Newborn

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Newborn
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Terms

• Acrocyanosis
• Appropriate for gestational age
• Caput succedaneum
• Cephalhematoma
• Circumcision
• Cold stress
• Conduction

3
Terms

• Convection
• Cryptorchidism
• Downs syndrome
• Epispadias
• Epsteins pearls
• Erythema toxicum neonatorum
• Evaportation

4
Terms

• Foremilk
• Gynecomastia
• Hindmilk
• Hallux varus
• Hydrocele
• Hyperbilirubinemia
• Hypospadius
• Kernicterus

5
Terms

• Lanugo
• Large for gestational age
• Meconium
• Milia
• Molding
• Mongolian spots
• Myelomeningocele
• Nevus flammeus

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Terms

• Radiation
• Theromoregulation
• Psuedomenstration

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Acrocyanosis

• Although some newborn infants are uniformly pink
  in color, many have some degree of
  "acrocyanosis." This means that the central
  portion (chest) is pink, but the extremities,
  particularly the hands and feet, are blue or
  purple.

• Acrocyanosis is normal for a newborn during the
  first few hours, disappearing over the next day.
  It is due to relatively sluggish circulation of
  blood through the peripheral structures, related
  to immaturity or inexperience of the newborn
  blood flow regulatory systems.

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Acrocyanosis

9
Appropriate for Gestational Age

• Assigning size is a way to measure and monitor
  the growth of the infant throughout the pregnancy
  as well as at the time of birth.

• The measurement is calculated based on the
  estimated gestational age (how many weeks the
  mother was pregnant) in comparison to what is
  considered normal height, weight, head size, and
  developmental level for a child of the same
  gestational age and gender.

10
Appropriate for Gestational Age

• Graphs are available showing the upper and lower
  normal limits for different gestational ages from
  the mid-20s through 42 weeks of gestation. See
  pg 1561, Figure 54-20

• An appropriate for gestational age full-term
  infant is heavier than 2500 grams (about 5.5
  lbs.) and lighter than about 4000 grams (about
  8.75 lbs.).

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Caput Succedaneum

• Caput succedaneum is swelling of the scalp in a
  newborn. It is most often brought on by pressure
  from the uterus or vaginal wall during a
  head-first (vertex) delivery.

• Symptoms
• Soft, puffy swelling of part of the scalp in a
  newborn infant
• Swelling may or may not have some degree of
  discoloration or bruising
• Swelling may extend over the midline of the scalp
  
• Most often seen on the portion of the head which
  presented first
• May be associated with increased molding of the
  head

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Caput Succedaneum

• TreatmentNo treatment is necessary, and it
  usually heals spontaneously within a few days.
• CausesA caput succedaneum is more likely to form
  during a prolonged or difficult delivery. This is
  especially true after the membranes have
  ruptured, because the amniotic sac is no longer
  providing a protective cushion for the baby's
  head. Vacuum extraction can also increase the
  chances of a caput succedaneum.

• A caput succedaneum is sometimes identified by
  prenatal ultrasound even before labor or delivery
  begins. It has been found as early as 31 weeks of
  pregnancy. More often than not, this is
  associated with either premature rupture of the
  membranes or too little amniotic fluid
  (oligohydramnios). All other things being equal,
  the longer the membranes are intact, the less
  likely it is that a caput will form. Pg 1554

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Cephalhematoma

• swelling caused by subcutaneous bleeding and
  accumulation of blood. It may begin to form in
  the scalp of a fetus during labor and enlarge
  slowly in the first few days after birth. It is
  usually a result of trauma, often caused by
  forceps.

• Large cephalhematomas may become infected,
  require surgical drainage, and take several
  months to resolve. Also called cephalhaematoma.

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Caput Succedaneum vs Cephalhematoma

Important! Know how to recognize the difference
between the two.
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Circumcision
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Breathing

• Four Factors
• Physical
• Thermal

• Chemical
• Sensory

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Immediate Needs

• Airway
• Newborns are usually nose breathers-if nose is
  stuffy-will open mouth to breathe
• Suctioning usually done by bulb syringe at birth
• Airway must be kept clear

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Needs

• Breathing
• Pressure factors, chilling, noise light,
  environmental stimuli encourage initial newborn
  breath
• Breathing movements began in uterus at about 11
  weeks

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Breathing

• At term 20 ml of fluid/kg in lungs
• Air is substituted for the fluid with the first
  breath
• Fluid moves into chest wall as trunk emerges at
  birth
• As more air enters the lungs, more fluid moves
  interstitial

20
Breathing

• Fluid is absorbed during the first day after
  birth
• May hear wet sounds in the lung
• After birth or soon after birth
• Wet sounds are more prominent on c-section infants

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Chemical factors

• Arterial oxygen decreases--
• Carbon dioxide increases---
• Respiratory center is stimulated-----
• Infant takes first breath
• Usually within 1 minute of birth

22
Thermal factors

• Change in temperature from uterus to environment
  is 20 degrees
• Cool environment is a stimulus to breathe

23
Sensory factors

• Auditory, visual, touch stimuli are increased
  when born
• All the stimuli are new and increase the stimuli
  to breathe

24
Circulation changes

• Pulmonary blood vessels
• Begin with the first breath
• Lungs inflate and reduces pulmonary vasculature
  resistance
• Reduces pulmonary artery pressure
• Dilation occurs and allows blood to flow for O2
  in the lungs

25
Circulation

• Pressure in the right atrium
• Decreases-- allowing increased pulmonary return
  to the left side of the heart
• Increased pressure in the left atrium promotes
  closure of the foramen ovale

26
Circulation

• Ductus arteriosus
• Blood is shunted from the pulmonary artery to the
  descending aorta before birth
• Closes soon after birth and permanently closed
  within 3-4 months of life

27
Circulation

• Foramen ovale
• Before birth the opening allows blood to flow
  directly to left atrium
• Functionally closes at birth and permanently
  closes in a few months

28
Circulation

• Ductus venosus
• Connection of umbilical vein and inferior vena is
  present before birth at birth the umbilical
  cord is cut
• With blood loss from the umbilical vein, the
  connection closes and becomes ligamentum
  arteriosum

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Warmth

• Thermoregulation must begin at birth-balance of
  heat loss and heat production
• When cold, the infant needs to raise the
  metabolism to increase the heat
• Infants do not shiver when cold
• Infant will break down brown fat on body to
  increase metabolism

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Warmth

• Brown at is on back of neck, between scapula,
  around kidneys and around adrenals
• Brown fat is deposited at 26-30 weeks
• Increased metaboism requires more oxygen
• Infant may present with hypoxia

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Heat retention

• Infant normaly lays in fetal or flexed position
  to maintain heat
• Vasoconstriction allows head retention

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Heat loss

• Newborn heat moves from internal to periphery to
  external environment
• Excess heat loss is cold stress
• Infant becomes cold and begins to break down
  brown fat
• To increase metabolism
• Increased metabolism requires more oxygenhypoxia
  can develop

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Heat loss

• Prolonged cold stress reduces surfactant
  production which increases lung resistance and
  respiratory distress
• When glucose stores depleted Hypoglycema
  develops from brown fat breakdown, fatty acids
  are releasedmetabolic acidosis

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Heat loss

• Excess fatty acid release causes less bilirubin
  to be transported to the liver and jaundice may
  develop

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Heat loss methods

• Conduction direct contact with a cool object
• Hands, stethoscope
• Convection movements of air
• Air conditioning, open door
• Evaporation water is changed into vapor
• Drying of wet infant

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Heat loss methods

• Radiation
• cooler objects near sides of crib walls of
  isolette
• Reduced by keeping cribs away from drafts

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APGAR
2 1 0
Heart rate (Pulse) over 100 Below 100 absent
Inspiratory effort (Rate and effort) good cry Slow absent
Muscle tone (Activity) active Some flexion flaccid
Color (Appearance) Completely pink body pink extremities blue pale blue-gray
Reflex irritability (Grimace) vigorous cry, pulls away, sneezes Grimace w/stimulation None
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Newborn Test

• The newborn is commonly assessed with the APGAR
  score, a quick test performed at 1 and 5 minutes
  after birth to determine the physical condition
  of the newborn. The five categories assessed are
  heart rate, respiratory effort, muscle tone,
  reflex irritability, and color. Each of these
  categories is scored 0, 1, or 2, depending on the
  observed condition of the newborn.

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Resucitation

• Usually suctioned with bulb syringe after birth
• May need wall suction/ suction trap for excess
  mucus
• May need oxygen
• RN or Physican will apply O2, suction as needed

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Thermal environment

• Infant temperature should be 97-99 f
• Warmth is important
• Infant is placed under warmer after birth and in
  isolette in the nursery until infant can maintain
  own heat

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Identification/ bonding

• Identification identification bands on one leg,
  one hand, foot prints (bold numbers on the band)
• May breastfeed in delivery room
• Parents may hold infant
• Infant is usually very awake during the first
  hour after birth

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Prophylactic care

• Vitamin k given in delivery room in left vastus
  lateralis IM
• Infant does not make vitamin K until food is
  present in intestine
• Usually about 8 days of age vitamin K is produced

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Prophylactic care

• Erythromycin ointment placed in both eyes in
  delivery room to prevent inflammation/ eye
  problems from gonorrhea or chlamydia

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Umbilical cord

• Cord is checked for 3 vessels
• Cord is clamped until cord is dry
• Cord is usually short and cleaned with alcohol
• Cord clamp is removed when the cord is dry

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Umbilical cord

• Cord may be kept long for Rh negative mother and
  Rh positive infant cord may be kept damp with
  normal saline dressings
• Some hospitals clean the cord with triple
  dye-purple color

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Physical characteristics

• Weight 2500-4000g 5 lb 8 oz-8lb and 13 oz
• Neonates loose 10 of birth weight and will gain
  weight back by 10-14 days of life
• Average infant 7 lbs 8 ounces and 20 inches long

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Height

• 45-55 cm or range 19-21 inches
• Head averages 13-14 inches and chest 12-13 inches
• Resp rate 30-60/min
• Heart rate 120-160/min
• Axillary temp 97.6--98.6 f
• (Hospitals 97-99f)

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Skin

• Generally pink
• Acrocyanosis of hands and feet
• Lanugo on shoulders or forehead
• Vernix caseosa-in creases
• Physiologic jaundice after 24 hours
• Pathologic jaundice before 24 hours

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Head

• Circumference 13-14 inches
• Molding
• Anterior fontanel-junction of saggital and
  coronal sutures
• Diamond shaped 5 cm in size
• Closes by 18 months
• Posterior fontanel-at junction of lambdoidal and
  saggital sutures-closes by 2 monthsmay not be
  palpable

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Eyes

• Sclera white and clear
• Pupils react to light
• Do not accommodate
• Strabismus (cross eyed) common for 3-4 months
• Dolls eyes for 10 days common
• Color slate blue, grey, brown
• Color established in 3 months

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Ears

• Ears symmetrical in shape and size
• Top of ear aligns with inner and outer canthi of
  eyes
• Hearing test should be done for all infants
• Loud noise will create the startle reflex

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Ear Alignment

• Top of ear aligns with inner and outer canthi of
  eyes

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Neck/ Chest

• Neck is symmetrical without webbing neck short,
  thick, several folds, flexible
• Allows free movement of the head from side to
  side

• Chest circumference 12-13 inches measured at
  the nipple line symmetrical

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Abdomen

• Symmetrical/round
• Moves with breathing
• Bowel sounds audible
• Umbilical cord clamped-whitish blue color, 3
  vessels
• Cord dries and falls of about 2 weeks after birth

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Meconium

• Meconium passed within 24 hours

    
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Genitalia

• Mature for gestational age
• Check for descent of testicles
• Scrotum covered with rugae
• Voiding should occur within 24 hours
• Rust stained urine (uric acid crystals) may occur
  
• Vernix in folds

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Back

• Spine should be straight and easily flexed
• No limitation of movement or abnormality of
  spinal column
• No bumps or tufts of hair seen

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Extremities

• Check the number of toes and fingers
• Absence of digits
• Excess digits
• Syndactly-webbing of fingers
• Symmetrical
• Range of motion
• Creases on anterior 2/3 of sole of foot

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Variations of newborn

• Vernix caseosa
• yellowish white cream substance on body
• Jaundice after 24 hours-yellow color on chest,
  face, sclera

• Acrocyanosis
• bluish color of hands/ feet
• Ecchymosis
• bruising
• Petechiae
• small spots of bruising

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Acrocyanosis

• Blue discoloration of hands and feet after birth
  and for about 24 hours but can last as long as
  7-10 days

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Variations

• Milia Tiny white papules (plugged sebaceous
  glands) located over nose, cheek, and chin.

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Variations

• Newborn rash/ erythema toxicum neonatorum
• hivelike rash that disappears without treatment

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Variations

• Talangietactic nevi/ stork bites
• Flat pink or red marks on eyelids, nose, neck
• Dilated capillaries and will disappear at 1-2
  years of age

   
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Variations

• Mongolian spots
• pigmentation of lumbar dorsal/ buttocks area
• Look like black and blue spots
• Seen in dark skinned persons
• Will dissapear in time

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Variations

• Nevus flammeus
• Port wine colored reddish/purple discoloration on
  face or neck
• May be lightened or treated by laser

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Variations

• Nevus vascularis/ strawberry birthmarkenlarged
  superficial blood vessels often on head , face,
  neck, arms, may disappear by school age

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Variations

• Molding
• will disappear in a day or two after delivery

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Caput Succedaneum

• Swelling of the soft tissue of the scalp caused
  by pressure of the fetal head on a cervix that is
  not fully dilated. Swelling crosses suture line
  and decreases rapidly in a few days after birth.

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Cephalhematoma

• Subperiosteal extravasation of blood due rupture
  of vessels. Swelling increases in size on second
  and third day after delivery. Often associated
  with delivery by forceps. Swelling does not cross
  suture line and may take several weeks after
  birth. Jaundice may occur as blood cells are
  broken down as the swelling resolves.

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Face

• Face movements symmetrical
• Epsteins pearls on hard palate
• Precocious teeth-if loose remove
• Nystagmus dissapears in 3-4 months
• Usually does not produce tears
• Check for candidia infection

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Eyes

• Eyelids edematous to ointment
• Strabismus common
• Can see 8-10 inches from face
• Ears pinna located with outer canthus of eye
• Low set ears may indicate chromosome disorder

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Chest

• Engorged breasts may be present due to estrogen
  nipples excrete whitish fluid-
• Witches milk- from day three to two weeks after
  birth
• Will stop without treatment

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Abdomen

• Check umbilical cord,bowel sounds, bowel
  movement
• Patent anus
• Elimination psuedomentration to estrogen
  withdrawal during first week blood tinged
  mucus from vagina will stop without treatment

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Stool

• First stool is black-green and thick called
  meconium
• Transitional stool is greenish brown to yellowish
  brown and thinner
• Milk stool about day 4 with yellow to golden
  stool breastfed infants have a looser stool than
  formula fed infants

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Stool

• Green watery stool is diarrhea and is serious in
  the newborn
• This is not a normal stool
• Notify physician immediately
• Infant can dehydrate quickly
• Monitor for hydrocele, cryptochidism, phimosis
  (foreskin), epispadias (urethra displacement),
  hypospadius (urethra displacement)

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Cryptorchidism

• In normal fetal development, during the last
  months of birth, the testicles develop in the
  abdomen and descend into the scrotum in the male
  fetus. Sometimes at birth, one or both testicles
  may fail to descend into the scrotum. If the
  testicle has not descended within the first year
  of the baby's life, surgery may be recommended to
  return the testicle to its proper position in the
  scrotum.

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Hydrocele

• A hydrocele is a collection of fluid inside the
  area of the scrotum, surrounding the testicle.
  Hydroceles are common in newborn infants and
  normally resolve after a few months after birth.
  The main symptom is a painless, swollen testicle,
  on one or both sides, which feels like a
  water-filled balloon. Hydroceles are usually not
  dangerous, and they are usually only treated when
  they cause discomfort or embarrassment, or they
  get so large that they threaten the blood supply
  of the testicle.

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Extremities

• Spine straight
• Extremities symetrical and move freely
• Polydactylyextra digits
• Syndactlywebbing of hands or feet
• Hip dysplasia-one leg longer
• Downs syndrome-one crease across hand

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Syndactly/Polydactyly
Repair of webbed fingers - series Indications
   
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Hip dysplasia

• One leg longer than other
• Asymmetrical skin folds

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Downs Syndrome Simian Line
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Reflexes

• Rooting touch face or corner of infant mouth
  and infant turns toward touch
• Sucking usually strong at birth
• Blink/ yawn/ gag at birth
• Cough/ swallow at birth
• Hiccup/sneeze at birth

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Reflexes

• Extrusion tip of tongue touched or depressed
  infant will force tongue outward
• Disappears at 4 months
• Grasp/palmar infants fingers tighten on finger
  when a finger is placed in the infants palm
• Present for 4 months

84
Reflexes

• Plantar toes curl downward when fingers are
  placed at the base of the toes
• Disappears at 8 months
• Tonic neck reflex (Fencing position) when
  infants head is turned to one side, the arm and
  leg on that side will extend while the opposite
  arm and leg will flex
• disappears in 3-4 months

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Reflexes

• Startle (Moro reflex)
• sudden jarring causes extension and abduction
  of extremities index finger and thumb form a c
• Disappears in 3-4 months
• Trunk incurvation(gallant) Infant prone run
  finger down back 1 ½ -2 inches from spine on one
  side and the other. Trunk is flexed and pelvis
  moved toward the stimulated side
• Disappears 1 month

86
Relfexes

• Dancing or stepping reflex when held, sole of
  foot touches hard surface there will be flexion
  and extension of leg as if walking
• Disappears 3-4 weeks

87
Reflexes

• Babinski sole of foot is stroked from heel to
  toe , the toes will fan out with dorsiflexion of
  the big toe
• Disappears in 12-18 months

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Normal periods of reactivity

• First period of reactivity-first 30 minutes after
  birth
• Infant is alert good time fore breastfeeding
• Spontaneous startle reflex, crying, tremors
• Sleep will last 2-4 hours

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Second period of reactivity

• Can range in time from 10 minutes to several
  hours
• Have increased muscle tone, often mucus
  production
• May spit up
• Brazelton behavioral states quiet sleepeyes
  closed
• Active sleepstretch,face changes

90
Sleep states

• Drowsy stateeyes open
• Quiet alertfocus on environment
• Active alertfussy
• Crying statecrying, jerking movements

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Gestational assessment

• External physical characteristics
• Resting posturenewborn is flexed
• Skinpreterm has transparent skin newborn may
  have cracking of skin at ankles and feet
• Lanugoabundant at 28-30 weeks

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Gestational assessment

• Lanugo full term
• Slight on shoulders, ears, side of forehead
• Plantar creases develop at 32 weeks and cover
  2/3 of sole by 37 weeks , cover entire sole at 40
  weeks

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Gestational assessment

• Breast size 1 cm at term
• Eye/ear32 weeks minimal ear cartilege
• Full term cartilage springs back when folded

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Neuromuscular maturity

• Square windowbend wrist so palm is flat against
  the arm
• Scarf sign arm is drawn across body toward
  opposite shoulder until resistance is felt

95
Birth classifications

• Small for gestational age infant is below 10th
  percentile for gestational age
• Appropriate for gestational ageinfant is between
  10th and 90th percentile for gestational age

96
LGA / sleep position

• Large for gestational age
• Infant is above the 90th percentile for
  gestational age
• Sleep position infant on back to prevent sudden
  infant death syndrome

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Infant bath

• In hospital usually one hour after birth or when
  infant can maintain temperature
• Washed with hypoallergenic soap
• Cord cleaned with alcohol
• Diaper foldes under cord

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Infant bath

• At home
• Sponge bath
• Room temperature 75 degrees free of drafts
• Water 100 degrees
• Clean each eye inner canthus to outer canthus
  with separate area of wash cloth
• Use water for face

99
Infant bath

• Infant not to have tub bath until cord falls off
• Clean front to back on perineal area
• Never leave infant alone during bath
• Do not use q tips to clean ears
• Dry well wrap in blanket

100
Circumcision

• For easy cleaning, religious reasons, prevent
  surgery later, reduce urinary tract infections
• Against painful, infection, adhesions,
  hemorrhage
• Parent signed consent required infant on
  circumcision board some physicians use
  lidocaine for nerve block

101
Circumcision

• Hospitals may use 20 sucrose solution for
  infant
• Sucking or pacifier
• Methods gomco clamp or plastibell
• Petroleum gauze used and changed with diaper
  change
• Assess for voiding and for bleeding may use ad
  ointment or petroleum jelly for moisture after
  procedure

102
Circumcision
   
Circumcision - series Procedure

• Circumsicion of a newborn boy is usually done
  before he leaves the hospital. A numbing
  medication (local anesthesia such as Xylocaine)
  is injected into the penis to reduce pain.
  Ring-type clamps are placed around the foreskin,
  tightened like a tourniquet to reduce bleeding,
  and the foreskin is removed below the clamp.
  Sometimes a plastic clamp is used (Plastibell).
  The Plastibell will fall off in 5 to 8 days,
  after the surgical site has healed.

103
Aftercare
Circumcision - series Aftercare
   

• For both newborns and older children,
  circumcision is considered a very safe procedure
  with complete healing expected. Healing time for
  newborns usually takes about 1 week. Apply
  petroleum jelly after diaper changes to protect
  the healing incision. Some initial swelling and
  yellow crust formation around the incision is
  normal. Healing time for older children and
  adolescents may take up to 3 weeks. In most
  instances, the child will be discharged from the
  hospital on the day of the surgery.

104
Breastfeeding positions

• Cradleinfant across mothers lap
• Foot ball holdinfant under mothers arm
• Lying downmother lying on her side
• Infant is on the side facing mother

105
Breast feeding

• Benefits
• Correct temperature, inexpensive, immunoglobins,
  better jaw and tooth alignment,
• Bonding, no allergies, antibodies, hormones
  reduce uterus

106
Breast milk

• Colostrumproduced for 2-4 days
• Transitional milk or foremilk is thinner and is
  more watery- more calories than colostrum
• Hindmilk or mature milk present in about 2 weeks
  has lactose, protein, minerals and vitamins

107
Formula

• Thicker and richer
• Feed q 3-4 hours
• Vitamin d may be supplemented
• Soy milk may be used for allergies
• Burp freqently
• Do not heat formula or food in the microwave

108
Hyperbilirubinemia

• Physiologic or pathologic jaundice
• Management increase feeding
• Feed q3h, bilirubin lights if needed-eye
  patches on when under the light
• Bilirubin levels daily monitor temperature q2h
• If severeexchange blood transfusion

109
Respiratory distress

• Preterm infant or deficient surfactant
• Isolette with o2,cpap, o2 sat continuously,
  monitor heart rate, resp rate, vs, retractions,
• Expiratory grunt, flaring of nares, cyanosis
• Iv fluid or tpn, artificial surfactant

110
Hydrocephalus

• Excess cerebral spinal fluid in the ventricles
• Monitor fontanells for buldging, vital signs,
  head circumference daily, change position q2h,
  careful handling

111
Spina bifida

• Etiology failure of the spinal column to close
• Category spina bifida cystica
• Meningoceleexternal sac containing meninges and
  spinal fluid protrudes through defect in
  vertebral column
• Visible at birth

112
Spina bifida

• Myelomeningoceleoften in lumbosacral area
• Covered with fragile thin membrane
• Sac contains cerebral spinal fluid, meninges,
  nerves
• Associated with motor and sensory deficits below
  lesion of the cord

113
Spina bifida

• Mylomeningoceleassociated with downward
  displacement and improper development of part of
  the brain, hydrocephalis which may not be
  present at birth
• Prefer delivery by c-section to prevent rupture
  of the sac

114
Spina bifida

• Management Surgical repair
• Prevent infection- from leaking csf from the sac,
  side lying or prone position, crede method to
  empty bladder, measure head circumference, neuro
  assessment, monitor sensation, movement, keep
  clean and dry

115
Down syndrome

• Trisomy of 21 chromosome
• Flat occiput, small ears, nose and mouth,
  protruding tongue, broad short hands with stubby
  fingers, simian palmar crease,
• Broad, stubby feet with wide space between big
  toe and second toe, mental retardation

116
Talipes equinovarus

• Club foot foot and ankle are twisted out of
  normal position
• Foot seems c shaped pointing downward and
  inward
• Management splint, cast, special shoes
• Treatment begins soon after birth

117
Infant of a diabetic mother

• Neonatal conditions
• Macrosomia, hypoglycemia, polyhydramnios, pre
  term birth, fetal lung immaturity
• Birth trauma polycythemia
• Hyperbilirubinemia

118
Infant of hiv positive mother

• Clean skin with soap and water before injections
  given
• Zidovudine given for 6 weeks following delivery
• If infant is positivetreatment with combination
  of antiretroviral medications
• Typically asymptomatic at birth

119
Hiv positive infants

• May be low birthweight
• May develop opportunistic infections within the
  first two years
• Some children who are positive show no symptoms
  for 8-10 years

120
Substance abuse

• Alcoholfasshort eyelid opening, flat midface,
  flat upper lip groove, thin upper lip,
  microcephaly, hyperactivity, developmental delays
• Cocaineprematurity, poor feeding, difficult to
  console, developmental delays, prune belly, skull
  defects

121
Substance abuse

• Heroinlow birth weight, poor feeding, vomiting,
  shrill cry, crying incessantly,
  convulsions,tachypnea, tremors, sweating
• Tobaccolow birth weight, bronchitis, pneumonia,
  developmental delays

122
Infant screening tests

• Pkuphenylketonuria
• Maple sugar diseaseproblems using fats,protein
• Hypothyroid
• Galactosemia
• Medium chain acyl-coa dehyrogenase
  deficiencyunable to convert fat into energy

123
Newborn tests

• Homocystinuriaproblems breaking down protein
• Congenital adrenal hyperplasia
• Adrenals do not make enough cortisol

124
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