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 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

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

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

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

Classification of Size

Classification of size for gestational 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

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

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”

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

Physical Maturity Skin Lanugo Plantar surface Breast Eyes & Ears Genital

Neonatal Gestational Age Physical Maturity

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

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

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

Differential Skin Findings Scalp Electrode

Differential Skin Findings Forcep Marks

Differential Skin Findings Vacuum Bruising

Differential Skin Findings Milia-exposed sebaceous glands No treatment necessary

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

Differential Skin Findings Mongolian Blue-Grey Spots Most common in Asian, Hispanic, and African descent Gradual fade over the first years Bluish-black or gray-blue pigmentation found on dorsal area on buttocks. May be mistaken as bruising and should be documented on newborn’s char.

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

Differential Skin Findings Salmon patches or nevus simplex Angel kisses Stork bites Telangiectatic Nevi- frequently found on eye lids, nose, lower occipital bone, and nape of neck. Common in light complexioned infants, most noticeable when crying. No clinical significance, usually fade by second birthday.

Differential Skin Findings Erythema toxicum White or yellow papule or pustule With erythematous base No treatment necessary Eruption of lesions in the area surrounding a hair follicle, that are firm, vary in size 1 mm-3mm. Often called “newborn rash” or “flea bite”, over trunk & diaper area. Peak incidence is 24-48 hours of life. Cause unknown, smear shows numerous eosinophils.

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

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

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 Vernix caseosa is the pasty, cheese-like, material present in varying degrees on the skin at birth (here a small amount of vernix is seen on the back shortly after delivery). It is a mixture of sebum produced by the infant's skin and cellular debris that has accumulated in utero. Normally, vernix is a creamy white color. The yellowish brown tint seen in this photo is a result of meconium staining.

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

Differential Findings Bilateral Club Feet Syndactyly Bilateral club feet-feet are plantar-flexed and inverted, this is a bone deformity. syndactyly is found occasionally on the physical examination, this is a subtle finding. If the exam is not a careful one, this can easily be missed since both digits are otherwise normally formed.Digits are fused in addition to being too numerous, the term polysyndactyly is used. Polysyndactyly

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

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

Differential Findings Congenital Cataracts Eyelid Edema Subconjunctival Hemorrhage Congenital cataracts require early intervention to preserve sight, so immediate referral to a pediatric ophthalmologist is indicated. It is important to remember that cataracts that are less dense may not be visibly cloudy, so any time red reflexes cannot be obtained on exam, even if the eye appears grossly normal, referral is required. MOST INFANTS EXHIBIT SOME DEGREE OF EYELID EDEMA AFTER BIRTH. THE PUFFINESS MAY MAKE IT SEEM THAT THE INFANT HAS DIFFICULTY OPENING ONE OR BOTH EYES, BUT WITH A GENTLE EXAMINATION, THE EYE CAN BE EASILY EVALUATED. EDEMA RESOLVES OVER THE FIRST FEW DAYS OF LIFE. Subconjunctival hemorrhage is a frequent finding in normal newborns. It results from the breakage of small vessels during the pressure of delivery. The red area may be large or small but is always confined to the limits of the sclera. It is asymptomatic, does not affect vision, and spontaneously resolves in several days.

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

Differential Findings Ear Tags Ear Pits (Preauricular pits) Lop Ear Prominent Ear A SINGLE, SMALL EAR TAG IS AN OCCASIONAL FINDING ON PHYSICAL EXAMINATION. IT IS OFTEN INHERITED AS A FAMILIAL TRAIT. Ear pits (preauricular pits) are often a rather subtle finding on physical exam. They are located at the superior attachment of the pinna to the face and may be unilateral or bilateral. Up to 10% of Asian infants will have pits -- they are less common among Caucasians and African Americans. Lop Ear is a pinna deformity where the superior edge of helix is folded down. “Prominent ear", cup ear refers to an auricle shape that stands away from the head at the superior, posterior, and inferior aspects, only a cosmetic concern.

Neonatal Gestational Age Assessment 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

Differential Findings Hydrocele Undescended testicles Hydroceles are a frequent finding in newborns. It is important on palpation to identify the normally small testicles (approximately 1 cm) as separate entities from the large, smooth-walled fluid collections of hydroceles. IN MANY GIRLS, A SMALL TAG OF MUCOSAL TISSUE CAN BE SEEN PROTRUDING FROM THE VAGINAL AREA AT BIRTH. THIS IS A HYMENAL TAG, A BENIGN PHYSICAL FINDING. WITH TIME, THIS TISSUE WILL RECEDE INTO THE VAGINA AND DECREASE IN SIZE. NO FURTHER EVALUATION IS NECESSARY. Hypospadias Hymenal Tag

Neonatal Gestational Age Neuromuscular Assessment

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

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

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

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

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

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

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

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

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.