The Lack of Red Reflex Clinical Information Discussion Responses

Please respond to at least 2 of your peer’s posts. To ensure that your responses are substantive, use at least two of these prompts:

Do you agree with your peers’ assessment?

Take an opposing view to a peer and present a logical argument supporting an alternate opinion.

Amanda’s Response

What is routine health follow-up for a normal newborn?

List the components of the newborn exam and what would be expected.

Name two ‘red flags’ that you would want to follow closely in the newborn period

.

List any special tests or services you may consider recommending to the caregivers.

Routine follow up for a normal newborn occurs 48-72 hours post hospital discharge. The purpose of a routine newborn health assessment is to detect abnormalities and monitor growth/development. The follow-up appointment also allows parents an opportunity to address any questions/concerns that have developed since discharge from the hospital.  The American Academy of Pediatrics has set forth recommendations for pediatric preventative health screenings at various age intervals. These recommendations are also known as a “periodicity schedule”. List the components of the newborn exam and what would be expected.

Vital signs: RR: 40-60, HR: 110-160, Systolic BP: 60-90mm Hg

Head circumference 13-15 inches

Length: 19-21 inches

Weight: 6lbs – 9lbs

Head: Inspect/palpate fontanels and sutures as well as the size, and shape of head

Expected Finding: Average head circumference 13-15 inches (Lewis, 2014).

Eyes: assess pupillary and red reflex

Expected Finding: pupils reactive, eyes blink, red reflex present (Lewis, 2014).

Mouth: inspect palate and oral mucosa

Expected finding: moist mucosa, palate high arched, uvula midline (Lewis, 2014).

Neck:assess ROM

Expected Finding: full ROM (Lewis, 2014).

Chest/Lungs: Assess respiratory effort, movement, and symmetry

Expected Finding: Symmetrical, lung sounds equal (Lewis, 2014).

Heart: Auscultate for murmurs, palpate femoral pulses

Expected finding: Heart rate regular, palpable regular femoral pulses (Lewis, 2014).

Abdomen: assess size, palpate for organomegaly, assess umbilical cord site

Expected finding: Slight protrusion, bowel sounds present, healing uninfected umbilical cord site (Lewis, 2014).

Genitalia: check for development

Expected finding: female = whitish/bloody vaginal discharge

male: testes descended in scrotum (Lewis, 2014).

Extremities: Inspected for syndactyly and polydactyly

Expected Finding: 10 fingers/10 toes (Lewis, 2014).

Skin: Inspect, assess, note any birthmarks/rashes

Expected Finding: Birthmarks, intact, appropriate warmth, tone, and color for race (Lewis, 2014).

Hips: Assess ROM, symmetry, and skin folds

Expected Finding: Hips should adduct and abduct without “clunk” (Lewis, 2014).

Neuro: Evaluate strength, tone, and symmetry of movements. Ventral suspension

Expected finding: Suck, Root, Moro, Step, reflexes present (Lewis, 2014).

Name two ‘red flags’ that you would want to follow closely in the newborn period

Lack of red reflex: This is the primary screening tool for retinoblastoma (Hered, 2011). The ophthalmoscope is held 12-18 inches away from the infant’s eyes and focused on the pupils. A normal reflex yields a symmetrical red reflex in both eyes (Hered, 2011). The presence of a white reflection could indicate retinal reflection (Hered, 2011). This would require immediate referral to pediatric ophthalmology (Hered, 2011).

Positive Ortolani Maneuver: This maneuver is conducted to assess hip stability. The maneuver is conducted with the infant in a supine position, one leg at a time (Roof, Jinguji, & White, 2013). The pelvis is stabilized, the hips and knees are flexed at 90 degrees (Roof, Jinguji, & White, 2013). Then, the provider applies gentle anterior pressure to the greater trochanters with their index fingers and abducts the legs with their thumbs (Roof, Jinguji, & White, 2013). A “clunk”, indicates a positive Ortolani maneuver (Roof, Jinguji, & White, 2013). The “clunk”, is the femoral head relocating anteriorly into the acetabulum (Roof, Jinguji, & White, 2013). This finding should be continually monitored in infants 2-5 weeks of age (Roof, Jinguji, & White, 2013). If the finding does not resolve within the first 2-5 weeks of age, the patient should be referred to a provider with experience managing developmental hip dysplasia (DDH) for further investigation and possible imaging (Roof, Jinguji, & White, 2013).

List any special tests or services you may consider recommending to the caregivers.

In my community, we enjoy the benefit of having several visiting nurse programs to help new parents. Healthy Families Arizona is for parents with an infant under 3 months of age. A registered nurse visits the family at home during the first week (post hospital discharge), then monthly until 3 months of age. The RN is able to provide in-home education regarding breast-feeding, milestones, safety, and anticipatory guidance. This program has proven exceedingly helpful for first time parents, and best of all, is free.

Eric’s Response

You have just finished seeing a 10 day old girl for newborn follow-up. Her mother is concerned because the infant has been stiffening up with eye rolling and her urine smells sweet. What are your initial thoughts? What information will you assess from the birth hospital? What are your treatment recommendations? What are the state requirements for your practice location regarding newborn screening results?

It could very well be type I diabetes because it can cause the fruity smelling urine which could be attributed to the sweet smell for which the parents are speaking

It sounds like this infant may be suffering from Maple Syrup Urine Disease (MSUD), which sounds kind of delicious, but before you grab a stack of flapjacks lets delve deeper into what it is, how its dangerous and how it is treated.

MSUD is a condition in which the body is unable to break down certain proteins, more specifically amino acids which are the building blocks of proteins; in MSUDs a group of enzymes called branched-chain ketoacid dehydrogenase complex is not working correctly, this group breaks down the amino acids leucine, isoleucine and valine for energy, if these are not broken down properly they can build up in the blood to toxic levels; early recognition of the disease and treatment can often prevent severe outcomes of the disease process; it affects approximately 185,000 babies worldwide; it received its name for the sweet odor of the urine in untreated babies ().Early signs of MSUD includes: poor appetite, trouble sucking during feeding, weight loss, high pitched cry, sweet smelling urine like maple syrup or burnt sugar, sleeping longer or more often, tiredness, irritability, vomiting and developmental delays; treatment can consist of dietary restrictions such as a protein-restricted diet that restricts specific proteins which the baby’s body cannot break down; special formulas for babies and children with MSUDs are also available; there are also supplements and medications that can help specific forms of MSUDs such as thiamine-responsive versions (Martin, 2014).

If treatment is initiated early then the outcomes for MSUDs children can be very good and they can have healthy and regular growth and development, however such children may experience signs and symptoms of MSUDs even with dietary restrictions and treatment; it is essential to treat MSUDs early as delays in treatment can put the babies at risk for brain damage, coma or death (Martin, 2014). MSUD can be confirmed by measuring the amount of branched chain amino acids in a blood sample, or diagnosed through enzyme test using a blood or skin sample (Martin, 2014). It would be worth checking if the newborn labs included a glutaric acid test as part of the screening test done for the newborn screen as well as seeing if any other anomalies were found, the lowest recommended screening is for 26 disorders and the highest is 40, Florida screens for 32 disorders that are recommended by the United States Department of Health and Human Services and an additional 22 secondary disorders unless the parents object in writing (floridahealth.gov, n.d.).