Neonate Examination

Question 1

Why would the moulding of the skull not disappear ?

Answer 1

Plagiocephaly (flat skull) remains because they are in specific position.
Craniosynostosis : premature joining of skull bone.

Question 2

Type of head swellings ?

Answer 2

Cephalohematoma : firm and fluctuating, unable to spread cross a suture

Capital succedaneum : subcutaneous oedema, able to spread across suture

Question 3

Signs and cause of facial palsy in neonate?

Answer 3

Nasolabial fold flattened, eye that do not close, corner of the mouth does not move.

Due to neuropraxia by intrauterine compression.

Question 4

Facial asymmetry of the corner of the mouth ?

Answer 4

Congenital defect of depressor anguli oris muscle.
Permanent condition.

Question 5

Abnormalities of the nose ?

Answer 5

Crooked nose : compression in the womb.

Non patent nostrils : choanal atresia (congenital disorder where the choana are obstructed by soft tissue)

Question 6

Abnormalities of the mouth ?

Answer 6

Cleft lip / palate
Microretrognathia : too small jaw, displacement of the chin posteriorly. Consequence of Pierre robin syndrome.

Question 7

What is Pierre Robin syndrome ?

Answer 7

Congenital birth defect characterized by an underdeveloped jaw, backward displacement of the tongue and upper airway obstruction.

Question 8

Abormalities of the ear ?

Answer 8

Abnormal shape and low ears : hereditary and chromosomal
Unilateral ear abnormality : look for kidney condition

Question 9

Symptoms of congenital cataract ?

Answer 9

Congenital clouding of the lens.
- bilateral one : 10% of blindness. If not treated nystagmus develop.

Absent pupillary light reflex (also in other condition)

Question 10

Cause of congenital cataract ?

Answer 10

Genetic abnormalities, intrauterine infection, metabolic storage, underlying eye disorder disorder, idiopathic.

Question 11

What are congenital abnormalities of the eyes ?

Answer 11

Congenital cataract

Congenital nystagmus
- may be caused by neuropathy

Congenital glaucoma : 5-13% of childhood blindness
- large eyes, tears excessively, photophobia

Congenital hole in iris : Colomboma of iris

Ptosis, abnormal iris color, conjunctivitis

Question 12

What are abnormalities of the neck ?

Answer 12

Neck position : often torticolis
- caused by oligohydramnios development in cervical spine

Sternocleidomastoid muscle hematoma causing lateral swellings in neck.
- also could be : lateral, median neck cyst

Enlarged thyroid

Question 13

What are abnormalities of the abdomen in neonates ?

Answer 13

Distended or depressed abdomen :
- bowel obstruction : vomiting and delayed méconium
- enlarged abdominal organ
- ascites

Local swelling in groin : inguinal / femoral hernia

Question 14

What are abnormalities of the umbilical cord ?

Answer 14

<1% of children : born with only one artery
- increased risk of abnormalities : gastrointestinal atresia
- ultrasound recommended

Question 15

What are genital abnormalities in males ?

Answer 15

Physiological retractile testis : in the inguinal canal and can be moved into scrotum.

Cryptorchidism = non scrotal testis : congenital or aquired

Question 16

Characteristics of cryptorchidism ?

Answer 16

Cannot be brought in stable scrotal position.
Normally testis descend around the term but can also be in the first 6 month. After that it should be surgically corrected, because of long term malignancy degeneration.

Question 17

What are abnormalities of external genitalia in females (neonates)?

Answer 17

Synechiea: labias stuck together
Highly enlarged clitoris : adrenogenital syndrome / use of virilisions medication by the mother

Question 18

What are abnormality of the back of a neonate?

Answer 18

Excessive body hair, skin abnormalities, swellings
- spinal malformation, spina bifida occulta

Lumbosacral dermal melanocytosis = Mongolian spot : harmlesss local blue patch

Asymmetrical gluteal fold
- hip dysplasia suspicion

Question 19

Clinical significance of hypertonia (neonate) ?

Answer 19

Acute or chronic intracerebral pathology
- asphyxia, convulsion, septic meningitis, congenital cerebral defect

Question 20

Clinical significance of hypotonia ? (MINSe)

Answer 20

• Severe illness : sepsis, post asphyxia
• Intoxicant : medication, drug, accumulation of toxic metabolites
• Neuromuscular disorder
• Metabolic disorder

Question 21

APGAR score ?

Answer 21

Ademhaling :
- strong crying, regular powerful breathing
- weak crying, irregular breathing, gasping
- none

Pulse rate :
- above 100 bpm
- under 100 bpm
- absent

SpierspanninG :
- resistance against extension, movement
- slow return to flexion after extension
- flaccid

Aspect :
- pink
- pink with blue extremities
- blue or pale

Reactie op prikkels :
- retraction, grimace, crying
- moderate response
- none

Question 22

Skull of a neonate ?

Answer 22

During delivery, it needs space between the skull bones to ensure that the skull can be distorted to pass more easily through the pelvis.
- moulding : temporary distortion with skull bones riding over each other

Sutures :
- lambdoid
- Sagittarius
- coronal
- metopic

Question 23

Fontanelles of the skull ?

Answer 23

Anterior fontanelle :
- Diamond shaped
- 2x2 cm large

Posterior fontanelle :
- triangle shaped over occipital
- Large as a fingertip

Question 24

Characteristics of foetal circulation ?

Answer 24

Lung do not perform any oxygenation function and intestines do not play part in digestion.
- Placenta perform these functions : oxygen and nutrients rich blood from placenta flows via umbilical vein, ductus venous to IVC

The 2 side of the heart still function as a unit.

Question 25

Heart of a foetus ?

Answer 25

Foramen ovale : blood flow from right atrium to the left - bypass lungs Ductus arteriosus : blood remaining in right ventricles goes to the right ventricle then pulmonary trunk where it flows directly to the aorta - bypass the lungs

Question 26

Transition from foetal to neonatal circulation ?

Answer 26

Closure of ductus venosus : Triggered by cessation of blood flow through the umbilical vein after umbilical cord is cut. Closure of foramen ovale : Alveoli fill with air and the resistance in pulmonary circulation is reduced. Increased pressurising left atrium. Closure of ductus arteriosus : 10-15h postpartum. Increase in Pa of O2 causing a decrease in prostaglandin production.

Question 27

What is present in the first routine examination ?

Answer 27

Apgar score General impression Skin Body part : - head and neck - chest - limbs - back - external genitalia General neurological reflex Weight Head circumference

Question 28

What do you inspect in general impression ?

Answer 28

Done just after first APGAR score then after 10 min. Characteristics : - color - attitude : calm, relaxed, agitated - muscle tone Signs of underlying cardiovascular or respiratory problems - cyanosis, pallor, tachycardia, tachypnea, dyspnea, nasal flaring - full term : 120-160 bpm, 30-40 breaths/min - pre-term : 140-180 bpm, 40-60 breaths/min

Question 29

Hypotonic infant ?

Answer 29

Arms extended along the body. Legs flat in frog position. Head and trunk unstable. Difficult to pick up.

Question 30

What do you assess in head and neck ?

Answer 30

General head : - size and shape of skull - palpate anterior and posterior fontanelle - symmetry Eyes : - Ocular alignment : straight, slanting - hypertelorism : abnormal distance between eyes - Epicanthic fold - width of palpebral fissures - transparency of the lens - red light reflex Nose : - position - patency of nostrils Mouth : - symmetry - color - palpate soft and hard palate - sucking reflex Ears : - shape and position - auricula appendage and pre-auricular fistulas

Question 31

What do you assess in the chest ?

Answer 31

Inspect : - symmetry and shape - signs of increased respiratory effort : nasal flaring, IC recession, thoracic breathing - audible breathing sounds Percuss and auscultate lungs : - use pediatric stethoscope - symmetry of breath sound, presence of adventitous sounds Palpate and auscultate heart : - check for thrill on the left thorax - assess possible murmur : type, timing in cycle, loudness, PMI, radiation Blood pressure Check if both clavicle are intact : infant will turn the head toward unaffected shoulder and move arm less

Question 32

What do you assess in the abdomen of a neonate?

Answer 32

Normal abdomen should bulge slightly due to underdeveloped abdominal muscle. Check umbilical cord Auscultate for peristalsis Palpation : - abnormal resistance - size of liver : 1-3 cm below costal arch - swelling in the groin - femoral pulse

Question 33

What do you assess in the limbs (neonate)?

Answer 33

Inspect : - hand crease : present and normal - spontaneous movement - count fingers and toes Hip examination : - increase risk of hip dysplasia if : breech birth, multiple birth, positive family history - skin fold and gluteal fold

Question 34

What primitive reflex do you check ? (9)

Answer 34

Grasp reflexes : - plantar : toe curling when finger under them - palmar : place finger inside hand, it will close Rooting reflex : - cheek stroked, head turns toward direction of stroke Sucking reflex : - touch the top of the mouth and attempt to suck Step reflex : - infant upright, feet touching a surface, leg movement like walking Moro reflex : - move trunk and head backward suddenly, they will extend then flex their arms again Startle reflex : - loud noise or unexpected movement, extension of arms then flexion Babinski reflex : - stroke bottom of foot, dorsiflexion and spreading Crawling reflex : - on the stomach, apply pressure on foot, tries to push against hand Tonic neck reflex : - turn head to the side, leg/arm of that side extend, the opposite flex

Question 35

Characteristics of Down syndrome infant ?

Answer 35

Small head, flat occipital and profile. One palmar crease. Up slanting eyes Epicanthic folds Low muscle tone Short broad, neck with excess skin