#70 – Newborn Examination

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***LISTEN TO THE PODCAST HERE***

PURPOSE

  • The first full examination of the child’s life
    • Occurs within 24 hours after birth
    • Comprehensive review of history (maternal, family, prenatal) and complete physical examination
  • Identify medical conditions while still in the hospital to address any significant pathologies
    • Congenital anomalies, birth injuries, cardiopulmonary disease, neurologic abnormalities

HISTORY

  • Maternal and Family History
    • Chronic medical conditions, medications taken during pregnancy, dietary habits during pregnancy, tobacco/alcohol/substance use during pregnancy
      • UTIs, PIH, eclampsia, gestational diabetes, vaginal bleeding
    • Family history of congenital anomalies
  • Obstetric History
    • Maternal age (<19 or >35), gravidity and parity, pregnancy outcomes, blood type
    • Procedures and tests performed during pregnancy (US, amniocentesis)
    • Results any antepartum well-being tests
  • Peripartum History
    • Maternal fever
    • Duration of labor
    • Fetal distress
    • Duration of ruptured membranes
    • Type of delivery, anesthesia used, complications
    • Any resuscitative measures performed

APGAR Scores

  • Recorded at 1- and 5-minutes after birth
  • Score out of 10, 2 points for each criteria
    • < 7 warrants resuscitation and intervention
  • Appearance, Pulse, Grimace, Activity, Respiration (APGAR)
  • How (heart rate) Ready (respiration) Is (irritability) This (tone) Child (color)

ASSESSMENT OF GESTATIONAL AGE AND PHYSICAL MATURITY

  • Important to calculate to determine what is physiologically “normal” for the infant

MEASUREMENTS

  • Compared in relation to gestational age
  • Birth weight
    • Appropriate for Gestational Age (AGA)
    • Small for Gestational Age (SGA) or Intrauterine Growth Restriction (IUG)
      • < 10th percentile
      • Low-Birth Weight < 2500g
      • Very-Low Birth Weight < 1500g
    • Large for Gestational Age (LGA)
      • >90th percentile
  • Length and Head Circumference
    • Length = top of head to bottom of feet with legs fully extended
    • HC = above eyebrows around most prominent posterior aspect of head
    • Use Olson Growth Curves to determine percentiles by gender
  • If SGA/IUG, then determine if symmetrical or asymmetrical
    • Symmetrical = weight, length, AND head circumference all < 10th percentile
      • Implies early pregnancy event
    • Asymmetrical = only weight < 10th percentile
      • Implies late pregnancy event

VITAL SIGNS

  • Should be documented every 30-60 minutes for first 6 hours of life, then every 8-12 hours
  • Axillary temperature (36.5-37.5oC) (97.7-99.5oF)
    • Any deviation from normal, proceed with rectal measurement
  • Respiratory Rate (35-60 bpm)
    • Counted over a FULL minute
  • Heart Rate (100-160 bpm)
  • Blood Pressure (60-80/30-50 mmHg)
    • General rule = MAP > GA

SKIN

HEAD

  • Assess the shape and size of the head
  • Presence of any abnormal hair/scalp defects, unusual protuberances
    • Cephalohematoma
      • Subperiosteal collection of blood
      • Does NOT cross suture lines, resolves over several weeks
    • Caput succedaneum
      • Edema over presenting part of the head
      • Crosses suture lines, resolves in a few days
    • Subgaleal hematoma
      • Collection of blood between aponeurosis and periosteum of scalp
      • Crosses suture lines, may be significant enough to cause hemodynamic problems
  • Fontanelles and Sutures
    • Anterior
    • Posterior
    • Should be open, soft, and flat
      • Closed = craniosynostosis
      • Tense, bulging = raised ICP, infections

FACE

  • Examine for symmetry during crying
  • Facial Palsies
    • Usually associated with forceps delivery with injury to the mandibular branch of the facial nerve
      • Loss of nasolabial fold, partial closing of the eye, inability to contract lower facial muscles
      • Generally, resolve over days to weeks
      • Persistent palsy may indicate complete nerve laceration
  • Asymmetric Crying Facies (ACF)
    • Syndromic condition due to congenital absence of depressor anguli oris muscle
    • Eye and forehead muscles normal, only affects the mouth

EYES

  • Spacing
    • Wide interpupillary distances suggest syndromic abnormality
  • Symmetry
    • Prominent epicanthal folds, size of globes, ptosis
  • Palpebral Fissures
    • Wide or narrow palpebral fissures can be normal or syndromic
  • Examine sclera, conjunctiva, cornea, pupils for abnormalities
  • Red Light Reflex

EARS

  • Examine for position, size, and appearance
    • Normal position = helix intersected by horizontal line drawn from outer canthus of eye perpendicular to the vertical axis of the head
  • Preauricular skin tags, branchial cleft cysts, and pits could indicate syndromic conditions

NOSE

  • Assess for patency, shape, and position
    • Hold mirror or cold metal under nose and look for bilateral fogging
    • Any concern for patency should be assessed with small NG tube passage

MOUTH

  • External
    • Assess for size and shape, cleft lip, micrognathism
  • Internal
    • Epstein pearls = benign, small, white inclusion cysts on palate
    • Lingual frenulum
    • Cleft of palate
    • Macroglossia associated with syndromic conditions

NECK

  • Masses
    • Cystic hygromas – transilluminated, soft mass above clavicles, posterior to SCM
    • Branchial cleft cysts – anterior margin of SCM
    • Thyroglossal cysts – midline neck mass
  • Mobility
    • Torticollis – caused by birth injury or neurologic syndrome
  • Excessive Skin
    • Webbing – feature of syndromic or genetic conditions

CLAVICLES

  • Palpate for BOTH clavicles
    • Absence associated with congenital syndrome
  • Fractures or birth injuries

CHEST

  • Assess for size, symmetry, and structure during respirations
    • Pectus excavatum, pectus carinatum

BREAST

  • Nipple spacing
    • Wide spaced may be associated with genetic conditions
  • Supernumerary nipple presence along milk line

LUNGS

  • Assess for retraction, grunting, nasal flaring
  • Abnormal breath sounds are unusual in the absence of other respiratory distress findings

CARDIAC

  • PMI in newborn is near left lower sternal border
    • RV is dominant in the newborn
  • Auscultation for murmurs
    • Most newborns have benign, transient flow murmur as physiology shifts from in-utero to ex-utero
  • Pulses

ABDOMEN

  • Assess for size and protuberance
    • Distension – congenital intestinal atresia, organomegaly, ascites
    • Scaphoid – diaphragmatic hernia
  • Assess for abdominal wall defects or masses
  • Palpate for tenderness or organomegaly
  • Umbilical Cord Stump
    • Assess for erythema or streaking of omphalitis

GENITALIA

  • Identify infant’s gender at birth
  • Phenotypic Female
    • Assess size and location of labia, clitoris, meatus, vaginal opening
  • Phenotypic Male
    • Presence of both testes, size of penis, appearance of scrotum, position of urethral opening
  • Ambiguous Genitalia
    • Female – enlarged clitoris, fused labial folds
    • Males – bifid scrotum, severe hypospadias, micropenis, cryptorchidism
    • Consultation with endocrinology, urology, and genetics is warranted

ANUS

  • Assess location, patency, sphincter tone

TRUNK AND SPINE

  • Assess down vertebral column for masses, hair tufts, dimples

EXTREMITIES

  • Hands and Feet
    • Inspect for syndactyly or polydactyly
    • Single palmar crease
  • Hips
    • Assess for developmental hip dysplasia
      • Ortolani – adduction and posterior pressure to feel dislocation
      • Barlowe – abduction and elevation to feel for reduction
  • Movement
    • Assess for spontaneous and symmetric movement
      • If upper asymmetric movement present:
        • Assess for brachial plexus injury
          • C5-6 – Erb’s Palsy
            • Upper arm is adducted, internally rotated, forearm extended (Waiter’s tip)
          • C7-T1 – Klumpke Palsy
            • forearm extension and pronation and flexion of wrist and fingers (“claw hand”)

NEUROLOGIC

  • Assess resting motor tone
    • Hypertonia
      • Spasticity, tractional positioning
    • Hypotonia – infant lying supine with hips fully abducted (frog-leg position) and limbs fully extended
      • Vertical Suspension Test
        • Decreased shoulder girdle tone allows infant to slip through examiner’s hands
      • Ventral Suspension Test
        • Infant appears limp with extended limbs and head drooping
      • Head Control Test
        • Head lags behind as infant is pulled up from supine to sitting position
  • Assess primitive reflexes
    • Why important
      • Brainstem mediated
      • Complex automatic movement patterns (not really reflexes)
      • Pathology may be present if absent when it should be present or present when it should be absent
  • Rooting and Sucking Reflex
    • Rooting – infant turns head toward examiner stroking cheek or mouth
    • Sucking – infant strongly latches onto finger
    • Present – at birth
    • Disappears – by 4 months
  • Moro or Startle Reflex
    • Lifting infants head and shoulders and allow head to drop relative to the body
    • Normal – infant extends and abducts arms, then flexes and adducts
    • Present – at birth
    • Disappears – by 6 months
  • Palmar Grasp Reflex
    • Examiner places finger in the palm and applies gentle pressure
    • Normal – fingers curl to grasp finger and hold
    • Present – at birth
    • Disappears – by 6 months
  • Stepping Reflex
    • Hold infant upright and slightly leaning forward and allow feet to touch a surface
    • Normal – infant raises leg as if stepping
    • Present – at birth
    • Disappears – by 2 months
  • Babinski Reflex
    • Apply lateral pressure on plantar surface moving from heel curving towards 1st metatarsal
    • Normal – fanning (extension) or toes
      • This is a POSITIVE Babinski and NORMAL in infants
    • Present – at birth
    • Changes from POSITIVE to NEGATIVE by 2 year’s of age
  • Asymmetric Tonic Neck Reflex
    • Infant is supine and examiner turns head for 15 seconds
    • Normal – Ipsilateral extremities extend and contralateral extremities flex
    • Present – at birth
    • Disappears – by 6 months

COTTAGE PHYSICIAN (1893)

REFERENCES

  1. Smith D. The Newborn Infant. In: Hay Jr. WW, Levin MJ, Abzug MJ, Bunik M. eds. Current Diagnosis & Treatment: Pediatrics, 25e. McGraw-Hill; Accessed April 24, 2021. https://accessmedicine-mhmedical-com.ezproxy.uthsc.edu/content.aspx?bookid=2815&sectionid=244254981
  2. Ballard JL, Khoury JC, Wedig K, Wang L, Eilers-Walsman BL, Lipp R. New Ballard Score, expanded to include extremely premature infants. J Pediatr. 1991; 119(3):417-23. [pubmed]
  3. Olsen IE, Groveman SA, Lawson ML, Clark RH, Zemel BS. New intrauterine growth curves based on United States data. Pediatrics. 2010; 125(2):e214-24. [pubmed]
  4. American Academy of Pediatrics, American College of Obstetricians and Gynecologists. Care of the Newborn. In: Guidelines for Perinatal Care, 7th ed, Riley LE, Stark AR (Eds), American Academy of Pediatrics, Elk Grove Village, IL 2012.
  5. Tveiten L, Diep LM, Halvorsen T, Markestad T. Respiratory Rate During the First 24 Hours of Life in Healthy Term Infants. Pediatrics. 2016; 137(4):. [pubmed]
  6. Red reflex examination in neonates, infants, and children. Pediatrics. 2008; 122(6):1401-4. [pubmed]
  7. Lewis ML. A comprehensive newborn exam: part I. General, head and neck, cardiopulmonary. Am Fam Physician. 2014; 90(5):289-96. [pubmed]
  8. Lewis ML. A comprehensive newborn exam: part II. Skin, trunk, extremities, neurologic. Am Fam Physician. 2014; 90(5):297-302. [pubmed]
  9. Salandy S, Rai R, Gutierrez S, Ishak B, Tubbs RS. Neurological examination of the infant: A Comprehensive Review. Clin Anat. 2019; 32(6):770-777. [pubmed]
  10. Hamer EG, Hadders-Algra M. Prognostic significance of neurological signs in high-risk infants – a systematic review. Dev Med Child Neurol. 2016; 58 Suppl 4:53-60. [pubmed]
  11. Futagi Y, Toribe Y, Suzuki Y. The grasp reflex and moro reflex in infants: hierarchy of primitive reflex responses. Int J Pediatr. 2012; 2012:191562. [PDF]
  12. Allen MC, Capute AJ. The evolution of primitive reflexes in extremely premature infants. Pediatr Res. 1986; 20(12):1284-9. [pubmed]
  13. Pediatric EM Morsels.  Primitive Reflexes in Children.  04/23/2021. https://pedemmorsels.com/primitive-reflexes-in-infants/

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