Newborn Assessment PDF Lecture Notes 2024

29/09/2024 Newborn assessment Dr. Mshari Alghadier Department of Health and Rehabilitation Sciences Prince Sattam bin Abdulaziz University...

29/09/2024 Newborn assessment Dr. Mshari Alghadier Department of Health and Rehabilitation Sciences Prince Sattam bin Abdulaziz University PDIA 631 – Lecture three faculty.psau.edu.sa/m.alghadier [email protected] 1 Outline Fetal transition and fetal circulation Apgar score Information of prenatal and birth history Preterm and postterm infant Gestational age estimation The New Ballard Score (NBS) Classifications of Newborn By Weight and gestational age Maternal Risk Factors for LBW, VLBW and IUGR Physical assessment Dr. Mshari Alghadier, Ph.D. 29 September, 2024 | 2 2 Dr. Mshari Alghadier, PhD 1  29/09/2024 Fetal transition The transition to extrauterine life marks a critical event for the newborn. Important physiologic adjustments occur in: pulmonary, cardiovascular, thermoregulatory, and immunologic adaptation to the external environment Dr. Mshari Alghadier, Ph.D. 29 September, 2024 | 3 3 Fetal lung During fetal life with development of the respiratory system, pulmonary fluid occupies the evolving alveoli due to secretions from pulmonary epithelial cells necessary to ensure alveolar growth. Chemical stimuli such as decreased oxygen concentration and pH prompt respiratory center receptors to facilitate initiation of respirations. Dr. Mshari Alghadier, Ph.D. 29 September, 2024 | 4 4 Dr. Mshari Alghadier, PhD 2  29/09/2024 Fetal circulation In utero pulmonary blood vessels are constricted to facilitate flow away from unventilated lungs not yet meant to participate in oxygenation. A series of circulatory shunts, the ductus arteriosus, ductus venosus, and foramen ovale. Facilitate optimized delivery of highly oxygenated blood from the placenta to the systemic circulation while bypassing the fetal lung. Dr. Mshari Alghadier, Ph.D. 29 September, 2024 | 5 5 Fetal circulation The newborn must transition to sustained pulmonary ventilation by establishing adequate respirations for the exchange of gases. Postnatal changes in pulmonary and systemic pressure dynamics include closure of the fetal circulatory shunts to allow establishment of an adult circulatory pattern and may result in transient murmurs in some newborns. Dr. Mshari Alghadier, Ph.D. 29 September, 2024 | 6 6 Dr. Mshari Alghadier, PhD 3  29/09/2024 Apgar score The Apgar score reflects the transition of the newborn postnatally and is performed at 1 minute and 5 minutes of life. The score provides a summative assessment of reliable indicators of successful transition, including heart rate, respiratory effort, muscle tone, reflex irritability, and color. Dr. Mshari Alghadier, Ph.D. 29 September, 2024 | 7 7 Apgar score 0-2: Sever asphyxia 3-4: Moderate 5-7: Mild 8-10: No asphyxia Dr. Mshari Alghadier, Ph.D. 29 September, 2024 | 8 8 Dr. Mshari Alghadier, PhD 4  29/09/2024 Postnatal transition Clinical findings such as nasal flaring, expiratory grunting, or chest wall retractions may indicate respiratory distress needing intervention. Although most systems are anatomically complete by approximately 24 weeks gestation, many systems including the pulmonary system are functionally immature until closer to term. Dr. Mshari Alghadier, Ph.D. 29 September, 2024 | 9 9 Information of prenatal and birth history Maternal and Prenatal History History of prenatal care access? Maternal weight gain during pregnancy? General health during pregnancy? Any maternal infections or chronic health conditions? History of gestational diabetes or thyroid disease? Any use of drugs or alcohol during pregnancy? Maternal smoking during pregnancy? Any partner violence? History of maternal depression or anxiety disorder? Immunization status? Term birth? GTPAL (Gravidity, number of pregnancies; Term deliveries; Premature deliveries; Abortions, spontaneous or induced; Living children) Dr. Mshari Alghadier, Ph.D. 29 September, 2024 | 10 10 Dr. Mshari Alghadier, PhD 5  29/09/2024 Information of prenatal and birth history Birth History Neonatal History Vaginal or cesarean birth? Risk factors for sepsis? Prolonged labor with prolonged third stage? Newborn screening results? Precipitous delivery? Difficulties in feeding or stooling? Vacuum-assisted delivery? Irritability or jitteriness? Breech or shoulder presentation? Jaundice? History of premature membrane rupture or Length of hospitalization? maternal intrapartum fever? Discharged with mother? Maternal group B streptococcal (GBS) screen? Respiratory distress at birth? Apgar score, if known? Dr. Mshari Alghadier, Ph.D. 29 September, 2024 | 11 11 Preterm and postterm infant Look up the complications associated with preterm and postterm infants. Submit this as discussion in BB. Dr. Mshari Alghadier, Ph.D. 29 September, 2024 | 12 12 Dr. Mshari Alghadier, PhD 6  29/09/2024 Gestational age estimation Prenatal assessments with calculated dates based on last menstrual period and prenatal ultrasonography. Postnatally using a standardized assessment tool that considers neuromuscular and physical criteria (postnatal maturation examination) The New Ballard Score (NBS) is the tool most commonly used to evaluate gestational age postnatally. Six neuromuscular and six physical criteria. Validated to accurately estimate gestational age within 2 weeks when performed within the first 48 hours following birth. Dr. Mshari Alghadier, Ph.D. 29 September, 2024 | 13 13 The New Ballard Score (NBS) Dr. Mshari Alghadier, Ph.D. 29 September, 2024 | 14 14 Dr. Mshari Alghadier, PhD 7  29/09/2024 Classifications of Newborn By Weight When a newborn demonstrates expected growth at a given gestational age (if within 2 standard deviations [SDs] from the mean), the infant is classified as appropriate for gestational age (AGA). Infants whose growth exceeds standards for a given gestational age are considered large for gestational age (LGA). Infants whose growth is less than the standard for a given gestational age are classified as small for gestational age (SGA). Dr. Mshari Alghadier, Ph.D. 29 September, 2024 | 15 15 Classifications of Newborn By Weight Gestational Age Expected Growth Parameters Growth parameters for gestational age between 10th and Appropriate for gestational age (AGA) 90th percentile Small for gestational age (SGA) Weight below 10th percentile for gestational age Large for gestational age (LGA) Weight above 90th percentile for gestational age Normal term birth weight Weight between 10th and 90th percentile Low birth weight (LBW) Weight below 2.5 kg Very low birth weight (VLBW) Weight below 1.5 kg Extremely low birth weight (ELBW) Weight below 1 kg Dr. Mshari Alghadier, Ph.D. 29 September, 2024 | 16 16 Dr. Mshari Alghadier, PhD 8  29/09/2024 Classification of Newborns By Gestational Age Postterm ≥ 42 weeks Term Completed > 37 weeks Preterm Born prior to 37 completed weeks Late Born between 34 weeks 0/7 days preterm and 36 weeks 6/7 days Dr. Mshari Alghadier, Ph.D. 29 September, 2024 | 17 17 Maternal Risk Factors for LBW and VLBW Maternal risks Maternal substance abuse Maternal age less than 16 or greater than 35 years of age Race and ethnicity Alcoholism Maternal chronic health conditions Tobacco use Maternal medications Illicit drug use Nutritional status Over-the-counter drug use Environmental toxins or occupational chemical toxins Access to prenatal care Dr. Mshari Alghadier, Ph.D. 29 September, 2024 | 18 18 Dr. Mshari Alghadier, PhD 9  29/09/2024 Small for gestational age Infants with birth weight below the 10th percentile for age are considered SGA. The head may be microcephalic, or small in proportion to the body, and head circumference may be below the 5th percentile for age. With adequate nutrition, SGA infants experience overall catch-up growth, head circumference is first to show catch-up, followed by weight and then length. Newborns with intrauterine growth restriction (IUGR) have restricted fetal weight, length, or head circumference (occipitofrontal head circumference [OFC]) due to a pathophysiologic process in utero. Dr. Mshari Alghadier, Ph.D. 29 September, 2024 | 19 19 Maternal Risk Factors for IUGR Maternal factors Placental factors Fetal factors Maternal hypertension Abnormal cord Multiple gestations Maternal diabetes— insertion or cord Chromosomal poorly controlled abnormalities abnormalities Autoimmune disease Abnormal placentation Fetal infection Cardiac or respiratory Placental abruption disease Maternal infection Maternal chronic health conditions Dr. Mshari Alghadier, Ph.D. 29 September, 2024 | 20 20 Dr. Mshari Alghadier, PhD 10  29/09/2024 Physical assessment Dr. Mshari Alghadier, Ph.D. 29 September, 2024 | 21 21 Skin The immature infant’s skin is thinner, friable and permeable, and more easily disrupted than in adults. The newborn’s skin is typically covered with vernix, a cheesy-white odorless protective sebaceous secretion that may collect in the skin folds. Acrocyanosis, cool and cyanotic hands and feet due to vasomotor instability of peripheral circulation. Pallor, a pale or ashen appearance, can be due to poor perfusion, acidosis, or anemia. Plethora, a ruddy appearance, may indicate polycythemia (increased red blood cell mass). Jaundice, a yellow discoloration of the skin, may occur from deposition of bilirubin. Dr. Mshari Alghadier, Ph.D. 29 September, 2024 | 22 22 Dr. Mshari Alghadier, PhD 11  29/09/2024 Head The head size is considered normal, microcephalic (2 SD or greater than the 90th percentile). Dr. Mshari Alghadier, Ph.D. 29 September, 2024 | 23 23 Head Assessment—Common Findings Caput Diffuse, soft swelling superior to cranial bones; common finding due to head compression during delivery that will resolve without intervention; not confined by suture lines and is maximally evident at birth. Does Succedaneum not require intervention. Cephalhematoma Subperiosteal collection of fluid or blood primarily associated with assisted deliveries; occurs in approximately 2% of deliveries; distinguished on exam as a soft swelling that can increase in size over the first 24–72 h but remains confined by the suture lines. Does not typically require intervention (but may be associated with skull fracture in up to 5% of cases. Cranial Molding Temporary skull asymmetry due to compression during delivery; common with prolonged labor; rarely associated with other anomalies; resolved without intervention. Subgaleal Subaponeurotic blood collection; occurs in 1.5/30,000 births; associated with mechanically assisted deliveries or coagulopathy; distinguished on exam as boggy, shifting mass that extends over cranial Hemorrhage surface to neck and behind ears; may increase substantially in size; need for intervention varies with degree of blood loss into potential space4, Dr. Mshari Alghadier, Ph.D. 29 September, 2024 | 24 24 Dr. Mshari Alghadier, PhD 12  29/09/2024 Common Newborn Diagnostic Screening Tests Screening Diagnostic Test Hearing Screening Universal screening recommended (but not mandated) prior to hospital discharge; testing done by either automated auditory brainstem response (ABR) or otoacoustic emission (OAE). ABR tests cochlear response to sound and auditory pathways; OAE tests cochlear transmission of sound. Screening for critical Universal screening recommended prior to discharge and after 24 h of age; testing done by congenital heart disease pulse oximetry determination of oxygen saturation simultaneously in upper and lower extremity. Positive result warranting additional evaluations: saturation 3% difference between upper and lower sites on repeat measurements. Newborn screening Mandated state-administered blood screening for identification an early treatment of genetic and metabolic conditions. Screening for 29 conditions required in all states; others optional state by state. Test performed 48 h after birth. Dr. Mshari Alghadier, Ph.D. 29 September, 2024 | 25 25 Musculoskeletal, extremities, and spine Normal resting position of the term newborn is inward flexion of upper and lower extremities, although postnatal positioning is affected by the lie in utero. The extremities should be assessed for size, shape, range of motion, alignment and symmetry of movement, and presence/number of digits. The skin overlying the spine is inspected for lesions, pits, tags, and hair tufts; the dermis should be continuous without breaks. The hips are assessed for stability and an evaluation for developmental dysplasia of the hips. Dr. Mshari Alghadier, Ph.D. 29 September, 2024 | 26 26 Dr. Mshari Alghadier, PhD 13  29/09/2024 Developmental dysplasia of the hips Dr. Mshari Alghadier, Ph.D. 29 September, 2024 | 27 27 Neurologic assessment The neurologic assessment can be integrated throughout the physical assessment and takes notes of changes in posture, activity, state, or muscle tone during handling. Infants should exhibit changes, especially in response to stimuli. Observing an infant successfully feeding, at breast or bottle, provides information about intactness of the cranial nerves. Most primitive reflexes generate symmetric responses, and this provides important information about brainstem function. Dr. Mshari Alghadier, Ph.D. 29 September, 2024 | 28 28 Dr. Mshari Alghadier, PhD 14  29/09/2024 Reflexes Primitive Reflexes Postural Reflexes Asymmetrical tonic neck Neck righting Moro Landau Palmar grasp Lateral parachute Placing Forward parachute Plantar grasp Positive support Rooting Stepping Sucking Truncal incurvation or Galant reflex Dr. Mshari Alghadier, Ph.D. 29 September, 2024 | 29 29 Thank you, any question? Dr. Mshari Alghadier, Ph.D. 29 September, 2024 | 30 30 Dr. Mshari Alghadier, PhD 15