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Detailed Newborn Examination

General: Measure and record height, weight, and head circumference.If the infant appears premature or is unusually large or small,perform a Dubowitz/Ballard exam to assess gestational age (see

Dubowitz/Ballard scoring grid. !he exam is di"ided into two parts#an external characteristics score, which is best done at birth, and aneuromuscular score, which should be done within $% hours afterbirth.

Small for gestational age (SGA)

Symmetric (HC = t = !en" all #$% &ile) '' & of SGA infants

Genetic

o Small maternal size

o Chromosomal abnormalities (Trisomies 13, 18, 21, and Turner's syndrome)o Congenital abnormalities

ntrauterine in!ections

o "iruses (rubella, C#", $%aricella, $&")

o acteria (tuberculosis)

o Sirochete (syhilis)

o rotozoan (to*olasmosis, malaria)

nborn errors o! metabolism

o &yohoshatasia

o +erechaunism

o Some amino acidurias

n%ironmental

o -rugs (heroin, methadone, ethanol, dihenylhydantoin)

o ./rays (theraeutic)

o Smo0ing

Asymmetric (HC = !en t" t #$% &ile) '' **& of SGA infants

terolacental insu!!iciency // onset usually a!ter 2 ee0s

o Chronic hyertension

o reeclamsia

o

4enal diseaseo Cyanotic heart disease

o &emoglobinoathies

o lacental in!arcts or chronic abrution, %elamentous insertion, circum%allate

lacenta, multile gestation5

o 6ltitude

Combined (symmetric or assymetric) '' $+& of SGA infants


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n%ironmental

o -rugs (including ethanol)

o Smo0ing

lacental unit insu!!iciency

o lacental in!arcts or chronic abrution, %elamentous insertion, circum%allate

lacenta, multile gestation5

!arge for gestational age (!GA)

n!ants o! diabetic mothers

ec0ith/7iedemann syndrome

&ydros !etalis

+arge mother

S,in: Color

&allor ' associated with low hemoglobinyanosis ' associated with hypoxemia&lethora ' associated with polycythemia)aundice ' *le"ated bilirubin+late grey colour ' associated with methemoglobinemia

!esions

Milia ' pinpoint white papules of eratogenous material usually on nose,chees and forehead, last se"eral wees.

Miliaria ' obstructed eccrine sweat ducts. &inpoint "esicles on foreheadscalp and sinfolds. lear within - wee.!ransient neonatal pustular melanosis ' small "esicopustules, generallypresent at birth, containing Bs and no organisms. !he intact "ersicleruptures to re"eal a pigmented macule surrounded by a thin sin ring.*rythema toxicum ' Most common newborn rash. ariable, irregularmacular patches. 0asts a few days. right1s +tain shows sheets ofeosinophils.afe au lait spots ' suspect neuro2bromatosis if there are many largespots.)unctional ne"i ' if large numbers, suspect tuberous sclerosis, xeroderma

pigmentosus, generalized neuro2bromatosis.

Ne-rological Exam

State of alertness: C.ec, for /ersistent let.argy orirritability0


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1ost-re: In term infant, normal position is one with hips abducted andpartially 3exed and with nees 3exed. 4rms are adducted and3exed at the elbow. !he 2sts are often clenched, with 2ngersco"ering the thumb.

2one: +upport the infant with one hand under his chest. !he necextensors should be able to hold the head in line for 5 seconds.+hould not ha"e more than -67 head lag when mo"ing fromsupine to sitting position.

3e4exes: 8e3exes must be symmetrical. Biceps 9er test : and ;,


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8ed 8e3ex ' ?old the ophthalmoscope ;'@A from the eye. se the C-6diopter lens. !he normal newborn transmits a clear red colour bac tothe obser"er. Blac dots may represent cataracts. 4 whitish color may besuggesti"e of retinoblastoma.

Ears

hec for asymmetry, irregular shapes. 0oo for auricular or pre'auricular pits, 3eshy appendages, lipomas, or sin tags.

Nose

0oo for 3aring of the alae nasi as a sign of increased respiratory eort.0oo for hyper' or hypo'telorism. hec for choanal atresia (4 asmanifested by respiratory distress (neonates are obligate nosebreathers. 4 soft >E tube should be passed through each nostril to

con2rm patency if choanal atresia is suspected.

1alate: hec for cleft lip and palate0

5o-t.

=bser"e the size and shape of the mouth.Microstomia ' seen in !risomy -@ and $-.Macrostomia ' seen in mucopolysaccharidoses.Fish mouth ' seen in fetal alcohol syndrome.*pstein pearls ' small white cysts which contain eratin, freGuently foundon either side of the median raphe of the palate.8anulas ' small bluish white swellings of "ariable size on the 3oor of themouth representing benign mucous gland retention cysts.

2ong-e: Macroglossia ' ?ypothyroidism, mucopolysaccharidoses

2eet.: >atal teeth ' occur in -/$,666 births. Mostly lower incisors. 8isof aspiration if loosely attached.

C.in: Micrognathia ' occurs with &ierre'8obin syndrome,!reacher'ollins syndrome, ?allerman +trei syndrome.

Nec,: &alpate o"er all muscles, palpate cla"icles for possiblefractures. eb nec found in !urner1s and >oonan1ssyndromes. !orticollis usually secondary tosternocleidomastoid hematoma. ystic hygromas most


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common nec mass. 0ymph nodes are unusual at birth andtheir presence usually indicates congenital infection.

Note# +uspect tracheo'esophageal 2stula (!*F if polyhydramnios ispresent.

C.est and !-ngs

=bser"e respiratory rate, respiratory pattern (periodic breathing, periodsof true apnea. =bser"e chest mo"ements for symmetry and forretractions. 0isten for stridor, grunting. >ote that there may be someenlargement of the breasts secondary to maternal hormones.

Cardio6asc-lar System

Measure heart rate, blood pressure in upper and lower extremities,respiratory rate.

7ns/ection: hec baby1s color for pallor, cyanosis, plethora.

1al/ation: hec capillary re2ll. hec pulsesH note any decrease infemoral pulses or radio'femoral delay as a sign of possiblecoarctation of the aorta, note character of pulses (bounding orthready. 0ocate &MI with single 2nger on chestH abnormal locationof &MI can be clue to pneumothorax, diaphragmatic hernia, situsin"ersus, or other thoracic problem.

A-sc-ltation: >ote rhythm and presence of murmurs which may bepathologic.

Abdomen: >ote shape of abdomen. Flat abdomens signifydecreased tone, abdominal contents in chest, or abnormalities inabdominal musculature. >ote abdominal distension. =bser"e fordiastasis recti. =bser"e for any ob"ious malformations e.g.omphalocoele. 4n omphalocoele has a membrane co"ering (unlessit has been ruptured during the deli"ery whereas a gastroschisis

does not.

*xamine umbilical cord and count the "essels. >ote color of cord.&alpate li"er and spleen. It may be normal for the li"er to be about $ cmbelow the right costal margin. !he spleen is not usually palpableH if thespleen is felt, be alert for congenital infection or extramedullaryhematopoeisis. 4fter locating these organs (checing for situs in"ersus,palpate for any abnormal masses.


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4uscultate for bowel sounds.*xamine for hernias ' umbilical or inguinal.Inspect anal area for patency and/or presence of 2stulas.

Genito-rinary Exam

8idneys: *xamined by palpation. !he idneys should be about%.:':.6 cm "ertical length in the full term newborn. !hetechniGue for palpation is either a one hand with four2ngers under the baby1s bac, palpation by rolling thethumb o"er the idneys, or b palpate the left idney byplacing the right hand under the left lumbar region andpalpating the abdomen with the left hand (do the re"ersefor the right idney.

5ale genitalia:!erm normal penis is 5.;6.J cm stretchedlength. Inspect glans, urethral opening, prepuce and shaft.>ormally diKcult to completely retract foresin. =bser"efor hypospadias, epispadias. Inspect circumcised penis foredema, incision, bleeding. Full term infant should ha"ebrownish pigmentation and fully rugated scrotum. &alpatethe testes.

9emale genitalia: Inspect the labia, clitoris, urethral openingand external "aginal "ault. =ften a whitish discharge ispresentH this is normal, as is a small amount of bleeding,which usually occurs a few days after birth and issecondary to maternal hormone withdrawal. ?ymenal tagsmay be present normally.

Extremities and S,eletal System

S/ine: +coliosis, yphosis, lordosis, spinal defects,meningomyelocoeles.

//er extremity: 0oo for cla"icular fracture, absence ofradius or ulna. Inspect creases and 2ngers.

!ower extremity: +ee posture abo"e. Do =rtolani maneu"er tochec for congenital hip dislocation. hec toes.


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;ibliogra/.y for Newborn Exams

-. eonate, 5rdedition, &hiladelphia, B +aunders, -L@;.$. Fishman, M4# &ediatric >eurology, =rlando, Erune and +tratton, -L@;.

5. Ereen, M and ?aggerty, 8)# 4mbulatory &edistrics III, &hiladelphia, B+aunders, -L@%.%. Barness, 04# Manual of &ediatric &hysical Diagnosis, Fifth *dition,hicago, ear Boo Medical &ublishers, -L@-.:. +canlon, ), et al.# 4 +ystem of >ewborn &hysical *xamination,Baltimore, ni"ersity &ar &ress, -L@-.;. 4"ery, E# >eonatology, +econd *dition, &hiladelphia, )B 0ippencott,[email protected]. Niai, M# &ediatrics, 5rd *dition, Boston, 0ittle, Brown and o., -L@%.@. ollier, )4B and 0ongmore, )M# =xford ?andboo of linical +pecialties,=xford, =xford ni"ersity &ress, -L@J.

L. Behrman and aughan# >elson1s !extboo of &ediatrics, -$th *dition,&hiladelphia, B +aunders, -L@5.

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