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APGAR Scarf sign

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					APGAR
          Sign                      0                            1                                   2
Heart rate                Absent              Slow (<100)                            >100
Respiratory effort        Absent              Slow, irregular                        Good, crying
Muscle tone               Flaccid             Some flexion of extremities            Active motion
Reflex irritability       No response         Grimace                                Vigorous cry
Color                     Blue, pale          Body pink, extremities blue            Completely pink

Apgar is done at intervals
1 minute                                                5 minutes
0-4 = severe depression, requires immediate             0-7 = ↑ risk of subsequent central nervous syst
resuscitation                                           and other organ syst dysfunction
5-7 = some nervous syst depression                      8-10 Normal
8-10 = normal

3 different classifications for the newborn
                        Classification                            Birth Weight in grams
        Extremely low                                                    <1000
        Very Low                                                         <1500
        Low                                                              <2500
        Normal                                                           > 2500

                      Classification                                    Gestational Age
        Preterm                                                      < 37 weeks (259th day)
        Term                                                              37-42 weeks
        Postterm                                                           > 42 weeks

                      Classification                            Intrauterine Growth Curve
        SGA                                                           < 10th percentile
        AGA                                                        10th to 90th percentile
        LGA                                                           > 90th percentile
                 Assessing Neuromuscular Maturity
Descriptor                            Description of Descriptor
Posture (0-4)                         Observed with infant quiet and in supine position
                                      Score: 0-arms and legs extended
                                              1-slight flexion of hips and knees, arms extended
                                              2-stronger flexion of legs arms extended
                                              3-arms slightly flexed, legs flexed and abducted
                                              4-full flexion of arms and legs.
Square Window (0-4)                   The hand is flexed on the forearm between the thumb and index finger of the
                                      examiner. Enough pressure is applied to get as full a flexion as possible, and the
                                      angle between the hypothenar eminence and the ventral aspect of the forearm is
                                      measured. 90 = 0; 60 = 1; 45 = 2; 30 = 3; 0 = 4. (measured angle = attributable
                                      score)
Arm Recoil (0-2)                      With the infant in the supine position, the forearms are first flexed for 5 secs., then fully
                                      extended by pulling on the hands, and then released. The sign is fully positive if the
                                      arms return briskly to full flexion and score = 2. If the arms return to incomplete flexion
                                      the score = 1, and if the arms stay extended the score = 0.
Popliteal Angle (1-5)                 With the infant supine and the pelvis flat on the examining table, the thigh is held in the
                                      knee chest position with the examiners left index finger and thumb supporting the knee.
                                      The leg is then extended by gentle pressure from the examiners right index finger behind
                                      the ankle, and the popliteal angle is measured. Scoring is 1-5. Full extension = 0 and 90
                                      degree angle = 5
Scarf Sign (0-3)                      With the baby supine, take the infant’s hand and try to put it around the neck as far as
                                      posteriorly as possible around the opposite shoulder. Assist this maneuver by lifting the
                                      elbow across the body. See how far the elbow will cross.
                                      Score: 0-elbow reaches opposite axillary line
                                              1-elbow between midline and opposite axillary line
                                              2-elbow reaches midline
                                              3-elbow will not reach midline
Heal to Ear Maneuver (1-4)            With the baby supine, draw the baby’s foot as near to the head as it will go without
                                      forcing it. Observe the distance between the foot and head, as well as the degree of
                                      extension at the knee. Grade (1-4) according to the diagram. Note that the knee is left
                                      free and may draw down alongside the abdomen. Foot to mouth = 0 & 90 flexion at
                                      knee with knee drawn down = 4
     Term/Concept                                                          Description
NL newborns lie this way      newborn resting tone should exhibit flexion of the upper and lower extremities. Extension of the
                              extremities should result in spontaneous recoil to flexed position. Asymmetrical movements of the
                              newborn may be indicative of a fracture or neurological injury.

Harlequin Dyschromia          A cutaneous vascular phenomenon unique to neonates in the 1 st week of life occurs when the infant
                              (particularly one of low birth weight) is placed on one side. The dependent ha lf develops an
                              erythematous flush with a sharp demarcation at the midline and the upper half of the body becomes
                              pale. The color changes usually subside within a few seconds after the infant is placed supine but may
                              persist for as long as 20 mins.
Acrocyanosis                  Benign condition in which extremities are cyanotic and cool but the trunk in pink and warm.
                              Common among newborns.
Mongolian spots               Benign blue-black macule found over the lumbosacral area in 90% of Native American, black
                              and Asian infants. Usually fade w/in first few years.
Lanugo                        Fine hair covering the preterm infant’s skin
Vernix caseosa                A whitish, greasy material covering the body that decreases as term approaches.
Milia                         Multiple white papules 1mm in diameter scattered over the forehead, nose and cheeks. They
                              are present in up to 40% of newborn infants. Histologicaly, they represent superficial
                              epidermal cysts filled with keratinous material associated with the developing pilosebaceous
                              follicle. They disappear in about 3 weeks
miliaria rubra                Scattered vesicles on erythematous base, usually on face and trunk, caused by sweat gland
                              duct obstruction. Disappears spontaneously w/in weeks
Vascular Markings
Capillary Malformations (3)   Flat vascular birthmarks can be divided into two types: those that are orange or light red
(General)                     (salmon patch) and those that are dark red or bluish-red (port-wine stain).
1) Salmon Patch               light red macule found over the nape of the neck, upper eyelids and glabella. 50% of infants have such
                              lesions over their necks. Eyelid lesions fade completely within 3-6 months; those on the neck fade
                              somewhat but usually persist into adult life.
2) Port Wine Stain            Dilated capillaries. Appears as a pink to purple macular lesion of variable size. Can be as
                              large as half the body. Always present at birth and is permanent
3) Hemangiomas                Protuberant lesions commonly seen on face, scalp, back and anogenital area. May be present
                              at birth but more commonly develops w/in first 2 months. Swartz p689
Supernumerary nipples         occasionally are found on the thorax or the abdomen along a vertical line below the true nipple(s).
                              They appear as small, round, flat or slightly raised, pigmented lesions and are not clinically significant.
Single umbilical artery       newborns with a single umbilical artery often have congenital renal abnormalities.
      Term/Concept                                                        Description
Physiologic Jaundice       Develops during the 2nd or 3rd day after birth and usually subsides in 1 to 2 weeks in full-
                           term infants and 2 to 4 weeks in premature infants. It is usually transient, benign icterus.
                           Physiologic jaundice is caused by mild unconjugated (indirect-reacting) hyperbilirubinemia.
                           It is caused due to increased bilirubin production, impaired hepatic uptake and excretion of
                           bilirubin, and reabsorption of bilirubin in the small intestine.
Pathologic Jaundice        Swartz doesn’t describe pathologic jaundice but does say that if Jaudice appears before day 3 then may
                                  be indication of pathology.
                           Unverified Portion: Clinical jaundice appears at a bilirubin level of 5mg/dL and appears first on the
                                  head, progressing down the chest and abdomen as the level increases.
Anterior Fontanelle        varies from 1-4cm in any direction. The diamond-shaped junction of the coronal frontal and sagittal
                           sutures; it becomes ossified within 18-24months.
Posterior Fontanelle       should be less than 1cm. The triangular fontanel at the junction of the sagittal and lambdoid
                           sutures; ossified by the end of the 1st year.
Third Fontanelle           bony defect along the sagittal suture in the parietal bones and may be a feature of certain
                           syndromes such as trisomy 21.
Neonatal Teeth             exception to the normal sequence of development. ~85% are lower primary incisors rather than
                           supernumerary teeth. Most are hypermobile due to inadequate root formation. If aspiration is feared
                           (because of hypermobility), the tooth should be removed.
Enlarged Newborn Breast    in both males and females are often enlarged and engorged with a white liquid, sometimes
                           colloquially called “witch’s milk.” This is due to maternal estrogen effect and usually lasts
                           only a week or two.
Umbilical Cord             The stub of the umbilical cord is white, translucent, and shiny right after birth. Falls off w/in 2-3 wks.
                           Look for evidence of yellow staining by meconium as a result of fetal distress. Normally there are two
                           thick-walled umbilical arteries and one larger but thin-walled umbilical vein. A single umbilical artery
                           may be associated with congenital anomalies (kidney). Pt needs to return to clinic for eval if there is
                           redness or swelling at the base of the cord. Umbilical hernias are detectable at a few weeks of age.
1st Stool                  The first stool, which consists of meconium, is usually passed within the first 24-48 hrs after birth. If it
                           does not, malformation of the GI tract is suspected.
1st urine                  The first voiding usually occurs within 24 hrs. If it does not , the infant should be evaluated for
                           adequacy of fluid intake and bladder distention.
Cephlohematoma             subperiosteal hemorrhage limited to one cranial bone, usually the parietal. There is no
                           discoloration of the overlying scalp, and the swelling does not cross the suture line
Caput succedaneum          edema of the soft tissues over the vertex of the skull that is related to the birth process. This swelling
                           crosses the sutures and disappears after a few days.
Absence of red reflex on   In all newborns, the presence of the red reflex bilaterally suggests grossly normal eyes and the absence
fundoscopy                         suggests glaucoma or intraocular disorders.
       Term/Concept                                                        Description
Enlarged or bulging         may indicate increased intracranial pressure
fontanelles
Congenital dislocation of   flex the newborn’s legs at the hips. Hold the legs by placing your thumbs over the lesser trochanters
the hip:                    and your index fingers over the greater trochanters, and press downward toward the examination table .
                            Then simultaneously abduct the hips to almost 90 degree. The presence of a palpable or audible click
                            suggests a dislocated hip as the femoral head suddenly snaps back into the acetabulum. This is called
                            Ortolani’s sign.
Abdominal concavity         If the abdomen is scaphoid or concave, suspect a diaphragmatic hernia and that the
                            abdominal organs may be located in the chest
PKU test                    Autosomal recessive disoder of amino acid metabolism. Chronic exposure to elevated levels
                            = classic symptoms of: eczema, mental retardation, severe behavior symptoms, often seizure.
                            Test for: blood phenylalanine
Congenital hypothyroidism   Many causes, including: agenesis, dysgenesis (the most common), ectopic thyroid, deficient
                            hormone synthesis, hypothamic-pituitary defects, other rarer etiologies. T-4 & TSH messured
Hip Exam                    Technique: 1.Inspect leg contour with child supine. Presence of asymmetrical skin folds on
                                 medial aspect of thigh suggests proximally dislocated femur. At this location perineum
                                 should not be visible, if visible suspect bilaral hip dislocation.
                            T2: Place feet side by side, soles on exam table, allow hips and knees to flex. Observe relative
                                 height of knees. If one at lower level, suspect shorter knee caused by dislocation of hip
                                 on that side and/or congentally shorter femur.
                            T3: Examine each hip for joint stability. Child supine:Flex legs at hips and press legs down towards
                                 pelvis, then abduct hips to 900 Listen/feel for clicks to suggest dislocated with replacement of
                                 femoral head into acetabulum (Ortolani’s sign). Perform gently on quiet infant
              Reflex            Disappears (Months)                                         Description
      Rooting response                  3-4            Head turns to the side of a facial stimulus
      Palmar grasp                      3-5            grasp with placement of the examiner’s finger in the palm
      Moro’s reflex (startle)           3-5            Hold baby supine and support head. Allow the head to drop1-2 cm suddenly.
                                                       The arms will abduct at the shoulder and extend at the elbow. Adduction with
                                                       flexion will follow. The hands show a prominent spreading or extension of the
                                                       fingers.
      Sucking                                          Sucking in response to a nipple of finger in the mouth
      Tonic neck                         8             With baby supine turn the head to one side. The arms/legs on that side will
                                                       extend while the opposite arm and leg flex
      Placing response                  2-5            Rub the dorsum of one foot on the underside of a surface. The infant will flex the knee
                                                       and bring the foot up. Response isn’t present until about 4-5 days after birth
      Babinski                                         Upgoing fan of toes. Sometimes several beats of ankle clonus
      Traction                                         The infant is pulled by the arms to a sitting position. Initially, the head lags,
                                                       then with active flexion comes to the midline briefly before falling forward

These are from current p7. Not all the disappearing dates are listed.