Approach to the Newborn:

Hello, baby!
Laura Bruno, M.D.

Proper Assessment After Birth

Estimates of gestational age: physical and

neurological
Size: wt, ht, hc SGA (sym/asym), AGA, LGA
Arousal
Posture and tone
Movements: spontaneous and sym.
Skin color changes
Respiratory distress
Birth trauma
Congenital malformations

Milia

White papules

Sebaceous glands

Commonly on nose

Mongolian Spot

Gray-blue

Common in dark-skinned
and Asian infants

Buttocks, or back,
shoulders

New overlying skin

Erythema
Toxicum

Maculopapular

Eosinophils

Appear after birth

Benign

Neonatal Pustular Melanosis

Small vesicles

Pigmented macule: freckle

Polymorphonuclear
leukocytes

May be present at birth

Neonatal Acne

Fetal glandular
development

Hormonal stimulation

Nose and cheeks

6 month resolution

Strawberry Hemangioma

At birth or days after

30% newborns

Commonly on face

May grow before fading

(after 1yo)

Wait and watch: can

recurr

Cavernous Hemangioma

Subcutaneous

Usually do not
involute

May compress: MRI?,

Surgical intervention

Port Wine Stain

Red, purple, black

Common on forehead and

nape

May grow

Sturge-Weber
assoc.:ophthalmic division
of trigemminal n.

Caf au Lait Spots

Flat and uniform

Usually benign

Associated with
neurocutaneous
syndromes: check #
and size (mm.)

Herpes Neonatorum

Vesicular

Erythema and ulceration

Via birth canal or

ascending

C/S mothers with visible

lesions

Isolate, viral cultures,

treatment

Caput Succedaneum

Prolonged labor

Serosanguinous fluid

Above periosteum

Across suture lines

Newborn Hematomas

QuickTime and a
decompressor
are needed to see this picture.

Cephalohematoma

Subperiosteal
hemorrhage

Well demarcated

Resorb, calcify

Hyperbilirubinemia?

Red Reflex

Orange in darkskinned babies

Indicates normal lens,

retina

Leukocoria

White reflex

Retinoblastoma: 30%
b/l

Retinal abnormalities

Subconjunctival Hemorrhage

Birth trauma: even c/s

Benign

Spontaneous
resolution in days

Conjunctivitis

Chemicalearly onset,
resolves 2-3 days,
esp.silver nitrate

Gonococcalonset at 2-3
days of life, intense

Chlamydialonset at 1-2
weeks of life, assoc.
pneumonia

Gram stain and cx, treat

Preauricular Skin Tag

Associated with renal

agenesis

Urogenital
malformations

Deafness

Preauricular Sinus

Failure of fusion of
hillocks arising from
branchial arches

Autosomal dominant

Recurrent infections
require antibiotics

Epsteins Pearls

White

Epithelialized

Gums = Epsteins,
may also be on roof of
mouth or soft palate

Cleft Lip

Incomplete embryonic
fusion of maxillary and
nasal processes

uni- or bi-lateral

Variable severity: nasal,

maxillary, dental
involvement

+/- cleft palate

inspection and palpation

Cleft Palate

Failure of fusion of
palatine plates
Variable severity
Concerns: cosmetic;
feeding: suck, milk
leaks into nasal cavity-infection: recurrent
otitis media, sinus
infections; t+a
hypertrophy; speech

Shoulder Dystocia

Can cause clavicular

fracture: crepitation or
callus formation on
palpation
No tx for fx

Brachial plexus injury:

Erbs palsey

Torticollis

Erbs Palsy
Damage to 5th and 6th
cervical roots
Paralysis of shoulder
and arm
Internal rotation,
adduction, flexed
wrist=waiters tip
Neuro, PT

Polydactyly

Hereditary

Commonly lateral to
5th digit

Tag vs. well-formed

digit

Estrogenization

Breast engorgement
f/m
Swollen labia
Vaginal d/c
Swollen scrotum
Ligamentous laxity

Coarctation of the Aorta

Justa-ductal narrowing
Symptomatic with closure
of ductus arteriosus: heart
failure, esp.if complicated
Prompt diagnosis and
treatment: femoral pulses,
heart mm, 4-limb BPs
Associations: Turners
Syndrome, cardiac
anomalies (VSD)

Transposition of Great
Arteries

Aorta and pulmonary

artery arise from wrong
ventricles
Severe hypoxia, metabolic
acidemia, CHF
Prompt diagnosis and
treatment--cyanosis, SOB,
poor feeding
Survival depends on
mixing of blood: PGs to
keep ductus open

Congenital Diaphragmatic
Hernia

1/2000 live births

Failure of fetal
development
Bowel in thorax
Variable severity at
presentation: resp., bowel
obstruction, asympto.
(routine CXR)
Flat, hollow abdomen
ABCs, surgery

Umbilical Hernia

Common, ~70%
infants

Usually benign

Resolution by 2 years

Incarceration <1%

Omphalocele

Periumbilical defect,
umbilical cord involved
Variable contents: bowel,
liver, spleen
Covered by fetal sac
Prenatal diagnosis
Associations in 50-70%
cases:Trisomy, congenital
heart, GI

Gastroschisis

Failure of lateral ventral

folds to close
Small and large intestine
pass through
No sac
No umbilical cord
involvement
Stabilize,
dress,decompress, fluids,
antibiotics, surgery
Better prognosis

Inguinal Hernia

0.5-1% term
5-10% preterm
R>L
Soft, NT, reducible
Increases with pressure
Complications:
incarceration,
strangulation
Surgery

Hypospadias

Failure of urethral folds to

fuse, 1:500 newborns

Variable location: below

and proximal

Contraindication to
circumcision

Urological consult,
surgery

Sacral Dimple

Palpate entire spine

Worry about large dimples
above the anal verge, floor
not visible, hair tuft, weak
lower extremities
Occult spina bifida,
bacterial portal to CSF,
Meningocele,
Meningomyelocele
MRI

Meningocele

Neural crest defect:

meninges +/- spinal cord
(meningomyelocele)

Prenatal diagnosis: AFP,

sono, amnio

Surgical repair, shunting

(meningomyelocele and
Arnold-Chiari assoc.)

Early maternal folic acid

Developmental Dysplasia of
the Hip

Uni- or bilateral, 3-4/1000

live births
Range: subluxatable,
dislocateable, or
dislocated
Clunk vs. soft tissue
clickOrtolani
(reduces dislocation) and
Barlow (dislocates)
maneuvers
Serial exams
Imaging (US) and
treatment

Club Foot

Talipes equinovarus
Abnormality of both foreand hindfoot and ankle
1-2/1000 live births
M>F
Hereditary
Early intervention:
manipulation and serial
casts vs. surgery

Breastfeeding Position

Observation

Infant parallel to
mothers body

Tongue below nipple

Newborn Stool

Meconium

Breastfeeding stools

Variable frequency

Discharge Planning:
Bye-bye, baby!

Before Discharge

How to reach M.D.

When is first visit
Safe home environ: carseat, smoke and CO
detectors, BTS
Feeding: Breast or bottle, regain BWT by 2 weeks
Discharge exam: cardiac (ductus closure), skin
(d/c bili), weight (feeding), fever (>100.4)
Parental concerns