09.05.23 CM_Evaluation of the Newborn_Unno_Notes (dragged).pdf

September 5, 2023 Evaluation of the Newborn Page 2 of 11 3. Match the following medication exposures to the appropriate newborn presentation. Medications Newborn Presentation Insulin Jittery, increased tone, excessive crying, poor feeding, diarrhea Zidovudine Jittery, large for gestational a...

September 5, 2023 Evaluation of the Newborn Page 2 of 11 3. Match the following medication exposures to the appropriate newborn presentation. Medications Newborn Presentation Insulin Jittery, increased tone, excessive crying, poor feeding, diarrhea Zidovudine Jittery, large for gestational age, found to have low glucose level Lithium A protrusion over the sacrum consistent with a meningocele/spina bifida Fentanyl Normal newborn exam Folic acid (not regularly taken during pregnancy) Blue discoloration of the lips and mucous membrane Birth History  Gestational Age o Full term: 37-42 weeks gestation o Preterm: before 37 weeks o Postterm: after 42weeks 0 days gestation  Birth weight o Appropriate for Gestational Age (AGA) o Small for Gestational Age (SGA): < 10th percentile  Symmetric: both head and body small. Usually due to genetic or infectious cause  Asymmetric: “head sparing”, usually due to placental insufficiency o Large for Gestational Age (LGA): > 90th percentile o Low Birth Weight (LBW): <2500g o Macrosomia: >4000g  Mode of Delivery o Vaginal o C-section: elective vs non-elective  Apgar Scores o Standardized way of communicating status of newborn infant and transition from intrauterine to extrauterine life September 5, 2023 Evaluation of the Newborn Page 3 of 11 o Five components: heart rate, respiratory rate, muscle tone, reflex irritability, color o Scored at 1 min and 5 min of life o Score of 7-10 considered normal  Plurality o Singleton o Twin: Dichorionic, Diamniotic; Monochorionic, Diamniotic; Monochorionic, Monoamniotic   Twin-Twin transfusion syndrome in monochorionic pregnancies Pregnancy Complications o Gestational hypertension, Pre-eclampsia, gestational diabetes, TORCH and other infections, fetal growth restriction, abnormal prenatal screening, Premature rupture of membranes, other chronic medical conditions, tobacco/alcohol/drug use, etc.  Birth Complications o Fetal intolerance of labor, meconium aspiration, breech position, shoulder dystocia, forceps delivery, chorioamnionitis, neonatal resuscitation, etc. Newborn Vital Signs (Normal Ranges)  HR: 120-160  RR: 40-60  Temp: 36.5-37.5C  BP: 65-85/45-55 Head  Fontanelles: Anterior and Posterior o Should be open and flat o Bulging fontanelle is sign of increased ICP o Sunken fontanelle is sign of dehydration  Size: o Microcephaly: causes include genetic conditions, TORCH infections September 5, 2023 Evaluation of the Newborn Page 4 of 11 o Macrocephaly  Swelling: Caput succedaneum vs Cephalohematoma  Intraventricular Hemorrhage: a complication of prematurity Eyes  Red Reflex o Should be symmetric in both eyes o Leukocoria is sign of Retinoblastoma o Absent red reflex could also suggest cataract, glaucoma  Conjunctivitis o Chemical: occurs in first 24 hrs of life, reaction to silver nitrate prophylaxis (no longer used) o Neisseria gonorrhea: 2nd – 4th day of life o Chlamydia: 5th- 14th day of life o Erythromycin ointment applied to eyes at birth to prevent bacterial conjunctivitis  Retinopathy of prematurity: a complication of prematurity ENT  Cleft lip/palate  Ankyloglossia (“tongue tie”) – can cause difficulties with breastfeeding Cardiovascular  Acrocyanosis: normal, due to immaturity of vasculature, will self-resolve  Congenital Heart Disease: o Cyanotic  Truncus Arteriosus, Transposition of Great Vessels, Tricuspid Atresia, Tetralogy of Fallot, Total Anomalous Pulmonary Venous Return, Hypoplastic Left Heart Syndrome, Ebstein’s anomaly o Acyanotic  PDA, ASD, VSD, Coarctation of Aorta September 5, 2023  Evaluation of the Newborn Page 5 of 11 Ductus Arteriosus (along with foramen ovale): structures of the fetal heart o Should close after birth o Might be necessary and life-saving to keep DA open in infants with ductal dependent congenital heart disease  Can maintain patency with Prostaglandin E1 o If doesn’t close = Patent ductus arteriosus (PDA)  associated with congenital Rubella syndrome  over time can lead to pulmonary hypertension and heart failure  can pharmacologically close the ductus arteriosus with Indomethacin Respiratory  Transient Tachypnea of the Newborn o Will self-resolve, as name implies o Typically occurs in infants born via C-section w/o labor  Respiratory Distress Syndrome (Hyaline Membrane disease) o Due to surfactant deficiency o Risk factors: prematurity, diabetes in the pregnant person  Meconium Aspiration o Can lead to pulmonary hypertension  Pneumonia/Sepsis Abdomen/Gastrointestinal  Umbilical cord o Umbilical hernia: very common, esp in premature infants. should be reducible, vast majority will close/resolve with time o Omphalitis: Emergency! must be treated aggressively with antibiotics, potential complications include necrotizing fasciitis, death  Vomiting due to bowel obstruction o Duodenal Atresia: “double bubble” on XR, associated with Trisomy 21 September 5, 2023 Evaluation of the Newborn Page 6 of 11 o Malrotation o Volvulus  Delayed massage of meconium o Meconium ileus  On imaging with contrast enema, would see microcolon  Early presentation of cystic Fibrosis o Hirschsprung disease   On imaging, would see a transition point  Diagnosis: rectal suction biopsy  Associated with Trisomy 21 Necrotizing Enterocolitis: a complication of prematurity o On imaging, Pneumatosis Intestinalis (air in bowel wall) Genitourinary  Urate crystals – benign  Vaginal bleeding – benign, due to exposure to in utero estrogen and then withdrawal of it after birth  Hydroceles – common in premature infants with testicles, majority resolve by first birthday  Hypospadias/Epispadias – contraindications to circumcision at birth. Refer to urology for repair  Atypical external genitalia – if known XX, think about congenital adrenal hyperplasia Musculoskeletal  Brachial plexus injury +/- Clavicular fracture o Risk factors: shoulder dystocia, LGA/Macrosomia o Erb palsy: C5-C6 nerve roots, “waiter’s tip” o Klumpke palsy: C8-T1 nerve roots, “claw hand”, can also have Horner syndrome o Clavicular fracture: +crepitus on palpation over clavicles  Hip dysplasia o Test for hip instability with Ortalani and Barlow maneuvers September 5, 2023 Evaluation of the Newborn Page 7 of 11 o Risk factors: breech (in third trimester), +family history, firstborn child, female, oligohydramnios Neurological  Newborn reflexes: Moro, Rooting, Grasping, Sucking, etc.  Tone: Hypertonia vs Hypotonia  Spina bifida o Can have occult spina bifida (i.e. no obvious meningocele or meningomyelocele)   Concern for possible tethered cord, which could cause issues later as body grows  Look for abnormal skin findings over sacrum such as dimple, skin tag, tuft of hair, nevus flameus, etc. Intraventricular hemorrhage: complication of prematurity Dermatology  Erythema toxicum o Benign, self-resolves. Microscopy: Eosinophils  Pustular melanosis o Benign, self-resolves. Microscopy: Neutrophils  “Blueberry Muffin” rash o Typically associated with congenital Rubella  Congenital dermal melanocytosis (“Mongolian spots”) o Benign, may fade over time. o Important to document because can be mistaken as bruising, abuse  Vascular birth marks: o Nevus flameus – “Port wine stain”, if over trigeminal nerve distribution, consider Sturge Weber o Nevus simplex  Jaundice o In newborns, physiologic hyperbilirubinemia is unconjugated o Conjugated hyperbilirubinemia is abnormal September 5, 2023 Evaluation of the Newborn Page 8 of 11 o Jaundice in first 24 hours is abnormal o In normal newborns, bilirubin levels will peak around days 3-5 of life o Phototherapy to prevent kernicterus, bilirubin encephalopathy o Risk factors: ABO or Rh incompatibility (Alloimmunization), cephalohematomas, significant bruising, poor feeding (due to enterohepatic recirculation of bilirubin) Neonatal Sepsis  Pathogens: Group B Strep, E. coli, Listeria  Can present in various (and initially subtle) ways: Temp instability (hypothermia actually more common than fever/hyperthermia), Tachypnea, Hypoglycemia, Irritability, Lethargy, poor feeding, etc.  Risk factors: o Perineal GBS colonization of the birthing person (esp with inadequate intrapartum antibiotic prophylaxis) o Prolonged Rupture of Membrane (greater than 18 hours prior to delivery) o Chorioamnionitis o Prematurity  Obtain blood culture and treat baby with Ampicillin and Gentamicin Neonatal Hypoglycemia  Unrecognized and untreated hypoglycemia can lead to significant neuro and developmental impairments  Risk factors: o Prematurity o SGA/Low Birthweight o Diabetes affecting the pregnant person o LGA/Macrosomia o Perinatal Asphyxia Neonatal Abstinence Syndrome September 5, 2023 Evaluation of the Newborn  Withdrawal following fetal exposure to opioids  but can also be due to exposure to SSRIs  Signs and symptoms Page 9 of 11 o Tremors, Jitteriness, Excessive or high-pitched crying, Hypertonia, Hyperreflexia, yawning, stuffy nose/congestion, vomiting, diarrhea, sweating, temp instability, etc