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Pedia - Newborn history & PE -2013

NEONATAL HISTORY (Hx) should: - Identify disabling diseases that are amenable to prompt preventive action or treatment - Anticipate conditions that may be of later importance - Uncover possible causative factors that may explain pathologic conditions PERINATAL HISTORY: (the mother) - Demographic & Social data - Socio-economic status - Age - Race - Past Medical Illness - Cardio-pulmonary disorders - Infectious diseases - Genetic disorders - Anemia - Jaundice - DM - Previous Maternal Reproductive problems - Stillbirth - Premature - Blood group sensitization (Rh incompatibility) -Present Pregnancy - Vaginal bleeding - Medications - Acute illness - Duration of rupture of membrane I. Prenatal Hx: - Mothers general health - Toxemias - Hormone or radiation therapy - Viral or other infections - Medications - Pain - Bleedings - Threatened abortion II. Birth / Natal Hx: (during labor & delivery) - Duration & circumstances of labor - Analgesia used - Place of delivery (home or hospital) - Type of delivery - Complications - Birth wt. - Age of Gestation (AoG) III. Neonatal Hx: - Activity (feeble or vigorous) - Dyspnea/signs of distress - Resuscitation - Convulsions - Hemorrhage - Congenital defects - Skin color: -Cynosis - acrocynosis or central -Pallor -Jaundice (onset, duration, intensity) I. Vital Signs (V/S) - T.C.R.Bp - Temperature (T) - Cardiac rate (CR) - Respiratory rate (RR) - Blood pressure (BP) II. Anthropometrics - Birth weight (BW) - Length (L) - lying - Head circumference (HC) - glabella to occiput - Chest circumference (CC) - nipple line - Abdominal circumference (AC) - umbilical line III. General Appearance - Spontaneous activity *Coarse tremors vs abnormal twitching & convulsions - Flexion of upper & lower extremities - Symmetric movement *Asymmetric = fractured humerus & damaged brachial plexus - Vigorous cry is assuring *Weak cry = sepsis, asphyxia, metabolic derangement or narcotic use NOTE: use of Anaesthesia during labor alters neonatal activities IV. Skin - Vernix caseosa - do not remove

- Lanugo - fine downy hairs

- Birthmarks & hemangiomas - Mongolian spots

- Mottling

PHYSICAL EXAMINATION OF THE NEWBORN ***Examination Precaution*** - Hand washing - Thermal environment - Proper lighting - Minimal noise - Examination time limit of 5-10mins

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Pedia - Newborn history & PE -2013

- Color: -Cynosis - acrocynosis vs *central - Caput vs Cephalhematoma - Caput succedaneum - localized, easily identifiable, soft area in the skull resulting from a long & difficult labor or by vacuum extraction - Cephalhematoma - collection of blood from ruptured blood vessels between a cranial bone & the periosteal membrane, unilateral or bilateral but do not cross the suture lines -Pallor -Plethora -Jaundice - physiologic vs *pathologic - Common rashes: -Erythema toxicum - blotchy red spots

Caput

Cephal

-Milia

VI, Face (Ears, Eyes, Nose, Mouth) 1. EYES - Subconjunctival hemorrhage/hyposphagma *Leukocoria - white reflection from retina *Epicanthal folds - chromosomal defects - (normal in some races) 2. EARS - Ear canals *Low set - chromosomal defects *Preauricular skin tag - kuntil 3. NOSE -Symmetry & patency of nares *Choanal atresia - nasal passage is blocked by a membrane 4. MOUTH - Natal teeth - remove - Epstein pearls - harmless

-Pustular melanosis

V. Skull - Shape - HC *Megalencephaly -Fontanells -Posterior - 2-3 mon closure -Anterior - 9 mon closure -Sutures *Cranio cynostosis - early closure

- Palate *Cleft * High palatine arch -Tongue *Ankyloglossia tongue tie

*Macroglossia - large tongue

*WoF - Widened sutures - Molding - changes in head contour to fit the cervical canal - Craniotabes - localized softening of a cranial bone in most preterms

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Pedia - Newborn history & PE -2013

VII. Neck *Webbing - Downs & Turners syndrome -Excess skin at the base of the neck *Abnormalities: -Goiter, cystic hygroma, brachial cleft cysts, lesion of the sternocleidomastoid, etc. *Fractured clavicle -Asymmetric moro reflex VIII. Chest & Lungs - Breast hypertrophy -Witchs milk -no redness -Cheyne-stokes rhythm - normal *Respiratory effort -Mild retraction -Use of accessory muscles -Nasal flaring -Grunting -Tachypnea *Pectus excavatum *Pectus carinatum Gastroschisis Omphalocele

2. Palpation - Kidneys are normaly palpated - Liver, 2-3cm - Spleen, palpable - Umbilical vessels - A.V.A *Hernias - umbilical & inguinal XI. Genitals 1. Males - Penile size - Urethral opening *Hypospadia - under *Epispadia - above - Testes *2% cryptorchid *Hydrocele 2. Females *Premature -Prominent clitoris & labia minora -Vaginal skin tag -Labial fusion -Vaginal discharge / blood XII. Anus - Patency - use rectal thermometer to assess - Passage of meconium usually w/in 1st 12 - 24 hrs XIII. Extremities *Erbs palsy - extended arm & internal rotation w/ limited movement *Humeral fracture *Digital abnormality -Syndactyly - webbing or fusion of fingers -Brachdactyly - shortness of fingers - Polydactyly - extra fingers -Single palmar crease / simian crease -May indicate Downs syndrome -But normal in some race *Hip dislocation (do Ortolanis maneuver) -Breach presentation -Female -Check for femoral pulses XIV. Neurologic Examination - Awakeness & alertness - Moving extremities - Flexed body posture - (+) moro refles

Pectus excavatum

Pectus carinatum

* Suprenumerary nipple *Asymetric chest rise -Lung or diaphragmatic pathology NOTE: -Inspection is the key - no grunting, flaring or retraction -Auscultate - air entry & symmetry IX. Heart - Location - HR 100-160 bpm - Pulses * Murmurs X. Abdomen 1. Inspection *Scaphiod abdomen - may indicate diaphragmatic hernia

*Distension *Gastroschisis - abdominal wall defect -herniation through the abdominal wall *Omphalocele - herniation through the umbilical cord

BALLARD SCORING -Standard AOG Assessment 1. Physical Maturity Rating - Skin (-1 to 5) - Lanugo (-1 to 4) - Plantar Crease (-2 to 5) - <36 wks: 1-2 transverse creases on anterior 1/3 of sole - By 40 wks: complete criss-crossing of creases over entire sole

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Pedia - Newborn history & PE -2013

-Breast (-1 to 4) - <34 wks: not generally palpable - At 36 wks: diameter does not usually exceed 3mm -Eye/Ear (-2 to 4) - appears mainly after 36 wks -Genitals M/F (-1 to 4) - <36 wks: few anterior, inferior scrotal rugae - 40 wks: rugae cover entire scrotum 2. Neuromuscular Maturity Rating -Posture (0 to 4) 0-Extremities extended 1-Slight-moderate flexion of hips/knees 2-Moderate-strong flexion of hips/knees 3-Legs flexed & abducted, arms slightly flexed 4-Full flexion of arms & legs -Square Window (-1 to 4) -1- >90 0 - 90 1 - 60 2 - 45 3 - 30 4-0 -Arm Recoil (o to 4) 0 - Extended, 180 or random movements 1 - Minimal flexion, 140-180 2 - Small amount flexion, 110-140 3 - Moderate flexion, 90-100 4 - Brisk return to full flexion, <90 -Popliteal Angle (-1 to 5) -Thigh held in knee chest position & leg is gently extended from behind the ankle. Measure the angle behind the knee -Scarf Sign (-1 to 1) -1 -Elbow reaches/near level of opposite shoulder 0 - Elbow crosses opposite anterior axillary line 1 - Elbow reaches opposite anterior axillary line 2 - Elbow reaches/near midline 3 - Elbow only at the same anterior axillary line 4 - Elbow cannot reach same anterior axillary line -Heel to Ear (-1 to 4) -1 -Foot to ear w/o force 0 - Foot to face w/o force 1 - Foot cannot reach face 2 - Foot crosses 90 angle 3 - Foot at 90 angle 4 - Foot cannot reach 90 angle SGA / IUGR Problems - Stillbirth - More RDS - High mortality - Hypoglycemia - Hypocalcemia - Polycythemia - Depression needing resuscitation at birth LGA - Associated w/ maternal diabetes - High fetal insulin even in absence of maternal diabetes - Morbidity -Birth trauma -Hypoglycemia - Polycytrhemia - Congenital heart diseases - Transposition of Great Arteries (TGA) - High caesarean delivery - cannot fit the pelvic outlet - Sacra agenesis

APGAR SCORING Appearance Pulse Grimace Activity Respiration 0 General cynosis (-) (-) Flaccid (-) 1 Acrocynosis <100 Weak Weak tone Irregular 2 Pink all over >100 Vigorous Good tone Regular

SCORE 7 - 10 -Normal infant -Suction oropharynx -Keep warm 4-6 -Moderate asphyxia -Suction oropharynx -Keep warm -Oxygenate 0-3 -Asphyxia -Resuscitate aggressively NOTE: -APGAR at 1 min: determines the need for resuscitation -APGAR at 5 min: outcome of resuscitation -Scores can be misleading -Do not work well with pre-term infants -Primarily measure brainstem function NEONATAL RESUSCITATION Goal: establish spontaneous respiration & cardiac output the soonest possible time A - Airway B - Breathing C - Circulation D - Drugs E - Environment -Resuscitation is determined by: 1. AOG 2. Character of amniotic fluid (presence of meconium may indicate respiratory distress) 3. Respiration 4. Muscle tone

CLASSIFICATION OF NEWBORN BY WEIGHT & AOG I. AOG 1. Preterm - <37 wks 2. Term - 37-42 wks 3. Post term - >42 wks II. Birth Weight 1. Low (LBW) - <2,500gm 2. Very low (VLBW) - 1,000-1,500gm 3. Extremely low (ELBW) - <1,000gm III. Size for Gestational Age 1. Small (SGA) - <10th percentile 2. Appropriate (AGA) - bet 10th & 90th percentile 3. Large (LGA) - >90th percentile -SGA -This is a purely statistical definition which uses the 10th percentile cut-off for a standard weight for gestation reference level -Intra-Uterine Growth Restriction (IUGR) -This is defined as failure to achieve full growth potential

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Pedia - Newborn history & PE -2013

-Routine Newborn Care 1. Provide warmth - Thermoregulation at 36.6-37.5C 2. Clear airway 3. Dry 4. Assess color, HR & respiration -Initial Steps in Stabilization -Provide warmth -position: clear airway if necessary (poor respiratory effort, HR<100bpm, poor muscle tone -Dry, stimulate, reposition -----------------------------------------------------------------------------END

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