CHARACTERISTICS TO OBSERVE GROSS APPEARANCE Posture: Tonic neck reflex or fencing position

NORMAL NEWBORN

With infant facing left side, arm and leg on that side extended; opposite arm and leg flex (turn head to right and extremities assume opposite postures. It is elicited by turning the infants head quickly to one side when infant is sleeping By 3 to 4 months The infant will have a concave curvature to the back Flexion

How is this reflex elicited

When should this disappear What is the contour of neonates back when held in sitting position? Is the infant in a general state of flexion or extension Skin and Hair What is the normal skin color at birth? Describe acrocyanosis

Pink but vary with ethnicity Peripheral cyanosis, blue color of hands and feet in most infants at birth that may persist for 7-10 days Protective gray- white fatty substance of cheesy consistency covering the fetal skin Downy, fine hair characteristic of the fetus between 20 weeks of gestation and birth that is most noticeable over the shoulder, forehead and cheeks but is found on nearly all parts of the body except the palms of the hands, soles of the feet and scalp. A transient newborn rash found during the first 3 weeks of life. Rash is thought to be an inflammatory response that may appear suddenly anywhere on the body

What is vernix caseosa?

What is lanugo

Erythema Toxicum Neonatorum

What is skin turgor? How is it evaluated?

Sign used to assess the degree of fluid loss or dehydration. It is evaluated by pulling the skin on the back of the hand of an adult or abdomen for a child for a few seconds and does not return to its original state. Unopened sebaceous glands appearing as tiny white pinpoint papules on forehead, nose, cheeks and chin of a neonate that disappear spontaneously in a few days or weeks Mongolian spots are blue or purple-colored splotches on the baby's lower back and buttocks. Over 80 percent of African-American, Asian, and Indian babies have Mongolian spots, but they occur in darkskinned babies of all races. The spots are caused by a concentration of pigmented cells. They usually disappear in the first four years of life. These are small pink or red patches often found on a baby's eyelids, between the eyes, upper lip, and back of the neck. The name comes from the marks on the back of the neck where, as the myth goes, a stork may have picked up the baby. They are caused by a concentration of immature blood vessels and may be the most visible when the baby is crying. Most of these fade and disappear completely. a flat capillary hemangioma that is present at birth and that varies from pale red to deep reddish purple. It most commonly occurs on the occiput and rarely causes any problems. If the lesion is on any other part of the body, it tends to be darker colored and, unlike the scalp lesions, does not regress spontaneously. These lesions most often occur on the face. The depth of the color depends on whether the superficial, middle, or deep dermal vessels are involved. On the face the lesion persists and develops a thick, verrucous, nodular surface. Nevus flammeus is usually unilateral, following the distribution of a cutaneous nerve. If the lesion is on the middle of the face, SturgeWeber syndrome is suspected. Treatment is often not satisfactory. Camouflage cosmetics are used to cover the lesion and are the

Wha is milia?

What are monglian spots?

What are telangiectatic nevi or Storks bite marks? Significance

What is nevus flammeus? Significance?

treatment of choice. What is cutis marmorata? Significance? Skin that has pink marblelike mottling caused by exposure to cold temperature or associated with various debilitating diseases.

Length at birth What is the average length at birth? Head Relationships of size to the rest of body?

45-55cm

Makes up of body length. Head circumference is normally about 1/2 the baby's body length plus 10 cm 32-36.8cm Molding is the elongation of the shape of a baby's head. It occurs when the movable bones of the baby's head overlap to help the baby pass through the mother's birth canal. Normal shape usually returns by the end of the first week. They are the anterior and posterior fontanels. The anterior is the largest and has a diamond shape about 3cn by 2cm. Lies at the junction of the sagittal, coronal and frontal sutures. It closes by 18 months after birth. The posterior lies at the junction of the sutures of the two parietal bones and the occipital bone, is triangular and is about 1cm by 2cm, closes 6 to 8 weeks after birth. Caput succedaneum is a generalized easily identifiable edematous area of the scalp, most commonly found on the occiput, and crosses suture line. Cephalhematoma is a collection of blood between a skull bone and its periosteum and does not cross a cranial suture line. Face is rounded and symmetric. Asymmetry face suggests structural disorders.

Circumference at birth? What is molding and why does it occur?

Describe the two largest fontanelles present at birth. When does each close?

Differentiate between caput succedaneum and cephalhematoma.

Is face normally symmetrical? What does asymmetry suggest?

Eyes Describe the shape, location and symmetry of the eyes. What is the eye color at birth? When is eye color permanent? What is a subconjunctival hemorrhage? Significance

Eyes are symmetric in size and shape. Dull grey, slate blue 9-12months Injuries resulting from rupture of subconjunctival capillaries caused by increased intracranial pressure during birth. Clear within 5 days after birth and present no further problems. Infection in the neonates eyes usually resulting from gonorrhea or other infection contracted when the fetus passes through the birth canal (vaginal). Highly contagious if not treated and may lead to blindness.

What is opthalmia neonatorium?

Describe prevention of this condition

Eye prophylaxis is administered within the first hour after birth to prevent opthalmia neonatorium Inflammation of the conjunctiva caused by exposure to a chemical The red orange spot in the center in the pupil made by light that reflects out of the eye. The test is done for early detection of vision and potential life threatening abnormalities Eyes are structurally incomplete and the muscles are immature. Pupils react to light, the blink reflex is stimulated, and the corneal reflex is activated by light touch. Term newborns can see objects as far away as 50cm (2.5 ft) It is established at birth with reflex tearing, emotional tearing is between 3 weeks and 3 months.

What is chemical conjunctivitis Describe red reflex. Significance

Describe the visual capabilities of the neonate

When is lacrimation established?

Ears Describe appearance (shape, firmness of pinna) and position of the ears. Significance How does the Eustacian tube differ from and adults? Significance

Well formed, firm cartilage, small/large, floppy. Low placement means chromosomal disorder, mental retardation, kidney disorder. Eustacian tube is the tube that runs from the middle ear to the pharynx. The tube is 17-18mm and horizontal at birth. AS it grows to double length, it grows to be at an incline of 45 degrees in adulthood so that the nsopharyngeal orifice (opening) in the adult is significantly below the tympanic orifice (the opening in the middle of the ear near the ear drum).

Mouth Describe the shape and symmetry of the mouth

Symmetry of lip movement, pink gums, mouth moist and pink, uvula midline. Small white blebs found along the gum margins and at the junction fo the soft and hard palate. They are normal manifestation and are typically seen in the newborn Fungal infection of the mouth or throat that is characterized by the formation of white patches on a red, moist, inflamed mucous membrane caused by candida albicans. Treated with antifungal cream for mother and nystatin, miconazole or fluconazole for infant. The vertical fold of mucous membrane under the tongue, attaching it to the floor of the mouth. The frenulum can sometimes be unusually short or tight. This can impair the infants ability to breastfeed. A procedure called frenotomy is done to correct it. When the roof of the baby's mouth is touched with the breast or bottle nipple, the baby will begin to suck. This reflex does not begin until about the 32nd week of pregnancy and is not fully developed until about 36 weeks. Premature babies may have a weak or immature sucking ability, because they are born prior to the development of this

What are Epsteins pearls

What is thrush? Cause? Treatment?

What is the frenulum and what are potential problems with it?

Describe how to check the sucking reflex and whether the palate is intact

reflex. Babies also have a hand-to-mouth reflex that accompanies rooting and sucking and may suck on their fingers or hands. Chest What is the normal shape and circumference? Relationship between head and chest circumference? Are breast swollen (buds)? Usual cause? Abdomen What is diastasis recti?

The chest is almost circular, barrel shape The head is 2-3cm bigger than the chest They are normally swollen caused by pregnancy hormone

Separation of the two rectus muscles along the median line of the abdominal wall. This is often seen in women with repeated childbirths or with multiple gestations. In the newborn, it is usually attributable to incomplete development The abdomen should feel warm, soft with no palpable masses or distention

How should the abdomen feel with soft palpation?

Umbilicus Appearance of cord at birth? What happens to the cord after birth

Whitish gray The cord is cut from the baby and clamped and it is left clamped for 24 hours. The cord is cleaned with sterile water on a neutral pH cleaner assessed for infection, and separated 10-14 days. An outward bulging (protrusion) of the abdominal lining or part of the abdominal organs through the area around the belly button Noises made by the intestines, heard in the abdomen. Bowel sounds mean the GI tract is working

Ongoing treatment

What is an umbilical hernia?

What are bowl sounds? Where are they heard? Significance

Genitalia Male: Size Color What are rugae? Significance? What is the position and normal size of the urinary meatus? What is circumcision? When is it usually done?

2.8-4.2cm Rugae is darker than surrounding skin Folds in the scrotum (wrinkles), indicate term gestation Meatus is at tip of penis, wide variations in size It is the removal of all or part of the foreskin (prepuce) of the penis. Performed during the first few days of life Descended Accumulation of fluid around the testes, causing the scrotum to swell.

Are testes descended? What is hydrocele? Female: Appearance of vulva? Significance?

Clitoris edematous, labia majora edematous and covering labia minora, labia minora possible protrusion over labia majora. Urinary meatus beneath clitoris, difficult to see. Increased pigmentation caused by pregnancy hormone Blood-tinged discharge from pseudo menstruation caused by pregnancy hormone. Smegma, mucoid discharge

Discharge present? If so, describe. Usual cause?

Extremities Extent of range of motion What is simian crease? Significance?

Full ROM A single palmar crease, often seen in Asian infants or infants with Down Syndrome. Legs are of equal length and gluteal folds symmetrical and this means no sign of developmental dysplasia of the hip

Are legs of equal length and gluteal folds symmetrical? Significance?

Define Subluxation. Describe the procedure of observing and manipulationg hips to check for dislocation.

When one or more of the bones of the spine move out of position and create pressure on or irritate spinal nerves. The hip integrity is assessed by using the Barlow test and the Ortolani maneuveer. Feet appears to turn inward but can be easily rotated externally, positional defects tend to correct while infant is crying Fingers or toes fused

What are the positons of the feet? Describe What is syndactyly?] Wh is polydactyly?

Extrea digits on fingers or toes Where are femoral pulses located? Significance of absence? Located in the inner thigh, at the mid-inguinal point. Absence means presence of coarctation or of interruption of the thoracic aorta. PHYSIOLOGICAL ADJUSTMENT: Weight Birth norms? Initial weight loss? Cause?

2500-4000g Acceptable weight loss is 10% or less in first 3-5 days. Caused by growth failure, dehydration. Regaining of birth weight within first two weeks.

When is birth weight regained? Temperature Body temperature at birth? Factors influencing it?

Axillary 36.5-37.2 degree Celsius Can be influenced by infection, inadequate clothing, preterm birth, dehydration Temperature is stabilized by 8 to 10 hours of age

When does body temperature stabilize? Pulse Range What is normal apical rate?

120-160bpm

Describe the technique for obtaining the heart rate What is the point of maximal impulse (PMI)? Significance

Auscultate for a full minute when the baby is asleep or in a quiet state The point of maximal is where the heart is heard clearest and it is at the 4th intercostal space

Respirations Describe respiratory movements in the neonate Where are breath sounds auscultated? Describe

lungs sounds should be clear and heard with equal volume bilaterally Heard in lateral midline under armpits, should be loud, bronchial and clear 40-60bpm

What is an average respiratory rate? Hematology What is bilirubin What is hyperbilirubinemia? What is physiological jaundice?

Brownish yellow substance found in bile Condition where there is too much bilirubin in the blood. Yellow tinge to skin and mucous membranes in response to increased serum levels of unconjugated bilirubin. Appears at 2 to 4 days of age because of the immaturity of the babys liver which leads to slow processing of bilirubin. Disappears by one to two weeks of age Jaundice that poses a higher than normal risk to a baby. Can be caused by a number of factors including blood or liver diseases, infections, and genetic issues. Utilization of lights to reduce serum bilirubin levels by oxidation of bilirubin into water soluble compounds that are then processed in the liver and excreted into bile and urine.

When do you expect physiological jaundice to appear and why?

When do you expect physiological jaundice to disappear? What is pathological jaundice?

Describe phototherapy for this condition

What is kernicterus?

Bilirubin encephalopathy involving the deposit of unconjugated bilirubin in brain cells, resulting in death or impaired intellectual, perceptive, or motor function and adaptive behavior. For concerns related to anemia, blood disorders or infection. Done after birth.

When would a CBC be indicated?

Nutrition Physiology: Stomach capacity?

During the first 2 days of life, fluid requirement is 60-80ml/kg/day. From day 3 to 7, it is 100-150ml/kg/day, and from 8 to 30 is 120180ml/kg/day Burping decreases spitting

Purpose of bubbling (burping)? Taste and smell: Extent of development and why?

Newborns have a highly developed sense of smell and can detect and discriminate distinct odors. Newborns are attracted to sweet smells. Newborns can recognize mothers smell by fifth day; they can also smell breast milk. The newborn can distinguish among taste. A tasteless solution produces no response; a sweet solution elicits eager sucking. A sour solution causes puckering of the lips and a bitter liquid produces a grimace. Develop about three months of age and also a digestive enzyme (amylase) starts to develop

When do the salivary glands develop? Significance?

Feeding (breast and bottle) First feeding Time? Type? First time feeding is immediately after birth Bottle fed with feeding readiness cues

Subsequent feedings Time? Type? Elimination Urine Time of first voiding? Typical pattern: frequency of voiding?

Every 3 to 4 hours Breastfed or bottle fed

Voiding at time of birth 30 hours after birth Varies from 2 to 6 times per day during first and 2nd days of life and from 5 to 25 times per day thereafter.

Stools: Time of passing first stool? What is meconium? Describe. What are the constituents of meconium?

First stool is passed within the first 12 to 24 hours of life Meconium is formed during the fetal life from the amniotic fluid and its constituents, intestinal secretions (including bilirubin) and cells (shed from the mucosa). It fills the lower intestine at birth. Meconium is greenish black and viscous and contains occult blood. The first meconium passed is usually sterile, but within hours all meconium passed contain bacteria Appear by third day after initiation of feeding, its greenish brown to yellowish brown. Breastfed stools: yellow to golden, pasty in consistency, resemble mixture of mustard and cottage cheese with an odor similar to that of sour milk. Formula fed infants: stools pale yellow to light brown, firmer in consistency, with a more offensive odor.

Time of passing transitional stool? Describe stool of breast fed and bottle fed infants

Neuro-Muscular Activity Character of movement?

Spontaneous motor activity especially during crying episodes and of the extremities, notably arms and hands. Posture of newborn

demonstrates flexion of the arms at the elbows and the legs at the knees. Hips are abducted and partially flexed and intermittent fisting of the hands is common What is the scarf sign? With infant supine, support head in midline with one hands, use other had to pull infants arm across the shoulder so that infants hand touches shoulder. Determine location of elbow in relation to midline. Elbow does not reach midline

Head control What control does the infant have over his head when on his abdomen? When held in sitting position The infant turns his/her head to the side

Head will be held in same with chest and shoulder momentarily before falling forward, infant will attempt to right head Its when a baby goes from lying down to sitting up, the head will naturally lag or droop forward or backward. A newborn should have complete head lag. At 20 weeks, the head lag should disappear altogether.

When is head lag?

Other reflexes: Describe Moro reflex? When should it disappear?

Generalized reflex in a young infant elicited by a sudden loud noise or striking the table next to the child resulting in flexion of the legs, an embracing posture of the arms and usually a brief cry. Should disappear by 6 months. Palmar reflex: Infants fingers curl around examiners fingers. Lessens by 3 to 4 months. Plantar reflex: toes curl downward. Lessens by 8 monthss All toes hyperextend, with dorsiflexion of big toe. Disappear after one year of age.

Describe grasp reflex (palmar and plantar). When should it disappear?

Describe Babinskis reflex. Significance? When should it disappear

Describe rooting reflex?

Response of the newborn to move toward whatever touches the area around the mouth and to attempt to suck. Disappear by 3 to 4 months Infant turns head toward stimulus, opens mouth, takes hold and sucks Hold infant vertically, allowing one foot to touch table surface. Infant will simulate walking, alternating flexion and extension of feet. Disappears after 3 to 4 weeks Heart rate based on auscultation with a stethoscope or palpation of the umbilical cord. Respiratory effort, based on observed movement of the chest wall. Muscle tone degree of flexion and movement of the extremities. Reflex irritability, based on response to suctioning of the nares or nasopharynx and generalized skin color, described as pallid, cyanotic or pink. Recorded at one and five minutes after birth Scores of 0 to 3 indicate sever distress, scores of 4 to 6 indicate moderate difficulty and scores of 7 to 10 indicate that the infant is having minimal or no difficulty adjusting to extra uterine life

Describe sucking reflex Describe stepping reflex. When should it disappear?

Apgar scale What five areas are assessed in an Apgar rating score?

When is it recorded? Describe the numerical rating system. Score for each area? Total score?

Draw the chart

Sign Heart Rate

Score = 0 Absent

Score = 1 Below 100 per minute Weak, irregular, or gasping Some flexion of arms and legs Grimace or weak cry

Score = 2 Above 100 per minute Good, crying Well flexed, or active movements of extremities Good cry

Respiratory Effort Absent Muscle Tone Reflex/Irritability Color Flaccid No response

Blue all over, or pale Body pink, hands and feet blue Pink all over