Newborn Examination Guidelines

Newborn Examination

• Objectives: Indication and importance, Precautions prior to exam, Systematic approach, Neonatal reflexes, Normal variants

Indications

• Earliest possible detection of deviations
• Establishes a baseline for subsequent examinations
• Parents' assurance and counseling

Newborn Examination Timing

• Immediately after birth
• Before discharge from maternity unit
• Whenever there is any concern about the infant's progress

Newborn First Exam (Apgar Score)

• Heart rate
• Respiratory effort
• Color
• Tone
• Reflex irritability

Examination Precautions

• Hand washing: Thorough hand washing is crucial
• Thermal environment: Maintain a suitable room temperature
• Light and noise: Minimize distractions
• Brief examination time: Keep the examination concise

General (Growth Parameters)

• Weight (Naked)
• Length (Straight)
• Head Circumference (3 Measurements)

General (Well, Distress, or Not?)

• Skin:
  • Pink is normal
  • Acrocyanosis is normal
  • Cyanosis
  • Bruised part looks blue
  • Jaundice
  • Common variants skin rash (erythema toxicum, mongolian spot, benign pustular melanosis)

DD: Impetigo Neonatorum

• Vesicular, pustular, or bullous lesions developing as early as day 2-3 up to 2 weeks of life
• Lesions occur in moist or opposing skin surfaces
• Unroofed lesions do not form crusts
• Treat with antibiotics

General (Inspection)

• Obvious dimorphism or malformations (e.g., Down syndrome, ear tag, neural tube defect)
• Tone & Movements: Flexion of upper and lower extremities—Asymmetric movement: Brachial plexus and fractured clavicle, Ventral, vertical suspension and head control for tone assessment
• Cry: Vigorous cry is assuring, Weak cry (sepsis, asphyxia, metabolic, narcotic use)—Hoarseness (hypocalcemia, airway injury)—High pitch cry (CNS causes, kernicterus).

Head

• Forceps and vacuum marks
• Caput succedaneum: Boggy edema in presenting part of head (cross suture lines), disappears in a few days
• Cephalhematoma: Subperiosteal, weeks to resolve (does not cross sutures)

Head (cont'd)

• Head circumference
• Shape: Molding, Brachycephaly: flat occiput
• Widening of suture
• Fontanelles
• Head auscultation: bruits

Infant Skull

• Includes images of coronal, lamboidal, squamous, sagittal sutures and fontanelles

Craniosynostosis

• Definition: premature closure of one or more cranial sutures
• Growth of the skull occurs parallel to the suture(s) involved
• Early correction optimizes cosmetic appearance
• Can be part of syndromes: Crouzon's, Apert's syndrome

Craniosynostosis (Types)

• Sagittal synostosis results in scaphocephaly
• Coronal synostosis results in brachycephaly
• Coronal, sagittal, and lambdoid synostosis results in acrocephaly
• Single suture on one side of the head can result in plagiocephaly

Craniotabes

• Description of craniotabes

Epicanthal folds

• Many variations exist—The boy on the left does not have folds—On the right image, the effect of the epicanthal fold extending above the inner canthus is illustrated

Chest and Abdomen

• Inspection: Scaphoid, Distention, Abdominal wall defect (gastroschisis)
• Palpation: Kidneys are normally palpable (liver 2-3 cm), spleen palpable, umbilical vessels (2 artery, one vein), hernias (umbilical and inguinal)

Umbilical cord cyst

• Description of umbilical cord cyst

Diastasis recti

• Description of diastasis recti

Genitalia

• Penile size
• Hypospadias, epispadias
• Testes (2% cryptorchid, hydrocele)
• Female: Prominent clitoris and minora, Vaginal skin tag, Vaginal discharge/blood, Labial fusion
• Anus: patency and location

Hydroceles & Inguinal Hernias

• Descriptions

Increased androgen production

• Results in ambiguous genitalia in newborn girls

Hip and Extremities

• Erb's palsy: Extended arm and internal rotation with limited movement
• Humerous fracture
• Digital abnormality (Syndactyly, brachyodactyly, polydactyly)
• Single palmar crease
• Hip dislocation (female, breach)

Feet and Back

• Feet deformities
• Back and spine (abnormal curvature, sinus tract, tuft of hair)

CNS

• Awakenes and alertness
• moving extremities
• Flexed body posture
• Minimal Head lag
• Ventral suspension
• Vertical suspension

Neonatal reflexes

• Also known as developmental, primary, or primitive reflexes
• They consist of autonomic behaviors that do not require higher-level brain functioning.
• They can provide information about lower motor neurons and muscle tone.
• They are often protective and disappear as higher-level motor functions emerge.

Suck Reflex

• Onset: ~28 weeks gestation (GA)
• Well-established: 32-34 weeks GA
• Disappears: around 12 months
• Elicited by stroking the lips—Infant's mouth opens—Examiner introduces gloved finger, sucking starts

Rooting Reflex

• Onset: 28 weeks GA
• Well-established: 32-34 weeks GA
• Disappears: 3-4 months
• Elicited by stroking the cheek or corner of the infant's mouth—Infant turns head toward the stimulus, opens mouth.

Palmar Grasp Reflex

• Onset: 28 weeks GA
• Well-established: 32 weeks GA
• Disappears: 2 months
• Elicited by placing finger on palmar surface—Infant grasps the finger—Attempts to remove finger result in tightening grasp

Tonic Neck Reflex

• Onset: 35 weeks GA
• Well-established: 4 weeks post-conception (PCA)
• Disappearance: 7 months
• Elicited by rotating the infant's head from midline to one side—Arm on side to which head is turned extends—Opposite arm flexes—Lower extremities respond similarly.

Moro Reflex

• Onset: 28-32 weeks GA
• Well-established: 37 weeks GA
• Disappearance: 6 months
• Examiner holds infant (one hand supports head, other supports buttocks)—Sudden dropping of head elicits reflex—Infant's hands open, extension and abduction of upper extremities—Followed by anterior flexion of upper extremities and audible cry

Moro Reflex Significance

• Absent or inadequate Moro response on one side: Hemiplegia, brachial plexus palsy, or fractured clavicle
• Persistence beyond 5 months of age indicates severe neurologic defects

Stepping Reflex

• Onset: 35-36 weeks GA
• Well-established: 37 weeks GA
• Disappearance: 3-4 months
• Elicited by touching infant's foot to edge of table—Infant makes stepping movements

Galant Reflex

• Onset: 28 weeks GA
• Well-established: 40 weeks GA
• Disappearance: 3-4 months
• Infant held in ventral suspension—Firm pressure applied to side parallel to spine in thoracic area—Response consists of flexion of pelvis toward the side of the stimulus

Babinski Reflex

• Onset: 34-36 weeks GA
• Well-established: 38 weeks GA
• Disappearance: 12 months
• Elicited by stimulus to outer edge of sole—Infant responds by plantar flexion and either flexion or extension of toes.

Postnatal Assessment of Gestational Age

• Ballard Score: Accuracy within 1-2 weeks (2 parts: neurologic characteristic & physical characteristic)
• Part of general examination

Physical Maturity

• Skin: thicker, less translucent, dry, peeling
• Lanugo: fine non-pigmented hair all over (27-28 weeks gestation), gradually disappears
• Plantar surface: presence or absence of creases
• Breast: areola development
• Ear cartilage
• Eyelid opening
• External genitalia (rugation, descent, prominent labia majora)

Neuromuscular Maturity

• Posture
• Square window
• Arm recoil
• Popliteal angle
• Scarf sign
• Heel to ear

Remember

• Wash hands prior to examination
• Inspect, inspect, inspect, then touch
• Neonatal reflexes implications
• Normal variations