pediaprelims - care of the newborn 2
DESCRIPTION
Transcription on Care of the Newborn (Part 2)TRANSCRIPT
-
Page 1 of 10
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
-
Page 2 of 10
PROPERTY OF AUFSOM BATCH 2017 v3.1 s2015-2016
PI | ARELLANO GAGUI GALVAN PAMINTUAN TIMBANG
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
-
Page 3 of 10
PROPERTY OF AUFSOM BATCH 2017 v3.1 s2015-2016
PI | ARELLANO GAGUI GALVAN PAMINTUAN TIMBANG
- 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
-
Page 4 of 10
PROPERTY OF AUFSOM BATCH 2017 v3.1 s2015-2016
PI | ARELLANO GAGUI GALVAN PAMINTUAN TIMBANG
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
-
Page 5 of 10
PROPERTY OF AUFSOM BATCH 2017 v3.1 s2015-2016
PI | ARELLANO GAGUI GALVAN PAMINTUAN TIMBANG
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
-
Page 6 of 10
PROPERTY OF AUFSOM BATCH 2017 v3.1 s2015-2016
PI | ARELLANO GAGUI GALVAN PAMINTUAN TIMBANG
- 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
-
Page 7 of 10
PROPERTY OF AUFSOM BATCH 2017 v3.1 s2015-2016
PI | ARELLANO GAGUI GALVAN PAMINTUAN TIMBANG
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
-
Page 8 of 10
PROPERTY OF AUFSOM BATCH 2017 v3.1 s2015-2016
PI | ARELLANO GAGUI GALVAN PAMINTUAN TIMBANG
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
-
Page 9 of 10
PROPERTY OF AUFSOM BATCH 2017 v3.1 s2015-2016
PI | ARELLANO GAGUI GALVAN PAMINTUAN TIMBANG
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
-
Page 10 of 10
PROPERTY OF AUFSOM BATCH 2017 v3.1 s2015-2016
PI | ARELLANO GAGUI GALVAN PAMINTUAN TIMBANG
APPENDIX