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Physical Examination Of The Newborn

Discussion in 'Pediatrics' started by Dr.Scorpiowoman, May 24, 2016.

  1. Dr.Scorpiowoman

    Dr.Scorpiowoman Golden Member

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    The purpose of the newborn physical examination is to assess the baby's transition from intrauterine line to extrauterine existence and to detect congenital malformations and actual or potential disease.

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    The baby should be examined briefly immediately after birth. This should be confined to quick assessment of respiration, circulation, temperature, neurological status, and screening for anomalies or disease that might mandate emergency treatment. The initial examination should be done with minimal disturbance to the baby, taking particular care to prevent excessive cooling from exposure.

    A complete examination should be performed within the first 24 hours and again at discharge from the nursery. The full examination should be performed when the baby is quiet. The baby should be observed from a distance before being touched since a great deal can be learned by observing the infant's spontaneous activity. See, then touch.

    Auscultate the heart and chest and feel the pulses before the baby begins to cry, and then proceed systematically to the rest of the examination.

    General examination

    Posture: The normal healthy newborn demonstrates flexion of the legs and arms when supine. Lack of this posture might indicate hypotonic conditions such as Down Syndrome or neurologic or muscle disease.

    Cyanosis: Mild cyanosis is normal at birth but after the first few minutes of life, the child's tongue and mucous membranes should be pink. Peripheral cyanosis might persist for one to two days. Persistent central cyanosis suggests an obstructed airway, respiratory disease, cardiac anomalies, neurologic depression, and rarely methemoglobinemia.

    Jaundice: Jaundice is common after the second day of life. The presence of jaundice within the first 24 hours of life suggests a hemolytic process.

    Skin

    The vernix caseosa, a cheesy white covering, is normally present at birth as our fine hair (lanugo) on the shoulders and back and pinpoint white papules caused by blocked sebaceous glands (milia) on the nose and cheeks.

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    milia

    Petechiae on the scalp and face are often seen after a vertex delivery.

    Large blue patches of pigment over the lumbar area, buttocks, or extremities are known as Mongolian spots and are a common phenomenon in the dark-skinned races. These tend to fade over time.

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    mongolian spots

    Capillary hemangiomas, common on the upper eyelids, forehead, and the nape of the neck are known as stork bite nevi and also tend to fade with time.

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    Erythema toxicum consists of yellow papules on a red base and may appear between the second and fourth days of life. These papules contain eosinophils and are seen mostly on the trunk.

    Head

    Molding of the head by pressure of the maternal pelvis is common after vaginal delivery. Caput succedaneum, a round boggy swelling of the soft tissues of the scalp from accumulation of fluid within the area of pressure from the pelvis during delivery is common. This should be distinguished from a cephalohematoma, which is a sub-periosteal hemorrhage. The former will cross suture lines; the latter does not.

    The anterior and posterior fontanelle should be soft to palpation. The anterior fontanelle should be between 1 and 3 cm in size and the posterior fontanelle should admit a fingertip. Following a vaginal delivery, over-riding of the skull bones may temporarily reduce the size of the anterior fontanelle.

    The head circumference should be between 33 and 35cm for a full-term infant.

    The slant and size of the eyes should be examined. Eyes that slant upward might be a sign of Down Syndrome

    6bf4d45fa7e46528a15be84fe1ac6d41.jpg

    Down Syndrome

    Large eyes suggest congenital glaucoma, a condition that requires early treatment to preserve vision. Eyes that are too close together are suggestive of fetal alcohol syndrome.

    Hemorrhage in the subconjunctival and retinal area is common with vertex delivery and has no significance. The pupillary light reflex and a red reflex of light from the retina should be checked with a flashlight or ophthalmoscope. Pupillary opacity indicates congenital cataracts and a white reflex suggests retinoblastoma.

    3b93d951e64a0d55dbac71e08c9ffb41.jpg

    red reflex

    The pinna of the ear usually joins the head above a horizontal line from the external canthus of the eye. A low-set ear suggests chromosomal anomaly and malformed ears are associated with renal abnormalities. Babies with Down Syndrome also may have small ears that fold over on top. However, a pre-auricular skin tag is usually of no significance.

    The nose should be checked for patency by auscultation with a stethoscope. Babies are obligate nose breathers for the first few months of life and blockage of the nasal canal, or choanal atresia, can be life-threatening. The nose in Down Syndrome may be small, with a flattened nasal bridge.

    A neonatal tooth is occasionally visible but requires extraction. The palate should be examined for the presence of a cleft. The neck should be checked for webbing, mass, or goiter.

    Chest and respiratory system

    The respiratory rate in the newborn range is between 40 and 60 breaths/minute. Respiration might be periodic with short periods of apnea. There should be no nasal flaring or intercostal of subcostal retractions.

    The breasts are palpable in term infants and may secrete a small amount of milk because of estrogenic effects from the mother (witch's milk). Unusually widely spaced nipples may be suggestive of a chromosomal anomaly.

    Cardiovascular system

    The normal pulse rate of a newborn is 120 to 140 beats/minute. A persistent heart rate of less than 100 or more than 160 beats/minute is a cause for concern.

    Absence of peripheral pulses, especially the femorals, suggests coarctation of the aorta.

    Normal blood pressure is about 60/30 mm of Hg at term.

    Transient murmurs are often heard after birth, but the presence of a loud murmur, heart sounds that are difficult to hear or are heard louder on the right side of the chest, or central cyanosis suggest a significant cardiac abnormality.

    Abdomen & Back

    The umbilical cord should have two arteries and one vein. A single umbilical artery is seen in 1% of babies and is sometimes associated with other congenital anomalies.

    Umbilical hernia is common and usually closes spontaneously before two years of age.

    The liver normally extends 2 cm below the costal margin, and the tip of the spleen can sometimes be felt. Both kidneys can be palpated. Abnormal masses such as Wilm's tumor, neuroblastoma, hydronephrosis or a multicystic-dysplastic kidney or renal vein thrombosis can be easily palpated. A tight abdomen or persistent abdominal distention suggests intestinal obstruction or ascites.

    The back should be checked for midline defects; a shallow sacral dimple is a common and normal finding. However, a deep dimple needs to be further investigated.

    Genitalia and anus

    In the female infant, the vaginal opening is visible and a mucoid discharge, which might be bloody secondary to estrogen withdrawal, is not uncommon. The labia minora and clitoris are prominent, but the clitoris should be contained within the prepuce.

    In the male newborn, the testes might not be fully descended at birth, especially if the baby is premature. Hydroceles and inguinal hernias are common. The prepuce adheres to the glans penis and should not be retracted. The meatus should be located at the tip of the penis.

    Any apparent abnormality in the size or shape of the genitalia mandates a consultation with the pediatric urologist and/or endocrinologist.

    2413feff8f6f8caae1144e74e8f71b59.jpg

    ambiguous genitalia

    The anus should be checked for patency, position, and the anal reflex.

    Extremities

    Each extremity should be carefully examined for polydactyly or syndactyly. Most babies have three palmar creases. A single palmar crease crossing the hand is present in about 4% of normal babies but may also be associated with chromosomal anomalies such as Down Syndrome.

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    single palmar crease

    Bowing of the legs is a normal variation, as are positional abnormalities such as metatarsus adductus which result from intrauterine compression, but one should be able to place the extremity easily in the normal position. Inability to do so suggests pathology.

    HIPS. Developmental hip dysplasia (congenital dislocation) occurs in 1-3/1000 live births. It is more common in females by a 9:1 ratio, and is more common in children who have been in a breech position in utero. Suspicion of hip dysplasia requires immediate consultation with a pediatric orthopedic surgeon.

    To check for this condition, the baby should be placed supine with the hips and knees flexed to 90°. The middle finger of each hand is placed over the greater trochanter of the tibia and the thumb on the opposite side of the hip joint, over the lesser trochanter. First a posterior pressure is applied; if the hip is dislocatable, it will snap out of the acetabulum with a click or a clunk. However, if the head of the femur is already dislocated, abducting the hips will result in a click as the head of the femur slips forward into the acetabulum. These maneuvers can best be performed on both hips simultaneously or while stabilizing the other hip with the opposite hand.

    Neurological evaluation

    Useful information can be gained simply by observation of the baby's posture, alertness, and level of activity. A normal term baby lies folded up in the fetal position with the hands closed, whereas a premature baby sprawls out with the hands open.

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    A normal baby is easily awakened by taking off the covers or by stimulating the foot or the cheek, while a depressed baby quickly goes back to sleep. And asphyxiated baby might be either depressed or irritable.

    A full-term baby who is not demonstrating flexor tone and is lying with the limbs extended may either be floppy or have increased extensor tone. This calls for immediate further evaluation for intracranial pathology, muscle disease, or a systemic disorder such as hypotension or infection.

    Cranial nerves may quickly tested by eliciting the pupillary responses and blink reflex to light (II), doll's eye phenomenon (III, IV, VI), corneal, sucking, and rooting reflexes (V, VII), response to the noise or sound (VIII), and the gag reflex (IX, X).

    The integrity of the lower brain centers can be checked by eliciting the neonatal reflexes: Moro reflex, grasp reflex, sucking and rooting reflex, and the stepping reflex. In addition, the Moro reflex is useful in establishing that movements of the extremities are symmetrical.

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    Last edited: Dec 6, 2018

  2. Riham

    Riham Bronze Member

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    These are very crucial examination tips to know. Thanks for sharing them :)
     

    Marie Curie likes this.
  3. surgeon marfo

    surgeon marfo Active member

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    I always loved being assigned to the paediatric unit during my clinical rotations.I love how these little ones literally fight me and prevent me from examining them
     

    Nada El Garhy and Riham like this.
  4. Dr.Scorpiowoman

    Dr.Scorpiowoman Golden Member

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    Hahaha their mothers should thank you for your devotion!
     

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  5. surgeon marfo

    surgeon marfo Active member

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