EXAMINATION IN NEONATES 1. general examination a.

Skin colour – pink (normal), cyanosis/acrocynosis, pallor, jaundice, plethora, bruises and petechial haemorrhages. b. Posture – term infants, normally hip abducted, partially flexed, arms adducted and flexed at elbow. Abnormal – limited range of movements, exaggerated or asymmetrical movements, hypotonia or stiffness. c. Cry – normal, high pitched, weak or hoarse. d. head i. shape of head 1. moulding and caput succedaneum – edematous thickening of the scalp, due to vaginal delivery (normal, disappear 2-3 days) 2. plagiocephaly – flattening occipital region on one side, due to position in utero, improves with age 3. scaphocephaly – long head with flattened temporoparietal regions, occurs commonly in premature infants, become less obvious with age. 4. cephalhematoma – bleeding outer space of skull, elevates periosteum cause soft fluctuant confine swelling. 5. head size – hydrocephaly or microcephaly. By measurement. 6. craniosynostosis – premature fusion of skull bone, commonly sagittal suture. In case of Crouzon syndrome. 7. craniotabes – ping-pong ball skull/softening of skull, more common in preterm, or in the congenital rickets. ii. scalp – bruises, fontanels (normally soft and flat, visible pulsation ant. is normal, bulging may be due increase ICP) iii. facies – certain syndromes (Couzon, Potter) iv. eyes 1. site – eyes too far apart = hypertelorism, eyes too closed = hypotelorism. 2. conjunctiva – conjunctivitis is serious symptom in infants – infection (gonococcus, Chlamydia) must be excluded. Excessive lacrimination may be associated with a blocked nasolacrimal duct. 3. cornea and iris – cornea should be clear, red reflex should be elicited. Pupils should be constricted both direct and consensual. 4. eyelids – mild lid edema may be present in prolonged labour, particularly in face or brow presentation. v. ears – skin tag vi. nose – patency, polyps vii. mouth 1. lips – absent of philtrum + thin virmillion border = fetal alcohol syndrome

2. palate a. Epstein’s pearl = small inclusion cysts in the midline of hard palate. Normal and eventually disappear b. Cleft palate, Bifid uvula, High arced 3. tongue – large protruding = hypothyroidism, Down syndrome, Beckwith – Weidemann syndrome. 4. jaw – micrognitia = Pierre Robin syndrome 5. teeth – natal teeth, mostly lower incisors, if loose removed it. 6. mucous membrane – white patches = candida or mild curd, ranulas (bluish-white mucous gland retention cysts on the floor of mouth – not required treat. 7. saliva – drooling or excessive saliva usually inability to swallow. Exclude esophageal atresia, neuromuscular disorder. e. Neck i. Sternomastoid tumour – limited range of movement ii. Turner syndrome and Down syndrome – redundant skin at the back of the neck iii. Kilppel-Feil – short neck with limited movement iv. Cystic hygroma – swelling a side of neck, transilluminated brilliantly v. Goitre – always midline f. Chest i. Respiratory 1. normal shape = symmetrical, move equally 2. size – small chest in hypoplastic lungs 3. respiratory distress = tachypnea (> 60 bpm), retractions, cyanosis, grunting, and nasal flaring 4. stridor – upper airway obstruction. Inspiratory stridor + suprasternal retraction, croupy cough + hoarse cry = extrathoracic obstruction, expiratory stidor = intrathoracic obstruction ii. breast 1. engorgement – usually estrogen effect. Milk may be secreted and it is normal. Palpation may cause infection. 2. supernumerary nipples are common findings iii. cardiovascular system 1. pulses a. Normal = 100-175 bpm b. Radial and femoral pulses should be palpated. c. Usually reduce peripheral pulses = hypoplastic left heart/cardiogenic shock. d. Absent of femoral pulse = coarctation of aorta. e. Collapsing / bounding = delayed closure of ductus arteriosus. 2. apex beat – normal location = left 4th intercostals space, midclavicular line. Right apex beat = left pneumothorax / left diaphragmatic hernia / dextrocardia

3. auscultation a. systolic murmur may be normal in first 24 h of life b. triple / gallop rhythm is always abnormal. g. abdomen i. general 1. distension = intestinal obstruction / intra-abdominal mass. 2. scaphoid abdomen = diaphragmatic hernia 3. lax abdominal wall with redundant skin = prune-belly syndrome ii. liver 1. normally palpable up to1 cm below right subcostal margin 2. hepatomegaly = lung hyperinflation, cardiac failure, sepsis, hepatitis, intrauterine infection, hemolysis iii. spleen 1. tip can be palpated in about ¼ of normal infants 2. splenomegaly = infection (prenatal or postnatal), haemolysis iv. kidneys 1. may be palpated normally, particularly if infant relaxes 2. moderate kidney enlargement = hydronephrosis, dysplastic / cystic kidneys, Wilm’s tumour. 3. massive kidney enlargement = bladder neck obstruction, cystic disease 4. adrenal mass may palpable, difficult to distinguish clinically from renal mass v. umbilicus 1. vessels a. normally 2 thick-walled arteries and thin-walled vein seen b. 1-2% infants have 1 umbilical artery – do ultrasound to exclude anomaly of renal tract 2. colour a. normally translucent due to Wharton’s jelly b. green due to meconium staining c. yellow staining due to hyperbilirubinemia 3. stump a. cord usually separates by 10 days, eschar is yellow or greenish b. eschar reddened / cellulitis or discharge = infection c. urine or meconium from the stump = patent urachus or patent omphalomesenteric duct repectively d. Any exomphalos and gastroschisis e. Umbilical granulomata, due to excessive granulation tissue at umbilical stump – red

swellings resemble a strawberry. Treat with silver nitrate stick f. Umbilical hernia – small hernia requires no treatment – spontaneous regression by 6-18 months. h. perineum i. genital 1. ambiguous genitalia 2. testes – 98% in male infants, fail descent by 6 weeks is abnormal. Ectopic testicles =? 3. penis and urethra a. hypospadias = meatus open ventral surface b. epispadias = urethra open at dorsal surface of penis 4. scrotum a. hydrocele = may disappear spontaneously by 1 year of age b. inguinal hernia – in preterm (patent ductus vaginalis). Swelling can be reduced. Need surgery in all cases to prevent incarceration and strangulation 5. hymen a. hymenal skin tag – assoc. with protrusion of redundant vaginal mucosa. No treatment, regress after 1st few weeks of life b. hydrometrocolpos = bulging imperforated hymen, due to vaginal secretions 6. vagina and vulva a. labial fusion = adrogenital fusion b. mucoid vaginal discharge – occur in most mature female infant shortly after birth. It white, thick and may continue for 2-3 weeks. c. vaginal bleeding may occur in normal infants. d. clitoris; if larger, consider adrenogenital syndrome, maternal progesterone effect or intersex state. ii. anus – should be patent (tested with rectal thermometer). Imperforated anus usually associated with fistula into bladder or vagina. i. Extremities i. Feet 1. Abnormalities – talipes equinovarus, talipes calcaneovalgus and metatarsus varus. ii. Hip – Barlow’s and Ortolani tests to detect developmental dysplasia of hip. iii. Hands 1. Polydactyl, sclerodactyl, clinodactyl. 2. Any signs of brachial plexus injury – check spontaneous movements 2. neurological examination

a. primitive reflexes i. Moro, sucking, rooting, gasping, walking, papillary – abnormal when absence of the reflexes. b. movements/tones i. spontaneous symmetrical movements – abnormal if flaccidity, rigidity, convulsion, tremor, asymmetrical movements. 3. assessment of maturity
NEUROMUSCULAR MATURITY SIGN SCORE -1 0 1 2 3 4 5 SIGN SCORE

Posture Square Window Arm Recoil Popliteal Angle Scarf Sign Heel To Ear TOTAL NEUROMUSCULAR SCORE

PHYSICAL MATURITY SIGN SCORE -1 Sticky, friable, transparent 0 1 2 3 4 5 SIGN SCORE

Skin

superficial cracking, parchment, gelatinous, smooth leathery, peeling &/or pale deep red, pink, visible cracked, rash, few areas, rare cracking, no translucent veins wrinkled veins veins vessels sparse abundant thinning anterior transverse crease only stippled areola 1-2 mm bud bald areas mostly bald

Lanugo

none heel-toe 4050mm: -1 <40mm: -2

Plantar Surface

>50 mm no crease

faint red marks

creases ant. 2/3 raised areola 3-4 mm bud

creases over entire sole

Breast

imperceptable

barely perceptable

flat areola no bud

full areola 5-10 mm bud

Eye / Ear

lids fused loosely: -1 tightly: -2

lids open sl. curved pinna flat pinna; soft; stays folded slow recoil scrotum empty, faint rugae testes in upper canal, rare rugae prominent clitoris & enlarging minora

well-curved pinna; soft but ready recoil testes descending, few rugae

formed & firm instant recoil testes down, good rugae majora large, minora small

thick cartilage ear stiff testes pendulous, deep rugae

Genitals (Male)

scrotum flat, smooth

Genitals (Female)

clitoris prominent & labia flat

prominent clitoris & small labia minora

majora & minora equally prominent

majora cover clitoris & minora

TOTAL PHYSICAL MATURITY SCORE

MATURITY RATING TOTAL SCORE (NEUROMUSCULAR + PHYSICAL) -10 -5 0 5 10 15 20 25 30 35 40 45 50 WEEKS 20 22 24 26 28 30 32 34 36 38 40 42 44

THE FIVE CRITERIA OF THE APGAR SCORE:

Score of 0

Score of 1

Score of 2

Component of Acronym

Skin color

blue all over

blue at extremities body pink

no blue cyanosis body and extremities pink

Appearance

Heart rate

absent

<100

>100

Pulse

Reflex irritability

no response to stimulation

grimace/feeble cry when stimulated

sneeze/cough/pulls away when stimulated

Grimace

Muscle tone

none

some flexion

active movement

Activity

Respiration

absent

weak or irregular

strong

Respiration

Reference; 1. Essential Neonatology 2. http://www.ballardscore.com/ScoreSheet.htm 3. http://en.wikipedia.org/wiki/Apgar_score Prague#

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