Providence Clinical Academy Perinatal Curriculum LAST REVIEWED: May 2016

Newborn Assessment Atlas *all pictures, unless otherwise noted, from Stanford University Photo Gallery (newborns.stanford.edu/PhotoGallery/)

Skin Findings Mongolian spot Erythema toxicum Café au lait Mongolian spots-gray or blue-green macule or patch commonly seen on the buttocks, flanks or shoulders of African-American, Asian and Hispanic infants ; benign Erythema Toxicum (Newborn Rash)-present in 50% of newborn; yellowish papule surrounded by a halo of erythema; benign; occurs within 5 days of birth (several weeks for PT babies) Café au lait spots-increased melanin; *6 or more may indicate neurofibromatosis Café au lait

Skin Findings Nevus simplex “Stork bites” Milia Nevus simplex (“Stork bite”)-dilated capillaries, blanches with pressure, more prominent with crying; common-70% of newborns; may last 1-2 years or into adulthood Milia-epidermal cysts, accumulation of sebaceous gland secretions; common- 40% of newborns; will resolve in first week of life

Skin Findings Forceps mark Hemangioma Nevus Forceps mark Nevus(pigmented) – dark brown macule, 10% undergo malignant changes Hemangioma (strawberry) – raised, lobular tumor caused by dilated capillaries, gradually increase in size for 6 months then spontaneously regress over years (1-3% occurrence) Nevus Hemagioma photo from: lugaluda.com

Skin Findings Circumoral cyanosis Acrocyanosis Mottling Acrocyanosis – bluish color of palms of hands and soles of feet, benign in the first 48 hours after delivery; exacerbated by cold Circumoral cyanosis – bluish color around the mouth (lips/tongue pink), benign in first 12-24 hours after birth Mottling – marbling of skin caused by dilation of capillaries, usually seen in response to chilling and disappears when warmed Mottling

Large for Gestational Age (LGA) Small for Gestational Age (SGA) Nutritional Status Large for Gestational Age (LGA) Small for Gestational Age (SGA)

Sutures, Fontanels & Bones of Neonatal Skull Why does molding happen? Fontanels: Anterior Posterior Molding is an adaptive mechanism to facilitate passage through the birth canal Sutures may be overlapping at birth Fontanels should be flat when infant is quiet AF is larger than PF AF normally closes by 18 months PF normally closes by 2 months From: Green-Hernandez, C. Et al.

Breech presentation molding Overlapping coronal sutures Head Molding Breech presentation molding Overlapping coronal sutures

Caput Succedaneum vs. Cephalohematoma Soft tissue edema Edema extends across suture lines Present at birth Poorly defined borders May include ecchymosis Disappears within 48 hrs Collection of blood between the periostium and the skull Swelling does not cross suture lines Not usually present at birth Usually due to traumatic birth Increases in size over 1st day of life Takes months to resolve

Caput vs. Cephalohematoma

Eye Assessment Iris is normally dark blue until 3-6 months of age then may change Sclera should be white Pupils should be equal, round and react to light Distance between inner and outer canthus of one eye should approximate the inner canthal distance; abnormal spacing is associated with various syndromes

Subconjunctival hemorrhage Eye Findings Dysconjugate eye movements Subconjunctival hemorrhage Eyelid edema after birth is common; resolves over first few days Dysconjugate eye movements-eyes may cross of diverge intermittently; normal finding in the first few months of life Subconjunctival hemorrhage – results from breakage of small blood vessels during pressure of delivery; resolves in several days Eyelid edema

Ear Assessment Position Pinna External auditory canal Normal position: 30% of pinna lies above imaginary line drawn between inner and outer canthus of eye Pg. 605 in Perinatal book Low-set ears may be associated with various syndromes and chromosomal anomalies Pinna should be completely formed; firm by 38-40 wks gestation External auditory canal should be visible Position Pinna External auditory canal

Ear Findings: Pits & Tags Pits and tags may be familial or part of a syndrome; increased incidence of deafness and renal anomalies

Ear Findings External canal not visualized Low –set ears Small, incompletely formed

Ear Findings “lop” ear “cup” ear “lop” ear and “cup” ear may be isolated, cosmetic findings

Nose Assessment Size/shape/symmetry Patency Flaring? Size and shape usually familial Broad, flat bridge may be associated with Down Syndrome Infants are obligate nose breathers – assess patency Mild stuffiness right after birth is normal Nasal flaring is abnormal Asymmetry may be due to positional deformity

Mouth Assessment Size/shape/symmetry Palates Reflexes Epstein’s pearls Color Epstein’s pearls Assess mouth for abnormal shape and size of mouth, lips, tongue, filtrum, frenulum and mandible Hard and soft palates should be intact Rooting and sucking reflexes are assessed Epstein’s pearls – benign small white epidermal cysts common on palate and gums; disappear after a few weeks

Mouth Findings Cleft Palate Cleft Lip Tight frenulum “tongue tied” Cleft lip: May be unilateral or bilateral, can vary from a notch in the lip to complete separation extending up to the floor of the nose Tight frenulum: May make feeding difficult requiring frenulectomy Tight frenulum “tongue tied”

Mouth Findings Natal teeth Microganthia Natal Teeth: If mobile, may need to be removed to reduce aspiration risk Micrognathia: Small mandible with very recessed chin; associated with chromosomal conditions Microganthia

Neck & Clavicles Assessment Fractured Clavicle Cystic hygroma Torticollus: injury to the sternocleidomastoid muscle; more common on the R side; congenital or during birth Stretching and PT Fractured clavicle: May see swelling, discoloration, asymmetric arm movements ; may feel crepitus on palpation Neck: May see webbing or mass; webbing is associated with syndromes Cystic hygroma is most common mass: can effect breathing and feeding; surgical intervention Neck webbing Cystic hygroma photo from adhb.govt.nz

Chest/Lung Assessment Normal Findings: Respiratory Rate: 40-60, irregular ok Breath sounds: Clear and equal bilaterally No grunting, nasal flaring or retractions Prominent xyphoid not uncommon Transient breast enlargement due to maternal estrogen Nipple spacing should be 25% of full chest circumference

Chest/Lung Assessment Intercostal and subcostal retractions are signs of respiratory distress or increased work of breathing

Chest/Lung Assessment Extra nipple Extra nipple(s) are a non-pathological finding Pectus excavatum: Chest appears to cave in; generally benign resulting in no functional impairment Pectus excavatum

Cardiovascular Assessment Observe Color Visible precordial activity is okay during 1st 6 hours of life Auscultate Heart rate & rhythm PMI location Murmurs cyanosis, pallor, plethora, mottling 120–160, term infant may be 80–90 during sleep but should increase when awakens; S1 S2 without irregularity PMI: normally lateral to left midclavicular line at 4th intercostal space Murmurs: may be related to transition during 1st 48 hours as opposed to CHD; loudest murmurs are often associated with relatively benign defects http://depts.washington.edu/physdx/heart/demo.html

Cardiovascular Assessment Palpate Capillary Refill Time (CRT) Pulses BP (if ordered): Cuff size should be 40-50% of arm circumference (or thigh circumference for lower extremity BP) Systolic BP in thigh should be 5-10 mm Hg higher than in arm. Capillary Refill Time (CRT): Central vs. peripheral site, should be 3 seconds or less Pulses: Brachial and femoral strength and equality; bounding pulses associated with PDA Absent femoral pulses associated with coarctation of aorta

Abdomen Assessment Size/shape/symmetry Auscultate Umbilical cord Anus Normal Findings Abdomen is slightly rounded, soft, smooth and intact Bowel tones audible shortly after delivery Umbilical cord has 3 blood vessels; single-umbilical artery is associated with renal anomalies Umbilical core may be meconium-stained Anus is patent

Normal drying and healing of cord

Abdominal Findings Umbilical Hernia Diastasis recti Diastasis rectii – benign vertical bulge down middle of abdomen, relative weakness of fascia between rectus muscles Umbilical hernia – most resolve spontaneously; surgery considered if still present at 2-3 years of age Diastasis recti

Abdominal Findings Gastroschisis Omphalocele Omphalocele: abdominal contents usually contained in membrane; cord inserts into sac; often associated with other anomalies Gastroschisis: abdominal wall defect resulting in no sac covering abdominal contents; cord is discrete; low incidence of other anomalies Omphalocele

Genitourinary Assessment - Female Labia Normal female findings: Labia may be smooth, wrinkled or edematous Urethra and vagina should be visible Perineum is smooth and fingertip width White or blood-tinged vaginal discharge is normal, may last for 2-4 weeks Vaginal skin tags will spontaneously recede into the vagina Vaginal Skin Tag Vaginal Discharge

Genitourinary Assessment - Male Penis Meatus Scrotum Testes Normal findings: Penis is straight ,proportionate to body and glans covered by foreskin Urinary meatus is midline at the glans tip Scrotum is symmetrical Testes are firm, smooth and equal size; palpable in the scrotal sac Uric acid crystal (rust colored) may be seen in diaper

Genitourinary Assessment - Male Hypospadias Undescended testicles Undescended testicles – bilateral rare in term baby, unilateral more common, often in canal Hypospadius – the urethral meatus is positioned ventrally, incomplete foreskin development common; affects 1:250 boys

Genitourinary Assessment - Male Inguinal hernia Hydrocele Inguinal hernia – fullness in the scrotum and inguinal area seen, more common in premature babies but term babies with hydroceles may develop hernias; a hernia that is not reducible may be incarcerated requiring immmediate attention Hydrocele – unilateral or bilateral fluid collection in sac, can’t be “reduced”, transillumination may aid in diagnosis, resolves spontaneously

Genitourinary Assessment Bladder Extrophy Ambiguous Genitalia Ambiguous genitalia – requires work-up to determine sex, very upsetting to parents Bladder extrophy – requires surgical correction

Uric Acid Crystals High during infancy Due to high protein content of breastmilk Hydration is important! Uric acid excretion is high during infancy The high protein content of breast milk facilitates acid urine Acid urine favors precipitation of uric acid crystals (Robson & Leung, 2006) Good hydration is important

Musculoskeletal Assessment Simian crease Most newborns have two creases neither of which extends completely across their palms A single transverse palmar crease or “Simian crease” is found in about 5% of newborns, frequently familial but may also be associated with Down Syndrome Abnormalities may be deformations related to compression and position in utero rather than congenital defects Assess for appropriate number of limbs and digits, size and symmetry of upper and lower extremities, movement, range of motion and trauma, spinal alignment and integrity and presence of lesions over spine Normal creases

Musculoskeletal Assessment Polydactyly and syndactyly are both often familial

Musculoskeletal Assessment Club Foot Club foot - may be unilateral or bilateral, feet are plantar-flexed and inverted, may be a boney deformity (rigid)or positional (moveable) Brachial plexus injury - may occur as a result of shoulder dystocia. Affected arm is extended with hand turned medially , grasp may or may not be intact, other arm is flexed with crying, moro will be asymmetrical; if no improvement in first day, should be referred to OT/PT Brachial Plexus Injury

Musculoskeletal Assessment Breech Baby! B before O Barlow: Hip popped out with this manuever Ortolani: Femoral head is reduced back into socket

Musculoskeletal Assessment Myelomeningocele Sacral dimple – most are benign, examine to make sure it is a simple pit Myelomeningocele – neural tube defect resulting from incomplete closure of the spine, spinal cord and meninges may be external or may be covered with skin, requires surgical intervention Sacral Dimple