Newborn examination


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1 : KABERA René,MD PGY III Resident Family and Community Medicine National University of Rwanda Newborn examination
2 : General consideration The neonatal examination should be carried out in a warm, draft-free room specifically equipped for this procedure, and preferably with the mother present. Observe the infant's appearance, posture, and state of consciousness before proceeding with the formal aspects of palpation and auscultation. Kabgayi hospital 2011-4 2
3 : gestational age and size The infant's gestational age should be estimated Body size compared with appropriate normal standards. Last menstrual period Gestation can also be assessed from the physical characteristics of the skin, external genitalia, ears, breasts, and from neuromuscular behavior Kabgayi hospital 2011-4 3
4 : gestational age and size Infants who are born after completing less than 37 completed weeks of gestation are considered to be preterm (or premature). Term infants have completed 37 to 42 weeks, and infants past 42 weeks of gestation are postterm (or postmature). Birth weight, occipito-frontal head circumference, and crown-to-heel length should be measured and recorded. Length is measured from vertex to heel with the infant's legs fully extended. Kabgayi hospital 2011-4 4
5 : gestational age and size An infant is considered to be appropriate for gestational age (AGA) if it falls within ±2 standard deviations (SD) of the mean on these charts. Infants who are more than 2 SD below the mean are small for gestational age (SGA). Those more than 2 SD above the mean are large for gestational age (LGA). Kabgayi hospital 2011-4 5
6 : ` Kabgayi hospital 2011-4 6
7 : General inspection Most babies born at term cry at birth and then establish normal regular breathing. Their eyes are often open, and they make sucking, chewing, and swallowing movements. They may have bursts of flexion and extension of the arms and legs and make facial grimaces. Following the first few hours after birth, the normal term baby spends approximately 80% of time in active or quiet sleep. The remaining 20% of the time is spent awake in varying states of activity with or without crying. Kabgayi hospital 2011-4 7
8 : General inspection When the infant cries, the normal cry is vigorous. A weak or whimpering cry is abnormal High-pitched or shrieking cry, which suggests a neurologic problem. A hoarse cry may result from vocal cord paralysis, hypothyroidism, or trauma to the hypopharynx. Newborn often adopt intrauterine position Kabgayi hospital 2011-4 8
9 : General inspection About 2% of infants have significant deformities caused by mechanical forces that acted in utero to restrict motion or to create pressure on the limbs, spine, thorax, or skull. This can occur with oligohydramnios, uterine malformations, or in multiple pregnancies. Kabgayi hospital 2011-4 9
10 : General Inspection Intrauterine position Kabgayi hospital 2011-4 10
11 : Temperature The normal infant is pink and feels warm to the touch Moderately cold environment leads to the hands and feet quickly becoming cool and slightly cyanotic. The normal axillary temperature is between 36.5 and 37.4°C. Sepsis may present with either fever, hypothermia, or an unstable temperature. Hypothermia may also occur with hypoglycemia, hypoxia, or hypothyroidism. Hyperthermia can be seen during drug withdrawal and with intracranial or adrenal hemorrhage. Kabgayi hospital 2011-4 11
12 : Skin GESTATIONAL CHANGES Fine, soft, lanugo hair covers the entire body in very preterm infants and disappears from the face and lower back between 32 and 37 weeks. The term infant has lanugo hair on the upper back and dorsal aspects of the limbs Vernix caseosa, a thick white material with the consistency of soft cheese, covers the skin of the entire body until 35 to 37 weeks. Kabgayi hospital 2011-4 12
13 : Skin If fetal hypoxia occurs at term, meconium may be passed into the amniotic fluid. If meconium has been in the amniotic fluid for several hours, it will also stain the skin, fingernails, toenails, and umbilical cord with a greenish hue. The postmature infant (beyond 42 weeks) may have a somewhat wasted appearance with dry, peeling skin, a decreased amount of subcutaneous tissue, long fingernails, and an alert appearance. Kabgayi hospital 2011-4 13
14 : Skin Color The skin of the normal white newborn is pink. Pallor may result from anemia or poor perfusion. With poor perfusion from vasoconstriction or low cardiac output, capillary filling after blanching of the skin over finger and toes is delayed (more than 3 seconds). Kabgayi hospital 2011-4 14
15 : Skin Color A generalized gray hue may indicate acidosis. Pale, mottled skin occurs with sepsis or hypothermia. There may be cyanosis of the hands and feet (acrocyanosis), which is normal immediately after birth or if the infant has been exposed to a cold environment. Generalized cyanosis occurs with significant arterial hypoxemia as well as with methemoglobinemia. Plethora may indicate polycythemia. Kabgayi hospital 2011-4 15
16 : Skin Color Neonatal jaundice with a yellow skin color, is caused by an elevation in indirect-reacting bilirubin. Elevation of direct-reacting bilirubin gives a yellow-to-green discoloration. The normal newborn commonly develops mild physiological jaundice between days 2 and 4 after birth. Kabgayi hospital 2011-4 16
17 : Skin RASHES The normal newborn often has some form of benign skin rash. Milia are tiny white papules formed at the surface of sebaceous glands; they commonly appear over the nose. Milaria are lesions that develop over obstructed sweat glands and are usually a result of overheating. The crystallina form of milaria are superficial clear vesicles, whereas the rubra type are inflamed and lie deeper in the epidermis Kabgayi hospital 2011-4 17
18 : Skin Erythema toxicum consists of small pustules filled with eosinophils surrounded by patchy erythema. This is benign, fades, and reappears in other sites rapidly. Pustular melanosis are small vesicles that leave a scaly ring and pigmented macule when they open; they can be present at birth and are not associated with any known infection. Kabgayi hospital 2011-4 18
19 : Head Scalp air is fine and silky. The head shape differs in infants who were in vertex or breech positions. Caput succedaneum is edema of the scalp caused by local pressure and trauma during labor. Cephalohematomas are subperiosteal hemorrhages caused by the trauma of labor and usually involve the parietal or occipital bones. Kabgayi hospital 2011-4 19
20 : Head Normally the anterior fontanelle is open, soft, and flat; mean diameter is less than 3.5 cm. The posterior fontanelle is often only fingertip size or just palpably open. A bulging or tense fontanelle, with separation of the bony sutures. indicates increased intracranial pressure. Kabgayi hospital 2011-4 20
21 : Face The newborn's face often gives the first clue to the presence of a dysmorphic syndrome. Cleft lip or a small mandible (micrognathia) - A high-arched or cleft palate, and a tongue that falls back into the hypopharynx (glossoptosis); this causes airway obstruction. Infants with fetal alcohol exposure may be more difficult to identify but may have growth deficiency, microcephaly, maxilla hypoplasia and short palpebral fissures. Kabgayi hospital 2011-4 21
22 : Face Intrauterine position may cause asymmetry of the face. a peripheral facial paralysis may be due to Pressure over the stylomastoid foramen during labor, which is most obvious during crying. The paralysis usually resolves. Kabgayi hospital 2011-4 22
23 : Eye Newborns keep their eyes closed except during brief awake periods. If you attempt to separate their eyelids, they will tighten them even more. Bright light causes infants to blink, so use subdued lighting. The eyes of many newborns are edematous from the birth process. Kabgayi hospital 2011-4 23
24 : Eye Small retinal hemorrhages may occur in normal newborns. Extensive Hemorrhages may suggest Severe anoxia, subdural hematoma, Subarachnoid hemorrhage, or severe Trauma. Nystagmus (wandering or shaking eye movements) persisting after a few days poor vision or central nervous system disease. Kabgayi hospital 2011-4 24
25 : Ear Structural abnormalities of the ear, otitis media, and hearing loss. Malformed or malpositioned (low-set or posteriorly rotated) ears are often associated with other congenital anomalies. The tympanic membranes should be visualized. Preauricular pits and tags are also common minor variants Kabgayi hospital 2011-4 25
26 : Age -That an Infant Can Hear 0–2 months Startle response and blink to a sudden noise Calming down with soothing voice or music 2–3 months Change in body movements in response to sound Change in facial expression to familiar sounds 3–4 months Turning eyes and head to sound 6–7 months Turning to listen to voices and conversation Kabgayi hospital 2011-4 26
27 : Mouth Check the integrity and shape of the palate; rule out cleft lip and cleft palate. A small mandible and tongue with cleft soft palate is seen with Pierre-Robin syndrome and can result in respiratory difficulty as the tongue occludes the airway. Prone positioning can be very beneficial. A prominent tongue can be seen in Trisomy 21 and Beckwith-Wiedemann syndrome. Excessive drooling suggests esophageal atresia. Kabgayi hospital 2011-4 27
28 : Mouth Epithelial (Epstein) pearls are retention cysts along the gum margins and at the junction of the hard and soft palates. Natal teeth may be present and sometimes need to be removed to avoid the risk of aspiration. Kabgayi hospital 2011-4 28
29 : neck Redundant skin or webbing is seen in Turner syndrome. Check for masses: midline (thyroid), anterior to the sternocleidomastoid (branchial cleft cysts), Kabgayi hospital 2011-4 29
30 : Chest & Lungs Check for fractured clavicles (crepitus, bruising, and tenderness). Increased anteroposterior diameter (barrel chest) can be seen with aspiration syndromes. Check air entry bilaterally and the position of the mediastinum and heart tone Kabgayi hospital 2011-4 30
31 : Chest and lungs Decreased breath sounds with respiratory distress and a shift in the mediastinum suggests pneumothorax (tension) or a space-occupying lesion (eg, diaphragmatic hernia). With pneumomediastinum, the heart sounds are muffled. Expiratory grunting and decreased air entry are observed in hyaline membrane disease. Rales are not of clinical significance at this age. Kabgayi hospital 2011-4 31
32 : Heart Murmurs are commonly present in the first hours and are most often benign. Severe congenital heart disease in the newborn infant may be present with no murmur at all. The two most common presentations of heart disease in the newborn infant are cyanosis and congestive heart failure with abnormalities of pulses. In hypoplastic left heart and critical aortic stenosis, pulses are diminished at all sites. In aortic coarctation and interrupted aortic arch, pulses are diminished in the lower extremities. Kabgayi hospital 2011-4 32
33 : Abdomen Check for softness, distention, and bowel sounds. If polyhydramnios was present or excessive oral secretions are noted, pass a soft catheter into the stomach to rule out esophageal atresia. Palpate for kidneys¾most abdominal masses in the newborn infant are associated with kidney disorders (eg, multicystic or dysplastic, hydronephrosis). Kabgayi hospital 2011-4 33
34 : Abdomen When the abdomen is relaxed, normal-sized kidneys may be felt but are not prominent. A markedly scaphoid abdomen plus respiratory distress suggests diaphragmatic hernia. Absence of abdominal musculature (prune belly syndrome) may occur in association with renal abnormalities. Check the size of the liver and the spleen. These organs are superficial and discernible by light palpation in the newborn infant. The outline of a distended bladder may be seen and palpated above the pubic symphysis. Kabgayi hospital 2011-4 34
35 : genitalia and anus In the female during the first few days, a whitish vaginal discharge with or without blood is normal. Check the patency and location of the anus. More characteristics in table Kabgayi hospital 2011-4 35
36 : Kabgayi hospital 2011-4 36
37 : Skeleton Check for obvious anomalies, for example, the absence of a bone, clubfoot, fusion or webbing of digits, and extra digits. Examine for hip dislocation by attempting to dislocate the femur posteriorly and then abducting the legs to relocate the femur. Look for extremity fractures and for palsies (especially brachial plexus injuries). Rule out myelomeningoceles and other spinal deformities (eg, scoliosis). Arthrogryposis (multiple joint contractures) results from chronic limitation of movement in utero, which may result from lack of amniotic fluid or from a congenital neuromuscular disease. Kabgayi hospital 2011-4 37
38 : Neurologic examination In examining the newborn, observe resting tone (normal-term newborns should exhibit flexion of the upper and lower extremities) and spontaneous movements. Look for symmetry of movements. Extension of extremities should result in spontaneous recoil to the flexed position. Assess the character of the cry; a high-pitched cry may be indicative of disease of the central nervous system (CNS) (eg, hemorrhage). Kabgayi hospital 2011-4 38
39 : Neurologic examination Hypotonia and a weak cry are indicative of systemic disease or a congenital neuromuscular disorder. Check for newborn reflexes: (1) Sucking reflex in response to a nipple or the examiner's finger in the mouth. This reflex is observed by 14 weeks' gestation. (2) Rooting reflex: Head turns to the side of a facial stimulus. This reflex develops by 28 weeks‘ gestation. Kabgayi hospital 2011-4 39
40 : Neurologic examination (3) Traction response: The infant is pulled by the arms to a sitting position. Initially, the head lags, then with active flexion comes to the midline briefly before falling forward. (4) Palmar grasp with placement of the examiner's finger in the palm. This reflex develops by 28 weeks' gestation and disappears by age 4 months. (5) Deep tendon reflexes: Several beats of ankle clonus and an upgoing Babinski reflex may be normal. Kabgayi hospital 2011-4 40
41 : Neurologic examination (6) Placing: Rub the dorsum of one foot on the underside of a surface. The infant will flex the knee and bring the foot up. (7) Moro (startle) reflex: Hold the infant and support the head. Allow the head to drop 1-2 cm suddenly. The arms will abduct at the shoulder and extend at the elbow. Adduction with flexion will follow. The hands show a prominent spreading or extension of the fingers. This reflex develops by 28 weeks' gestation (incomplete) and disappears by age 3 months. Kabgayi hospital 2011-4 41
42 : Neurologic examination (8) Tonic neck reflex: Forcibly turn the infant's head to one side, and the arm and leg on that side extend while the opposite arm and leg flex ("fencing position"). This reflex disappears by age 8 months. Kabgayi hospital 2011-4 42
43 : End Thank you Kabgayi hospital 2011-4 43

 

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