Newborn Exam Flashcards
Neonatal Hx includes?
- Maternal & paternal Hx
a. Medical
b. Genetic - Maternal OB Hx
- Current OB Hx
a. Antepartum
b. Intrapartum
- Gestational age of infant
Physical Exam @ Birth
- Observation
- Cyanosis
- Respiratory distress
- Genetic anomalies
- Rashes - Auscultation
- Lungs
- Heart - APGAR Score
- Skin color
- Indicator of CO - Skeletal
- Detect obvious congenital anomalies - Birth trauma
- Fx clavicle - Number umbilical cord vessels
- 2 arteries and 1 vein - Placenta
- Placental infarcts or clots
What is the APGAR Score? (Look at the chart)
- Assessed at 1 & 5 minutes
a. Low scores alert clinician to the need for resuscitation efforts
- ≥ 7 normal
- 4 - 6 fairly low
- ≤ 3 critically low
b. 10 min if score remains low
Physical Exam in Nursery
- Weight
- Height
- Head Circumference
- Chest Circumference
- Vital signs
a. Temperature
b. Pulse, Heart Rate
- 100-180/min
c. Respiration
- 40-60/min
d. Blood Pressure
- @ 12 hr 50-70/25-45
- @ 96 hr 60-90/20-60
Exam of the Skin
Color Texture & Turgor Edema Birth Marks Infectious lesions Capillary bleeding Trauma
PE: Normal Skin Findings vs Abnormal Skin Findings
- Normal Skin Findings
- Erythema toxicum
- Milia
- Miliaria
- Mongolian spots
- Hemangioma
- Vervex caseosa
- Lanugo
- Mottling - Abnormal Skin Findings
- Pale conjunctiva
- Jaundice
- Cyanosis
What is Erythema Toxicum?
- Small pustules on erythematous bases
- Very common
- Appears 3-5 days after birth
- Spontaneous resolution 1-2 weeks
What is Milia?
- Tiny white papules
- Keratin-filled epidermal cyst
- Concentrated on nose, cheeks, forehead & chin
- Resolves spontaneously 1-2 months
What is Miliaria?
- “Heat rash”
- Blockage of sweat glands
- Flushed macular appearance of neck, face, scalp & diaper area
What are Mongolian Spots?
- Hereditary in dark skinned infants
- Entrapped melanocytes in dermis
- Involves small to large blue black macules on back & buttocks
- Present at birth or appears w/in 1st weeks of life
- Disappear spontaneously by 4 yr but can persist for life
What is an Hemangioma?
- Appear during 1st few weeks of life
- Most common childhood tumor
- Proliferation stage up to 12 mo
- 50% disappear by age 5 yr
What is the “Stork Bite” Mark?
- Salmon colored patches most commonly found on nape of neck
- Due to stretching or dilation of blood vessels
- Darker when infant cries
- Fades when pressure applied
- Frequently visible into adulthood
What is a Port Wine Stain?
- Usually flat & pink
- May deepen in color as child grows
- Often on face, but can appear anywhere
- Thickens & takes on a cobblestone-like appearance
- Laser therapy best Tx
What is Lanugo?
- Thin hair overlying shoulder
- Normally shed before birth @ 7-8 mo. of gestation
- Usually present in premature infants
- Sometimes present in full term
What is Vernex Caseosa?
- Waxy or greasy covering
- Protects skin from damage by amniotic fluid
- More abundant in pre-term infants
What is Mottling?
- Lacy light purple appearing discoloration of skin
- Accentuated vasomotor response
- Common in newborns when exposed to cold temp or high altitude
- Asst. w/ trisomy 18 & trisomy 13
Physical Exam: Head & Face
- Head ( symmetry of skull and face )
- Molding (over-riding cranial bone)
- Fontanelles ( soft, not sunken or bulging )
- Head circumference 33-38 cm
- Facial symmetry
Fontanelles: When does the Anterior and Posterior close?
- Anterior
- 1-4 cm in size
- Closes @ 6-12 months of age - Posterior
- 1 cm in size
- Closes @ 1-3 months of age
What is cephalhematoma?
- Hematoma between skull & periosteum
- Boundaries limited by individual bones
- 2° to prolonged labor or instrument delivery
What is caput succedaneum?
- Benign subcutaneous hematoma that crosses suture lines
- Tourniquet effect of the cervix during delivery
What is molding?
Ridges that develop when one bone slightly overlaps the other during delivery
Complete resolution over time
What is Facial Nerve Palsy?
- Often 2° to birth trauma
- Infant monitored closely to determine if resolves
- May require PT
Physical Exam: Head & Neck
- Head and Neck
a. Eyes
b. Ears
- Look for low set
c. Nose breathers til 4 months
d. Mouth
- Cleft palate - Neck
a. Webbing
- Congenital abnormalities
b. Masses (thyroid rare)
Parts of the Eye Exam
Red reflex Visual following at 5-6 wks 180 degree tracking at 4 months Irritation & infection PERRLA Fundoscopic exam
What to look for during the eye exam?
- Asymmetric red reflex warrants immediate referral to pediatric ophthalmologist
- Congenital cataracts
- Glaucoma
- Retinoblastoma - Brushfield spots asst w/ Down Syndrome
- Grey or pale yellow spots @ periphery of iris - Strabismus
- Common in newborns
- Resolves by 6 - 12 mo - Subconjunctival hemorrhage (hyposphagma)
- Commonly asst w/ traumatic delivery
- Resolve spontaneously
Low Set Ears
- Draw imaginery line from canthus of eye straight back to occiput
- Low set ears asst w/ trisomy 18
On Exam --> a. Visualize TM’s b. Hearing -Auditory brainstem response (Screening for congenital deafness)
Bradycardia in an infant is under what?
What does APGAR stand for?
Activity Pulse Grimace Appearance Respiration
Can get a score of 0, 1, or 2
7 or above = NORMAL
Nose
- Nasal patency is best checked by placing a cold metal object below nose to check for fogging
- Choanal atresia presents with unilateral or bilateral obstruction
a. Usually asst w/ other congenital anomalies
What is a large tongue often assisted with?
Trisomy 21
Physical Exam: Heart & Lungs
- Breasts-galactorrhea
- Cardiopulmonary
a. Chest wall deformity
- Fractures from birth trauma
- Clavicle most commonly fractured - Respiratory
a. Grunting
- Asst w/ serious illness
- Sign of resp distress - Cardiovascular
- VS
- Murmurs
- Altered position of heart sounds
When does a hemangioma start to decrease and go away?
Normally around age 3, if not - can be lasered later on in life
Chest Fractures or deformities in an infant
- Clavicle Fracture
- Prominent Xiphoid
a. common finding in newborn
b. becomes less prominent over time - Pectus Excavatum
What is Pectus Excavatum?
- With deep inspiration, sternum appears to be almost collapsed
- Can be found in normal infants
- Sometimes asst w/ connective tissue disorders
a. Marfan Syndrome
What are Retractions?
- One of the most important physical findings in a newborn
a. Sign of resp distress - Asst w/sepsis, pulmonary pathology, cardiac disease, metabolic disorders, polycythemia
Cardiac Exam of the Infant
- Heart rate is rapid
a. Avg 140 bpm - Murmurs are common
a. Not always asst w/ pathology - Congenital heart disease signs
a. Cyanosis, CHF, ↓ peripheral pulses
Abdominal Exam of the Infant
- Check for diaphragmatic hernia
a. Severe scaphoid belly + resp distress - Masses &/or distention
- Liver & kidneys
a. Prune belly or absence abd musculature asst w/ renal anomalies
b. Prominent kidneys suggest hydronephrosis
What is a Meconium Stained Umbilical Cord?
- Cord is about 7 hrs old
- Cord was stained by meconium in utero –> dark green color
- Indicates meconium present in amniotic fluid for some time
a. R/O Meconium Aspiration
Which head delivery injury needs an X-ray?
Cephalo Hematoma!!!
NOT CAPUT SUCCEDANEUM (more swelling and a superficial bruise)
What is Meconium Aspiration Syndrome?
- Rapid or labored breathing
- Cyanosis
- Slow heartbeat (
What is Diastasis Recti?
- Separationbetween the 2 sides ofrectus abdominis muscle
- Spontaneously resolves
- More common inpremature& African-Americannewborns
Physical Exam: Genitalia & Anus
- Inspect & palpate for anal patency
- Male genitalia
a. Inguinal hernia
b. Hypospadias - Female Genitalia
a. Imperforate hymen
b. Vaginal bloody discharge - Ambiguous genitalia
Normal Female Genitalia
- When examining the genitalia of a girl, it is important to visualize hymenal tissue
- Hymenal tissue is light pink tissue that can be seen between labia minora
- There should be a central opening, bulging suggests imperforate
What are hypospadias?
Opening of urethra on ventral (underside of) penile shaft
How common are congenital hip dislocations/dysplasia?
1 in 500 infants
Higher frequency in breech births
What is the Barlow Maneuver?
- Attempt to dislocate hip w/posterior pressure
- W/knees adducted & fully flexed, examiner’s thumb & index finger grasp knees while middle finger placed on outside of femur
- (+) test is palpable click
What is the Ortolani Maneuver?
- Grasp medial aspect of flexed knee w/ thumb & fully abduct hips
- (+) test spasm or “clunk” as hips are brought to full abduction
Physical Exam: Extremities
Inspect for: -Rudimentary digits -Club foot -Spinal deformities (Spinal bifida)
What is Club Feet?
Severe eversion of plantar surface
Warrants immediate Ortho referral
What is Spina Bifida?
- Tufts of hair or hemangiomas that cross midline may represent spina bifida
a. Portion of spinal cord & meninges exposed through gap in vertebral column
Neuro Exam of the Infant
- Newborn Reflexes
- Sucking & rooting
- Moro or startle reflex
- Palmar grasp
- Placing reflex
- DTR’s
What is Rooting?
Stroking face of newborn elicits turning of head toward stimulus
What is Sucking?
When offered a nipple, the infant will instinctively suckle
What is the Moro Reflex?
- Also called startle reflex
- Allow infant’s head to drop suddenly by 1-2 cm
- Observe for abduction at shoulders & elbows along w/ spreading & extending fingers
- Disappears by 3-4 months of age
What is the palmers Grasp?
Placement of examiner’s finger in infant’s
Disappears by 4 months of age
What is the Traction Response?
- Pull infant by arms to sitting position
2. Observe head lag initially, finally coming to midline before falling forward
What is the placing reflex?
When dangling infant, natural response will be toes/foot touch table w/stepping response
DTR’s of the Newborn
- Reflexes in newborn are brisk
- (+) Babinski may be noted as late as 2 yr of age
- Upward fanning of toes
NYS Newborn Screening: Endocrine Disorders
Congenital adrenal hyperplasia
Congenital hypothyroidism
NYS Newborn Screening: Hemoglobinopathies
Sickle cell disease.
Sickle cell trait (sickle cell carrier)
NYS Newborn Screening: Infectious Disease
HIV
NYS Newborn Screening: Inborn Errors of Metabolism - AA Disorders
Homocystinuria Hypermethioninemia Branched-chain ketonuria (Maple syrup urine disease -MSUD) Phenylketonuria Tyrosinemia
NYS Newborn Screening : Inborn Errors of Metabolism - Fatty Acid Oxidation Disorders
Carnitine-acylcarnitine translocase deficiency.
Carnitine palmitoyltransferase I deficiency
Carnitine palmitoyltransferase II deficiency
Carnitine uptake defect
2,4-Dienoyl-CoA reductase deficiency
Long-chain hydroxyacyl-CoA dehydrogenase deficiency
Medium-chain acyl-CoA dehydrogenase
Medium-chain ketoacyl-CoA thiolase deficiency
Medium/short-chain hydroxyacyl-CoA dehydrogenase deficiency.
Mitochondrial trifunctional protein deficiency
Multiple acyl-CoA dehydrogenase deficiency - MADD, also known as glutaric acidemia type II (GA-II)
Short-chain acyl-CoA dehydrogenase deficiency
Very long-chain acyl-CoA dehydrogenase deficiency
NYS Newborn Screening : Inborn Errors of Metabolism - Organic Acid Disorders
Cobalamin A,B cofactor deficiency
Cobalamin C,D cofactor deficiency
Glutaric acidemia type I
3-Hydroxy-3-methylglutaryl-CoA lyase
Isobutyryl-CoA dehydrogenase deficiency
Isovaleric acidemia
Malonic acidemia
2-Methylbutyryl-CoA dehydrogenase deficiency
3-Methylcrotonyl-CoA carboxylase deficiency
3-Methylglutaconic acidemia
2-Methyl-3-hydroxybutyryl-CoA dehydrogenase deficiency
Methylmalonyl-CoA mutase deficiency
Mitochondrial acetoacetyl-CoA thiolase deficiency
Multiple carboxylase deficiency
Propionic acidemia
NYS Newborn Screening: Inborn Errors of Metabolism - Urea Cycle Disorders
Argininemia
Argininosuccinic acidemia
Citrullinemia
Hyperammonemia/ hyperornithinemia/ homocitrullinemia
NYS Newborn Screening: Other Genetic Conditions
Biotinidase deficiency
Cystic fibrosis
Galactosemia
Common Inborn Errors of Metabolism
- Hypothyroidism
a. 1:4500 live births
b. Signs/Sx’s
- Mental retardation, lethargy, thick tongue
- 75% newborns asymptomatic
c. Rx: thyroid replacement - Congenital adrenal hyperplasia
a. 1:5000 live births
- Ambiguous genitalia
b. Rx: corticosteroid replacement - Phenylketonuria
a. 1:12,000 live births
b. Signs/Sx’s
- Mental retardation, seizures. Autism
c. Rx: Low protein diet, avoid phenylalanine - Galactosemia
a. 1:60,000 live births
- Mental retardation, neonatal jaundice
b. Rx: lactose & galactose free diet
