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Neonatal Gestational Age Assessment

Neonatal Gestational Age Assessment. Objectives. By the end of this presentation the learner should…. Understand the prenatal gestational age assessment tools Classify the size differences between IUGR, SGA, AGA, & LGA infant

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Neonatal Gestational Age Assessment

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  1. Neonatal Gestational Age Assessment

  2. Objectives By the end of this presentation the learner should…. Understand the prenatal gestational age assessment tools Classify the size differences between IUGR, SGA, AGA, & LGA infant Complete the physical maturity portion of the neonatal gestational age assessment tool Conduct the neuromuscular portion of the neonatal gestational age assessment Compile the maturity score on the neonatal gestational age assessment tool Identify those common differential findings found on newborn exam

  3. Prenatal Gestational Age Assessment • Calculation by the mother estimated date of confinement (EDC) • Collection of prenatal data • First fetal movement (16-20 weeks) • Fetal heart tones (20 weeks) (with doppler 9-12 weeks) • Fundal height (One cm = 1 week after 18-20 weeks) • 20 weeks (fundus normally at umbilicus) • Term (fundus at xyphoid) • Amniotic fludi creatinine levels • Maternal serum and urine estriols • Fetal US

  4. Prenatal Gestational Age Assessment Fetal US Measurements • Crown to rump length • Biparietal diameter • Femur length • Abdominal Circumference • Head Circumference • Placental grade

  5. Basics of Newborn Physical Exam • Review the perinatal history for clues to potential pathology • Begins with conception and includes events that occurred throughout gestation • Genetic history • Labor & delivery history • Assess the infant’s color for clues for potential pathology • Auscultate in a quiet environment • Keep infant warm during exam • Calm the infant before exam • Handle gently

  6. Classification of Size

  7. Classification of size forgestational age • Growth for dates can be determined by weight, length, and head circumference • Plotted on a graph appropriate for gestation • Preterm before 37 weeks • Term 38-41 weeks • Post term after 42 weeks

  8. Classification of size for gestational age • Using the gestational age score the weight, height and head circumference can be plotted on the infants growth chart • This information is how the infant is diagnosed as SGA, LGA, or AGA

  9. Classification of size for gestational age • SGA- small for gestational age-weight below 10th percentile • AGA-weight between 10 and 90th percentiles (between 5lb 12oz (2.5kg ) and 8lb 12 oz (4kg). • LGA-weight above 90th percentile • IUGR-deviation in expected fetal growth pattern, caused by multiple adverse conditions, not all IUGR infants are SGA, may or may not be “head sparing”

  10. Neonatal Gestational Age- Ballard Exam • The physical maturity part of the examination should be done in the first two hours of birth • The neuromuscular maturity examination should be completed with 24 hours after delivery • Derived to look at various stages in an infants gestational maturity and observe how physical characteristics change with gestational age • Neonates who are more physically mature normally have higher scores than premature infants • Points are awarded in each area -2 for extreme prematurity to 5 for postmature infants

  11. Physical Maturity • Skin • Lanugo • Plantar surface • Breast • Eyes & Ears • Genital

  12. Neonatal Gestational AgePhysical Maturity

  13. Physical Maturity-Skin • Examine the texture, color and opacity • As the infant matures: • More subcutaneous tissue develops • Veins become less visible and the skin becomes more opaque

  14. Neonatal Gestational Age Assessment • Physical Maturity • Skin • Before 28 weeks-gelatinous red, friable • 28-37 weeks-skin over abdomen thin, translucent, pink with visible veins • 37-39 weeks smooth, pink, increased thickness, rare veins over abdominal wall

  15. Neonatal Gestational Age Assessment • Physical Maturity • Skin • 40 Weeks-vessels have now appeared, skin may be leathery with deep cracking

  16. Differential Skin Findings • Scalp Electrode

  17. Differential Skin Findings • Forcep Marks

  18. Differential Skin Findings • Vacuum Bruising

  19. Differential Skin Findings • Milia-exposed sebaceous glands • No treatment necessary

  20. Differential Skin Findings • Sebaceous hyperplasia • More yellow than milia • Result of maternal androgen in utero • Resolves in time

  21. Differential Skin Findings • Mongolian Blue-Grey Spots • Most common in Asian, Hispanic, and African descent • Gradual fade over the first years

  22. Differential Skin Findings • Skin Tags • Most common on ears • Usually tied off or clipped

  23. Differential Skin Findings • Salmon patches or nevus simplex • Angel kisses • Stork bites

  24. Differential Skin Findings • Erythema toxicum • White or yellow papule or pustule • With erythematous base • No treatment necessary

  25. Differential Skin Findings • Café Au Lait spots • Increased amount of melanin, may increase in number in age • Presence of 6 or more- greater then 0.5 cm in size may be indicative of neurofibromatosis

  26. Neonatal Gestational Age Assessment • Physical Maturity • Lanugo • After 20 weeks-begins to appear • 28 weeks-abundant • After 28 weeks-thinning, starts to disappear from the face first • 38 weeks-bald areas slight amount may be present on shoulders

  27. Neonatal Gestational Age Assessment • Vernix • Before 34 weeks-vernix thick and covers entire body • 34-38 weeks-vernix is absorbed gradually, portions over shoulder and neck is the last to be absorbed • 38-40 weeks-vernix only present in folds of skin • After 40 weeks-no vernix present

  28. Neonatal Gestational Age Assessment • Plantar Surface • Before 28 weeks-no creases • 28-32 weeks-virtually no sole creases, faint thin red lines over anterior aspect of foot • 34-37 weeks-1-2 anterior creases • 37-39 weeks-creases now over the anterior 2/3 of the sole

  29. Differential Findings Syndactyly Bilateral Club Feet Polysyndactyly

  30. Neonatal Gestational Age Assessment • Physical Maturity • Breast • Before 28 weeks-nipples imperceptible • 28-32 weeks-nipple barely visible, no areola • 32-37 weeks-well defined nipple areola • 38-40 weeks-well defined nipple raised areola

  31. Neonatal Gestational Age Assessment • Physical Maturity • Eyes • Eyes are evaluated as either fused as seen in extremely premature infants or open • Before 26 weeks eyes are fused

  32. Differential Findings • Congenital Cataracts • Eyelid Edema • Subconjunctival Hemorrhage

  33. Neonatal Gestational Age Assessment • Physical Maturity • Ears • Before 34 weeks-pinna is very immature cartilage not present, lies flat, remains folded • 34-37 weeks-pinna curved with soft recoil • 37-40 weeks-formed, firm instant recoil • After 40 weeks-thick cartilage ear stiff

  34. Differential Findings • Ear Tags • Ear Pits (Preauricular pits) • Lop Ear • Prominent Ear

  35. Physical Maturity Genitalia-Male Before 28 weeks-scrotum empty and flat 28-30 weeks-testes undescended into scrotal sac 30-36 weeks testes descending with a few rugae over the scrotum 36-39 weeks-testes have descended into scrotum which is now pendulous and complete with rugae Genitalia-Female Before 28 weeks-clitoris prominent labia flat 28-32 weeks-prominent clitoris, enlarging labia minora 33-36 weeks-labia majora widely spaced with equally prominent labia minora 33-39 weeks-labia extends over the labia minora but not over the clitoris 39 weeks-labia majora completely covers the labia minora and clitoris Neonatal Gestational Age Assessment

  36. Differential Findings Hydrocele Undescended testicles Hypospadias Hymenal Tag

  37. Neonatal Gestational Age Neuromuscular Assessment

  38. Neonatal Gestational Age Assessment • Neuromuscular Maturity • Posture & Tone • Square Window • Arm Recoil • Popliteal Angle • Scarf Sign • Heel to Ear

  39. Neonatal Gestational Age Assessment • Neuromuscular Maturity • Posture/Tone-Total body muscle tone is reflected in the infants preferred posture at rest and resistance to stretch of individual muscle groups • Make sure infant is quiet • The more mature an infant is the greater their tone will be • A more flexed position indicated greater tone

  40. Neonatal Gestational Age Assessment • Neuromuscular Maturity • Posture & Tone • Before 30 weeks-hypotonic, little or no flexion seen • 30-38 weeks-varying degrees of flexed extremities • 38-42 weeks-may appear hypertonic

  41. Neonatal Gestational Age Assessment • Neuromuscular Maturity • Square Window-wrist flexibility and/or resistance to extensor stretching resulting in angle or flexion at wrist • Flex hand down to wrist-measure the angle between the forearm & palm • Before 26 weeks-wrist can’t be flexed more than 90 degrees • Before 30 weeks-wrist can be flexed no more than 90 degrees • 36-38 weeks-wrist can be flexed no more than

  42. Neonatal Gestational Age Assessment • Neuromuscular Maturity • Arm Recoil-measures the angle of recoil following a brief extension of the upper extremity • For 5 seconds flex the arms while infant is in the supine position, pulling the hands fully extend the arms to the side, then release-measure the degree of arm flexion & strength (recoil) • Before 28 weeks-no recoil • 28-32 weeks-slight recoil • 32-36 weeks-recoil does not pass 90 degrees • 36-40 weeks-recoils to 90 degrees • After 40 weeks-rapid full recoil

  43. Neonatal Gestational Age Assessment • Neuromuscular Maturity • Popliteal Angle-assesses maturation of passive flexor tone about the knee joint by testing resistance to extension of the leg • The angle decreases with advancing gestational age • Before 26 weeks-angle 180 degrees • 26-28 weeks-angle 160 degrees • 28-32 weeks-angle 140 degrees • 32-36 weeks angle 120 degrees

  44. Neonatal Gestational Age Assessment • Neuromuscular Maturity • Scarf Sign-tests the passive tone of the flexors about the shoulder girdle • Increased resistance to this maneuver with advancing gestational age • Before 28 weeks-elbow passes torso • 28-34 weeks-elbow passes opposite nipple line • 34-36 weeks-elbow can be pulled past midline, no resistance • 36-40 weeks-elbow to midline with some resistance • After 40 weeks-doesn’t reach midline

  45. Neonatal Gestational Age Assessment • Neuromuscular Maturity • Heel to Ear-measures passive flexor tone about the pelvic girdle by testing passive flexion or resistance to extension of the posterior hip flexor muscles • Breech infants will score lower than normal • Before 34 weeks-no resistance • 40 weeks-great resistance may be difficult to perform

  46. References Aby, J. (2008). Stanford School of Medicine. Newborn Nursery at LPCH. Retrieved October 10th, 2009 from http://newborns.stanford.edu/RNMDEducation.html Ballard J. (1991). New Ballard Score, expanded to include extremely premature infants. Journal of Pediatrics, 119, 417-423. Tappero, E. & Honeyfield, M. (1996). Physical assessment of the newborn. Santa Rosa, CA: NICU Ink Publishers.

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