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 ?

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 ?

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 ?

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 ?

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 ?

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 ?

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 ?

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