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ED Evaluation of the Newborn Anita Eisenhart, DO, FACOEP, FACEP CRASH Course Chandler, AZ September, 2012.

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Presentation on theme: "ED Evaluation of the Newborn Anita Eisenhart, DO, FACOEP, FACEP CRASH Course Chandler, AZ September, 2012."— Presentation transcript:

1 ED Evaluation of the Newborn Anita Eisenhart, DO, FACOEP, FACEP CRASH Course Chandler, AZ September, 2012

2 Overview Generally healthy newborn 1 st month of life History of the newborn Routine head-to-toe exam Anitas Top Ten complaints/diagnosis How to quickly rule out badness …and never miss badness

3 Evaluation Chief complaint & vital signs Temp may be most important General appearance Triage nurses assessment (pre-hospital care) Color Activity Tone Cry

4 History of the Newborn Birth weight Compared to todays 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

5 History of the Newborn, cont. Diet Formula/breast/both/how much/how long Family Other children Significant stressors Sick contacts Young parents

6 Head-To-Toe Examination Head Size & shape Anterior fontanelle Flat, sunken, bulging AFOF Cephalohematoma Babys reaction to head exam

7 Anterior Fontanelle


9 Head-To-Toe, cont. EENT Red reflex Anatomic abnormalities Infectious evidence Nasal congestion Eye exudates, injected sclera Oral thrush Mucous membranes (pink & moist)

10 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

11 Head-To-Toe, cont. Abdomen General appearance Umbilical stump Palpate for mass and for organomegaly Bowel sounds Babys comfort with exam i.e. tenderness

12 Head-To-Toe, cont. Back General morphology Defects Hair patterns

13 Head-To-Toe, cont. Pelvis Open the diaper General appearance of genitals Ambiguity Rash Foreskin or circumcision site Testicles Femoral pulses

14 Ambiguous Genitalia

15 Dont Forget The Family Jewels

16 Head-To-Toe, cont. Extremities General morphology Capillary refill Neuro Moving 4 extremities Moro Suck Rooting

17 Head-To-Toe, cont. Skin Rash Desquamation Cutis marmorata Turgor Lanugo

18 Newborn Exam

19 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

20 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

21 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)

22 7. Yellow Baby Neonatal Jaundice Very common Outcome is very good Kernicterus (encephalopathy) exceedingly rare General exam Jaundice starts north and works its way south Check levels Compare to standards AAP 2004 recommendations

23 AAP Recommendations 2004

24 Theres an App! Based on the AAP Guidelines, hours of life, and measured bilirubin level

25 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

26 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

27 Neonatal Acne

28 Diaper Dermatitis Satellite lesions nystatin

29 Newborn Desquamation

30 Cutis Marmorata Lattice appearance mottled

31 Cradle Cap Overactive oil glands Maternal hormones Anti-dandruff shampoo Soft brush

32 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

33 Umbilical Granuloma

34 Silver Nitrate Burn Use with caution

35 Omphalitis Fever Cellulitis Discharge

36 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

37 2. Hasnt 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 Hirschprungs Disease Usually can rule out by history

38 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

39 Bonus: Neonatal Menarche??? Breast buds & bloody vaginal discharge Maternal estrogen withdrawal General inspection Re-assurance

40 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


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