Newborn Examination: Rafat Mosalli

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
– 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
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
– 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?
Head
 Forceps and 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
Cephalhematoma
Caput Succadaneum
Cephalhematoma
Caput Succadaneum
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
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
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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
– 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, 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
 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)
 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
 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

 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)
 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
 Well-established: 38 weeks
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

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Newborn Examination

Rafat Mosalli MD FAAP FRCP

 Establishes a baseline for subsequent

 Parents assurance and counseling

 Before discharge from maternity unit

 Whenever there is any concern about the

 Head circumference(3 measurements)

Flexion of upper and lower extremities

 Onset: 35-36 weeks GA

 Part of general examination

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