physical assessment of the newborn: part 1...physical assessment of the newborn: part 1 the...

Physical Assessment of the Newborn: Part 1

The S.T.A.B.L.E® Program © 2013. Handout may be reproduced for educational purposes. 1

® ®

®

© K. Karlsen 2013

Review history

Prenatal

Labor/delivery

Presentation of illness

Approach

Systematic

Gentle

© K. Karlsen 2013

Perform hand hygiene (hand sanitizer or wash)

Wear personal protective equipment as indicated(gloves, mask, gown)

Perform while infant in quiet state whenever possible

Use clean equipment

Keep infant warm

Shield eyes from exam light

Comfort during / after exam

Change soiled diapers / redressfollowing exam

Perform hand hygiene after exam

© K. Karlsen 2013

Observe before touching



© K. Karlsen 2013


Auscultate before palpating – in quiet environment

© K. Karlsen 2013


Auscultate before palpating – in quiet environment

Gentle palpation

Avoid if acute abdomen

Extra care withpreterm infants

© K. Karlsen 2013

Ballard et al. (1991). J Pediatr.,119(3): 417-423.Neuromuscular illustrations were adapted

with permission of Dr. Ballard

A detailed monograph and explanationabout how to perform the Ballard exam(written by Dr. Ballard), may be found

at www.BallardScore.com

.

Ballard Score

Developed by Jeanne L. Ballard, MD

Set of procedures and assessment parameters usedto determine gestational age

Evaluation of physical and neuromuscular maturity

© K. Karlsen 2013

Principles of Ballard Exam

Timing

Most reliable if performedby 12 hours of life

Keep infant warm

© K. Karlsen 2013

-1 0 1 2 3 4 5

Skin

Sticky

Friable

Transparent

Gelatinous

Red

Translucent

Smooth pink

Visible veins

Superficialpeeling

and/or rash

Few veins

Cracking

Pale areas

Rare veins

Parchment

Deepcracking

No vessels

Leathery

Cracked

Wrinkled

Lanugo No lanugo Sparselanugo

Abundantlanugo

ThinningLanugo Bald areas Mostly bald

Plantarsurface

Heel- toe40-50 mm

<40 = 2

Heel- toe> 50 mm

No crease

Faint redmarks

Anteriortransversecrease only

Creasesanterior 2/3

Creases overentire sole

Breast Im-perceptible

Barelyperceptible

Flat areolano bud

Stippledareola

1-2 mm bud

Raisedareola

3-4 mm bud

Full areola

5-10 mm bud

Eyes /ears

Lids fused:

Loosely: -1

Tightly: -2

Lids open

Pinna flat

Stays folded

Slightly

curved pinna

Soft slowrecoil

Well-curvedpinna

Soft butready recoil

Formedand firm

Instant recoil

Thickcartilage

Ear stiff

MaleGenitals

Scrotumflat, smooth

Scrotumempty

Faint rugae

Testes inupper canal

Rare rugae

Testesdescending

Few rugae

Testes down

Good rugae

Testespendulous

Deep rugae

FemaleGenitals

Clitorisprominent

Labia flat

Prominentclitoris

Small labiaminora

Prominentclitoris

Enlargingminora

Majora andminoraequally

prominent

Majora large

Minora small

Majora coverclitoris and

minora

© K. Karlsen 2013

Skin – largest organ in the body

Stratum corneum outer layer of epidermis

Begins to develop after 21 weeks

28 to 30 weeks is a few cell layers thick

By term is 10 to 20 cell layers thick

Before epidermis and stratum corneum develop,skin is transparent and thin

-1 0 1 2 3 4 5

Sticky

Friable

Transparent

Gelatinous

Red

Translucent

Smoothpink

Visible veins

Superficialpeeling

and/or rash

Few veins

Cracking

Pale areas

Rare veins

Parchment

Deepcracking

No vessels

Leathery

Cracked

Wrinkled



© K. Karlsen 2013

01

–1

-1 0 1 2 3 4 5

Sticky

Friable

Transparent

Gelatinous

Red

Translucent

Smoothpink

Visible veins

Superficialpeeling

and/or rash

Few veins

Cracking

Pale areas

Rare veins

Parchment

Deepcracking

No vessels

Leathery

Cracked

Wrinkled

© K. Karlsen 2013

-1 0 1 2 3 4 5

Sticky

Friable

Transparent

Gelatinous

Red

Translucent

Smooth pink

Visible veins

Superficialpeeling

and/or rash

Few veins

Cracking

Pale areas

Rare veins

Parchment

Deepcracking

No vessels

Leathery

Cracked

Wrinkled

2

© K. Karlsen 2013

-1 0 1 2 3 4 5

Sticky

Friable

Transparent

Gelatinous

Red

Translucent

Smooth pink

Visible veins

Superficialpeeling

and/or rash

Few veins

Cracking

Pale areas

Rare veins

Parchment

Deepcracking

No vessels

Leathery

Cracked

Wrinkled

3

© K. Karlsen 2013

-1 0 1 2 3 4 5

Sticky

Friable

Transparent

Gelatinous

Red

Translucent

Smooth pink

Visible veins

Superficialpeeling

and/or rash

Few veins

Cracking

Pale areas

Rare veins

Parchment

Deepcracking

No vessels

Leathery

Cracked

Wrinkled

4

© K. Karlsen 2013

5

-1 0 1 2 3 4 5

Sticky

Friable

Transparent

Gelatinous

Red

Translucent

Smooth pink

Visible veins

Superficialpeeling

and/or rash

Few veins

Cracking

Pale areas

Rare veins

Parchment

Deepcracking

No vessels

Leathery

Cracked

Wrinkled

© K. Karlsen 2013

Fine, downy hair that begins to appear 24 to 25 weeks

Abundant across shoulders and upper back by28 weeks

With increasing gestation lower back area thins first

bald areas appear over lumbo-sacral area

By term, minimal to no lanugo present on back

Amount and location may vary with nutritional status,ethnicity, hormonal and metabolic factors

-1 0 1 2 3 4

No lanugo Sparse Abundant Thinning Bald areas Mostly bald



© K. Karlsen 2013

-1 0

-1 0 1 2 3 4


© K. Karlsen 2013

-1 0 1 2 3 4


1

© K. Karlsen 2013

-1 0 1 2 3 4


1

© K. Karlsen 2013

4

2 3

-1 0 1 2 3 4


© K. Karlsen 2013

Prior to foot creases appearing, for very preterminfants, measure foot length from tip of great toe toback of heel

Foot crease begins to appear on ball of foot between28 and 30 weeks gestation

As infant approaches term, creases should coverentire plantar surface

-1 0 1 2 3 4

Heel–toe40 – 50 mm

< 40 = – 2

> 50 mm

No crease

Faint redmarks

Anteriortransverse

crease only

Creasesanterior 2/3

Creasesover entire

sole

© K. Karlsen 2013

-1 0 1 2 3 4


< 40 = – 2

> 50 mm

No crease

Faint redmarks


Creasesanterior 2/3

Creasesover entire

sole

0-1 1



© K. Karlsen 2013

4

3

-1 0 1 2 3 4


< 40 = – 2

> 50 mm

No crease

Faint redmarks

Anteriortransverse

crease only

Creasesanterior 2/3

Creasesover entire

sole

2

© K. Karlsen 2013

As gestation advances, breast tissue is stimulated togrow by maternal estrogen

Evaluate size of areola and presence of any stippling

Palpate breast tissue and estimate diameter inmillimeters

36 weeks 1 to 2 mm nodule of breast tissuepalpable

By term 10 mm nodule of breast tissue usuallypalpable

-1 0 1 2 3 4

Im-perceptible

Barelyperceptible

Flat areolano bud

Stippledareola

1–2 mm bud

Raisedareola

3–4 mm bud

Full areola

5–10 mmbud

© K. Karlsen 2013

-1

-1 0 1 2 3 4

Im-perceptible

Barelyperceptible

Flat areolano bud

Stippledareola

1–2 mm bud

Raisedareola

3–4 mm bud

Full areola

5–10 mmbud

0

1

© K. Karlsen 2013

3

2

-1 0 1 2 3 4

Im-perceptible

Barelyperceptible

Flat areolano bud

Stippledareola

1–2 mm bud

Raisedareola

3–4 mm bud

Full areola

5–10 mmbud

4

© K. Karlsen 2013

Cartilage content increases as infant matures

Palpate for cartilage thickness, then fold pinnatoward face and release it evaluate speed pinnasprings back

If pinna remains folded, evaluate whether eyelids arefused or whether one or both eyelids are open

If eyelids loosely or partially fused, assign a numberof minus one (-1)

-1 0 1 2 3 4

Lids fused:

Loosely: -1

Tightly: -2

Lids open

Pinna flat

Stays folded

Slightlycurved pinna

Soft slowrecoil

Well-curvedpinna


Formedand firm

Instantrecoil

Thickcartilage

Ear stiff

© K. Karlsen 2013

-2

-1 0 1 2 3 4

Lids fused:

Loosely: -1

Tightly: -2

Lids open

Pinna flat

Stays folded


Soft slowrecoil

Well-curvedpinna


Formedand firm

Instantrecoil

Thickcartilage

Ear stiff

0



© K. Karlsen 2013

34

2

-1 0 1 2 3 4

Lids fused:

Loosely: -1

Tightly: -2

Lids open

Pinna flat

Stays folded


Soft slowrecoil

Well-curvedpinna


Formedand firm

Instantrecoil

Thickcartilage

Ear stiff

1

© K. Karlsen 2013

Testes

Begin to descend from peritoneal cavity between28 to 30 weeks

Both palpated in lower inguinal canals by end of33rd to 34th week / scrotal skin thickens

Completely descended by 40 weeks

Rugae (creases over scrotum)

Extremely preterm scrotum flat and smooth

By 40 weeks, scrotum covered with numerousthickened rugae and scrotum pendulous

-1 0 1 2 3 4

Scrotumflat, smooth

Scrotumempty

Faint rugae


Rare rugae

Testesdescending

Few rugae

Testesdown

Good rugae

Testespendulous

Deep rugae

© K. Karlsen 2013

01

-1 0 1 2 3 4

Scrotumflat, smooth

Scrotumempty

Faint rugae


Rare rugae

Testesdescending

Few rugae

Testesdown

Good rugae

Testespendulous

Deep rugae

3

4

2

© K. Karlsen 2013

Assess with hips abducted to 45

Extremely preterm labia flat, clitoris very prominent

As fetus matures, clitoris less prominent, labia minorabecomes more prominent

Closer to term clitoris and labia minora envelopedby enlarging labia majora

Labia majora contains fat – size affected by intrauterinenutrition correlate findings with assessment ofgrowth (small, average or large for gestational age)

-1 0 1 2 3 4

Clitorisprominent

Labia flat

Prominentclitoris

Small labiaminora

Prominentclitoris

Enlargingminora


prominent

Majoralarge

Minorasmall

Majoracover

clitoris andminora

© K. Karlsen 2013

1

3

4

-1 0 1 2 3 4

Clitorisprominent

Labia flat

Prominentclitoris

Small labiaminora

Prominentclitoris

Enlargingminora


prominent

Majoralarge

Minorasmall

Majoracover

clitoris andminora

0

© K. Karlsen 2013

-1 0 1 2 3 4 5

Posture

Squarewindow(wrist)

Armrecoil

Poplitealangle

Scarfsign

Heel toear



© K. Karlsen 2013

Positioning

Head midline

Hips flat

Reliability ofexam altered by:

Sedation

Anesthesia

Paralysis

Critically ill state

Breech position

Neuromuscular exam may be toostressful for preterm and sick infants

should only be performed ifindicated and by skilled neonatal ICUpersonnel once infant stabilized and

able to tolerate the exam

© K. Karlsen 2013

-1 0 1 2 3 4

1

2

© K. Karlsen 2013

-1 0 1 2 3 4

3

4

© K. Karlsen 2013

-1 0 1 2 3 4

Assesses wrist flexibility and/or resistance to extensorstretching at the wrist

Press gently on knuckles to straighten fingers

Apply gentle pressure on back of hand close to fingers avoid wrist rotation

Stop pressing when resistance felt

Angle decreases as gestational age increases

90 60 45 30 0> 90

© K. Karlsen 2013

-1 0 1 2 3 4

1

90 60 45 30 0> 90

0

–1

© K. Karlsen 2013

23

4

-1 0 1 2 3 4

90 60 45 30 0> 90



© K. Karlsen 2013

0 1 2 3 4

Tests for passive flexor tone of biceps muscle

Test one arm at a time in order to avoid Moro reflex

Supine position

Hold infant’s hand

Briefly flex arm then momentarily extend armand release hand

Scores based on angle of recoil when arms returnto flexion

180 140-180 110-140 90-110 < 90

© K. Karlsen 2013

0 1 2 3 4

180 140-180 110-140 90-110 < 90

FlexFlex

ExtendExtend

ReleaseRelease

ScoreScore

© K. Karlsen 2013

0 1 2 3 4

1 2

180 140-180 110-140 90-110 < 90

© K. Karlsen 2013

4

0 1 2 3 4

180 140-180 110-140 90-110 < 90

3

© K. Karlsen 2013

4 53210-1 4 53210-1

Assesses maturation of passive flexor tone aboutthe knee joint

Refrain from touching hamstrings (muscle group beingtested) during maneuver

Measurement unreliable if frankbreech in utero

180 160 140 120 < 90100 90

© K. Karlsen 2013

4 53210-1 4 53210-1

Place thigh in knee-chest position with knee fully flexed

Allow infant to relax, then grasp foot at sides

Extend leg until resistance is felt

Estimate angle behind the knee

180 160 140 120 < 90100 90



© K. Karlsen 2013

4 53210-1 4 53210-1

0

1

180 160 140 120 < 90100 90

© K. Karlsen 2013

2

4

3

4 53210-1 4 53210-1

180 160 140 120 < 90100 90

© K. Karlsen 2013

-1 0 1 2 3 4

Tests passive tone of the posteriorshoulder girdle flexor muscles

Supine position with head midline

neck axillaryline

nippleline

xiphoidprocess

nippleline

axillaryline

© K. Karlsen 2013

-1 0 1 2 3 4

Tests passive tone of the posteriorshoulder girdle flexor muscles

Supine position with head midline

Hold infant’s handacross chest

neck axillaryline

nippleline

xiphoidprocess

nippleline

axillaryline

© K. Karlsen 2013

-1 0 1 2 3 4

Use thumb of other hand to gently pushelbow across chest or gently pull armacross chest

Stop when resistance is felt

Scores based on position of elbow atlandmarks

neck axillaryline

nippleline

xiphoidprocess

nippleline

axillaryline

© K. Karlsen 2013

-1 0 1 2 3 4

1

neck axillaryline

nippleline

xiphoidprocess

nippleline

axillaryline

2



© K. Karlsen 2013

3 4

-1 0 1 2 3 4

neck axillaryline

nippleline

xiphoidprocess

nippleline

axillaryline

© K. Karlsen 2013

-1 0 1 2 3 4

Tests for passive flexion or resistance to extensionof posterior hip flexor muscles

Measurement unreliable iffrank breech in utero

ear nose chin nippleline

umbilicalarea

femoralcrease

© K. Karlsen 2013

Refrain from touching gluteusmuscle (muscle group beingtested) during maneuver

Rest leg alongside body

-1 0 1 2 3 4


umbilicalarea

femoralcrease

© K. Karlsen 2013

Refrain from touching gluteusmuscle (muscle group beingtested) during maneuver

Rest leg alongside body

Grasp foot along both sides

-1 0 1 2 3 4


umbilicalarea

femoralcrease

© K. Karlsen 2013

Gently pull toward ear untilresistance felt

Scores based on location of heelto landmarks

-1 0 1 2 3 4


umbilicalarea

femoralcrease

© K. Karlsen 2013

1

0

-1 0 1 2 3 4


umbilicalarea

femoralcrease

2



© K. Karlsen 2013

43

-1 0 1 2 3 4


umbilicalarea

femoralcrease

© K. Karlsen 2013

Neuromuscular Maturity

Posture

Squarewindow(wrist)

Arm recoil

Poplitealangle

Scarf sign

Heel to ear

Physical Maturity

-1 0 1 2 3 4 5

Skin

Sticky

Friable

Transparent

Gelatinous

Red

Translucent

Smooth pink

Visible veins

Superficialpeeling and/or

rash

Few veins

Cracking

Pale areas

Rare veins

Parchment

Deep cracking

No vessels

Leathery

Cracked

Wrinkled

Lanugo No lanugo Sparse lanugo Abundantlanugo

ThinningLanugo Bald Areas Mostly bald

Plantarsurface

Heel- toe40-50 mm

< 40 = -2

> 50 mm

No creaseFaint red marks


Creasesanterior 2/3

Creasesoverentire sole

Breast Im-perceptible Barelyperceptible

Flat areola nobud

Stippled areola

1-2 mm bud

Raised areola

3-4 mm bud

Full areola

5-10 mm bud

Eyes / ears

Lids fused:

Loosely: -1

Tightly: -2

Lids open

Pinna flat

Stays folded

Slightly

curved pinna

Soft slow recoil

Well-curvedpinna

Soft but readyrecoil

Formed andfirm

Instant recoil

Thick cartilage

Ear stiff

MaleGenitals

Scrotum flat,smooth

Scrotum empty

Faint rugae

Testes in uppercanal

Rare rugae

Testesdescending

Few rugae

Testes down

Good rugae

Testespendulous

Deep rugae

FemaleGenitals

Clitorisprominent

Labia flat

Prominentclitoris

Small labiaminora

Prominentclitoris

Enlargingminora

Majoraandminora equally

prominent

Majora large

Minorasmall

Majoracoverclitoris and

minora

© K. Karlsen 2013

Sum scores

Physical maturity

Neuromuscular maturity

Total score correlates toweeks gestation

Score Weeks

-10 20

-5 22

0 24

5 26

10 28

15 30

20 32

25 34

30 36

35 38

40 40

45 42

50 44

25 34

physical assessment of the newborn: part 1...physical assessment of the newborn: part 1 the...

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