Newborn assessment

1. New Born Health Assessment Hafiza AfrinHafiza Afrin Nursing Instructor, JBFNINursing Instructor, JBFNI BSN(DU),MPH(NSUBSN(DU),MPH(NSU)

2. Health Assessment of the Newborn The newborn requires thorough skilled observation to ensure a satisfactory adjustment to extra uterine life.

3. Health assessment of newborn after delivery can be divided into: 1. Initial Assessment 2. Transitional Assessment 3. Assessment of gestational age 4. Behavioural assessment 5. Systemic physical examination

4. Initial Assessment Initial assessment is done by using the APGAR scoring system. APGAR Score APGAR score: It is method use to assess the newborn’s immediate adjustment to extra uterine life The score based on five signs • 1. Appearance (colour) • 2. Pulse ( Heart rate) • 3. Grimace (Reflex irritability ) • 4. Activity(Muscle tone) • 5. Respiratory rate

5. • Each item is given a score 0, 1, or 2 • 0-3 severe distress • 4-6 moderate difficulty • 7-10 no difficulty adjusting to life • Evaluation of all five categories are made on 1- 5 min after birth.

6. Apgar Score Sign 0 1 2 Appearance (colour) Blue or pale Body pink, Extrimities Blue Completely Pink Pulse (Heart rate) Absent Slow (<100/min) > 100/m Grimace (Reflex irritability ) No response Grimace Cough Or Sneeze Activity(Muscle tone Limp Some flexion Active movement Respiratory rate Absent Slow, Irregular Good, Crying

7. Other initial assessment are- • Stabilization • Measuring weight.

8. Transitional Assessment Transitional Assessment during the period of reactivity: First period of reactivity (6- 8 hours after birth): • During the first 30 minutes the newborn is very alert, cries vigorously, may suck a fist greedily, and appears very interested in the environment. Physiologically the respiratory rate can be as high as 80 breaths/ min, crackles may be heard, heart rate may reach 180 beats/min, bowel sound are active, mucus secretions are increased and temperature may decrease slightly.

9. Second period of reactivity: Began when the newborn awake from the deep sleep, it lasts about 2-5 hours. The newborn is alert and responsive, heart and respiratory rate are increased, gastric and respiratory secretions are increased, and passage of meconium commonly occurs. Following this stage is a period of stabilization of physiologic systems & vacillating patern of sleep & activity.

10. Gestational Age Assessment: • An accurate assessment of age is important for 2 reasons • Age and growth patterns appropriate to that age aid in identifying neonatal risks • Help in developing management plans Gestational age can measure by weight for gestational age chart.

11. Gestational Age Number of weeks that have elapsed since the first day of the last menstrual period to the time of birth. This is usually retrieved from mother’s Antenatal History. Gestational Age: • SGA- small for gestational age-weight below 10th percentile • • AGA-weight between 10 and 90th percentiles • LGA-weight above 90th percentile

12. Behavioural Assessment • While babies may not speak their first word for a year, they are born ready to communicate with a rich vocabulary of body movements, cries and visual responses: all part of the complex language of infant behavior.

13. • The Neonatal Behavioral Assessment Scale (NBAS) was developed in 1973 by Dr. T. Berry Brazelton and his colleagues. The scale represents a guide that helps parents, health care providers and researchers understand the newborn's language. " The scale is designed to reveal an infant’s strengths and preferences, so that parents may have a better understanding of their newborn’s capabilities.”

14. • The scale contains 28 behavioral and 18 reflex items for parents and doctors to assess. It also reviews a baby’s capabilities in several different developmental areas: autonomic, motor, state regulation, and social-interactive systems. The result is not a score, but instead an understanding of how infants integrate these areas as they adapt to their new environment.

15. Definition •Head to toe physical examination of a newborn to look for any abnormalities or pathology. •Includes biochemical screening & certain special screening (hearing assessment, Echocardiography)

16. • Assesment at birth • Physical examination • Biochemical screening • Special screening • Retinopathy Of Prematurity • Hearing assesment • Echocardiography

17. Physical examination • Complete physical examination within 24 hours of birth. • It is best to examine when the infant is quiet. • Ensure infant is naked : he/she can be in diapers, but you have to open it. • Do not forget to wash your hands prior to examination.

18. Measurements… • Head circumference : - Occipitofrontal circumference - place measuring tape around front of head, below the brow and occipital area. - Normal range 32cm-37cm • Length & Percentile (refer growth chart) • Weight & Percentile (refer groth chart)

19. Vital signs a) Temperature : Rectal b) Respirations : Normal rate is 40-60 c) Blood pressure : Correlates with gestational age, post natal age, birth weight. d) Pulse rate : Awake 120-160bpm, Asleep 70- 80bpm

20.  Colour  Plethora (deep rosy red)  Jaundice  Pallor  Cyanosis(central, peripheral, acrocyanosis)  “Blue on pink: or “Pink on blue”  Harlequin colouration  Mottling  Rashes  Milia  Erythema toxicum  Candida albicans rash  Transient neonatal pustular me  Acne neonatorum SKIN

21. SKIN  Nevi/ Pigmented Lesions  Macular hemangioma (“stork bites”)  Port –wine stain (nevus flammeus)  Mongolian spot  Cavernous hemangioma  Strawberry hemangioma

22. HEAD : General, Cuts, Bruises o Anterior and posterior fontanelles - Large anterior fontanelle - Small anterior fontanelle - Bulging fontanelle o Molding o Caput succedaneum o Cephalohematoma o Increased intracranial pressure o Craniosynostosis o Craniotabes

23. Neck & Facial Features • Face : Look for obvious abnormalities.Note the general shape of the nose, mouth and chin. Presence of syndromic features is often diagnosed clinically throughout experience. • Neck : Note shape, range of motion, and any webbing; palpate for masses – Brachial palsy – Erb’s palsy – Fractured clavicle • Ears : Unusual shape, low set ears, periauricular skin tags (papillomas), hairy ears.

24. • Eyes : Observe shape, size and position of eyes. Note integrity and color of iris and sclera. Ophthalmoscopic examination to assess pupillary size and red retinal reflex • Nose : Size and Shape; Note placement of the septum Formation of the nasal bridge; Verify patency (Flat nasal bridge , Deviated septum , Choanal atresia , Nasal pit ) • Mouth : Hard & soft palate for evidence of cleft palate Neck & Facial Features

25. Chest • Observation : respiratory rate, chest symmetrical, sternal/intercostal /subcostal recession, nasal flaring, grunting, stridor • Breath sounds : Equality bilaterally, presence of any additional sound. • Pectus excavatum : sternum that is altered in shape. • Breast in newborn : May be abnormally enlarged (3-4cm) due to effects of maternal estrogens.

26. Heart : • Observation : heart rate, rhythm, quality of heart sounds, active precordium • Position of heart : may be determined by auscultation • Presence of murmur • Palpate the pulses (femoral) & define whether its normal, weak or absent. • Check for perfusion • Signs of congestive heart failure : gallop, tachycardia & abnormal pulses

27. Abdomen • Observation : scaphoid abdomen, omphalocele, gastroschisis • Palpation : Check for distension, tenderness or masses. Palpate liver, spleen, kidneys and groin and note any masses • Auscultation : Listen for bowel sound • Inspect anus for position and verify patency

28. Umbilicus • Should have 2 arteries 1 vein. • Inspect for discharge, redness or edema around base of the cord • Appearance : should be translucent. A greenish yellowish colour suggest meconium staining

29. Genitalia : Any infant with ambiguos genitalia should not undergo gender assignment until a formal endocrinology evaluation• Male • Length : > 2cm • Determine site of meatus • Palpate bilateral testicles • Examine for inguinal hernia • Look for hypospadias, epispadias, chordae. • Observe colour of scrotum • Phimosos-foreskin cannot be retracted • Cryptotorchidism-testes not descended • Female • Inspect for size and location of the labia, clitoris, meatus, and vaginal opening • Pseudomenses • Vaginal tag a small appendage or flap on the mucous membranes; common neonatal variation that usually disappears in a few weeks

30. Extremities : Examine the arms & legs paying close attention to the digits • Syndactyly • Polydactyly • Oligodactyly • Congenital Talipes Equinovarus (CTEV) • Metarsus Varus

31. Trunk & Spine • Observe curvature and integrity • Check for any gross defects of the spine. An abnormal pigmentation/ hairy patches over the lower back should increase the suspicion that an underlying vetebral abnormality exists. • A sacral or pilonidal dimple may indicate a small meningocele or other anomaly. • Spina bifida – defect in closure of the neural tube that is associated with malformations of the vertebrae & spinal cord

32. Hips • Congenital hip dislocation ( Ortolani & Barlow Maneuvers) • Assymetry of the skin folds on the dorsal surface • Shortening of the affected leg

33. Nervous System : Observe for any abnormal movement/ excessive irritability • Muscle tone – Hypotonia : Floppiness – Hypertonia : Extended arms&legs, hyperextension of back & tightly clenched fists. • Reflexes – Rooting reflex – Glabellar reflex – Grasp reflex – Neck righting reflex – Moro’s reflex

34. Biochemical screening • Simple laboratory investigation to diagnose congenital metabolic disorder that may lead to mental retardation and even death if left untreated. • The goal of this screening is to give all newborns a chance to live a normal life. • It provides the opportunity for early treatment of diseases that are diagnosed before symptoms appear • Malaysia : G6PD deficiency & Congenital Hypothyroidism

35. G6PD deficiency • G6PD deficiency is one of the most common genetic diseases affecting an estimated 400 000 000 people worldwide. • All newborn screened for G6PD and in case of deficiency should be explained to both parents. • Test : Beutler fluorescent spot test : rapid & cheap test that identifies NADPH produced by G6PD under UV light.

36. Congenital Hypothyroidism • Significant decrease in, or absence of thyroid function present at birth. • Approximately 1 in 4000 newborn infants has a severe deficiency of thyroid function, while even more have mild or partial degrees. • If untreated for several months after birth, severe congenital hypothyroidism can lead to growth failure and permanent mental retardation.

37. Screening for ROP : is a disorder of the developingretina of low birth weight preterm infants that potentiallyleads to blindness. • Infants with a birth weight of less than 1500 g • Gestationalage of 32 weeks or less • Infants who required oxygen supply

38. Hearing Assesment • Early identification of hearingloss and appropriate intervention within the first 6 monthsof life has been demonstrated to prevent many of these adverseconsequences and facilitate language acquisition.

39. • Family History of Hearing Loss • Perinatal Infection • Craniofacial Anomalies • Very Low Birth Weight • Hyperbilirubinemia (>340mmol/L) • Bacterial Meningitis • Ototoxic Medications • Syndrome Associated with Hearing Loss • Prolonged Ventilation • Severe Asphyxia at Birth Hearing Assesment

40. ECHOCARDIOGRAPHY • GDM ON S/C INSULIN • GDM ON DIET CONTROL • ANY CLINICALLY HEARD MURMUR • LARGE FOR GESTATION AGE • NEWBORN WITH MACROSMIC FEATURES • SYNDROMIC NEWBORN (DOWN’S SYNDROME,

41. Physical Examination Eyes Ears < Normal Ear Pinna Ear Deformity >

42. Physical Examination Nose Mouth

43. Physical Examination

44. Physical Examination Normal Umbilical Cord Umbilical Hernia

45. Physical Examination Gastroschisis

46. Physical Examination Normal Abnormal Configuration Female Genitalia

47. Physical Examination Normal Undescended Testes Male Genitalia

48. Physical Examination Ambiguous Genitalia Closed Rectum

49. Neuromuscular Maturity • Neuromuscular system evaluation: -Gestational maturity rating is measured after the baby is born by the Ballard Scale, it consists of six evaluation areas of Neuromuscular maturity and seven items of physical maturity -A score is assigned to each area. The more neurologically mature the baby, the higher the score.

50. Neuromuscular Maturity Neuromuscular system evaluation, includes: • Posture - how does the baby hold his/her arms and legs • Square window - how far the baby's hands can be flexed toward the wrist • Arm recoil - how far the baby's arms "spring back" to a flexed position • Popliteal angle - how far the baby's knees extend • Scarf sign - how far the elbows can be moved across the baby's chest • Heel to ear - how close the baby's feet can be moved to the ears.

51. Posture • • • • •

52. Square Window

53. Arm Recoil • • • •

54. Popitleal Angle • • • • •

55. Scarf Sign

56. Heel to ear 0 if he heel can easily be pulled to ear

57. Assessment of Reflexes • Rooting & Sucking: touch infant’s lip, cheek or corner of mouth with pacifier -Infant turns head toward stimulus, opens mouth, takes hold and sucks Grasp: Palmar- (between 3-4 months) Place finger in palm of hand -Infants finger curl around examiners fingers Plantar- (lessens by 8 months) Place finger at base of toes -infants toes curl downward

58. Assessment of Reflexes • Glabellar: tap forehead, bridge of nose, or maxilla -Newborn blinks for first 4 or 5 taps (continuos blinking means extrapyramidal disorder) • Babinski Sign: stroke upward along lateral aspect of sole, then move finger across ball of foot • -All toes hyperextend, big toe will dorsiflex (record as a positive sign) -Absence requires neurological evaluation -This should disappear after 1 yr. of age

59. Assessment of Reflexes • Stepping or Walking: Hold infant vertically allowing one foot to touch table surface -Infant will simulate walking, term infant walk on soles of feet & preterm walk on their toes • Crawling: place newborn on abdomen -newborn makes crawling movements with arms and legs (disappears at 6 wk of age)

60. Nutrition •An Infant may be put to breast feed shortly after birth or at least within 4 hours of birth. •Most infants are on demand feeding schedules and are allowed to fed when they awaken •Usually mothers are encouraged to feed their children every 3 to 4 hours during the day, and only when the when the infant awakens during the night for the first few days after work •Formula fed infants usually eat every 3 to 4 hours •Water supplements are not recommended

61. Diagnostic Tests •Blood glucose levels •Urinalysis •Bilirubin levels •CBC •Methods: heel-stick blood sample is obtained to detect a variety of congenital conditions. •Screening mandated by law, all states screen for phenylketonuria (PKU) and hypothyroidism, but each state determines which test is administered.

62. References • Assessment of Growth of Infants Fed a New Formula - Full Text View - ClinicalTrials.gov." Home - ClinicalTrials.gov. Web. 07 May 2010. <http://clinicaltrials.gov/ct2/show/NCT00937014>. • Excellent Care from the Moment of Birth. Web. 07 May 2010. <http://newborns.stanford.edu/>. • HMHB - Home. Web. 07 May 2010. <http://www.hmhb.org/parent.html#new>. • Olds, Sally B., Maternal-newborn Nursing & Women's Healthcare. Upper Saddle River, N.J.: Pearson/Prentice Hall, 2004. Print

63. Skin: • Note skin color: • Usually pink • If fingers and toes have a bluish tinge that sign of poor blood circulation during the first few hours. • Petechiae: Tiny reddish-purple spots on parts of the body that were pressed hard during delivery. However, petechiae on all parts of the body could be a sign of a disorder. • Erythema toxicum :About half of all newborns develop a rash about 24 hours after birth. It is harmless and disappears in 7 to 14 days.

64. Head and neck: • HEAD : Anterior and posterior fontanelles • Large anterior fontanelle • Small anterior fontanelle • Bulging fontanelle • Molding • Caput succedaneum • Cephalohematoma • Increased intracranial pressure • Craniosynostosis • Craniotabes

65. Bulging fontanelle

66. Molding

67. Craniosynotosis

68. Neck & Facial Features: • Face : Look for obvious abnormalities. Note the general shape of the nose, mouth and chin. • Neck : The neck is examined for swelling, growths, and twisting or spasms. • Nose : Size and Shape. Note placement of the septum & Formation of the nasal bridge;

69. • Ears : Examine the ears and note whether they are properly formed and in the correct place. For example, low-set or incorrectly formed ears may mean the newborn has a genetic disorder and/or hearing loss. • Eyes : Observe shape, size and position of eyes. Note integrity and color of iris and sclera. Ophthalmoscopic examination to assess pupillary size and red retinal reflex • Mouth: examine the mouth for problems. Some newborns are born with teeth, which may need to be removed, or a cleft lip or cleft palate .

70. Heart & lungs: • Need to listens the heart and lungs through a stethoscope to detect any abnormality. Abnormal sounds such as a heart murmur or lung congestion. • Inspects the newborn's skin color. A blue color of the face and torso may be a sign of congenital heart or lung disease. • Should watch the newborn breathe and count the number of breaths in a minute. Grunting and/or flaring nostrils with breathing and breathing too fast or too slow can be signs of problems. Heart & lungs:

71. Abdomen and genitals : • Examines the general shape of the abdomen and also checks the size, shape, and position of internal organs, such as the kidneys, liver, and spleen. Enlarged kidneys may indicate a blockage to the outflow of urine. • Examines the genitals to ensure: Urethral opening and proper location, testes should be present in the scrotum, the labia are prominent because of exposure to the mother's hormones, and they remain swollen for the first few weeks. Secretions from the vagina that contain blood and mucus are normal. Also examines the anus to make sure the opening is normally placed.