Newborn Examination
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Transcript of Newborn Examination
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