Newborn Appraisal Benita

APPRAISAL OF NEWBORN BY: Benita David

Objectives: • To detect congenital anomalies which are not identified at birth. (e.g. congenital heart disease, DDH etc) • To determine any wide range of acute neonatal problems

• To check for problems arising due to maternal diseases, familial disorders or problems present during pregnancy

 Give opportunity to the parents to discuss regarding their neonate.  To initiate health promotion of the newborn.

Introduction: • Conducting a thorough neonatal assessment is necessary to ensure that the new born transitions appropriately to extra-uterine life. Skilled observation should begin at the time of birth and continue frequently during the first 24 hours. Nurses should be aware of the normal features of the transition period in order to detect disorders in adaptation soon after birth. The new born assessment provides much needed information concerning the state of health of the transitioning new born as well as a basis with which to formulate further care.

Time for examination  Immediately after birth  Within 24hrs of birth

 Daily during hospital stay  At discharge

 On follow up  During episodes of illness

Minimum pre-requisites Mother and baby together Warm room, fresh clean sheets/ clothes Thermometer Infantometer Watch with seconds Stethescope Measuring tape Chart for documentation

Point to be considered Examine the baby in the presence of parents if possible. Ensure adequate warmth and lighting. Prevent cross infection by implementing standard precaution.

Significant history for neonatal assessment  The mother’s medical and obstetrical history  Risk factors: • Intrapartum temp ≥ 100°F • Membrane rupture ≥18hrs • Delivery ˂ 37 weeks of gestation

• Chorioamnitis • Sustained fetal tachycardia

Events around delivery:  Duration of labor  Mode of delivery  Newborn’s condition at delivery  Need of resuscitation

Assessment of newborn I.

Apgar scoring

II. Anthropometric measurement

III. Vital signs IV. Assessment of gestational age

V. Head to toe examination VI. Neonatal reflexes

APGAR SCORE

Anthropometric Measurements:

Head circumference: • 33-35cms

Chest Circumference: • 2 cm less than head circumference

Weight : • Average weight- 2.5 kg • Second born children weight more than the first born • Exceeding 4.7 kg is unusual • 5-10% weight loss in the first few days • 75-90% weight is due to fluid • 2lb/month during 1st 6 months

Length: • Average birth length of a mature female neonate is 53cm and that of male neonate is 54cm.

• The lower limit of normal length is 46cm.

VITAL SIGNS

• Normal Vital signs-

• Temp 97.7-99.5 F Axillary( 37.2 C) Temperature falls immediately with heat loss and immature temperature regulating system

• Apical Pulse 120-140 beats/min- may raise to 160 bpm as infant struggles to initiate respiration.( apical-1 full min). • Respirations 30-60 breaths/min.( Initially 80 breaths/min), (short periods of

apnoea and irregularities in rate rhythm and depth when the child is at rest are normal)

convection

Radiation

Evaporation Conduction

Blood pressure: • The blood pressure of a new born is approx. 80/46 mm/Hg at birth. By the 10th day, it rises to about 100/50mm/Hg.

• Blood pressure is not routinely measured unless a cardiac anomaly is suspected.

Head to toe examination

Posture: Extremities Flexed And Fists Clutched

Skin: •

Velvety smooth and puffy esp. at the legs, dorsal aspects of hands & feet and in the scrotum or labia • Pinkish red (light skinned) to pinkish brown to yellow (dark skinned) • “Ruddy” or reddish due to increased RBC concentration and decreased subQ tissues

Skin Color • • • •

Cyanosis/ Acrocyanosis Pallor Jaundice Meconium Staining

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Acrocynosis- Bluish Purple Discolouration of hands and feet (Normal in first 24-48 hours after birth)

Acrocyanosis • Bluish discoloration of palms of hands & soles of feet • Due to immature peripheral circulation • Exacerbated by cold temperatures • Normal within 1st 24 hrs 051104

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Central Cyanosis: Temporary Respiratory Obstruction

HyperbilirubinemiaPhysiological Jaundice, occurs on the 2nd or 3rd day of life in about 50% of all newborn

Jaundice • Under natural light • Blanch skin over the chest or tip of the nose

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•

Physiologic – FT: after the 1st 24 hrs (2-7 days) – PT:after the 1st 48 hrs – Peaks at 5-7 days & disappears by the 2nd week – Due to immaturity of liver – Usually found over the face, upper body and conjunctiva of eyes

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• Pathologic – Within 1st 24 hrs – May indicate early hemolysis of RBC or underlying disease process – Duration: • FT: 1 wk • PT: 2 wks

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Pallor: • Gray colour: Indicative of infection • CNS Damage may cause pallor as well as cyanosis

Pallor/ Cyanosis • May indicate hypothermia, infection, anemia, hypoglycemia, cardiac, respiratory or neurological problems

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Meconium Staining • Over the skin, fingernails & umbilical cord • Due to passage of meconium in utero r/t fetal hypoxia

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Harlequin Sign: Due Immature circulation

Harlequin Sign • When on side, dependent side turns red and upper side/ half turns pale • Due to gravity and vasomotor instability or immature circulation • Skin resembles a CLOWN’S SUIT 051104

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Vernix caseosa:

Vernix caseosa: • Protective cheesy-like, gray-white fatty substance • FT: skin folds under the arms and in the groin under the scrotum or in the labia • Nursing Considerations: – Use baby oil – DO NOT attempt to remove vigorously

Lanugo: • Fine downy hair over shoulders, back and upper arms. • Post mature infants rarely have lanugo • Disappears by the age of 2 weeks

Nursing Considerations: • More mature, less lanugo • May disappear within 2 weeks • Preterm: woolly patches of lanugo on skin and head • Post term: parchment-like skin w/o lanugo

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Desquamation: • Peeling of the skin that occurs within 2-4 weeks of life because of pressure and erosion of sheets.

Milia: • Pin point white sebeceous papule found on the cheek or across the bridge of the nose, disappears by 2-4 weeks of age, as the sebeceous glands mature and drain.

Birthmarks

Mongolian Spots • Blue-green or gray pigmentation • Lower back, sacrum & buttocks • Disappears by 4 years of age

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Salmon Patches • Seen commonly in NB • More on Caucasian • Naevus simplex, "angel kisses" (when on the forehead or eyelids), and "stork bites" (over the nape of the neck) • midline malformations consisting of ectatic capillaries in the upper dermis with normal overlying skin. 051104

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Mottling • Cutis marmorata • reticulated pattern of constricted capillaries and venules due to vasomotor instability in immature infants • Bluish mottling or marbling of skin in response to chilling, stress or overstimulation 051104

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Petechiae • Pinpoint hemorrhages on skin • Due to increased vascular pressure, infection or thrombocytopenia • Within 48 hrs 051104

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Ecchymosis • Bruises • As a result of rupture of blood vessels • May appear over the presenting part as a result of trauma during delivery • May also indicate infection or bleeding problems 051104

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Erythema Toxicum: It is a rash seen in normal mature infants, usually appears in 1-4th day of life but may appear upto 2 weeks of age.

•HEAD

What to assess • For symmetry, shape, swelling, movement –Soft, pliable, moves easily –With some molding round & wellshaped Measure HC; HC = or > CC 051104

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Head: Anterior Fontanelle:

• Soft spot, is diamond-shaped and demarcated by the coronal and sagittal sutures. • Its anteroposterior measurement is approximately 4–5 cm, and it can be palpated midline, above the forehead .The anterior fontanelle normally closes by 18 months of age.

Posterior Fontanelle: • The posterior fontanelle can be palpated midline, toward the back of the head, above the occiput. • It is triangular in shape and demarcated by the sagittal and lambdoidal sutures. • Its posterolateral measurement is approximately 0.5–2 cm. • The posterior fontanelle normally closes by 2 months of age; it is possible for a newborn to be born with a posterior fontanelle already closed.

Sunken fontanelle: • A sunken fontanelle presents as a concave area that feels spongy but depressed. • Sunken fontanelles are associated with dehydration and decreased ICP. • Decreased peripheral perfusion, poor skin turgor, and sunken eyes may also be present.

Sutures: • Overriding sutures are a normal finding resulting from birth trauma and molding and usually resolve spontaneously. • There are four suture lines that can be palpated: the frontal, coronal, sagittal, and lambdoid sutures.

Caput Succedaneum: • Caput succedaneum is the formation of edema of the scalp at the presenting part of the head. • It has a generally symmetrical appearance and crosses the suture lines, will gradually be absorbed and disappear about 3rd day of life. It needs no treatment.

Cephalohematoma: • Cephalohematoma, a collection of blood beneath the periosteum, may also occur as a result of increased force to the newborn's head during vaginal birth. • It has a generally asymmetrical appearance and does not cross suture lines. • It may look like a large "goose egg." It is blueblack because of the presence of coagulated blood.

Craniotabes: • It is a localized softening of then cranial bones caused by pressure of fetal skull against the mothers pelvic bone in utero.

Craniosynostosis • Premature closure of the fontanelles

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Forcep Marks • U –shaped bruising usually on the cheeks after forcep delivery

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Face/Eyes/Ears/ Nose /Mouth

What to Assess • Facial movement & symmetry • Symmetry, size, shape and spacing of eyes, nose and ears

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Eyes: • Newborn’s usually cry tearlessly because the lacrimal ducts are not fully mature until about 3 months of age. • Infants eye assume their permanent colour between 3-12 months of age. Gray in color • Eyes should be clear without redness and purulent discharges. • Edema is often present around the orbit or eyelids (2-3 days) • Pupil: React to light • A white pupil suggests of congenital cataract. • Blinking reflex is present in response to touch • Can not follow an object (Rudimentary fixation on objects).

Normal Eye:

Eyelid edema:

Dysconjugate Eye Movements

Sub Conjunctival Haemorrhage

Congenital glaucoma:

Congenital Cataracts

Ears: • Position Startle Reflex Pinna flexible, cartilage present. • Low set ears indicate chromosomal anomalies.

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Congenital preauricular sinus: ends blindly risk for infection

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Ear Tag

Nose:

• A small amount of clear or white discharge from the nose may be noted as a normal finding in the newborn. However, copious or discolored nasal discharge may be a sign of congenital syphilis or respiratory problems.

Dislocated/ Deviated Nasal Septum

Mouth: • Intact, high arched palate. - Sucking reflex – strong and coordinated - Rooting reflex - Gag reflex - Minimal salivation • Crying- Look for any Cranial nerve injury • Epstein pearls- glistening well circumcised cysts present on the palate as a result of temporary accumulation of epithelial cells. • Mucus that seems to be blowing bubbles is suggestive of TEF • Natal Teeth is unusual- Extraction has to be done if they are loose

Natal Teeth

Irregular Edges With Natal Teeth

Cleft Palate:

Cleft Lip:

Cheeks: • Have a chubby appearance due to development of fatty sucking pads that help to create negative pressure inside the mouth which facilitates sucking.

Epstein Pearls

Tongue Tie

Ankyloglossia -Short Frenulum ("Tongue Tie")

• Small mouth or large tongue = chromosomal problems • (+) white patches on tongue or side of the cheek = Oral thrush

Neck: • Shorter and more flexible than that of an adult or child. • Exhibit creasing and skinfolds on the neck. • Generally not capable of supporting their heads at birth and will experience head lag when they are moved to a sitting position from a lying one. • Assess lymph nodes and monitor for webbing and any masses. Webbing of the neck, generally noticed from the back of the neck, may be indicative of chromosomal abnormalities

Neck

• Trachea midline • Thyroid gland not palpable • Intact clavicle

Chest: • Assessment of the infant's breasts should include size, shape, and nipple formation, placement, and number. • Breast bud size is an important indicator of gestational age. Some infants are born with supernumerary nipples, usually located vertically, below the normal nipple. These are very rarely associated with any adverse effects or conditions.

• Gynecomastia is common in either gender and may be noted as late as the second or third day of life. It is caused by high levels of maternal estrogen that have passed through the placenta and should resolve spontaneously.

Neonatal gynecomastia is often accompanied by galactorrhea, also called pseudomenses milk or "witch's milk". In infants with galactorrhea, the discharge is usually bilateral.

Chest Retractions Slight substernal retraction evident during inspiration, which needs to be tackled.

Xiphesternal process evident:

Contd…. • Respiration is chiefly abdominal-chest is ‘Bell-shaped’ at birth. Cough reflex is absent at birth, present by 1-2 days postnatal. Possible signs of RDS are: - Cyanosis other than hands & feet. - Flaring of nostrils. -Intercostal retractions. - Expiratory grunt-heard with or without stethoscope. • A high crowing sound on inspiration suggests stridor or immature tracheal development.

Cardiovascular Examination: • Heart murmurs are very common in newborns as their cardiopulmonary systems adjust to extrauterine life. These benign murmurs in newborns are usually transient in nature and caused by the foramen ovale not being closed completely. Murmurs are usually benign and not necessarily indicative of heart disease. They generally resolve spontaneously. •.

• CHD-Feeding difficulties are often a first sign, and they may be evident as early as 6 to 12 hours prior to symptoms of heart failure. Because feeding difficulty may be attributed to many different causes, it should exceed 30 minutes and be accompanied by tachypnea, sweating, and subcostal retraction to be considered related to a CHD or heart failure. • Assess for capillary refill time

Abdomen: • Cylindrical shape and protruberant. • The umbilical stump initially is white and gelatinous in appearance and begins to dry within the first few hours. • The umbilical stump should be inspected for the presence of two umbilical arteries and one vein. • They make the appearance of a "smiley face," as the musculature in the arteries makes them appear round, like the eyes of a face, and the vein tends to collapse due to lack of musculature.

Normal shape .

Normal Cord

Meconium stained umbilical cord

Abdomen contd… • A scaphoid or sunken appearance may indicate missing abdominal contents or diaphragmatic hernia. • Inspect cord clamp to be certain it is secure. It begins to dry in 1st hr, turns black by 2-3days. It falls by 6-10days. • The base of the cord should appear dry. • Bowel sound should be present within an hour after birth. • Bruits heard on auscultation may reveal AV fistula, renal artery stenosis.

Abdomen… • Palpate and percuss beginning below the umbilicus and proceeding upward. The abdomen should feel soft. • Infants may draw their legs up or cry if in pain during palpation of the abdomen. The liver is palpable 1–3 cm below the right costal margin. • The kidneys are moderately firm and lobulated. The bladder can be assessed for distension by palpating for a firm dome shape midline, in the lower portion of the abdomen

• GIT: – Capacity: 90 ml, with rapid intestinal peristalsis ( 2 ½ to 3 hrs) – Bowels sounds; (+) within 1-2 hrs after birth – Presence of mass, distention depression or protrusion – (+) Scaphoid = diaphragmatic hernia – (+) Distended = LGIT obstruction/ mass

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GenitoUrinary System • Observe for colour, odour, frequency, and amount of void. • Failure to void with in the first 24 hours is considered a

warning sign and warrants further evaluation. • The normal urine output for an infant is at least 1–2

cc/kg/hr. Output may be as high as 4 cc/kg/hr in the first few days of life.

Female Genitalia: • Labia & Clitoris are usually edematous. • Vulva may be swollen. • Blood tinged mucous vaginal secretions.This is due to the action of the maternal hormones.

Pseudomenstruation or Infantile Menstruation

• Anus – Check patency – First stool (Meconium) – within 1st 24 hrs • Sticky, tarlike, blackish-green, odorless material

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Transitional Stool • Within 2- 10 days after birth • Breastfed: – golden yellow, mushy, more frequent 3-4x and sweet smelling

• Bottlefed: – Pale yello, firm, less frequent 2-3x, with more noticeable odor

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Nursing Considerations • Breastfeeding can usually begin immediately after birth • Bottlefeeding may be started with sterile water to 4 hrs after birth prior to formula feeding • Burp during and after feeding • Position properly during and after feeding

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Male Genitalia: • Urethral opening is at tip of glans pens. • Testes are palpable in each scrotum. • Scrotum is usually pigmented, pendulous & rugaeted • Penis is about 2 cm long if less should be referred to endocrinologist. • Inspect for epispadiasis and hypospadiasis

Extremities: • The Arms And Hands Should Be Evaluated For Symmetry, Webbing,( Syndactly Or Polydactly), Signs Of DDH, Range Of Motion, And The Number Of Digits. • Fingernails Are Generally Long And In Need Of Trimming In The Term New Born. • The Palms Should Be Examined For The Presence Of A Simian Crease, Which Is A Single Palmar Crease That Extends All The Way Across The Hand. A Simian Line Is Associated With Down Syndrome.

• (+) Creases on soles of feet – (-) Creases = prematurity

• Check for hip fractures or dysplasia – (+) Ortolani’s click & uneven gluteal folds = Hip dysplasia

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• (+) inward turning of the foot = club foot or talipes equinovarus

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• (+) extra digits = Polydactyly • (+) web fingers = Syndactyly

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Legs: • The new born's legs should be assessed for flexion, symmetry, and length. • In some cases, the uterine position can make an infant's foot appear clubbed, such as in the case of metatarsus adductus. • In cases of true club foot, both the foot and the ankle are turned inward and offer resistance.

Back and spine: • The spine of a new born typically appears flat in the lumbar and sacral areas. • The curves appear only when the child is able to sit and walk • The base of the spine should be inspected carefully to sure there is no pin point opening or dimpling on the skin, which would suggest a spinabifida. • Gluteal folds should also be symmetrical and may have small dimples within the gluteal crease

Spinal bifida

Mongolian spots: • Greenish-Black coloration on the lower back, buttocks, anterior trunk, & around the wrist or ankle. • They are not bruise marks or a sign of mental retardation, they usually disappear during preschool years without any treatment.

• (+) Creases on soles of feet – (-) Creases = prematurity

• Check for hip fractures or dysplasia – (+) Ortolani’s click & uneven gluteal folds = Hip dysplasia

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• (+) inward turning of the foot = club foot or talipes equinovarus

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• (+) extra digits = Polydactyly • (+) web fingers = Syndactyly

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ASSESSMENT OF GESTATIONAL AGE

Neuromuscular maturity

Physical maturity

Maturity rating

Physical maturity

19 051104

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Neuromuscular Maturity

17 051104

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Scoring

19+17=36

36

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Reflexes

Reflexes in newborn

New Ballard Score, expanded to include extremely premature infants. •

The Ballard Maturational Score was refined and expanded to achieve greater accuracy and to include extremely premature neonates. To test validity, accuracy, interrater reliability, and optimal postnatal age at examination, the resulting New Ballard Score (NBS) was assessed for 578 newly born infants and the results were analyzed. Gestational ages ranged from 20 to 44 weeks and postnatal ages at examination ranged from birth to 96 hours. In 530 infants, gestational age by last menstrual period was confirmed by agreement within 2 weeks with gestational age by prenatal ultrasonography (C-GLMP). For these infants, correlation between gestational age by NBS and C-GLMP was 0.97. Mean differences between gestational age by NBS and CGLMP were 0.32 +/- 1.58 weeks and 0.15 +/- 1.46 weeks among the extremely premature infants (less than 26 weeks) and among the total population, respectively. Correlations between the individual criteria and C-GLMP ranged from 0.72 to 0.82. Interrater reliability of NBS, as determined by correlation between raters who rated the same subgroup of infants, ws 0.95. For infants less than 26 weeks of gestational age, the greatest validity (97% within 2 weeks of C-GLMP) was seen when the examination was performed before 12 hours of postnatal age. For infants at least 26 weeks of gestational age, percentages of agreement with C-GLMP remained constant, averaging 92% for all postnatal age categories up to 96 hours. The NBS is a valid and accurate gestational assessment tool for extremely premature infants and remains valid for the entire newborn infant population.

1.A method of transmission of heat by circulation of warmed molecules of liquid or a gas? • Evaporation • Conduction • Convection • Radiation

2.Head circumference of a new born in cms • 33-34 • 31-32 • 33-35 • 35-40

3.Which is the principle of heat loss here?

4.Harlequin sign is due to an infection • True • False

5. Retractions are inward movement of the chest • True • False

6.Which the method of thermoregulation?

7. Infantometer is used to check • Weight • length • Chest circumference • Head circumference

8.Which is the principle of thermoregulation ?

9. Witch’s Milk is due to withdrawal of maternal Estrogen Progestron Testosterone Growth hormone

10.Which is the principle of thermoregulation?

Congratulations……

Conclusion:

“Eyes sees what mind

Knows”