Neonatal 20 examination

NEONATAL EXAMINATIONBy Dr/ Mohamed AbbassNeonatologist in Elnasr NICU 1

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THE FIRST 24 HOURS: The newborn infant should undergo a complete physical examination within 24 h of birth.It is easier to listen to the heart and lungs first when the infant is quiet.Warming the stethoscope..

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Appearance:

Signs such as cyanosis, nasal flaring, intercostal retractions, and grunting suggest pulmonary disease.Meconium staining of the umbilical cord, nails, and skin suggest fetal distress and the possibility of MAS. The level of spontaneous activity, passive muscle tone, quality of the cry, and apnea are useful screening signs to evaluate the state of the nervous system.

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1-VITAL SIGNS:Temprature: axillary method is prefered (36.0-37 °C).

Heart rate :(normal rate, 120 to 160 beats/ min when awake, 70-80 beats/min when asleep).

Respiratory rate: ( normal rate is 40 to 60 cycle per min) should be assessed within a whole minute.

Blood pressure: (often reserved for sick infants). 5

II-Length, Weight, and Head circumference: should be measured and plotted on growth curves.

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GESTATIONAL AGE :prenatally by the following techniques:

date of last menstrual period.

date of first reported fetal activity (quickening usually occurs at 16-18 weeks).

first reported heart sounds (10-12 weeks by Doppler ultrasound examination).

ultrasound examination (very accurate if obtained before 20 weeks' gestation).

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Postnatally is determined by an assessment of various physical signs and neuromuscular characteristics that vary according to fetal age and maturity.

A. Rapid delivery room assessment. :creases in the sole of the foot, size of the breast nodule, nature of the scalp hair, cartilaginous development of the ear lobe, and scrotal rugae and testicular descent in males.

B. New Ballard Score. The Ballard maturational score has been expanded and updated to include extremely premature infants. It has been renamed the New Ballard Score (NBS). The score now spans from 10 (correlating with 20 weeks' gestation) to 50 (correlating with 44 weeks' gestation). It is best performed at <12 h of age if the infant is <26 weeks' gestation. If the infant is >26 weeks' gestation, there is no optimal age of examination up to 96 h.

The examination is accurate whether the infant is sick or well to within 2 weeks of gestational age. 8

NEW BELLARD SCOREPhysical criteria , including increasing firmness of the pinna of the ear; increasing size of the breast tissue; decreasing fine, immature lanugo hair over the back; and decreasing opacity of the skin.

Neurologic criteria including increasing flexion of the legs, hips, and arms; increasing tone of the flexor muscles of the neck; and decreasing laxity of the joints. These signs are determined during the first day of life and are assigned scores.9

Classification. Infants are classified as preterm (<37 weeks), term (37-41weeks), or post term (>42 weeks).

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SMALL FOR GESTATIONAL AGE

Defined as 2 standard deviations below the mean weight for gestational age or below the 10th percentile.

Seen in infants of mothers who have hypertension or preeclampsia or who smoke. also been associated with TORCH infections, chromosomal abnormalities, and other congenital malformations.

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B. Appropriate for gestational age (AGA)

Normal full term.

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LARGE FOR GESTATIONAL AGE

Defined as 2 standard deviations above the mean weight for gestational age or above the 90th percentile.

Seen in infants of diabetic mothers, infants with Beckwith's syndrome,familial and infants with hydrops fetalis.. 14

III-GENERAL APPEARANCE

Observe the infant and record the general appearance (eg, activity, skin color, and obvious congenital abnormalities).

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1. Plethora (deep, rosy red color). Plethora is more common in infants with polycythemia but can be seen in an overoxygenated or overheated infant. It is best to obtain a central hematocrit on any plethoric infant.

IV. SKINA-COLOR:

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2. JaundiceWith jaundice, bilirubin levels are usually >5 mg/dL. This condition is abnormal in infants <24 h old and may signify Rh incompatibility, sepsis, and TORCH infections. After 24 h, ABO incompatibility or physiologic causes. 17

3-Pallor

Pallor may be secondary to anemia, birth asphyxia, shock, or patent ductus arteriosus (Ductal pallor).

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4-CYANOSISDesaturation of 5 g of hemoglobin usually necessary for one to note a bluish color

Central cyanosis (bluish skin, including the tongue and lips). Central cyanosis is caused by low oxygen saturation in the blood. It may be associated with congenital heart or lung disease.

Acrocyanosis (bluish hands and feet only). normal, cold stress. decreased peripheral perfusion secondary to hypovolemia.

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associated with a prolonged and difficult delivery and may result in early jaundice.

Petechiae (pinpoint hemorrhages). If they are widespread and progressive do coagulation profile.

5-ECCHYMOSES

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B-HARLEQUIN COLORATIONclear line of demarcation between an area of redness and an area of normal coloration).

The cause is usually unknown.

The coloration can be benign and transient (lasting usually <20 min) or can be indicative of shunting of blood (persistent pulmonary hypertension or coarctation of the aorta).

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C- MOTTLING

(lacy red pattern) may be seen in healthy infants and in those with cold stress, hypovolemia, or sepsis.

Persistent mottling, referred to as cutis marmorata, is found in infants with Down syndrome, trisomy 13, or trisomy 18.

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D-VERNIX CASEOSAgreasy white substance that covers the skin until the 38th week of gestation. Its purpose is to provide a moisture barrier. It is completely normal.

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E-COLLODION INFANT

Congenital ichtyosisskin resembles parchment, and there can be some restriction in growth of the nose and ears.

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F-RASHES1. MILIA:Whitish, tiny, sebaceous retention cysts are usually on the chin, nose, forehead, and cheeks.

No erythema is seen.

These benign cysts disappear within a few weeks after birth.

These are seen in approximately 33% of infants.25

2-ERYTHEMA TOXICUM

Numerous small areas of red skin with a yellow white papule in the centre.Appear 48hr after birth last for 7-10 days.Common in full term.

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3-ACNE NEONATORUMSeen over the cheeks, chin, and forehead and consist of comedones and papules.Benign and requires no therapy; however, severe cases may require treatment with mild keratolytic agents.

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4-NEONATAL PUSTULAR MELANOSIS Three stages of lesions,

which may appear over the entire body: • Pustules.• Ruptured vesicopustules with scaling/typical halo appearance.• Hyperpigmented macules.This benign, self-limiting condition requires no specific therapy.

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5-HERPES SIMPLEX

Pustular vesicular rash, vesicles, bullae, or denuded skin

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6-CANDIDA ALBICANS RASHCommon seen in napkin area so called Napkin Dermatitis

Erythematous plaques with sharply demarcated edges. Satellite bodies are also seen.

Gram's stain of a smear or 10% potassium hydroxide preparation of the lesion reveals budding yeast spores

Treated with nystatin cream applied to the rash 4 times daily for 7-10 days. 30

G-NEVI1- MACULAR HEMANGIOMA ("STORK BITES")(ANGEL KISS)True vascular nevus normally seen on the occipital area, eyelids, and glabella.

The lesions disappear spontaneously within the first year of life.

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2-PORT-WINE STAIN (NEVUS FLAMMEUS) Seen at birth, does

not blanch with pressure, and does not disappear with time.SturgeWeber syndrome (port-wine stain over the forehead and upper lip, glaucoma, and contralateral jacksonian seizures).

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3-CAVERNOUS HEMANGIOMA large, red, cyst-like, firm, ill-defined mass and may be found anywhere on the body. The majority of these lesions regress with age, but some require corticosteroid therapy or surgical resection.Kasabach-Merritt syndrome: (thrombocytopenia associated with a rapidly expanding hemangioma) should be considered.

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4-STRAWBERRY HEMANGIOMA

Flat, bright red, sharply demarcated lesions that are most commonly found on the face.Spontaneous regression usually occurs (70% disappearance by 7 years of age). 34

5-MONGOLIAN SPOTDark blue or purple bruise-like macular spots usually located over the sacrum.Usually present in 90% of blacks and Asians, and disappear by 4 years of age. They are the most common birthmark.

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V. HEAD

Note the general shape of the head.

Inspect for any bruises secondary to forceps or fetal monitor leads.

Transillumination can be done for severe hydrocephalus.

Check for microcephaly or macrocephaly36

A. ANTERIOR AND POSTERIOR FONTANELLES

Anterior fontanelle usually closes at 9-12 months and the posterior fontanelle at 2-4 months.

A large anterior fontanelle is seen with hypothyroidism ,osteogenesis imperfecta, hypophosphatasia, and chromosomal abnormalities and in those who are small for gestational age.

A bulging fontanelle may be associated with increased intracranial pressure, meningitis, or hydrocephalus.

Depressed (sunken) fontanelles are seen dehydration.

A small anterior fontanelle may be associated with hyperthyroidism, microcephaly, or craniosynostosis.

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B-SKULL MOLDINGTemporary asymmetry of the skull resulting from the birth process.Most often seen with prolonged labor and vaginal deliveries, it can be seen in cesarean deliveries if the mother had a prolonged course of labor before delivery. A normal head shape is usually regained within 1 week.

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C. CAPUT SUCCEDANEUMDiffuse edematous swelling of the soft tissues of the scalp that may extend across the suture lines.It is secondary to the pressure of the uterus or vaginal wall.It resolves within several days

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D. CEPHALHEMATOMASubperiosteal hemorrhage that never extends across the suture line. It can be secondary to a traumatic delivery or forceps delivery.X-ray films or(CT) scans of the head should be obtained if an underlying skull fracture is suspected (<5% of all cephalhematomas). Hematocrit and bilirubin levels should be monitored in these patients.Most cephalhematomas resolve in 2-3 weeks. Aspiration of the hematoma is rarely necessary

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E. SUBGALEAL HEMATOMABleeding below the epicranial aponeurosis.It can cross over the suture line and into the neck or ear.It may be necessary to replace blood volume lost and correct coagulopathy if present

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F. INCREASED INTRACRANIAL PRESSURE

• Bulging anterior fontanelle

• Separated sutures

• Paralysis of upward gaze (setting-sun sign)

• Prominent veins of the scalp

• Increasing macrocephaly

Secondary to hydrocephalus, hypoxic- ischemic brain injury, intracranial hemorrhage, or subdural hematoma. 42

G. CRANIOSYNOSTOSISPremature closure of one or more sutures of the skull. It should be considered in any infant with an asymmetric skull.On palpation of the skull, a bony ridge over the suture line may be felt, and inability to freely move the cranial bones may occur.X-ray studies of the head should be performed, and surgical consultation may be necessary.

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H. CRANIOTABESsoftening of the skull that usually occurs around the suture lines and disappears within days to a few weeks after birth.It may be secondary to a calcium deficiency, and osteogenesis imperfecta and syphilis.

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VI. NECK Rooting reflex causes the infant to turn the head and allows easier examination of the neck.

Palpate the sternocleidomastoid for a hematoma and the thyroid for enlargement, and check for thyroglossal duct cysts.

A short neck is seen in Turner's, Noonan's, and Klippel-Feil syndromes.

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VII. FACELook for obvious abnormalities, general shape of the nose, mouth, and chin.hypertelorism (eyes widely separated) or low-set ears.

A. Facial nerve injury:

facial asymmetry with crying. The corner of the mouth droops, and the nasolabial fold is absent in the paralyzed side. The infant may be unable to close the eye, move the lip, and drool on the side of the paresis.

If the palsy is secondary to trauma, most symptoms disappear within the first week of life, but sometimes resolution may take several months. If the palsy persists, absence of the nerve should be ruled out.

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VIII. EARS:Hairy ears are seen in infants of diabetic mothers.

Gross hearing can be assessed when an infant blinks in response to loud noises.

Tympanic membranes are dull, gray, opaque, and immobile in the first 1 to 4 weeks. These findings should not be confused with otitis media.

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Seen with many congenital anomalies (most commonly Treacher Collins, trisomy 9,21 and 18 syndromes).

Low set ear

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benign, are often seen.

The 2007 Joint Committee on Infant Hearing statement lists ear pits as one of the physical findings associated with higher risk for Hearing impairment.

Preauricular skin tags

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Red reflex with an ophthalmoscope.

Opacification of the lens and loss of the reflex are apparent with Congenital cataract.

IX. EYES

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Normally white, can have a bluish tint if the infant is premature.

If the sclera is deep blue, osteogenesis imperfecta should be ruled out

Sclera

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Prader-Willi syndrome

Cystinosis

Pierre Robin syndrome

Rubella

Fetal alcohol syndrome

MucopolysaccharidosesSturgeWeber syndrome

Congenital glucoma

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Salt-and-pepper speckling of the iris are often seen with Down syndrome.

Brushfield's spots

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Rupture of small conjunctival capillaries can occur after a traumatic delivery.

This condition is seen in 5% of newborn infants.

Subconjunctival hemorrhage

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Aseptic chemical neonatal conjunctivitis that is induced by silver nitrate solution, which is used for prophylaxis of infectious conjunctivitis.

Septic neonatal conjunctivitis, with Chlamydia being the most common infectious agent.

Conjunctivitis

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X. NOSEChoanal atresia is suspected, verify the patency of the nostrils with gentle passage of a nasogastric tube. Infants are obligate nose breathers; therefore, if they have bilateral choanal atresia, they will have severe respiratory distress.

Nasal flaring is indicative of respiratory distress.

Sniffling and discharge are typical of congenital syphilis.

Sneezing can be a response to bright light or drug withdrawal.

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XI. MOUTH

A. RANULAcystic swelling in the floor of the mouth. Most disappear spontaneously.

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B. EPSTEIN'S PEARLS

Keratin-containing cysts, which are normal, are located on the hard and soft palatesResolve spontaneously.

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C. MUCOCELE

Secondary to trauma to the salivary gland ducts.It is usually benign and subsides spontaneously.

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D. NATAL TEETH lower incisors X-ray films are needed1. Predeciduous teeth. They are usually loose, and the roots are absent or poorly formed. Removal is necessary to avoid aspiration.2. True deciduous teeth. These teeth are true teeth that erupt early. They should not be extracted.

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E. MACROGLOSSIAEnlargement of the tongue can be congenital or acquired. Localized macroglossia is usually secondary to congenital hemangiomas. Macroglossia can be seen in Beckwith's syndrome (macroglossia, gigantism, omphalocele, and severe hypoglycemia), congenital hypothyrodism and Pompe's disease.

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F-THRUSH Infection resulting from C. albicans.Whitish patches appear on the tongue, gingiva, or buccal mucosa. Thrush is easily treated with nystatin suspension (0.1-1.0 mL) applied to each side of the mouth, 3-4 times per day for 7 days.

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6- CLEFT LIP AND PALATE

Isolated or part of trisomy 13.

Interfere with oral feeding.

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XII. CHESTA. Observation. First, note whether the chest is symmetric.

An asymmetric chest may signify a tension pneumothorax.

Tachypnea, sternal and intercostal retractions, and grunting on expiration indicate respiratory distress.

B. Breath sounds. A good place to listen is in the right and left axillae.

Absent or unequal sounds may indicate pneumothorax or atelectasis.

Absent breath sounds with the presence of bowel sounds indicates a diaphragmatic hernia.

C. Pectus excavatum: sternum is altered in shape. Usually, this condition is of no clinical concern. 64

D. Breasts in a newborn:

1 cm in diameter in term male and female infants.

They may be abnormally enlarged (3-4 cm) secondary to the effects of maternal estrogens. This effect, which lasts <1 week, is of no clinical concern.

A usually white discharge, commonly referred to as may be present, Never squeeze it.

Supernumerary nipples are extra nipples and occur as a normal variant. 65

XIII. HEARTThe position of the heart in infants is more midline than in older children.

The first heart sound is normal, whereas the second heart sound may not be split in the first day of life. Decreased splitting of the second heart sound is noted in PPHN, TGA, and pulmonary atresia.

Heart murmurs in newborns are common in the delivery room and during the first day of life. Most of these murmurs are transient and are due to closure of the ductus arteriosus, peripheral pulmonary artery stenosis, or a small VSD.

Pulses should be palpated in the upper and lower extremities (over the brachial and femoral arteries).

Blood pressure in the upper and lower extremities should be measured in all patients with a murmur or heart failure. An upper to lower extremity gradient of more than 10 to 20 mm Hg suggests coarctation of the aorta.

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XIV. ABDOMEN

A. Observation. Obvious defects may include an omphalocele, in which the intestines are covered by peritoneum and the umbilicus is centrally located

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Gastroschisis

Intestine are not covered by peritoneum (the defect is usually to the right of the umbilicus).

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A scaphoid abdomen may be associated with a diaphragmatic hernia.

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B. Auscultation: Listen for bowel sounds.

C. Palpation: Check the abdomen for distention, tenderness, or masses.

The liver can be palpated 1-2 cm below the costal margin and the spleen tip at the costal margin.

Hepatomegaly can be seen with congestive heart failure, hepatitis, or sepsis.

Splenomegaly is found with cytomegalovirus (CMV) or rubella infections or sepsis.

The kidneys (especially on the right) can often be palpated. Kidney size may be increased with polycystic disease, renal vein thrombosis, or hydronephrosis. Abdominal masses are more commonly related to the urinary tract.

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XV. UMBILICUSPresence of only two vessels (one artery and one vein) could indicate renal or genetic problems (most commonly trisomy 18).

If there is a single umbilical artery, there is an increased prevalence of congenital anomalies and intrauterine growth retardation and a higher rate of perinatal mortality.

If the umbilicus is abnormal, ultrasonography of the abdomen is recommended. In addition, inspect for any discharge, redness, or edema around the base of the cord that may signify a patent urachus or omphalitis.

The cord should be translucent; a greenish-yellow color suggests meconium staining, usually secondary to fetal distress.

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XVI. GENITALIAAny infant with ambiguous genitalia should not undergo gender assignment until a formal endocrinology evaluation has been performed.

A male with any question of a penile abnormality should not be circumcised until he is evaluated by a urologist or a pediatric surgeon.

A. Male. Check for dorsal hood, hypospadias, epispadias, and chordee. Normal penile length at birth is >2 cm. Determine the site of the meatus. Verify that the testicles are in the scrotum and examine for groin hernias. Undescended testicles are more common in premature infants. Hydroceles are common and usually disappear by 1 year of age. Observe the color of the scrotum. A bluish color may suggest testicular torsion and requires immediate urologic/surgical consultation. Infants will have well-developed scrotal rugae at term. A smooth scrotum suggests prematurity.

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B. Female:

Examine the labia and clitoris. A mucosal tag is commonly attached to the wall of the vagina.

Discharge from the vagina is common and is often blood tinged secondary to maternal estrogen withdrawal.

If the labia are fused and the clitoris is enlarged, adrenal hyperplasia should be suspected. 73

XVII. Lymph nodes:

Palpable lymph nodes, usually in the inguinal and cervical areas, are found in ~33% of normal neonates.

XVIII. Anus and rectum:

Check for patency of the anus to rule out imperforate anus.

Check the position of the anus.

Meconium should pass within 48 h of birth.74

XIX. EXTREMITIESA. Syndactyly abnormal fusion of the digits, most commonly involves the second and third toes. A strong family history exists.Surgery is performed when the neonates are older.

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B. Polydactyly is extra digits on the hands or the feet. This condition is associated with a strong family history. An x-ray film should done

If there are no bony structures, a suture can be tied around the digit until it falls off.

If bony structures are present, surgical removal is necessary.

Axial extra digits are associated with heart anomalies

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C. Simian crease. A single transverse palmar crease is most commonly seen in Down syndrome but is occasionally a normal variant.

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D- Talipes equinovarus(clubfoot) is more common in males.If this problem can be corrected with gentle force, it will resolve spontaneously. If not, orthopedic treatment and follow-up are necessary. 78

E. Metatarsus varus:adduction of the forefoot. This condition usually corrects spontaneously.

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XX. Trunk and spine.Check for any gross defects of the spine.

Any abnormal pigmentation or hairy tufts over the lower back should increase the suspicion that an underlying vertebral abnormality exists.

A sacral or pilonidal dimple may indicate a small meningocele or other anomaly. 80

XXI. HIPSCongenital hip dislocation occurs in ~1 in 800 live births. More common in white females, unilateral left hip.

Two clinical signs of dislocation are asymmetry of the skinfolds on the dorsal surface and shortening of the affected leg.

Evaluate for congenital hip dislocation by using the Ortolani and Barlow maneuvers.

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XXII. NERVOUS SYSTEM

A. Muscle tone 1. Hypotonia. Floppiness and head lag.

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2. Hypertonia:Increased resistance is apparent when the arms and legs are extended.Hyperextension of the back and tightly clenched fists are often seen.

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B. Reflexes. The following reflexes are normal for a newborn infant.

1. Rooting reflex. Stroke the lip and the corner of the cheek with a finger and the infant will turn in that direction and open the mouth.

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2. Glabellar reflex (blink reflex). Tap gently over the forehead and the eyes will blink.

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3. Grasp reflex. Place a finger in the palm of the infant's hand and the infant will grasp the finger.

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4. Neck-righting reflex. Turn the infant's head to the right or left and movement of the contralateral shoulder should be obtained in the same direction.

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5. Moro reflexSupport the infant behind the upper back with one hand, and then drop the infant back 1 cm or more tobut not onthe mattress. This should cause abduction of both arms and extension of the fingers.

Asymmetry may signify a fractured clavicle, hemiparesis, or brachial plexus injury. 88

Suckling reflex

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C. Cranial nerves. Note the presence of gross nystagmus, the reaction of the pupils, and the ability of the infant to follow moving objects with his or her eyes.

D. Movement. Check for spontaneous movement of the limbs, trunk, face, and neck.

A fine tremor is usually normal. Clonic movements are not normal and may be seen with seizures.

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E. Peripheral nerves

1. Erb-Duchenne paralysis involves injury to C5,6. This condition can be associated with diaphragm paralysis.

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2. Klumpke's paralysis involves C7,8 T1. The hand is flaccid with little or no control.

If the sympathetic fibers of the first thoracic root are injured, ipsilateral ptosis and miosis can occur.

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F. General signs of neurologic disorders

1. Symptoms of increased intracranial pressure.

2. Hypotonia or hypertonia.

3. Irritability or hyperexcitability.

4. Poor sucking and swallowing reflexes.

5. Shallow, irregular respirations.

6. Apnea.

7. Apathy.

8. Staring.

9. Seizure activity (sucking or chewing of the tongue, blinking of the eyelids, eye rolling, and hiccups).

10. Absent, depressed, or exaggerated reflexes.

11. Asymmetric reflexes. 93

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