WILKINS CHAPTER 12

Neonatal and Pediatric Assessment qcdc

ASSESSMENT OF THE NEWBORN
MATERNAL HISTORY
● GTPAL —
○ Gravidity — # of pregnancies
○ Term — # pregnancies carried to 37 weeks
○ Preterm — # pregnancies carried 20th-37 weeks
○ Abortion — # of pregnancies delivered before 20 weeks
○ Living — Number of current living children
● Suggestive of Perinatal asphyxia
○ Variable or late decelerations
○ Low biophysical profile score
○ Decrease in fetal movement
○ Presence of meconium in amniotic fluid
○ Long labor
○ Abnormal vaginal bleeding
● Suggestive of Infection
○ Maternal fever
○ High maternal WBC count
○ Tender uterus
○ Rupture of amniotic membranes for more than 24 hours
○ Foul-smelling or colors amniotic fluid
○ Fetal tachycardia
● Cesarean Delivery — greater risk for respiratory distress such as TTN — failure to
reabsorb fetal lung fluid after birth
● Anesthesia of the mother during delivery
○ Narcotics and general anesthetics — enter fetus’s blood stream and produce
respiratory depression in newborn
○ Spinal anesthetics — lower mother’s blood pressure thus compromising the
oxygen supply to the fetus
● APGAR Score — most standard objective measurement of newborn’s well-being
during perinatal period — assess newborns status immediately after birth
○ Evaluated at 1- and 5-minute mark
○ Five specific criteria
○ For sick infant: 1-, 2-, 5-, 10, 15, 20- minute Apgar scores
○ Adjusting well (Score: 7-10)
■ May still show acrocyanosis (bluish discoloration of hands and feet),
irregular respirations, or hypotonia (decreased muscle tone)
■ Require only routine newborn care — drying, temperature
maintenance, and clearing of the airway
■ Occasionally require supplemental oxygen or BVM for brief period
○ Moderately depressed (Score: 4 - 6)
■ Need more than routine care and often require increased fraction of
inspired oxygen (FiO2) with BVM ventilation
○ Severely Depressed: (score: 0 - 3)
■ Extensive medical resuscitation — intubation and mechanical
ventilation
○ 5-minute score — better predictor of infant’s neurologic outcome
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Neonatal and Pediatric Assessment qcdc
● Simplest resuscitation — clearing the airway and drying the skin
● Fetal Assessment
○ Fetal movement — maternal observation, fetal ultrasound, fetal doppler
ultrasound
■ Maternal observation — simplest; mother keep a log of the timing,
strength, and duration of the fetal movements for period of time
■ Fetal ultrasound and doppler ultrasound — provide more quantifiable
data for shorter periods
○ Biophysical profile — ultrasound evaluation
■ Fetal breathing
■ Body movement
■ Tone
■ Reactive heart rate
■ Amniotic fluid volume — predicts the presence or absence of fetal
asphyxia and risk for fetal death
■ Maximum score 2, minimal score 0
■ Normal fetus score: 8 - 10
■ Lower biophysical profile — increase significance of fetal and newborn
problems
○ Amniocentesis — allows for evaluation of L/S ratio — assess pulmonary lung
maturity
■ L/S Ratio of greater than 2 = lung maturity (2:1)
■ L/S ratio of less than 1 indicates high likelihood of RDS
■ Two surfactant phospholipids
● Lecithin - Increase steroid = increase lecithin = increase
surfactant
○ Makes up majority of the weight of surfactant
○ 24 weeks — levels begin to rise
○ Increasing lecithin — improving maturation of lung’s
surfactant system
● Sphingomyelin
○ Levels do not change during late gestation
■ Presence of phosphatidylinositol (PI) and phosphatidylglycerol (PG) —
indicative of advancing lung maturation (synthesis late in gestation)
○ Fetal Monitoring — continuous graphic method of recording fetal heart rate
and uterine contractions
○ Fetal NST (Nonstress Test) — method of evaluating the stability of the fetus’s
physiology within the uterine environment
■ Monitors the acceleration of fetal heart rate in response to fetal
movement
● Healthy fetus — Minimum increase in HR of at least 15
beats/min in response to fetal movement
● Reactive — minimum of two accelerations exceeding 15
beats/min in 20 minutes for term pregnancies
● Nonreactive — fails to have heart rate response in two
consecutive 20-minute periods
WILKINS CHAPTER 12
Neonatal and Pediatric Assessment qcdc
○ Prolonged fetal sleep states, immaturity, maternal
ingestion of sedatives, fetal cardiac or neurological
anomalies
■ Fetal Decelerations
● Early deceleration — Decreased fetal heart rate at the start of
contraction
○ Cause: vagal response related to compression of fetal
head in the birth canal
● Late deceleration — decrease fetal HR 10 - 30 seconds after
onset of contraction
○ Cause: impaired maternal-fetal blood flow —
uteroplacental insufficiency — not fully developed
placenta or placental damage
● Variable deceleration — no clear relationship between
contraction and fetal heart rate
○ Cause: umbilical cord compression

Physical Examination of the Newborn and Infant

● Three of four classic physical examination principles: inspection, palpation,
auscultation
● Percussion — rarely used, due to small cavity of the newborns and organ sizes —
possibility of injury
● Growth and Gestational Age:
○ Low Birthweight (LBW): <2500 g
○ Very Low Birthweight (VLBW): <1500 g
○ Extremely Low Birthweight (ELBW): <1000 g
○ Appropriate for Gestational Age (AGA): weight is appropriate for gestational
age
○ Small for Gestational Age (SGA): falls below 10th percentile for gestational age
○ Large for Gestational Age (LGA): birthweight above 90th percentile
● Gestational Age Assessment Tool
○ Original Assessment tools developed by Dubowitz & Dubowitz
○ Ballard Examination — modification of Dubowitz examination
■ Ballard Examination: neuromuscular maturity and physical maturity
■ Infant’s neuromuscular and physical characteristics are scored by
matching infants characteristics to the table’s description and marking
the table
■ Accurate within 2 WEEKS of gestational age
● Vital Signs Assessment
○ Body temperature — balance of heat production and heat loss
■ Heat loss is determined by surface area: total body mass ratio
■ Premature — lack of brown fat tissue and low surface-to-mass ratio
● Brown fat tissue — major source of heat production for newborn
and helps to maintain internal body temperature
● 28-week gestational age neonate: BSA approx. 0.15m2 and
body mass of 1kg = surface area-to-mass ratio of 0.15m2/kg (6x
greater than that of an adult male)
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Neonatal and Pediatric Assessment qcdc
● Neutral Thermal Environment (NTE) — environmental
temperature at which the infant’s metabolic demands and
therefore oxygen consumption is least
○ NTE is essential to avoid stressing the infant causing
“cold stress”
● Neonates loose heat to environment by one of four
mechanisms
○ Conduction — touching a cold or wet object
○ Convection — gas blowing over the skin surface
○ Evaporation — liquid evaporating from the skin surface
○ Radiation — attempting to warm a cold surface in
contact with the skin
■ Hyperthermia — core body temperature of more than 37.5C or 99.5 F
● Usually caused by environmental factors
■ Hypothermia — core body temperature of less than 36.5C or 97.7F
● More common and significantly more serious sign of infection in
the newborn
● Newborn is unstable to maintain normal heat production
● Increase in heat loss caused by environmental factors
● Newborn does not shiver when hypothermic
■ Axillary and rectal — most common methods to measure temperature
○ Pulse
■ N in newborns: 100 - 160 beats/min
■ Heart rate is age and size dependent
■ Normal resting heart rate is higher in premature infants
■ Cannot increase CO by increasing stroke volume — SV at rest is more
than 90% of maximal stroke volume
■ Infants increase CO by increasing HR
● Too high (>189 beats/min) — impede ventricular refill leads to
cardiovascular collapse and shock
■ Tachycardia — HR greater than 160 beats/min
● Causes: crying, pain, decrease in circulating blood volume,
dugs, hyperthermia, heart disease
■ Bradycardia — less than 100 beats/min
● Causes: hypoxia, Valsalva Maneuver (often occurs during
crying), heart disease, hypothermia, vagal stimulation, critical
congenital heart disease (CCHD), certain drugs
● Sinus bradycardia (normal variant) — resting HR between 70 to
100 beats/min
■ Via brachial or femoral artery — because of the small size of radial
artery
■ Can also be felt at the base of umbilical cord — preferred side in the
L&D room during resuscitation of neonate
○ Respiratory Rate
■ N for neonates: 30 - 60 breaths/min
■ RR decreases with age
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Neonatal and Pediatric Assessment qcdc
■ Infant’s chest walls are more compliant — prone to excessive inward
movement of the chest (retractions) on inhalation
■ Infants NORMALLY breathe RAPIDLY and SHALLOWLY to help
avoid retractions and chest wall collapse
■ Tachypnea — RR >60 breaths/min
● Causes: hypoxemia, metabolic and respiratory acidosis, CCHD,
anxiety, pain, hyperthermia, and crying
● Non-Intubated patients with lung disease — eventually leads to
bradypnea before ventilatory RF
■ Bradypnea — RR <30 breaths/min (infant) / <40 breaths/min
(newborn) — not normal physiologic response in newborns
● Causes: certain medications (narcotics), hypothermia, CNS
disease
● Important clinical sign of imminent decompensation from fatigue
of newborn with significant lung disease
■ All newborns display an IRREGULAR breathing pattern
● RR >60 breaths/min but normalize next several hours —
indicative of TTN
■ Apnea (cessation of respiratory effort) — common respiratory pattern
of infants
● Pathologic condition: breathing ceases for >15 seconds to 20
seconds
● May be accompanied by cyanosis, bradycardia, pallor,
hypotonia
● 6 events of apnea w/ bradycardia in an HOUR — needs
treatment
■ Periodic Breathing — infant has multiple episodes of respiratory
pauses or short apnea interspersed with normal-appearing ventilation
■ Visually observing chest motion or counting respirations
○ Blood pressure
■ Term neonate SBP: <70 mmHg — DBP: <50 mmHg
■ Normal Pulse Pressure: difference between systolic and diastolic
blood pressure — 15 - 25 mmHg
■ Two methods of assessment:
● Blood pressure cuff (sphygmomanometer) - more common
method
● Direct arterial pressure monitoring — direct measurement of
pressure through arterial cannula — arterial pressure catheter
■ Important measure all blood pressure in four extremities after birth
■ Indication of CCHD — difference in blood pressures of upper and lower
extremities — like in coarctation of the aorta (narrowing of ascending
aorta in newborn)
● Morphometric Measurements
○ Three important measurements: weight, length, head circumference
● Lung Topography
○ Infant’s chest has greater anteroposterior diameter than adult’s chest
WILKINS CHAPTER 12
Neonatal and Pediatric Assessment qcdc
TECHNIQUES OF EXAMINATION
● INSPECTION
○ Most important and often most neglected portion of physical examination
○ Unclothed in SUPINE position
○ Look first infant’s overall appearance
○ At full term neonate: reflexes arms and legs into fetal position
○ Premature infants: less muscle tone and extremities are less flexed at rest
○ Skin: check for cyanosis
○ Infants with HYPOTHERMIA or infants with POLYCYTHEMIA (hct >65%) —
may have bluish extremities yet not really hypoxemic
○ Color: pink — preterm and immature with thin skin in hypoxemic state
○ Color of mucus membranes in mouth, tongue, and nail beds — give more
reliable indication
○ Acrocyanosis — peripheral cyanosis of hands and feet. During the first 24 to
72 hours of life —NORMAL due to immature development of peripheral
capillary beds
○ Retractions — sinking inward of the skin around the chest wall during
inspiration
■ Generally, indicate:
● Decrease in lung compliance
● Increase in work of breathing or airway resistance (or both)
■ Occurs when LUNG’S COMPLIANCE is less than the COMPLIANCE
OF CHEST WALL or when there is significant airway obstruction
■ sign of INCREASED WOB
■ Diaphragm contracts in inspiration — lowering negative pressure in
intrapleural space
■ Lung is the MOST compliant structure in normal respiratory system
■ In healthy infant — chest wall is as compliant as the lungs
■ Decrease in compliance = lung becomes less compliant than chest wall
■ When chest is most compliant — it collapses inward in response to the
increasing negative intrathoracic pressure generated by diaphragmatic
contraction
■ Three common points of collapse
● Intercostal area — between the ribs
● Subcostal are — below the lower rib margin
● Substernal area — below the bottom of the sternum
● (4th) Supraclavicular area — above the clavicles
■ Infants with LUNG DISEASE — retraction toward the center of the body
● Substernal and subcostal
■ Infants with HEART disease — intercostal retractions on side of their
bodies — large heart prevents backward motion of the sternum
■ Infants with OBSTRUCTED airways — large suprasternal retractions
due to pronounced use of accessory respiratory muscles
○ Nasal Flaring
■ CARDINAL SIGN of respiratory distress and increased WOB
■ Dilation of the ale nasi during inspiration
■ Infants — obligatory nose breathers
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Neonatal and Pediatric Assessment qcdc
■ Attempt by an infant to achieve airway dilation to
● Decrease airway resistance
● Increase gas flow
● Achieve larger tidal volume
■ Attempt to compensate for increased WOB
○ Grunting
■ Typically heard in infants with disease that DECREASE LUNG
VOLUME (RDS)
■ Sound heard at the end of expiration just before rapid inspiration
■ Caused by CLOSURE OF GLOTTIS during EXPIRATION in an
attempt to provide increased positive end-expiratory pressure and
maintain lung volume and functional residual capacity (FRC)
■ Sound is produced when the infant suddenly opens the glottis and
quickly exhales, inhales, and again closes the glottis
○ Precordium
■ Area over the heart
■ Observed for increase in motion (Hyperdynamic precordium)— Chest
wall is visibly lifting or moving as the heart contracts
● Indication: INCREASED VOLUME LOAD on the heart, usually
secondary to left-to-right shunt of blood through ductus
arteriosus or any other shunt
● This is a CLUE: infant is in respiratory distress not completely
of pulmonary origin
■ Patent Ductus Arteriosus: anatomic connection between aorta and
pulmonary artery remains open
● Blood from aorta flows into pulmonary artery – congestive heart
failure and pulmonary edema
● PALPATION
○ Directed less at the lungs
○ Easiest organ to palpate: SKIN – valuable information: Cardiac output and fluid
volume status
○ Three useful aspects of skin:
■ Perfusion – capillary refill time on trunk and extremities – <3 seconds
■ Temperature
■ Peripheral pulses
○ Pathologic states that can decrease blood flow to skin and prolong capillary
refill:
■ Acidosis
■ Hypoxemia
■ Hypoglycemia
■ Hypothermia
○ Dorsum – more sensitive to temperature than palms
○ Cool
■ Hypothermia
■ Low cardiac output
■ Shock
■ Abnormality that decreases skin blood flow
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Neonatal and Pediatric Assessment qcdc
○ If pulses in lower extremities are weaker than upper extremities – infant
may have obstruction such as Coarctation of the Aorta or Interrupted Aortic
Arch Syndrome
○ Fluid volume: Turgor or fullness of infant’s skin
■ Low fluid volume = loss of skin turgor – tenting or gathering of skin when
lightly pinched together
○ Palpation of abdomen: help in assessing infant’s pulmonary status
■ Anything that impedes the motion of the abdomen or its organs hinders
infants’ respiration
● Hepatomegaly & Splenomegaly – Liver or spleen enlargement
● Enlargement of kidneys, bladder, or bowel
● Intraabdominal tumors
● (+) ascites – distention of abdomen by fluid
● (+) gaseous bowel distension – distention of abdomen by air
● (+) Pneumoperitoneum – free air in the abdomen
■ Liver – should be soft, and mobile, and palpable on the right side of the
abdomen parallel to and 1cm to 2cm below the costal margin
■ Spleen – soft tip below the left costal margin at the anterior axillary
line
■ Kidney – one hand placed under posterior flank and the other hand
firmly pressing in from anterior abdominal wall
■ Cholestasis (internal obstruction to bile flow)
■ Tension of anterior fontanel – IVH or hydrocephalus – full, tense –
cranial structures may be widely separated
● Depressed fontanel – mild to severe hypovolemia
● AUSCULTATION
○ Least definitive of the three examinations
○ Warm chest piece that has small diaphragm and bell – 1.0 - 1.5 cm diameter
○ Auscultatory examination – ideally PRONE position
○ Normal infant breath sound – bronchovesicular in character and are
harsher than in adult
○ Decrease in breath sounds = decrease in gas flow through the airways
■ Respiratory Distress Syndrome
■ Atelectasis
■ Pneumothorax
■ Pleural effusion
○ Wheezing – gas flow through constricted airways – BPD
○ Crackles – excess fluid or secretions in the lungs – pulmonary edema or
pneumonia or RDS
○ Loud ripping sound like separation of Velcro – pulmonary interstitial
emphysema
○ Loud sounds of air movement can are heard over the stomach during
inspiration if the ET tube is in the esophagus
○ Bruit (murmur-like sound) – in liver or neck – infant has arteriovenous
malformation in the liver or head
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Neonatal and Pediatric Assessment qcdc
● TRANSILLUMINATION
○ Examine chest of neonates – used in infants due to thin chest wall enough to
shine a light
○ Source – fiberoptic light placed against the chest wall in a dark room
○ Normal – lighted halo
○ Pneumothorax or pneumomediastinum – entire hemithorax lights up,
dispersing the light in irregular shape

CLINICAL LABORATORY DATA

● Infants blood volume - 80 to 110 mL/kg of body weight
● Most infants can tolerate an acute blood loss of no more than 10% of their blood
volume
● 0.5 kg infant – all laboratory test should require <5.5 mL of blood
● HEMATOLOGY
○ Leukocytosis – WBC count greater than 15,000/mm3 – more often result of
environmental stress than infection
○ High WBC count – clinician should consider infection
■ Crying, hyperthermia from excess wrapping, high environmental
temperature
○ Leukopenia, particularly neutropenia (Absolute neutrophil count <2000/mm3)
– serious condition
■ Usually indicates an infection and implies overwhelming infection
■ Neutropenia from infection mechanism:
● Peripheral consumption of neutrophils
● Failure to produce and release neutrophils from bone marrow
○ Anemia – normal physiologic stimulus – normal newborn severely limits or
ceases the production of RBCs until a new stimulus received
■ Healthy term infants – physiologic anemia occurs between 6 and 8
weeks of age
■ Healthy preterm infant – lowest decrease in hemoglobin occurs
between 8 and 12 weeks
■ Infants who received transfusions – 4-to-6-week delay in onset of RBC
production
○ Platelet – evaluation for thrombocytopenia, disseminated intravascular
coagulation, and other bleeding disorders
■ Normal values: between 100,000 and 350,000/mm3
■ Physicians do not transfuse until <25,000/mm3 and infant is bleeding
■ Thrombocytopenia– <100,000/mm3 – sign of disseminated
intravascular coagulation from severe infection
■ Thrombocytosis – >350,000/mm3 – usually not a clinical problem –
can be seen in patients with
● iron deficiency anemia or hemolytic anemia
● during recovery from thrombocytopenia
● mother have inflammatory collagen vascular disease
● Can be seen in infants after cardiac transplantation
WILKINS CHAPTER 12
Neonatal and Pediatric Assessment qcdc
● BLOOD CHEMISTRY
○ Blood glucose – most frequent blood chemistry determination in newborns
● Most physicians treat an infant with a glucose level of <40 mg/dL (<20
mg/dL in preterm infants)
● Hypoglycemia – caused by variety of metabolic disturbances
○ infection
○ Hyperinsulinemia secondary to maternal diabetes mellitus
○ And inadequate glycogen stores secondary to SGA
● Hyperglycemia – blood glucose level >125 mg/dL in term and >150
mg/dL in preterm infant
○ Most often iatrogenic
○ Total Protein and Albumin – evaluating nutritional status of the ill newborn &
helpful in evaluating cause of pulmonary edema
● Colloid osmotic pressure – not measured – large sample needed
○ Serum Enzymes
● Lactate dehydrogenase (LDH), Aspartate Transaminase (AST),
Alanine Transaminase (ALT) – Liver function
● Creatine phosphokinase (CPK) and its isoenzymes – myocardial
injury
● Alkaline Phosphatase – evaluate bone growth and adequacy of
infant’s nutrition
○ Serum Bilirubin
● Some abnormalities in bilirubin metabolism are likely to affect
pulmonary function
○ Hyperbilirubinemia from a cause that requires treatment by
phototherapy
○ Hyperbilirubinemia caused by hemolytic disease that requires
an exchange transfusion
○ Most severe: Hyperbilirubinemia associated with hemolytic
disease and hydrops fetalis
■ Fundamental problem: Infant has anasarca (massive
total body edema) with pleural effusion and abdominal
ascites that may cause profound respiratory failure
○ Electrolytes, Blood Urea Nitrogen (BUN, Serum Creatinine
● Assess infant’s fluid status and renal function
○ Calcium and Phosphorus
● Indirectly important in evaluation of newborn with chronic lung disease
● Chronically ill infant with poor nutrition – low levels of calcium and
phosphorus & increased risk for developing rickets
● Osteopenia of the premature – rickets like disease caused by
chronically low phosphorus intake
○ Worsen: increase chest wall compliance secondary to decrease
mineralization of the ribs
○ Decreasing infant’s depth of respiration secondary to pain from
rib fractures
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Neonatal and Pediatric Assessment qcdc
● MICROBIOLOGY
○ Polymorphonuclear neutrophil (PMN) count – increased in tracheal or
stomach samples are strongly suggestive of infection rather than colonization

NEWBORN BLOOD GASSES

● FETAL HEMOGLOBIN
○ Meets the needs of the fetus in the oxygen-poor environment of intrauterine life
○ Fetal hemoglobin curve shift to LEFT of the adult Hemoglobin (HbA)
■ HbF has higher affinity for oxygen than HbA
■ HbF absorbs oxygen more readily and releases it slowly
■ Half-life of RBCs with HbF is about 45 days
■ Newborn will have significant portion of RBC population with HbF
until 60 to 90 days of life
● ARTERIAL BLOOD GAS
○ Most reliable source for blood gas analysis in newborns
○ Transitional Period: PaO2 lower, PaCO2 higher, pH lower
○ Infants who are crying change their ventilation:
■ Hyperventilate
■ Hold breath and stop ventilating
○ Placement of umbilical artery catheter
■ Obtain blood gas samples
■ Continuous blood pressure monitoring
■ Large scale blood replacement
● CAPILLARY BLOOD GASSES
○ Capillary samples obtained by puncturing the skin of infant’s warmed
heel
○ Other sites: Fingers and earlobes
○ Capillary carbon dioxide tension (PcCO2) and pH vs. Arterial Sample
■ PcCO2 – 2 to 5 mmHg higher
■ pH – 0.01 to 0.03 units lower
○ Values will be unreliable if extremities are
■ Edematous
■ Acrocyanotic
■ Not warmed / infant has poor peripheral circulation
○ PO2 – in CBG significantly below arterial blood – do not use for clinical
decision making
● VENOUS BLOOD GASSES
○ Useful in computing the oxygen extraction or carbon dioxide function of
tissues
● NONINVASIVE MONITORS
○ Give caregivers up to date information
○ Can be used sound the clock to monitor sick infants and for trending
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Neonatal and Pediatric Assessment qcdc
○ Transcutaneous Oxygen Monitor
■ Transcutaneous oxygen pressure (tcPO2) monitors – measure
electrical current that is directly proportional to the number of
oxygen molecules present in the electrode (Clark – oxygen)
● Measures oxygen present in the underlying capillaries and
tissues of the skin and not PaO2 directly
■ Decrease blood flow under electrode – falsely lower than PaO2
● Acidosis
● Shock
● Hypovolemia
● Hypoglycemia
■ Good for evaluating physiologic changes that occur with blood
gas sampling
■ Note tcPO2 value 3 times:
● Before disturbing the infant
● At beginning of blood flow
● 40 to 60 seconds after completion of sampling
■ Neonate with CCHD (heart condition) – position of PtCO2
electrode allows for the comparison of preductal and post
ductal PO2 values
● Recommended preductal electrode position: right upper
chest just below the right clavicle
● Any other position in the body for post ductal EXCEPT right
arm
○ Transcutaneous Carbon Dioxide Monitors
■ Trend monitor for carbon dioxide
■ Both tcPO2 and tcPCO2 – use heated electrodes and must be
repositioned every 2 to 4 hours
■ Most common problem with tc monitoring: air leaks around the
adhesive ring
● Air leaks causes dramatic fall in tcPCO2
● Large air leak – mimic room air values
○ PO2 – 150 mmHg
○ PCO2 – 0 mmHg
○ Pulse Oximeters
■ Useful monitoring tool and a standard of care in neonatal and
pediatric medicine
■ Measure the changing transmission of red and infrared light
through pulsating capillary bed to identify the saturation of
hemoglobin
■ During first 48 hours of life can identify some infants with CCHD
before they show an signs
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Neonatal and Pediatric Assessment qcdc
■ Positive pulse oximeter screen: greater than 3% absolute
difference in oxygen saturation between the right hand and foot
on three measures, each separated by 1 hour
■ Negative pulse oximeter screen: finding 95% or higher in
either extremity with 3% or less absolute difference in oxygen
saturation between the upper and lower extremities.

PULMONARY FUNCTION TESTING

● VOLUMES
○ Three measures can be measured easily in newborns
■ Functional Residual Capacity (FRC)
● Most important clinical lung volume measurement
● Measured by: closed-system helium dilution and open-
system nitrogen washout
○ Nitrogen washout curve – distribution of ventilation
■ Pulmonary Clearance Delay (PCD) – divide
lung into fast, intermediate, slow ventilating
areas based on calculations from expired
nitrogen concentrations obtained during
Nitrogen washout – evaluate what
percentage of the lung is ventilating
effectively
● High or low FRC:
○ Compliance decreases
○ Resistance increases
○ PCO2 elevated
○ Low FRC– PO2 drop significantly – RDS: MAS and
PIE
■ Thoracic gas volume (TGV)
● Use of body plethysmograph – measures all gas in the
thoracic cavity whether communicating with airway or not
■ Crying Vital Capacity (CVC)
● Measurement of tidal volume while the infant is crying
● Useful in infants with lung disease that cause changes in
FRC (RDS)
● Does not require infant to cry vigorously
○ By comparing TGV with FRC – determine presence of trapped gas in the
thorax
○ To compare results for test – results must be described against a
standard unit
■ Body weight in kilograms (kg)
■ Body length in centimeter (cm)
■ Body surface area (BSA)
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● MECHANICS
○ Compliance – measure of the distensibility of the lung
■ Change in volume/ Change in pressure
■ Requires measurement of tidal volume and transpulmonary
pressure
● Tidal volume – pneumotachography / body
plethysmography
● Transpulmonary pressure: alveolar pressure - pleural
pressure
○ Approximation: intubated – airway and esophageal
pressure & non-intubated: esophageal pressure
○ Air-filled balloon or saline-filled catheter can be
used – mid esophagus
● Compliance of chest wall can also be measured by
changing 2 pressure sources:
○ Airway – esophageal
○ Esophageal – atmospheric pressure
■ Compliance significantly lower in RDS infants: BPD, PIE,
Pneumonia
○ Resistance – measure of the inhibition of gas flow through the airways
■ Change in transpulmonary pressure/change in flow
■ Elevated: MAS (resolve) and BPD (do not resolve)
○ Work of Breathing
■ Cumulative product of pressure generated and the volume at
each instant of the respiratory cycle
■ Calculated by:
● Planimetry of pressure-volume curve
● Electrically integrating the pressure volume signals
■ Airway resistance – major contributor to planimetric area of a
pressure-volume loop
■ Increased WOB: major restrictive components – MAS & BPD
○ Lung Mechanics with Mechanical Ventilators
■ Possible to diagnose: overdistention, air leak, short inspiratory
time and other dysfunctional patient-ventilator interactions
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Neonatal and Pediatric Assessment qcdc

■ Airway Pressure Release Ventilation-Assist (APRV), Neurally

Adjusted Ventilatory Assist (NAVA), closed-loop ventilation –
these newer modes of ventilation:
● Respond to patient’s chest and lung mechanics
● Provide lung-protective strategies
● Improve patient ventilator synchrony
● Optimize gas exchange and lung volume in neonates and
infants
● Provide plethora of clinical data regarding infant’s lungs
and patient-ventilator interface
● CHEMORECEPTORS RESPONSE
○ Sudden Infant Death Syndrome – newborns have blunted response to
hypercapnia and severely diminished or paradoxical response to
hypoxia
○ Studies usually performed by measuring:
■ tidal volume
■ Minute ventilation
■ end-tidal oxygen and carbon dioxide
■ Transcutaneous oxygen levels
○ Infants minute ventilation is plotted against PaCO2 or FiO2 to assess the
infant’s ventilatory response to increased PaCO2

RADIOGRAPHS
● Preferred position
○ Older pediatric patient: Upright
○ Infant: Supine, lying on the x-ray film
● AP View – X-ray beam passes from the front to the back of the infant
● Most adult (PA) view – minimizes distortion and enhances quality of the film
● Typical views used to evaluate infant’s lung: AP and Lateral
● Decubitus films of chest and abdomen – useful in detecting the presence of
fluid or air in pleural space
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Neonatal and Pediatric Assessment qcdc
● Inspiratory and Expiratory chest films – useful in evaluating the presence of
foreign body
○ Aspirated foreign objects – radiolucent and will not show on chest radiograph
○ Expiratory film – lung area below mechanical obstruction will remain
hyperinflated when compared with an inspiratory film on the same patient
● Two classic newborn diseases: RDS and MAS
○ RDS: Diffuse, hazy ground-glass appearance; air bronchograms
extending out to periphery of the lungs; low lung volumes
○ MAS – Two Phases: Early Mechanical Phase & Late Chemical Phase
■ Typical pattern of mixed atelectasis and local emphysema
● TTN: Diffuse streakiness and fluid in the major and minor fissures – rapid
resolution of the disease by 24 hours

● Fluoroscopy: can quickly identify life-threatening abnormalities of GI tract such

as Meconium ileus and atresia
● Ultrasound: remains essential in neonatal imaging of the brain, chest, and
abdomen because of lack of radiation, the portability, and lack of sedation
requirements

APNEA MONITORING
● Designed to warn life-threatening respiratory and cardiac events
● Use 2 electrodes placed on chest wall to detect respiratory movements
● Indicated in neonates at risk for:
○ Recurrent apnea
○ Bradycardia
○ Hypoxemia
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● May also be considered in infants
○ Receiving drug therapy for a history of apnea and bradycardia
○ With BPD, especially those requiring supplemental O2
○ With symptomatic GER
○ Born to substance-abusing mother if clinically symptomatic
○ With tracheostomy or an airway abnormality that increases risk for
obstruction
○ With neurologic or metabolic disorders affecting respiratory control

ASSESSMENT OF CRITICALLY ILL INFANT

AIRWAY
● Infant whose right main stem bronchus is intubated may have breath sounds in left
hemithorax as well as left chest wall motion – occur because of short tracheal lengths
and increased chest wall compliance
● Misplace ET tube creates a subtle difference in breath sounds – particularly in
apices
● Infant who exhales during the inspiratory phase of the ventilator can generate
tremendous intrathoracic pressures – potentially damaging the lung
● Inward motion of the chest or absence of outward motion of the chest wall
during mechanical inspiration – indicate that the infant is breathing
asynchronously with the ventilator
● One major cause of ventilator asynchrony: trigger setting of the ventilator –
Ventilator sensitivity
● These triggers are
○ Volume – through either pneumotachography or hot-wire anemometry
○ Abdominal wall motion
○ Thoracic impedance
○ Flow triggering
● The most important characteristic that must be present for any systems to be
useful are sensitivity to small changes and rapid response time
● Airway pressure monitored in infants
○ Peak inspiratory pressure
○ Mean airway pressure
○ Positive end expiratory pressure
○ Occasionally, esophageal pressure
● Airway resistance and lung compliance are being used clinically more often
with the advent of reproducible, easy-to-use neonatal pulmonary function
equipment
● Tracheostomy
○ Most common indications:
■ Congenital defects
■ Acquired airway lesions
■ Tracheomalacia
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■ Neuromuscular disorders
■ Ventilator dependency
○ Factors to consider when assessing the risk for complications:
■ Age
■ Size of tracheostomy
■ Degree of airway obstruction
■ Behavior of a child
■ Underlying airway pathology
■ Presence of other medical conditions
■ Social environment
○ Signs and symptoms for airway patency compromise
■ Rattling or “noisy” secretions
■ Thick and inspissated secretions
■ Inability to cough and clear secretions
■ Silent cough
■ Absent or diminished breath sounds
■ Lack of air movement around the tracheostomy/mouth
■ Increased work of breathing
■ Pallor or cyanosis
○ Airway instability – 24-hour home nursing monitoring

HEMODYNAMIC ASSESSMENTS
● Indications for umbilical artery catheterization
○ Source for frequent ABG sampling
○ Continuous blood pressure monitoring
○ Large scale blood replacement
● Indications for umbilical venous catheterization
○ Central venous pressure monitoring
○ Large scale blood replacement
● Difficult/Impossible calculation of Cardiac output – varying degrees of right-to-
left shunt depending on PVR with PDA and PFO

ASSESSMENT OF OLDER INFANT AND CHILD

HISTORY
● Until age of 2, it is important to include birth history
● At 3 months of age – begin to include a review of systems in historical
assessment
● Most obvious of signs – general activity
● Gastrointestinal upset is a common complaint in infants and children – can lead
to dehydration and hypovolemia
● Major causes for hospitalization: Vomiting and Diarrhea (maybe a manifestation
of pneumonia)
● CF and GERD may have gastrointestinal and pulmonary symptoms
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● Infant/child does not maintain growth appropriate for developmental age —
“Failure to thrive” group:
○ Asthma
○ Cystic fibrosis
○ GERD
○ Foreign body aspiration
○ Chronic infection
○ Nonasthmatic pulmonary disease
○ Neuromuscular disease affecting chest wall
○ Immotile cilia syndrome

PHYSICAL EXAMINATION
● It is most important to gain trust and cooperation
● First examine the parts that upset or frighten the infant or child the least – save
it for the last part
● Make game out of the examination
● Let the child hold and play with the stethoscope or other instruments that are
used in the examination
● Two major diseases in young child: Croup and Epiglottitis
○ CROUP– viral disease affecting the trachea and small airways of the
children
■ Tends to appear in children between 3 months and 5 years old
■ Cold symptoms: stuffy or runny nose, fever
■ Progress: loud, seal-like barking cough, rapid or difficult
respiration, grunting or wheezing while breathing
■ Severe cases: development of stridor and cyanosis
● Stridor – high pitched squeaking noise during inspiration or
cyanosis
■ AP neck radiograph – steeple sign – narrowed subglottic
airway
■ Leipzig and colleagues – Croup scoring system
● Score greater than 5 – indication of impending airway
obstruction
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○ EPIGLOTTITIS – bacterial disease that causes significant edema and
inflammation of epiglottis
■ Caused by Haemophilus influenzae type B (Hib)
■ Most often seen in children aged 2 to 6 years
■ 4D’s: Drooling, Dysphagia, Dysphonia, Distress, (+) Dyspnea
■ CXR: Lateral film: Thumb Sign — swollen epiglottis blocking
the upper airway
○ ASTHMA – chronic airway disease that is caused by airway
inflammation and hyperresponsiveness to irritants
■ Typical symptoms: Intermittent dry cough and expiratory
wheezing
■ May report: nonfocal chest pain (young children), SOB and chest
tightness (older children)
■ Ultimate goal of treatment: to enable a patient to live symptom
free

CLINICAL LABORATORY DATA

● Sweat chloride test – used to diagnose cystic fibrosis
○ >60 mmol/L – indicative
○ 39 mmol/L – threshold for cystic fibrosis

BLOOD GASSES
● Pulse oximeter is more reliable than tc monitoring at this age
● Greater difference between arterial and transcutaneous gas values because of
the increased thickness of the skin and subcutaneous tissue

PULMONARY FUNCTION TESTING

● Standard pulmonary function testing is not possible until the child is 5 years of
age
● TWO IMPORTANT POINTS to remember:
1. The validity of the result is directly related to the child's cooperativeness.
Children in the 5- to 8-year age range can have remarkably short
attention spans and be frustratingly uncooperative
2. The lungs of the child are still growing, and the results of pulmonary
function test must be adjusted to body size
● Increasing bronchospasm: lower peak flows and scooped rather than linear
expiratory flow pattern
● Impulse Oscillometry (IOS) – fairly new technique being used for the
diagnosis and management of respiratory and allergic disease in children
○ Measures respiratory function during normal breathing by transmitting
mixed-frequency rectangular impulses down the airways and measuring
the resultant pressure and flow relationships – describe the mechanical
parameters of the lungs
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Neonatal and Pediatric Assessment qcdc
○ Requires little patient cooperation – only tidal volume breaths are
required
○ Children as young as 2 years old can be examined

PEDIATRIC BRONCHOSCOPY
● Rigid bronchoscopy – bronchoscopy technique of choice for infants and
children
● Pediatric flexible bronchoscopy
● Indications:
○ Stridor and wheeze
○ Cough
○ Radiographic abnormalities
○ Foreign body aspiration
○ Hemoptysis
○ Inhalation injury
RADIOGRAPHS
● Lateral view of neck can help distinguish croup and epiglottitis
○ Subglottic narrowing – laryngotracheobronchitis
○ Supraglottic narrowing with large thump-shapes epiglottis – epiglottitis