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