The Newborn Infant Flashcards
3 components to a complete newborn hx
- Maternal and paternal medical history
- Maternal past obstetric history
- Current antepartum and intrapartum history
- Courtesy of most Pediatric office – usually no charge for the visit
- Valuable for 1st time parents or families searching for right provider
- Allows family to meet and visit with PCP and their office
what type of visit is this?
Prenatal visit
components of a maternal an paternal hx
- Chronic medical issues in the family ?
- Dietary habits
- Smoking or substance abuse ?
- Occupational history ?
- Social history – abuse or neglect ?
- Family illnesses and congenital anomalies ?
components of a maternal OB hx
- Maternal age ?
- How many time pregnant ? Gravida
- How many times has she given birth ? Para
- Pregnancy outcomes ? ( TPAL = Term, preterm , abortus , living )
- Maternal blood type
occuring right prior to delivery
what is this term
antepartum
occuring during labor or delivery
what is this term
intrapartum
time after delivery up to 6 wks
what is this term?
post partum
wha to Review on antepartum and intrapartum Hx
- Review mom’s hx – US , amnio, screening labs (HBV, RPR, HIV and Rubella)
- Look at tests that determine fetal well being – NST, dopplers of blood flow and BPP
- Did mom have prenatal issues like Gestational DM, UTI’s, HTN , pre-eclampsia, preterm labor ?
- Siginificant issues - maternal fevers , difficult delivery, meconium stained fluid, vaginal vs C/S, forceps used, and any resuscitation at birth ?
what viral hx do you want to receive for the maternal/newborn hx
Hep B
Routinely give a Hep B vaccine shortly after birth to ALL newborns ( with parents consent )
For women who are + for what antigens through vertical transmission is about 90 %
HBsAg and HBeAg
If mom has HBsAg +, the baby needs ?
- HBIG (Hep B immune globulin)
- AND the Hep B vaccine ASAP after birth . Opposite legs .
- Then Hep B is given again at 1 and 6 months of life.
IfHBsAg is NOT tested, and mom is high risk, what is the next step?
give Hep B vacine ASAP and do labs. IfHBsAg is + can give HBIG up to 48 hours after
T/F: there is a Hep C vaccine and prevention for newborns
F: no vaccine or prevention
If mom is HIV +, babies receive antiretroviralswithin ?
6-12 hours
Mothers who have Hep B, what is completely CI for newborns?
Breast feeding is NOT recommended
- system that helps determine overall condition at birth = neonatal survival
- Recorded at 1 and 5 minutes after birth ( every 5 minutes if needed )
APGAR
Appearance
Pulse
Grimace
Activity
Rsp
T/F: APGAR does NOT predict long term outcomes
T
What is the scoring of APGAR and what is the minimum you want?
1-10, you want at least a 7
exam of the newborn that evaluates both physical characteristics AND neurological characteristics of a newborn
Dubowitz / Ballard Exam and Scoring
The total score of Dubowitz / Ballard Exam estimates ?
gestational age
Why is it important to know gestation
Ballard Age
due to knowing what behavior and medical issues can arise at different ages
What is the best indicator of gestational age (if known)?
Ballage Age
- Date of LMP
- If periods were regular
Physical and neurological development are cues to gestational age also
What imaging can also add to predictive value for Ballard Age?
Fetal US
When is it best to perform the Ballard Postnatal assessment?
Plantar creases
30-42 hrs of age
- Takes about 3-4 minutes to complete – even on sick infants
- New Ballard can test infants from 20-44 weeks
This is an unexplained death of a healthy baby that is younger than one
Usually happens during sleep
The true reason is unknown
SIDS (Sudden Infant Death)
theory of SIDS etiology
an area in the brainthat controls breathing and waking from sleep
RF for SIDS
- Certain brain defects – brain area that controls breathing is underdeveloped
- Low birth wt - similar to above - less control over autonomic processes
- Rsp infections - Many infants who die recently had a cold .
- Sleeping ontheir stomach or side
- Sleeping on a soft surface (fluffy blanket , soft mattress or waterbed)
- Sharing a bed- with parents, siblings or pets.
- Overheating - Being too warm can increase the risk also.
- Sex - males > females
- Age- largest risk between 2 and 4 months
- Race – for unknown reasons, it is more likely in Black , Native American and Alaskan Native babies .
- FHx- babies with siblings who died of SIDShave a higher risk
- 2nd hand smoke- babies who live with a smoker are at higher risk
- Premature births - being born early and having a LBW increase the risk also
How to reduce the risk of SIDS
- Placing baby on the back to sleep / never the side or stomach
- Keep the crib as bare as possible. Firm/ flat mattress
- No pillows, blankets or stuffed animals.
- Don’t overheat the baby. Never cover the baby’s head
- The baby should sleep in parents room for the first 6 months
- Breast feed if possible
- Do not rely on commercial devices that predict SIDS. They do not prevent it.
- Offer a pacifier.
- Get vaccines on time.
Components of the PE of the newborn
beginning/general
- Simple observation is important - Note color, tone, cry and movement. Best if the baby is undressed and quiet.
- Best if the baby is not hungry, and if the room is warm.
- Make sure your hands are warm.
- Talk to parents to tell them what you are doing.
- Suggest eye exam and listening first (heart & lungs)
- Then the ears, throat and groin for the latter – most upsetting
- Listen to the cry
- measurements - wt, height, head circumference
how should the cry of the newborn sound?
A normal cry is strong usually
abnormal cries from a newborn
- High pitched cry can be a sign of an abnormality
- Low , hoarse cry can be a sign of hypothyroidism
- Weak, poor cry can mean a sick infant
how should the skin of a newborn look like?
Normal is pink and uniform
Skin has a “mottled look “- like a cobblestone street
More commonwhen skin is cold
Superficial blood vesselsdilate and give red color then constrict and give bluecolor
Cutis marmorata
bluish discoloration of the infants HANDS and FEET
This effect is due to vasomotor changes that results in peripheral vasoconstriction and is benign.
acrocyanosis
Thie is a normal finding in all newborns.
Cutis marmorata is a common skin finding in what condition?
Down syndrome
Normal finding-waxy or cheesy like appearance after birth .
It is a biofilm that covers the fetus during the last trimester
Protects newborn skinand also provides a barrier against infection.
Vernix Caseosa
Delayed bathingis common, why is it helpful for vernix caseosa?
delaying over 12 hoursmay help thermoregulation, hypoglycemia and and the rates ofbreast feeding
Light, fine hair that covers the newborn baby.
Lanugo
- The earlier the baby is, the hairier it is
- The hair is thought to insulate the baby and to help the vernix “stick” to the baby.
- Disappears over time
4 common skin “rashes” in newborns
- Erythema Toxicum
- Newborn acne ( Ance neonatorum )
- Milia
- Sebaceous gland hyperplasia
- Red base , papular - vesicular rash that is COMMON in newborns
- Involves eosinophils in tiny vesicles
Erthythema toxicum
Appears 2-5 days after birth and resolves in weeks
Closed comedones – red and inflamed
Looks like real acne on the cheeks , forehead and sometimes chest and back
Acne neonatorium (Newborn acne)
Resolves on its own
Tiny, white epidermal cysts filled with keratin.
Milia
what are Epstein’s pearls?
Milia in the roof of the mouth
what are Hemangiomas
- Very common vascular birth mark.
- Cause is notknown.
- MC on face, scalp, thorax, can be anywhere.
- small, densely packed blood vessels
- They grow rapidly, then remain fixed and then start to resolve.
- Most are gone by the age of 9.
Hemangiomas may require immediate treatment if:
- Visual, hearing, rectal, vaginal, nasal obstructions
- Any airway obstruction
- Huge hemangiomas may cause cardiac decompensation
- Light red macules that are found over the nape of the neck ,upper eyelids and between eyebrows.
- We also call this a “Stork Bite “
Nevus simplex
Dark red macules anywhere on the body
Thick , dilated blood vessels
Nevus Flammeus/ port wine stain
If a nevus flammeus is seen on the face along the opthalmic branch, they have a risk to develope what syndrome?
Sturge Weber Syndrome
Nevus flammeus is associated with what vision problem?
glaucoma
what neuro complications can happen if a newborn has a nevus flammeus
- angiomas that grow in the brain
- seizures
- developmental disabilities
- Darkish blue birthmark over the lower back and butt
- More common in darker skinned babies .
- Also known as a “Mongolian Spot “
Congenital dermal melanocytosis
light brown oddly shaped flat macules that can be anywhere
They persist for life and may even increase in number
Café au lait spots
if Café au lait spotsare > 6 macules over 1/2 a cm, this is a major diagnostic criteria for ?
neurofibromatosis1
what can cause the newborn head to eb elongated?
vaginal births
____ babies have a narrow face and head at times
Breech
what is Hydrocephalus and causes
- Can be present at birth due to slowly increasing ICP ( intracranial pressure )
- causes ventricles to enlarge = head
- grows in circumference
- d/t obstruction of flow (Malformations in the brain like blocked 4th ventricle , Dandy walker malformation or Arnold Chiari malformation)
- overproduction ofCSF ( Choroid plexuspapilloma )
cause of Sunsetting eyes
increased pressure
management for hydrocephalus
- Serial head measurements
- VP ( ventriculo- peritoneal ) shunt to shunt fluid from the brain into the abdominal cavity
how many fontaelles do newborns have at birth
2 - anterior and posterior
which fontanelle closes from 9-24 months?
anterior
posterior - closes 2-3 months
Tense and bulging anterior fontanelle may indicate ?
Depressedfontanelle may show ?
- increased intracranial pressure
- dehydration
- Caused by swelling of scalp d/t pressure on head during a vaginal birth
- decreased blood flow to the area = edema
- Can extend across suture lines
- Localized soft tissue edema with poorly defined borders
- Resolves after 2-3 days
Caput Succedaneum
Head feels soft like a cyst and usually occurs after a difficult delivery, or an instrument associated delivery
Well defined outline, does not cross suture lines and takes several weeks to resolve
Cephalohematoma ( Head bruise )
This is actually a subperiosteal hemmorhage
- abnormal thinning of the parietal bones in preterm babies
- Gives the sensation of a ping pong ball on pressure
- Usually disappears in a few weeks.
Craniotabes
Craniotabes is usually along what parts of the skull
parietal bones , sometimes occipital , running along lambdoid suture lines .
If craniotabes does not disppear in a few weeks, what must you start thinking?
pathology - rickets, osteogenesis imperfectaor hydrocephalus
- Serious, but rare complication usually associated with vacuum-assisted delivery
- Caused by rupture of the emissary veins, which are connections between dural sinuses and scalp veins
Subgaleal hematoma/hemorrhage
cause of Subgaleal hematoma/hemorrhage
- rupture of the emissary veins, which are connections between dural sinuses and scalp veins
- Blood accumulates between the epicranial aponeurosis of scalp and periosteum
- This space can easily accommodate up to one half of the blood volume of a neonate
- Need to monitor blood pressure, hematocrit, bilirubin, signs of hypovolemia
Why is examining the face important and what to look for?
- Odd faces may mean a genetic condition
- Should be examined carefully in regard to shape, size , eye position , ears , nose , mouth and chin
- If there are several anomalies, one must think of an associated syndrome .
Short jaw (Micrognathia) , cleft palate and airway obstruction
Life threatening congenital anomaly .
Pierre Robin Syndrome
cause of Pierre Robin Syndrome
- Happens due tofailure of the mandible to grow. Tongue blocks fusion of the palate- so a cleftforms
- Tongue then obstructs the airway .
tx for Pierre Robin syndrome
fixing the lower jaw
supporting the child with feeding help and breathing helpin the meantime
What cranial nerve can be damaged during delivery?
CN VII - facial nerve palsy
It can be due to difficult/ forcep assisted delivery
A newborn has an asymmetrical face while crying, what may you suspect?
facial nerve palsy
tx for facial nerve palsy?
observation
- Collection of blood beneath the conjunctiva due to trauma
- Likely due to the birth process.
- A common eye finding
- Goes away on its own and needs no treatment
Subconjunctival hemorrhage
newborns with Conjunctivitis are all given?
- erythromycin ointment to prevent chlamydia eye infection right after birth
- leading cause of blindness in developing countries
- This is a clouding of the lens of the eye – present at birth .
- May indicate medical issue- metabolic disease, congenital infection or problems with the thyroid
Congenital cataracts
- rarely affects newborn’s eyes and cause major damage to the optic nerve .
- If undiagnosed and untreated, can lead toblindness.
- These kids have tearing, tight eyelids and terrified of light
Glaucoma
how to examine the red reflexes of the newborn eyes?
- Red reflex with the ophthalmoscope
- Examine about 6 inches away .
- Every visit for the first 3 years .
Absent,blunted or white reflex can mean what when testing red reflexes of the eyes?
glaucoma , congenital cataract or retinoblastoma
White response during red reflex testing is indicative of?
Leukoria
This is an immediate referralto Opthalmology
This is a rapidly developing eye tumor from immature cells in the retina.
white pupillary response ( cat’s eye) or luekocoria
Retinoblastoma
The most common cause oftearing and discharge from the eye.
There is heavy mattingof the eye and debris on the lashes
Dacryostenosis
T/F: redness of the conjunctiva is not normal
T
management for Dacryostenosis
Spontaneous resolution occurs in 90 % ofbabies by 6 months
Can be referred for probing if not resolved
- when the tear duct becomes infected .
- There is redness, warmth and swelling of the area
Acute dacryocystitis
pathogenicity of Acute dacryocystitis
staph aureus
Acute dacryocystitiscan lead to what other eye condition?
orbital cellulitis
tx for acute dacryocystitis
consulting Ophthalmology , probing to open the area, and systemic antibiotics.
cause of septal deviation
trauma with birth
- Make sure the nares are patent on exam
- Newborns all are obligate nose breathers and will have respiratory distress if not addressed.
- Surgery can be used as the child grows older
congenital disorder where the back of the nose is blocked due to abnormal bony tissue (happens during fetal development)
Choanal atresia
tx for Choanal atresia
- surgery to open the area .
- This can cause feeding and breathing issues.
how are natal teeth dangerous?
They do not have strong roots and can be easy to aspirate.
These are usually removed and can be associated with several syndromes
White , thick coating inside the mouth and inside the cheeks
Cannot be scraped off .
Painful for the baby and cause trouble eating .
Oral thrush
tx for Oral thrush
antifungal applied inside the mouth
hygiene considerations for oral thrush
If mom is breast feeding, she needs to clean her breasts well and apply the same medication
Boil all bottle nipples and pacifiers during treatment
A normal location of the ears is determined by ?
drawing an imaginary line from inner canthus of the eye perpendicular to the vertical axis of the head
If the helix of the ear lies beneath this line , this can be associated with other syndromes
small indentions in front of the ear of newborns
Preauricular pits of ears
- Common, but can be associated with other congenital anomalies
- Risk of permanent hearing loss with ear pits or tags is 5x than normal population
- A simple ear pit alone does not increase the risk.
cause of ear tags and pits
issues with the timing of congenital development
if a child has an ear pit / tag and any other craniofacial developmental issue, what imaging should be obtained?
renal ultrasound
For kids with associated facial , dysmorphic appearance, they can have renal abnormalities.
how to exam newborn lungs?
- Lungs : Watch rate and effort in the infant
- Newborns breathe about 30-60 bpm
- Observe for any noisy breathing , increased effort, such as pulling the skin in between ribs. Watch for difficulty .
how to examine heart of newborn?
- murmurs - great majority are benign
- Watch skin color and check pulse ox.
- check pulses in the upper and lower body - delay/absence in LE could indicate coarctation of the aorta .
- Look for central cyanosis – sign of congenital heart disease
how to examine abdomen of newborn
- Observe and palpate and complete the exam by looking at anus - imperforate anus means itis missing or blocked
- abdomen is relaxed - kidneyscan be palpated .
- Most abdominalmasses - kidney anomalies.
- The liver and spleen are superficialand can be feltin the abdomen.
a birth defect where there is an abnormal opening in the diaphragm that allows the abdominal content to move into the chest cavity
Diaphragmatic hernia
management for Diaphragmatic hernia
Surgery is required for this . Diagnosed prenatally
presentation of Diaphragmatic hernia
- tachypnea , tachycardia and cyanosis .
- One side of the chest islarger than the other
- Concave abdomen
what is omphalitis
umbilical cord area infection
how do umbilical hernias happen?
- As the fetus develops , there is a small opening in the abdominal muscles.
- This allows umbilical cord to pass through connecting to mother to the baby.
- After the baby is born , the abdominal musclesclose (rectus abdominus).
- Sometimes the musclesdo not meet and growtogethercompletely , leading to an umbilical hernia.
MC in AA
- Appears as a soft bulge at the belly button.
- Easy to reduce .
- Usually gives no medical issues for the baby
- Rarely could have the complication of incarceration.
- Usually resolves spontaneously by 3-4 months.
Umbilical hernia
If not resolved by about 3, can send to surgery for an evaluation
Soft, pink, friable lesion of granulation tissue at the belly button.
Somepersistent drainageof serous fluid , sometime greendischarge or moisture around the cord.
Umbilical granuloma
Tx for umbilical granuloma
- silvernitrate- cauterizes the area
- This can be treatedseveral times with silvernitrate and may require surgery .
what is leukorrhea
milky white or blood streaked vaginal discharge as a result of maternal hormone withdrawal
how may the labia of a newborn look?
Can be swollen or even bruisedafter birth .
how to perforn genitourinary exam for males?
- confirm both testicles are in the scrotum.
- Scrotum has morefolds the closer they are to term
- The foreskin cannot be retracted at birth.
- Consent must be given for circumcision
- If there are anomalies of the penis , circ is held
what genitourinary function of a newborn must do to be considered for DC home?
baby must void
how to exam newborn extremities?
- Watch for equal and symmetric movements
- Look for fusion of digits (Syndactyly)
- Also look for extra digits (polydactyly)
- All of these things can be isolated , or associated with syndromes
where the head of the femur does not fit into the hip well
congenital hip dysplasia
cause of congenital hip dysplasia
socket of the hip being too shallow and not holding the head of the femur in place
congenital hip dysplasia is MC in who and which hip?
- left hip
- girls
- firstborn children, also in multiples
- FHx
- Breech babies and multiples
result of congenital hip dysplasia if left untreated or missed?
life long limp and osteoarthritis of the hip
what are the test to use to observe for congenital hipe dysplasia?
barlow and ortolani tests
MC used for treating congenital hip dysplasia
Helps keep hips and knees bent and thighs spread apart. It can also help promote healing in babies with broken thighbones (femurs).
Pavlick harness
MC fracture in a newborn?
clavicular fracture
Associated with a difficult vaginal delivery .
RF for clavicular fracture?
shoulderdystocia, post term, being induced and higher birth weight
s/s of clavicular fracture
crepitus, swelling of the area , abnormal bone contour, crying with movement.
management for clavicular fracture
- immobilize with a sling
- Will heal on its ownwith the formation of a callous
what does the neurological exam observe for?
Looks at primitive reflexes , sensory systems and cranial nerves
what is a Sucking reflex?
newborns suck in response to a nipple or pacifier in the mouth
what is the rooting reflex?
newborn will turn their head to the side of facial stimulation
what is the palmar grasp
newborns hand will grasp the examiners finger - develops by 28 wks
what is babinski
The examiner takes an object such as a key or the back of a reflex hammer to stroke the bottom of a baby’s foot from heel up to big toe.
what is the normal reaction when doing babinski?
- The big toe should bend up and backwardwhile the other 4 toes fan out
- This response is only normal in kids under 2 .
how to perform Moro(startle) reflex
Hold the infant’s upper body off the table, and carefully allowthe head to drop 1-2cm
The arms should abduct at the shoulder and extend at the elbow.
Adduction with flexion will follow
- Turn the infants head to one side and the same side leg and arm will extend , and the opposite leg will flex
- Appears like a “fencingposition” Gone by 8 months.
what is this reflex
tonic neck reflex
An infant is pulled from lying by it’shands to a sitting position. FIrst the head will lag , then come to the midline, then flex forward . The baby will help a little
what is this reflex?
Traction response
how can the brachial plexus be injured during delivery?
- with a hard pull on the neck as the shoulders pass through
- Pulling on the infant’s shouldersduring a head first delivery
- Pressure on the baby’s raised armsduring a feet first delivery
RF for brachial plexus injury
- large babies ( diabetic moms)
- Breech delivery
- Difficulty getting the shoulder through ( Shoulder dystocia)
Much less common than before due to improved delivery techniques.
tx for brachial plexus injury
- Most recover by 3-6 months with observation
- Massage and ROM exercises can help
- Rarely – surgery is needed if nervesare ruptured or avulsed
This is a small hole or dimple near an infants lower back in the gluteal folds . (above the rectum near the tailbone )
Sacral dimple
when would a Sacral dimpleneed to be studied more and why?
- if large or has tufts
- could be related to a spina bifida occultacondition or a tethered cord. Ultrasound or MRI can help with the diagnosis.
