By David E Hertz

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Bilious or copious gastric secretions and/or abdominal distension should prompt concern about bowel obstruction. When suspected, orogastric tube placement to low intermittent (feeding tube) or continuous (Replogle tube) suction is warranted until a diagnosis is established. If oral secretions are copious, swallowing dysfunction or esophageal atresia should be considered. Esophageal atresia can be confirmed by an inability to pass a catheter into the stomach and chest radiograph that includes the neck; the catheter is often curled in the proximal esophageal pouch.

Hypovolemic shock associated with acute blood loss during delivery, asphyxia, or overwhelming sepsis will require volume expansion with normal saline, Ringer's lactate, and/or red blood cell transfusion. The volume of fluid administered to expand intravascular volume and the time frame to add dopamine must be based on clinical response and physician judgment. Pneumothorax, congenital diaphragmatic hernia, excessive mean airway pressure with positive-pressure ventilation, pneumopericardium, and other respiratory disorders may lead to compromise of cardiac output and venous return and diminished pulses with acidemia.

The anterior fontanel is diamond-shaped and formed by the convergence of the metopic, coronal, and sagittal sutures (Fig. 3-8). The posterior fontanel, at the convergence of the sagittal and lambdoidal sutures, is fingertip in size in the newborn period. It generally closes by 6 to 8 weeks of age. The suture lines are often overriding during the immediate newborn period. One can palpate the movable ridges in the benign overriding sutures, unlike the fixed ridges seen in craniosynostosis, a condition resulting from the premature closure of sutures.

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