Week 11: Assessing Newborns and Infants

Question 1

Infant primary care well visits

Answer 1

Emphasis on: Wellness, growth, and developmental monitoring

Primary care well visits occur systematically, and less frequent with age

Question 2

Subjective history

Answer 2

Purpose of wellness visits:

1. Inquire about immunizations and developmental milestones
2. Nutrition and I&Os
3. Crying and sleeping pattern
4. Allergies
5. Medications
6. Injuries/hospitalizations

Prenatal care:

1. General health
2. Number of pregnancies – multigravida (more than one pregnancy)
3. Prenatal diseases – STDs, HIV, DM, thyroid
4. Medications (prescribed or OTC) – teratogenic agents (harmful to developing infant)
5. Tobacco, drug, and alcohol use

Labor & delivery (“Ideal term” = 37-41 weeks):

1. Length of labor
2. Anesthesia
3. Type of delivery
4. Apgar scores
5. Complications

Family & social history:

1. Parents and/or siblings
2. Grandparents
3. Religion/culture
4. Daycare
5. Healthcare insurance/CHIP/WIC – medical and nutritional assistance (government programs)

Enviornment & safety:

1. Environmental safety/fall prevention – gating/out of reach, car seats
2. Smoke detectors
3. Poison control number
4. CPR lessons for parents

Question 3

At birth: Newborn assessment

Answer 3

At birth (within first few hrs. to days):
1. Establish breastfeeding <1 hr. of life – first antibodies

2. Skin-to-skin with parents – bonds and soothes infant
3. Initial birth weight, length (0-2 yrs.), and head circumference
4. “Eyes and thighs” – eye prophylaxis (erythromycin protects against pathogens, STDs) & vitamin K IM injection (within 1 hr. of birth for clotting)
5. Pulse ox. and cardiac screening
6. Hep. B immunization
7. Newborn metabolic screening tests
8. Newborn hearing screen

Question 4

APGAR score

Answer 4

Score at 1st and 5th minute after delivery; determines how well a newborn is transitioning from delivery

Categories scored on a 0-2 scale:

1. Heart rate (>100 bpm)
2. Respiratory effort (Strong cry)
3. Muscle tone (Well flexed)
4. Reflex irritability – flick on heal (Cry on stimulation)
5. Color (Pink)

**Score: 7-10 = Normal; 0-6 = Abnormal (difficult transition)

Question 5

Newborn/infant crying and sleeping patterns

Answer 5

Crying – change in frequency may indicate illness; Colic (high crier)

**As infants age, they learn to communicate in other ways (i.e. Cooing, smiling, giggling)

Sleeping & Sudden infant death syndrome (SIDS) – Sleeping in a safe environment = In their own space, laying on their back, without items in crib, and no smoking

**No swaddling after 2-3 mos. (or when baby can roll)

Question 6

Subjective assessment: I&Os

Answer 6

Nutritional intake:
1. Breastfeeding – assess latch and milk transfer, suck and swallow coordination/strength (especially preemies), maternal milk supply volume, and monitor weight gain/output

2. Formula feeding – bottle and nipple size/style, monitor weight/output/upset GI
3. Output (# of wet diapers = ~# of days old)
4. Stool pattern – changes color over first weeks
5. Common GI concerns – excessive gas (problematic if crying/clenching), D/ or constipation, lactose intolerance, GER/spitting up, formula insensitivities (upset GI), and breastmilk or food issues (sensitivities)

**RED FLAGS: Projectile vomiting (indicative of pyloric stenosis), bowel obstruction, bloody stool, and severe complete or partial constipation (indicative of Hirschprungs)

Question 7

Urine and stool pattern

Answer 7

From day 1 to 7, the number of wet diapers and bowel movements increase

Progression of stool color:
1. Black tarry stool – meconium (lubricates the intestines while in utero)

2. Brown-green
3. Brown-yellow
4. Yellow
5. Yellow-seedy – Seeds = Milk globules in breastmilk

Question 8

Stool characteristics

Answer 8

Normal stool characteristics:

1. Stools change with advanced diet
2. ODOR – Sweet/mild = Breastfed vs. Neutral = Formula; Foul is concerning
3. CONSISTENCY – Pasty/loose; NEVER hard/”rabbit pebbles”
4. Red stool – Bloody? (Fissure if threadlike)
5. Green stool – Bile? (Normal with certain formulas)
6. Black stool – CONCERNING (Hemacult test for blood; can be a sign of milk-protein allergy)

Criteria for CONSTIPATION – Must have experienced at least 2 of the following symptoms over the preceding 3 months:
1. <3 bowel movements/week

2. Straining
3. Lumpy or hard stools
4. Sensation of obstruction or incomplete defecation
5. Manual maneuvering required to defecate (Moving knees, rubbing belly)

Question 9

GER

Answer 9

Normal physiologic process (fairly common) characterized by reflux of gastric contents into esophagus; “Happy-Spitters”

NOT caused by breastmilk; may require change in formula (regular cow’s milk to hypoallergenic/lactose-free)

Interventions:

1. Positioning – put baby on stomach and elevate head for 20min. after feeding
2. Change feeding schedule & methods
3. Change to slow-flow nipple/bottle with less air intake
4. Burp frequently
5. BF strategies
6. Feed baby smaller amounts more often

Question 10

Growth and developmental milestone screenings

Answer 10

Denver II assesses: General disposition, neuromuscular maturity, and developmental milestones

Sensory perception – vision, hearing, and others (should be screened at birth)

4 developmental parameter areas of Denver screening:

1. Gross motor
2. Fine motor
3. Language
4. Personal/Social

**Red flags: PLATEAU = Motor development stops and next milestone is not mastered; DELAY = Milestone is never reached

Question 11

Newborn reflexes

Answer 11

Reflex and age of disappearance:
1. STEPPING (2 mos.) – looks like a walking motion

2. MORO (3 mos.) – response to a sudden loss of support and involves three distinct components: spreading out the arms (abduction) pulling the arms in (adduction) crying (usually)
3. ROOTING (3-4 mos.) – automatically turn the face toward the stimulus and make sucking (rooting) motions with the mouth when the cheek or lip is touched
4. PALMER GRASP (3-4 mos.) – elicited when a finger touches the infant’s palm
5. TONIC NECK (4-6 mos.) – when a baby’s head is turned to one side, the arm on that side stretches out and the opposite arm bends up at the elbow
6. SWIMMING/PARACHUTE (4-6 mos.)
7. PLANTAR GRASP (8-10 mos.) – when touching the ball of the newborn’s foot
8. SUCKING (10-12 mos.) – elicited when gloved finger is placed in the infant’s mouth
9. BABINSKI (2 yrs.) – stroke the lateral edge and across the ball of the foot (toes fan)

Question 12

Vital signs

Answer 12

RR – higher than adult (note apnea, tachypnea, grunting, retractions)

Temperature – axillary & rectal (vulnerable to heat loss/hypothermia and/or fever)

BP

HR – higher than adults (count for 1 minute and follow murmurs with ECHO); Acrocyanosis (bluish hands/feet, around lips) vs. central cyanosis (lips, tongue)

Question 13

Heart rate & Respiration rate

Answer 13

Normal newborn HR & RR:
Newborn:
120-160 HR, 30-60 RR

1 yr. old:
80-160 (~110) HR, 20-40 RR

3 yr. old:
80-120 HR, 20-30 RR

6 yr. old:
75-115 HR, 16-22 RR

10 yr. old:
70-110 HR, 16-20 RR

**Newborns are obligatory nose breathers = They automatically breathe through their nose and not their mouth – teach parents to suction

Question 14

Infant weight, length, and head circumference

Answer 14

BODY WEIGHT: Newborn weight is 2,500-4,000g – Daily weight gain: First 3-4 mos. = 20-30g; Remainder of first 12 mos. = 15-20g

**5-10% loss in first few days is WNL (>10% warrants attention and monitoring); BW doubles by 4-5 mos. and triples by 12 mos.

LENGTH: Doubles by 4 yrs. of age

HEAD CIRCUMFERENCE: Monitor growth and any abnormal measurements (until 3 yrs. of age)

Question 15

Soft spots

Answer 15

A/P Fontanels – accommodate brain growth (anterior fontanel closes by 18 mos.); diamond-shaped and flat, may bulge when crying (and good indicator of dehydration)

Abnormalities:
1. MACROCEPHALY – largely due to buildup of CSF

2. CAPUT SUCCEDANEUM: Serum build-up in scalp
3. CEPHALOHEMATOMA: Blood build-up in scalp

Question 16

Derm/skin birth variants

Answer 16

Derm/skin variants:
1. VERNIX: Waxy antibacterial/antifungal substance

2. MILIA: Tiny white bumps across the nose, chin or cheeks
3. LUGANO: Fine hair on shoulders, belly (abnormal if found on sacrum)

Question 17

Skin presentations

Answer 17

Common skin presentations:
1. STRAWBERRY HEMANGIOMA – Often NOT present/noticeable at birth, gradually becomes more noticeable, but begins to shrink by 12-18 mos.; Refer to dermatology if large and near eyes

2. MONGOLIAN SPOTS – Often evident at birth (permanent or gradually fades); higher incidence among POC and Asian decent
3. CAFE-AU-LAIT SPOTS – Irregular, oval non-elevated lesions of varying size and distribution (6+ spots or >1.5cm. indicate neurofibromatosis)
4. PORT-WINE NEVI – Pink to deep purple, sharply demarcated areas, and usually permanent; Refer to dermatology, especially if large and/or hairy
5. TELANGIECTATIC NEVI (40% newborns) – Flat, red, localized areas of capillaries on eyelids, forehead, or nape of neck; Fade by 2 yrs. of age (50% continue into adulthood)
6. INFANTILE JAUNDICE – Pathologic (<24 hrs. of birth) vs. Physiologic (>24 hrs. to 7 days)
7. NEWBORN ACNE – Develops 3-5 weeks after birth due to reaction to mother’s hormones released during delivery (treat with gentle soap)
8. INFANTILE ECZEMA
9. CRADLE CAP – Thick, yellow, crusty or greasy patch on scalp; Common and clears by 6 mos. (treat with mild shampoo/petroleum)

Question 18

Other PE presentations

Answer 18

Spine & Sacrum:
1. DIMPLES/CURVES/LUMPS/HAIR-TUFT – Associated with spinal bifida (spine and spinal cord do NOT form properly)

Musculoskeletal:
1. CLAVICLE FX – Can sometimes heal by themselves

2. INFANTILE TORTICOLLIS – Head persistently turns to one side
3. DEVELOPMENTAL HIP DISLOCATION (DDH) – Screened with Barlow’s (hip ADDuction while knee is flexed) & Ortolani’s (hip ABDuction while knee is flexed); predominates W>B and F>M
4. TIBIAL TORSION – Inward twisting of the tibia
5. POLYDACTYL – >5 fingers/toes in U/L extremities
6. CLUBFOOT – Adduction/inversion of foot