Pediatrics - Newborn Infant

Front 1

Newborn or neonate ages

Back 1

Birth to 28 days

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Infant ages

Back 2

Under the age of 1

Front 3

Term infant gestation length

Back 3

37-42 weeks

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Preterm infant gestation length

Back 4

Less than 37 weeks

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Postterm infant gestation length

Back 5

More than 42 weeks

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Macrosomia

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Abnormally large size of the body of the neonate.

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Normal birth weight

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2500 g or more, about 5.2 lbs

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Low birth weight

Back 8

Less than 2500 g

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Very low birth weight

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Less than 1500 g

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Gestational age

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Age of the fetus or newborn based upon the completed weeks from the date of the mother's last menstrual period (LMP).

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What percentile is considered small or large for gestational age?

Back 11

Weight, length or head circumference:
Small - less than 10% percentile
Large - more than 90% percentile

Front 12

What is an APGAR score?

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Scoring system comprised of five elements (Appearance, Pulse, Grimace, Activity, Respiration) that serves as a rapid method of assessing the clinical status of an infant immediately after birth.

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Prophylactic erythromycin

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Applied to eyes within one hour of birth to prevent gonococcal ophthalmia.

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Vitamin K

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Administered within 4 hours, 1 mg IM or SQ to prevent hemorrhagic disease.

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Hepatitis B vaccine

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Administered to newborn before 12 hours of age.

If mother is Hep B positive, Hep B vaccine and Hep B immune globulin are both administered.

Front 16

When should newborn screenings be performed?

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At 24-28 hours after birth.

Front 17

How often should a newborn be bathed?

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Three times weekly is sufficient.

Front 18

How should one care for an umbilical stump?

Back 18

Keep clean and dry until it shrivels and falls off, usually within 1-2 weeks of birth. Sponge baths only until then.

Front 19

Omphalitis

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Umbilical stump infection includes foul-smelling, yellowish discharge, redness around base, crying when cord or skin is touched.

Front 20

What is circumcision?

Back 20

Removal of the foreskin from the penis. Elective procedure only to be performed on healthy, stable infants.

Front 21

What are the benefits of circumcision?

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Decreased rates of UTIs in first year, foreskin abnormalities, risk of STIs (HIV, HPV, HSV, BV), penile cancer and improved hygiene.

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Phimosis

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Inability to retract foreskin over the glans.

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Paraphimosis

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Entrapment of retracted foreskin.

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Balanoposthitis

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Inflammation of foreskin and glans.

Front 25

What are the risks of circumcision?

Back 25

Local infection, bleeding, removal of too much skin, urethral injury.

Contraindicated in infants with genital abnormalities.

Front 26

How do you care for a circumcision?

Back 26

Takes about 7 – 10 days to heal
Apply small amount of Vaseline to gauze and change with every diaper change.
Stool on penis-cleanse area with warm soapy water.
Give sponge baths until circumcision is healed.
After circumcision is healed, gently pull foreskin back at bath time to prevent it from adhering to the glans

Front 27

What is an appropriate weight loss after birth?

Back 27

About 5-7% in the first few days of life.

Front 28

Weight gain guidelines

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Baby should regain birth weight 2 weeks after birth.

Appropriate weight gain is 1 ounce/day for the first 6 months and .5 ounce/day for the next 6 months.

As a general rule, infants should triple their birth weight by their 1st birthday.

Front 29

AAP follow-up visit guidelines

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Visit should occur within 48-72 hours for newborns discharged before 49 hours of age.

Front 30

Subconjunctival Hemorrhage

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Breakage of small blood vessels in the eyes of a newborn.

One or both eyes may have a bright band around the iris.

Causes: traumatic delivery, spontaneous, occasionally results from severe sneezing or coughing. Rarely due to blood dyscrasia.

Resolves within 1-2 weeks without any permanent damage to the eye (or eyes).

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Milia

Back 31

Very common, benign, keratin-filled cysts that appear as superficial pearly white to yellow domed papules measuring 1-2 mm in diameter.

Usually on the face, especially the nose.
Spontaneously disappear within the first few weeks of life.

Front 32

Epstein pearls

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Milia that are located intraoral.

Small, pearly nodules along the midline of the hard palate and are benign retention cysts.

Front 33

Erythema Toxicum

Back 33

Most common neonatal skin lesion.
May occur anytime during the first week of life but most commonly presents on the second and third days.
1-2 mm white to yellowish papules/pustules on an erythematous base.

Found on chest, arms, legs and back.
Generally disappears within the 2 - 4 weeks of life.

Front 34

Mongolian spots

Back 34

Areas (macules) of blue to slate gray discoloration due to uneven migration of melanocytes, resemble bruise.

Usually found on base of spine and buttocks.
Affects >50% of African American, Native American and Asian infants.
Most fade within 2-3 years but can persist for life.

Front 35

Nevus simplex

Back 35

“Salmon patch” or “stork bite”
Pink-red capillary malformations found on neck, eyes, forehead or upper lip.
Most fade and disappear by age 2.
If persist into adolescence, they may be treated with laser therapy.

Front 36

Nevus Flammeus

Back 36

Port-Wine Stain
Macular, sharply circumscribed, pink to purple lesions.
These are vascular malformations consisting of mature, dilated dermal capillaries and represent a permanent developmental defect.
Most common regions are head and neck.

Front 37

Neonatal Cephalic Pustulosis

Back 37

Baby acne
Inflammatory papules or pustules, absence of comedomes.
Generally limited to the face.
Onset at 3 weeks and generally resolves around 4 months.
No treatment necessary but may use soap and water, 1% hydrocortisone or 2% ketoconazole.
Avoid oils and lotions.

Front 38

Lacrimal duct obstruction

Back 38

Obstruction in any part of the drainage system.
Commonly due to incomplete canalization of the duct or membranous obstructions.
Risk factors include craniofacial abnormalities and amniotic band syndrome.
Occurs in up to 6% of infants.
Signs and symptoms include wet eye with mucoid drainage, erythema of one or both lids and conjunctivitis.

Front 39

Treatment of lacrimal duct obstruction

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Most cases clear spontaneously but refer to opthalmologist if persists after 6 months.
Nasolacrimal massage
Mainstay of surgical treatment is probing.

Front 40

Colic

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Characterized by severe and paroxysmal crying that occurs mainly in the late afternoon.

Begins in first few weeks of life and peaks at age 2-3 months.

Front 41

Rule of Threes of Colic

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Wessel Criteria
Infant who is healthy and well fed but cries for more than 3 hours a day, for more than 3 days per week, and for more than 3 weeks.

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Other criteria for colic

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In addition to Wessel criteria some suggest that dx should meet three of four of the additional criteria:
Paroxysmal
Qualitatively different from normal crying
Associated with hypertonia
Inconsolability

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Proposed etiologies of colic

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GI: cow’s milk protein, lactose intolerance, immaturity, intestinal motility, fecal microflora

Biologic: feeding technique, motor regulation, increased serotonin, tobacco exposure

Psychosocial: temperament, hypersensitivity, parental variables

Front 44

Evaluation of colic

Back 44

During an episode infant will have knees drawn up, fists clenched, flatus may be expelled, faces appear pained and there is minimal response to soothing.
Assess:
- Stooling, urination and sleeping patterns
- Growth pattern
- Social situation and parent-infant interactions

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Questions to ask the family regarding colic

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When does crying occur and how long does it last?
What do you do when the baby cries?
What does the cry sound like? Pain, hunger?
How and what do you feed the baby?
How does it make you feel when the baby cries?
How has colic affected your family?
What is your theory on why the baby cries?

Front 46

Management of colic

Back 46

Educate parents about developmental characteristics of crying behavior.
Reassure the parents.
Track crying patterns and weight gain.
Strategies for soothing and comforting the infant.
Create quiet environment w/o excessive handling.
Alternate sensory stimulation such as swinging, rocking, soft music, drives in the car, warm bath, belly massage.
If refractory to behavioral management, trial of hypoallergenic diet.
Sedatives, antihistamines, and motion sickness medications (dicyclomine) are not safe or effective for colic treatment.
- Dicyclomine can cause breathing cessation, seizures and coma.

Front 47

Neonatal jaundice

Back 47

Yellowing of the skin, sclera and mucus membranes due to elevated bilirubin levels.
Common neonatal problem.

65% of newborns develop clinical jaundice (bilirubin >5 mg/dL) during the first week of life.

1-2% of infants have total serum bilirubin >20 mg/dL.

Front 48

How is bilirubin metabolized?

Back 48

In the lymph nodes and spleen, heme is metabolized into iron (conserved) and carbon monoxide (exhaled).
Biliverdin - Metabolized to unconjugated bilirubin
Unconjugated bilirubin is then bound to albumin and is carried to the liver where it is conjugated with two glucuronide molecules.
Conjugated bilirubin is then excreted through the bile into the intestine and in the presence of normal gut flora, is excreted in the stool.
If stool is not passed, conjugated bilirubin reabsorbed.
Unconjugated bilirubin = indirect bilirubin
Conjugated bilirubin = direct bilirubin

Front 49

What causes physiologic jaundice?

Back 49

Absent gut flora and slowed peristalsis (as in the first few days of life) causes conjugated bilirubin to remain in the intestinal lumen rather than being readily excreted.
Due to stasis, much of the conjugated bilirubin in the intestinal lumen is hydrolyzed back to unconjugated bilirubin by an enzyme present in the intestinal mucosa.
The unconjugated bilirubin is then reabsorbed into the blood stream via enterohepatic circulation, adding an additional bilirubin load to the already overstressed liver of the neonate.

Front 50

Physiologic jaundice

Back 50

Physiologic jaundice is visible jaundice appearing after 24 hours of age.
If jaundice apparent before 24 hours it is pathologic in origin!
Total bilirubin increases by <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.
Visible jaundice resolves by 1 week in the full-term infant and by 2 weeks in the preterm infant.

Front 51

Causes of increased bilirubin production

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Labs show elevated reticulocyte count.
Increased rate of hemolysis
Presence of maternal antibodies against fetal cells (Coombs test-positive)
ABO incompatibility, Rh incompatibility
Abnormal RBC shape
Spherocytosis
Abnormal RBC enzymes
G6PD deficiency, pyruvate kinase deficiency
Nonhemolytic causes
Extravascular hemorrhage, polycythemia, exaggerated enterohepatic circulation of bilirubin

Front 52

Breast-feeding jaundice

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Breast feeding-associated jaundice
“Lack of breast milk jaundice”
Primarily due to decreased nutritional intake combined with increased enterohepatic circulation.

Front 53

Acute Bilirubin Encephalopathy

Back 53

Lethargy, hypotonia, poor sucking progressing to hypertonia, irritability, backward arching of the neck (retrocolis) and the trunk (opisthotonos).

Front 54

Chronic Bilirubin Encephalopathy

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(Kernicterus) – yellow staining and degenerative lesions in basal ganglia associated with high levels of unconjugated bilirubin in infants.
Consequences include cerebral palsy, deafness, limitation of upward gaze and dental dysplasia.

Front 55

Risk factors of jaundice

Back 55

Pre discharge TSB or TcB in the high risk zone
Jaundice observed in the first 24 hours
Blood group incompatibility
Gestational age 35 – 36 weeks
Previous sibling received phototherapy
Cephalohematoma (or significant bruising)
Exclusively breast feeding, particularly if nursing is not going well and weight loss excessive
East Asian race

Front 56

Evaluation of jaundice

Back 56

Feeding and elimination history
Weight (and comparison with birth weight)
Blood type
Direct Coomb’s testing
CBC with smear
Serum albumin
Total bilirubin
Clinical jaundice appears at bilirubin levels of 5mg/dL.
Appears first on the head, progressing down the chest and abdomen as the level increases.
If distal extremities affected, level is likely to be at least 15 mg/dL.

Front 57

Phototherapy

Back 57

Used most commonly to treat jaundice.
Light is absorbed by unconjugated bilirubin in the skin converting it to water soluble compound that can be excreted in the bile without conjugation.
Decreases or blunts the amount of total bilirubin regardless of the rise of TB, patient’s ethnicity or etiology of hyperbilirubinemia.

Front 58

Treatment of jaundice

Back 58

When should phototherapy be initiated?
If TSB 40 – 75%ile: Recheck level in 48 hours.
If TSB 75 – 95%ile: Recheck level next day.
If > 95%ile: Start phototherapy and follow level every 6 hours.
For TSB levels ≥ 20 mg/dL phototherapy should be administered continuously, until the TSB falls below 20 mg/dL.

Front 59

Exchange transfusion

Back 59

Rarely needed to treat jaundice
Necessary in some cases of ABO incompatibility, Rh isoimmunization, Hereditary spherocytosis
*Protoporphyrins – inhibitors of heme oxygenase, an enzyme that initiates heme catabolism. Currently not approved for use in the U.S.

Front 60

Jaundice pearls

Back 60

Most common causes of unconjugated hyperbilirubinemia are physiologic jaundice, prematurity and breast feeding-associated jaundice.
Infants with clinical jaundice within the first 24 hours most likely have a pathologic cause.
Kernicterus is yellow staining and degenerative lesions in basal ganglia associated with high levels of unconjugated bilirubin in infants. It is synonymous with chronic bilirubin encephalopathy and can lead to cerebral palsy and deafness.
Phototherapy is the most commonly used intervention to treat and prevent severe hyperbilirubinemia.

Front 61

When should the APGAR be completed?

Back 61

At 1, 5 and 10 minutes

Front 62

How is Activity (muscle tone) scored on the APGAR?

Back 62

0 points - activity absent
1 point - arms and legs flexed
2 points - active movement

Front 63

How is Pulse scored on the APGAR?

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0 points - absent pulse
1 point - <100 bpm
2 points - >100 bpm

Front 64

How is Grimace (reflex irritability) scored on the APGAR?

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0 points - no response
1 point - grimace
2 points - sneezes, coughs, pulls away

Front 65

How is Appearance (skin color) scored on the APGAR?

Back 65

0 points - blue-gray, pale all over
1 point - pink, except extremities
2 points - pink all over

Front 66

How is Respiration scored on the APGAR?

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0 points - absent respiration
1 point - slow, irregular
2 points - good, crying

Front 67

What are some possible causes of a newborn being small for its gestational age?

Back 67

Maternal drug use
Chromosomal abnormalities
Exposure to intrauterine viral infection
Multiple gestation
Advanced maternal age (>35 years old)
Placental insufficiency
Lack of maternal weight gain

Front 68

What are some possible causes of a newborn being large for its gestational age?

Back 68

Most commonly large size is due to gestational diabetes.

Front 69

When should a newborn exam be completed?

Back 69

Within 24 hours of birth.

Front 70

Fontanelles

Back 70

Anterior - 1-4 cm
- closes around 4-26 months

Posterior - 1 cm in size
- closes around 1-3 months

Front 71

What are the most common causes of unconjugated hyperbilirubinemia?

Back 71

Physiologic jaundice, prematurity and breast-feeding jaundice

Front 72

Etiology of neonatal jaundice

Back 72

Overproduction of bilirubin

Decreased rate of conjugation

Front 73

At what bilirubin levels can kernicterus result?

Back 73

Toxicity begins at levels greater than 20-25 mg/dL

Front 74

Complications of jaundice

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Kernicterus can result and may cause encephalopathy, mental retardation or death.

Front 75

When does neonatal jaundice peak?

Back 75

Total bilirubin increases by <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.