CMC Lec Pediatrics | Lesson 2.pdf

Lesson 2: Newborn Assessment / Examination Post-Term ○ It is measured with a tape measure drawn ○ after 42 weeks...

Lesson 2: Newborn Assessment / Examination Post-Term ○ It is measured with a tape measure drawn ○ after 42 weeks across the center of the forehead and the Newborn Examination most prominent portion of the posterior It is systematic examination (physical and INITIAL ASSESSMENT OF NEWBORN head. (33-35 cm) neurological) of newborn. Chest Circumference Identification ○ It is measured at the level of nipples and is OBJECTIVES 1. Check and identify the sex of the infant and verify about 2 cm less than head circumference. 1. To provide an assessment of infant's state of the records with the correct name, sex and 30-33 cm development of wellbeing. registration number. Weight 2. To detect any deviation from normal. 2. Gestational Age Full Term/Preterm/Post-Term ○ Average birth weight: 2.5 - 3.5 kg 3. To assess the progress of the child. 1. Posture and Movements INDICATIONS Supine position with partial flexion of arms, First examination: a detailed one in labor room legs and hand commonly turned a little to within 2 hours of birth. one side. Hip joints are partially abducted. Second examination: Before discharge. Movement is most evident in face and Third examination: After 6-8 weeks of neonatal life. limbs. Unusual movement or lack of movements and asymmetry should be We need to consider a proper hygiene of nipple for noted and reported. the breastfeeding of the mother. Nipple and areola of the breasts should be clean as Vital Signs well for proper hygiene Check the vital signs in the following order: 16th weeks (baby) should be given a penta Respiration: normal value of respiration is 40-60 vaccine. breaths/min Heart Rate: normal value of heart rate is 120-140 TERMINOLOGIES beats/min Small for Gestational Age (SGA) Temperature: normal value of temperature is ○ less than 10% for weight at the time of birth. 36.5-37.5 degree celsius Large for Gestational Age (LGA) 2. Skin ○ more than 90% for weight at the time of Physical Examination Color birth. Length ○ Most term newborns have a ruddy Appropriate for Gestational Age (AGA) ○ Crown to heel length with infant supine/ complexion because of the ○ the birth weight between 10-90%. upside down/ with the knees slightly increased concentration of red blood Full Term pressed down to obtain maximum leg cells in the blood vessels and a ○ 37 to 42 weeks or 259 to 294 days extension. (47-50 cm) decrease in the amount of Pre-Term Head Circumference subcutaneous fat. ○ after 28 weeks and before 37 weeks  This ruddiness fades slightly over the 1st Forceps mark month. ○ If forceps were used for birth, there 3. Cyanosis may be circular or linear contusion Peripheral cyanosis appears due to matching the rim of the blade of the immature peripheral circulation. This is a forceps on the infant’s cheek. normal phenomenon in the first 24 to 48 Desquamation ○ These marks disappear in 1 to 2 hours after birth. ○ Peeling of the skin takes place a few days along with the edema that Central cyanosis indicates decreased days after birth and is most marked accompanies it. oxygenation. It may be the result of on the hands and feet. Skin turgor temporary respiratory obstruction or an ○ If a fold of skin is grasped between underlying disease. the thumb and fingers, it should feel elastic. Fontanelle: posterior fontanelle will open first and ○ When it is released, it should fall anterior fontanelle will last open back to form a smooth surface. Pelvimetry: Cephalopelvic disproportion (CPD) ○ If severe dehydration is present, the Pelvic inlet Milia skin will not smooth out again and ○ Newborn sebaceous glands are will remain in an elevated ridge. Vernix Caseosa immature, therefore pinpoint white Mongolian spots ○ It is a white, cream cheese-like papule can be found on the cheek or ○ Slate-gray to blue- black lesions substance that serves as a lubricant, across the bridge of the nose of usually over lumbo sacral area and is secreted by the fetal sebaceous newborn. buttocks glands and disappears within a few ○ It disappears by 2 to 4 weeks. ○ Accumulation of melanocytes within days. the dermis. ○ Generally, fade by age 7 years. Erythema toxicum ○ It begins as a papule, increasing in Lanugo severity to become erythema by the ○ is the fine, downy hair that covers a 2nd day and then disappearing by newborn’s shoulder, back and upper 4. Head the 3rd day. arms. It may be found also on the A newborn’s head appears forehead and ears. disproportionately large because it is one ○ Preterm newborns have more fourth of the total length. lanugo than post-term. Fontanelles  ○ The anterior fontanelle will be felt as Cephalohematoma Mouth a soft spot. Bleeding between the skull and periosteum of Mouth should be observed for cleft lip, cleft palate ○ The posterior fontanelle is so small newborn baby. and tongue tie. that it cannot be palpated readily. Secondary to suture of blood vessel crossing the The palate of newborns should be intact. periosteum. Occasionally, one or two small round, glistening, It does not cross the suture line. well-circumscribed cysts (EPSTEIN PEARLS) are Disappears by weeks and months. present on the palate, a result of the extra load of calcium that was deposited in utero. Sutures Eyes Suture lines should never appear widely separated Newborn’s usually cry tearlessly because the in newborns. lacrimal ducts are not fully mature until about 3 Separation denotes increased intracranial pressure months of age. Sometimes in some newborns one or two natal from either abnormal brain formation, abnormal Eyes should appear clear without any redness or teeth may have erupted. accumulation of CSF in the cranium purulent discharge. (hydrocephalus), or an accumulation of blood from We should observe subconjunctival hemorrhage, Neck a birth injury. ophthalmia neonatorum etc. The neck of newborn is short, often chubby and creased with skin fold. Fused Suture Lines Ears The head should rotate freely on it. also are abnormal and need to be confirmed with The level of the top part of the external ear should X-ray and further evaluation. be on a line drawn from the inner canthus to the Chest outer canthus of the eye and back across the side It looks small because the infant’s head is large in Caput Succedaneum of head. proportion. Swelling or edema of the presenting portion of ○ Ear Cartilage: Pinna firm, cartilage felt along Possible breast engorgement with possible scalp. with the edge. secretion of thin’ watery fluid popularly termed Goes away few days ○ Ear Recoil: Instant recoil. witch’s milk. Absence of retraction. Abdomen Bowel sounds present within an hour after birth.  Edge of the liver usually palpable at 1 to 2 cm below the right costal margin. Edge of the spleen usually palpable at 1 to 2 cm below the left costal margin. Umbilical Cord It has 2 arteries and 1 veins Anogenital Area At birth cord appears bluish white and moist The anus of newborn must be inspected to be Simian Crease After clamping , it begin dry and appears a dull certain that is present, patent, and not covered by a Unusual curvature of the little finger and a simian yellowish brown and sheds after 6-10 days. membrane (imperforate anus). crease (a single palmar crease) are signs of Down Male Genitalia: Scrotum is pendulous, and both the syndrome. testes are present in the scrotum. Males with one or both undescended testicles Soles (cryptorchidism) needs further evaluation. A full-term newborn has creases covering the entire sole of the foot Post –mature infants have deep crease over the foot A premature infant sole crease mat partially covers the upper two-third or may be absent. If presence of 1 artery, then it is associated with: Female Genitalia: in female newborns labia majora V - ertebral fully covers labia minora. A - norectal Some newborns have a mucous vaginal secretion, C - ardiac which is sometimes blood tinged, called pseudo TE - tracheoesophageal menstruation. R - enal This discharge disappears as soon as the infant’s L – imbic system has cleared the hormones. ABNORMALITIES Meconium It is the first fecal material, is a sticky, odorless Back material, greenish black to brownish green which is The spine of a newborn typically appears flat in the passed from 8-24 hours after birth lumbar and sacral areas. The base of the spine should be free of any Urine pinpoint openings, dimpling, or sinus tracts in the Extremities The first urine is diluted because of immaturity of skin, which would suggest a dermal sinus or SPINA We should observe for syndactyly or polydactyly the kidneys and lack of ability to concentrate urine. BIFIDA or occulta, Lumbar hair tuft & hemangioma. Neonatal Reflexes opens, and the examiner introduces Elicited by rotating the infant’s head Also known as developmental, primary, or primitive their gloved finger and sucking from midline to one side. reflexes. starts. The infant should respond by They can provide information about lower motor 7. Rooting Reflex extending the arm on the side to neurons and muscle tone. Disappears: 3-4 months which the head is turned and flexing They are often protective and disappear as Elicited by the examiner stroking the the opposite arm. The lower higher-level motor functions emerge. cheek or corner of the infant’s extremities respond similarly. 1. Blinking or Corneal Reflex mouth. 13. Moro’s Reflex Infant blinks at the sudden The infant’s head turns toward the Onset: 28-32 weeks GA appearance of a bright light or at stimulus and opens its mouth. Well-established: 37 weeks GA approach of an object towards 8. Gag Reflex Disappearance: 6 months cornea. Stimulation of posterior pharynx by The examiner holds the infant so It persists throughout life. food, suction or passage of a tube that one hand supports the head and 2. Pupillary causes infant to gag. the other supports the buttocks. Pupil constricts when a bright light Persists throughout life. The reflex is elicited by the sudden shines toward it. 9. Extrusion Reflex dropping of the head in her hand. It persists throughout life When tongue is touched or The response is a series of 3. Doll’s Eye Reflex depressed, infant responds by movements: the infant’s hands open As head is moved slowly to right or forcing it outwards. and there is extension and abduction left, eyes lag behind and do not Disappears by age 4 months. of the upper extremities. immediately adjust to a new position 10. Yawn This is followed by anterior flexion of of head Spontaneous response to decreased the upper extremities and audible Disappears as fixation develops. oxygen by increasing amount of cry. If persists, indicate neurologic inspired air. damage. 11. Palmar Grasp Reflex 4. Sneezing Reflex Disappears: 2 months Spontaneous response of nasal Elicited by the examiner placing his passages to irritation or obstruction. finger on the palmar surface of the Persists throughout life. infant’s hand and the infant’s hand 5. Glabellar Reflex grasps the finger. Tapping briskly on glabella (bridge of 14. Moro’s Significance nose) causes eyes to close tightly. An absent or inadequate Moro Disappears as brain mature. response on one side: hemiplegia, 6. Sucking Reflex brachial plexus palsy, or a fractured Disappears: around 12 months. clavicle 12. Tonic Neck (Fencing Posture) Elicited by the examiner stroking the Disappearance: 7 months lips of the infant; the infant’s mouth  Persistence beyond 5 months of age deficiency of an enzyme necessary to digest an is: indicate severe neurological amino acid called methionine defects. STARTLE REFLEX Biotinidase Deficiency 15. Stepping (Dancing) Reflex 18. Harlequin Color Change This inherited disorder is characterized by a Disappearance: 3-4 months The color changes as the infant lies deficiency of the biotinidase enzyme. This enzyme Elicited by touching the top of the on the side, the lower half of the is important in metabolizing biotin, a B vitamin. It infant’s foot to the edge of a table body becomes pink or red, and affects one in 60,000 to 75,000 babies in the U.S. while the infant is held upright. upper half is pale. and is most common in the people of European The infant makes movements that It is entirely harmless and has never descent. Lack of the enzyme can lead to severe resemble stepping. been associated with a permanent acid build up in the blood, organs, and body problem. systems. RA #9288 - Newborn Screening Act of 2004 Performed after twenty-four (24) hours of life but not later than three (3) days from delivery of the newborn. A newborn in the ICU must be tested by seven (7) days of age 16. Babinski Reflex NEW GUIDELINES 19. Torticollis (Wry Neck) Disappearance: 12 months ○ A newborn screening test should be Head held to one side with chin Elicited by stimulus applied to the collected when the infant is 24-48 hours of pointing to opposite side due to outer edge of the sole of the foot. age. If the infant is discharged prior to 24 positioning in the womb. The infant responds by plantar hours of age, a specimen MUST be Exercise the neck gently in opposite flexion and either flexion or obtained before discharge, and the parent direction. extension of the toes. or guardian must be informed of the importance of obtaining a repeat test before one week of age Sickle Cell Disease FOOD FOR THE BRAIN This inherited disorder occurs primarily in African 17. Crawling Reflex Newborn babies have more bones than adults: 300 Americans, but may also occur in Hispanics and When placed on abdomen, infant Native Americans. The disease causes a severe makes crawling movements with Homocystinuria form of anemia. There are different types of the arms and legs Disappears at about This inherited disorder affects one in 200,000 disease. The disease occurs in about one out of age 6 weeks. babies and causes intellectual disability, bone every 365 African American births and one out of disease, and blood clots. It is caused by a every 16,300 Hispanic American births. Early diagnosis of sickle cell disease can help lower  some of the risks which include severe infections, blood clots, and stroke. Maple Syrup Urine Disease This is an inherited disorder that is very common in the Mennonite population. The disorder is caused by an inability of the body to properly process certain parts of protein called amino acids. The name comes from the characteristic odor of maple syrup in the baby's urine caused by the abnormal protein metabolism. If untreated, it is life threatening as early as the first two weeks of life. Even with treatment, severe disability and paralysis can occur. The daily routine care of the neonates are as follows: Warmth Breastfeeding Skin care & baby bath Care of umbilical cord Care of the eyes Clothing of the baby General Care: Rooming-in ○ Gentle approach Aseptic technique Sensory stimulation Tender & loving care