Newborn examination


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how to examine a baby after delivery before discharge to home

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Newborn examination

  2. 2. Definition <ul><li>Head to toe physical examination of a newborn to look for any abnormalities or pathology. </li></ul><ul><li>Includes biochemical screening & certain special screening ( ROP, hearing assesment, Echocardiography) </li></ul>
  3. 3. <ul><li>Assesment at birth </li></ul><ul><li>Physical examination </li></ul><ul><li>Biochemical screening </li></ul><ul><li>Special screening </li></ul><ul><ul><ul><li>Retinopathy Of Prematurity </li></ul></ul></ul><ul><ul><ul><li>Hearing assesment </li></ul></ul></ul><ul><ul><ul><li>Echocardiography </li></ul></ul></ul>
  4. 4. Newborn first exam : Apgar Score 0 1 2 1m 5m 10m 15m 20m Colour Blue or pale Body pink, extremities blue Complete pink Heart rate Absent Slow <100/min >100/min Respiratory effort Absent Slow irregular Good, crying Muscle tone Limp Some flexion Active motion Reflex irritability No response Grimace Cry/active withdrawals TOTAL
  5. 5. Physical examination <ul><li>COMPLETE physical examination within 24 hours of birth. </li></ul><ul><li>It is best to examine when the infant is quiet. </li></ul><ul><li>Ensure infant is naked : he/she can be in diapers, but you have to open it. </li></ul><ul><li>Do not forget to wash your hands prior to examination. </li></ul>
  6. 6. Measurements… <ul><li>Head circumference : </li></ul><ul><li>- a.k.a Occipitofrontal circumference </li></ul><ul><li>- place measuring tape around front of head, below the </li></ul><ul><li>brow and occipital area. </li></ul><ul><li>- Normal range 32cm-37cm </li></ul><ul><li>Length & Percentile (refer growth chart) </li></ul><ul><li>Weight & Percentile (refer groth chart) </li></ul><ul><li>Assesment of Gestational Age & Percentile </li></ul><ul><ul><ul><li>-Small for Gestational Age </li></ul></ul></ul><ul><ul><ul><li>- Appropriate for Gestational Age </li></ul></ul></ul><ul><ul><ul><li>- Large for gestational age </li></ul></ul></ul>
  7. 7. Vital signs <ul><li>Temperature : Rectal </li></ul><ul><li>Respirations : Normal rate is 40-60 </li></ul><ul><li>Blood pressure : Correlates with gestational age, post natal age, birth weight. </li></ul><ul><li>Pulse rate : Awake 120-160bpm, Asleep 70-80bpm </li></ul>
  8. 8. <ul><ul><li>Colour </li></ul></ul><ul><ul><li>Plethora (deep rosy red) </li></ul></ul><ul><ul><li>Jaundice </li></ul></ul><ul><ul><li>Pallor </li></ul></ul><ul><ul><li>Cyanosis( central , peripheral , acrocyanosis ) </li></ul></ul><ul><ul><li>“ Blue on pink: or “Pink on blue” </li></ul></ul><ul><ul><li>Harlequin colouration </li></ul></ul><ul><ul><li>Mottling </li></ul></ul><ul><li>Rashes </li></ul><ul><li>Milia </li></ul><ul><li>Erythema toxicum </li></ul><ul><li>Candida albicans rash </li></ul><ul><li>Transient neonatal pustular melanosis </li></ul><ul><li>Acne neonatorum </li></ul>SKIN
  9. 9. SKIN <ul><li>Nevi/ Pigmented Lesions </li></ul><ul><li>Macular hemangioma (“stork bites”) </li></ul><ul><li>Port –wine stain (nevus flammeus) </li></ul><ul><li>Mongolian spot </li></ul><ul><li>Cavernous hemangioma </li></ul><ul><li>Strawberry hemangioma </li></ul>
  10. 10. HEAD : General, Cuts, Bruises <ul><li>Anterior and posterior fontanelles </li></ul><ul><ul><li>Large anterior fontanelle </li></ul></ul><ul><ul><li>Small anterior fontanelle </li></ul></ul><ul><ul><li>Bulging fontanelle </li></ul></ul><ul><ul><li>Molding </li></ul></ul><ul><ul><li>Caput succedaneum </li></ul></ul><ul><ul><li>Cephalohematoma </li></ul></ul><ul><ul><li>Increased intracranial pressure </li></ul></ul><ul><ul><li>Craniosynostosis </li></ul></ul><ul><ul><li>Craniotabes </li></ul></ul>
  11. 11. Neck & Facial Features <ul><li>Face : Look for obvious abnormalities.Note the general shape of the nose, mouth and chin. Presence of syndromic features is often diagnosed clinically throughout experience. </li></ul><ul><li>Neck : Note shape, range of motion, and any webbing; palpate for masses </li></ul><ul><ul><li>Brachial palsy </li></ul></ul><ul><ul><li>Erb’s palsy </li></ul></ul><ul><ul><li>Fractured clavicle </li></ul></ul><ul><li>Ears : Unusual shape, low set ears, periauricular skin tags (papillomas), hairy ears. </li></ul>
  12. 12. <ul><li>Eyes : Observe shape, size and position of eyes. Note integrity and color of iris and sclera. Ophthalmoscopic examination to assess pupillary size and red retinal reflex </li></ul><ul><li>Nose : Size and Shape; </li></ul><ul><li>Note placement of the septum </li></ul><ul><li>Formation of the nasal bridge; </li></ul><ul><li>Verify patency ( Flat nasal bridge , Deviated septum , Choanal atresia , Nasal pit ) </li></ul><ul><li>Mouth : Hard & soft palate for evidence of cleft palate </li></ul><ul><li>: Neonatal tooth (predeciduos,true deciduos) </li></ul><ul><li>: Macroglossia </li></ul><ul><li>: Oral thrush </li></ul><ul><li> : Smooth philtrum </li></ul>Neck & Facial Features
  13. 13. Chest <ul><li>Observation : respiratory rate, chest symmetrical, sternal/intercostal /subcostal recession, nasal flaring, grunting, stridor </li></ul><ul><li>Breath sounds : Equality bilaterally, presence of any additional sound. </li></ul><ul><li>Pectus excavatum : sternum that is altered in shape. </li></ul><ul><li>Breast in newborn : May be abnormally enlarged (3-4cm) due to effects of maternal estrogens. </li></ul>
  14. 14. Heart : <ul><li>Observation : heart rate, rhythm, quality of heart sounds, active precordium </li></ul><ul><li>Position of heart : may be determined by auscultation </li></ul><ul><li>Presence of murmur </li></ul><ul><li>Palpate the pulses (femoral) & define whether its normal, weak or absent. </li></ul><ul><li>Check for perfusion </li></ul><ul><li>Signs of congestive heart failure : gallop, tachycardia & abnormal pulses </li></ul>
  15. 15. Abdomen <ul><li>Observation : scaphoid abdomen, omphalocele, gastroschisis </li></ul><ul><li>Palpation : Check for distension, tenderness or masses. Palpate liver, spleen, kidneys and groin and note any masses </li></ul><ul><li>Auscultation : Listen for bowel sound </li></ul><ul><li>Inspect anus for position and verify patency </li></ul>
  16. 16. Umbilicus <ul><li>Should have 2 arteries 1 vein. </li></ul><ul><li>Inspect for discharge, redness or edema around base of the cord </li></ul><ul><li>Appearance : should be translucent. A greenish yellowish colour suggest meconium staining </li></ul>
  17. 17. Genitalia : Any infant with ambiguos genitalia should not undergo gender assignment until a formal endocrinology evaluation <ul><li>Male </li></ul><ul><li>Length : > 2cm </li></ul><ul><li>Determine site of meatus </li></ul><ul><li>Palpate bilateral testicles </li></ul><ul><li>Examine for inguinal hernia </li></ul><ul><li>Look for hypospadias, epispadias, chordae. </li></ul><ul><li>Observe colour of scrotum </li></ul><ul><li>Phimosos-foreskin cannot be retracted </li></ul><ul><li>Cryptotorchidism-testes not descended </li></ul><ul><li>Female </li></ul><ul><li>Inspect for size and location of the labia, clitoris, meatus, and vaginal opening </li></ul><ul><li>Pseudomenses </li></ul><ul><li>Vaginal tag a small appendage or flap on the mucous membranes; common neonatal variation that usually disappears in a few weeks </li></ul>
  18. 18. Extremities : Examine the arms & legs paying close attention to the digits <ul><li>Syndactyly </li></ul><ul><li>Polydactyly </li></ul><ul><li>Oligodactyly </li></ul><ul><li>Congenital Talipes Equinovarus (CTEV) </li></ul><ul><li>Metarsus Varus </li></ul>
  19. 19. Trunk & Spine <ul><li>Observe curvature and integrity </li></ul><ul><li>Check for any gross defects of the spine. An abnormal pigmentation/ hairy patches over the lower back should increase the suspicion that an underlying vetebral abnormality exists. </li></ul><ul><li>A sacral or pilonidal dimple may indicate a small meningocele or other anomaly. </li></ul><ul><li>Spina bifida – defect in closure of the neural tube that is associated with malformations of the vertebrae & spinal cord </li></ul>
  20. 20. Hips <ul><li>Congenital hip dislocation ( Ortolani & Barlow Maneuvers) </li></ul><ul><ul><li>Assymetry of the skin folds on the dorsal surface </li></ul></ul><ul><ul><li>Shortening of the affected leg </li></ul></ul>
  21. 21. Nervous System : Observe for any abnormal movement/ excessive irritability <ul><li>Muscle tone </li></ul><ul><ul><li>Hypotonia : Floppiness </li></ul></ul><ul><ul><li>Hypertonia : Extended arms&legs, hyperextension of back & tightly clenched fists. </li></ul></ul><ul><li>Reflexes </li></ul><ul><ul><li>Rooting reflex </li></ul></ul><ul><ul><li>Glabellar reflex </li></ul></ul><ul><ul><li>Grasp reflex </li></ul></ul><ul><ul><li>Neck righting reflex </li></ul></ul><ul><ul><li>Moro’s reflex </li></ul></ul>
  22. 22. Biochemical screening <ul><li>Simple laboratory investigation to diagnose congenital metabolic disorder that may lead to mental retardation and even death if left untreated. </li></ul><ul><li>The goal of this screening is to give all newborns a chance to live a normal life. </li></ul><ul><li>It provides the opportunity for early treatment of diseases that are diagnosed before symptoms appear </li></ul><ul><li>Malaysia : G6PD deficiency & Congenital Hypothyroidism </li></ul>
  23. 23. G6PD deficiency <ul><li>G6PD deficiency is one of the most common genetic diseases affecting an estimated 400 000 000 people worldwide. </li></ul><ul><li>All newborn screened for G6PD and in case of deficiency should be explained to both parents. </li></ul><ul><li>Test : Beutler fluorescent spot test : rapid & cheap test that identifies NADPH produced by G6PD under UV light. </li></ul>
  24. 24. Congenital Hypothyroidism <ul><li>Significant decrease in, or absence of thyroid function present at birth. </li></ul><ul><li>Approximately 1 in 4000 newborn infants has a severe deficiency of thyroid function, while even more have mild or partial degrees. </li></ul><ul><li>If untreated for several months after birth, severe congenital hypothyroidism can lead to growth failure and permanent mental retardation. </li></ul>
  25. 25. Screening for ROP : is a disorder of the developing retina of low birth weight preterm infants that potentially leads to blindness. <ul><li>Infants with a birth weight of less than 1500 g </li></ul><ul><li>Gestational age of 32 weeks or less </li></ul><ul><li>Infants who required oxygen supply </li></ul>
  26. 26. Hearing Assesment <ul><li>Early identification of hearing loss and appropriate intervention within the first 6 months of life has been demonstrated to prevent many of these adverse consequences and facilitate language acquisition. </li></ul>
  27. 27. <ul><li>Family History of Hearing Loss </li></ul><ul><li>Perinatal Infection </li></ul><ul><li>Craniofacial Anomalies </li></ul><ul><li>Very Low Birth Weight </li></ul><ul><li>Hyperbilirubinemia (>340mmol/L) </li></ul><ul><li>Bacterial Meningitis </li></ul><ul><li>Ototoxic Medications </li></ul><ul><li>Syndrome Associated with Hearing Loss </li></ul><ul><li>Prolonged Ventilation </li></ul><ul><li>Severe Asphyxia at Birth </li></ul><ul><li>Admission to NICU </li></ul>Hearing Assesment
  28. 28. ECHOCARDIOGRAPHY <ul><li>GDM ON S/C INSULIN </li></ul><ul><li>GDM ON DIET CONTROL </li></ul><ul><li>ANY CLINICALLY HEARD MURMUR </li></ul><ul><li>LARGE FOR GESTATION AGE </li></ul><ul><li>NEWBORN WITH MACROSMIC FEATURES </li></ul><ul><li>SYNDROMIC NEWBORN (DOWN’S SYNDROME, </li></ul>
  29. 29. JAUNDICE
  30. 30. PALLOR