Transcript Newborn Pearls-Evidence Based - Northeast Iowa Family Practice

Newborn Pearls-Evidence Based
Ann Soenen, D.O.
May 16, 2014
Objectives
• Become familiar with the Stanford online
photo gallery
• Recognize unique newborn exam findings
• Formulate a treatment plan for these issues
• Provide valuable instructions to the parents
through use of a post-nursery discharge
checklist
• http://newborns.stanford.edu/PhotoGallery/
Gimme the vitals
• Apgars
– Know how to calculate
• Temp
– axilla of 36.1 to 37°C (97 to 98.6°F) in an open crib
• HR
– 120 to 160
• RR
– 40 to 60
• BP
– depends on gestational age, weight
Apgars
Newborn Hypertension?
40 weeks
50%
95%
99%
SBP
80
95
100
DBP
50
65
70
MAP
60
75
80
SBP
77
92
97
DBP
50
65
70
MAP
59
74
79
SBP
72
87
92
DBP
50
65
70
MAP
57
72
77
38 weeks
36 weeks
Newborn Skin Rashes-Birthmarks
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CONGENITAL MELANOCYTIC NEVI
DERMAL MELANOSIS
HEMANGIOMAS
NEVUS FLAMMEUS
NEVUS SIMPLEX
Newborn Skin Rashes- Common
Rashes
• Transient Vascular Phenomenon
– CUTIS MARMORATA
– HARLEQUIN COLOR CHANGE
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Erythema Toxicum Neonatorum
Transient Neonatal Pustular Melanosis
Acne Neonatorum
Milia
Miliaria (crystallina and rubra)
Seborrheic Dermatitis
Yellow?
• Never normal in 1st 24 hours
• Eyeball vs TcB vs TsB?
– Visual assessment not as reliable
– TcB not reliable during phototherapy, ?darkly
pigmented skin
– TcB can replace TB in most circumstances when TB
is <15 mg/dL
• Universal screening or Selective screening?
• If intermediate-risk zone -> now what?
Phototherapy
• Plot the curve or online calculator- bilitool.org
• NNT
– It is estimated that 5 to 10 infants with TB between 15
and 20 mg/dL must receive phototherapy to prevent
one patient from developing a TB >20 mg/dL.
• Decline of TB at least 2 to 3 mg/dL within four to
six hours
– Result in 30-40% decrease in 24 hours
• Additional evaluation or not?
• Home Bili-blankets?
For infants at low risk (≥38 weeks GA and without risk factors),
phototherapy is started at the following TB values.
24 hours of age: >12 mg/dL
48 hours of age: >15 mg/dL
72 hours of age: >18 mg/dL
Infants in this category who have TB levels 2 to 3 mg/dL below the
recommended levels may be treated with fiberoptic or conventional
phototherapy at home.
Murmurs
• Innocent or not?
• Guess the problem? (Stanford audio file)
Congenital Heart Disease
• Didn’t you hear it?
– Often Missed
• CHD O2 screening (Lancet 2012-universal)
– Postductal (NOT R arm)
– SpO2 <95 %
• Detection rate on prenatal ultrasound
– Highly variable
– Better if 4-chamber view w/ outflow tracts or
fetal echo
Head
• The Abnormal Fontanel
– Large anterior fontanel or delayed closure
– Achondroplasia, Hypothyroidism, Down
Syndrome, Rickets, Increased intracranial pressure
• Caput vs cephalohematoma
– When will it improve?
• Subgaleal protocols
• Craniosynostosis
Red Reflex- now I see it now I don’t
• Leukocoria
– DDx: retinoblastoma, congenital cataract
– How soon to see ophthalmology?
• Darker pigmented skin?
Dacro- what?
• Dacryostenosis
– Nasolacrimal duct obstruction, m/c cause of tearing in
infants
– Spontaneous resolution by 6 months in 90%
– Tx:
• Lacrimal cyst massage
• Probing
• Dacrocystocele or dacryocele or NLD cyst
– Refer to opthalmology urgently
• Dacrocystitis
– Systemic antibiotics
Tongue-Tied
• History of Frenotomy for Ankyloglossia:
• Popularity of casual frenotomy in the early 20th
century
• Procedure fraught with complications: bleeding,
infection, scarring, "regenerating"
• Fell into disrepute in the mid 20th century
• Concurrent popularity of formula feeding
• Older and recent text books claimed frenotomy
unnecessary
• Current resurgence of breastfeeding demands revisit of
topic
Frenotomy or Frenulectomy
• Maternal complications- sore nipples
• Infant complications- FTT
• Pediatric complications- speech, orthodontic,
social
• Hazelbaker Assessment Tool for Lingual
Frenulum Function
• No anesthesia if performed under 3-4 months,
can do in office
Abdominal masses
• Normal or not?
– Diastasis recti
• Umbilical hernia
– Management
• Umbilical cord
– Single umbilical artery
– Care & Normal detachment (in 1 wk)
– Umbilical granuloma tx?
Preauricular Skin tags/pits
• Do all need screened for renal anomalies?
• Screen for hearing impairment
Extra digits
• Polydactyly vs Syndactyly
• Tie off or leave?
• Associations?
Newborn Foot
• Metatarsus adductus
– m/c, medial deviation forefoot
– Most resolve, exercises, rare splinting
• Positional calcaneovalgus feet (talipes calcaneovalgus)
– hyperdorsiflexion of the foot with the abduction of the
forefoot
– Most resolve, exercises, splinting
• Clubfoot (talipes equinovarus)
– Most spontaneous, can be genetic
– manipulation that includes casting and bracing (referred to
as the Ponseti method
V-finger Test
Calcaneovalgus
Clubfoot
Sacral dimple
• When do you need an ultrasound?
– If visible intact base-> OK
– If deep/large > 0.5cm, > 2.5cm from anus, or have
tuft hair/vascular lesion -> Need u/s
DDH-Click or Clunk?
• Algorithm AAP
• Exam (until age 2)
– Ortolani and Barlow maneuvers
– Galeazzi and Klisic signs
• U/s use
• Referral for tx
– Triple diapers not recommended
– Pavlik harness
Screening for developmental hip dysplasia—clinical algorithm.
Committee on Quality Improvement, Subcommittee on
Developmental Dysplasia of the Hip Pediatrics
2000;105:896-905
©2000 by American Academy of Pediatrics
It’s a Boy or Girl?
• Vaginal skin tags, discharge
• Hydroceles vs inguinal hernias
– transillumination
• Undescended testicle
– 2-5% at term
– When to refer?
• Hypospadias, epispadias
• Ambiguous
Gomco Circumcision Q’s
• If don’t get circumcised- do they have to
retract foreskin and clean?
– No, just clean like rest of body
• Potential Benefits
• Potential complications
• When to call urology?
Discharge Instructions
Properly feeding the infant
Instruction on proper breastfeeding position, attachment, and adequacy of
swallowing Discharge Checklist for Healthy Newborns
Breastfeeding mothers should consult their physicians before taking any new
medications.
Parents should not give their infant supplemental water or honey.
Breastfed and bottle-fed infants receiving less than 500 mL of formula per day
should receive 200 IU of a vitamin D supplement per day.
Urination patterns Six or more wet diapers per day is normal for a breastfed infant
after the mother’s milk has come in, as well as for bottle-fed infants.
Bowel movements More than three bowel movements per day is normal in
breastfed infants.
Bottle-fed infants may have fewer bowel movements.
Umbilical cord care Instruction on proper cleaning
Skin care Review of common rashes
Genital care Instruction on proper care of circumcised or uncircumcised penises, as
well as care of newborn girls’ genitals
Signs of illness Rectal temperature of 100.5˚F (38˚C) or higher
Signs of dehydration, lethargy, poor feeding
Prevention of sudden infant death syndrome
Instruction on properly positioning the infant for sleep
Discharge Instructions, cont..
• Parental smoking cessation
• Car seat selection and proper use See Table 2
• Follow-up appointment made at discharge
Infants younger than 24 hours, follow up
within 72 hours of age
• Infants 24 to 48 hours of age, follow up within
96 hours of age
• Infants older than 48 hours, follow up within
120 hours of age