Evaluation of the neonate and infant
Transcription
Evaluation of the neonate and infant
Evaluation of the neonate and infant Alison C. Essary, MHPE, PA-C Pediatrics Learning objectives z z z Describe the components of the history and physical examination for a newborn and infant Describe abnormal findings in the history and physical examination Discuss the tools used to measure growth in the newborn and infant (eg, height, weight and head circumference) Learning objectives z z z z z Identify methods used to monitor growth over time in the infant Identify the potential benefits associated with breastfeeding Describe the nutritional components of infant formulas Discuss developmental milestones in the neonate and infant Read Bates! Definitions z z Neonate = The first 28 days of life Infant = A child up to 2 years of age Tips for evaluating the newborn z z Examine the newborn in the presence of the parents Observe breastfeeding if possible z z Newborn is most “compliant” when well fed Allow for minimal disruption of the newborn z z z z z z z General survey Head, neck, heart, lungs, abdomen, GU Ears, mouth Eyes Skin Neuro Hips Bickley, 2007 The newborn examination Timing z The first neonatal examination takes place immediately after birth z z z z Measure APGAR score Score each infant at 1 minute and again at 5 minutes after birth Total score ranges from 0-10 The next examination occurs within 24 hours of birth 0 Points 1 Point 2 Points Heart rate 0 <100/min >100/min Respiration None Weak Cry Vigorous Cry Muscle Tone None Some arms, legs flexion Arms, legs well flexed Reflex Irritability None Some motion Cry, withdrawal Color of body Blue Pink body, blue extremities Pink all over APGAR SCORES Clinical signs APGAR score z At ONE minute: z z Scores of <4 require immediate resuscitation At FIVE minutes: z Scores <7 put the infant at a high risk for CNS or other organ system dysfunction APGAR score z At FIVE minutes: z If the APGAR score is >8 proceed to a more thorough examination The newborn examination General principles z z z z z Temperature (normal 97-98.5F) Pulse (normal 120-160 beats/min.) Respiratory rate (normal 30-60 breaths/min) Color Level of consciousness z z z z z Tone Activity Type of respirations Blood pressure if neonate appears ill All newborns monitored every 30 min. after birth for 2 hours or until stabilized The newborn examination The physical examination z z z Auscultate the anterior thorax Palpate the abdomen Inspect the head, face, oral cavity, extremities, genitalia, and perineum The newborn examination Measurements z z z Head Circumference Length Weight Bickley, 2007 The newborn examination Bickley, 2007 The newborn examination History z z z z z Socioeconomic status Age Race Past medical illnesses in the family (genetic disorders, DM, infectious diseases, cardiopulmonary disorders) Prior maternal reproductive problems (stillbirth, pre-maturity, blood group sensitization) The newborn examination Maternal (obstetric) history z z z z Vaginal bleeding Acute illness Duration of rupture of membranes Medications The newborn examination Labor and delivery z z z z z Duration Fetal presentation Fetal distress Fever Delivery z z z z z C-section, vaginal Anesthesia or sedation Usage of forceps APGAR Score Need of resuscitation The newborn examination Gestational age & birth weight z Gestational age z z z z PRE-TERM = gestational age < 37 weeks TERM = gestational age 37 to 42 weeks POST-TERM = gestational age > 42 weeks Birth weight z z z Small for Gestational Age (SGA) – birth weight is less than 10th percentile Appropriate for Gestational Age (AGA)- birth is between 10th percentile and 90th percentile Large of Gestational Age (LGA) - >90th percentile The newborn examination: Screening tests in Arizona z z z z z z z Phenylketonuria (PKU) Congenital hypothyroidism Galactosemia Maple syrup urine disease Homocystinuria Biotinidase deficiency Sickle cell disease http://www.aboutnewbornscreening.com/stats.htm The newborn examination: Prophylaxis z Silver nitrate ophthalmic ointment or erythromycin ointment z z z Protection against ophthalmia neonatorum Occurs secondary to gonorrhea Vitamin K IM z Protect against hemorrhagic disease of the newborn AAP The newborn examination: Hearing screening z Significant hearing loss present in 1-3/1,000 newborns in the nursery z z z Higher in the NICU Hearing loss correlates with speech and language development Screening completed before discharge from the nursery z Auditory brainstem evoked responses (ABR) or evoked otoacoustic emissions (OAE) z Sensitivity and specificity of ~100% The physical examination: Inspection/General survey z z z z z z z Note color Size Body Proportions Nutritional status Posture Respirations Movement of the head and extremities The physical examination: Skin examination z z z z Lanugo Port wine stain Acrocyanosis Mongolian spots z z z z Milia Capillary hemangioma Café au lait spots Jaundice Skin examination: Lanugo www.merckmedicus.com Skin examination: Port wine stain www.merckmedicus.com Skin examination: Port wine stain z z Facial port wine stains may be associated with ocular abnormalities Consult an ophthalmologist if the port wine stain approaches the ocular region www.merckmedicus.com Skin examination: Acrocyanosis http://www.medicine.ucsd.edu/clinicalimg Skin examination: Acrocyanosis http://connection.lww.com Skin examination: Perioral cyanosis http://newborns.stanford.edu/PhotoGallery/PerioralCyanosis1.html Skin examination: Mongolian spots http://sinoemedicalassociation.org/pediatric/usmlepediatricsreview_files/image012.jpg Skin examination: Milia z Benign keratin-filled papules located on the face z z z Nose, cheeks Develop secondary to developing sebaceous glands Disappear by 4 weeks http://www.adhb.govt.nz Skin examination: Capillary hemangioma www.merckmedicus.com www.mayoclinicproceedings.com Skin examination: Capillary hemangioma z z z A Æ Capillary hemangioma under the right eye B Æ Spontaneous resolution 2 years later Ocular concerns include amblyopia and strabismus www.mayoclinicproceedings.com Skin examination: Café au lait spots z z z >6 café au lait spots that measure at least 5mm in size Æ evaluate for neurofibromatosis Genetic disorder of the nervous system that leads to bone and skin changes Tumor development on nerves http://www.understandingnf1.org/glossary/pop_img_cafe.html Skin examination: Jaundice http://newborns.stanford.edu/PhotoGallery/Jaundice1.html Jaundice z z z z Red blood cell destruction Æ heme in hemoglobin converted to bilirubin in the spleen Æ conjugated in the liver, enters the bile and excreted through the feces Jaundice occurs when bilirubin spills into the blood 65% of newborns develop hyperbilirubinemia Neonatal jaundice usually benign z z Due to developing liver at birth Develops within 2-5 days and disappears within 2 weeks http://www.nlm.nih.gov/medlineplus/ency/article/001559.htm Current Pediatrics, 15th Ed. Physiologic jaundice z z z z z The most common type of jaundice Not present within the first 24hr of life Peaks at 48-72hr in full-term infants and 4-5 days in premature infants Disappears by one week in full-term infants and two weeks in preterm infants Serum bilirubin does not exceed 13mg/dl in full-term infant and 15mg/dl in preterm infant Physiologic jaundice: Breast milk jaundice z z z z 5-10% of infants develop breast milk (or breastfeeding) jaundice Component of breast milk which interferes with conjugation? Inadequate breast milk consumption? Diagnosis of exclusion Substitute formula until jaundice cleared z z Reintroduce breast feeding Can do concurrent phototherapy Nonphysiologic jaundice z Primarily elevated conjugated (direct) bilirubin z z Conjugated in the liver Secondary to infection, metabolic abnormalities, anatomic abnormalities or cholestasis Nonphysiologic jaundice z Primarily elevated unconjugated (indirect) bilirubin z z Secondary to increased production of bilirubin or delayed excretion of bilirubin Examples: ABO incompatibility, Rh isoimmunization (mother is Rh- and neonate is Rh+) Treatment of neonatal jaundice: Bili lights Bilirubin is light sensitive (will break down) Jaundice Clinical pearls z z z z z Jaundice within the first 24 hours is pathologic Jaundice that starts after 2 weeks is pathologic Is the unconjugated or conjugated bilirubin elevated? Is there ABO or Rh incompatibility? Infants discharged early (before 48 hours) need to be followed up within 2 days Jaundice z Treatment: z z z z Treat underlying disorder Phototherapy Æ number of banks of lights determined by total bilirubin level, the rate of rise and the course of underlying condition. Follow bilirubin level q12hr. Discontinue when level reaches 13mg/dl, then recheck level in 12hr. Ensure adequate hydration and stooling status If severe cases are left untreated Æ kernicterus, bilirubin encephalopathy may result (>20mg/dL) The physical examination: HEENT z Head: z Plagiocephaly z z z z z z AAP “Back to Sleep” campaign (1992) Decreased incidence of SIDS Hydrocephaly Cephalohematoma Microcephaly Chvostek’s sign z Normal in newborns and in early childhood Am Fam Physician. 2003 May 1;67(9):1953-6. Head: Fontanelles and sutures z z Should be palpated on all well-child and on all acutely ill infants Depressed fontanelle is a sign of dehydration Head: Fontanelles z Anterior fontanelle z z z z Birth measures 4-6 cm Closes between 4 and 26 months 94% will close by 24 months Increased intracranial pressure produces a bulging, full anterior fontanelle Bickley, 2007 Head: Fontanelles z Posterior fontanelle z z z Birth measures 1-2 cm Closes at 2 months of age Large posterior fontanelle may be present in congenital hypothyroidism Bickley, 2007 Head: Plagiocephaly Flattening of the occipital region of the skull z z 4mo child demonstrates facial changes consistent with right occipital positional head deformity. The right occiput is flattened and has pushed the right ear more anterior, causing the right forehead and right eye to appear more prominent. Head: Plagiocephaly Am Fam Physician. 2003 May 1;67(9):1953-6. Plagiocephaly Positional vs. synostotic Am Fam Physician. 2003 May 1;67(9):1953-6. Plagiocephaly Head orthosis (eg, Helmet) Am Fam Physician. 2003 May 1;67(9):1953-6. Head: Hydrocephaly A buildup of CSF in the ventricles and subarachnoid spaces Head: Hydrocephaly z z Can occur secondary to infection, trauma, bleeding, mass lesion or congenital defects Management z z Shunt placement Ventricle Æ peritoneum Principles of Neurosurgery, 2nd edition, Edited by Setti S. Rengachary, Richard G. Ellenbogen, Copyright 2005 Cephalohematoma A collection of blood under the scalp z z z Typically caused by the trauma of birth Commonly associated with vacuum extraction Resolves spontaneously within approximately 3 months Bickley, 2007 Bickley, 2007 Head: Microcephaly z The circumference of the head is smaller than normal z z z z z The brain has stopped growing The brain has not developed properly May be diagnosed at birth or over time Children have neurologic abnormalities, stunted growth and development, etc. Prompt intervention by a pediatric neurologist to minimize the effects of the structural defect Bickley, 2007 Head: Microcephaly The physical examination: HEENT z Eyes: z z Follow a face or bright light within a few weeks Nystagmus is common immediately following birth z z z After a few days can indicate blindness Intermittent strabismus (crossed eyes) normal within the first three months Conjunctival and retinal hemorrhages are usually benign Bickley, 2007 The physical examination: HEENT z Eyes: z z Cornea > 1cm in diameter suggests congenital glaucoma Funduscopic examination Æ look for bilateral red light reflexes z z z If absent think of cataracts or intraocular pathology White pupillary reflex (leukokoria) suggests cataracts, retinoblastoma, or other pathology Refer to an ophthalmologist Bickley, 2007 Eye: Retinoblastoma The physical examination: HEENT z Eyes: z Visual milestones: z z z z z Birth 1 mos 1 ½- 2 mos 3 mos 12 mos Blinks, regards a face Fixes on an object Coordinated eye movement Eyes converge, baby reaches Acuity 20/50 Bickley, 2007 The physical examination: HEENT z Ears: z z Acoustic blink reflex: Snap your finger about 12 inches from the infant’s ear Neck: z z Child can turn the head at 2weeks Evaluate for torticollis z z z Injury to the sternocleidomastoid at birth May be a precipitating factor for plagiocephaly Evaluate for clavicular fracture z Complication of delivery Bickley, 2007 Neck: Torticollis z z z z Recognizing signs of torticollis Look at both sides of the lower jaw. Does one side look flat and the other filled out? Inspect the lower gum line and compare it to the upper one. Are they parallel or is the jaw tilted? If any asymmetry is present, look closely for other findings and assess neck mobility. Look at the top of the head. Is there flattening? Stellwagen L et al, 2004 Neck: Torticollis Stellwagen L et al, 2004 The physical examination: HEENT z Nose: z z Most newborns and infants are obligate nasal breathers Check nasal patency z z z Choanal atresia Æ septum between nose and pharynx Unilateral or bilateral Mouth: z z Inspect and palpate Little saliva until >3 months Bickley, 2007 Nose: Choanal atresia Mouth: Epstein pearls Mucous retention cysts http://newborns.stanford.edu/PhotoGallery/EpsteinPearl2.html The physical examination: Thorax z z z May see the xiphoid process Newborns alternate between periods of regular vs. periods of irregular breathing Evaluate for audible breathing and work of breathing z z Grunting, wheezing, stridor, or lack of breath sounds Nasal flaring, grunting, retractions Bickley, 2007 Thorax: Retractions http://newborns.stanford.edu/PhotoGallery/Retractions1.html The physical examination: Cardiac examination z z Palpate peripheral pulses Very common for children to have sinus dysrhythmia z z z HR increases with inspiration and decreases with expiration Normal finding Evaluate for the presence of murmurs z z z Location, timing, intensity, quality Evaluate via ECG, echo, CXR Evaluate the patient for noncardiac findings of cardiac disease (Bates, pp.716) The cardiac examination: Structural abnormalities Approximately 4% of newborns will be affected by VSD—the most common cardiac abnormality. The physical examination: Abdominal examination z z Protuberant Inspect the umbilical cord z z z Two arteries and one vein The cord becomes black and falls off over a few weeks Palpate all abdominal organs Bickley, 2007 The physical examination: The musculoskeletal examination z z Inspect the upper and lower extremities Ortolani test z z Barlow test z z Test for posteriorly dislocated hip Test for the ability to sublux or dislocate an intact but unstable hip Galeazzi test z Test for femoral shortening Bickley, 2007 The musculoskeletal examination: Ortolani test 1. Flex legs to right angles at the hips and knees 2. Place your index finger over the greater trochanter of each hip, thumbs over lesser trochanters 3. Abduct both hips simultaneously until the lateral aspect of each knee touches the examining table 4. Positive if you see and/or feel a “clunk” as the femoral head enters the acetabulum The musculoskeletal examination: Barlow test 1. Stabilize infant’s pelvis 2. Place thumb medially over lesser trochanter and index finger laterally over greater trochanter 3. Flex and adduct the opposite hip while applying a posterior force 4. If dislocation occurs, it will spontaneously reduce when posterior pressure is released The musculoskeletal examination: Galeazzi test Dislocated left femoral head sits lower http://newborns.stanford.edu/PhotoGallery/Galeazzi3.html The physical examination: The musculoskeletal examination z Check the LS region z z z z Abnormalities over the skin Pigmented spots Hairy patches Deep pits that may overlie external openings of the sinus tracts The physical examination: The neurologic examination z Evaluate motor tone z z Assess sensory function z z Hold the child up and assess for spasticity or flaccidity Gently flick the palm or sole with your finger Cranial nerves z z z z Can be challenging in the newborn Rooting/sucking reflex = CN V Acoustic blink reflex = CN VIII See Bates pp.732 The physical examination: The neurologic examination z Primitive reflexes z z z Assess newborn’s developing nervous system These reflexes develop during gestation and disappear by certain ages Abnormalities in any and/or all of these reflexes indicates further evaluation z z z z Absent reflexes Reflexes that persist for longer than the appropriate duration Asymmetric reflexes Associated posturing, twitching, spasticity Bickley, 2007 The neurologic examination: Rooting reflex The neurologic examination: Moro reflex Disappears by 3-6mos of age Table—don’t perform reflex over empty space! The neurologic examination: Palmar grasp Disappears by 3-6mos of age The neurologic examination: Plantar grasp Disappears by 3-6mos of age The neurologic examination: Asymmetric tonic neck reflex z z z z Turn the baby’s head to one side, holding the jaw over the shoulder The arms and legs on the side to which the head is turned extend while the opposite arms and legs flex Repeat on the other side Disappears by 2mos The neurologic examination: Positive support reflex Disappears by 2-4mos of age; positive full support by 6mos http://ecatp.usu.edu/resources/general/atdatabase/positioning/images/IMAGE107.jpg The physical examination: Genitalia z Male: z z z May be scrotal edema secondary to maternal estrogens Unable to retract foreskin Female: z z May be labial edema secondary to maternal estrogens May note thin white discharge Hypospadias http://www.medscape.com/content/2004/00/48/99/489956/art-adnc489956.fig4.jpg Hydrocele http://health.yahoo.com/media/mayoclinic/images/image_popup/r7_hydrocele.jpg Hydrocele http://www.jsps.gr.jp/img/students/e_learning/hydrocele.jpg Imperforate hymen http://www.indianpediatrics.net/oct1998/oct-1028_files/image002.jpg Breastfeeding z Healthy People 2010 Goals z z z z 75% of mothers upon discharge 50% continuing at 6 months 25% continuing at 12 months Realities z z z 70% upon discharge 36% at 6 months (14% exclusive) 18% at 12 months Breastfeeding should be continued for at least the first year of life and beyond for as long as mutually desired by mother and child (AAP). CDC Breastfeeding: Advantages z z z z Presence of immunologic, antimicrobial, and anti-inflammatory agents to protect against URI’s and GI Decreases childhood eczema and asthma Promotion of mother-infant bonding Improves neurodevelopmental outcomes Breastfeeding: Advantages z z z Recommended source of nutrition for infants up to 6 months of age Secretory antigens (IgA) passed from mother to infant protects against infectious and allergic etiology Physical benefits for mother: z z z z Decreases postpartum bleeding by enhancing uterine involution Lactational amenorrhea Speeds weight loss Improves bone remineralization Breastfeeding: Advantages z Psychological benefits for mother: z z z z z z Facilitates mother-infant bonding Enhances self-confidence Portable Easy to digest Economical Improved cognitive development in children Breastfeeding: Disadvantages z z z z Can be inconvenient (working mother) Some physical discomfort-nipple soreness, cracking Social embarrassment Food and medication avoidances Breastfeeding: Mastitis z z z Staph aureus-most common pathogen 2-4 weeks after initiation is peak onset Treat with Penicillinase resistant antibioticz z Keflex 500 mg one PO TID x 10 days Breast feeding is NOT contraindicated z If mastitis occurs, breast feeding should continue through infection with the help of a pump. Breastfeeding: Process z z z z Infant draws the nipple and areola into their mouth Nipple is compressed and elongates to about twice the normal length Suckling infants compress the areola with their gums, which stimulates the ejection of milk from the lactiferous sinuses If infants suck only on the nipple, not the areola, they will not cause the release of oxytocin and the milk ejection reflex AAP Breastfeeding: Process z Baby should be put to breast at least 8-12 times per 24 hours (every 2 to 3 hours) for 10-15 minutes z z z Alternate sides The first 24 hours mother may only be able to express a few drops of milk Don’t wait for crying z z z Increased alertness Increased physical activity Mouthing or rooting Breastfeeding: Process The correct latching position http://newborns.stanford.edu/Breastfeeding/ABCs.html Breastfeeding: Process z Three phases: z z z Colostrum Transitional milk Mature milk z Hind milk is higher in fat Colostrum <1 tsp each breastfeeding in the first couple of days. Yellow, sticky fluid. http://newborns.stanford.edu/Breastfeeding/ABCs.html Mature milk Milk “comes in” ~3d postpartum. Thick, creamy milk. http://newborns.stanford.edu/Breastfeeding/ABCs.html Breastfeeding: Process for the mom z z z z Relax Rest while baby sleeps Consume an extra 500 kcal/day Drink plenty of fluids z z z z 8 oz while nursing Avoid alcohol Avoid or reduce caffeine Avoid tobacco use AAP Formula feeding Studies suggest <5% intolerant to milk-based formula z Milk-based z z z Lactose-free z z Lactofree Hypoallergenic lactose-free z z Enfamil (Enfamil Lipil) Similac Nutramigen Specialty formulas (preemies) z z More protein, vitamins, minerals Similac Neosure Formula feeding Studies suggest <5% intolerant to milk-based formula z Semi-elemental and elemental formulas z z Invaluable formulas for infants with short bowel syndrome, malabsorption syndromes, cystic fibrosis, chronic diarrhea, and babies unable to tolerate soy or cow’s milk based formulas Soy-based z z z Isomil Enfamil Prosobee Galactosemia, hereditary lactase deficiency Formula feeding Process z z Select a milk-based formula (if possible) Select a formula supplemented with DHA and ARA (Lipil©) z z z Beneficial for brain and eye development Select an iron-fortified formula Formula comes in the following forms (from least to most expensive): powder, concentrated and ready-to-serve Formula feeding: Advantages z z z Readily available and portable Multiple formulations for infants Not dependant on mothers diet Formula feeding: Amounts z Newborn: z z 4 month old: z z 4-5 ounces every 4-5 hours 6 month old: z z 2-3 ounces every 2-3 hours 6-8 ounces every 6-8 hours Bottom line: z Babies should take in about 24-32 ounces of breast milk or formula per day in the first year of life AAP Foods to avoid in the first year z z z z z z z Eggs (whites) Peanut butter Chocolate Citrus fruits Beans Seafood Honey AAP Bowel and bladder habits z z z z z Baby must have at least one wet diaper in the first 24 hours By day 5, baby should have 6-8 wet diapers per day of light yellow urine Stool color will change from black-green to a seedy yellow By day 5, baby should have three to four yellow seedy stools per day Normal for a two-month old to have a stool every other day Alyson Smith, MS, PA-C Urate crystals Normal within the first week http://newborns.stanford.edu/PhotoGallery/Urates1.html Meconium http://newborns.stanford.edu/PhotoGallery/Meconium1.html Transitional stool Occurs by day 4 http://newborns.stanford.edu/PhotoGallery/ Well child visits Intervals z z z z 2-4 weeks 2 months 4 months 6 months z z z z z 9 months 12 months 18 months 24 months Every year after Bickley, 2007 Principles of child development 1. 2. 3. 4. Child development proceeds along a predictable pathway governed by the maturing brain The range of normal development is wide Various physical, disease-related, social, and environmental factors affect child development and health The child’s developmental level affects the nature of the medical history and the physical examination Bickley, 2007 References and Resources z Thanks to… z z z z z Cathy Kelley, PA-C Alyson Smith, MS, PA-C http://www.brightfutures.org/ Stellwagen L, Hubbard E, Vaux K. Look for the "stuck baby" to identify congenital torticollis. Contemporary Pediatrics May 2004;21:55. Principles of Neurosurgery, 2nd edition, Edited by Setti S. Rengachary, Richard G. Ellenbogen, Copyright 2005 References and Resources z http://library.med.utah.edu/pedineurologicexa m/html/newborn_n.html z z z http://newborns.stanford.edu/ z z Great peds neuro site Lots of videos Great site for pics Bates, Bates, Bates! References and Resources z American Academy of Pediatrics z z z http://www.aap.org/healthtopics/breastfeeding.cfm PEDIATRICS Vol. 103 No. 4 April 1999, pp. 870-876 www.lalecheleague.org