Neonatal examination
HISTORY taking and Neonatal examination:
Perinatal history:
- Prenatal: (maternal history during pregnancy):
-Blood group.
-Illness.
-Drugs, X-rays.
-Trauma.
- Natal:
-Site of labor.
-Type of labor.
-Duration.
-Premature rupture of the membrane.
- Postnatal:
-resuscitation.
Past history:
-History of abortions.
-IUFD or premature.
Family history:
-Number of kids.
-Similar condition.
-Consanguinity.
-Inherited diseases.
** Newborns are examined immediately after birth to check for major abnormalities and then should be examined with a complete physical examination within 24 hours of delivery.
EXAMINATION:
- Quick examination.
- Detailed examination.
- Special examination.
Quick examination: (in the delivery room).
- Agar score:
-At 10 and 20 minutes if the score at 5 minutes <7.
-Check the baby's activity, pulse, grimace, appearance, and respiratory rate.
-Placed on the servo with neck baby.
- Color:
-Normal is pink.
-Acrocyanosis means coldness.
-In infants of diabetic mothers and premature babies, they become pinker than usual.
-Post-date babies' pallor than usual.
1. Pallor:
*Anemia.*Shock.
*Acidosis.
*Odema.
*PAD.
2. Cyanosis:
➤Central:
In the tongue and inner surface of lips due to low oxygen saturation as in cases of CVS, CNS, pulmonary abnormality, and methemoglobinemia.
➤Perioral.
➤Pheripheral:
The outer surface of lips and limps with pink tongue due to hypothermia.
3. Plethorea:
The deep purple color of skin and mucous membrane, HCT >65%.
Due to polythycemia, over-oxygenation, and /or overheated.
4. Jaundce:
Yellowish discoloration of the skin, sclera, and mucous membrane.
Bilirubin level at least 5mg/dl or more.
- VITAL SIGNS:
Normal rate 120-160 beats/minute at rest in term and post-term babies may be <100/min. and changes with activity, crying, breathing, and change of temperature.
Tachycardia >180 b/min.
Bradycardia <90-100b/min.
Respiratory rate:
40-60/min. with periodic breathing(short periods of no breathing 5-10 sec.)
Abdominal ( diaphragmatic ) pattern.
Normal with crying with some or mild chest retraction.
Tachypnea R.R.>60 min.
Apnea > 15 sec. of cessation of respiratory with or without cyanosis and bradycardia.
Temperature:
Normal 36.5-37.4 degrees.
Fever >38 degrees.
Measure axillary or rectal.
Causes (dehydration, overheating, febrile)
Hypothermia <35.5 degrees caused by (cold environment, sepsis, premature and/or maternal diazepam).
**Persistent hypothermia may be due to ( facial edema, ileus, or death).
Blood pressure:
Correlates directly with gestational age, post-natal age of the infant, and birth weight.
Measure in upper and lower limbs to detect a correlation of the aorta.
The cuff must cover the upper 2/3 of the arm.
Normal 70/50 mmHg increase of 10 systolic and 5 diastolic every 3 years.
Detailed Examination:
**Measurements:
weight:
Average 2500-3999kg.
Macrosomia>4kg.
LBW 1-2.5kg.
VLBW 1-1.5kg.
ELBW 750-1kg.
Incredible LBW<750gm.
Physiological weight loss in 1st few days 10-15% due to pass of meconium, urination, contraction of EVC improv-ental function).
weight gain from 2nd week of life by 10-20g/kg/d.
Length:
Normal in full term 47-53cm average 50cm.
Premature <47cm.
Head circumference:
Full term 33-38cm(35cm), preterm<33cm.
microcephaly <33cm.
Macrocephaly>38cm.
measured by placing the measuring tape around the front of the head above the brow and the occipital area and above the ears.
# At birth H.C/C.C ratio >1.
**Regional:
Head:
skull:
_trauma (caput, cephalohematoma).
-Craniosynostosis.
-Molding (subside within 5 days).
-Craniotabes in premature.
Fontanells:
6 fontanelles at birth 2anterolateral, 2posterolateral, 1 anterior,1 posterior.
Anterior fontanelle at birth measures 3 fingertips.
-At 6 months 2 fingertips, at 12 months 1 fingertip.
-Large delayed closure in monglism, rickets, cretinism, osteogenesis imperfecta, premature, hypopituitarism, increased intracranial pressure, and/or achondroplasia.
-Small <6 mm in craniosynostosis, microcephaly, hypercalcemia, and /or congenital hyperthyroidism.
-Bluging in increased intracranial tension with infection, hemorrhage, or hydrocephaly.
-Deppresed in cases of shock and dehydration.
-Absent in molding or caput succodanuem.
Eyes:
- microphthalmia or macroophthalmia.
-Cataract in case of TORSH or galactosemia.
-subconjunctival hemorrhage is normal in NVD
-Deep blue sclera in osteogenesis
-Absent lower lid lashes, hypoplastic mandible, and malformed ear pinna in Teacher Collin's syndrome.
-Present of discharge in case of conjunctivitis.
-Widely spaced eyes >20mm. I'm hypertelorism.
Ears:
-low set ear and malformed pinna may be a part of congenital syndromes.
Nose:
-Choanal atresia 90% membronus examed by gentile passing of nasogastric tube.
-Depressed nasal bridge(septum) may be a part of congenital syndromes.
Mouth:
-cleft palate.
-cleft lip
-Natal teeth
-Tongue tie.
-Macroglossia.
-Micrognathia (small jaw) in Pierre Robin syndrome.
Neck:
-Exclude masses, torticollis, goiter, and thymic cyst.
-Widening neck associated with Turner syndrome.
-Sternomatoid tumor, ectopic thyroid.
-Enlarged cervical L.N. <12mm is normal in half of neonates.
Limbs:
-Trauma, or deformity.
-Fanconi anemia.
-Holt-Oram syndrome A.D. (left limb reduction or hypoplastic thumb and ASD or VSD in the heart).
Skin:
-Mottling (poor-peripheral perfusion) may be due to sepsis, shock, or hypothermia.
-Abnormal coloring.
-Wrinkled skin is common in post-term.
-Milia (tinny plugged sweat glands on the nose).
-Languo hair is common in preterm.
-Cavernous hemangioma and capillary hemangioma may find in examination.
Black-spine:
-Hold the baby in your hand with his face down to examine him well.
Genitalia & Anus:
-Ambiguous genitalia (medical emergency) means congenital adrenal hyperplasia.
-Undescended testicles common in premature need follow-up.
-Hydrocele commonly disappears by 1st year of age.
-Indirect oblique inguinal hernia is common on the right side in preterm babies.
-Penis normal length overstretched <2.5cm (micropenis may associate with hypopituitarism).
-Hypospedius(glandular) is an abnormal location of the urethral meatus on the ventral surface of the penis.
-Penile abnormality should not be circumcised until he is evaluated by a urologist or pediatric surgeon.
-Imperforate the anus to exclude it insert a small feeding tube not more than 1cm in the anus or observe
for passage of meconum.
Systemic examination:
Chest:
**Respiratory rate:
-Rhythm.
-Shape of chest and symmetry.
-Respiratory depression.
**Auscultation:
-Airentery.
-Adential sounds.
**Inspection:
-Breast hypertrophy and milk passage (transplacental maternal hormones) don't express manually to avoid infection mostly relieved spontaneously.
-Observation for nasal flaring, grunting, retraction, and/or phonatory abnormalities e.g. stridor.
Cardiac examination:
**Heart rate:
Apex: normal in left 4th infraclavicular space (ICS) midclavicular line (MCL).
-Right to sternum in dextrocardia, pneumothorax, or diaphragmatic hernia.
**Auscultation:
-rythm.
-murmurs may be innocent in 90% of neonate.
**Femoral pulsation:
To exclude coarctation of the aorta.
Abdominal examination:
**Inspection:
-Distention in cases of intolerance, obstruction, or/and ileus.
-Scaphoid abdomen in cases of atresia or diaphragmatic hernia.
-Absent muscle in (prune belly syndrome).
**Palptation:
Superficial:
from lower to upper.
Deep:
To detect organomegaly and masses is mainly renal in 55%in cases.
**Auscultation:
To detect intestinal sounds.
➤UMBLICAL EXAMINATION:
If the umbilicus is abnormal abdominal sonar is recommended.
Normal umbilicus contains 2 arteries & one vein in a gelatinous substance called Wharton's jelly.
Its length is 55 cm.
Stay patent for 10-20 days.
Delayed separation > one month may indicate immunodeficient or factor XIII deficiency.
A single umbilical artery may associated with Trisomy 18 & IUGR & GIT obstruction lesion or urogenital anomalies.
*Umbilical hemorrhage:
-ligation inadequate.
-Trauma.
-Hemorrhagic disease.
-local infection.
⇨Treated by vitamin K and treat the cause.
*Umbilical infection(OMPHALITIS):
-Colonization of bacteria.
-Leads to septicemia.
-Foul odor discharge.
-Periumbilical erythema.
-Sepsis-like picture.
⇨Prevention by frequent Alchool on umbilical stump.
*Umbilical granuloma:
-in the base of the umbilicus as a soft pink vascular granular mass with sero-purulent discharge.
differential diagnosis with polyp ( present with part of omphalomesenteric duct firm, bright red, and may discharge urine or stool).
*Congenital umbilical hernia:
soft swelling produced during crying and cough, about 1-5cm usually resolved during the first year of life.
*Patent omphalomesenteric duct may be due to intestinal obstruction.
*Persistent urachus may be associated with bladder outlet obstruction.
*Congenital omphalocele (herniation of abdominal contents into the base of the umbilical cord usually associated with chromosomal anomalies and syndromes covered with saline-soaked dressing till urgent surgical repair.
Neurological examination:
- Level of consciousness & crying & activity.
- muscle tone &posture :
- Normal complete flexion of four limbs.
- Hypotonia (frog-leg).
- Hypertonia increases resistance when the limbs are extended.
- Primitive (Moro's & suckling & glabellar & grasp &rooting).
- Abnormal response of planter reflex normal till the end of 1st year.
Reference:
American Academy of Pediatrics. Committee on Quality Improvement, Subcommittee on Developmental Dysplasia of Hip. Clinical Guideline: early detection of developmental dysplasia of the hip. Pediatrics. 2000;105:896-905.
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