Physical Assessment of the Newborn

Table of Contents

Normal Newborn: General Appearance Vital Signs and General Measurements Skin Head, Eyes, Ears Nose, Mouth, Throat, and Neck Chest and Abdomen Female Genitalia and Male Genitalia Back and Rectum. Extremities Neuromuscular System

Normal Newborn: General Appearance

Vital signs : Weight

Weight : 2.5 kg 3.5 kg
75 90 %of the newborns weight is fluid.

Sigs of potential distress or deviation from expected findings

4.7 kg is unusual.. A maternal illness should be suspected like diabetes.

Vital Signs: Heart rate

Range: 120 to 160 beats per minute Common variations:

Heart rate range to 100 when sleeping to 180 when crying Color pink with acrocyanosis Heart rate may be irregular with crying

Signs of potential distress or deviations from expected findings:

Although murmurs may be due to transitional circulation-all murmurs should be followed-up and referred for medical evaluation Deviation from range Faint sound

Vital Signs: Respiration

Range: 30 to 60 breaths per minute Common variations: Bilateral bronchial breath sounds Moist breath sounds may be present shortly after birth

Vital Signs: BP
Blood pressure - not done routinely Factors to consider:

Varies with change in activity level Appropriate cuff size important for accurate reading Average newborn (1 to 3 days) oscillometry pressure value: 65/41 in both upper and lower extremities

Vital Signs: Temperature

Range: 36.5 to 37.5 rectal 36.5 37.2 axillary Common variations:

Crying may elevate temperature Stabilizes in 8 to 10 hours after delivery

Signs of potential distress or deviations from expected findings:

Temperature is not reliable indicator of infection A temperature less than 36.5

Vital Signs
Newborn lose heat by 4 mechanism: a. Convection b. Conduction c. Radiation d. Evaporation

Important terms to remember:

Brown fats Kangaroo care.

Normal newborn
General appearance Well flexed full range of motion , spontaneous movement.

Skin: Expected findings

Skin reddish in color, smooth and puffy at birth At 24 - 36 hours of age, skin flaky, dry and pink in color Edema around eyes, feet, and genitals Vernix caseosa - white, cheesy substance covering the newborn's body. Often present only in the skin folds. Lanugo - Fine downy body hair usually distributed over shoulders, sacral area, and back of newborns. Usually disappears before birth or shortly after birth. Turgor good with quick recoil Hair silky and soft with individual strands Nipples present and in expected locations Cord with one vein and two arteries Cord clamp tight and cord drying Nails to end of fingers and often extend slightly beyond

Skin: Expected findings

Skin reddish in color, smooth and puffy at birth

Skin: Common Variations

Acrocyanosis - result of sluggish peripheral circulation

Skin: Common Variations

Mongolian spots in infants of African-American descent Patch of purple-black or blue-black color distributed over coccygeal and sacral regions of infants of African-American or Asian descent. Not malignant. Resolves in time.

Skin: Common Variations

Mottling: Generalized red and white discoloration of skin of chilled infants with fair complexion.

Skin: Common Variations

Physiologic Jaundice: Hyperbilirubinemia not associated with hemolytic disease or other pathology in the newborn Jaundice that appears in full term newborns 24 hours after birth and peaks at 72 hours Bilirubin may reach 6 to 10 mg/dl and resolve in 5 to 7 days.

Skin: Common Variations

Milia: Tiny white papules (plugged sebaceous glands) located over nose, cheek, and chin.

Skin: Common Variations

Erythema toxicum:

Skin: Common Variations

Petechiae/ bruises over presenting part Petechiae:

Pinpoint, flat hemorrhages often visualized on head, face, and chest. Associated with rapid onset of pressure followed by immediate release of pressure during birthing process. Larger than petechia, hemorrhagic areas associated with rapid delivery or breech birth.

Bruises/Ecchymoses:

Skin: Common Variations

Skin

tags usually around ears or digits (tied off) Harlequin color change:

The color of the newborn's body appears to be half red and half pale. This condition is transitory and usually occurs with lusty crying. Harlequin Coloring may be associated with to an immature vasomotor reflex system.

Skin: Common Variations

Signs of potential distress or deviations from normal Findings: Jaundice within 24 hours of birth

Unconjugated bilirubin circulating in the blood stream that is deposited in the skin Skin color may range from yellow to orange to greenish hues.

General cyanosis Circumoral cyanosis between feedings Petechiae or ecchymoses other than on presenting part All rashes with exception of erythema toxicum Pigmented nevi Yellow vernix Hemangioma Pallor Forceps marks

Skin: Common Variations

Forceps marks:

Desquamation : within 24 hours of birth, the skin of the newborn has become dry , particularly evident in the palm o the hand and sole of the feet.

Vernex caseosa : a white cream like substance that serves as skin lubricant.

The color of the vernix carefully noted because it takes on the color of the amniotic fluid.

Lanugo. : is a fine downy hair that

cover the newborn shoulder, back and upper arm
Age of two weeks they are disappear.

Birth marks
Hemangiomas

Nevus flammeus :
Dark lesions commonly called port wine stain due to its deep color.

Do not fade either.

Straberry hemangiomas :
Elevate areas that forms by immature capillaries and endothelial cells.

Appear in termed neonates appear up to 2 weeks.

Not present in preterm infants. Because of immature epidermis.

Up to 10 ears older before its complete absorption.

Cavernous heangiomas :

are dilated vascular spaces. They are usually raised and resemble a strawberry hemangiomas in appearance.

Craniotabes

: is localized softening of the cranial bones. The bones is so soft that the examminindg finger can indent it..
The condition correct itself without treatment.

Normal Newborn
General Appearance:

A. Head symmetry

-minor asymmetry is common and should equalize by approximately 4 mos.

General Measurements
Head circumference: 33 to 35 cm Expected findings

Head should be 2 to 3 cm larger than the chest

HEAD: Expected findings

Anterior

fontanel - diamond shaped 2-3 3-4 cm Posterior fontanel - triangular 0.5 - 1 cm

Fontanels

should be soft, firm and flat Sutures should palpable with small separation between each Forehead is large and prominent

Head: Common Variations

Caput succedaneum: Swelling of the soft tissue of the scalp caused by pressure of the fetal head on a cervix that is not fully dilated. Swelling crosses suture line and decreases rapidly in a few days after birth. Reabsorb within 12 hours after birth or few days

Head: Common Variations

Molding of fontanels and suture spaces

Head: Common Variations

Signs of potential distress or deviations from normal findings: Fontanels that are bulging or depressed Hydrocephalus Macrocephaly Cephalhematoma Closed sutures

Cephalhematoma

Head: Common Variations

Cephalhematoma: Subperiosteal extravasation of blood due rupture of vessels. Swelling increases in size on second and third day after delivery. Often associated with delivery by forceps. Swelling does not cross suture line and may take several weeks after birth. Jaundice may occur as blood cells are broken down as the swelling resolves.

Neck: Expected Findings

Short

and thick Turns easily side to side Clavicles intact Tonic neck reflex present Neck-righting reflex present Some head control

Neck
Signs of potential distress or deviations from expected findings: Torticollis-stiff neck drawing head to one side Resistance to flexion Webbing of neck Large fat pad on back of neck Palpable crepitus, movement with palpation of clavicle

Turner syndrome:

Abnormal skin folds over the back of the neck can be a marker of for genetic abnormality

Examining the neck

In newborn and infant. Nuchal rigidity is a more reliable indicator of meningeal irritation than is brudzinski sign or kernigs sign

Normal newborn
Eyes
-bruised &/or puffy eyelids are normal

-sclerae white to bluish white; slightly brownish frequent in newborns of African descent -small conjunctival, scleral & retinal

-erythromycin & tetracycline are now frequently used prophylactically instead of silver nitrate. If silver nitrate drops are used, it may cause edema & chemical conjunctivitis which may appear a few hrs after instillation and disappear in 1-2 days

Eyes: Expected findings

Slate gray or blue eye color No tears Fixation at times - with ability to follow objects to midline Red reflex Blink reflex Distinct eyebrows Cornea bright and shiny Pupils equal and reactive to light

Red reflex :

Is extremely important in the detection of retinoblastoma, a childhood eye cancer.

Red reflex absent

Red Reflex Absent

Eyes: Common Variations

Edematous eyelids:

Uncoordinated movements:

May focus for a few seconds

Eyes
Signs of potential distress or deviations from expected findings: Discharges Opaque lenses Absence of Red Reflex Epicanthal folds in newborns not of Oriental descent "Doll's eyes" Reflex beyond 10 days of age

When the head is moved slowly to the right or left, the eyes do not follow nor adjust immediately to the position of the head. This reflex should not be elicited once fixation is present. The persistence of the Doll's Eyes Reflex suggests neurologic damage. Reflexes absent

Eyes

Chemical conjunctivitis

Subconjunctival hemorrhage

Ears: Expected findings

Pinna top on horizontal line with outer canthus of eye Loud noise elicits Startle Reflex Flexible pinna with cartilage present Trisomy 18 and 13 syndrome.

Ears: Common variations

Skin tags on or around ears Ringing a bell by 6 inches from each ear.

Ears
Signs of potential distress or deviations from expected findings: Ear placement low Clefts present Malformations Cartilage absent
Preauricular sinus

Nose: Expected findings

Nostrils

patent bilaterally Obligate nose breathers No nasal discharge

Nose: Common variations

Sneezes

to clear nostrils Bridge appears absent Thin white nasal mucus discharge

Nose
Signs of potential distress or deviations from expected findings Choanal atresia and discharge Malformation Nasal flaring beyond first few moments after birth

Mouth & Throat: Expected Findings

Mucosa moist. Shortly after birth may visualize sucking calluses on central portions of lips.

Mouth & Throat: Expected Findings

Palate high arched Uvula midline Minimal or absent salivation Tongue moves freely and does not protrude Well developed fat pads bilateral cheeks Sucking reflex Rooting reflex Gag reflex Extrusion reflex

Mouth & Throat: Common Variations

Epstein's pearls on ridges of gums

Thrush : Candida infection : usually

appear on the tongue and side of the chicks are as white or as gray patches.

Mouth & Throat

Signs of potential distress or deviations from expected findings: Cleft lip or cleft palate Circumoral pallor Lip movement asymmetrical Reflexes absent or incomplete Protruding tongue Candida Albicans Diminished tongue movement

Mouth & Throat

Candida Albicans

Percocious teeth

Physiologic function
Cardiovascular system
Blood Values : newborn blood volume is 80 110 ml per kilogram (300 ml )

Newborn common have high erythrocyte count 6 million per cubic mm. and increase hemoglobin average of 17 18 g/100ml and hemactocrit 4 and 50% Newborn usually high in WBC at birth 15000 30000 cells /mm3 . As high as 40000 if birth is stressful Blood coagulation: most newborn have prolong coagualtion time

Chest: Expected Findings

Evident

xiphoid process Equal anteroposterior and lateral diameter Bilateral synchronous chest movement Symmetrical nipples

Chest: Common Variations

Witch's milk Enlarged breasts Accessory nipples Fluid should never expressed from infants breast.

Urinary System
Average newborn void within 24 hours after birth. (24 hours is the golden rule. Male should void with enough force to produce projected arc. Female : produce a steady stream , not a continuous dribbling.

Usually light colored and odorless. Specific gravity : 1.008 1.010 1st voiding: :pink or dusky because of uric crystal that formed in the bladder in utero

Gastrointestinal system
Stool
Stool

passed within 24 hours after birth. Consist of meconium ( blackish green, odorless material If not pass within 24 48 hours check for possibility of of imperfobnate anus 2nd and third day stools ( transitional stool.)

Newborn under photo therapy

Bright green stools because of increase bilirubin excretion.

Newborn with bile obstruction: will have clay colored gray stools. Because of bile pigments do not enter the intestinal tract

Immune system:
Passive anti bodies ( IgG ) against poliomellitis, measles diptheria, pertusis ,chicken pox rubella and tetanus.

Pallor : pallor is the result of anemia:

1. Excessive blood loss when the cord is cut.

2. addewquate floww of blood from the cord in to the infant at birth.

3. Fetal maternal transtransfusion 4. Low iron stores that caused by poor maternal nutrition during pregnancy 5. Blood incompatibility which large number of RBC were hemolzed in utero.

7. Internal bleeding.

GRAY colored newborn generally indicates infection

At about 20 mg / 100 mlKernicterus.

Harlequin sign

Twins transfusion phenomenon:

Abdomen: Expected Findings

Dome-shaped abdomen Abdominal respirations Soft to palpation Well formed umbilical cord Three vessels in cord Cord dry at base Liver papable 2 - 3 cms below right costal margin Bilaterally equal femoral pulses Bowel sounds auscultated within two hours of birth Voiding within 24 hours of birth Meconium within 24 - 48 hours of birth

Abdomen: Common Variations

Small umbilical hernia

Abdomen
Signs of potential distress or deviations from expected findings: Bowel sounds absent Peristaltic waves visible Abdominal distention Palpable masses Scaphoid-shaped abdomen Omphalocele Base of cord with redness or drainage Cord with two vessels

Female Genitalia
Expected findings: Edematous labia and clitoris Labia majora are larger and surrounding labia minora Vernix between labia

Female Genitalia
Common variations: Hymenal tag Pseudomenstruation Smegma Increased pigmentation Ecchymosis and edema after breech birth "Red brick" pink-stained urine due to uric acid crystals

Female Genitalia
Signs of potential distress or deviations from expected findings: Labia fused Fecal discharge from vaginal opening Imperforate hymen Ambiguous genitalia Widely separated labia

Male Genitalia
Expected findings: Urinary meatus at tip of glans penis Palpable testes in scrotum Large, edematous, pendulous scrotum, with rugae Smegma beneath prepuce Stream adequate on voiding

Male Genitalia
Common variations: Prepuce ( foreskin ) covering urinary meatus Erections Increased pigmentation Edema and ecchymosis after breech delivery

Male Genitalia
Signs of potential distress or deviations from expected findings: Non palpable testes Hypospadius ( ventral surface ) Epispadius ( dorsal surface ) Scrotum smooth Ambiguous genitalia

Back and Rectum

Expected findings: Intact spine without masses or openings Trunk incurvature reflex Patent anal opening "Wink reflex" present

Back and Rectum

Signs of potential distress or deviations From expected findings: Limitation of movement Fusion of vertebrae Spina bifida Tuft of hair Imperforate anus Anal fissures Pilonidal cyst

Extremities
Expected findings: Maintains posture of flexion Equal and bilateral movement and tone Full range of motion all joints Ten fingers and ten toes Legs appear bowed Feet appear flat

Extremities

Palmar creases present Sole creases present Negative hip click Grasp reflex present

Extremities
Signs of potential Distress or deviations from expected findings: Unequal tone Asymmetrical movement of extremities Polydactyly

Syndactyly

Extremities

Syndactyly Unequal leg length Asymmetrical skin creases posterior thigh Simean crease Persistent cyanosis of nail beds

Extremities

Dislocation of hip Marked metatarus varus

Neuromuscular System
Expected findings: Maintains position of flexion When prone, turns head side to side Holds head and back in horizontal plane when held prone Ability to hold head momentarily erect

Neuromuscular System
Signs of potential distress or deviations from expected findings: Hypotonia Quivering Limp extremities or straightening of extremities Clonic jerking Paralysis