question 2

Pediatrics 01: Newborn male infant evaluation and care User: Daniela Fernandez Email: [email protected] Date: July 20, 2021 9:23PM

Learning Objectives

Upon completion of the case, the student should be able to:

List elements of the maternal prenatal history that are relevant to the care of the newborn. Discuss the potential effect of maternal use of tobacco, alcohol, marijuana, and other drugs on the fetus.

Discuss the epidemiology and approach to prevention of neonatal Group B Streptococcal sepsis. Summarize clinical findings in the infant that are associated with intrauterine( TORCH) infections. Outline initial steps in neonatal resuscitation. Describe the components of the APGAR score and explain its significance. Describe and perform components of a complete physical examination of a newborn infant, including primitive reflexes and red reflex. Discuss the use of the Ballard Gestational Age Assessment Tool in the evaluation of the newborn infant. Define the terms small for gestational age (SGA) and intrauterine growth restriction (IUGR). Differentiate symmetric and asymmetric IUGR. Outline a differential diagnosis for an infant noted to be small for gestational age. List potential complications in infants who are born small for gestational age. List medications and immunizations routinely given in the immediate newborn period and explain the rationale for their use. Summarize elements of routine discharge teaching for parents of newborns. Discuss the potential role of social work in facilitating the transition from newborn nursery to home. Identify signs of respiratory distress in a newborn. Describe signs of respiratory distress in newborns and infants. Describe types and prevention of hemorrhagic diseases of the newborn. Describe guidelines for the prevention of vertical transmission of hepatitis B infection.

Knowledge

Adverse Effects of Prenatal Substance Use

Tobacco

Maternal tobacco use during pregnancy increases the risk for low birth weight in the fetus. There are no characteristic facial abnormalities associated with maternal tobacco use during pregnancy.

Alcohol

There is no "safe" amount of alcohol that can be consumed during pregnancy to ensure that fetal alcohol syndrome (FAS) does not occur. Fetal alcohol syndrome is a distinct pattern of facial abnormalities (microcephaly, smooth philtrum, thin upper lip), growth deficiency, and evidence of central nervous system dysfunction. Victims of fetal alcohol syndrome may exhibit cognitive disability and learning problems (i.e., difficulties with memory, attention, and judgment) as well as neurobehavioral deficits such as poor motor skills and impaired hand-eye coordination.

Marijuana

Distinctive effects of marijuana have not been identified. Heroin and other opiate medications

Maternal heroin use is associated with increased risk of fetal growth restriction, placental abruption, fetal death, preterm labor and intrauterine passage of meconium. All infants born to women who use opioids during pregnancy should be monitored for symptoms of neonatal abstinence syndrome (i.e. uncoordinated sucking reflexes leading to poor feeding, irritability, and high-pitched cry) and treated if indicated.

Cocaine and Other Stimulants

These cause vasoconstriction leading to placental insufficiency and low birth weight, premature delivery, smaller head circumferences and shorter lengths. In addition, the National Institute on Drug Abuse notes that "exposure to cocaine during fetal development may lead to subtle, yet significant, later deficits in some children, including deficits in some aspects of cognitive performance, information processing, and attention to tasks abilities that are important for success in school."

Small for Gestational Age

Newborns who are noted to be smaller than expected for their gestational age are considered small for gestational age (SGA). Although they are not synonymous, this term is often used interchangeably with:

Fetal growth restriction (FGR) Intrauterine growth retardation and/or Intrauterine growth restriction (IUGR)

SGA: An infant is diagnosed as being SGA at time of birth. There are varying definitions for SGA, ranging from less than the third percentile to less than the 10th percentile for weight. Depending on the cutoff level used, up to 70% of SGA infants are small simply due to constitutional factors determined by maternal ethnicity, parity, weight or height. IUGR: A fetus is noted to be IUGR during the pregnancy. A growth-restricted fetus is one that has not reached its growth potential at a given gestational age due to one or more causative factors. Etiologies of SGA at Birth

Maternal factors

Both young and advanced maternal age Maternal prepregnancy short stature and thinness Poor maternal weight gain during the latter third of pregnancy Nulliparity Lack of medial care during pregnancy Cigarette smoking, cocaine use, other substance use Lower socioeconomic status (a proxy for limited access to good nutrition, healthcase, and structural biases) Polyhydramnios Short interpregnancy interval Preeclampsia and/or chronic hypertension Chronic maternal illness, such as:

1. Chronic kidney disease 2. Pregestational diabetes mellitus 3. Systemic lupus erythematosus and antiphospholipid syndrome 4. Cyanotic heart disease 5. Chronic pulmonary disease 6. Severe chronic anemia 7. Sickle cell disease

Fetal factors Chromosomal abnormalities (e.g., trisomies) and syndromes Metabolic disorders Congenital infections (e.g., "TORCH" infections: toxoplasmosis, rubella, cytomegalovirus, herpes simplex 2, and "others" including HIV, hepatitis B, human parvovirus, syphilis and zika.

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Medications and other exposures

Amphetamines

Antimetabolites (e.g., aminopterin, busulfan, methotrexate)

Bromides

Cocaine

Ethanol

Heroin and other narcotics (e.g., morphine, methadone)

Hydantoin

Isotretinoin

Metal (e.g., mercury, lead)

Phencyclidine

Polychlorinated biphenyls (PCBs)

Propranolol

Steroids

Tobacco (carbon monoxide, nicotine, thiocyanate)

Toluene

Trimethadione

Warfarin

Uterine and placental abnormalities

Avascular villi

Decidual or spiral artery arteritis

Multiple gestation (limited endometrial surface area, vascular anastomoses)

Multiple infarctions

Partial molar pregnancy

Placenta previa and abruption

Single umbilical artery

Umbilical thrombosis

Abnormal umbilical vascular insertions

Syncytial knots

Tumors, including chorioangioma and hemangiomas

Uterine malformations

Diagnosis of Congenital Rubella

Detection of rubella-specific IgM antibodies usually indicates recent postnatal infection or congenital infection. Because false-positives can occur, diagnosis can also be confirmed by stable or increasing serum concentrations of rubella IgG over several months. Diagnosis is difficult after one year of age.

Diagnosis of Congenital Toxoplasmosis

The serologic diagnosis of congenital toxoplasmosis is based on positive toxoplasma-specific IgM, IgG, or IgA assay in the newborn period, increasing IgG titers in the first year, or persistently positive IgG titers beyond the first year of life.

Diagnosis of Congenital Cytomegalovirus (CMV)

Because newborn infants with congenital cytomegalovirus (CMV) shed large amounts of virus in the saliva and urine, urine or saliva culture is sufficient for diagnosis. Polymerase chain reaction (PCR) may also be used for diagnosis. Detection of CMV in urine, oral fluids, respiratory tract secretions, blood, or cerebral spinal fluid (CSF) obtained within 2 to 3 weeks of life is considered proof of congenital CMV infection.

Newborn Resuscitation

In addition to remembering the ABCs (or airway-breathing-circulation), keep in mind some of the special features of newborn resuscitation: Use universal precautions Warm and dry the infant and remove any wet linens immediately. Infants have a large surface area relative to their body weight and can thus experience significant hypothermia from evaporation. Stimulate the infant to elicit a vigorous cry. This helps clear the lungs and mobilize secretions. Position airway Suction amniotic fluid from the infant's mouth and nose. This helps clear the upper airway. Initiate further resuscitation if required. This may include using blow-by oxygen, continuous positive airway pressure (CPAP), placement of an alternate airway, chest compressions, and medications.

While approximately 10% of newborns require some assistance to initiate breathing, fewer than 1% require extensive resuscitation.

Growth Terms Reviewed

Small for gestational age (SGA) = Weight below the 10th percentile for gestational age Preterm = < 37 weeks' gestation Early term = Born at 37 0/7-38 6/7 weeks' gestation Term = Born at > 37 weeks' gestation Late term = 41 0/7-41 6/7 weeks’ gestation Post Term = > 42 0/7 weeks’ gestation See this Committee Opinion from the American College of Obstetricians and Gynecologists from 2017 for a suggested revision of the "term" nomenclature.

Symmetric vs Asymmetric Intrauterine Growth Restriction (IUGR)

Symmetric IUGR refers to a growth pattern in which head, length, and weight are decreased proportionately. Congenital infections or other fetal factors may adversely affect brain growth and often result in symmetrical IUGR. Asymmetric IUGR refers to a greater decrease in length and/or weight without affecting head circumference ("head-sparing phenomenon"). Maternal factors that cause poor delivery of nutrition to the fetus (for example, maternal smoking) often results in asymmetric IUGR.

Risks for Small for Gestational Age (SGA) Newborns

Risk Etiology Symptoms

Hypoglycemia

Decreased glycogen stores

Heat loss

Possible hypoxia

Decreased gluconeogenesis

Commonly asymptomatic, though may exhibit seizures, poor feeding, jitteriness, irritability, tachypnea, pallor and listlessness

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Hypothermia

Cold stress

Hypoxia

Hypoglycemia

Increased surface area

Decreased subcutaneous insulation

Commonly asymptomatic, though may exhibit poor feeding and listlessness

Polycythemia Chronic hypoxia

Maternal-fetal transfusion

"Ruddy" or red color to skin

Respiratory distress*

Poor feeding

Hypoglycemia

*Infants with sluggish blood flow (hyperviscosity syndrome) because of a critically elevated hemoglobin/hematocrit may have respiratory distress secondary to inadequate oxygenation of end-organ tissues.

The Value of Social Workers

Social workers are a rich resource to many families. This is particularly true for new adolescent parents who may be of low socioeconomic status. Hospital social workers can help connect new parents to community resources, including home nursing visits, support groups for new parents, and the Women, Infants and Children program. Link to https://www.fns.usda.gov/wic/women-infants-and-children-wic for more information on this nationwide program. Other current community resources in your area also may be available, such as:

Early childhood development classes Parenting classes Counseling for tobacco cessation and alcohol abuse High school education completion Crisis nurseries (short-term emergency daycare)

Clinical Skills

Apgar scores

The Apgar score is an assessment of the condition of the newborn immediately after birth. Components of Apgar score include: Appearance (skin color) Pulse (heart rate) Grimace (reflex irritability) Activity (muscle tone) Respiration A newborn receives a score of 0, 1, or 2 for each component, with the final Apgar score ranging from 0 to 10.

Expanded Apgar score reporting form The score is reported at 1 minute and 5 minutes after birth for all infants. The change in Apgar score between 1 and 5 minutes may be a useful indicator of response to resuscitation. According to Neonatal Resuscitation Program (NRP) guidelines, a score below 7 at 5 minutes should prompt continued resuscitation, with reassessment every 5 minutes, up to 20 minutes, until a score of 7 is achieved. The Apgar score does not identify birth asphyxia and does not predict individual neurologic outcome or mortality.

Newborn Respiratory Distress

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Signs of respiratory distress in the newborn include: Apnea Poor respiratory effort Tachypnea (rapid respiratory rate): a normal newborn's respiratory rate will be in the 30s to 50s. Nasal flaring Chest wall retractions: Retractions are observed when the skin over the chest wall is "sucking in"; this is usually noted as intercostal (between the ribs), suprasternal (above the sternum) or subcostal (below the ribcage) retractions. Grunting; Grunting is a noise that is heard on expiration when an infant in respiratory distress is working to keep his or her alveoli open to increase oxygenation and/or ventilation. This is sometimes referred to as “auto-PEEP (positive end-expiratory pressure).”

Ballard Gestational Age Assessment Tool

The Ballard assessment tool uses signs of physical and neuromuscular maturity to estimate gestational age. This can be particularly helpful if there is no early prenatal ultrasound to help confirm dates, or if the gestational age is in question because of uncertain maternal dates.

View an interactive version of the Ballard assessment tool.

Demonstration of Primitive Reflexes and Red Reflex

Rooting

Newborn turns his head toward your finger when you touch his cheek. Sucking

Newborn sucks on your finger when you touch the roof of his mouth. Startle (Moro)

The reflex is elicited by pulling up on the infant's arms while in a supine position and quickly letting go of the arms causing the sensation of falling. Production of the reflex is by the suddenness of the stimuli and not the distance of the drop. There is no need to lift the infant's head off of the bed to elicit this reflex. In response, the newborn will flex his thighs and knees, fan and then clench his fingers, with arms first thrown outward and then brought together as though embracing something. A video of the moro reflex can be seen here: Moro Reflex

Palmar and Plantar Grasps

Newborn grasps your finger when you stroke it against the palm of his hand or plantar surface of his foot. Asymmetrical Tonic Neck Response

Turning the newborn's head to one side causes gradual extension of arm toward direction of infant's gaze with contralateral arm flexion--like a fencer. Stepping Response

Newborn's legs make a stepping motion when you hold him vertically above the table and stroke the dorsum of his foot against the table edge. Red Reflex Examination in Neonates

The best method for evaluating the red reflex is to turn off the room lights and stand at least a foot away from the child's face with the illuminated ophthalmoscope; this allows the examiner to look for both red reflexes simultaneously. Infants with more darkly pigmented skin will have a light golden colored or silver-tinged "red reflex." An absent red reflex (no reflection noted) may be caused by:

A cataract An opacified cornea (such as in mucopolysaccharidosis) Inflammation of the anterior chamber Developmental anomalies of the eye Retinoblastoma, a potentially lethal malignancy (careful examination of the eye of an infant with retinoblastoma often identifies a white, irregular mass within the globe).

Treating Neonates to Prevent Gonococcal Eye Infection

Although N. gonorrhoeae causes ophthalmia neonatorum relatively infrequently in the United States, identifying and treating this infection is especially important because ophthalmia neonatorum can result in perforation of the globe of the eye and blindness. Chlamydia trachomatis conjunctivitis in newborns is more common than gonococcal, but chlamydia typically occurs at 7-14 days after birth, and neonatal prophylaxis does little to prevent chlamydia conjunctivitis.

Management

Prenatal lab screening

Look for the following prenatal screening lab tests in the maternal record:

Maternal blood type, Rh and antibody screen Rubella IgG Hepatitis B Surface Antigen (HBSAg) HIV antibody RPR or VDRL Urinalysis Urine nucleic acid amplification testing (NAAT) for chlamydia and gonococcus Urine or vaginal culture for group B streptococcus Hepatitis C antibody (in women with a history of IV drug use) Tuberculosis skin test (e.g. Mantoux) or TB blood test (e.g. Quantiferon) (in women with HIV or who live in a household with someone with active TB) Patient information on routine testing during pregnancy U.S. Centers for Disease Control and Prevention guidelines Centers for Disease Control and Prevention website World Health Organization Global Update on the Health Sector Response to HIV, 2014, Executive Summary, page 3

Early Onset Group B Streptococcal (GBS) Disease

Neonatal GBS Facts

GBS infection is a major cause of neonatal bacterial sepsis. The incidence of early onset GBS disease is 0.23/1000 live births. 20-30% of pregnant women have vaginal or rectal colonization of GBS. Without antibacterial prophylaxis 1-2% of infants born to colonized women develop invasive disease (sepsis, pneumonia and meningitis). Risk factors for early onset GBS disease include rupture of membranes > 18 hours, prematurity, intrapartum fever and previous delivery of an infant who developed GBS disease. Newborn Management

The management of babies born to mothers who are colonized with Group B streptococcus depends on a number of factors: Clinical appearance Evidence of maternal chorioamnionitis Receipt of appropriate GBS prophylactic antibiotics by mother during labor Duration of membrane rupture Gestational age less than 37 weeks

Any infant who is ill appearing should undergo a full diagnostic evaluation (complete blood count [CBC], blood culture, chest x-ray and lumbar puncture) and receive IV antibiotics. Well-appearing infants may undergo a limited laboratory evaluation (CBC and blood culture) or simply be closely monitored over the first few days of life. American Academy of Pediatrics. Red Book: 2018 Report of the Committee on Infectious Diseases, 31st Edition. Kimberlin, Brady, Jackson

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Routine Newborn Medications

Vitamin K: Newborns routinely receive an intramuscular injection of vitamin K to prevent hemorrhagic disease of the newborn (also referred to as vitamin K deficiency bleeding, or, VKDB). The efficacy of oral Vitamin K is unknown. Hepatitis B vaccine: For all infants with birth weight of at least 2,000 g born to HBsAg-negative mothers, the American Academy of Pediatrics (AAP) recommends the practitioner administer Hepatitis B vaccine as a universal routine prophylactic treatment within 24 hours of birth. Erythromycin (also tetracycline or silver nitrate): One of these antibiotics is administered topically to prevent gonococcal conjunctivitis.

Treating Neonates to Prevent Hemorrhagic Disease of the Newborn

American Academy of Pediatrics (AAP), Center for Disease Control (CDC), and the World Health Organization (WHO) recommend intramuscular administration of Vitamin K at birth. There are no standardized oral solution preparations of Vitamin K in the United States and therefore efficacy is unknown. Early and classical Vitamin K deficient bleeding (VKDB) occur in 1/60-1/250 newborns, although the risk is much higher for early VKDB among those infants whose mothers used certain medications during the pregnancy. Late VKDB is rarer, occurring in 1/14,000- 1/25,000 infants. Infants who do not receive a vitamin K shot at birth are 81 times more likely to develop late VKDB than infants who do receive a vitamin K shot at birth.

Type of VKDB When it occurs Characteristics

Early 0-24 hours after birth Severe

Mainly found in infants whose mothers used medications (e.g antiepileptic drugs or isoniazid) that interfere with how the body uses vitamin K

Classical 1-7 days after birth Bruising

Bleeding from the umbilical cord

Late 2-12 weeks after birth is typical, but can occur up to 6 months of age inpreviously healthy infants

30-60% of infants have bleeding within the brain

Tends to occur in breastfed only babies who have not received the vitamin K shot

Warning bleeds are rare

http://www.cdc.gov/ncbddd/vitamink/facts.html

Addressing Parents’ Questions about the Administration of Medications to their Baby

Many families have concerns about the routine medications recommended for their babies. These concerns may include the following misperceptions: that the recommended dose is too high to be given safely, that the medication may contain preservatives which are toxic, that there may be unforeseen consequences later in life, and that it is unnatural to cause a painful experience. Studies have shown parents may not be aware of serious and even life threatening risks of the diseases that these medications are intended to prevent. For example: Vitamin K Deficiency Bleeding can result in severe cerebral hemorrhage, Hepatitis B can lead to chronic hepatitis and liver failure, and Gonococcal eye infection can cause blindness. The clinician should actively but respectfully elicit parents' concerns and fears about medications. Verbal and written information should be provided to the family that targets those concerns and fears. When parents feel fully informed and yet still refuse to allow recommended medications, refusal should be documented on a medication refusal form signed by the parent.

Routine Newborn Discharge Instructions for Parents

Discharge teaching should include the following: Reasons to seek immediate medical care, including fever, signs of poor feeding, worsening jaundice Expectations for normal feeding, stooling, urine output Safety issues (including placing the newborn on his back to sleep, proper infant auto restraint, avoiding cigarette smoke exposure.) Plan for physician outpatient followup in 48-72 hours Social Services follow up plan 24 hour emergency contact information

Adjusting to having a new infant can be challenging. For more detailed guidance for parents of newborns, link to the following Bright Futures Parent Handout - often provided at the first outpatient visit after newborn discharge. https://brightfutures.aap.org/materials-and-tools/guidelines-and-pocket-guide/Pages/default.aspx

References

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