Newborn infants Classification, History, physical examination and common issues 4 th year rotation.
Newborn infants Classification, History, physical examination and common issues
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Newborn infantsClassification, History, physical
examination and common issues 4th year rotation
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Course description by day1&2
• Day 1:introduction to – history related to newborn care
• PROM, oligo/poly hydramnios, vaginal delivery..etc– Apgar score – Resuscitation
• HR, Respiration, Color
• Day 2,3:Examination of newborn with unique component and demonistration– Fontanell, reflexes, DDH, dysmorphism and gross
abnormalities, red reflex, femoral pulses ……see next– Performing examination independently
•
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Course description by day3,4&5• Day 4:• nutritional issues and breast feeding and counseling mother about • common issues of newborn like
– Physiologic Jaundice– Umbilical care– Circumcision
• Day5:• newborn screening : Thyroid, PKU • Screening for DDH, G6PD,, neonatal cataract by red reflex • Give write up of complete history, exam and counseling regarding
above mentioned issues• Follow up visit after dicharge
– Weight gain– Feeding, stooling, urination, sleeping, activities– education
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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 42 week
• Premature; less than 37 weeks gestation
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Other Classification
• SGA <10th centile• LGA>90th centile• AGA 10-90th centiles• IUGR; describe less than optimal pattern of
growth over a period of time intrauterine. It is possible to be IUGR not SGA
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SGA / IUGR problems
• Stillbirth• More RDS• High mortality• Hpoglycemia• Hypocalcemia• Polycythemia• Depression needing resuscitation at birth• Low Apgar score
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LGA
• Associated with maternal diabetes• High fetal insulin even in absence of maternal
diabetes• Morbidity
– Birth trauma– Hypoglycemia– Polycythemia– Congenital heart disease TGA– High cesarean delivery – Sacral agenisis
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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
• Breach presentation • IUGR • Consanguinity, family history
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• 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
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Examination precaution
• Hand washing
• Thermal environment
• Light and noise
• 5-10 minutes examination time
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Cardiopulmonary stability
• Apgar score– Heart rate – Respiratory effort– Color– Tone– Reflex irritability
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Physical Eamination
• Vital signs– RR 40-60– HR 120-160– Temperature axilary 35.5-37.5
• Over bundling• Heater
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Physical Examination
• skin– Pink is normal– Acro cyanosis is normal– Cyanosis– Bruised part look blue– Jaunduce
• 1st 24 hours• Cephalopedal distribution
– Pale and grayish color in anemia and acidosis respectively
– Common skin rash• Erythema toxicum, mongolian spot,
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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
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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
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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
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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
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head
• Head cicumference
• Molding
• Brachycephaly: flat occiput
• Widening of suture
• Fontanelles
• Head auscultation: bruits
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Ears, Nose, Mouth
• Low set ears?,Preauricular pits, External meatus tie
• Natal teath
• Choanal atresia
• Epstein pearls
• Cleft, submucosal
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Neck and clavicle
• Webbing; turner syndrome
• Excess skin at base of neck posterior in Down syndrome
• Goiter
• Fracture in clavicle– Asymmetric moro reflex
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Respiratory
• Tachypnea
• Nasal flaring
• Respiratory effort– Mild retraction
• Grunting
• asymetric chest rise
• supra-sternal, intercostal, subcostal retraction
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Chest, back
• Pectus excavatum• Pectus carinatum• Suprmammary nipple• Breast hpertrophy
– Milk production– No redness
• Back – abnormal curvature– Sinus trsct, tuft of hair, MMC…
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Respiratory
• Inspection is the key– No grunting, flaring. Retraction
• Auscultate – Air entry, symmetry– Early crepitation sound is transmitted upper
sound– Late inspiratory crepitation
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cardiovascular
• HR 100-160 beats/min
• Color, perfusion
• Central cyanosis
• Single S1
• Splited S2– No split ;single ventricle, pulmonary
hypertension
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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
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Genitalia and anus
• Penile size• Hypospadias, epispadias• Testes
– 2% crypoorchid– Hydrocele
• Premature– Prminent clitoris and minora– Vaginal skin tag– Vaginal discharge /blood– Labial fusion
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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
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Anus
• Patency
• location
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CNS
• Awakenes and alertness
• moving extremities
• Flexed body posture
• Minimal Head lag
• Ventral suspension
• Vertical suspension
• Moro reflex
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Postnatal assessment of gestational age( leave nect 3 slids
to NICU week)
• Accuracy within 1-2 weeks• New Ballard Score
– Neurologic characterstic– Physical characterstic
• Part of general examination
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Neuromuscular Maturity
• Posture
• Square window
• Arm recoil
• Poplitteal angle
• Scarf sign
• Heel to ear
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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