Examination of the Newborn Flashcards
What maternal medical information is needed before you start the exam?
- Maternal age
- Previous pregnancies, complications, and any medical problems experienced by those children
- Maternal disease and medication taken during pregnancy
- Maternal occupation and social background
- Maternal drug or alcohol abuse, socially high-risk circumstances (e.g., severe learning difficulties, maternal mental health problems, domestic violence, child protection issues, unsatisfactory home conditions)
- Family history of medical problems
- Results of pregnancy screening tests (e.g., blood tests including maternal syphilis, HIV, and hepatitis B surface antigen, prenatal ultrasound scans)
Results of special diagnostic procedures (e.g., noninvasive prenatal testing, amniocentesis, chorionic villus sampling)
Problems during labor and delivery (e.g., prolonged rupture of membranes, maternal fever)
What infant medical records are needed before you start the exam?
- Infant’s condition at birth and if resuscitation was required
- Infant’s birth weight
- Infant’s gender
- Gestational age and if there is any uncertainty about it
- Any concerns about the infant from nursing staff or parents (e.g., feeding concerns)
Introduction to the parents?
- Introduce yourself to the mother (Preferably, to both parents)
- Explain the purpose of the examination
- Ask for feeding problems or any other worries
- Conduct hand hygiene before starting the examination
- Ensure warm, private area with good lighting
Order of the examination?
head to foot
What is used to measure the infants growth parameters?
- Weight for age z-scores
- Head circumference z-scores
How do you determine gestational age?
measured from the first day of your last menstrual period to the current date - typically in weeks
Note: pregnancies last 38 to 42 weeks; babies born before 37 weeks are considered premature
General observation - appearance, posture and movements?
- Central cyanosis: on the tongue
- Acrocyanosis: Peripheral cyanosis on hands and feet (no clinical significance)
- Blue discoloration of presenting part (face/breech/nuchal cord)
Why do polycythemic infants sometimes appear cyanotic?
Polycythemic infants (central hematocrit >65%) sometimes appear cyanotic because of the high concentration of reduced hemoglobin in their blood, even though they are adequately oxygenated
What does blue discolouration with petichiae indicate?
the umbilical cord was wrapped around the infant’s neck
- this can be distinguished from central cyanosis because the tongue remains pink.
Features of Down syndrome in neonates?
- Hypotonia
- Flat occiput
- Bilateral single palmar creases
- Pronounced sandal gap (an abnormal spacing between the first two toes)
Note: Characteristic facies difficult in newborns
Inspection of the skin?
- Cracked, peeling skin: common in post-term infants
- Plethoric (very pink or flushed): Polycythemia
- Pale: Anemia or shock
- Jaundice: Within the first 24 hours of birth (hemolytic/congenital infections)
Note: Inspect the skin for color, texture, rashes, and birthmarks
Name benign, self-limited lesions?
- neonatal urticaria (erythma toxicum)
- neonatal pustular melanosis
- milia: white cysts
- epstein pearls
- epulis
- ranula
- mangolian spots
What is Neonatal urticaria (erythema toxicum)?
- Usually starts on the second or third day of life
- White pinpoint papules at the center of an erythematous base
- Eosinophils are present on microscopy
- Migrate to different sites and resolves around the fifth day
What is Neonatal pustular melanosis?
- Present from birth
- Contains neutrophils
- Readily removed by wiping
- May be mistaken for staphylococcal infection
What are milia (white cysts)?
- May be on nose and cheeks
- Retention of keratin and sebaceous material in the pilaceous follicles
What are epstein pearls?
White pearls along the midline of the palate
What is epulis?
cysts of the gums
What is ranula?
Mucus-retention cysts on the floor of the mouth
What are mongolian spots?
- Present in over 80% of black and Asians
- 10% of causian infants
- present at birth
- fade over time and treatment is not needed
What is the vernix caseosa?
- White to gray, cheesy, greasy layer of sebum, keratin, and hair
- Protected the fetus in utero
Inspection of the head?
- Note the shape of the head
- Palpate fontanelles and suture lines
- Anterior and posterior
Note: After delivery, the sagittal suture is often separated and the coronal sutures are overriding. The posterior fontanelle is often open but small.
What does a tense fontanelle indicate?
A tense fontanelle can also be a sign of meningitis; therefore, a lumbar puncture should also be considered if concerns are raised by the history or physical examination
What can we find on the head of a newborn?
- caput succedeneum
- cephalohematoma
- subgleal hemorrhage
- craniosynostosis
Caput succedaneum?
- Diffuse edematous swelling of the scalp
- Extravasation of blood or serum above the periosteum
- Caused by venous congestion due to pressure on the infant’s head
- Swelling crosses midline and not limited by the suture lines
- Resolves within a few days
Features of prolonged labour in a newborn?
petechiae, purpura, and ecchymoses, as well as molding of the head and overriding sutures, may be prominent features
Cephalohematoma?
- Caused by rupture of the emissary or diploic veins of the skull
- Subperiosteal hemorrhage
- Almost always unilateral
- Most often over the parietal bone
- Sharply demarcated
- Restricted by suture lines
- Overlying scalp is not discolored
When do you see the swelling of a cephaohematoma?
- The swelling may not become apparent until several hours to days after birth
- As the hematoma ages, it develops a calcified rim and is gradually completely overlaid with bone
Note: severe hemorrhage resulting in anemia and hyperbilirubinemia are rare complications for which antibiotics, blood transfusions, and phototherapy may be required
Subgaleal hemorrhage?
- Rupture of emissary veins
- Bleeding into the loose connective tissue of the subgaleal (subaponeurotic) space
- Swelling crosses suture lines; can extend from the brow line up to temporal fascia behind the ears.
Consequences of subgaleal hemorrhage?
Bleeding can be extensive, leading to:
1. severe anemia
2. disseminated intravascular coagulation (DIC)
3. hypovolemic shock
- the aponeurotic space may accommodate up to 260 mL of blood, approaching the circulating blood volume of a neonate, which is approximately 80 mL/kg
Craniosynostosis?
- Premature fusion of cranial sutures
- Results in asymmetric skull
- Palpable ridge along the suture line
Note: Surgery may be required nonurgently to avoid neurologic impairment and to improve cosmetic outcome
Inspection of the eyes?
size, slant, and position of the eyes - palpebral fissures
Inspection of breathing and chest?
- Observe breathing and chest wall movement
- Breathing should be normal, with no signs of respiratory distress - Periodic breathing with pauses of up to 10 seconds is normal
- Breast enlargement can occur
- A small amount of milk (“witch’s milk”) may be discharged
Signs of respiratory distress?
- respiratory rate greater than 60 breaths per minute
- retractions of accessory respiratory musculature
- flaring of the alae nasi
- grunting
What is considered abnormal in the ears?
- Low set ears is associated with some syndromes
- Preauricular tags are often benign but infants should be referred for hearing test if other dysmorphic features are present
Inspection of the mouth?
Observed mouth: size, position, and symmetry
What is a coloboma?
coloboma is a defect in the normal tissue in or around the eye that can involve the lid, cornea, iris, retina, or optic disc. efects internal to the pupil can only be diagnosed by ophthalmologic examination
What is the pupillary reflex?
- Red reflex: Normal
- White reflex (leukocoria):
- Suggest retinoblastoma
What is considered abnormal in the mouth and palate?
- Cleft lip and palate (may be recognized prenatally)
- Micrognathia
Inspection of the ears?
Note shape, size, and position
Normal: top third of the ear is level with a line drawn from the inner to the outer canthus of the eye
Eye discharge?
- Mucoid: usually spontaneously resolve
- Conjunctivitis:
- Gonococcal, Chlamydia trachomatisor HSV
Subconjunctivial hemorrhages?
- Common
- Occur during delivery and resolve in 1 to 2 weeks.
What to look for in inspection of the eyes?
- coloboma
- pupillary reflex
- congenital cataract
- subconjunctivial hemorrhages
- discharge
Abnormal things to look for in the neck?
- Redundant skin over the posterior neck and flat occiput in Down syndrome
- Webbed neck in Turner syndrome (may have lymphedema of the feet)
- Fluctuant swellings (Cystic hygromas) posterior triangle that transilluminate
What to be seen during the cardiovascular exam?
- Normal heart rate is 120-160 beats per minute
- Heart sounds loudest on the left side of the chest
- Murmurs heard in 2% of newborns; mostly innocent
- Femoral pulses palpable in a quiet infant
Features of an innocent murmur?
- Soft (grade 1/6 – 2/6) at left sternal edge
- No audible click
- Normal pulses
- Normal vital signs and clinical examination
Features of a hemodynamically significant Murmurs?
- Pansystolic
- Grade ≥ 3/6
- Harsh quality
- Best heard in the upper left sternal edge
- Abnormal 2nd heart sound
- Femoral pulses difficult to feel
- Abnormal vital signs or clinical examination
How do you determine coarctation of the aorta clinically?
- diminished femoral pulse
- comparing the systolic blood pressure in the upper and lower extremities
Note: decrease of more than 20 mm Hg in the legs is significant.
Abdominal examination?
Observe for abdominal distension, asymmetry and umbilical inflammation
What to see in an abdominal exam?
- Liver of 1-2cm and tip spleen: normal
- Exclude renal masses and palpable bladder
- Umbilical hernia: usually resolve a few years
- Inguinal hernia: 4% in term and 13% in <33 weeks gestation
Examination of the genitalia in boys?
- Penis: <2cm is micropenis (congenital hypopituitarism)
- Hypospadias: Abnormal urethral meatus position
- Testis: Hydroceles(confirmed on transillumination)
- Undescended if the testis
- is described as undescended if the testis has failed to descend from its embryologic position from the urogenital ridge on the posterior abdominal wall through the inguinal canal to the scrotum
Examination of genitalia in girls?
- the clitoris and labia minora are prominent if the infant is preterm but are covered by the labia majora at full term
- white vaginal discharge or small amount of bleeding from maternal hormone withdrawal
- prolapse of a ring of vaginal mucosa
- These resolve spontaneously.
Examination of genitalia in both girls and boys?
- Anus: inspected for position, appearance, and tone
- Passage of urine and meconium: expected within 24 hours of birth in most term newborns
Inspection of limbs, hands and feet?
- For general appearance, symmetry, and posture
- Spontaneous movement of all four limbs
- Limb reduction defects
- Extra digits
Upper limb abnormalities?
- extra digits
- nervous system conditions
- clavicle fractures
Abnormalities in the hands?
- Extra digits (polydactyly)
- Fused digits (syndactyly)
- Bent digits (clinodactyly)
- Single palmar transverse creases (in 45% of infants with trisomy 21)
Nervous system conditions that cause upper limb abnormalities?
- Brachial plexus lesions
- No active movement of the affected limb
- No restricted passive; not painful - Erb palsy: C5, C6, and sometimes C7
- Arm adducted and internally rotated flexion of the wrist (“waiter’s tip”) - Klumpke’s Palsy: C8 and T1
- Weak hand flexors of the wrist and fingers (“claw hand”)
- Respiratory distress (if accompanying phrenic nerve injury)
Clavicle fractures?
- Difficult delivery of the shoulders
- Infant appears to be uncomfortable
- Decreased arm movement on the affected side
- Therapy: supportive care (pain control and pinning outfit sleeve contralateral shoulder for immobilization)
Lower limb abnoralities?
- Positional talipes equinovarus
- developmental dysplasia
What is talipes equinovarus?
Feet turned inward from intrauterine compression
Commonly associated with oligohydramnios
Feet can passively be brought to normal position
Show parents passive exercises
Causes of talipes equinovarus?
Oligohydramnios
Malformation syndrome
Neuromuscular (e.g., spina bifida)
Referred to a pediatric orthopedic surgeon
- Early treatment casting and bracing usually avoids the need for surgery
What is developmental dysplasia of the hip?
Posteriorly dislocated (subluxated) femoral head
returned to acetabulum (Ortolani maneuver)
Femoral head in acetabulum dislocatable posteriorly (Barlow maneuver).
Inspection of the back and spine?
Back and spine are inspected and palpated for
1. Midline and other defects
2. Curvature of the spine
Assessment of gestation method?
The Ballard Method
- Uses Neurologic and Physical criteria
- Accurate only to ±2 weeks
Physical maturation of the skin?
Very premature infants (24 to 28 weeks) have nearly translucent, paper-thin skin that is easily abraded. A diffuse red hue and a prominent venous pattern are characteristic. At term, the skin no longer appears thin, and the general color is a pale pink. Some superficial peeling and cracking around the ankles and wrists may be visible. Post-term infants (42 to 44 weeks) often have more diffuse peeling and cracking of the skin because the outermost layers are sloughed (sluhft).
Physical maturation of the hair?
The general quality of scalp hair changes during development from rather fine, thin hair (24 to 28 weeks) to coarser, thicker hair (term). Racial differences in hair quality can make this change difficult to assess. Lanugo, a fine body hair that resembles peach fuzz, appears and disappears during development. It is absent before weeks 20 to 22, becomes diffuse until weeks 30 to 32, and then begins to thin. Assessment of the presence and extent of lanugo is best accomplished by observing the back tangentially
Physical maturation of the plantar surface?
Transverse sole creases appear
on the anterior portion the feet at 32 weeks
anterior two-thirds of the sole
covered with creases by 36 weeks
Note: Transverse sole creases cover approximately half the sole in this infant, indicating a gestational age of approximately 34 weeks
Physical maturation of breast tissue?
- progressively increase in size with advanced gestational age
- infants younger than 28 weeks’ have barely perceptible breast tissue
Note: Occasionally, a term infant has active glandular secretions, which resolve spontaneously. Breast tissue can remain palpable for 2 to 3 months.
Physical maturation of breast tissue?
Cartilaginous development
Assessed by examination of the ear
Feel the edge and fold the ear
Minimal recoil until 32 weeks
Instant recoil at term
Cartilaginous development proceeds in an orderly manner during gestation and can be assessed by examination of the external ear. Although the normal incurving of the upper pinnae begins at 33 to 34 weeks and is complete at term, it is more reliable to assess the extent of cartilage in the pinnae by feeling its edge and folding the ear. Until approximately 32 weeks, there is only minimal recoil of a folded ear, but by term there is instant recoil
Physical maturation of male genitalia?
Nature of rugae on scrotum
Presence of testicles
Physical maturation of female genitalia?
Relative sizes of majora, minor and clitoris
Neuromuscular maturity in posture?
Mature infant: marked flexor
posture of the extremities
Premature: extensor posture
Neuromuscular maturity of flexion angles?
Assess:
muscle tone
ligament and tendon laxity
flexion/extension development
Inspection in neurological exam?
Undress the infant to the nappy
Posture
Limb movements
Character of cry – strength and pitch
Abnormal movements
Antigravity movements
Fontanelle
Fix and following objects
Assessing tone and reflexes in neurological exams?
Use fingertips
No reflex hummer unless > 1 year old
Other reflexes:
Moro (persists in CP)
Grasp; rooting; asymmetric tonic neck reflex; placing or stepping – All disappear by 3 -6 months
Parachute : appears by about 3-6 months
