2/25/2010

Learning objective:
Interpret findings from physical and
physiological assessments of the
Assessment of the Neonate newborn.

Arthur Jones, EdD, RRT

http://rc-edconsultant.com/

Apgar score
Rated at one and five minutes
Intended only to assess general
Neonatal condition
Does not:
Scoring Systems define asphyxia
predict future development
influence Ivy League admission
Health premature infants will
likely have low Apgar scores
FYI - Click for article on use and abuse of Apgar score
http://pediatrics.aappublications.org/cgi/content/abstract/pediatrics;98/1/14
1

Apgar scoring system Apgar scoring system

0 1 2
ƒObservations
Color central peripheral pink
Color - skin colorimetry reflects cyanosis cyanosis
illness severity
Heart rate
Reflex activity
Activity
Respirations

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Apgar scoring system Apgar scoring system

0 1 2 0 1 2
Color central peripheral pink Color central peripheral pink
cyanosis cyanosis cyanosis cyanosis
Heart rate none <100 >100 Heart rate none <100 >100
detectable detectable
Respiratory apnea irregular, crying
effort shallow

Apgar scoring system Apgar scoring system

0 1 2 0 1 2
Color central peripheral pink Color central peripheral pink
cyanosis cyanosis cyanosis cyanosis
Heart rate none <100 >100 Heart rate none <100 >100
detectable detectable
Respiratory apnea irregular, crying Respiratory apnea irregular, crying
effort shallow effort shallow

Reflex none grimace crying Reflex none grimace crying

(withdraw) (withdraw)
Muscle tone flaccid some well-flexed
(activity) flexion

Gestational age estimation Gestational age estimation

Prenatal Postnatal
menstrual cycle - 1st day of last ultrasound measurement - femur
menstrual period + 280 days length
fundal height measurement - Ballard score - AKA Ballard-
mom's abdomen Dubowitz score
ultrasound

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Ballard score - physical signs

Ballard score Gestational age/ 24-26 wk 35-40 wk
ƒEstimation of gestational age score score = 0 score = 4
Skin gelatinous, parchment, deep
ƒPhysical signs red, translucent cracks, no visible
Skin vessels

Breast
Lanugo
Eye/ear
Plantar surface
Genitalia
FYI - Click to view/bookmark Ballard Score videos
http://www.ballardscore.com/Pages/videos.aspx

Ballard score - physical signs Ballard score - physical signs

Gestational age/ 24-26 wk 35-40 wk Gestational age/ 24-26 wk 35-40 wk
score score = 0 score = 4 score score = 0 score = 4
Skin gelatinous, parchment, deep Skin gelatinous, parchment, deep
red, translucent cracks, no visible red, translucent cracks, no visible
vessels vessels
Lanugo none to sparse none to sparse Lanugo sparse mostly bald

Plantar no crease creases over entire

surface sole

Click to see skin scoring

http://www.ballardscore.com/Pages/mono_phys_skin.aspx
Click to see lanugo scoring
http://www.ballardscore.com/Pages/mono_phys_lanugo.aspx
Click to see plantar surface scoring
http://www.ballardscore.com/Pages/mono_phys_plantar.aspx

Ballard score - physical signs Ballard score - physical signs

Gestational age/ 24-26 wk 35-40 wk Gestational age/ 24-26 wk 35-40 wk
score score = 0 score = 4 score score = 0 score = 4
Skin gelatinous, parchment, deep Skin gelatinous, parchment, deep
red, translucent cracks, no visible red, translucent cracks, no visible
vessels vessels
Lanugo sparse mostly bald Lanugo sparse mostly bald

Plantar no crease creases over entire Plantar no crease creases over entire
surface sole surface sole
Breast barely perceptible full areolae; 5-10 mm Breast barely perceptible full areolae; 5-10 mm
bud bud
Click to see breast scoring Eye and ear lids open, pinna flat eyes open, ear thick
http://www.ballardscore.com/Pages/mono_phys_breast.aspx & stays folded cartilage, stiff

Click to see eye & ear scoring

http://www.ballardscore.com/Pages/mono_phys_eyear.aspx

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Ballard score - physical signs

Gestational age/ 24-26 wk 35-40 wk
Ballard score - neuromuscular signs
score score = 0 score = 4 ƒPosture
Genitalia- male scrotum empty, testes pendulous
faint rugae deep rugae degree of extremity flexion
Genitalia-female prominent clitoris
small labia minora
majora cover clitoris
and minora
greater flexion ==> maturity
ƒSquare window
flexion of hand to forearm
Click to see male genitalia scoring
greater flexion ==> maturity
http://www.ballardscore.com/Pages/mono_phys_male.aspx
Click to see female genitalia scoring Click to see posture scoring
http://www.ballardscore.com/Pages/mono_phys_female.aspx http://www.ballardscore.com/mono_neuro_posture.htm
FYI - Click for pictures of ambiguous genitalia Click to see square window scoring
http://www.images.md/users/explore_chapter.asp?ID=ACU0401-10&colID=ACU0401&coltitle=Pediatric+Urology http://www.ballardscore.com/mono_neuro_squarewindow.htm

Ballard score- neuromuscular signs Ballard score- neuromuscular signs

ƒArm recoil ƒScarf sign
recoil of arm after full extension put hand on opposite shoulder
full recoil ==> maturity lesser travel of elbow across midline
ƒPopliteal angle ==> maturity
angle of knee, with thigh on chest ƒHeel-to-ear
lesser angle ==> maturity non-forceful movement of heel to ear
greater distance heel - ear ==>
Click to see arm recoil scoring mature
Click to see scarf sign scoring
http://www.ballardscore.com/mono_neuro_armrecoil.htm http://www.ballardscore.com/mono_neuro_scarf.htm
Click to see popliteal angle scoring Click to see heel-to-ear scoring
http://www.ballardscore.com/mono_neuro_pop.htm http://www.ballardscore.com/mono_neuro_heel.htm

Ballard scoring Acute illness scoring

ƒMaturity ratings Purposes
0 24 weeks to predict mortality
10 28 weeks guide patient management
20 32 weeks set standards for research,
30 36 weeks benchmarking across institutions
40 40 weeks
50 44 weeks

Click to see the Ballard score calculator

http://www.medcalc.com/ballard.html

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Acute illness scoring Acute illness scoring

Score systems Parameters SNAP II
Score for neonatal acute mean blood pressure
physiology (SNAP II) lowest temperature
Clinical risk index for babies PO2/FIO2%
(CRIB II) lowest pH
oxygenation index (later section) multiple seizures
Validity - CRIB II may be more urine output
discriminatory Apgar score
Scoring systems are not very good birth weight
at predicting mortality small for gestational age

Normal physical features

Acute illness scoring
ƒLanugo - fine hair
Parameters CRIB II
ƒPeripheral cyanosis - due to reduced
gender
peripheral perfusion
gestation weeks
birthweight ƒVernix caseosa - white coating
admission temperature ƒFontanelles - anterior, posterior
base excess

FYI - Click to see SNAP II score calculator

http://www.sfar.org/scores2/snap22.html
FYI - Click to see CRIB II score calculator
http://www.sfar.org/scores2/crib22.html

Normal physical features

Normal physical features
ƒLanugo - fine hair
ƒPeripheral cyanosis - due to reduced ƒRespirations
normal RR = 30-60/min
peripheral perfusion
auscultation ==> sounds transmitted
ƒVernix caseosa - white coating
easily across small chest
ƒFontanelles - anterior, posterior periodic breathing - apnea < 10 sec
ƒPhysiologic jaundice - > 24 hrs ƒnormal in preterm newborns
postpartum ƒnon-pathologic
ƒTelangiectatic nevi - "stork bites" apnea of prematurity - apnea > 10
ƒMinimal ecchymoses & petechiae Sec
Click to see stork bite
http://pregnancy.about.com/od/newbornbabies/ig/Newborn-Photo-Gallery/Stork-Bite---Newborn.htm

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Silverman Respiratory Status Index Silverman Respiratory Status Index

ƒPurpose - objectively score ƒParameters
physical evidence of increased Synchrony of upper & lower chest -
work of breathing (WOB) seesawing = 2
ƒFive observations, scored 0-2 Nasal flaring - marked = 2
ƒHigher score ==> greater WOB Lower chest retractions = marked
(maximum score = 10) intercostal retractions = 2
Xiphoid retractions - marked
retraction of skin over xiphoid = 2
Expiratory grunt - audible to ear = 2
Click to see Downes and Silverman scoring systems
http://members.tripod.com/puffnicu/rd.html

Cardiovascular assessment Cardiovascular assessment

ƒHR = 120 - 160 /min ƒauscultation for murmurs - turbulent
ƒBP (term infant) = 50-70/25-50 blood flow across valves
ƒumbilical stump- 2 arteries, 1 vein abnormal valves
abnormal vessels
septal defects
ƒbrachial pulses compared to femoral
for equal intensity - unequal ==>
aortic coarctatation
Click to see neonatal blood pressure charts FYI - click for website with heart murmurs (bookmark?)
http://www.uihealthcare.com/depts/med/pediatrics/iowaneonatologyhandbook/general/bloodpressure.html http://www.wilkes.med.ucla.edu/inex.htm
Click to see umbilical stump Click for more information and pictures of coarctation
http://www.biosci.ohiou.edu/introbioslab/Bios171/images/lab5/umb_cord2.jpg
http://www.pted.org/?id=coarctation1

Neurologic responses (reflexes) Abnormal features

ƒGrasp- grasps with hand ƒMeconium stains - aspiration
ƒSuck - starts early, in utero ƒFlaring, grunting, retractions
ƒRooting - turns head to suck ƒCentral cyanosis - hypoxemia
ƒMoro - startle reflex ƒJaundice < 24 H postpartum
ƒBabinski - normal newborn toes color due to bilirubin
curl upward causes: hemolysis, liver failure

Click for video of neonatal reflex evaluation (2.5 min.)

http://www.youtube.com/watch?v=gyVLD0hl0XY&feature=related

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Abnormal features Abnormal features

ƒFontanelles - anterior and posterior ƒFacies
bulging ==> increased ICP ƒmicrognathia (small mandible)
sunken ==> dehydration ƒPierre-Robin syndrome
ƒUpper extremity immobility ƒTreacher Collins syndrome
Broken clavicles ƒmicrostomia (small mouth) -
Brachial plexus injury trisomy 18
ƒcleft lip, palate
Click to see radiograph of birth trauma (clavicle) Click to see image of micrognathia
http://niyaf.com/post/31434342/birth-trauma-fractured-clavicle-collar-bone http://www.mdconsult.com/das/pdxmd/media/1206/6120625/large.jpg
Click to see a picture of birth trauma (forceps marks) Click to see image of microstomia
http://pregnancy.about.com/od/newbornbabies/ig/Newborn-Photo-Gallery/Newborn-with-Forcep-Marks.htm
http://www.nndb.com/people/905/000091632/joeebrown02.jpg

Abnormal features Abnormal features

ƒCri-du-chat (cat's cry) - deletion of ƒPolydactyly - sometimes associated
partial chromosome (normal in feline with lethal anomalies
newborns) ƒLethal anomalies - lethal; but,
ƒSimian crease - single palmar crease when?
ƒpresent in some normal infants cystic fibrosis (Caucasians)
ƒcommon in trisomy 21 (Down sickle cell anemia (African)
syndrome) trisomy 13 (Patau syndrome)
ƒcommon in cri-du-chat trisomy 18 (Edwards syndrome)
Click to hear cri-du-chat FYI - Click for video about cri-du-chat (4.5 min.)
http://fs6.depauw.edu:50080/~cfornari/DISGEN/CriDuChat%20Website/images/babycryb.wav http://www.youtube.com/watch?v=pxh9m1dTU0Q
Click to see image of simian crease FYI - Click for Atlas of congenital anomalies
http://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/17226.jpg http://www.gfmer.ch/genetic_diseases_v2/index.php?disinit=L

Abnormal features Abnormal features

ƒLethal anomalies ƒLethal anomalies - ethical & legal
inoperable cardiac anomalies issues
(acardia) futility of efforts
Potter's syndrome allocation of resources
pulmonary hypoplasia - end-of-life care for parents
undeveloped lung(s)
renal agenesis
anencephaly
lethal white disease (horses)
FYI - Click for picture of anencephaly
http://isc.temple.edu/neuroanatomy/lab/embryo_new/nt/4/anen.html

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Abnormal features
Physiologic features
ƒGastroschisis - externalized,
ƒLung mechanics
uncovered bowel
ƒTV = 7 mL/kg
ƒOmphalocoele
ƒFRC = 21 mL/kg
bowel covered with peritoneum
ƒVD = 5 mL/kg
associated with other anomalies
ƒRespiratory system compliance
ƒSpina bifida - exposed spinal cord ƒterm newborn..........5 mL/cm H2O
ƒHydrocephaly - cerebral edema ƒpreterm newborn....3 mL/cm H2O
Click to see picture of gastroschisis
http://bms.brown.edu/pedisurg/images/ImageBank/AbdWallDefects/Gastroschisis%201.jpg
ƒadult.........................100 mL/cm H2O

Click to see picture of spina bifida

http://www.scienceclarified.com/images/uesc_02_img0090.jpg
Click to see picture of hydrocephaly
http://www.flickr.com/photos/hydroassoc/2073488415/

Physiologic features Physiologic features

ƒLung mechanics ƒAirway resistance
ƒhigh chest wall compliance ==> ƒterm newborn..........70 cm H2O/L/sec
decreased support of lung expansion ƒpreterm newborn.....97 cm H2O/L/sec
by chest wall ƒadult..........................2.5 cm H2O/L/sec
thoracic retractions- early sign of ƒInspiratory flow
distress ƒterm newborn...........3-6 L/min
ƒadult...........................30-60 L/min

Click for illustration of retractions

http://www.wrongdiagnosis.com/bookimages/13/4970.png

Blood gases Blood gases

ƒSample sources ƒHypoxia sources
ƒumbilical cord - partum ƒhypoxemia (decreased PO2,
ƒumbilical artery catheter SPO2)
ƒperipheral artery; e.g., brachial ƒanatomic shunts
ƒvein - pH and PCO2 only ƒpulmonary shunts

ƒcapillary ƒanemia - includes

ƒpainfulfor patient ƒ HbCO from maternal smoking
ƒpH and PCO2 only ƒ HbMET from nitric oxide (NO)
ƒunreliable if patient is in shock ƒcirculatory
ƒ anatomic shunts
ƒ shock

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Blood gases Umbilical arterial gas sea level norms

ƒAcid-base disturbances
ƒrespiratory acidemia 20 min 1 hour 4 hours
ƒrespiratory alkalemia pH 7.35 7.40 7.40
ƒmetabolic acidemia
PaCO2 35 30 35
ƒshock, sepsis
PaO2 50-65 50-65 65-70
ƒdiarrhea - loss of bicarbonate

ƒmetabolic disorders; e.g., diabetes

ƒmetabolic alkalemia Note: shift in HbO2 curve ==> infant

ƒdiuretics p50 = 21 mm Hg
ƒgastric suctioning

Blood gases Blood gases

Oxygenation index - calculated Oxygenation index (OI)
score advantage over other indexes -
used for all patient groups takes mean airway pressure into
purposes: account
ƒpredict outcomes oxygen index equation:
ƒguide management choices; e.g., OI = FiO2 * MAP
ECMO PaO2
ƒcompare outcomes among
institutions; e.g., for benchmarking
FYI - Click to download article on oxygenation index FYI - Click for oxygen index calculator
http://ajrccm.atsjournals.org/cgi/reprint/172/2/206 http://www.medcalc.com/oxygen.html

Pulse oximetry TOSCA monitor

Purposes:
adjust FIO2
ƒensure adequate oxygenation
ƒprevent hyperoxia
screening for ductal-dependent
cardiac anomalies
perfusion index from signal
amplitude reflects illness severity
Optimal range for SPO2 for
infants on O2 therapy = 85% - 93%
Made by Linde Medical Sensors
Ear sensor with SPO2 and
transcutaneous PCO2 (PTCCO2)
measurement
Found accurate and reliable by
several studies
FYI - click to see abstract of study on TOSCA
http://pediatrics.aappublications.org/cgi/content/abstract/peds.2004-0946v1

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Neonatal Blood
ƒfetal Hb
greater affinity for O2 than adult Hb
- partial compensation for low fetal
PaO2 (<29 mm Hg)
present, with adult Hb for 1st year
ƒinitial CBC (term)
Hb = 16.5 - compensation for
PaO2
Hct = 50
WBC = 18,000
Weight/gestational age
Gestational age - extremely low
gestational age (ELGAN) - < 28 wks.
Weight/GA categories
ƒAppropriate for gestational age
(AGA)
ƒSmall for gestational age (SGA)
ƒLarge for gestational age (LGA)
Infants who are SGA, show greater
mortality, independent of gestational
age
Review & Summary
ƒApgar score - general health
ƒBallard score - gestational age
ƒSilverman respiratory status index
ƒCritical care scores - CRIB, SNAPPE
Copyright 2008 AP Jones
2/25/2010
Neonatal Blood
ƒimmunoglobulins
IgG from mom while in utero
IgA from breast milk
newborn starts developing own IgG
post-natally
increased IgM at birth ==>
intrauterine infection
FYI - click for more information on immunoglobulins
http://www.cehs.siu.edu/fix/medmicro/igs.htm
Weight categories
Weight
Moderately low (MLBW).........1501-2500g
Very low (VLBW).....................1001-1500g
Extremely low (ELBW)..........<1000g
Review & Summary
ƒNormal physical features
ƒAbnormal physical features
ƒNormal neurologic responses
ƒCardiovascular assessment
ƒNormal physiologic features
lung mechanics
blood gases, pulse oximetry
ƒWeight/gestational age relationships
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END
References
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Copyright 2008 AP Jones
2/25/2010
References
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Lippincott Publishers, Philadelphia. Chap. 11
ƒBarnhart SL, Czervinski MP. Perinatal and Pediatric
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ƒSasidharan K, Dutta S, Narang A. Validity of New Ballard
Score till 7th day of postnatal life in moderately preterm
neonates. Arch Dis Child. 2008 Mar 12.
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illness severity in the high-risk newborn. Pediatric
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References
ƒHjalmarson O, Sandberg K. Abnormal lung function in
healthy preterm infants. Am J Respir Crit Care Med
2002;165:83-87.
ƒCastillo A, et al. Pulse oxygen saturation levels and
arterial oxygen tension values in newborns receiving
oxygen therapy in the neonatal intensive care unit: is
85% to 93% and acceptable range? Pediatrics
2008;121:882-889.
ƒde Wahl, GA, et al. Impact of pulse oximetry screening
on the detection of duct dependent congenital heart
disease: a Swedish prospective screening study in
39,821 newborns. BMJ. 2009 Jan 8;338:a3037.
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