Pediatric Exam 1: Newborn Assessment

Pediatric Exam 1: Newborn Assessment

• Age Classifications:

• Neonate: 1-28 days old

• Infant: 0-1 years old

• History:

• Heavily reliant on maternal and family history

• Includes maternal history, family history, genetic history, previous pregnancies/outcomes, labor/delivery details

• Apgar Score:

• Purpose: Evaluate CNS depression and immediate intervention need

• Components: Appearance, Pulse, Grimace, Activity, Respiration

• Scoring: 0-2 points per component; 0-4 = severe CNS depression, 5-7 = some CNS depression, 8-10 = normal

• Timing: 1 minute and 5 minutes after birth; repeat every 5 minutes until score of 8 or above.

• Abnormal Score (0-7): High risk for CNS/organ depression

• Scoring Details:

• Appearance: 0 = blue/pale, 1 = body pink, extremities blue (acrocyanotic: peri-oral, hands, feet), 2 = pink

• Pulse: 0 = none, 1 = <100 bpm, 2 = >100 bpm

• Grimace: 0 = none, 1 = grimace, 2 = cries

• Activity: 0 = limp, 1 = some activity, 2 = active

• Respiration: 0 = absent, 1 = slow/irregular, 2 = strong cry

• Normal Respiration: 40-60 breaths/minute

• Vitals:

• Heart Rate: Awake 100-165 bpm, Crying up to 180 bpm, Sleeping 90-160 bpm

• Blood Pressure: Systolic 67-84, Diastolic 35-53

• Temperature: 36.5°C to 37°C (axillary)

• Growth:

• Weight: Full-term average 7 lb 9 oz (3.5-6 kg); expected 5-10% weight loss in the first week, regained in 7-10 days; double birth weight by 4 months, triple by 1 year

• Length: Full-term average 20 inches (51 cm); about 10 inches of growth in the first year; 2 inches per year until puberty

• Head Circumference: 35 cm at birth; increases 1 cm/month in the first year

• Gestational Age Classification:

• Preterm: Less than 37 weeks

• Term: 37-42 weeks

• Postterm: Greater than 42 weeks

• Low birth weight: Less than 2,500 grams (5.5 lb)

• Normal birth weight: Greater than or equal to 2,500 grams (5.5 lb)

• Apnea: Respiratory pause lasting >20 seconds, most common in <34 week gestation, onset before 2 weeks of age. Treated with caffeine

• Percentiles:

• Less than 10th%: small

• 10th-90th%: normal

• Greater than 90th%: large

Physical Exam

• General Appearance: Size appropriate for gestational age? Inspect and palpate
• Head: Inspect and palpate for deformities
• Neck & Clavicles: Inspect and palpate
• Chest: Inspect and auscultate
• Back & Spine: Inspect for deformities (e.g., sacral dimple, spina bifida)
• Eyes: Inspect
• Ears: Inspect
• Nose: Inspect
• Throat: Inspect, looking for tongue tie
• Mouth: Inspect; look for feeding challenges, or cleft lip
• Genitalia: Inspect for abnormalities; vaginal discharge and mucous normal.
• Anus: Inspect for closed rectum; sacral dimple above the gluteal cleft (Spina Bifida)
• Abdomen: Inspect and evaluate
• Extremities (Hands & Feet): Inspect for abnormalities (polydactyly, hip dysplasia)

Hip Examination:

• Ortolani: Flex the hip and knees, gently abduct the hip
• Barlow: Flex and adduct the hip, then apply pressure to the knee

Reflexes

• Sucking: Present by 14 weeks gestation; assessment of feeding
• Moro: Present by 28 weeks gestation; disappears by age 3 months
• Babinski: Present until 1 year old; absence could indicate CNS issues.
• Palmar Grasp: Present by 28 weeks; disappears by 4 months
• Rooting: Helps in feeding

Umbilical Cord & Placenta

• Cord Vessels: Usually 2 arteries and 1 vein; variations possible (1-6%)
• Placenta: Examine for size, membranes, vessels, and infarcts/clots (abruption) on the maternal side. Small placentas are frequently associated with smaller infants.

Screenings

• General Population Screenings: Genetic (2 screenings immediately after birth, repeated 1.5-2 weeks in NICU and 3 before discharge/28 days) and Neonatal Metabolic Screening (NM) (24-48 hours after birth, NICU repeat 1.5-2 weeks, 3 tests before discharge or day 28) with 6 categories: amino acids, fatty acid oxidation, organic acids, hemoglobin, endocrine, bilirubin, and others. Genetic and NM screenings (initial and repeats) must be done within this timeframe.
• Hearing Screening: Common at age 1 month, 3 months, 6 months
• Critical Congenital Heart Disease: Possible pulse oximetry, SCID if indicated

Common Newborn Problems

• Jaundice: Usually not pathologic if after 24 hours, well perfused, palpable and symmetrical pulses, and stable.
• Murmurs: Grade 1-3/6, soft heard at left upper/midsternal border, often louder first 24 hours. Not necessarily abnormal, unless present before 24 hours (potential valve problems). Do not discharge infants with murmurs before 24 hours of life (must rule out valvular problems)
• Hypoglycemia: Should rise to normal levels within 0-4 hours; <40 mg/dL at 4-24 hrs, <45 mg/dL
• Respiratory Distress: Tachypnea (>60 bpm), Intercostal retractions, Grunting, Cyanosis
• Birth Trauma: Possible bruising, fractures (clavicle, humerus, femur), and cervical plexus palsies. Maternal drug use is a serious concern and prevents discharge.
• Prematurity: Physiological challenges like difficulty with sucking, swallowing, and breathing.
• Apnea: Respiratory pause lasting >20 seconds, most common in <34 week gestation, onset before 2 weeks of age. Treated with caffeine. Consider apnea a respiratory pause lasting >20 seconds.