Newborn Evaluation and Care

Newborn Evaluation

• Assess vital signs, weight (g/kg), head circumference (cm), and length (cm) during the physical examination.
• Use a growth chart to plot and assess weight, length, and head circumference based on gestational age to classify as Term Adequate for Gestational Age (TAGA), Small for Gestational Age (SGA), or Large for Gestational Age (LGA).
• The Ballard score is assigned.
• Obtain prenatal history including weeks of gestation (WGA), rupture of membrane (ROM), and Group B Strep (GBS) status.
• Determine the appropriate admission location: nursery, NICU-2, or NICU.
• Complete necessary orders for admission.
• It is important to inform the mother and neonatologist about the newborn's status.

Physical Examination & Preventive Interventions

• Keep the baby warm while performing a complete physical exam.
• Preventive interventions include administering an antimicrobial agent (e.g., 0.5% erythromycin) into both eyes to prevent gonococcal ophthalmia.
• Administer phytonadione (vitamin K): 1 mg IM for infants weighing over 1500 g, or 0.3 to 0.5 mg/kg IM for infants weighing 1500 g or less, within 6 hours of birth to prevent hemorrhagic disease.
• Administer Hepatitis B vaccination if the mother consents to it.

Newborn Apgar Scores

• Created by Dr. Virginia Apgar.
• Apgar scores performed at 1 and 5 minutes after birth.
• These scores determine the need for immediate medical care (e.g., ventilation, suctioning, fluids) and indicate how well the infant transitions to extrauterine life.

Pediatric Vital Signs Reference Chart

• Neonate heart rate (less than 28 days): Awake 100-205 beats/min, Asleep 90-160 beats/min
• Infant respiratory rate (less than 1 year): normal 30-53 breaths/min

Weight Assessment

• Small for Gestational Age (SGA): Weight is less than the 10th percentile.
• Large for Gestational Age (LGA): Weight is greater than the 90th percentile.
• Term Adequate for Gestational Age (TAGA): Weight is appropriate for gestational age.

Head Circumference Assessment

• Microcephaly definition: Head circumference is more than 2 standard deviations (SDs) below the mean for age and sex, or if it is less than the 2nd percentile.
• Macrocephaly definition: Head circumference is more than 2 SDs above the mean for age and sex, or greater than the 98th percentile.

ROM Considerations

• If Rupture of Membranes (ROM) is equal to or greater than 18 hours (prolonged ROM), the baby may require intravenous antibiotics.

Prenatal Care Questions

• Ask about the adequacy of prenatal care (adequate vs. late or none).
• Consult OB/GYN residents if prenatal information is missing.
• Address Group B Streptococcus (GBS) status and treatment to mitigate risk of neonatal infection.
• Identify maternal infections and treatments.
• Check conditions and medications the mother received during pregnancy.
• Enquire about Blood Type Group (BTG) and Rh status, checking for the presence of Coombs and RhoGAM, especially if Rh-negative, to prevent Rh isoimmunization.

Infants of Rh-Mothers

• Order the baby's blood type and group (BTG).
• Order a direct Coombs test for the baby to identify potential antibody-mediated hemolysis.
• Confirm the mother's indirect Coombs test and RhoGAM status to determine the risk of Rh alloimmunization.

Maternal Hep B Status

• Ask the mother, family, or check OB/GYN records regarding maternal hepatitis B status.
• Order the infant's hepatitis B surface antigen level; do it before 3 PM.
• Administer the hepatitis B vaccine and hepatitis B immune globulin (HBIG) within 12 hours of life, giving in separate thighs to prevent interference.

Infants of Zika Positive Mothers

• Order Zika titers in blood and urine.
• Order a neurosonogram to evaluate for intracranial abnormalities.
• Order RetCam as per protocol, and note for eye drop instructions.
• Contact SEDSS/POPZE personnel for guidance on management and reporting.

Hypoglycemia Protocol

• This protocol focuses on Large Gestational Age (LGA), Small Gestational Age (SGA), late preterm infants, and infants of diabetic mothers.
• Regularly measure blood glucose levels (dextrose checks) before feeding, every 3 hours, for 24 hours.
• Hypoglycemia must be confirmed with a venous sample.

Phototherapy & Hyperbilirubinemia

• Use total bilirubin levels; do not subtract direct reacting or conjugated bilirubin when considering phototherapy.
• Risk assessment includes isoimmune hemolytic disease, G6PD deficiency, asphyxia, significant lethargy, sepsis, acidosis, or albumin < 3.0g/dL.
• For well infants between 35-37 6/7 weeks, adjust total serum bilirubin levels according to gestational age and risk factors.

Reminders for hyperbilrubinemia treatment

• Consider administering intravenous fluids (IVF), checking bilirubin profile, complete blood count (CBC), reticulocyte count, BTG, & Coombs.
• Remember sepsis can also lead to hyperbilirubinemia.

Cardiovascular Assessment in Newborns

• Determine point of maximal impulse to rule out dextrocardia.
• HR (100-160 bpm) and rhythm should be checked, which are often regular although irregular rhythm may occur from premature atrial or ventricular contractions.
• Murmurs in the first 24 hours are commonly caused by patent ductus arteriosus, daily heart examination confirms the disappearance of this murmur (about 3 days).
• Compare femoral pulses with brachial pulse to reveal coarctation of aorta, central cyanosis indicates congenital heart disease of pulmonary disease or sepsis.

Respiratory Examination

• Count respirations for a full minute; neonates have irregular breathing patterns, with a normal range of 40 to 60 breaths/minute.
• Examine chest wall for symmetry, and ensure lung sounds are equal throughout.
• Grunting, nasal flaring, and retractions indicate respiratory distress.

Head Examination

• Vertex deliveries often result in head molding due to overriding cranial bones.
• Molding is minimal in breech deliveries.
• Fontanelle size varies, large anterior and posterior fontanelles indicate hypothyroidism.
• Cephalohematomas do not cross Suture lines, a soft-tissue oedema usually disappears over a week and a common cause of jaundice.

Vertex Delivery

• In a vertex delivery, the head is commonly molded with overriding of the cranial bones at the sutures.
• Swelling and ecchymosis of the scalp may be present (caput succedaneum).

Breech Delivery

• In a breech delivery, the head has less molding.
• Swelling and ecchymosis occur in the presenting part (buttocks, genitals, or feet).

Fontanelles

• Fontanelle size varies from a fingertip breadth to several centimeters in diameter.
• Large anterior and posterior fontanelles may indicate hypothyroidism.

Cephalohematoma

• Blood accumulates between the periosteum and the bone, with a swelling that does not cross suture lines.
• Usually aren't noted until soft tissue edema subsides and will gradually disappear over months-Can be seen with nondepressed skull fracture.
• Cephalohematoma are not evident at birth but can increase in size over first few days.
• Cephalohematoma involves the bone (subperiosteal hemorrhage).
• Is slow resolution (3 weeks-3 months).

Caput Succedaneum

• Crosses suture lines
• Usually resolves within 24-48 hours
• Involves the scalp only (soft tissue swelling)
• Usually present at birth
• Common cause of jaundice

Facial Examination

• Inspect the face for symmetry, including mandible, palate, pinnae, and external auditory canals.
• Eyes should be examined for the red reflex to rule out glaucoma, cataracts, and retinoblastoma, as well as subconjunctival hemorrhages.
• Assess the patient for genetic syndromes (trisomy 18, 21) to rule out low-set ears, malformed ears, and external auditory canals.

Abdomen

• Check if the abdomen is round and symmetric, scaphoid abdomen indicates diaphragmatic hernia, asymmetric indicates abdominal mass.
• Kidneys, liver, umbilical hernia, and patent anus needs confirmation.

Reproductive examination in newborn males

• The penis should be examined to identify hypospadias or epispadias
• Testes descend into the scrotum

Scrotal Swelling Examination

• Hydrocele: Scrotum transilluminates.
• Torsion: A surgical emergency, with ecchymosis and firmness.

Reproductive examination in newborn females

• Labia is prominent in term girls.
• Mucoid vaginal and serosanguineous secretions (pseudomenses) from maternal hormones exposure.
• Hymenal tissue at the posterior fourchette disappears

Disorders of ambiguous genitals

• Ambiguous genitals Disorders: congenital adrenal hyperplasia, 5-alpha-reductase deficiency, Klinefelter, Turner, and Swyer syndromes.
• Consult endocrinologist.

Musculoskeletal Examination

• Extremities for deformities, contractures, and maldevelopment.
• Assessment of extremities for absence of limb deformities.
• The spine is inspected for spinal cord problems.

Assessment of birth Trauma

• Brachial nerve palsy examination: limited or no spontaneous arm movement, sometimes with adduction and internal rotation of the shoulder, pronation of the forearm.

Erb's Palsy

• Muscoloskeletal birth trauma or injury.

Orthopedic Examination

• Long bones should be palpated for birth injuries, detect hip dysplasia. The Barlow and Ortolani maneuvers are used to check for dysplasia.
• To identify dysplasia high risk infant (female and breech position), hip ultrasonography should be done at 4 to 6 weeks.

Erythema Toxicum

• Benign rash
• Erythematous base with a white or yellow papule
• Appears 24 hours after birth,
• Scattered over the body and can last for up to 2 weeks.

Reflex assessment

• Commonly elicited reflexes: Moro, suck, and rooting.
• Moro reflex: pulling arms slightly off the bed and releasing suddenly, extends arms with fingers extended, flexes the hips, and cries.
• Rooting reflex: stroking cheek or lateral lip.
• Suck reflex: elicited used a pacifier or gloved finger.

Glabellar Tap Sign

• Tapping the glabella elicits blinking, from birth to 6 months.
• Clinical significance for elicited blinking is unknown.

Rooting Reflex

• Occurs at 24 weeks gestation to 4 months.
• A stroke to the cheek causes the mouth to open and head to turn.
• Required for newborn feeding.