Rafat Mosalli MD FAAP FRCP Newborn Examination Rafat Mosalli MD FAAP FRCP

Newborn examination objectives Indication and importance Precautions prior to exam ! Systematic approach Neonatal reflexes Normal variants

Newborn examination Earliest possible detection of deviations. Establishes a baseline for subsequent examinations Parents assurance and counseling

Newborn examination indications Immediately after birth Before discharge from maternity unit Whenever there is any concern about the infant's progress

Newborn first exam Apgar score Heart rate Respiratory effort Color Tone Reflex irritability

Examination precaution Hand washing,hand washing ,hand washing Thermal environment Light and noise Brief examination time

General(Growth parameters) Weight (Naked) Length(straight) Head circumference(3 measurements)

Vital Sign Respiratory Rate RR 40-60 Temperature 36.5-37.5 C Heart Rate HR 120-160 Respiratory Rate RR 40-60 Temperature 36.5-37.5 C Blood Pressure

General Well, Distress or not? 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

Erythema Toxicum Erythematous macules and firm 1-3 mm yellow or white papules or pustules Etiology obscure Pustules contain eosinophils and are sterile Appear in the first 3-4 days of life Range: Birth to 14 days Benign and self limited

Erythema Toxicum

DD: Impetigo Neonatorum Vesicular, pustular, or bullous lesions developing as early as day of life 2-3 up to 2 weeks of life Lesions 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, 81% of Asian, and 9.6% of Caucasian infants Slate-gray to blue-black lesions Usually over lumbosacral area and buttocks Accumulation of melanocytes within the dermis Generally fade by age 7 years

Mongolian Spots

Benign Pustular Melanosis of the Newborn Etiology is unknown Smears from the pustules reveal polymorphonuclear leukocytes with absence of organisms . DD: Erythema Toxicum Pigment fade in 3w-3m

Pustular Melanosis

General Obvious Dimorphism or malformations E:g(Down syndrome ear tag neural tube defect ) Tone & Movements: Flexion of upper and lower extremities -Asymmetric movement Brachial plexus and fractured clavicle -Ventral, vertical suspension and head control for tone assessment

General inspection Vigorous cry is assuring Weak cry Hoarseness sepsis, asphyxia, metabolic, narcotic use Hoarseness Hypocalcemia, airway injury High pitch cry CNS causes, kernicterus

Head and Face Shape of the head Fontanels? Sutures? Eyes? Nose? Mouth,lips,palate? Ears? Neck? Low set ears?,Preauricular pits, External meatus tie Natal teath Choanal atresia Epstein pearls Cleft, submucosal

Head Forceps and vacuum marks Caput succedaneum Cephalhematoma Boggy edema in presenting part of head Cross suture lines Disappear in few days Cephalhematoma Subperiosteal Weeks to resolve Dose not cross sutures

Cephalhematoma

Caput Succadaneum

Cephalhematoma Collection of blood beneath the periostium Borders limited by suture lines Slow resolution over 1 or more months Underlying hairline fractures frequently present but are usually insignificant Complications include calcifications, jaundice, anemia, infections, and (very rarely) leptomeningeal cysts

Caput Succadaneum Scalp edema secondary to compression via the birth canal Overlies both the occipital bones and portions of the parietal bones bilaterally Resolves spontaneously within a few days Differentiate from the rare subgaleal bleed Will show signs of progressive hypovolemia

Newborn Scalp Hematomata

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 Crouzon,s: brachycephalic craniosynostosis, significant hypertelorism, proptosis, maxillary hypoplasia, beaked nose and possibly, cleft palate. Intracranial anomalies include hydrocephalus, Chiari 1 malformation, and hindbrain herniation (70 Apert syndrome;Craniosynostosis and symmetric syndactyly of the extremities are hallmarks of this syndrome. The clinical features include misshapen skull caused by coronal suture synostosis, wide-set eyes, midface hypoplasia, choanal stenosis, and shallow orbitspercent).

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 and Abdomen

Chest Distress signs(Grunting,Tachypnea,Nasal flaring,asymetric chest rise,supra-sternal, intercostal, sub costal retraction). Deformities(Pectus excavatum, carinatum) 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 and females Pink or brown papules along the milk line, most commonly on the chest or abdomen May contain breast tissue and 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

Femoral Pulses

Abdomen Inspection Palpation; baby sucking and use warm hands 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 Anus : Patency and location Penile size Hypospadias, epispadias Testes 2% crypoorchid Hydrocele Female: Prominent clitoris and minora Vaginal skin tag Vaginal discharge /blood Labial fusion Anus : Patency and location

Hydrocoeles

Inguinal Hernias

Hip and Extremities Erb’s palsy: extended arm and 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 and Back Feet deformities Back and spine abnormal curvature Sinus tract, tuft of hair

Lumbar hair tuft & haemangioma

CNS Awakenes and alertness moving extremities Flexed body posture Minimal Head lag Ventral suspension Vertical suspension

Neonatal Reflexes

Neonatal reflexes Also known as developmental, primary, or primitive reflexes. They consist of autonomic behaviors that do not require higher level brain functioning. They can provide information about lower motor neurons and muscle tone. They are often protective and disappear as higher level motor functions emerge.

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

Rooting Onset: 28 weeks GA Well-established: 32-34 weeks GA Disappears: 3-4 months Elicited by the examiner stroking the cheek or corner of the infant’s mouth. The infant’s head turns toward the stimulus and opens its mouth.

Palmar grasp Onset: 28 weeks GA Well-established: 32 weeks GA Disappears: 2 months Elicited by the examiner placing his finger on the palmar surface of the infant’s hand and the infant’s 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 examiner holds the infant so that one hand supports the head and the other supports the buttocks. The reflex is elicited by the sudden dropping of the head in her hand. The response is a series of movements: the infant’s hands open and there is extension and abduction of the upper extremities. This is followed by anterior flexion of the upper extremities and and 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 is : indicate severe 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 infant’s 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 examiner’s hand. Firm pressure is applied to the infant’s 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 Poplitteal angle Scarf sign Heel to ear

Remember Wash your hand prior to examination Inspect,Inspect,Inspect,then Touch. Neonatal reflexes implicatons Normal variations