The Newborn Infant (High-Risk Neonate) IMMEDIATE NEWBORN 1.

EENC Protocol (4)

History Taking Of The Newborn CARE 2. APGAR Score
3. Routine Newborn Care
Early Essential Newborn Care
EENC (Unang Yakap) 1. Drying & Providing Warmth with simultaneous
Neonatal Period Highly vulnerable time: Complete physiological adjustments evaluation (color, muscle tone, HR, respiratory
(almost all organs) effort)
2. Skin-to-skin contact (abdomen or chest)
3. Properly-timed cord clamping (after pulsation
Birth → 1st month of life (0-28 days) stops, or between 1-3 minutes)
4. Keeping the mother and infant dyad together
Asphyxia in Utero May develop Perinatal asphyxia (non-separation)

Focus of Management of ● Anticipatory guidance (taken from a good maternal Routine Newborn Care 1. Eye Prophylaxis (Erythromycin ophthalmic eye
Newborn history) drops/ointment) -prevent opthalmia neonatorum
● Early detection of conditions and complications 2. Vitamin K Prophylaxis (IM) -prevent
hemorrhagic disease
Commonly anticipated ● Respiratory 3. Cord care (air dry)
Problems of Neonates ● Cardiovascular
Newborn Immunizations (Given upon birth)
Gas Exchange In Utero: placenta (lungs are fluid filled → pulmonary 1. Hep B vaccine
pressure is higher) 2. BCG vaccine (can also be given before discharge)
Extra Uterine: adult circulation (lungs)
Neonatal Screening 1. Expanded Newborn Screening (metabolic diseases
Important Periods to and hemoglobinopathies)
Remember PERINATAL 28th week of gestation → 7th day after birth 2. Hearing Screening
(Fetal life → 1st week of life) 3. Critical Congenital Heart Screening (congenital
heart disease)
NEONATAL 4. Additional (for Preterm Infants)
● Very Early ● Birth → less than 24 hrs
● Early a. Cranial Ultrasound (intraventricular hemorrhage)
● Birth → less than 7 days
● Late ● 7 days → 28 days b. Screening for Retinopathy of Prematurity

Critical Congenital Heart ● Pulse Oximeter

PHYSIOLOGY OF 1. Complex changes, in a relatively short period Screening ● RIGHT hand - LEFT foot
TRANSITION 2. Reliance on mother → self-sufficiency ● More than 5-10% difference: indicative of critical
3. Most of the work of transition is accomplished in the congenital heart disease
first 4-6 hours after delivery
4. Final completion of cardiovascular changes: 6 weeks Retinopathy of Prematurity ● Babies less than 34 weeks
(attributed to closing ducts) ● Those given oxygen at birth

FAVORABLE TRANSITION
Medical Risks
1. Absence of maternal.antenatal risk factors Newborn Practices 1. Rooming-In (non-separation)
a. Biologic-genetic 2. Exclusive breastfeeding
b. Reproductive 3. Measurement of Anthropometrics at Birth
c. Medical Risks 4. Monitoring of Vital Signs
d. Socio-cultural 5. Complete PE (at least twice: at birth, 24 hrs of life,
2. Absence of Fetal Risks upon discharge)
3. Absence of Exposure to environmental hazards 6. Monitoring passage of stools and urine
7. Ensuring mother-infant bonding
● DM (Macrosomic → RDS, Polycythemia, Inc
Glucose, Fetal Hyperinsulinemia) Anthropometrics ● Head circumference***
● Hypertension (intrauterine growth restricted) ● Chest circumference
● Genetic Disorders ● Length***
● Asymptomatic bacteriuria ● Weight***
● Rheumatologic Illnesses (congenital heart block)
Vital Signs First 1-2 hours: every 15 minutes
 After first 2 hours: every 30 minutes (until stable) 6. Multiple Gestation Pregnancies (Twin
Usually stabilizes after 4-6 hours pregnancies, considered high risk)
7. The Neonate
Complete PE Birth: congenital malformations
24 hrs of Life: murmurs, abdominal distention, respiratory Present Pregnancy ● Vaginal bleeding (Abruptio placenta, placenta previa)
effort ● TORCH or STIs
Discharge: in front of mother ● PROM
● Short interpregnancy time
Meconium Term Babies: 24 hours ● Polyhydramnios: gestational disorders
Preterm Babies: 48 hours (Term Babies: 99%) ● Oligohydramnios: renal disorder
Gas: Present in the Rectum by 24 hours of age
Failure to pass: check imperforate anus or Hirschprung’s Multiple Gestation Highest: Blacks, East Indians
disease Pregnancies Lowest: Asians

Criteria for Discharge 1. Good sucking and swallowing (good latch) → “fish Twin-Twin Transfusion Communication between vessels causes transfer of blood
mouth” Syndrome from one fetus to another
2. Thermoregulation: 36.5 C - 37.5 C
3. No abnormal PE findings Preterm Infant Infants delivered before 37 weeks completed gestation
4. Regular urination and passage of stool ● Gelatinous skin
5. Vaccinated ● Bigger head
6. Complete screening tests performed ● Small babies
7. Evidence of parental knowledge, ability and
confidence to care for baby
Identifiable Causes of 1. Fetal
8. Availability of family & physician support
Preterm Birth 2. Placental
9. Assessment of risk factors (family, environment,
3. Uterine
social)
4. Maternal
10. Identified source of continuing medical care
5. Others

High-Risk Infant ● Any gestational age: lower birth weight, higher

Classification According to
neonatal mortality
Birth Weight
● Any gestational weight: shorter gestational duration,
higher neonatal mortality

Highest Risk of Mortality < 1000g at birth and < 28 weeks of gestation
> 4000g at birth and >42 weeks of gestation

Large Babies ● Prone to clavicular fracture

● Prone to meconium passage (aspirate meconium in Classification According to
utero and develop meconium aspiration → asphyxia) Birth Weight and AOG

Lowest Risk of Mortality BW: 3000-4000 g

AOG: 38-42 weeks gestation

Groups of High-Risk Infants 1. Preterm Infant

2. Infant at Risk due to Family Issues ● Based on plotting of Lubchenco or Colorado chart
3. Infant with Anticipated Early Death
4. Infants with Special Health Care Needs or IUGR Always pathologic
Dependence on Technology ● Maternal History: Cyanotic Heart Disease,
Drug Addiction, HTN, Obesity, Poor Nutrition
High-Risk Infant Factors 1. Demographics/Social Factors
2. Past Medical History Small for Gestational Age Can be normal due to constitutionality
3. Previous Pregnancy
4. Present Pregnancy
Types of IUGR 1. Symmetric (W/L/Head: all are < 10th percentile)
5. Labor and Delivery
Insult: early onset
 Fetal response to nutritional or oxygen biparietal diameter and long bones)
deprivation
2. Asymmetric (W < 10th percentile| H/Head: Normal) Prenatal Care Where? With Whom? When? Adequacy?
Insult: late onset
Results of Any Fetal Testing
Factors Associated with ● Fetal ● Amniocentesis
IUGR ● Maternal ● Congenital Anomaly Scan
● Placental ● Fetal Monitoring

Prenatal Care: Adequacy Regular prenatal check up: 4-6 visits (at least 2x every
trimester)
Neonatal History 1. Maternal History
2. Gestational History Drug INtake & Supplements ● Multivitamins
3. Perinatal & Birth History ● Folic Acid
● Iron
Maternal History 1. Maternal Demographic & Social Data ● Maintenance Drugs (check for compatibility)
a. Maternal Factors
b. Social Data Factors Categorical Classification of
2. Previous Maternal Reproductive Problems Drugs

Maternal Factors ● Age: Teens and > 40 years old (especially

primiparous)
Advanced maternal age- increased risk for chromosomal
and non-chromosomal fetal malformations

Risk Factors ● Maternal illness/infections

● Multiple pregnancies
● Use of ART
● History of infertility

Information for Maternal ● Mother’s age

History ● Parity (G _ P _)
○ Gravids: pregnancies
○ Para: live births
● Marital Status First Trimester (Drugs) Category A or B
● Blood Type and Rh (especially jaundice or
hyperbilirubinemia)
Alcoholic Mother Fetal Alcohol Syndrome
● State of Health
- Severe intellectual disability
● Occupation
● History of STD/Chronic Illness
Radiation Exposure Background Fetal Radiation Exposure (Pregnancy)
~ 0.1 rad
Gestational History 1. Gestational Age Dating
2. Prenatal Care
3. Drug Intake & Supplements Dosage & Effect of Radiation
4. Illnesses & Infection Exposure during Pregnancy
5. Alcohol & Tobacco Use
6. Use of Illicit Drugs
7. Radiation Exposure
8. Hepatitis B Screening
9. DM Screening
10. Pregnancy-Related Risks & Complications

Gestational Age Dating ● LMP (predict baby’s expected date if the mother
has a regular cycle)
● Early ultrasound (estimate AOG- measure the
 DM Screening HbA1C or OGTT Benefits of SSC ● Breastfeeding success
● Lymphoid tissue system stimulation
Preeclampsia Hypertension during pregnancy “BLEST” ● Exposure to maternal skin flora
● Protection from hypoglycemia
● Thermoregulation
Infection Risk of concomitant appendicitis

Blood Sugar Level At first 90 minutes of life, blood sugar level of a baby on
Perinatal History Description of Labor & Events Around the Time of Delivery
SSC with the mother is at 11 mg/dL or higher
Risk: Presentation of Baby Breech Position & Footling Breech Position
Oxytocin Mediates thermal response of maternal skin temperature
Membrane Rupture > 18 hours: infection into the uterine space
SSC Place baby in prone position on mother’s abdomen or chest
First: last uninterrupted for at least 1 hour after birth or until
Anesthesia General Anesthesia given 4 hours before delivery may 1st breastfeeding
increase the risk for respiratory problem
Temperature Room: 25-28 C
Fetal Heart Rate Monitoring Normal: 120-160 bpm Baby: 36.5-37.5 C
< 100 bpm: Congenital Heart Problem
> 160 bpm: Perinatal Asphyxia
Timed Cord Clamping ● Wait 1-3 minutes
● Until cord pulsations have stopped
Method of Delivery 1. Cesarean section
2. NSD/VSD
Benefits of Properly Timed ● Lowers incidence of Anemia
3. Forceps Delivery
Cord Clamping ● Decreases need for blood transfusion in preterm
4. Vacuum Extraction
infants
● Lowers risk for IVH in preterm infants
● Higher Hgb levels at birth + Improved Iron stores
Four Core Steps in 1. Immediate and Thorough Drying ● Improves hemodynamic stability and decreases
Immediate Newborn Care 2. Skin-to-Skin Contact need for inotropic support
3. Properly Timed Cord Clamping
4. Non-Separation of Newborn from Mother Cord Clamping Steps ● Clamp the cord 2 cm from umbilical base
● Add 2nd clamp: 5 cm from umbilical base
Immediate and Thorough ● Immediately for 30 seconds
Drying ● Perform rapid assessment of breathing Cord Care Dry Cord Care
If soiled: soap and water
Floppy/Limp and Apneic Additional Resuscitative Measures: Ambu Bag and In low resource communities (with high neonatal mortality):
Endotracheal Intubation topical chlorhexidine

Importance of Immediate ● Stimulates breathing Non-Separation of Newborn ● Never leave unattended

Drying ● Prevents hypothermia from Mother

Immediate and Thorough 1. Baby in PRONE position Breathing Assessment Listen for grunting, look for chest in-drawing and
Drying STEPS 2. Turn over into SUPINE Tachypnea
3. Thoroughly Dry (30 secs), Wipe Gently
4. Stimulate and Check Breathing Temperature Assessment Check and feel if feet are cold to touch
5. Remove wet cloth → replace with dry
6. Put cap or bonnet Breastfeeding Cues ● Eye movement (closed lids)
● Increased alertness and movement of arms &
● Do NOT wipe off VERNIX legs
● Tossing, turning or wiggling
Vernix Caseosa Cheesy-like substance that gives baby warmth and acts as ● Rooting
a barrier against infection ● Mouthing, licking, tonguing
● Changes in facial expression
Washing Do NOT wash the baby within the first 6 hours of life ● Squeaking noises/light fussing
 Crying Late sign of hunger Twin-Twin Transfusion
Syndrome (Recipient &
Crawling Reflex Mudge baby towards the mother’s breast to seek out the Donor)
nipple

Notes on Routine Newborn ● After FIRST FULL breastfeeding episode

Care ● Injections are last (crying infants cannot latch)
●

Erythromycin sterile Silver nitrate 1% solution leads to transient chemical

ophthalmic ointment conjunctivitis in 10-20% of cases

Vitamin K1 Phytonandione (1 mg)

Active Management of the ● IM Injection: 10 IU Oxytocin

3rd Stage of Labor ● Controlled cord traction with counter-traction on
uterus
● Gentle uterine massage
Microcephaly Persistently small fontanels are suggestive of:
Circulation Fetal Circulation: R → L shunting
Adult Circulation: L → R shunting Single Umbilical Artery Increased risk for occult renal anomaly

Exclusive Breastfeeding Birth → 6 months Frenulectomy Problems with feeding

Sleep Newborns: Asleep for 20 hours, Awake for 4 hours 90-95% Ideal target O2 saturation for extremely low BW infants

Breastfeeding Positions
Attachment and Sucking
● Neck: NOT flexed or twisted Bronchovesicular Normal breath sounds in newborns
● Faces the breast
● Close to the mother’s body
Drying thoroughly of the Delayed fetal to newborn circulatory adjustment
● Whole body is supported
Infant
● Mouth wide open
Early SSC Protection from hypoglycemia
● Lower lip: turned outwards
Exposure to maternal skin flora
● Baby’s chin: touches the breast
● Sucking → slow, deep with some pauses (no
noises) Properly Timed Cord Prevents anemia in both term and preterm infants
Clamping

Non-Separation Early breastfeeding

Lanugo Fine, soft, unpigmented hair that is often present in fetuses,
newborns and in certain disease states Flexor Predominant posture of the newborn

Hair growth starts on the scalp around the eyebrow, nose,

Prematurity Most common cause of neonatal death
and forehead area and proceeds in a cephalocaudal
direction from head to toe
Crawling reflex Removal of the vernix hinders the?
Maternal Milk For (Premature) Infants: may have protective effect on
● Diarrhea, Otitis Media, UTI, Necrotizing 20-60 minutes How long after birth is the newborn ready to be breastfed?
enterocolitis, Septicemia, Infant botulism,
IDDM, Celiac disease Drying If the baby is born floppy and limp, immediately do:
● Also: Crohn disease, Childhood cancer,
Lymphoma, Leukemia,
● Allergy, Hospitalizations, Infant Mortality
 Physical Examination of the Newborn Anthropomorphic Measures 1. Birth Weight
APGAR/Ballad 2. Birth Length
3. Head Circumference
Recognizing Patterns of Health & Disease
Birth Weight N: 2,500g-4,000g
Physical Examination Performed as soon as possible after delivery ● Use infant weighing scale
● Identify any congenital abnormalities ● Plot using:
https://www.youtube.com/w ● Exclude medical concerns ○ Lubchenco’s Chart
atch?v=cracmPo3iYo ● Reassurance to the parents ○ WHO Z-Score Chart (recommended for use)

Full Newborn Examination ● Within 24 hours of birth (when infant has Lubchenco’s Chart Plots weight, length and head circumference
completed transition: intrauterine → extrauterine ● X-axis: gestational age
life) ● Y-axis: weight/length
● General Rule: From the least disturbing/noxious Can be used for preterm babies
stimuli → most likely to irritate the infant
○ Order may depend on the infant’s state WHO Z-Score CHart ● Only used for term babies
○ Must be organized (no sequence but must
still be complete) Birth Weight Assessment 1. Small for Gestational Age (SGA)
○ BW: < 10th percentile
Interpretation of Findings → Time dependent 2. Appropriate for Gestational Age (AGA)
→ Age dependent ○ BW: 10th-90th percentile
● A suspicious finding should later be reevaluated 3. Large for Gestational Age (LGA)
○ BW: >90th percentile
Tips for Examining the ● At the presence of the parents
Newborn ● Rock the baby (encourages the eyes to open) Birth Length N: 49-50 cm (20 in.)
● Demo calming maneuvers to the parents → baby should be lying flat, supine, recumbent position
● Newborn must be fully undressed ● Recorded to the nearest 0.1 cm
● Infantometer
Skin and Neurobehavioral Observed throughout the exam, but more directed ○ Head: positioned against an inflexible
State assessments are at the end of the exam measuring board in the Frankfurt plane
● Plot Using: Lubchenco’s Chart
PE of the Newborn 1. Inspection, Palpation, Auscultation (NO ● Recumbent length is most accurately measured
percussion) by 2 examiners

GENERAL APPEARANCE 1. Obvious congenital anomalies Infantometer → head steady, baby’s leg stretched
2. Skin color
3. Activity Head Circumference Occipito-Frontal Circumference (OFC)
4. Tone N: 33-36 cm (term), Ave: 35 cm
○ Predominant: Flexion Reflection of brain growth
● Tape measure placed around the head, above
VITAL SIGNS Newborns the glabella and the occipital area at the back
1. Cardiac/HR: 120-160 beats/min (get the widest circumference)
○ Pulse rate is NOT measured ○ Just above the eyebrows
2. RR: 40-60 breaths/min (or 30-60) ● Plot using:
○ Babies are abdominal breathers ○ Lubchenco’s Chart
○ Observation of the abdominal excursions ○ WHO Z-Score
3. Temperature: 36.5-37.2 C
○ Axillary route
○ Rectal → NOT used
○ Tympanic → inaccurate due to narrow ear
canal (< 2 y/o)
4. O2 Sat.: ≥ 95% at room air (once completed
transition)
○ ≥ 85% is normal, only until 5 minutes
Summary of Anthropometric Color 1. Pallor/Pale
Measures 2. Cyanotic (Circumoral or Perioral Area)
→ suggestive of hypoxemia
3. Peripheral/Acrocyanosis (Hands and Feet)
→ Normal; Peripheral vasoconstriction (due to
vasomotor instability leading to sluggish flow of
blood to the peripheries)
4. Mongolian Spots (Congenital Dermal Melanocytosis)
→ Normally seen in Asian babies
→ Blue or slate gray macular lesions, well defined
margins in: buttocks (common), presacral area, thighs,
legs, back and shoulders
→ Fades in the first year of life
→ Documented as: birthmark
5. Jaundice
→ Pathologic if within 24 hours and > 2 weeks

Pale VS Plethoric ● Plethoric: most likely has polycythemia

(Bloody red) ● Pallor/Pale: Anemic, low hematocrit

Harlequin Color Change ● Vasomotor instability

● Color Difference can be observed
○ Division: vertical
○ Transient

Milia ● Tiny, White bumps that appear frequently on the

nose and chin (superficial epidermal inclusion
cysts that contain laminated keratinized
materials)
● Normal newborn rashes that disappears over
time (within 3 days)
● Miliaria crystallina
Skin 1. Color
2. Rashes Epstein Pearls ● Milia on the hard palate
3. Birthmarks ● Small, harmless cysts
4. Anomalies
Erythema Toxicum ● Normal
Skin at Birth ● Extensively covered with vernix caseosa (dries ● Like a papule with an overlying erythematous
up and disappears within 24 hours) base, contains eosinophils
● Red and Smooth → Dry, Flaky and Pink (2nd or ● Few hours → 3 days after birth (disappears on
3rd Day) 7th day)
● Subcutaneous Tissue: may be moderately
edematous for several days (eyes, legs, hand &
Neonatal Pustular ● Pustules similar to Staphylococcus aureus
feet-dorsal)
Melanosis infection, contains neutrophils
● Difference: under microscopy, should be sterile
Mottling Sign of general circulatory instability
Pathologic: undergoing serious illness
Macular Hemangioma ● Strawberry type hemangioma, considered a
● If not present at birth but the day after, may
birthmark
suggest infection
Physiologic: due to transient fluctuation in skin
temperature Nevus Flammeus Stork bites/Salmon Patch
● Normal in Trisomy 21 ● Flat erythematous patches seen on the glabellar
area or nape of the neck (or EYE: petechiae or
telangiectasia called Vascular Nevi)
Vernix Caseosa ● Cheesy, White Substance
● Common birthmark
● Protective (thermoregulation)
● Gradually dissipates after 38 weeks
 Portal Wine Stain ● Deep stained patches Macrocephaly & → Macrocephaly
● If big and in the cheeks → Sturge Weber Microcephaly ● Found in: Hydrocephalus and Achondroplasia
Syndrome May be familial
→ Microcephaly
Angel Kisses ● Form of Nevus Flammeus ● Found in: Trisomies, Craniosynostosis
● Smaller
● Found in: over the eyelid or glabellar area Face 1. General
2. Eyes
Sacral Dimpling, Dermal ● May signify occult spina bifida 3. Ears
Sinuses of Tufts of Hair ● May also suggest underlying abnormalities such 4. Nose
along Midline of Back as sinus tract or tumor 5. Mouth

Collagen Synthesis (Ehlers-Danlos syndrome, Marfan syndrome, etc.) General Facial Dysmorphic ● Epicanthal Folds
Syndromes ● Cause excessive skin fragility and extensibility Features ● Widely-spaced Eyes
● With joint hypermobility ● Long Philtrum
● Low-Set Ears
Head and Neck Assessment ● Reflects evaluation of the CNS
● Palpate the entire head Facial Dysmorphism 1. Orbital Hypertelorism
2. Cornelia De Lange Syndrome
Molding ● Common in prolonged vaginal deliveries
● When head has been engaged in the pelvic canal Orbital Hypertelorism ● Increased distance between the eyes
for a time
● Overriding sutures Cornelia De Lange ● Thick continuous eyebrows (synophrys)
○ Prominent shadow-like appearance on Syndrome ● Low Set Ears
the coronal suture ● Small Nose
● Small stature
Cephalhematoma ● Subperitoneal hemorrhage, limited to the surface ● Long Philtrum
of the cranial bone ● Thin Upper lip
● Usually overlying the parietal bone (periosteal ● Downturned Mouth
position)
● Contains blood inside, secondary to rupture of Asymmetrical Face 1. Facial Nerve Palsy (7th CN)
small capillaries 2. Peripheral Nerve Palsy: whole half of face is
affected, involves peripheral part of the facial
Caput Succedaneum ● Diffuse (sometimes ecchymosis) swelling of the nerve
soft tissues of the skull that is usually in the 3. Central Nerve Palsy
middle 4. Moebius Syndrome
● More superficial, involves the area presenting
during vertex delivery Eyes ● Normal: White Sclerae
● Contains edema fluid ● Doll’s Eye Maneuver (inspection)
● Appears as circular boggy area of edema with ●
indistinct borders, often with overlying
ecchymosis Red Orange Reflex (ROR) ● Normal
● If Absent: presence of congenital cataracts →
Anterior & Posterior 1. Anterior Fontanelle White Pupillary Reflex (Leukocoria)
Fontanelles ○ Palpate the diamond shape
○ Disappears: 6 weeks Subconjunctival/Retinal ● Benign (brought about by traumatic/difficult
2. Posterior Fontanelle Hemorrhages deliveries)
○ Palpate the triangular shape
○ Disappears: < 18 months
Ears ● Normal: Dull gray tympanic membrane
❢ Hold the head with one hand → move the pointer finger
(other hand) to the front of the head → palpate the anterior
fontanelle → trace your finger down the juncture of the Benign Abnormalities ● Preauricular skin tags and pimples
(Clue to Renal Abnormalities) ● Preauricular sinuses
sagittal suture and lambdoid suture → trace the posterior
fontanelle
Nose ● Normal: Broad appearance
 ● Nares should be symmetric and patent disappear in a few days
● Heart Sounds: should be heard at the point of
Mouth ● Assess tongue (attachment, mobility, size) maximal intensity (PMI)
● Check the suck reflex ○ Location: 3rd-4th LICS, lateral to MCL
○ Abnormal Findings:
■ Dextrocardia
Ankyloglossia ● Tongue has short frenulum (tongue-tie)
■ Sinus bradycardia
● Only needs frenotomy if baby has difficulty
breastfeeding
PDA ● Transitory
● Closes after 48 hours
Epstein’ Pearls/ Bohn’s ● Normal finding of whitis cyst on:
Nodules ○ Hard Palate: Epstein’s
○ Gums: Bohn’s Abdomen ● Normal: round/globular and soft

Neck Normal: short neck visible on observation
● Check movement and position of head
● Palpate simultaneously for intactness and
crepitus of clavicles
● Assess ROM of arms
Abdominal Palpation ● Liver (edge): palpable 1-2 cm below right
subcostal margin
● Spleen (tip): must NOT be palpated
● Palpate entire abdomen, check for masses
(kidney is most commonly involved)

Congenital Torticollis ● Friction on the movement due to wry neck Scaphoid Abdomen ● Extremely inflated chest
● Abdomen is flat → concave
● Suggestive of: Congenital Diaphragmatic Hernia
Clavicular Fracture ● In LGA babies
● May be caused by traumatic vaginal delivery
Umbilical Hernia ● Observe first (muscles are in diastasis recti)
● Goes away on its own in 4 months, once the
Respiratory & Cardiac ● Best when patient is quiet
newborn develops abdominal muscles
Assessment ● Observe chest for evenness of respirations
● Infant’s state of activity (ex: feeding or crying)→
causes normal variation of rate and rhythm Umbilical Cord ● Whitish gray, gelatinous, odorless
● 2 arteries, 1 vein
● Cut and clamped → cord will shrivel, dry up and
Respiratory Distress ● Chest retractions or see-saw respirations
fall off on its own
Respiratory ● Breathing at REST is diaphragmatic (abdominal
Other Abdominal 1. Omphalitis: infection of the umbilical cord, acute
and chest movements are equal)
Abnormalities local inflammation that may spread which may
● Babies are abdominal breathers
result in portal hypertension
● After observation/inspection, auscultate breath
2. Gastroschisis: Intestines found outside the body,
sounds: should be clear (bronchovesicular) and
exiting through the hole beside the belly button
equal bilaterally
3. Omphalocele: intestine or other abdominal
● ❢ Warm the stehtoscope bell
organs outside the body because of the hole in
the belly button (navel) area
Crying Infant ● Insert gloved finger in mouth to initiate sucking
● Swaddle to soothe infant
Sex Organs ● Respond to transplacentally acquired maternal
hormones
Chest Breast Tissue
● Present in both sexes
Male Genitalia ● Examine the penis and scrotum
○ Penis: 2-2.5 cm length
Lungs Abnormal: ● Prepuce/Foreskin of a Newborn Infant is normally
● Apnea (greater than 20 seconds) tight and cannot be retracted (should separate
● Crackles or Rales naturally eventually)
● Scrotum
Periodic Breathing Breathing will suddenly go faster → then will slow down ○ Premature: fewer rugae, testicles may be
undescended
Heart and Pulses ● Asucultate HS and listen to: S1, S2 and for murmurs ○ Term: deep rugae, more pendulous
○ Systolic Mumurs (can be common in infants ○ Color: pink → dark brown
especially in the first 24-48 hours) → will ● Testis

Male Genital Abnormalities
Female Genitalia
○ 2 hard, round testicles
○ If not felt, tyr to lcoate in the inguinal canal
→ “milk” it toward th scrotum APGAR Scoring ● Dr. Virginia Apgar
● Assessed at 1 and 5 minutes of life
● NOT used to determine need for resuscitation or
● Hydrocele (type of welling in the scrotum that
to guide steps for resuscitation (should be done
occurs when fluid collects in the thin sheath
before 1 minute)
surrounding it)
● If the 5-minute score remains ≤ 7, additional
● Hypo-/Epi-spadias (first evidance of
scores should be assigned every 5 minutes
adrenogenital syndrome)
○ 1, 5, 10, 15 20
● Ambiguous genitalia
○ 5 minute: valid predictor of neonatal
mortality
● Clitoris ● Done at the DR
○ Usually edematous
● Vaginal/Hymenal Tag
Heart Rate Single most important parameter (use cardiac rate)
○ Imperformate/Vaginal obstruction →
Hydrometrocolpos and lower abdominal
mass

Extremities ● Note the ROM (+ symmetry) and flexed position of

legs and arms
● Normal Position of Baby: Flexed position (arms and
legs)
● Count toes and fingers (note: absences, excesses or
webbing)
● Examine hips
● Check for femoral pulses (full and equal): rule out
coarctation of the aorta

Ortolani and Barlow’s Assess developmental dysplasia of the hips (DDH)

Maneuvers ● Barlow’s Test: hip started reduced test will
dislocate hips
● Ortolani’s Test: hip started dislocated, test will
reduce the hip
Test to reduce a hip that is already dislocated

❢ locate femoral head → adduct + push the thigh of both

legs posteriorly → “dislocate the femoral head from the
acetabulum” → release pressure → return back to normal
BARLOW’S
❢ (if still displaced) abduct the thigh → “try to put back the
acetabulum”
→ CLUCK: (+) DDH

Back and Spine ● Inspect: Spin + Shoulders → straightness

Dimples associated with
Spinal Dysraphism
Myelomeningocele
Anus Abnormalities
● Midline masses
● Coccygeal pit (normal)
Appearance ● Brown/Black-skinned babies: assess the mucous
● > 5 mm diameter membrane of the lips, mouth and tongue
● > 2.5 cm above the anal verge
● In combination with other dimples, hair patches,
Pulse ● Listen to the apical GR or palpate pulsation in the
birthmarks, skin tags or masses
umbilical cord (or even femoral pulse)
● 6 seconds x 10
● Meninges + spinal cord + CSF
APGAR score interpretation
● Imperforate Anus

Asphyxia related to APGAR
score
False Negatives & Positives
7-10 Good cardiopulmonary adaptation,
Normal newborn will do well
CNS Implication: reassuring
4-6 Need for resuscitation, especially
Borderline ventilatory support and medical
intervention
CNS Implication: moderately abnormal
0-3 Need for immediate resuscitation and
Severely may need NICU care
depressed CNS Implication: Low (at 5 minutes,
does not predict future neurologic
dysfunction)
More common: False positives
More dangerous: False negatives
Classification of the
Newborn Infant based on
AOG
Birth Weight Lower BW, Higher neonatal mortality
● Low: 2,500 g
● Very Low: < 1, 500 g
● Extremely Low: < 1,000 g
Ballard Scoring → For Gestational Age Assessment
1. LMP
2. Fundal Height
3. Early Ultrasound
4. Date of Quickening
5. Ballard Scoring/Maturity Testing (expanded)
6. Fundoscopic Exam
Last Menstrual Period Gestational Age:
LMP: MONTH / DATE / YEAR
-3m / -7d / +1y
Early Ultrasound ● Most accurate if done before the 13th week of
gestation
Date of Quickening ● 16-18 weeks of Gestation
● First fetal movement felt by mother
Ballard Scoring ● Accurate to within 2 weeks of actual gestation
age
Expanded Ballard Score ● 2 Parts:
○ Physical maturity Testing
○ Neuromuscular Testing
● Relies on the intrauterine changes that the fetus
undergoes during its maturation
Examination for Ballard ● Done once the infant is stable
Scoring ○ Extremely preterm: scored within the first 12
hours of life (before skin undergoes
significant changes)
 ○ Term: scored asap, but can be assessed
reliably until 72 hours

Ballard Scoring is NOT 1. Asphyxia

PERFORMED with: 2. Breech delivery
3. Congenital anomalies
4. Fracture or Bone Disorders

Computing for Ballard 1.Get the TOTAL SUM

Score 2.Look for the corresponding AOG
3.If the score is not divisible by 5:
○ Do not round-off
○ With score it lies between, is the equivalent
week it is also between
4. If the situation does not allow neuromuscular
maturity test:
○ Multiple physical maturity scores by 2
○ (only an approximation)
→ Remember that scoring is ± 2 weeks in accuracy

Physical Maturity 1. Skin

2. Lanugo
3. Plantar Surface
4. Breast Bud
5. Ear/Eye
6. Genitalia (Male, Female)

Skin ● Maturation: development of its intrinsic structures

concurrent with the gradual loss of vernix
caseosa → skin thickens, dries and becomes
wrinkled/peeled
● Meconium (in amniotic fluid): may have drying
effect → peeling, cracking → dehydration of the
skin (leathery appearance)
● Feature most prone to changes in extremely
preterm infants
● Must be scored immediately or not later than 12
hours of life
 Lanugo ● Fine, thin, short hairs resembling”peach fuzz”
● Begins to appear at around 24th-25th week
● Abundant especially around: shoulders, upper
back
● Moved downward by 28th week of gestation
● Thinning: lower back (first occurs) → bald areas
appear and become larger over the lumbo-sacral
area
● Lanugo is shed in utero → replaced by vellus
hair (36-40 weeks of gestation)
Plantar Surface ● Major foot creases (sole of the foot)
● First appearance: anterior sole at the ball of the
foot → going downward as the fetus matures
● Very premature and extremely immature: no
detectable foot creases
● No creases:
○ 50 mm (toe- heel)
○ 40-50 mm: -1
○ < 40 mm: -2
Breast Bud ● Based on the size of the areola and the presence
or absence of stippling
○ Created by the developing papillae of
Montgomery
Ear ● Pinna of the fetal ear changes configuration and
increases in cartilage content
● Assessment: palpation for cartilage thickness →
folding of pinna forward → release
● More mature: easier for the ear to spring back,
increased cartilage content
Eye ● Assessment: Place thumb and forefinger on the
upper and lower lids → gently move them apart
(separate)
● More fused = More preterm
Male Genitalia ● Testes: often palpable in the inguinal canal by
28-30 weeks AOG, descend during last month of
gestation
● Scrotum: Rugae → parallels testicular migration
○ Extreme prematurity: flat, smooth, sexually
undifferentiated
Female Genitalia ● Prematurity: clitoris and labia minora are more
prominent
● Maturation: recession
○ Enlarging labia majora envelopes the clitoris
and labia minora
■ Becomes prominent by 34-36 weeks
■ Contains fat
■ Size affected by intrauterine nutrition
Posture ● Gauges muscular tone of the infant (more mature
= more flexed)
Square Window ● Tests mobility, flexibility, and resistance to
extensor stretch of the hand
● Angle between volar aspect of the forearm
and palm is measured
● Wrist flexibility and/or resistance to extensor
stretching → resulting angle of flexion at the wrist
○ Angle between gets smaller as the infant
matures
○ Forearm gets smaller
○ More mature → more flexible → less
resistance to extensor stretch
Arm Recoil ● Passive flexor tone of the biceps muscle by
measuring the angle of recoil
● Angle of recoil to which the forearm springs
back into flexion
Popliteal Angle ● Assess maturation of passive flexor tone above
the knee joint testing for resistance to extension
of the lower extremity
● Infant is placed in knee chest position (allow
infant to relax into this position) → leg is
extended until a definite resistance to extension
is appreciated
● Measures: angle between thigh and leg at
knee
● Prenatal Frank Breech Position: causes
prolonged intrauterine flexor fatigue, interferes
with the maneuver for 24-48 hours
● More mature = lesser popliteal angle
Scarf Sign ● Tests the passive tone of the flexors above the
shoulder girdle
● Examiner nudges the elbow across the chest,
feeling for passive flexion or resistance to
extension of posterior shoulder girdle flexor
muscles
Notable Landmarks for
Scarf Sign -1 Full scarf at the level of the neck
0 Contralateral axillary line
1 Contralateral nipple line
2 Xiphoid process
3 Ipsilateral nipple line
4 Ipsilateral axillary line
 Heel to Ear ● Measures passive flexor tone above the pelvic
girdle by testing for passive flexion or resistance
to extension of posterior hip flexor muscles
● Examiner feels for resistance to extension of the
posterior pelvic girdle flexors and notes the
location of the heel where significant resistance is
appreciated
○ More immature = easier for the heel to be
pulled towards the ear
Weight Loss Management
● Acute Illness: cardiac or metabolic
● Sepsis
● If secondary to inadequate fluid intake →
dehydration, risk of jaundice and hypernatremia
● Lactation Management
● Supplementation (preferably: Pasteurized milk)
● Hospitalization: IV hydration & correction of
hypernatremia

Landmarks for Heel to Ear Jaundice ● Over 60% of all newborn infants become visibly
-1 Ear jaundiced is the first few days of life
○ Hemoglobin concentration rapidly falls in the
0 Nose first few days
○ Increased bilirubin production
1 Chin Level ○ 70 days lifespan of newborn RBC
● Less efficient hepatic bilirubin metabolism (liver)
2 Nipple line ● Jaundice during the first 24 hours of life
warrants diagnostic evaluation and should be
considered pathologic until proven otherwise
3 Umbilical area
→ Kernicterus (bilirubin encephalopathy): hearing loss,
4 Femoral crease cerebral palsy, learning disability

● Jaundice beyond the first 24 hours may be

physiologic

Neonatal Period Period of most dramatic physiologic changes CAUSES OF PATHOLOGIC ● Hemolytic conditions
First 4 weeks (28 days) JAUNDICE ● Breastfeeding inadequacy
● UTI
CLINICAL 1. Weight Loss ● G6PD Deficiency
MANIFESTATIONS OF 2. Jaundice ● Metabolic Disorders (Congenital hypothyroidism)
DISEASES 3. Cyanosis ● TORCH
4. Apnea
5. Abnormal Measurements Breastfeeding Jaundice ● Increased bilirubin during 1st week of life in
6. Altered Mental Status breastfed infants due to: caloric and fluid
7. Temperature Instability deprivation
8. Congenital Anomalies ● Increased enterohepatic circulation
9. Gastrointestinal Disturbances → Don’t stop breastfeeding, increase the frequency
10. Hypotension
11. Pain Jaundice CRITERIA Time of appearance: 2nd-3rd day of life
12. Edema → If >10 days, not physiologic
13. Hypocalcemia Pattern: peaks 2nd-4th day
14. Hypermagnesemia Duration: disappears 5th-7th day

Weight Loss ● Physiologic: first week of life (5-10%) Bilirubin levels:

○ Due to: contraction of ECF compartment ● Rise: <5mg/dL per 24 hours
(uncompensated); Removal of vernix ● Peak total bilirubin (TB):
caseosa; Passage of urine and meconium ○ For full term: <12mg/dL
● BW Regain: 7th-10th day after birth (if preterm: 2 ○ For preterm: <15 mg/dL
weeks) ○ B2 (conjugated bilirubin) should <20% of
● Concern: Significant Weight Loss Total Bilirubin

Significant Weight Loss ● Poor attachment

● Lack of sufficient breastfeeding (poor transfer of Cyanosis 1. Acrocyanosis
milk, lack of milk supply) 2. Central Cyanosis
 ACROCYANOSIS ● Cyanosis in extremities (palms of hands, soles of
feet)
● All newborn infants are acrocyanotic in the first
few minutes to hours after birth
● Peripheral venous congestion/sluggish blood flow
→ Management: observe
○ Abnormal facial movements
● Apnea: possible first manifestation
● Considered pathologic with an APGAR score of 4
Jitteriness VS Seizures

CENTRAL CYANOSIS ● Bluish discoloration of the skin and mucous

membranes because of increased deoxygenated
hemoglobin in the blood (skin, lips, oral mucosa
or tongue)
○ 5 g/dL
→ Differential Diagnosis
● Respiratory
● Cardiac
● CNS
● Infectious
● Metabolic
→ Management: Oxygen (give 100%)
● Improved: Respiratory Motor Automatisms ● Characterized by:
● Did not Improve: CHD ○ Recurrent oral-buccal-lingual movements
○ Rotary limb activities
Periodic Breathing ● Normal (no prognostic significance) ○ Tonic posturing
● Neonatal Respiration ○ Myoclonus
● Brief episodes of respiratory pauses (5-10 ● Due to incomplete myelination
seconds) → burst of rapid respirations (rate:
50-60 breaths/min for 10-15 seconds) Altered Mental Status 1. Irritability
2. Hyperactivity
Apnea ● Pathologic: recurs → hypoxia, hypocalcemia, drug withdrawal,
○ Breathing ceases for > 20 seconds neonatal thyrotoxicosis, or discomfort from cold
○ Period of < 20 seconds with change in tone, environment
pallor, cyanosis, bradycardia 3. Lethargy
● Causes: → manifestation of infection, asphyxia,
○ CNS, Respiratory, Infectious, Metabolic, hypoglycemia, or sedation from maternal
Prematurity medications
4. Poor Suck/Failure to Feed (important sign of a
Abnormal Movements 1. Jitteriness sick newborn)
2. Seizures
3. Motor Automatisms Temperature Instability 1. Hyperthermia
4. Pseudoparalysis 2. Hypothermia

Jitteriness ● Series of rapid movements of equal amplitude in Hyperthermia ● Temperature: ≥ 38 C

alternating directions ● Serious infection should always be considered in
● Tremor-like movements neonate with fever
● Often benign
● Seen in Normal Preterm and Term neonates with Dehydration Fever ● Elevations of temperature (38-39 C or 100-103 F)
vigorous crying on 2nd and 3rd day of life
● Can be elicited by noise, touch or other
environmental stimulus
Hypothermia ● Temperature: ≤ 36.5 C
● Unexplained hypothermia may also be
Seizures ● Alternating muscular contractions and relaxation associated with infection (sepsis or other serious
of unequal amplitude disturbances)
● Clonic jerking ● Cold Stress
● Abnormal series of movements of CNS origin
● Often subtle and associated with:
○ Abnormal eye movements Congenital Anomalies ● Major cause of stillbirths in US and other

Malformations that require
IMMEDIATE
medical/surgical therapy for
postnatal survival
GIT Disturbances
→ Imaging studies are considered when obstruction is
suspected
Hypotension
Pain
Hypocalcemia
Hypermagnesemia
developed countries PHYSIOLOGIC CHANGES IN 1. Pseudomenstruation
● Major cause of acute illness and long term THE NEWBORN PERIOD 2. Heart Murmur
morbidity 3. Falling Off the Umbilical Cord
4. First Bowel Movement
1. Congenital Heart Disease 5. Yawning
2. Tracheoesophageal fistula 6. Sneezing
3. Diaphragmatic Hernia 7. Physiologic Anemia
4. Choanal atresia
5. Intestinal obstruction Pseudomenstruation ● Scant mucoid, serosanguinous (blood-tinged)
vaginal secretions that appear always in the 1st
● Vomiting during 1st Day of Life can be week
suggestive of diseases ● Highest frequency: 5th day of life
● Common manifestation of overfeeding, ● Physiologic response of some female infants to
inexperienced feeding technique, or normal reflex exposure of high levels of maternal hormones
● Vomitus containing dark blood: sign of serious
illness Heart Murmur ● Very common finding
● Abdominal distention with emesis ● Created by abnormal flow patterns in the heart
● Diarrhea and vessels resulting from congenital heart
abnormalities
● Most common reason for pediatric cardiologist
consultation
● Physiologic: innocent, normal
● Normal stool of breastfed infants: Loose, Seedy, ● Most common cause: a grade of 1 to 2/6 soft,
yellow systolic heart murmurs heard in the first 48-72
hours after birth secondary to closing PDA
● Implies: ● Most common single lesion: VSD → PDA
○ Hypovolemic Shock
○ SIRS Falling Off the Umbilical ● Normally, UC slowly dries up and shrivels up and
○ Cardiac dysfunction Cord then falls off
○ Pneumothorax ● Term: 7-14 days
○ Pneumopericardium ● Preterm: a but later but not > 1 month
○ Pericardial effusion ● Delayed: due to defects in neutrophil chemotactic
○ Metabolic disorders factors
● Common in SICK PRETERM infants
Signs of UC Problems ● Oozing green-yellow fluid (pus) with foul smell:
● May be unrecognized and/or undertreated infection
● Pain in neonates results in obvious distress ● Redness and induration around base: omphalitis
● Common causes of Pain (neonates): ● Delayed umbilical cord separation: leukocyte
○ Circumcision adhesion defect
○ Phlebotomy
First Bowel Movement ● MECONIUM
● Manifests as: irritability, jitteriness, clonus or ○ First stools: odorless, thick, blackish/dark
seizures green substance
● EKG shows prolonged QT interval ○ Usually passed during first 24 hours after
● May represent tan exaggerated physiologic birth
decrease in serum calcium levels within the first ○ Amniotic fluid, mucus, skin cells, other
24 hours of life or pathologic conditions substances
● Management: IV or oral calcium ● Replaced by: yellow-green stools (as infant
digests breast milk)
● Often caused my maternal administration in
perinatal period
● Present at birth but improves over the next 24-48
hours
● Symptoms: Respiratory depression, Hypotonia,
Lethargy, Feeding intolerance
● No treatment, only supportive measures
Color Chart Guide on Stool

Yawning ● Check nasolabial folds if equal

● Asymmetry may relate to: facial nerve palsy,
hypoplasia of mandibular muscle

Sneezing → Normal
● Sneeze a lot
● Newborns are mouth breathers, have smaller
nasal passages
● Purpose is to get rid of anything from breastmilk
to mucus, smoke, and dust in air
Treatment: Saline spray

→ Sign of Sickness
● Frequent: Respiratory Infection

Physiologic Anemia ● Normal decline in Hgb levels during first few

weeks of life
● Half life of Neonate RBC: 70 days
● Lowest level: 6-8 weeks after birth (hgb: 11 g/dL)
○ Abrupt cessation of erythropoiesis
○ Downregulation of EPO
○ Shortened survival of fetal RBCs
○ Expansion of blood volume
● Pathologic: hgb levels are still LOW for more than
5 months