Physical & Gestational Age Assessment of Newborns Flashcards by Francisco Andrade

White or Asian: pink, reddish, pale
Black: warmish brown tone
All babies: more ruddy if crying, acrocyanosis

Healthy, well-oxygenated, full term - Color Changes & Skin Characteristics

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especially if cold
lacy pattern of dark & light areas
vasomotor fluctuations

Mottling

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vasomotor disturbance; blood vessels on one side of body dilate (deep pink), other side constrict (pale)
Single or multiple episodes

Harlequin sign

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first detectable on face & mucus membranes of mouth
Blanch tip of nose, gum line, forehead, sternum
Also examine sclera

Jaundice

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Non-pathologic
Unknown etiology
Seen in first few days of life
“flea-bite” dermatitis
No Rx, peaks 24-48 hours of life, then disappears in hours or days

Erythema Neonatorum Toxicum (“normal newborn rash”)

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Assess over abdomen
Should be elastic
Used to evaluate hydration, need to initiate feedings, presence of infectious process

Skin Turgor

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Covers fetus in utero
Lubricates skin
White, cheeselike substance
Term or postterm: less present

Vernix Caseosa

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Exposed sebaceous glands

Raised white spots on face, especially nose

Milia

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Reddened areas over cheeks & jaws
Seen with difficult forceps delivery
Disappear in 1-2 days
Rare: facial paralysis

Forceps Marks

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“Marked from birth”
Frequent cause of concern, anxiety, and blame
Cultural context

Birthmarks

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Birthmark; Pale pink or red spots
Seen on eyelids, nose, lower occipital bone, nape of neck
Light-complected newborn; more noticeable if cries
Blanch, no clinical significance, disappear around age 2

Telangiectatic Nevi (“stork bites”, salmon patches)

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Grey-blue pigmented areas
Lumbosacral or buttocks
Dark-skinned & Asian newborns
Disappear in late infancy or early childhood

Mongolian Spots

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Flat, purple-red, sharply demarcated
Most often on face
Do not blanch, fade, or increase in size
Can be disfiguring

Nevus Flammeus (“port-wine stain”)

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Dark red, rough-textured, sharply demarcated, raised
Usually head or face
Grow for several months, then shrink, but can take 7-10 years to disappear

Nevus Vasculosus (“strawberry marks”)

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Flat, pigmented, sharply demarcated, “coffee with milk”
1 in 5 have them
1-3 spots okay, ># or > 5 mm linked to neurofibromatosis

Café au Lait Spots

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Head 1/3 adult size
Circumference: 32-38 cm
Head circumference 2-3 cm > chest circumference
Measure from most prominent part of occiput to just above eyebrows

Head Circumference

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Average: 30-36 cm

Lower edge of scapula, bring around anteriorly over nipple line

Chest Circumference

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Large, ¼ total body size
Palpate suture lines: open sutures or overriding?
Identify fontanels
Evaluate symmetry
Evaluate molding

Newborn’s Head

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Diamond-shaped, 2-3 cm wide x 3-4 cm long
Flat, but may swell with stooling, crying
Depressed = dehydration
Can feel pulsation of heart through it
Closes within 18 months

Fontanels: Anterior

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Smaller, triangular in shape
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May be almost closed at birth, but will be fully-closed by end of 2nd month

Fontanels: Posterior

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Overriding of skull bones
Occurs as head accommodates to diameters of birth canal
Head seems elongated
Disappears spontaneously within few days

Asymmetry of Head: Molding

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Diffuse, soft-tissue edema of scalp
Caused by pressure on head in L & D
Crosses suture lines
Scalp ecchymosis ( blood into tissue) may be present
Resolves in a few days

Asymmetry of Head: Caput Succadaneum (“caput”)

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Collection of blood due to rupture of blood vessels between skull and periosteum
No ecchymosis 
Doesn’t cross suture lines
Slow process
Resolves slowly; 2-6 weeks

Asymmetry of Head: Cephalohematoma

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Closed much of time
Most often blue or slate-gray at birth
Darker eyes in darker-skinned
Permanent eye color can take up to 1 year
White spots (Brushfield’s) in periphery of iris
Lacrimal glands immature

Eyes

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“cross-eyes”; Transient Immature neuromuscular control Disappears by 3-4 months

Strabismus

eye bleeding; (black filled) Harmless Due to pressure Disappear in about a week

Subconjunctival Hemorrhages

Red reflex: pupil appears red-orange when ophthalmoscope directed on it Blink reflex: response to shining bright light into eyes

Eyes: Reflexes

Pink, moist mucosa Inspect lips, gums, palates Epstein’s pearls - white or yellow cystic vesicles (fluid) Precocious teeth - removed to orevent aspiration Tongue: midline, mobile, normal short frenulum

Mouth

“Tongue-tied”; TX: frenotomy (ingual frenulum is cut)

Ankyloglossia

Short compared to abdomen Round chest, thin chest wall with little musculature Ribs soft & compliant Tip of xiphoid may protrude

Thorax

Extra nipples, found along the “milk line” from upper, outer shoulders to middle of pubic bone Within normal limits

Thorax: Supernumerary Nipples

Males and females Maternal hormones, crossed placenta Persists 2-3 weeks “Witch’s milk” - milk from newborn breast

Thorax: Breast Hypertrophy

Normal newborn cry

strong & lusty, medium pitch

High-pitched newborn cry

neurological disorders, hypoglycemia

Diaphragmatic, in synchrony with abdomen Respiratory distress: G,F,R, seesaw respirations, sustained tachypnea, stridor on inspiration Note abnormalities of AP diameter Lung sounds: check anterior/posterior chest; noisy until lung fluid clears

Respirations

Auscultate entire cardiac region Apical pulse for a full minute 120-150 BPM normal rate; no obvious irregularities in rhythm S1: mitral & tricuspid valves closing S2: aortic & pulmonary valves closing Check peripheral pulses (brachial, femoral)

Heart Sounds

Becoming a routine measurement Doppler or brachial cuff Especially needed if distress, preterm, suspected cardiac anomaly Normal BP range: 63-70/40-50

Blood Pressure Measurement

Round, symmetric contour, slightly protuberant, superficial veins often visible Note bowel sounds Palpation Umbilical hernias

Abdomen

Note presence & size of labia majora/minora, clitoris, vaginal opening Labia majora usually covers minora and vestibule Clitoris large in neonatal period Enlarged labia or vaginal discharge present due to maternal hormones Pseudomenstruation: “withdrawal bleed”

Female Genitalia

``` Scrotum: relatively large, ⁭pigment Testes palpable Prepuce Phimosis - foreskin cannot be fully retracted over the glans penis Position of meatus Hydrocele ```

Male Genitalia

Inspect area for patency, fissures Note passage first meconium; 90% by 24 hours R/O imperforate anus & rectal atresia with digital exam if no stool by 48 hours

Anus

Place NB prone, inspect, palpate Normal spinal curvature is C-shaped Pilonidal region: √ for tuft of hair or sinus Perianal area: normal dimpling

Posterior Surface

Symmetry of size & movement, posture at rest, fractures, lacerations, bruising, functional deficiencies Breech NB may have hips, knees extended Moro Reflex: checks damage to structures and function of CNS Hands & feet: normal # digits, with normal formation Nails not meconium-stained; nail length Single palmar crease = Simian line Plantar creases cover entire sole at term Check position of feet: neutral midline position

Extremities

Affected hip has limited abduction; femur appears shortened, deeper thigh creases “Ortolani’s Maneuver” & “Barlow”s Maneuver”: puts hip through full ROM, “click” if hip dislocation suspected

Congenital Hip Dislocation

a brace used mostly for babies who have a hip disorder.

Pavlik Harness

- Jitteriness or tremors: rhythmic movements equal in amplitude; provoked by external stimuli like noise or handling - Seizures: fast & slow components and don’t stop when examiner holds down limb

Neurologic Assessment

Protective: blink, gag, sneeze Primitive: Moro Feeding: rooting, sucking Human Interaction: palmar grasp

Reflexes

Gestational age calculated from mother’s LMP Prenatally, assess fetal age by ultrasound After birth, physical exam leads to more accurate assessment of maturity 1970: Dubowitz exam 1979, rev. 1991: Ballard exam

Gestational Age Assessment

Posture: NB undisturbed, flat surface More mature = more flexed 34 weeks’: froglike posture 36-38 weeks’: all extremities flexed

Neuromuscular Evaluation: Posture

Flex hand towards ventral forearm; wrist flexion 28-32 weeks’: 90 degrees 38-40 weeks’: 30 degrees 40+: 0 degrees

Neuromuscular Evaluation: Square Window

Flex arms for 5 seconds, then extend for 30 seconds, release 36-37 weeks’: stay extended term: prompt recoil with passive extension

Neuromuscular Evaluation: Arm Recoil

Degree of knee flexion; measure angle Place NB supine, flex thigh against abdomen, then extend lower leg Immature: no resistance Term: resistance

Neuromuscular Evaluation: Popliteal Angle

Supine, draw arm across chest towards opposite shoulder & note location of elbow Term: marked resistance

Neuromuscular Evaluation: Scarf Sign

Supine, draw foot towards ear until resistance met Immature: leg stays straight, foot goes to ear or beyond Term: marked resistance Breech: allow leg positioning to resolve first or inaccurate

Neuromuscular Evaluation: Heel-to-Ear

Preterm: thin, transparent, veins prominent Term: opaque Postterm: little or no vernix, skin cracks and peels

Physical Characteristics: Skin

Fine, downy hair covering body Decreases as gestational age increases Greatest amount at 28-30 weeks’ gestation; then disappears from face first, then trunk, then extremities

Physical Characteristics: Lanugo

Sole crease exam only reliable first 12 hours, then skin dries Develop anterior to posterior Peeling noted Blacks have less-developed sole creases at term

Physical Characteristics: Plantar Creases

Palpate with forefinger and middle finger; don’t grasp nipple, avoid trauma Measures 5-10 mm at term; areola raised and stippled As gestational age increases, breast tissue and areola enlarge

Physical Characteristics: Areola/Breast Bud

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Physical Characteristics: Ear Formation/Cartilage

<36 weeks’: scrotum few rugae, testes in inguinal canal 36-38 weeks’: rugae anteriorly, testes upper part scrotum Term: both testes descended, rugae cover pendulous scrotum

Physical Characteristics: Male Genitalia

30-32 weeks’: clitoris prominent, labia majora small & widely separated 36-40 weeks’: labia majora nearly covers clitoris 40+ weeks’: labia majora covers minora and clitoris

Physical Characteristics: Female Genitalia

Growth Grids

Plot NB’s weight, head circumference, length 90th percentile = Large for Gestational Age (LGA) Remainder = Accurate or Appropriate for Gestational Age (AGA)

G, F, R

Grunting, flaring, retractions