NEWBORN ASSESSMENT

• Thorough physical exam during the first 24 hours of life.

• Inspection occurs before physical contact is made
- newborn’s attitude and position
- body proportions
- ease of movement
- respiratory effort
- presence of gross anomalies and color
Periods of Reactivity:
A. Transition period:
1. First period of Reactivity
- from birth to first 30 minutes of life
- infant is alert, awake, and active with strong sucking
- acrocyanosis may be present
- HR as much as 180 bpm when crying
- RR are rapid, 30-90 bpm and irregular with some nasal flaring and occasional retraction
- falling body temperature
- bowel sounds present after first 15 minutes
2. Sleep Period
- NB falls asleep for about 3 hours and will be difficult to arouse
- color is stabilizing
- temp is stabilizing at 37.2-degree celcius
- HR and RR slows down
- bowel sounds present at this time
3. Second Period of reactivity
- onset is 4-8 hours
- temp increases to 37.6 degrees celcius
- awake, alert
- mild cyanosis may occur
- respiration becoming irregular
- first meconium is often passed at this time
B. Stabilization period
- vital signs stabilize and NB sleeps every 3-4 hrs
Physical Assessment
Posture:
• Breech born babies may have extended legs
• Premature infants have frog legs
• Brow born babies may arch their back
Normal Newborn: General Appearance
Well-flexed, full range of motion, spontaneous movement
Dysmorphic features:
- cleft lip/palate
- missing limb
- spina bifida
- hydrocephalus
Vital Signs and General Measurements
• Temperature - Range 36.5 to 37.5 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
• 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:
- Deviation from range
- Faint sound
 • Respiration - Range 30 to 60 breaths per minute
• Common variations:
- Bilateral bronchial breath sounds
- Signs of potential distress or deviations from expected findings:
- Asymmetrical chest movements
- Apnea >15 seconds
- Diminished breath sounds
- Seesaw respirations
- Grunting
- Nasal flaring
- Retractions
- Deep sighing
- Tachypnea
- Persistent irregular breathing
- Excessive mucus
- Persistent fine crackles
- Stridor (Crowing respiratory sound)
GENERAL MEASUREMENTS
• Head Circumference - 33 to 35 cm
• Expected findings:
- Head should be 2 to 3 cms larger than the chest
• Chest circumference - 30.5 to 33 cm
• Common variations:
• Molding* of head may result in a lower head circumference measurement
• Head and chest circumference may be equal for the first 24 to 48 hours of life
• Weight range - 2500 - 4000 gms (5 lbs. 8oz. - 8 lbs. 13 oz.) – appropriate for gestational age
(AGA)
SGA (small for gestational age) - Birth weight is below the 10th percentile on an intrauterine growth
curve for that age.
• May be born preterm, term or postterm.
• Intrauterine growth restriction or failed to grow at the expected rate in utero.
 • Large for Gestational Age (LGA) - Birthweight is above the 90th percentile on an intrauterine
growth chart for that gestational age.
• Length range - 45 to 55 cms

REVIEW OF SYSTEMS
Integumentary system:
• The skin of the newborn is smooth and elastic with fair amount of subcutaneous tissue
Preterm: appear almost transparent
Postterm: paler, dry and peeling skin
Skin Color:
normal ruddy complexion at birth. High erythrocyte count and small amount of subcutaneous
fat makes blood vessels under the skin more visible.
Acrocyanosis – normal during the first 24 hours of life
Mongolian spot – bluish discoloration of the lower back and buttocks seen mostly in children of African
and Asian ancestry
- Usually disappears at school age
Mottling – irregular discoloration of the skin; when the baby is hypothermic
Harlequin’s sign – when the infant is lying on her side, the dependent portion of the body develops a
deep red color and the upper half turns pale
there is low melanin level at birth that results in the NB to have fairer complexion than adult.
Deviations from normal:
1. Infant turns cyanotic when crying but becomes pink when asleep and quiet
2. Soles of the feet do not turn pink when rubbed
3. cyanosis persisting beyond the 2nd day of life
4. Central cyanosis or cyanosis of the trunk
5. Gray color indicates infection
6. Pallor indicate anemia which can be caused by:
a. Excessive blood loss during cord cutting
b. Poor blood flow from cord to the infant during birth
c. Rh incompatibility in which massive fetal RBC destruction occured in utero
d. Fetal low iron stores related to poor maternal nutrition
• Skin Turgor: indicator of the hydration status of the NB
• Sweat Glands: eccrine glands which produce sweat are present and functional
• Sebaceous glands: begin to function in utero in response to androgen hormones.
– Very active late in fetal life in producing vernix caseosa.
- Milia – clogged and distended sebaceous glands found on the newborn’s face.

- disappears without treatment within 2-4 weeks after birth when the glands mature and drain.

HAIR:

 LANUGO – a fine downy hair that usually covers the infant’s shoulders, back, forehead, ears,
cheeks and upper arm

- first appears at 19 weeks fetal life and becomes most obvious at 27-28 weeks. It
disappears within 2 weeks after birth

- an indicator of gestational age

Less lanugo – premature

 More lanugo – term

No lanugo at all - postmature

Erythema Toxicum Neonatorum

- A harmless rash, also known as flea bite rash

- Not present at birth but appears anytime during the first four hours of life and persists upto 3
weeks.

- It is a reaction of the infant’s skin to clothes and sheets. It subsides without treatment

- Desquamation:

- NB skin usually becomes dry one day after birth which leads to peeling during the first 2-4 weeks

- Post mature infants experience more desquamation than normal term infants

• Cyanosis

- Bluish discoloration of the skin

- Acrocyanosis – bluish discoloration of the hands and feet of the NB due to poor peripheral
circulation; seen only during the first 24-48 hours of life

- Disappears when the infant cries vigorously and when the soles of the feet are
rubbed

Neonatal Physiologic Jaundice

- Jaundice – yellowish discoloration of the skin caused by build-up of bile pigment, bilirubin

- among the most common conditions that require medical attention in newborn

- Appears first in the face and forehead progressing to the abdomen and the extremities.

• Risk Factors:

1. Race: incidence is higher in East Asians and American Indians and is lower in African Americans

2. Geography: higher in populations living at high altitudes.

3. Genetics and familial risk

4. Nutrition

5. Maternal factors

6. Birthweight and gestational age

7. Congenital infection

Causes:

1. Rapid RBC destruction

 2. Indirect bilirubin

Characteristics of Physiologic Jaundice

• Appears 24 hours after birth

• Total serum bilirubin is less than 12 mg/dl

• Direct serum bilirubin does not increase more than 5 mg/100ml per 24 hours

• Infant does not show any signs of illness or cardiac decompensation

• Jaundice disappears in 1 week in FT and in 2 wks in preterm infants

Assessment of jaundice

1. Blanch the skin by applying direct pressure over bony prominence such as the nose and sternum

2. Observe color of nails, sclera, mucous membrane, skin of palms and soles

3. In dark skinned infant, check the conjunctiva, sclera and oral mucous membrane

Management:

1. Early feeding to speed passage of meconium through the intestines and prevent bilirubin
reabsorption

2. Phototherapy or exposure to early morning sunlight to hasten liver cell maturity

Pathologic Jaundice

- Occurs before 24 hours after birth and which is

• Causes:

1. Rh incompatibility

2. Liver damage

3. Blood dyscrasias

4. Sepsis

Birthmarks

1. Vascular Nevi

a. Nevus flammeus or port wine stain

- Dark red lesion of varying size

- Usually found in the face or other parts of the body

b. Strawberry marks or nevus vasculosus

- These are elevated areas of skin that are bright to dark red and with a rough surface
 - They resemble the outside of fresh strawberry

- Lesions may be present at birth or appear months after during the infancy period.

- They may continue to enlarge upto 1 year of age before disappearing completely by school age

- No intervention is required but application of cortisone may speed up its disappearance

c. Stork Bites or teleangiectatic nevi

- -common among fair skinned newborns and occurs more frequently in girls than in boys

- They are pink and easily blanch under pressure

- Appear mostly in the nape of the neck and sometime in the eyelid

- Not associated with other disorders and fade quickly

d. Cavernous hemangiomas

- Found in subcutaneous tissue and usually do not affect the skin over it

- Maybe present at birth or appear several months after

- They may require surgical intervention if they manifest problems like bleeding or rapid growth.

2. Pigmented Nevi

a. Nevus spilus – this skin lesion is more commonly known as mole

- it is flat, hairless and with coloration that can vary from pale yellow to brown or black

- does not require any intervention

b. Nevus pilosus

- type of nevus that is rarely found in newborn

- a mole with short fine or coarse hair

- hairy nevus found along the spine requires further examination as it may be associated with spina
bifida

HEAD

• Expected findings:

• Anterior fontanel diamond shaped 2-3 - 3-4 cms

• Posterior fontanel triangular 0.5 - 1 cm

• Fontanels soft, firm and flat

• Sutures palpable with small separation between each

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.

Deviations from expected findings:

• 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.

Eyes:
Common variation: edematous eyelids

Subconjunctival Hemorrhage

Signs of potential distress or deviations from expected findings:

• Discharges

• Reflexes absent

• "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.

EARS

• Expected findings:

• Loud noise elicits Startle Reflex

• Flexible pinna with cartilage present

• Pinna top on horizontal line with outer canthus of eye

Signs of potential distress or deviations from expected findings:

• Ear placement low

• Clefts present

• Malformations

• Cartilage absent

Mouth and Throat

• Expected findings:
 • 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

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

Common variations:
Epstein's pearls on ridges of gums

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

• Diminished tongue movement

Candida Albicans

Precocious teeth

Nose

• Expected findings:

• Nostrils patent bilaterally

• Obligate nose breathers

• No nasal discharge

Common variations:

• Sneezes to clear nostrils

• Bridge appears absent

• Thin white nasal mucus discharge

gSigns of potential distress or deviations from expected findings:

 • discharge

• Malformation

• Nasal flaring beyond first few moments after birth

Neck

Expected findings:

• Short and thick

• Turns easily side to side

• Clavicles intact

• Tonic neck reflex present

• Neck-righting reflex present

• Some head control

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

Chest

Expected findings:

• Evident xiphoid process

• Equal anteroposterior and lateral diameter

• Bilateral synchronous chest movement

• Symmetrical nipples

Common variations:

• "Witch's milk"

• Enlarged breasts

• Accessory nipples

Signs of potential distress or deviations from expected findings:

• Asymmetrical chest movements

• Sternum depressed
 • Marked retractions

• Absent breast tissue

• Flattened chest

• Nipples widely spaced

Abdomen

Expected findings:

• Abdominal respirations

• Soft to palpation

• Well formed umbilical cord

• Three vessels in cord

• Cord dry at base

• Liver palpable 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

Signs of potential distress or deviations from expected findings:

• Bowel sounds absent

• Peristaltic waves visible

• Abdominal distention

• Palpable masses

• 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

Common variations:

• Pseudomenstruation

• Smegma

• Increased pigmentation

• Ecchymosis and edema after breech birth

• "Red brick" pink-stained urine due to uric acid crystals

Signs of potential distress or deviations from expected findings:

• Labia fused

• Fecal discharge from vaginal opening

• Imperforate hymen

• 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

Common variations:

• Prepuce covering urinary meatus

• Erections

• Increased pigmentation

Signs of potential distress or deviations from expected findings:

• Non palpable testes

• Hypospadias

• Epispadias

• Scrotum smooth

• Ambiguous genitalia

Back and Rectum

Expected findings:

• Intact spine without masses or openings

• Trunk incurvature reflex

• Patent anal opening

Signs of potential distress or deviations from expected findings:

• Limitation of movement

• Fusion of vertebrae

• Spina bifida

• Tuft of hair

• Imperforate anus

• Anal fissure

Extremities

Expected findings:

• Maintains posture of flexion

• Equal and bilateral movement and tone

• Full range of motion all joints

• Ten fingers and ten toes

• Negative hip click

• Grasp reflex present

• Legs appear bowed

• Feet appear flat

Signs of potential distress or deviations from expected findings:

• Unequal tone

• Asymmetrical movement of extremities

• Syndactyl

• Unequal leg length

• Asymmetrical skin creases posterior thigh

• Dislocation of hip

• Persistent cyanosis of nail beds

 • Polydactyl

NEUROMUSCULAR SYSTEM

• The brain is 10% of the total body weight at birth

• Myelinization is completed at 6-12 months

• Intactness of the nervous system is demonstrated by the newborn’s:

- state of alertness

- Cry

- muscle tone

- motor activity

- resting posture

• The nervous system is immature at birth

NEWBORN REFLEXES

• MORO REFLEX

- its presence indicates integrity of the nervous system

- present from 32 weeks gestation to 4-5 months after birth

- its absence indicates brain damage

- asymmetric arm movement could be due to paralysis of the arm, fractured clavicle or humerus or
dislocated hip

-Persistence beyond 6 mos of age requires neurologic examination

• BABINSKI REFLEX

- from birth to 3 mos

- persistence beyond 3 mos and abnormal movement of toes require further neurologic examination

• PLANTAR GRASP REFLEX

- birth to 8 mos

- may be present during sleep for a longer period

• PALMAR GRASP REFLEX

- present as early as 28 weeks fetal life to 6 weeks after birth

• NECK RIGHTING REFLEX

- birth to 10 mos
- place infant supine then turn head to one side, infant’s shoulder and trunk should follow the head’s
position

ROOTING REFLEX
- birth to 6 weeks

• SUCKING REFLEX

- birth to 7-9 mos

• EXTRUSION REFLEX

- birth to 4 mos

• STEPPING, DANCING, WALK-IN-PLACE REFLEX

- birth to 3 mos

- abnormal : stiffiness, crossing of the legs

• CRAWLING REFLEX

- birth to 6 weeks

• TRUNK INCURVATION OR GALANT REFLEX

- test of spinal cord integrity

- birth to 3 mos

- the infant curves the body towards the side stroked

• TONIC NECK OR FENCING REFLEX

- birth to 3 mos

- persistence beyond 6 mos is a sign of major cerebral damage

-PARACHUTE REFLEX

- place infant in vertical suspension and suddenly lower toward a flat surface

- there is forward extension of both arms and dorsiflexion of the infant’s hands during movement

• MAGNET REFLEX

- test of spinal cord injury

- place NB in supine position on a flat surface

- apply pressure on the soles of the feet, NB pushes back against the pressure

• CROSS EXTENSION REFLEX

- place NB in supine position, extend one leg and rub the sole with a sharp object
- infant raise the opposite leg and extends it as if trying to push away the hand irritating the leg

SPECIAL SENSES

• VISION:

- muscles are immature resulting in strabismus and nystagmus until 4 mos

- NB can see at birth

- clearest vision: 9-12 inches

- tear gland begin to function after 2 weeks

- they can detect color at 2 mos

- can focus on objects and can follow up to midline.

- at 6 mos, the vision of the infant is as acute as that of the adult

- visual acuity of 20/20 is achieved at 7 years

- they prefer human face and recognize strangers at 6 mos old

- they prefer to look at:

- black and white patterns like check boards to plain ones

- medium colors like yellow, green, and pink over bright and dark colors like red, orange and blue

- reflecting objects than dull ones

- large object with medium complexity than small complex objects

• HEARING

- fetus can hear in utero and have well developed sense of hearing at birth

- they can hear as soon as after the first cry

- they stop crying and tend to relax when they hear low pitched sounds

- they prefer sounds that have regular rate and rhythm

- by 2 mos of age, they move their head towards the direction of the sound

- in 6 mos, the infant can recognize familiar voices

• SMELL

- well developed at birth

• TASTE

- NB has s well developed sense of taste at birth

- prefer sweet tasting substances

 • TOUCH

- the most highly developed of all the sensesin the NB

- can be demonstrated by the rooting, sucking, babinski, and palmar grasp reflex

- the most sensitive to touch are the face and sole of the feet

- the failure of the infant to grasp nipple is a sign of brain damage

RESPIRATORY SYSTEM

• Obligatory nose breather

• Indicators of lung maturity

- phosphatidyglycerol – appears at 35-36 weeks gestation

- Lecithin/spingomyelin ratio of 2:1

GASTROINTESTINAL SYSTEM

• Not fully developed at birth

• Attains maturity at 2-3 yrs of age

• Sterile at birth

• The most immature GI organ is the liver

• Enzymes for digesting simple carbohydrates and protein are present at birth but not enzymes
for complex CHO (amylase) and fats (lipase) – until 4 -5 mos of life

• Most of the salivary glands are not yet functional at birth until 2-3 mos of age

• During the first few days, regurgitation after feeding is due to immature cardiac sphincter

• Gastric capacity is only up to 90 ml at birth

• 3 mos old – 5 ounces

• Milk ingested leaves the stomach after 2-3 hrs in neonate and after 3-6 hrs in older infant

Stool

- meconium – first stool, odorless, greenish black, viscuous and contains occult blood

- should be passed within 24 hours after birth

- transitional stool – 2nd to 4th day – composed of milk and some meconium

- brownish to yellow green, more watery than meconium, thin and slimy

- normal stool – after 4 days of life

 - breastfed infants – stool has a pleasant smell, golden or bright yellow in color, loose,
nonirritating to the infant’s skin

- pass stools more frequently than bottled infants

• TEETH

- development begins in utero with enamel formation lasting up to 10 years of age

- central incisors: lower: 5-7 mos

upper: 6-8 mos

- lateral incisors: lower: 12-15 mos

upper: 8-11 mos

- canines: lower: 16-20 mos

upper: 16-20 mos

- First molars: lower: 10-16 mos

upper: 10-16 mos

- second molars: lower: 20-30 mos

upper: 20-30 mos

RENAL SYSTEM

• Fetal kidneys produce urine as early as the fourth month in utero

• NB should void within 24 hrs after birth

• First urine may have pinkish color due to the presence of uric crystals

• Kidneys do not concentrate urine well

• Appear light and colorless with specific gravity of 1.008 to 1.010

• Bladder capacity at birth is about 40 ml. Daily urinary output is about 30-60 ml during the first
few days and increasing to 300 ml after a week with each voiding about 15 ml

• First 2-3 days – 5-6x/day

• After the first week - 15 to 20x/day

CARDIOVASCULAR SYSTEM

• Blood Volume

- NB has about 10% more blood volume and 20% more RBCs than the adult

- about 50-100 ml of placental blood is transfused to the NB if cord is clamp after pulsation has stopped.
 • Blood Values

- NB’s blood volume – 80-110 ml/kg of body weight

- high RBC count – abt 6 million/cu. Mm

- end of 3 rd month: 3-4 M/cu. mm

- Hgb level – 17-18mg/100 ml of blood

-end of 3 rd month: 11-12mg/100ml

- Hct – 45-50%

- erythropoiesis slows down during the first 6-8 weeks after birth, and fetal RBC continue to break down
during the first 5 mos of infancy

- Iron stores are enough until 5-6 mos

- It is normal for high WBC count at birth

- By 6 yrs of age – the blood values of the child are almost similar to that of the adult

Special structures

1. Ductus arteriosus – closes functionally at 4th day after birth, converted to ligamentum arteriosum

2. Foramen ovale – closes functionally immediately after birth but anatomically closes at around 3 mos
of age. It is converted to fossa ovalis

3. Umbilical vein – to ligamentum teres hepatis

Umbilical arteries – umbilical ligaments

4. Ductus venosus – in 3 mos, it is obliterated and converted to ligamentum venosum

IMMUNE SYSTEM

• During the first month, the NB is not capable of producing its own antibodies

• Late in pregnancy, mat antibodies are transferred to the fetus in the form of Ig G

• Antibodies found in the cord blood: antitoxin, diptheria antitoxin, small pox agglutinins,
toxoplasma antibodies,

• Antibodies obtained by the infant from the mother via the breastmilk: IgA, IgD, IgE

• Presence of IgM in NB circulation indicates exposure to infection during fetal life