NEONATAL EXAMINATIONBy Dr/ Mohamed AbbassNeonatologist in Elnasr NICU 1

2

THE FIRST 24 HOURS:

The newborn infant should

undergo a complete physical

examination within 24 h of birth.

It is easier to listen to the heart

and lungs first when the infant is

quiet.

Warming the stethoscope..3

Appearance:

Signs such as cyanosis, nasal flaring,

intercostal retractions, and grunting suggest

pulmonary disease.

Meconium staining of the umbilical cord, nails,

and skin suggest fetal distress and the

possibility of MAS. The level of spontaneous

activity, passive muscle tone, quality of the cry,

and apnea are useful screening signs to

evaluate the state of the nervous system. 4

1-VITAL SIGNS:

Temprature: axillary method is prefered (36.0-37

°C).

Heart rate :(normal rate, 120 to 160 beats/ min

when awake, 70-80 beats/min when asleep).

Respiratory rate: ( normal rate is 40 to 60 cycle

per min) should be assessed within a whole

minute.

Blood pressure: (often reserved for sick infants).5

II-Length, Weight, and Head

circumference: should be measured and plotted

on growth curves.

6

GESTATIONAL AGE :

prenatally by the following techniques:

date of last menstrual period.

date of first reported fetal activity (quickening usually

occurs at 16-18 weeks).

first reported heart sounds (10-12 weeks by Doppler

ultrasound examination).

ultrasound examination (very accurate if obtained

before 20 weeks' gestation).7

Postnatally is determined by an assessment of various physical signs

and neuromuscular characteristics that vary according to fetal age

and maturity.

A. Rapid delivery room assessment. :creases in the sole of the

foot, size of the breast nodule, nature of the scalp hair, cartilaginous

development of the ear lobe, and scrotal rugae and testicular descent

in males.

B. New Ballard Score. The Ballard maturational score has been

expanded and updated to include extremely premature infants. It has

been renamed the New Ballard Score (NBS). The score now spans

from 10 (correlating with 20 weeks' gestation) to 50 (correlating with

44 weeks' gestation). It is best performed at <12 h of age if the infant

is <26 weeks' gestation. If the infant is >26 weeks' gestation, there is

no optimal age of examination up to 96 h.

The examination is accurate whether the infant is sick or well to

within 2 weeks of gestational age. 8

NEW BELLARD SCORE

Physical criteria , including

increasing firmness of the pinna of

the ear; increasing size of the breast

tissue; decreasing fine, immature

lanugo hair over the back; and

decreasing opacity of the skin.

Neurologic criteria including

increasing flexion of the legs, hips,

and arms; increasing tone of the

flexor muscles of the neck; and

decreasing laxity of the joints.

These signs are determined during

the first day of life and are assigned

scores.9

Classification. Infants are classified as

preterm (<37 weeks), term (37-

41weeks), or post term (>42 weeks).

10

SMALL FOR GESTATIONAL AGE

Defined as 2 standard deviations

below the mean weight for

gestational age or below the

10th percentile.

Seen in infants of mothers who

have hypertension or

preeclampsia or who smoke.

also been associated with

TORCH infections,

chromosomal abnormalities,

and other congenital

malformations.11

12

B. Appropriate for gestational age (AGA)

Normal full term.

13

LARGE FOR GESTATIONAL AGE

Defined as 2 standard

deviations above the mean

weight for gestational age

or above the 90th

percentile.

Seen in infants of diabetic

mothers, infants with

Beckwith's

syndrome,familial and

infants with hydrops fetalis.. 14

III-GENERAL APPEARANCE

Observe the infant and record the general

appearance (eg, activity, skin color, and

obvious congenital abnormalities).

15

1. Plethora (deep,

rosy red color).

Plethora is more

common in infants with

polycythemia but can

be seen in an

overoxygenated or

overheated infant. It is

best to obtain a central

hematocrit on any

plethoric infant.

IV. SKINA-COLOR:

16

2. Jaundice

With jaundice, bilirubin

levels are usually >5

mg/dL.

This condition is abnormal

in infants <24 h old and

may signify Rh

incompatibility, sepsis, and

TORCH infections.

After 24 h, ABO

incompatibility or

physiologic causes.17

3-Pallor

Pallor may be

secondary to

anemia, birth

asphyxia, shock, or

patent ductus

arteriosus (Ductal

pallor).

18

4-CYANOSISDesaturation of 5 g of hemoglobin usually necessary for one to note a bluish

color

Central cyanosis (bluish skin, including the tongue and lips). Central cyanosis

is caused by low oxygen saturation in the blood. It may be associated with

congenital heart or lung disease.

Acrocyanosis (bluish hands and feet only). normal, cold stress. decreased

peripheral perfusion secondary to hypovolemia.

19

associated with a prolonged

and difficult delivery and may

result in early jaundice.

Petechiae (pinpoint

hemorrhages). If they are

widespread and progressive

do coagulation profile.

5-ECCHYMOSES

20

B-HARLEQUIN COLORATIONclear line of demarcation

between an area of redness

and an area of normal

coloration).

The cause is usually

unknown.

The coloration can be benign

and transient (lasting usually

<20 min) or can be indicative

of shunting of blood

(persistent pulmonary

hypertension or coarctation

of the aorta).21

C- MOTTLING

(lacy red pattern) may be seen

in healthy infants and in those

with cold stress, hypovolemia,

or sepsis.

Persistent mottling, referred to

as cutis marmorata, is found

in infants with Down syndrome,

trisomy 13, or trisomy 18.

22

D-VERNIX CASEOSA

greasy white

substance that covers

the skin until the 38th

week of gestation. Its

purpose is to provide a

moisture barrier. It is

completely normal.

23

E-COLLODION INFANT

Congenital ichtyosis

skin resembles

parchment, and there

can be some

restriction in growth of

the nose and ears.

24

F-RASHES

1. MILIA:

Whitish, tiny, sebaceous retention

cysts are usually on the chin,

nose, forehead, and cheeks.

No erythema is seen.

These benign cysts disappear

within a few weeks after birth.

These are seen in approximately

33% of infants.25

2-ERYTHEMA TOXICUM

Numerous small areas of

red skin with a yellow

white papule in the

centre.

Appear 48hr after birth

last for 7-10 days.

Common in full term.26

3-ACNE NEONATORUMSeen over the cheeks,

chin, and forehead and

consist of comedones

and papules.

Benign and requires no

therapy; however, severe

cases may require

treatment with mild

keratolytic agents.

27

4-NEONATAL PUSTULAR MELANOSIS

Three stages of lesions, which

may appear over the entire

body:

• Pustules.

• Ruptured vesicopustules with

scaling/typical halo

appearance.

• Hyperpigmented macules.

This benign, self-limiting

condition requires no specific

therapy. 28

5-HERPES SIMPLEX

Pustular vesicular

rash, vesicles, bullae,

or denuded skin

29

6-CANDIDA ALBICANS RASH

Common seen in napkin area so

called Napkin Dermatitis

Erythematous plaques with sharply

demarcated edges. Satellite bodies

are also seen.

Gram's stain of a smear or 10%

potassium hydroxide preparation of

the lesion reveals budding yeast

spores

Treated with nystatin cream applied

to the rash 4 times daily for 7-10

days. 30

G-NEVI

1- MACULAR HEMANGIOMA ("STORK BITES")(ANGEL KISS)

True vascular nevus normally seen

on the occipital area, eyelids, and

glabella.

The lesions disappear

spontaneously within the first year

of life.31

2-PORT-WINE STAIN (NEVUS FLAMMEUS)

Seen at birth, does not

blanch with pressure,

and does not disappear

with time.

SturgeWeber syndrome

(port-wine stain over

the forehead and upper

lip, glaucoma, and

contralateral jacksonian

seizures). 32

3-CAVERNOUS HEMANGIOMA

large, red, cyst-like, firm, ill-

defined mass and may be

found anywhere on the body.

The majority of these lesions

regress with age, but some

require corticosteroid therapy or

surgical resection.

Kasabach-Merritt syndrome:

(thrombocytopenia associated

with a rapidly expanding

hemangioma) should be

considered. 33

4-STRAWBERRY HEMANGIOMA

Flat, bright red, sharply

demarcated lesions

that are most

commonly found on

the face.

Spontaneous

regression usually

occurs (70%

disappearance by 7

years of age).34

5-MONGOLIAN SPOT

Dark blue or purple

bruise-like macular spots

usually located over the

sacrum.

Usually present in 90% of

blacks and Asians, and

disappear by 4 years of

age.

They are the most

common birthmark. 35

V. HEAD

Note the general shape of the head.

Inspect for any bruises secondary to forceps or

fetal monitor leads.

Transillumination can be done for severe

hydrocephalus.

Check for microcephaly or macrocephaly36

A. ANTERIOR AND POSTERIOR FONTANELLES

Anterior fontanelle usually closes at 9-12 months and the posterior

fontanelle at 2-4 months.

A large anterior fontanelle is seen with hypothyroidism

,osteogenesis imperfecta, hypophosphatasia, and chromosomal

abnormalities and in those who are small for gestational age.

A bulging fontanelle may be associated with increased

intracranial pressure, meningitis, or hydrocephalus.

Depressed (sunken) fontanelles are seen dehydration.

A small anterior fontanelle may be associated with

hyperthyroidism, microcephaly, or craniosynostosis. 37

B-SKULL MOLDING

Temporary asymmetry of the

skull resulting from the birth

process.

Most often seen with

prolonged labor and vaginal

deliveries, it can be seen in

cesarean deliveries if the

mother had a prolonged

course of labor before delivery.

A normal head shape is

usually regained within 1 week.38

C. CAPUT SUCCEDANEUM

Diffuse edematous

swelling of the soft

tissues of the scalp that

may extend across the

suture lines.

It is secondary to the

pressure of the uterus or

vaginal wall.

It resolves within several

days39

D. CEPHALHEMATOMASubperiosteal hemorrhage that

never extends across the suture

line. It can be secondary to a

traumatic delivery or forceps

delivery.

X-ray films or(CT) scans of the

head should be obtained if an

underlying skull fracture is

suspected (<5% of all

cephalhematomas). Hematocrit

and bilirubin levels should be

monitored in these patients.

Most cephalhematomas resolve in

2-3 weeks. Aspiration of the

hematoma is rarely necessary

40

E. SUBGALEAL HEMATOMA

Bleeding below the

epicranial aponeurosis.

It can cross over the

suture line and into the

neck or ear.

It may be necessary to

replace blood volume

lost and correct

coagulopathy if present 41

F. INCREASED INTRACRANIAL PRESSURE

• Bulging anterior fontanelle

• Separated sutures

• Paralysis of upward gaze

(setting-sun sign)

• Prominent veins of the scalp

• Increasing macrocephaly

Secondary to hydrocephalus,

hypoxic- ischemic brain injury,

intracranial hemorrhage, or

subdural hematoma. 42

G. CRANIOSYNOSTOSISPremature closure of one or

more sutures of the skull. It

should be considered in any

infant with an asymmetric

skull.

On palpation of the skull, a

bony ridge over the suture line

may be felt, and inability to

freely move the cranial bones

may occur.

X-ray studies of the head

should be performed, and

surgical consultation may be

necessary.

43

H. CRANIOTABES

softening of the skull

that usually occurs

around the suture lines

and disappears within

days to a few weeks

after birth.

It may be secondary to

a calcium deficiency,

and osteogenesis

imperfecta and syphilis.44

VI. NECK

Rooting reflex causes the infant to turn the head

and allows easier examination of the neck.

Palpate the sternocleidomastoid for a hematoma

and the thyroid for enlargement, and check for

thyroglossal duct cysts.

A short neck is seen in Turner's, Noonan's, and

Klippel-Feil syndromes.

45

VII. FACELook for obvious abnormalities, general shape of the nose,

mouth, and chin.hypertelorism (eyes widely separated) or

low-set ears.

A. Facial nerve injury:

facial asymmetry with crying. The corner of the mouth

droops, and the nasolabial fold is absent in the paralyzed

side. The infant may be unable to close the eye, move the

lip, and drool on the side of the paresis.

If the palsy is secondary to trauma, most symptoms

disappear within the first week of life, but sometimes

resolution may take several months. If the palsy persists,

absence of the nerve should be ruled out. 46

VIII. EARS:

Hairy ears are seen in infants of diabetic mothers.

Gross hearing can be assessed when an infant

blinks in response to loud noises.

Tympanic membranes are dull, gray, opaque, and

immobile in the first 1 to 4 weeks. These findings

should not be confused with otitis media.

47

Seen with many

congenital anomalies

(most commonly

Treacher Collins,

trisomy 9,21 and 18

syndromes).

Low set ear

48

benign, are often seen.

The 2007 Joint Committee

on Infant Hearing

statement lists ear pits as

one of the physical findings

associated with higher risk

for Hearing impairment.

Preauricular skin tags

49

Red reflex with an

ophthalmoscope.

Opacification of the

lens and loss of the

reflex are apparent

with Congenital

cataract.

IX. EYES

50

Normally white,

can have a bluish

tint if the infant is

premature.

If the sclera is deep

blue,

osteogenesis

imperfecta should

be ruled out

Sclera

51

Prader-Willi syndrome

Cystinosis

Pierre Robin syndrome

Rubella

Fetal alcohol syndrome

Mucopolysaccharidoses

SturgeWeber syndrome

Congenital glucoma

52

Salt-and-pepper

speckling of the iris

are often seen with

Down syndrome.

Brushfield's spots

53

Rupture of small

conjunctival

capillaries can occur

after a traumatic

delivery.

This condition is seen

in 5% of newborn

infants.

Subconjunctival hemorrhage

54

Aseptic chemical neonatal

conjunctivitis that is induced

by silver nitrate solution,

which is used for prophylaxis

of infectious conjunctivitis.

Septic neonatal

conjunctivitis, with

Chlamydia being the most

common infectious agent.

Conjunctivitis

55

X. NOSE

Choanal atresia is suspected, verify the patency of the

nostrils with gentle passage of a nasogastric tube.

Infants are obligate nose breathers; therefore, if they

have bilateral choanal atresia, they will have severe

respiratory distress.

Nasal flaring is indicative of respiratory distress.

Sniffling and discharge are typical of congenital

syphilis.

Sneezing can be a response to bright light or drug

withdrawal.56

XI. MOUTH

A. RANULA

cystic swelling in the

floor of the mouth.

Most disappear

spontaneously.

57

B. EPSTEIN'S PEARLS

Keratin-containing

cysts, which are

normal, are located on

the hard and soft

palates

Resolve

spontaneously.

58

C. MUCOCELE

Secondary to trauma

to the salivary gland

ducts.

It is usually benign

and subsides

spontaneously.

59

D. NATAL TEETH lower incisors X-ray films

are needed

1. Predeciduous teeth.

They are usually loose, and

the roots are absent or

poorly formed. Removal is

necessary to avoid

aspiration.

2. True deciduous teeth.

These teeth are true teeth

that erupt early. They should

not be extracted. 60

E. MACROGLOSSIA

Enlargement of the tongue can

be congenital or acquired.

Localized macroglossia is

usually secondary to congenital

hemangiomas.

Macroglossia can be seen in

Beckwith's syndrome

(macroglossia, gigantism,

omphalocele, and severe

hypoglycemia), congenital

hypothyrodism and Pompe's

disease. 61

F-THRUSH

Infection resulting from C.

albicans.

Whitish patches appear

on the tongue, gingiva, or

buccal mucosa.

Thrush is easily treated

with nystatin suspension

(0.1-1.0 mL) applied to

each side of the mouth, 3-

4 times per day for 7 days.62

6- CLEFT LIP AND PALATE

Isolated or part of trisomy 13.

Interfere with oral feeding.

63

XII. CHESTA. Observation. First, note whether the chest is symmetric.

An asymmetric chest may signify a tension pneumothorax.

Tachypnea, sternal and intercostal retractions, and grunting on

expiration indicate respiratory distress.

B. Breath sounds. A good place to listen is in the right and left

axillae.

Absent or unequal sounds may indicate pneumothorax or

atelectasis.

Absent breath sounds with the presence of bowel sounds indicates

a diaphragmatic hernia.

C. Pectus excavatum: sternum is altered in shape. Usually, this

condition is of no clinical concern. 64

D. Breasts in a newborn:

1 cm in diameter in term male and female infants.

They may be abnormally enlarged (3-4 cm)

secondary to the effects of maternal estrogens. This

effect, which lasts <1 week, is of no clinical concern.

A usually white discharge, commonly referred to as

may be present, Never squeeze it.

Supernumerary nipples are extra nipples and occur

as a normal variant.65

XIII. HEARTThe position of the heart in infants is more midline than in older

children.

The first heart sound is normal, whereas the second heart sound

may not be split in the first day of life. Decreased splitting of the

second heart sound is noted in PPHN, TGA, and pulmonary atresia.

Heart murmurs in newborns are common in the delivery room and

during the first day of life. Most of these murmurs are transient and

are due to closure of the ductus arteriosus, peripheral pulmonary

artery stenosis, or a small VSD.

Pulses should be palpated in the upper and lower extremities (over

the brachial and femoral arteries).

Blood pressure in the upper and lower extremities should be

measured in all patients with a murmur or heart failure. An upper to

lower extremity gradient of more than 10 to 20 mm Hg suggests

coarctation of the aorta.

66

XIV. ABDOMEN

A. Observation. Obvious

defects may include an

omphalocele, in which the

intestines are covered by

peritoneum and the

umbilicus is centrally

located

67

Gastroschisis

Intestine are not

covered by

peritoneum (the

defect is usually

to the right of the

umbilicus).

68

A scaphoid

abdomen

may be

associated

with a

diaphragmati

c hernia.

69

B. Auscultation: Listen for bowel sounds.

C. Palpation: Check the abdomen for distention, tenderness,

or masses.

The liver can be palpated 1-2 cm below the costal margin and

the spleen tip at the costal margin.

Hepatomegaly can be seen with congestive heart failure,

hepatitis, or sepsis.

Splenomegaly is found with cytomegalovirus (CMV) or rubella

infections or sepsis.

The kidneys (especially on the right) can often be palpated.

Kidney size may be increased with polycystic disease, renal

vein thrombosis, or hydronephrosis. Abdominal masses are

more commonly related to the urinary tract. 70

XV. UMBILICUSPresence of only two vessels (one artery and one vein)

could indicate renal or genetic problems (most commonly

trisomy 18).

If there is a single umbilical artery, there is an increased

prevalence of congenital anomalies and intrauterine growth

retardation and a higher rate of perinatal mortality.

If the umbilicus is abnormal, ultrasonography of the

abdomen is recommended. In addition, inspect for any

discharge, redness, or edema around the base of the cord

that may signify a patent urachus or omphalitis.

The cord should be translucent; a greenish-yellow color

suggests meconium staining, usually secondary to fetal

distress. 71

XVI. GENITALIAAny infant with ambiguous genitalia should not undergo gender

assignment until a formal endocrinology evaluation has been

performed.

A male with any question of a penile abnormality should not be

circumcised until he is evaluated by a urologist or a pediatric

surgeon.

A. Male. Check for dorsal hood, hypospadias, epispadias, and

chordee. Normal penile length at birth is >2 cm. Determine the site

of the meatus. Verify that the testicles are in the scrotum and

examine for groin hernias. Undescended testicles are more

common in premature infants. Hydroceles are common and

usually disappear by 1 year of age. Observe the color of the

scrotum. A bluish color may suggest testicular torsion and requires

immediate urologic/surgical consultation. Infants will have well-

developed scrotal rugae at term. A smooth scrotum suggests

prematurity.

72

B. Female:

Examine the labia and clitoris. A mucosal tag

is commonly attached to the wall of the

vagina.

Discharge from the vagina is common and is

often blood tinged secondary to maternal

estrogen withdrawal.

If the labia are fused and the clitoris is

enlarged, adrenal hyperplasia should be

suspected. 73

XVII. Lymph nodes:

Palpable lymph nodes, usually in the inguinal and cervical

areas, are found in ~33% of normal neonates.

XVIII. Anus and rectum:

Check for patency of the anus to rule out imperforate

anus.

Check the position of the anus.

Meconium should pass within 48 h of birth.

74

XIX. EXTREMITIES

A. Syndactyly abnormal

fusion of the digits, most

commonly involves the

second and third toes.

A strong family history

exists.

Surgery is performed

when the neonates are

older.75

B. Polydactyly is extra digits on

the hands or the feet. This

condition is associated with a

strong family history. An x-ray film

should done

If there are no bony structures, a

suture can be tied around the digit

until it falls off.

If bony structures are present,

surgical removal is necessary.

Axial extra digits are associated

with heart anomalies 76

C. Simian crease. A

single transverse

palmar crease is most

commonly seen in

Down syndrome but is

occasionally a normal

variant.

77

D- Talipes

equinovarus(clubfoot)

is more common in

males.

If this problem can be

corrected with gentle

force, it will resolve

spontaneously. If not,

orthopedic treatment and

follow-up are necessary.78

E. Metatarsus

varus:

adduction of the

forefoot.

This condition

usually corrects

spontaneously.79

XX. Trunk and spine.

Check for any gross defects

of the spine.

Any abnormal pigmentation

or hairy tufts over the lower

back should increase the

suspicion that an underlying

vertebral abnormality exists.

A sacral or pilonidal dimple

may indicate a small

meningocele or other

anomaly.80

XXI. HIPS

Congenital hip dislocation occurs in

~1 in 800 live births. More common

in white females, unilateral left hip.

Two clinical signs of dislocation are

asymmetry of the skinfolds on the

dorsal surface and shortening of

the affected leg.

Evaluate for congenital hip

dislocation by using the Ortolani

and Barlow maneuvers.

81

XXII. NERVOUS SYSTEM

A. Muscle

tone

1. Hypotonia.

Floppiness and

head lag.

82

2. Hypertonia:

Increased resistance is

apparent when the

arms and legs are

extended.

Hyperextension of the

back and tightly

clenched fists are often

seen. 83

B. Reflexes. The following

reflexes are normal for a

newborn infant.

1. Rooting reflex. Stroke the

lip and the corner of the cheek

with a finger and the infant will

turn in that direction and open

the mouth.

84

2. Glabellar reflex

(blink reflex). Tap

gently over the

forehead and the eyes

will blink.

85

3. Grasp reflex.

Place a finger in the

palm of the infant's

hand and the infant

will grasp the finger.

86

4. Neck-righting

reflex. Turn the

infant's head to the

right or left and

movement of the

contralateral shoulder

should be obtained in

the same direction.

87

5. Moro reflex

Support the infant behind the

upper back with one hand, and

then drop the infant back 1 cm or

more to but not on the

mattress. This should cause

abduction of both arms and

extension of the fingers.

Asymmetry may signify a

fractured clavicle, hemiparesis,

or brachial plexus injury.

88

Suckling reflex

89

C. Cranial nerves. Note the presence of gross

nystagmus, the reaction of the pupils, and the

ability of the infant to follow moving objects with his

or her eyes.

D. Movement. Check for spontaneous movement

of the limbs, trunk, face, and neck.

A fine tremor is usually normal. Clonic movements

are not normal and may be seen with seizures.

90

E. Peripheral nerves

1. Erb-Duchenne

paralysis involves

injury to C5,6.

This condition can be

associated with

diaphragm paralysis.

91

2. Klumpke's

paralysis involves C7,8

T1. The hand is flaccid

with little or no control.

If the sympathetic fibers

of the first thoracic root

are injured, ipsilateral

ptosis and miosis can

occur.

92

F. General signs of neurologic disorders

1. Symptoms of increased intracranial pressure.

2. Hypotonia or hypertonia.

3. Irritability or hyperexcitability.

4. Poor sucking and swallowing reflexes.

5. Shallow, irregular respirations.

6. Apnea.

7. Apathy.

8. Staring.

9. Seizure activity (sucking or chewing of the tongue, blinking of the eyelids, eye rolling, and

hiccups).

10. Absent, depressed, or exaggerated reflexes.

11. Asymmetric reflexes. 93

94