Evaluation of a newborn:

What hx is important to ask for??

Medical hx of Mom & Dad / Genetic hx

Hx of Mom's previous pregnancies

G/P, maternal age, blood type, preg. outcomes, obstetric hx

Hx of current pregnancy-antepartum/intrapartum

Evaluation of a newborn:

what is being looked at for assessment of growth & gestational age??

LMP, Fundal height, Early US

Post natal:

Ballard score-neuromuscular exam of muscle tone & strenght, physical maturity=determines gestational age

Determine if infant AGA,SGA,LGA

based on growth chart

Evaluation of a newborn:

What exams are done immediatly at birth??

APGAR score at 1 & 5 minutes

Skeletal Exam-r/o congenital abn. / birth trauma

Umbilical cord-look for AVA

Evaluation of a newborn-What is being looked at in the general exam for:

HR, RR

Skin

Head

Face

Neck

HR 120-160, RR 30-60

Skin- Petechiae/Bruising/Jaundice/Cyanosis

Head- Cephalhematoma (w/ in suture lines)

Caput succedaneum (cross suture lines)

Fontanelles

Face-Odd facies, Nerve palsy

Neck-Webbing, Reduntant skin

Evaluation of a newborn-What is being looked at in the general exam for:

cardiac

lungs

abdomen

skeleton/back

genital/anus

cardiac-murmurs, cyanosis, abnormal pulses

lungs-A/P diameter, air entry bilaterally, mediastimum position, heart tones

abdomen-softness, distention, bowel sounds, r/o prune belly, prominent kidneys, size of liver & spleen

skeleton/back-fx clavicle, obvious abnormalities, extremity fx/palsies, spinal deformities, arthrogryposis (multiple jt. contractures)

genital/anus-appearance

Evaluation of a newborn-What is being looked at in the general exam for:

eyes

nose

ears

mouth

eyes-EOMs, iris inspected to r/o brushfield spots, red reflex

nose-check patency, size, shape

ears-alignment, periauricular pits & tags

mouth-Epstein pearls, natal teeth, r/o cleft palate

Evaluation of a newborn-What is being looked at in the general exam for:

Neuro exam

 Hips

Neuro exam:

Tone-flexion of UE & LE

Newborn reflexes-sucking, rooting, palmar grasp, DTR, tonic neck reflex

 Hips:

Check for congenital hip dysplasia

ortolani/barlow

Evaluation of a newborn:

What screening test are done??

Hearing- auditory brainstem evoked

Newborn Genetic screen:

Phenylketonuria-PKU

Galactosemia

Sickle Cell disease

Hypothyroidism

Cystic Fibrosis

Evaluation of a newborn:

What routine prophylactic treatments are done??

Erythromycin ointment:  prevent gonococcal opthalmia

Vit K 1mg IM/SC:  prevent hemorrhagic dz of newborn

given in 1st 4 hrs of life

Hep B vaccine (HGIG immune globin if mom HbsAg +)

Cord Blood: Collected & blood/coombs typing if mom is type O or Rh negative 

Evaluation of a newborn:

Physiological Jaundice

when does it appear?

how much does total bilirubin rise per day-nl?

when does peak bilirubin occur w/ no more than 15-nl?

when does it appear?

after 24 hrs of life

how much does total bilirubin rise per day?

<5 mg/dL per day nl

when does peak bilirubin occur w/ no more than 15?

3-5 days nl

Evaluation of a newborn-Physiological Jaundice:

what time frame is this usually resolved in??

1 wk for full term baby

2 wk for preterm babies

Evaluation of a newborn-Physiological Jaundice:

what 3 things cause this to occur??

Glucuronly transferase inactivity in liver to conjugate bilirubin at birth

High red cell mass

Abscence of intestinal flora w/ initially slow intestinal mobility leading to active enerohepatic circulation of bilirunin

Evaluation of a newborn-Physiological Jaundice:

what's the management??

NOTHING does not require tx

if tx needed, then it is not physiological & needs further eval

Circumcision

What does it involve??

medical benefits??

What does it involve??

elective surgery to remove distal portion of foreskin

usually performed in 1st 2 days of HEALTHY infants

medical benefits??

PREVENTS-phimosis, paraphimosis, balanoposthitis, UTI

Circumcision:

Risks

Procedure

 Risks:

local infx

Bleeding

Removal of too much skin

Urethral injury

Procedure:

Local anesthesia of 1% lidocaine

dorsal penile nerve block OR circumferential ring block

Use plastibell or Gomco clamp

Circumcision:

contraindication

test prior to procedure

contraindication:

infants w/ congenital abnormalities-hypospadias

test prior to procedure:

coagulation screening

PATHOLOGICAL Neonatal Jaundice:

causes

evaluation

causes:

overproductin of bilirubin

decreased conjugation of bilirubin

other causes-BM jaundice, breast feeding jaundice, congenital hypothyroidism

evaluation:

appears at bilirubin of 5-1st appears of head & descends

if it reaches extremities, likely to be 15

-check standardized chart w/ hours of life

-check ht, wt, feeding/elimination

Labs-Coombs, CBC w/smear, total bili, G6PD

PATHOLOGICAL Neonatal Jaundice:

Tx

Comlications

Tx:

Exchange transfusion

Phototherapy when bili 3-5 lower than exchange level

ADR: diarrhea

Comlications:

Kernicterus-bilirubin encephalopathy

Kernicterus-bilirubin encephalopathy:

Signs of acute & chronic

Acute:

Lethargy

Hypotonia

Poor sucking

progression to Hypertonia

Irritable

Retrocollis & Opisthotonos

High pitched cry

Chronic:

Athetoid CP

Sensorineural deafness

Goal: keep bili <20 w/ exchange transfusion or phototherapy to prevent Kernicterus

Respiratory distress d/t aspiration/surfactant deficiency

Persistent pulmonary HTN

Hypotension d/t myocardial dysfunction

Transient tricuspid valve insufficiency

Anuria/Oliguria d/t to ATN-acute tubular necrosis

NEC-necrotizing enterocollitis/feeding intolerance

Elevate aminotransferase d/t liver injury

Adrenal insufficiency d/t hemorrhage

DIC

Hypocalcemia, Hypoglycemia, Hyperkalemia

 birth asphyxia complications:

Is it

single or multiorgan involvement

seizures present or absent

single or multiorgan involvement:

Multiorgan dysfunction

seizures present or absent:

Present

??

 Prodromal Adults sx only: Fever, H/A, Backache, Sore throat

 Rash: 1st appears on trunk then head,face, extremities

??

Crops of red macules

Progressing to vesicles on erythematous base

Then to pustules

Then to crusted lesions (tear drop on rose petal)

Varicella  "Chicken Pox":  TRUE or False

Lesions present are only in 1 stage of development

FALSE

Will see simultaneous presence of lesions in ALL stages of development

Varicella  "Chicken Pox": 

When can you tell by the lesions that a pt is not contagious ??

New crops stop forming after 5-7 days

&

Once the crusting begins-NOT CONTAGIOUS

Varicella  "Chicken Pox": 

What's the common complaint from pts??

ITCHY

Pruitis

Varicella  "Chicken Pox": 

How do you treat this virus??

SUPPORTIVE:

Hydration

Acetaminophen

Diphenhydramine-itchiness

Severe cases:

IV Acyclovir 20 mg/kg 4x per day X 5 days

Immunization:

Live attentuated varicella

immunocompromised-VZIG post exposure protection

Varicella  "Chicken Pox": 

Complications??

Secondary bacterial infx w/ Staph aureus, S pnuemoniae, Group A strep

Pnuemonia in adults UNCOMMON IN KIDS

CXR-b/l nodular densities & hyperinflation

Reye Syndrome-varicella & aspirin

Immunocompromised

increased risk of morbidity & mortality

??

1st presentation of 3 presentations:

Prodromal period 3 Cs

Cough

Corzya

Conjunctivitis

Fever, Sneezing, Eyelid Edema, Photo

??

2nd presentation of 3 presentations:

Koplik's spots

appear 1-2 days before or after rash

appear opposite lower molars

Measles

Rubeola

??

3rd presentation of 3 presentations:

Rash phase

Macular rash BEGINS HEAD & NECK & DESCENDS DOWN BODY within 24 hrs

Fever up to 104-105

lesions petchial / hemorrhagic (more dangersous)

rash fades in same manner as onset in 6 days

MEASLES

RUBEOLA

SUPPORTIVE: Antipyretic, Isolation, Fluids

if Hemorrhagic-admit

Recover in 7-10 days

Vaccinate- 2 doses (12 months & 5 yrs)

Are these complications of Measles/Rubeola??

Otitis Media

Interstitial Pneumonia

Encephalomyelitis

Subacute sclerosing panencephalitis

Myocarditis

??

Prodromol phase:  Coryza & Cough-mild

Low grade fever, Ocular pain, Sore throat, Myalgia

Rash: erythematous maculopapular rash

more INSIDIOUS spread, 3-4 days

??

Rash: erythematous maculopapular rash

more INSIDIOUS spread, 3-4 days

Lesions BEGIN on FACE, then to TRUNK/EXTREMITIES

only last for 3-4 days

Post auricular, Posterior Cervical & Occipital Lymphadenompathy

What will the labs look like for:

Rubeola/Measles

Rubella/German Measles

Rubeola/Measles:

Lymphopenia

Measles IgM Ab

total leukocytes may fall to 1500 u/L

Rubella/German Measles:

Leukopenia

Congenital-High Rubella Ig M Ab

Low platelets

Abnormal LFTs

Hemolytic Anemia

Blindness

Deafness

Mental retardation

Growth retardation

Cardiac anomalities

Cerebral d/o

Hematological d/o

Encephalitis

Adult women:  arthralgias & myalgias

What disorder is this??

Hematological disorder

"blueberry muffin rash at birth d/t petechiae"

SUPPORTIVE

Antipyretics

Fluids

Rest

VACCINATION for prevention

live attentuated at 12 months & 5 yrs