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NEONATAL EXAM

Dr Fawzi Ghanouni
Consultant Paediatrician

Newborn examination
objectives
Indication

& importance
Precautions prior to exam !
Systematic approach
Neonatal reflexes
Normal variants

Remember

Newborn
examination
Earliest

possible detection of
deviations.

Establishes

a baseline for
subsequent examinations

Parents

assurance & counseling

Newborn examination
indications
Immediately
Before

after birth

discharge from maternity

unit
Whenever

there is any concern


about the infant's progress

Examination
precautions

Hand washing,hand
washing ,hand washing ..
Thermal environment
Light & noise
Brief examination time

Common parental
concerns on
Syndactyly

/ Polydactyly
Feeding issues
Mild talipes gue tie
Skin tags
Sinuses
Birthmarks
Pseudomenstruation,Moulding
,Caput

Contd parental
concerns

Cephalohaematoma
Birth

trauma
Intergenerational eczema,
dermatitis & asthma
Intergenerated conditions &
syndromes
Congenital abnormalities in
first-degree relatives

Newborn first
exam
Apgar score

Heart rate
Respiratory effort
Color
Tone
Reflex irritability

General
Vigorous cry is assuring
inspection

Weak cry
sepsis, asphyxia, metabolic,
narcotic use
Hoarseness
Hypocalcemia, airway injury
High pitch cry
CNS causes, kernicterus

General(Growth
parameters)
Weight

(Naked)

Length(straight)
Head

circumference(3
measurements)

Vital
Signs(TPR)
-Heart Rate ( 120-160 )

-Respiratory Rate ( 40-60 )

-Temperature ( 36.5-37.5 C )

-Blood Pressure

General
Well,

Distressed or not?
Obvious Dymorphism or
malformations
Tone & Movements:
Flexion of upper & lower
extremities
-Asymmetric movement
Brachial plexus & fractured clavicle

-Ventral, vertical suspension and


head control for tone assessment

Can you tell


everything
about this
? baby

General contd
Skin

Pink is normal
Acro cyanosis is normal
Cyanosis
Bruised part look blue
Jaundice
Common variants skin rash
Erythema toxicum, mongolian spot,
Benign Pustular Melanosis

Erythema toxicum
Erythematous

macules & firm 1-3


mm yellow or white papules or
pustules
Aetiology obscure
Sterile pustules contain
eosinophils
Appear in the first 3-4 days of
life
( range: Birth to 14 days )
Benign

& self limited

Erythema toxicum

Erythema
toxicum

Impetigo Neonatorum
Vesicular,

pustular, or bullous
lesions developing as early as
2-3days up to 2 weeks of life
Occur in moist or opposing
surfaces of skin
Unroofed lesions do not form
crusts
Treat with antibiotics

Impetigo
Neonatorum

Mongolian Spots
90%

of African infants, 80% of


Asian, and 10% of Caucasian
infants
Slate-gray to blue-black lesions
Usually over lumbosacral area
& buttocks
Accumulation of melanocytes
within the dermis
Generally fade by age 7 years

Mongolian Spots

Benign Pustular
Melanosis

Pustular
Melanosis

Head & Face


Shape of the head
Fontanels?
Sutures?
Eyes?
Nose?
Mouth,lips,palate?
Ears?
Neck?

Head
Forceps

& vacuum marks


Caput succedaneum
Boggy edema in presenting part
of head
Cross suture lines
Disappear in few days
Cephalhematoma

Subperiosteal
Weeks to resolve
Dose not cross sutures

Caput Succadaneum

Scalp

edema secondary to
compression via the birth
canal overlies both the
occipital bones & portions of
the parietal bones bilaterally
Resolves spontaneously
within a few days
Differentiate from the rare
subgaleal bleed

Scalp Hematomata

Cephalohemato
ma

Head
Head

circumference
Shape :Molding,
Brachycephaly: flat occiput
Widening of suture
Fontanelles
Head auscultation: bruits

Infant skull

Craniosynostosis
Definition:

premature closure of
one or more cranial suture.
Growth of the skull occurs
parallel to the suture(s) involved
Early correction optimizes
cosmetic appearance
Can be part of
syndromes:Crouzon's , Apert's
syndrome

Craniosynostosis
Types:
Sagittal synostosis
results in scaphocephaly
coronal synostosis
results in brachycephaly
coronal, sagittal, and
lambdoid synostosis
results in acrocephaly
single suture on one
side of head can result
in plagiocephaly
www.uscneurolosurgery.com

Chest &
Abdomen

Chest
Distress

signs(Grunting,Tachypnea,Nasal
flaring,asymetric chest rise,suprasternal, intercostal, sub costal
retraction).

Deformities(Pectus

carinatum)

excavatum,

Auscultate

Air entry, symmetry


Early crepitation sound is transmitted
upper sound
Late inspiratory crepitation

chest
Suprmammary nipple

Breast

hypertrophy
Milk production
No redness

Supernumerary
Nipples
Found in males & females
Pink

or brown papules along


the milk line, most commonly
on the chest or abdomen
May contain breast tissue &
in women carry the same
relative neoplasia risks
Not considered a marker for
other anomalies

Supernumerary
Nipples

Heart

HR

100-160 beats/min
Color, perfusion,Central
cyanosis
Murmur
Single S1
Splited S2
No split ;single ventricle,
pulmonary hypertension

Palpable femoral
Pulses
One side is sufficient
85

% rules out coarctation


15% still risk of coarctation
Check BP
Think of Turner syndrome

Abdomen
Inspection

Scaphoid
Distention
Abdominal wall defect (gastroschisis)
Palpation; baby sucking and use warm hands
Kidneys are normaly palpable
Liver 2-3 cm
Spleen palpable
Umbilical vessels
2 artery, one vein

Hernias ; umbilical and inguinal

Genitalia
Penile size
Hypospadias,
Testes

epispadias

2% cryptorchid
Hydrocele
Female:
Prominent clitoris & minora
Vaginal skin tag
Vaginal discharge /blood
Labial fusion
Anus

Patency & location

Hydrocoeles

Inguinal Hernias

Hip & Extremities


Erbs

palsy: extended arm &


internal rotation with limited
movement
Humerous fracture
Digital abnormality
Syndactaly, brachdactaly,
polydactaly
Single

palmar crease
Hip dislocation
Female, breach

Subluxation of the
Hip

Subluxation of the
Hip

Feet & Back


Feet
Back

deformities

& spine
abnormal curvature
Sinus tract, tuft of hair

Lumbar hair tuft &


haemangioma

CNS
Awakenes & alertness

moving extremities
Flexed body posture
Minimal Head lag
Ventral suspension
Vertical suspension

Neonatal
reflexes
Known as developmental,

primary, or primitive reflexes.


Consist of autonomic behaviors
that do not require higher level
brain functioning & can provide
information about lower motor
neurons & muscle tone.
protective & disappear as higher
level motor functions emerge.

Suck
Onset:

~24-28weeks GA
Well-established: 32-34 weeks
GA
Disappears: around 12 months
Elicited by the examiner
stroking the lips of the infant;
the infants mouth opens &
the examiner introduces their
gloved finger sucking starts.

Rooting
Onset:

28 weeks GA
Well-established: 3234 weeks GA
Disappears: 3-4
months
Elicited by the
examiner stroking the
cheek or corner of the
infants mouth. The
infants head turns
toward the stimulus
and opens its mouth.

Palmar grasp
Onset:

28 weeks GA
Well-established: 32
weeks GA
Disappears:
Elicited

2 months

by placing the
finger on the palmar
surface of the infants
hand & the infants hand
grasps the finger.
Attempts to remove the
finger result in the infant
tightening the grasp.

Tonic neck (Fencing


posture)
Onset: 35 weeks GA

Well-established:

4 weeks

PCA
Disappearance: 7 months
Elicited by rotating the
infants head from midline to
one side. The infant should
respond by extending the
arm on the side to which the
head is turned and flexing
the opposite arm. The lower
extremities respond similarly.

Moro

Onset:

28-32 weeks GA
Well-established: 37 weeks GA
Disappearance: 6 months
The

baby is held so that one hand supports


the head & the other supports the buttocks.
The reflex is elicited by the sudden
dropping of the head in examiners hand.
The response is a series of movements: the
infants hands open & there is extension &
abduction of the upper extremities. This is
followed by anterior flexion of the upper
extremities & audible cry.

Moro

Moro significance
An

absent or inadequate
Moro response on one side :
hemiplegia, brachial plexus
palsy, or a fractured clavicle
Persistence beyond 5 months
of age indicates significant
neurological defects.

Stepping
Onset:

35-36 weeks GA
Well-established: 37 weeks
GA
Disappearance: 3-4 months
PCA
Elicited by touching the
top of the infants foot to
the edge of a table while
the infant is held upright.
The infant makes
movements that resemble
stepping.

Galant (Trunk
incurvation)
Onset: 28 weeks GA

Well-established:

40 weeks

GA
Disappearance: 3-4 months
The infant is held in ventral
suspension with the chest
in the palm of the
examiners hand. Firm
pressure is applied to the
infants side parallel to the
spine in the thoracic area.
The response consists of
flexion of the pelvis toward
the side of the stimulus.

Babinski
Onset:

34-36 weeks GA
Well-established: 38
weeks
Disappearance: 12
months PCA
Elicited by stimulus
applied to the outer
edge of the sole of the
foot. The infant
responds by plantar
flexion and either
flexion or extension of
the toes.

Postnatal
assessment of
gestational age

Ballard Score
Accuracy within 1-2 weeks
2 parts

Neurologic characteristic
Physical characteristic
Part

of general examination

Physical
Maturity
Skin:

thicker , less translucent, dry,


peeling
Lanugo:
fine non pigmented hair all over 27-28
wks
disappears gradually
Plantar surface: presence or absence of
creases
Breast: areola development
Ear cartilage
Eyelid opening
External genitalia
Rugation, desend
Prominent labia majora

Neuromuscular
Maturity
Posture
Square

window
Arm recoil
Popliteal angle
Scarf sign
Heel to ear

Remember
Wash

your hands prior to


examination
Inspect,Inspect,Inspect ,then
Touch.
Neonatal reflexes
implications
Normal variations

He is watching you
! doctor

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THANKS
BABIES

ARE
FRAGILE, SO HANDLE
WITH CARE

NEWBORN EXAMINATION
Dr

Fawzi
Ghanouni

Consultant
Paediatrician