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Neonatal Period 6. Newborn Exam and Gestational Age Sources: WHO, Pocket book of hospital care for children, 2013; Bugando Medical Centre, Paediatrics management guidelines, 2011; Neonatal Resuscitation Program-­ Reference Chart, AHA, AAP, 2011. Normal Newborn Care 1. Dry infant with clean towels/cloth; keep infant dry 2. Place skin-­ to-­ skin on mother and cover infant to prevent heat loss 3. Clamp and cut umbilical cord with clean instruments (string, rope, scissors, razor blade, etc) by 1 minute of life 4. Encourage breastfeeding within first hour 5. Give IM vitamin K 1mg once to all infants • For premature or LBW infants, give 0.4mg/kg max 1mg 6. Apply antiseptic or tetracycline eye ointment to both eyes once to prevent conjunctivitis 7. Give oral polio, hepatitis B, and BCG vaccines according to national policies 24 Neonatal Period Physical Exam Typical style (some countries may vary in requirements for presentations): General: General mental status of infant, signs of jaundice/pallor/ edema, rash, dehydration status (sunken eyes, mucous membranes, tears, skin pinch, ability to drink) Vital Signs: Temperature (Celsius), pulse rate, respiratory rate, pulse oximetry (should be encouraged, though rarely do medical students have a pulse oximeter, and interns only sometimes do). Anthropometric measurements: Weight, length, head circumference , classify malnutrition status (none/mild is -­ 2 to -­ 1 SD; moderate , -­ 3 to -­ 2 SD; severe, less than -­ 3 SD) HEENT: Dysmorphic facies, eye distance, ear positioning/folds, nares patent, nose shape, palpate anterior/posterior fontanelle, palate intact or not Neck: Palpate for any masses or deformities Cardiovascular: Inverted “J” format—extremities warm/cold, capillary refill, nail/hand findings, brachial pulse rate/strength and synchronicity with contralateral and femoral, increased JVP or not, inspect precordium for hyperactivity, palpate apex beat location, auscultation Respiratory: Respiratory rate, inspection (scars, symmetric chest movement, nasal flaring, chest wall indrawing = retractions), palpation (chest wall tenderness, tactile vocal fremitus), percussion (dullness, egophany), auscultation (vesicular breath sounds = clear auscultation; anterior supramammary/mammary/inframammary areas, posterior suprascapular/intrascapular/infrascapular areas; bronchial breath sounds; decreased breath sounds) Abdominal: Inspection (scars, distension, inverted/everted umbilicus , surrounding erythema or discoloration of umbilicus, number of vessels in umbilicus, peristaltic movement, visible veins), palpation (comment on superficial and deep palpation: soft, tenderness, hepatosplenomegaly or not and distance from costal margin, other 6. Newborn Exam and Gestational Age 25 masses), percussion (tympanic sounds vs dullness, fluid thrill, liver span by percussion), auscultation (bowel sounds) Genitourinary: Male → inspection, palpate for testes; female → inspection; both → inspect patency of anus Musculoskeletal: Inspect for deformities, hands/feet for creases, extra digits, back/spine; palpate clavicles for crepitus; hip stability (Ortolani: rotating hip externally creates a click felt by finger at joint; Barlow: same maneuver but while applying posterior pressure) Central nervous system: GCS preferred; acceptable AVPU scale (A = alert, V = responds to voice, P = responds to pain, U = unconscious ); cranial nerves grossly examined; motor includes bulk (normal/abnormal), tone (same), power = strength (same 5 point scale); sensation (same); Babinski sign; reflexes (sucking, rooting, Moro, grasp, stepping, anal wink) Gestational Age: Preferred is Finnström, but also acceptable is Dubowitz Finnström Assessment for Neonatal Gestational Age Source: Finnström, “Studies on maturity in newborn infants,” Acta Paediatr . 1977. Score 1 2 3 4 Breast tissue 10 mm Nipples Hardly visible Well defined Edge of areola lifted Skin vessels Big vessel visible over abdomen Some veins and branches visible A few vessels visible No vessels visible Hair Thin and wooly Thick and silk-­ like Finger nails Do not reach fingertips Reach fingertips but distal edge not distinct Reach past fingertips and distal part hard Cartilage of ear No cartilage in antitragus Cartilage present in antitragus Cartilage in antihelix Cartilage in the whole ear Soles of feet No lines visible No lines present in posterior 2/3 of foot No lines present in posterior 1/3 of foot Lines over whole foot 26 Neonatal Period Scoring: Points Gestational Age Goal Preductal Oxygen Saturations Immediately after Birth 7 27 1 minute 60–65% 8 28 2 minutes 65–70% 9 29 3 minutes 70–75% 10 30 4 minutes 75–80% 11 31 5 minutes 80–85% 12 32 10 minutes 85–95% 13 33 ≥15 minutes ≥90% 14 33 15 34 16 35 17 36 18 37 19 38 20 39 21 40 22 41 23 42 7. Prematurity Sources: WHO, Pocket book of hospital care for children, 2013; Eddleston et al, Oxford handbook of tropical medicine, 2008. 35–37 weeks GA and 2–2.5kg in BW • Ensure infant breastfeeds within 1 hour...

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