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cme paeds.pptx
- 1. NEWBORN EXAMINATION NUR ALYA INANI BT ROSNI
- 2. Newborn examination Vital sign Anthropometry measurement Physical examination
- 3. • Vital sign • Temperature ( N : 36.5 – 37.5 ) • Heart rate (N : 120-160) • Respiratory rate (N : 30-60) • Blood pressure • Capillary refill time ( <3sec at trunk ) • Anthropometry measurement • Weight • Length • Head circumference -- should be plotted in growth chart ( SGA : < 10TH centil/ AGA : Between 10th to 90th centile/ LGA : > 90th centile
- 5. Physical examination General examination: • Inspection of general appearance • awake/ sleep and active/ crying • Color: pink/ pale/ cyanosis/ jaundice/ plethora • Posture: • normal posture (flex UL and LL symmetrically) • abnormal posture (extended/ asymmetry)
- 6. SKIN • Evaluate for pallor, plethora, jaundice, cyanosis, meconium staining, petechia (general) • Skin is covered with lanugo hair (hair tuff) • Vernix caseosa • Mongolian spots • Nevus simplex • Nevus flammeus/ port-wine stain • Hemangiomas ( Cappilary / Cavernous ) • Milia
- 7. Nevus simplex Nevus flammeus/ port-wine stain Mongolian spots Vernix caseosa Lanugo hair Hemangiomas Milia
- 8. Head • Round and symmetry • Abnormal swelling or bruises of the scalp • Signs of trauma or laceration • caput succedaneum • cephalohaematoma • subglial haematoma • Fontanelle (bulging or sunken) –Anterior and Posterior fontanelle • Soft, non bulging • Suture:- • 2 sutures palpable which are coronal and sagittal sutures. • Separated or overidding • Abnormal: macrocephaly/ microcephaly
- 9. Face • Symmetry • Dysmorphic features • Ears: • Both ears are present • No low set ears • External auditory meatus is patent • periauricular tag/ pit • Eyes: • Sclera is white and not jaundice. • Conjunctiva is pink and not anaemic. • Red eye reflect- cataract, retinoblastoma • Nose: patency of each nostril to exclude choanal atresia • Mouth: • Central cyanosis • Cleft palate or cleft lips seen or not • Natal teeth • Rooting reflex present • Suckling reflex present. • Neck: • Short neck • Abnormal swelling such as cystic hygroma. • Clavicular fracture.
- 10. Upper Limb • All the 5 digits are present • Abnormalities: • syndactyly (2 or more digits fused together) • polydactyly (extra digit) • bradydactyly (shortening of the digit) seen • single palmar crease • Pulse rate • Check radio-radial delay and radio-femoral delay • Palmar grasp reflex
- 11. Chest • Respiratory rate • Chest movement - symmetrical bilaterally • Chest recession and audible grunting • Chest deformity - pectus excavatum or pectus carinatum • Inspection of breast tissue • Palpate for: • Apex beat • parasternal heave or thrill. • Auscultate for breath sound and heart sound
- 12. Abdomen • Move with respiration – abdomen breather • Shape of abdomen, which normally cylindrical shape • Scaphoid shape suggest diaphragmatic hernia • Palpation: • Soft, non- tender and no guarding • No mass palpable • Palpate for liver and spleen • If distended – obstruction/ mass • Umbilical cord • Pink/ infected • Any discharge or foul smelling • 2 arteries and 1 vein (couldn’t be seen if cord is dry) • Auscultate for bowel sound and renal bruit. • Abnormal: 1. omphalocele ( defect of the abdominal belly wall ) 2. gastroschisis(birth defect in which the baby's intestines extend outside of the abdomen through a hole next to the belly button)
- 14. Genitalia • Male – • Scrotum • Urethral meatus is present at the tip of the penis. • Testes • No hypo/epispadias, hydrocoele/ undesended testis or hernia • Female – • Labia edematoes • Clitoris enlarged • May have discharge- pseudomensturation • Anus patency • Palpate for femoral pulse
- 15. Lower Limb • Shortening of the limb • Presence of 5 toes are present in each leg • Any wide sandal gap • Creases on soles of feet • Premature < crease • Check for DDH • Barlow and Ortolani test • Look for CTEV- inward turning of the foot • Plantar grasp reflex
- 17. • Back • Stable spine • Any hyperpigmented skin - mongolian spot • Spina bifida - sacral dimple and no tuft of hair. • Abnormalities - scoliosis and kyphosis. • Moro reflex Symerical abduction and extension of arm, then adduction of arm to embracing position and returns to relaxed state
- 19. BALLARD SCORE NOZIE BINTI ROSSLI
- 20. • Evaluation of gestational age • Maternal menstrual history • Prenatal USG • Post natal assessment • Methods of post natal assessment • Dubowitz method - difficult to administer due to its complexity (assessment of 34 parameters) - over estimate GA in very preterm infants • Ballard method
- 23. • Ballard method Original New Scores range from 5 to 50 (26w - 44w) Scores range from -0 to 50 (20w - 44w) Score starts with 0 Score starts with -1 Inaccurate in extremely preterm More accurate Not include eye assessment Include eye assessment
- 24. NEW BALLARD SCORE • 2 major components 1. Neuromuscular maturity • Posture • Square window test • Arm recoil • Popliteal angle • Scarf sign • Heal to ear test 2. Physical maturity • Skin texture, colour and opacity • Lanugo • Plantar surface • Breast • Eye/ear • Genitals
- 26. 1) POSTURE • Observe in supine position at rest • Score is assigned based on degree 2) SCARF SIGN Grasp the hands and pull the arm across the chest and around neck The point on the chest which the elbow moves • full scarf (-1) • contralateral axillary line(0) • contralateral nipple line (1) • xyphoid process (2) • ipsilateral nipple line (3) • ipsilateral axillary line (4)
- 27. 3) ARM RECOIL • Flex the neonates arms for 5 sec • Fully extend arms by pulling on the hands and release 4) SQUARE WINDOW • Fully flexed infants hands on the wrist joint without rotating the wrist • Measured angle between forearm and palm
- 28. 5) POPLITEAL ANGLE • Holds the knee adjacent to the chest and abdomen, extend the leg with index finger • Measure angle between lower leg, thigh and posterior knee 6) HEEL TO EAR Grasp one foot and draw foot as near to head as possible
- 30. 1) EYE/EAR • Lids open and complete eyelash develop at term • <34w pinna stays folded • Incurving upper pinna at 34w • At 36w some cartilage present and will spring back
- 31. 2) BREAST • Areola raised by 34w • A 1-2mm nodule palpable by 36w and become 10mm by 40w
- 32. 3) SKIN Less transparent and thicker with increasing gestational age 4) LANUGO Fine downy hair covering fetus from 20-28w
- 33. 6) GENITALIA Male: • Testes descend by 28w • At 37w testes can be palpated high in scrotum and completely descended by 40w Female: Early gestation, clitoris prominent and widely separated labia
- 34. 6) PLANTAR SURFACE • 28-30w appear and cover anterior portion of plantar surface • Extend toward heels as GA increases
- 35. 20 w = -10 30 w = 15 40 w = 40 Score + 5 = GA + 2 Extremely preterm: <28w Very preterm: 28-31w 6/7 Moderate preterm: 32-33w 6/7 Late preterm: 34-36w 6/7 Term: 37w
- 36. Thank you
Editor's Notes
- HC measurement: From the most prominent part of occiput to just above the eyebrows/ frontal Acceptable 33-38cm HC >/= CC Length crown to heel, acceptable 48-52cm
- In full term baby: -symmetric -head turned to one side -flexed extremities -hand toghtly fisted with thumb covered by fingers #special concerned if: 1.asymmetric -fracture of clavice or humerus -Nerve injuries 2. Breech presentation -knee and legs straightened or tin FROG position Birth mark Mongolian spot Blue –green or gray pigmentation Lower back, sacrum & buttocks Disappears by 4 y/o age Port wine stain Capillary malformation Flat red to purple, sharply demarcated with dense area beneath the capillaries Usually at face a/w sturge-weber syndrome Others: Mottling ( cutis marmorata) Reticulated pattern of constricted capillaries and venules Due to vasomotor instability in inmature infant Bluish mottling- in response to chilling, stress or overstimullation Café au laif spot Tan or light brown macules or pathcees No pathological significant, if < 3cm in length and < 6 in number If >3 and > 6 cutaneous neurofibromatosis
- Abnormal swelling or bruises of the scalp 1.caput succedaneum (edematous swelling of presenting part) -due to pressure against cevix during crowning - Swelling subside within days 2. cephalohaematoma (subperiosteal haemorrhage) due to plonged second stage / instrumental delivery Resolve spontaneously within 4-6weeks Limited by suture line May complicated with: Anemia, jaundice Calcified( hard around edge but sof in centre- will resolve Hypotension Focus of infection:meningitis/ osteomyelitis 3. subglial haematoma (bleeding below epicranial aponeurosis, above the periosteum) Diffused head swelling that shift with repositioning and indents on palpation Swelling not limited by suture line-may extend to the orbits and the subcutaneous muscles of the neck Since the Subgaleal space is capable of holding large volume of the baby's blood, it may result in haemorrhagic shock. SAH- Subarachnoid hemorrhage Prolonged labour, forcep or ventouse delivery Presure exerted on baby head during labour +/- hematology disorder Features: apnea, seizure, lethargy Bulging of fontanelle, HC increase rapidly, lack of symmetric movement Ix: FBC, coagulation profile, CT brain or USG ranium Fontanelle – -Anterior fontanelle is diamond in shape Posterior fontanelle is triangular in shape Abnormal: macrocephaly/ microcephaly macrocephaly – hydrocephalus + dilated scalp veins, bulging anterior fontanelle, separation of suture lines, sun-setting eyes #craniosynostosis- premature closure of the fontanelles
- dysmorphic features such as low set ears, hypertelorism -distance between 2 medial canthi is > size of 1 eye up slanting eyes flat nasal bridge Sucking/ rooting reflex: -touch the lip. Cheeck or corner of the mouth= turn head toward
- Palmar grasp reflex Place finger in the palm of baby- curl or grasp the finger
- Male – Prepuce covers glans of penis- adherent to foreskin = phimosis Scrotum – enlarged = hernia/ hydrocyele (illumation test) Urethral meatus – ventral / dorsal = hypo/epispadias Testes – undesended= cryptorchidism Female – Vaginal discharge is not seen/ seen. Urethral meatus, vaginal opening ,clitoris, labia majora and labia minora are present. Anus is patent.
- Plantar reflex: Place finger at the base of the toes = toes curls downward
- Simple sacral dimple: -solitary dimple -<5mm in diameter, < 2.5 cm from the anus -midline location No visible drainage -no associated cutaneous stigmata such as hemangioma, skin tag or tail no need firther imaging eg. Xray or USG of the back
- Maturational assessment of newborn Ideally within first 24 hours
- Neuromuscular signs more reliable than physical Higher GA more brain growth neuro muscular more mature
- Increase passive flexor tone, decrease joint laxity (in centripetal direction) higher score In caudo cephalad : lower limb mature first then upper limb 1 sign = general 3 signs = upper limbs 2 signs = lower limbs Popliteal angle = -1 to +5 Posture and arm recoil = 0 to +4 Others = -1 to +4
- POSTURE: baby should be in well flexed, if more extended, flaccid – premature infant SCARF SIGN: decrease distance pull of arm to contralateral side – higher score – more mature
- ARM RECOIL: pull arm down, should recoil back SQUARE WINDOW: wrist flexibility, prem cannot bend, term baby can bend wrist until hit the arm (max passive flexor tone, min passive extensor tone)
- POPLITEAL ANGLE: flex hip joint, if can go to face, more premature HEEL TO EAR: bend knee, try to extend the knee, if can go to ear, more premature
- Eyes/ear Breast bud Skin Lanugo Genital male Genital female Plantar surface Score -1 to +4 for all -1 to +5 for skin
- Eye ear: thin and fused thick and stiff cartilage
- Breast bud: imperceptible to developed with areolar
- Skin: thin and friable leathery and wrinkled Lanugo: in very premature no lanugo
- Genitals: smooth scrotum pendulous testes with rugae prominent clitoris majora covering clitoris and minora
- Plantar surface: no creases crease entire soles
- 26 = 34w 27 = 34w 28 = 35w 29 = 35w