neonate exam

7/28/2019 Neonate Exam

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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 Syndromeor neurologic or muscle disease.

Cyanosis: Mild cyanosis is normal at birth but after the first few minutes of life, the child

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.

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

Large blue patches of pigment over the lumbar area, buttocks, orextremities are known as Mongolian spots and are a common phenomenon in the dark

skinned races. These tend to fade over time.

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.

Erythema toxicum consists of yellow papules on a red base and may appear between tsecond 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


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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-perioste

hemorrhage. The former will cross suture lines; the latter does not.

The anterior and posterior fontanelle should be soft to palpation. The anterior fontanelleshould be between 1 and 3 cm in size and the posterior fontanelle should admit a fingert

Following a vaginal delivery, over-riding of the skull bones may temporarily reduce the s

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 sig

of Down Syndrome

Down Syndrome

Large eyes suggest congenital glaucoma, a condition that requires early treatment topreserve 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 andhas 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 indicatescongenital cataracts and a white reflex suggests retinoblastoma.

red reflex

The pinna of the ear usually joins the head above a horizontal line from the externalcanthus of the eye. A low-set ear suggests chromosomal anomaly and malformed ears a

associated with renal abnormalities. Babies with Down Syndrome also may have small eathat 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 areobligate nose breathers for the first few months of life and blockage of the nasal canal, o

choanal atresia, can be life-threatening. The nose in Down Syndrome may be small, with

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, orgoiter.

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 flarinor intercostal of subcostal retractions.

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

be su estive of a chromosomal anomal .


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Cardiovascular system

The normal pulse rate of a newborn is 120 to 140 beats/minute. A persistent heart rate oless 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, orcentral cyanosis suggest a significant cardiac abnormality.

Abdomen & Back

The umbilical cord should have two arteries and one vein. A single umbilical artery is see

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 tumoneuroblastoma, hydronephrosis or a multicystic-dysplastic kidney or renal vein thrombos

can be easily palpated. A tight abdomen or persistent abdominal distention suggestsintestinal obstruction or ascites.

The back should be checked for midline defects; a shallow sacral dimple is a common an

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 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 tothe glans penis and should not be retracted. The meatus should be located at the tip of t

penis.

Any apparent abnormality in the size or shape of the genitalia mandates a consultation

with the pediatric urologist and/or endocrinologist.


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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.

single palmar crease

Bowing of the legs is a normal variation, as are positional abnormalities such asmetatarsus 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 birth

It is more common in females by a 9:1 ratio, and is more common in children who havebeen 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. Firstposterior 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 stabilizingthe 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 hand

closed, whereas a premature baby sprawls out with the hands open.

A normal baby is easily awakened by taking off the covers or by stimulating the foot or t


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cheek, while a depressed baby quickly goes back to sleep. And asphyxiated baby might b

either depressed or irritable.

A full-term baby who is not demonstrating flexor tone and is lying with the limbs extendemay either be floppy or have increased extensor tone. This calls for immediate furtherevaluation 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 additionthe Moro reflex is useful in establishing that movements of the extremities are

symmetrical.


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FIGURE 67-3 (A) Caput succedaneum: From the pressure of the birth canal, an edematous area is present beneath the scalp. Note how it crossethe midline of the skull. (B) Cephalhematoma: A small capillary beneath the periosteum of the skull bone hasruptured, and blood has collected under the periosteum of the bone. Note how the swelling now stops at themidline. Because the blood is contained under the periosteum, it is necessarily stopped by a suture line.

neonate exam

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