suckling reflexes, emesis and diarrhea - dehydration and poor weight gain Symptoms get worse 5-7 days after abrupt loss of whatever the drug is that the baby is addicted to secondarily Treatment - low noise, dim light, higher calorie formula - titrate and taper short or long acting opioids if the baby has a high score or really bad symptoms (ween them off very slow) - morphine (short acting) = 3-4 hrs, methadone (long acting) = 2x a day - can add phenobarbital and Clonidine as adjuvant therapy as you ween them off

Question 27

Long term outcome for neonatal abstinence syndrome

Answer 27

Impaired auditory information processing Developmental delay Learning disabilities Low IG and cognitive learning impairments

Question 28

When a re women screened for gestational diabetes

Answer 28

24-28 weeks or pregnancy

Question 29

Effects of diabetic mothers -> babies

Answer 29

First trimester - CNS abnormalities - heart and kidney abnormalities - caudal regression syndrome with potential Mermaid legs 2nd trimester and 3rd trimester = macrosomia primarily and neonatal hypoglycemia when born

Question 30

Infant of diabetic mother work up

Answer 30

All babies need to be feed within the first hour of life (hypoglycemia) All babies need to have a bedside glucose measurement approximately 30 minutes after feeding Blood glucose <40 mg/dL with any symptom of hypoglycemia at anytime requires IV glucose If there is no symptoms of hypoglycemia after feeding = infant is refer and the glucose is remeasured to make sure they re still stable **MUST continue monitoring glucose for the first 12 hrs of life (or longer) until 3 consecutive preprandial measurements are normal **must correct hypoglycemia if present (irritability, sweating or seizures) = IV calcium carbonate**

Question 31

Polycythemia in macrosomial infants

Answer 31

Almost always seen and is defined as > 65% Hct - often gives ruddy or plethoric hue to the infants skin Contributes to elevated bilirubin levels and can cause hyperviscosity syndrome which can cause VTEs in infants! - treatment = excess hydration until the polycythemia (which is transient) disappears in about 1-2 weeks

Question 32

Neonatal sepsis

Answer 32

1) Early-onset = sepsis within the first 6 days of life - majority occur within 24 hrs of life - usually some sort of genitourinary tract infection from mother (most common = GBS) 2) Late-onset = sepsis after 7 days but before approximately 90 days of life - infection source is often the caregivers home ``` Signs/symptoms are very nonspecific - temperature instability either way - tachypnea - hypotension - bradycardia - pallor - poor capillary refill = seziures - AMS - bulging anterior fotnanelle - focal cranial nerve signs ``` CNS signs are more common in late sepsis Respiratory signs are more common in early sepsis Evaluation for sepsis - check CBC (low or high WBC, increased neutrophil counts, increase band/immature:total neutrophil ratios, thrombocytopenia all indicate sepsis as possible) - blood cultures and urine cultures are needed - chest imagining is needs with respiratory symptoms

Question 33

Most common pathogens for sepsis infants

Answer 33

GBS, E. coli, haemophilus influenza, listeria monocytogenes are most common **if the babies are hospitalized = have to work up for staph aureus, staph epidermis, pseudomonas and enterobacter species also**

Question 34

GBS neonatal infection

Answer 34

Most common cause of neonatal sepsis from brith - 3 months - has a motility of up to 10% * *80% shows early onset sepsis symptoms, especially the respiratory symptoms** - may show hypotension also - 50% develop seizures within 24hrs of infection also **30% chance to produce major neurological sequelae (cortical blindness, spasticity may global retardation) after treatment (so need to stop this before ideally) Late onset GBS is rare (<20%) bit is more subtitle - MAJOR risk factor = prematurity - all you usually see are nonspecific bacteremia signs and lab values - 20% does show meningitis though - can show septic arthritis and osteomyelitis Treatment: - early = penicillin B + gentamycin - late = vancomycin + ceftriaxone * *antibiotics are given IV for 48-72 hrs** - if the cultures come back negative and the baby is fine = stop antibiotics before 72 hrs (if the cultures are negative but baby is doing bad still = keep giving antibiotics - positive cultures = give for 10 days

Question 35

Risk factors for GBS infections

Answer 35

ROM more than 18 hrs before delviery Chorioamnionits or intrapartum temp > 100.4/ 38C Previous infant with GBS Mother is younger than 20 years old Low birth weight baby or premature

Question 36

Neonatal hyperbilirubinemia

Answer 36

Normal physiological unconjugated jaundice that can occur during neonatal period - due to limited ability to excrete unconjugated bilirubin from the liver getting up to speed - seen in the first week of life in about 60% of full term and 80% of preterm infants - usually peaks at 5-6 mg/dL and between 2nd and 4th days of life Risk factors - male gender - Asian ancestry - breast feed baby - cephalohematoma history of - trisomy 21 - hypothyroidism Need to get serum or transcutaneous bilirubin levels

Question 37

Kernicterus

Answer 37

Neurological syndrome resulting from high levels of unconjugated bilirubin deposition in brain cells in infants with extreme jaundice - usually deposits on the basal ganglia, globus pallidus, putamen and the caudate nuclei Produces - lethargy - poor feeding - any sepsis symptoms - any hypoglycemia symptoms - loos of the Moro reflex **always look horrible**

Question 38

Concerns for non physiologic jaundice

Answer 38

Appearance within first 24-36 hrs of life and is usually > 5 mg/dL/24hr Bilirubin > 12 mg/dL in a full term infant without other physiologic jaundice risk factors Jaundice that persist after 10-14 days of life **usually fails phototherapy treatment to lower bilirubin levels also** Causes: - sepsis - congenital rubella, CMV or toxoplasmosis - biliary atresia - hepatitis - hypothyroidism - CF - drug induced hemolytic anemia or congenital hemolytic anemia

Question 39

Breast milk hyperbilirubinemia (jaundice)

Answer 39

Increased concentration B-glucuronidase in breast milk (since baby has difficulty breaking it down initially) results in increased de conjugated and reabsorption of bilirubin - causes unconjugated hyperbilirubinemia (can get as high as 30mg/dL) Usually presents within 2 weeks after birth and lasts 4-13 weeks - treatment = continue breastfeeding and supplementation with formula as needed (to rapidly decrease the bilirubin level)(overtime the neonate will be able to break down glucuronidase normally) - phototherapy if needed - do need to follow with GI just to make sure

Question 40

Breast feeding jaundice

Answer 40

Insufficient breast milk intake results in lack of calories and decreased bowl movements to properly remove bilirubin from GI tract = more gets reabsorbed of unconjugated bilirubin Onset within 1 week Treatment = rehydration and increase breastfeeding sessions

Question 41

Protocols for evaluation of jaundice

Answer 41

Measure total seru, bilirubin level or noninvasive TcB levels - measured levels at the newborn sternum sternum correlates with serum levels TcB measurements are NOT reliable after the infant has undergone phototherapy however

Question 42

Phototherapy

Answer 42

Used if hyperbilirubinemia is present - unconjugated bilirubin only Converts unconjugated bilirubin via isomerization -> water soluble forms which get excreted in urine and/or bile Is used until total bilirubin levels are < 15mg/dL - DONT use only unconjugated bilirubin as the measurement ONLY total **DONT use in congenital erythropoietic porphyria or family history of any porphyria infants** Risk factors refractory hyperbilirubinemia - isoimmune hemolytic disease - G6PD Deficiency - asphyxia - significant lethargy - temperature instability - sepsis - acidosis - albumin <3g/dL (severe hypoalbuminemia)

Question 43

Neonatal herpes infections

Answer 43

Risk of maternal passage of HSV to neonate is 25-60% in primary herpes - **this is because the protective antibody is not present in primary and the viral load is very high** - less than 2% in secondary/flare up herpes infection (there is antibodies present) Incubation period = 2-21 days and peaks at 6 days **remember that any young infant that presents with irritability + fever is assumed to have a bacterial or viral infection(** Symptoms - irritability - poor feeding - bulging fontanelle - *fever 100.4F/38C (or greater) - tachycardia and tachypnea - *shows herpes lesions - *focal seizures **often will show meningitis signs and symptoms with diagnosis of viral meningitis w/ hepatitis and thrombocytopenia** Diagnosis - all subtypes = get blood urine and CSF specimens to rule out bacterial causes - need to get surface cultures from the conjunctiva, nasopharynx, mouth, rectum and any vesicular lesions for HSV - PCR from CSF and blood cultures to rule in HSV DNA Treatment - Skin eye and mouth herpes = IV acyclovir and get a LP to determine its not disseminated - disseminated = IV acyclovir, get LP and look for chorioretintis via ophthalmology referral