Newborn Examination

1. Newborn Examination
Dr. Mahr Shoblack , Dr. Hussam KhodairDr. Mahr Shoblack , Dr. Hussam Khodair
and Dr. Zuhair Aldajaniand Dr. Zuhair Aldajani

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

8. General(Growth parameters(
 Weight (Naked)Weight (Naked)
 Length(straight)Length(straight)
 Head circumference(3 measurements)Head circumference(3 measurements)

10. Vital Sign
– Heart Rate
HR 120-160
 Respiratory RateRespiratory Rate
RR 40-60RR 40-60
 TemperatureTemperature
36.5-37.5 C36.5-37.5 C
 Blood PressureBlood Pressure

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

13. Erythema Toxicum

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

16. Impetigo Neonatorum

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

18. Mongolian Spots

19. Benign Pustular Melanosis of the
Newborn

20. Pustular Melanosis

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

25. Cephalhematoma

26. Caput Succadaneum

27. Newborn Scalp Hematomata

28. Head
 Head circumferenceHead circumference
 Shape :Molding, Brachycephaly: flatShape :Molding, Brachycephaly: flat
occiputocciput
 Widening of sutureWidening of suture
 FontanellesFontanelles
 Head auscultation: bruitsHead auscultation: bruits

29. Infant skull

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

33. Craniotabes

36. Orbital Placement
Hypertelorism is defined by an increased
interpupillary distance. Hypertelorism
(right); normal (middle); hypotelorism (left).

37. Palpebral Fissure Length
Often this length is actually measures and
plotted. Short (left); normal (middle); large
(right)

38. Palpebral Fissure Slant
This varies greatly with ethnic origin. Up
(left); normal (middle); down (right)

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.

40. Sternomastoid Tumor

44. Chest and Abdomen

45. Chest
 Distress signs(Grunting,Tachypnea,NasalDistress signs(Grunting,Tachypnea,Nasal
flaring,asymetric chest rise,supra-sternal,flaring,asymetric chest rise,supra-sternal,
intercostal, sub costal retraction).intercostal, sub costal retraction).
 Deformities(Pectus excavatum, carinatum)Deformities(Pectus excavatum, carinatum)
 AuscultateAuscultate
– Air entry, symmetry
– Early crepitation sound is transmitted upper sound
– Late inspiratory crepitation

46. excavatum pectus

47. chest
 Suprmammary nippleSuprmammary nipple
 Breast hypertrophyBreast hypertrophy
– Milk production
– No redness

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

49. Supernumerary Nipples

51. Heart
 HR 100-160 beats/minHR 100-160 beats/min
 Color, perfusion,Central cyanosisColor, perfusion,Central cyanosis
 MurmurMurmur
 Single S1Single S1
 Splited S2Splited S2
– No split ;single ventricle, pulmonary hypertension

52. auscultation area of neonatal heart

53. Femoral Pulses

54. Abdomen
 InspectionInspection
– Scaphoid
– Distention
– Abdominal wall defect (gastroschisis)
 Palpation;Palpation; babybaby sucking and use warm handssucking and use warm hands
– Kidneys are normaly palpable
– Liver 2-3 cm
– Spleen palpable
– Umbilical vessels
• 2 artery, one vein
– Hernias ; umbilical and inguinal

56. umbilical cord cyst

58. diastasis recti

59. Genitalia
 Penile sizePenile size
 Hypospadias, epispadiasHypospadias, epispadias
 TestesTestes
– 2% crypoorchid
– Hydrocele
 Female:Female:
– Prominent clitoris and minora
– Vaginal skin tag
– Vaginal discharge /blood
– Labial fusion
 Anus :Anus : Patency and locationPatency and location

61. Hydrocoeles

62. Inguinal Hernias

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

67. Subluxation of the Hip

68. Subluxation of the Hip

69. DDH Examination

70. Feet and Back
 Feet deformitiesFeet deformities
 Back and spineBack and spine
– abnormal curvature
– Sinus tract, tuft of hair

71. Lumbar hair tuft & haemangioma

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

78. Neonatal Reflexes
‫القادمة‬ ‫المحاضرة‬ ‫حنان‬ ‫للدكتورة‬ ‫تكملة‬‫القادمة‬ ‫المحاضرة‬ ‫حنان‬ ‫للدكتورة‬ ‫تكملة‬

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.

85. Moro

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