Neonates PDF

Newborn Examination Dr. Sazlina Kamaralzaman 010-5667969 [email protected] Special thanks to Dr. Mahr Shoblack , Dr. Hussam Khodair authors: and Dr. Zuhair Aldajani  Newborn examination o...

Newborn Examination Dr. Sazlina Kamaralzaman 010-5667969 [email protected] Special thanks to Dr. Mahr Shoblack , Dr. Hussam Khodair authors: and Dr. Zuhair Aldajani  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 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 precaution Hand washing,hand washing ,hand washing Thermal environment Light and noise Brief examination time  (General(Growth parameters Weight (Naked) Length(straight) Head circumference(3 measurements)  General Well, Distress or not? skin – Pink is normal – Acro cyanosis is normal – Cyanosis – Bruised part look 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 of life 2-3 up to 2 weeks of life Lesions occur in moist or opposing surfaces of skin Unroofed lesions do not form crusts Treat with antibiotics Erythema toxicum Mongolian Spot benign pustular melanosis of newborn Impetigo Neonatorum  Mongolian Spots 90% of African infants, 81% of Asian, and 9.6% of Caucasian infants Slate-gray to blue-black lesions Usually over lumbosacral area and buttocks Accumulation of melanocytes within the dermis Generally fade by age 7 years Mongolian Spots Benign Pustular Melanosis of the Newborn Pustular Melanosis  General 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  General inspection 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 – Disappear in few days Cephalhematoma – Subperiosteal – Weeks to resolve – Dose not cross sutures Cephalhematoma Caput Succadaneum Newborn Scalp Hematomata  Head Head circumference Shape :Molding, Brachycephaly: flat occiput Widening of suture Fontanelles Head auscultation: bruits Infant skull  Craniosynostosis Definition: premature closure of one or more cranial suture. 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 head can result in plagiocephaly www.uscneurolosurgery.com 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  Chest Distress signs(Grunting,Tachypnea,Nasal flaring,asymetric chest rise,supra-sternal, intercostal, sub costal retraction). Deformities(Pectus excavatum, carinatum) Auscultate – Air entry, symmetry – Early crepitation sound is transmitted upper sound – Late inspiratory crepitation excavatum pectus  chest Suprmammary nipple Breast hypertrophy – Milk production – No redness  Supernumerary Nipples Found in males and females Pink or brown papules along the milk line, most commonly on the chest or abdomen May contain breast tissue and in women carry the same relative neoplasia risks Not considered a marker for other anomalies Supernumerary Nipples  Heart HR 100-160 beats/min Color, perfusion,Central cyanosis Murmur Single S1 Splited S2 – No split ;single ventricle, pulmonary hypertension auscultation area of neonatal heart Femoral Pulses  Abdomen Inspection – Scaphoid – Distention – Abdominal wall defect (gastroschisis) Palpation; baby sucking and use warm hands – Kidneys are normaly palpable – Liver 2-3 cm – Spleen palpable – Umbilical vessels 2 artery, one vein – Hernias ; umbilical and inguinal umbilical cord cyst diastasis recti  Genitalia Penile size Hypospadias, epispadias Testes – 2% crypoorchid – Hydrocele Female: – Prominent clitoris and minora – Vaginal skin tag – Vaginal discharge /blood – Labial fusion Anus : Patency and location Hydrocoeles Inguinal Hernias  Hip and Extremities Erb’s palsy: extended arm and internal rotation with limited movement Humerous fracture Digital abnormality – Syndactaly, brachdactaly, polydactaly Single palmar crease Hip dislocation – Female, breach Subluxation of the Hip Subluxation of the Hip DDH Examination  Feet and Back Feet deformities Back and spine – abnormal curvature – Sinus tract, tuft of hair Lumbar hair tuft & haemangioma  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 Onset: ~28weeks GA Well-established: 32-34 weeks GA Disappears: around 12 months Elicited by the examiner stroking the lips of the infant; the infant’s mouth opens and the examiner introduces their gloved finger and sucking starts.  Rooting Onset: 28 weeks GA Well-established: 32-34 weeks GA Disappears: 3-4 months Elicited by the examiner stroking the cheek or corner of the infant’s mouth. The infant’s head turns toward the stimulus and opens its mouth.  Palmar grasp Onset: 28 weeks GA Well-established: 32 weeks GA Disappears: 2 months Elicited by the examiner placing his finger on the palmar surface of the infant’s hand and the infant’s hand grasps the finger. Attempts to remove the finger result in the infant tightening the grasp.  (Tonic neck (Fencing posture Onset: 35 weeks GA Well-established: 4 weeks PCA Disappearance: 7 months Elicited by rotating the infants head from midline to one side. The infant should respond by extending the arm on the side to which the head is turned and flexing the opposite arm. The lower extremities respond similarly.  Moro Onset: 28-32 weeks GA Well-established: 37 weeks GA Disappearance: 6 months The examiner holds the infant so that one hand supports the head and the other supports the buttocks. The reflex is elicited by the sudden dropping of the head in her hand. The response is a series of movements: the infant’s hands open and there is extension and abduction of the upper extremities. This is followed by anterior flexion of the upper extremities and and audible cry. Moro  Moro significance An absent or inadequate Moro response on one side : hemiplegia, brachial plexus palsy, or a fractured clavicle Persistence beyond 5 months of age is : indicate severe neurological defects.  Stepping Onset: 35-36 weeks GA Well-established: 37 weeks GA Disappearance: 3-4 months PCA Elicited by touching the top of the infant’s foot to the edge of a table while the infant is held upright. The infant makes movements that resemble stepping.  (Galant (Trunk incurvation Onset: 28 weeks GA Well-established: 40 weeks GA Disappearance: 3-4 months The infant is held in ventral suspension with the chest in the palm of the examiner’s hand. Firm pressure is applied to the infant’s side parallel to the spine in the thoracic area. The response consists of flexion of the pelvis toward the side of the stimulus.  Babinski Onset: 34-36 weeks GA Well-established: 38 weeks Disappearance: 12 months PCA Elicited by stimulus applied to the outer edge of the sole of the foot. The infant responds by plantar flexion and either flexion or extension of the 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 wks – disappears gradually Plantar surface: presence or absence of creases Breast: areola development Ear cartilage Eyelid opening External genitalia – Rugation, desend – Prominent labia majora  Neuromuscular Maturity Posture Square window Arm recoil Poplitteal angle Scarf sign Heel to ear  Remember Wash your hand prior to examination Inspect,Inspect,Inspect,then Touch. Neonatal reflexes implicatons Normal variations