Newborn Reflexes + Exam Flashcards
Moro reflex
Stimulation by sudden movement or loud noise resulting in the child suddenly extending then flexing both the arms and legs
Emergences 8-9 wks in utero and disappears around 6 mos
Palmar grasp reflex
Placing a finger or other object in the palm of the infant produces a grasp-like response and flexion of the hand
This arises 11 wks in utero and tends to disappear by 6 mos
Rooting reflex
Tactile stimulation near the infant’s mouth results in the mouth moving towards the stimuli and producing a sucking-like response
Imperative for newborn feeding
Present at birth, disappears after 4-6 mos
Galant reflex
AKA the trunk incurvation reflex
Occurs when skin along the edge of the vertebral column is stroked and results in a curvature of the spine with concavity to the side of the side
Disappears 18 wks to 12 mos
Asymmetric tonic neck reflex
AKA fencing position
With the infant supine, turning the head results in an ipsilateral extension of the arm and leg with flexion of the opposite extremities
Usually disappears within 3 mos
Parachute reflex
Does not appear until 8-10 mos and once present never goes away
Produced when suspended face down and moved towards an object- the arms will extend outward in a parachute-like fashion for protection
Babinski reflex
AKA the plantar reflex
Occurs by stroking the lateral aspect of the sole from the heel up, causing dorsiflexion of the great toe and a fanning out of the remaining toes
Present at birth, should go away at 12-18 mos
Standing/stepping reflexes
Sometimes referred to as placing reflex- occurs when the infant’s foot comes in contact with the ground while being held. Baby will make efforts to stand take step-like movements
Typically disappears by 4-6 mos
What age is considered a neonate?
Birth to 28 days
What age is considered a toddler?
12-36 mos
What age is considered an adolescent?
10-25 yo
Early adolescence
Focused on the present and the peer group
Middle adolescence
Developing insight of own feelings and others
Late adolescence
Formal operational style thinking
Tips for the exam
Newborns have poor temp regulation, keep the exam room warm or use warming blankets or tables
Auscultate prior to moving the baby
Parents should be present during the exam unless emergent or concerns of abuse
Head has most heat leakage
When should APGAR scores be taken?
1 and 5 mins after birth
Nl APGAR scores
8-10
<7 can be indicative of nervous system depression
<4 warrant immediate resuscitation
Activity scores
0: Absent
1: Flexed arms and legs
2: Active
Pulse scores
0: Absent
1: <100
2: >100
Grimace scores
0: Floppy
1: Minimal response to stimulation
2: Prompt response to stimulation
Appearance scores
0: Blue, pale
1: Pink body, blue extremities
2: Pink
What should be done after obtaining APGAR score?
Measure vitals, including height, weight, and head circumference
What will happen to weight during the first week?
Will lose 3-7% of body weight in the first few days of life
How does weight gain happen after the first week?
Will gain weight at the rate of approximately 10-20 g daily
Where should BP be obtained?
In both upper and lower extremities
What is nl BP?
(75-100)/(50-70)
What is nl newborn HR?
100-160 bmp at rest
What is nl newborn RR?
30-50 at rest
What is nl newborn temp?
98.0 -98.6 degrees
Vernix caseosa
A waxy white substance found on newborns immediately after delivery: Recent studies suggest that vernix may have antioxidant, moisturizing and antibacterial properties
Acrocyanosis
Blue discoloration of the tips of the fingers and toes
Mongolian spot
A naturally occurring blue/gray discoloration of the skin of a newborn, most commonly seen on the sacral area
Salmon patch
A birth mark that typically presents a salmon colored lesion on the face- it is also referred to as an angel’s kiss
Stork bite
AKA nevus flammeus nuchae
A pink or red birth mark located on the back of a newborn’s neck
Milia
Small, pinpoint white lesions that appear on the skin, typically the face. They are keratin-filled cysts
just below the epidermis
Don’t squeeze them- resolve after a couple of days
Cafe au lait spots
Coffee colored birthmarks, often permanent and with time may increase in size or number
Usually posterior back
Document bc of neurofibromatosis
Lanugo
Fine hair that is often seen on the newborn and typically disappears within a few days to weeks. It is replaced later by hair known as vellus hair, and in adulthood called terminal hair
Fontanelles
Soft membranous gaps between sutures that allow the fetus’s head to more easily pass through the birth canal
When does the posterior fontanelle close?
2-3 mos after birth
When does the sphenoidal fontanelle close?
6 mos after birth
When does the mastoid fontanelle close?
6-18 mos after birth
When does the anterior fontanelle close?
12-18 mos
Caput succedaneum
The swelling of the head after delivery secondary to pressure or trauma from the vaginal canal
Will reshape, but keep an eye on it
Cephalohematoma
A subperiosteal hematoma that does not cross suture lines
Pose no risk of brain damage and are often self-resolving in the first days to weeks of life
Subgaleal hemorrhage hematoma
Not a nl variant of birth and can lead to severe complications (anemia, resp. distress, seizures, shock death)
Occur when emissary veins rupture, leading to the accumulation of blood below the aponeurosis of the scalp and above the periosteum
Onset of swelling often occurs within 12-72 hours postpartum and will present as a fluctuate boggy mass over the scalp
Occasionally babies will develop raccoon eyes
Eyes
Examine and ensure red reflex is present in both eyes
Nose
Assess- newborns are obligate nose-breathers untile 4 mos
R/o choanal atresia
Choanal atresia
MC congenital nose malformation
Blockage of back of nose. Occlude a nostril to check whether it’s even
Ears
Examine ears for placement, mobility, and cartilage
Automated Auditory Brainstem Response (AABR)
Measures how the acoustic nerve responds to sound. Clicks or tones are played through soft earphones into the baby’s ears. 3 electrodes placed on the baby’s head measure nerve response.
Otoacoustic emissions (OAE)
Measures sound waves produced in the inner ear. A tiny probe is placed inside the ear canal. It measures the response (echo) when clicks or tones are played into the baby’s ears
General mouth exam
Assess for any evidence of cleft palate, cleft lip or ankyloglossia
-Use a wooden tongue depressor and a pen light
-Examine the palate all the way to the uvula, which should be midline on exam
Newborn should have minimal salivation, gag reflex should be intact, as should the sucking and rooting reflexes, gums are pink and moist, rarely will a neonatal tooth be present at birth
Ankyloglossia
The fancy medical term for tongue-tied
The frenulum tethers the tongue to the anterior floor of the mouth
Comprehensive neck exam
Examine the neck by palpating the sternocleidomastoid muscles and rotating the head to either side to r/o congenital torticollis
Note any evidence of webbing of the neck
Examine the clavicles to ensure there is no evidence of clavicular fx from a traumatic delivery
Torticollis
AKA Wry neck
A dystonic condition resulting most commonly from a shortened sternocleidomastoid muscle
Causes an asymmetric head and neck position
Refer to PT
Characteristics of Turner syndrome
Low posterior hairline Short stature Heart-shaped face Webbing of neck Coarctation of aorta Broad chest with widely spaced nipples Cubitus valgus Streak ovaries, amenorrhea, infertility
Comprehensive chest exam
Watch to see that the chest rises and fall with inspiration and expiration
Pectus carinatum
Pigeon chest
More prominent
Pectus excavatum
Funnel chest
Looks scooped out
What will occasionally be heard on cardiopulmonary exam?
Crackles
Respiratory distress presentation
Cyanosis
Nostril flaring
Expiratory grunt
Any of these things warrant an additional work up
Transient Tachypnea of the Newborn (TTNB)
MC reason of crackles
Defined by intermittent patterns of tachypnea, is most commonly seen in full term babies who are born via C-section
Believed to be linked to retained fluid in the lungs from gestation, this is often a condition that resolves with supportive care within 24-48 hrs
How to do a cardiopulmonary exam
Listen on both the anterior and posterior thorax of the newborn to assess heart tones
-Murmurs that are transient and present at birth are typically benign
-Furthermore, congenital cardiac defects may not produce any murmur at time of birth
Next, feel both the brachial and femoral pulse of the infant. Absences of the femoral pulse, or evidence of a brachial-femoral delay is concerning for coarctation of the aorta and/or left sided heart defects
What are relatively common in a newborn abdomen?
Diastasis recti and umbilical hernias
Components of the umbilical cord
Comprised of 2 arteries and 1 vein, any deviation from this venous pattern would warrant immediate evaluation
When will the umbilical cord typically dry up?
Within first 2 wks of life
What should occur after inspection of the abdomen?
Auscultate the abdomen to ensure normoactive bowel sounds
What does absence of bowel sounds indicate?
Obstruction, often resulting from meconium ileus
Meconium
A dark green, tarry substance
The first feces to be passed by the newborn
Within first 24 hrs of life
What can failure to pass meconium indicate?
Meconium ileus
Cystic fibrosis
Imperforate anus
Where is the liver often palpable?
Approximately 2 cm below costal margin
What can be palpated in the abdomen at birth?
Right kidney with deep palpation
Female genital exam
Inspect the genitals noting that the labia majora is typically prominent
Nonpurulant d/c considered nl
Confirm the urethral meatus is located behind the clitoris by spreading the labia majora and using a pen light to examine the genitals
What to look for in the scrotum
Typically large and should have 2 descended testicles present at time of birth
-Undescended has risk for testicular cancer
Scrotal swelling can be seen in the presence of hydrocele or hernia
Foreskin info
The prepuce of the newborn male is often tight and cannot be retracted past the glans of the penis
-Don’t force retraction
Avg age of initial retraction is 10-11 yo
Urination
Most newborns urinate within the first mins to hrs of life.
Newborns who have not urinated within the 24 hrs should be sent for additional workup such as renal u/s
Musculoskeletal comprehensive exam
Assess all major joints and muscle groups on the newborn. Spontaneous bilateral movements of all extremities should be observed
Start by assessing the hands and palms for polydactyly, syndactyly or abnormal dermatoglyphic patterns, all of which can potentially indicate an underlying genetic disorder
Congenital talipes equinovarus (CTEV)
AKA clubbed foot
The Barlow maneuver
Performed by adducting the hip (bringing the thigh towards the midline) while applying light pressure on the knee, directing the force posteriorly. If the hip is dislocated the test is considered positive
The Ortolani maneuver
Performed by flexing the hips and knees of a supine infant to 90 degrees, thenp lacing anterior pressure on the greater trochanters, while abducting the infant’s legs. A positive Ortolani sign is noted when the femoral head relocates anteriorly into the acetabulum, thus correcting for the Barlow maneuver
Spinal exam
Check for any evidence of scoliosis, or abnl dimpling above the gluteal crease as this can be indicative of neural tube defects
Brace when angle is lower, surgery if angle is higher
Neuro exam
Observe the posture of the infant
There should be flexion at the knees, hips and elbows
-Infants with hypotonia often assume a frog leg position
Next assess level of alertness
-Lightly touch the cheek or foot of the baby to see that they are easily arousable
Also assess reflexes
