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DETAILED. NEWBORN EXAM. Belen Escober-Velasco, M.D. GENERAL. Measure and record height, weight , and head circumference . If the infant appears premature or is unusually large or small, perform a Dubowitz/Ballard exam to assess gestational age. Two parts:

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  1. DETAILED NEWBORN EXAM Belen Escober-Velasco, M.D.

  2. GENERAL • Measure and record height, weight, and head circumference. If the infant appears premature or is unusually large or small, perform a Dubowitz/Ballard exam to assess gestational age. • Two parts: • an external characteristics score, which is best done at birth, and • a neuromuscular score, which should be done within 24 hours after birth.

  3. GESTATIONAL AGE ASSESSMENT

  4. TERMINOLOGIES: VERY LOW BIRTH WEIGHT Less than 1500 grams

  5. TERMINOLOGIES: LOW BIRTH WEIGHT Less than 2500 grams

  6. TERMINOLOGIES: FULL BIRTH WEIGHT 2500 - 4000 grams

  7. TERMINOLOGIES: GESTATIONAL AGE Number of weeks that have elapsed since the first day of the last menstrual period to the time of birth

  8. TERMINOLOGIES: PRETERM Birth occuring prior to completion of the 37th week

  9. TERMINOLOGIES: TERM Birth occuring between the beginning of 38th week and before the completion of the 41st week.

  10. TERMINOLOGIES: POSTTERM Birth at onset of 42nd week or thereafter

  11. PHYSICAL CHARACTERISTICS

  12. NEW BALLARD SCORE PHYSICAL MATURITY Skin Lanugo Plantar surface Breast Eye/Ear Male genitals Female genitals

  13. NEUROMUSCULAR REACTIONS

  14. NEW BALLARD SCORE NEUROMUSCULAR MATURITY Posture Square window Arm recoil Popliteal angle Scarf sign Heel to ear

  15. NEW BALLARD SCORE PRETERM TERM POSTTERM

  16. PRETERM Infants delivered before 37 completed weeks Incidence: 6-15% Difficulty in adapting to extrauterine life with susceptibility to the ff: Infection Hyperbilirubinemia Hypoglycemia Hypocalcemia Cold stress

  17. PRETERM PHYSICAL FEATURES: Thin transparent skin and subcutaneous tissue Lanugo hair all over except in face Scarcely felt breast buds and barely visible nipples Flat shapeless pinna of ears Non-pigmented scrotum with undescended testes Widely separated labia majora with protruding labia minora Barely perceptible plantar creases

  18. PRETERM NEUROLOGIC FEATURES: Hypotonic Weak and slow sucking, rooting, grasp and Moro reflexes at 28 weeks

  19. POST TERM INFANTS Infants delivered after 42 weeks of gestation Predisposed to have the ff: Little vernix No lanugo hair Pale, dry and desquamating skin Long fingernails

  20. CLIFFORD STAGING (PLACENTAL DYSFUNCTION) FIRST STAGE Alert with loose hairless skin SECOND STAGE Meconiums stained navel and fingernails THIRD STAGE Old man facies

  21. SMALL FOR GESTATIONAL AGE (SGA) • SYMMETRIC (hc=wt=len, all <10%): 33% of SGA • Genetic • Small maternal size • Chromosomal abnormalities (Trisomies 13, 18, 21, and Turner's syndrome) • Congenital abnormalities • Intrauterine infections • Viruses (rubella, CMV, ?varicella, ?HIV) • Bacteria (tuberculosis) • Spirochete (syphilis) • Protozoan (toxoplasmosis, malaria)

  22. SMALL FOR GESTATIONAL AGE (SGA) • SYMMETRIC (hc=wt=len, all <10%): 33% of SGA • Inborn errors of metabolism • Hypophosphatasia • Leprechaunism • Some amino acidurias • Environmental • Drugs (heroin, methadone, ethanol, diphenylhydantoin) • X-rays (therapeutic) • Smoking

  23. SMALL FOR GESTATIONAL AGE (SGA) • ASYMMETRIC (hc=len>wt, wt<10%): 55% of SGA • Uteroplacental insufficiency • Chronic hypertension • Preeclampsia • Renal disease • Cyanotic heart disease • Hemoglobinopathies • Placental infarcts or chronic abruption, velamentous insertion, circumvallate placenta, multiple gestation. • Altitude

  24. SMALL FOR GESTATIONAL AGE (SGA) • COMBINED: 12% of SGA infants • Environmental • Drugs (including ethanol) • Smoking • Placental unit insufficiency • Placental infarcts or chronic abruption, velamentous insertion, circumvallate placenta, multiple gestation

  25. LARGE FOR GESTATIONAL AGE (LGA) • Large mother (familial) • Infants of diabetic mothers • Beckwith-Wiedemann syndrome • Hydrops fetalis

  26. SKIN • COLOR • Pallor: Ass. with anemia • Cyanosis: Sign of hypoxemia • Plethora: Ass. with polycythemia • Jaundice: Yellowish discoloration of skin and mucous membrane • Slate grey color : Methemoglobinemia

  27. NORMAL SKIN VARIANTS • Milia - pinpoint white papules of keratogenous material usually on nose, cheeks and forehead, last several weeks. • Miliaria - obstructed eccrine sweat ducts. Pinpoint vesicles on forehead scalp and skinfolds. Clear within 1 week. • Transient neonatal pustular melanosis - small vesicopustules, generally present at birth, containing WBCs and no organisms. The intact versicle ruptures to reveal a pigmented macule surrounded by a thin skin ring.

  28. NORMAL SKIN VARIANTS • Erythema toxicum - Most common newborn rash. Variable, irregular macular patches. Lasts a few days. Wright's stain shows sheets of eosinophils. • Cafe au lait spots - suspect neurofibromatosis if there are many large spots. • Junctional nevi - if large numbers, suspect tuberous sclerosis, xeroderma pigmentosus, generalized neurofibromatosis.

  29. NORMAL SKIN VARIANTS • Harlequin phenomenon – Half erythema, half pallor commonly seen in preterms • Cutis marmorata – Mottling. Lacy pattern seen in newborns less than 12 hours of age. Ass with cold stress. If persist, suspect congenital hypothyroidism • Sucking blisters – Blisters seen in hands and wrists documenting ability of fetus to suck.

  30. NEUROLOGICAL EXAM • State of alertness • Posture: Normal position is fetal attitude with hips abducted and partially flexed, with knees flexed, and with arms adducted and flexed at the elbow. Fists are clenched with fingers covering the thumb • Tone: Support with one hand under chest. Neck extensors should hold head in line for 3 seconds. Should have > 10% head lag.

  31. NEUROLOGICAL EXAM • Reflexes Symmetrical Includes: Biceps jerk (C5-6) Knee jerk (L2-4) Ankle jerk (S1-2) Truncal incurvation reflex (T2-S1) Anal wink (S4-5) Other primitive reflexes: Moro, Palmar and plantar grasp Sucking, swallowing and rooting reflexes Asymmetric tonic neck reflex

  32. NEUROLOGICAL EXAM When reflexes appear and disappear:

  33. HEAD AND NECK • Check the size and shape of the head • Measure the head circumference • Check for number and size of fontanelles • Check for overriding sutures • Note for encephalocoeles

  34. EYES • Check for presence and size of the eyeball • Check for colobomas, heterochromia • Check for cloudiness of the cornea • Inspect the conjunctiva as to presence of erythema, exudate, hemorrhage and jaundice. • Check for pupillary size and reactivity to light • Red reflex. Black dots may mean cataracts. Whitish color may suggest retinoblastoma

  35. EARS • Check for asymmetry and irregular shapes • Check for auricular or pre-auricular pits, fleshy appendages, lipomas or skin tags • Check for the patency of the auditory canal

  36. NOSE • Check for asymmetry and irregular shapes • Look for flaring of the alae nasi as a sign of respiratory distress • Check for hyper- or hypo-telorism • Check for choanal atresia indicated by resistance to insertion of nasal catheter beyond 4cm mark

  37. MOUTH • Check the size and shape of the mouth Microstomia: Trisomy 18 & 21 Macrostomia: Mucopolysaccharidoses Fish mouth: Fetal alcohol syndrome • Normal lesions: Epstein pearls: Small white cysts containing keratin found on either side of the median raphe of palate Ranulas: Small bluish white swellings of variable size on the mouth floor representing benign mucous gland retention cysts

  38. PALATE • Check for cleft lip and palate

  39. TONGUE • Check for the size of the tongue • Macroglossia: Found in congenital hypothyroidism and mucopolysaccharidoses

  40. TEETH • Check for natal teeth which may occur in 1/2000 l.b. Mostly lower incisors. If loosely attached, risk of aspiration

  41. CHIN • Check for size and shape of the mandible • Micrognathia: Seen in Pierre-Robin syndrome, Treacher-Collins syndrome, and Hallerman Streiff syndrome

  42. NECK • Palpate over all muscles • Palpate clavicles for possible fracture • Note for web neck as found in Turner’s, Noonan’s and Downs’ syndrome

  43. NECK • Check for torticollis secondary to sternocleidomastoid hematoma. • Note for neck masses, most common of which, cystic hygroma • Lymph nodes, if present, indicate congenital infection

  44. CHEST AND LUNGS • Observe respiratory rate and pattern Normal respiratory rate: 40-60 per minute Periodic breathing vs apnea Periodic breathing: Regular burst of breaths followed by respiratory pause of 5-10 seconds Apnea: Cessation of breathing for 20 seconds with/without bradycardia or cyanosis

  45. CHEST AND LUNGS • Observe chest movements for symmetry and for retractions • Listen for stridor, most common neonatal cause of which, laryngomalacia. • Diminished breath sounds on either side suggests pneumonic consolidation, atelectasis, effusion, and other pulmonary problem. • Some enlargement of the breasts may be secondary to maternal hormones (estrogen).

  46. CARDIOVASCULAR SYSTEM • Measure heart rate and blood pressure in both upper and lower extremities • Inspect the baby’s color for pallor, cyanosis or plethora • Check for dynamic precordium indicative of heart failure

  47. CARDIOVASCULAR SYSTEM • Check capillary refill (normal: 2 seconds) • Check presence and character of pulses:  in femoral pulses or radio-femoral delay indicates possible coarctation of aorta Bounding pulses suggest PDA • Locate PMI with single finger on chest Abnormal location suggests situs inversus, pneumothorax, diaphragmatic hernia, or other thoracic problem

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