Assessment of the Neonate

5/23/2013

Copyright 2008 AP Jones 1

Assessment of the Neonate

Arthur Jones, EdD, RRT

http://rc-edconsultant.com/

Learning objective:

Interpret findings from physical andphysiological assessments of thenewborn.

Neonatal

Scoring Systems

FYI - Click for article on use and abuse of Apgar scorehttp://pediatrics.aappublications.org/cgi/content/abstract/pediatrics;98/1/141

Apgar score

Rated at one and five minutes

Intended only to assess generalcondition

Does not:

define asphyxia

predict future development

influence Ivy League admission

Health premature infants willlikely have low Apgar scores

Apgar scoring system

ƒObservations

Color - skin colorimetry reflectsillness severity

Heart rate

Reflex activity

Activity

Respirations

0 1 2

Color centralcyanosis

peripheralcyanosis

pink


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0 1 2


peripheralcyanosis

pink

Heart rate nonedetectable

<100 >100

Apgar scoring system0 1 2


peripheralcyanosis

pink


<100 >100

Respiratoryeffort

apnea irregular,shallow

crying


0 1 2


peripheralcyanosis

pink


<100 >100

Respiratoryeffort


crying

Reflex none grimace(withdraw)

crying

Apgar scoring system0 1 2


peripheralcyanosis

pink


<100 >100

Respiratoryeffort


crying

Reflex none grimace(withdraw)

crying

Muscle tone(activity)

flaccid someflexion

well-flexed


Gestational age estimation

Prenatal

menstrual cycle - 1st day of lastmenstrual period + 280 days

fundal height measurement -mom's abdomen

ultrasound

Gestational age estimation

Postnatal

ultrasound measurement - femurlength

Ballard score - AKA Ballard-Dubowitz score

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Ballard score

ƒEstimation of gestational age

ƒPhysical signs

Skin

Breast

Lanugo

Eye/ear

Plantar surface

Genitalia

FYI - Click to view/bookmark Ballard Score videoshttp://www.ballardscore.com/Pages/videos.aspx

Gestational age/score

24-26 wkscore = 0

35-40 wkscore = 4

Skin gelatinous,red, translucent

parchment, deepcracks, no visiblevessels

Ballard score - physical signs


24-26 wkscore = 0

35-40 wkscore = 4



Lanugo none to sparse none to sparse

Ballard score - physical signsGestational age/score

24-26 wkscore = 0

35-40 wkscore = 4



Lanugo sparse mostly bald

Plantarsurface

no crease creases over entiresole


Click to see skin scoringhttp://www.ballardscore.com/Pages/mono_phys_skin.aspx

Click to see lanugo scoringhttp://www.ballardscore.com/Pages/mono_phys_lanugo.aspx

Click to see plantar surface scoringhttp://www.ballardscore.com/Pages/mono_phys_plantar.aspx


24-26 wkscore = 0

35-40 wkscore = 4




Plantarsurface


Breast barely perceptible full areolae; 5-10 mmbud


Click to see breast scoringhttp://www.ballardscore.com/Pages/mono_phys_breast.aspx


24-26 wkscore = 0

35-40 wkscore = 4




Plantarsurface


Breast barely perceptible full areolae; 5-10 mmbud

Eye and ear lids open, pinna flat& stays folded

eyes open, ear thickcartilage, stiff


Click to see eye & ear scoringhttp://www.ballardscore.com/Pages/mono_phys_eyear.aspx

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24-26 wkscore = 0

35-40 wkscore = 4

Genitalia- male scrotum empty,faint rugae

testes pendulousdeep rugae

Genitalia-female prominent clitorissmall labia minora

majora cover clitorisand minora


Click to see male genitalia scoringhttp://www.ballardscore.com/Pages/mono_phys_male.aspx

Click to see female genitalia scoringhttp://www.ballardscore.com/Pages/mono_phys_female.aspx

FYI - Click for pictures of ambiguous genitaliahttp://lh4.ggpht.com/-u5SwxozUhSk/SR8VWtH-RBI/AAAAAAAAD4I/E6eD7RW7vpQ/DSC00229.JPG

Ballard score - neuromuscular signs

ƒPosture

degree of extremity flexion

greater flexion ==> maturity

ƒSquare window

flexion of hand to forearm

greater flexion ==> maturity

Click to see posture scoring

http://www.ballardscore.com/mono_neuro_posture.htm

Click to see square window scoring

http://www.ballardscore.com/mono_neuro_squarewindow.htm

Ballard score- neuromuscular signs

ƒArm recoil

recoil of arm after full extension

full recoil ==> maturity

ƒPopliteal angle

angle of knee, with thigh on chest

lesser angle ==> maturity

Click to see arm recoil scoring

http://www.ballardscore.com/mono_neuro_armrecoil.htm

Click to see popliteal angle scoring

http://www.ballardscore.com/mono_neuro_pop.htm

Ballard score- neuromuscular signs

ƒScarf sign

put hand on opposite shoulder

lesser travel of elbow across midline==> maturity

ƒHeel-to-ear

non-forceful movement of heel to ear

greater distance heel - ear ==>mature

Click to see scarf sign scoring

http://www.ballardscore.com/mono_neuro_scarf.htm

Click to see heel-to-ear scoring

http://www.ballardscore.com/mono_neuro_heel.htm

Ballard scoring

ƒMaturity ratings

0 24 weeks

10 28 weeks

20 32 weeks

30 36 weeks

40 40 weeks

50 44 weeks

Click to see the Ballard score calculatorhttp://www.medcalc.com/ballard.html

Acute illness scoring

Purposes

to predict mortality

guide patient management

set standards for research,benchmarking across institutions

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Score systems

Score for neonatal acutephysiology (SNAP II)

Clinical risk index for babies

(CRIB II)

oxygenation index (later section)

Validity - CRIB II may be morediscriminatory

Scoring systems are not very goodat predicting mortality


Parameters SNAP II

mean blood pressure

lowest temperature

PO2/FIO2%

lowest pH

multiple seizures

urine output

Apgar score

birth weight

small for gestational age


Parameters CRIB II

gender

gestation weeks

birthweight

admission temperature

base excess

FYI - Click to see SNAP II score calculator

http://www.sfar.org/scores2/snap22.html

FYI - Click to see CRIB II score calculator

http://www.sfar.org/scores2/crib22.html

Normal physical features

ƒLanugo - fine hair

ƒPeripheral cyanosis - due to reduced

peripheral perfusion

ƒVernix caseosa - white coating

ƒFontanelles - anterior, posterior


ƒLanugo - fine hair

ƒPeripheral cyanosis - due to reduced

peripheral perfusion

ƒVernix caseosa - white coating

ƒFontanelles - anterior, posterior

ƒPhysiologic jaundice - > 24 hrs

postpartum

ƒTelangiectatic nevi - "stork bites"

ƒMinimal ecchymoses & petechiae

Click to see stork bitehttp://pregnancy.about.com/od/newbornbabies/ig/Newborn-Photo-Gallery/Stork-Bite---Newborn.htm


ƒRespirations

normal RR = 30-60/min

auscultation ==> sounds transmitted

easily across small chest

periodic breathing - apnea < 10 sec

ƒnormal in preterm newborns

ƒnon-pathologic

apnea of prematurity - apnea > 10Sec

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Silverman Respiratory Status Index

ƒPurpose - objectively scorephysical evidence of increasedwork of breathing (WOB)

ƒFive observations, scored 0-2

ƒHigher score ==> greater WOB

(maximum score = 10)

Silverman Respiratory Status Index

ƒParameters

Synchrony of upper & lower chest -

seesawing = 2

Nasal flaring - marked = 2

Lower chest retractions = marked

intercostal retractions = 2

Xiphoid retractions - markedretraction of skin over xiphoid = 2

Expiratory grunt - audible to ear = 2

Click to see Downes and Silverman scoring systems

http://members.tripod.com/puffnicu/rd.html

Cardiovascular assessment

ƒHR = 120 - 160 /min

ƒBP (term infant) = 50-70/25-50

ƒumbilical stump- 2 arteries, 1 vein

Click for more informatino on neonatal blood pressurehttp://www.netsvic.org.au/nets/handbook/index.cfm?doc_id=450

Click to see umbilical stumphttp://www.biosci.ohiou.edu/introbioslab/Bios171/images/lab5/umb_cord2.jpg

Cardiovascular assessment

ƒauscultation for murmurs - turbulent

blood flow across valves

abnormal valves

abnormal vessels

septal defects

ƒbrachial pulses compared to femoralfor equal intensity - unequal ==>aortic coarctatation

FYI - click for website with heart murmurs (bookmark?)

http://www.wilkes.med.ucla.edu/inex.htm

Click for more information and pictures of coarctation

http://www.pted.org/?id=coarctation1

Neurologic responses (reflexes)

ƒGrasp- grasps with hand

ƒSuck - starts early, in utero

ƒRooting - turns head to suck

ƒMoro - startle reflex

ƒBabinski - normal newborn toescurl upward

Click for video of neonatal reflex evaluation (2.5 min.)

http://www.youtube.com/watch?v=gyVLD0hl0XY&feature=related

Abnormal features

ƒMeconium stains - aspiration

ƒFlaring, grunting, retractions

ƒCentral cyanosis - hypoxemia

ƒJaundice < 24 H postpartum

color due to bilirubin

causes: hemolysis, liver failure

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Abnormal features

ƒFontanelles - anterior and posterior

bulging ==> increased ICP

sunken ==> dehydration

ƒUpper extremity immobility

Broken clavicles

Brachial plexus injury

Click to see radiograph of birth trauma (clavicle)

http://niyaf.com/post/31434342/birth-trauma-fractured-clavicle-collar-bone

Click to see a picture of birth trauma (forceps marks)http://pregnancy.about.com/od/newbornbabies/ig/Newborn-Photo-Gallery/Newborn-with-Forcep-Marks.htm

Abnormal features

ƒFacies

ƒmicrognathia (small mandible)

ƒPierre-Robin syndrome

ƒTreacher Collins syndrome

ƒmicrostomia (small mouth) -

trisomy 18

ƒcleft lip, palate

Click to see image of micrognathiahttp://www.mdconsult.com/das/pdxmd/media/1206/6120625/large.jpg

Click to see image of microstomiahttp://www.nndb.com/people/905/000091632/joeebrown02.jpg

Abnormal features

ƒCri-du-chat (cat's cry) - deletion ofpartial chromosome (normal in felinenewborns)

ƒSimian crease - single palmar crease

ƒpresent in some normal infants

ƒcommon in trisomy 21 (Downsyndrome)

ƒcommon in cri-du-chat

Click to see image of simian creasehttp://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/17226.jpg

Click to hear cri-du-chathttp://fs6.depauw.edu:50080/~cfornari/DISGEN/CriDuChat%20Website/images/babycryb.wav

FYI - Click for Atlas of congenital anomalieshttp://www.gfmer.ch/genetic_diseases_v2/index.php?disinit=L

Abnormal features

ƒPolydactyly - sometimes associatedwith lethal anomalies

ƒLethal anomalies - lethal; but,when?

cystic fibrosis (Caucasians)

sickle cell anemia (African)

trisomy 13 (Patau syndrome)

trisomy 18 (Edwards syndrome)FYI - Click for video about cri-du-chat (4.5 min.)http://www.youtube.com/watch?v=pxh9m1dTU0Q

FYI - Click for picture of anencephalyhttp://isc.temple.edu/neuroanatomy/lab/embryo_new/nt/4/anen.html

Abnormal features

ƒLethal anomalies

inoperable cardiac anomalies(acardia)

Potter's syndrome

pulmonary hypoplasia -undeveloped lung(s)

renal agenesis

anencephaly

lethal white disease (horses)

Abnormal features

ƒLethal anomalies - ethical & legalissues

futility of efforts

allocation of resources

end-of-life care for parents

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Abnormal features

ƒGastroschisis - externalized,

uncovered bowel

ƒOmphalocoele

bowel covered with peritoneum

associated with other anomalies

ƒSpina bifida - exposed spinal cord

ƒHydrocephaly - cerebral edemaClick to see picture of gastroschisishttp://www.medword.net/images/clinical/omphalocele/flut041216d_001.jpg

Click to see picture of hydrocephalyhttp://www.flickr.com/photos/hydroassoc/2073488415/

Click to see picture of spina bifidahttp://www.scienceclarified.com/images/uesc_02_img0090.jpg

Physiologic features

ƒLung mechanics

ƒTV = 7 mL/kg

ƒFRC = 21 mL/kg

ƒVD = 5 mL/kg

ƒRespiratory system compliance

ƒterm newborn..........5 mL/cm H2O

ƒpreterm newborn....3 mL/cm H2O

ƒadult.........................100 mL/cm H2O


ƒLung mechanics

ƒhigh chest wall compliance ==>

decreased support of lung expansion

by chest wall

thoracic retractions- early sign of

distress

Click for video of retractions (.25)

http://www.youtube.com/watch?v=sgJNTnhf8v0&feature=related


ƒAirway resistance

ƒterm newborn..........70 cm H2O/L/sec

ƒpreterm newborn.....97 cm H2O/L/sec

ƒadult..........................2.5 cm H2O/L/sec

ƒInspiratory flow

ƒterm newborn...........3-6 L/min

ƒadult...........................30-60 L/min

Blood gases

ƒSample sources

ƒumbilical cord - partum

ƒumbilical artery catheter

ƒperipheral artery; e.g., brachial

ƒvein - pH and PCO2 only

ƒcapillary

ƒpainful for patient

ƒpH and PCO2 only

ƒunreliable if patient is in shock

Blood gases

ƒHypoxia sources

ƒhypoxemia (decreased PO2,SPO2)

ƒanatomic shunts

ƒpulmonary shunts

ƒanemia - includes

ƒHbCO from maternal smoking

ƒHbMET from nitric oxide (NO)

ƒcirculatory

ƒanatomic shunts

ƒshock

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Blood gases

ƒAcid-base disturbances

ƒrespiratory acidemia

ƒrespiratory alkalemia

ƒmetabolic acidemia

ƒshock, sepsis

ƒdiarrhea - loss of bicarbonate

ƒmetabolic disorders; e.g., diabetes

ƒmetabolic alkalemia

ƒdiuretics

ƒgastric suctioning

Umbilical arterial gas sea level norms

20 min 1 hour 4 hours

pH 7.35 7.40 7.40

PaCO2 35 30 35

PaO2 50-65 50-65 65-70

Note: shift in HbO2 curve ==> infant

p50 = 21 mm Hg

Blood gases

Oxygenation index - calculatedscore

used for all patient groups

purposes:

ƒpredict outcomes

ƒguide management choices; e.g.,ECMO

ƒcompare outcomes amonginstitutions; e.g., for benchmarking

FYI - Click to download article on oxygenation index

http://ajrccm.atsjournals.org/cgi/reprint/172/2/206

Blood gases

Oxygenation index (OI)

advantage over other indexes -takes mean airway pressure intoaccount

oxygen index equation:

FYI - Click for oxygen index calculator

http://www.medcalc.com/oxygen.html

OI = FiO2 * MAP

PaO2

Pulse oximetry

Purposes:

adjust FIO2

ƒensure adequate oxygenation

ƒprevent hyperoxia

screening for ductal-dependentcardiac anomalies

perfusion index from signalamplitude reflects illness severity

Optimal range for SPO2 forinfants on O2 therapy = 85% - 93%

TOSCA monitor

Made by Linde Medical Sensors

Ear sensor with SPO2 andtranscutaneous PCO2 (PTCCO2)measurement

Found accurate and reliable byseveral studies

FYI - click to see abstract of study on TOSCAhttp://pediatrics.aappublications.org/cgi/content/abstract/peds.2004-0946v1

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Neonatal Blood

ƒfetal Hb

greater affinity for O2 than adult Hb- partial compensation for low fetalPaO2 (<29 mm Hg)

present, with adult Hb for 1st year

ƒinitial CBC (term)

Hb = 16.5 - compensation forPaO2

Hct = 50

WBC = 18,000

Neonatal Blood

ƒimmunoglobulins

IgG from mom while in utero

IgA from breast milk

newborn starts developing own IgG

post-natally

increased IgM at birth ==>

intrauterine infection

FYI - click for more information on immunoglobulinshttp://www.wellness.com/reference/allergies/newborn-immune-system

Weight/gestational age

Gestational age - extremely lowgestational age (ELGAN) - < 28 wks.

Weight/GA categories

ƒAppropriate for gestational age(AGA)

ƒSmall for gestational age (SGA)

ƒLarge for gestational age (LGA)

Infants who are SGA, show greatermortality, independent of gestationalage

Weight categories

Weight

Moderately low (MLBW).........1501-2500g

Very low (VLBW).....................1001-1500g

Extremely low (ELBW)..........<1000g

Review & Summary

ƒApgar score - general health

ƒBallard score - gestational age

ƒSilverman respiratory status index

ƒCritical care scores - CRIB, SNAPPE

Review & Summary

ƒNormal physical features

ƒAbnormal physical features

ƒNormal neurologic responses

ƒCardiovascular assessment

ƒNormal physiologic features

lung mechanics

blood gases, pulse oximetry

ƒWeight/gestational age relationships

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END

References

ƒJohnson KB, Oski FA. Oski's Essential Pediatrics 1997.Lippincott Publishers, Philadelphia. Chap. 11

ƒBarnhart SL, Czervinski MP. Perinatal and PediatricRespiratory Care 2nd Ed 2003. W.B. Saunders Company,Philadelphia. Chap. 3

ƒWhitaker KL. Comprehensive Perinatal & PediatricRespiratory Care (2nd ed.) 1996. Delmar Publishers,Albany. Chap 5.

ƒCommittee on fetus and newborn. Use and abuse of theApgar score. Pediatrics 1996;98:141-142.

ƒSasidharan K, Dutta S, Narang A. Validity of New BallardScore till 7th day of postnatal life in moderately pretermneonates. Arch Dis Child. 2008 Mar 12.

ƒDe Felice C, et al. Predictive value of skin color forillness severity in the high-risk newborn. PediatricResearch 2002;51:100-105.

References

ƒMackanjee HR, Iliescu BM, Dawson WB. Assessment ofpostnatal gestational age using sonographicmeasurements of femur length. J Ultrasound Med. 1996Feb;15(2):115-20.

ƒMeadow W, et al. Just, in time: ethical implications ofserial predictions of death and morbidity for ventilatedpremature infants. Pediatrics. 2008 Apr;121(4):732-40.

ƒGagliardi L, eta al. Assessing mortality risk in lowbirthweight infants: a comparison of CRIB, CRIB-II andSPAPPE-II. Arch Dis Child Fetal Neonatal Ed.2004;89:F419-F422.

ƒTrachsel D, McCrindle BW, Nakagawa S, Bohn D.Oxygenation index predicts outcome in children withacute hypoxemic respiratory failure. Am J Respir CritCare Med. 2005 Jul 15;172(2):206-11. Epub 2005 Apr 7.

ƒBrouillette RT, Waxman DH. Evaluation of the newborn'sblood gas status. Clin Chem 1997;43:215-221.

References

ƒHjalmarson O, Sandberg K. Abnormal lung function inhealthy preterm infants. Am J Respir Crit Care Med2002;165:83-87.

ƒCastillo A, et al. Pulse oxygen saturation levels andarterial oxygen tension values in newborns receivingoxygen therapy in the neonatal intensive care unit: is85% to 93% and acceptable range? Pediatrics2008;121:882-889.

ƒde Wahl, GA, et al. Impact of pulse oximetry screeningon the detection of duct dependent congenital heartdisease: a Swedish prospective screening study in39,821 newborns. BMJ. 2009 Jan 8;338:a3037.

ƒDe Felice C, Latini G, Vacca P, Kopotic RJ. The pulseoximeter perfusion index as a predictor for high illnessseverity in neonates.Eur J Pediatr. 2002;161(10):561-2.

Documents

Assessment of the Neonate