NEONATAL EXAMINATION : Summarized

NEONATAL EXAMINATION

                                                Dr Faeez Qasem

DIVIDED IN TO THREE ASPECTS:

General physical examination                                                  Organs and systems examination

                                                         Vital signs and anthropometric measurements

1.GENERAL PHYSICAL EXAMINATION

       -     Assess conscious level

             * Sleeping ,cries on stimulation                                    <  Normally

             * Lethargic,the patient can be aroused by moderate stimuli and then go back to sleep

             * Stupor , only vigorous and repeated stimuli will arouse the individual, then would go back to staring gaze

             * Comatose, unarousable ; proceed with modified pediatric Glasgow coma scale

-           Assess the Color

·         pink   or  acrocyanosis     ------------------------ Normally

·         cyanosis

·         central  /   peripheral

·         pale

·         jaundice

till face/ chest/ abdomen/ thighs/ soles(jaundice progress cephalon caudal in neonates :from face to foot : and so its serum levels can be judged)

-          Assess the Posture

Limbs flexed      --------------------------------- Normally

Limp

-           Assess for Dymorphism

Slanting eyes/ hypertelorisim / depressed nasal bridge

Low set ears/  micrognathia /

-           Assess Respiratory effort

-Normally  abdominothoracic movement ,   no nasal flaring or recessions

- Note for apnea or shallow breathing

- Assess Neonatal Reflexes
Moro’s Reflex, Rooting Reflex, Sucking Reflex.

2.  Vital signs and anthropometric measurements

        -     Temperature: Normally 97.7 – 99.5 F

        -     Heart rate :Normally 100- 190 b/m while awake and 85-90 b/m while sleeping

-          Respiratory rate: Normally 30 -59 b/m

-          Blood pressure

Different according to gestational age and weight

-          Weight :Normally between 2.5-3.5 kg in a term baby

-          Head circumference:Average is 35 cm

-          Length:Average is 50 cm

3. Systemic Examination

From head to toe but utilize when the baby is calm to auscultate the chest for heart and breath sounds. At birth occasional coarse crepitations may be heard in chest which are considered normal due to minute residual fluid in the lungs.
Murmurs are not usually audible at birth , and become audible after 1 to 2 weeks as the systemic resistance becomes higher than the pulmonary resistance and more flow related turbulence creates a murmur.

-          Skin

Inspect for abnormal pigmentation, nevi, hemangiomas

-          Head

Note the size, shape, swellings injuries.

Palpate the fontanels while in sitting position

Usually the anterior Fontanel is open with variable size and is flat, post fontanel could be open but usually less than 1 cm

-          Face

Inspect for any asymmetry, micrognathia

-          Eyes

Put the baby in vertical position in a low light environment that would make the baby open the eyes rather than trying to separate the eye lids

Note the position, symmetry, palpebral fissures, movement,

Sclera ------normally white and clear prematures can have dark sclera

 Conjunctiva ------- look for hemorrhage or inflammation

Cornea ---------  size normally less than 10mm if more may indicate glaucoma.

Pupils --------- shape and reaction to right.

Red reflex ---------- should be done in all newborns using an opthalmoscope, lens power 0 approximately 18 inches from the baby’s eyes if the light relfexed is white (leucocoria) that warrants  further evaluation.

-          Ears

Note the size, and development,  any anomalies

-          Mouth

Note the size of the mandible, tongue size and inspect the palate

-          Neck

Inspect the size, torticollis and note for any swellings, redundant skin, orweb

-          Chest

Comment on the shape, symmetry, expansion,  nipples

Auscultate and comment on

 intensity of first and second heart sounds         presence of added sounds           murmurs

Auscultate the breath sounds and comment on 

                             

     Air entry                type of breath sounds                                added sounds

-          Abdomen

·         Inspect the shape-------- normally it is slightly protuberant.

 Note for any distension

Examine the  umbilical stump and its base. Nothing should be applied on cord of neonate. Dry cord care is recommended. If there is cellulitis if the umbilical stump base topical antibiotics (such as fucidic acid may be recommended).

·         Palpate gentle superficially then deeply  while legs in flexion

Liver edge normally palpable 1-3cm and is soft with smooth edge, spleen may be palpable, palpate the kidneys using fingertips above and below the lower quadrants.

Any other palpable masses are abnormal  and requires investigation

-          Genitalia

Identify the gender

·         Female: examine the size and location of labia, clitoris, meatus, and vaginal opening.

·         Male: examine the presence of testes, penis size, appearance of scrotum, and the position of the urethral opening.

·         Ambiguous genitalia

   Phenotypic female include enlarged clitoris, fused labial folds, or palpable gonads.

   Phenotypic male include bifid scrotum, severe hypospadias, micropenis or cryptorchidism

-          Anus

Examine the location and patency

-          Trunk and spine

Palpate along the vertebral column to detect any anomalies. (Spina bifida occulta?)

Examine for the presence of sacral dimples:Overlying the coccyx are typically benign, whereas  deep and large more  than 0.5cm are above the gluteal crease ( more that 2.5cm from anal verge) may  be associated with neural tube defects ----Ultrasound should be performed

-          Limbs:

look for deformities, and movement,Inspect for syndactyly and polydactyly,Hips should be examined for developmental dysplasia of the hips.

All neonates are given Oral Polio Vaccine,BCG ,  Hep B vaccine , and Vitamin K  at birth in Pakistan.

Additionally, neonates born to HbsAg+ mothers receive Hep B immunoglobulins at birth.