Teaching Files:Teaching Files:Detailed Newborn Detailed Newborn

ExaminationExamination

GeneralGeneral

Measure and record height, weight, and head Measure and record height, weight, and head circumference. If the infant appears premature circumference. If the infant appears premature or is unusually large or small, perform a or is unusually large or small, perform a Dubowitz/Ballard exam to assess gestational Dubowitz/Ballard exam to assess gestational age (see Dubowitz/Ballard scoring grid). The age (see Dubowitz/Ballard scoring grid). The exam is divided into two parts: an exam is divided into two parts: an external external characteristics score, which is best done at characteristics score, which is best done at birth, and a birth, and a neuromuscularneuromuscular score, which score, which should be done within 24 hours after birth.should be done within 24 hours after birth.

Small for gestational age (SGA)Small for gestational age (SGA)

Symmetric (HC = Wt = Len, all <10 %ile) -- 33% of SGA infantsSymmetric (HC = Wt = Len, all <10 %ile) -- 33% of SGA infants

Genetic Genetic – Small maternal size Small maternal size – Chromosomal abnormalities (Trisomies 13, 18, 21, and Turner's Chromosomal abnormalities (Trisomies 13, 18, 21, and Turner's

syndrome) syndrome) – Congenital abnormalities Congenital abnormalities

Intrauterine infections Intrauterine infections – Viruses (rubella, CMV, ?varicella, ?HIV) Viruses (rubella, CMV, ?varicella, ?HIV) – Bacteria (tuberculosis) Bacteria (tuberculosis) – Spirochete (syphilis) Spirochete (syphilis) – Protozoan (toxoplasmosis, malaria) Protozoan (toxoplasmosis, malaria)

Inborn errors of metabolism Inborn errors of metabolism – Hypophosphatasia Hypophosphatasia – Some amino acidurias Some amino acidurias

Environmental Environmental – Drugs (heroin, methadone, ethanol, diphenylhydantoin) Drugs (heroin, methadone, ethanol, diphenylhydantoin) – X-rays (therapeutic) X-rays (therapeutic) – Smoking Smoking

Asymmetric (HC = Len > Wt, Wt <10 %ile) -- 55% of SGA infantsAsymmetric (HC = Len > Wt, Wt <10 %ile) -- 55% of SGA infants

Uteroplacental insufficiency -- onset usually Uteroplacental insufficiency -- onset usually after 24 weeks after 24 weeks – Chronic hypertension Chronic hypertension – Preeclampsia Preeclampsia – Renal disease Renal disease – Cyanotic heart disease Cyanotic heart disease – Hemoglobinopathies Hemoglobinopathies – Placental infarcts or chronic abruption, velamentous Placental infarcts or chronic abruption, velamentous

insertion, circumvallate placenta, multiple gestation. insertion, circumvallate placenta, multiple gestation. – Altitude Altitude

Combined (symmetric or assymetric) -- 12% of SGA Combined (symmetric or assymetric) -- 12% of SGA infants infants

Environmental Environmental – Drugs (including ethanol) Drugs (including ethanol) – Smoking Smoking

Placental unit insufficiency Placental unit insufficiency – Placental infarcts or chronic abruption, velamentous Placental infarcts or chronic abruption, velamentous

insertion, circumvallate placenta, multiple gestation. insertion, circumvallate placenta, multiple gestation.

Large for gestational age (LGA)Large for gestational age (LGA)

Infants of diabetic mothers Infants of diabetic mothers Beckwith-Wiedemann syndrome Beckwith-Wiedemann syndrome Hydrops fetalis Hydrops fetalis Large mother Large mother

Preterm infantsPreterm infants

Preterm infantsPreterm infants

Preterm infantsPreterm infants

SkinSkin

ColorColor Pallor - associated with low hemoglobinPallor - associated with low hemoglobin Cyanosis - associated with hypoxemiaCyanosis - associated with hypoxemia Plethora - associated with polycythemiaPlethora - associated with polycythemia Jaundice - Elevated bilirubinJaundice - Elevated bilirubin Slate grey colour - associated with Slate grey colour - associated with

methemoglobinemiamethemoglobinemia

LesionsLesions

Milia - pinpoint white papules of keratogenous material Milia - pinpoint white papules of keratogenous material usually on nose, cheeks and forehead, last several weeks.usually on nose, cheeks and forehead, last several weeks.

Miliaria - obstructed eccrine sweat ducts. Pinpoint vesicles Miliaria - obstructed eccrine sweat ducts. Pinpoint vesicles on forehead scalp and skinfolds. Clear within 1 week.on forehead scalp and skinfolds. Clear within 1 week.

Transient neonatal pustular melanosis - small Transient neonatal pustular melanosis - small vesicopustules, generally present at birth, containing vesicopustules, generally present at birth, containing WBCs and no organisms. The intact versicle ruptures to WBCs and no organisms. The intact versicle ruptures to reveal a pigmented macule surrounded by a thin skin ring.reveal a pigmented macule surrounded by a thin skin ring.

Erythema toxicum - Most common newborn rash. Variable, Erythema toxicum - Most common newborn rash. Variable, irregular macular patches. Lasts a few days. Wright's Stain irregular macular patches. Lasts a few days. Wright's Stain shows sheets of eosinophils.shows sheets of eosinophils.

Cafe au lait spots - suspect neurofibromatosis if there are Cafe au lait spots - suspect neurofibromatosis if there are many large spots.many large spots.

Junctional nevi - if large numbers, suspect tuberous Junctional nevi - if large numbers, suspect tuberous sclerosis, xeroderma pigmentosus, generalized sclerosis, xeroderma pigmentosus, generalized neurofibromatosisneurofibromatosis

Neurological ExamNeurological Exam

State of alertnessState of alertnessCheck for persistent lethargy or irritability.Check for persistent lethargy or irritability.

PosturePostureIn term infant, normal position is one with hips abducted and In term infant, normal position is one with hips abducted and partially flexed and with knees flexed. Arms are adducted and partially flexed and with knees flexed. Arms are adducted and flexed at the elbow. The fists are often clenched, with fingers flexed at the elbow. The fists are often clenched, with fingers covering the thumb.covering the thumb.

ToneToneSupport the infant with one hand under his chest. The neck Support the infant with one hand under his chest. The neck extensors should be able to hold the head in line for 3 seconds. extensors should be able to hold the head in line for 3 seconds. Should not have more than 10% head lag when moving from Should not have more than 10% head lag when moving from supine to sitting position.supine to sitting position.

ReflexesReflexesReflexes must be symmetrical. Biceps jerk test C5 and C6, Knee Reflexes must be symmetrical. Biceps jerk test C5 and C6, Knee jerk tests L2-L4, Ankle jerk tests S1, S2. Truncal incurvation reflex jerk tests L2-L4, Ankle jerk tests S1, S2. Truncal incurvation reflex tests T2 through S1. Anal wink test S4, S5. Other primitive reflexes tests T2 through S1. Anal wink test S4, S5. Other primitive reflexes include the Moro, palmer and planter grasps, sucking and rooting include the Moro, palmer and planter grasps, sucking and rooting reflexes, and the asymmetric tonic neck reflex (ATNR). Asymmetric reflexes, and the asymmetric tonic neck reflex (ATNR). Asymmetric tonic neck reflex (seen in ventral suspension with arms rigidly tonic neck reflex (seen in ventral suspension with arms rigidly extended and fists clenched) is abnormal.extended and fists clenched) is abnormal.

When reflexes appear and disappear:When reflexes appear and disappear:

Reflex Reflex Appears Appears Disappears Disappears

Moro Moro Newborn Newborn 3 months3 months

GraspGrasp Newborn Newborn 3 months 3 months

Extensor plantar Extensor plantar Newborn Newborn 8-12 8-12 monthsmonths

Placing/stepping Placing/stepping Birth Birth 1-2 1-2 monthsmonths

ATNRATNR Newborn Newborn 3 months 3 months

Head and NeckHead and NeckHeadHeadCheck for overriding sutures, the number of fontanelles and Check for overriding sutures, the number of fontanelles and

their size. Check for abnormal shape of head. Check for their size. Check for abnormal shape of head. Check for encephalocoeles. Measure the head circumference.encephalocoeles. Measure the head circumference.

EyesEyesCheck for colobomas, heterochromia.Check for colobomas, heterochromia.Cornea - Check for cloudiness.Cornea - Check for cloudiness.Conjunctiva - Inspect for erythema, exudate, edema, jaundice Conjunctiva - Inspect for erythema, exudate, edema, jaundice

and hemorrhage. Silver nitrate prophylaxis can cause a and hemorrhage. Silver nitrate prophylaxis can cause a chemical conjunctivitis. Check for pupillary size and chemical conjunctivitis. Check for pupillary size and reactivity to light.reactivity to light.

Red Reflex - Hold the ophthalmoscope 6-8" from the eye. Use Red Reflex - Hold the ophthalmoscope 6-8" from the eye. Use the +10 diopter lens. The normal newborn transmits a clear the +10 diopter lens. The normal newborn transmits a clear red colour back to the observer. Black dots may represent red colour back to the observer. Black dots may represent cataracts. A whitish color may be suggestive of cataracts. A whitish color may be suggestive of retinoblastoma.retinoblastoma.

EarsEarsCheck for asymmetry, irregular shapes. Look for auricular or Check for asymmetry, irregular shapes. Look for auricular or

pre-auricular pits, fleshy appendages, lipomas, or skin tags. pre-auricular pits, fleshy appendages, lipomas, or skin tags.

NoseNoseLook for flaring of the alae nasi as a sign of increased respiratory Look for flaring of the alae nasi as a sign of increased respiratory

effort. Look for hyper- or hypo-telorism. Check for choanal atresia effort. Look for hyper- or hypo-telorism. Check for choanal atresia (CA) as manifested by respiratory distress (neonates are obligate (CA) as manifested by respiratory distress (neonates are obligate nose breathers). A soft NG tube should be passed through each nose breathers). A soft NG tube should be passed through each nostril to confirm patency if choanal atresia is suspected.nostril to confirm patency if choanal atresia is suspected.

PalatePalateCheck for cleft lip and palate.Check for cleft lip and palate.

MouthMouthObserve the size and shape of the mouth.Observe the size and shape of the mouth.Microstomia - seen in Trisomy 18 and 21. Microstomia - seen in Trisomy 18 and 21. Macrostomia - seen in mucopolysaccharidoses.Macrostomia - seen in mucopolysaccharidoses.Fish mouth - seen in fetal alcohol syndrome.Fish mouth - seen in fetal alcohol syndrome.Epstein pearls - small white cysts which contain keratin, frequently Epstein pearls - small white cysts which contain keratin, frequently found found oneither side of the median raphe of the palate.oneither side of the median raphe of the palate.Ranulas - small bluish white swellings of variable size on the floor Ranulas - small bluish white swellings of variable size on the floor of the mouth representing benign mucous gland retention cysts.of the mouth representing benign mucous gland retention cysts.

TongueTongueMacroglossia - Hypothyroidism, mucopolysaccharidosesMacroglossia - Hypothyroidism, mucopolysaccharidoses

TeethTeethNatal teeth - occur in 1/2,000 births. Mostly lower incisors. Risk of Natal teeth - occur in 1/2,000 births. Mostly lower incisors. Risk of aspiration if loosely attached.aspiration if loosely attached.

ChinChinMicrognathia - occurs with Pierre-Robin Micrognathia - occurs with Pierre-Robin

syndrome, Treacher-Collins syndrome, syndrome, Treacher-Collins syndrome, Hallerman Streiff syndrome.Hallerman Streiff syndrome.

NeckNeckPalpate over all muscles, palpate clavicles for Palpate over all muscles, palpate clavicles for

possible fractures. Web neck found in Turner's possible fractures. Web neck found in Turner's and Noonan's syndromes. Torticollis usually and Noonan's syndromes. Torticollis usually secondary to sternocleidomastoid hematoma. secondary to sternocleidomastoid hematoma. Cystic hygromas most common neck mass. Cystic hygromas most common neck mass. Lymph nodes are unusual at birth and their Lymph nodes are unusual at birth and their presence usually indicates congenital infection.presence usually indicates congenital infection.

NoteNote: Suspect tracheo-esophageal fistula (TEF) if : Suspect tracheo-esophageal fistula (TEF) if polyhydramnios is present.polyhydramnios is present.

Chest and LungsChest and LungsObserve respiratory rate, respiratory pattern (periodic breathing, Observe respiratory rate, respiratory pattern (periodic breathing,

periods of true apnea). Observe chest movements for symmetry periods of true apnea). Observe chest movements for symmetry and for retractions. Listen for stridor, grunting. Note that there and for retractions. Listen for stridor, grunting. Note that there may be some enlargement of the breasts secondary to maternal may be some enlargement of the breasts secondary to maternal hormones.hormones.

Cardiovascular SystemCardiovascular SystemMeasure heart rate, blood pressure in upper and lower extremities, Measure heart rate, blood pressure in upper and lower extremities,

respiratory rate.respiratory rate.InspectionInspection

Check baby's color for pallor, cyanosis, plethora.Check baby's color for pallor, cyanosis, plethora.PalpationPalpation

Check capillary refill. Check pulses; note any decrease in femoral Check capillary refill. Check pulses; note any decrease in femoral pulses or radio-femoral delay as a sign of possible coarctation of pulses or radio-femoral delay as a sign of possible coarctation of the aorta, note character of pulses (bounding or thready). Locate the aorta, note character of pulses (bounding or thready). Locate PMI with single finger on chest; abnormal location of PMI can be PMI with single finger on chest; abnormal location of PMI can be clue to pneumothorax, diaphragmatic hernia, situs inversus, or clue to pneumothorax, diaphragmatic hernia, situs inversus, or other thoracic problem.other thoracic problem.AuscultationAuscultation

Note rhythm and presence of murmurs which may be pathologic.Note rhythm and presence of murmurs which may be pathologic.

AbdomenAbdomenNote shape of abdomen. Flat abdomens signify decreased Note shape of abdomen. Flat abdomens signify decreased

tone, abdominal contents in chest, or abnormalities in tone, abdominal contents in chest, or abnormalities in abdominal musculature. Note abdominal distension.abdominal musculature. Note abdominal distension.

Observe for diastasis recti. Observe for any obvious Observe for diastasis recti. Observe for any obvious malformations e.g. omphalocoele. An omphalocoele has malformations e.g. omphalocoele. An omphalocoele has a membrane covering (unless it has been ruptured a membrane covering (unless it has been ruptured during the delivery) whereas a gastroschisis does not.during the delivery) whereas a gastroschisis does not.

Examine umbilical cord and count the vessels. Note color Examine umbilical cord and count the vessels. Note color of cord. Palpate liver and spleen. It may be normal for of cord. Palpate liver and spleen. It may be normal for the liver to be about 2 cm below the right costal the liver to be about 2 cm below the right costal margin. The spleen is not usually palpable; if the spleen margin. The spleen is not usually palpable; if the spleen is felt, be alert for congenital infection or is felt, be alert for congenital infection or extramedullary hematopoeisis. After locating these extramedullary hematopoeisis. After locating these organs (checking for situs inversus), palpate for any organs (checking for situs inversus), palpate for any abnormal masses.abnormal masses.

Auscultate for bowel sounds.Auscultate for bowel sounds.Examine for hernias - umbilical or inguinal.Examine for hernias - umbilical or inguinal.Inspect anal area for patency and/or presence of fistulas.Inspect anal area for patency and/or presence of fistulas.

Genitourinary ExamGenitourinary Exam

KidneysKidneys

Examined by palpation. The kidneys should be about 4.5-5.0 cm Examined by palpation. The kidneys should be about 4.5-5.0 cm vertical length in the full term newborn. The technique for vertical length in the full term newborn. The technique for palpation is either a) one hand with four fingers under the baby's palpation is either a) one hand with four fingers under the baby's back, palpation by rolling the thumb over the kidneys, or b) back, palpation by rolling the thumb over the kidneys, or b) palpate the left kidney by placing the right hand under the left palpate the left kidney by placing the right hand under the left lumbar region and palpating the abdomen with the left hand (do lumbar region and palpating the abdomen with the left hand (do the reverse for the right kidney).the reverse for the right kidney).

Male genitaliaMale genitaliaTerm normal penis is 3.6±0.7 cm stretched length. Inspect glans, Term normal penis is 3.6±0.7 cm stretched length. Inspect glans,

urethral opening, prepuce and shaft. Normally difficult to urethral opening, prepuce and shaft. Normally difficult to completely retract foreskin. Observe for hypospadias, epispadias. completely retract foreskin. Observe for hypospadias, epispadias. Inspect circumcised penis for edema, incision, bleeding. Full term Inspect circumcised penis for edema, incision, bleeding. Full term infant should have brownish pigmentation and fully rugated infant should have brownish pigmentation and fully rugated scrotum. Palpate the testes.scrotum. Palpate the testes.

Female genitaliaFemale genitaliaInspect the labia, clitoris, urethral opening and external vaginal vault. Inspect the labia, clitoris, urethral opening and external vaginal vault.

Often a whitish discharge is present; this is normal, as is a small Often a whitish discharge is present; this is normal, as is a small amount of bleeding, which usually occurs a few days after birth amount of bleeding, which usually occurs a few days after birth and is secondary to maternal hormone withdrawal. Hymenal tags and is secondary to maternal hormone withdrawal. Hymenal tags may be present normally.may be present normally.

Extremities and Skeletal SystemExtremities and Skeletal System

SpineSpine

Scoliosis, kyphosis, lordosis, spinal defects, Scoliosis, kyphosis, lordosis, spinal defects, meningomyelocoeles.meningomyelocoeles.

Upper extremityUpper extremity

Look for clavicular fracture, absence of radius or Look for clavicular fracture, absence of radius or ulna. Inspect creases and fingers.ulna. Inspect creases and fingers.

Lower extremityLower extremity

See posture above. Do Ortolani maneuver to See posture above. Do Ortolani maneuver to check for congenital hip dislocation. Check toes.check for congenital hip dislocation. Check toes.