Neonatal History and Exammination.pptx MBBS

Paediatrics

1. Neonatal History and Examination Part 1

2. The neonatal period is the period of life extending from birth to 4 weeks It is a period of physiological adjustments required by the infant for extra uterine existence. The fragility of life, during this period, is responsible for the high morbidity and mortality.

3. The neonatal mortality rate is defined as the number of death per thousand live births in the first 28 days after birth. In India, 60 % of deaths during infancy occur in the newborn period. 50% of neonatal deaths occur during first week and 25% occur in the first 24 hours

4. The common causes of neonatal deaths: Prematurity-low birth weight, Infection, Birth asphyxia–trauma and Congenital malformations The irony of the situation is that two of the causes of neonatal mortality viz. infection and birth asphyxia are completely preventable with simple measures like anticipation and whereas the other two are partially preventable.

5. Basic information : Date of birth, gestational age, and birth weight, age of the mother and father Chief complains: The complains regarding the baby, for which the mother has brought the baby to the hospital. History of present illness consist of the elaboration of the chief complains and the course of illness after admission/ treatment. Previous obstetrical history : Parity, gravida, h/o recurrent abortions, stillbirth, interval between successive pregnancies and their outcome, the neonatal course of siblings . Pre-pregnancy health status : Chronic illness in the mother, height, weight. History taking

6. History of present pregnancy : Antenatal : The points to be noted are h/o exposure to drugs & radiation, h/o of active or passive smoking, chronic illness and pregnancy induced complications, weight gain of mother, tetanus immunization. Natal : risk factors for early and late onset sepsis, duration of labour, mode of delivery, augmentation of labour with oxytocin, cry at birth, need for resuscitation, analgesics and anesthetics used during labour. Postnatal / Neonatal : time of initiation of breast feeding, time of passage of urine, and passage of meconium, any major illness, immunization at birth. - Family history: of major diseases viz. cardiovascular disease, infectious disease, hereditary diseases in the siblings and the elders.

7. Prerequisites Warm room Clean and warm hands and a Completely undressed baby Examinations: The baby should be examined as early as possible after birth, after 2 hours, then on the next day and at discharge . A high-risk baby should be closely monitored in the first 2 hours . Physical Examination

8. Examination at birth or soon after consists of the following: Check the vitals: temperature, respiration, heart rate, and color. Look for life threatening congenital anomalies, and signs of sickness. Assess gestational age Take weight.

9. In a healthy term newborn baby, Temperature is between 36.5 C to 37.5 C. Heart rate 140/minute (range 90 – 180 /minute). Respiration 40 – 60 / minute Blood pressure systolic/diastolic 60/40. The color of a term baby is pale pink and that of the preterm is pink . Vital signs:

10. Axillary temperature Rectal temperature Human touch method Thermister: A thermister (telethermometer) is taped to the skin of the abdomen and the temperature is noted. Ear drum temperature Methods of measurement of temperature

11. Steps of measurement The clinical thermometer is shaken to bring the mercury column to the lowest level. The axilla is wiped dry. The thermometer is placed in the axilla vertically upwards so that the mercury bulb is covered on all sides by the axillary folds. The thermometer is kept for 3 minutes and the reading is taken. Axillary temperature

12. Steps of measurement The baby should be in supine position with both legs lifted up. The rectal thermometer should be held in the pen holding method and inserted through the anal opening in the downward and backward direction upto 2cm. Thermometer is kept for 3 minutes and reading taken. Rectal temperature

13. Normal: 36.5 – 37.5 C Cold stress 36.5 – 36.0 C Moderate hypothermia 36.0 - 32.0 C Severe hypothermia less than 32 C Body temperature

14. Human Touch Method

15. Human touch method Step 1 Step 2

16. Interpretation: Normothermia: the abdomen will be warm and the soles of the feet will be pink and warm. Cold stress: Soles are cold and abdomen is warm to touch Hypothermia : Both abdomen and soles are cold to touch. Human Touch Method

17. The respiratory rate should be counted in a quiet baby. It should be always counted for 1 minute, 1-2 hours after a feed. This is because breathing is irregular in newborn and feeding increases the respiratory rate. The cardinal signs of respiratory distress are: Tachypnoea (RR > 60/minute) Sub costal in drawing Grunt Cyanosis. Any 2 or more should be present . Counting of respiratory rate

18. Respiratory distress

19. The radial pulse is difficult to palpate. The heart rate should be counted for one minute. The heart rate may vary normally from 90 / minute in relaxed sleep to 180/ minute during activity. Premature infants have a resting heart rate of 140 – 150 / minute. The pulses of the upper and lower limb should be palpated at birth and at the time of discharge to detect any difference in order to exclude vascular anomalies like coarctation of aorta and stenosis of left subclavian artery. The easily palpable arteries in the newborn are the brachial and femoral. The radial and carotid are difficult to palpate. Counting the heart rate and palpation of pulse

20. Direct methods Flush method Doppler method Indirect methods Capillary refill time Color Measurement of Blood pressure

21. Capillary Refill Method

22. Neural tube defects: encephalocele, meningocele, enencephaly. Bilateral Choanal atresia Esophageal atresia with tracheo esophageal fistula Gastrochisis and Exomphalos Urethral obstruction Anal atresia. Life threatening anomalies

23. Life threatening anomalies Anencephaly Encephalocele

24. Life threatening abomalies Meningocele Omphalocele

25. Life threatening anomalies Gastrochisis Anal atresia

26. Presence of jaundice, cyanosis, pallor, and respiratory distress. Signs of sickness

27. Prerequisites Jaundice should be examined in natural light. There should be no yellow background. Peculiarities Jaundice is examined on the skin: Physiological photophobia The examiner’s finger is pressed on the baby’s skin, preferably over a bony part, till it blanches. The underlying skin is then noted for yellow color: Physiological plethora Examination of jaundice

28. Peculiarities Jaundice in newborn has a cephalocaudal progression The level of serum bilirubin can be roughly interpreted on the basis of the level of yellow staining of skin by the following criteria:

29. ------------------------------------ Area of body Bilirubin levels mg/dl _________________________________________ Face 4 – 8 Upper trunk 5 – 12 Lower trunk & thighs 8 – 16 Arms & legs 11 – 18 Palms and soles > 15 _______________________________________   An estimation of serum bilirubin should be ordered when there is staining of the upper trunk and yellow tinge of palms and soles and the baby closely monitored for further increase. Kramer criteria

30. Last menstrual period: When LMP is correct and menstrual cycle is regular Physical features: Can fairly assess Modified Ballard Scoring: Specific gestation Assessment of gestational age

31. Physical Features Sole creases Deep creases covering anterior two third Single deep crease in anterior two third or superficial creases

32. Genitals (Female) Labia minora completely covered by majora. Clitoris normal Labia minora exposed. Clitoris hypertrophied.

33. Genitals (Male) Scrotum pendulous. Rugocities normal. Dark brown in color. Both testes in the sac Scrotum small. Rugocities scanty. Testes in ext ring or above.

34. Breast nodule Breast nodule > 5 mm Breast nodule < 5 mm

35. Ear cartilage Ear cartilage well formed Ear recoil quick Ear cartilage deficient Ear recoil slow

36. Black silky hair. Cannot be separated Fuzzy hair. Individual hair can be separated

37. Posture and color Posture: flexed all limbs Color pale pink Posture partial flexion Color pink

38. Is term or preterm Can be bedded in with the mother or transferred to the special care/ intensive care neonatal unit. Can be given breast feed, or expressed breast milk with cup or infant feeding tube. For example, a preterm baby below 34 weeks of gestation does not have coordinated sucking and swallowing. They need to be given nasogastric feeding. A quick assessment of gestation at birth helps to decide whether the baby

39. Prerequisites Warm room and warm weighing machine (electronic or beam type) Baby should be completely undressed Steps Zero correction in a beam type scale. Wait till the zero appears in the electronic machine. Put the naked baby on the scale and take the reading. Measurement of weight

40. Is appropriate for date, small for date or large for date irrespective of the gestation. Plotting the birth weight and gestation on the “intra uterine growth chart” can do this. Can be roomed in with the mother or sent to the special care or intensive care neonatal unit. Decide the mode of feeding. Weighing the baby at birth helps to decide whether the baby

41. The baby should be examined after 2 hours to ensure the following: Whether the neonate is well covered and protected from cold. There is no bleeding from the umbilical cord Whether breast-feeding is initiated. No sign of illness has been missed. Examination after 2 hours:

42. Methods of Rewarming

43. Kangaroo method Overhead lamp and hot water bags Radiant warmers and incubators

44. Kangaroo Method

45. Over head lamps Radiant warmer

46. Incubator

47. Thank you

48. Neonatal History and Examination Part 2

49. Examination on next day Examination during post natal stay Examination at discharge Advice at discharge

50. The purpose of examination of the neonate includes the following: Enquire about passage of meconium and urine and enquire about feeding behaviour. To make sure that no anomalies have been over looked To take measurements of the baby viz. weight, length, and head circumference. Precise estimation of gestation in preterm babies. General and systemic examination.

51. Passage of meconium and urine: Term babies should pass meconium within 24 hours and urine within 48 hours provided they have not passed during labour. The preterm babies may take a longer time. Feeding behaviour Adequate milk flow starts from around the 4 th day only. So during the first few days the infant will need breast feed frequently. The infant should be suckled on demand. Frequent suckling in the first few days will help production of adequate breast milk subsequently.

52. Ask and look for : Respiratory difficulty when the child breast-feeds : may indicate presence of bilateral Choanal atresia. A thick rubber catheter introduced through the external nares will not pass through the internal nares. Presence of frothiness and choking or vomiting after breast feeds may indicate esophageal atresia. In such cases, a firm rubber catheter introduced into the esophagus will get stuck at 8 to 10 cm distance. An x ray chest and abdomen in erect posture is confirmatory. No passage of urine and meconium in the schedule time should raise suspicion of congenital anomalies viz. urethral obstruction and anal atresia respectively. To make sure that no anomalies have been overlooked:

53. The weight, length and head circumference at birth are indicators of intra uterine growth. The weight is taken at birth. Other measurements are taken in the examination on the next day. To take measurements:

54. Crown heel length : is measured on an infantometer. In a term baby the crown heel length 48 – 50 cm. Head circumference : should be measured after 24 hours when caput succedaneum and over riding of sutures have disappeared. The head circumference in a term baby is around 34 – 35 cm. It increases by 2 cm per month in the first 3 months. If the head circumference increases by more than 1 cm after 15 days, one should suspect hydrocephalous.

55. Weight Head circumference

56. Length Chest circumference

57. Precise estimation of gestational age The precise estimation of gestational age in the preterm is done with the help of Modified Ballard scoring system.

58. The head: Inspection, palpation, percussion and auscultation Inspection: Size and shape, presence of swellings Palpation: sutures, fontanelle, swellings, head circumference Percussion: for crack pot sound Auscultation: for a bruit General Examination

59. There are 6 fontanels in the skull. Two fontanels can be palpated at birth – the anterior and the posterior. The anterior closes by 18 – 24 months (may normally close as early as 9 months) and the posterior by 2 months age. The other 4 fontanelle close at birth. The anterior fontanel is normally slightly depressed and pulsatile. It is best evaluated with the infant held upright or while sleeping or feeding. Fontanels

60. The sutures are open at birth; closes by 3 months age. The squamo parietal sutures are not separated except in hydrocephalous, preterm and small for date babies. Closure of the sutures can be felt by palpating a ridge over the closed suture. A ridge at the midline of forehead (metopic suture) is normal while sutural ridges at other places suggest Craniostenosis. There may be over riding of the skull bones as a result of molding of the skull during labour. Sutures

61. Auscultation of the skull may reveal a bruit in infants with arteriovenous fistula or angiomatous malformation. The swellings, which may be palpated over the skull, are caput succedaneum, cephalhematoma and encephalocele.

62. Caput succedaneum: It is an edematous area of the scalp over the presenting part of the head. It pits on pressure and is not fluctuant It is a result of venous and lymphatic obstruction as a result of pressure over the presenting part. It disappears by 24 hours. Cephalhematoma: Is a result of subperiosteal hemorrhage in the skull bones. It appears a few days after birth as a large cystic swelling limited by suture lines. It resolves relatively slowly over a few months and may leave a calcified edge. It may appear spontaneously or after a traumatic delivery. Encephalocele: It is a swelling located over the suture line usually with a stem. It is caused by protrusion of the meninges through the suture line. It contains CSF or brain matter. The swelling becomes tense while crying and transillumination test is positive. Swellings

63. Note for jaundice, cyanosis and pallor. Peripheral cyanosis is a common finding in a normal newborn. Central cyanosis indicates cardiac or respiratory disease. Look for the following physiological phenomena in the skin: The Skin:

64. Stork bites: a collection of dilated capillaries on the upper eyelids and nape of the neck. It fades after a few weeks. Erythema toxicum: a crop of small papules on the trunk during the first week. They usually fade away after a few days. Superficial peeling of the skin , especially over the peripheries, is common, and is mostly seen in post term and small for date babies. Physiological phenomena

65. Milia: These are whitish, pinhead spots concentrated mainly around the nose. They are sebaceous retention cysts. They usually disappear within a month. Lanugo hair: May cover the body, especially in preterm babies. It usually disappears over the first 2 or 3 weeks. Mongolian blue spots : These are dark blue areas of pigmentation commonly seen over the sacrum and buttocks or back of the legs. They fade away by 6 months age.

66. The face for craniofacial maldevelopment Check the position of the ears and whether they are normal and symmetrical. A low set ear is said to be present when the pinna lies below the line joining the outer canthus of the eye and the tragus of the ear. Make sure that the upper lip is intact. The mouth and tongue can be examined when the baby is crying or with the help of a spatula. Look for a cleft palate, bifid uvula, epithelial pearls and macroglossia Face, Mouth and Tongue

67. Epithelial pearls are small, white areas, best seen on the hard palate. Macroglossia is seen in babies with Mucopolysaccharidoses, Congenital hypothyroidism and Beckwith’s syndrome. Teeth may be present at birth. They are usually incisors and may be green in color. If the tooth is loose or creates problems in breast-feeding it should be removed.

68. The eyes can be examined when the baby open the eyes spontaneously or during feeding. They can be made to open the eyes when awake and held against diffuse light. Look for any abnormalities in the cornea, iris or conjunctiva. The sclera normally has a bluish tinge. Tears normally appear after 3 – 4 weeks. The setting sun sign may be normally present in the newborn. If persistent it suggests hydrocephalous and Kernicterus. Eyes

69. The neck: The neck in the newborn is short. Look for cystic swellings which may be rarely present. They are dermoid and thyroglossal cysts in the midline and branchial cyst just in front of the upper third of the sternomastoid muscles. The limbs: Should be examined for abnormalities viz. polydactyly, syndactyly, talipes equinovarus. Talipes requires early orthopedic referral.

70. Look for the shape of the chest, symmetry of chest wall, type of respiration and any chest in drawing. The breathing of the newborn is entirely diaphragmatic. So during inspiration, the soft front of the thorax is usually drawn inward while the abdomen protrudes. Hence, mild chest in drawing is normal in a quiet, relaxed newborn with good color. Premature infants may breathe with a Cheyne stokes rhythm, known as periodic respiration. A weak grunt during expiration may be present in the newborn. If it is persistent beyond 30 – 60 minutes, it indicates a potentially serious cardio pulmonary disease. Normally the breath sounds are broncho vesicular. Suspicion of any abnormal finding viz. diminished breath sounds, dullness, rales etc should always be verified with a chest x ray. Chest and lungs:

71. Location of the heart apex is important to exclude Dextrocardia. Normally the apex in the newborn period is located in the 4 th left intercostal space outside the left midclavicular line. Transitory benign murmurs are common in newborn period, which reflect the closing of the ductus or nonspecific flow murmurs. Ejection systolic murmurs in the pulmonary or aortic areas are significant murmurs indicating obstructive lesions. The pan systolic of VSD appears by 2 weeks of life and is prominent by 6 – 8 weeks. Heart

72. Some congenital heart disease may present with congestive heart failure. The signs of congestive heart failure in the newborn period are tachypnoea, tachycardia, enlarging soft tender liver, sudden unexplained weight gain. Jugular venous pressure cannot be evaluated because the newborn baby has a short neck. Signs of CHF in Newborn

73. The abdomen is distended in the newborn baby. This may be exaggerated by presence of slight divarication of rectus muscles. The intestines are filled with air of varying amount. Gas should be normally present in the rectum on a roentgenogram by 24 hours of age. The liver is palpable 2 – 4 cm below the right costal margin. Less commonly the tip of the spleen may be palpable. The lower poles of the kidneys can be normally palpated. An unusual mass should be investigated immediately by ultrasonography. Abdomen

74. The perineum should be examined for hypospadius, hydrocele, inguinal hernias or undescended testis. Inguinal hernia should be operated on by 4 – 6 weeks age. Hydrocele need excision if it does not resolve by 6 months. Undescended testis needs surgery around 1 year age. Perinium

75. A twice a day visit to the mother and baby in the postnatal ward should be a routine during the stay at hospital till discharge. No detailed examination is necessary during these visits. The mother should be enquired about any problem regarding lactation, bowel movement, and reassured about the normal developmental peculiarities. The baby should be examined for appearance of jaundice and monitored. Daily clinical screening of the baby

76. The mother should be enquired about any problem regarding lactation, bowel movement, and reassured about the normal developmental peculiarities. The conditions that may affect the baby during this period are superficial infections like conjunctivitis, pyoderma, umbilical sepsis and oral thrush. They should be looked for. Daily clinical screening of the baby

77. An examination at the time of discharge is essential to ensure that No obvious congenital anomalies and birth injuries have been missed. Previously detected murmurs on auscultation of the heart have disappeared and no new murmurs have appeared. Functional murmurs may be present at birth which disappears during neonatal period. Organic murmurs may be present at birth or may appear any time during the neonatal period. The initial lactation problems have been surpassed. Examination at discharge

78. Maintenance of warmth through out the neonatal period. Exclusive breast-feeding upto 6 months age. Follow up and start vaccination at the earliest contact within 2 weeks and then at 6 weeks age. Monitoring of danger signs. The mother should be made aware of the 4 important milestones Advised about personal hygiene, birth spacing, nutrition (an extra meal over and above the normal food every day), and to continue Iron folic acid tablets. Discuss about traditional practices. Promote good traditional practices. Discourage harmful ones and ignore the harmless ones. Teach mother craft. Advice on discharge

79. Cold to touch or febrile Poor activity, not arousable. Respiratory rate > 60/minute, chest retractions. Stoppage of breathing or laboured respiration. Blue discoloration of lips/ tongue. Jaundice involving palms and soles. Convulsion. Bleeding from any site. Diarrhea or vomiting or abdominal distension Umbilical discharge or skin boils. Mother should be made aware of the danger signs during the neonatal period. She should be advised to report if any danger sign appears. Danger Signs

80. The 4 milestones and their cut points are: Social smile: 2 months, Head holding: 4 months, Sitting without support: 8 months Standing without support: 12 months. The mother should be advised to report immediately if there is any delay beyond the cut off point. Babies with delayed milestones need a detail neurodevelopmental examination and early intervention. Important milestones

81. Modalities of treatment Exchange transfusion Phototherapy others Hyperbilirubinemia

82. Exchange transfusion

83. Most effective method for lowering serum bilirubin A double volume (i.e. 160 ml / kg body weight whole blood) exchange transfusion removes 87 % of infant’s blood volume Lowers the bilirubin level to about 50% of the pre -exchange levels Exchange transfusion

84. Phototherapy units

85. Biliblanket Halogen

86. A neonate under phototherapy

87. Bili blanket therapy

88. Should be given continuously till S. bil level below safe level (< 10 mg/dl) Brief interruptions for breast feeding Infants should be kept naked except for eye patches and diapers. Kept 45 cm from light source. 15 – 20 cm for intensive therapy Infants should be weighed daily (small infants twice daily) Between10-20 % extra fluid over the usual requirements Procedure

89. Phenobarbitone Agar Metalloporphyrins ( tin or protoporphyrins) Other treatment modalities

90. Thank you