The Neonatal Infant Flashcards
Ballard scores
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
Lanugo
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
Transverse sole creases
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
Breast tissue
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
SGA and LGA
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
Ear cartilage
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
Male reproductive genitalia for gestational age
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
Female genitalia for gestational age
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
Details about the neuromuscular maturity testing for Ballard scoring
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
Square window test
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
Scarf sign
Measures if the elbow can be drawn across the infants chest with gentile traction
- not all the way = term
- all the way across = preterm
Heel-ear maneuver
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
Primitive reflexes review
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)
Intrauterine growth restriction (IUGR)
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
Caput succedaneum
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
Cephalhematoma
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
Clavicle fracture
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
Supernumerary digit vs polydactyly
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
Surgical correction of syndactyly
Usually postponed until 3 years of age unless synchondrosis is present
Midline cleft lip/palate
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
Congential hip dislocation
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
Umbilical hernia
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**
Respiratory distress syndrome
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
Transient tachypnea of the newborn (TTN)
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
Meconium aspiration
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)
Neonatal abstinence syndrome
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
Long term outcome for neonatal abstinence syndrome
Impaired auditory information processing
Developmental delay
Learning disabilities
Low IG and cognitive learning impairments
When a re women screened for gestational diabetes
24-28 weeks or pregnancy
Effects of diabetic mothers -> babies
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
Infant of diabetic mother work up
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
Polycythemia in macrosomial infants
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
Neonatal sepsis
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
Most common pathogens for sepsis infants
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
GBS neonatal infection
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
Risk factors for GBS infections
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
Neonatal hyperbilirubinemia
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
Kernicterus
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
Concerns for non physiologic jaundice
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
Breast milk hyperbilirubinemia (jaundice)
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
Breast feeding jaundice
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
Protocols for evaluation of jaundice
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
Phototherapy
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)
Neonatal herpes infections
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
