Week 11 Examining NB Flashcards
Prep for discharge: Eyes & Thighs
- eye prophylaxis first hour of life (erythromycin or tetracycline) to prevent chlamydia / gonorrhea conjunctivitis
- NB immature hepatic systems → bleeding risk
- thighs; vitamin K & hepatitis B vaccine
- vit K w/in 1-6 hrs after birth
- hep b: first 24 hrs
Gonorrhea conjunctivitis can lead to
blindness
chlamydia conjunctivitis can lead to
pneumonia
single vitamin K injection lasts
til 6months until solid foods
vitamin K doesn’t cross placenta and not in breastmilk/formula
For Infants Born to Hepatitis B NEGATIVE mother
- give vaccine if > 2000 grams within the first 24 hours
- if < 2000 grams- (4lbs 4 oz)
- administer at 1 month of age or at hospital discharge, whichever comes first
- 1 kg = 2.2 lbs
- 1000 g = 1 kg = 2.2 lb
- **many women asymptomatic that have hep B
For Infants Born to Hepatitis B POSITIVE mother
- Administer Hepatitis B vaccine to all infants within the first 24 hours regardless of weight
AND
- Administer Hepatitis B immunoglobulin
discharge screening:
newborn metabolic disorder screening
- Metabolic, hormonal, hematologic, infectious
- Recommended Uniform Screening Panel (RUSP) aka Newborn Screen (NBS) has 35 core conditions, 26 secondary conditions
- Simple heel prick between 24-48 hrs after birth. Drops of blood are blotted on a special absorbent filter card
- Air dry for 4 hours → state’s Newborn Screening lab- takes 10-14 days for results
Factors that can affect Newborn metabolic screening (NBS) results
- obtaining too early
- Before 24 hrs of life
- antibiotics
- blood transfusion
- failure to wipe away first drop of blood
- not enough feeding
- inadequate sample
NBS result treatments
- Institute immediate treatment for a positive screen for:
- Galactosemia
- Rare auto recessive met disorder, can’t metabolise sugar galactose
- Galactosemia
- Maple Syrup Urine Disease (MSUD)
- Rare auto rec metabolic disorder
- Can’t metabolize amino acids causing sweet ordor or newborn urine
- Maple Syrup Urine Disease (MSUD)
- Excluding these 2; this is SCREENING test. All other +’s need more testing to confirm
- Otherwise no treatment for any other + screening results until further testing confirms diagnosis
Discharge screening:
Glucose screening
- Glucose tends to drop 25 mg within the first 1-2 hours after birth
- after 4 hrs, 25-35g is threshold, then > 45g
- Screening NOT rec for healthy full term infants
- At risk infants need screening if:
- Diabetic or GD- baby used to increased glucose so has increased insulin levels at birth
- Preeclampsia/HTN
- Substance abuse
- Exposure to medications (tocolytics, glucose)
Neonate
- Prematurity- esp late preterm 34-37 weeks
- LGA or SGA
- HIE event or birth injury
- Sepsis
- Congenital cardiac, endocrine, inborn errors of metabolism disorders
- if infant is showing signs/sx’s of hypoglycemia..?
- what if there are no sx’s but low blood sugars?
- give IV glucose!
- if not showing sx’s, recommend feeding
s/sx hypoglycemia in neonates
- Most Common:
- Irritability
- Tremors
- Severe: Lethargy, changes in LOC
- Can also be seen:
- Seizures
- Hypotonia
- Feeding difficulty
- Respiratory distress
- High pitched cry
discharge screening:
jaundice screening
- using transcutaneous hyperbilirubinemia or jaundice monitor or blood draw
- If discharged sooner than 72 hours→ do at primary care office
- F/u in 1 -2 day
- High levels of unconjugated bilirubin lead to jaundice from immature hepatic system and lack of PO
- Screen if “too high too soon” or shows up w/in first 24 hrs → pathologic cause than physiologic
- Jaundice goes head to toes
- further down body = higher the level of bilirubin
ALWAYS get family history! Did mom have a previous child that had hyperbilirubinemia?
- If yes, that’s a huge risk factor for future pregnancies
discharge screening:
hearing loss
- Otoacoustic Emission Test (OAE) [top pic]: using probe in ear measures ciliary hair movement
- Automated Auditory Brainstem Response (AABR) [bottom pic]:
- Measures acoustic nerve and brain respond to sound. Tones are played through headphones and electrodes measure brain’s response to sound.
- If no pass initial hearing screen → repeat testing within 3 months
- Goal: screen by 1 month, identify deficit by 3 months, be receiving services and/or treatment by 6 months of age
discharge screening:
when to do congenital heart disease screening
- Clamp umbilical cord → the transition from fetal circulation to neonatal circulation
- Arteries and veins constrict and systemic blood pressure increases
- When systemic vascular resistance > pulmonary vascular resistance the 3 major fetal shunts close
- Ductus Venosus
- Foramen Ovale
- Ductus Arteriosus
- Screening is performed after 24 hours of life to detect any potential congenital cardiac anomalies
how to screen for congenital heart disease
- screen AFTER 24 hours of birth, before discharge
- Pre and postductal pulse oximetry screening
- Right hand and Left foot test both at the same time
- Normal results: both hand and foot 95% > and < 3% difference between them
-
Discrepancies should receive urgent referral to pediatric cardiology
- If < 95% or difference hand/foot sat > 3%
Newborn Discharge Criteria
- Stable vital signs
- Axillary temp 36.5-37.4 C
- RR <60
- No signs of distress
- HR 80-180 bpm
- Established Feeding
- At least 2+ feedings
- Established Elimination pattern
- At least 1 void and 1 stool
- Screening and therapies completed
- Parent education completed
Rooting lasts until
4 months
sucking reflex ends at
2-3 months
moro lasts until
6-8 months
Plantar grasp lasts until
8-10 months
palmar grasp lasts until
5-6 months
tonic neck resolves by
6 months
truncal incurvation/galant reflex resolves by
4 months
babinski reflex
- occurs after the sole of the foot has been firmly stroked. The big toe then moves upward or toward the top surface of the foot
- Positive babinski is normal up to 2 years of age, diminishes after 1 yr
CN 1
CN 1 = alcohol pad to nose = grimace/make a face
CN II
blink in response to bright light (optic blink reflex)
recognition of objects introduced into visual fields
CN III, IV (4), VI
pupillary response to light, extra ocular movements tracking, ptosis
vestibulo-ocular reflex (doll’s eyes maneuver). When the head is turned, there is conjugate eye movement in the opposite direction.
CN VII
Crying - symmetry of facial expressions
CN V
light facial touch and assess response
CN IX, X
quality and strength of crying
symmetrical rise of soft palate, gag reflex
CN V, VII, IX, X
Feeding - sucking and swallowing
CN VIII
response to sound made outside of visual fields
clap → blink → hearing intact
Common NB skin findings
- acrocyanosis
- harlequin sign (unilateral color change (LBW))
- erythema toxic
- milia
- mongolian spots
- **strawberry hemangioma (refer orbital/large hemangioma or in airway)
- nevus simplex
- **cafe au last spots( > 6 greater than1 cm = w/u for neurofibromatosis)
- port wine stain
- stork bites
- lanugo (premie)
- linea nigra
- vernix caseosa
- neonatal acne
abnormal skin findings
immediate referral for workup
-
Petechiae
- Normal on presenting parts
- Resolve 24-48 hrs
- If head down from vaginal delivery, expect petechiae on head but if breech or c section, see petechiae on butt
- But if see it ANYWHERE else = sx’ of infection
- Doesn’t grow; don’t get new sites
- rule out sepsis and TORCH
- Normal on presenting parts
-
Vesicular rash
- HSV and varicella → clustered vesicles a few days after birth
- if high suspicion → start IV acyclovir ASAP! (dont need culture first)
- Bacterial infections like staph and strep
- HSV and varicella → clustered vesicles a few days after birth
still’s murmur
- most common innocent heart murmur, vibratory and musical in nature, along left sternal border, louder when supine
pathologic murmur red flags
holosystolic, diastolic, grade 3 or higher, harsh
-
PDA: continuous machine-like murmur,
- Heard best at left sternal upper Sternal Border
- ASD: grade 2 or 3 systolic ejection murmur, ULSB, split S2
-
VSD: harsh holosystolic, LLSB, sometimes can palpate thrill
- If can palpate thrill, the intensity is at least grade 4 / 6
cephalohematoma is a risk factor for
jaundice and sepsis
ear pits/tags evaluate
- hearing and renal system
- Assess placement of ear by drawing Imaginary line to inner campus to outer campus of the eye to occipitus
- If top of pinna ear touches imaginary line = ear is correctly placed
light spot /leukocoria can indicate
retinoblastoma - refer!
diastasis recti
1 cm gap, bulges when cries, resolves in 1 week
- Cryptorchidism
failure to descend is associated with increased risk of testicular cancers and reduced fertility (should descend by 3-6 months- orchiopexy if not descended by 1 yr)
- If patient has bilateral undescended testes with micropenis, or bifid scrotum
- or fused labia / clitoromegaly
prompt eval for ambiguous genitalia
torticollis
- twisting of neck
- most common in Multiple sclerosis anomaly
- Assess for torticollis by parent “does the infant only look 1 way , sleep 1 side, feed 1 direction, or holding head like that?
- Birth trauma of sternocleidomastoid, can lead to plagiocephaly (flat head from toricollis = misalignment of ear) and ear misalignment
- Send to PT for correction
maneuvers for hip dysplasia
- Barlow → dislocate
- ortolani → relocate
- symmetry of skin folds (gluteal/ femur)
- feet: size, shape, positioning
parental discharge education
- General care of infant- bathing, diapering, cord care, circ care, temperature
- Infection control- handwashing, caregiver vaccinations
- Feeding- breast/bottle, schedule, burping, storage, concerning patterns
- Elimination- voiding/stooling with each feed, concerning patterns
- Sleep- positioning, location
- Safety- car seat, fall prevention, siblings, pets, CPR, Emergency Services contact information
dialysis recti and umbilical hernias are more common in
premature infants
Most formula-fed infants will feed at least
8x a day
on average, FF infants take 2.5 oz formula for every lb of body weight
