PEDIAPrelims - Care of the Newborn 2

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MED AUF

CARE OF THE NEWBORN II Dr. Rodolfo Ng | June 25, 2015 | Pediatrics

PROPERTY OF AUFSOM BATCH 2017 v3.1 s2015-2016

PI | ARELLANO GAGUI GALVAN PAMINTUAN TIMBANG

ANTHROPOMETRIC MEASUREMENTS

Weight -average: 3000g -LBW= below 2500 gms; regardless of AOG

Length - average: 50cm -techniques: using tape measure (supine with legs extended) - crown to rump - head to heel

Head Circumference (HC): - average: 35cm - technique: using tape measure - from the most prominent part of the OCCIPUT to just above the EYEBROWS - 1/3 the size of an adults head - disproportionately LARGE for its body - HC should be = or 2cm > CC

Chest Circumeference (CC): - 30 to 33cm - Technique: using tape measure - from the lower edge of the SCAPULAS to directly over the NIPPLE LINE anteriorly - CC should be = of 0.5 mg/dl/hr - peak bilirubin >12mg/dl term and >15mg/dl in preterm during the first week of life - hepatosplenomegaly and anemia - clinical jaundice persisting >1 week (term) and > 2 weeks (preterm) *Ask the mother what the color of the urine is because usually babies are red after birth. Breastfeeding jaundice

Early onset of jaundice within the first 3-4 days

Also called exaggerated jaundice, lack of breastmilk jaundice

Factors: oral administration of water of glucose water, inadequate nursing and decreased stool output

Rx: continuous breastfeeding; no complementary feedings

Breast Milk Jaundice

Later onset of jaundice occurring towards the end of the 1st week and persisting for 3 weeks to 3 months

Cause: unknown, unknown constituent in breastmilk

Dx by exclusion

Rx: stop breastfeeding x 2-3 days

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Reassure the mother that the jaundice is not because of breastfeeding Phototherapy (eyes and sex organs should be covered to prevent damage)

Meconium Staining

Over the skin, fingernails and umbilical cord

Due to passage of meconium in utero due to fetal hypoxia

Passage of meconium due to asphyxia in baby < 34 week gestation is UNUSUAL

The baby was in a state of hypoxia and underwent fetal distress.

Prematures do not pass meconium Lanugo

Found after 20 weeks of gestation on the entire body except the palms and soles

Fine downy hair that covers the shoulders, back and upper arms

NURSERY CARE CONSIDERATIONS More mature, less lanugo May diappear within 2 weeks Preterm: woolly patches of lanugo on skin and

head Post term: parchment-like skin without lanugo

Vernix Caseosa

Protective cheesy-like, gray-white fatty substance

FT: skin folds under the arms and in the groin under the scrotum or in the labia

Nursing considerations: -Use baby oil -DO NOT attempt to remove vigorously It is helpful if you do not totally remove especially for prematures Post matures usually look paranoid Desquamation

Dryness/ peeling of the skin

Usually occure after 24-36 hours

Marked scalliness and desquamation= signs of postmaturity

Milia

Multiple, yellow or pearly white papules approx. 1 mm wide

Due to enlarged or clogged sebaceous gland

Usually found on the nose, chin, cheeks, eyebrows and forehead

BIRTHMARKS

1. Mongolian Spots - Blue-green or gray pigmentation - Lower back, sacrum & buttocks - Disappears by 4 years of age

2. Strawberry Marks - Nevus Vasculosus or Capillary Hemangioma - Dark red, raised lobulated tumor - Head, neck trunk & extremities - After 7 to 9 years of age

3. Large Capillary Hemangioma

4. Cavernous Hemangioma

5. Sturge-Weber Syndrome - A sporadic vascular disorder and - Consists of a constellation of symptoms and

signs including:

facial capillary malformation (port-wine stain)

abnormal blood vessels of the brain (leptomeningeal angioma)

abnormal blood vessels of the eye leading to glaucoma

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- Patients present with seizures, hemiparesis, stroke-like episodes, headaches, and developmental delay

- Port-wine stain (nevus flamneus) involving the forehead and upper lip, glaucoma and contralateral jacksonian seizures

6. Kasabach-Merritt Syndrome - Association of a giant hemangioma with

localized intravascular coagulation causing thrombocytopenia and hypofibrinogenemia

- The site of the hemangioma is obvious, but retroperitoneal and intraabdominal hemangiomas may require body imaging for detection

- Inside the hemangioma there is platelet trapping and activation of coagulation, with fibrinogen consumption and generation of fibrin(ogen) degradation products. Arteriovenous malformation within the lesions can cause heart failure

- Peripheral blood smear shows microangiopathic changes

- Cavernous hemangioma - Thrombocytopenia - Microangiopathic changes in RBC (detected

thru peripheral blood smear)

OTHER SKIN MARKS

1. Mottling - Cutis marmorata - Reticulated pattern of constricted capillaries

and venules due to vasomotor instability in immature infants

- Bluish mottling or marbling of skin in response to chilling, stress or overstimulation

- *Infection of blood/sepsis may also manifest as mottling in newborns

2. Erythema Toxicum - Newborn rash; urticaria of newborn;

eosinophil rash (because eosinophils are present upon examination of lesion under the microscope)

- Small, white, yellow, or pink to red popular rash

- Trunk, face and extremities - Within 48 hrs. - May be mistaken for septic spots. Careful

examination must be done to prevent unnecessary administration of antibiotics.

- Suspect allergic or hypersensitivity reaction

3. Petechiae - Pinpoint hemorrhages on skin - Due to increased vascular pressure, infection

or thrombocytopenia - Within 48 hrs. - *Petechiae do not disappear after blanching - *May result from mechanical causes such as

cordcoil and pressure during delivery.

4. Ecchymosis - Bruises - As a result of rupture of blood vessels - May appear over the presenting part as a

result of trauma during delivery - May also indicate infection or bleeding

problems

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5. Harlequin Sign - When on side, dependent side turns red and

upper side/half turns pale - Due to gravity and vasomotor instability or

immature circulation - Clowns Suit

6. Caf-au-lait spots

- Tan or light brown macules or patches - No pathologic significance, if CC

Fontanelles soft spot - Anterior fontanel closes between 9-18

months - Posterior fontanel closes at 2 months

- *At birth, it is possible that there is no more posterior fontanel present due to early closure/overlapping of sutures

- Bulging or sunken

Sutures - Overriding or separated

Head lag - Common when pulling newborn to a sitting

position - When prone, NB should be able to lift the

head slightly and turn head from side to side

1. Caput Succeedaneum - Swelling of soft tissues of scalp - Due to pressure - Crosses the suture lines - Presenting part

2. Cephalhematoma - Subperiosteal hemorrhage with collection of

blood - Due to rupture of capillaries as a result of

trauma - Does not cross suture lines

Molding

- Overlapping of skull bones - Due to compression during labor and delivery - Disappears in a few days

Forceps Marks

- U-shaped bruising usually on the cheeks after forceps delivery

Craniotabes

- Localized softening of the cranial bones - Can be indented by pressure of fingers - MOST common among 1st born babies,

pathological in older children (consider possibility of metabolic dosorders)

- Caused by pressure of the fetal skull against the mothers pelvic bone in utero

Craniosynostosis

- Premature closure of the fontanelles

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FACE, EYES, EARS, NOSE, MOUTH What to Assess:

- Facial movement and symmetry - Symmetry, size, shape, and spacing of eyes,

nose, and ears Eyes

- Color: white sclerae; slate gray, brown, or dark blue; final eye color is acheieved after 6-12 months

- Symmetrical - Pupils equally round, reactive to light and

accommodation (PERRLA) - (+) Blink reflex - (+) transient strabismus due to weak EOM,

maybe normal up to 4-5 months of life

- Able to move and fixate momentarily - (+) red reflex; if (-), screen for congenital cataract

or retinoblastoma

- (+) edema on eyelids related to pressure during delivery or as effect of medications

- (-) tear formation (begins at 2-3 months) - The child may be crossed eyes, normal, within 4-

5 months

- At this point in the lecture, Dr.Ng started enumerating oddities that are physiologic for the child:

o Anemia (as long as Hgb is not

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- TRANSITIONAL STOOL o Within 2 to 10 days antenatal o Breastfed infants : golden yellow,

mushy, more frequent (TID/QID) and has a sweet smell; watery like

o Bottle-fed infants : pale yellow, firm, less frequent (BID/TID) and has a more distinct odor

GENITALS Female

- Labia is edematous - Clitoris is enlarged - Pseudomenstruation is possible - Visible hymen tag - Initial voiding within 24 hours

Male

- Prepuce covers the glans penis o (+) adherent foreskin : Phimosis

- Scrotum is edematous o Enlarged : hernia

- Meatus is centrally located o If Ventral / Dorsal : Hypo / Epispadias

- Testes are fully descended o Undescended : Cryptorchidism

AMBIGUOUS GENITALIA - The assessment of ambiguous genitalia may be

summarized through the use of the following parameters:

o U pelvic ultrasound o G palpable gonads o L electrolytes: if there is hyponatremia and

hyperkalemia, suspect CONGENITAL ADRENAL HYPERPLASIA (CAH)

o Y chromosomal studies o S steroid tests: urine CS & 17-KS: to rule out

CONGENITAL ADRENAL HYPERPLASIA (CAH)

Ambiguous Genitalia: Note that the clitoris is enlarged (resembles glans) and the labia are

thickened (resemble scrotum) EXTREMITIES

- Flexed, full ROM, symmetrical - Clenched fists; flat soles - With 10 fingers and toes in each hand - Legs bowed - Even gluteal folds - (+) Creases on soles of feet

o (-) Creases = PREMATURITY - Check for hip fractures or dysplasia

o (+) Ortolanis Click & uneven gluteal folds = CONGENITAL HIP DYSPLASIA - (+) inward turning of the foot = CLUB FOOT or

TALIPES EQUINOVARUS - (+) extra digits = POLYDACTYLY - (+) web fingers = SYNDACTYLY - OSTEOGENESIS IMPERFECTA

o Brittle Bone Disease o Autosomal recessive o Etiology: unknown o Multiple fractures and callus formation o Severe form: stillbirth or early death o If lived beyond infancy, prognosis is good but

potential to be handicapped

Skin Creases over the Palms and Soles

Eliciting the ORTOLANIS SIGN

CLUBFOOT/TALIPES EQUINOVARUS

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POLYDACTYLY (Above) and SYNDACTYLY (Below)

OSTEOGENESIS IMPERFECTA

NEUROLOGIC SYSTEM REFLEXES o Sucking/Rooting Reflex

Touch the lip, cheek or corner of the mouth

Turns head toward the nipple, opens mouth, takes hold of the nipple and sucks

Disappears after 3-4 mos up to 1 year

o Extrusion Reflex

Anything place on the anterior portion of the tongue will be spit out

To prevent swallowing of inedible substances

Disappears after 4 months

Disappearance indicates readiness for semi-solid to solid foods

o Swallowing Reflex

Occurs spontaneously after sucking and obtaining fluids

NEVER disappear

Newborn swallows in coordination with sucking without gagging, coughing or vomiting

o Tonic Neck Reflex/Fencing Reflex

While the baby is falling asleep or sleeping, gently and quickly turn the head to one side

As the baby faces the left side, the left arm and leg extend outward while the right arm or leg flex and vice-versa

Disappears within 3-4 mos

o Palmar (Grasping)/Plantar Reflex

Place a finger in the palm of the babys hand, then place a finger at the base of the toes

Fingers will curl or grasp the examiners finger and the toes will curl downward

Palmar: fades within 3-4 mos

Plantar: fades within 8 mos

o Moro Reflex

Hold baby in a semi sitting position then allow the head and trunk to fall backward to at least a 30-degree angle

Symmetrically abducts and extends the arms; fans the fingers out and forms a C with the thumb and the forefinger; and adducts the arms to an embracing position & returns to a relaxed state

Present at birth; complete response at 8 weeks

MOST significant singular reflex indicative of CNS problem (>6 mos)

Disappears after 4-5 mos

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o Startle Reflex

Best elicited if baby is 24 hrs old

Make a loud noise or claps hands

Babys arms adduct while elbows flex with fists clenched

Disappears within 4 mos

o Babinski Reflex

Gently stroke upward along the lateral aspect of the sole, starting at the heel of the foot to the ball of the foot

Dorsiflexion of big toe and fanning of little toes

Disappears starts a 3 mos to 1 year

Disappearance indicates maturity of CNS

o Stepping/Walking/Dancing Reflex

Hold baby in a standing position allowing one foot to touch a surface

Simulates walking by alternately flexing and extending feet

Disappears after 3-4 mos

Other Nursing Responsibilities:

Identification band

Band registration

Birth record and documentation NEWBORN SCREENING

The Newborn Screening Reference Center (NSRC) is an office under the National Institutes of Health (NIH), University of the Philippines Manila created under RA 9288 The Newborn Screening Act of 2004

Performed after 24 hours of life up to 3 days except for patient in intensive care, must be tested by 7 days.

o Congenital Hypothyroidism (CH) o Congenital Adrenal Hyperplasia (CAH) o Galactosemia (GAL) o Phenylketonuria o Glucose-6-Phosphate-Dehydrogenase

Deficiency (G6PD Def) o Maple Syrup Urine Disease (MSUD)

Infant Care Skills

HOLDING THE BABY 1. Football Hold 2. Cradle Hold 3. Shoulder Hold

Football Hold

Purpose: to carry on one hand free

A holding technique in bathing a baby

Use for small babies

Procedure: 1. Slide forearm under his back 2. Support neck and head with your hand

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3. Press his arm firmly against your side 4. His head faces you 5. Infants feed tucked under your elbow

Cradle Hold

Purpose: used for feeding and cuddling a baby

Procedure: 1. Support head in crook of your arm 2. Encircle the body with your arm 3. Press baby firmly against your side 4. Use other hand to support bottom and

thigh

Shoulder Hold

Purpose: used for burping

Procedure: 1. Draw baby towards your chest with one

forearm 2. Bracing his back and your hand cradling

his head 3. Support your babys bottom and thighs

with your other arm 4. Gently press his head against your

shoulder ADDITIONAL INFORMATION In an article published in the ACTA MEDICA PHILIPPINA in 2012 authored by UP-Manila Chancellor Carmencita D. Padilla entitled Enhancing Case Detection of Selected Inherited Disorders through Expanded Newborn Screening in the Philippines, the following disorders were proposed to be added: A. Hemoglobinopathies

Alpha-Thalassemia Major

Beta-Thalassemia Major

Hb E/Beta + Thalassemia

Hb H Disease

Hb H/Constant Spring Disease

Hb Variant/Beta + Thalassemia

Homozygous EE

Sickle Cell Disease (Hb S/C Disease)

Sickle Cell Anemia (Hb S/S Disease)

B. Amino Acid Disorders

Phenylketonuria (PKU)

Variant Hyperphenylalaninemia

Maple Svrup Urine Disease (MSUD)

C. Organic Acid Disorders

Methylmalonic Acidemia MMA - (Mut0) Methylmalonic Acidemia MMA - (Mut-)

Beta-Ketothiolase Deficiency (BKT)

Isobutyryl-Coa Dehydrogenase Deficiency (IBDHD)

D. Fatty Acid Oxidation Disorders

Medium Chain acyl-Coa Dehydrogenase Deficiencv (MCAD Deficiency)

Short Chain acyl-Coa Dehvdrogenase Deficiency (SCAD Deficiency)

Very Long Chain acyl-Coa Dehydrogenase Deficiency (VLCAD Deficiency)

Other Fatty Acid Oxidation Disorders E. Cystic Fibrosis and Related Disorders

Partial BD Deficiency

CFTR-Related Metabolic Syndrome (CRMS)

Cystic Fibrosis

Classical Galactosemia

Duarte Galactosemia (D/G)

Other Disorders

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APPENDIX

PEDIAPrelims - Care of the Newborn 2

Documents

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