MCHNewborn Exam

1.         List the five components of the Apgar scoring system and the physical findings associated with each. 

Jenny B., Swartz p.682, Peds. Current p.5

A-Appearance:  Color

P-Pulse:  Heart Rate

G-Grimace:  Reflex Irritability

A-Activity:  Muscle Tone

R-Respiratory:  Respiratory Effort

                                                            SCORE

SIGN                           0                                  1                                  2

Color:                           blue,pale                       pink body                     pink

                                                                        blue ext.

HR:                              Absent                         <100                            >100

Reflex:                          No response                 Grimace                       Sneeze or Cough

Muscle Tone:                Flaccid                         Some Flexion               Good Flexion

Resp:                            Absent                         Weak irreg.                  Good, crying

Anonymous Roberts: Clinical Procedures in Emergency Medicine, 3rd ed., pp. 1012, Table 60-5. Copyright © 1998 W. B. Saunders Company

APGAR Scoring system

VB. Swartz pg 682

-Appearance- Color

- Pulse- HR

- Grimace- reflex irritability

-Activity- muscle tone

-Respitatory- effort

Anonymous  Bates, pp 624-625

Apgar Scoring System is used to assess the infant’s immediate adaptation to extrauterine life by making the following observations:  Score each infant at 1 minute and 5 minutes after birth. Range from 0 to 10. 

NOTE:  One-minute Apgar scores of 7 or less usually indicate nervous system depression. Scores of 4 or less indicate severe depression requiring immediate resuscitation.

Five-minute Apgar scores of < 7 place the infant at high risk for subsequent CNS and other organ system dysfunction.

Anonymous Current Pediatric, p.5

The APGAR scale evaluates the infant at birth one minute and five minutes after complete birth of the infant (disregarding the cord and placenta).  Note:  the response to catheter in nose is tested after oropharynx is clear.  Score each category a 0, 1 or 2 and then add all five individual scores to reach a total score which can be 0 at a minimum and 10 at a maximum.

A=Appearance / Color

P=Pulse / Heart Rate

G=Grimace / Reflex Irritability

A=Activity / Muscle Tone

R=Respiratory / Respiratory Effort

Score of 0 = HR absent, Resp. effort absent, Muscle tone limp, Response to catheter in nostril - no response, Color - blue or pale.

Score of 1 = HR slow (<100), Resp. effort slow/irregular, Muscle tone - some flexion, Response to catheter in nostril - grimace, Color - body pink; extremities blue.

Score of 2 = HR > 100, Resp. effort good/crying, Muscle tone - active motion, Response to catheter in nostril - cough or sneeze, Color - completely pink.

2.         Given the physical exam results of a newborn be able to assign an Apgar score.

Jenny B., Swartz p.682, Peds Current p. 5

See #1

Anonymous. Bates p.624 - 625

Assess the infant’s immediate adaptation to extrauterine life by making the five observations. Score each infant at 1 min. and 5 min. after birth. – Each observation is scored on a three- point scale (0,1,2). The Apgar sore may range from 0 to 10

If at 5 min. the Apgar sore is 8 or more, proceed to a more complete examination.

VB. Swartz pg 682

Record at one and five minutes after birth.  Score of 3-4 at one minute indicates severe cardiopulmonary depression. Score of 5-6 indicates mild central nervous system depression.  Repeat at five minutes.  If score is equal or greater than 8, then a grossly normal cardiopulmonary exam exists.

Anonymous

See above.

3.         Discuss the classification of newborns by their birth weight, (SGA, AGA, and LGA), their gestational age (maturity), or a combination of these two dimensions.

Jenny B., Swartx p. 682-684 See Chart p. 687

SGA-Small for Gestational Age.  Less than 10^th percentile on the intrauterine growth curve.

AGA-Appropriate for Gestational Age.  10^th to 90^th percentile on the intrauterine growth curve.

LGA-Large for Gestational Age.  Greater than 90^th percentile on the intrauterine growth curve.

Classification of newborns by birth weight and gestational age is done on page 687.

Anonymous Dimensions- SGA, AGA, LGA

Gestational age is based on neuromuscular sign and physical characteristics that change with gestational maturity.

A Ballard score estimates gest. age by looking at certain features to determine the gest age of the newborn. Ballard score sheet example on pg. 626

SGA- is a birth weight small for gestational age, which is a birth wt <10th percentile on the intrauterine growth curve.

AGA- appropriate for gest age which is a birth wt. within 10-90th percentile

LGA- large for gestational age is a birth wt. >90th percentile.

An example would be a baby delivered who is 40 weeks by dates and is born weighing 5 pounds. After assessment he Ballard's out to be only 36 weeks gestational age and is AGA for weight because 5 pounds, lets say, is an appropriate weight for a 36 weeks vs. if he were truly 40 weeks gestation.

VB. Swartz pg 682.

SGA- birth weight is less than 10^th  percentile on intrauterine growth curve.

AGA- birth weight between 10^th and 90^th percentile.

LGA- birth weight larger than 90^th percentile.

Anonymous  Bates, pgs 627-28

By birth weight:

• Extremely low birth wt = <1000 grams

• Very low birth wt = 1000-1499 grams

• Low birth wt = 1500 – 2499 grams

• Normal birth wt = > 2500 grams

By gestational age:  (based on specific neuromuscular signs and physical characteristics that change with gestational maturity)

• Pre-term = gestational age < 37 weeks

• Term = gestational age 37 to 42 weeks

• Post-term = gestational age > 42 weeks

Classification by birth weight and gestational age:

• Weight small for gestational age (SGA) = birth wt < 10^th percentile on the intrauterine growth curve

• Weight appropriate for gestational age (AGA) = birth wt within the 10^th and 90^th percentiles on the intrauterine  growth curve

• Weight large for gestational age (LGA) = birth wt > 90^th percentile on the intrauterine growth curve

NOTE:  Refer to Bates, pg 629, for example of intrauterine growth curves for 10^th and 90^th percentiles.

Anonymous Swartz, p. 682

If the birth weight is from the 10th to 90th percentile on the intrauterine growth curve, the infant is AGA - Appropriate for Gestational Age.  If the birth weight is less than the 10th percentile on the intrauterine growth curve, the infant is SGA - Small for Gestational Age.  If the birth weight is greater than the 90th percentile on the intrauterine growth curve, the infant is LGA - Large for Gestational Age.

The value of the weight-gestational age determination lies in its ability to predict certain risk groups.  LGA can = risk for hypoglycemia and polycythemia.  SGA can = indication of congenital abnormalities, hypoglycemia or congenital infections.

See Fig. 23-5 on p. 687, Swartz, for classification of newborns by birth weight and gestational age.

4.         Describe the following techniques for assessment of neuromuscular maturity:

                        Posture

                        Square window

                        Arm recoil

                        Popliteal angle

                        Scarf sign

                        Heel-to-ear maneuver

Jenny B., Swartz p. 685, refer to diagram p.684

Posture:  Observed with infant quiet and in supine position

Score:  0-arms and legs extended

            1-slight flexion of hips and knees, arms extended

            2-stronger flexion of legs arms extended

            3-arms slightly flexed, legs flexed and abducted

            4-full flexion of arms and legs.

Square Window:  The hand is flexed on the forearm between the thumb and index finger of the examiner.  Enough pressure is applied to get as full a flexion as possible, and the angle between the hypothenar eminence and the ventral aspect of the forearm is measured and graded according  to the diagram.

Arm recoil:  With the infant in the supine position, the forearms are first flexed for 5 secs., then fully extended by pulling on the hands, and then released.  The sign is fully positive if the arms return briskly to full flexion.  If the arms return to incomplete flexion the score is a 1, and if the arms stay extended the score is a 0.

Popliteal Angle:  With the infant supine and the pelvis flat on the examining table, the thigh is held in the knee chest position with the examiners left index finger and thumb supporting the knee.  The leg is then extended by gentle pressure from the examiners right index finger behind the ankle, and the popliteal angle is measured.

Scarf Sign:  With the baby supine, take the infant’s hand and try to put it around the neck as far as posteriorly as possible around the opposite shoulder.  Assist this maneuver by lifting the elbow across the body.  See how far the elbow will cross. 

Score:  0-elbow reaches opposite axillary line

            1-elbow between midline and opposite axillary line

            2-elbow reaches midline

            3-elbow will not reach midline

Heel to Ear Maneuver:  With the baby supine, draw the baby’s foot as near to the head as it will go without forcing it.  Observe the distance between the foot and head, as well as the degree of extension at the knee.  Grade according to the diagram.  Note that the knee is left free and may draw down alongside the abdomen.

Anonymous All material is from Bates, chap. 19, pp. 626-627

Posture- w/ infant supine and quiet, score:

arms and legs extended=0
slight or moderate flexion of hips/knees= 1
moderate or strong flexion of hips/knees= 2
legs flexed and abducted, arms slightly flexed= 3
full flexion of arms= 4

Square window- flex the hand at the wrist (exert sufficient pressure to get as much flexion as possible); do not rotate the wrist. Measure and score the angle between the hypothenar eminence and the anterior aspect of the forearm. Compare angle to chart (Bates, p. 626).

Arm recoil- with the infant supine, fully flex the forearm for 5 seconds, then fully extend by pulling the hands and releasing. Score the reaction according to the following:

Remains extended or random movements= 0
up to 40 degree flexion= 1
between 40 and 70 degree flexion= 2
from 70 to 90 degrees= 3
brisk return to 90 degree flexion= 4

Popliteal angle- with the infant supine and the pelvis flat on the examining surface, use one hand to flex the leg on the thing and then fully flex the thigh; use the other hand to extend the leg. Score the angle as follows:

180 degrees= -1
160 degrees= 0
140 degrees= 1
120 degrees= 2
100 degrees= 3
90 degrees= 4
<90 degrees= 5

Scarf sign- With the infant supine, take the infant's hand and draw it across the neck and as far across the opposite shoulder as possible (assistance to the elbow is permissible by lifting it across the body). Score according to the location of the elbow:

Elbow reaches beyond the opposite anterior axillary line= 0
Elbow reaches to the opposite anterior axillary line= 1
Elbow is between opposite anterior axillary line and midline of thorax= 2
Elbow is at midline of thorax= 3
Elbow does not reach midline of thorax= 4

Heel-to-ear maneuver- With the infant supine, hold the infant's foot with one hand and move it as near to the head as possible without forcing it. Keep the pelvis flat on the examining surface. Score based on matching pictures in chart, Bates, p. 626 (Ballard scoring).

Although not part of the question, these techniques, when combined with the assessment of physical maturity, make up the Ballard scoring system for gestational age in weeks. You add the scores from above, add the physical maturity score and use this total with the scale on p. 626 of Bates to determine the gestational age of the newborn..

VB. Swartz 685

Posture- observe with patient quiet and in supine position

Square window-hand is flexed on forearm between thumb and index finger and angle between hypothenar eminence and ventral aspect of forearm is measured andgreaded accordingly to diagram.

Arm recoil- forearms are fist flexed fully for 5 seconds, then fully extended and released.  Positive if arms return briskly to full flextion=2.  Incomplete or sluggish=1.  remain extended =0

Popliteal angle-  supine and pelvis flat.  Thigh is held in knee-chest position.  Left thumb and index fingers hold knee and right index behind ankle applies pressure to extend the knee and measure angle.

Scarf sign- supine- take infant’s hand and try to put it aroung the neck as far posteriorly as possible around other shoulder.

Heel-to-ear maneuver- Supine- bring baby’s foot as near to thehead as it will go without forcing it.  Observe distance between foot and head as well as degree of exention of knee.

Anonymous  Refer to neuromuscular maturity chart in Bates, pg 626

Posture: With the infant supine and quiet, score as follows:

• Arms and legs extended = 0

• Slight or moderate flexion of hips and knees = 1

• Moderate to strong flexion of hips and knees = 2

• Legs flexed and abducted, arms slightly flexed = 3

• Full flexion of arms and legs = 4

Square window: Flex the hand at the wrist (exert pressure sufficient to get as much flexion as

• possible); do not rotate the wrist. Measure and score the angle between the hypothenar eminence

• and the anterior aspect of the forearm according to chart.

Arm recoil: With the infant supine, fully flex the forearm for 5 seconds, then fully extend by

• pulling the hands and releasing. Score the reaction according to the following:

• Remains extended or random movements = 0

• Up to 40º flexion = 1

• Between 40º and 70º flexion = 2

• From 70º through 90º flexion = 3

• Brisk return to 90º flexion = 4

Popliteal angle: With the infant supine and the pelvis flat on the examining surface, use one hand

• to flex the leg on the thigh and then fully flex the thigh; use the other hand to extend the leg.

• Score the angle attained as in the chart.

Scarf sign: With the infant supine, take the infant’s hand and draw it across the neck and as far

• across the opposite shoulder as possible (assistance to the elbow is permissible by lifting it across

• the body). Score according to the location of the elbow:

• Elbow reaches beyond the opposite anterior axillary line = 0

• Elbow reaches to the opposite anterior axillary line = 1

• Elbow is between opposite anterior axillary line and midline of thorax = 2

• Elbow is at midline of thorax = 3

• Elbow does not reach midline of thorax = 4

Heel-to-ear maneuver: With the infant supine, hold the infant’s foot with one hand and move it

• as near to the head as possible without forcing it. Keep the pelvis flat on the examining surface.

• Score as in the chart.

Zen Seeker Swartz 684

Anonymous Swartz, p.685

POSTURE - Observed with infant quiet and in supine position.  Score 0, arms and legs extended; 1, beginning of flexion of hips and knees, arms extended; 2, stronger flexion of legs, arms extended; 3, arms slightly flexed, legs flexed and abducted; 4, full flexion of arms and legs.

SQUARE WINDOW - The hand is flexed on the forearm between the thumb and index finger of the examiner.  Enough pressure is applied to get as full a flexion as possible, and the angle between the hypothenar eminence and the ventral aspect of the forearm is measured and graded according to the diagram.  Care is taken not to rotate the infant's wrist while performing this maneuver.

ARM RECOIL - With the infant in the supine position, the forearms are first flexed for 5 seconds, then fully extended by pulling on the hands, and then released.  The sign is fully positive if the arms return briskly to full flexion (score 2).  If the arms return to incomplete flexion or the response is sluggish, it is scored as 1.  If they remain extended or show only random movements, the score is 0.

POPLITEAL ANGLE - With the infant supine and the pelvis flat on the examining couch, the thigh is held in the knee-chest position with the examiner's left index finger and thumb supporting the knee.  The leg is then extended by gentle pressure from the examiner's right index finger behind the ankle, and the popliteal angle is measured.

SCARF SIGN - With the baby supine, take the infant’s hand and try to put it around the neck as far posteriorly as possible around the opposite shoulder.  Assist this maneuver by lifting the elbow across the body.  See how far the elbow will go across, and grade according to the illustrations found on p. 684, Swartz.  Score 0, elbow reaches opposite axillary line; 1, elbow between midline and opposite axillary line; 2, elbow reaches midline; 3, elbow will not reach midline.

HEEL-TO-EAR MANEUVER - With the baby supine, draw the baby’s foot as near to the head as it will go without forcing it.  Observe the distance between the foot and the head, as well as the degree of extension at the knee.  Grade according to the diagram.  Note that the knee is left free and may draw down alongside the abdomen.

5.         Inspection - describe the position in which normal full-term newborns lie.  Discuss the significance of asymmetrical movements in the newborn.

Jenny B., Peds. Current p.7

In examining the newborn resting tone should exhibit flexion of the upper and lower extremities.  Extension of the extremities should result in spontaneous recoil to flexed position.  Asymmetrical movements of the newborn may be indicative of a fracture or neurological injury.

Anonymous Normal full-term newborns lie in a symmetrical position with the limbs semiflexed and the legs partially abducted at the hip. The head is slightly flexed and positioned in the midline or turned to one side. Normal newborns have spontaneous motor activity of flexion and extension, alternation between the arms and the legs. The forearms supinate with flexion at the elbow and pronate with extension. The fingers are usually flexed in a tight fist, but may extend in slow athetoid posturing movements. Asymmetrical movements of the arms or legs at any time should alert the clinician to the possibility of central or peripheral neurological deficits, birth injuries, or congenital anomalies.

VB. Swartz pg 683

Normal newborne lies on one side with arms and legs flexed.  A term infant who lies on back with extremeties abducted in a frog position has abnormal  posture

Anonymous  Bates, pg 630

•        Normal full-term newborns lie in a symmetrical position with the limbs semiflexed and the legs partially abducted at the hip. The head is slightly flexed and positioned midline or turned to one side.

•        Spontaneous motor activity of flexion and extension alternating between the arms and legs. Forearms supinate with flexion at the elbow and pronate with extension. Fingers usually flexed in a tight fist, but may extend in slow athetoid posturing movements. Low amplitude and high-frequency tremors of the arms, legs, and body are seen with vigorous crying and at rest during 1^st 48 hours of life.

•        Asymmetrical movements of the arms and legs at any time should alert clinician to the possibility of central or peripheral neurologic defects, birth injuries, or congenital anomalies.

Anonymous Current Pediatrics, p.7 & Swartz, p.683

In examining the newborn, observe resting tone (normal-term newborns should exhibit flexion of the upper and lower extremities) and spontaneous movements.  Look for symmetry of movements.  Extension of extremities should result in spontaneous recoil to the flexed position.

A normal newborn lies on one side with the arms and legs flexed.  A term infant who lies on his or her back with arms and legs abducted in a frog position has an abnormal posture.  However, this posture can be consistent with prematurity.

MORE:  on significance of asymmetry of movements in newborn.  From objectives on web - asymmetrical movements can be suggestive of neurologic defects, birth injuries or congenital anomalies.

6.         Skin - describe the following:

                        harlequin dyschromia/harlequin color change

                        acrocyanosis

                        mongolian spots

                        lanugo

                        vernix caseosa

                        milia

                        miliaria rubra

                        vascular markings

Anonymous Bates pg. 650

-In normal newborns, a striking color change is often seen: one side of the body is red, the other pale, and an abrupt border separates the two sides at the midline. This phenomenon is transient, etiology unknown and called Harlequin dyschromia.

-Hands and feet may be blue at birth called acrocyanosis.

-Melanotic pigmentation of the skin common in African American, Native American and Asian newborns. Blackish-blue areas located over the buttocks and lower lumbar regions are called Mongolian spots. The eventually disappear in early childhood.

-Lanugo is a fine, downy growth of hair over the entire body, but mostly on shoulders and back. Prominent in premature infants. Most of this hair is shed within 2 weeks.

-A cheesy white material made from sebum and desquamated epithelial cells that covers the entire body at birth is called vernix caseosa.

-Milia is a pinhead-sized, smooth, white, raised areas without surrounding erythema noted on the nose, chin, and forehead. Caused by retention of sebum in the openings of the sebaceous glands. May be present at birth but more often appear within the first few weeks of life and disappear spontaneously over several weeks.

-Miliaria Rubra consists of scattered vesicles on an erythematous base, usually on the face and trunk caused by sweat gland duct obstruction. Usually disappears spontaneously within 1-2 weeks.

-Vascular markings are irregular pink areas frequently found over the nape of the neck (called a "stork’s beak" mark),on the upper eyelids, forehead and upper lip (called angel kisses). Redness is due to proliferation of the skin’s capillary bed. Usually disappear at about a year of age.

Jennifer Lynn Tso-Garcia

a.      harlequin dyschromia/harlequin color change pg.403

A cutaneous vascular phenomenon unique to neonates in the 1^st week of life occurs when the infant (particularly one of low birth weight) is placed on one side.  The dependent half develops an erythematous flush with a sharp demarcation oat the midline and the upper half of the body becomes pale.  The color changes usually subside within a few seconds after the infant is placed supine but may persist for as long as 20 mins.

b.      acrocyanosis pg.557

Bluish discoloration around the mouth (acrocyanosis) is a feature of skin that has not been sun exposed and it does not correlate with cyanosis.

c.       mongolian spots pg.403

A blue-black macule found over the lumbosacral area in 90% of Native American, black and Asian infants.

d.      Lanugo pg.5

Fine hair covering the preterm infant’s skin

e.      vernix caseosa pg.5

A whitish, greasy material covering the body that decreases as term approaches.

f.        Milia pg.402

Multiple white papules 1mm in diameter scattered over the forehead, nose and cheeks.  They are present in up to 40% of newborn infants.  Histologicaly, they represent superficial epidermal cysts filled with keratinous material associated with the developing pilosebaceous follicle.

g.      miliaria rubra pg.403

Obstruction of the eccrine duct deeper in the epidermis results in erythematous grouped papules in the same areas.

h.      vascular markings pg.404-405

1.            Capillary Malformations  Flat vascular birthmarks can be divided into two types: those that are orange or light red (salmon patch) and those that are dark red or bluish-red (port-wine stain).

i.  The salmon patch is a light red macule found over the nape of the neck, upper eyelids and glabella.  50% of infants have such lesions over their necks.  Eyelid lesions fade completely within 3-6 months; those on the neck fade somewhat but usually persist into adult life.

ii. Port-wine stains are dark red or purple macules appearing anywhere on the body.

2.            Hemangioma.  A red, rubbery nodule with a roughened surface.  The lesion is often not present at birth but is represented by a permanent blanched area on the skin that is supplanted at age 2-4 wks by red nodules.

3.            Lymphatic Malformations.  They may be superficial or deep.

i.         Superficial lymphatic malformations present as fluid-filled vesicles often described as looking like frog spawn.

ii.    Deep lymphatic malformations are rubbery, skin-colored nodules occurring in the parotid area (cystic hygromas) or on the tongue.

Pam Hay, p. 403:

• Harlequin dyschromia/harlequin color change:  A cutaneous vascular phenomenon unique to neonates in the first week of life occurs when the infant (particularly one of low birth weight) is placed on one side.  The dependent half develops an erythematous flush with a sharp demarcation at the midline, and the upper half of the body becomes pale.  The color changes usually subside within a few seconds after the infant is placed supine but may persist for as long as 20 min.

• Acrocyanosis (Hay, p.557):  Bluish discoloration around the mouth.

• Mongolian spots (Hay, p.403):  A blue-black macule found over the lumbosacral area in 90% of Native American, black and Asian infants is called a Mongolian spot.  These spots are occasionally  noted over the shoulders and back and may extend over the buttocks.  Histologically, they consist of spindle-shaped pigment cells located deep in the dermis.  The lesions fade somewhat with time as a result of darkening of the overlying skin, but some traces may persist into adult life.

• Lanugo (Hay, p.5):  The fine hair covering the preterm infant’s skin.

• Vernix caseosa (Hay, p.5):  A whitish, greasy material covering the body that decreases as term approaches.

• Milia (Hay, p.5):  small white keratogenous cysts which can be found scattered over the cheeks, forehead, nose and nasolabial folds.  (Hay, p. 402):  Multiple white papules 1mm in diameter scattered over the forehead, nose and cheeks are present in up to 40% of all infants.  Histologically, they represent superficial epidermal cyst filled with keratinous material associated with the developing pilosebaceous follicles. 

• Miliaria rubra (Hay, p. 403):  Obstruction of the eccrine sweat duct deeper in the epidermis results in erythematous grouped papules over the neck and upper chest.  Rarely, these may progress into pustules.  Heat and high humidity predispose the pt to eccrine duct pore closure.  Removal to a cooler environment is the treatment of choice.

• Vascular markings (Hay, p.404): 

1. Capillary malformations:  Flat vascular birthmarks can be divided into two types:  those that are orange or light red (salmon patch) and those that are dark red or bluish-red (port-wine stain).  The salmon patch is a light red macule found over the nape of the neck, upper eyelids and glabella.  50% of infants have such lesions over their necks.  Eyelid lesions fade completely within 3-6 months; those on the neck fade somewhat but usually persist into adult life.          Port-wine stains are dark red or purple macules appearing anywhere on the body.  A bilateral facial port-wine stain or one covering the entire half of the face may be a clue to Sturge-Weber syndrome.  Most infants with smaller, unilateral facial port-wine stains do not have Sturge-Weber syndrome.  Similarly, a port-wine stain over an extremity may be associated with hypertrophy of the soft tissue and bone of that extremity (Klippel-Trenaunay syndrome). 

2. Hemangioma:  A red, rubbery nodule with a roughened surface.  The lesion is often not present at birth but is represented by a permanent blanched area on the skin that is supplanted at age 2-4 weeks by red nodules.  Hemangiomas may be superficial, deep or mixed.  Histologically, these are benign tumors of capillary endothelial cells.  50% resolve spontaneously by age 5 years, 70 % by age 7 years, and 90% by age 9 years; leaving redundant skin, hypopigmentation, and telangiectasia. 

3. Lymphatic Malformations:  Lymphatic malformations may be superficial or deep.  Superficial lymphatic malformations present as fluid-filled vesicles often described as looking like frog spawn.  Deep lymphatic malformations are rubbery, skin-colored nodules occurring in the parotid area or on the tongue.  They often result in grotesque enlargement of soft tissues.

Anonymous  Bates, pp 650–51

•        harlequin dyschromia: One side of body is red, other side is pale with an abrupt border separating the two sides at midline.  Transient and etiology is unknown.

•        Acrocyanosis: Hands and feet “blue” at birth and remain so for several days. May recur throughout early infancy when baby is cold. After 4 to 5 hours, cyanosis becomes less marked in the hands than in the feet.

•        mongolian spots: Due to the presence of pigmented cells in the deeper layers of the skin. Ill-defined blackish-blue areas located over buttocks and lower lumbar regions. Become less noticeable as pigment in overlying cells becomes more prominent and disappear in early childhood.

•        lanugo: Fine, downy growth of hair over entire body, mostly on shoulders and back. Most shed within 2 weeks.

•        vernix caseosa: Cheesy, white material composed of sebum and desquamated epithelial cells. Covers body in varying degrees at birth, present in vaginal labial folds and under fingernails. Puffiness and edema may be present but disappears by 2^nd or 3^rd day.

•        milia: pinhead-sized, smooth, white, raised areas without surrounding erythema on the nose, chin, and forehead. Caused by retention of sebum in the openings of the sebaceous glands. Appear within first few weeks of life and disappear spontaneously over several weeks.

•        miliaria rubra: Scattered vesicles on an erythematous base, usually on face and trunk, caused by sweat gland duct obstruction. Disappears spontaneously within 1-2 weeks.

•        vascular markings: Irregular pink areas frequently found over the nape of the neck (“stork’s beak” mark) and on the upper eyelids, the forehead, and the upper lip (“angels kisses”).  Due to proliferation of the skin’s capillary bed (capillary hemangioma, nevus flammeus, nevus vasculosus, telangiectatic nevus). Disappear at about a year of age, may reappear in adulthood when skin is flushed. Appear in other areas of skin as larger, darker (purplish) and more sharply demarcated and may involve mucosa of mouth or the vagina.  These “port wine stains” not likely to fade.

Anonymous Current Pediatric

Harlequin dyschromia/harlequin color change = A cutaneous vascular phenomenon unique to neonates in the first week of life.  Occurs when the infant (particularly one of low birth weight) is placed on one side.  The dependent half develops an erythematous flush with a sharp demarcation at the midline, and the upper half of the body becomes pale.  The color changes usually subside within a few seconds after the infant is placed supine but may persist for as long as 20 minutes.  p.403

Acrocyanosis = Bluish discoloration around the mouth.  p. 557

Mongolian spot = A blue-black macule found over the lumbosacral area in 90% of Native American, black and Asian infants.  p. 403

Lanugo = The fine hair covering the preterm infant's skin.  p. 5

Vernix caseosa = A whitish, greasy material covering the body that decreases as term approaches.  p.5

Milia = Small white keratogenous cysts.  p. 5

Miliaria rubra = Blocked ducts of sweat glands that appear as small erythematous papules.  p. 5

Vascular markings = Capillary malformations (flat vascular birthmarks of 2 types - salmon patch and port-wine stain), hemangioma (red, rubbery nodule with roughened surface) and lymphatic malformations (superficial fluid filled vesicles or deep rubbery skin-colored nodules in parotid area).  p. 404

7.         Compare and contrast physiologic jaundice and pathologic jaundice including when jaundice appears.

Anonymous PP 1396 Pathophysiology Text by McCance

Physiologic                                                                                        

Develops during the second or third day after birth and usually subsides in 1 to 2 weeks in full-term infants and 2 to 4 weeks in premature infants. It is usually transient, benign icterus. Physiologic jaundice is caused by mild unconjugated (indirect-reacting) hyperbilirubinemia. It is caused due to increased bilirubin production, impaired hepatic uptake and excretion of bilirubin, and reabsorption of bilirubin in the small intestine.

Pathologic      

A high level of indirect hyperbilirubinemia (greater than 15 mg/dl ). It is persistent and causes bilirubin encephalopathy (kernicterus).

Jennifer Lynn Tso-Garcia pg.11-14

a.       Physiologic jaundice.  The contributing factors include UDPGT (enzyme-uridyldiphosphoglucuronyl transferase) inactivity at birth, a relatively high red cell mass even in the non-polycythemic neonate and an absence of intestinal flora, with initially slow intestinal motility leading to an active enterohepatic circulation of bilirubin.

For jaundice to physiologic rather than pathologic, the following criteria should be satisfied:

1) clinical jaundice appears after 24 hrs of age;

2) total bilirubin rises by less than 5mg/dL per day;

3) peak bilirubin occurs at 3-5 days of age, with a total bilirubin of no more than 15mg/dL;

and 4) clinical jaundice is resolved by 1 wk in the term infant and by 2 wks in the preterm infant. 

Hyperbilirubinemia outside of these parameters or jaundice that requires treatment is no physiologic and must be evaluated further.

b.   Pathologic jaundice:  Causes of prolonged unconjugated hyperbilirubinemia include hemolytic disease, breast milk jaundice, Crigler-Najjar syndrome, bowel obstruction and congenital hypothyroidism.  Galactosemia generally presents with hepatomegaly in an ill-appearing, often septic infant and the hyperbilirubinemia is usually mixed.

Clinical jaundice appears at a bilirubin level of 5mg/dL and appears first on the head, progressing down the chest and abdomen as the level increases.

Pam Hay, p. 14:

            The contributing factors to physiologic jaundice include UDPGT inactivity at birth, a relatively high red cell mass even in the non-polycythemic neonate, and an absence of intestinal flora, with initially slow intestinal motility leading to an active enterohepatic circulation of bilirubin.  For jaundice to be physiologic rather than pathologic, the following criteria must be satisfied: 

1. clinical jaundice appears after 24 hours of age

2. total bilirubin rises by less than 5mg/dL per day

3. peak bilirubin occurs at 3-5 days of age, with a total bilirubin of no more than 15 mg/dL

4. clinical jaundice is resolved by 1 week in the term infant and by 2 weeks in the preterm infant.

Hyperbilirubinemia outside of these parameters—or jaundice that requires

treatment—is not physiologic and must be evaluated further.

Anonymous  Bates 651 Tintinalli 764

            Physiologic jaundice occurs in approximately 50 percent of all babies, appears on the second or 3rd day, peaks during the fourth and fifth days, and usually disappears within a week but may persist for as long as a month.  Physiologic jaundice is due to the breakdown of fetal red blood cells, and bilirubin rises at the rate of less than 5 mg per dl per 24 hours, with a peak of five to six mg per dl during the second and fourth day of life, returning to less than two mg per dl by five to seven days.

            Pathologic jaundice appears within 24 hours of birth and should alert one to the possibility of hemolytic disease (erythroblastosis fetalis) and its accompanying hyperbiliruminemia; jaundice that persists beyond two weeks of age should raise suspicions of biliary obstruction.  Jaundice may indicate severe infection at any time in infancy, particularly in the newborn.

Anonymous Current Pediatric, p. 14

For jaundice to be physiologic rather than pathologic, the following criteria should be satisfied:  clinical jaundice appears after 24 hours of age, total bilirubin rises by less than 5 mg/dL per day, peak bilirubin occurs at 3-5 days of age, with a total bilirubin of no more than 15 mg/dL and clinical jaundice is resolved by 1 week in the term infant and by 2 weeks in the preterm infant.  Hyperbilirubin outside of these parameters - or jaundice that requires treatment - is not physiologic and must be evaluated further.  (Look into factors concerning high altitude, racial differences, prematurity, breast feeding and jaundice, breast milk jaundice, breast feeding associated jaundice.)

8.         Describe the normal size and location of the fontanelles.

Anonymous A & P Marieb pg 227-230 and from handouts in class.

There are 6 fontanelles which are unossified remnants of fibrous membrane. The major fontanelles are the Anterior Fontanel located between the frontal bones and the parietal bones midline of the skull (4-6 cm in size) and the Posterior Fontanel located midline between the parietal bones and occipital bone (1-2 cm in size). There are also the 2 Sphenoidal fontanel located at the sides of the head where the parietal, frontal, temporal and sphenoid bone meet as well as the 2 mastoid fontanel where the parietal, occipital and temporal bone meet. (similar in size to the posterior fontanel 1-2 cm)

Jennifer Lynn Tso-Garcia pg.6

1. The anterior fontanelle varies from 1-4cm in any direction.  The diamond-shaped junction of the coronal frontal and sagittal sutures; it becomes ossified within 18-24months.

2. The posterior fontanelle should be less than 1cm.  The triangular fontanel at the junction of the sagittal and lambdoid sutures; ossified by the end of the 1^st year.

c.       A third fontanelle is a bony defect along the sagittal suture in the parietal bones and may be a feature of certain syndromes such as trisomy 21.

Pam Hay, p. 6:

            The anterior fontanelle varies from 1 to 4 cm in any direction, whereas the posterior fontanelle should be less than 1 cm.  A third fontanelle is a bony defect along the sagittal suture in the parietal bones and may be a feature of certain syndromes such as trisomy 21.  Sutures should be freely mobile.  Craniosynostosis is a prematurely fused suture.

Anonymous  Bates 653

 The anterior fontanelle at birth measures 4 cm to 6 cm at its largest diameter and normally closes between 4 and 26 months of age.  The posterior fontanelle measures 1 cm to two cm at birth and usually closes by two months of age. 

Anonymous Current Pediatric, p. 6

Anterior Fontanelle - 1-4 cm in any direction = normal size/location.

Posterior Fontanelle - less than 1 cm = normal size/location.

A bony defect along the sagital suture in the parietal bones is a possible fontanelle.  It may be a feature of certain syndromes such as Trisomy 21.  

Sutures should be freely mobile.  Craniosynostosis is a prematurely fused suture.

9.         Discuss natal or neonatal teeth including identification and treatment.

Anonymous – Dershewitz, pp. 493

A natal or neonatal tooth eruption is an exception to the normal sequence of development. ~85% are lower primary incisors rather than supernumerary teeth - a roentgenogram can determine the type of tooth. Most are hypermobile due to inadequate root formation. If aspiration is feared (because of hypermobility), the tooth should be removed. This can be done in the clinic with gauze and light finger pressure. If not taken care of quickly, the immature primary incisor will become more firm as the root develops. Occasionally, odontogenic remnants remain after removal of the natal teeth and these continue to form abnormal teeth that should be extracted as they are seen.

Jennifer Lynn Tso-Garcia pg.449

The primary teeth usually begin to erupt at approximately age 6-7 months.  However, on rare occasions, teeth are present at birth (natal teeth) or erupt within the first month (neonatal teeth).

Pam Hay, p.449

            The mouth of the normal newborn is lines with an intact, smooth, moist and shiny mucosa.  The alveolar ridges are continuous and relatively smooth.  Within the alveolar bone are numerous tooth buds, which at birth are mostly primary teeth and a few permanent teeth just starting to calcify.  The primary teeth begin to form at approximately 6 week’s gestation, and their calcification  starts in the second trimester.  The permanent teeth are just beginning to develop at birth.  There is enough development of permanent teeth to permit their damage by perinatal or antenatal insults such as anoxia, severe jaundice, or infection.  The primary teeth usually begin to erupt at approximately age 6-7 months.  These are most common in the anterior mandible or can be “real” primary teeth or supernumerary teeth. 

Anonymous  Dershewitz 493

About 85 percent are lower primary incisors rather than supernumerary teeth.  A roentgenogram will determine the type of tooth.  Most natal/neonatal teeth are hypermobile because of the inadequate root formation.  If the tooth is so mobile that aspiration is feared, it should be removed.  The removal is accomplished by gauze (to reduce the chance of losing the tooth due to the small, slippery nature of these teeth) with light finger pressure.  This can be done by the pediatrician rather than referring to patient to a dentist; otherwise, the immature primary incisors will become more firm as the root develops.  Occasionally, odontogenic remnants remain after removal of the natal teeth and these continue to form abnormal teeth that should be extracted as they are seen.

Anonymous Current Pediatric, p. 449

The mouth of the newborn is lined with mucosa and the alveolar ridges are continuous + smooth.  Within the alveolar bone are numerous tooth buds, which at birth are mostly primary teeth and a few permanent teeth just starting to calcify.

The primary teeth begin to form at 6 week's gestation, and their calcification starts in the second trimester.  The permanent teeth are just beginning to develop at birth.  There is enough development of permanent teeth to permit their damage by perinatal or antenatal insults such as anorexia, severe jaundice, or infection.

The primary teeth begin to erupt at 6-7 months.  On rare occasions teeth are present at birth (natal teeth) or erupt within the first month (neonatal teeth).  These are most common in the anterior mandible and can be "real" primary teeth or supernumerary teeth.  On occasion these teeth must be removed to facilitate nursing, heal persistent ulceration of the tongue, or eliminate the risk of aspiration.

10.       Breasts - Discuss why the breast of a newborn may be enlarged, how long the enlargement may last, and “witch’s milk”.  Describe supernumerary nipples.

Anonymous       Bates, pg. 676.

The breasts of a newborn in both male and female are often enlarged and engorged with the white liquid, sometimes colloquially called "witch’s milk." This is due to maternal estrogen effect and usually last only a week or two. Supernumerary nipples occasionally are found on the thorax or the abdomen along a vertical line below the true nipple(s). They appear as small, round, flat or slightly raised, pigmented lesions and are not clinically significant.

Jennifer Lynn Tso-Garcia Bates,pg 676

The breasts of the newborn in both male and female are often enlarged and engorged with a white liquid, sometimes colloquially called “witch’s milk.”  This is due to maternal estrogen effect and usually lasts only a week or two.  Supernumerary nipples occasionally are found on the thorax or the abdomen along a vertical line below the true nipple(s).  They appear as small, round, flat or slightly raised, pigmented lesions and are not clinically significant.

Pam    

Witch's milk: A folk term for the milk that often comes from the breast of a newborn baby. This temporary phenomenon is due to stimulation of the baby's breasts by the mother's hormones that cross the placenta during pregnancy. The ability of the baby's breasts to respond in this fashion is a mark of baby born at (or near) full-term. The breast of a baby born prematurely cannot enlarge or produce witch's milk. 

Source: emedicine.com Supernumerary nipples (SNs) are a common minor congenital malformation that consist of nipples and/or related tissue in addition to the 2 nipples normally appearing on the chest. SNs are located along the embryonic milk line. Ectopic SNs are found beyond the embryonic milk line. The embryonic milk line is the line of potentially appearing breast tissue as observed in many mammals. In humans, the embryonic milk line extends bilaterally from a point slightly beyond the axilla on the arm, down the chest and the abdomen towards the groin, and ends at the proximal inner side of the thigh. SNs can appear complete with breast tissue and ducts and are then referred to as polymastia, or they can appear partially with either of the tissues involved.

Anonymous  Bates 676

            The breast of the newborn in both male and female are often enlarged and engorged with a white liquid, sometimes colloquially called witch's milk.  This is due to maternal estrogen effect and usually lasts only a week or two.  The supernumerary nipples occasionally are found on the thorax or the abdomen along a vertical line below the true nipples.  They appear as small, round, flat or slightly raised, pigmented lesions and are not clinically significant.

Anonymous Swartz, p. 695

The breasts of both male and female newborns are enlarged.  Commonly, a milky discharge from the nipple, known as witch's milk, may be present.  This is the effect of maternal estrogen and is present for 1-2 weeks after birth.  

Supernumerary nipples may be present along the milk line.  They may or may not have areolae.  They are often mistaken for congenital nevi and have no clinical significance.

11.       Describe the appearance of the umbilical cord including color at birth, and when to expect it to fall off. Discuss when to have the patient return to clinic for evaluation of the umbilical cord or surrounding area.

Fassil  Maternal and Child health nursing 8th ed  299-300

•        Three blood vessels are found in the umbilical cord- one vein and two arteries. They are easily seen in the cut umbilical stumps.

•        The cord has no sensory nerves; the new born does not feel it when the cord is clamped or cut. It should drop off in about 7-10 days, the place of attachment heals shortly thereafter. 

•        Since healthy newborns are usually discharge within 24 hrs of delivery, infants are scheduled to visit a health care provider within 1 week for well-child care.

Anonymous Beckman p. 133

            Normally there are 2 thick-walled umbilical arteries and one thin-vein. The diameter of the arteries is smaller than the diameter of the vein. It is covered by a firm gelatinous substance which dries up and falls off in 1 week, The skin portion retracts and becomes flush w/ the abdominal wall (Bates p. 682). The cord loses its bluish/ white appearance 24hr after birth. After a few days it turns black and then the dried stump sloghs leaving the granulating wound.

Kim B./Bates pg. 701and swartz pg. 696

The stub of the umbilical cord is white, translucent, and shiny right after birth.  It should fall off within 2-3 wks.  Look for evidence of yellow staining by meconium as a result of fetal distress.  Normally there are two thick-walled umbilical arteries and on larger but thin-walled umbilical vein.  A single umbilical artery may be associated with congenital anomalies.  Pt needs to return to clinic for eval if there is redness or swelling at the base of the cord.  Umbilical hernias are detectable at a few weeks of age.     

Anonymous  Bates 682

            Normally there are two thick walled arteries and one thin walled umbilical vein.  The diameter of the arteries is smaller than that of the vein, and the vein is usually found at the 12 o'clock position at the level of the abdominal wall.  The umbilical cord may have a relatively long cutaneous portion (umbilicus cutis), which is covered with skin, or a relatively long amniotic portion (umbilicus amnioticus), which is covered by a firm gelatinous substance.  The amniotic portion dries up within one week and falls off within two, while the cutaneous portion retracts to become flushed with the abdominal wall. 

Have parents bring baby back to clinic for any bleeding, redness, warmth, swelling or increased pain in the area of the umbilical cord.

Anonymous Swartz, p. 696

The normal umbilical cord contains two ventrally placed thick-walled arteries and one dorsally placed thin-walled vein.  Newborns with a single artery often have congenital renal abnormalities.  Drainage of a clear discharge from the umbilicus suggests the presence of a patent urachus or possibly an omphalomesenteric duct.  Yellow staining of the umbilical cord may be evidence of meconium that caused fetal distress.

MORE:  on when to expect cord to fall off, when to have px return to clinic for umbilical eval.

12.       Discuss when first stool and urine are passed. Discuss when and why you would become concerned if urine or stool not passed in a timely manner.

Fassil  Tintinalli 758 & Maternal and Child health nursing 299-300

•        The first stool, which consists of meconium, is usually passed within the first 24-48 hrs after birth. If it does not, malformation of the GI tract is suspected.

•        The newborn infant’s renal system does not have the ability to concentrate urine to the degree of the older child or adult.

•        The first voiding usually occurs within 24 hrs. If it does not , the infant should be evaluated for adequacy of fluid intake and bladder distention.

Anonymous      The first stool, which consists of meconium, is usually passed within the first 24h after birth.  If the infant has never passed stools, the possibility of intestinal stenosis or atresia.  Hirschsprung disease, or meconium ileus or plug should be considered.  Tintinalli p. 758, 762

Imperforate anus may be suspected if a stool has not been passed during the first 36h of life. Obstetrics and Gynecology p. 134

Voiding typically occurs shortly after birth.  Concern about a congenital defect of the urinary tract is appropriate if voiding has not occurred after the first two days of life.  O&G p. 134   

Kim B./Current pediatrics pg. 10/Swartz pg. 696

Baby must have a minimum of one wet diaper and a black-green (meconium) stool within the first 24 hours.  If there is absence of meconium stool within the first 24 hrs suspect either cystic fibrosis of Hirschsprung’s disease. 

Anonymous    Beckmann on 133-134

            Over 90 percent of newborns past stool within the first 24 hours.  A congenital abnormality such as imperforate anus may be suspected if a stool has not been passed during the first 36 hours of life.  Voiding typically occurs shortly after birth.  Concern about a congenital defect of the urinary tract is appropriate if voiding has not occurred after the first two days of life.

Anonymous Swartz, p. 696 & Current Pediatric, p. 10

Patency of the GI tract is confirmed by the passage of meconium, which usually occurs within the first 12 hours after birth.  If there is an absence of meconium stool in the first 24 hours, suspect either cystic fibrosis or Hirschsprung's disease.  In either case, examine the rectum.

Baby must have a minimum of one wet diaper in first 24 hours.  On day two of life, baby must have at least one wet diaper every 8-11 hours.  On day three of life, you should see an increase in wet diapers (up to 4-6) in 24 hours.  On day four of life, baby's urine should be light yellow.  On day six of life, baby should have 6-8 wet diapers per day of colorless or light yellow urine.

MORE:  on why concerned over urine passage problem.  Likely reasons (source KY):  renal disorders, urinary tract anomalies, renal vein thrombosis, dehydration/inadequate fluid intake.

13.       Discuss the physical findings associated with:

                        cephlohematoma

                        caput succedaneum

                        single umbilical artery

                        congenital dislocation of the hip

Fassil    Swartz  692, 696

Cephlohematoma: is subperiosteal hemorrhage limitednto one cranial bone, usually the parietal. There is no discoloration of the overlying scalp, and the swelling does not cross the suture line.

Caput succedaneum: is edema of the soft tissues over the vertex of the skull that is related to the birth process. This swelling crosses the sutures and disappears after a few days.

Single umbilical artery: newborns with a single umbilical  artery often have congenital renal abnormalities.

Congenital dislocation of the hip: flex the newborn’s legs at the hips. Hold the legs by placing your thumbs over the lesser trochanters and your index fingers over the greater trochanters, and press downward toward the examination table . Then simultaneously abduct the hips to almost 90 degree. The presence of a palpable or audible click suggests a dislocated hip as the femoral head suddenly snaps back into the acetabulum. This is called Ortolani’s sign.

Anonymous      Cephlohematoma-a type of localized swelling involving the scalp is often seen in newborns. It is due to subperiosteol hemorrhage involving the outer table of one of the cranial bones. Swelling does not extend across a suture(like caput succedenaum). It may be small and well localized or may involve the entire bone. Occasionally, bilateral symmetrical swellings occur after difficult deliveries. Although initially soft the swellings develop a raised bony margin within 2-3 days, due to the rapid deposition of calcium at the edges of the elevated periosteum. The entire process usually disappears within a few weeks, but may remain as a residual osteoma that is not resorbed for a year or two. bates p 653

            caput succedenaum- a newborn baby’s scalp often is swollen from edema and bruising over the occipitoparietal region. It is caused by the by the drawing of that portion of the scalp into the cervical os when the amniotic sac ruptures. The negative pressure or vacuum effect caused by the loss of amniotic fluid produces distended capillaries with the local extravasation of blood and fluid. These findings subside within the first 24 hours of life. Bates p653

            Single umbilical artery-normally there are 2 thick walled arteries and 1 thin walled vein. A high correlation exists between a variety of congenital anomalies and the presence of only a single umbilical artery. Bates p682

            Congenital dislocation of the hip- When a congenitally dislocated hip is present, you will see and feel a "clunk" and sometimes hear a "click" as the femoral head, which in this condition lies posterior to the acetabulum, enters the acetabulum at some point in the 90" abduction arc. This finding is known as Ortolani’s sign. Beyond the newborn period, as the muscles surrounding the hip increase in strength, the clunk and click of the Ortolani sign is less obtainable; then decreased abduction of the flexed legs ( at the hip on one or both sides) becomes the significant finding in detecting unilateral or bilateral congenital dislocation of the hip. Bates 692

Kim B./Current Pediatrics pg. 5/Bates pg. 667 

Cephlohematoma:  a swelling over one or both parietal bones contained within suture lines.  Due to subperiosteal hemorrhage from the trauma of birth.  This swelling does not cross over suture lines and resolves within 3 wks.  As the hemorrhage resolves and calcifies, there may be a palpable bony rim with a soft center. 

Caput succedaneum: edema from localized subcutaneous edema over the occipitoparietal region caused by distension of capillaries and extravasation of blood and fluid resulting from the vacuum effect of rupture of the amniotic sac.  This swelling often crosses over suture lines and resolves in 1-2 days.

            Current Pediatrics pg.4/Bates pg. 701

Single umbilical artery: Normally there are two arteries and one vein.  In 1% of deliveries (5-6% twin deliveries) the cord has only two vessels: one artery and a vein.  This may be associated with congenital anomalies, but also occurs in normal infants as an isolated anomaly.

             Current Pediatrics pg. 794/Bates pg. 716

Congenital dislocation of the hip: Occurs in about 1:1000 live births.  At birth there is lack of development of both the acetabulum and the femur.  The dysplasia becomes progressive with birth unless the dislocation is corrected.  If corrected in the first few days or weeks of life, the dysplasia is completely reversible and a normal hip will develop.  Diagnosis in the newborn depends on demonstrating instability of the joint by placing the infant on its back and obtaining complete relaxation while performing two technigues, the Ortilani test and the Barlow test (see picture in Bates on pg.716).  With hip dysplasis you feel a “clunk” as the femoral head enters the acetabulum while performing the Ortolani maneuver.

Anonymous 

• Cephlohematoma Dershewitz 819-diffuse swelling external to the cranium and not limited by suture lines.  This is simple scalp edema.

• Caput succedaneum Dershewitz 819-a hemorrhage located under the periosteum of a skull bone and limited by suture lines.  May be large and cause the infant to go into shock from a falling hematocrit. 

• Single umbilical artery Bates 682-Normally there are two thick-walled arteries and on thin-walled umbilical vein.  The diameter of the arteries is smaller than that of the vein, and the vein is usually found at the 12 o’clock position at the level of the abdominal wall.

• Congenital dislocation of the hip Dershewitz 686-9-presents with either an adduction contracture of the hip or more commonly, no overt physical findings.  If the child is of walking age, a Trendelenburg limp will be present.

• Coarctation of the aorta Dershewitz 367-present at 7-14 days of age.  Coincident with obstruction to descending aortic blood flow with closure of the ductus arteriosus.  The hallmark is the disparity of arterial pulses and B.P. between the arms and the legs, with stronger palpable pulses in the arms.

• Tetralogy of Fallot Dershewitz 368-May become cyanotic at several months of age, or they may present only with a murmur of the VSD.

Anonymous Swartz, p. 692

Cephalohematoma is a subperiosteal hemorrhage limited to one cranial bone, usually the parietal.  There is no discoloration of the overlying scalp, and the swelling does not cross the suture line.  The swelling is usually not visible until several hours after birth.  

Caput succedaneum is edema of the soft tissues over the vertex of the skull that is related to the birth process.  This swelling crosses the sutures and disappears after a few days.

Single umbilical artery - see above, #11.

Congenital dislocation of the hip involves a lack of development of the acetabulum and femur.  The most important part of the musculoskeletal examination of the newborn is the evaluation of the lower extremities.  The hips are examined for the possibility of dislocation.  Inspect the contours of the legs while the child is lying supine.  The presence of asymmetrical skin folds on the medial aspect of the thigh is suggestive of a proximally dislocated femur.  The perineum should not be visible when the child is in this position, because the normal position of the thighs should cover most of it.  If the perineum is visible, you must suspect bilateral hip dislocation.  

Ortolani's test and Barlow's test check for congenital hip dislocation. 

14.       Discuss the possible significance of the following physical findings:

                        absence of red reflex on fundoscopy

                        enlarged or bulging fontanelles

                        abdominal concavity

Fassil  Swartz 693

Absence of red reflex on fundoscopy: In all newborns, the presence of the red reflex bilaterally suggests grossly normal eyes and the absence suggests glaucoma or intraocular disorders.

Enlarged or bulging fontanelles: may indicate increased intracranial pressure

Abdominal concavity: If the abdomen is scaphoid or concave, there should be a high index of suspicion that a diaphragmatic hernia is present and that the abdominal organs may be located in the chest.

Anonymous  Absence of red reflex on funduscopy:  Both retinal anomalies and opacities of the cornea, anterior chamber, or lens interrupt the light pathway and give a partial red or a completely dark reflex.  (Cataracts, persistent posterior lenticular fibrovascular sheath, and retinopathy of prematurity). Bates p. 664

Enlarged or bulging fontanelles:  hydrocephaly Bates p. 656

Congenital hypothyroidism Bates p. 653

Abdominal concavity:  diaphragmatic hernia with displacement of some of the abdominal organs into the thoracic cavity. Bates p. 682

Kim B./Swartz pg.693

Absence of red reflex on fundoscopy exam: could suggest glaucoma, retinoblastoma, or an intraocular disorders.  A full fundoscopy exam needs to be done at this time.

            Swartz pg. 691/Bates pg.666

Enlarged of buldging fontanels: May indicate increased intracranial pressure.  Which

 may be due to central nervous system infections, neoplastic disease, or hydrocephalus

 (obstruction of the circulation of CSF within the ventricles of the brain).

             Swartz pg. 695

Abdominal concavity: suggests a high suspicion that a diaphragmatic hernia is present

 and that the abdominal organs may be located in the chest.   

Anonymous 

• Absence of red reflex on fundoscopy (Bates 192-a glass eye or more seriously a   retinoblastoma may obscure the reflex.  Also any opacities like cataracts.

• Enlarged or bulging fontanelles Bates 653-a large posterior fontanelle may be present in congenital hypothyroidism.  A large anterior fontanelle may represent increased cranial pressure.

• Abdominal concavity Bates 682-should immediately be investigated for diaphragmatic hernia with displacement of some of the abdominal organs into the thoracic cavity.

Anonymous

Swartz, p. 693 & Current Pediatric, p. 227

Absence of red reflex on fundoscopy - In all newborns, the presence of the red reflex bilaterally suggests grossly normal eyes and the absence of glaucoma or intraocular disorders.  The presence of the red reflex indicates that there is no serious obstruction to light between the cornea and the retina.  If a red reflex is absent, funduscopic examination is required.  Absence of red reflex on fundoscopy could indicate congenital cataracts or retinoblastoma.

Swartz, p. 691

Enlarged or bulging fontanelles - Normally, fontanelles are flat.  A bulging fontanelle may indicate increased intracranial pressure; a depressed fontanelle may be seen in dehydration.  Normally, during crying, the fontanelles bulge.

Swartz, p. 695

Abdominal concavity - If the abdomen is scaphoid, there should be a high index of suspicion that a diaphragmatic hernia is present and that the abdominal organs may be located in the chest.  The abdomen of a newborn is normally protuberant as a result of the poor development of the abdominal musculature.

15.       List the reflexes/automatisms which are present in the newborn and when they disappear.

Fassil  Swartz 699

•        Rooting response: disappears after 3-4 months

•        Planter grasp: disappears 9-12 months

•        Palmar grasp: disappears 3-5 months

•        Moro’s reflex : disappears 3-5 months

•        Galant’s reflex: disappears 2-3 months

•        Perez’s reflex :  disappears 2-3 months

•        Placing response: disappears 2-5 months

•        Stepping response : disappears 2-5 months

Anonymous Bates, p.630

"Normal full-term newborns lie in a symmetrical position with limbs semiflexed and legs partially abducted at the hip. The head is slightly flexed and positioned in the midline or turned to one side. Normal newborns have spontaneous motor activity of flexion and extension, alternating between the arms and legs. The forearms supinate with flexion at the elbow and pronate with extension. The fingers are usually flexed in a tight fist, but may extend in slow athetoid posturing movements. Low-amplitude and high-frequency tremors of the arms, legs and body are seen with vigorous crying and even at rest during the first 48 hours of life."

Kim B./Current pediatrics pg. 7/Swartz pg.699

(A.)  Sucking reflex in response to a nipple or examiner’s finger in the mouth.  Observed by 14 wks gestation. 

(B.)   Rooting reflex: Head turns to the side of a facial stimulus.  This reflex develops by 28 wks gestation and disappears after 3-4 months old. 

(C.)  Traction response: The infant is pulled by the arms to a sitting position.  Initially, the head lags, then with active flexion comes to the midline briefly before falling forward. 

(D.)  Palmar grasp with placement of the examiner’s finger in the palm.  Reflex develops by28 wks gestation and disappears by 4 months old.

(E.)   Deep tendon reflexes: Babinski reflex is usually present in newborns and doesn’t  disappear until about age 4.  Other DTRS are variable in newborns/infants.     

(F.)   Placing: Rub the dorsum of one foot on the underside of a surface.  The infant will flex the knee and bring the foot up.  Response isn’t present until about 4-5 days after birth and disappears after 2-5 months.

(G.)  Moro (startle) reflex: Hold baby supine and support head.  Allow the head to drop1-2 cm suddenly.  The arms will abduct at the shoulder and extend at the elbow.  Adduction with flexion will follow.  The hands show a prominent spreading or extension of the fingers.  This reflex develops by 28 wks gestation and disappears by 3 months of age.

(H.)  Tonic neck reflex: With baby supine turn the head to one side.  The arms/legs on that side will extend while the opposite arm and leg flex.  Reflex present at birth and disappears by 8 months. 

Anonymous  Bates 697-701

• Blinking(Dazzle) reflex- Disappears after first year.  The eyelids close in response to bright light and if absent, may indicate blindness.

• Acoustic Blink(Cochleopalpebral) reflex- Disappearance time is variable.  Both eyes blink in response to a sharp loud noise and absence may indicate decreased or absent hearing.

• Palmar grasp reflex- Disappears at 3-4 months and persistence of greater than 4 months suggests cerebral dysfunction.

• Rooting reflex-Disappears at 3-4 months; may be present longer during sleep.  Absence of this reflex indicates severe generalized or CNS disease.

• Trunk incurvation (Galant’s) reflex- Disappears at 2 months.   Absent in transverse spinal cord lesions or injuries.

• Vertical Suspension Positioning- Disappears after 4 months.  Fixed extension and adduction of legs indicates spastic paraplegia or diplegia.

• Placing Response- Best elicited after the first 4 days.  Disappearance time is variable.

• Rotation test- Disappearance time is variable.  Strabismus may be detected with this maneuver.

• Tonic Neck reflex- Usually appears at 2 months and disappears at 6 months.  It will persist 6 months with major cerebral damage.

• Perez reflex-Absence of  ths during the first 3 months of life may indicate severe cerebral insult, injury to the upper cervical cord, advanced anterior horn cell disease, or severe myopathy.

• Moro response-Persistence of this beyond 4 months may indicate neurologic disease; persistence beyond 6 months is almost conclusive evidence of such.

Anonymous Swartz, p. 699

Rooting response - disappears after 3-4 months.  This primitive response ensures nursing - the head retroflexes and the jaw drops.

Plantar grasp - disappears after 9-12 months.  This is a plantar flexion response.

Palmar grasp - disappears after 3-5 months.  Holding the hand in a fist after 2 months of age suggests neuroligic disease.  Persistence of palmar grasp after 5 months suggests cerebral disease.

Moro's reflex - disappears after 3-5 months.  This is the startle reflex.

Galant's reflex - disappears after 2-3 months.  This is a lateral curvature of the trunk response toward the stimulated side.

Perez's reflex - disappears after 2-3 months.  This is a response of flexion of the knees and extension of the head and spine.

 Placing response & Stepping response - disappear after 2-5 months; best observed after 4-5 days of life.   

16.        List the routine screening tests for a newborn and what they test for.

Anonymous Amb. Ped. Care pgs. 33-34, Tabers Med. Dict. ed 18

            Presymptomatic detection of dz. with treatment = alters natural dz. hx, prevents complications/death.

            PKU (phenylketonuria) hyperphenylalaninemias - defect in enzyme phenylalanine hydroxylase (rarely defect in enzymes pterin factor.) Autosomal recessive disoder of amino acid metabolism. Incidence = 1:10,000 in USA. Chronic exposure to elevated levels = classic symptoms of: eczema, mental retardation, severe behavior symptoms, often seizure. Test for: blood phenylalanine (normal range: 1-2 mg/dl., mild hyper. - mild chronic state when levels <6-10, but still elevated. Levels >6-10 = treatment.

            Congenital hypothyroidism (CH) - Incidence = 1:4000 births. Many causes, including: agenesis, dysgenesis (the most common), ectopic thyroid, deficient hromone synthesis, hypothamic-pituitary defects, other rarer etiologies. T-4 checked - if low, TSH quantified. Low T-4, elevated TSH = endocrine workup, frequently a radionuclide scan ordered. Treatment (L-thyroxine) especially important 1st 1-2 years of life.

            Apgar score - test of infants physical condition at birth. Checks HR, resps., muscle tone, response to stimuli, color. Rated at 1min. and 5 min., scored 0-2 w/max score of 10. (7-10 good, 4-6 fair, <4poor) If low at 1 min. sign of paranatal asphyxia - need for assisted vent., <7 at 5min. = recheck again in 5 min., <6 anytime may need resuscitation.

Some states routinely test for:

Galactosemia (3 types, 1:50,000 - rare)
            Homocystinuria
            Maple syrup urine dz.
            Sickle cell dz.
            Congenital adrenal hyperplasia

Kate M  Current Peds. pp.228, 995

Phenylketonuria (PKU) *Autosomal recessive disease of amino acid metabolism caused by decreased activity of phenylalanine hydroxylase, the enzyme that converts phenylalanine to tyrosine.

Re: Tyosine is used by melanocytes to manufacture melanin and catecholamines and thyroid hormones are synthesized from molecules of  tyrosine.

Pt. with untreated PKU exhibits severe mental retardation, hyperactivity, seizures, light complexion, eczema, and urine has a “mouse-like” odor.

Treatment involves limiting dietary intake of phenylalanine.  Prompt tx allows normal physical and mental development.

            Current Peds pp.228,947 Congenital Hypothyroidism *is usually due to aplasia, hypoplasia or maldescent of the thyroid.  It leads to growth retardation, diminished physical activity, impaired tissue perfusion, constipation, thick tongue, poor muscle tone, hoarseness, anemia and intellectual retardation.  Findings can arise in the first 2 months of life but are absent in 75% of newborns with documented hpothyroidism.  Because this must be treated ASAP to avoid intellectual impairment, diagnosis should be based on newborn screening not just abnormal physival findings.

Treatment: Levothyroxine is drug of choice.

            Current Peds.pp 228, 991 Galactosemia• Autosomal recessive disorder in which an almost total deficiency of galactose-1-phosphate uridyltransferase allows accumulation of galactose-1-phosphate in the liver, brain and renal tubules causing hepatic parenchymal disease, mental retardation, renal Fancuni syndrome, cataracts and possible death.  With prompt institution of galactose-free diet, prognosis for survival without severe mental retardation is excellent.  Heterozygous mothers may be advised to maintain galactose-free diet during pregnancy.

            Current Peds. pp.228,852 Sickle Cell Disease• High prevalence of sickle HgB in persons of central Africa descent and ethnic groups of Sicily, Italy, Greece, Turkey, Saudi Arabia and India.  Sickle hemoglobinapthies lead to high amounts of deoxygenated HgB, deformed erythrocytes, decreased red cell life span, increased blood viscosity and increased risk of vaso-occluson.  Treatment: patient/family education, prophylactic penicillin, maintenance of adequate hydration . . .see pg.854.

* all states

• most states

following tests are perfomed in some states: Cystic Fibrosis, Toxoplasmosis, Biotinidase deficiency, Congenital Adrenal hyperplasia, Homocystinuria, Maple syrup urine disease, Tyrosinemia.

KIM R. Pg 682-696 Swartz.

- after the Apgar score has been determined, the GESTATIONAL AGE should be assessed.  The standard system for assessing gestational age is the Dubowitz Clinical Assessment.  This is based on 10 clinical neurologic signs and 11 external signs..such as skin texture, breast size, and genital development.  The total scores of the neurologic and external signs are summed.

The newborn infant is also weighed, but weight alone does not determine maturational age.  The birth weight is correlated with gestational age according to the standard classification of Battaglia and Lubchenco.   By this method the infant is classified as being small, appropriate, or large for gestational age.

The value of the weight-gestational age determination lies in its ability to predict certain risk groups. 

NEXT COMES...

1. Resp. Rate and the degree of effort.  Newborn varies between 30 to 50 breaths per minute.

2. Measure Temperature with a rectal thermometer.  Newborns have a relative thermal instability...for this the ambient temp should be considered.

3. Pulse by auscultation of the heart.  Average range is 120 to 140 beats per minute.  There may be wide fluctuations from 190 to 90 beats per minute.  Anything below 90 is a CONCERN.

4. Measure the head and chest...the head is measured at its greatest circumference..around the occipitofrontal area.  Three measurements are taken..the largest is recorded.  The chest measurement is usually smaller than the head by 2-3 cm.  Take the chest measurement at the level of the nipples MIDWAT BETWEEN INSPIRATION AND EXPIRATION.

5. Note the POSTURE.  A normal newborn lies on one side with arms and legs flexed.  A term infant who lies on his/her back with arms and legs abducted in a frog position had an abnormal posture.

6. Note the MOVEMENTS.  Normally, all 4 limbs should be moving in random and asymmetrical manner.  Fine movements of the face and fingers are usually present.  ABNORMAL movements include jerky, symmetrical, course movements.

Anonymous Swartz, p. 228

All states screen for phenylketonuria (PKU) and Congenital hypothyroidism.

Most states screen for Galactosemia and Sickle cell disease.

Additional diseases screened for in some state programs include adrenal hyperplasia, homocystinuria, maple syrup urine disease, biotinidase deficiency, tyrosinemia, cystic fibrosis and toxoplasmosis.

17.       Discuss the importance of examining the hips of a newborn and describe the techniques used.

Anonymous  Examined for signs of dislocation. 

            Place the baby supine with the legs pointing toward you.  Flex the legs to right angles at the hips and knees, placing your index fingers over the greater trochanter of each femur and your thumbs over the lesser trochanters.  Abduct both hips simultaneously until the lateral aspect of each knee touches the examining table.  This is known as the Ortolani test.

            Detect an unstable (nondislocated but potentially dislocatable) hip by placing your thumbs medially over the lesser trochanters and your index fingers laterally over the greater trochanters; press your thumb backward and outward.  Feel for movement of the head of the femur laterally against some resistance as it slips out onto the posterior lip of the acetabulum.  Normally no movement is felt.  Then, with your index finger, press the greater trochanter forward and inward.  Feel for a sudden movement of the femoral head inward as it returns to the hip socket.  Again, movement is not normally felt.  Movement in both directions constitutes Barlow’s sign. 

Kate M.  Swartz, 697  

Purpose: detect gross abnormalities and possible dislocation

Technique: 1.Inspect leg contour with child supine. Presence of asymmetrical skin folds on medial aspect of thigh suggests proximally dislocated femur. At this location perineum should not be visible, if visible suspect bilaral hip dislocation. 2. Place feet side by side, soles on exam table, allow hips and knees to flex.  Observe relative height of knees.  If one at lower level, suspect shorter knee caused by dislocation of hip on that side and/or congentally shorter femur. 3. Examine each hip for joint stability.  Child supine:Flex legs at hips and press legs down towards pelvis, then abduct hips to 900  Listen/feel for clicks to suggest dislocated with replacement of femoral head into acetabulum (Ortolani’s sign).  Perform gently on quiet infant.

KIM R Pg 697 Swarts or 716-717 Bates

The hips are examined for possible dislocation. 

INSPECT the contours of the legs while the child is lying supine.  The perineum should be not be visible when the child is in this position.  If the perineum is visible you should suspect bilateral hip dislocations.

Place the infants feet side by side with the soles on the exam table, allowing the hips and knees to flex.  Observe the height of the knees.  If one knee is at a lower level, you should suspect that the shorter knee is secondary to a dislocation of the hip on that side, a congenitally shorter femur or both.  If both knees are at the same height..either bother hips are normal or both are dislocated. 

After inspection of the knee heights, each hip is examined to determine joint stability.  Flex the newborn’s legs at the hips.  Hold the legs by placing your thumbs over the lesser trochanters and your index fingers over the greater trochanters, and press downward toward the exam table.  Then simultaneously abduct the hips to almost 90 degrees.  The presence of an audible click suggests a dislocated hip as the femoral head suddenly snaps back into tha acetabulum. This is called the ORTOLANI’s SIGN.  THE TEST SHOULD BE PERFORMED GENTLY ON A QUIET INFANT.

Anonymous  Dershewitz 686-9

• To check for Developmental Dysplasia of the Hip (DDH).  The earlier it is detected, the better the end result.    The two classic signs for DDH are the Ortolani sign and Barlow sign.

• Ortolani sign—the maneuver is performed with the hips held in 90 degrees of flexion.  Each hip is tested independently while the opposite side of the pelvis is stabilized.  The hip is first gently abducted while at the same time gentle pressure is placed on the greater trochanter to push the femoral head forward into the acetabulum, but when released, the femoral head again moves out of the acetabulum.  Will hear a sound, “thump”,

• Barlow sign—is positive when the hips are held in 90 degrees of flexion and pressure is applied over the lesser trochanter while adducting the hip, forcing the femoral head out of the acetabulum.  When the pressure is released, the dislocatable hip usually returns into the acetabulum. 

Anonymous Swartz, p. 697  

Congenital dislocation of the hip involves a lack of development of the acetabulum and femur.  The most important part of the musculoskeletal examination of the newborn is the evaluation of the lower extremities.  The hips are examined for the possibility of dislocation.  Inspect the contours of the legs while the child is lying supine.  The presence of asymmetrical skin folds on the medial aspect of the thigh is suggestive of a proximally dislocated femur.  The perineum should not be visible when the child is in this position, because the normal position of the thighs should cover most of it.  If the perineum is visible, you must suspect bilateral hip dislocation.  (Please read 2 additional paragraphs on p. 697 if you are interested in more detail.)  

Ortolani's test and Barlow's test check for congenital hip dislocation.