PEDIAPrelims - Care of the Newborn 2

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AUFMED ANTHROPOMETRIC MEASUREMENTS  Weight -average: 3000g -LBW= below 2500 gms; regardless of AOG 

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Length - average: 50cm -techniques: using tape measure (supine with legs extended) - crown to rump - head to heel Head Circumference (HC): - average: 35cm - technique: using tape measure - from the most prominent part of the OCCIPUT to just above the EYEBROWS - 1/3 the size of an adult’s head - disproportionately LARGE for its body - HC should be = or 2cm > CC Chest Circumeference (CC): - 30 to 33cm - Technique: using tape measure - from the lower edge of the SCAPULAS to directly over the NIPPLE LINE anteriorly - CC should be = of 0.5 mg/dl/hr - peak bilirubin >12mg/dl term and >15mg/dl in preterm during the first week of life - hepatosplenomegaly and anemia - clinical jaundice persisting >1 week (term) and > 2 weeks (preterm) *Ask the mother what the color of the urine is because usually babies are red after birth. Breastfeeding jaundice  Early onset of jaundice within the first 3-4 days  Also called exaggerated jaundice, lack of breastmilk jaundice  Factors: oral administration of water of glucose water, inadequate nursing and decreased stool output  Rx: continuous breastfeeding; no complementary feedings Breast Milk Jaundice  Later onset of jaundice occurring towards the end of the 1st week and persisting for 3 weeks to 3 months  Cause: unknown, unknown constituent in breastmilk  Dx by exclusion  Rx: stop breastfeeding x 2-3 days

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Reassure the mother that the jaundice is not because of breastfeeding Phototherapy (eyes and sex organs should be covered to prevent damage)

BIRTHMARKS 1. Mongolian Spots - Blue-green or gray pigmentation - Lower back, sacrum & buttocks - Disappears by 4 years of age

Meconium Staining     

Over the skin, fingernails and umbilical cord Due to passage of meconium in utero due to fetal hypoxia Passage of meconium due to asphyxia in baby < 34 week gestation is UNUSUAL The baby was in a state of hypoxia and underwent fetal distress. Prematures do not pass meconium

Lanugo  Found after 20 weeks of gestation on the entire body except the palms and soles  Fine downy hair that covers the shoulders, back and upper arms NURSERY CARE CONSIDERATIONS  More mature, less lanugo  May diappear within 2 weeks  Preterm: woolly patches of lanugo on skin and head  Post term: parchment-like skin without lanugo 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

2. Strawberry Marks - Nevus Vasculosus or Capillary Hemangioma - Dark red, raised lobulated tumor - Head, neck trunk & extremities - After 7 to 9 years of age

3. Large Capillary Hemangioma

4. Cavernous Hemangioma

It is helpful if you do not totally remove especially for prematures Post matures usually look paranoid Desquamation  Dryness/ peeling of the skin  Usually occure after 24-36 hours  Marked scalliness and desquamation= signs of postmaturity Milia   

Multiple, yellow or pearly white papules approx. 1 mm wide Due to enlarged or clogged sebaceous gland Usually found on the nose, chin, cheeks, eyebrows and forehead

5. Sturge-Weber Syndrome - A sporadic vascular disorder and - Consists of a constellation of symptoms and signs including:  facial capillary malformation (port-wine stain)  abnormal blood vessels of the brain (leptomeningeal angioma)  abnormal blood vessels of the eye leading to glaucoma

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Patients present with seizures, hemiparesis, stroke-like episodes, headaches, and developmental delay Port-wine stain (nevus flamneus) involving the forehead and upper lip, glaucoma and contralateral jacksonian seizures

6. Kasabach-Merritt Syndrome - Association of a giant hemangioma with localized intravascular coagulation causing thrombocytopenia and hypofibrinogenemia - The site of the hemangioma is obvious, but retroperitoneal and intraabdominal hemangiomas may require body imaging for detection - Inside the hemangioma there is platelet trapping and activation of coagulation, with fibrinogen consumption and generation of fibrin(ogen) degradation products. Arteriovenous malformation within the lesions can cause heart failure - Peripheral blood smear shows microangiopathic changes - Cavernous hemangioma - Thrombocytopenia - Microangiopathic changes in RBC (detected thru peripheral blood smear)

OTHER SKIN MARKS 1. 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 - *Infection of blood/sepsis may also manifest as mottling in newborns

2. Erythema Toxicum - Newborn rash; urticaria of newborn; eosinophil rash (because eosinophils are present upon examination of lesion under the microscope) - Small, white, yellow, or pink to red popular rash - Trunk, face and extremities - Within 48 hrs. - May be mistaken for septic spots. Careful examination must be done to prevent unnecessary administration of antibiotics. - Suspect allergic or hypersensitivity reaction

3. Petechiae - Pinpoint hemorrhages on skin - Due to increased vascular pressure, infection or thrombocytopenia - Within 48 hrs. - *Petechiae do not disappear after blanching - *May result from mechanical causes such as cordcoil and pressure during delivery.

4. 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

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5. Harlequin Sign - When on side, dependent side turns red and upper side/half turns pale - Due to gravity and vasomotor instability or immature circulation - “Clown’s Suit”

*At birth, it is possible that there is no more posterior fontanel present due to early closure/overlapping of sutures - Bulging or sunken Sutures - Overriding or separated Head lag - Common when pulling newborn to a sitting position - When prone, NB should be able to lift the head slightly and turn head from side to side

1. Caput Succeedaneum - Swelling of soft tissues of scalp - Due to pressure - Crosses the suture lines - Presenting part

2. Cephalhematoma - Subperiosteal hemorrhage with collection of blood - Due to rupture of capillaries as a result of trauma - Does not cross suture lines 6. Café-au-lait spots - Tan or light brown macules or patches - No pathologic significance, if CC  Fontanelles “soft spot” - Anterior fontanel closes between months - Posterior fontanel closes at 2 months

Craniotabes Localized softening of the cranial bones Can be indented by pressure of fingers MOST common among 1st born babies, pathological in older children (consider possibility of metabolic dosorders) Caused by pressure of the fetal skull against the mother’s pelvic bone in utero

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Craniosynostosis Premature closure of the fontanelles

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FACE, EYES, EARS, NOSE, MOUTH What to Assess: Facial movement and symmetry Symmetry, size, shape, and spacing of eyes, nose, and ears Eyes -

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Color: white sclerae; slate gray, brown, or dark blue; final eye color is acheieved after 6-12 months Symmetrical Pupils equally round, reactive to light and accommodation (PERRLA) (+) Blink reflex (+) transient strabismus due to weak EOM, maybe normal up to 4-5 months of life Able to move and fixate momentarily (+) red reflex; if (-), screen for congenital cataract or retinoblastoma (+) edema on eyelids related to pressure during delivery or as effect of medications (-) tear formation (begins at 2-3 months) The child may be crossed eyes, normal, within 45 months At this point in the lecture, Dr.Ng started enumerating oddities that are physiologic for the child: o Anemia (as long as Hgb is not 6 mos)  Disappears after 4-5 mos

NEUROLOGIC SYSTEM REFLEXES o Sucking/Rooting Reflex  Touch the lip, cheek or corner of the mouth  Turns head toward the nipple, opens mouth, takes hold of the nipple and sucks  Disappears after 3-4 mos up to 1 year

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Extrusion Reflex  Anything place on the anterior portion of the tongue will be ―spit out‘  To prevent swallowing of inedible substances  Disappears after 4 months  Disappearance indicates readiness for semisolid to solid foods

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Startle Reflex  Best elicited if baby is 24 hrs old  Make a loud noise or claps hands  Baby’s arms adduct while elbows flex with fists clenched  Disappears within 4 mos

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Babinski Reflex  Gently stroke upward along the lateral aspect of the sole, starting at the heel of the foot to the ball of the foot  Dorsiflexion of big toe and fanning of little toes  Disappears starts a 3 mos to 1 year  Disappearance indicates maturity of CNS

Stepping/Walking/Dancing Reflex  Hold baby in a standing position allowing one foot to touch a surface  Simulates walking by alternately flexing and extending feet  Disappears after 3-4 mos

Other Nursing Responsibilities:  Identification band  Band registration  Birth record and documentation NEWBORN SCREENING  The Newborn Screening Reference Center (NSRC) is an office under the National Institutes of Health (NIH), University of the Philippines Manila created under RA 9288 – The Newborn Screening Act of 2004  Performed after 24 hours of life up to 3 days except for patient in intensive care, must be tested by 7 days. o Congenital Hypothyroidism (CH) o Congenital Adrenal Hyperplasia (CAH) o Galactosemia (GAL) o Phenylketonuria o Glucose-6-Phosphate-Dehydrogenase Deficiency (G6PD Def) o Maple Syrup Urine Disease (MSUD)

Infant Care Skills  HOLDING THE BABY 1. Football Hold 2. Cradle Hold 3. Shoulder Hold Football Hold  Purpose: to carry on one hand free  A holding technique in bathing a baby  Use for small babies  Procedure: 1. Slide forearm under his back 2. Support neck and head with your hand

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3. Press his arm firmly against your side 4. His head faces you 5. Infant’s feed tucked under your elbow

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Hb E/Beta + Thalassemia Hb H Disease Hb H/Constant Spring Disease Hb Variant/Beta + Thalassemia Homozygous EE Sickle Cell Disease (Hb S/C Disease) Sickle Cell Anemia (Hb S/S Disease)

B. Amino Acid Disorders  Phenylketonuria (PKU)  Variant Hyperphenylalaninemia  Maple Svrup Urine Disease (MSUD) Cradle Hold  Purpose: used for feeding and cuddling a baby  Procedure: 1. Support head in crook of your arm 2. Encircle the body with your arm 3. Press baby firmly against your side 4. Use other hand to support bottom and thigh

Shoulder Hold  Purpose: used for burping  Procedure: 1. Draw baby towards your chest with one forearm 2. Bracing his back and your hand cradling his head 3. Support your baby’s bottom and thighs with your other arm 4. Gently press his head against your shoulder

C. Organic Acid Disorders  Methylmalonic Acidemia – MMA - (Mut0)  Methylmalonic Acidemia – MMA - (Mut-)  Beta-Ketothiolase Deficiency (BKT)  Isobutyryl-Coa Dehydrogenase Deficiency (IBDHD) D. Fatty Acid Oxidation Disorders  Medium Chain acyl-Coa Dehydrogenase Deficiencv (MCAD Deficiency)  Short Chain acyl-Coa Dehvdrogenase Deficiency (SCAD Deficiency)  Very Long Chain acyl-Coa Dehydrogenase Deficiency (VLCAD Deficiency)  Other Fatty Acid Oxidation Disorders E. Cystic Fibrosis and Related Disorders  Partial BD Deficiency  CFTR-Related Metabolic Syndrome (CRMS)  Cystic Fibrosis  Classical Galactosemia  Duarte Galactosemia (D/G)  Other Disorders

ADDITIONAL INFORMATION In an article published in the ACTA MEDICA PHILIPPINA in 2012 authored by UP-Manila Chancellor Carmencita D. Padilla entitled “Enhancing Case Detection of Selected Inherited Disorders through Expanded Newborn Screening in the Philippines”, the following disorders were proposed to be added: A. Hemoglobinopathies  Alpha-Thalassemia Major  Beta-Thalassemia Major

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APPENDIX

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