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.
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