for prospective parents, pediatricians, neonatologists

1. L S Deshmukh
DM ( Neonatology )
Professor ( Pediatrics )
GMC, Aurangabad

2. Assessing a newborn infant is like looking
at an iceberg.
Only the grossest of abnormalities are apparent
immediately. Some problems can be resolved by
careful examination and by investigations .

3. evaluation Checklist
 Physical and neurologic examination
 Medical and social history
 Vision and hearing screening
 Laboratory analysis of complete blood count,
chemistries
 serology screening for human immunodeficiency virus,
hepatitis B and C, and syphilis
 Genetic screening for cystic fibrosis, Fragile X and Down
syndromes
 metabolic screening
 TsH

4. Evaluation
 A comprehensive medical evaluation
thorough review of the medical history,
including
 an assessment of health risks
 a Neurological assessment and
 a complete , unclothed physical
examination

5. comprehensive medical evaluation
 not necessary during only one medical visit.
 complete the assessment of the Baby’
history
 Review laboratory findings
 Referrals
 Subsequent evaluations

6. The cardinal rule :
All information should be taken seriously, but
...
All information is suspect.

7. One of the greatest indicators of
the wellness of a newborn is the
general observation or gestalt that
a clinician obtains by simply
watching a baby before the start of
a physical exam.

8. Components of the General Physical
Examination
 A review of the medical history including:
family history, maternal, antenatal and perinatal
history,
infant, fetal and neonatal history
including any previously plotted birth-weight and
head circumference
 A review of parental concerns
 Feeding
 Ensure relevant information is available to
healthcare professionals

9. History
 Of particular importance are
 histories of the natural parents in order to assess
possible genetic disorders and
 information relating to the quality of the mother's
pregnancy

10. assessment of history
 Prenatal blood and urine test results of mother
○ Exposure to medications, illegal substances, alcohol,
tobacco
○ Gestational age, birth weight, length, head size; Apgar
scores
○ Prenatal concerns, neonatal complications
○ Newborn hearing screening results
○ newborn metabolic screening

11. Family history
○ Vision, hearing deficits
○ Genetic diseases
○ Concerns related to H/o eg,
sickle cell anemia, thalassemia,
Tay Sachs disease, lactose
intolerance
○ Mental health diagnoses

12. Components of the General Physical
Examination
 Examine fontanelle(s), face, nose, mouth including
palate, ears, neck and general symmetry of head,
vault, sutures, fontanelles and facial features
 Check eyes – opacities and ‘red reflex’
 Examine the neck and clavicles, limbs, hands, feet
and digits, assessing proportions and symmetry
 Cardiovascular system – heart rate, rhythm and
sounds, murmurs and femoral pulse volume

13. Components of the General Physical
Examination
 Initial Communication
 Give relevant information to parents before the
examination together with an opportunity to
discuss the forthcoming screens
 Whether the baby has passed meconium and
urine (and the nature of the urine stream in a boy)
 Observe the baby’s appearance including colour,
breathing, behaviour, activity and posture

14. Components of the General Physical
Examination
 Respiratory system – effort rate and lung sounds
 Abdomen – shape and palpate to identify any
organomegaly. Check condition of the umbilical cord
 Genitalia and anus. Check anus for patency. Check
genitalia for form and undescended testicles in
males
 Spine – inspect and palpate bony structures and
integrity of skin

15. Components of the General Physical
Examination
 Skin – note the colour and texture of the skin as well
as any birthmarks or rashes
 Central nervous system – observe tone, behaviour,
movements, and posture and elicit newborn reflexes
only if concerned
 Hips – check symmetry of the limbs and skin folds.
Perform Barlow and Ortolani’s manoeuvres
 Cry – note sound of baby’s cry
 Measurement of weight and head circumference

16. Head Size
 pay careful attention to the size of a child's head.
 The head circumference is the most important
measurement to follow in the pre adoption
evaluation.
 This measurement is the most accurate reflection
of brain growth during the first years of life.
 A small head (microcephaly) may suggest
malnutrition, fetal alcohol exposure, or a birth
defect, either genetic or resulting from the birth
process.

17. Genetic Testing
Because the primary justification for genetic testing
of any child is a timely medical benefit to the child,
genetic testing of newborns and children in the
adoption process should be limited to testing for
conditions that manifest themselves during
childhood or for which preventive measures or
therapies may be undertaken during childhood.

18. Genetic Testing
 In the adoption process, newborns and children
should not be tested for the purpose of detecting
genetic variations of or predispositions to physical,
mental, or behavioral traits within the normal range.
 timely medical benefit to the child should be the
primary justification
 If the medical or psychosocial benefits of a genetic test
will not accrue until adulthood, as in the case of carrier
status or adult-onset diseases, genetic testing generally
should be deferred.

19. Points to Consider: Ethical, Legal,
and Psychosocial

20. Imp Considerations
 Some parents expect the guarantee of a “perfect child.”
 not to create a “vulnerable Child”
 not the pediatrician’s role to judge the advisability of a
proposed adoption
 apprised clearly and honestly of any special health
needs detected now or anticipated for the future.

21. Imp Considerations
 the pediatrician should resist unreasonable
demands
 empathize with the parents’ anxieties and
concerns.
 The welfare of children should be the first
concern in the practice .

22. Adoptive Parents’ Interests
 the best interest of the child has been and continues to
be the legal benchmark of the adoption process
 laws also seek to protect the interests of the adoptive
parents and the birth Parents
 Distinguish Preventive and therapeutic medical
decisions from predictive testing.
 Disclose fully child’s medical background before
adoption
 predictive testing goes well beyond this standard
and is neither advisable nor necessary

23. Pediatrician’ Dilemma
 The mere threat of litigation may cause some Docs to
require testing without a clear understanding of their
duties.
 As the availability of tests increases, this pressure to
test based on a fear of litigation can be expected to
increase.
 Docs are not guarantors of the health of the children.
 They can only guarantee that the assessment &
information in their possession is disclosed

24. Imp : eye & ear
 Hearing
○ Validate newborn screening when available
○ Screen all children if possible, particularly
those with risk factors for hearing loss as well
as developmental (speech) delays .
• Vision
○ Eye examination as appropriate for age
○ Funduscopic examination for children with
birth wt <1500

25. Full-term newborns with
appropriate growth parameters
have the best chance for normal
growth and development in the
future.

26. Immunization issues
 written documentation for immunizations given
 ? vaccine potency, storage and handling, age when
given and reliability of accurate records.
 two alternatives to this problem.
- Either serologic testing may be done to
determine whether protective antibody levels are
present or
- the child may be re-immunized.

27. Laboratory tests
 a crucial part of the initial medical
evaluation.
 ensure that the child is free of
diseases that could have an adverse
affect on long-term health

28. Laboratory tests – Consider in all babies
 CBC
 TsH
 Metabolic screen
 TORCH
 HIV testing
 ? Karyotype

29. HIV Testing
 a positive virological test at 6 weeks for HIV or its
components
 usually by HIV-DNA PCR
 The diagnosis should be confirmed by a second
test on a separate sample should be repeated at the
earliest
 Positive antibody testing is not recommended for
definitive or confirmatory diagnosis of HIV
infection in children until 18 months of age

30. Laboratory tests
 reassuring when test results are
normal,
 convey to parents ( that we do not
know much ) about the quality
control standards
 Consider timing of the laboratory
tests

31. Potential Risk factors
 Prematurity
 Medical and developmental risks depend
on gestational age/birth weight
 AND complications in the nursery …
 Major and minor (but functionally
important) outcomes common
But long term adult outcomes may be
good

32. Potential Risk factors
Pediatr Clin N Am 52 (2005) 1247– 1269

33. Prematurity and Low Birthweight
Increased risk of:
 - cerebral palsy
 - vision and hearing
deficits
 - learning disabilities
 - ADHD
 - Asthma
 - Feeding problems

34. Look Specially for
 Congenital Heart
 Cleft Lip and Palate
 Limb deficiencies
 Genetic Syndromes
 Hip Dyslplasia

35. Specific Concerns or Diagnoses to Discuss With
Families (? Gray Areas)
 Family history of mental illness or mental
retardation
 Antenatal drug or alcohol exposure
 Prematurity
 Low birthweight
 Hepatitis B/C
 Maternal syphilis
 Developmental dysplasia of the hip
 Increased muscle tone

36. All the conditions
may not be manifest at birth
 At six weeks most congenital heart lesions
will have become apparent and
 by three months a reasonable assessment
of the infant’ neurological status can be
made

37. Remember
 Usually, the features that may make a normal
newborn look strange are temporary.
 In the eyes of the adoring parent, every infant
looks like “the perfect baby” anyway.

38. Child Information Sheet

39. Child Information Sheet

40. It is not the pediatrician’s role to
choose a Baby for the family or to
judge the advisability of a proposed
adoption / tubectomy. Rather, the
clinician should help the family make
a fully informed decision.