ED Evaluation of the Newborn

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

2. 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

3. Evaluation • Chief complaint & vital signs • 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 • 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 • Head • 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 • 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 • 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 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 • 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. 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