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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
SCORE SIGN
SIGN
-1 0 1 2 3 4 5 SCORE

Posture

Square
Window

Arm
Recoil

Popliteal
Angle

Scarf Sign

Heel To
Ear

TOTAL NEUROMUSCULAR SCORE

PHYSICAL MATURITY
SCORE SIGN
SIGN
-1 0 1 2 3 4 5 SCORE

superficial cracking, parchment,


gelatinous, smooth leathery,
Sticky, friable, peeling &/or pale deep
Skin red, pink, visible cracked,
transparent rash, few areas, rare cracking, no
translucent veins wrinkled
veins veins vessels

Lanugo none sparse abundant thinning bald areas mostly bald

heel-toe 40- anterior


Plantar >50 mm faint red creases creases over
50mm: -1 transverse
Surface no crease marks ant. 2/3 entire sole
<40mm: -2 crease only
raised
stippled
barely flat areola areola full areola
Breast imperceptable areola
perceptable no bud 3-4 mm 5-10 mm bud
1-2 mm bud
bud
well-curved formed &
lids fused lids open sl. curved thick
pinna; soft firm
Eye / Ear loosely: -1 pinna flat pinna; soft; cartilage
but ready instant
tightly: -2 stays folded slow recoil ear stiff
recoil recoil
testes in testes
scrotum testes testes
Genitals scrotum flat, upper down,
empty, descending, pendulous,
(Male) smooth canal, good
faint rugae few rugae deep rugae
rare rugae rugae

prominent prominent majora & majora


clitoris majora cover
Genitals clitoris & clitoris & minora large,
prominent & clitoris &
(Female) small labia enlarging equally minora
labia flat minora
minora minora prominent small

TOTAL PHYSICAL MATURITY SCORE

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

THE FIVE CRITERIA OF THE APGAR SCORE:

Component of
Score of 0 Score of 1 Score of 2
Acronym

blue at extremities no blue cyanosis


Skin color blue all over Appearance
body pink body and extremities pink
Heart rate absent <100 >100 Pulse

no response to grimace/feeble cry sneeze/cough/pulls away


Reflex irritability Grimace
stimulation when stimulated when stimulated

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#