baby examination

EXAMINATION OF THE NEWBORN BABY

The objective of doing an examination of the newborn baby is :-


Also to answer the naturally anxious parents after delivery to know if their baby is all right and appear normal?

The exam should be carried out twice or preferably 3 times during the 1st few days of life.


The first exam done in the hospital delivery room to:- -Identify any obvious major or minor malformations. -To asses gestational age, nutrition and vigor. -To determine how well the baby handles the transition from intra to extrauterine life, this can be done by assessing what

is called the APGAR scoring which is assessed at 1 and 5 min after birth and as follows:-

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The 2nd examination performed in the hospital newborn nursery and during the 1st 24 hours of life. The 3rd examination is carried out just before the family discharge to home.
Its main purpose is to discover any postnatally acquired problems such as infection or excessive jaundice & to detect any malformations that were not apparent at the 1st examination such as


forms of cong H dis whose murmur were not audible on the 1st day of life. To have successful examination of the NBB the baby should be naked, warm, well illuminated, and stable.The ideal time to examine the baby is a couple of hours after feeding, when the baby is not too deeply asleep as they often are after feeding,nor awake and screaming as just before a feeding.

General examination: First of all does the baby looks normal or abnormal, do the body proportions,head, face,and neck appears grossly normal,are there any obvious deformities or unusual appearance, is the baby in distress or resting comfortably.Also you have to look for signs of prematurity and postmaturity

What is the color of the skin is it pink or it is pale which may represent asphyxia, anemia, shock or edema.If he is cyanosed is it involving the hands and feet known as (acrocyanosis) especially when they are
cold which is a normal phenomena due to vasomotor instability, or the cyanosis is central one due to cardiac pulmonary or CNS disease.

Acrocyanosis

cyanosis

The extremities may be mottled with a net like pattern if they are cool.

Generalized mottling may signify acidosis or vasomotor instability.Another variationin skin color is the so called harlequin color change mostly seen in LBW infants where the baby’s skin is dark pink or reddish on the dependent half of the body while the upper half appears pale the two colors sharply demarcated along the midline (it is not pathological).

Look for petechiae which can be associated with increased intravascular pressure during labor or due to thrombocytopenia.


Mongolian blue spots: are blue well demarcated areas of pigmentation are seen over the buttocks, back and sometimes other parts of the body, they tends to disappear within the first year of life.

Mongolian spots

Fine soft immature hair lanugo hair frequently covers the scalp and may cover the face & shoulders in premature infants.

Salmon patch (nevus simplex): are small pale pink ill defined flat vascular lesions that occur mostly on the glabella, eye lid upper lip & nuchal area in 30-40% of normal NBB, they may persist for several months & become more visible with crying

Erythema toxicum: benign self limited, the lesion are firm yellow white, 1-2 mm papule or pustules with a surrounding erythematous flare they may be sparse or numerous peak incidence is in the 2nd day of life. Aspirate from the lesion show eosinophils infiltrate & absence of M.O. on a stained smear.

Milia:superficial epidermal inclusion cysts the lesion is firm papule of 1-2 mm in diam and pearly opalescent white, they are most frequently scattered over the face, gingiva and on the midline of the palate called Epistein pearl, it disappear spontaneously.


Miliaria: erythematous minute papulovesic- ular lesions may impact a prickly sensation the lesions are usually located to sites of occlusion or to flexural areas such as the neck, groin, and axilla. It is due to retention of sweat in occluded sweat ducts.


Portwine stain (nevus flammeus): dilated dermal capillaries macular sharply demarcated pink to purple, vary in size, head and neck are most commonly involved, usually unilateral.


Strawbery nevus: bright red capillary hemangiomas protuberant, compressable, any part of the body can be affected.



Cavernous hemangioma: ill define & more diffuse, cystic, compressable, the overlying skin color either normal or bluish.


Head: may be molded particularly if the baby is the 1st born. A rounded symmetrical head is seen if a baby is born by c-section or breach delivery, whereas babies born by vaginal vertex delivery usually has a head that is elongated occipitally with some overriding of the sutures & possibly a caput succedaneum or cephalhematoma.

Caput is a collection of subcutaneous oedema fluid caused by pressure during passage through the birth canal disappear within the 1st few days of life.

Caput succedaneum

Cephalhematoma is a subperiosteal collection of blood limited by the sutures of the skull it is soft to fluctuant it lasts for several weeks gradually gets smaller.

The anterior fontanel should be flat or slightly sunken when the baby is held in the upright position & is quite, the size of the ant fontanel 1-3 cm in diameter, post fontanel is either closed at birth or it is closed during the 1st 4 months of life.


Causes of large anterior fontanel:- -Prematurity. -Hydrocephalus. -Achondroplasia. -Hypothyroidism. -Intrauterine growth retardation. -Osteogenesis imperfecta. -Congenital rubella. -Hypophosphatasia. Trisomies (21,18,13). Rickets (in older infants).

Eyes:subconjunctival or retinal hemorrhage are not significant, occur during difficult labor.



conjunctivitis


Pupillary reflex should be present, the iris should be inspected for colobomas or heterochromias:-


Presence of bilateral red reflex exclude cataract or other intraoccular pathology. But white pupillary reflex (leukocorea) is seen in:- cataract, tumor (retinoblastoma), chorioretinitis, retinopathy of prematurity, persistent hypeplastic primary viterious.

-A cornea of more than 1cm (megalocornea) suggest congenital glaucoma:-

Mouth: natal tooth in the lower incisor position may be seen, these teeth are usually shed before the eruption of the deciduous teeth. The hard & the soft palate should be inspected for a cleft palate. Epstein pearl may be seen on the hard palate.

Neck: It is relatively short in the newborn, there may be goiter, cystic hygroma, sternomastoid tumor, webbing of the neck in female suggest Turner syndrome, both clavicles should be palpated for fractures.


Chest: breast hypertrophy is common & milk may be present. Asymmetry,erythema tenderness, induration suggest abscess formation. Widely spaced nipples suggest turner syndrome. Also observe the respiratory rate which is normally between 30-40/min in full term baby and in resting state, a rate of >60 is abnormal. The resp rate in preterm baby is higher, the premature infant may have a cheyne stoke breathing.

Breast enlargement

Heart: localize the heart to exclude dextro-cardia & there may be transitory murmur in normal heart and cong heart dis may not initially produce a murmur that will be present later. The rate may vary from 100 per min in relaxed sleep to 180 per min during activity, the pulse should be palpated in the upper & lower extremities to detect coarctation of the aorta.

Abdomen:the liver is usually palpable sometimes as much as 2cm less commonly the spleen tip may be felt , the abdominal wall is usually weak especially in premature infant , umbilical hernia is a common finding.

Omphalitis:- Is an acute local inflammation of the periumbilical tissue that may extent to the abdominal wall, the peritoneum, the umbilical vein and portal vessels, or the liver and may result in later portal hypertension.

omphalitis

Abdominal masses:- may be cystic as in:- 1. Hydronephrosis. 2. Polycystic kidney. 3. Adrenal hemorrhage. 4. Intestinal duplication. 5. Choledocal cyst. 6. Ovarian, omental, or pancreatic cyst.

Or the abdominal masses are solid as in: 1. Neuroblastoma. 2. Hepatoblastoma. 3. Teratoma. 4. Renal vein thrombosis(flank mass).


Abdominal distention at or shortly after birth suggests either intestinal obstruction or GIT perforation.later distention suggests lower bowel obstruction, sepsis, or peritonitis. A scaphoid abdomen suggests diaphragmatic hernia . Omphalocele is an abdominal wall defect through the umbilicus where a herniation of the abdominal viscera which are covered by the peritoneum.

Gastroschisis:

The abdominal defect lies to the right of an intact umbilical cord, and the intestine lie exposed without a covering sac, free in the amniotic fluid.


gastroschisis


Omphalitis: acute inflammation of the periumbilical tissues that may extent to the portal vein ending up by portal hypertension. Genitalia: look for ambiguous genitalia, vaginal discharge or bleeding may occur normally after birth, it is transient due to the effects of maternal hormones,


Anus: should be examined for unperforated anus although not all the cases are visible you may need to have gentle insertion of the little finger or a rectal tube. Extremities: hands &feet for polydactyly or syndactyly, nerve injury or fracture seen by observing spontaneous or stimulated movements of the extremities.

Clubfeet

Examine for developmental dysplaia of the hips:- The examiner adducts the flexed hip and gently pushes the thigh posteriorly in an effort to dislocate the femoral head. In a positive test, the hip is felt to slide out of the acetabulum.

The Ortolani test is the reverse of Barlow test: The examiner attempts to reduce a dislocated hip. The examiner grasps the child's thigh between the thumb and index finger and, with the 4th and 5th fingers, lifts the greater trochanter while simultaneously abducting the hip. When the test is positive, the femoral head will slip into the socket with a

delicate clunk that is palpable but usually not audible. It should be a gentle, nonforced maneuver.

Primitive neonatal reflexes:- Moro reflex: To elicit the reflex, the head is supported and allowed to drop to the level of the bed. There will be initial extension response of the upper limbs, followed by flexion and crying.

Moro reflex

2nd phase
1st phase



Grasp reflex: it is elicited by placing a finger or object in the open palm, the normal infant will grasp the object and with attempted removal the grip is reinforced.

Rooting reflex:- The infant opens the mouth and turns the head towards the pacifier or the examiner finger stimulating the cheek.

Sucking reflex:- Vigorous sucking movements are initiated when an object is placed in the infant's mouth..

Tonic neck reflex:- when manually turning the head to one side while supine, extension of the arm occurs on that side of the body corresponding to the direction of the face while flexion develops on the contralateral extremities.