Examination of the Neonate - A Quick Review

The aim is to screen for abnormality, and to see if the mother has any questions or difficulties.
The following is a recommended routine before the baby leaves hospital—or during the 1st week of life for home deliveries.

Before the examination find out :

• If the birth weight was normal?
• Was the birth and pregnancy normal? 
• Is mother Rh–ve? 

For Examination 

• Find a quiet, warm, well-lit room. 
• Enlist the mother’s help. 
• Explain your aims. 
• Does she look angry or depressed? 
• Listen if she talks. 

Examine systematically, from head-to-toe. 

• Wash your hands meticulously.
• Note observations (eg T°; rectal is more reliable than tympanic). 

Head:

• Circumference (50th centile=35cm, ), 
• shape (odd shapes from a difficult labour soon resolve), 
• fontanelles (tense if crying or intracranial pressure increased; sunken if dehydrated). 

Eyes:

• Red reflex (absent in cataract & retinoblastoma);
• corneal opacities; 
• conjunctivitis. 

Ears:

• Shape; 
• position. Are they low set (ie below eyes)? 

Nose: 

• The tip of the nose, when pressed, shows jaundice in white babies.
• Breathing out of the nose (shut the mouth) tests for choanal atresia
• Ensure oto-acoustic screening is done 

Complexion: 

• Cyanosed, pale, jaundiced, or ruddy (polycythaemia)?

Arterial Puncture In Children

Arterial puncture is done to obtain blood from an artery. The procedure is summarized as follows:

Indications

• Blood gas determination
• Arterial blood sampling to determine blood chemistries.

Contraindications

• Poor collateral circulation.
• Skin infection near planned puncture site.
• Bleeding disorders, including thrombocytopenia, systemic fibrinolytic states and thrombolytic therapy.

Materials Needed for the procedure
Blood gas sampling kit,or 3-5 ml syringe, 1 ml heparin (1000 units/ml), alcohol or povidone-iodine swabs, and a cup of ice, 23-25 gauge needle (20-22 gauge for femoral artery), sterile gloves, sterile dressing, adhesive tape.

Procedure

1. Use a heparinized syringe for blood gas and a non heparinized syrine for chemistry determinations. Obtain a blood gas kit.

2. The radial artery is the most frequently used site for arterial blood gas sampling.

3. It may be helpful to secure the dorsum of the wrist and place gauze behind the wrist to hyperextend the joint. Elevating the wrist will often bring the radial and brachial arteries closer to the surface.

4. Prepare the area with either povidone-iodine or an alcohol swab. Hold the syringe like a pencil with the needle bevel up and enter the skin at a 60 to 90 degree angle. Maintain slight negative pressure on the syringe.

5. Aspirate very slowly. A good arterial blood sample requires only minimal back pressure. If the vessel cannot be located , redirect the needle without taking it out
of the skin.

6. Obtain about 2 -3 ml of blood.

Introduction To Mental Retardation

Definition
Mental retardation is defined as significantly subnormal intellectual functioning for a child’s developmental stage, with problems in self care, home living, communication and social interaction.

It is defined statistically as cognitive performance that is 2SD below the mean of the general population as measures on a standard intelligence testing.

Levels Of Mental Retardation

Mild: Have a Stanford-Binet IQ score of 67 -52 and a WISC-III IQ score of 70 – 55 and are educable.

Moderate: Have a Stanford-Binet IQ score of 51 -36 and a WISC-III IQ score of 54 – 40 and are trainable.

Severe: Have a Stanford-Binet IQ score of 35 -20 and a WISC-III IQ score of 39 – 25 .

Profound: Have a Stanford-Binet IQ score of <20 and a WISC-III IQ score of <24.

Caution must be exercised in interpretation , however because these categories do not reflect the actual functioning level of the tested individual. Children who perform in the severe or profound ranges of MR also are capable of responding to some educational intervention.

Etiology
The etiology of the CNS insult resulting in MR may involve genetic disorders, teratogenic influences, perinatal insults, acquired childhood diseases and environmental and social factors. Mild MR correlates with socioeconomic status although profound MR does not.

A Child Presenting With Diarrhea- Important Questions In History

Diarrhea is a common presenting complaint in pediatric practice and following questions are important to be asked from the parent as these help in determining the condition of the child and the cause of diarrhea.

Immediate Questions

1. How old is patient?
In a young infant the intestinal mucosa tends to be more permeable to water than in an older child or adult. This can result in greater net fluid and electrolyte losses. Diarrhea in the first few months of life requires more immediate attention.

2.What are the vital signs?
Tachycardia suggests volume depletion. Hypotension suggests hypovolemic or septic shock. fever implies an infectious etiology. Diarrhea with associated tachycardia, hypotension or fever should be evaluated immediately.

3. Is diarrhea grossly bloody?
Bloody diarrhea is caused by invasive bacterial infections, ischemic bowel or infarction, allergic phenomenon or inflammatory bowel disease. It requires more active and immediate intervention.

4. Is this acute or chronic problem?
Acute diarrhea: Usually a self limited disease, which can often be treated symptomatically. The most common cause is infection. Other common causes include drugs e.g antibiotics as well as excessive intake of high carbohydrate fluids or non absorbable fillers (e.g sorbitol).

Chronic diarrhea: defined as diarrhea that lasts longer than 4 weeks. Common causes include chronic non specific diarrhea (toddler’s diarrhea), lactose intolerance, milk-protein allergy, encopresis, irritable bowel syndrome, various infections, drugs and IBD. It can also present as an acute exacerbation.

5. Are there risk factors that suggest a specific cause?
Risk factors include day care, winter season, ill contacts, drugs, travel, animal exposure, constipation, excessive juice intake, poorly perpared or stored poultry or salads, untreated water sources, prior abdominal surgery, immunodeficiency and prematurity.

List Of Anatomic And Mucociliary Defects That Result In Recurrent Or Opportunistic Infections

The major components of host defense include an anatomic barrier, innate immunity and adaptive immunity. Integrity of the anatomic-mucociliary barrier at the interface between the body and its environment is essential for protection against infection. 

Here is a list of anatomic and mucociliary defects that can result in recurrent or opportunistic infections.

Anatomic defects in upper airways

• Aspiration syndromes ( gastroesophageal reflux, ineffective cough, foreign body )
• Cleft palate, eustachian tube dysfunction
• Adenoidal hypertrophy
• Nasal polyps
• Obstruction of paranasal sinus discharge
• Post-traumatic or congenital sinus tracts ( CSF rhinorrhea )

Anatomic defects in the tracheo-bronchial tree

• Tracheo-esophageal fistula, bronchobiliary fistula
• Pulmonary sequestration, bronchogenic cysts, vascular ring
• Tumor, foreign body or enlarged nodes

Physiologic defects in upper and lower airways

• Primary ciliary dyskinesia syndrome
• Cystic fibrosis, Bronchopulmonary dysplasia
• Bronchiectasis
• Allergic diseases (allergic rhinitis, asthma)
• Chronic cigarette smoke exposure

Initial Laboratory Evaluation Of Respiratory Distress In Newborn

A newborn baby may present to the pediatric nursery with respiratory distress that is manifested by tachypnea, intercostal retractions, reduced air exchange, cyanosis, expiratory grunting and nasal flaring. These are all non specific responses to an underlying serious illness. The following tests are needed in the initial evaluation:

1. Chest Radiograph:
To determine reticular granular pattern of Respiratory distress syndrome; to determine presence of pneumothorax, cardiomegaly and any life threatening congenital anomalies.

2. Arterial Blood Gases:
To determine the severity of respiratory compromise, hypoxemia and hypercapnia and type of acidosis; the severity helps in the treatment strategy.

3. Complete Blood Count:
Hemoglobin and hematocrit to determine anemia and polycythemia; white blood cell count to determine neutropenia and underlying sepsis; platelet count and blood smear to rule out DIC.

4. Blood Culture:
To recover the potential pathogen and also helpful to start the specific treatment against the involved organism.

5. Blood Glucose:
To determine presence of hypoglycemia, which may produce or occur simultaneously with respiratory distress and if present should be treated immediately. Also sometimes patient has stress hyperglycemia .