Transcript Document

GENERAL
Measure and record height, weight, and
head circumference. If the infant appears
premature or is unusually large or small,
perform a Dubowitz/Ballard exam to
assess gestational age.
Two parts:

an external characteristics score,
which is best done at birth, and

a neuromuscular score,
which should be done within
24 hours after birth.
VERY LOW BIRTH WEIGHT
Less than 1500 grams
LOW BIRTH WEIGHT
Less than 2500 grams
FULL BIRTH WEIGHT
2500 - 4000 grams
GESTATIONAL AGE
Number of weeks that have
elapsed since the first day of the
last menstrual period to the time
of birth
PRETERM
Birth occuring prior to
completion of the 37th week
TERM
Birth occuring between the
beginning of 38th week and before
the completion of the 41st week.
POSTTERM
Birth at onset of 42nd week or
thereafter
NEW BALLARD SCORE
PHYSICAL MATURITY
Skin
Lanugo
Plantar surface
Breast
Eye/Ear
Male genitals
Female genitals
NEW BALLARD SCORE
NEUROMUSCULAR MATURITY
Posture
Square window
Arm recoil
Popliteal angle
Scarf sign
Heel to ear
NEW BALLARD SCORE
SCORE
WEEKS
-10
20
-5
22
0
24
5
26
10
28
15
30
20
32
28
34
30
36
38
38
40
40
48
42
50
44
PRETERM
TERM
POSTTERM
PRETERM
Infants delivered before 37 completed weeks
Incidence: 6-15%
Difficulty in adapting to extrauterine life with susceptibility
to the ff:
Infection
Hyperbilirubinemia
Hypoglycemia
Hypocalcemia
Cold stress
PRETERM
PHYSICAL FEATURES:
Thin transparent skin and subcutaneous
tissue
Lanugo hair all over except in face
Scarcely felt breast buds and barely visible
nipples
Flat shapeless pinna of ears
Non-pigmented scrotum with undescended
testes
Widely separated labia majora with
protruding labia minora
Barely perceptible plantar creases
PRETERM
NEUROLOGIC FEATURES:
Hypotonic
Weak and slow sucking, rooting, grasp and
Moro reflexes at 28 weeks
POST TERM INFANTS
Infants delivered after 42 weeks of gestation
Predisposed to have the ff:
Little vernix
No lanugo hair
Pale, dry and desquamating skin
Long fingernails
CLIFFORD STAGING
(PLACENTAL DYSFUNCTION)
FIRST STAGE
Alert with loose hairless skin
SECOND STAGE
Meconiums stained navel and fingernails
THIRD STAGE
Old man facies
SMALL FOR GESTATIONAL AGE
(SGA)
SYMMETRIC (hc=wt=len, all <10%): 33% of SGA
Genetic
Small maternal size
Chromosomal abnormalities (Trisomies 13,
18, 21, and Turner's syndrome)
Congenital abnormalities
Intrauterine infections
Viruses (rubella, CMV, ?varicella, ?HIV)
Bacteria (tuberculosis)
Spirochete (syphilis)
Protozoan (toxoplasmosis, malaria)
SMALL FOR GESTATIONAL AGE
(SGA)
SYMMETRIC (hc=wt=len, all <10%): 33% of SGA
 Inborn errors of metabolism
Hypophosphatasia
Leprechaunism
Some amino acidurias
 Environmental
Drugs (heroin, methadone, ethanol,
diphenylhydantoin)
X-rays (therapeutic)
Smoking
SMALL FOR GESTATIONAL AGE
(SGA)
ASYMMETRIC (hc=len>wt, wt<10%): 55% of SGA
 Uteroplacental insufficiency
Chronic hypertension
Preeclampsia
Renal disease
Cyanotic heart disease
Hemoglobinopathies
Placental infarcts or chronic abruption,
velamentous insertion, circumvallate placenta,
multiple gestation.
Altitude
SMALL FOR GESTATIONAL AGE
(SGA)
COMBINED: 12% of SGA infants
 Environmental
Drugs (including ethanol)
Smoking
 Placental unit insufficiency
Placental infarcts or chronic abruption,
velamentous insertion, circumvallate placenta,
multiple gestation
LARGE FOR GESTATIONAL AGE
(LGA)
 Large mother (familial)
 Infants of diabetic mothers
 Beckwith-Wiedemann syndrome
 Hydrops fetalis
SKIN
COLOR
 Pallor: Ass. with anemia
 Cyanosis: Sign of hypoxemia
 Plethora: Ass. with polycythemia
 Jaundice: Yellowish discoloration of skin and
mucous membrane
 Slate grey color : Methemoglobinemia
NORMAL SKIN VARIANTS
Milia - pinpoint white papules of keratogenous
material usually on nose, cheeks and forehead,
last several weeks.
Miliaria - obstructed eccrine sweat ducts.
Pinpoint vesicles on forehead scalp and skinfolds.
Clear within 1 week.
Transient neonatal pustular melanosis - small
vesicopustules, generally present at birth,
containing WBCs and no organisms. The intact
versicle ruptures to reveal a pigmented macule
surrounded by a thin skin ring.
NORMAL SKIN VARIANTS
Erythema toxicum - Most common newborn
rash. Variable, irregular macular patches. Lasts a
few days. Wright's stain shows sheets of
eosinophils.
Cafe au lait spots - suspect neurofibromatosis if
there are many large spots.
Junctional nevi - if large numbers, suspect
tuberous sclerosis, xeroderma pigmentosus,
generalized neurofibromatosis.
NORMAL SKIN VARIANTS
Harlequin phenomenon – Half erythema, half
pallor commonly seen in preterms
Cutis marmorata – Mottling. Lacy pattern
seen in newborns less than 12 hours of age. Ass
with cold stress. If persist, suspect congenital
hypothyroidism
Sucking blisters – Blisters seen in hands and
wrists documenting ability of fetus to suck.
NEUROLOGICAL EXAM
 State of alertness
 Posture:
Normal position is fetal attitude with hips
abducted and partially flexed, with knees
flexed, and with arms adducted and flexed
at the elbow. Fists are clenched with
fingers covering the thumb
 Tone:
Support with one hand under chest.
Neck extensors should hold head in line for
3 seconds. Should have > 10% head lag.
NEUROLOGICAL EXAM
 Reflexes
Symmetrical
Includes:
Biceps jerk (C5-6)
Knee jerk (L2-4)
Ankle jerk (S1-2)
Truncal incurvation reflex (T2-S1)
Anal wink (S4-5)
Other primitive reflexes:
Moro,
Palmar and plantar grasp
Sucking, swallowing and rooting reflexes
Asymmetric tonic neck reflex
NEUROLOGICAL EXAM
When reflexes appear and disappear:
REFLEXES
APPEARS
DISAPPEARS
Moro
Newborn
3 months
Grasp
Newborn
3 months
LE crossed
extensors
Extensor plantar
Birth
1 month
Newborn
8-12 months
Placing/stepping
Birth
1-2 months
ATNR
Newborn
3 months
HEAD AND NECK
 Check the size and shape of the head
 Measure the head circumference
 Check for number and size of fontanelles
 Check for overriding sutures
 Note for encephalocoeles
EYES
 Check for presence and size of the eyeball
 Check for colobomas, heterochromia
 Check for cloudiness of the cornea
 Inspect the conjunctiva as to presence of
erythema, exudate, hemorrhage and jaundice.
 Check for pupillary size and reactivity to light
 Red reflex. Black dots may mean cataracts.
Whitish color may suggest retinoblastoma
EARS
 Check for asymmetry and irregular shapes
 Check for auricular or pre-auricular pits,
fleshy appendages, lipomas or skin tags
 Check for the patency of the auditory canal
NOSE
 Check for asymmetry and irregular shapes
 Look for flaring of the alae nasi as a sign of
respiratory distress
 Check for hyper- or hypo-telorism
 Check for choanal atresia indicated by
resistance to insertion of nasal catheter beyond
4cm mark
MOUTH
 Check the size and shape of the mouth
Microstomia: Trisomy 18 & 21
Macrostomia: Mucopolysaccharidoses
Fish mouth: Fetal alcohol syndrome
 Normal lesions:
Epstein pearls:
Small white cysts
containing keratin found on either side of
the median raphe of palate
Ranulas: Small bluish white swellings of
variable size on the mouth floor
representing
benign
mucous
gland
retention cysts
PALATE
 Check for cleft lip and palate
TONGUE
 Check for the size of the tongue
 Macroglossia:
Found
in
congenital
hypothyroidism and mucopolysaccharidoses
TEETH
 Check for natal teeth which may occur in
1/2000 l.b. Mostly lower incisors. If loosely
attached, risk of aspiration
CHIN
 Check for size and shape of the mandible
 Micrognathia:
Seen in Pierre-Robin
syndrome, Treacher-Collins syndrome, and
Hallerman Streiff syndrome
NECK
 Palpate over all muscles
 Palpate clavicles for possible fracture
 Note for web neck as found in Turner’s,
Noonan’s and Downs’ syndrome
NECK
 Check
for
torticollis
secondary
sternocleidomastoid hematoma.
to
 Note for neck masses, most common of which,
cystic hygroma
 Lymph nodes, if present, indicate congenital
infection
CHEST AND LUNGS
 Observe respiratory rate and pattern
Normal respiratory rate: 40-60 per minute
Periodic breathing vs apnea
Periodic breathing: Regular burst of
breaths followed by respiratory pause of
5-10 seconds
Apnea: Cessation of breathing for 20
seconds with/without bradycardia or
cyanosis
CHEST AND LUNGS
 Observe chest movements for symmetry and
for retractions
 Listen for stridor, most common neonatal
cause of which, laryngomalacia.
 Diminished breath sounds on either side
suggests pneumonic consolidation, atelectasis,
effusion, and other pulmonary problem.
 Some enlargement of the breasts may be
secondary to maternal hormones (estrogen).
CARDIOVASCULAR SYSTEM
 Measure heart rate and blood pressure in
both upper and lower extremities
 Inspect the baby’s color for pallor, cyanosis or
plethora
 Check for dynamic precordium indicative of
heart failure
CARDIOVASCULAR SYSTEM
 Check capillary refill (normal: 2 seconds)
 Check presence and character of pulses:
 in femoral pulses or radio-femoral
delay indicates possible coarctation of aorta
Bounding pulses suggest PDA
 Locate PMI with single finger on chest
Abnormal location suggests situs inversus,
pneumothorax, diaphragmatic hernia, or
other thoracic problem
CARDIOVASCULAR SYSTEM
 Note rhythm of heart rate
 Check presence of murmur.
If present,
determine intensity, timing, location and
radiation
Functional vs pathologic
Functional murmur: brief, soft, systolic
and lasts < 24 hours
Pathologic murmur: loud, persistent,
may have diastolic component
ABDOMEN
 Note shape of abdomen – globularly shaped.
Flat abdomen suggests decreased tone
with abdominal contents in chest (CDH) or
abnormal abdominal musculature.
Distended abdomen signifies functional
(ileus) or mechanical GI obstruction
 Observe for diastasis recti
 Observe for any obvious malformations (eg.
omphalocoele, gastroschisis)
ABDOMEN
 Examine umbilical cord and determine its
color, number of vessels.
 Palpate liver which is normally about 2cm
below the right costal margin
 Palpate spleen which is usually not palpable.
If palpable, investigate for congenital infection or
extramedullary hematopoiesis.
 Palpate for any abnormal masses
ABDOMEN
 Auscultate for bowel sounds
 Examine for hernias – umbilical or inguinal
 Inspect anal area for patency and/or presence
of fistulas
GENITOURINARY EXAM
KIDNEYS
 Palpate kidneys which should be about 4.55.0cm vertical length
With one hand under the baby’s back,
palpate by rolling the thumb over the
kidneys
Place right hand under the left lumbar
region and palpate abdomen with left hand.
Do reverse for right kidney
GENITOURINARY EXAM
MALE GENITALIA
 Inspect glans, urethral opening, prepuce and
shaft.
 Observe for hypospadias or epispadias
GENITOURINARY EXAM
MALE GENITALIA
 Inspect penis. Term normal penis is 3.6+/0.7cm stretched length.
After circumcision,
inspect for edema, incision, bleeding
 Inspect the scrotum. Normal scrotum in term
should have brownish pigmentation and rugae.
 Palpate the testes.
GENITOURINARY EXAM
FEMALE GENITALIA
 Inspect the labia, clitoris, urethral opening and
external vaginal vault
Whitish discharge, as is a small amount of
bleeding, occurs a few days after birth
secondary
to
maternal
hormone
withdrawal
Hymenal tags may be present
EXTREMITIES and
SKELETAL SYSTEM
SPINE
 Check the curvature of the spine for scoliosis,
kyphosis,
lordosis,
spinal
defects,
and
meningomyelocoeles
EXTREMITIES and
SKELETAL SYSTEM
UPPER EXTREMITY
 Check for clavicular fracture, absence of
radius or ulna
 Inspect creases and fingers
EXTREMITIES and
SKELETAL SYSTEM
LOWER EXTREMITY
 Assess posture
 Do Ortolani maneuver to check for congenital
hip dislocation
 Check toes
APGAR SCORE
APPEARANCE
PULSE RATE
GRIMACE
ACTIVITY
RESPIRATORY EFFORT
Normal skin variants in newborns, EXCEPT:
A. Milia
B. Harlequin phenomenon
C. Sclerema
D. Epstein pearls
E. Cutis marmorata
Features of preterm infants:
A. Scrotum with little rugae
and
undescended testes
B. Breast with 5mm breast nodule and nipple
C. Creases on anterior third of sole
D. Labia majora well coaptated
E. Thinning lanugo
Apgar score of a newborn delivered limp, cyanotic
all over, apneic with cardiac rate 50/min
A. One
B. Two
C. Three
D. Four
E. Zero
Routine newborn care, EXCEPT
A. Tetracycline ophthalmic ointment
B. Vitamin K
C. Cord dressing
D. Immunization – BCG and Hepatitis B
E. None of the above