ed evaluation of the newborn anita eisenhart, do, facoep, facep crash course chandler, az september,...

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