Normal Newborn
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NORMAL NEWBORN Prof. RODOLFO C. NG, MD, FPPS, FSPCCMP, FPSCCM, MAEd
1
Pattern of Successful Transition from Intrauterine to Extrauterine Life…..
Expansion of lungs following initiation of first several breaths which clear the fetal lung fluid and termination of right-to-left shunting Elevation of P02 in both the alveoli and the arterial circulation (50-70 mm Hg) Decrease in pulmonary vascular resistance Conversion from fetal to neonatal circulation
2
Transitional Period:The First 6 Hours of Adaptation From Intrauterine to Extrauterine Life
Patterns of Activity A. First 15 to 30 minutes 1. immediate tachycardia to 160-180 beats/min, gradual drop to 100-120 beats/min. 2. irregular respirations, tachypnea to 60-80/min, brief apnea. 3. moist-sounding lung fields, transient grunting and retraction. 4. awake, moving, alert, easily startled, crying, transient tremors.
3
Next 60 to 90 minutes….. 1.
2.
3. 4.
sleepy, or sleeping, somewhat unresponsive. Heart rate 100-120 beats/min, transient tachycardia. RR 50-60/min, transient tachypnea Usually, passage of meconium.
4
The next 10 min to several hours…
Again, awake, alert, easily startled, crying, easily stimulated, and reactive At last, behaving like a baby, “Over” being born, eager for feeding and the world, and eager at times for sleep.
5
Routine Newborn Care….. Thermoregulation: > First temperature reading – rectal* route; succeeding readings-axillary route. > whenever possible, a digital thermometer is preferred over a mercurial thermometer > delivery room temp. should be at 250 to 280C w/o drafts > Keep baby temperature between 36.50 to 37.50C *not affected by the environment
6
Thermoregulation…..
Kangaroo Mother Care - skin to skin contact specific for low birth weight babies
7
Latching on…..
Initiating breastfeeding within 1 hour after birth Check for signs of the baby’s readiness to breastfeed (e.g., baby looking around/moving, mouth open, searching) Neonatal risk of death increased by delayed initiation of breastfeeding 8
Neonatal Risk of Death….. Breastfeeding Within 1hr Day 2 Day 3 After day 3
RR of Death 1 4 5 11
9
Cord care…..
Initial cord care should include an iodophor solution for its bactericidal properties, followed by 70% alcohol. Thereafter, 70% alcohol may be continued as an antiseptic agent to minimize microbial colonization
10
Eye care…..
Erythromycin 0.5% or tetracycline 1% eye ointment should be applied soon after birth to prevent gonococcal or chlamydia opthalmia. Bathing: between 1-4 hours after birth. Immediate bathing is indicated for babies born to mothers with infection like HIV.
11
Vitamin K…..
Natural vitamin K1 oxide (phyto nadione) 1 mg IM for term; 0.5 mg IM for prematures to prevent Hemorrhagic Disease of the Newborn.
12
Other preventive care…..
BCG Hepatitis B vaccination Newborn Screening
13
Danger signs to watch out for…..
Deepening jaundice up to palms and soles or persistent jaundice beyond two weeks of life Decreased sucking reflex or refusal to feed Unusual sleepiness No urine output for > 8 hours Temperature instability Unusual movements Fast breathing w/ or w/o cyanosis or pallor 14
The Newborn Behavioral Observations System (NBO)…..
Provides a formal measure of an infant’s neurodevelopmental competencies, including state control, autonomic reactivity, reflexes, habituation, and orientation toward auditory and visual stimuli. Used to demonstrate to parents an infant’s capabilities and vulnerabilities. Used to support the development of positive early parent-infant relationships Served as therapeutic alliance with the caregiver 15
The First 3 Months of Life…. A period of rapid developmental transition First Month: - dominate face to face interactions o Second Month: - show a wide range of facial expressions and emotional responses, from interest to concentration to astonishment and pleasure o Third Month: - duration of smiles and cooing increased
16
Basic Developmental Tasks….. 1.
2.
To organize his autonomic or physiologic behavior. It involves the tasks of stabilizing breathing, reducing the number of startles and tremors and maintaining temperature control. To regulate or control motor behavior. This means gaining control over and inhibiting random motor movements, developing well-modulated muscle tone, and reducing excessive motor activity.
17
Basic Developmental Tasks….. 3. State regulation or organization of state. This is the ability to develop robust and predictable sleep and wake states called sleep protection, or the ability to screen out negative stimuli while asleep. State control means that the infant is able to deal with stress either through selfregulation strategies like hand-to-mouth maneuvers or through communication with the caregiver by crying. 18
Basic Developmental Tasks….. 4. Regulation of attentionalinteractive, or social, behavior. This involves the capacity to maintain prolonged alert periods, the ability to attend to visual and auditory stimuli within his range, and the ability to seek out and engage in social interaction with the caregiver.
19
First Months of Life…..
Constitute a major transition stage in the development of the parent-infant relationship. Affective attunement between the parent and infant is taking shape. NBO identifies where the infant needs support and how they can provide this support such as concerns about sleep and crying of the infant
20
Neonatal Behavioral States of Arousal…
Deep sleep state: regular, shallow breathing, eyes closed, no spontaneous movement, and no rapid eye movement; startles or jerky movements appear at regular intervals (every 5 minutes)
21
22
Light sleep state…..
Eyes closed, irregular respirations in depth and rate and more modulated or low motor activity; rapid eye movement is present along with facial expressions, even half-smiles, and sucking.
23
24
Drowsy or semi-alert state…..
Eyes may be half-open or open and closed; eyelids fluttering; activity levels are variable with occasional mild startle.
25
26
Quiet alert state…..
Bright look, focused attention on source of stimulation and minimal motor activity.
27
28
Active alert state…..
Eyes open; considerable motor activity with thrusting movements of the extremities;fussing may or may not be present.
29
30
Crying state…..
intense crying; require helps to stop crying.
31
32
Organization of Autonomic or Physiological Behavior: Response to Stress (Color Change)
33
Response to Stress: Startle
34
Regulating or Controlling Motor Behavior: Rooting Response
35
Sucking Response…..
36
Hand grasp…..
37
Crawling Response…..
38
State Regulation or Organization of State: Habituation to Light (Flashlight)
39
Habituation to Sound (Rattle)…..
40
Crying…..
41
Soothability…..
42
Regulation of Attentional-Interactive, or Social Behavior: Response to Face and Voice
43
Visual Response to Face
44
Orientation to Voice and to Sound (Rattle)
45
Visual Tracking (Red Ball)
46
NBO Sequence
A – Autonomic: color changes, tremors, and startles M – Motor/Reflexes: muscle tone, rooting, sucking, hand grasp, crawling response, crying, and soothability. O – Organization of state: Habituation to flashlight/rattle R – Responsivity: response to face and voice, visual response to face, orientation of voice/sound, visual tracking.
47
Profile Elicited from NBO
Infant’s competencies Infant’s individuality Parent-child relationship Supporting strategies
48
Mongolian Blue Spot
Gray or bluish pigmentation usually in the lumbo-sacral region, but maybe seen anywhere on the trunk or limbs Common among asian newborns Occurs as a result of infiltration of melanocytes deep in the dermis May be mistaken for bruising among inexperienced medical personnels or MD Rx: none; disappears gradually as infant grows older (2-4 years old)
49
Erythema Toxicum (Toxic erythema; Urticaria of NB; Eosinophil rash)
Erythematous maculo-papular rashes seen anytime during 1-3 weeks of life. Not seen in preterm infants (represent an inflammatory reaction in mature skin) Matbe mistaken for septic spots Cause unknown; suspect allergic or immediate hypersensitivity reactions Disappear spontaneously (6 days to 2 weeks) with no treatment needed
50
Vernix Caseosa
Slowy, ointment-like white substance covering the skin anywhere Amount correlates well with age of gestation (plenty among preterm while scanty term
51
Milia
Hypertrophic sebaceous glands appear as fine white spots seen on the nose and cheeks, forehead, chin Mistaken for infection Resolves spontaneously within few weeks after birth No treatment required
52
Epithelial Pearls (Epstein pearls)
Epiderma cysts which appear as clusters of white spots in the mouth at the junction of the soft and hard palate in the midline. Less commonly on the alveolar margin or on the prepuce Mistaken for infection Disappear spontaneously with no treatment 53
Ranula
Mucous retention cyst in the anterior part of the floor of the mouth Often disappear spontaneously. However, if the cyst is large which can interfere with feedings, then require surgery (Marsupialization)
54
Natal Teeth
Uncommon; often with positive family history of similar teeth (autosomal dominant) Commonly occur in the central lower incisor region in pairs, loosely attached Increased incidence of cleft lip/palate Others advocate early removal to prevent aspiration and ulceration of the tongue Dental x-ray is always indicated to differentiate premature eruption of deciduous teeth from supernummerary teeth (for extraction) 55
Sucking Pad
Appear as dry thick mucous membrane of the lips to form a pad or callous Cause unknown Resolve spontaneously with no therapy
56
Simple Nevus
are capillary hamangioma seen on the eyelids, bridge of nose, upper lip and nape Grow in size for 3-7 mos, stabilizing and then involute completely over 1-5 years Does not blanch on pressure Sturge-Weber Syndrome: nevus flammeus of the forehead and upper lip; glaucoma and contralateral Jacksonian seizures
57
Neonatal Gynecomastia/Vaginal Bleeding
Gynecomastia can occur in both sexes; gradual involution takes some months to disappear Probably due to placental transfer of maternal estrogen, progesterone and prolactin Breast enlargement with lactation (witch’s milk); mastitis No treatment except antibiotic for mastitis
58
Sacral Pits/Dimples
May have associated abnormalities like hemangiomata, hairy nevi, or lipomas and assocaited with tethering (tieing) of the cauda equina (diastatomyelia) r/o fistula, require X-Ray Frequent cause of recurrent meningitis 59
Vulval tag
A long and pedunculated tag of membrane in the posterior vulval region of female NB Resolves spontaneously
60
Umbilical Cord
Normally, 2 arteries and 1 vein Average length at term 50-60 cm Greenish-yellow staining of umbilicus: rH blood incompatibilities or with fetal distress 2 vessels (1A1V) indicates congenital renal malformations or genetic problem like Trisomy 18 Usually falls off w/in 7-10 days after birth
61
Stools
Meconium stools are sticky, tarry, greenish-black stools within 48 hrs after birth Failure to pass after 48 hrs: intestinal obstruction and Hirschprung disease Pass before birth: fetal distress Transitional stools are softer, greenish with mucus and occur at the time of onset of feeding
62
Stools
Breastfed baby’s stools: mustard yellow or greenish yellow; soft or semi-formed and occasional liquid, faint sweet odor and pass frequently after or during feeding Bottle-fed baby’s stool: firmer, browner, and passed less frequently; odor vary accordingly to the milk formula
63
Neonatal Jaundice
Very common; 50% full term and 80% preterm infants visibly jaundiced by 3-5 days of life Clinical jaundice once the serum bilirubin reaches 5 mg/dl Physiologic jaundice noted after 24-48 hr of life: Term peak 3th-4th day and disappear 7th-10th day Preterm peak 5th day and ends at 2 wk old Reasons: increase red cell mass ( high hct) and short RBC life span ( 70-90 days which normally, 120 days
64
Neonatal Jaundice
Pathologic jaundice: Occurs on the 1st 24 hr of life Bilirubin increase >0.5 mg/dl/hr Peak bilirubin >12 mg/dl term and >15 mg/dl preterm during the 1st wk of life Associated with hepatosplenomegaly Clinical jaundice persisting > 1 wk term and > 2 week preterm
65
Breastfeeding Jaundice
Early onset of jaundice within the first 3-4 days of life Also called exaggerated physiologic jaundice; lack of breast milk jaundice Factors: oral water or glucose intake; inadequate nursing and decrease stool output Rx: continue breastfeeding; no complementary feeding
66
Breast Milk Jaundice
Late-onset jaundice toward the end of 1st wk of life and persists to 3 wks to 3 mo Etiology: unknown constituent in BM but exact mechanism unknown Diagnosis by exclusion Rx: Bilirubin levels < 20 mg/dl : no intervention > 20 mg/dl: stop BM X 1-2 days; resume BM if jaundice decreases; otherwise, phototherapy
67
Primitive Reflexes
Generally assesses the extent of CNS maturational development Does not localize a particular pathological or anatomical lesion in the brain Delayed disappearance of primitive reflexes may be an early sign of cerebral palsy 68
Primitive Reflexes
Moro reflex: appear at birth and disappear at 4-5 mo Assymetric moro reflex: fracture of humerus or clavicle; brachial plexus palsy Grasp reflex: plantar disappear 9 mo while palmar gone 4 mo Sucking/rooting reflexes Automatic walking reflex gone 2-3 mo Assymetric tonic reflex disappear 6 mo (prerequisite for sitting) 69
Cephalhematoma
Subperiosteal bleeding caused by rupture of small vessels in the periosteum Often associated with caput succedaenium Not apparent at birth Swelling never crosses the suture (However if crosses, R/0 fracture) Disappear spontaneously, sometimes accpd by calcification and takes 2-3 months to disappear Jaundice is a common complication in the first few week of life
70
Facial Palsy
Compression of the facial nerve Caused by pressure from forceps blade but may occur even after normal delivery Clinically, decrease forehead wrinkling; increase eye opening; decrease naso-labial fold and flattening of corner of the mouth Majority resolves spontaneously 71
Brachial Plexus Palsy
Stretch injury to brachial plexus Major predisposing factors: shoulder dystocia (unanticipated or unrecognized) Associated factors: fetal macrosomia; breech delivery; multiparity; prolonged 2nd stage labor; midforceps delivery Types: a. Erb’s Palsy: secondary to injury of C5-C6 nerve roots (90-95%) > clinically, assymetric moro reflex; affected arm in waiter’s tip position; decraese to absent DTR; R>L; breech-bilateral
72
a. Erb’s Palsy….. Associated findings: asphyxia; facial palsy; fractured clavicle/humerus; cephalhematoma; cervical cord injury; diaphragmatic paralysis (5%) b. Klumpe’s Palsy: > injury to C7, C8-T1 nerve roots > loss of wrist movement and grasp reflex > Horner’s syndrome(ptosis; miosis; anhidrosis) c. Combination
73
Brachial Plexus Palsy
Prognosis: 75-90% resolves spontaneously within weeks to 3 mo. Recovery better for Erb’s than Klumpe’s (+) Horner’s syndrome is a bad prognostic sign
74
Postural Talipes
Breech delivery Affected foot is held in varus (inturned) position Easily reduced by passive manipulation or spilnting In contrast to Talipes equinovarus (fixed flexion) can’t be passively corrected; require surgery 75
Strawberry Nevi
Are dilated capillaries commonly seen among preterms Usually not present at birth;appear w/in 1st few weeks of life Single or multiple; may occur anywhere on the body Disappear eventually w/ no rx
76
Cavernous Hemangiomata
Bigger size of hemangioma; mixture of veins and capillaries Majority don’t regress and may actually incraese in size If present together with thrombocytopenia and microangiopathic changes of rbc : Kasabach-Meritt syndrome Require surgery 77
Neural Tube Defects
Inheritance: polygenic; recurrence risk 1:20 in the next pregnancy Antenatal dx: increase alphafetoprotein in amniotic fluid and maternal serum during the second trimester and ultrasound Meningocoele; meningomyelocoele; encephalocoele and spina bifida 78
Hydrocephalus
Occur as an isolated congenital deformity Commonly due to aqueductal stenosis or secondary to IVH or meningitis or neural tube defects
79
Cleft Lip/ Palate
Inheritance: polygenic Cleft lip repairs first followed by cleft palate
80
Anencephaly
Causes hypopituitarism Incompatible to life (seldom live beyond 24 hrs)
81
Congenital Cataract
Inheritance: autosomal dominant May be seen in rubella or galactosemia Rule out: retinoblastoma
82
Cystic Hygroma
Cystic swelling of the lateral part of neck Can cause dysphagia or respiratory obstruction if it enlarges rapidly Rx: surgery
83
Congenital Hip Dislocation Common in girls and in breech presentation Test: Ortolani test (reduction test) causes reduction by abduction producing “clunk” (bringing back the femoral head to acetabulum) *Early dx is crucial because it may affect baby’s crawling or walking potential later on
84
Cyanosis Central cyanosis: bluish skin including tongue and lips > secondary to decrease 02 saturation to blood > secondary to heart or lung diseases *Peripheral cyanosis: bluish skin with pink lips and tongue > secondary to methhemoglobinemia • Acrocyanosis: bluish hands and feet only • >normal during the first few hours of life or due to cold stress • > poor tissue perfusion as in shock
85
Down Syndrome (Trisomy 21)
Extra chromosome at 21 Parents should be screened for translocation because of high probability to recur Mosaic type has better developmental outcome, less complication
86
Ambiguous Genitalia
UGLYS
87
Osteogenesis Imperfecta (Brittle Bone Disease)
Autosomal recessive Multiple fractures and callus formation
88
Congenital Hypothyroidism (Cretinism)
89
Infant of Diabetic Mother
LGA
90
Hydrops Fetalis
Gross generalized edema Causes: 1. immune hydrops: Rh isoimmunization; Rhogam 300 mg IM at 28-32 weeks gestation 2. Non-immune hydrops: TORCH; thalassemia; congenital nephrotic syndrome etc 91
Impetigo
Secondary to Staph aureus
92
Neonatal Opthalmia
Gonococcal: w/in 48 hrs after birth Chlamydia: 2nd week of life but may co-exist with gonococcal
93
Oral Thrush
Secondary to Candida albicans Common especially after antibiotic therapy
94
Congenital Chickenpox
Maternal history of chickenpox 1421 days before delivery Lesions appear by 10 days of life
95
Umbilical Hernia
96
Umbilical Granuloma
A pedunculated pink mass inside the umbilicus with sero-sanguinous discharge
97
Inguinal Hernia
98
Hydrocoele
99
Hypospadia
100
Imperforate Anus
VATER: vertebral abnormalities; anal atresia; TEF and radial and renal dysplasia VACTERL: same as in VATER plus cardiac and limb abnormalities
101
Meconium Staining of Skin and Nails
Sign of fetal distress Passage of meconium in NB < 34 wks gestation UNUSUAL
102
pulse (normal, 120–160 beats/min), respiratory rate (normal, 30–60 breaths/min) Blood pressure is determined if a neonate appears ill or has a heart murmur. . Such movements tend to occur when an infant is active, whereas convulsive twitching usually occurs in a quiet state 103
Edema may produce a superficial appearance of good nutrition but the skin of the fingers and toes lacks the normal fine wrinkles when filled with fluid. Edema of the eyelids commonly results from irritation caused by the administration of silver nitrate. Generalized edema may occur with prematurity, hypoproteinemia secondary to severe erythroblastosis fetalis, nonimmune hydrops, congenital nephrosis, Hurler syndrome, or unknown cause. Localized edema suggests a congenital malformation of the lymphatic system; when confined to one or more extremities of a female infant, it may be the initial sign of Turner syndrome
104
o
Vasomotor instability and peripheral circulatory sluggishness are revealed by deep redness or purple lividity in a crying infant, whose color may darken profoundly with closure of the glottis preceding a vigorous cry, and by harmless cyanosis (acrocyanosis) of the hands and feet, especially when they are cool Mottling, another example of general circulatory instability extraordinary division of the body from the forehead to the pubis into red and pale halves is known as harlequin color change, a transient and harmless condition cyanosis may be masked by the pallor of circulatory failure or anemia; the relatively high hemoglobin content of the 1st few days and the thin skin may combine to produce an appearance of cyanosis at a higher Pao2 than in older children. 105
Pallor may represent asphyxia, anemia, shock, or edema. Early recognition of anemia may lead to a diagnosis of erythroblastosis fetalis, subcapsular hematoma of the liver or spleen, subdural hemorrhage, or fetalmaternal or twin-twin transfusion. Without being anemic, postmature infants tend to have paler and thicker skin than term or premature infants do. The ruddy red appearance of plethora is seen with polycythemia. Cavernous hemangiomas are deeper, blue masses that if large, may trap platelets and produce disseminated intravascular coagulation or interfere with local organ function Scattered petechiae , seen on(usually the scalp or 106 face) after difficult delivery
vernix, skin, and especially the cord may be stained brownish yellow if the amniotic fluid has been colored by the passage of meconium during or before birth. skin of premature infants is thin and delicate and tends to be deep red; in extremely premature infants, the skin appears almost gelatinous and bleeds and bruises easily Fine, soft, immature hair, lanugo, frequently covers the scalp and brow and may also cover the face of premature infants. Lanugo has usually been lost or replaced by vellus hair in term infant Tufts of hair over the lumbosacral spine suggest an underlying abnormality such as occult spina bifida, a sinus tract, or a tumor. 107
nails are rudimentary in very premature infants, but they may protrude beyond the fingertips in infants born past term. Post-term infants have peeling, parchment-like skin, a severe degree of which suggests ichthyosis congenita Pustular melanosis, a benign lesion seen in black neonates, contains neutrophils and is ; it lasts 2–3 days
108
Amniotic bands may disrupt the skin, extremities (amputation, ring constriction, syndactyly), face (clefts), or trunk (abdominal or thoracic wall defects). Their cause is uncertain but may be related to amniotic membrane rupture or vascular compromise with fibrous band formation.
109
Excessive skin fragility and extensibility with joint hypermobility suggest EhlersDanlos syndrome, Marfan syndrome, congenital contractural arachnodactyly, or other disorders of collagen syn by cesarean section or breech presentation is characterized by its roundness Premature fusion of sutures (cranial synostosis) is identified by a hard nonmovable ridge over the suture and an abnormally shaped skull. 110
small fontanels suggest microcephaly, craniosynostosis, congenital hyperthyroidism, or wormian bones 3rd fontanel suggests trisomy 21 but is seen in preterm infants Soft areas (craniotabes) are occasionally found in the parietal bones 111
common in premature infants and in infants who have been exposed to uterine compression. Soft areas in the occipital region suggest the irregular calcification and wormian bone formation associated with osteogenesis imperfecta, cleidocranial dysostosis, lacunar skull, cretinism, and, occasionally, Down syndrome 112
excessively large head (megalencephaly) suggests hydrocephaly, storage disease, achondroplasia, cerebral gigantism, neurocutaneous syndromes, or inborn errors of metabolism skull of a premature infant may suggest hydrocephaly
113
Atrophic or alopecic scalp areas may represent aplasia cutis congenita Symmetric facial palsy suggests absence or hypoplasia of the 7th nerve nucleus (Möbius syndrome). Retinal hemorrhages are more common with vacuum-assisted deliveries resolve in most infants by 2 wk (85%) and in all infants by 4 wk
114
cornea larger than 1 cm in diameter in a term infant (with photophobia and tearing) suggests congenital glaucoma presence of bilateral red reflexes suggests the absence of cataracts and intraocular pathology
115
Leukokoria (white pupillary reflex) suggests cataracts, tumor, chorioretinitis, retinopathy of prematurity, or a persistent hyperplastic primary vitreous and warrants Dislocation of the nasal cartilage from the vomerian groove results in asymmetric nares. 116
Anatomic obstruction of the nasal passages secondary to unilateral or bilateral choanal atresia results in respiratory distress. Neonates do not have active salivation. The tongue appears relatively large
117
frenulum may be short, but rarely is shortness (tongue-tied or ankyloglossia marble-sized buccal mass is usually due to benign idiopathic fat necrosis throat of a newborn infant is hard to see because of low arch of the palate; viewed because it is easy to miss posterior palatal or uvular clefts. The tonsils are small.
118
Congenital torticollis causes the head to turn toward and the face to turn away from the affected side\ Redundant skin or webbing in a female infant suggests intrauterine lymphedema and Turner syndrome Both clavicles should be palpated for fractures
119
rate consistently over 60/min during periods of regular breathing usually indicates pulmonary, cardiac, or metabolic disease (acidosis). rate consistently over 60/min during periods of regular breathing usually indicates pulmonary, cardiac, or metabolic disease (acidosis 120
breathing of newborn infants is almost entirely diaphragmatic, so during inspiration the soft front of the thorax is usually drawn inward while the abdomen protrudes. If the baby is quiet, relaxed, and of good color, this “paradoxical movement” breath sounds are bronchovesicular
121
Transitory murmurs usually represent a closing ductus arteriosus. Premature infants, whose resting heart rate is usually 140–,150/min, may have a sudden onset of sinus bradycardia Pulses should be palpated in the upper and lower extremities to 122 detect coarctation of the aorta
oscillometric method is the easiest and most accurate noninvasive method Renal pathology is the cause of most neonatal abdominal masses solid flank mass may be caused by renal vein thrombosis, s/s hematuria, hypertension, and thrombocytopenia.
123
Abdominal distention at birth -suggests either obstruction or perforation of GIT result of meconium ileus; later distention suggests lower bowel obstruction, sepsis, peritonitis. scaphoid abdomen in a newborn suggests diaphragmatic hernia 124
Abdominal wall defects produce an omphalocele when through t umbilicus gastroschisis when they occur lateral to the midline Omphaloceles are assd with as Beckwith-Wiedemann, conjoined twins, trisomy 18, meningomyelocele, and imperforate anus
125
Omphalitis is an acute local inflammation of the periumbilical tissue LEAD TO PORTAL HYPERTENSION single umbilical artery suggests an occult renal anomaly. imperforate hymen may result in hydrometrocolpos and a lower abdominal mass 126
SCROTUM increased by the trauma of breech delivery or by a transitory hydrocele manifestations of fetal neuromuscular disease -breech presentation, polyhydramnios, failure to breathe at birth, pulmonary hypoplasia, dislocated hips, undescended testes, thin ribs, and clubfoot. 127
1
Pattern of Successful Transition from Intrauterine to Extrauterine Life…..
Expansion of lungs following initiation of first several breaths which clear the fetal lung fluid and termination of right-to-left shunting Elevation of P02 in both the alveoli and the arterial circulation (50-70 mm Hg) Decrease in pulmonary vascular resistance Conversion from fetal to neonatal circulation
2
Transitional Period:The First 6 Hours of Adaptation From Intrauterine to Extrauterine Life
Patterns of Activity A. First 15 to 30 minutes 1. immediate tachycardia to 160-180 beats/min, gradual drop to 100-120 beats/min. 2. irregular respirations, tachypnea to 60-80/min, brief apnea. 3. moist-sounding lung fields, transient grunting and retraction. 4. awake, moving, alert, easily startled, crying, transient tremors.
3
Next 60 to 90 minutes….. 1.
2.
3. 4.
sleepy, or sleeping, somewhat unresponsive. Heart rate 100-120 beats/min, transient tachycardia. RR 50-60/min, transient tachypnea Usually, passage of meconium.
4
The next 10 min to several hours…
Again, awake, alert, easily startled, crying, easily stimulated, and reactive At last, behaving like a baby, “Over” being born, eager for feeding and the world, and eager at times for sleep.
5
Routine Newborn Care….. Thermoregulation: > First temperature reading – rectal* route; succeeding readings-axillary route. > whenever possible, a digital thermometer is preferred over a mercurial thermometer > delivery room temp. should be at 250 to 280C w/o drafts > Keep baby temperature between 36.50 to 37.50C *not affected by the environment
6
Thermoregulation…..
Kangaroo Mother Care - skin to skin contact specific for low birth weight babies
7
Latching on…..
Initiating breastfeeding within 1 hour after birth Check for signs of the baby’s readiness to breastfeed (e.g., baby looking around/moving, mouth open, searching) Neonatal risk of death increased by delayed initiation of breastfeeding 8
Neonatal Risk of Death….. Breastfeeding Within 1hr Day 2 Day 3 After day 3
RR of Death 1 4 5 11
9
Cord care…..
Initial cord care should include an iodophor solution for its bactericidal properties, followed by 70% alcohol. Thereafter, 70% alcohol may be continued as an antiseptic agent to minimize microbial colonization
10
Eye care…..
Erythromycin 0.5% or tetracycline 1% eye ointment should be applied soon after birth to prevent gonococcal or chlamydia opthalmia. Bathing: between 1-4 hours after birth. Immediate bathing is indicated for babies born to mothers with infection like HIV.
11
Vitamin K…..
Natural vitamin K1 oxide (phyto nadione) 1 mg IM for term; 0.5 mg IM for prematures to prevent Hemorrhagic Disease of the Newborn.
12
Other preventive care…..
BCG Hepatitis B vaccination Newborn Screening
13
Danger signs to watch out for…..
Deepening jaundice up to palms and soles or persistent jaundice beyond two weeks of life Decreased sucking reflex or refusal to feed Unusual sleepiness No urine output for > 8 hours Temperature instability Unusual movements Fast breathing w/ or w/o cyanosis or pallor 14
The Newborn Behavioral Observations System (NBO)…..
Provides a formal measure of an infant’s neurodevelopmental competencies, including state control, autonomic reactivity, reflexes, habituation, and orientation toward auditory and visual stimuli. Used to demonstrate to parents an infant’s capabilities and vulnerabilities. Used to support the development of positive early parent-infant relationships Served as therapeutic alliance with the caregiver 15
The First 3 Months of Life…. A period of rapid developmental transition First Month: - dominate face to face interactions o Second Month: - show a wide range of facial expressions and emotional responses, from interest to concentration to astonishment and pleasure o Third Month: - duration of smiles and cooing increased
16
Basic Developmental Tasks….. 1.
2.
To organize his autonomic or physiologic behavior. It involves the tasks of stabilizing breathing, reducing the number of startles and tremors and maintaining temperature control. To regulate or control motor behavior. This means gaining control over and inhibiting random motor movements, developing well-modulated muscle tone, and reducing excessive motor activity.
17
Basic Developmental Tasks….. 3. State regulation or organization of state. This is the ability to develop robust and predictable sleep and wake states called sleep protection, or the ability to screen out negative stimuli while asleep. State control means that the infant is able to deal with stress either through selfregulation strategies like hand-to-mouth maneuvers or through communication with the caregiver by crying. 18
Basic Developmental Tasks….. 4. Regulation of attentionalinteractive, or social, behavior. This involves the capacity to maintain prolonged alert periods, the ability to attend to visual and auditory stimuli within his range, and the ability to seek out and engage in social interaction with the caregiver.
19
First Months of Life…..
Constitute a major transition stage in the development of the parent-infant relationship. Affective attunement between the parent and infant is taking shape. NBO identifies where the infant needs support and how they can provide this support such as concerns about sleep and crying of the infant
20
Neonatal Behavioral States of Arousal…
Deep sleep state: regular, shallow breathing, eyes closed, no spontaneous movement, and no rapid eye movement; startles or jerky movements appear at regular intervals (every 5 minutes)
21
22
Light sleep state…..
Eyes closed, irregular respirations in depth and rate and more modulated or low motor activity; rapid eye movement is present along with facial expressions, even half-smiles, and sucking.
23
24
Drowsy or semi-alert state…..
Eyes may be half-open or open and closed; eyelids fluttering; activity levels are variable with occasional mild startle.
25
26
Quiet alert state…..
Bright look, focused attention on source of stimulation and minimal motor activity.
27
28
Active alert state…..
Eyes open; considerable motor activity with thrusting movements of the extremities;fussing may or may not be present.
29
30
Crying state…..
intense crying; require helps to stop crying.
31
32
Organization of Autonomic or Physiological Behavior: Response to Stress (Color Change)
33
Response to Stress: Startle
34
Regulating or Controlling Motor Behavior: Rooting Response
35
Sucking Response…..
36
Hand grasp…..
37
Crawling Response…..
38
State Regulation or Organization of State: Habituation to Light (Flashlight)
39
Habituation to Sound (Rattle)…..
40
Crying…..
41
Soothability…..
42
Regulation of Attentional-Interactive, or Social Behavior: Response to Face and Voice
43
Visual Response to Face
44
Orientation to Voice and to Sound (Rattle)
45
Visual Tracking (Red Ball)
46
NBO Sequence
A – Autonomic: color changes, tremors, and startles M – Motor/Reflexes: muscle tone, rooting, sucking, hand grasp, crawling response, crying, and soothability. O – Organization of state: Habituation to flashlight/rattle R – Responsivity: response to face and voice, visual response to face, orientation of voice/sound, visual tracking.
47
Profile Elicited from NBO
Infant’s competencies Infant’s individuality Parent-child relationship Supporting strategies
48
Mongolian Blue Spot
Gray or bluish pigmentation usually in the lumbo-sacral region, but maybe seen anywhere on the trunk or limbs Common among asian newborns Occurs as a result of infiltration of melanocytes deep in the dermis May be mistaken for bruising among inexperienced medical personnels or MD Rx: none; disappears gradually as infant grows older (2-4 years old)
49
Erythema Toxicum (Toxic erythema; Urticaria of NB; Eosinophil rash)
Erythematous maculo-papular rashes seen anytime during 1-3 weeks of life. Not seen in preterm infants (represent an inflammatory reaction in mature skin) Matbe mistaken for septic spots Cause unknown; suspect allergic or immediate hypersensitivity reactions Disappear spontaneously (6 days to 2 weeks) with no treatment needed
50
Vernix Caseosa
Slowy, ointment-like white substance covering the skin anywhere Amount correlates well with age of gestation (plenty among preterm while scanty term
51
Milia
Hypertrophic sebaceous glands appear as fine white spots seen on the nose and cheeks, forehead, chin Mistaken for infection Resolves spontaneously within few weeks after birth No treatment required
52
Epithelial Pearls (Epstein pearls)
Epiderma cysts which appear as clusters of white spots in the mouth at the junction of the soft and hard palate in the midline. Less commonly on the alveolar margin or on the prepuce Mistaken for infection Disappear spontaneously with no treatment 53
Ranula
Mucous retention cyst in the anterior part of the floor of the mouth Often disappear spontaneously. However, if the cyst is large which can interfere with feedings, then require surgery (Marsupialization)
54
Natal Teeth
Uncommon; often with positive family history of similar teeth (autosomal dominant) Commonly occur in the central lower incisor region in pairs, loosely attached Increased incidence of cleft lip/palate Others advocate early removal to prevent aspiration and ulceration of the tongue Dental x-ray is always indicated to differentiate premature eruption of deciduous teeth from supernummerary teeth (for extraction) 55
Sucking Pad
Appear as dry thick mucous membrane of the lips to form a pad or callous Cause unknown Resolve spontaneously with no therapy
56
Simple Nevus
are capillary hamangioma seen on the eyelids, bridge of nose, upper lip and nape Grow in size for 3-7 mos, stabilizing and then involute completely over 1-5 years Does not blanch on pressure Sturge-Weber Syndrome: nevus flammeus of the forehead and upper lip; glaucoma and contralateral Jacksonian seizures
57
Neonatal Gynecomastia/Vaginal Bleeding
Gynecomastia can occur in both sexes; gradual involution takes some months to disappear Probably due to placental transfer of maternal estrogen, progesterone and prolactin Breast enlargement with lactation (witch’s milk); mastitis No treatment except antibiotic for mastitis
58
Sacral Pits/Dimples
May have associated abnormalities like hemangiomata, hairy nevi, or lipomas and assocaited with tethering (tieing) of the cauda equina (diastatomyelia) r/o fistula, require X-Ray Frequent cause of recurrent meningitis 59
Vulval tag
A long and pedunculated tag of membrane in the posterior vulval region of female NB Resolves spontaneously
60
Umbilical Cord
Normally, 2 arteries and 1 vein Average length at term 50-60 cm Greenish-yellow staining of umbilicus: rH blood incompatibilities or with fetal distress 2 vessels (1A1V) indicates congenital renal malformations or genetic problem like Trisomy 18 Usually falls off w/in 7-10 days after birth
61
Stools
Meconium stools are sticky, tarry, greenish-black stools within 48 hrs after birth Failure to pass after 48 hrs: intestinal obstruction and Hirschprung disease Pass before birth: fetal distress Transitional stools are softer, greenish with mucus and occur at the time of onset of feeding
62
Stools
Breastfed baby’s stools: mustard yellow or greenish yellow; soft or semi-formed and occasional liquid, faint sweet odor and pass frequently after or during feeding Bottle-fed baby’s stool: firmer, browner, and passed less frequently; odor vary accordingly to the milk formula
63
Neonatal Jaundice
Very common; 50% full term and 80% preterm infants visibly jaundiced by 3-5 days of life Clinical jaundice once the serum bilirubin reaches 5 mg/dl Physiologic jaundice noted after 24-48 hr of life: Term peak 3th-4th day and disappear 7th-10th day Preterm peak 5th day and ends at 2 wk old Reasons: increase red cell mass ( high hct) and short RBC life span ( 70-90 days which normally, 120 days
64
Neonatal Jaundice
Pathologic jaundice: Occurs on the 1st 24 hr of life Bilirubin increase >0.5 mg/dl/hr Peak bilirubin >12 mg/dl term and >15 mg/dl preterm during the 1st wk of life Associated with hepatosplenomegaly Clinical jaundice persisting > 1 wk term and > 2 week preterm
65
Breastfeeding Jaundice
Early onset of jaundice within the first 3-4 days of life Also called exaggerated physiologic jaundice; lack of breast milk jaundice Factors: oral water or glucose intake; inadequate nursing and decrease stool output Rx: continue breastfeeding; no complementary feeding
66
Breast Milk Jaundice
Late-onset jaundice toward the end of 1st wk of life and persists to 3 wks to 3 mo Etiology: unknown constituent in BM but exact mechanism unknown Diagnosis by exclusion Rx: Bilirubin levels < 20 mg/dl : no intervention > 20 mg/dl: stop BM X 1-2 days; resume BM if jaundice decreases; otherwise, phototherapy
67
Primitive Reflexes
Generally assesses the extent of CNS maturational development Does not localize a particular pathological or anatomical lesion in the brain Delayed disappearance of primitive reflexes may be an early sign of cerebral palsy 68
Primitive Reflexes
Moro reflex: appear at birth and disappear at 4-5 mo Assymetric moro reflex: fracture of humerus or clavicle; brachial plexus palsy Grasp reflex: plantar disappear 9 mo while palmar gone 4 mo Sucking/rooting reflexes Automatic walking reflex gone 2-3 mo Assymetric tonic reflex disappear 6 mo (prerequisite for sitting) 69
Cephalhematoma
Subperiosteal bleeding caused by rupture of small vessels in the periosteum Often associated with caput succedaenium Not apparent at birth Swelling never crosses the suture (However if crosses, R/0 fracture) Disappear spontaneously, sometimes accpd by calcification and takes 2-3 months to disappear Jaundice is a common complication in the first few week of life
70
Facial Palsy
Compression of the facial nerve Caused by pressure from forceps blade but may occur even after normal delivery Clinically, decrease forehead wrinkling; increase eye opening; decrease naso-labial fold and flattening of corner of the mouth Majority resolves spontaneously 71
Brachial Plexus Palsy
Stretch injury to brachial plexus Major predisposing factors: shoulder dystocia (unanticipated or unrecognized) Associated factors: fetal macrosomia; breech delivery; multiparity; prolonged 2nd stage labor; midforceps delivery Types: a. Erb’s Palsy: secondary to injury of C5-C6 nerve roots (90-95%) > clinically, assymetric moro reflex; affected arm in waiter’s tip position; decraese to absent DTR; R>L; breech-bilateral
72
a. Erb’s Palsy….. Associated findings: asphyxia; facial palsy; fractured clavicle/humerus; cephalhematoma; cervical cord injury; diaphragmatic paralysis (5%) b. Klumpe’s Palsy: > injury to C7, C8-T1 nerve roots > loss of wrist movement and grasp reflex > Horner’s syndrome(ptosis; miosis; anhidrosis) c. Combination
73
Brachial Plexus Palsy
Prognosis: 75-90% resolves spontaneously within weeks to 3 mo. Recovery better for Erb’s than Klumpe’s (+) Horner’s syndrome is a bad prognostic sign
74
Postural Talipes
Breech delivery Affected foot is held in varus (inturned) position Easily reduced by passive manipulation or spilnting In contrast to Talipes equinovarus (fixed flexion) can’t be passively corrected; require surgery 75
Strawberry Nevi
Are dilated capillaries commonly seen among preterms Usually not present at birth;appear w/in 1st few weeks of life Single or multiple; may occur anywhere on the body Disappear eventually w/ no rx
76
Cavernous Hemangiomata
Bigger size of hemangioma; mixture of veins and capillaries Majority don’t regress and may actually incraese in size If present together with thrombocytopenia and microangiopathic changes of rbc : Kasabach-Meritt syndrome Require surgery 77
Neural Tube Defects
Inheritance: polygenic; recurrence risk 1:20 in the next pregnancy Antenatal dx: increase alphafetoprotein in amniotic fluid and maternal serum during the second trimester and ultrasound Meningocoele; meningomyelocoele; encephalocoele and spina bifida 78
Hydrocephalus
Occur as an isolated congenital deformity Commonly due to aqueductal stenosis or secondary to IVH or meningitis or neural tube defects
79
Cleft Lip/ Palate
Inheritance: polygenic Cleft lip repairs first followed by cleft palate
80
Anencephaly
Causes hypopituitarism Incompatible to life (seldom live beyond 24 hrs)
81
Congenital Cataract
Inheritance: autosomal dominant May be seen in rubella or galactosemia Rule out: retinoblastoma
82
Cystic Hygroma
Cystic swelling of the lateral part of neck Can cause dysphagia or respiratory obstruction if it enlarges rapidly Rx: surgery
83
Congenital Hip Dislocation Common in girls and in breech presentation Test: Ortolani test (reduction test) causes reduction by abduction producing “clunk” (bringing back the femoral head to acetabulum) *Early dx is crucial because it may affect baby’s crawling or walking potential later on
84
Cyanosis Central cyanosis: bluish skin including tongue and lips > secondary to decrease 02 saturation to blood > secondary to heart or lung diseases *Peripheral cyanosis: bluish skin with pink lips and tongue > secondary to methhemoglobinemia • Acrocyanosis: bluish hands and feet only • >normal during the first few hours of life or due to cold stress • > poor tissue perfusion as in shock
85
Down Syndrome (Trisomy 21)
Extra chromosome at 21 Parents should be screened for translocation because of high probability to recur Mosaic type has better developmental outcome, less complication
86
Ambiguous Genitalia
UGLYS
87
Osteogenesis Imperfecta (Brittle Bone Disease)
Autosomal recessive Multiple fractures and callus formation
88
Congenital Hypothyroidism (Cretinism)
89
Infant of Diabetic Mother
LGA
90
Hydrops Fetalis
Gross generalized edema Causes: 1. immune hydrops: Rh isoimmunization; Rhogam 300 mg IM at 28-32 weeks gestation 2. Non-immune hydrops: TORCH; thalassemia; congenital nephrotic syndrome etc 91
Impetigo
Secondary to Staph aureus
92
Neonatal Opthalmia
Gonococcal: w/in 48 hrs after birth Chlamydia: 2nd week of life but may co-exist with gonococcal
93
Oral Thrush
Secondary to Candida albicans Common especially after antibiotic therapy
94
Congenital Chickenpox
Maternal history of chickenpox 1421 days before delivery Lesions appear by 10 days of life
95
Umbilical Hernia
96
Umbilical Granuloma
A pedunculated pink mass inside the umbilicus with sero-sanguinous discharge
97
Inguinal Hernia
98
Hydrocoele
99
Hypospadia
100
Imperforate Anus
VATER: vertebral abnormalities; anal atresia; TEF and radial and renal dysplasia VACTERL: same as in VATER plus cardiac and limb abnormalities
101
Meconium Staining of Skin and Nails
Sign of fetal distress Passage of meconium in NB < 34 wks gestation UNUSUAL
102
pulse (normal, 120–160 beats/min), respiratory rate (normal, 30–60 breaths/min) Blood pressure is determined if a neonate appears ill or has a heart murmur. . Such movements tend to occur when an infant is active, whereas convulsive twitching usually occurs in a quiet state 103
Edema may produce a superficial appearance of good nutrition but the skin of the fingers and toes lacks the normal fine wrinkles when filled with fluid. Edema of the eyelids commonly results from irritation caused by the administration of silver nitrate. Generalized edema may occur with prematurity, hypoproteinemia secondary to severe erythroblastosis fetalis, nonimmune hydrops, congenital nephrosis, Hurler syndrome, or unknown cause. Localized edema suggests a congenital malformation of the lymphatic system; when confined to one or more extremities of a female infant, it may be the initial sign of Turner syndrome
104
o
Vasomotor instability and peripheral circulatory sluggishness are revealed by deep redness or purple lividity in a crying infant, whose color may darken profoundly with closure of the glottis preceding a vigorous cry, and by harmless cyanosis (acrocyanosis) of the hands and feet, especially when they are cool Mottling, another example of general circulatory instability extraordinary division of the body from the forehead to the pubis into red and pale halves is known as harlequin color change, a transient and harmless condition cyanosis may be masked by the pallor of circulatory failure or anemia; the relatively high hemoglobin content of the 1st few days and the thin skin may combine to produce an appearance of cyanosis at a higher Pao2 than in older children. 105
Pallor may represent asphyxia, anemia, shock, or edema. Early recognition of anemia may lead to a diagnosis of erythroblastosis fetalis, subcapsular hematoma of the liver or spleen, subdural hemorrhage, or fetalmaternal or twin-twin transfusion. Without being anemic, postmature infants tend to have paler and thicker skin than term or premature infants do. The ruddy red appearance of plethora is seen with polycythemia. Cavernous hemangiomas are deeper, blue masses that if large, may trap platelets and produce disseminated intravascular coagulation or interfere with local organ function Scattered petechiae , seen on(usually the scalp or 106 face) after difficult delivery
vernix, skin, and especially the cord may be stained brownish yellow if the amniotic fluid has been colored by the passage of meconium during or before birth. skin of premature infants is thin and delicate and tends to be deep red; in extremely premature infants, the skin appears almost gelatinous and bleeds and bruises easily Fine, soft, immature hair, lanugo, frequently covers the scalp and brow and may also cover the face of premature infants. Lanugo has usually been lost or replaced by vellus hair in term infant Tufts of hair over the lumbosacral spine suggest an underlying abnormality such as occult spina bifida, a sinus tract, or a tumor. 107
nails are rudimentary in very premature infants, but they may protrude beyond the fingertips in infants born past term. Post-term infants have peeling, parchment-like skin, a severe degree of which suggests ichthyosis congenita Pustular melanosis, a benign lesion seen in black neonates, contains neutrophils and is ; it lasts 2–3 days
108
Amniotic bands may disrupt the skin, extremities (amputation, ring constriction, syndactyly), face (clefts), or trunk (abdominal or thoracic wall defects). Their cause is uncertain but may be related to amniotic membrane rupture or vascular compromise with fibrous band formation.
109
Excessive skin fragility and extensibility with joint hypermobility suggest EhlersDanlos syndrome, Marfan syndrome, congenital contractural arachnodactyly, or other disorders of collagen syn by cesarean section or breech presentation is characterized by its roundness Premature fusion of sutures (cranial synostosis) is identified by a hard nonmovable ridge over the suture and an abnormally shaped skull. 110
small fontanels suggest microcephaly, craniosynostosis, congenital hyperthyroidism, or wormian bones 3rd fontanel suggests trisomy 21 but is seen in preterm infants Soft areas (craniotabes) are occasionally found in the parietal bones 111
common in premature infants and in infants who have been exposed to uterine compression. Soft areas in the occipital region suggest the irregular calcification and wormian bone formation associated with osteogenesis imperfecta, cleidocranial dysostosis, lacunar skull, cretinism, and, occasionally, Down syndrome 112
excessively large head (megalencephaly) suggests hydrocephaly, storage disease, achondroplasia, cerebral gigantism, neurocutaneous syndromes, or inborn errors of metabolism skull of a premature infant may suggest hydrocephaly
113
Atrophic or alopecic scalp areas may represent aplasia cutis congenita Symmetric facial palsy suggests absence or hypoplasia of the 7th nerve nucleus (Möbius syndrome). Retinal hemorrhages are more common with vacuum-assisted deliveries resolve in most infants by 2 wk (85%) and in all infants by 4 wk
114
cornea larger than 1 cm in diameter in a term infant (with photophobia and tearing) suggests congenital glaucoma presence of bilateral red reflexes suggests the absence of cataracts and intraocular pathology
115
Leukokoria (white pupillary reflex) suggests cataracts, tumor, chorioretinitis, retinopathy of prematurity, or a persistent hyperplastic primary vitreous and warrants Dislocation of the nasal cartilage from the vomerian groove results in asymmetric nares. 116
Anatomic obstruction of the nasal passages secondary to unilateral or bilateral choanal atresia results in respiratory distress. Neonates do not have active salivation. The tongue appears relatively large
117
frenulum may be short, but rarely is shortness (tongue-tied or ankyloglossia marble-sized buccal mass is usually due to benign idiopathic fat necrosis throat of a newborn infant is hard to see because of low arch of the palate; viewed because it is easy to miss posterior palatal or uvular clefts. The tonsils are small.
118
Congenital torticollis causes the head to turn toward and the face to turn away from the affected side\ Redundant skin or webbing in a female infant suggests intrauterine lymphedema and Turner syndrome Both clavicles should be palpated for fractures
119
rate consistently over 60/min during periods of regular breathing usually indicates pulmonary, cardiac, or metabolic disease (acidosis). rate consistently over 60/min during periods of regular breathing usually indicates pulmonary, cardiac, or metabolic disease (acidosis 120
breathing of newborn infants is almost entirely diaphragmatic, so during inspiration the soft front of the thorax is usually drawn inward while the abdomen protrudes. If the baby is quiet, relaxed, and of good color, this “paradoxical movement” breath sounds are bronchovesicular
121
Transitory murmurs usually represent a closing ductus arteriosus. Premature infants, whose resting heart rate is usually 140–,150/min, may have a sudden onset of sinus bradycardia Pulses should be palpated in the upper and lower extremities to 122 detect coarctation of the aorta
oscillometric method is the easiest and most accurate noninvasive method Renal pathology is the cause of most neonatal abdominal masses solid flank mass may be caused by renal vein thrombosis, s/s hematuria, hypertension, and thrombocytopenia.
123
Abdominal distention at birth -suggests either obstruction or perforation of GIT result of meconium ileus; later distention suggests lower bowel obstruction, sepsis, peritonitis. scaphoid abdomen in a newborn suggests diaphragmatic hernia 124
Abdominal wall defects produce an omphalocele when through t umbilicus gastroschisis when they occur lateral to the midline Omphaloceles are assd with as Beckwith-Wiedemann, conjoined twins, trisomy 18, meningomyelocele, and imperforate anus
125
Omphalitis is an acute local inflammation of the periumbilical tissue LEAD TO PORTAL HYPERTENSION single umbilical artery suggests an occult renal anomaly. imperforate hymen may result in hydrometrocolpos and a lower abdominal mass 126
SCROTUM increased by the trauma of breech delivery or by a transitory hydrocele manifestations of fetal neuromuscular disease -breech presentation, polyhydramnios, failure to breathe at birth, pulmonary hypoplasia, dislocated hips, undescended testes, thin ribs, and clubfoot. 127
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