L S Deshmukh

DM ( Neonatology )

Professor ( Pediatrics )

GMC, Aurangabad

Assessing a newborn infant is like looking at an iceberg.

Only the grossest of abnormalities are apparent immediately. Some problems can be resolved by careful examination and by investigations .

evaluation Checklist Physical and neurologic examination

Medical and social history

Vision and hearing screening

Laboratory analysis of complete blood count,

chemistries

serology screening for human immunodeficiency virus, hepatitis B and C, and syphilis

Genetic screening for cystic fibrosis, Fragile X and Down syndromes

metabolic screening

TsH

Evaluation

A comprehensive medical evaluation

thorough review of the medical history, including

an assessment of health risks

a Neurological assessment and

a complete , unclothed physical

examination

comprehensive medical evaluation

not necessary during only one medical visit.

complete the assessment of the Baby’ history

Review laboratory findings

Referrals

Subsequent evaluations

The cardinal rule :

All information should be taken seriously, but ...

All information is suspect.

One of the greatest indicators of the wellness of a newborn is the general observation or gestalt that a clinician obtains by simplywatching a baby before the start of a physical exam.

Components of the General Physical Examination

A review of the medical history including:

family history, maternal, antenatal and perinatalhistory,

infant, fetal and neonatal history

including any previously plotted birth-weight and head circumference

A review of parental concerns

Feeding

Ensure relevant information is available to healthcare professionals

History Of particular importance are

histories of the natural parents in order to assess possible genetic disorders and

information relating to the quality of the mother's pregnancy

assessment of history

Prenatal blood and urine test results of mother

○ Exposure to medications, illegal substances, alcohol, tobacco

○ Gestational age, birth weight, length, head size; Apgarscores

○ Prenatal concerns, neonatal complications

○ Newborn hearing screening results

○ newborn metabolic screening

Family history

○ Vision, hearing deficits

○ Genetic diseases

○ Concerns related to H/o eg, sickle cell anemia, thalassemia, Tay Sachs disease, lactose intolerance

○ Mental health diagnoses

Components of the General Physical Examination

Examine fontanelle(s), face, nose, mouth including palate, ears, neck and general symmetry of head, vault, sutures, fontanelles and facial features

Check eyes – opacities and ‘red reflex’

Examine the neck and clavicles, limbs, hands, feet and digits, assessing proportions and symmetry

Cardiovascular system – heart rate, rhythm and sounds, murmurs and femoral pulse volume

Components of the General Physical Examination

Initial Communication Give relevant information to parents before the

examination together with an opportunity to discuss the forthcoming screens

Whether the baby has passed meconium and urine (and the nature of the urine stream in a boy)

Observe the baby’s appearance including colour, breathing, behaviour, activity and posture

Components of the General Physical Examination

Respiratory system – effort rate and lung sounds

Abdomen – shape and palpate to identify any organomegaly. Check condition of the umbilical cord

Genitalia and anus. Check anus for patency. Check genitalia for form and undescended testicles in males

Spine – inspect and palpate bony structures and integrity of skin

Components of the General Physical Examination

Skin – note the colour and texture of the skin as well as any birthmarks or rashes

Central nervous system – observe tone, behaviour, movements, and posture and elicit newborn reflexes only if concerned

Hips – check symmetry of the limbs and skin folds. Perform Barlow and Ortolani’s manoeuvres

Cry – note sound of baby’s cry

Measurement of weight and head circumference

Head Size pay careful attention to the size of a child's head.

The head circumference is the most important measurement to follow in the pre adoption evaluation.

This measurement is the most accurate reflection of brain growth during the first years of life.

A small head (microcephaly) may suggest malnutrition, fetal alcohol exposure, or a birth defect, either genetic or resulting from the birth process.

Genetic Testing

Because the primary justification for genetic testing

of any child is a timely medical benefit to the child,

genetic testing of newborns and children in the

adoption process should be limited to testing for

conditions that manifest themselves during

childhood or for which preventive measures or

therapies may be undertaken during childhood.

Genetic Testing

In the adoption process, newborns and children should not be tested for the purpose of detecting genetic variations of or predispositions to physical, mental, or behavioral traits within the normal range.

timely medical benefit to the child should be the primary justification

If the medical or psychosocial benefits of a genetic test will not accrue until adulthood, as in the case of carrier status or adult-onset diseases, genetic testing generally

should be deferred.

Points to Consider: Ethical, Legal, and Psychosocial

Imp Considerations

Some parents expect the guarantee of a “perfect child.”

not to create a “vulnerable Child”

not the pediatrician’s role to judge the advisability of a proposed adoption

apprised clearly and honestly of any special health needs detected now or anticipated for the future.

Imp Considerations

the pediatrician should resist unreasonable

demands

empathize with the parents’ anxieties and concerns.

The welfare of children should be the first concern in the practice .

Adoptive Parents’ Interests

the best interest of the child has been and continues to be the legal benchmark of the adoption process

laws also seek to protect the interests of the adoptive parents and the birth Parents

Distinguish Preventive and therapeutic medical decisions from predictive testing.

Disclose fully child’s medical background before adoption

predictive testing goes well beyond this standard and is neither advisable nor necessary

Pediatrician’ Dilemma

The mere threat of litigation may cause some Docs to require testing without a clear understanding of their duties.

As the availability of tests increases, this pressure to test based on a fear of litigation can be expected to increase.

Docs are not guarantors of the health of the children.

They can only guarantee that the assessment & information in their possession is disclosed

Imp : eye & ear

Hearing

○ Validate newborn screening when available

○ Screen all children if possible, particularly those with risk factors for hearing loss as well as developmental (speech) delays .

• Vision

○ Eye examination as appropriate for age

○ Funduscopic examination for children with birth wt <1500

Full-term newborns with appropriate growth parameters have the best chance for normal growth and development in the future.

Immunization issues written documentation for immunizations given

? vaccine potency, storage and handling, age when given and reliability of accurate records.

two alternatives to this problem.

- Either serologic testing may be done to determine whether protective antibody levels are present or

- the child may be re-immunized.

Laboratory tests

a crucial part of the initial medical evaluation.

ensure that the child is free of diseases that could have an adverse affect on long-term health

Laboratory tests – Consider in all babies

CBC

TsH

Metabolic screen

TORCH

HIV testing

? Karyotype

HIV Testing a positive virological test at 6 weeks for HIV or its

components

usually by HIV-DNA PCR

The diagnosis should be confirmed by a second test on a separate sample should be repeated at the earliest

Positive antibody testing is not recommended for definitive or confirmatory diagnosis of HIV infection in children until 18 months of age

Laboratory tests

reassuring when test results are normal,

convey to parents ( that we do not know much ) about the quality control standards

Consider timing of the laboratory tests

Potential Risk factors

Prematurity

Medical and developmental risks depend on gestational age/birth weight

AND complications in the nursery …

Major and minor (but functionally important) outcomes common

But long term adult outcomes may be good

Potential Risk factors

Pediatr Clin N Am 52 (2005) 1247– 1269

Prematurity and Low Birthweight

Increased risk of:

- cerebral palsy

- vision and hearing deficits

- learning disabilities

- ADHD

- Asthma

- Feeding problems

Look Specially for

Congenital Heart

Cleft Lip and Palate

Limb deficiencies

Genetic Syndromes

Hip Dyslplasia

Specific Concerns or Diagnoses to Discuss With Families (? Gray Areas)

Family history of mental illness or mental retardation

Antenatal drug or alcohol exposure

Prematurity

Low birthweight

Hepatitis B/C

Maternal syphilis

Developmental dysplasia of the hip

Increased muscle tone

All the conditions may not be manifest at birth

At six weeks most congenital heart lesions will have become apparent and

by three months a reasonable assessment of the infant’ neurological status can be made

Remember Usually, the features that may make a normal

newborn look strange are temporary.

In the eyes of the adoring parent, every infant looks like “the perfect baby” anyway.

Child Information Sheet

Child Information Sheet

It is not the pediatrician’s role tochoose a Baby for the family or to judge the advisability of a proposed adoption / tubectomy. Rather, the clinician should help the family make a fully informed decision.