1.

Evaluation and Care of the Newborn Infant Thomas

January 27, 2017 11:55:40 AM EST

Learning objectives
The student should be able to...
identify the known benefits of feeding human breast milk to infants.
define the important elements of a prenatal history as they relate to the health of the unborn child,
including the importance of maternal age.
recognize factors in the perinatal and newborn history that may put a neonate at risk for medical
problems.
identify intrauterine factors that affect the growth of the fetus.
demonstrate knowledge of the indication for newborn screening for TORCH infections, including
human immunodeficiency virus (HIV).
discuss factors that affect maternal-to-fetus HIV transmission and those that play a role in the
prevention of vertical HIV transmission.
identify the key concepts used in the clinical evaluation of gestational age and stability at birth
(e.g., the Ballard score and Apgar score). Use weight and gestational age to categorize potential
clinical problems.
determine what medications are routinely given to all newborns (e.g., vitamin K, hepatitis B
vaccine, eye infection prophylaxis).
discuss the common etiologies for small-for-gestational-age (SGA) infants.
recognize the salient physical findings of congenital cytomegalovirus (CMV) infection and name
potential long-term complications associated with this condition.

Blaty Justin - jblaty@msu.edu

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Knowledge
Risks for Infants of Adolescent Mothers
Infants born to adolescent mothers are at greater risk for:
lower birth weight
vertically acquired STIs (due to the higher incidence of STIs in the adolescent population)
poorer developmental outcomes
increased risk of fetal death
Infants born to adolescent mothers do not have increased incidence of chromosomal
abnormalities. Trisomy 21 is more likely to occur in older mothers.

Adverse Effects of Prenatal Substance Use

Tobacco
Maternal tobacco use during pregnancy increases the risk for low birth weight in the fetus.
There is not a characteristic facies 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 does not occur.
Fetal alcohol syndrome is a distinct pattern of facial abnormalities, growth deficiency, and
evidence of central nervous system dysfunction.
In addition to cognitive disability, victims of fetal alcohol syndrome exhibit other
neurobehavioral deficits such as poor motor skills and hand-eye coordination and learning
problems (i.e., difficulties with memory, attention, and judgment).
Marijuana
Distinctive effects of marijuana have not been identified.
Cocaine and Other Stimulants
These cause vasoconstriction leading to placental insufficiency and low birth weight.
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."

Factors Limiting Fetal Growth in Utero

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Factors Limiting Fetal Growth in Utero

Maternal factors

Poor weight gain in the third trimester

Preeclampsia
Maternal prescription or illicit drug use
Maternal infections
Uterine abnormalities

Placental abnormalities

Placenta previa
Placental abruptions
Abnormal umbilical vessel insertions

Fetal abnormalities

Fetal malformations
Metabolic disease
Chromosomal abnormalities
Congenital infections

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

Risks for Vertical Transmission of HIV

Factors that increase the risk of HIV transmission from mother to infant include:
Frequent, unprotected sex during pregnancy (This increases the risk for chorioamnionitis,
and chorioamnionitis and other sexually transmitted infections increase the risk of HIV
transmission.)
Advanced maternal HIV disease, which may indicate high viral load
Membrane rupture greater than 4 hours prior to delivery if mother is not on antiretroviral
therapy
Vaginal delivery
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Breastfeeding
Premature delivery (i.e., delivery before 37 weeks' gestation)

Components of the Apgar Score

A ppearance (skin color)
P ulse (heart rate)
G rimace (reflex irritability)
A ctivity (muscle tone)
R espiration
A newborn receives a score of 0, 1, or 2 for each component, with the final Apgar score ranging
from 0 to 10.

Growth Terms Reviewed

Small for gestational age (SGA) = Weight below the 10th percentile for gestational age
Microcephalic = Head circumference below the 10th percentile for gestational age
Term = Born at > 37 weeks' gestation
(See this Committee Opinion from the American College of Obstetricians and Gynecologists from
November 2013 for a suggested revision of the "term" nomenclature:
http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-ObstetricPractice/Definition-of-Term-Pregnancy.)

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 (http://www.medcalc.com/ballard.html) .

Risks for SGA Newborns

Risk

Etiology

Symptoms
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Hypoglycemia

Hypothermia

Decreased
glycogen stores
Heat loss
Commonly asymptomatic, though may exhibit poor
Possible hypoxia
feeding and listlessness
Decreased
gluconeogenesis

Cold stress
Hypoxia
Hypoglycemia
Increased
surface area
Decreased
subcutaneous
insulation

Commonly asymptomatic, though may exhibit poor

feeding and listlessness

"Ruddy" or red color to skin

Respiratory distress*
Poor feeding
Hypoglycemia

Polycythemia

Chronic hypoxia
Maternal-fetal
transfusion
*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.

View a table showing other clinical problems that may be seen in the SGA newborn.

Hyperlink "View a table showing other clinical problems that may be seen in the SGA
newborn. "
This Multimedia material is not included in this Summary, please open Case to review.

TORCH Infections
TORCH is an acronym used to refer to prenatal or congenital infections.
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It was originally coined from the first letters of TOxoplasmosis, Rubella, Cytomegalovirus and
Herpes virus type 2. (Recent revisions ascribe the "O" to Other transplacental infections, including
HIV, hepatitis B, human parvovirus, and syphilis.)

Sequelae of Congenital CMV

Hearing loss

In many infected infants, the onset of hearing loss may be after the
newborn period.
The loss is often progressive.
Even if the newborn hearing screen is normal, an infant infected with
CMV may develop hearing loss and progress to severe-to-profound
bilateral hearing loss during the first year of life.

Microcephaly and
intracranial
calcifications

These findings are associated with an increased risk of CNS

sequelae of congenital CMV infection, such as developmental
delay.
Infants with congenital CMV must have ongoing developmental
assessments and may ultimately demonstrate intellectual disabilities
and/or cerebral palsy.

Hepatosplenomegaly

These nonneurological neonatal clinical abnormalities can be expected to

resolve spontaneously within weeks.

Rash

Brain Imaging Findings in Congenital CMV

Brain imaging obtained in infants with congenital CMV may show the following:
Intracranial calcifications (these appear as bright areas on CT)
Diminished number of gyri and abnormally thick cortex (a condition known as lissencephaly
or agyria-pachygyria)
Enlarged ventricles
Cranial imaging with ultrasound, magnetic resonance imaging (MR), or computed tomography
(CT) may all be utilized to assess the degree of CNS. However, given the radiation exposure, CT
is utilized less frequently in the workup of CMV.

Breastfeeding

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Indications

Recognized by the American Academy of Pediatrics as the optimal

feeding for infants.
Exclusive breastfeeding is recommended for the first 6 months of
life, followed by breastfeeding plus complementary foods until the
infant is at least 12 months of age.
Breast milk plus fortifier is recommended for premature babies.
Mothers should nurse their babies whenever there are signs of
hunger, which often is 8-12 times per day.

These are rare, but may include:

Absolute
Contraindications

Benefits for Child

Maternal HIV infection (in the industrialized world)

Active herpes simplex lesions on the breast
Active untreated tuberculosis
Active maternal use of some (not all) non-prescription drugs of
abuse
Infants with galactosemia

Stimulates gastrointestinal growth and motility, which enhances the

maturity of the gastrointestinal tract.
In both developed and developing nations, human milk compared
to formula decreases the risk of acute illnesses during the time that
the infant is fed breast milk.
Breastfed babies have lower rates of diarrhea, acute and recurrent
otitis media, and urinary tract infections.
There are reported associations between the duration of
breastfeeding and a reduction in incidence of obesity, cancer, adult
coronary artery disease, certain allergic conditions, type 1 diabetes
mellitus, and inflammatory bowel disease.
A number of studies have shown small neurodevelopmental
advantages, including cognitive and motor development.

Potential maternal benefits include decreased risk of:

Maternal Benefits

Breast cancer
Ovarian cancer
Osteoporosis

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Education/Assessment

Prior to hospital discharge, evaluate adequacy of latch-on, suckling

and milk transfer, and progress of lactogenesis.
Provide mothers with the education, resources, and follow-up to
ensure breastfeeding success.
Within 24 to 48 hours after discharge, an in-home lactation
specialist or physician needs to assess adequate urine and stool
output as well as weight change.

Newborn Screening
Newborns are routinely screened for the following:

Metabolic disorders

The newborn screen helps test for conditions that

might not be readily picked up.
It is critical that all newborns be screened so that
early identification of metabolic conditions can
be ensured.
All states screen for PKU and hypothyroidism.
Some states also screen for galactosemia,
biotinidase deficiency, hemoglobinopathy, maple
syrup urine disease (MSUD), homocystinuria,
congenital adrenal hyperplasia, cystic fibrosis,
G6PD deficiency, and toxoplasmosis
Many states now screen for more than 30
diseases using tandem mass spectrometry.

Congenital deafness
In 2010 guidelines were published
recommending screening all newborns
for significant congenital heart defects
using measurement of transcutaneous
oxygen saturation.

Signs and Symptoms of Inborn Errors of Metabolism

Inborn errors of metabolism can present in neonates with a number of signs, including but not
limited to:
anorexia
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lethargy
vomiting
seizures
These symptoms tend to present 24 to 72 hours after birth.
One of five sick full-term neonates without risk factors for infection will have a metabolic disorder.
While some infants with metabolic disorders will be obviously ill, other metabolic conditions have a
more insidious onset.

Clinical Findings in Newborns with Congenital CMV Infection

CMV is the leading cause of congenital infection in the U.S.
More than 90% of children with congenital CMV infection have no clinical evidence of disease as
newborns.
Among newborns with symptomatic congenital CMV infection, the severity of illness varies widely:
Some infants have one or two abnormalities on exam but are otherwise healthy.
Other infants have multisystem disease with clear evidence of CNS damage.
Mortality is 10% to 15% among symptomatic infants.
Among survivors, neonatal clinical abnormalities can be expected to resolve spontaneously
within weeks, except for those involving the CNS and hearing.
Frequency of findings in newborns with symptomatic congenital CMV infection:
System

Skin

Hepatobiliary

Feature

Frequency (%)

Petechiae

75

Purpura, ecchymosis

10

Jaundice

67

Direct bilirubin > 2mg/dL (> 34.2 mcmol/L)

80

Elevated ALT (> 80 IU/mL)

80

Hepatomegaly

60

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Thrombocytopenia < 100x103/mcL (<100x109/L) 77

Hematopoietic Anemia

50

Splenomegaly

60

Microcephaly

53

Intracranial calcifications on CT

54

Poor feeding, lethargy

30

Seizures

Increased CSF protein (> 120 mg/dL)

47

Auditory

Sensorineural hearing loss

50

Visual

Chorioretinitis

10

CNS

Routine Newborn Discharge Instructions for Parents

Red flags requiring immediate evaluation (including signs of significant jaundice)
Feeding instructions and signs of poor feeding
Safety issues (including placing the newborn on his back to sleep, proper infant auto
restraint, and how to access emergency help)

Clinical Skills
Approach to the Adolescent Interview
Always complete at least a brief HEEADSSS interview when you obtain a history from adolescent
patients-in any setting-to screen for risk-taking behavior that may result in the three leading causes
of death for adolescents in the U.S.:
Accidents
Homicide
Suicide

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When conducting a HEEADSSS interview, remember the following guidelines:

Be direct
Contextualize your questions
Ask one question at a time
Click to review sample HEEADSSS questions.

Hyperlink "Click to review sample HEEADSSS questions."

Sample HEEADSSS questions:

H ome

Who lives with you? Where do you live?

Do you have your own room?
What are relationships like at home?
What do your parents and relatives do for a living?
Have you ever lived outside your home? (ever
incarcerated, institutionalized?)
Have you moved recently? Have you ever thought of
running away?
Are there any new people in your home environment?

E ducation / E mployment

What are your favorite subjects? Worst subjects?

Have there been any changes in your grades?
Are you in any special programs in school?
Have you repeated any years? Have you failed any
classes?
Have you changed schools recently?
Have you been suspended?
Do you have plans for future education and
employment?
Are you working now?
How many hours do you work per week?
How are your relations with your teachers or
employers?

E ating disorder screening

Where and with whom do you eat?

What do you eat?

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A ctivities / A ffiliations / A
spirations

What do you like to do for fun?

In what activities do you participate in school or
outside of school?
Do you participate in any sports or get regular
exercise?
Do you attend church or clubs, or take part in projects?
Do you have any hobbies or other home activities?
Do you read for fun: What?
How much TV do you watch weekly? What are your
favorite shows?
What music do you like to listen to?
What do you want to do when you grow up?

D rugs (including alcohol, tobacco,

steroids)

Do any of your friends smoke or use alcohol or other

drugs? If the answer is yes, How do you feel about
their use?
Have you ever tried cigarettes, alcohol, marijuana or
other drugs? Any performance-enhancing
substances?
If yes, How much do you use and how often? Do you
do this in any particular setting?
Do your family members use drugs, including alcohol
and tobacco?

S exuality

S uicidal behavior (along with

depression and mental health
concerns)

Have you and your parents talked about sex?

Have you ever had a crush on anyone or has anyone
ever had a crush on you?
Have you ever had sex?
Have you ever had unwanted or forced sex?
How many partners have you had?
Do you use contraception?
Do you know about sexually transmitted diseases?
Have you ever been pregnant?

Do you feel sad or down more than usual?

Do you have trouble getting to sleep?
Have you ever thought that life isn't worth living?
Have you thought a lot about hurting yourself or
someone else?

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S afety (abuse, fights, weapons,

seatbelts, etc.)

Have you ever been seriously injured? How?

Have you ever done anything that you thought was
dangerous?
Have you ever ridden with a driver who was drunk or
high? When? How often?
Do you use a seat belt in the car?
Is there violence in your home?
Have you every been physically or sexually abused?

Newborn Resuscitation
In addition to remembering the ABCs (or airway-breathing-circulation), keep in mind some of the
special features of newborn resuscitation:
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.
Helps clear the lungs and mobilize secretions.
Suction amniotic fluid from the infant's nose and mouth.
This helps clear the upper airway.
Initiate further resuscitation if required.
This may include using blow-by oxygen, positive pressure (bag-valve mask) ventilation with
oxygen, chest compressions, and even medications.
While approximately 10% of newborns require some assistance to initiate breathing, fewer than
1% require extensive rescuscitation.

Elements of Routine Newborn Care

Use universal precautions.
Stabilize the infant's temperature via:
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Skin-to-skin contact with the mother

Radiant warmer, or
Incubator.
Obtain Apgar scores at 1 and 5 minutes post delivery.

Demonstration of Primitive Reflexes

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)
Support the newborn's head with one hand and buttocks with the other. With the head in a
midline position, the hand supporting it is quickly dropped to a position approximately 10 cm
below its original supporting position, and the head is caught in its new position. 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.
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.

Clinical Reasoning
Differential Diagnosis for SGA Newborn with Microcephaly and Purpuric
Rash
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TORCH
infection

TORCH infections-such as congenital rubella syndrome, congenital

toxoplasmosis, and congenital CMV-may result in hepatosplenomegaly,
purpuric rash, and microcephaly.
It is difficult to distinguish each of the different infections solely by physical
examination; additional studies are needed.

Fetal alcohol
syndrome

Fetal alcohol syndrome is a possibility, but this constellation of physical

findings would argue against this diagnosis as the sole etiology.

Chromosomal
abnormality

A chromosomal abnormality can cause an infant to be small for gestational

age.
The findings of hepatosplenomegaly, rash, and no other dysmorphic
features argue against this possibility.

Prenatal
tobacco
exposure

Maternal tobacco use may cause SGA due to placental insufficiency.

HIV infection

Infants with vertically acquired HIV may have hepatosplenomegaly and/or

microcephaly, although most newborns are asymptomatic at birth.

Studies
Prenatal Lab Screening
These are usually included in the prenatal lab screening:
Serological screening to determine status for infections such as HIV, rubella, and hepatitis B
Blood type and Rh
Urine drug screen

Testing for TORCH Infections

TORCH Infection Test
Hepatitis B

Maternal hepatitis B surface antigen (HBsAg)

Rubella

Maternal and infant rubella titer

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Toxoplasma

Infant toxoplasma titer

CMV

Infant urine culture

Management
Decreasing the Risk of Vertical HIV Transmission
In situations in which the maternal HIV antibody test is positive, the following steps should be
considered in an effort to decrease the risk of HIV transmission to the fetus:
Treatment of the mother with combination antiretroviral therapy (if viral load > 1000
copies/mL)
When possible, a cesarean delivery should be performed prior to the onset of labor (at 38
weeks' gestation) and the rupture of membranes.
In the U.S. and other developed nations where alternative sources of feeding are readily
available, affordable, and are mixed with clean water, HIV-infected women should be
counseled not to breastfeed their infants.

Routine Newborn Medications

Vitamin K: Newborns routinely receive an intramuscular injection of vitamin K to prevent
hemorrhagic disease of the newborn (now also referred to as vitamin K deficiency bleeding).
Hepatitis B vaccine: The CDC recommends that all delivery hospitals develop policies that
ensure administration of hepatitis B vaccine at birth as part of the routine care of all medically
stable newborns weighing > 2000 grams. This is true for all of these babies, regardless of maternal
testing results. Hepatitis B immunoglobulin (HBIG) is given only to newborns at risk for vertical
transmission of hepatitis B virus.
Erythromyc in (also tetracycline or silver nitrate): One of these antibiotics is administered
topically specifically to prevent gonococcal conjunctivitis. 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.

Antiviral Treatment of Congenital CMV

Studies have shown decreased progression of hearing impairment and diminished developmental
impairment in infants with congenital CMV infection and CNS involvement when they are treated
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with either parenteral ganciclovir or oral valganciclovir.

Treatment of symptomatic congenital CMV with CNS involvement for 6 months is accepted
practice to improve hearing and developmental outcomes if treatment can be started in the first
month of life.
There are no controlled data supporting the treatment of asymptomatic congenital CMV infection.

CMV Follow-up Assessment Guidelines

Audiometry
ABR or otoacoustic emissions until at least 12 months, then age-appropriate.
Recommended for patients when newborn, then at 3, 6, 9, 12 18, 24, 30 and 36 months, then
annually until school age.
Ophthalmoscopy, Vision Function
Test when patient is newborn, 12 months, 3 years and preschool.
Neurologic Examination/Developmental Assessment by Primary Care Physician
Perform at each check-up until patient is school age.
Neurology and/or Neuropsychology Referral
As indicated by clinical findings.

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Own Entries
Summary Statement
Thomas is a infant born at 37w vaginal delivery without complications and apgar 9 and 9 at 1 and 5 min. Thomas is SGA and initial
physical exam is unremarkable.