Neonatology Redirected from Pediatrics/Neonatology

    History/Physical

    APGAR Score

    • Done at 1min and 5min
    Criteria 0 pt 1 pt 2 pt
    Appearance blue/pale acrocyanosis body/extremities pink
    Pulse None <100 >100
    Grimce no response to stim feeble cry to stim cry or pull away from stim
    Activity No Tone Some Flexion Flexed arms+legs
    Respiration None Weak/Gasping Spont. Breaths

     

     History

  • Pregnancy History
  • Delivery
    • Birth weight (2500g 5lb 8oz to 4000g 8lb 13oz)
    • circ HC (mean 35cm), Length (mean 50cm)
    • GA
  • Neonatal
    • if jaundice -- repeat bili
    • discharge wt
    • if >10% birth wt, in 2 weeks regain wt
  • Now:
    • Poop - BM 1-4, Urinating ~5x/day
      • Black tarry (Meconium) to greenish, yellowish color
    • Pee ~5x/day
    • Feed - Feed on demand, q2h
    • Sleep on back.
  • Mother:
    • Breasts? Latching? Feeding?
    • Moods?
     

    Physical Exam

    • General appearance, Active, Alert, Non-toxic - resp distress. Cyanosis? acrocyanosis?
    • Heart (S1, S2, no murmurs no S3/4)
    • Lungs (GBAE, no adv sounds - no transmitted upper airway sounds)
    • Fontanelle? (Size? flat? soft?)
    • Face:
      • Facial deformities?
        • Ears not below line of the lateral eye canthas  (low set) 
        • Cleft lip, etc..
      • Eyes - (Red Reflex)
      • Root and Suck reflex + Check soft+hard palate clefts.
    • Tone (lift by arms, to check tone) - check clavicle for fracture
    • Abdo (Check for HSM, palpate liver and spleen, masses?)
      ------------Undo Diaper------------
    • Pulses (Brachial, Femoral)
    • Penis (Patent)
    • Testicles (Descended, no hydrocele)
      ------------Turn over ----------------
    • Check for spinal alignment.
    • Check for NTD (Hair, Dimpling)
    • Check Anus patency
    • Neurologic

     

    Reflexes

    • Galant - stroke back approx 1cm from midline with baby held prone, trunk curves towards stroked side.
    • Placing - Baby upright, trouch top of foot to table edge, child mimics walking.
    • Rooting - Stroke cheeck, head turns to same side.
    • Palmer/Plantar grasp - place finger into palm or sole of foot - fingers/toes curl.
    • Moro - startle baby with loud noise or suddenly lower supine baby, arms extend/abduct & hand open with extended fingers then arms - ensure symmetrical (otherwise consider early CP - presents ~3mo)
    • Asymmetric Tonic Neck- Turn head to one side, arm/leg on that side extend, flex on opposite side (fencing position).

    Neonatal Jaundice

    DDx

    • Unconjugated
      • Physiologic
        • Breast feeding jaundice - breast milk - dehydration
        • Bresast milk jaundice - some metaloproteinase inhibits glycosyl transferase, preventing conjugation (Usually persistent jaundice).
      • Hemolytic  (See Hemolytic Anemia Section)
    1. Intristic to RBC
      • Cell membrane: spherocytosis, elliptocytosis
      • Enzyme Defects: G6PD (mediterranean, Middle Eastern, African, SE Asia), PKD
      • Hemoglobinopathies: Alpha thalassemia.
    2. Extrinsic to RBC
      • ABO or Rh incompatibility
      • Fragmentation
    • Non-Hemolytic
      • Cephalohematoma, excessive bruising
      • Gilbert- decreased production of glucuronyl transferase. (Cannot conjugate bilirubin)
      • Crigler Najjar (Abnormal glucuronyl transferase)
      • Sepsis
      • Hypothyroidism
    • Conjugated
      • Anatomical
        • Biliary Atresia (Abdo U/S, HIDA scan[IV radioactive tracer], liver bx)
        • Choledochal cysts (Japan, China, East asia)
      • Infections
        • Sepsis
        • Viral, (Hep A/B, EBV, HSV), TORCH, UTI
      • Metabolic/Endocrine
        • Galactosemia [Lactose --> glucose+galactose, galactose-1-ph not broken down - hepato/nephrotoxic]
        • Alpha-1-anti-trypsin deficiency {A1AT buildup in lungs + liver}
        • Alagille Disease (dysmorphic)
        • Hypothyroidism
      • Other
        • NICU - long-term TPN
        • Idiopathic neonatal hepatitis

    Assessment

    • Likely pathologic (non-breast milk) if:
      • Jaundice <24hrs of age
      • Serum unconjugated bili rises too fast (check chart)
      • Jaundice persists >1-2 weeks.
      • Conjugated Hyperbilirubinemia.
    • Investigations
      • Baby & Mom blood group
      • DAT (coombs) if mother is group O
      • CBC, differential, smear, retic count
      • Conj vs Unconj. bili (direct vs. indirect) - direct bilirubin is considered normal if <10% of total bilirubin
        • bilirubin should be very low  (~20) after 2 weeks of life, if not considered persistent (check causes)
      • G6PD (if risk such as SE Asia)
      • Blood culture, urine culture if concerned sepsis.
    • Management
      • Use Nomogram to determine adequate follow-up.

    Jaundice Nomogram.png

     

    HyperbiliNeonateGraph.png

     

    • Complications:
      • Kernicterus: Mental retardation, dental abnormalities, chorea-athetoid movements, sensorineural hearing loss, upward gaze palsy, hypotonic initally, hypertonic with time, cerebral palsy.

    Weights

  • Birth Weight

     

    • Traditionally 2500-4500g (small for gestational age vs. large for gestational age)
    • Large for Gestational Age (LGA): usually due to hyperglycemic mother (Diabetes).
      • Neonate at risk for hypoglycemia because mother is hyperglycemic, glucose transfers to fetus.  Fetus produces insulin to reduce blood glucose.  Once born, no more glucose intake, but insulin still high => hypoglycemia.  Needs to go on a hypoglycemia protocol
    • Smal for Gestational Age (SGA):
    • Should double their birth weight by 5mo and triple by 12mo. (double birth length by 4yrs)

     

    Other Measurements at Birth

    • Head Circ: Mean 35cm
    • Length: Mean 50cm
    • (Remember: 35 and 50)

     

    Feeding / Weight Gain

    • Babies should be gaining:   (if <3 months)
      • Ideally: 30-50 g/day
      • 20-30 is tolerable, raises eyebrow
      • <20: Concerned, bring them back sooner.
      • When in doubt, check the growth chart
    • If not gaining weight inquire about:
      • Breast feeding
        • ~30min/breast
        • q2-3hours during day
        • q3-4hours during night. (wake them if baby not waking up to feed)
      • If feeding schedule ok, suggest:
        • If not enough milk: breast pump in between feeds and supplementing with own breast milk.
          • Mother often needs help... can give baby to father, and can pump between feeds.
        • Poor latching.
          • Try finger feeding (use feeding tube connected to a cyringe without plunger).  Attach feeding tube to finger with tape, and let baby suck on finger and get milk.  Start with cyringe elevated above baby, so gravity helps.  Eventually lower slowly below level of baby, so that the baby has to suck against gravity to get milk.

    Preterm Issues

    • High risk for:
      • Osteopenia of prematurity (mother's breast milk must be fortified)
        • Must track ALP, Ca, Phosphate
        • Initially within 8days, milk high in protein, should not supplement due to kidney overload.
        • Day 8 milk we fortify w/ protein, calcium, etc... (1:12 dose)
        • Later on <Not sure age> can switch to 1:25
      • Anemia of prematurity - check CBC in premature infants.
      • ...

     

    Respiratory Distress

    • three most common types:
      • TTN - Transient Tachypnea of newborn
        • Persistent lung fluid, usually resolves, often no/little hypoxia or cyanosis
        • Supportive care, oxygen if hypoxic.
      • RDS - Respiratory Distress Syndrome
        • Not enough surfactin (surfactant) - gives surfactin via mask.
        • Can help by giving celestone (i.e. betamethasone) prior to delivery (if GA 28-34).
        • Once born, no role for steroids because there is already a huge drive to produce surfactin.
      • MAS - Meconium Aspiration Syndrome
        • Do not stimulate baby when born because it's better for them not to breathe - high risk of aspiration, unless already crying/breathing/vigorous.
        • If they are non-vigorous.  Need to intubate, and suction the airway through endotracheal tube.

     

    • Caffeine to support respiration
      • Used in <34 weeks and is effective in stimulating respiration.
      • Interesting story:
        • Caffeine has been traditionally used to stimulate respiration, but some animal studies show it leads to decreased neurocognitive development.
        • International Study called CAP (Caffeine for Apnea of Prematurity) performed randomized trial ~1500 newborns caffeine vs. placebo.  Doctor prescribes caffeine, which is then randomized

    Fever Neonatal

     

  • neonatalFever.gif

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