Newborn Examination

Rafat Mosalli Rafat Mosalli MD FAAP FRCPMD FAAP FRCP

Newborn examination objectives

Indication and importanceIndication and importance Precautions prior to exam !Precautions prior to exam ! Systematic approachSystematic approach Neonatal reflexesNeonatal reflexes Normal variantsNormal variants

Newborn examination

Earliest possible detectionEarliest possible detection of deviations. of deviations.

Establishes a Establishes a baselinebaseline for subsequent for subsequent examinations examinations

Parents assurance and counselingParents assurance and counseling

Newborn examination indications

Immediately after birth Immediately after birth

Before discharge from maternity unit Before discharge from maternity unit

Whenever there is any concern about the Whenever there is any concern about the infant's progress infant's progress

Newborn first exam

Apgar scoreApgar score– Heart rate – Respiratory effort– Color– Tone– Reflex irritability

Examination precaution

Hand washing,hand washing ,hand Hand washing,hand washing ,hand washingwashing

Thermal environmentThermal environment Light and noiseLight and noise Brief examination timeBrief examination time

General(Growth parameters)

Weight (Naked)Weight (Naked)

Length(straight) Length(straight)

Head circumference(3 measurements)Head circumference(3 measurements)

Vital Sign

– Heart Rate

HR 120-160

Respiratory RateRespiratory Rate

RR 40-60RR 40-60 TemperatureTemperature

36.5-37.5 C36.5-37.5 C Blood Pressure Blood Pressure

General

Well, Distress or not?Well, Distress or not? skinskin

– 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 Erythematous macules and firm 1-3 mm yellow or white papules or pustulesyellow or white papules or pustules

Etiology obscureEtiology obscure Pustules contain eosinophils and are Pustules contain eosinophils and are

sterilesterile Appear in the first 3-4 days of lifeAppear in the first 3-4 days of life

– Range: Birth to 14 days

Benign and self limitedBenign and self limited

Erythema Toxicum

DD: Impetigo Neonatorum

Vesicular, pustular, or bullous lesions Vesicular, pustular, or bullous lesions developing as early as day of life 2-3 up to developing as early as day of life 2-3 up to 2 weeks of life2 weeks of life

Lesions occur in moist or opposing Lesions occur in moist or opposing surfaces of skinsurfaces of skin

Unroofed lesions do not form crustsUnroofed lesions do not form crusts Treat with antibioticsTreat with antibiotics

Impetigo Neonatorum

Mongolian Spots

90% of African infants, 81% of Asian, and 90% of African infants, 81% of Asian, and 9.6% of Caucasian infants9.6% of Caucasian infants

Slate-gray to blue-black lesionsSlate-gray to blue-black lesions Usually over lumbosacral area and Usually over lumbosacral area and

buttocksbuttocks Accumulation of melanocytes within the Accumulation of melanocytes within the

dermisdermis Generally fade by age 7 years Generally fade by age 7 years

Mongolian Spots

Benign Pustular Melanosis of the Newborn

Pustular Melanosis

General

Obvious Dimorphism or malformations Obvious Dimorphism or malformations E:g(Down syndrome ear tag neural tube E:g(Down syndrome ear tag neural tube defect )defect )

Tone & Movements:Tone & Movements:Flexion of upper and lower extremitiesFlexion of upper and lower extremities

-Asymmetric movement-Asymmetric movement– Brachial plexus and fractured clavicle

-Ventral, vertical suspension and head -Ventral, vertical suspension and head control for tone assessmentcontrol for tone assessment

General inspection

Vigorous cry is assuringVigorous cry is assuring Weak cryWeak cry

– sepsis, asphyxia, metabolic, narcotic use HoarsenessHoarseness

– Hypocalcemia, airway injury High pitch cryHigh pitch cry

– CNS causes, kernicterus

Head and Face

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

Head

Forceps and vacuum marksForceps and vacuum marks Caput succedaneumCaput succedaneum

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

CephalhematomaCephalhematoma– Subperiosteal– Weeks to resolve– Dose not cross sutures

Cephalhematoma

Caput Succadaneum

Cephalhematoma

Caput Succadaneum

Newborn Scalp Hematomata

Head

Head circumferenceHead circumference Shape :Molding, Brachycephaly: flat Shape :Molding, Brachycephaly: flat

occiputocciput Widening of sutureWidening of suture FontanellesFontanelles Head auscultation: bruits Head auscultation: bruits

Infant skull

Craniosynostosis

Definition: premature closure of one or Definition: premature closure of one or more cranial suture.more cranial suture.

Growth of the skull occurs parallel to the Growth of the skull occurs parallel to the suture(s) involvedsuture(s) involved

Early correction optimizes cosmetic Early correction optimizes cosmetic appearanceappearance

Can be part of syndromes:Can be part of syndromes:Crouzon's , Crouzon's , Apert's syndromeApert's syndrome

Craniosynostosis

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

Deformities(Pectus excavatum, carinatum)Deformities(Pectus excavatum, carinatum) Auscultate Auscultate

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

chest

Suprmammary nippleSuprmammary nipple Breast hypertrophyBreast hypertrophy

– Milk production– No redness

Supernumerary Nipples

Found in males and femalesFound in males and females Pink or brown papules along the milk line, Pink or brown papules along the milk line,

most commonly on the chest or abdomenmost commonly on the chest or abdomen May contain breast tissue and in women May contain breast tissue and in women

carry the same relative neoplasia riskscarry the same relative neoplasia risks Not considered a marker for other Not considered a marker for other

anomaliesanomalies

Supernumerary Nipples

Heart

HR 100-160 beats/minHR 100-160 beats/min Color, perfusion,Central cyanosisColor, perfusion,Central cyanosis MurmurMurmur Single S1Single S1 Splited S2Splited S2

– No split ;single ventricle, pulmonary hypertension

Femoral Pulses

Abdomen

InspectionInspection– Scaphoid– Distention– Abdominal wall defect (gastroschisis)

Palpation; Palpation; babybaby sucking and use warm handssucking 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 sizePenile size Hypospadias, epispadiasHypospadias, epispadias TestesTestes

– 2% crypoorchid– Hydrocele

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

Anus : Anus : Patency and locationPatency and location

Hydrocoeles

Inguinal Hernias

Hip and Extremities

Erb’s palsy: extended arm and internal Erb’s palsy: extended arm and internal rotation with limited movementrotation with limited movement

Humerous fractureHumerous fracture Digital abnormalityDigital abnormality

– Syndactaly, brachdactaly, polydactaly

Single palmar creaseSingle palmar crease Hip dislocationHip dislocation

– Female, breach

Subluxation of the Hip

Subluxation of the Hip

Feet and Back

Feet deformitiesFeet deformities Back and spineBack and spine

– abnormal curvature– Sinus tract, tuft of hair

Lumbar hair tuft & haemangioma

CNS

Awakenes and alertnessAwakenes and alertness moving extremitiesmoving extremities Flexed body postureFlexed body posture Minimal Head lagMinimal Head lag Ventral suspensionVentral suspension Vertical suspensionVertical suspension

Neonatal Reflexes

Neonatal reflexes

Also known as developmental, primary, Also known as developmental, primary, or primitive reflexes.or primitive reflexes.

They consist of autonomic behaviors that They consist of autonomic behaviors that do not require higher level brain do not require higher level brain functioning. They can provide information functioning. They can provide information about about lower motor neurons and muscle lower motor neurons and muscle tone.tone.

They are often protective and disappear They are often protective and disappear as higher level motor functions emerge.as higher level motor functions emerge.

Suck

Onset: ~28weeks GAOnset: ~28weeks GA Well-established: 32-34 weeks GAWell-established: 32-34 weeks GA Disappears: around Disappears: around 12 months12 months Elicited by the examiner stroking the lips of Elicited by the examiner stroking the lips of

the infant; the infant’s mouth opens and the infant; the infant’s mouth opens and the examiner introduces their gloved finger the examiner introduces their gloved finger and sucking starts.and sucking starts.

Rooting

Onset: 28 weeks GAOnset: 28 weeks GA Well-established: 32-34 weeks Well-established: 32-34 weeks

GAGA Disappears: Disappears: 3-4 months3-4 months Elicited by the examiner Elicited by the examiner

stroking the cheek or corner of stroking the cheek or corner of the infant’s mouth. The infant’s the infant’s mouth. The infant’s head turns toward the head turns toward the stimulus and opens its mouth.stimulus and opens its mouth.

Palmar grasp

Onset: 28 weeks GAOnset: 28 weeks GA Well-established: 32 weeks GAWell-established: 32 weeks GA Disappears: Disappears: 2 months2 months Elicited by the examiner placing Elicited by the examiner placing

his finger on the palmar surface his finger on the palmar surface of the infant’s hand and the of the infant’s hand and the infant’s hand grasps the finger. infant’s hand grasps the finger. Attempts to remove the finger Attempts to remove the finger result in the infant tightening the result in the infant tightening the grasp.grasp.

Tonic neck (Fencing posture)

Onset: 35 weeks GAOnset: 35 weeks GA Well-established: 4 weeks PCAWell-established: 4 weeks PCA Disappearance: Disappearance: 7 months7 months Elicited by rotating the infants Elicited by rotating the infants

head from midline to one side. head from midline to one side. The infant should respond by The infant should respond by extending the arm on the side to extending the arm on the side to which the head is turned and which the head is turned and flexing the opposite arm. The flexing the opposite arm. The lower extremities respond lower extremities respond similarly.similarly.

Moro Onset: 28-32 weeks GAOnset: 28-32 weeks GA Well-established: 37 weeks GAWell-established: 37 weeks GA Disappearance: Disappearance: 6 months6 months The examiner holds the infant so that one hand The examiner holds the infant so that one hand

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

Moro

Moro significance

An absent or inadequate Moro response An absent or inadequate Moro response on one side : hemiplegia, brachial plexus on one side : hemiplegia, brachial plexus palsy, or a fractured claviclepalsy, or a fractured clavicle

Persistence beyond 5 months of age is : Persistence beyond 5 months of age is : indicate severe neurological defects.indicate severe neurological defects.

Stepping

Onset: 35-36 weeks GAOnset: 35-36 weeks GA Well-established: 37 weeks GAWell-established: 37 weeks GA Disappearance: Disappearance: 3-4 months 3-4 months

PCAPCA Elicited by touching the top of Elicited by touching the top of

the infant’s foot to the edge of a the infant’s foot to the edge of a table while the infant is held table while the infant is held upright. The infant makes upright. The infant makes

movementsmovements that resemble that resemble stepping.stepping.

Galant (Trunk incurvation) Onset: 28 weeks GAOnset: 28 weeks GA Well-established: 40 weeks GAWell-established: 40 weeks GA Disappearance: Disappearance: 3-4 months3-4 months The infant is held in ventral The infant is held in ventral

suspension with the chest in the palm suspension with the chest in the palm of the examiner’s hand. Firm of the examiner’s hand. Firm pressure is applied to the infant’s pressure is applied to the infant’s side parallel to the spine in the side parallel to the spine in the thoracic area. The response consists thoracic area. The response consists of flexion of the pelvis toward the side of flexion of the pelvis toward the side of the stimulus.of the stimulus.

Babinski

Onset: 34-36 weeks GAOnset: 34-36 weeks GA Well-established: 38 weeksWell-established: 38 weeks Disappearance: Disappearance: 12 months 12 months

PCAPCA Elicited by stimulus applied Elicited by stimulus applied

to the outer edge of the sole to the outer edge of the sole of the foot. The infant of the foot. The infant responds by plantar flexion responds by plantar flexion and either flexion or and either flexion or

extensionextension of the toes.of the toes.

Postnatal assessment of gestational age

Ballard ScoreBallard Score Accuracy within 1-2 weeksAccuracy within 1-2 weeks 2 parts2 parts

– Neurologic characteristic– Physical characteristic

Part of general examinationPart of general examination

Physical Maturity

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

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

Plantar surface: presence or absence of creasesPlantar surface: presence or absence of creases Breast: areola developmentBreast: areola development Ear cartilageEar cartilage Eyelid openingEyelid opening External genitaliaExternal genitalia

– Rugation, desend– Prominent labia majora

Neuromuscular Maturity

PosturePosture Square windowSquare window Arm recoilArm recoil Poplitteal anglePoplitteal angle Scarf signScarf sign Heel to ear Heel to ear

Remember

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