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

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

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

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

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

Head-To-Toe Examination Size & shape Anterior fontanelle Flat, sunken, bulging “AFOF” Cephalohematoma Baby’s reaction to head exam

Anterior Fontanelle

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

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

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

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

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

Ambiguous Genitalia

Don’t Forget The Family Jewels

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

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

Newborn Exam

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

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

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)

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

AAP Recommendations 2004

There’s an App! www.BiliTool.org Based on the AAP Guidelines, hours of life, and measured bilirubin level

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

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

Neonatal Acne

Diaper Dermatitis Satellite lesions nystatin

Newborn Desquamation

Cutis Marmorata Lattice appearance “mottled”

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

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

Umbilical Granuloma

Silver Nitrate Burn Use with caution

Omphalitis Fever Cellulitis Discharge

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

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

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

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

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