1. Newborn Examination
Dr. Mahr Shoblack , Dr. Hussam KhodairDr. Mahr Shoblack , Dr. Hussam Khodair
and Dr. Zuhair Aldajaniand Dr. Zuhair Aldajani
2.
3. Newborn examination objectives
Indication and importanceIndication and importance
Precautions prior to exam !Precautions prior to exam !
Systematic approachSystematic approach
Neonatal reflexesNeonatal reflexes
Normal variantsNormal variants
4. Indications
Earliest possible detectionEarliest possible detection of deviations.of deviations.
Establishes aEstablishes a baselinebaseline for subsequentfor subsequent
examinationsexaminations
Parents assurance and counselingParents assurance and counseling
5. Newborn examination
Immediately after birthImmediately after birth
Before discharge from maternity unitBefore discharge from maternity unit
Whenever there is any concern about theWhenever there is any concern about the
infant's progressinfant's progress
6. Newborn first exam
Apgar scoreApgar score
– Heart rate
– Respiratory effort
– Color
– Tone
– Reflex irritability
7. Examination precaution
Hand washing,hand washing ,handHand washing,hand washing ,hand
washingwashing
Thermal environmentThermal environment
Light and noiseLight and noise
Brief examination timeBrief examination time
11. General
Well, Distress or not?Well, Distress or not?
skinskin
– Pink is normal
– Acro cyanosis is normal
– Cyanosis
– Bruised part look blue
– Jaundice
– Common variants skin rash
• Erythema toxicum, mongolian spot, Benign Pustular
Melanosis
12. Erythema Toxicum
Erythematous macules and firm 1-3 mmErythematous macules and firm 1-3 mm
yellow or white papules or pustulesyellow or white papules or pustules
Etiology obscureEtiology obscure
Pustules contain eosinophils and arePustules contain eosinophils and are
sterilesterile
Appear in the first 3-4 days of lifeAppear in the first 3-4 days of life
– Range: Birth to 14 days
Benign and self limitedBenign and self limited
15. DD: Impetigo Neonatorum
Vesicular, pustular, or bullous lesionsVesicular, pustular, or bullous lesions
developing as early as day of life 2-3 up todeveloping as early as day of life 2-3 up to
2 weeks of life2 weeks of life
Lesions occur in moist or opposingLesions occur in moist or opposing
surfaces of skinsurfaces of skin
Unroofed lesions do not form crustsUnroofed lesions do not form crusts
Treat with antibioticsTreat with antibiotics
17. Mongolian Spots
90% of African infants, 81% of Asian, and90% of African infants, 81% of Asian, and
9.6% of Caucasian infants9.6% of Caucasian infants
Slate-gray to blue-black lesionsSlate-gray to blue-black lesions
Usually over lumbosacral area andUsually over lumbosacral area and
buttocksbuttocks
Accumulation of melanocytes within theAccumulation of melanocytes within the
dermisdermis
Generally fade by age 7 yearsGenerally fade by age 7 years
21. General
Obvious Dimorphism or malformationsObvious Dimorphism or malformations
E:g(Down syndrome ear tag neural tubeE:g(Down syndrome ear tag neural tube
defect )defect )
Tone & Movements:Tone & Movements:
Flexion of upper and lower extremitiesFlexion of upper and lower extremities
-Asymmetric movement-Asymmetric movement
– Brachial plexus and fractured clavicle
-Ventral, vertical suspension and head-Ventral, vertical suspension and head
control for tone assessmentcontrol for tone assessment
22. General inspection
Vigorous cry is assuringVigorous cry is assuring
Weak cryWeak cry
– sepsis, asphyxia, metabolic, narcotic use
HoarsenessHoarseness
– Hypocalcemia, airway injury
High pitch cryHigh pitch cry
– CNS causes, kernicterus
23. Head and Face
Shape of the headShape of the head
Fontanels?Fontanels?
Sutures?Sutures?
Eyes?Eyes?
Nose?Nose?
Mouth,lips,palate?Mouth,lips,palate?
Ears?Ears?
Neck?Neck?
24. Head
Forceps and vacuum marksForceps and vacuum marks
Caput succedaneumCaput succedaneum
– Boggy edema in presenting part of head
– Cross suture lines
– Disappear in few days
CephalhematomaCephalhematoma
– Subperiosteal
– Weeks to resolve
– Dose not cross sutures
30. Craniosynostosis
Definition: premature closure of one orDefinition: premature closure of one or
more cranial suture.more cranial suture.
Growth of the skull occurs parallel to theGrowth of the skull occurs parallel to the
suture(s) involvedsuture(s) involved
Early correction optimizes cosmeticEarly correction optimizes cosmetic
appearanceappearance
Can be part of syndromes:Can be part of syndromes:Crouzon's ,Crouzon's ,
Apert's syndromeApert's syndrome
31. Craniosynostosis
Types:Types:
– Sagittal synostosis results in
scaphocephaly
– coronal synostosis results in
brachycephaly
– coronal, sagittal, and
lambdoid synostosis results
in acrocephaly
– single suture on one side of
head can result in
plagiocephaly
www.uscneurolosurgery.com
39. Epicanthal folds
Many variations exist. The boy on the left
does not have folds. On the right image, the
effect of the epicanthal fold extending above
the inner canthus is illustrated.
48. Supernumerary Nipples
Found in males and femalesFound in males and females
Pink or brown papules along the milk line,Pink or brown papules along the milk line,
most commonly on the chest or abdomenmost commonly on the chest or abdomen
May contain breast tissue and in womenMay contain breast tissue and in women
carry the same relative neoplasia riskscarry the same relative neoplasia risks
Not considered a marker for otherNot considered a marker for other
anomaliesanomalies
64. Hip and Extremities
Erb’s palsy: extended arm and internalErb’s palsy: extended arm and internal
rotation with limited movementrotation with limited movement
Humerous fractureHumerous fracture
Digital abnormalityDigital abnormality
– Syndactaly, brachdactaly, polydactaly
Single palmar creaseSingle palmar crease
Hip dislocationHip dislocation
– Female, breach
77. CNS
Awakenes and alertnessAwakenes and alertness
moving extremitiesmoving extremities
Flexed body postureFlexed body posture
Minimal Head lagMinimal Head lag
Ventral suspensionVentral suspension
Vertical suspensionVertical suspension
79. Neonatal reflexes
Also known as developmental, primary,Also known as developmental, primary,
or primitive reflexes.or primitive reflexes.
They consist of autonomic behaviorsThey consist of autonomic behaviors
that do not require higher level brainthat do not require higher level brain
functioning. They can providefunctioning. They can provide
information aboutinformation about lower motor neuronslower motor neurons
and muscle tone.and muscle tone.
They are often protective and disappearThey are often protective and disappear
as higher level motor functions emerge.as higher level motor functions emerge.
80. Suck
Onset: ~28weeks GAOnset: ~28weeks GA
Well-established: 32-34 weeks GAWell-established: 32-34 weeks GA
Disappears: aroundDisappears: around 12 months12 months
Elicited by the examiner stroking the lipsElicited by the examiner stroking the lips
of the infant; the infant’s mouth opens andof the infant; the infant’s mouth opens and
the examiner introduces their gloved fingerthe examiner introduces their gloved finger
and sucking starts.and sucking starts.
81. Rooting
Onset: 28 weeks GAOnset: 28 weeks GA
Well-established: 32-34 weeksWell-established: 32-34 weeks
GAGA
Disappears:Disappears: 3-4 months3-4 months
Elicited by the examinerElicited by the examiner
stroking the cheek or corner ofstroking the cheek or corner of
the infant’s mouth. The infant’sthe infant’s mouth. The infant’s
head turns toward thehead turns toward the
stimulus and opens its mouth.stimulus and opens its mouth.
82. Palmar grasp
Onset: 28 weeks GAOnset: 28 weeks GA
Well-established: 32 weeks GAWell-established: 32 weeks GA
Disappears:Disappears: 2 months2 months
Elicited by the examiner placingElicited by the examiner placing
his finger on the palmar surfacehis finger on the palmar surface
of the infant’s hand and theof the infant’s hand and the
infant’s hand grasps the finger.infant’s hand grasps the finger.
Attempts to remove the fingerAttempts to remove the finger
result in the infant tightening theresult in the infant tightening the
grasp.grasp.
83. Tonic neck (Fencing posture(
Onset: 35 weeks GAOnset: 35 weeks GA
Well-established: 4 weeks PCAWell-established: 4 weeks PCA
Disappearance:Disappearance: 7 months7 months
Elicited by rotating the infantsElicited by rotating the infants
head from midline to one side.head from midline to one side.
The infant should respond byThe infant should respond by
extending the arm on the side toextending the arm on the side to
which the head is turned andwhich the head is turned and
flexing the opposite arm. Theflexing the opposite arm. The
lower extremities respondlower extremities respond
similarly.similarly.
84. Moro
Onset: 28-32 weeks GAOnset: 28-32 weeks GA
Well-established: 37 weeks GAWell-established: 37 weeks GA
Disappearance:Disappearance: 6 months6 months
The examiner holds the infant so that one handThe examiner holds the infant so that one hand
supports the head and the other supports the buttocks.supports the head and the other supports the buttocks.
The reflex is elicited by the sudden dropping of theThe reflex is elicited by the sudden dropping of the
head in her hand. The response is a series ofhead in her hand. The response is a series of
movements: the infant’s hands open and there ismovements: the infant’s hands open and there is
extension and abduction of the upper extremities. Thisextension and abduction of the upper extremities. This
is followed by anterior flexion of the upper extremitiesis followed by anterior flexion of the upper extremities
and and audible cry.and and audible cry.
87. Moro significance
An absent or inadequate Moro responseAn absent or inadequate Moro response
on one side : hemiplegia, brachial plexuson one side : hemiplegia, brachial plexus
palsy, or a fractured claviclepalsy, or a fractured clavicle
Persistence beyond 5 months of age is :Persistence beyond 5 months of age is :
indicate severe neurological defects.indicate severe neurological defects.
88. Stepping
Onset: 35-36 weeks GAOnset: 35-36 weeks GA
Well-established: 37 weeks GAWell-established: 37 weeks GA
Disappearance:Disappearance: 3-4 months3-4 months
PCAPCA
Elicited by touching the top ofElicited by touching the top of
the infant’s foot to the edge of athe infant’s foot to the edge of a
table while the infant is heldtable while the infant is held
upright. The infant makesupright. The infant makes
movementsmovements that resemblethat resemble
stepping.stepping.
89. Galant (Trunk incurvation(
Onset: 28 weeks GAOnset: 28 weeks GA
Well-established: 40 weeks GAWell-established: 40 weeks GA
Disappearance:Disappearance: 3-4 months3-4 months
The infant is held in ventralThe infant is held in ventral
suspension with the chest in the palmsuspension with the chest in the palm
of the examiner’s hand. Firmof the examiner’s hand. Firm
pressure is applied to the infant’spressure is applied to the infant’s
side parallel to the spine in theside parallel to the spine in the
thoracic area. The response consiststhoracic area. The response consists
of flexion of the pelvis toward the sideof flexion of the pelvis toward the side
of the stimulus.of the stimulus.
90. Babinski
Onset: 34-36 weeks GAOnset: 34-36 weeks GA
Well-established: 38 weeksWell-established: 38 weeks
Disappearance:Disappearance: 12 months12 months
PCAPCA
Elicited by stimulus appliedElicited by stimulus applied
to the outer edge of the soleto the outer edge of the sole
of the foot. The infantof the foot. The infant
responds by plantar flexionresponds by plantar flexion
and either flexion orand either flexion or
extensionextension of the toes.of the toes.
91. Postnatal assessment of gestational
age
Ballard ScoreBallard Score
Accuracy within 1-2 weeksAccuracy within 1-2 weeks
2 parts2 parts
– Neurologic characteristic
– Physical characteristic
Part of general examinationPart of general examination
92. Physical Maturity
Skin: thicker , less translucent, dry, peelingSkin: thicker , less translucent, dry, peeling
Lanugo:Lanugo:
– fine non pigmented hair all over 27-28 wks
– disappears gradually
Plantar surface: presence or absence of creasesPlantar surface: presence or absence of creases
Breast: areola developmentBreast: areola development
Ear cartilageEar cartilage
Eyelid openingEyelid opening
External genitaliaExternal genitalia
– Rugation, desend
– Prominent labia majora
93. Neuromuscular Maturity
PosturePosture
Square windowSquare window
Arm recoilArm recoil
Poplitteal anglePoplitteal angle
Scarf signScarf sign
Heel to earHeel to ear
94. Remember
Wash your hand prior to examinationWash your hand prior to examination
Inspect,Inspect,Inspect,then Touch.Inspect,Inspect,Inspect,then Touch.
Neonatal reflexes implicatonsNeonatal reflexes implicatons
Normal variationsNormal variations
Editor's Notes
Etiology is unknown
Smears from the pustules reveal polymorphonuclear leukocytes with absence of organisms .
DD: Erythema Toxicum
Pigment fade in 3w-3m
Low set ears?,Preauricular pits, External meatus tie
Natal teath
Choanal atresia
Epstein pearls
Cleft, submucosal
Crouzon,s: brachycephalic craniosynostosis, significant hypertelorism, proptosis, maxillary hypoplasia, beaked nose and possibly, cleft palate. Intracranial anomalies include hydrocephalus, Chiari 1 malformation, and hindbrain herniation (70
Apert syndrome;Craniosynostosis and symmetric syndactyly of the extremities are hallmarks of this syndrome. The clinical features include misshapen skull caused by coronal suture synostosis, wide-set eyes, midface hypoplasia, choanal stenosis, and shallow orbitspercent).