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Newborn Assessment by Hadi Hospital NICU.


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How you should assess a Normal New Born...

Newborn Assessment by Hadi Hospital NICU.

  2. 2. General Appearance APGAR is a quick test performed on a baby at 1 and 5 minutes after birth. •The 1-minute score determines how well the newborn tolerated the birthing process. •The 5-minute score tells the doctor how well the newborn is doing outside the mother's womb.
  3. 3. General Appearance Scoring •0-3 points—the newborn is serious danger and need immediate resuscitation. •4-6 points—the newborn’s condition is guarded and may need more extensive clearing of the airway and supplementary oxygen. •7-10 points—are considered good and in the best possible health.
  4. 4. General Appearance A. Head Circumference Range: 32–37 cm (12.5–14.5 in) Approximately 2 cm larger than chest circumference B. Chest Circumference Average: 32 cm (12.5 in) Range: 30–35 cm (12–14 in) C. Body Length – Height Average: 50 cm (20 in) Range: 48–52 cm (18–22 in) Growth: 2.5 cm (1 in) per month for first 6 months D. Abdominal Circumference Average: 32 cm (12.5 in) Range: 31 to 33 cms ANTHROPOMETRIC MEASUREMENTS
  5. 5. General Appearance
  6. 6. General Appearance Weight Average: 3405 g (7 lb, 8 oz) Range: 2500–4000 g (5 lb, 8 oz–8 lb, 13 oz) Physiologic weight loss: 5%–10% for term newborns, newborns Growth: 198 g (7 oz) per week for first 6 months Weight is influenced by racial origin and maternal
  7. 7. Gestational Age Number of weeks that have elapsed since the first day of the last menstrual period to the time of birth. This is usually retrieved from mother’s Antenatal History.
  8. 8. Gestational Age • SGA- small for gestational age-weight below 10th percentile • AGA-weight between 10 and 90th percentiles (between 5lb 12oz (2.5kg ) and 8lb 12 oz (4kg). • LGA-weight above 90th percentile • IUGR-deviation in expected fetal growth pattern, caused by multiple adverse conditions, not all IUGR infants are SGA, may or may not be “head sparing” Classification of Size
  9. 9. Gestational Age
  10. 10. Gestational Age Physical Maturity The physical maturity part of the examination should be done in the first two hours of birth.
  11. 11. Gestational Age Neuromuscular Maturity – Ballards The neuromuscular maturity examination should be completed with 24 hours after delivery.
  12. 12. Physical Examination - Skin
  13. 13. Physical Examination - Skin Milia Petechiae
  14. 14. Physical Examination - Skin Facial Bruising It is more common when there is a tight nuchal chord, when the delivery is precipitous or difficult or when the infant in bundled. This facial appearance could be mistaken for cyanosis, but with a quick comparison to the color of the rest of the body, the diagnosis is obvious. This type of bruising resolves over the course of several days. Perioral Cyanosis
  15. 15. Physical Examination - Skin Milia Petechiae
  16. 16. Physical Examination - Skin Peeling Meconium Stained
  17. 17. Physical Examination - Skin Forcep marksForcep marks Vacuum Bruising
  18. 18. Physical Examination - Skin Jaundice
  19. 19. Physical Examination - Head A baby's head is easily molded. Many newborns have slightly lopsided heads. Sometimes a baby's head is molded unevenly while passing through the birth canal.
  20. 20. Physical Examination - Head Molding This picture shows what is usually noted primarily on palpation: the ridges that develop when one bone slightly overlaps the adjacent one during delivery. These overriding sutures are part of molding. Complete resolution is expected with time.
  21. 21. Physical Examination - Head Breech Molding With Breech positioning in utero, the head is in a position against the uterine fundus. This gives the newborn head molding that is flat on the top and elongated in AP diameter. As with any molding, this appearance will be improved significantly over the next few days.
  22. 22. Physical Examination - Head Bruising Bruising of the vertex of the head is a fairly common finding in newborns. The affected area may be rather large (6-8cm is not unusual) and may be various shades of red and blue. In some cases, traumatic blisters or bullae may be present. If a scalp electrode was used during delivery, a small scab is often visible is this area as well. No treatment is required.
  23. 23. Physical Examination - Head Caput Succedaneum There is some molding present here, but much of what is frequently mistaken for molding is caput (scalp edema). In the following photos, the extent of the edema is easily seen.
  24. 24. Physical Examination - Head Caput Succedaneum Firm, constant pressure in one spot is the easiest way to elicit the characteristic of pitting edema of caput. In the following photo, the extent of the edema is easily seen.
  25. 25. Physical Examination - Head After the pressure is released, the pitting indentation is clearly seen. Although caput can cross over suture lines (since it affects the scalp), it is often predominantly or entirely unilateral. Evaluating for pitting edema is a much more useful diagnostic tool than location. The following day, caput is much less prominent. This is consistent with the natural course of caput -- maximal at birth, with rapid resolution over the next 24 - 48 hours
  26. 26. Physical Examination - Head Cephalohematoma When digital pressure is applied, the fullness shifts from under the finger to the surrounding areas. In this photo, a bulge can be appreciated anterior and superior to the pressure point. When pressure is released, blood immediately refills this area and the appearance (unlike caput) is identical to the way it was before. In this baby, blood was ballotable across most of the left parietal bone.
  27. 27. Physical Examination - Eyes Eyelid Edema Most infants exhibit some degree of eyelid edema after birth. The puffiness may make it seem that the infant has difficulty opening one or both eyes, but with a gentle examination, the eye can be easily evaluated. Edema resolves over the first few days of life.
  28. 28. Physical Examination - Eyes Dysconjugate Eye Movements Dysconjugate eye movements is observed when the eyes appear to move independently. Eyes may transiently appear crossed or divergent.
  29. 29. Physical Examination - Eyes Subconjunctival hemorrhage is a frequent finding in normal newborns. It results from the breakage of small vessels during the pressure of delivery. The red area may be large or small but is always confined to the limits of the sclera. Subconjunctival Hemorrhage
  30. 30. Physical Examination - Eyes Congenital Glaucoma This infant presented with hazy bilateral corneal opacities on the initial newborn exam. The diagnosis of was relatively easy as there was a strong family historyof congenital glaucoma. Congenital Cataracts The opacities here occur behind the pupil, as the pupil is easily and clearly seen along its entire circumference.
  31. 31. Physical Examination - Tongue Ankyloglossia/Tongue-tie Tongue-tie occurs in approximately 4% of newborns. Many babies with this condition can breastfeed without difficulty, but in some cases, a tight frenulum makes latching on difficult.
  32. 32. Physical Examination - Tongue Epstein Pearl The small papule seen in the midline of the palate. It represents epithelial tissues that becomes trapped during the palatal fusion. It is very common and benign finding.
  33. 33. Physical Examination - Tongue
  34. 34. Physical Examination - Ears Ears Many variations in size and shape exist within the label of normal ear, but in general, the normal ear is one in which all structures (Helix, Antiehelix, Tragus, Antitragus, Scaphoid/ Triangular fossa and external auditory canal) are present and well formed.
  35. 35. Physical Examination - Ears Ear Tag A single, small ear tag is an occasional finding on physical examination. It is often inherited as familial trait.
  36. 36. Physical Examination - Ears Ear Pit PREAURICULAR PITS are often a subtle finding on Physical Exam. They are located at a superior attachment of the pinna to the face and may be unilateral or bilateral. Up to 10% of Asian infants will have pits. They are less common among Caucasians and African Americans. There is rare association between ear pits and brachio-oto-renal syndrome, so audiologic testing of these infant is recommended. But otherwise, this is considered benign finding.
  37. 37. Physical Examination - Ears Stahl's Ear Also known as Satyr ear, Spock ear, or Vulcan ear, this deformity of the pinna is characterized by a flat helix at the superior pole, a third crus extending into the helix, and a flattened scaphoid fossa.
  38. 38. Physical Examination - Ears Lop Ear This pinna deformity where superior edge of the helix is folded down. It may be improved with Splinting.
  39. 39. Physical Examination - Ears Microtia This pinna is not well formed and is smaller than a normal ear. Hearing evaluation is mandatory in these infants and referral to Paediatric ENT Specialist.
  40. 40. Physical Examination - Nose NOSE This picture shows a normal nasal appearance.
  41. 41. Physical Examination - Nose Positional Nasal Deformity An occasional finding on Physicial exam is an asymmetric appearance of a nose due to a positional deformity Most likely, this results from an unfortunate position in utero. The nares in this case are assymetric and slightly flattened towards the infant’s right, eventhough the septum is still centrally located.
  42. 42. Physical Examination - Nose
  43. 43. Physical Examination - Nose Choanal Atresia Appearance may LOOK NORMAL outside but symptoms include: 1. Chest retracts unless the child is breathing through mouth or crying 2. Difficulty breathing following birth, which may result in cyanosis (bluish discoloration), unless infant is crying 3. Inability to nurse and breathe at same time 4. Inability to pass a catheter through each side of the nose into the throat 5. Persistent one-sided nasal blockage or discharge Physical examination may show nasal obstruction. Tests that may be done include: 1. CT scan 2. Endoscopy of the nose 3. Sinus x-ray
  44. 44. Physical Examination - Mouth Micrognathia Some babies are born with an abnormally small jaw bone (mandible is another name for the lower jaw.) This condition is called micrognathia [my-kroh-NATH-ee- ah] and can be associated with a number of problems. Infants with a small jaw can have trouble eating and breathing. This is because the small jaw pushes the baby's tongue into the back of the throat causing blockage of breathing and swallowing.
  45. 45. Physical Examination - Mouth Bohn’s Nodules Bohn’s nodules are remnants of dental lamina (cells which are involved in tooth development) They are normally found on the labial (front) or buccal aspect of the upper alveolar ridge. Similar to Epstein pearls, there is no form of treatment needed and they will disappear over time. Both Epstein pearls and Bohn’s nodules are often mistaken as neonatal teeth.
  46. 46. Physical Examination - Mouth Neonatal Teeth Natal teeth are present in the oral cavity at the time of birth where as neonatal teeth erupt during 30 days of life. They might resemble normal primary teeth in terms of size and shape. However, they can be smaller, yellowish and root formation of the teeth may not be completed during the time of eruption. The lack of root development at this stage can usually cause the mobility of the neonatal tooth. Babies who have neonatal teeth are often associated with syndromes such as cleft lip and palate. Neonatal teeth can be removed easily with a cloth if they are interfering with your breast feeding.
  47. 47. Physical Examination - Respiratory Nasal Flaring Nasal flaring is when the newborn’s nostrils widen when breathing. It is often a sign that baby is having difficulty of breathing.
  48. 48. Comparison: Common in newborn with Tachypnea. A. Normal respiration. Chest and abdomen rise with inspiration. B. Seesaw respiration. Chest wall retracts and abdomen rises with inspiration. Physical Examination - Respiratory In this photo, taken during inspiration, the shadows between the ribs can be clearly seen. Retractions may or may not occur in combination with other signs of distress: nasal flaring, grunting, and tachypnea.
  49. 49. Physical Examination - CVS Murmur A heart murmur is not a disease; it is an extra or unusual sound heard by the Paediatrician in the newborn’s heartbeat during auscultation with a stethoscope. Murmurs range from very faint to very loud and sometimes sound like a whooshing or swishing noise. Normal heartbeat sounds – "lub-DUPP" or "lub- DUB" – are the valves closing as blood moves through the heart. It may be normal, or it could be a sign that something may be wrong. Most heart murmurs are harmless. Some are signs of heart problems, especially if other signs or symptoms of a heart problem are present.
  50. 50. Physical Examination - CVS Murmur A newborn with an abnormal murmur usually has other signs or symptoms of a heart problem, or due to congenital heart defects – heart defects present at birth. Congenital heart defects occur when the heart, heart valves, or blood vessels attached to the heart do not develop normally before a baby is born. A newborn with an innocent murmur has a normal heart and usually has no other signs or symptoms of a heart problem. Blood is flowing faster than usual through the heart and blood vessels attached to the heart.
  51. 51. Physical Examination - Abdomen Inspection by assessing the symmetry and shape of the abdomen.
  52. 52. Physical Examination - Abdomen Scaphoid Abdomen Scaphoid abdomen is when the abdomen is sucked inwards suggests the presence of a gross diaphragmatic hernia.
  53. 53. Physical Examination - Abdomen Distended with Hepatomegaly Infant had significant abdominal distention secondary to a palpable smooth mass extending from the right upper quadrant to the right pelvis; liver edge difficult to determine. Mild cutaneous venous congestion over the abdominal wall; no other lesions or rashes. Abdomen firm; no guarding or dullness to percussion. Bowel sounds normal. No splenomegaly or other palpable abdominal masses.
  54. 54. Physical Examination - Abdomen Variable Abdominal Veins
  56. 56. Physical Examination – Umbilical Cord Meconium Stained This cord was stained by the presence of meconium in utero, which gives it a dark green color. When an infant shows signs of meconium staining, it is evidence that meconium has been present in the amniotic fluid for some time.
  57. 57. Physical Examination – Genitorectal (A) Hypospadias is a birth defect that affects the foreskin and urethral tube. Instead of the urethra being on the tip of the penis, it is located on the underside of the penis. This abnormality occurs during fetal development when the urethra is growing. (B) A meatus located on the upper surface is called Epispadias. Both congenital conditions are usually repaired surgically at a young age if they are severe.
  58. 58. Physical Examination – Genitorectal Cryptorchidism is the condition that absence of one or both testes from the scrotum. This usually represents failure of the testis descend, during fetal development from an abdominal position, through the inguinal canal, into the ipsilateral scrotum.
  59. 59. Physical Examination – Genitorectal Anorectal atresia, also known as imperforate anus, is a birth defect of the anus that may require surgery to allow feces to pass out of the body. There is no known cause for the condition, but immediate care may be required to open the rectum within the first 24 hours after birth.
  60. 60. Physical Examination – Genitorectal (A) Anterior and (B) side view of ambiguous genitalia. Note, enlarged clitoris, giving genitalia a phallic appearance.
  61. 61. Physical Examination – Genitorectal Hymenal Tag Hydrocele
  62. 62. Physical Examination – Musculoskeletal Check the curvature of the spine for scoliosis, kyphosis, lordosis, spinal defects, and meningomyelocoeles. SPINE
  63. 63. Physical Examination – Musculoskeletal Scoliosis is an abnormal curvature of the spine. Instead of going from top to bottom in a relatively straight line, a spine with scoliosis may appear to have a side-to-side “S-shaped” or “C-shaped” curve.
  64. 64. Physical Examination – Musculoskeletal Kyphosis is an abnormal rounding of the spine that occurs in the upper and middle part of the back. Only the most serious cases will result in a hunchback or cause discomfort or breathing problems.
  65. 65. Physical Examination – Musculoskeletal A normal spine, when viewed from behind appears straight. However, a spine affected by Lordosis shows evidence of a curvature of the back bones (vertebrae) in the lower back area, giving the child a "swayback" appearance.
  66. 66. Physical Examination – Musculoskeletal Myelomeningocele is a neural tube defect in which the bones of the spine do not completely form, and the spinal canal is incomplete. This allows the spinal cord and meninges (the membranes covering the spinal cord) to protrude out of the newborn's back.
  67. 67. Physical Examination – Musculoskeletal In this condition there is a disruption in the normal relationship between the head of the femur and the acetabulum (hip socket). DDH can affect one or both hips. It can be mild to severe. In mild cases called unstable hip dysplasia the hip is in the joint but easily dislocated. More involved cases are partially dislocated or completely dislocated. A partial dislocation is called subluxation Developmental dysplasia of the hip (DDH), previously known as congenital hip dysplasia is a common disorder affecting newborn. The change in name reflects the fact that DDH is a developmental process that occurs over time. It develops either in utero (in the uterus) or during the first year of life. It may or may not be present at birth. Hip
  68. 68. Physical Examination – Musculoskeletal Extremity Fingers and/or toes are webbed or joined, and that the condition was present at birth.
  69. 69. Physical Examination – Musculoskeletal Left: polydactyly of the little finger (ulnar, post-axial); right: polydactyly of the thumb—also called thumb duplication (radial, pre-axial) Presence of additional toes or fingers also called Polydactylia or Polydactylism. (Greek, poly = many, dactyly = digit)
  70. 70. Physical Examination – Musculoskeletal Metatarsus Adductus is a foot deformity characterized by a sharp, inward angle of the front half of the foot. It is thought to occur as a result of the infant's position inside the uterus where the feet are bent inward at the instep.
  71. 71. Physical Examination – Neurological - Tone Passive Tone is generally assessed by observing the resting neonatal posture, and may be measured by the resistance to passive movement of the limbs. The normal resting posture and passive tone of the neonate varies with conceptional age (CA)
  72. 72. Physical Examination – Neurological - Tone The hypotonic term infant lies supine in a frog-like position with the hips abducted and the limbs abnormally extended. Spontaneous activity is decreased. Decreased muscle tone can also be recognized when the following are observed: •Vertical suspension Decreased tone of the shoulder girdle allows the infant to slip through the examiner's hands and the legs are extended.
  73. 73. Physical Examination – Neurological - Tone The hypotonic term infant lies supine in a frog-like position with the hips abducted and the limbs abnormally extended. Spontaneous activity is decreased. Decreased muscle tone can also be recognized when the following are observed: • Ventral suspension The infant appears limp with the extended limbs and the head drooping
  74. 74. Physical Examination – Neurological - Tone The hypotonic term infant lies supine in a frog-like position with the hips abducted and the limbs abnormally extended. Spontaneous activity is decreased. Decreased muscle tone can also be recognized when the following are observed: • Head control The head lags behind as the infant is pulled from the supine to sitting position and continues to lag when the sitting position is reached
  75. 75. Physical Examination – Neurological - Tone Hypertonia is associated with dysfunction of the pyramidal or extrapyramidal systems. Spasticity is a form of hypertonia that accompanies pyramidal tract dysfunction. It is characterized by an abnormal lengthening-shortening reaction of the muscle that is most apparent in the distal portion of extremities. • Opisthotonus persistent arching of the neck and trunk
  76. 76. Physical Examination – Neurological - Reflexes The Moro Reflex is present starting at 32 weeks gestation and disappears by three to six months of age. It is elicited by the sudden dropping of the infant's head in relation to the trunk and results in abduction and extension of the infant's arms and opening of the hands, followed by flexion. Moro Reflex
  77. 77. Physical Examination – Neurological - Reflexes The Plantar Reflex is well established by 32 weeks conceptional age and disappears by three months of age. During the normal plantar grasp, the toes plantar flex around the examiner's finger when it is brought across the ball of the foot.
  78. 78. Physical Examination – Neurological - Reflexes Asymmetrical tonic neck reflex is characterized by extension of the upper and lower extremities on the side to which the head and neck is turned with flexion of the contralateral upper extremity (fencing posture).
  79. 79. Physical Examination – Neurological - Reflexes Stroking the palm of a baby's hand causes the baby to close his/her fingers in a grasp. The grasp reflex lasts only a couple of months and is stronger in premature babies. Grasp Reflex Step Reflex This reflex is also called the walking or dance reflex because a baby appears to take steps or dance when held upright with his/her feet touching a solid surface.
  80. 80. Physical Examination – Neurological - Reflexes This reflex begins when the corner of the baby's mouth is stroked or touched. The baby will turn his/her head and open his/her mouth to follow and "root" in the direction of the stroking. This helps the baby find the breast or bottle to begin feeding. Root Reflex Sucking Reflex Rooting helps the baby become ready to suck. When the roof of the baby's mouth is touched, the baby will begin to suck. This reflex does not begin until about the 32nd week of pregnancy and is not fully developed until about 36 weeks.
  81. 81. Physical Examination – Neurological - Cry Cry assessment is easy to administer and provides an early window into the neurological status of the infant. Atypical cries can be viewed as a positive screen that should be referred for a full neurological work up. Therapy with parents to understand their infants who show atypical cry characteristics can facilitate a positive developmental context during infancy and young childhood.
  82. 82. A complete physical assessment is a vital step to be completed on a newborn straight after birth to determine wellbeing of the baby. Throughout herhospital stay, Physicians, Nurses and otherHealthcare Providers should continually assess the newborn forchanges in