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

2. Overview Generally healthy newborn History of the 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

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

4. History of the Newborn Birth weight Birth history
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

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
Size & shape
Anterior fontanelle
Flat, sunken, bulging
“AFOF”
Cephalohematoma
Baby’s 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 Chest 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
Baby’s 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. Don’t Forget The Family Jewels

16. Head-To-Toe, cont. Extremities Neuro 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 General exam Check levels
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

23. AAP Recommendations 2004

24. There’s an App! www.BiliTool.org
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 Diaper dermatitis Desquamation Cutis Marmorata
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 Anti-dandruff shampoo
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 Obstruction
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. 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

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