Neonatal Examination

Lecture two

Neonatal examination

Goals of neonatal examination :

Assess wellness of the newborn , screening for general abnormalities , birth trauma or acquired medical problems .
Assess the newborn for gestational age and appropriateness of size for gestational age .
When appropriate confirm infants normality to parents .
When appropriate demystify and reassure parents about common , benign variation in newborn physical examination or behavior .
Foster early infants –parent bonding and parental self-confidence .

Physical examination :

general appearance .important observation include body proportion , activity , quality of cry ,skin color , gross abnormalities ,unusual features and signs of respiratory distress , weight , length and head circumference measurement are obtained and recorded .
skin color may suggest cyanosis , pallor or jaundice .
normal peripheral vascular instability presentation include skin mottling . peri-oral cyanosis and cyanosis of the hand and feet , with lips , mucous membrane , nail beds and tongue remaining pink .
cracking or desquamation of the skin is normal in the term and postmature infants . in the term infant fine downy hair known as lanugo covers the skin , particularly the shoulder and upper back .
jaundice in the neonate is first visible on the face and as the serum bilirubin level rises it progress caudally to include the rest of the body and the sclera .natural sunlight should be used to inspect the skin for the extent of jaundice .
birth marks are common and visible at birth include flat vascular nevi (e.g.salmon patch nevus and port wine stains ) and Mongolian spots .raised vascular nevi usually become apparent several wks after birth ( e.g. capillary or strawberry hemangioma , cavernous hemangioma ) .
benign rashes are common :
erythema toxi has a flea-bite appearance with scattered erythematous macules that may contain papulopustular centers filled with eosinophils . this rash typically changes distribution from day to day .
milia are transient fin , pinpoint, yellow-white papules caused by retain sebum that typically cover the bridge of the nose, chin,and cheeks .
neonatal pustular melanosis consists of small vesiculopustules that are present at birth and rupture within a few days , leaving transient pigmented macules with scaly borders .
3-head and neck .the head and face frequently exhibit sequelae of the birth
process including bruises and asymmetries . most resolve spontaneously .facial features should be carefully inspected for size , placement and symmetry .
.palpation of skull determines contour , extent of separation or over riding of sutures and the size of the fontanelles .
molding of the head shape into elongated or asymmetric contour occurs secondary to intrauterine pressure or forces during labor .
cephalhematoma and caput succedaneum .
eyes : dimming the room light cradling the occiput in the examiner hand to left the baby head off the mattress may stimulate the baby to open her or his eyes .
conjunctival or sclera hemorrhage resolve with time and usually benign .
the presence of a red reflex exclude the presence of lens opacities .
up to 3 months the eyes normally may appear to cross intermittently.
Ears patency of the canal should be determined . malformed or low set ears may be associated with auditory or renal abnormalities .
Nose newborns are nose breathers obstruction of the nasal passage result in respiratory distress .
Mouth . should be examined by inspection and palpation . common minor abnormalities include small, white epithelial pearls along the gum margins . small white cyst termed epistein pearls along the median raphe of the hard palate . palpation may reveal a submucosal bony cleft of palate .
Neck must be hyperextended to inspect adequately for masses . congenital masses include goiter ,cystic hgroma , brachial cleft cysts and thyroglossal cysts . a webbing of the neck is seen in turner syndrome .
4-chest :
Clavicles are palpated for signs of fractures
Respiratory rate and pattern and the presence of chest asymmetry , retraction granting and nasal flaring must be determined in some healthy infants , transient crackles may be auscultated during the first few hrs after birth , unaccompanied by signs of respiratory distress . a normal pattern of periodic breathing with pauses up to 10-15 seconds unaccompanied by bradycardia or change in the color and tone may be observed .
Cardiac location is screened by determined that the heart sound s are loudest in the left chest . soft systolic murmurs are commonly heard in the first 24 hours of life , probably because of closing ductus arteriosus or normal changes in the pulmonary vascular resistance . these murmur usually disappear within 48 hrs after birth.
5-abdomen is convex and moves prominently with respiration .
A normal liver edge may be palpated 1-2 cm below the right costal margin , and the tip of the normal spleen may be palpated ate the left costal margin .
Because the most common abdominal masses in the newborn involve the genitourinary tract , palpation of the kidneys is important . the kidney may be palpated in the fingertips pressing deeply onto the lower lateral aspect of the abdomen with opposite hand rested under the baby back at a level just superior the iliac crest .
6 - inguinal region and genitalia :
Femoral pulses must always be palpated because diminished pulse suggest coaractation of aorta .
Male genitalia examination should include location of the urethral meatus , palpation of the testes and a for bulge in the groin or scrotum suggesting hernia or hydrocele .
Female genitalia examination should a certain the presence of urethral and vaginal opening as well as a normal sized clitoris to exclude ambiguous genitalia , imperforated hymen and vaginal atresia . in normal infants a transient swelling of the labia minora or a vaginal discharge that is mucoid or bloody results from the influence of maternal hormones .
Anus is inspected for patency and placement .
Extremities temporary flexion contractures at the elbow , hips and knees are seen in the term newborn as a result of intrauterine pressure effects .approximately 5% of all newborn have more significant limb deformities either deformities caused by positional abnormalities and intrauterine posture or true malformation .
Developmental dysplasia of the hip (DDH) .occurs in 1 in 1000 live birth and is much more common in girls and breech delivery .. asymmetry in lower limb length , placement of the medial thigh and gluteal folds or degree of hip flexion should raise suspicion for unilateral hip dislocation . when the hips are flexed to 90 degrees the legs normally can be abducted fully to touch the examining table " telescoping " of the femoral head with subluxation ( barlow ) maneuver or a palpable " thump " with ortalani maneuver suggest dislocation .
Erbs and klumpke palsy as a result of trauma to the brachial plexus result in asymmetric or diminished arm movements .
Back .the spine is inspected and palpated for sinus tract or overlying lesions such as lipomas , hairy tufts , or hemangiomas ,any of which may be signs of a covert neural tube defect .
Neurological examination . overall state of consciousness and the ease with which the infant makes transition from waking to sleeping or fussing to calming as well as strength of cry should be noted .primitive primary reflexes , cranial nerves .
Gestational age . and appropriateness of size for gestational age .
Gestational age may be determined by assessing certain physical and neurological characteristic that evolve in a predictable and progressive fashion during the later part of gestation . finding are assigned numerical values when compared to standard rating scales and summed totals are correlated to specific gestational ages .
After determining gestational age , weight ,length , and head circumference values are plotted on graphs that classified newborns according to appropriateness of size for gestational age .


CARE OF THE NEWBORN .

Fluid and electrolyte requirements .
Water represents 94% of the fetal weight at three months of gestation. At term ,water content has decline to 80% of the birth weight of the newborn.
Fluid loss and replacement :
Fluid loss.
During the first week of life , the extracellular fluid space contracts ,resulting in large reduction in body water . This water loss is responsible for 5% of the weight loss observed in term infants .the preterm infant may loss up to 10-15% of his birth weight .
Water loss through evaporation from the skin and from expired air is referred to as insensible water loss. Water loss through the urine and stool is referred as sensible water loss .stool accounts for a very small amount of sensible water loss .
Fluid replacement , is based on fluid loss and calculated as the sum of insensible and sensible water loss. Initial parenteral fluid replacement should be accomplished with a 10% of dextrose solution .
Fluid intake in term infants is usually begun at 60-70 ml/kg on day one and increased to 100-120 ml/kg by days 2-3.smaller , more premature infants may need to start with 70-80 ml /kg on day one and advance gradually to 150 ml/kg .day .
Volume and when given bol .
Electrolyte loss and replacement :
Sodium , potassium and chloride , are the principle salts that are lost through the urine and should be replaced accordingly .assuming an adequate urine output , replacement is begun 24 hrs after birth at the following rates:
(1)- sodium 1-3 mEq/kg/day .
(2)- potassium 1-2 mEq /kg/day .
(3)- chloride 1-3 mEq /kg /day .
b- Calcium .a decrease in serum calcium concentration frequently occurs
during the first week of life . serum calcium concentration below 7
mg/dl or below 3-3.5 mg/dl(ionized )bare considered hypocalcemia .
(1)- early neonatal hypocalemia . nearly all infants experience small decline in total serum calcium during the first few days of life owing to intrauterine parathyroid hormone suppression . early neonatal hypocalcemia rarely requires treatment except in preterm , infant of diabetic mother and asphyxiated infants .
(2)- late neonatal hypocalcemia (non physiological )is seen at the end of
the first week of life , may be due to :
(a)- increased phosphate ingestion , as occur in infant who are fed
cows milk .
(b)- hypomagnesemia .
( c)- hypoparathyroidisim .
(3)- therapy usually consists of calcium replacement with calcium
gluconate and treatment of underling cause of hypocalcemia .
( c )- other required mineral as phosphorus , magnesium , iron and trace
Metals .
Nutritional consideration . the composition of the nutritional solution and the route of delivery depend on the gestational age , general medical condition and possible special nutritional need of the newborn
Enteric nutrition .
(1)- Route of feeding :
(a)-the term infant can be breast- fed or bottle fed on demand as long as attention is paid to intake and fluid balance .
(b)- the otherwise healthy preterm infant who is between 34-38-wks should be fed every 3 hrs by breast bottle or gavage depend on the infant strength and alertness .
( c)- the preterm infant who is less than34 wks does not have a well coordinated suck and swallow reflex , and therefore should be fed via a feeding tube . the feeding may be gastric bolus every 2-3 hrs except in infant weighting less than 1000 g .
(d)- continuous gastric or transpyloric feeding is employed in the infant who weight less than 1000 g , because this infant has a limited gastric volume and may experience intermittent hypoglycemia and hypoxia when given bolus feedings .so trophic feeding can be given at 10-20 ml/kg/day and the volume increased accordingly .intravenous fluid are needed until feeding provide approximately 120/kg/day .

(2)- feeding solution .
The composition of the feeding solution depends on the presence or absence of special protein , carbohydrate , or fat requirements or intolerance which in turn depend on gestational age , gastrointestinal motility status , and the possibility of intestinal enzyme deficiencies or other metabolic disorders .
(a)- term infant who do not have complicating metabolic problem :
All of the water calorie , protein , and vitamin requirement of the normal term infant are met by human milk or 20 kcal/oz cows milk based formula .
The specific nutritional need of these infant for normal growth are as follow:
(!) the normal term infant needs 100- 120 kcal/kg /day to meet basal and growth requirement .
(!!) the infant also needs 2-3g/kg/day of protein for cellular growth which represent approximately 10% of total daily calorie intake .
(!!!) in addition ,40% of the daily calorie requirement should be derived from carbohydrates with remainder provided by dietary fat.
(b)- preterm infant :have decreased gastric motility and intestinal lactase activity as well as increased calcium and phosphorus requirement ,among other nutritional problems. The initial feeding solution should be a dilute whey –based formula or human milk as positive nitrogen balance is achieved , the infant may be advanced to a formula that is high in calcium ,phosphorus and protein , or to supplemented human milk .a 24kcal/oz formula is reserved for infants whose water intake must be restricted and infants who can not tolerate adequate feeding volumes .
( c)- infant with special metabolic needs . special formula solutions are available for infant with selected intestinal enzyme deficiencies ( sucrase – isomaltase deficiencies ) or metabolic diseases (PKU) .


(3)- Vitamins and mineral . commercially available formula now are fortified with vitamins ,minerals, and trace elements .therefore formula fed term infants do not routinely require vitamins or mineral addition .
(a)- special vitamins need .
(i) infants who are fed human milk may receive a multiple – vitamins supplement containing vit. A,D and C .
(ii) Owing to small body store and inadequate feeding volumes , preterm infants should routinely receive a multiple –vitamin supplement containing a the fat soluble vitamins ( A and D ) and the water –soluble vitamins (B and C ). In addition , the preterm infant who is less than 36 wks and should receive vitamin E to prevent hemolytic anemia .
(b)- special mineral and trace element needs :
(i) Iron .all infant require iron supplementation ,which may be obtained via iron –fortified formula or through a separate supplement . iron supplement may be delayed in the preterm infant until enteric feeding are tolerated . because of the increased bioavailability of iron in human milk ,iron supplementation in term breast –fed infants may wait the introduction of iron –fortified cereal at 4-6 months of age .
Folic acid also needed to be added for DNA and produce new cells .
( ii) fluoride .supplementation probably should not be given to infant younger than 6 months of age , even when otherwise indicated , because the danger of fluorosis .
( iii) calcium and phosphorus . the needs of the growing term infant are met by either commercial formula or human milk . owing to rapid bone growth , the calcium and of phosphorus requirements of the preterm infants are greater and necessitate special fortified formula or supplementation if fed human milk .

b. Total parenteral nutrition .
preterm and other sick infants may required total parenteral nutrition because of gastrointestinal disorders ( e.g. neonatal necrotizing enterocolitis ) as well as nongastrointestinal disorders ( e.g.respiratory diseases , sepsis ) an intravenous solution of dextrose , aminoacid , fat , vitamins ,and mineral can be administered by either peripheral or central venous access . appropriately used ,total parentral nutrition can provide adequate calories and protein to support the basal need and growth of the sick infants .