ed evaluation of the newborn anita eisenhart, do, facoep, facep crash course chandler, az september,...
TRANSCRIPT
ED Evaluation of the Newborn
Anita Eisenhart, DO, FACOEP, FACEPCRASH CourseChandler, AZSeptember, 2012
Overview
•Generally healthy newborn ▫1st month of life
•History of the newborn•Routine head-to-toe exam•Anita’s Top Ten complaints/diagnosis’
▫How to quickly rule out badness …and never miss badness
Evaluation
•Chief complaint & vital signs▫Temp may be most important
•General appearance▫Triage nurse’s assessment (pre-hospital
care)▫Color▫Activity▫Tone▫Cry
History of the Newborn•Birth weight
▫Compared to today’s weight•Birth history
▫Gestational age▫Perinatal infections/fevers/antibiotics/serology▫Delivery type▫Neonatal hospitalization
NICU/well-baby nsy/duration/ complications▫Single or multiple birth▫Prenatal care
History of the Newborn, cont.
•Diet▫Formula/breast/both/how much/how long
•Family▫Other children▫Significant stressors▫Sick contacts▫Young parents
Head-To-Toe Examination
•Head▫Size & shape▫Anterior fontanelle
Flat, sunken, bulging “AFOF”
▫Cephalohematoma ▫Baby’s reaction to head exam
Anterior Fontanelle
Head-To-Toe, cont.
•EENT▫Red reflex▫Anatomic abnormalities▫Infectious evidence
Nasal congestion Eye exudates, injected sclera Oral thrush
▫Mucous membranes (pink & moist)
Head-To-Toe, cont.•Neck
▫Babies have no neck!▫Evaluate for stridor▫Skin break-down
•Chest▫Appearance of respiratory effort
Chest movement Rate Nasal flaring or retractions
▫Heart & lung auscultation
Head-To-Toe, cont.
•Abdomen▫General appearance▫Umbilical stump▫Palpate for mass and for
organomegaly▫Bowel sounds▫Baby’s comfort with exam
i.e. tenderness
Head-To-Toe, cont.
•Back▫General morphology▫Defects▫Hair patterns
Head-To-Toe, cont.•Pelvis
▫Open the diaper▫General appearance of genitals▫Ambiguity ▫Rash ▫Foreskin or circumcision site▫Testicles▫Femoral pulses
Ambiguous Genitalia
Don’t Forget The Family Jewels
Head-To-Toe, cont.
•Extremities▫General morphology▫Capillary refill
•Neuro▫Moving 4 extremities▫Moro▫Suck▫Rooting
Head-To-Toe, cont.
•Skin▫Rash▫Desquamation▫Cutis marmorata▫Turgor▫Lanugo
Newborn Exam
10. Difficulty Breathing•Could be very serious
▫Look at vitals/general appearance/time of year/sick contacts/chronic lung disease
▫Consider Pneumonia Bronchiolitis Cardiac anomaly Electrolyte derangement
•Likely diagnosis: Nasal Congestion▫Suggest saline/bulb syringe/humidifier▫Never use OTC cough & cold remedies on infants
9. Eye Boogies•Neonatal conjunctivitis
▫May be viral▫May be simple bacterial▫Must evaluate for Chlamydia & GC
Intracellular cultures Erythromycin ophthalmic ointment for low
index of suspicion I.V. erythromycin for positive Hx or culture
Admit with a full sepsis workup
8. White Stuff in Mouth•Oral Thrush – very common in
newborns▫Plaques and ulcers▫Painful (+/-)▫Treatment
Nystatin 100,000 U/mL ½ mL in each cheek QID until clear
Advise not to let baby fall asleep with bottle in mouth (more so in older babies)
7. Yellow Baby
•Neonatal Jaundice▫Very common
Outcome is very good Kernicterus (encephalopathy) exceedingly rare
▫General exam Jaundice starts north and works it’s way
south▫Check levels
Compare to standards AAP 2004 recommendations
AAP Recommendations 2004
There’s an App!
•www.BiliTool.org ▫Based on the AAP
Guidelines, hours of life, and measured bilirubin level
6. Not Moving Arm
•Clavicle Fracture▫Very common from vaginal deliveries
Especially with large babies▫Often not noticed in the first couple days
of life▫Seen on exam if gently palpated▫Easily seen on radiograph
Not generally associated with foul play▫No specific treatment necessary▫Feels like a knuckle crack during delivery
5. Rash•Neonatal acne
▫Normal▫Nothing to do
•Diaper dermatitis▫Determine whether candida or simple
irritation•Desquamation
▫normal – reassurance•Cutis Marmorata
▫Normal – not shock•Cradle Cap
Neonatal Acne
Diaper Dermatitis
•Satellite lesions▫nystatin
Newborn Desquamation
Cutis Marmorata
•Lattice appearance▫“mottled”
Cradle Cap•Overactive oil
glands▫Maternal
hormones•Anti-dandruff
shampoo▫Soft brush
4. Belly Button Complaints
•Bleeding stump▫Normal process of the dry stump parting
from live fresh tissue▫Re-assurance▫Bacitracin
•Umbilical granuloma▫Usually resolves spontaneously
May use silver nitrate stick to “burn” granuloma•Omphalitis
▫Infection – pretty rare
Umbilical Granuloma
Silver Nitrate Burn
•Use with caution
Omphalitis
•Fever•Cellulitis•Discharge
3. Vomits All The Time•Spit-up
▫Overfeeding (volume &/or frequency)▫Positioning
Could have reflux and need upright position•Obstruction
▫Evidence of dehydration▫Failed PO challenge▫Consider
Hypertrophic pyloric stenosis Gut malrotation
2. Hasn’t Pooped in 2 Days
•Physiologic constipation of the newborn▫More common in bottle-fed babies
Especially with high iron formulas▫Re-assurance
•Need to consider Hirschprung’s Disease▫Usually can rule out by history
1. My Baby is Hot
•Over-bundled•Not measured•Measured and was not actually a fever•Measured and had a fever
▫That might require a work-up
Bonus: Neonatal Menarche???•Breast buds & bloody vaginal discharge
▫Maternal estrogen withdrawal▫General inspection▫Re-assurance
Bottom Line…
•Always be suspicious of serious illness
•Consistent H & P will effectively rule out badness
•Parents are in the ED because they are worried