Aquifer Case Study – Developmental Evaluation and Screening Pediatrics 01: Newborn male infant evaluation and care
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Case Editor: Jenelle Little, MD
Associate Editor: Erin McMaster, MD
You are working with Dr. Martin on the Newborn Service. She directs you to obtain a prenatal history of Rose, a 20-year-old who is being admitted to obstetrics from the emergency department.
You jot down what Dr. Martin knows about her:
You introduce yourself to Rose as a member of the pediatric team who will help care for her baby, and start by asking questions about her pregnancy:
About Teen Pregnancy. Centers for Disease Control and Prevention. http://www.cdc.gov/TeenPregnancy/AboutTeenPreg.htm. Accessed July 14, 2021.
You ask Rose a few questions to explore her social and substance use history:
Which of the following statements are true about substance use during pregnancy? Select all that apply.
The best options are indicated below. Your selections are indicated by the shaded boxes.
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A. Cocaine and other stimulants such as amphetamines cause vasoconstriction that can lead to placental insufficiency and low birth weight.
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B. Drinking even one beer per week puts Rose’s infant at risk of fetal alcohol syndrome.
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C. Marijuana use during pregnancy causes characteristic facial abnormalities in the infant.
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D. Tobacco use during pregnancy can cause infants to have low birth weight.
Tobacco
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Maternal tobacco use during pregnancy increases the risk for low birth weight in the fetus.
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There are no characteristic facial abnormalities associated with maternal tobacco use during pregnancy.
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Alcohol
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There is no “safe” amount of alcohol that can be consumed during pregnancy to ensure that fetal alcohol syndrome (FAS) does not occur.
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Fetal alcohol syndrome is a distinct pattern of facial abnormalities (microcephaly, smooth philtrum, thin upper lip), growth deficiency, and evidence of central nervous system dysfunction.
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Victims of fetal alcohol syndrome may exhibit cognitive disability and learning problems (i.e., difficulties with memory, attention, and judgment) as well as neurobehavioral deficits such as poor motor skills and impaired hand-eye coordination.
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Marijuana
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Distinctive effects of marijuana have not been identified.
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Heroin and other opiate medications
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Maternal heroin use is associated with increased risk of fetal growth restriction, placental abruption, fetal death, preterm labor and intrauterine passage of meconium.
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All infants born to women who use opioids during pregnancy should be monitored for symptoms of neonatal abstinence syndrome (i.e. uncoordinated sucking reflexes leading to poor feeding, irritability, and high-pitched cry) and treated if indicated.
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Cocaine and Other Stimulants
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These cause vasoconstriction leading to placental insufficiency and low birth weight, premature delivery, smaller head circumferences and shorter lengths.
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In addition, the National Institute on Drug Abuse notes that “exposure to cocaine during fetal development may lead to subtle, yet significant, later deficits in some children, including deficits in some aspects of cognitive performance, information processing, and attention to tasks abilities that are important for success in school.”
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Mother to Baby Fact Sheets. Organization of Teratology Information Services. https://mothertobaby.org/fact-sheets/. Accessed July 14, 2021
What are the effects of maternal cocaine use? National Institute on Drug Abuse. https://www.drugabuse.gov/publications/research-reports/cocaine/what-are-effects-maternal-cocaine-use. Accessed July 14, 2021.
You read in the OB team admission note that Rose’s weight gain has been limited when her current weight is compared to her self-reported pre-pregnancy weight. Her fundal height is less than expected, and her fetus is possibly small for dates. In preparation for meeting with Dr. Martin to present Rose’s case information you quickly review factors that affect fetal growth.
Newborns who are noted to be smaller than expected for their gestational age are considered small for gestational age (SGA).
Although they are not synonymous, this term is often used interchangeably with:
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Fetal growth restriction (FGR)
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Intrauterine growth retardation and/or
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Intrauterine growth restriction (IUGR)
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SGA: An infant is diagnosed as being SGA at time of birth. There are varying definitions for SGA, ranging from less than the third percentile to less than the 10th percentile for weight. Depending on the cutoff level used, up to 70% of SGA infants are small simply due to constitutional factors determined by maternal ethnicity, parity, weight or height.
IUGR: A fetus is noted to be IUGR during the pregnancy. A growth-restricted fetus is one that has not reached its growth potential at a given gestational age due to one or more causative factors.
Etiologies of SGA at Birth
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Maternal factors |
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Fetal factors |
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Medications and other exposures |
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Uterine and placental abnormalities |
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DEEP DIVEEstimating Fetal Age Using Fundal HeightYou now organize the maternal history:
20-year-old female at estimated 38 weeks’ gestation based on last menstrual period. Membranes ruptured; in active labor. G1P0. No previous prenatal care.
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Meds: Tylenol prn. No prescribed medications; no vitamins, supplements, or complementary or alternative medicines.
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PMHx: Asthma, last attack several years ago.
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SHx: Living with friends. No insurance. Unemployed. Food insecure.
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ROS: Four previous partners. No history of sexually transmitted infection (STI). Smokes 1-3 cigarettes daily (started smoking half pack per day at age 15. Cut back in early pregnancy). Drinks beer on weekends. Smokes marijuana occasionally. No ankle swelling. No headache/vision changes. No abdominal pain until today.
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PE: BP 115/70 mm Hg; fundal height: 33 cm; fetal heart tones 135 bpm.
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Lab results: Urinalysis (UA) negative protein and glucose
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Based on the information you have obtained about Rose so far, what are some possible etiologies for her baby’s apparent small size? Select all that apply.
The best options are indicated below. Your selections are indicated by the shaded boxes.
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A. Asthma during pregnancy
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B. Chromosomal abnormality, such as trisomy 13
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C. Congenital infection
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D. Fetal Alcohol Syndrome/Alcohol use
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E. Placental abnormality such as chronic placental abruption
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F. Poor maternal nutrition and weight gain
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G. Pregnancy-induced hypertension or preeclampsia
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H. Prematurity (inaccurate dates)
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I. Structural abnormality in the fetus, such as renal dysplasia or a diaphragmatic hernia
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J. Tobacco exposure
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K. Undiagnosed gestational diabetes
> The correct answers are B, C, D, E, F, H, I, J.
Potential causes for Rose’s fetus’s apparent intrauterine growth restriction:
Structural or chromosomal abnormalities (B, I)
Congenital infections (C)
Fetal Alcohol Syndrome/Alcohol use (D)
Placental insufficiency (E)
Poor maternal nutrition and weight gain (F)
Inaccurate dates (H)
Tobacco use (J)
Rose did not experience asthma during pregnancy (A). Asthma generally does not cause inadequate fetal growth; the unlikely exception would be severe chronic lung disease in the mother with maternal hypoxia.
Although pre-eclampsia and hypertension can cause infants to be SGA, Rose does not have hypertension, proteinuria or swelling, so poor growth of her fetus to this date cannot be secondary to pregnancy-induced hypertension or preeclampsia (G).
Gestational diabetes (K) most often results in macrosomia although it can result in IUGR due to poor placental blood flow. Rose does not have glucose in her urine making this less likely.
Lausman A, Kingdom J; Maternal Fetal Medicine Committee. Intrauterine growth restriction: screening, diagnosis, and management. J Obstet Gynaecol Can. 2013;35(8):741-748. doi:10.1016/S1701-2163(15)30865-3.
You and Dr. Martin observe as the OB team performs a brief fetal ultrasound. No physical abnormalities of the fetus or placenta are detected, but his size is consistent with a 35-week gestation fetus.
Dr. Martin points out that Rose has not had the laboratory studies that are usually included in routine prenatal care. The results of prenatal screening labs may have a significant impact on the care of the newborn baby. The OB team will include these as part of Rose’s admission orders.
Which one of the following disorders meets the ideal criteria for universal newborn screening?
Choose the single best answer.
The best option is indicated below. Your selections are indicated by the shaded boxes.
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A. Cri du chat syndrome
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B. Galactosemia
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C. Myotonic dystrophy
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D. Prader Will Syndrome
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E. Trisomy 13
The correct answer is B.
Of the disorders listed above, there is effective treatment only for galactosemia (B), so screening for the others would not be appropriate.
Which of the following statements are true about substance use during pregnancy?
Select all that apply.
The best options are indicated below. Your selections are indicated by the shaded boxes.
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A. Cocaine and other stimulants such as amphetamines cause vasoconstriction that can lead to placental death
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B. Drinking even one beer per week puts Rose’s infant at risk of fetal alcohol syndrome.
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C. Marijuana use during pregnancy causes characteristic facial abnormalities in the infant.
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D. Tobacco use during pregnancy can cause infants to have low birth weight.
The correct answers are A, B, D.
Vasoconstriction decreases the flow of blood to the placenta, thereby reducing the caloric intake of the fetus (A). There is no known “safe” amount of alcohol ingestion to avoid fetal alcohol syndrome, so even one beer per week puts the infant at risk (B). There are no characteristic facial abnormalities associated with maternal use of marijuana (C). Tobacco use, like cocaine, decreases blood flow to the placenta (D).
If you had been the physician who saw this patient on the initial visit what would you have done?
Choose the single best answer.
- A. Given an intramuscular injection of penicillin.
- B. Started oral amoxicillin and discontinued it if the throat culture came back negative.
- C. Started oral penicillin and discontinued it if the throat culture came back negative.
- D. Waited for the result of the throat culture and started oral amoxicillin if positive for Group A Strep.
Look for the following prenatal screening lab tests in the maternal record:
Maternal blood type, Rh and antibody screen
Rubella IgG
Hepatitis B Surface Antigen (HBSAg)
HIV antibody
RPR or VDRL
Urinalysis
Urine nucleic acid amplification testing (NAAT) for chlamydia and gonococcus
Urine or vaginal culture for group B streptococcus
Hepatitis C antibody (in women with a history of IV drug use)
Tuberculosis skin test (e.g. Mantoux) or TB blood test (e.g. Quantiferon) (in women with HIV or who live in a household with someone with active TB)
Patient information on routine testing during pregnancy
U.S. Centers for Disease Control and Prevention guidelines
Centers for Disease Control and Prevention website
Kimberlin D, Barnett E, Lynfield R, Sawyer M. Red Book: 2021 Report of the Committee on Infectious Diseases. 32nd ed. AAP; 2021.
Breastfeeding. Centers for Disease Control and Prevention. https://www.cdc.gov/breastfeeding/breastfeeding-special-circumstances/maternal-or-infant-illnesses/hiv.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fbreastfeeding%2Fdisease%2Fhiv.htm. Accessed July 1 4, 2021.
Global Update on the Health Sector Response to HIV, 2014. World Health Organization. https://apps.who.int/iris/bitstream/handle/10665/128196/WHO_HIV_2014.15_eng.pdf;jsessionid=0A123F823FAE2875C44F7A9F98231B03?sequence=1. Accessed July 14, 2021.
HIV Basics. Centers for Disease Control and Prevention. https://www.cdc.gov/hiv/basics/statistics.html. Accessed July 14, 2021.
Routine Tests During Pregnancy. American College of Obestricians and Gynecologists. https://www.acog.org/womens-health/faqs/routine-tests-during-pregnancy?utm_source=redirect&utm_medium=web&utm_campaign=otn. Accessed July 14, 2021.
You ask Dr. Martin whether or not it is too late to check Rose for Group B Streptococcal (GBS) colonization, as she is already in labor. She discusses the basics of GBS infections with you, noting that Rose does not meet the criteria for empiric intrapartumantibiotic treatment (see Deep Dive) if she is considered to be 38 weeks as per Rose’s last menstrual period dates. On the other hand if the gestation is actually only 35 weeks, then GBS prophylaxis is indicated. Dr. Martin will discuss this with the OB team.
Neonatal GBS Facts
GBS infection is a major cause of neonatal bacterial sepsis.
The incidence of early onset GBS disease is 0.23/1000 live births.
20-30% of pregnant women have vaginal or rectal colonization of GBS.
Without antibacterial prophylaxis 1-2% of infants born to colonized women develop invasive disease (sepsis, pneumonia and meningitis).
Risk factors for early onset GBS disease include rupture of membranes > 18 hours, prematurity, intrapartum fever and previous delivery of an infant who developed GBS disease.
Newborn Management
The management of babies born to mothers who are colonized with Group B streptococcus depends on a number of factors:
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Clinical appearance
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Evidence of maternal chorioamnionitis
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Receipt of appropriate GBS prophylactic antibiotics by mother during labor
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Duration of membrane rupture
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Gestational age less than 37 weeks
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Any infant who is ill appearing should undergo a full diagnostic evaluation (complete blood count [CBC], blood culture, chest x-ray and lumbar puncture) and receive IV antibiotics.
Well-appearing infants may undergo a limited laboratory evaluation (CBC and blood culture) or simply be closely monitored over the first few days of life.
American Academy of Pediatrics. Red Book: 2018 Report of the Committee on Infectious Diseases, 31st Edition. Kimberlin, Brady, Jackson
Current American Academy of Pediatrics (AAP) and American College of Obstetricians and Gynecologists (ACOG) guidelines indicate that intrapartum antimicrobial prophylaxis against Group B streptococcal disease (GBS) should be administered if one of the following is present and the mother is in labor with ruptured membranes:
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Previous infant with invasive GBS disease
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GBS bacteriuria during any trimester of the current pregnancy
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Positive GBS vaginal-rectal screening culture in the 36 0/7-37 6/7th weeks of current pregnancy
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Unknown GBS status at the onset of labor (culture not done, incomplete, or results unknown) and any of the following:
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Delivery at < 37 weeks’ gestation
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Amniotic membrane rupture ≥ 18 hours
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Intrapartum temperature ≥ 38°C (100.4°F)
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Intrapartum nucleic acid amplification testing (NAAT) positive for GBS
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Appropriate antibiotics for intrapartum antibiotic prophylaxis include penicillin, amoxicillin, and cefazolin. In the penicillin-allergic mother, clindamycin or vancomycin may be used after determining sensitivity.
Puopolo K. Early-onset group B strep: New guidance includes changes in dosing, assessment. AAP News. https://www.aappublications.org/news/2019/07/08/gbs070819. Accessed July 14, 2021.
Puopolo K, Lynfield R, Cummings J. Committee on Fetus and Newborns and Committee on Infectious Disesases. Pediatrics. August 2019, 144 (2) e20191881; DOI: https://doi.org/10.1542/peds.2019-1881
Committee Opinion No. 797: Prevention of Group B Streptococcal Early-Onset Disease in Newborns: Correction.Obstet Gynecol. 2020;135(4):978-979. doi:10.1097/AOG.0000000000003824.
Dr. Martin points out that routine prenatal labs include testing for potential congenital infections.
In addition to affecting fetal growth, congenital infections can impact the health of the fetus in many significant ways. Dr. Martin shares this table, comparing the key clinical findings of each of the congenital (or TORCHZ) infections.
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Detection of rubella-specific IgM antibodies usually indicates recent postnatal infection or congenital infection.
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Because false-positives can occur, diagnosis can also be confirmed by stable or increasing serum concentrations of rubella IgG over several months.
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Diagnosis is difficult after one year of age.
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Diagnosis of Congenital Toxoplasmosis
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The serologic diagnosis of congenital toxoplasmosis is based on positive toxoplasma-specific IgM, IgG, or IgA assay in the newborn period, increasing IgG titers in the first year, or persistently positive IgG titers beyond the first year of life.
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Diagnosis of Congenital Cytomegalovirus (CMV)
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Because newborn infants with congenital cytomegalovirus (CMV) shed large amounts of virus in the saliva and urine, urine or saliva culture is sufficient for diagnosis.
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Polymerase chain reaction (PCR) may also be used for diagnosis.
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Detection of CMV in urine, oral fluids, respiratory tract secretions, blood, or cerebral spinal fluid (CSF) obtained within 2 to 3 weeks of life is considered proof of congenital CMV infection.
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American Academy of Pediatrics. Red Book: 2018 Report of the Committee on Infectious Diseases, 31st Edition. Kimberlin, Brady, Jackson
Cytomegalovirus (CMV) and Congenital CMV Infection. Centers for Disease Control and Prevention. https://www.cdc.gov/cmv/. Accessed July 14, 2021.
Plosa EJ, Esbenshade JC, Fuller MP, Weitkamp JH. Cytomegalovirus infection. Pediatr Rev. 2012;33(4):156-163. doi:10.1542/pir.33-4-156.
You review the results of Rose’s screening labs. The rapid HIV antibody test, Hepatitis B surface antigen test, rapid plasma reagin (RPR), urine nucleic acid amplification testing (NAAT) for chlamydia and gonorrhea are negative. The serum Rubella IgM titer is negative and IgG titer is positive indicating that Rose has acquired Rubella immunity. The urine analysis finds no protein or glucose. A urine drug screen is negative.
Rose’s labor progresses without further complication and with no signs of fetal distress. Her membranes have now been ruptured for 10 hours, and the amniotic fluid has been clear. She remains afebrile and normotensive.
As you prepare to observe the delivery, consider the steps in basic newborn resuscitation:
In addition to remembering the ABCs (or airway-breathing-circulation), keep in mind some of the special features of newborn resuscitation:
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Use universal precautions
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Warm and dry the infant and remove any wet linens immediately. Infants have a large surface area relative to their body weight and can thus experience significant hypothermia from evaporation.
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Stimulate the infant to elicit a vigorous cry. This helps clear the lungs and mobilize secretions.
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Position airway
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Suction amniotic fluid from the infant’s mouth and nose. This helps clear the upper airway.
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Initiate further resuscitation if required. This may include using blow-by oxygen, continuous positive airway pressure (CPAP), placement of an alternate airway, chest compressions, and medications.
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While approximately 10% of newborns require some assistance to initiate breathing, fewer than 1% require extensive resuscitation.
Neonatal Resuscitation Program. American Academy of Pediatrics. https://services.aap.org/en/learning/neonatal-resuscitation-program/. Accessed July 14, 2021.
The baby is delivered vaginally in vertex position with clear amniotic fluid. The OB team reports that there are no apparent placental abnormalities.
The baby, a boy, is transferred to the warmer bed crying and wet. You assist by drying the infant quickly and vigorously to minimize heat loss and stimulate the infant to cry.
Rose names the baby Thomas. Dr. Martin asks you to assign an Apgar score.
Which of the following are components of the Apgar score? Select all that apply.
The best options are indicated below. Your selections are indicated by the shaded boxes.
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A. Capillary refill
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B. Color
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C. Grimace
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D. Pulse
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E. Respiratory effort
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F. Tone
> The correct answers are B, C, D, E, F.
Assessment of the infant’s color (B), irritability (C), pulse (D), and respirations (E) comprise 4 of the 5 components of the Apgar score. The fifth is tone (F). Capillary refill is not part of the Apgar score (A).
The Apgar score is an assessment of the condition of the newborn immediately after birth.
Components of Apgar score include:
Appearance (skin color)
Pulse (heart rate)
Grimace (reflex irritability)
Activity (muscle tone)
Respiration
A newborn receives a score of 0, 1, or 2 for each component, with the final Apgar score ranging from 0 to 10.
The score is reported at 1 minute and 5 minutes after birth for all infants.
The change in Apgar score between 1 and 5 minutes may be a useful indicator of response to resuscitation. According to Neonatal Resuscitation Program (NRP) guidelines, a score below 7 at 5 minutes should prompt continued resuscitation, with reassessment every 5 minutes, up to 20 minutes, until a score of 7 is achieved.
The Apgar score does not identify birth asphyxia and does not predict individual neurologic outcome or mortality.
The Apgar Score. American Academy of Pediatrics. https://pediatrics.aappublications.org/content/136/4/819/ Accessed July 14, 2021.
Description of findings at one minute of life for this infant:
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Pulse |
Palpation of umbilical cord shows heart rate > 100 beats/minute |
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Color |
Pink centrally but still has acrocyanosis [cyanosis of the hands and feet] |
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Respiratory effort |
Active with a strong cry No signs of respiratory distress |
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Tone |
Actively moving with arms and legs flexed |
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Grimace |
Facial expression shows response to interventions; he cries when you use the bulb suction to clear out his oral secretions and when you warm him vigorously with the towel. |
What is Thomas’s Apgar score at one minute? Choose the single best answer.
The best option is indicated below. Your selections are indicated by the shaded boxes.
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A. 7: 2 points each for heart rate, respiratory effort and grimace; 1 point for tone; zero points for color.
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B. 8: 2 points each for heart rate, grimace and tone; 1 point each for respiratory effort and for color.
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C. 9: 2 points each for heart rate, respiratory effort, grimace and tone, with 1 point for color.
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D. 10: 2 points each for heart rate, respiratory effort, grimace (facial response), color and tone.
> The correct answer is C.
All categories of scoring receive a 2, except color, which has 1 point taken off for blue hands and feet (C). The infant has a normal heart rate, tone (A), respiratory effort (B) and grimace, but does not have normal color (D).
Signs of respiratory distress in the newborn include:
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Apnea
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Poor respiratory effort
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Tachypnea (rapid respiratory rate): a normal newborn’s respiratory rate will be in the 30s to 50s.
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Nasal flaring
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Chest wall retractions: Retractions are observed when the skin over the chest wall is “sucking in”; this is usually noted as intercostal (between the ribs), suprasternal (above the sternum) or subcostal (below the ribcage) retractions.
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Grunting; Grunting is a noise that is heard on expiration when an infant in respiratory distress is working to keep his or her alveoli open to increase oxygenation and/or ventilation. This is sometimes referred to as “auto-PEEP (positive end-expiratory pressure).”
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At five minutes of life you reassess Thomas’s Apgar score and take his measurements.
Five-minute Apgar score: 9
Weight: 2100 grams
Length: 43 centimeters
Head circumference: 32 centimeters
When plotted on a newborn growth chart, Thomas’s weight is below the 10th percentile at 38 weeks. You wonder whether Rose’s dates were inaccurate and Thomas is really premature.
When you show the growth chart to Dr. Martin, she asks you to perform a Ballard exam to estimate the gestational age.
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Bulleted item 1
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Bulleted item 2
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Bulleted item 3
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Numbered item 1
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Numbered item 2
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Numbered item 3
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The Ballard assessment tool uses signs of physical and neuromuscular maturity to estimate gestational age.
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This can be particularly helpful if there is no early prenatal ultrasound to help confirm dates, or if the gestational age is in question because of uncertain maternal dates.
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View an interactive version of the Ballard assessment tool.
View the fetal growth charts and Ballard exam worksheet and results in the window above. What do you conclude from the measurements and the Ballard exam? Select all that apply.
The best options are indicated below. Your selections are indicated by the shaded boxes.
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A. Thomas is a term infant.
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B. Thomas is microcephalic.
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C. Thomas is normocephalic.
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D. Thomas is small for gestational age (SGA).
> The correct answers are A, C, D.
Based on the Ballard exam, Thomas’s score (36) most closely correlates to 38 weeks’ gestation, or term (A). This corroborates Rose’s dates. His head circumference is at the 25th percentile, so he is normocephalic, not microcephalic (C). His weight is below the 10th percentile, so he is SGA (D).
Small for gestational age (SGA) = Weight below the 10th percentile for gestational age
Preterm = < 37 weeks’ gestation
Early term = Born at 37 0/7-38 6/7 weeks’ gestation
Term = 39 0/7–40 6/7 weeks’ gestation
Late term = 41 0/7-41 6/7 weeks’ gestation
Post Term = > 42 0/7 weeks’ gestation
See this Committee Opinion from the American College of Obstetricians and Gynecologists from 2017 for a suggested revision of the “term” nomenclature.
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Symmetric IUGR refers to a growth pattern in which head, length, and weight are decreased proportionately. Congenital infections or other fetal factors may adversely affect brain growth and often result in symmetrical IUGR.
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Asymmetric IUGR refers to a greater decrease in length and/or weight without affecting head circumference (“head-sparing phenomenon”). Maternal factors that cause poor delivery of nutrition to the fetus (for example, maternal smoking) often results in asymmetric IUGR.
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Ballard JL, Khoury JC, Wedig K, Wang L, Eilers-Walsman BL, Lipp R. New Ballard Score, expanded to include extremely premature infants. J Pediatr. 1991;119(3):417-423. doi:10.1016/s0022-3476(05)82056-6.
Definition of Term Pregnancy. The American College of Obstetricians and Gynecologists. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2013/11/definition-of-term-pregnancy. Accessed July 14, 2021.
Lee AC, Panchal P, Folger L, et al. Diagnostic Accuracy of Neonatal Assessment for Gestational Age Determination: A Systematic Review. Pediatrics. 2017;140(6):e20171423. doi:10.1542/peds.2017-1423..
Mayer C, Joseph KS. Fetal growth: a review of terms, concepts and issues relevant to obstetrics. Ultrasound Obstet Gynecol. 2013;41(2):136-145. doi:10.1002/uog.11204.
Maulik D. Fetal growth compromise: definitions, standards, and classification. Clin Obstet Gynecol. 2006;49(2):214-218. doi:10.1097/00003081-200606000-00004.
You’ve determined that Thomas is term, SGA and normocephalic.
What additional risks should you consider for a baby known to be SGA? Select all that apply.
The best options are indicated below. Your selections are indicated by the shaded boxes.
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A. Hyperthermia
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B. Hypoglycemia
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C. Hypothermia
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D. Polycythemia (increased hemoglobin/hematocrit)
> The correct answers are B, C, D.
Maternal factors that decrease placental blood flow result in caloric restriction and hypoxia in the fetus, leading to decreased glycogen stores (B) and increased red blood cell production (D). Smaller infants have less subcutaneous fat, so they may become hypothermic (C), not hyperthermic (A).
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Risk |
Etiology |
Symptoms |
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Hypoglycemia |
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Hypothermia |
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Polycythemia |
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*Infants with sluggish blood flow (hyperviscosity syndrome) because of a critically elevated hemoglobin/hematocrit may have respiratory distress secondary to inadequate oxygenation of end-organ tissues. |
Thureen PJ, Anderson MS, Hay WW. The small-for-gestational age infant. NeoReviews. June 2001;2(8):143-145; DOI: https://doi.org/10.1542/neo.2-6-e139.
You proceed with Thomas’s physical exam:
Vital signs: Temperature is 36.9 C (98.4 F); respiration rate is 44 breaths/minute.
General: Lying quietly in the crib, alert.
Head: Normal appearing face and skull shape; no obvious dysmorphic features. Anterior fontanelle is soft and flat; sagittal, coronal, and lambdoidal sutures are palpable.
Eyes: Red reflex present bilaterally.
Ears: Position and size of pinnae normal. No pits or tags.
Mouth: Normal palate. No teeth or tongue tie.
Cardiac: Regular rate and rhythm; no murmurs; strong femoral pulses bilaterally.
Lungs: Clear to auscultation bilaterally. No retractions, nasal flaring, or grunting.
Abdomen: Flat appearance. No masses palpable; liver edge is palpated 1 cm below right costal margin; three vessel umbilical cord.
Extremities: Moves all extremities equally; hips have full range of motion; Ortolani and Barlow examinations demonstrate no instability of the hips; no “clicks” or “clunks” heard or palpated.
Neurological: Primitive reflexes are intact. General posture of flexion with normal muscle tone (not “floppy”).
Skin: Normal vernix and lanugo.
Rooting
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Newborn turns his head toward your finger when you touch his cheek.
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Sucking
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Newborn sucks on your finger when you touch the roof of his mouth.
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Startle (Moro)
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The reflex is elicited by pulling up on the infant’s arms while in a supine position and quickly letting go of the arms causing the sensation of falling. Production of the reflex is by the suddenness of the stimuli and not the distance of the drop. There is no need to lift the infant’s head off of the bed to elicit this reflex. In response, the newborn will flex his thighs and knees, fan and then clench his fingers, with arms first thrown outward and then brought together as though embracing something.
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A video of the moro reflex can be seen here: Moro Reflex
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Palmar and Plantar Grasps
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Newborn grasps your finger when you stroke it against the palm of his hand or plantar surface of his foot.
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Asymmetrical Tonic Neck Response
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Turning the newborn’s head to one side causes gradual extension of arm toward direction of infant’s gaze with contralateral arm flexion–like a fencer.
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Stepping Response
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Newborn’s legs make a stepping motion when you hold him vertically above the table and stroke the dorsum of his foot against the table edge.
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Red Reflex Examination in Neonates
The best method for evaluating the red reflex is to turn off the room lights and stand at least a foot away from the child’s face with the illuminated ophthalmoscope; this allows the examiner to look for both red reflexes simultaneously.
Infants with more darkly pigmented skin will have a light golden colored or silver-tinged “red reflex.”
An absent red reflex (no reflection noted) may be caused by:
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A cataract
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An opacified cornea (such as in mucopolysaccharidosis)
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Inflammation of the anterior chamber
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Developmental anomalies of the eye
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Retinoblastoma, a potentially lethal malignancy (careful examination of the eye of an infant with retinoblastoma often identifies a white, irregular mass within the globe).
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Dr. Martin asks you to consider the pertinent positive and negative data and to identify the issues that most concern you as you plan to care for Thomas.
Based on what you know about the patient so far, write a one- to three-sentence summary statement to communicate your understanding of the patient to other providers.
Your response is recorded in your student case report.
Letter Count: 329/1000
Thomas is a term normocephalic SGA male newborn with normal vital signs and physical exam. He is born to a 20 year old mother with a history of tobacco and alcohol use during pregnancy and no prenatal care. Pre-delivery ultrasound and screening labs for infection are normal.
The ideal summary statement concisely highlights the most pertinent features without omitting any significant points. The summary statement above includes:
Epidemiology and risk factors: Thomas is a term neonate with in utero exposure to alcohol and tobacco. Mother is normotensive and received no prenatal care. HIV, Hepatitis B and urine drug screens are negative.
Key clinical findings about the present illness using qualifying adjectives and transformative language:
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Term
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SGA
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Normal vital signs
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Normal physical exam
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Normocephaly
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Based on your summary statement, choose the two most likely causes of Thomas’ small size from the list below. Select all that apply.
The best options are indicated below. Your selections are indicated by the shaded boxes.
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A. Chromosomal abnormality, such as trisomy 13
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B. Congenital infection
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C. Fetal alcohol syndrome
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D. Placental abnormality such as chronic placental abruption
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E. Poor maternal nutrition and weight gain
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F. Prematurity (date discrepancy)
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G. Structural abnormality in the fetus, such as renal dysplasia or a diaphragmatic hernia
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H. Tobacco use
> The correct answers are E and H.
In most cases of asymmetric IUGR, a definitive diagnosis is never identified. Rose has a known history of tobacco use during pregnancy (H), current financial difficulty and food insecurity, and potentially inadequate weight gain based on her OB intake exam (E). Tobacco exposure and poor nutrition are therefore the most likely causes of Thomas’ small size.
Thomas’ normal exam, with no dysmorphic features, also argues against structural or chromosomal abnormalities (A, G).
TORCH infections that cause IUGR generally cause symmetric growth restriction. Thomas’ normal head circumference argues against this diagnosis (B).
Although there was alcohol exposure during pregnancy, a diagnosis of Fetal Alcohol Syndrome (FAS) requires abnormal facial features as well as growth restriction and CNS abnormalities. Thomas has no features to strongly suggest FAS (C).
Placental abnormality is unlikely, based on normal ultrasound findings before delivery and normal appearance of the placenta afterward (D).
The Ballard score finds that Thomas is not premature (F).
You and Dr. Martin order a bedside blood glucose test.
Blood glucose: 50 mg/dL (2.8 mmol/L)
(Blood glucose > 40 mg/dL (2.5 mmol/L) is normal for a newborn infant in the first 4 hours of life.)
Because, as an SGA infant, Thomas is at risk for hypoglycemia, you recheck Thomas’s glucose level several more times over the first 24 hours of life. They are all above the minimal threshold for his age.
You and Dr. Martin also place orders for routine newborn medications.
Which medications are routinely given to newborns and why? Select all that apply.
The best options are indicated below. Your selections are indicated by the shaded boxes.
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A. Erythromcycin topical eye antibiotic
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B. Hepatitis B Immunoglobulin
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C. Hepatitis B vaccine
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D. Intramuscular Vitamin K
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E. Oral Vitamin K
> The correct answers are A, C, D.
Erythromycin ointment (A), Hepatitis B vaccine (C) and intramuscular vitamin K (D) are recommended for routine prophylaxis of gonococcal eye infection, Hepatitis B, and hemorrhagic disease of the newborn, respectively. Oral Vitamin K is not available in the United States and has unproven efficacy (E). Hepatitis B Immunoglobulin is not given routinely to all infants, only those that are at high risk of infection (B).
Vitamin K: Newborns routinely receive an intramuscular injection of vitamin K to prevent hemorrhagic disease of the newborn (also referred to as vitamin K deficiency bleeding, or, VKDB). The efficacy of oral Vitamin K is unknown.
Hepatitis B vaccine: For all infants with birth weight of at least 2,000 g born to HBsAg-negative mothers, the American Academy of Pediatrics (AAP) recommends the practitioner administer Hepatitis B vaccine as a universal routine prophylactic treatment within 24 hours of birth.
Erythromycin (also tetracycline or silver nitrate): One of these antibiotics is administered topically to prevent gonococcal conjunctivitis.
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DEEP DIVESample Deep DiveAmerican Academy of Pediatrics. Red Book: 2018 Report of the Committee on Infectious Diseases, 31st Edition. Kimberlin, Brady, Jackson
Hepatitis B Vaccination. Centers for Disease Control and Prevention. https://www.cdc.gov/hepatitis/hbv/hbvfaq.htm#vaccFAQ. Accessed July 14, 2021.
Elimination of Perinatal Hepatitis B: Providing the First Vaccine Dose Within 24 Hours of Birth. American Academy of Pediatrics. https://pediatrics.aappublications.org/content/140/3/e20171870. Accessed July 14, 2021.
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American Academy of Pediatrics (AAP), Center for Disease Control (CDC), and the World Health Organization (WHO) recommend intramuscular administration of Vitamin K at birth. There are no standardized oral solution preparations of Vitamin K in the United States and therefore efficacy is unknown.
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Early and classical Vitamin K deficient bleeding (VKDB) occur in 1/60-1/250 newborns, although the risk is much higher for early VKDB among those infants whose mothers used certain medications during the pregnancy.
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Late VKDB is rarer, occurring in 1/14,000- 1/25,000 infants.
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Infants who do not receive a vitamin K shot at birth are 81 times more likely to develop late VKDB than infants who do receive a vitamin K shot at birth.
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|
Type of VKDB |
When it occurs |
Characteristics |
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Early |
0-24 hours after birth |
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|
Classical |
1-7 days after birth |
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|
Late |
2-12 weeks after birth is typical, but can occur up to 6 months of age in previously healthy infants |
|
http://www.cdc.gov/ncbddd/vitamink/facts.html
Infants weighing more than 2000 grams born to mothers positive for hepatitis B surface antigen (HBsAg):
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Should receive the hepatitis B vaccine as well as hepatitis B immune globulin (HBIG) within 12 hours of delivery, regardless of antenatal anitviral treatment.
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Additionally, these infants should receive the routine series of the vaccine beginning at age 1 month.
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Vertical transmission can be prevented in 85-95% of cases using these interventions.
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At 9-18 months of age, the child should be tested for anti-HBs (antibody to Hepatitis B surface antigen) and HBsAg, and, if found to have inadequate antibody protection, should be re-immunized.
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Infants born to mothers not tested for HBsAg:
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Should receive hepatitis B vaccine within 12 hours of delivery.
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For infants with a birth weight of at least 2,000 g, administer HBIG by 7 days of age or by hospital discharge (whichever occurs first) if maternal HBsAg status is confirmed positive or remains unknown.
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For infants with a birth weight of less than 2,000 g, administer HBIG by 12 hours of birth unless maternal HBsAg status is confirmed negative by that time.
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Special considerations and guidelines for premature infants and/or infants less than 2,000 grams are provided by the American Academy of Pediatrics (AAP). For all infants with a birth weight of less than 2,000 g born to HBsAg-negative mothers, administer Hepatitis B vaccine as a universal routine prophylactic treatment at 1 month of age or at hospital discharge (whichever is first).
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Although N. gonorrhoeae causes ophthalmia neonatorum relatively infrequently in the United States, identifying and treating this infection is especially important because ophthalmia neonatorum can result in perforation of the globe of the eye and blindness.
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Chlamydia trachomatis conjunctivitis in newborns is more common than gonococcal, but chlamydia typically occurs at 7-14 days after birth, and neonatal prophylaxis does little to prevent chlamydia conjunctivitis.
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Many families have concerns about the routine medications recommended for their babies. These concerns may include the following misperceptions: that the recommended dose is too high to be given safely, that the medication may contain preservatives which are toxic, that there may be unforeseen consequences later in life, and that it is unnatural to cause a painful experience.
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Studies have shown parents may not be aware of serious and even life threatening risks of the diseases that these medications are intended to prevent. For example: Vitamin K Deficiency Bleeding can result in severe cerebral hemorrhage, Hepatitis B can lead to chronic hepatitis and liver failure, and Gonococcal eye infection can cause blindness.
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The clinician should actively but respectfully elicit parents’ concerns and fears about medications. Verbal and written information should be provided to the family that targets those concerns and fears.
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When parents feel fully informed and yet still refuse to allow recommended medications, refusal should be documented on a medication refusal form signed by the parent.
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How do you interpret this infant’s total bilirubin level from the Bhutani nomogram?
The suggested answer is shown below.
Letter Count: 109/1000
The total bilirubin of 17.0 mg/dL is in the high-intermediate risk zone.
Ardell S, Offringa M, Ovelman C, Soll R. Prophylactic vitamin K for the prevention of vitamin K deficiency bleeding in preterm neonates. Cochrane Database Syst Rev. 2018;2(2):CD008342. Published 2018 Feb 5. doi:10.1002/14651858.CD008342.pub2.
Conjunctivitis (Pink Eye) in Newborns. Centers for Disease Control and Prevention. https://www.cdc.gov/conjunctivitis/newborns.html. Accessed July 14, 2021.
Kapoor VS, Evans JR, Vedula SS. Interventions for preventing ophthalmia neonatorum. Cochrane Database Syst Rev. 2020;9:CD001862. Published 2020 Sep 21. doi:10.1002/14651858.CD001862.pub4.
Kimberlin D, Barnett E, Lynfield R, Sawyer M. Red Book: 2021 Report of the Committee on Infectious Diseases. 32nd ed. AAP; 2021.
Prevention Through Vaccination. Centers for Disease Control and Prevention. https://www.cdc.gov/hepatitis/hbv/bfaq.htm?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fvaccines%2Fvpd%2Fhepb%2Fpublic%2Findex.html#prevention. Accessed July 14, 2021.
Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). USDA Food and Nutrition Service. https://www.fns.usda.gov/wic. Accessed July 14, 2021.
What is Vitamin K Deficiency Bleeding? Centers for Disease Control and Prevention. https://www.cdc.gov/ncbddd/vitamink/facts.html. Accessed July 14, 2021.
Over the next 24 hours, Thomas continues to do well. He has maintained his bedside blood glucose levels above 50 mg/dL (2.8 mmol/L) and has also maintained a normal body temperature in an open crib.
You recall that Thomas and his mother are at risk in that Rose is financially insecure, unemployed, medically uninsured and estranged from her family.
You discuss your concerns with Dr. Martin and decide to consult social services.
Social workers are a rich resource to many families. This is particularly true for new adolescent parents who may be of low socioeconomic status. Hospital social workers can help connect new parents to community resources, including home nursing visits, support groups for new parents, and the Women, Infants and Children program. Link to https://www.fns.usda.gov/wic/women-infants-and-children-wic for more information on this nationwide program.
Other current community resources in your area also may be available, such as:
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Early childhood development classes
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Parenting classes
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Counseling for tobacco cessation and alcohol abuse
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High school education completion
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Crisis nurseries (short-term emergency daycare)
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Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). USDA. https://www.fns.usda.gov/wic. Accessed July 14, 2021.
On rounds on the day of discharge, Rose’s nurse reports that despite his small size Thomas is breastfeeding well and maintaining his body temperature.
With Dr. Martin you explain that all of Thomas’ routine newborn screening tests have been normal, including transcutaneous bilirubin measurement, hearing screening, and critical congenital heart disease screening. You also explain that a blood sample has been sent to the state health department lab to test for inborn errors of metabolism.
Rose then asks how she will know if her baby is ill and when she should bring him in for medical care.
Dr. Martin reviews routine newborn discharge instruction with Rose.
Discharge teaching should include the following:
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Reasons to seek immediate medical care, including fever, signs of poor feeding, worsening jaundice
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Expectations for normal feeding, stooling, urine output
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Safety issues (including placing the newborn on his back to sleep, proper infant auto restraint, avoiding cigarette smoke exposure.)
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Plan for physician outpatient followup in 48-72 hours
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Social Services follow up plan
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24 hour emergency contact information
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Adjusting to having a new infant can be challenging. For more detailed guidance for parents of newborns, link to the following Bright Futures Parent Handout – often provided at the first outpatient visit after newborn discharge.
https://brightfutures.aap.org/materials-and-tools/guidelines-and-pocket-guide/Pages/default.aspx
Bright Futures Guidelines and Pocket Guide. American Academy of Pediatrics. https://brightfutures.aap.org/materials-and-tools/guidelines-and-pocket-guide/Pages/default.aspx. Accessed February 17, 2021.
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This case has been reviewed and updated by the Aquifer Pediatrics editorial course board.
Upon completion of the case, the student should be able to:
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List elements of the maternal prenatal history that are relevant to the care of the newborn.
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Discuss the potential effect of maternal use of tobacco, alcohol, marijuana, and other drugs on the fetus.
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Discuss the epidemiology and approach to prevention of neonatal Group B Streptococcal sepsis.
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Summarize clinical findings in the infant that are associated with intrauterine (TORCH) infections.
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Outline initial steps in neonatal resuscitation.
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Describe the components of the APGAR score and explain its significance.
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Describe and perform components of a complete physical examination of a newborn infant, including primitive reflexes and red reflex.
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Discuss the use of the Ballard Gestational Age Assessment Tool in the evaluation of the newborn infant.
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Define the terms small for gestational age (SGA) and intrauterine growth restriction (IUGR). Differentiate symmetric and asymmetric IUGR.
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Outline a differential diagnosis for an infant noted to be small for gestational age.
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List potential complications in infants who are born small for gestational age.
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List medications and immunizations routinely given in the immediate newborn period and explain the rationale for their use.
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Summarize elements of routine discharge teaching for parents of newborns.
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Discuss the potential role of social work in facilitating the transition from newborn nursery to home.
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Identify signs of respiratory distress in a newborn.
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Describe signs of respiratory distress in newborns and infants.
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Describe types and prevention of hemorrhagic diseases of the newborn.
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Describe guidelines for the prevention of vertical transmission of hepatitis B infection.
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A 33-year-old G1P0 female with a history of medically controlled seizures gives birth vaginally to a boy with IUGR at 38 weeks’ gestation. The newborn is noted to have dysmorphic cranial features and his head circumference is 28.5 cm (< 5th percentile). What is another associated abnormality you might expect to see in this newborn?
- A. Absent red reflex
- B. Cardiac defects
- C. Chorioretinitis
- D.Hepatosplenomegaly
- E. Tremors
A 19-year-old female in her 38th week of pregnancy goes into active labor. Within the first few days following birth, her baby is noted to have a high-pitched cry, tremulousness, hypertonicity, and feeding difficulties. The baby is otherwise developmentally normal and the remainder of the physical exam also is normal. Which drug was likely abused by mother during her pregnancy?
- A. Alcohol
- B. Cocaine
- C. Heroin
- D. Marijuana
- E. Tobacco
A 19-year-old G1P0 female presents in labor to the ED at 38 gestational weeks. When taking the history, it is discovered that she has had irregular prenatal care, drank a couple of beers every weekend, and smoked 4 cigarettes a day during her pregnancy. She delivers a baby boy who is small for gestational age. On exam, it is noted the baby has microcephaly, a smooth philtrum, and a thin upper lip. What do you suspect caused these features in the baby?
- A. Alcohol exposure
- B. Congenital CMV infection
- C. Congenital rubella
- D. Tobacco exposure
- E. Vertically transmitted HIV
Thank you for completing Pediatrics 01: Newborn male infant evaluation and care.
Aquifer Case Study – Developmental Evaluation and Screening Pediatrics 01: Newborn male infant evaluation and care
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Answer Comment
> The correct answers are A, B, D.
Vasoconstriction decreases the flow of blood to the placenta, thereby reducing the caloric intake of the fetus (A). There is no known “safe” amount of alcohol ingestion to avoid fetal alcohol syndrome, so even one beer per week puts the infant nt at risk (B). There are no characteristic facial abnormalities associated with maternal use of marijuana (C). Tobacco use, like cocaine, decreases blood flow to the placenta (D).
Teratogens
A teratogen is an agent, or factor, that produces a malformation in the developing embryo. The agent may come from the external environment or may be a metabolite produced in excess by the mother or the fetus. Such agents include:
Drugs
Chemicals
Infections
Radiation
The effects of teratogens cannot be inherited.
For information on specific teratogens, see these fact sheets from the Organization of Teratology Information Services.