Paediatrics: Physical Exam of Newborn Flashcards
Examination - Special Features of the Newborn
- Small size
- Uncooperative
- Hypothermia on cold exposure (skin-mottling)
- Neurological state varies with sleep, feeding, etc.
- On going transitional changes in first few days of life e.g. changes in pulmonary pressure will affect the signs related to congenital heart disease (even if baby has VSD, since pulmonary pressure is still very high, there won’t be significant flow, thus you can’t hear the murmur in the first few weeks until there is pressure difference between L & R side)
- Impact of intrauterine pressure effect (deformation) and birth process e.g. head molding, abnormal posture associated with breech presentation
Aims of Newborn Examination
- Assess baby’s ability in adapting to extra-uterine life especially the cardiopulmonary status
- Look for major congenital anomalies, esp. those requiring urgent treatment
- Identify at risk babies that need postnatal monitoring and investigation based on perinatal history, stage of maturity, variation in size, presence of systemic or neurological abnormalities
- Mother’s competence in child care
Examination- General observation
- Size, body proportion, maturity
- Colour e.g. plethora, pallor, cyanosis, jaundice, (skin mottling)
- Posture
- Cutaneous discoloration
- Generalized edema
- Gross malformation and dysmorphic features
What is this?
Vernix caseosum: Cheesey whiteish thing covering the baby
[This is a protective layer, can help with better skin development] = some mothers may ask baby not to take bath for a few days, no need to wipe away
Sebum + protective factors
Mixture of detached skin, sebum
What is this?
Erythema toxicum: Erythematous base with white papules, if you take away white papules and put under microscope, you will see eosinophils
Skin reaction to change from utero environment to external environment
What is this?
Mongolian spot: usually over lumbosacral region, by 6-8 y/o will go away, it goes away
NOT melanocytic naevus
What is this?
Petechiae: Should not be blanchable (DDx vascular lesions, which are blanchable)
Exclude congenital infections, clotting disorders (i.e. platelet)
Could be due to shoulder dystocia
Examination of head and face
Head
* size (head circumference) and shape
* sutures and fontanelles, anterior fontanelle pressure (full and bulging in meningitis)
* caput succedenum, cephalhaematoma, subaponeurotic haemorrhage
Face
* dysmorphic features
* mouth lesion e.g. cleft palate
* eyes
Salmon patch: Capilary malformation, blanchable
If it is very dark, if could be Sterg Weber
Cephalhaematoma: Never cross suture line [not bleeding tendency, just due to combression to bony prominence]
Subaponeurotic haematoma: bleeding below aponeurosis, crosses midline! Subaponeurotic space can hold up to 200-300ml in newborn baby [life-threatening]
Baby looks like he’s wearing helmet, ears are pulled forward = subaponeurotic haematoma
Examination of Neck & Skeletal System
Down’s syndrome, Noonan’s syndrome
What is this?
Lymphedema of foot (if it is not pitting, it is lymphaedema, if it is pitting, could be heart failure, liver problem, kidney syndrome)
Down syndrome
What is this?
Patau syndrome
What is this?
Corneal opacity
How to perform cardio-respiratory assessment?
Look and Listen:
* peripheral vs central cyanosis
* stridor, grunting
* respiratory distress (tachypnoea, intercostal insucking)
* asymmetry
Feel:
* pulses
* cardiac impulses
Auscultate:
* Heart sounds, murmur
* Breath sounds, added sounds
What are normal cardio-respiratory parameters?
- HR 120 (range -90 to160/min), slower when sleeping
- Pulses volume equal
- Normal apex beat at 5th ICS mid clavicular line
- Transient Innocent murmur common
- Respiratory rate 40-50 /min, higher in preterm infants with occasional periodic breathing
abd examination of newborn
Look
* shape and size, umbilicus; visible veins, visible peristalsis (pyloric stenosis)
* External genitalia, perineum
* Hernia
* Anal patency
Feel
* Superficial palpation for or obvious mass / tenderness
* for liver ( normal 1-2 cm below costal margin soft), spleen, kidneys and other masses
Listen
* bowel sounds
* bruits
This is Hirschsprung disease
NEC is very red
Anal atresia with fistula: no proper anus, meconium coming out from fistula
Hypospadias: DON’T CIRCUMCISE YET
The excess skin is needed to repair the hypospadias
How to examine spine and hip?
Back
* Spina bifida, swellings
* Stigmata of underlying spinal defect –midline dimples, mass, tufts of hair, haemangioma
* Deformities e.g. scoliosis
Hips
Neurological Examination
- State of alertness
- Posture e.g. flaccid, spasticity, focal abnormality e.g. Erbs palsy
- Muscle tone, tendon jerks
- Spontaneous movements
- Primitive reflexes –Moro, grasp, suckling, rooting
- Cranial nerves: eye movements, facial asymmetry, swallowing
Norms and warning signs in neurological examination
Norms
* Predominantly flexor tone (reduced tone in premature infants)
* Sleeping for 18-20 hours/day, most alert mid-way between feeding, irritable when hungry
* Best visual at 18 inches but no consistent visual fixation
* Concomitant squint
Warning signs
* Frog like posture
* Jitteriness
* Altered conscious state
* Bulging fontanelles
What posture is this?
Flexed posture
Frog-like posture, abnormal
L-side is flaccid = Erb’s palsy [C5-C6 injury] (internal rotation of arm + waiter’s tip)
Can have fractured clavicle
How to screen for hip dislocation?
Ortolani: dislocate a dislocatable hip, then relocate to socket (flex hip and knee region, then push it back while holding knee = if it an unstable hip, you will dislocate the hip out of the socket) [ABduction, then push it back] (open the hip, then use finger to relocate dislocated hip back into the socket)
Barlow
If you hear any sound, book U/S and refer to orthopaedics [if you miss this, you will affect baby’s walking] = stabilise hip with pelvic harness (help hip develop)
Socket may be underdeveloped initially
