1. Rafat Mosalli MD FAAP FRCP
Newborn Examination
Rafat Mosalli MD FAAP FRCP

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

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

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

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

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

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

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

9. 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

10. Erythema Toxicum

11. 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

12. Erythema Toxicum

13. 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

14. Impetigo Neonatorum

15. 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

16. Mongolian Spots

17. 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

18. Pustular Melanosis

19. 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

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

21. 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

22. 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

23. Cephalhematoma

24. Caput Succadaneum

25. 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

26. 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

27. Newborn Scalp Hematomata

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

29. Infant skull

30. 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).

31. 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

32. Chest and Abdomen

33. 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

34. chest
Suprmammary nipple
Breast hypertrophy
Milk production
No redness

35. 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

36. Supernumerary Nipples

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

38. Femoral Pulses

39. 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

40. 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

41. Hydrocoeles

42. Inguinal Hernias

43. 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

44. Subluxation of the Hip

45. Subluxation of the Hip

46. Feet and Back Feet deformities Back and spine abnormal curvature
Sinus tract, tuft of hair

47. Lumbar hair tuft & haemangioma

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

49. Neonatal Reflexes

50. 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.

51. 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.

52. 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.

53. 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.

54. 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.

55. 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.

56. Moro

58. 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.

59. 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.

60. 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.

61. 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.

62. Postnatal assessment of gestational age
Ballard Score
Accuracy within 1-2 weeks
2 parts
Neurologic characteristic
Physical characteristic
Part of general examination

63. Physical Maturity Skin: thicker , less translucent, dry, peeling
Lanugo:
fine non pigmented hair all over wks
disappears gradually
Plantar surface: presence or absence of creases
Breast: areola development
Ear cartilage
Eyelid opening
External genitalia
Rugation, desend
Prominent labia majora

64. Neuromuscular Maturity
Posture
Square window
Arm recoil
Poplitteal angle
Scarf sign
Heel to ear

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