Newborn Assessment PDF

Chapter 7 The Newborn RUBY D. ESPARES, LPT, RN, MAN, PhD Professor Profile of the Newborn Contents: Physiologic function and appearance APGAR Score Ballard’s Score Review of Systems Anthropometric Measurements Ballard’s Scoring The Ballard score is common...

Chapter 7 The Newborn RUBY D. ESPARES, LPT, RN, MAN, PhD Professor Profile of the Newborn Contents: Physiologic function and appearance APGAR Score Ballard’s Score Review of Systems Anthropometric Measurements Ballard’s Scoring The Ballard score is commonly used to determine gestational age. Here’s how it works: Scores are given for 6 physical and 6 nerve and muscle development (neuromuscular) signs of maturity. The scores for each may range from -1 to 5. The scores are added together to determine the baby’s gestational age. The total score may range from -10 to 50. Premature babies have low scores. Babies born late have high scores. Ballard’s Scoring How is neuromuscular maturity assessed? The neuromuscular assessment includes an exam of the following: Posture. How the baby holds their arms and legs. Square window. How far the baby's hands can be flexed toward the wrist. Arm recoil. How well the baby's arms spring back to a flexed position. Popliteal angle. How well the baby's knees bend and straighten. Scarf sign. How far the elbows can be moved across the baby's chest. Heel to ear. How close the baby's feet can be moved to the ears. Ballard’s Scoring How is physical maturity assessed? The physical assessment includes an exam of the following physical characteristics: Skin texture. Skin may be sticky, smooth, or peeling. Lanugo. This is the soft downy hair on a baby's body. It's absent in premature babies. It's present in full-term babies, but not in babies born late. Plantar creases. These are the creases on the soles of the feet. They range from absent to covering the entire foot. Breast. The thickness and size of the breast tissue and the areola (the darkened area around each nipple) are assessed. Eyes and ears. Eyelids are checked to see if they are open or fused shut (more likely in a premature baby). The amount of cartilage and stiffness of the ear tissue are also noted. Male genitals. The presence of testes and the look of the scrotum, from smooth to wrinkled, is verified. Female genitals. The appearance and size of the clitoris and the labia are noted. Anthropometric Measurements Head Circumference 33-35 cm; Expected findings: Head should be 2 -3cms larger than the chest. Chest Circumference 30-33 cm Abdominal Circumference 31-33cm Weight Range 2500-4000gms Length range 46-54cms (19-21 inches)  Four mechanisms of heat loss and corresponding interventions 1. Evaporation - Dry infant immediately 2. Conduction - Place on mothers body skin to skin 3. Convection - Cover with a blanket, wear a cap 4. Radiation - Keep away from cold windows and cold objects  Vital Signs – Heart Rate (rates/min) (apical pulse – left lower nipple) 120 – 160 bpm – Respiratory Rate (breaths/min) 30 – 60 breaths/min – Temperature Axilla: 36.5 – 37.5 deg Celsius Rectal: To rule out imperforate anus. Take it once only, 1 inch insertion – Blood Pressure 80/40 mmHg @ birth 100/50 by 10 day th Routine Medications - Erythromycin Eye Ointment - Aquamephyton (vitamin K) - First Hepatitis B vaccine Neonatal Physical Assessment  Head Examination Head Check overriding sutures, number and size of fontanelles Molding Over-riding of cranial bones Normal finding at delivery Resolves spontaneously over first 5 days of life Fontanelles Anterior Junction of coronal suture and sagittal suture (diamond shape) Often enlarges in first few months of life Closes between 12 – 18 months Posterior Junction of lambdoidasuture and sagittal suture (triangular shape) Junction of occipital and parietal bones Closes by 2 months Head Trauma Caput Succedaneum Common after prolonged labor. Accumulation of blood above periosteum. Soft tissue swelling that crosses suture lines with overlying petechiae, purpura or bruising. Usually resolves spontaneously over several days. Cephalohematoma collection of blood between skull bone and periosteum DOES NOT CROSS SUTURE LINES Uncomplicated resolves in 2 weeks to 3 months, if fracture, Xray in 4-6 weeks to ensure closure, depressed fractures require neurosurgical consult.  Difference between Caput Succedaneum & Cephalhematoma Caput succedaneum Cephalhematoma 19 Fontanelles Bulging fontanelle Crying, coughing or vomiting Increased intracranial pressure Sunken fontanelle Decreased intracranial pressure (dehydration) Large fontanelle or delayed closure Congenital hypothyroidism, Trisomy 21, Rickets, Achondroplasia, Increased Intracranial Pressure Facial Examination Facial Nerve Paralysis Usually caused by compression of the facial nerve against the sacral promontory or by trauma of a forceps delivery. The nasolabial fold on the affected side is not present, the corner of the mouth droops and the affected eye is unable to close. Infant will have difficulty with feeding, drooling from the paralyzed side. Most palsies resolved spontaneously within days.  Eye Examination Normal Eye findings following delivery Permanent color Normal Eye Eyelid Edema develops 3 -12 months Lacrimal glands – not fully mature First 6 weeks – transient strabismus; not able to focus “PERRL” = Pupils Equal, Round and Reactivity to Light Subconjunctival hemorrhage: from stress of vaginal delivery Nose Examination Babies are obligate nose breathers until 4 months old. Check patency with stethoscope (listen over nares). Look for nasal flaring as a sign of increased respiratory effort. Mouth Examination Examine palate with index finger Cleft Lip Can be seen with or without cleft palate Common in Trisomy 13 Repair is usually at 3 months of age Cleft Palate May involve soft and hard palate and incisive foramen Repair is usually before age 1 for normal speech Note size and shape of tongue and length of frenulum membrane -superior labial frenulum -lingual frenulum -inferior labial frenulum Epstein pearls - small white cysts which contain keratin; frequently found on either side of the median raphe of the palate; Resolves in 1-2 months. Ankyloglossia - also known as tongue-tie, is a congenital oral anomaly that may decrease mobility of the tongue tip and is caused by an unusually short, thick lingual frenulum, a membrane connecting the underside of the tongue to the floor of the mouth. Normal Tongue Ankyloglossia Epstein pearls Ear Examination Pinna should be fully formed and firm Assess for asymmetry or irregular shape Note presence of skin tags. Low set ears Below lateral canthus of eye Malformed ears Can be associated with Downs or Turners Syndromes Neck Examination Palpation Palpate all neck muscles Webbed neck Associated with Turner’s and Noonan’s Syndromes Torticollis Sternocleidomastoid muscle injury from birth trauma. Hematoma and fibrosis results in muscle shortening. Muscle adaptation from abnormal intrauterine position. Chest /Lungs Examination Observe Auscultation Respiratory pattern Audible stridor, grunting Brief periods apnea are normal in transition, Wheeze, rales, rhonchi called “periodic breathing” Chest movement Symmetry Retraction Abdominal Examination Palpate for masses / organs Kidneys may be felt on right and left side of abdomen by deep palpation Umbilicus Umbilical Cord Count number of vessels 1 vein and 2 arteries (AVA) Umbilicus Check for signs of bleeding, infection, granuloma, or abnormal communication with the intra-abdominal organs  Male Genitourinary Examination Inspection Check glans, urethral opening, prepuce and shaft Normally it is difficult to completely retract the foreskin. Circumcised infants should be checked for edema, bleeding or complications at the incision site. AGENESIS – no testes or closed scrotal sac Full term infants should have brownish *Normal length of NB penis = 2cm long pigmentation and fully rugate scrotums  Female Genitourinary Examination Inspection Check labia, clitoris, urethral opening and external vaginal vault Common normal findings Prominent labia minora and clitoris Clitoris can have a relatively prominent appearance, especially if the labia are underdeveloped or the infant is premature. PSEUDOMENSTRUATION – blood tinged vaginal discharge occuring during the first week of life as a result of the withdrawal of maternal estrogen Preterm female genitalia Ambiguous Genitalia Newborns with ambigious genitalia: require rapid diagnosis and treatment! Potential clinical manifestations: hypoglycemia, hyperpigmentation, apneic episodes, seizures, hyperkalemia, dehydration, hypotension, vascular collapse, shock Also social emergency: Refer to the infant as “your baby” or “your child,” delay naming the child/birth certificate until sex is determined Rectum and Anus Anus patent and not ectopic – Assess with probe or small finger – Or assess rectal patency with 1st temp; lubricated thermometer. If rectum not patent, called Imperforate anus Meconium passed within 48 hours of birth  Spinal Dysraphism Spina Bifida Occulta No abnormality of meninges, spinal cord or nerve roots Spinal Meningocele Meninges herniate through posterior vertebral arches Spinal cord and nerve roots are not involved. Most often occurs in low back Anterior herniation at sacrum may also occur May result in constipation or bladder abnormality Usually asymptomatic and covered by full layer skin Myelomeningocele Meninges, spinal cord and nerve roots are involved Lumbosacral region in 75% of cases Associated with dysfunction of multiple organ systems Signs Flaccid paralysis of lower extremities Deep Tendon Reflexes absent Orthopedic Examination Polydactyl Extra-digit is located more often on the foot. Bone is palpable within the extra-digit. The digit may have voluntary movement. Amputation of digit when child is > 1 year old. Syndactyl - webbing of fingers or toes Orthopedic Examination Upper Extremity Single Palmar Crease Seen in Down's Syndrome Seen in 4% of normal babies Lower Extremity Bowing of legs is normal variation Positional deformities of foot Foot should be easily replaced to normal position Talipes Equinovarus (Clubfoot) Heel inversion (varus) with internal rotation Forefoot inverted and adducted (soles face each other) Plantar flexion with inability to dorsiflex Leg internal rotation Refer immediately for serial casts Severe clubfoot requires surgery Metatarsus Adductus (In-Toeing) Forefoot rotated inwardly Banana shaped or C-shaped foot Both feet are inverted (face each other) Mild or flexible improves during first 3 months of life Full resolution spontaneously in 85% of cases Rigid deformity requires treatment Calcaneovalgus Deformity Foot has up and out appearance Foot dorsiflexes easily (long heel cord, ligaments lax) Limited plantar flexion (less than 90 degrees) Lateral Sole deviation (banana shaped) Feet are everted (facing away from each other) Heel position is valgus (medial malleoli are closer) Skin Examination Jaundice - elevated bilirubin Desquamation Dryness/ peeling of the skin Usually occurs after 24-36 hours Marked scaliness & desquamation = signs of postmaturity 051104 Neonatal Care 41 Mongolian spots Well demarcated symmetric bluish gray to deep brown to black skin markings Common among people of Asian, East Indian, African, and Latino heritage. Often on the base of the spine, on the buttocks and back Generally fade in a few years Erythema Toxicum Neonatorum Normal harmless pinkish popular newborn rash Lesions may be found in face, trunk and limbs. Lasts about 5-7 days. Milia Pinpoint white papules of keratogenous material. Usually on nose, cheeks and forehead. Can last for several weeks. Lanugo – Fine hair on shoulders and back – Common in preterms – Usually disappears in 2-4 weeks Vernix Caseosa – Cheesy white covering  Harlequin Sign When on side, dependent side turns red and upper side/ half turns pale. Due to gravity and vasomotor instability or immature circulation.IT 051104 Neonatal Care 45 Telangiectatic Nevi Also called salmon patches or stork bite nevi Flat, pink lesion found on upper eyelids, forehead, nape of neck Fade by 1-2 years old except those on nape of neck which may persist Cutis Marmorata Transient mottling of the skin Occurs when baby is exposed to the cold Petechiae On scalp and face after vertex delivery Hemangiomas Is a type of benign (non-cancerous) tumor in infants Usually enlarges in 1st year of life. Large facial hemangiomas may be associated with posterior fossa malformations. Most require no intervention  Strawberry Hemangiomas Nevus Vasculosus or Capillary Hemangioma Dark red, raised lobulated tumor Head, neck trunk & extremities Usually disappears after 7 to 9 years of age 051104 Neonatal Care 48 Port-wine stain Nevus Flammeus or Capillary Angioma capillary malformation Flat Red to purple, sharply demarcated dense areas beneath the capillaries Face Does not fade with time 49 051104 Miliaria Obstructed eccrine sweat ducts. Pinpoint vesicles on forehead, scalp, and skinfolds. Usually clears within one week. Transient Neonatal Pustular Melanosis Small vesicopustules, generally present at birth. Contain WBCs and no organisms. Intact vesicle ruptures to reveal a pigmented macule surrounded by a thin skin ring.