PEDIATRICS

 3B   PHYSICAL  EXAMINATION  OF  THE  NEWBORN  

APPLIED  NEONAT    
Dr.  Becina   GENERAL  PRINCIPLE:  
  1. PREPARE  PATIENT  FOR  EXAMINATION  
CASE:  5  day  old,  ER,  boy  isn’t  feeding  well   a. Undressed  
-­‐ WHAT  SHOULD  BE  ASKED  RIGHT  AWAY   b. But  prevent  hypothermia  in  newborn  
o WHEN  did  it  start?   i. Neutral  thermal  environment  
o WHAT  DO  YOU  MEAN  by  not  feeding   ii. WHY?  Neutral  thermal  
well?   environment?  What  is  the  
o HOW  FREQUENT  is  the  feeding?   importance/significance?  
o Have  differentials  ready?  Most  common   THERMAL  CONTROL  
§ TETANUS  (need  to  know   The  survival  rate  of  LBW  &  sick  infants  is  higher  when  they  
location  of  delivery)   are  cared  for  at  or  near  their  NEUTRAL  THERMAL  
• Spasm,  risus  sardonicus   ENVIRONMENT.  This  environment  is  a  set  of  thermal  
• Where  was  the  child   conditions,  including  air  &  radiating  surface  temperatures,  
delivered?   relative  humidity,  &  airflow  at  which  heat  production  
• Fever?  Arching  of  the   (measured  experimentally  as  oxygen  consumption)  is  
back   minimal  &  the  infant’s  core  temperature  is  within  the  
• Opisthotonus   normal  range.  The  neutral  thermal  environment  is  a  
• Predisposing  factors   function  of  the  size  &  postnatal  age  of  an  infant;  larger,  
• Clinical  symptoms   older  infants  require  lower  environmental  temperatures  
• Cord  cutting  is  no.1  site   than  smaller,  younger  infants  do.  Incubators  or  radiant  
of  infection   warmers  can  be  used  to  maintain  body  temperature.  Body  
• Immunizations  of  the   heat  is  conserved  through  provision  of  a  warm  environment  
mother   and  humidity.  The  optimal  environmental  temperature  for  
minimal  heat  loss  and  oxygen  consumption  for  an  
• Lip  smacking,  episodic  
§ HYPOGLYCEMIA   unclothed  infant  is  one  that  maintains  the  infant’s  core  
temperature  at  36.5-­‐37.0°C.  It  depends  on  an  infant’s  size  
• Usually  in  the  1st  few  
and  maturity;  the  smaller  and  more  immature  the  infant,  
hours  of  life  (2  hrs),  so  
the  higher  the  environmental  temperature  required.  An  
why  after  5  days  
additional  acrylic  resin  (Plexiglas)  heat  shield  or  head  cap  
• Frequency  of  feedings  
and  body  clothing  may  be  required  to  keep  an  extremely  
§ SEPSIS    
LBW  (ELBW)  preterm  infant  warm.  Infant  warmth  can  be  
• (weeks  after  birth)  
maintained  by  heating  the  air  to  a  desired  temperature  or  
• Recent  infections  of  the   by  servo-­‐controlling  the  infant’s  body  temperature  at  a  
mother   desired  set  point.  Continuous  monitoring  of  the  infant’s  
• Be  specific  with   temperature  is  required  so  that  the  environmental  
questions   temperature  can  be  adjusted  to  maintain  optimal  body  
• If  not  know,  perhaps   temperature.  Kangaroo  mother  care  with  direct  skin-­‐to-­‐
ask  about  if  mother  had   skin  contact  and  a  hat  and  blanket  covering  the  infant  is  a  
medications  taken,  or  if   safe  alternative,  with  careful  monitoring  to  avoid  the  risk  of  
she  was  going  for   serious  hypothermia  when  incubators  are  unavailable  or  
regular  check-­‐up   when  the  infant  is  stable  and  the  parents  desire  close  
• Did  she  have  vaginal   contact  with  their  infant.  
discharge  
• Weakness,  lethargy,  
Maintaining  a  relative  humidity  of  40-­‐60%  aids  in  
fever,  thermia  (hypo  or  
stabilizing  body  temperature  by  reducing  heat  loss  at  lower  
hyper),  diarrhea  
environmental  temperatures;  by  preventing  drying  and  
§ MANNER  OF  DELIVERY  
irritation  of  the  lining  of  respiratory  passages,  especially  
§ COMPLICATIONS  WITH  
during  the  administration  of  oxygen  and  after  or  during  
DELIVERY  
endotracheal  intubation  (usually  100%  humidity);  and  by  
 
thinning  viscid  secretions  and  reducing  insensible  water  
CASE:  2  day  old,  patient  had  episodic  cyanosis  
loss  from  the  lungs.  An  infant  should  be  weaned  and  then  
-­‐ DIFFERENTIALS  
removed  from  the  incubator  or  radiant  warmer  only  when  
o Cardiac,  infection,  CNS,  seizures  (seizures  
the  gradual  change  to  the  atmosphere  of  the  nursery  does  
can  display  as  cyanosis),  hypoglycemia,  
not  result  in  a  significant  change  in  the  infant’s  
hypocalcemia  
temperature,  color,  activity,  or  vital  signs.  
-­‐ SEIZURE  
MANNER  OF  DELIVERY  à  Intracerebral  hypoxia  
 

1   CJCASTILLO  
Administering  oxygen  to  reduce  the  risk  of  injury  from   PHYSIOLOGIC  JAUNDICE   PATHOLOGIC  
hypoxia  and  circulatory  insufficiency  must  be  balanced   JAUNDICE  
against  the  risk  of  hyperoxia  to  the  eyes  (retinopathy  of   Unconjugated  hyperbilirubinemia     Considered  if  time  
prematurity)  and  oxygen  injury  to  the  lungs.  Oxygen  should   Visible  on  2nd-­‐3rd  d,  peaks  bet  2-­‐4d,   of  appearance,  
be  administered  via  a  head  hood,  nasal  cannula,  continuous   decreases  thereafter,  adult  bilirubin   duration,  or  
positive  airway  pressure  apparatus,  or  endotracheal  tube   levels  reached  by  10-­‐14d   pattern  varies  from  
to  maintain  stable  and  safe  inspired  oxygen  concentrations.   Less  than  3%  of  FT  w/  level  >15   that  of  physiologic  
Although  cyanosis  must  be  treated  immediately,  oxygen  is  a   mg/dL     jaundice;  or  
drug,  and  its  use  must  be  carefully  regulated  to  maximize   Believed  to  be  due  to  breakdown  of   physiologic,  but  
benefit  and  minimize  potential  harm.  The  concentration  of   fetal  rbc  &  immaturity  of  liver   with  risk  factors      
inspired  oxygen  must  be  adjusted  in  accordance  with  the   enzymes   Exaggerated  
oxygen  tension  of  arterial  blood  (Pao2)  or  a  noninvasive   RISK  FACTORS:     physiologic  
method  such  as  continuous  pulse  oximetry  or   maternal  age     Trisomy  21   jaundice  
transcutaneous  oxygen  measurements.  Capillary  blood  gas   race   cutaneous   Hyperbilirubinemia  
determinations  are  inadequate  for  estimating  arterial   maternal   bruising   of  the  newborn  
oxygen  levels.   diabetes   blood   Bilirubin-­‐induced  
2. PRIORITIZE   prematurity   extravasation   neurologic  
a. Most  newborns  are  quiet   drugs   oxytocin   dysfunction    
  altitude   induction    
-­‐ WHAT  DO  YOU  SEE  IN  NEWBORN   Polycythemia   BF  
o Color   male  sex   wt  loss  
-­‐ WHAT  QUESTION  DO  YOU  ASK  IF  IT’S   delayed  BM    
PHYSIOLOGIC  OR  PATHOLOGIC  JAUNDICE?   similarly  
o TIME:  how  many  days  old?   involved  
§ E.g.  4  days  old   sibling  
• ASK  THE  HISTORY   Diagnosis  of  exclusion,  based  on  Hx,  
o When  did  the   clinical  manifestations  &  
jaundice  start?   laboratory  data  
o JAUNDICE  starts  in   WORK  UP  JAUNDICE  W/C:  
the  face  &  spreads                occurs  in  1st  24-­‐36h,  rises  more  
downward.  If  it   than  
covers  the  whole                5  mg/dL/d,  FT  level  >12,  PT  
body  it’  already     level  >  
o PHYSIOLOGIC                10-­‐14,  jaundice  beyond  10-­‐14d,    
JAUNDICE  starts  at                  conjugated  bil  level  >2mg/dL  
72  hrs.  So  yellow    
over  the  whole  body   PICTURE  OF  CHILD  WITH  PATCHY  REDDISH  SKIN  
on  Day  4  means  it’s   -­‐ MOTTLING  of  the  
probably  pathologic   skin  from  vascular  
• 24  HOURS   instability  
o most  common  is   -­‐ Common  when  
HDN   exposed  to  cold  
§ blood  type   temperature  
§ ask  the  Rh   -­‐ Can  be  both  a  
  pathologic  (shock)  sign  or  
  physiologic  sign  of  cold  temperature  on  the  
  outside  
   
  WELL-­‐CONTOURED  HEAD  
  -­‐ Probably  CS,  because  no  disfigurement  in  the  
  delivery  
  -­‐ Hair  &  well-­‐developed  ear  à  probably  mature  or  
  post-­‐mature  
   
   
   
   
   
   
   
2   CJCASTILLO  
CAPUT  SUCCEDANEUM?  No,  It’s  CEPHALIC  HEMATOMA  
-­‐ HEMATOMA  usually  doesn’t  pronounce  right  
after  birth,  it  usually  takes  days  to  hours,  
especially  if  accompanying  caput  succedaneum  
-­‐ WHAT  TO  ASK  
o Manner  of  delivery  
o Duration  of  duration  &  labor  
o APGAR  score,  it  may  direct  us  to  hypoxia  
-­‐ If  it  occurred  during  delivery,  It’ll  RESOLVE  BY    
ITSELF  usually    
o Don’t  aspirate   EYES  OF  A  DOWN  SYNDROME  PATIENT  
-­‐ It  is  common  that  in  this  hematoma,  there  would    
be  é  breakdown  of  the  blood   -­‐ Look  for  accompanying  
  defects  
CAPUT  SUCCEDANEUM  à  diffuse,  sometimes  ecchymotic,   o Cardiac  
edematous  swelling  of  the  soft  tissues  of  the  scalp  involving   -­‐ Susceptible  to  
the  area  presenting  during  vertex  delivery.  It  may  extend   hyperbilirubinemia  
across  the  midline  &  across  suture  lines.  The  edema    
disappears  within  the  1st  few  days  of  life.  Molding  of  the    
head  &  overriding  of  the  parietal  bones  are  frequently    
associated  with  caput  succedaneum  &  become  more  evident    
after  the  caput  has  receded;  they  disappear  during  the  1st    
weeks  of  life.  Rarely,  a  hemorrhagic  caput  may  result  in   UNILATERAL  CONGENITAL  CATARACT  
shock  &  require  blood  transfusion.  Analogous  swelling,   -­‐ MATERNAL  INFECTION  
discoloration,  &  distortion  of  the  face  are  seen  in  face   o Rubella  
presentations.  No  specific  treatment  is  needed,  but  if   -­‐ HOW  TO  OPEN  EYES  OF  THE  NEWBORN?  
extensive  ecchymoses  are  present,  hyperbilirubinemia  may   o Lift  head  upright  &  then  the  baby  will  
develop.   open  their  eyes  
  § “DOLL’S  EYE”  look  it  up  
CEPHALHEMATOMA  à  is  a  subperiosteal  hemorrhage,    
hence  always  limited  to  the  surface  of   CHILD  WITH  PETECHIAE  IN  THE  HEAD  
1  cranial  bone.  It  occurs  in  1-­‐2%  of    
live  births.  No  discoloration  of  the   -­‐ If  it’s  in  UPPER  à  there  is  
overlying  scalp  occurs,  &  swelling  is   tight  cord  coil  
not  usually  visible  for  several  hours   -­‐ If  it’s  GENERALIZED  à  it  is  
after  birth  because  subperiosteal   something  else  
bleeding  is  a  slow  process.  The  lesion    
becomes  a  firm  tense  mass  with  a    
palpable  rim  localized  over  1  area  of  the  skull.  Most  are    
resorbed  within  2  wk-­‐3  mos,  depending  on  their  size.  They    
may  begin  to  calcify  by  the  end  of  the  2nd  wk.  They  require    
no  treatment  although  phototherapy  may  be  necessary  to    
treat  hyperbilirubinemia.  Infection  is  a  very  rare    
complication.    
   
MARK  ON  FACE    
-­‐ WAS  THIS  A  FORCEPS  DELIVERY?    
o ASPHYXIA,  HYPOXIA    
§ Hypoxia  à  CNS  complications    
à  seizure    
§ Urinary  output  means  the    
hypoxia  is  not  severe  enough  to    
compromise  other  organs    
§ Want  baby  to  cry  à  see  if  it’s    
bilateral  to  see  if  there  is  nerve    
palsy    
o APGAR  SCORE   SOURCE:  
-­‐ DE  Notes  
-­‐ Nelson’s  Textbook  of  
Pediatrics  19th  ed.  
3   CJCASTILLO