Chapter? * TheNewborn * 91 <1ke | Milero See Ss Fas 2e¢ | mmeoors | ee eps one rom | F50 3kg | Miller. uate Sy 30 mL F50 4kg | Miler 1 tee Senne 40 mL F50 ‘Adapted from NRP 5th ed. 2006 AAP for possible pulmonary hypertension, meconium aspiration syndrome, and pneumonia. Provide oxygen supplementation and positive pressure or ventilatory support with diligence to prevent hyperoxic injury and barotrauma, Aim to keep the oxygen saturation between 85%-95% for preterm infants. Monitor cardiovascular and respiratory status to observe episodes of apnea, bradycardia, and hypotension. Treat hypotension with volume and consider inotropes. Maintain a high index of suspicion for infection and initiate prompt treatment whenever infection is considered. Check blood sugar at frequent intervals and promptly correct hypoglycemia by early feeding with colostrum and breastmilk and dextrose containing intravenous solutions if necessary. Delay feeding if the infant is in severe respiratory distress. Feeding must also be cautiously monitored as preterm infants and infants with hypoxic events are at risk for necrotizing enterocolitis. Consider parenteral nutrition, Watch out for complications of resuscitation discussed previously and promptly correct any problem. Maintain open communication with the parents and encourage contact and bonding, For infants who need to be transported to another facility, stabilize them prior to transport. The S:T.A.B.LE. program focuses on post-resuscitation, pre-transport stabilization. The acronym stands for Safe care, sugar-ensuring euglycemia by correcting hypoglycemia and hyperglycemia, keeping Temperature normal, maintaining Airway, Blood pressure, Laboratory evaluations, and Emotional support. Jean T. Uyboco PHYSICAL AND NEUROLOGIC DD aS ty All newborns are examined after birth to check for major abnormalities and to make sure the transition to extrauterine life is without difficulty. The newborn should undergo a detailed and complete physical examination within 24 hours after birth. The neonate should be undressed for the examination, ideally in a well-lit room under a radiant warmer or floor lamp to avoid hypothermi Vital signs should be monitored every 15-30 minutes after birth for at least 2 hours until stable. ‘The clinician needs to perform a comprehensive examination while minimizing disturbance to the baby. If possible, use a 3-stage approach that begins with an initial hands-and-stethoscope off period, followed by a minimal disturbance portion, and concludes with a head-to-toe review. VITAL SIGNS The respiratory and heart rates of the normal newborn vary considerably in the first few hours of life. During the remainder of the first day of life, most newborns have a respiratory rate of 40 to 60 breaths per minute. The respiratory rate is obtained by looking at the upper abdomen for a full minute. The normal heart rate is 120 to 160 beats per minute. The heart rate varies with the neonate's activity; it increases when the baby is crying, active, or breathing rapidly and decreases when the baby is ENT WTYYD92 + Part2 © Pediatric Norms quiet and breathing slowly. The temperature can be accurately assessed using an axillary thermometer. Rectal temperature is usually 1° higher than oral temperature while axillary temperature is usually 1° lower than oral. A temperature between 36.5 °C and 37.5 °C is normal. An elevated temperature may represent fever but more commonly is the result of external factors such as over-bundling or an ambient heat source. Blood pressure correlates directly with gestational age, postnatal age, and birth weight. <1 Blood Pressure Blood pressure is not routinely measured in otherwise well newborns. When blood pressure measurement is clinically indicated, the proper cuff size is chosen and the extremity used is documented in the blood pressure recording The flush method for obtaining mean pressure is easier in an active infant and requires only a sphygmomanometer. The arm or leg is wrapped with the cuff and inflated enough to blanch the skin. ‘The pressure is slowly lowered until there is a flush of color. This is considered the estimated systolic pressure. The Doppler method provides systolic and diastolic pressures; however, it requires a specific electronic equipment and a quiet infant. ANTHROPOMETRIC ‘A more detailed examination with measurements of the weight, length, and head and chest circumference must be performed. These measurements should be plotted on standard growth curves (Lubchenco chart) to determine if the newborn is appropriate for gestational age (AGA), small for gestational age (SGA), or large for gestational age (LGA). The weights of newborns vary; however, a normal term newborn has an average weight of 3,000 g or 6% Ibs. An infant weighing scale is used. Weight is recorded in kilograms and plotted on Lubchenco’s chart. a Small for Gestational Age (SGA) - birthweight below the 10th percentile. ‘Symmetric - onset is early in gestation; brain size corresponds to body size. WEIGHT PERCENTILES 0 00 200] Weight (g) oha2SRSEREESEES EERE 22526 27 28 29 0ST SS MSS 85TH AO Gestational Age (week) FIGURE 7-2. Birth weights of liveborn singleton white infants at gestational ages from 24 to 42, weeks Source: Battaglia F. Lubchenco L: A practical classification of ‘newborn infants by weight and gestational age. J Pediatr 7459 All measurements fall within the same percentile range on the Lubchenco chart. Asymmetric - onset is late in gestation; no or minimal effects on fetal brain growth so that only the weight and length gains are affected. b. Appropriate for Gestational Age (AGA) = birth weight between 10th to 90th percentile. c. Large for Gestational Age (LGA) - birthweight above the 90th percentile. ‘The neonate lies supine on a recumbent length table or measuring rod. The crown of the head touches the stationary vertical head board. Ensure that the legs remain flat on the table and shift the movable board against the heel. The length is recorded to the nearest 0.1 cm and plotted on Lubchenco’s chart.Chapter 7 + TheNewborn * 93 WEIGHT PERCENTILES 000 2 LENGTH PERCENTILES Pe t es ton a Fe " on = a 7 aus gx a3 z8 en 3 Zc a: = 2000] Sx ‘a = cl z tows a i a = a Oem 26 77 26 5031 22 9835 36 "39 40 at 42 43 ONGFRSDO 2 26-70 90332 993903 9097 HE AAT AD 2 Gestational Age (week) Gestational Age (week) HEAD CIRCUMFERENCE PERCENTILES: Head Circumferences (cm) NU RUBSBB SHR Bes Eee Place an °X" in the appropriate box (LGA, AGA, or SGA) for weight, for length, and for head circumference. WSBT BORK OTH ONE Gestational Age (week) FIGURE 7-3. Classification of newborns by intrauterine growth and gestational age ‘The head circumference is normally 32-37 em at term, Place the measuring tape around the front of the head (above the brow or frontal area) and the occipital area. The tape should be above the ears. The head circumference is usually bigger than the chest circumference at birth, Plot the measurement in the percentile chart for head circumference. ‘Transverse and anteroposterior diameters of the chest may be measured in certain diseases. The ratio of the transverse to the anteroposterior diameter, ‘Standards of newborn care. Philippine Society of Newborn otherwise known as the thoracic index, is 1.0 at birth. Medicine. 3rd ed. 2008.94 + Part2 © Pediatric Norms GESTATIONAL AGE 2 Clinical Signs Infants are classified as preterm (< 37 weeks or 259 days), term (37-41 6 or 7 weeks or 260-294 days), and postterm (2 42 weeks or 295 days or more). There are observable clinical signs that can identify whether an infant is term or preterm. Postterm infants have long fingernails. With experience, most postterm infants can be identified by their general appearance (Table 7-9). 65%). The skin of immature infants is gelatinous with visible veins. Jaundice is not found at birth and its development during the first 24 hours may indicate a hemolytic process which needs immediate attention. A transient harlequin color change is sometimes observed. There is a sharp line of demarcation in the midline of the body separating a red from a pale half. Mottling of the skin, especially when the body is exposed to cold, is due to the instability of the circulation which disappears as the baby becomes older, Bluish grey pigmented areas (Mongolian spots) in the buttocks, back, and occasionally in the extremities are commonly seen among Filipinos and other Asian neonates. These have no clinical significance and disappear within a couple of years or a little later. 2 Skin Rash and Lesions There are benign self-limiting skin rashes in the newborn that do not require treatment. Milia are whitish pinhead-sized sebaceous retention cysts commonly found in the chin, nose, forehead, and cheeks, and is found in 33% of infants. Pearls are large single milia that can occur in the genitalia and areola, and disappear a few weeks after birth. Neonatal acne consists of comedones and papules caused by maternal hormones and are distributed in the cheeks, chin, and foreheads. Erythema toxicum neonatorum are eosinophil-containing vesiculopustular papules on an erythematous base distributed in the face, trunk, and extremities. They usually appear 1-3 days after birth or as late as 7-10 days, Pustular melanoses are neutrophil-flled vesiculopustular eruptions commonly found in black infants and distributed around the chin, neck, back, extremities, palms, and soles. These lesions are present at birth and last for 2-3 days. Mongolian spots and macular hemangiomas (stork bites) also disappear spontaneously at a later time. These lesions should be differentiated from pustular dermatitis by a Gram stain of the skin discharge. Generalized petechiae signify a systemic disease, but if lesions are localized to areas that were exposed to pressure, like a loop of cord around the neck, they may be safely observed. Bleeding is due to the fragility of the capillaries. Position and Movement ‘The careful observation of an infant's position at rest and spontaneous movement provides a great deal of information about the neurologic status, Gestational age, illness, maternal medications, and sleep state influence both the tone and spontaneous movements and must be considered during evaluation. Normal babies of all gestational ages have symmetric tone and movements. Asymmetry in range of spontaneous movement may indicate the presence of local birth trauma (brachial plexus injury; fracture of the clavicle, humerus, or femur) or rarely, a central nervous system anomaly. Asymmetry of position may be due to fetal position in utero and this should improve with time. <1 Face and Crying The face may be asymmetrical due to the fetal position. Facial paralysis or paresis may be due to pressure on the facial nerve because of impingement against the birth canal or the application of forceps. Typical facies of certain syndromes are recognizable at birth, the most common of which is Down syndrome. Symmetry of the mouth and eyes is the normal finding. An asymmetric mouth (the abnormal side does not “droop” with crying), an ipsilateral eye that does not close, and a forehead that does not wrinkle usually indicate an injury to the peripheral facial nerve (cranial nerve Vil). A palsy confined to the lower portion of the face (central facial palsy) may indicate an intracranial hemorrhage or infarct. A normal newborn has a lusty cry. Illness, respiratory distress, depression from maternal narcotics, or central nervous system disturbance ‘ill cause the baby to have a weak or whining cry.Central nervous system problems may also result in a persistent high-pitched cry. Hoarseness can be caused by laryngeal edema after airway manipulation, hypocalcemia, or airway anomalies. Conditions resulting in either internal obstruction or external compression of the airway often cause stridor, which is exacerbated by crying; therefore, stridor in the newborn infant is a serious finding. © Congenital Anomalies ‘A quick survey for dysmorphic features, whether malformations or deformations, must be undertaken. OQ Eyes ‘The eyes of a crying baby cannot be examined. Gently rocking the infant backward and forward often prompts the baby to open the eyes. Subconjunctival hemorrhages are sometimes seen. Congenital cataracts, if present, should alert the examiner to look for other anomalies that are associated with rubella and galactosemia. Funduscopic examination is often deferred due to technical difficulties but should be done before discharge of babies who have been given prolonged high concentrations of oxygen for early detection of retinopathy of prematurity. A quick ophthalmoscopic examination for the red orange reflex of both eyes should be elicited and visualized before discharge in all newborns. Cardiovascular System The heart is routinely examined to check for heart disease and, in cases of a sick neonate, to determine whether the heart is the source of the problem. Examination of the cardiovascular system begins with an assessment of general appearance, color, perfusion, and respiratory status. The presence of congenital anomalies increases the likelihood of associated congenital heart defects. Central cyanosis with comfortable breathing suggests cyanotic heart defect with diminished pulmonary blood flow. Because of the hypertrophy of the normal newborn's right ventricle, the point of maximal impulse (PMI) is found just to the left of the lower sternum. In the term newborn, the precordial impulse is visible during the first few hours of life, but generally disappears by 6 hours of age. Chapter 7 * The Newborn + 97 ‘The size of the heart is difficult to estimate, Its position is ascertained by auscultation. The first heart sound is typically single and is accentuated at birth and in conditions where there is increased flow across an atrioventricular valve. The second heart sound (S2) is best heard at the upper left sternal border. Itis split, although it can be difficult to appreciate because of the relatively fast heart rate. The presence of a normally split S2 is 1 of the most important physical findings to be mastered as it signifies absence of heart defect. A cardiac murmur soon after birth may not be clinically significant although an exceptionally loud one which is also heard at the back may be suggestive of an anomaly. Absence of a heart murmur does not entirely rule out structural heart defect. The classic murmurs of specific lesions may not be heard in the neonate. Heart rate is about 120-140 per minute and sinus arrhythmia is not uncommon especially in preterm infants. Pathologic states such as respiratory distress syndrome or cardiac failure increase the heart rate. Slowing of the heart may be due to congenital heart block, hypoxia, or intracranial hemorrhage. Q Respiratory System ‘The most important part of the respiratory system examination is performed while simply watching the infant breathe. The stethoscope is used to assess the quantity, quality, and equality of breath sounds (particularly in infants on mechanical ventilation); to ensure the absence of bowel sounds in the chest; and to better localize the source of stridor or other abnormal sounds. Alveolar pathology results in end inspiratory rales while airway secretions give rise to harsh breath sounds in early inspiration. Abdomen ‘The abdomen is globular but not distended. Distention suggests intestinal obstruction, especially if accompanied by vomiting after feeding and the absence of meconium stools. Separation of recti muscles is common in the newborn (diastases recti). A small umbilical hernia may be present but this usually closes when the abdominal muscles become stronger in about 3 years. When the defect is large enough to allow intestinal contents covered98 + Part2 » Pediatric Norms by amnion to protrude, itis called an omphalocoele. Because the intestines are exposed, infection is very likely. Surgical intervention is needed for repair and skin grafting may be necessary. The liver is usually palpable, with its edge felt about 2-3 cm below the right costal arch. The spleen is not palpated as easily and considered abnormally large if palpable more than 1 cm below the left costal margin. The kidneys are normally palpable by bimanual palpation. Enlargement of the kidneys as a result of hydronephrosis or cystic kidney disease is the most common abdominal mass found in the newborn. Any palpable mass warrants immediate investigation. Renal embryoma, hydronephrosis, ovarian cysts, or duplication of the gut are the more common abdominal masses. Spinal cord lesions may be evident at the back such as meningomyelocele and spina bifida. Dermal sinuses at the sacral area are occasionally encountered, the more common of which is the “pilonidal dimple” The tiny pore is surrounded by hair and may exude a whitish secretion. i Top-to-Bottom Review Head Babies born by Cesarian section or breech extraction have rounded heads. When the head is the presenting part in vaginal delivery, varying degrees of molding can occur resulting in asymmetry with overlapping of the sutures. Head normalizes within a few days. Head circumference (HC) must be measured at the widest diameter from the occiput to the glabella. Fontanels vary in size, but if they are small or closed and associated with a small head, microcephaly or craniosynostosis should be suspected. A tense fontanel may be a sign of increased intracranial pressure. As the head passes through the cervical ring, the pressure on the scalp may produce edema (with or without ecchymosis), resulting in caput succedaneum. The size of the caput varies with the extent and duration of the pressure. Its borders are not well defined, merging with the rest of the tissues. This also disappears after a few days. Cephalhematoma, on the other hand, is the result of a subperiosteal bleed and is limited by periosteal attachments. It does not cross the suture lines. Qozing may continue during the next few days, causing the hematoma to increase in size. The outer border of the cephalhematoma is raised, giving a sensation of a depressed fracture. Some cephalhematomas do have an underlying skull fracture, Absorption is slower than that of a caput, sometimes resulting in calcification. Palpation of the parietal bones may elicit soft areas (craniotabes) which give the sensation of a “pingpong” ball when pressed. In the newborn, it may not be significant. Persistence of craniotabes beyond infancy is a sign of bone pathology as seen in rickets and osteogenesis imperfecta. Bony defects in the skull may result in a cranial meningocele, noted asa pulsating mass which becomes more tense when the baby cries. Ears ‘There is wide variation in external ear configuration. Syndromes have malformed auricles as part of their spectrum but findings are not usually pathognomonic. Low-set ears are associated with chromosomal disorders and renal anomalies. Ear tags in the tragus and periauricular area have no clinical significance. Ear canals filled with amniotic fluid which is found on Gram stain of a sample to have 3-5 WBC are suggestive of an infection. Nose Patency of the nares should be established during the initial examination and suctioning. The nose may be misshapen as a result of in utero deformation. It usually self-corrects in a few days. Several syndromes and teratogens have nasal manifestations including small (fetal alcohol) to large (trisomy 13) noses and low (achondroplasia) to prominent (seckel syndrome) nasal bridges. ‘Mouth The relationship of the mandible and maxilla should be assessed. Micrognathia is a component of many malformations, with Pierre Robin sequence being the most obvious example. The frenulum linguae is a band of tissue that connects the floor of the mouth tothe tongue; even if it extends to the tip of the tongue (tongue-tie), suckling and later speech are not affected, hence, surgical correction is not indicated. If Itrestricts tongue protrusion though, frenulorrhaphy should be done. Occasionally, supernumerary teeth are seen at birth. They are easily pulled out or are shed early. Epithelial cysts on the palate and gums known as Epstein pearls are present in most babies. Harelip is obvious but a careful visualization is needed to see cleft palate or uvula. Neck ‘The short neck is hardly discernible with the head atop the shoulders. Redundant skin along the posterolateral line (webbing) is seen in Turner's syndrome. The neck of infants with Down syndrome is notable because excess skin is concentrated at the base of the neck posteriorly. A variety of branchial cleft remnants are manifested by pits, tags, and cysts. The most common neck mass is a lymphangioma (cystic hygroma), a multiloculated cyst comprised of dilated lymphatics. Sternocleidomastoid hematomas may be felt along the course of the muscle which become more prominent a few days after birth. The dlavicles are palpated for the presence of fractures which typically manifest as an asymmetric Moro response, tenderness, and/or crepitus. Chest A. Observe the symmetry of the chest. Tachypnea and retractions indicate respiratory distress. Barrel chest is seen in meconium aspiration pneumonia due to hyperaeration and air trapping. Mild subcostal and intercostal retractions are common, even in healthy neonates because of their compliant chest walls. Because the diaphragm is the primary muscle of breathing, with little contribution by accessory muscles, quiet breathing is abdominal. Clavicular fracture is the most common fracture in newborns, especially among large infants. Affected infants may present with decreased or absent movement and tenderness in the movement of the arm on the affected side, Chapter7 * TheNewborn « 99 deformity and discoloration over the fracture site, and crepitus or irregularity along the clavicle. Treatment is directed at minimizing the newborn's pain or discomfort. Breasts are usually 1 cm in diameter at term. ‘They may be abnormally enlarged (3-4 cm) secondary to the effects of maternal estrogens. A white discharge, commonly referred to as “witch's milk,” may be present both in male and female infants. Supernumerary nipples may occur as a normal variant. B. Listen for presence and equality of breath sounds, Absent or unequal sounds may indicate pneumothorax or atelectasis. Absent breath sounds and presence of bowel sounds indicate diaphragmatic hernia, The newborn's lung sounds are relatively more bronchial than vesicular because of better transmission of large airway sounds across a thin chest. The back ‘The back is examined for the presence of abnormal curvatures and evidence of an occult dysraphic state. The presence of a tuft of hair, a subcutaneous lipoma, sinus, hemangiomata, dimples separate from the gluteal crease, aplasia cutis, or skin tag should raise suspicion regarding the possibility of an underlying occult dysraphic state. Finding of a structural aberration requires intervention in the neonatal period in order to prevent the development of neurologic deficits, pain, and other complications. The extremities Careful inspection and palpation of the extremities can determine whether the extremities are normally formed, Joint contractures, asymmetries, or discolorations should be noted. Erb's palsy is manifested by an arm that is extended, internally rotated, and with limited movement. The humerus and ulna are the second and third most commonly fractured bones at delivery. Abnormalities of the digits, a single palmar crease, and nail hypoplasia can be important clues to dysmorphic syndromes. A careful examination of the hips is crucial in detecting developmental dysplasia of the hips.100 + Part2 + Pediatric Norms This disorder is more common in females, infants with underlying neurologic abnormalities, and those presenting in the breech position. The genitalia The genitalia of the female infant may show a mucoid non-purulent or sometimes bloody vaginal discharge. The hymen may have prominent tags. Vaginal skin tags are inconsequential and regress within a few weeks. The clitoris may be large and confused for a penis. The labia minora are relatively more prominent in the preterm compared to the term infant. The sizes of the scrotum and penis vary. The testes may not have fully descended but are palpable in the canals. Hydrocele may be present with or without an accompanying hernia. An unusually large penis with a urogenital sinus is associated with adrenogenital syndrome, Ambiguity in the external genitalia requires further investigation and sex assignment of the newborn is postponed until definitive tests become available. ‘Anus ‘The presence, patency, and location of the anus should be noted. Patency of the anus is often assessed by cautious use of rectal thermometer. Absent (imperforate) anus may be associated with other anomalies like esophageal atresia (VATER association). The neurologic examination is not routinely performed but a complete examination is necessary in the following cases: (1) low APGAR scores, (2) prematurity, (3) hypotonia, (4) diminished alertness, (5) seizures, (6) CNS infections, (7) palsies, (8) trauma, and (9) evidence of dysmorphisms and congenital anomalies. Neonatal neurological evaluation is predominantly observational. For sick neonates, multiple visits for evaluation may be required to make a complete assessment. Timing is important because conditions such as feeding, crying, cold exposure, irritation, and others may affect findings. Repeat assessment may be necessary to confirm abnormal signs. 1 Important Historical Data to Note 1. Gestational age 2. APGAR scores 3. Maternal and obstetrical history Important Data from Physical Examination 1. Head examination * Shape and size (percentile) ‘+ Sutures (closed, open, gaping) + Fontanel (size, bulging, depressed, full, tense, flat) 2. Skin lesions + Midiine dimpling, tracts, tufts of hair along the spinal area * Hyper- or hypopigmented skin lesions * Portwine stains * Hemangiomas and telangiectasias 3. Masses—encephalocoeles, tumors 4. Dysmorphisms and other congenital anomalies Neurobehavioral examination is used to detect subtle changes in the hours-old neonate. After delivery, there is a 1-hour periods of alertness followed by 3- to 4-hour period of deep sleep and decreased responsiveness. The Brazelton Neonatal Behavioral Assessment Scale is a comprehensive behavioral assessment of the term newborn, It assesses the basic reflex repertoire of the infant and focuses on motor system integration, state regulation, attention-interactive capacities, and reactivity; and consoling capacities as measured by cuddliness, peak of excitement, rapidity of build- up to crying, and irritability. It differs from other newborn assessments in its use of intervention by parents and medical staff, “EXAMINATION LEVEL OF ALERTNESS The assessment consists of observation, examination, and recording.‘Awake, fussing, and uncooperati Crying See x From Brazelton TB, Neanatal behavioral assessment scale. Ciines in developmental medicine, No. 50. London: SIMP: 1973, CRANIAL NERVE EXAMINATION 2) Olfactory (CN I) Neonates can discriminate odors manifested by changes in cardiac and respiratory rates and movement, but these are rarely tested. CN I is functional by 5-7 months of age. © Optic Nerve (CN II) Gross visual acuity testing + Visual fixation on the human face + Light perception (glare response), blinking with bright light + Pupillary response + Visual tracking may be present Funduscopy + The optic disc is normally light pink or pale gray. Check for retinal hemorrhages. © Oculomotor, Trochlear. Abducens Nerves (CW UN, WWI) + Eye movements may be disconjugate at birth. * Observe for spontaneous eye movements in all directions. + May do doll’s maneuver to check for conjugate eye movements. * Check for ptosis (CN III). + Pupillary size, reactivity, and symmetry (present in neonates > 32 weeks AOG) <2 Trigeminal Nerve (CN ¥) * Check facial sensation with the rooting reflex. = Check for corneal reflexes—their presence and symmetry. Chapter 7 * TheNewborn + 101 * Check for grimace or any movement, change in respiratory or cardiac rate with tactile stimulation over the forehead, cheeks, and mandibular area 2 Facial Nerve (CN Vil) * Check the symmetry of the face at rest and movement (during crying). * Check the size and symmetry of palpebral fissures, nasolabial folds, position of the corners ofthe mouth. 2 Vestibulocochlear Nerve (CN Vill) + Hearing is normally present in term babies. Neonates blink or are startled with loud noise. Glossopharyngeal, Vagus, Hypogiossal Nerves (CN IX.X.XIl) Considered intact if the following are normal and + Sucking - CN V, VII, XII + Swallowing ~ CN IX, X (Observe coordination) * Gag reflex - CN IX, X (Use small tongue blade covered with gauze) + Normal response is active contraction of the soft palate with upward movement of the uvula and ofthe posterior pharyngeal muscles. + Observe for tongue movement and loss of bulk - CN XI 2 Spinal Accessory Nerve (CN XI) ‘+ Testing cannot be done on sick neonates since it requires flexion and rotation of the head. + For term newborns, passive rotation of the head shows the bulk of the neck muscles. This examination is done when the baby is alert. Q Posture This provides valuable information. Normal term newborns have a flexor attitude which when coupled with spontaneous movement indicates good muscle tone and power. Preterms lie in an extension position.102 * Part2 + Pediatric Norms Q Tone Passive tone may be tested by determining the degree of resistance to passive movements of the joint in an awake infant (not crying). This test is done through a gentle flapping of the hands and feet. ‘Active tone is tested by observing the response to gentle pulling from supine to upright position. A hypotonic or floppy infant shows severe head lag. Respiratory rhythm and chest movements. should exhibit adequate contraction of the intercostal muscles. “Sucking in” or retractions of the intercostal muscles may indicate lower motor neuron disease. 1 Motor Strength Check spontaneous movements as well as movement against resistance. Note symmetry of movements as preferential movement may suggest hemiparesis. <2 Deep Tendon Reflexes ‘The examiner's index or middle fingers may be used instead of a hammer for small babies. Knee jerks and biceps reflexes are tested as in older infants and children. Ankle clonus (rapid rhythmic plantar flexion in response to ankle dorsiflexion) up to 10 beats is normal. Developmental reflexes are primitive reflexes that indicate integrity of the brainstem and spinal cord, Their disappearance indicates maturation of the cerebral hemispheres. Persistence beyond the ‘Adopted from Pe Benito R, Easy and practical pediatric neurology, 2008expected date suggests maturational lag or impaired central nervous system. Sensory Testing Sensory testing is of limited use and rarely needed in the newborn examination. Gross responses to stroking and pin prick are withdrawal, crying, arousal, facial grimace, and changes in sucking rates which may be used as behavioral cues. In general however, tests for pain and sensation are imprecise at this period. Aurea D. Matias Ag UD VA TO ‘As soon as the baby is born and assessed to be normal, the baby is placed skin-to-skin on the mother’s chest with the mother’s gown or an additional blanket covering both. This position is maintained to promote bonding and latching-on. Subsequent routine newborn care after 6 hours of life or after the 1st breastfeed involves the following steps: Remove blood and other maternal secretions on the skin by using mild soap and warm water. This procedure is done to minimize the risk of infection with potentially contaminating microorganisms such as hepatitis B, herpes simplex, and HIV. Apply 1% tetracycline eye ointment on both eyes as prophylaxis to prevent gonococcal ophthalmia neonatorum. Care should be taken to ensure that the agent reaches all parts of the conjunctival sac. The eyes should not be irrigated with saline or distilled water after application; after 1 minute, the excess ointment can be wiped away with sterile cotton. Inject aqueous vitamin Ki (phytomenadione) 1 mg IM to prevent vitamin K deficiency bleeding (hemorrhagic disease of the newborn). Give hepatitis B vaccine IM, preferably within 12 hours. Early hepatitis B immunization is recommended for all medically stable infants with birth weight greater than 2 kgs irrespective of maternal hepatitis B status. Chapter7 * The Newborn * 103 ‘Administer BCG vaccine intradermally on the right deltoid to prevent tuberculosis. For cord care, do not put anything on the stump and fold the diaper below it. Keep the cord stump loosely covered with clean clothes. If the stump is soiled, wash it with soap and clean water and dry thoroughly with a clean cloth. Bandaging the stump or abdomen is not recommended. Do not apply any substance or medicine on the stump and avoid ‘touching it. Feed the infant immediately with breastmilk, Provide support for initiation of breastfeeding within ‘90 minutes. Place the newborn on the mother’s chest in skin-to-skin contact. Observe the newborn, When the newborn shows feeding cues (e.g, opening of the mouth, licking, rooting), tell the mother to encourage her newborn to move toward the breast by nudging. Counsel the mother on positioning and attachment: + Make sure the newborn's neck is not flexed or twisted. + Make sure the newborn is facing the breast, with the newborn's nose opposite her nipple and chin touching the breast. + Hold the newborn's body close to her body ‘+ Support the newborn's whole body, not just the neck and shoulders. ; ‘+ Wait until the newborn's mouth is opened le. The baby should be roomed-in with the mother. Put the newborn on the bed or within easy reach. Keep the baby in skin-to-skin contact with the mother as much as possible. For bathing and hygiene, wipe the face, neck, and underarms with a damp cloth daily. Wash the perineum when soiled and dry thoroughly. Bathe when necessary. The room should be warm and draft-free and always use warm water. After bathing, dry the baby and dress him or her appropriately. Vital signs must be monitored at least once per shift. Daily weight should be taken. Input and output should also be recorded. 24 HOURS-DISCHARGE Physical examination should be repeated prior to discharge. Review recorded vital signs and re-assess during physical examination. Look for jaundice, other104 + Part2 » Pediatric Norms changes in color, and signs of local infection of the skin, eyes, and umbilicus. Check whether the urine output is adequate. There should be passage of ‘meconium stools. Observe a breastfeeding event and assess for difficulty in latching-on and positioning on to the breast. Evaluate efficiency of breastfeeding by observing the suckling and swallowing movements of the baby. Encourage the mother to assume a relaxed, comfortable breastfeeding position to avoid strain on the shoulders and back. The baby is ready for discharge when he or she is feeding and sleeping ‘well; normal body temperature is maintained; and other vital functions are evidently normal with no danger signs of infection. Hepatitis B Vaccine in the Newborn The Philippines is 1 of the Asian countries where hepatitis B virus (HBV) is considered endemic. As many as 8 million Filipinos are believed to be infected with the virus, most of them unaware and undiagnosed. The virus can be passed on by the mother to her baby during birth. This is the reason why hepatitis B vaccination is mandatory at birth. There is a 5%-10% risk of infection in utero with acute maternal HBV infection in the first and second trimesters. There is little risk to the newborn because antigenemia is cleared at term and the baby acquires anti-HBS. Vertical transmission occurs mainly during the perinatal or postpartum period. Acute infection during late pregnancy or near the time of delivery ‘may result in 50%-75% transmission rate. Hepatitis Bis a progressive disease, especially if acquired at birth. The main strategy in preventing neonatal HBV disease is immunoprophylaxis. Vaccination of all infants is also an important part of perinatal prevention, and it affords protection against postnatal exposure as well. This strategy effectively reduces the risk of chronic HBV infection with an overall protective efficiency rate in neonates exceeding 90%. Universal immunization of newborns is, therefore, one of the most important public health measures in disease control. The first dose of HB vaccine is given at birth, preferably within 12 hours of life. The vaccine is repeated between ages 1 and 6 months. All infants born to mothers who are positive for HBsAg should receive HB immunoglobulin (0.5 mL) in the first 12 hours of life in addition to the hepatitis B vaccine. Local adverse reactions include pain, swelling, and redness at site of injection. They are usually mild and self-limited. There are no known contraindications. 2 BCG Vaccine at Birth Bacillus Calmette-Guerin (BCG) vaccination is recommended for all Filipino infants at birth. BCG isa live attenuated vaccine against Mycobacterium tuberculosis, the causative agent of tuberculosis. It is transmitted through droplet infection and, ‘once inhaled, infects the lungs. Unfortunately in the Philippines where TB is common, BCG does not prevent the initial infection of the lungs, but it remains useful in preventing other forms of extrapulmonary TB such as TB meningitis. BCG is given intradermally on the right deltoid at birth and is not repeated. Adverse reactions include lymphadenopathy and BCG abcess. There are no known contraindications. © Philippine Health Insurance [PhilHealth) Newborn Package ‘This package consists of umbilical cord care, eye prophylaxis, administration of vitamin K, thermal care, BCG, first dose of hepatitis B vaccine, and Newborn Screening Test. Aurea D. Matias ROSAS TAPED IDES LIL Ay J] xewonx seneeune test Republic Act 9288, known as the Newborn Screening ‘Act of 2004, was enacted on April 7, 2004 with the goal that by year 2025, all Filipino newborns will be screened for common and life-threatening congenital metabolic disorders. Newborn screening is an essential test for heritable metabolic disorders that, if left untreated, may lead to mental retardation or even death.© Congenital Adrenal Hyperplasia Congenital adrenal hyperplasia (CAH) is a group of inherited disorders characterized by defects in genes encoding for enzymes, resulting in abnormal production of certain hormones by the adrenal glands. The most common deficient enzyme is 21-a-hydroxylase (90% of the cases). Abnormal genes are inherited from both parents (autosomal recessive inheritance). Congenital Hypothyroidism Congenital hypothyroidism (CH) is characterized by the absence or deficiency of thyroid hormones which may be caused by (1) defective development of the thyroid gland, (2) abnormal location of the thyroid gland (ectopic), (3) ingestion of medication (ant thyroid drugs or excessive iodine) by the mother during pregnancy, and (4) inherited deficiency of enzymes involved in the synthesis of thyroid hormone. Q Galactosemia Galactosemia (Gal) is a disorder of carbohydrate metabolism in which the body is unable to utilize the sugar galactose, leading to its accumulation in the body. This is due to defective genes that code for the enzyme involved in the breakdown of galactose, which are inherited from both parents (autosomal recessive inheritance). The most common enzyme that is deficient is galactose-1-phosphate uridyl transferase (GALT). Deficiency in the enzymes galactokinase and epimerase may also cause galactosemia. (1 Glucose-6-Phosphate Dehydrogenase Deficiency Glucose-6-phosphate dehydrogenase (G6PD) deficiency is an inherited disorder which may cause hemolytic anemia. This is due to defective genes located in the X chromosome that code for the enzyme G6PD (X-linked inheritance). Chapter 7 * TheNewborn + 105 2 Phenylketonuria Phenylketonuria (PKU) is an inherited disorder of amino acid metabolism characterized by high levels of phenylalanine in the blood or phenylketones in the urine. This is due to defective genes coding for the enzyme phenylalanine hydroxylase (PAH), which are inherited from both parents (autosomal recessive inheritance). PROCEDURE OF NEWBORN SCREENING Blood sample from a heel prick, placed on a standard filter card is sent to the Newborn Screening Center (NSC) laboratory for analysis. When the result is positive for congenital disorders, a confirmatory test must be done. NBS is done between 24-72 hours after birth or when the newborn has received milk feeding for at least 24 hours. Samples taken < 24 hours from birth require repeat screening at 2weeks of age. Sample collection done before the ideal time may result in: a, Falsely elevated thyroid-stimulating hormone (TSH) = false (+) screen for CH b. Falsely elevated 17 hydroxyprogesterone (170HF) = false (+) screen for CH c. Falsely low galactose and phenylalanine because of inadequate feeding = false (-) screen for GAL and PKU ‘The Hearing Loss Screening Act of 2007 or Senate Bill No. 1372 is “An act providing for the early detection, diagnosis, and intervention for congenital hearing oss among children in the Philippines and for other purposes” Its aim is to protect and promote the right to health of the people, including the rights of children to survival and full and healthy development into normal individuals by the institutionalization of the early detection, diagnosis, referral, and intervention of hearing loss among children 1 year old and below, to ensure that every baby born in the Philippines is afforded all the opportunities106 + Part2 + Pediatric Norms to be productive members of the family and the community. The policy statement of the Philippine Pediatric Society, Inc. reiterates that “physicians should recommend neonatal hearing screening for all infants, whether high risk or non-high risk” All babies born in public hospitals in the Philippines are to be screened for hearing loss before leaving the hospital, provided that a parent ora legal guardian submits a written consent prior to the performance of the procedure. Hearing loss screening is a procedure that can be performed after 24 hours of life but not later than 6 months. Newborns in the NICU may be exempted from the 3-day requirement but must be tested by 7 days of age. + Afamily history of sensorineural hearing loss + TORCHS infection (toxoplasmosis, other infections, rubella, cytomegalovirus, herpes simplex, syphilis) + Craniofacial anomalies + Birth weight of less than 1,500 grams + Hyperbilirubinemia necessitating exchange transfusion * Ototoxic medications including chemotherapy + Bacterial meningitis + One-minute Apgar score of 0-4 ‘+ Five-minute Apgar score of 0-6 ‘+ Mechanical ventilation for 2 5 days + Neurodegenerative disorders + Syndromes known to include hearing loss + Trauma TYPES OF SCREENING TESTS _ 1 Auditory Brainstem Response Auditory brainstem response (ABR) measures evoked electrical signals which are detected by surface electrodes from within the hearing pathways of the brain in response to sounds at predetermined frequencies and loudness. ABR tests the whole auditory pathway rather than just the cochlea and is more valuable in screening high-risk babies particularly those from the NICU who are more at risk for developing retrocochlear hearing impairment {auditory neuropathy). Itis able to localize the site of lesion and also estimate the degree of hearing loss by ‘measuring electrophysiologic response to stimulus presentation. Otoacoustic Emission Test Otoacoustic emission (OAE) is defined as acoustic energy generated by the cochlea in response to auditory stimuli which travels through the middle ear and back to the ear canal where it can be measured with a microphone. OAE detects the physiological response of outer hair cells within the cochlea which are present in 98% of babies with normal hearing. Sensory hearing impairment is due to abnormal function of outer hair cells. This makes OAE a very sensitive and accurate test for auditory impairment. HEARING LOSS 2 Forms of Hearing Impairment Sensorineural loss. Any abnormality or damage to the cochlea or brainstem nuclei causes “nerve” deafness. Conductive loss. Abnormalities of the external auditory meatus, tympanic membrane, or the ossicles within the middle ear cause conductive hearing loss. 1 Follow-up of Patients with Hearing Loss Infants at risk should be tested prior to discharge and those with abnormal screening ABR or OAE in both ears should have follow-up testing within 2 weeks. Patients with unilateral abnormal results should have follow-up testing within 3 months.Infants with risk factors for progressive or delayed onset sensorineural and/or conductive hearing loss require continued surveillance even if the initial newborn hearing screen results are normal. They should have audiologic testing performed at least every 6 months for the first 3 vyears of age. Aurea D. Matias OMAR et La UCU VAC A Neonatal mortality accounts for more than 60% of infant mortality. The first day of life has the highest risk for death and accounts for 40% of neonatal mortality. The Department of Health prescribes EINC and health facility-based delivery for all pregnancies as interventions to address this problem. The mother-baby dyad is encouraged to go home together as soon as both are stable. The Philippine Society of Newborn Medicine and the Philippine Pediatrie Society recommend a minimum stay of 24 hours postpartum, After passing this critical period, the newborn infant remains at risk because 80% of neonatal deaths occur in the first 3 days of life and only a very small percentage happens after the first week of life-Therefore, reliable discharge criteria, discharge instructions, and good follow-up care post- discharge in the first 7-28 days of life are essential to save a newborn's life. The Philippine Society of Newborn Medicine and the Philippine Pediatric Society recommend the following discharge criteria for newborns: 1. Normal vital signs and physical examination 2. Ability to suckle on the breast effectively with satisfaction after each breastfeeding. In the rare event that the mother cannot breastfeed, the ability to feed by another method must be demonstrated. Chapter 7 * TheNewborn + 107 3. Documented urine and stool output 4. Completion of neonatal screening tests. If these were not done prior to discharge, there should be clear instructions as to where and when the tests will be done. 5. Complete anthropometric measurements 6. Demonstration of maternal (or surrogate's) ability to care for her neonate DISCHARGE INSTRUCTIONS Ideally, instructions in the care of the newborn at home is explained to the parents in their preferred language or dialect. Requesting them to repeat the instructions is a helpful way of ensuring comprehension. Parents must be encouraged to ask questions and must be provided with simple and clear answers. Discharge instructions must cover the following: 1. Hygienic care of the infant 2. Monitoring feeding, urination, and bowel movements 3. Sleep and a 4, Follow-up visits 5. Jaundice and other changes in skin color 6. Danger signs that require immediate medical consultation 7. Routine and emergency contact number(s) and place(s) ity patterns 2 Hygienic Care of Infant. ‘Hand hygiene Infants must not be exposed to anyone who is ill, no matter how minor the illness is. Exposure to people must be kept to a minimum. Proper hand hygiene protects the infant from potential pathogens and infections. Persons handling the infant must remove their hand jewelries (rings, watches, bracelets, etc.) and wash hands following the WHO hand-washing protocol before touching the baby (washing hands with soap and water, rinsing well, and drying thoroughly with clean, single-use towel). Alternatively, 3-5 mL of alcohol hand rub/ sanitizers to clean all hand surfaces including the areas between the fingers and under the nails may be used. Recommended is washing off with soap and