2. Newborn Examination Dr Badr H. Sobaih Adapted from: Rafat Mosalli MD FAAP FRCP

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

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

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

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

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

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

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

11. General Well, Distress or not? Well, Distress or not? skin 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

12. Erythema Toxicum

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

14. Erythema Toxicum

15. DD: Impetigo Neonatorum Vesicular, pustular, or bullous lesions developing as early as day of life 2-3 up to 2 weeks of life 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 Lesions occur in moist or opposing surfaces of skin Unroofed lesions do not form crusts Unroofed lesions do not form crusts Treat with antibiotics Treat with antibiotics

16. Impetigo Neonatorum

17. Mongolian Spots 90% of African infants, 81% of Asian, and 9.6% of Caucasian infants 90% of African infants, 81% of Asian, and 9.6% of Caucasian infants Slate-gray to blue-black lesions Slate-gray to blue-black lesions Usually over lumbosacral area and buttocks Usually over lumbosacral area and buttocks Accumulation of melanocytes within the dermis Accumulation of melanocytes within the dermis Generally fade by age 7 years Generally fade by age 7 years

18. Mongolian Spots

19. Benign Pustular Melanosis of the Newborn

20. Pustular Melanosis

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

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

23. Head and Face Shape of the head Shape of the head Fontanels? Fontanels? Sutures? Sutures? Eyes? Eyes? Nose? Nose? Mouth,lips,palate? Mouth,lips,palate? Ears? Ears? Neck? Neck?

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

25. Cephalhematoma

26. Caput Succadaneum

27. Newborn Scalp Hematomata

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

29. Infant skull

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

31. Craniosynostosis Types: 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

32. Chest and Abdomen

33. Chest Distress signs(Grunting,Tachypnea,Nasal flaring,asymetric chest rise,supra-sternal, intercostal, sub costal retraction). Distress signs(Grunting,Tachypnea,Nasal flaring,asymetric chest rise,supra-sternal, intercostal, sub costal retraction). Deformities(Pectus excavatum, carinatum) Deformities(Pectus excavatum, carinatum) Auscultate Auscultate –Air entry, symmetry –Early crepitation sound is transmitted upper sound –Late inspiratory crepitation

34. chest Breast hypertrophy Breast hypertrophy –Milk production –No redness

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

36. Abdomen Inspection Inspection –Scaphoid –Distention –Abdominal wall defect (gastroschisis) Palpation; baby sucking and use warm hands 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

37. Genitalia Penile size Penile size Hypospadias, epispadias Hypospadias, epispadias Testes Testes –2% crypoorchid –Hydrocele Female: Female: –Prominent clitoris and minora –Vaginal skin tag –Vaginal discharge /blood –Labial fusion Anus : Patency and location Anus : Patency and location

38. Hydrocoeles

39. Inguinal Hernias

40. Hip and Extremities Erb’s palsy: extended arm and internal rotation with limited movement Erb’s palsy: extended arm and internal rotation with limited movement Humerous fracture Humerous fracture Digital abnormality Digital abnormality –Syndactaly, brachdactaly, polydactaly Single palmar crease Single palmar crease Hip dislocation Hip dislocation –Female, breach

41. Subluxation of the Hip

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

44. Lumbar hair tuft & haemangioma

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

46. Neonatal Reflexes

47. Neonatal reflexes Also known as developmental, primary, or primitive 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 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. They are often protective and disappear as higher level motor functions emerge.

48. Suck Onset: ~28weeks GA Onset: ~28weeks GA Well-established: 32-34 weeks GA Well-established: 32-34 weeks GA Disappears: around 12 months 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. 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.

49. Rooting Onset: 28 weeks GA Onset: 28 weeks GA Well-established: 32-34 weeks GA Well-established: 32-34 weeks GA Disappears: 3-4 months 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. 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.

50. Palmar grasp Onset: 28 weeks GA Onset: 28 weeks GA Well-established: 32 weeks GA Well-established: 32 weeks GA Disappears: 2 months 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. 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.

51. Tonic neck (Fencing posture) Onset: 35 weeks GA Onset: 35 weeks GA Well-established: 4 weeks PCA Well-established: 4 weeks PCA Disappearance: 7 months 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. 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.

52. Moro Onset: 28-32 weeks GA Onset: 28-32 weeks GA Well-established: 37 weeks GA Well-established: 37 weeks GA Disappearance: 6 months 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. 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.

53. Moro

54. Moro significance An absent or inadequate Moro response on one side : hemiplegia, brachial plexus palsy, or a fractured clavicle 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. Persistence beyond 5 months of age is : indicate severe neurological defects.

55. Stepping Onset: 35-36 weeks GA Onset: 35-36 weeks GA Well-established: 37 weeks GA Well-established: 37 weeks GA Disappearance: 3-4 months PCA 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. 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.

56. Galant (Trunk incurvation) Onset: 28 weeks GA Onset: 28 weeks GA Well-established: 40 weeks GA Well-established: 40 weeks GA Disappearance: 3-4 months 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. 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.

57. Babinski Onset: 34-36 weeks GA Onset: 34-36 weeks GA Well-established: 38 weeks Well-established: 38 weeks Disappearance: 12 months PCA 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. 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.

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

60. Physical Maturity Skin: thicker, less translucent, dry, peeling Skin: thicker, less translucent, dry, peeling Lanugo: Lanugo: –fine non pigmented hair all over 27-28 wks – disappears gradually Plantar surface: presence or absence of creases Plantar surface: presence or absence of creases Breast: areola development Breast: areola development Ear cartilage Ear cartilage Eyelid opening Eyelid opening External genitalia External genitalia –Rugation, desend –Prominent labia majora

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

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