Newborn Care

• Vitamin K IM
• Prophylactic eye erythromycin
• Umbilical cord care
• Hearing test
• Newborn screening tests

Common Injuries During Deliveries

Injury	Specifics	Outcome
Skull fractures	In utero from pressure against bones or forceps; linear: most common	•    Linear: no symptoms and no treatment needed •    Depressed: elevate to prevent cortical injury
Brachial palsy	Erb-Duchenne: C5–C6; cannot abduct shoulder; externally rotate and supinate forearm; Klumpke: C7–C8 ± T1; paralyzed hand ± Horner syndrome	Most with full recovery (months); depends on whether nerve was injured or lacerated; Rx: proper positioning and partial immobilization; massage and range of motion exercises; if no recovery in 3–6 mo, then neuroplasty
Clavicular fracture	Especially with shoulder dystocia in vertex position and arm extension in breech	Palpable callus within a week; Rx: with immobilization of arm and shoulder
Facial nerve palsy	Entire side of face with forehead; forceps delivery or in utero pressure over facial nerve	Improvement over weeks (as long as fibers were not torn); need eye care; neuroplasty if no improvement (torn fibers)
Caput succedaneum	Diffuse edematous swelling of soft tissues of scalp; crosses suture lines	Disappears in first few days; may lead to molding for weeks
Cephalohematoma	Subperiosteal hemorrhage: does not cross suture lines	May have underlying linear fracture; resolve in 2 wk to 3 mo; may calcify; jaundice

Note:

• caput succedaneum (caput = cap over; succed = continuous); caphalohematoma = bleeding subperiosteum (stay in bone border)
• most trauma need only follow up

Physical Examination—Common Findings (see remaining chapter for other specific findings)

Finding/Diagnosis	Description/Comments
Skin
Cutis marmorata (pix)	Lacy, reticulated vascular pattern over most of body when baby is cooled; improves over first month; abnormal if persists
Milia	Firm, white papules; inclusion cyst; on palate midline: Epstein pearls; spontaneous resolution
Salmon patch (nevus simplex) (pix)	Pale, pink vascular macules; found in nuchal area, glabella, eyelids; usually disappears
Mongolian spots	Blue to slate-gray macules; seen on presacral, back, posterior thighs; > in nonwhite infants; arrested melanocytes; usually fade over first few years; differential: child abuse
Erythema toxicum neonatorum (pix)	Firm, yellow-white papules/pustules with erythematous base; peaks on second day of life; contain eosinophils; benign
Hemangioma	Superficial: bright red, protuberant, sharply demarcated; most often appear in first 2 months; most on face, scalp, back, anterior chest; rapid expansion, then stationary, then involution (most by 5–9 years of age); deeper: bluish hue, firm, cystic, less likely to regress; Rx: (steroids, pulsed laser) only if large and interfering with function
Neonatal acne	Erythematous papules on face; high maternal androgens; no treatment
Head
Preauricular tags/pits (pix)	Look for hearing loss and genitourinary anomalies.
Coloboma of iris (pix)	Cleft at “six o’clock” position; most with other eye abnormalities; CHARGE association
Aniridia (pix)	Hypoplasia of iris; defect may go through to retina; association with Wilms tumor
Extremities
Syndactyly	Fusion of fingers or toes. Get x-ray first for surgical planning.
Polydactyly Finger tag	>5 number of fingers or toes. No treatment needed if good blood supply. Thin stalk, poor circulation; tie off at base → autoamputation

NEWBORN SCREENING

Newborn Screening

• Every newborn before discharge or day 4 of life
• More reliable if done after 48 hours of oral feedings (substrates for metabolic diseases)
• Total diseases screened are determined by individual Some examples:
  − Phenylketonuria
  − Galactosemia
  − Hypothyroidism
  − Hb SS
  − Cystic fibrosis
  − Hb C
  − Tyrosinemia
  − 21-hydroxylase deficiency

Comparison of Two Newborn Screening Diseases*

	Phenylketonuria (PKU)	Classic Galactosemia
Defect	Phenylalanine hydroxylase; accumulation of PHE in body fluids and CNS	Gal-1-P uridylyltransferase deficiency; accumulation of gal-1-P with injury to kidney, liver, and brain
Presentation	Mental retardation, vomiting, growth retardation, purposeless movements, athetosis, seizures	Jaundice (often direct), hepatomegaly, vomiting, hypoglycemia, cataracts, seizures, poor feeding, poor weight gain, mental retardation
Associations	Fair hair, fair skin, blue eyes, tooth abnormalities, microcephaly	Predisposition to E. coli sepsis; developmental delay, speech disorders, learning disabilities
Other comments	Normal at birth; gradual MR over first few months	May begin prenatally— transplacental galactose from mother
Treatment	Low PHE diet for life	No lactose—reverses growth failure, kidney and liver abnormalities and cataracts, but not neurodevelopmental problems

FETAL GROWTH AND MATURITY

Intrauterine Growth Restriction (IUGR)

Type	Reason	Main Etiologies	Complications
Symmetric	Early, in utero insult that affects growth of most organs	Genetic syndromes, chromosomal abnormalities, congenital infections, teratogens, toxins	Etiology dependent; delivery of oxygen and nutrients to vital organs usually normal
Asymmetric (head sparing)	Relatively late onset after fetal organ development; abnormal delivery of nutritional substances and oxygen to the fetus	Uteroplacental insufficiency secondary to maternal diseases (malnutrition, cardiac, renal, anemia) and/or placental dysfunction (hypertension, autoimmune disease, abruption)	Neurologic (asphyxia) if significant decreased delivery of oxygen to brain

Gestational Age and Size at Birth

Preterm	Large for Gestational Age (LGA)—Fetal Macrosomia	Post-term
•      Premature—liveborn infants delivered prior to 37 weeks as measured from the first day of the last menstrual period •      Low birth weight— birthweight ≤2,500 grams. This may be due to prematurity, IUGR, or both	•      Birth weight >4,500 grams at term •      Predisposing factors: obesity, diabetes •      Higher incidence of birth injuries and congenital anomalies	•      Infants born after 42 weeks’ gestation from last menstrual period •      When delivery is delayed ≥3 weeks past term, significant increase in mortality. •      Characteristics −   Increased birth weight −   Absence of lanugo −   Decreased/absent vernix −   Desquamating, pale, loose skin −   Abundant hair, long nails −   If placental insufficiency, may be meconium staining