Babies make us nervous. It’s a simple fact. And it’s nothing to be embarrassed about. Assessment and evaluation of the newborn infant is the patient assessment equivalent of a high-wire act. The stakes are high and it’s easy to make a mistake.
Obstetricians and pediatricians spend years learning how to properly assess the neonatal patient. Even with their training and experience, proper evaluation of a newborn remains remarkably difficult. They are not simple little adults.They are a unique and challenging patient population.
Here are some tips and thoughts to consider the next time you are called to assess a newborn infant in the prehospital environment. Hopefully these clinical pearls will help make the next newborn evaluation a little less intimidating.
1) Take a good history.
When asking about the newborns brief medical history, there are several important points to consider. Ask about the baby’s birth weight and consider weight gain or loss since discharge from the hospital. If the newborn is failing to gain weight in the out-of-hospital environment, that is cause for concern.
Also ask about the length of the hospital stay prior to discharge home. If a newborn baby was kept in the hospital for longer than 48 hours after delivery, it is likely that the child’s obstetrician had some concerns regarding the baby’s health. Also ask if the newborn received any specific diagnosis prior to being discharged home.
2) Consider the events of pregnancy.
Don’t just ask if the delivery went well. Specifically ask about meconium staining, nuchal cord presentations, delivery style (vaginal vs. Cesarean), the APGAR score at birth (if known), and if the doctor had any concerns about the newborn post-delivery.
3) Never trust a baby.
Listen to the parents closely and believe what they describe to you. When a pink, healthy normal newborn is resting comfortably in its mothers arms, it’s easy to dismiss the parents observations as overly-exaggerated parental anxiety. (We are especially good at doing this with first-time parents.) There is a medical term for newborn behaviors that scare the tar out of their parents. They are called ALTE’s (Apparent Life Threatening Events.)
Pay close attention if a parent saw their child do something that concerned them enough to call 911. Our most concerning ALTE’s are choking, gagging and a momentary belief that the child was dead. (Change in interactiveness and responsiveness.) Newborn’s often present with extraordinarily subtle presentations. Don’t trust that normal looking, cooing baby. Trust the parent.
4) Consider sepsis.
Early sepsis can be challenging to recognize in an adult patient. It is even more challenging in the newborn. Septic neonates can be warm or cold. High fevers (Above 101) are rare in septic babies.
5) Know the physical assessment basics.
Newborn vital signs can be cryptic and confusing. For years we felt blood pressure assessments were worthless in this patient populating. We were wrong. Take a full set of vitals and remember the 60-60-20 rule. A systolic blood pressure below 60 is a concern. A respiratory rate above 60 is also abnormal. Any episode of apnea that lasts greater than 20 seconds is cause for evaluation at the emergency room. Don’t wait for an appointment with the pediatrician in the morning. Transport the baby and observe.
Also give the kid a through head-to-toe assessment. (Or toe-to-head). Assess the fontanelle’s with the baby’s body tilted at 45 degrees. You cannot properly assess if a fontanelle is bulging, sunken or normal with a baby lying flat or sitting fully upright. Don’t forget those lung sounds. Spontaneous pneumothorax is not uncommon in newborns.
6) Consider seizures.
Seizures in neonates can be ridiculously subtle. Babies brains aren’t mature enough to develop the rhythmic motions we typically associate with seizures. Behaviors like lip smacking, brief apnea, continual blinking and random uncoordinated movement can all be signs of seizure. Don’t blow off a babies random movements or behaviors simply because they don’t look like typical adult seizures.
The “big get it” with pediatric assessment is to pay attention. Pay attention to the baby, pay attention to the parent and pay attention to your instincts.