Newborn Examination

Newborn examination objectives

Indication and importance Precautions prior to exam ! Systematic approach Neonatal reflexes Normal variants

Newborn examination

Earliest possible detection of deviations. Establishes a baseline for subsequent examinations Parents assurance and counseling

Newborn examination indications

Immediately after birth Before discharge from maternity unit Whenever there is any concern about the infant's progress

Newborn first exam

Apgar score
Heart rate Respiratory effort Color Tone Reflex irritability

Examination precaution

Hand washing,hand washing ,hand washing Thermal environment Light and noise Brief examination time

General(Growth parameters)

Weight (Naked) Length(straight) Head circumference(3 measurements)

Vital Sign
Heart Rate HR 120-160

Respiratory Rate RR 40-60 Temperature 36.5-37.5 C Blood Pressure

General

Well, Distress or not? skin

Pink is normal Acro cyanosis is normal Cyanosis Bruised part look blue Jaundice Common variants skin rash
Erythema toxicum, mongolian spot, Benign Pustular Melanosis

Erythema Toxicum

Erythema Toxicum

Erythematous macules and firm 1-3 mm yellow or white papules or pustules Etiology obscure Pustules contain eosinophils and are sterile Appear in the first 3-4 days of life
Range: Birth to 14 days

Benign and self limited

Erythema Toxicum

DD: Impetigo Neonatorum

Vesicular, pustular, or bullous lesions developing as early as day of life 2-3 up to 2 weeks of life Lesions occur in moist or opposing surfaces of skin Unroofed lesions do not form crusts Treat with antibiotics

Impetigo Neonatorum

Mongolian Spots

90% of African infants, 81% of Asian, and 9.6% of Caucasian infants Slate-gray to blue-black lesions Usually over lumbosacral area and buttocks Accumulation of melanocytes within the dermis Generally fade by age 7 years

Mongolian Spots

Benign Pustular Melanosis of the Newborn

Pustular Melanosis

General
Obvious Dimorphism or malformations E:g(Down syndrome ear tag neural tube defect ) Tone & Movements: Flexion of upper and lower extremities -Asymmetric movement

Brachial plexus and fractured clavicle

-Ventral, vertical suspension and head control for tone assessment

General inspection

Vigorous cry is assuring Weak cry

sepsis, asphyxia, metabolic, narcotic use

Hoarseness
Hypocalcemia, airway injury

High pitch cry

CNS causes, kernicterus

Head and Face

Shape of the head Fontanels? Sutures? Eyes? Nose? Mouth,lips,palate? Ears? Neck?

Head

Forceps and vacuum marks Caput succedaneum

Boggy edema in presenting part of head Cross suture lines Disappear in few days

Cephalhematoma
Subperiosteal Weeks to resolve Dose not cross sutures

Cephalhematoma

Caput Succadaneum

Cephalhematoma

Caput Succadaneum

Newborn Scalp Hematomata

Head

Head circumference Shape :Molding, Brachycephaly: flat occiput Widening of suture Fontanelles Head auscultation: bruits

Infant skull

Craniosynostosis

Definition: premature closure of one or more cranial suture. Growth of the skull occurs parallel to the suture(s) involved Early correction optimizes cosmetic appearance Can be part of syndromes:Crouzon's , Apert's syndrome

Craniosynostosis

Types:
Sagittal synostosis results in scaphocephaly coronal synostosis results in brachycephaly coronal, sagittal, and lambdoid synostosis results in acrocephaly single suture on one side of head can result in plagiocephaly

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Chest and Abdomen

Chest

Distress signs(Grunting,Tachypnea,Nasal flaring,asymetric chest rise,supra-sternal, intercostal, sub costal retraction).

Deformities(Pectus excavatum, carinatum)

Auscultate
Air entry, symmetry Early crepitation sound is transmitted upper sound Late inspiratory crepitation

chest

Suprmammary nipple Breast hypertrophy

Milk production No redness

Supernumerary Nipples

Found in males and females Pink or brown papules along the milk line, most commonly on the chest or abdomen May contain breast tissue and in women carry the same relative neoplasia risks Not considered a marker for other anomalies

Supernumerary Nipples

Heart

HR 100-160 beats/min Color, perfusion,Central cyanosis Murmur Single S1 Splited S2

No split ;single ventricle, pulmonary hypertension

Femoral Pulses

Abdomen

Inspection
Scaphoid Distention Abdominal wall defect (gastroschisis)

Palpation; baby sucking and use warm hands

Kidneys are normaly palpable Liver 2-3 cm Spleen palpable Umbilical vessels
2 artery, one vein

Hernias ; umbilical and inguinal

Genitalia

Penile size Hypospadias, epispadias Testes

2% crypoorchid Hydrocele

Female:
Prominent clitoris and minora Vaginal skin tag Vaginal discharge /blood Labial fusion

Anus : Patency and location

Hydrocoeles

Inguinal Hernias

Hip and Extremities

Erbs palsy: extended arm and internal rotation with limited movement Humerous fracture Digital abnormality
Syndactaly, brachdactaly, polydactaly

Single palmar crease Hip dislocation

Female, breach

Subluxation of the Hip

Subluxation of the Hip

Feet and Back

Feet deformities
Back and spine
abnormal curvature Sinus tract, tuft of hair

Lumbar hair tuft & haemangioma

CNS

Awakenes and alertness moving extremities Flexed body posture Minimal Head lag Ventral suspension Vertical suspension

Neonatal Reflexes

Neonatal reflexes

Also known as developmental, primary, or primitive reflexes. They consist of autonomic behaviors that do not require higher level brain functioning. They can provide information about lower motor neurons and muscle tone. They are often protective and disappear as higher level motor functions emerge.

Suck

Onset: ~28weeks GA Well-established: 32-34 weeks GA Disappears: around 12 months Elicited by the examiner stroking the lips of the infant; the infants mouth opens and the examiner introduces their gloved finger and sucking starts.

Rooting

Onset: 28 weeks GA Well-established: 32-34 weeks GA Disappears: 3-4 months Elicited by the examiner stroking the cheek or corner of the infants mouth. The infants head turns toward the stimulus and opens its mouth.

Palmar grasp

Onset: 28 weeks GA Well-established: 32 weeks GA Disappears: 2 months Elicited by the examiner placing his finger on the palmar surface of the infants hand and the infants hand grasps the finger. Attempts to remove the finger result in the infant tightening the grasp.

Tonic neck (Fencing posture)

Onset: 35 weeks GA Well-established: 4 weeks PCA Disappearance: 7 months Elicited by rotating the infants head from midline to one side. The infant should respond by extending the arm on the side to which the head is turned and flexing the opposite arm. The lower extremities respond similarly.

Moro

Onset: 28-32 weeks GA Well-established: 37 weeks GA Disappearance: 6 months

The examiner holds the infant so that one hand supports the head and the other supports the buttocks. The reflex is elicited by the sudden dropping of the head in her hand. The response is a series of movements: the infants hands open and there is extension and abduction of the upper extremities. This is followed by anterior flexion of the upper extremities and and audible cry.

Moro

Moro significance

An absent or inadequate Moro response on one side : hemiplegia, brachial plexus palsy, or a fractured clavicle Persistence beyond 5 months of age is : indicate severe neurological defects.

Stepping

Onset: 35-36 weeks GA Well-established: 37 weeks GA Disappearance: 3-4 months PCA Elicited by touching the top of the infants foot to the edge of a table while the infant is held upright. The infant makes movements that resemble stepping.

Galant (Trunk incurvation)

Onset: 28 weeks GA Well-established: 40 weeks GA Disappearance: 3-4 months The infant is held in ventral suspension with the chest in the palm of the examiners hand. Firm pressure is applied to the infants side parallel to the spine in the thoracic area. The response consists of flexion of the pelvis toward the side of the stimulus.

Babinski

Onset: 34-36 weeks GA Well-established: 38 weeks Disappearance: 12 months PCA Elicited by stimulus applied to the outer edge of the sole of the foot. The infant responds by plantar flexion and either flexion or extension of the toes.

Postnatal assessment of gestational age

Ballard Score Accuracy within 1-2 weeks 2 parts

Neurologic characteristic Physical characteristic

Part of general examination

Physical Maturity

Skin: thicker , less translucent, dry, peeling Lanugo:

fine non pigmented hair all over 27-28 wks disappears gradually

Plantar surface: presence or absence of creases Breast: areola development Ear cartilage Eyelid opening External genitalia
Rugation, desend Prominent labia majora

Neuromuscular Maturity

Posture Square window Arm recoil Poplitteal angle Scarf sign Heel to ear

Remember

Wash your hand prior to examination Inspect,Inspect,Inspect,then Touch. Neonatal reflexes implicatons Normal variations