Pediatrics: History and Physical Examination of Newborns and

Infants
16 August 2018 ∙ Vanessa Cenabre, MD

OUTLINE • Maternal History

® Assessment of risk factors for sepsis in the immediate
I. Pre-test B. Vasomotor instability intrapartum period before delivery:
II. Periods of Growth C. Hormonal Effects in
§ Intra-partum temperature: ≥38.5°C
A. Prenatal the Newborn
§ Membrane rupture: ≥18hrs
B. Birth D. Transitional stools
III. Components of E. Inanition fever § Delivery at <37wks gestation
Assessment of a F. Physiologic § Chorioamnionitis (intra-amniotic infection)
Newborn desquamation § Urinary tract infection
A. Immediate post- G. Falling off of the cord § Sustained fetal tachycardia
partum assessment H. Physiologic anemia - Can be a sign of fetal distress
B. Physical assessment V. Review Questions • Perinatal History
C. Maturity testing VI. References ® Duration of labor and membrane rupture
IV. Physiological Changes VII. Summary ® Manner of delivery
of Newborn ® Hour of delivery of the baby and the placenta
A. Physiologic jaundice ® Obstetrical blood loss
I. PRE-TEST ® Condition of newborn at delivery
® APGAR score
1 & 2. Two components of the Apgar Score. ® Resuscitation of newborn
3 & 4. What are the 2 components measured by the Ballard
® Part of the birth history
Score?
• Family History
5. What is the normal range of heart rate in the newborn?
® Check for presence of heredo-familial disease
6 & 7. Two components of the anthropometric measurements.
8, 9, & 10. Three physiologic changes in the newborn. ® Do pedigree analysis

II. PERIODS OF GROWTH B. BIRTH

Table 1. Periods of Growth • Initiation of respiration and own circulation, period of
Stage Time Period adaptability to extra-uterine environment
Ovum 0 – 14 days* ® Poses a lot of problems especially in terms of ventilation
Prenatal Embryo 14 days – 9 weeks* and perfusion
® Intra-uterine environment speaks of the gas exchange
Fetus 9 weeks* – birth
through the placental circulation
Birth Term 37 – 42 weeks*
® Newborn needs to transition from a placental circulation
Infancy 0 – 2 years to a fully functioning respiratory system
Early/Preschool 2 – 5 years • Behavioral states of newborn: quiet sleep, active sleep,
Childhood
Late 6 – 10 (or 12) years drowsy, alert, fussy, or crying
Adolescence 10 – 20 years III. COMPONENTS OF ASSESSMENT OF A NEWBORN
*AOG – Age of Gestation
• The ideal time for delivery is 37 to 42 weeks AOG.
A. PRENATAL
Ovum (0 to 14 days AOG)
• Characterized by increase in complexity and cell
multiplication
• Little increase in total size
• Self-sufficient
• Food stored in yolk sac
Embryo (14 days to 9 weeks AOG)
• Parasitic
• Derives nutrition from maternal origin
• Rapid differentiation
• All organ systems established and is the period of
Organogenesis
• Maternal History
® Mother’s medical and pregnancy history should be
reviewed thoroughly
§ i.e. maternal exposure to infection, teratogenic drugs
and medications, significant radiation
® 1st trimester (Period of Organogenesis) screening tests:
§ Maternal blood and Rhesus type
- Tests for maternal and fetal Rh compatibility
§ TORCH Screening
- Tests for a group of infectious diseases that can Figure 1. Systematic Overview of the Newborn
cause congenital infection [de Jong, et al] 1. Immediate post-partum assessment
- Toxoplasmosis, Others, Rubella, Cytomegalovirus 2. Physical examination
(CMV), and Hepatitis 3. Maturity testing
o Others: Syphilis, HIV, Herpes Simplex Virus
§ Hepatitis B surface antigen, HIV screen A. IMMEDIATE POST-PARTUM ASSESSMENT
§ Gestational Diabetes Mellitus and Hypertension General Appearance
Fetus (9 weeks AOG to birth) • The newborn should be naked when being examined
• Early functional activities apparent • Observe the infant’s posture, skin color, activity, muscle
tone, and gross abnormalities
• Increase in body mass most pronounced
• Maturity of organ systems
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 History and Physical Examination of Newborns and Infants

Apgar Score • RR 50-60 respirations per minute, transient tachypnea

• This is done immediately after birth • Usually passage of meconium
• Classifies the newborn’s neurologic recovery from the stress • The next several hours
of birth and immediate adaptation to extrauterine life [Bates’] ® Awake, alert, easily startled, crying, easily stimulated and
• Five components reactive
1. Appearance = Color Vital Signs
2. Pulses = Heart Rate
1. Temperature
3. Grimace = Reflex Irritability
4. Activity = Muscle tone
• Maintain thermoregulated at 36.5 - 37.5°C
5. Respiration = Respiratory effort • Axillary temperature is usually measured in a neonate in
• The newborn is scored at 1 and 5 minutes after birth based the absence of thermometer with rectal probe.
on a 3-point scale (0, 1, or 2) for each component • For infants, axillary and thermal-tape skin temperatures are
® Highest total score is 10 inaccurate, auditory canal temperatures are accurate.
• Does NOT indicate the NEED for resuscitation, instead Rectal temperatures are the most accurate [Bates’].
indicates EFFECTIVE neonatal resuscitation • Rectal temperature is done if the axillary is abnormal.
® Need for resuscitation is determined by your clinical • To take a rectal temperature, place infant prone, seprate
judgement and the immediate vital signs (HR, color, and the buttocks with the thumb and forefinger with one hand.
respiration) of the patient Gently insert a well-lubricated rectal thermometer to a
depth of 2-3 cm. Keep in place for at least 2 minutes [Bates’].
Table 2. Apgar Scoring System [Bates’]
• Fever >38˚C in infants < 2 or 3 months can be a sign of
Clinical Assigned Score
serious infection or disease.
Sign 0 1 2
Heart rate Absent <100 >100
• Anxiety may elevate the body temperature of children.
Respiratory Absent Slow and Good; strong • Excessive bundling elevates skin temperature but not core
temperature.
effort irregular
Muscle tone Flaccid, Some flexion Active • Temperature instability may be due to sepsis, metabolic
limp of the arms movement abnormality, or other serious conditions.
and legs 2. Respirations
Reflex No Grimace Vigorous cry, • Normal RR: 40 – 60 breaths/min
Irritability* responses sneeze, or • Periodic breathings (≥3 apneic episode lasting within a 20s
cough period of otherwise normal respirations) is normal and
Color Blue, pale Pink body, Pink all over common in newborns.
blue • Sleeping RR is the most reliable measurement [Bates’].
extremities • Extremely rapid and shallow RR are seen in newborns with
*reaction to suction of nares with bulb syringe cyanotic cardiac disease and right-to-left shunting, and
Table 3. Apgar Score Classification [Bates’] metabolic acidosis.
1-Min Apgar Score 5-Min Apgar Score • RR can be raised by fever.
8-10 Normal 8-10 Normal ® An increase of 10 respirations per minute for each
5-7 Some nervous 0-7 High risk for degree centigrade of fever.
system depression subsequent central • Tachypnea and increase respiratory effort – signs of lower
0-4 Severe depression, nervous system respiratory diseases such as bronchiolitis or pneumonia.
requiring immediate and other organ 3. Blood Pressure
resuscitation system dysfunction • Not routinely assessed
• Sustain hypertension can be due to renal artery disease
Essential Intrapartum Newborn Care (EINC)
(stenosis, thrombosis), congenital renal malformations,
• Done in order to address the increasing problems in and coarctation of the aorta.
neonatal morbidity
4. Heart Rate or Pulse
® Improving the mechanism by which newborns are
• Normal HR: 120 – 160 bpm
delivered
• How newborns are handled after delivery
• Sleeping HR of a newborn: ~100 bpm
• Done in the immediate post-partum in the first minute of life • At ≥ 180 bpm, medication must be given to lower the HR
[Cenabre]
until the “first latch” or effective breastfeeding
® Has four components which aims to ensure better ® May indicate paroxysmal supraventricular tachycardia
outcomes and decrease in neonatal morbidities or deaths (PSVT)
[WHO] • Bradycardia may be due to drug ingestion, hypoxia,
§ Immediate and thorough drying of the newborn intracranial or neurologic conditions, or, rarely, cardiac
§ Early skin-to-skin contact between mother and the dysrhythmia
newborn; • In a squirming infant, obtaining the HR may be difficult.
§ Properly-timed cord clamping and cutting Palpate the femoral arteries or brachial arteries or
§ Non-separation of the mother and her newborn for auscultate the heart to get the HR [Bates’].
early breastfeeding initiation Table 4. Vital Signs at Various Ages [Nelson, 18th Ed]
First 15 to 30 minutes Age HR RR BP
• Assess the immediate vital signs Preterm 120 – 170 40 – 70 55-75 / 35-45
• Period to effectively address ventilation or perfusion 0-3 mos 100 – 150 35 – 55 65-85 / 45-55
problems 3-6 mos 90 – 120 30 – 45 70-90 / 50-65
• Immediate tachycardia to 160-180bpm, with a gradual drop
6-12 mos 80 – 120 25 – 40 80-100 / 55-65
to 100-120bpm
• Irregular respirations, tachypnea to 60-80 respirations per 1-3y 70 – 110 20 – 30 90-105 / 55-70
minute, brief moments of apnea 3-6y 65 – 110 20 – 25 95-110 / 60-75
• Moist-sounding lung fields, transient grunting and retractions 6-12y 60 – 95 14 – 22 100-120 / 60-75
• Awake, moving, alert, easily startled, crying, transient > 12y 55 – 85 12 – 18 110-135 / 65-85
tremors
• With increasing age, there is decreasing HR due to a
Next 60 to 90 minutes
decreased metabolic state and increased adaptability to the
• Sleepy or sleeping environment such as changes in temperature. The
• HR 100-120bpm, transient tachycardia circulatory system also becomes more developed. [Cenabre]
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 History and Physical Examination of Newborns and Infants

Anthropometrics
1. Head Circumference (HC)
• Occipital-frontal circumference: 32-37cm at term
® Landmarks:
§ Anterior head - Glabella/supraorbital ridge
§ Posterior head - Most prominent part of the occiput
• Taken up to 3 years of age
• Related to intracranial volume and rate of brain growth.
• Small head size may be due to premature closure of the
sutures or microcephaly.
• Large head size (>95th percentile or 2 standard deviations
above mean) is macrocephaly.
2. Birth Length (BL)
• Normal: 48-52cm
• Reduced growth velocity (drop in height percentile on a
growth curve) can signify a chronic conditions [Bates’].
® Chronic conditions can be neurologic, renal, cardiac,
gastrointestinal, and endocrine disorders, and cystic
fibrosis.
• Growth velocity is normally less during the 2nd year than
during the 1st year [Bates’].
3. Chest Circumference
• Normal: 30-35cm
Figure 2. Level of intrauterine growth based on gestational age and birth
4. Abdominal Circumference weight of liveborn, single, white infants.
5. Weight (BW)
• Common indicators for failure to thrive or inadequate Assessment of Gestational Age
weight gain for age: 1. Mother’s Menstrual History
® Growth <5th percentile for age 2. Early Fetal Ultrasound
® Drop >2 quartiles in 6 months 3. Ballard Score
® Weight for length <5th percentile • Performed as soon as possible after initial stabilization or
• Causes for failure to thrive: environmental, psychosocial 12hrs after birth
factors, and gastrointestinal, neurologic, cardiac, • Examination consists of two parts:
endocrine, renal, and other diseases. ® Neuromuscular maturity
Table 5. Birth Weight Classification ® Physical maturity
Birth Weight Lubchenco Weight • See appendix for The New Ballard Score System
Classification (Bates) Classification Table 7. Classification by Gestational Age [Bates’]
Extremely low birth SGA <1000 g Gestational Age Gestational At Risk For
weight Classification Age
Very low birth weight <1500 g Preterm <34 weeks Short-term complications
Low birth weight <2500 g (mainly in respiratory and
Normal birth weight AGA ≥2500 g cardiovascular) and long-
High birth weight LGA >4000 g term sequalae (eg.
Newborn Classifications (Lubchenco Classification) neurodevelopmental)
Late preterm 34-36 weeks Prematurity complications
• LGA infants
Term 37-42 weeks
® May encounter difficulties during delivery [Bates’]
Postterm >42 weeks Perinatal mortality or
® At risk for metabolic and congenital anomalies [Bates’] morbidity (eg. asphyxia,
® Common complication is hypoglycemia meconium aspiration)
§ Can result in jitteriness, irritability, cyanosis, or other
health issues B. PHYSICAL ASSESSMENT
• SGA infants • Newborn infant should have thorough physical examination
® Associated with maternal smoking performed within 24 hours to identify anomalies, birth
injuries, jaundice, or cardiopulmonary disorders
® Symmetric – onset early in gestation
® Ideally, this should be performed as soon as possible
® Asymmetric – onset is late in gestation
after delivery to identify potential impediments to a normal
§ There is brain sparing.
newborn course.
§ Condition can be secondary to maternal
undernutrition. • Examination should be conducted in a systematic manner.
• Preterm AGA infants • Although the exact order is not important, a consistent
approach ensures that all aspects are evaluated.
® Prone to respiratory distress syndrome, apnea, patent
ductus arteriosus (PDA) with left-to-right shunt, and • It must be done in a warm and quiet area with good lighting.
infection • Date, time, and age of the neonate must be recorded.
• Preterm SGA infants • Done from Head to Toe.
® More likely to experience asphyxia (loss of oxygen due to i. SKIN
abnormal breathing), hypoglycemia and hypocalcemia Color
Table 6. Lubchenco Classification • Pallor
Category Abbreviation Percentile ® Associated with: low hemoglobin (anemia), birth asphyxia,
Small for SGA Symmetric shock, and PDA
Gestational Age (HC, BW and BL <10th)
• Cyanosis
Asymmetric (HC and BL
normal; only BW <10th)
® Mostly associated with hypoxemia
Appropriate for AGA 10-90th ® Central cyanosis
Gestational Age § Caused by low oxygen saturation in the blood
Large for LGA >90th § Usually cardiac in origin [Cenabre]; consider the
Gestational Age possibility of congenital heart disease [Bates’]

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History and Physical Examination of Newborns and Infants

§ Rule out cardiac, lung, CNS, metabolic, or • Milia

hematologic diseases ® A rash with tiny (pinhead-sized) sebaceous retention
§ Look for central cyanosis at the tongue and oral cysts
mucosa [Bates’]. ® Appear within a few weeks after birth and disappears over
® Acrocyanosis several weeks.
§ Bluish discoloration usually appears in the palms and • Erythema toxicum
soles ® Usually appears on days 2 to 3 of life and disappear
§ May be normal immediately after birth or within the within 1 week of birth.
first few hours after birth or stress ® Unknown etiology.
§ Secondary to vasomotor instability or temperature ® Consists of numerous small areas of red skin with a
changes but not necessarily due to cardiac disease yellow-white papule in the center.
[Cenabre]
® Usually have flares when there are extreme temperature
§ If acrocyanosis does not disappear within 8 hours or changes.
with warming, cyanotic congenital heart disease
should be considered since it can present with severe Other skin characteristics
acrocyanosis.
® Perioral cyanosis
§ Common after birth
® Differential cyanosis
§ Secondary to presence of right to left shunt through
the PDA
• Plethora A B C
® Deep rosy red color
D
® Associated with polycythemia
§ Newborns with polycythemia have a “ruddy” (reddish
purple color) complexion.
- Hematocrit > 67%. If hematocrit is > 70%, partial
exchange transfusion (PET) is done.
E F
® Can also be seen among over-oxygenated or overheated
Figures 5: A. Nervus simplex. B. Port-wine stain.
infant. C. Cavernous hemangioma. D. Strawberry hemangioma.
• Jaundice E. Mongolian spots. F. Café-au-lait Spots
® Yellowish discoloration of the skin
• Nevus simplex / Nevi / Salmon Patch
® Seen among infants with: Elevated bilirubin
® Macular stain (a common capillary malformation) normally
(hyperbilirubinemia), Rh incompatibility, Sepsis, TORCH,
seen on the occipital area, eyelids, and glabella; usually
ABO incompatibility
symmetric
® Most commonly observed beyond the first 24 hours of life.
® Represents localized vascular ectasia [Nelson]
® If secondary to ABO incompatibility, then there will be
® If capillary malformation: monitor its growth
development of hemolytic disease of the newborn that will
lead to anemia (jaundice → pallor) [Cenabre]. ® Responsive to steroids.
® Sometimes, after a year, it may resolve if it’s a type of
® May be physiologic or pathologic depending on the timing
strawberry hemangioma [Cenabre].
of appearance
§ Physiologic: occurs days 2 to 5 of life; progresses • Port-wine stain
from head to toe as it peaks [Bates’]. ® A unilateral dark, purplish lesion that usually end along
§ Pathologic: occurs within the 1st 24 hours of life [Nelson] the midline
® Clinical estimation of the degree of jaundice ® Does not blanch with pressure and does not disappear
§ Face: 5-8 mg/dL with time.
§ Face and upper trunk only: 8-12 mg/dL ® Port-wine stain over the ophthalmic branch of the
§ Lower trunk and extremity: >12mg/dL trigeminal nerve may be a sign of Sturge-Weber
syndrome [Bates’].
§ Associated with seizures, hemiparesis, glaucoma, and
mental retardation.
• Mongolian spots
® Disappear by age 4
® Appears as blue or slate-gray macular lesions [Nelson].
® Occurs mostly in the presacral area but can be found in
A B C the posterior thighs, legs, back, and shoulders [Nelson].
• Cavernous hemangioma
® Large, red, cyst-like, firm, ill-defined mass
® Usually disappears over time
§ However, if it affects major feeding vessels, it grows
as the newborn grows.
® Management will depend on aesthetic or vascular
compromise
D E F • Strawberry hemangioma
Figure 3. A. Pallor. B. Central cyanosis. C. Acrocyanosis. D. Perioral ® Flat, bright red, sharply demarcated lesions
cyanosis. E. Plethora. F. Jaundice s ® Most commonly found on the face
Rashes ® Spontaneously regresses by age 7
• Café-au-lait Spots
® Uniform light brown pigmented lesions, usually with
borders.
® If more than 5 café-au-lait spots exist, consider
neurofibromatosis [Bates’].
• Extensive bruising (ecchymoses)
® May be associated with difficult delivery and may result in
A B early jaundice due to increase in red blood cell
Figure 4. A. Milia. B. Erythema toxicum. destruction.
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History and Physical Examination of Newborns and Infants

• Harlequin sign/discoloration ® Caput succadaneum

® A clear line of demarcation between the area of redness ® Cephalhematoma
and the area of normal coloration ® Skull defects
® May be due to immaturity of hypothalamic center that ® Fontanelles
controls the dilation of peripheral blood vessels ® Head circumference
§ May sometimes be caused by vasomotor immaturity ® Scalp veins
or infection [Cenabre]
Suture and Fontanelles
- But most of the time, Harlequin sign is physiologic
and transient.
• Cutis Marmorata
® Reticular mottling, lacy red pattern of the skin, marbled,
purplish skin discoloration
® Secondary to changes or differences in temperature
regulation.
® Prominent in premature infants and infants with congenital
hypothyroidism and Down syndrome [Bates’].
• Lanugo [Nelson]
® Fine, soft, immature hair that can cover the scalp, brow,
and face of premature infants.
® Usually, in term infants, lanugo has been replaced by Figure 7. Fontanelles
vellus hair. • Suture: tissue spaces that separates bones of the skull from
• Vernix caseosa one another
® Greasy white substance covering the skin • Fontanelles: areas where the major sutures intersect in the
® Provides moisture barrier anterior and posterior portions of the skull
® Does not need to be removed immediately when seen in ® Fullness of fontanelles reflects the intracranial pressure.
newborn § Palpation can be done with the baby sitting or held
§ Protective against hypothermia upright.
§ Said to have immunologic properties that can protect § Fontanelles should be soft, flat, and not bulging.
the baby against skin infections [Cenabre]. ® Bulging, tense fontanelle is observed when there is
• Collodion infant increased intracranial pressure [Bates’].
® Skin resembles parchment § Can be caused by: central nervous system infection,
neoplastic disease, or hydrocephalus
- Hydrocephalus – obstruction of the circulation of
cerebrospinal fluid within the ventricles of the brain
§ Dilated scalp veins is indicative of long standing
increased intracranial pressure
® Early closure of fontanelles is usually secondary to
syndromic defects [Cenabre]
B
® Anterior fontanelle
A
§ Diamond shape
§ Measures 4-6 cm at birth [Bates]
§ 90% closes at 7-19 months [Bates]
§ Closes at 12 – 18 months [Cenabre]
§ Depressed anterior fontanelle may be a sign of
dehydration [Bates’].
® Posterior fontanelle
§ Measures 1 – 2 cm at birth [Bates]
C D E § Closes at 2 – 4 months [Bates]
Figure 6. A. Ecchymoses. B. Harlequin sign. C. Cutis marmorata or mottling. § Closes at 3 – 4 months [Cenabre]
D. Vernix caseosa. E. Collodion baby. § An enlarged posterior fontanelle may be present in
Hydration or Turgor of Skin [Bates’] congenital hypothyroidism [Bates’].
• Assess the degree of hydration of a newborn skin: Head circumference
® Roll a fold of loosely adherent skin on the abdominal wall
between your thumb and forefinger.
§ If well hydrated: skin immediately returns to normal
position upon release.
§ If there is significant dehydration: ‘tenting’ occurs
wherein there is a delay in return to the normal
position.
A B C
• Significant edema of the hands and feet may be suggestive
of Turner Syndrome Figure 8. A. Macrocephaly. B. Normal size. C. Microcephaly

® Other features: webbed neck • Normal: 32-37 cm

ii. HEAD • Macrocephaly
® Head circumference > 2SD above the mean
• Note the general shape ® May be manifestation of other anomalies including
• Inspect for any cuts or bruises secondary to forceps or fatal hydrocephalus and skeletal disorders
monitor leads • Microcephaly
• Check for microcephaly or macrocephaly ® Head circumference <3SD below the mean
• Look for unusual hair growths ® It can be familial, with autosomal dominant or recessive
• Compare the size of the head with appropriate standards inheritance
® Head size vary with age, sex and ethnicity, and has ® May be associated with infections, and syndromes such
general correlation with body size as trisomy 13 and 18
• Check for: • How to measure head circumference (HC)?
® Molding ® Determined by measure the greatest occipitofrontal
® Rounded heads in CS babies circumference
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 History and Physical Examination of Newborns and Infants

® From the occipital prominence to the frontal prominence ® It can be caused by:
® Take the biggest measurement of three § Asphyxia
• Average HC: 35 cm at birth (13.5) § Vacuum extraction
• HC increases: 1 cm per month for first year § Forceps deliver
® 2 cm per month for first 3 months, then slower § Coagulopathy
• Cephalohematoma
Molding
® Secondary to rupture of blood vessels that traverse the
periosteum [ABC Law Centers]
® Well demarcated
® Does not cross the suture lines or midline
® Swelling is initially soft, then develops a raised bony
margin within a few days from calcium deposits at the
edge of the periosteum [Bates’]
® Usually resolves within 2-3 weeks
• Dolichocephaly
® Premature infants
® Head is long in the occipitofrontal diameter and narrow in
the bitemporal diameter
® Normalized within 1 to 2 years.
x • Facial Symmetry
Figure 9. Molding ® Micrognathia or a shortened chin may be a symptom of
• Temporary asymmetry of the skull due to overlapping of the Pierre Robin syndrome.
cranial bones at sutures resulting from the birth process • Plagiocephaly
• Most often seen in prolonged labors and vaginal deliveries ® Positional plagiocephaly occurs when infants lie mostly on
• A normal shaped head is usually regained within 1 week one side causing a flattening parieto-occipital region.
• Usually disappears within 2 days [Bates’] ® Usually normalizes as the infant spends less time on one
Head or Skull Asymmetry position. It can be prevented by frequently repositioning
the infant or allowing for “tummy time” when the infant is
awake.
® May also be reflective of torticollis.

A B C
Figure 10. A. Bilateral parieto-occipital subgaleal hematoma. B.
Cephalohematoma. C. Caput succedaneum

Figure 11. Steps in determining cause of asymmetric head

Figure 9. Caput succedaneum vs Cephalohematoma vs Subgaleal hemorrhage • Torticollis [ABC Law Centers]
® Condition that occurs when an infant’s neck becomes
• Caput succedaneum
twisted
® Type of swelling that gives the head of the infant a
§ Causes infant head to tilt to one side
conehead appearance [ABC Law Centers]
® Caused by a shortened sternocleidomastoid (SCM)
® Swelling over the occipitoparietal region that is due to
muscle or injury to the SCM at birth or due to lack of
capillary distension and extravasation of blood and fluid.
stimulation of the infant.
® Crosses the suture line or midline
• Craniosynostosis
® Resolves spontaneously within 1 to 2 days.
® Premature closure of one or more sutures of the skull
• Subgaleal hematoma / hemorrhage
® This results in an abnormal growth and shape of the skull
® Blood accumulates outside of the baby’s skull [ABC Law because growth will occur across sutures that are not
Centers]
affected but not across sutures that are affected
§ Accumulation occurs in the space between the
® Scaphocephaly and frontal plagiocephaly are the most
periosteum of the skull and the scalp aponeurosis,
common forms of craniosynostosis
where there is loose areolar tissue.
® Early closure (synostosis) of the sagittal suture causes a
® Crosses the suture lines and onto the neck or ear
narrow head due to the lack of growth of parietal bones.
® Progresses after birth
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History and Physical Examination of Newborns and Infants
® Examples of craniosynostosis due to FGFR 2 Gene
defect (Not thoroughly discussed):
§ Crouzon’s syndrome [NIH]
- Affects the shape of the head and face
- Abnormal growth of these bones leads to:
o Wide-set bulging eyes
o Vision problems caused by shallow eye sockets
o Eyes that do not point in the same direction
(strabismus)
o Beaked nose
o Underdeveloped upper jaw
§ Pfeiffer syndrome [NIH]
- Also affects bones in the hands and feet
- Leads to:
o Wide-set eyes
o High forehead
o Underdeveloped upper jaw
o Beaked nose
§ Apert syndrome [NIH]
- Varied number of fingers and toes are fused
together (syndactyly)
- Leads to:
o Sunken appearance in the middle of the face
o Bulging and wide-set eyes
o Beaked nose
o Underdeveloped upper jaw leading
A B
B
C
Figure 12. A. Crouzon’s. B. Pfeiffer. C. Apert
Others
• Rounded heads in CS babies
• Skull defects
• Check for Chvostek Sign
® Test is done by percussing the cheek just below the
zygomatic bone in front of the ear using the tip of you
index or middle finger.
® Positive sign: facial grimacing due to repeated
contractions of the facial muscles.
® Present in cases of hypocalcemic tetany, tetanus, and
tetany due to hyperventilation.
iii. EYES, EARS, NOSE, AND MOUTH
Eyes
• Inspection
® For newborns, do not attempt to separate the eyelids.
Instead, gently awaken the baby and support the baby in
a seated position.
® Some newborns can follow your face and turn their heads
up to 90˚ to both sides.
® Examine: eye movements, sclerae, pupils, irises,
extraocular movements, and pupillary reactions to light.
® The emphasis is on the structure and appearance of the
eye and its surroundings, rather than the assessment of
visual acuity or extraocular muscles
® Take note of the following when examining the eyes:
§ Failure of the newborn to follow your gaze may
indicate a visual impairment
§ During the first 10 days of life, baby might exhibit
doll’s eye reflex.
- Doll’s eye reflex – eye stare in one direction if head
is turned without moving the body.
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§ During the first few months of life, baby might have
intermittent crossed eyes (intermittent alternating
convergent strabismus or esotropia) or laterally
deviated eyes (intermittent alternating divergent
strabismus or exotropia).
- Alternating convergent or divergent strabismus or
any type of strabismus that persists beyond 3
months can be indicative of an ocular motor
weakness or an abnormality in the visual system.
§ Nystagmus that persists after a few days may indicate
poor vision or a central nervous system disease.
§ Colobomas or missing tissue in or around the eye
may be seen with the naked eye and represents
defects in the iris.
A
B C
Figure 13. A. Discharge of gonococcal ophthalmia.
B. Subconjunctival hemorrhage. C. Leukocoria
Figure 14. Red orange reflex
• Neonatal conjunctivitis / ophthalmia neonatorum [Cenabre]
® Presents during the first month of life
® May be aseptic or septic
§ Aseptic: most often is a chemical conjunctivitis that is
induced by silver nitrate solution used in the eyes at
birth for prophylaxis of infectious conjunctivitis
§ Septic: bacterial/ viral conjunctivitis
- E.g. gonococcal ophthalmia
o Secondary to maternal gonococcal disease
o Usually present in the first seven days
o Purulent eye discharge
- E.g. Chlamydial ophthalmia
o Most of the time concomitant with pneumonia in
the second week of life
• Subconjunctival hemorrhages
® Benign and may occur even after a non-traumatic delivery
® Usually secondary to birth trauma [Cenabre]
® Resolves by two weeks
• Ophthalmoscopic Examination
® Check the Red Orange Reflex (ROR)
§ Set the ophthalmoscope at 0 diopters and view the
pupil from about 10 inches [Bates’].
§ Normal: Red or orange color is reflected from the
fundus through the pupil.
§ Abnormalities
- Dark spots
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 History and Physical Examination of Newborns and Infants
- White reflections
o White pupillary reflex / Leukocoria / Cat’s
Eye Reflex
o Denotes an abnormality of the lens, vitreous, or
fundus
o Can be due to cataract, retinal detachment,
chorioretinitis, or retinoblastoma
o Rubella is the most notorious etiologic agent of
congenital cataract.
® The cornea can be seen at +20 diopters, lens at +15
diopters, and fundus at 0 diopters [Bates’].
§ Congenital glaucoma may cause cloudiness of the
cornea.
§ Occlusion can be indicative of cataract.
® For the optic disc area, it is lighter in color with less
macular pigmentation when compared to adults. The
foveal light reflection may not be visible.
Table 8. Visual Milestones of Infancy
Age Signs
Birth Blinks, may regard face
1 month Fixes on objects
1 ½ - 2 months Coordinated eye movements
3 months Eye converge, baby reaches
toward a visual stimulus
12 months Acuity around 20/60 – 20/80
Ears
• Each ear is examined for shape, size, position, presence of
canal, and any tags or pits.
® To determine the patency of the ear canal in infants, the
auricle must be gently pulled downwards [Bates’].
• Assess the tympanic membrane and hearing within 72 hours
through an OAE (otoacoustic emissions hearing test).
® The tympanic membrane is usually obscured with vernix
caseosa during the first few days of life. Once visible, note
that the light reflex is diffuse.
§ It becomes cone-shaped after several months.
• Normal position is determined by drawing an imaginary
horizontal line form the inner and outer canthi of the eyes
across the face, perpendicular to the vertical axis of the
head.
® If the helix of the ears lies below this horizontal line, the
ears are designated low set.
Figure 15. Determining position of ears
• Ears are usually broad in appearance
• Pre-auricular skin tags are usually benign
® Sometimes correlated with the presence of renal agenesis
® Sometimes, it is recommended to clear the ultrasound if
patient has ear tag [Cenabre]
• Hairy ears are often seen in infants of diabetic mothers
Figure 16. Pre-auricular tag (left); Hairy ear (right)
Trans 1.02 Group # 2: Baobao, Lara | TH: Castro
Table 9. Signs of Hearing in Infants [Bates’]
Age Sign
(months)
0–2 Startle response and blink to a sudden noise
Calms down with soothing voice or music
2–3 Change in body movement in response to
sound
Change in facial expression to familiar
sounds
Turning eyes and head to sound
3–4 Turning to listen to voices and conversation
6–7 Appropriate language development
Nose
Figure 17. Choanal atresia
• The most important component of the examination of the
infant nose is to test for patency of the nasal passages [Bates’]
® Do this by gently occluding each nostril alternately while
holding the infant’s mouth closed
® Some infants are obligate nasal breathers and have
difficulty breathing through their mouths
§ Do not occlude both nares simultaneously, as this will
cause considerable distress.
® Check for inability to pass feeding tube through nostrils If
unilateral or bilateral choanal atresia is suspected:
§ Choanal atresia is a medical emergency
- Infant is usually cyanotic but gets pink when crying
due to air passing through the mouth
• Inspect the nose to ensure that the nasal septum is midline
[Bates]
• Check for nasal flaring
• Assess for shape, size, and for the presence of swelling over
the nasolacrimal duct, size of the philtrum, and the definition
of the nasolabial folds
® Nasal deformation with asymmetry of the snares and
apparent deviation: occurs as a part of facial compression
and molding
Mouth
Figure 18. Cleft lip and palate
• Inspection can be done with a tongue depressor and
flashlight and palpation with a gloved finger.
• Tongue, buccal surface, palate, and back of the mouth
should be visualized while gums and hard palate are best
assessed through palpation.
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History and Physical Examination of Newborns and Infants

• Appearance • Forceps mark may be present if infant is delivered by

® Mouth should be checked to ensure that there are neither forceps.
hard nor soft palatal clefts, no gum clefts, and no • Mobius syndrome
deciduous teeth present. ® Symmetric facial palsy caused by absence of the 7th
§ Cleft lip/ cleft palate nerve nucleus.
- 7-8th week of development ® Infant will lack facial expressions; they cannot smile,
- Autosomal dominant frown, or raise their eyebrows [NIH].
- Cleft lip: failure of the medial nasal and maxillary • Facial nerve palsy
processes to join ® Caused by compression of the facial nerve against the
- Cleft palate: failure of the palatal process to fuse sacral promontory or by trauma resulting from the use of
- Seen in ultrasound forceps during delivery.
- Midline cleft may cause microaspirations [Cenabre] ® Paralysis is apparent on the first or second day of life.
® Lips should symmetrically retract. ® Most cases resolve spontaneously within days.
• Look out for: § Full recovery may require weeks to months.
® Large tongue v. NECK
§ Macroglossia: enlargement of the tongue
- Can be congenital or acquired
- Can be seen in Beckwith-Wiedemann syndrome
and congenital hypothyroidism
® Tongue tie
® Supernumerary teeth
§ Usually dysmorphic and are shed within days.
§ If movable, they are removed to prevent aspiration.
® Epstein’s pearls
A B
§ Keratin containing cysts which are normal and
resolves spontaneously.
§ Located on the hard and soft palate.
® Ranula
§ Cystic swelling in the floor of the mouth which
disappears spontaneously.

A B
C D E syndrome, Sternocleidomastoid hematoma
Figure 19. A. Macroglossia. B. Tongue tied
C. Supernumerary teeth. D. Epstein’s pearls. E. Ranula
iv. FACE
A B
C D
Figure 20. A. Hypertelorism. B. Forceps mark.
C. Mobius syndrome. D.Facial nerve palsy (right)
• Observe for any abnormalities
• Note general shape of the nose, mouth, and chin
• Note the presence of hypertelorism (eyes widely separated)
or low set ears
Trans 1.02 Group # 2: Baobao, Lara | TH: Castro
C D
Figure 21. A. Rooting reflex. B. Webbing-Turner;
C. Klippel-Feil. D. Sternocleidomastoid hematoma
• Eliciting the rooting reflex causes the infant to turn the head
that allows easier examination of the neck
• Palpate the sternocleidomastoid for hematoma, the thyroid
for enlargement, and check for presence of thyroglossal duct
cysts.
• Normal: Short and not readily visible
• Cystic hygroma-soft swellings from lymphoid tissue are
readily transilluminate
• Possible abnormalities:
® Webbing-Turner syndrome (webbing), Klippel-Feil
® Cervical torticollis: secondary to position of newborn in
vitro
vi. THORAX, LUNGS, AND HEART
• General notes:
® Normal: chest is rounder than older infant or adult
® Chest circumference should be 2 cm less than the head
circumference
§ Average chest circumference: 33 cm
® Abdominal breathing
§ Retractions
® Normal respiratory rate: 30-60 cycles per minute (cpm)
§ 40 cpm at rest
§ 60 cpm during distress
® Normal heart rate: 120 – 160 bpm
® LOOK, LISTEN, AND FEEL
Chest
• Assess the general appearance, respiratory rate, color of
skin, nasal component of breathing, audible breath sounds,
work of breathing, and symmetry of chest.
® Observe for retractions, nasal flaring, malformations,
abnormal pulsations, and feel for parasternal heave.
® Asymmetric chest movement may indicate a space-
occupying lesion.
® Best sign for ruling out pneumonia is the absence of
tachypnea.
• Barrel chest
® May be present in babies with meconium aspiration
pneumonia due to hyperaeration and air trapping
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History and Physical Examination of Newborns and Infants
• Mild subcostal and intercostal retractions are common,
even in healthy neonates, because of their compliant chest
walls.
• Tachypnea and retractions indicate respiratory distress.
® Other signs of distress are nasal flaring and grunting.
Figure 22. Intercostal retractions where the shadows between the ribs are
observable.
• Quiet breathing is abdominal.
• Clavicular fracture
® Most common fracture in the newborn, especially among
infants
® May present with:
§ Decreased or absent tenderness on movement and
pain or tenderness on movement of the arm of the
affected side
§ Deformity and discoloration over the fracture site
§ Crepitus or irregularity along the clavicle
® Treatment is directed at minimizing the newborn’s pain or
discomfort
® Healed clavicle will have a firm lump in the area, as new
bone develops
B
A
Figure 23. A. Barrel chest. B. Clavicular fracture
A B
Figure 24. A. Witch’s milk. B. Supernumerary nipples
• Breasts
® Usually is 1cm in diameter in term male and female
infants
® May be abnormally enlarged (3-4cm) secondary to the
effects of maternal estrogens
® Witch’s milk or white discharge may be present in both
male and female infants
® Supernumerary nipples
§ Extra nipples but occur as normal variant
• Respiration
® In newborns, thoracoabdominal paradox (seesaw
breathing) is a normal finding.
® Hoover sign or seesaw breathing may be observed in
older infants who have an airway obstruction or a lower
respiratory tract infection.
Figure 24. Normal and Seesaw Respiration
Trans 1.02 Group # 2: Baobao, Lara | TH: Castro
Lungs
• Examination of the respiratory system can be done through
inspection, palpation, and auscultation.
® There is limited room to percuss on a newborn. Do not
percuss a newborn unless one is sure that there are no
cystic adenomatous disease [Cenabre]
® Percussion might not be helpful since an infant’s chest is
hyperresonant throughout.
• Palpation can be done to asses tactile fremitus. Place your
hand or fingertips over each side of the chest and feel for
vibrations which should be symmetric.
• Listen for:
® Bilateral breath sounds, crackles, wheezes, or rhonchi
§ Wheezes are common in infants with asthma or
bronchiolitis
§ Ronchi reflect obstruction of larger airways and occur
with respiratory infections.
§ Crackles are discontinuous sounds which can be
heard near the end of inspiration and can be heard in
infants with pneumonia and bronchiolitis.
Heart
• Observe:
® Precordial activity, rate, rhythm, presence or absence of
murmurs, quality of heart sounds, gallops, clicks
® If sound is loudest on right side or left side
® Location and strength of point of maximal impulse (PMI)
§ PMI is usually found at 4th left intercostal space
midclavicular line
• Heart is more centrally located within thoracic cavity
® Listen to patent ductus arteriosus murmur sound
• Check for peripheral pulses:
® Carotid, brachial, radial, femoral, dorsalis pedis, and
posterior tibial
® Abnormalities:
§ Absence or diminution of femoral arteries may be
indicative of coarctation of the aorta.
§ Weak or thready pulse may reflect myocardial
dysfunction and heart failure.
• Compare femoral pulses with brachial pulses
• Measure blood pressure:
® Systolic: 40-80 mmHg
® Diastolic: 20-55 mmHg
® Mean: 25-60 mmHg
• Heart rate should also be checked
• Heart Sounds
Figure 25. Healthy heart sounds in a newborn
® The splitting of S2 is easier to hear when the infant is
completely quiet or sleeping.
® Fourth heart sounds represent decreased ventricular
compliance which suggests heart failure.
• Murmur
® In newborns, presence of a murmur does not always
signify the presence of heart disease, nor does the
absence of murmur provide reassurance of normalcy
® The most common murmur in the immediate newborn
period are flow murmurs
§ It represents a transition from fetal to neonatal
circulation (e.g. tricuspid atresia, benign patent
foramen ovale)
® Functional closure of PDA is 2 – 4 days
§ Sometimes persistent among premature newborns
® Murmurs persisting after the first 12 hours of life are likely
to reflect structural abnormalities. However, they may not
be hemodynamically significant.
® Further evaluation is required if:
§ Murmur persists beyond several weeks in a healthy
newborn.
§ Murmur is present in a critically ill infant.
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History and Physical Examination of Newborns and Infants

vii. ABDOMEN • Full term infant scrotum should:

• Examine the penis
A B
® Have brownish pigmentation
® Rugated
§ Infants will have well-developed scrotal rugae at term
§ A smooth scrotum suggests prematurity
® Median raphe visible
® Newborn males always have marked phimoses and
foreskin may not be easily retracted
® Normal penile length at birth is >2cm
® Check for hypospadias, epispadias, and chordae
® Hydrocele are common and usually disappears by 1 year
of age
® Undescended testis
§ Testes should be easily palpable
® Inguinal hernia

C D

E F
.
Figure 26. A. Umbilical arteries and vein. B. Omphalocoele.
C. Middle gastrochisis. D. Exstrophy of bladder.
E. Scaphoid abdomen. F. Umbilical hernia.
• General notes:
® Appearance
§ Globular or rounder
® Abdomen of newborns are usually soft on palpation
® Umbilical cord
® Liver: situated 2 cm below the right coastal margin
® Spleen is usually not palpable Figure 27. Top: Male genitalia for different lengths of gestation;
• Abdominal examination: Bottom: Hydrocoele
® Normal: umbilicus has two arteries and one vein Female Genitalia
® Congenital defects may include: • Inspect:
§ Omphalocoele – intestines are covered by ® Labia
peritoneum and umbilicus is centrally located ® Clitoris
§ Gastroschisis – intestines are not covered by ® Urethral opening
peritoneum ® External vaginal vault
§ Exstrophy of the bladder – bladder develops outside
• Whitish discharge or bleeding is normally present
the fetus
(pseudomenses)
§ Scaphoid abdomen – usually associated with
® Secondary to maternal hormone (estrogen) withdrawal
congenital diaphragmatic hernia
§ Umbilical hernia – protrusion through a defective • Hymen:
umbilical ring which usually closes within 1 to 2 years ® All female newborns have a redundant hymenal tissue
® Look for obvious defects ® Hymenal tags may be present normally
§ Tags of tissue may extend from 1 to 15mm beyond
® In abdomen examination, auscultate first, then inspect,
then palpate, then do percussion if necessary the rim of the hymen
§ Usually disappears within few weeks
® Listen for bowel sounds
§ Infants normally have relatively inactive bowel sounds: • Large labia majora
- On their first days of life ® Red and edematous
- If they are extremely premature • Ovaries and uterus assessed thru rectal exam
- Never fed for several days or weeks • Clitoris
® Palpate the abdomen for distention, tenderness, or ® Can have a relatively prominent appearance
masses § Especially if the labia are underdeveloped or if the
§ Palpation should start below the umbilicus on both infant is premature
sides and proceed towards the diaphragm.
§ In the normal circumstances, the liver is palpated 2
cm below the coastal margin and the spleen tip at the
costal margin.
§ The kidney, especially on the right side, can often be
palpated.
viii. GENITALIA
Male Genitalia
• Term: normal penis size is 3.6 ± 0.7 (at least one cm)
® Micropenis: 1.5-2 cm [Cenabre]
• Inspect glans, urethral opening, prepuce, and shaft
Figure 28. Clitoromegaly
• Retraction of foreskin may be difficult
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 History and Physical Examination of Newborns and Infants
® Clitoromegaly: enlargement of clitoris
§ May be a sign of masculinization or a virilizing tumor
§ May also be caused by increased maternal androgen
production or maternal drug use
• Ambiguous genitalia
® Involves masculinization of the female external genitalia
which can be caused by endocrine disorders such as
congenital adrenal hyperplasia
ix. TRUNK, BACK, AND SPINE
A B
Figure 29. A. Hairy patches. B. Sacral dimple.
Figure 30. Spinal defects
• Check for any gross defects of the spine
® Any abnormal pigmentation or hairy patches (tufts of hair)
over the lower back should increase the suspicion that an
underlying vertebral anomaly exists, such as spina
bifida.
® A sacral or pilonidal dimple may indicate a small
meningocele or other anomaly.
• Common defects:
® Craniorachischisis: completely open brain and spinal
cord
® Anencephaly: open brain and lack of skull vault
® Encephalocele: herniation of the meninges and brain
® Iniencephaly: occipital skill and spine defects with
extreme retroflexion of the head
® Spina bifida occulta: Closed asymptomatic NTD in
which some of the vertebrae are not completely closes
® Closed spinal dysraphism: deficiency of at least two
vertebral arches, here covered with a lipoma
® Meningocele: protrusion of the meninges (filled with
CSF) through a defect in the skull or spine
® Myelomeningocele: open spinal cord (with a meningeal
cyst)
Trans 1.02 Group # 2: Baobao, Lara | TH: Castro
x. ANUS
Figure 31. Imperforated anus
• Check for patency of the anus to rule out imperforate anus
® Not always a medical emergency, but surgery is still
needed at least within the minimum time required for the
patient to be stabilized [Cenabre]
® If there are obstructive symptoms it becomes a medical
emergency
® Insert a small feeding tube or observe for passage of
meconium
• Check the position of the anus
• Meconium should pass within 48 hours of birth for term
infants
® Premature infants are usually delayed in passing
meconium
xi. EXTREMITIES
A B C
D E
Figure 32. A. Simian crease. B. Polydactyly. C. syndactyly.
D. Talipas equinovas. E. Metatarsus varus
• Examine the arms and legs, paying close attention to the
creases and digits
® Most infants have 2 major creases on the palm
® A single transverse palmar crease (Simian crease) can
be associated with Down Syndrome
• Diminished pulses in all extremities indicate poor cardiac
output or in peripheral vasoconstriction
• Absent or diminished femoral pulses suggest the presence of
coarctation of aorta
• Polydactyly: supernumerary digits
• Syndactyly: abnormal fusion of digits, most commonly on 3rd
and 4th fingers, and 2nd and 3rd toes
• Talipes equinovas (club foot): More common in males; the
foot is turned downward and inward, sole is directed medially
• Metatarsus varus: adduction of the forefoot; usually corrects
spontaneously
Figure 33. Rocker bottom feet: characteristic of Edward Syndrome
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 History and Physical Examination of Newborns and Infants

Table 10. Primitive Reflexes [Bates’]

xii. HIPS
Primitive Reflex Maneuver Ages
Palmar Grasp Place your finger into Birth to 3-4
Reflex the infant’s hand and months
press against the palmar
surface.
Infant will flex all fingers
to grasp your finger.
Plantar Grasp Touch the sole at the Birth to 6-8
Reflex base of the toes. months
Toes will curl.
Rooting Reflex Stroke the perioral skin Birth to 3-4
at the corners of the months
mouth.
Infant will open mouth
and turn head towards
the stimulated side.
Moro / Startle Reflex Hold the infant supine, Birth to 4
Figure 34. Hip examination tests
support the head, back, months
• Barlow test and legs. Abruptly lower
the entire body about 2
® Bad: adducts [Cenabre]
feet.
® Test for the ability to sublux or dislocate an intact but Arms will abduct and
unstable hip extend, hands will open,
® Hip started reduced legs will flex, and infant
® Test will dislocate the hip may cry.
® Barlow maneuver: Asymmetric Tonic With the infant supine, Birth to 2
§ Adduction with posterior pressure on the hip Neck Reflex turn head to one side, months
• Ortolani test holding the jaw over
® Test for knowing the presence of posteriorly dislocated shoulder. Do both sides.
hip Arms/legs on side to
which head is turned will
® Hip starts dislocated
extend while opposite
® Test will reduce the hip arm/leg will flex.
® Ortolani maneuver: Trunk Incurvation Support the infant prone Birth to 2
§ Abduction with anterior lifting of the hip (Galant) Reflex with one hand then months
xiii. NEUROLOGIC EXAMINATION stroke one side of the
back, from shoulder to
buttocks, 1 cm from
midline.
Spine will curve toward
the stimulated side.
Landau Reflex Suspended the infant Birth to 6
prone with one hand. months
Head will lift up, and
spine will straighten.
Parachute Reflex Suspend the infant 8 months and
prone and slowly lower does not
A B the head towards a disappear
Figure 35. A. Hypotonia. B. Hypertonia surface.
Arms and legs will
• Optimal time to conduct test: prior to feeding because patient
extend in a protective
is awake and responsive [Bates’]
fashion
• Check level of consciousness [Bates’] Positive Supportive Hold the infant around Birth or 2
• Posture among term infants: Reflex the trunk and lower until months to 6
® Normal position is one with hips abducted and partially the feet touch a flat months
flexed, with knees flexed surface.
® Arms are abducted and flexed at the elbow Hips, knees, and ankles
® Fists are often clenched with fingers covering the thumb will extend, infant will
• Limbs move spontaneously and equally stand up, partially
• Sensory: bearing weight, then
sags after 20-30 sec.
® Difficult to assess
Placing and Hold the infant upright Birth (best
® Test for pain Stepping Reflex and have one sole touch after 4 days)
• Muscle tone: the tabletop. to variable
® Hypotonia Hip and knee of age
§ In ventral suspension, the head drops very low. There stimulated foot will flex
is exaggerated convex curvature of the spine. and other foot will step
Floppiness and head lag are seen forward. Alternate
® Hypertonia stepping will occur.
§ Hyperextension of the back and tightly clenched fists *More details about the reflexes can be found in the appendix.
are often seen. Peripheral nerves
• Primitive reflexes:
• Brachial plexus injuries
® Moro reflex: 28 weeks gestation – ends at 4 months
® Erb – Duchenne palsy (upper arm paralysis)
® Palmar grasp: 28 – 2-3 months § Involves the 5th and 6th cervical nerves and is the most
® Asymmetric tonic neck response: 35 weeks – 6 months common brachial plexus injury
§ Fencing posture
- There is adduction and internal rotation of the arm
® Stepping response (involuntary walking): 35-36 week – - The forearm is in pronation.
2 months
- Power of extension of forearm is retained
- Wrist is flexed
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History and Physical Examination of Newborns and Infants

- Moro reflex is absent • Lymphoid tissues develop rapidly

§ This condition can be associated with diaphragm ® Reaches adult size by 6 years of age
paralysis • Physiologic anemia at 2 months
® Klumpke paralysis (lower arm paralysis) • Vision acuity of 20/20 achieved at 7 years
§ Involves the 7th and 8th cervical nerves and the 1st
IV. PHYSIOLOGIC CHANGES IN THE NEWBORN
thoracic nerve
- The hand is flaccid with little or no control A. PHYSIOLOGIC JAUNDICE
- If the sympathetic fibers of the first thoracic root are • Jaundice is observed in the 1st year of life in 60% of term and
injured, ipsilateral ptosis, enophthalmos, miosis, 80% of preterm
and anhidrosis (Horner’s syndrome) can rarely • If onset is <24 hrs of life: always pathologic [Cenabre]
occur • If extends beyond 1st to 3rd month of life: Investigate
® Phrenic nerve injury • Unconjugated (indirect) bilirubin = neurotoxic
§ This can occur secondary to a brachial plexus injury • Conjugated (direct) bilirubin = indicates a hepatic or systemic
§ It causes paralysis of the diaphragm, leading to illness
respiratory distress • Rises at a rate of <5 mg/dL/24 hrs
® Should be <12 mg/dL in full term, 10-14 mg/dL in
preterm
® Direct bilirubin should be <2 mg/dL at any given time
• Visible on the 2nd-3rd day and peaks between the 2nd and 4th
days of life
• Decreases between the 5th and 7th days of life
• Why?
® Because of increased bilirubin production after the
breakdown of fetal red blood cells and transient limitation
in the conjugation of bilirubin by the liver
® Impaired conjugation of bilirubin by the liver
® Increased bilirubin reabsorption in the intestinal tract
A B Factors suggesting non-physiologic jaundice
Figure 36. A. Erb-Duchenne. B. Klump paralysis • Family history of hemolytic disease
C. MATURITY TESTING • Pallor
• Hepatosplenomegaly
i. GROWTH VS DEVELOPMENT
• Failure of phototherapy to lower bilirubin
• Growth: process by which a living being and any of its parts
• Light colored stools
increase in size and mass, either by multiplication or by
enlargement of component parts • Dark urine and is (+) for bilirubin
• Development: enhancement of function, skills, and • Vomiting, lethargy, poor feeding, apnea
maturation • Excessive weight loss, bradycardia, hypothermia
ii. GROWTH MONITORING AND ASSESSMENT Breastmilk jaundice
• Growth charts • 1-5% of breastfed newborns
® Weight for age • Bilirubin level rises after 1 week
® Length for age / Height for age • Peaks at 2-3 weeks: 20-25 mg/dL bilirubin level
® Head circumference for age • Temporary cessation of breastfeeding if level of bilirubin
® Weight for height reach >20mg/dl
® BMI
Table 11. Kramer’s rule
• Other indices
Serum Bilirubin
® Body proportions Zone Jaundice Areas
(mg/dL)
® Skeletal maturation I Head/neck 6-8
Weight II Upper trunk 9-12
• Best index of growth and nutrition III Lower trunk/thigh 12-14
• Mnemonics: IV Arms/legs/elbows/knees 15-18
® Infants < 6 months: V Hands/ feet >18
§ Wt. in grams = Age in months x 600 + birth weight
§ Expected weight gain of 600g per month
® 6-12 months
§ Wt. in grams = age in months x 500 + birth weight
® 2 years and above
§ Wt. in kgs = Age in years x 2 + 8
• At 4-5 months = double the birth weight (BW)
• At 1 year = triple the BW
Height
• Length/ stature
• Reflects growth failure and chronic malnutrition
• Mnemonics
® Average length at birth: 50 cm
® Ht. in cm: Age in years x 5 + 80
® At 1 year: length is increased by 50%
® 4 years: doubles
® 13 years: tripled
iii. PHYSIOLOGIC AND STRUCTURAL GROWTH
• RR and PR decrease rapidly during the first two years
• Paranasal sinuses – ethmoid, sphenoid, and maxillary
sinuses are present at birth. Figure 37. Progression and estimate of jaundice level according to Kramer’s
• Frontal sinuses appear radiologically around 6 years of age rule (jaundice starts on the head, and extends towards
the feet as the level rises)
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 History and Physical Examination of Newborns and Infants
Figure 38. Phototherapy graph- guide to lower the bilirubin level and to
avoid exchange transfusion among infants
B. VASOMOTOR INSTABILITY
• Vasomotor instability and peripheral circulatory
sluggishness are revealed by:
® Deep redness or purple lividity in a crying infant, whose
color may darken profoundly with closure of the glottis,
preceding a vigorous cry
® Harmless cyanosis (acrocyanosis) of the hands and feet
especially when they are cold
• Examples:
® Cutis marmorata
® Mottling
§ An example of general circulatory instability
§ May be associated with serious illness or related to a
transient fluctuation in skin temperature
® Harlequin color change
C. HORMONAL EFFECTS IN THE NEWBORN
• The placenta acts as a barrier to many substances, but other
than chemicals freely or partially enter the fetal bloodstream.
• Maternal hormones are among the chemicals that penetrate
the placental barrier and influence the fetus.
• During pregnancy, estrogen is particularly high and cause
breast enlargement in the mother.
• Similar influences are commonly found in newborns, both
boys and girls, by the third day after birth.
Pseudomenses
• Newborn girls may initially have prominent labia as a result of
estrogen exposure
• Pseudomenstruation
® A type of vaginal discharge due to withdrawal of maternal
hormones
® Discharge is white and occasionally tinged with blood
® Should not last beyond first week of life
Witch’s milk
• Breast enlargement is temporary in an infant and secondary
to the effects of maternal estrogens
® Should subside by the second week as the hormones are
cleared from the newborn’s system
• Witch’s milk
® Discharge from the nipples in addition to the enlargement
® Disappears within two weeks
® Caused by elevated circulating endogenous steroid
hormone in late gestation and subsequent withdrawal of
androgen after delivery
® May be present in both male and female infants.
D. TRANSITIONAL STOOLS
• Meconium: very first stool of an infant
• Passage of meconium usually occur with the first 24 hours
after birth
• 99% of term infants and 95% of premature infants pass
meconium within 48 hours of birth
• However, passage of meconium does not rule out an
imperforate anus if rectal vaginal fistula is present
Trans 1.02 Group # 2: Baobao, Lara | TH: Castro
Figure 39. Meconium
E. INANITION FEVER
• Transitory fever in the newborn or dehydration fever
• Elevations in temperature (38-39˚C) are occasionally noted
on the 2nd- 3rd day of life
® Beyond this, investigate for infection
• More likely to occur in breast fed infants whose intake of fluid
has been particularly low or in infants exposed to high
temperature environment (incubator, sunlight, etc).
• Diminished sweating capacity as a contributing factor
• Other signs include decreased urinary output and decreased
frequency of voiding
• Temperature regulation: 36.5-37.5˚C
® Reasons:
§ Infants have less subcutaneous fat than in adults
§ Thin epidermis
§ Blood vessels closer to skin
F. PHYSIOLOGIC DESQUAMATION
Figure 40. Desquamation
• The barrier function of the stratum corneum is a fundamental
element in maintaining cutaneous hydration.
® Alteration in the stratum corneum leads to the loss of the
barriers function with increased transdermal water loss,
decreased water content and installation of xerosis.
• Moisturizers corrects cutaneous xerosis by restoring the
stratum corneum.
• In newborns, the architectural and biochemical structure of
the stratum corneum is identical to that of infants and adults.
• Physiologic desquamation
® Exhibited by 60% of newborns
§ Demonstrates a transitory functional deficit in the
stratum corneum
§ Justifies emollient treatment
• In premature infants, the epidermis and particularly the
stratum corneum are immature
® Trans-epidermal water loss is elevated, and the skin is dry
or even fissural.
G. FALLING OFF OF THE UMBILICAL CORD
• Umbilical cord usually sloughs off within first 2 weeks of life
• Cord contains:
® 2 arteries
® 1 vein
® Rudimentary allantois
® Remnant of the omphalomesenteric duct
® Wharton’s jelly
• Portions of these structures remain in the base
• Vessels functionally close but remains anatomically patent
for 10-20 days.
• Delayed separation of the cord (after >1month) has been
associated with neutrophil chemotactic defect and
overwhelming bacterial infection.
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 History and Physical Examination of Newborns and Infants

H. PHYSIOLOGIC ANEMIA 7. Physical check-up for the eyes gives more emphasis on
• Normally newborns have higher hemoglobin (Hgb) and a. Assessment of visual acuity
hematocrit (Hct) levels with larger RBCs than older children b. Structure and appearance of eyes
and adults. c. Assessment of extraocular muscles
• Physiologic anemia 8. Hairy ears are often seen in infants of:
® Within the 1st week, a progressive decline in Hgb levels a. Hypertensive mothers
begins and persists for 6-8 weeks. b. Diabetic fathers
® The transition from fetal to adult Hgb begins before birth. c. Diabetic mothers
The abrupt increase in PaO2 (25-30 mmHg → 90-95 d. Anemic mothers
mmHg) from fetus to normal newborn causes serum 9. I. Necks are short and readily visible
erythropoietin to fall. II. Eliciting rooting reflex causes the infant to turn the
§ Explains the shutdown of RBC production that head that allows easier examination of the neck
normally occurs at birth and persists for 6-8 weeks. Which is/are true?
§ This bone marrow shutdown results in physiologic a. I
anemia. b. II
- Particularly found among premature newborns c. I and II
whose body mass and blood volume are now d. None of the above
increasing rapidly 10. Umbilical cord contains
® Falling Hgb eventually results in reduced O2 tension and a. Remnant of the omphalomesenteric duct, rudimentary
an appropriate increase in erythropoietin release which allantois, Wharton’s jelly, 2 arteries, 1 vein,
stimulates the bone marrow to produce RBCs. b. 1 arteries, 2 veins, rudimentary allantois, remnant of
• Erythropoietin may prove to be effective in treating anemia of omphalomesenteric duct, wharton’s jelly
prematurity c. Wharton’s jelly, rudimentary omphalomesenteric duct,
• Anemia of prematurity should not be confused with iron- rudimentary allantois, 2 arteries, 1 vain
deficiency anemia, which usually occurs around 4-6 months d. 2 arteries, 1 vein, remnant of omphalomesenteric duct,
of age. rudimentary allantoin, Wharton’s jelly
V. REVIEW # Answer Page Section
1. TORCH screening is done to test for infectious diseases 1 A 1 II.A. Embryo
during which period of pregnancy? 2 B 2 Table 3
3 B 3 Table 6
a. 1st trimester
4 D 13 - 14 Peripheral Nerves
b. 2nd trimester 5 F 13 xii. Hips
c. 3rd trimester 6 D 9 vi. Thorax, Lungs and Heart
2. What does a 1-min APGAR score of 7 indicates? 7 B 7 iii. Eyes, Ears, Nose, and Mouth
a. Normal neonate 8 C 8 iii. Eyes, Ears, Nose, and Mouth
b. Some nervous system depression 9 B 9 v. Neck
10 A 15 G. Falling Off of the Umbilical Cord
c. Severe depression
3. A newborn with HC=33cm, BL=50cm, and BW=2000g is VI. REFERENCES
classified as
• American Baby Child Law Centers. (2019). American Baby Child Law
a. SGA, Symmetric
Centers [Website]. Retrieved from https://www.abclawcenters.com
b. SGA, Asymmetric • Bickley LS, and Szilagyi PG. (2017) Bates’ Guide to Physical Examination
c. AGA and History Taking. 12th ed. Philadelphia: Wolters Kluwer pp. 803-807
4. I. Erb-duchenne paralysis: upper arm paralysis • De Jong EP, Vossen AC, Walther FJ and Lopriore E. (2013). How to use…
II. Klumpke paralysis: Lower arm paralysis neonatal TORCH testing. Retrieved from https://www.ncbi.nlm.
nih.gov/pubmed/23470252
III.Phrenic nerve injury: Occur secondary to brachial
• Government of Western Australia. Clinical practice guideline: Jaundice and
plexus injury phototherapy. Retrieved from
Which is/are true? https://www.kemh.health.wa.gov.au/~/media/Files/Hospitals/WNHS/For
a. I, II %20health%20professionals/Clinical%20guidelines/NEO/WNHS.NEO.J
aundiceHyperbilirubinaemiaandPhototherapy.pdf
b. II, III
• Kliegman, R. M., Stanton, B. F., Schor, N. F., & St Jeme, J. W.
c. III only (2016). Nelson Textbook of Pediatrics. (R. E. Behrman, Ed.) (20th ed.).
d. All of the above Philadelphia, PA: Elsevier, Inc.
5. T/F. Ortolani test is used for knowing the presence of • National Institute of Health. (2019). Genetics Home Reference [website].
posteriorly dislocated hip, test starts with hip reduced. Retrieved from https://ghr.nlm.nih.gov
• WHO. Retrieved from http://origin.wpro.who.int/philippines/areas/materna
6. I. Older infants have rounder chest than newborns and
l_child_nutrition/newborn_mother_care/einc_protocols/en/
adults
II. Chest circumference should be 2 cm more than the
head circumference
III. At rest normal respiratory rate is 40 cpm
Which is/are true?
a. I, II
b. I, III
c. II
d. III

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 History and Physical Examination of Newborns and Infants

VII. SUMMARY
Table 12. Periods of growth and duration
Period Sub-category Duration Remarks
Ovum 0-14 day AOG Increase in complexity and cell number but little increase in size
Period of Organogenesis
Embryo 14 days to 9 weeks of AOG Maternal screening is important: blood and Rh type, TORCH,
Prenatal Gestational DM, Hypertension
Maternal Hx: risk factors for sepsis
Fetus 9 weeks to birth Birth Hx
Family Hx: heredo-familial diseases
Behavioral state of newborn (quiet/active sleep, drowsy, alert, fussy,
Birth term - 37-42 weeks AOG
or crying)
Infancy - 0-2 years
Early/ Preschool 2-5 years
Childhood
Late 6-10/12 years
Adolescence - 10-20 years
Table 13. Assessment of a Newborn
Immediate Post-Partum Assessment
Clinical Sign 0 1 2
Heart Rate Absent <100 >100
Respiratory Effort Absent Slow, irregular Good, strong
Muscle Tone Flaccid, limp Some flexion of the arms and legs Active movement
Reflex Irritability No responses Grimace Vigorous cry, sneeze, or cough
Color Blue, pale Pink body, blue extremities Pink all over
Apgar Score 1 – Min Apgar Score 5 – Min Apgar Score
Normal 8– Normal
8 – 10
10
Some nervous system depression 0– High risk for subsequent central nervous system
5–7
7 and other organ system dysfunction
Severe depression, requiring immediate
0–4
resuscitation
1. Drying of the newborn
Essential Intrapartum 2. Skin-to-skin contact
Newborn Care 3. Delayed cord clamping
4. Non-separation of child from mother and early initiation of breastfeeding
Vital Sign Normal Values Increase/Decrease Remarks
Temperature 36.5 - 37.5°C Increased: infection, anxiety, Most accurate: rectal
excessive bundling (skin temp only) temperature
Respiratory 40 – 60 breaths/min Increased: cyanotic cardiac disease, Most reliable: Sleeping
Rate right-to-left shunting, metabolic RR
acidosis, fever, respiratory disease
Vital Signs
Pulse/Heart 120 – 160 bpm Increased: paroxysmal Palpate femoral or
Rate supraventricular tachycardia brachial arteries or
Decreased: drug ingestion, hypoxia, auscultate heart for HR
intracranial or neurologic conditions
Blood Systolic: 40 – 80 mmHg Not routinely measured
Pressure Diastolic: 20 – 55 mmHg
Anthropometric Data Normal Values Remarks
Head Circumference 32 – 37 cm (term) Low: premature closure of sutures, microcephaly
High: macrocephaly

Landmarks: glabella/supraorbital ridge and most

Length (birth length)
Chest Circumference
Anthropometrics Abdominal Circumference
Birth Weight
Lubchenco Classification:
§ SGA (< 2500 – 1000g)
§ AGA (≥2500g)
§ LGA (> 4000g)
prominent part of occiput
48 – 52 cm Low growth velocity: chronic conditions
30 – 35 cm Head Circumference – 2cm
- -
2500 – 4000 g SGA can be symmetric or asymmetric. Preterm SGA
are prone to asphyxia, hypoglycemia, and
hypocalcemia
Preterm AGA are prone to respiratory distress
syndrome, apnea, PDA, and infection
LGA are at risk for: metabolic and congenital anomalies

Failure to thrive can be due to a multitude of factors:

environmental, gastrointestinal, neurologic, etc.
Methods of Determination
1. Mother’s menstrual history
2. Early fetal ultrasound
Gestational Age
3. Ballard Score see Figure 42
Gestational Age: Preterm < 34 weeks; Late preterm: 34 – 24 weeks; Term: 37 – 42 weeks; Postterm > 42
weeks
Physical Assessment
Observable Physiologic/Pathologic State
Pallor Cavernous hemangioma
Cyanosis (Central, Acrocyanosis, Perioral, Differential) Strawberry hemangioma
Plethora Café-au-lait Spots
Skin
Physiologic Jaundice (dependent on onset) Extensive bruising (ecchymoses)
Milia Harlequin sign
Erythema toxicum Cutis marmorata (mottling)
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 History and Physical Examination of Newborns and Infants

Nevus simplex Lanugo

Port-wine stain Vernix caseosa
Mongolian spots Collodian infant
Molding Plagiocephaly
Caput succedaneum Torticollis
Subgleal hemorrhage Craniosynostosis (Crouzin’s, Pfeiffer, Apert)
Cephalohematoma Hypertelorism
Head, Face
Dolichocephaly Low Set Ears
Macrocephaly Mobius Syndrome
Microcephaly Facial Nerve Palsy
Micrognathia
Eyes: Nose:
Doll’s eye reflex Choanal atresia
Esotropia Asymmetry of snares
Exotropia Mouth:
Nystagmus Unilateral cleft lip
Colobomas Cleft lip and palate
Eyes, Ears, Nose, Mouth Neonatal conjunctivitis Macroglossia
Subconjunctival hemorrhage Tongue-tie
*Leukocoria Supernumerary teeth
Ears: Epstein’s pearls
Pre-auricular skin tags Ranula
Hairy ears
Low set ears
Webbing-Turner syndrome Sternocleidomastoid hematoma
Neck
Klippel-Feil syndrome Cervical torticollis
Thorax: Lungs:
Barrel chest Bilateral breath sounds
Retractions Crackles
Thorax, Lungs Clavicular fracture Wheeze
Witch’s milk Rhonchi
Supernumerary nipples
Seesaw respiration
Point of maximal impact at ~4th left intercostal space
Heart Splitting of S2
Flow murmurs
Omphalocele Scaphoid abdomen
Abdomen Gastroschisis Umbilical hernia
Exstrophy
Spina bifida occulta Craniorachischisis
Closed spinal dysraphism Anencephaly
Trunk, Back, Spine Encephalocele Myelomeningocele
Iniencephaly Hairy patches
Meningocele Sacral dimple
Male: Female:
Micropenis Pseudomenses
Undescended testis Hymen
Inguinal hernia Clitoromegaly
Genitalia
Hypospadia Ambiguous genitalia
Epispadia
Chodae
Hydrocele
Anus Imporforate anus
Simian crease Talipes equinovas (club foot)
Extremities Polydactyly Metatarsus varus
Syndactyly
Hypotonia Klumpke paralysis
Neurologic Hypertonia Phrenic Nerve Injury
Erb-Duchenne Palsy Primitive reflexes see Table 10, Figure 41
Test Use Hip Started Outcome Maneuver
Ortolani Knowing presence of posteriorly Dislocated Reduce the hip Abduction with anterior
Hips dislocated hip lifting of the hip
Barlow Test for ability to sublux or Reduced Dislocate the hip Adduction with posterior
dislocate an intact but unstable hip pressure on the hip
Maturity Testing
Growth Charts Weight for Age, Length for Age / Height for Age, Head circumference for Age, Weight for Height, BMI

Table 14. Summary of physiological changes of the newborn

Changes Onset/ Reason General characteristics Example Regression
regression
Physiological • Increased bilirubin production after • Rises at a rate of <5 mg/dL/24 5th and 7th
nd
Jaundice Visible: 2 - the breakdown of fetal red blood cells hrs day of life
3rd day and transient limitation in the ® Should be <12 mg/dL in full
Peak: 2 and conjugation of bilirubin by the liver term, 10-14 mg/dL in preterm
4th days of • Impaired conjugation of bilirubin by ® Direct bilirubin should be <2
life the liver mg/dL at any given time
• Increased bilirubin reabsorption in • Observed in the 1st year or life in
the intestinal tract 60% of term and 80% preterm
Vasomotor • Deep redness or purple lividity in Cutis
instability a crying infant preceding a marmorata
vigorous cry Mottling
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 History and Physical Examination of Newborns and Infants

• Harmless cyanosis Harlequin

(acrocyanosis) of the hands and color change
feet especially when they are cold
Hormonal 3rd day after • Estrogen is particularly high among Large labia Pseudomen
effects in the birth mothers during pregnancy Pseudomenst- s: should not
newborn ® Estrogen influences are ruation last beyond
commonly found in newborns, Witch’s Milk 1st week of
both boys and girls Breast life
• Withdrawal of maternal hormones enlargement Witch’s Milk:
(Pseudomenstruation) within 2
weeks
Transitional First 24 Meconium
stools hours after
birth
Inanition 2nd – 3rd day • Infants have less subcutaneous fat • Transitory fever in the newborn or
fever of life than in adults dehydration fever
• Thin epidermis • Elevations in temperature (38-
• Blood vessels closer to skin 39C)
• More likely to occur in breast fed • Other signs include decreased
infants whose intake of fluid has urinary output and decreased
been particularly low or in infants frequency of voiding
exposed to high environment
(incubator, sunlight, etc)
• Diminished sweating capacity is a
contributing factor
Physiological Transitory functional deficit in the Elevated trans-epidermal water loos
desquamation stratum corneum Skin is dry or fissural
Immature stratum corneum and
epidermis among preterm infants
Falling off the 1st two Vessels that are contained by the
umbilical cord weeks of life umbilical cord functionally close but
remains anatomically patent for 10-
20 days
Physiologic 1st week • Decrease in bone marrow • Normally newborns have higher 6-8th weeks
anemia erythropoietin hemoglobin (Hgb) and hematocrit
® The abrupt increase in PaO2 (Hct) levels with larger RBCs than
from about 25–30 mmHg in fetus older children and adults
to 90-95 mmHg in the normal • Within the 1st week, a
newborn causes serum progressive decline in Hgb levels
erythropoietin to fall begins and persists for 6-8 weeks
• Increased hemolysis • Commonly found among
premature newborns
• Decreased in O2 tension due to
low Hgb increases erythropoietin
release which stimulates
production of new RBC

Figure 41. Primitive reflex chart

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History and Physical Examination of Newborns and Infants

Figure 42. Ballard Score

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