Evaluation of the neonate and infant

Evaluation of the
neonate and infant
Alison C. Essary, MHPE, PA-C
Pediatrics
Learning objectives
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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
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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
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Neonate = The first 28 days of life
Infant = A child up to 2 years of age
Tips for evaluating the
newborn
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Examine the newborn in the presence of the parents
Observe breastfeeding if possible
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Newborn is most “compliant” when well fed
Allow for minimal disruption of the newborn
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General survey
Head, neck, heart, lungs, abdomen, GU
Ears, mouth
Eyes
Skin
Neuro
Hips
Bickley, 2007
The newborn examination
Timing
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The first neonatal examination takes place
immediately after birth
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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
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At ONE minute:
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Scores of <4 require immediate resuscitation
At FIVE minutes:
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Scores <7 put the infant at a high risk for CNS or
other organ system dysfunction
APGAR score
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At FIVE minutes:
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If the APGAR score is >8 proceed to a more
thorough examination
The newborn examination
General principles
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Temperature (normal
97-98.5F)
Pulse (normal 120-160
beats/min.)
Respiratory rate
(normal 30-60
breaths/min)
Color
Level of consciousness
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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
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Auscultate the anterior thorax
Palpate the abdomen
Inspect the head, face, oral cavity,
extremities, genitalia, and perineum
The newborn examination
Measurements
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Head Circumference
Length
Weight
Bickley, 2007
The newborn examination
Bickley, 2007
The newborn examination
History
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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
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Vaginal bleeding
Acute illness
Duration of rupture of membranes
Medications
The newborn examination
Labor and delivery
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Duration
Fetal presentation
Fetal distress
Fever
Delivery
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C-section, vaginal
Anesthesia or sedation
Usage of forceps
APGAR Score
Need of resuscitation
The newborn examination
Gestational age & birth weight
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Gestational age
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PRE-TERM = gestational age < 37 weeks
TERM = gestational age 37 to 42 weeks
POST-TERM = gestational age > 42 weeks
Birth weight
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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
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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
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Silver nitrate ophthalmic ointment or
erythromycin ointment
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Protection against ophthalmia neonatorum
Occurs secondary to gonorrhea
Vitamin K IM
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Protect against hemorrhagic disease of the
newborn
AAP
The newborn examination:
Hearing screening
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Significant hearing loss present in 1-3/1,000
newborns in the nursery
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Higher in the NICU
Hearing loss correlates with speech and language
development
Screening completed before discharge from
the nursery
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Auditory brainstem evoked responses (ABR) or
evoked otoacoustic emissions (OAE)
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Sensitivity and specificity of ~100%
The physical examination:
Inspection/General survey
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Note color
Size
Body Proportions
Nutritional status
Posture
Respirations
Movement of the head
and extremities
The physical examination:
Skin examination
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Lanugo
Port wine stain
Acrocyanosis
Mongolian spots
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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
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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
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Benign keratin-filled
papules located on the
face
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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
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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
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>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
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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
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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
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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
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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
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Reintroduce breast feeding
Can do concurrent phototherapy
Nonphysiologic jaundice
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Primarily elevated conjugated (direct)
bilirubin
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Conjugated in the liver
Secondary to infection, metabolic abnormalities,
anatomic abnormalities or cholestasis
Nonphysiologic jaundice
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Primarily elevated unconjugated (indirect)
bilirubin
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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
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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
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Treatment:
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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
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Head:
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Plagiocephaly
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AAP “Back to Sleep” campaign (1992)
Decreased incidence of SIDS
Hydrocephaly
Cephalohematoma
Microcephaly
Chvostek’s sign
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Normal in newborns and in early childhood
Am Fam Physician. 2003 May
1;67(9):1953-6.
Head:
Fontanelles and sutures
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Should be palpated on all well-child and on all
acutely ill infants
Depressed fontanelle is a sign of dehydration
Head:
Fontanelles
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Anterior fontanelle
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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
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Posterior fontanelle
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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
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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
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Can occur secondary to infection, trauma,
bleeding, mass lesion or congenital defects
Management
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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
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Typically caused by the
trauma of birth
Commonly associated
with vacuum extraction
Resolves
spontaneously within
approximately 3
months
Bickley, 2007
Bickley, 2007
Head:
Microcephaly
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The circumference of the head is smaller
than normal
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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
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Eyes:
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Follow a face or bright light within a few weeks
Nystagmus is common immediately following birth
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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
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Eyes:
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Cornea > 1cm in diameter suggests congenital
glaucoma
Funduscopic examination Æ look for bilateral red
light reflexes
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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
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Eyes:
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Visual milestones:
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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
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Ears:
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Acoustic blink reflex: Snap your finger about
12 inches from the infant’s ear
Neck:
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Child can turn the head at 2weeks
Evaluate for torticollis
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Injury to the sternocleidomastoid at birth
May be a precipitating factor for plagiocephaly
Evaluate for clavicular fracture
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Complication of delivery
Bickley, 2007
Neck:
Torticollis
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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
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Nose:
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Most newborns and infants are obligate nasal
breathers
Check nasal patency
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Choanal atresia Æ septum between nose and pharynx
Unilateral or bilateral
Mouth:
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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
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May see the xiphoid process
Newborns alternate between periods of
regular vs. periods of irregular breathing
Evaluate for audible breathing and work of
breathing
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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
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Palpate peripheral pulses
Very common for children to have sinus
dysrhythmia
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HR increases with inspiration and decreases with
expiration
Normal finding
Evaluate for the presence of murmurs
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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
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Protuberant
Inspect the umbilical cord
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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
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Inspect the upper and lower extremities
Ortolani test
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Barlow test
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Test for posteriorly dislocated hip
Test for the ability to sublux or dislocate an intact
but unstable hip
Galeazzi test
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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
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Check the LS region
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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
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Evaluate motor tone
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Assess sensory function
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Hold the child up and assess for spasticity or
flaccidity
Gently flick the palm or sole with your finger
Cranial nerves
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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
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Primitive reflexes
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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
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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
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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
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Male:
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May be scrotal edema secondary to maternal
estrogens
Unable to retract foreskin
Female:
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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
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Healthy People 2010 Goals
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75% of mothers upon discharge
50% continuing at 6 months
25% continuing at 12 months
Realities
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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
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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
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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:
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Decreases postpartum bleeding by enhancing uterine
involution
Lactational amenorrhea
Speeds weight loss
Improves bone remineralization
Breastfeeding:
Advantages
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Psychological benefits for mother:
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Facilitates mother-infant bonding
Enhances self-confidence
Portable
Easy to digest
Economical
Improved cognitive development in children
Breastfeeding:
Disadvantages
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Can be inconvenient (working mother)
Some physical discomfort-nipple soreness,
cracking
Social embarrassment
Food and medication avoidances
Breastfeeding:
Mastitis
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Staph aureus-most common pathogen
2-4 weeks after initiation is peak onset
Treat with Penicillinase resistant antibioticz
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Keflex 500 mg one PO TID x 10 days
Breast feeding is NOT contraindicated
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If mastitis occurs, breast feeding should continue
through infection with the help of a pump.
Breastfeeding:
Process
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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
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Baby should be put to breast at least 8-12
times per 24 hours (every 2 to 3 hours) for
10-15 minutes
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Alternate sides
The first 24 hours mother may only be able to
express a few drops of milk
Don’t wait for crying
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Increased alertness
Increased physical activity
Mouthing or rooting
Breastfeeding:
Process
The correct latching position
http://newborns.stanford.edu/Breastfeeding/ABCs.html
Breastfeeding:
Process
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Three phases:
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Colostrum
Transitional milk
Mature milk
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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
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Relax
Rest while baby sleeps
Consume an extra 500 kcal/day
Drink plenty of fluids
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8 oz while nursing
Avoid alcohol
Avoid or reduce caffeine
Avoid tobacco use
AAP
Formula feeding
Studies suggest <5% intolerant to milk-based
formula
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Milk-based
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Lactose-free
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Lactofree
Hypoallergenic lactose-free
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Enfamil (Enfamil Lipil)
Similac
Nutramigen
Specialty formulas (preemies)
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More protein, vitamins, minerals
Similac Neosure
Formula feeding
Studies suggest <5% intolerant to milk-based
formula
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Semi-elemental and elemental formulas
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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
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Isomil
Enfamil Prosobee
Galactosemia, hereditary lactase deficiency
Formula feeding
Process
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Select a milk-based formula (if possible)
Select a formula supplemented with DHA and
ARA (Lipil©)
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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
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Readily available and portable
Multiple formulations for infants
Not dependant on mothers diet
Formula feeding:
Amounts
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Newborn:
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4 month old:
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4-5 ounces every 4-5 hours
6 month old:
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2-3 ounces every 2-3 hours
6-8 ounces every 6-8 hours
Bottom line:
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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
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Eggs (whites)
Peanut butter
Chocolate
Citrus fruits
Beans
Seafood
Honey
AAP
Bowel and bladder habits
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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
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2-4 weeks
2 months
4 months
6 months
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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
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Thanks to…
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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
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http://library.med.utah.edu/pedineurologicexa
m/html/newborn_n.html
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http://newborns.stanford.edu/
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Great peds neuro site
Lots of videos
Great site for pics
Bates, Bates, Bates!
References and Resources
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American Academy of Pediatrics
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http://www.aap.org/healthtopics/breastfeeding.cfm
PEDIATRICS Vol. 103 No. 4 April 1999, pp.
870-876
www.lalecheleague.org