Topic 4Topic 4

THE NEWBORN THE NEWBORN CHILDCHILD

LESSON 2LESSON 2

Terms:

newborn

Neo-natal

Pre-natal

Peri-natal

Intra-

natal

Classification of newborn by weight and gestational

age• Help in predict potential problems

– LBW: <2500gm– VLBW: <1500gm– ELBW: <1000gm

• Term :completed 37 weeks gestation till 40 week

• Premature; less than 37 weeks gestation• After term: 40-42 week

Apgar Score• Originally proposed as a predictor for

newborns at risk for complications for bad outcomes (cerebral palsy)

• Outcomes– If the Apgar score at twenty minutes after

delivery is less than five, there is still only a 20% chance of a handicapping condition. Level of evidence (LOE) 5

Apgar Score Score 0 1 2Heart Rate Absent <100 >100Respiratory Effort

Absent, irregular

Slow, crying Good

Muscle Tone Limp Some flexion of extremities

Active motion

Reflex irritability (nose suctioning)

No response Grimace Cough or sneeze

Color Blue, pale Acrocyanosis Completely pink

Apgar V. Anesth Analg 1953; 32:260.

Scoring at 1 and 5 minutes of age

Additional scoring could be continued at 5 minute intervals if needed.

METHODS OF HEAT LOSS

• Evaporation eg wet with amniotic fluid

• Convection- e.g. removed from incubator

• Radiation- e.g. placing cold objects near incubator

• Conduction-e.g. cold stethoscope

DESCRIBE FUNCTIONAL ABILITIES OF THE NEWBORN GASTROINTESTINAL TRACT AND

LIVER

• By birth the newborn has experienced swallowing, gastric emptying, and propulsion

• Meconium is formed in utero

• Newborn passes meconium witin 48 hours

Assessment of the Newborn

• Newborn Care In The Delivery Room – Maternal

history/labor data– Apgar Scoring– Brief physical exam– Nursing

Interventions

ACROCYANOSIS

GESTATIONAL AGE ASSESSMENT

• Two parts– External physical characteristics– Neurological characteristicsMaternal conditions, such as pre eclampsia, diabetes,

and maternal analgesics and anesthesia may impact certain components of gestational assessment

COMPARISON OF CEPHALHEMATOMA AND CAPUT SUCCEDANEUM

• CEPHALHEMATOMA –is a collection of blood resulting from ruptures blood vessels between the surface of a cranial bone and the periosteal membrane. They may be bilateral or unilateral and do not cross the suture lines

• CAPUT SUCCEDANEUM

is a localized, easily identifiable, soft area of the scalp, generally resulting from a long and difficult labor or vacuum extraction.

Cephalohematoma Caput

Examination precaution• Hand washing• Thermal environment• Light and noise• 5-10 minutes examination time

Important History points in caring of newborn

• Maternal diabetes– Metabolic and congenital defect

• Polyhydramnios– Swallowing defect, GI obstruction

• Oligohydramnios– Renal disease, pulmonary hypoplasia

• Maternal age– Old age and chromosomal

• IUGR • family history

Important History points in caring of newborn

• Rupture of membrane– sepsis

• Delivery type– c/s and TTN

• Prenatal care• Maternal blood group

– ABO, Rh disease

• Infection risk– Maternal Hepatitis carrier– Maternal GBS colonization

Physical Eamination

• Vital signs– RR 40-60– HR 120-160– Temperature axilary 35.5-37.5

• Over bundling• Heater

Physical Examination• skin

– Pink is normal– Acro cyanosis is normal– Cyanosis– Jaunduce

• 1st 24 hours• Cephalopedal distribution

– Pale and grayish color in anemia and acidosis respectively

– Common skin rash• Erythema toxicum, mongolian spot,

General inspection

• Flexion of upper and lower extremities

• Cortical thumb• Asymetric movement

– Brachial plexus and fractured humerous

• Ventral, vertical suspension and head control for tone assessment

General inspection• Symmetry of the mouth and face

– Facial nerve

• Vigorous cry is assuring• Weak cry

– sepsis, asphyxia,metabolic, narcotic use

• Hoarseness– Hypocalcemia, airway injury

• High pitch cry– CNS causes, kernicterus

Congenital anomalies

• Facial gestalt; overall look of facial features that give impression of diagnosis ie: Down syndrome

• Minor anomaly: common and no effect on organ function such as simian crease or ear tag

• Major anomaly: less common and involve main organ dysfunction like neural tube defect, multicystic dysplastic, kidney

Head

• Forceps and vaccum marks• Caput succedaneum

– Boggy edema in presenting part of head– Cross suture lines– Disapear in few days

• Cephalhematoma– Subperiosteal– Weeks to resolve– Dose not cross sutures

head

• Head cicumference• Molding• Brachycephaly: flat occiput• Widening of suture• Fontanelles• Head auscultation: bruits

Ears, Nose, Mouth

• Low set ears?,Preauricular pits, External meatus tie

• Natal teath• Choanal atresia• Epstein pearls• Cleft, submucosal

Neck and clavicle

• Webbing; turner syndrome• Excess skin at base of neck

posterior in Down syndrome• Goiter• Fracture in clavicle

– Asymmetric moro reflex

Respiratory• Tachypnea• Nasal flaring• Respiratory effort

– Mild retraction

• Grunting • asymetric chest rise• supra-sternal, intercostal,

subcostal retraction

Chest, back

• Pectus excavatum• Pectus carinatum• Suprmammary nipple• Breast hpertrophy

– Milk production– No redness

• Back – abnormal curvature– Sinus trsct, tuft of hair, MMC…

Respiratory

• Inspection is the key– No grunting, flaring. Retraction

• Auscultate – Air entry, symmetry– Early crepitation sound is transmitted

upper sound– Late inspiratory crepitation

Cardiovascular

• HR 100-160 beats/min• Color, perfusion• Central cyanosis• Single S1• Splited S2

– No split ;single ventricle, pulmonary hypertension

Abdomen• Inspection

– Scaphoid– Distention– Abdominal wall defect (gastroschisis)

• Palpation; baby sucking and use warm hands

– Kidneys are normaly palpable– Liver 2-3 cm– Spleen palpable– Umblical vessels

• 2 artery, one vein

– Hernias ; umbilical and inguinal

Genitalia and anus

• Penile size• Hypospadias, epispadias• Testes

– 2% crypoorchid– Hydrocele

• Premature– Prminent clitoris and minora– Vaginal skin tag– Vaginal discharge /blood– Labial fusion

Extremities• Erb’s palsy: extended arm and internal

rotation with limited movement• Humerous fracture• Digital abnormality

– Syndactaly, brachdactaly, polydactaly

• Single palmar crease• Hip dislocation

– Female, breach

CNS

• Awakenes and alertness• moving extremities• Flexed body posture• Minimal Head lag• Ventral suspension• Vertical suspension• Moro reflex

Neuromuscular Maturity

• Posture• Square window• Arm recoil• Poplitteal angle• Scarf sign• Heel to ear

Physical Maturity, with maturity

• Skin: thicker , less translucent, dry, peeling• Lanugo:

– fine non pigmented hair all over 27-28 wks– disappears gradually

• Plantar surface: presence or absence of creases

• Breast: areola development• Ear cartilage• Eyelid opening• External genitalia

– Rugation, desend– Prominent labia majora

Condition Time of appearance Time of disappearance

Hyperventilation At birth 2nd-3rd day of life Physiological erythema

On the 3rd-5th day of life By the end of the 1st week

Toxical erythema On the 2nd -5th day of life By the end of the 1st week Physiological jaundice

On the 3rd - 4th day The 7th-10th day

Hyperthermia On the 3rd - 5"1 day By the end of the 2nd week Physiological weight loss

On the 2nd -3rd day By the end of the Is' week

Physiological oliguria

At birth The 3rd day

Albuminuria At birth The 3rd day Urea crystalluria On the 3rd-4m day By the end of the 2nd week Sex crisis On the 3rd - 4th day By the end of the 1st week Disbacteriosis The first week By the end of the 2nd week