Course:PostgradFamilyPractice/ExamPrep/99 Priority Topics/Newborn
Newborn - Key Features
1. When examining a newborn, systematically look for subtle congenital anomalies (e.g., ear abnormalities, sacral dimple) as they may be associated with other anomalies and genetic syndromes.
2. In a newborn, where a concern has been raised by a caregiver (parent, nurse),
a) Think about sepsis, and
b) Look for signs of sepsis, as the presentation can be subtle (i.e. not the same as in adults, non-specific, feeding difficulties, respiratory changes)
c) Make a provisional diagnosis of sepsis.
3. Resuscitate newborns according to current guidelines.
4. Maintain neonatal resuscitation skills if appropriate for your practice.
5. When a parent elects to bottle feed, support their decision in a non-judgemental manner.
6. In caring for a newborn ensure repeat evaluations for abnormalities that may become apparent over time (e.g., hips, heart, hearing).
7. When discharging a newborn from hospital,
a) Advise parent(s) of warning signs of serious or impending illness, and
b) Develop a plan with them to access appropriate care should a concern arise.
History:
Review of current prenatal and delivery history:
- Pregnancy - planned/not, prenatal care, results of routine tests (ABO blood type, Rh antibody, Hemoglobin, TSH [if done], Urinalysis and urine culture, Chlamydia and Gonorrhea screen) maternal infection screen, prenatal genetic screening, gestational DM, GBS swab result
- Labour - length of labour, duration of ROM, presence of meconium
- Delivery - mode of delivery, Apgars, need for resuscitation
Review of mother’s previous OB history:
History of congenital abnormalities, stillbirths, genetic/syndromic conditions
Mother and father’s medical and genetic history - e.g., maternal lupus, pre-eclampsia
Sepsis Risk Factors:
- • GBS+
- • Intrapartum fever ≥38ºC (100.4ºF)
- • Membrane rupture ≥18 hours
- • Delivery at <37 weeks gestation
- • Chorioamnionitis
- • 5 minute Apgar <6
- • Fetal distress during labour
Check if maternal intrapartum antibiotics received (at least 2 doses for GBS+)
Physical Exam:
General Appearance:
- • Body position at rest - posture often reflects the position the fetus was in in utero
- • Body Movement - check symmetry
- • Nutritional state - subcutaneous fat in anterior thigh, gluteal region; amount of Wharton’s jelly in umbilical cord
- • Colour - pale, ruddy, jaundiced
- • Respiratory effort - increased RR, nasal flaring, accessory muscle use, indrawing, grunting
Measurements:
- • Head circumference: avg. 35 cm at 40 weeks, may change over first few days because of moulding, edema
- • Length: avg. 51 cm at 40 weeks
- • Weight: avg. 3.6 kg for males, 3.5 kg for females at 40 weeks
- • Vital signs (axillary temp 36.1 to 37ºC (97.0 to 98.6ºF) in an open crib; RR 40-60/minute, count over full minute; HR 120-160 bpm)
Organ system:
- • Skin
- o Possible underlying disorder beneath abnormal pigmentation, macular stains, congenital nevi, or hemangiomas
- o Benign conditions include milia (white papules resulting from collection of keratin and sebaceous material, often on nose and cheeks); transient pustular melanosis (superficial pustules on top of hyperpigmented macules, mostly in African-American neonates); erythema toxicum (white pustules on erythematous base); Mongolian spots (congenital bluish-grey or brown pigmented macules, iindefinite borders, especially in African-American or Asian babies); nevus simplex (i.e., macular stain, angel kiss, or stork bite); nevus flammeus (i.e., port wine stain, may or may not be benign)
- • Head - check shape and size; presence of abnormal hair; unusual lesions or protuberances; lacerations, abrasions or contusions; scalp defects
- o Fontanelles - normal is soft and flat with infant sitting. Tense or bulging fontanelles - suspect increased ICP (e.g. bacterial meningitis, subdural hematoma)
- o Sutures - often have moulding with transit through birth canal, but asymmetric skull that persists for longer than 2-3 days after birth or a persistent palpable ridge along the suture line may suggest craniosynostosis; consider increased ICP due to hydrocephalus with widely split sutures with full fontanelle
- o Bleeding: caput succedaneum (edema over presenting part of head, common, crosses suture line, resolves within days); cephalohematoma (fluctuant mass, does not cross suture line, takes weeks - months to resolve); subgaleal hemorrhages (blood between aponeurosis of scalp and periosteum, extend across suture lines, feel fluctuant and firm, can get ++bleeding, can be life-threatening)
- • Face – check symmetry
- o Facial palsies (increased risk if have forceps delivery or prolonged labour and delivery in mother with prominent sacral promontory) should resolve within days to weeks; ensure baby can feed prior to discharge; persistent facial palsy may be due to central lesion
- o Asymmetric Crying Facies due to inadequate depressor anguli oris muscle, causes mouth asymmetry when crying; may be associated with cardiovascular anomalies
- • Eyes
- o Spacing (hypertelorism [wide interpupillary distance] associated with numerous syndromes
- o Symmetry: epicanthal folds, globe size, ptosis, extra-ocular movements
- o Palpebral fissures: may be widened or narrow; could be normal variant or part of syndrome; upward slanting from inner canthus seen in Down syndrome
- o Sclera: normally white, clear; may be light blue in premature infants; consider osteogenesis imperfecta if dark blue
- o Conjunctiva: check for hemorrhage, inflammation, purulent discharge
- o Cornea: consider glaucoma if enlarged (>12 mm), photophobia, increased tearing, corneal haze
- o Pupils: check shape, reactivity to light
- o Iris: check for defects (e.g. coloboma), which may be part of syndrome
- o Red reflex: abnormalities may be caused by cataracts, retinoblastoma, or persistent fetal vasculature
- • Ears: check position, size, and appearance
- o Position – helix should be along horizontal line from outer canthus of eye and perpendicular to vertical axis of head
- o Malformations – check for sinuses, preauricular skin tags or pits, or dysplastic features; may indicate anomalies of inner ear and associated hearing loss; may be part of syndrome, esp. renal.
- o Hearing – may need to repeat
- • Nose: check shape (abnormal if extremely thin or broad or depressed nasal bridge) and patency (rule out septal deviation, choanal atresia)
- • Mouth: check size and shape; small jaw may be associated with Robin sequence; check for cleft lip and palate; check tongue for tongue tie; assess gingival, palate, uvula; natal teeth may be associated with syndrome
- • Neck: check for masses (e.g., branchial cleft cyst, cystic hygroma, lymphangioma, hematoma, thyroglossal duct cyst, thyromegaly, lymphadenopathy), decreased mobility (torticollis), redundant skin (may be associated with syndrome, e.g. Turner), and clavicles
- • Cardio: auscultate, palpate chest and pulses
- o Murmur: worrisome murmur: Grade III or higher, harsh quality, pansystolic, loudest LUSB, abnormal S2, decreased femoral pulses, other abnormalities; patent ductus murmur – continuous, harsh; some murmurs develop in few days, so auscultation needs to be repeated prior to discharge and in outpatient visit
- o Pulses: decreased femoral in coarctation; increased pulse pressure in PDA
- • Resp: check size, symmetry, structure of chest, chest wall movement, and resp effort
- • Breast: check size and nipple position (>25% of chest circumference = wide-spaced, may occur in genetic syndromes, like Turner syndrome)
- • Abdo: check size, overall appearance, normally slightly protuberant; look for distension (e.g. with organomegaly, bowel obstruction, or ascites) or scaphoid appearance (e.g. with diaphragmatic hernia), and abdo wall defects (umbilical hernia, omphalocele, or gastroschisis). Palpate while infants’ legs are flexed, check liver edge (normal 1-3 cm below R. costal margin), palpate for spleen (not usually palpable) and kidneys; check for masses; inspect umbilical cord for signs of infection, number of vessels (single umbilical artery associated with higher number of chromosomal and congenital abnormalities)
- • Genitalia: confirm sex.
- o Female: check labia, clitoris, meatus, and vaginal opening; labia minora and clitoris more prominent in preterm infants
- o Male: check testes (descent), penis, scrotum, position of urethral opening
- o Ambiguous genitalia: may indicate sexual differentiation problem or congenital adrenal hyperplasia (can get salt-wasting crisis)
- o Anus: check location, patency; imperforate anus may be part of syndrome (e.g. VACTERAL association)
- • Hands and feet: check digits (fused or extra digits may be normal variant or part of syndrome), palmar crease (single crease more common in Down syndrome), movement of all 4 limbs (may have brachial plexus injury or palsies, like Erb’s palsy, which is damage to C5 and C6 nerve roots)
- • Hips: check for developmental dysplasia (risk factors: female, breech position, family hx), needs to be repeated at outpatient follow-up visits
- • Spine: visualize and palpate, check for neural tube defect (NTD), soft tissue masses (lipomas, mylomeningoceles), sacral cleft or dimple (more worrisome if deep, big > 0.5 cm, above gluteal crease, skin changes associated with NTD). May have underlying spinal cord abnormality if have tuft of hair, discolouration, or hemangioma over sacrococcygeal region
- • Neuro: check alertness, spontaneous motor movement, strength, tone, primitive reflexes
Exam for sepsis:
May have subtle, non-specific signs: temperature instability, respiratory distress, anorexia, vomiting, jaundice, hepatomegaly, lethargy, cyanosis, irritability, apnea, abdo distension, diarrhea
Newborn Resuscitation Guidelines:
Follow-up:
Ensure newborn able to feed, void, stool; advise parents to seek immediate advice with physician if baby lethargic or febrile; seek prompt help if other signs of sepsis. Should have follow-up within first week for 1st newborn visit, esp. to check weight, feeding pattern, voiding/stooling, address parental concerns