Newborn

Pop C. Fonghe Group 6

PHYSICAL AND NEUROLOGIC
EXAMINATIONS OF THE NEWBORN
Vital Signs

Heart Rate: 120-160 bpm

Respiratory Rate: 40-60
breaths/min
Rectal Temperature: 36.5-
37.5°C rectally
Anthropometric Measurements
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• Small for Gestational
Age (SGA): birthweight
below the 10th percentile
• Appropriate for
Gestational Age (AGA):
birthweight between the
10th to 90th percentile
• Large for Gestational
Age: birthweight above
the 90th percentile
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Gestational Age

Preterm: (< 37 weeks or 259 days)

Term: (37-41 6 or 7 weeks or 260 –
294 days)
Post Term: (≥ 42 weeks or 295
days or more
Ballards Score
Skin Color and Perfusion

Vernix caseosa
usually covers
the babies
which protects
the skin from
maceration
while in utero
Skin Color and Perfusion
Acrocyanosis
(bluish coloration
of the hands, feet
and perianal
areas) is not
unusual on the
first day of life
Skin Color and Perfusion

 Harlequin
Skin Rash and Lesions

Milia

Neonatal Acne
Mongolian spot
Position and Movement
Face and Crying
 Symmetry of the
mouth and eyes is a
normal finding. An
asymmetrical mouth,
an ipsilateral eye that
does not close, and a
forehead that does
not wrinkle usually
indicate an injury to
the peripheral nerve
(CN VII)
Face and Crying

Normal cry: lusty cry

Hoarseness: laryngeal edema after airway
manipulation, hypocalcemia or airway
anomalies
Stridor: Internal obstruction or external
compression of the airway
Cardiovascular system

Central cyanosis with

comfortable breathing
suggests cyanotic heart
defect with diminished
pulmonary blood flow
Point of Maximal
Impulse (PMI): left of
the lower sternum
Normal heart rate: 120-140 bpm
Increased heart rate: pathologic states
e.g. respiratory distress syndrome, or
cardiac failure
Decreased heart rate: congenital heart
block, hypoxia or intracranial hemorrhage
Respiratory System

The most important part of the respiratory

examination is performed while simply
watching the infant breathe
Alveolar pathology results in end
inspiratory rales
Airway secretions give rise to harsh breath
sounds in early inspiration
Abdomen

Globular but not

distended
Distention: suggests
intestinal obstruction
especially if
accompanied by
vomiting after feeding
and the absence of
Separation of recti muscles is common in newborn
meconium stools
 Umbilical hernia –
usually closes when the
abdominal muscles
become stronger in
about 3 years
Omphalocele
 when bowel, liver,
sometimes other organs
remain outside covered
with amnion
Top-to-Bottom View
Head

 Cesarian
section/breech
extraction: rounded
heads
 Molding: head is the
presenting part in
vaginal delivery
resulting in asymmetry
and overlapping sutures
Head circumference

Must be
measured at the
widest diameter
from the occiput
to the glabella
Ears
Assess for asymmetry or
irregular shape:
 Note a presence of auricular or
pre-auricular pits, fleshy
appendages, lipomas or skin tags
 Low set ears
Below lateral canthus of eye
Associated with genitourinary
anomalies because these areas
develop at similar times
 Malformed ears
Can be associated with Down or
Turners Syndromes
Nose

Seckel syndrome
achondroplasia
Mouth
Neck
Chest

Seen in MAS Pneumonia

Witch’s Milk

Supernumerary Nipples ->

Newborn lung sounds: relatively more bronchial
than vesicular because of better transmission of
large airway sounds across a thin chest
 Absent or unequal breath
sounds- Pneumothorax
or atelectasis
• Absent breath sound
and presence of bowel
sounds –
diaphragmatic hernia
The back
Presence of a tuft of hair,
subcutaneous lipoma, sinus,
hemangiomata, sacral
dimple, aplasia cutis, or
skin tag should raise
suspicion regarding the
possibility of an underlying
dystrophic state
Extremities

• Erb’s palsy: extended arm, internally

rotated, and with limited moement caused
by excessing pulling, twisting, or pushing
the baby’s head during delivery. This is
often caused by a shoulder dystocia
delivery
• Klumpke’s palsy (Claw hand) – The upper
arm has normal movement but the lower
arm, wrists and hands are affected
The Genitalia
Hydrocoele may be present with or
without an accompanying hernia
 Anus
 Presence, patency, and location of the anus should be noted.
Patency of the anus if often assessed by cautious use of rectal
thermometer
 Absent(imperforate) anus may be associated with other
anomalies like esophageal atresia (VATER association)
V stands for vertebrae, which are the bones of the spinal column.
A stands for imperforate anus or anal atresia, or an anus that does not open to
the outside of the body.
C is added to the acronym to denote cardiac anomalies.
TE stands for tracheoesophageal fistula, which is a persistent connection
between the trachea (the windpipe) and the esophagus (the feeding tube).
R stands for renal or kidney anomalies.
L is often added to stand for limb anomalies (radial agenesis).
 Neurologic
Examination of the
Newborn
Complete examination is necessary in the
following cases:

1. Low APGAR scores 1. CNS infections

2. Prematurity 2. Palsies
3. Hypotonia 3. Trauma
4. Diminished 4. Evidence of
alertness dysmorphisms and
5. Seizures congenital
anomalies
Important Historical Data to Note

1. Gestational age
2. APGAR Scores
3. Maternal and obstetrical history
 Important Data from Physical
Examination
1. Head examination
Shape and size (percentile)
Sutures (closed, open, gaping)
Fontanel (size, bulging, depressed, full, tense, flat)
2. Skin Lesions
Midline dimpling, tracts, tufts of hair along the spinal area
Hyper- or hypopigmentel skin lesions
Portwine stains
Hemangiomas and telangiectasias
Important Data from Physical
Examination

3. Masses- encephalocoeles, tumors

4. Dysmorphisms and other congenital
anomalies
Basic Neurological Examination
Level of Alertness

Level of alertness
State I Quiet sleep
State II Active sleep
State III Semi-awakefulness
State IV Awake, alert, cooperative
State V Awake, fussing, and uncooperative
State VI Crying
Cranial Nerve Examination
 Olfactory (CN I)
Neonates can discriminate odors manifested by changes in
cardiac and respiratory rates and movement, but these are
rarely tested. It is functional by 5-7 months of age

 Optic Nerve(CN II)

Gross visual acuity testing
Fundoscopy – optic disk is normally light pink or pale gray.
Check for retinal hemorrhages
Oculomotor, Trochlear, Abducens
Nerves (CN III, IV, VI)
Eye movements may
disconjugate at birth
May do doll’s maneuver to
check for conjugate eye
movements
Check for ptosis (CN III)
Doll’s head rotation. As the head is turned toward the Pupillary size, reactivity,
shoulder, a tonic neck muscle reflex produces
corresponding ocular rotation in the opposite direction as and symmetry ( present in
though the eyes were remaining in their original position
as the head moves neonates > 32 weeks AOG
Trigeminal Nerve (CN V)

Check for facial sensation with the rooting reflex

Check for corneal reflexes – their presence and
symmetry
Check for grimace or any movement, change in
respiratory or cardiac rate with tactile stimulaton
over the forehead, cheeks and mandibular area
Facial Nerve (CN VII)

Check for facial symmetry at rest and movement

(during crying)
Check for size and symmetry of palpebral fissures,
nasolabial folds, postion of the corners of the mouth

Vestibulocochlear Nerve (CN VIII)

• Hearing is normally present in term babies
• Neonates blink or are startled with loud noise
Glossopharyngeal, Vagus,
Hypoglossal Nerves (CN IX, X, XII)
Considered intact if the following are normal and active:
Sucking – CN V, VII, XII
Swallowing – CN IX, X (Observe coordination)
Gag reflex – CN IX, X (Use small tongue blade covered with
gauze)
Normal response- active contraction of the soft palate with
upward movement of the uvula and of the posterior pharyngeal
muscles
Observe for tongue movement and loss of bulk – CN XII
Spinal Accessory Nerve (CN XI)

Cannot be done on sick neonates since

it requires flexion and rotation of the
head
For term newborns, passive rotation of
the head shows the bulk of the neck
muscles
Motor Examination
This is done when the baby is alert.
Posture

Normal term newborns: flexor attitude which

when coupled with spontaneous movement
indicates good muscle tone and power
Preterm newborns: lie in an extension position

Tone
• Passive tone – determining the degree of
resistance to passive movements of the joinh in
an awake, not crying infant
• Done through gentle flapping of hands and feet
Active tone
 Tested by observing the response to gentle pulling
from supine to upright position
 Hypotonic / floppy infant – shows severe head lag
Respiratory rhythm and chest movements
should exhibit adequate contraction of the
intercostal muscles.
Motor Strength – check spontaneous movements
as well as movement against resistance
Some Important Intergrated and Protective Reflexes
Reflex Moro Grasp Rooting and sucking Tonic neck; obligatory,
Palmar and plantar always abnormal

Technique Carry baby by the back and drop • Stroke ulnar side of the • Stroke angle of the Turn head sidewise
him/her onto the examiner’s hand palm (palmar) mouth;
• Apply pressure on the ball • Insert clean finger
of the foot (plantar)

Response Extension followed by flexion of the • Hand grasps stimulus • “Search to suck “fencing posture”- extension
upper limb (palmar) stimulus” of limbs towards direction of
• Toes “grasps” stimulus • Sucks finger strongly the head
(plantar)

Onset Birth Birth Birth Birth, well developed at 1-

month

Disappears 5 months • Palmar: 6 mos 3 months 5-6 months

• Plantar: 9-10 mos

Absent Young prematures, severe systemic Young preterm, severe systemic Young preterm, depressed Young preterm of first few
disease, depression kernictus disease, general depression babies, recent feeding days of life
Asymmetric • Brachial plexus palsy • Brachial plexus injury,
• Clavicular and/or humeral congenital hemiplegia
fracture; congenital hemiplegia • Lumbosacral plexopathy
(rare)

Persistent Cerebral palsy (CP), Spastic CP, neurodegenerative CP, neurodegenerative CP, all types
neurodegenerative disease disease disease
Subsequent Care of the Normal
Newborn
Remove blood and other maternal
secretions
Apply 1% tetracycline ointment on both
eyes
Inject aqueous vitamin K1
(phytomenadione) 1mg
Give hepatitis B IM preferably within 12
hours.
Administer BCG vaccine intradermally on
the R deltoid
Cord care
Breastfeeding
24 Hours Discharge

Hepatitis B vaccine in newborn

BCG vaccine at birth
Philippines Health Insurance
(PhilHealth) Newborn package
 Newborn Screening Test

Metabolic Disorders detected in NBS:

Congenital adrenal Hyperplasia
Congenital Hypothyroidism
Galactosemia
Glucose-6-Phosphate Dehydrogenase Deficiency
Phenylketonuria
 Newborn Screening Test

If+, a confirmatory test is done

NBS is done within 24-72 hrs after birth
 Or when NB has received milk feeding at least 24 hrs
Falsely ↑ TSH = False (+) screen for CH
Falsely ↑ 17 hydroxyprogesterone (170HF) = False (+) screen for
CH
Falsely↓ galactose and phenylalanine due to inadequate
feeding = False (-) screen for GAL and PKU
Hearing Screening
The Hearing Loss Screening Act of 2007 or Senate Bill No.
1372
“ An act of providing for the early detection, diagnosis, and
intervention for the congenital hearing loss among children
in the Philippines and for other purposes
 All babies born in the public hospitals are to be
screened for hearing loss before leaving the hospital
 Performed after 24 hours of life but not later than 6
months
 Risk Factors for Hearing Loss
A family history of sensineural 1 min APGAR score of 0-4
hearing loss 5 min APGAR score of 0-6
 TORCHS infection  Mechvent for ≥ 5 days
 Craniofacial anomalies  Neurodegenerative d/o
 Birth wt < 1500 grams  Syndromes known to include
 Hyperbilirubinemia hearing loss
necessitating exchange  Trauma
transfusion
 Ototoxic medications including
chemo
 Types of Screening Test

Auditory Brainstem Response (ABR) An Otoacoustic Emissions Test is a form of

measures evoked electrical signals which diagnostic testing for hearing. The test
are detected by surface electrodes from indicates if the cochlear outer hair cells are
within the hearing pathways of the brain functioning normally
in response to sounds
Hearing Loss

Forms of hearing Impairment: Degree and Severity of Hearing

Loss
Sensorineural loss – cochlea or Mild 15-30 dB HL
brainstem nuclei ; nerve Moderate 30-50 dB HL
deafness Severe 50-70 dB HL
Conductive loss – external Profound 70+ db HL

auditory meatus, tympanic

membrane, or the ossicles
within the middle ear
Discharge and Follow-up
Of a Normal Newborn up to 28 Days of Life
Discharge Criteria
Normal VS and PE
Able to suckle on breast effectively
Documented urine and stool output
Completion of neonatal screening tests
Complete anthropometric measurements
Demonstration of maternal (or surrogate’s)
ability to care for her neonate
Discharge Instructions

1. Hygenic care of the infant

2. Monitoring feeding, urination and bowel movements
3. Sleep and activity patterns
4. Follow-up visits
5. Jaundice and other changes in skin color
6. Danger signs that require immediate medical
consultation
7. Routine emergency contact number(s) and place(s)
First Week of Life

Breastfeeding
Ensure safety and comfort
Educate and assure
parents about infant care
Early diagnosis and
treatment of disease
conditions
Second Week to 28 days of Life

Goals:
Support breastfeeding
Ensure optimal growth and
development
Support and assure parents
Detect and treat potential
life threatening conditions
Thank you!