Neonatal Examination

Overview

• Prior history

• May not be possible at one setting

• Need to look back

• Interobserver variability

• Need of measurement

• Examination at birth

• Examination of a sick baby

• Examination at discharge

• Examination in follow up

State of awakefulness: Brazelton (1984)

• State I – Deep or Quiet sleep (regular breathing with eyes closed, no eye movements, no spontaneous activity)

• State II – Light or Active sleep (irregular respiration with eyes closed, rapid eye movements)

• State III – Drowsy or semi dozing; eyes open or closed, activity variable, movements usually smooth

• State IV – Alert with bright look; minimal motor activity

• State V – Eyes open, considerable motor activity

• State VI – Crying

Babies should be examined about 1 hours after the last feed when baby is in State 3 or 4 of wakefulness.

Vitals

• Heart rate/Pulse

• RR

• Temperature

• Blood pressure

• Saturation/ PI

Heart rate

• Should be counted for full 1 minute using a stop watch.

• Normal heart rate is 120 – 160 beats/min

• To be written as HR/PR /min.

• Regular and all peripheral pulses well felt, both femorals are palpable.

RR

• Should be checked for complete 1 minute with stop watch.

• Normal rate is 40 – 60/min.

• Look for apnea and pattern of breathing.

• Periodic breathing

• Look for signs of respiratory distress -audible grunt, Chest retractions, flaring of alae nasi

RDS Scores

• Silverman Anderson Score – 5 parameters, not correlated with blood gas

– 7 abnormal – Impending respiratory failure

• Downe’s score – 5 parameters (RR, Chest retraction, Cyanosis, Air entry, Grunting). 6 is abnormal. Correlated with blood gas.

• Acute care of high risk newborn

Downe’s score

A score of >6 is indicative of impending respiratory failure.

Silvermann score

A score of >6 is indicative of impending respiratory failure.

AcorN respiratory score

Temperature

• Clinical- tactile method

• Thermometer

• Thermister probe- open care/incubator

Blood pressure

• Non invasive- oscillomatric method

• Invasive-Intraarteial, most accurate

• Choose appropriate extremity (typically upper arm)

• Take care of intravenous lines, spo2 monitor

• Choose appropriate cuff size depending upon arm circumference

• Four limb blood pressure for conditions

• Use nomograms-Zubrow

Saturation

• Pulse oximetry

• Preferable Masimo SET technology

• Pre and post ductal difference for PPHN

• Caution in cold extremities and shock

• Correlate with arterial Sao2 and Pao2

• Low Spo2 and normal Pao2-methemoglobinemia

• Co-oximetry

Perfusion

• CRT – Capillary refill time (normal < 3 sec)

• Press at sternum with thumb for 5 seconds by counting 1 and 2 and 3 and 4 and 5, then leave and look for refilling and count as seconds.

• Perfusion index-serial values

Anthropometry

• Weight

• Length

• OFC

• Ponderal index

• US:LS

Weight

• Baby’s clothing and ornaments should be completely removed

• Use electronic weighing scale providing results in three digits to decimel

• Frequent monitoring in VLBW, AKI, Edema, sodium abnormalities

• Weekly plot on growth chart

Length

• Measured using infantometer

• Make the baby lie supine with legs fully extended. Head end at the fixed end of infantometer.

• It is necessary to press the knees lightly back to ensure maximum length. Stretching of single feet is as accurate

• The feet should be pressed against the movable foot piece with ankle fixed to 900

• Usually two persons are needed to hold the baby correctly and take measurement

OFC

• Measured using a non stretchable plastic measuring tape.

• Should be measured after 24 hours of birth (changes occur due to moulding during labour, scalp edema).

• Measured at maximum circumference around the glabella and supraorbital ridges and the occipital protuberance.

• Measure head circumference by overriding techniques

• Record three times and calculate the average

• Normal head circumference in a term baby is 33 – 35 cm.

Ponderal index

• To be done in case of IUGR/SGA

• PI = birth weight x 100

(Crown heal length)3

• Weight to be taken in grams and length in cm

Gestational age assessment

• Best guide – 1st trimester USG combined with mother’s last menstrual period

• Clinical methods have 95% CI of 17 days

Antenatal USG have 95% CI of less than 7 days

• Clinical methods: Physical criteria + Neurological criteria

• Dubowitz and Dubowitz – 11 physical criteria + 10 neurologic findings

• Ballard’s score – 6 physical and 6 neurological criteria. Better than Dubowitz as requires less time.

• Revised Ballard’s score – Includes assessment of extremely premature.

• Physical criteria help in distinction of infants with gestational age > 34 weeks

• Neurological criteria helps to differentiate infants b/w 26 – 34 weeks because physical changes are less evident

• Clinical methods accurate only to 2 weeks with tendency towards overestimation in extremely premature infants.

Head to toe examination

Skull

• Size

• Shape

• Swellings/Birth trauma

• Sutures

• Fontanelles

• Sound-bruit

• Shunt-functional

• Sunset sign

Size of head

• Microcephaly – If head circumference < 3 SD for the mean gestational age.

• Macrocephaly – Head circumference > 2 SD for the mean gestational age

• Causes

Abnormal shapes

• Caput succedanum• Cephalhematoma• Subgaleal hemorrhage• Encephalocele• Dolicocephaly• Brachycephaly• Anencephaly• Depressed fracture• plagiocephaly

Cephalic index = Maximum biparietal diameterMaximum occipitofrontal diameter

Normal cephalic index is 75 – 85%Dolicocephaly – AP > transverse (CI < 75%), due to premature fusion of saggital sutureBrachycephaly – Transverse > AP (CI > 85%)

Sutures and fontanelles

• Sutures (coronal, lambdoid, sagittal, frontal [metopic]): Strong, flexible fibrous tissue connecting the five major bones of the skull

• Squamosal suture should not be palpable in full term infants and

• If it is open it should be considered pathognomonic of impending hydrocephalus

• Premature infants may have wide sutures

• Causes of wide sutures

Sutures and fontanelles

• Wider spaces at the intersections of the sutures.

• The size of the fontanelles varies widely. • Anterior: Located at the junction of the sagittal and

coronal sutures, diamond shaped, measuring from 4 – 6 cm at the largest diameter (Duc and Largo, 1986).

• Closure – 9 – 18 months

• Depressed in dehydration

• Bulging

• Large anterior fontanelle

Sutures and fontanelles

– Posterior: Located at the junction of the lambdoidand sagittal sutures, usually triangular, and barely admits a fingertip.

– A third fontanelle may be located between the anterior and posterior fontanelles; varies in size and may be associated with congenital anomalies

Transillumination of skull

• A flare > 1.5 – 2 cm is considered positive in frontal area and > 1 cm in popliteal area.

• It is indicative of

– subdural effusion

– subdural hematoma

– hydrocephalus,

– hydranencephaly

– porencephaly

Eyes

• Hold the baby up and more gently forward and backward.

• This maneuver as a result of labyrinthine and neck reflexes make baby’s eyes open.

Eyes

• Position: upward/ downward slant• Size: Interpupillary distance• Epicanthal folds • Cataract• Purulent discharge/ redness• Subconjunctival hemorrhage• Iris-heterochromia, brushfeield spots, coloboma• Pupil-size, irregularity, asymmetry• Cornea-lusture, opacities,megalo/micro• Eyelid-ptosis

Ears

• Shape

• Size

• Position-low set ears

• Feel of cartilage

• Preauricular skin tags

• Hairy ears

• Hearing

Nose

• Shape-triangular, pointed nose

• Nasal bridge

• Size

• Position on the face

• Patency-Choanal atresia

• Presence of swelling over the nasolacrimal duct-Dacryocystocele

• Nasolabial folds-facial palsy

• Philtrum-smooth in syndromes

Mouth and chin

• External observations– Microstomia/macrostomia– Short and receding chin– Deviation of mouth when opens– Cleft Lip

• Internal examination– buccal surface– Palate– Uvula– back of mouth.– Sucking/Gag

Mouth and chin

– Epstein’s pearls:.

– Mucocele:

– Natal teeth

– Ranulae:

– Macroglossia

– Ankyloglossia

Neck

• Neonatal neck is relatively short• Inspect for shape, size, symmetry • Palpate for any lump or swelling and tested for full range

of movements• Rooting reflex –turning of neck to both sides• Short neck• Swellings in neck-cystic hygroma, sternomastoid tumor• Torticollis• Webbing • Redundant skin fold• Clavicle-fracture, absent

Skin

• Pallor• Cyanosis• Plethora• Jaundice –kramer’s rule• Edema• Mongolian spots• Milia• Erythema toxicum• Harlequin phenomenon • Cutis marmorata• Acne neonatorum• Petechiae• Hemangioma• Nevus• Scerema• Blister

Spine

• Curvature

• Defect

• Tuft of hair

• Swelling

• Neural tube defect

Genitals and perineum

• Gender• Maturity• Hernial sites• Hydrocoele• Torsion• UDT• Hypospadias• Amnigous genitila• Anorectal malformation• Abnormal openings• Patency• Flat bottom

Upper limbs

• Inspect arms for shape, posture, symmetry and size.• In normal babies upper limbs reach up to midthigh when the arms are

adducted.• Arm length is distance from acromian to tip of 3rd finger with arm in full

extension and parallel to body.• Short limbs are seen in

– Rhizomelic(proximal shortening -upper arm)– Mesomelic (middle shortening -forearm)– Acromelic(distal shortening – palm & fingers )

• Long limbs seen in– Marfans– Kleinfelters

• Examine for the movements• Lack of active movements and pain on passive movements suggest

fracture/infection• Erb’s palsy (C5,6and sometimes C7)

Lower limbs

• Measurements useful to evaluate skeletal dysplasia

• Total lower limb length is the distance from trochanter to lateral malleolus

• Upper segment/lower segment ratio -Normal ratio in neonates is 1.7:1.

• Lower segment is measured as distance from pubic symphysisto sole

• Upper segment is (length - lower segment distance)

Skeletal examination

– Polydactyly-Extra finger/toes. Preaxial (towards thumb),Postaxial(towards side of little finger).

– Campylodactyly –fixed flexion of interphalengeal joint

– Clinodactyly-deflection of finger

– Amputation of finger-amniotic band syndrome

– Contractures of joints-congenital arthrogryposis, myotonic dystrophy

– Hemihypertrophy- wilms tumour,AV fistula,neurofibramatosis

– Syndactyly- cutaneous,bony

– Club foot-planter flexion, inversion and adduction of foot. Either postural or bony

– Calcaneovalgus deformity (dorsiflexion &eversion of foot)

– Rocker bottom foot-seen in Edward syndrome (Rocker Bottom shape, short hallux)

Skeletal examination

• Developmental dysplasia of Hip

• Ortolani

• Barlow

• Swelling of joints-compare

• Sinus

• Osteomyelitis

Ortolani and Barlow test

Systemic examination

Resp System

• Supernumerary breast or nipple is common• (10%)• Breast enlargement secondary to maternal

hormones• Unilateral absence or hypoplasia of pectoralis major• Widely spaced nipples• Chest deformity• Respiratory pattern• Chest movement

• Auscultation-air entry, added sounds, grunt

CVS

• Tachypnea,tachycardia

• Increased pericordial activity

• Cyanosis: hyperoxia test

• Auscultation of heart sounds, murmurs or Irregular heart rhythm

• Perfusion: Capillary refill time

• Palpate femoral pulsation: absent in coarctation of the aorta

• Bounding pulses often indicated PDA

Abdomen

• Organomegaly: liver may be palpable 1-2 cm below the costal margin .spleen is at the costal margin

• Masses

• Distension , scaphoid abdomen

• Umbilical stump: bleeding , meconium straining,

granuloma, discharge, inflammation

• Omphalocele and Gastroschisis

• Bowel sounds

Neurological examination

• Higher function

• Cranial nerves

• Posture and tone

• Reflexes

• Abnormal signs

Higher functions

– Alertness

– Irritability

– Consolability

– Cry

– Aversive reaction

– Eye appearance

– Habituation

– Auditory orientation

– Visual orientation

Posture and tone

– Posture

– Arm recoil

– Arm traction

– Leg recoil

– Leg traction

– Popliteal angle

– Head control 1 (flexor tone)

– Head control 2 (extensor tone)

– Head lag

– Ventral suspension

Posture

• Infant should be supine and head in midline

• Gently uncover the baby and take off or loosen diaper with minimal disturbance

• Posture should be recorded when infant is in quiet state and is greatly influenced by crying

• If no recording can be made in a quiet state, it should be noted

Tone Assessment

• Passive tone : Evaluation of how easily and fully muscle stretch as various segments are moved and infants lie passively.

Scarf sign, square window, arm recoil, adductor

angle, popliteal angle, ankle dorsiflexion, heel to ear.

• Active tone : Assessment of infant’s response to change in position or stimulation to elicit reflex

Placing, stepping, palmar grasp, pull to sit

Tone in limbs

• Assessed from arm and leg traction, recoil and popliteal angle

• Infant should be in supine position and head should be midline

• All items should be scored separately for two sides

• Difference is recorded by looking for asymmetry

Upper segment : Passive tone

Scarf sign

Hold the infant in semi reclining position by supporting neck and hand with one hand

Draw one hand and arm as far as possible across the chest towards the opposite shoulder

Normal response is symmetry between two sides and reaching as expected for gestational age

Arm Recoil

• Arms are extended by pulling hands alongside the trunk

• Hold them for 1 or 2 seconds

• Release them

• Test both arms simultaneously

• Note the speed of recoil and angle at elbow

Square window

• With the elbows flexed, flex the wrists as far as possible and determine angle between palm and flexor surface of forearm

Active Tone : Palmar grasp

• Infant supine and head in midline

• Test each side separately or together by placing index finger in palm of hand

• Do not touch dorsum of infants hand as it may inhibit grasp response

• Appears at 28 weeks, is well established by 32 weeks and disappears by 2 months

Arm traction

• Arm is slowly pulled to vertical position by traction on wrist

• Resistance is noted and angle at elbow is scored

• In some infants response is better felt than seen

• Avoid pulling infants hand, as this produces palmar grasp

Axial toneAnterior neck muscles (flexor tone)

• Infant in sitting position is held by shoulder

• Encircle infants chest

• Head is allowed to fall forward

• Note the degree of head flexion within 30 seconds

Posterior neck muscles (extensor tone)

• Infant in sitting position is held by shoulder

• Encircle infants chest

• Head is allowed to fall backward

• Note the degree of head extension within 30 seconds

Ventral suspension

• Suspend the infant in prone position by hand under chest

• Note the posture of head, trunk and limbs

• If there is discrepancy in head, limb or trunk posture, diagram most resembling trunk posture should be circled

• Draw the deviation of head or limb on diagram

Head lag

• Grasp wrists together and pull towards sitting position

• Note the posture of head when shoulders are elevated to 45 degree

• Avoid hyperextension of head by supporting it with one hand and pulling up with the other

Lower Segment: Passive Tone

Popliteal Angle:

• Test each leg separately

• Hold the thigh against infants abdomen by grasping knee between thumb and index finger

• Extend the leg by pressing back of ankle with other index finger

• Stop when resistance is felt

• Record the angle between lower leg and thigh

Leg Recoil

• Two ankles are held in one hand

• Legs are fully flexed for 5 seconds

• Then fully extended and released after 1-2 seconds

• Repeat test three times and note predominant response

• Grade response according to speed and completeness of recoil

• If infant is actively stretching , repeat the test

Heel to ear manueuver

• With the infant supine, bring the feet towards the ear as closely as possible without lifting the pelvis off the table.

• Measure the angle made by arc from table to infants heels

• As gestation increases, angle decreases

Adductor angle

• With infant supine and lower extremities fully extended, place forefinger of each hand along femoral axis

• Gently pull legs apart as far as possible

• Normal angle at term is 40 to 80 degree

• Angle decreases with advancing age to 40 weeks and increases over first year

Dorsiflexion angle

• Hold leg extended and flex foot towards leg by applying pressure with thumb to plantar surface

• Measure angle between dorsum of foot and anterior shin

• Angle decreases with increasing gestation

Leg traction

• Test each leg separately

• Raise them into vertical position using gentle traction on ankle

• Repeat three times and record the best response

• Record the resistance and angle at knee when buttock becomes elevated from surface

NEONATAL

REFLEXES

Tendon reflex

• Test biceps, knee and ankle jerks using gentle tap using small patella hammer or especially in preterms, just finger.

Suck Reflex

• Place the index finger with pad towards palate in mouth

• Note rhythmicity and strength of sucking response

• Strong sucking may also occur in presence of gross neurological abnormality

• Appears at 27-28 weeks• By 32 to 34 weeks sucking, swallowing and

breathing gets coordinated• Disappears by 6 months

Plantar grasp

• Infant supine and head in midline

• Test both sides simultaneously by placing thumb underneath toes

• Response is curling of toes over examiners fingers

• Do not touch dorsum of foot, as it will produce dorsiflexion of toes

• Developed in infants of 26 weeks

Placing reflex

• Hold infant upright by encircling chest under arms with both hands

• Stroke the front of infants leg with edge of table

• Response is scored according to degree of flexion of leg

• Elicited readily by 37 weeks

Moro reflex

Head drop method

• Hold infant in supine position raised at 45 degrees with one hand behind upper back and other supporting head

• Infants arms should be over chest

• Head is held in midline position and dropped back about 10 degree

• Test may be repeated 2 to 3 times for detailed observation

• At 25 to 27 weeks, only response is opening of hand

• With increasing maturity, abduction and extension of upper extremity is seen

• Adduction at shoulder appears at 34 weeks

• Disappears by 3 to 6 months

Stepping reflex

• Hold the baby upright over table, so that sole of foot presses against table

• This initiates reciprocal flexion and extension of legs, stimulating walking

• Is present in preterm, but differs from full term in walking on their toes

• Disappears by 5 to 6 weeks

Tonic neck response

• Elicited by rotation of head

• Consists of extension of upper extremity on side to which face is rotated and flexion of upper extremity on side of occiput

• Lower extremities respond similarly but not so strikingly

• Appears - 35 weeks

• Well established - 1 month

• Disappears – 6 months

Cranial Nerves

• Olfactory

• Optic-response to light, pupil reaction, fixation and tracking, fundus

• 3rd, 4th and 6th-ocular movements

• 5th-rooting, conjunctival reflex, opening of mouth

• 7th-facial symmetry, nasolabial folds

• 8th-hearing

• 9th, 10th-swallowing, pooling, regurgitation

• 12th-tongue movement

Abnormal signs

• Persistent irritability, hyperalertness

• Difficulty in feeding

• Persistent deviation of head or eyes

• Persistent asymmetry in posture and movement, opisthotonus, excessive extensor tone

• Pithed frog position in supine , little spontaneous movements

• Head size small or large in relation to weight. Bulging fontanelle ,abnormal separation ofsutures especially squamoparietal

• Eyes : roving nystagmus,conjugate deviation,pupils pin point/fixed, sun set sign

• Jitteriness when not crying

• Shrill cry/high pitch cry

• Abnormal moro’s, poor suck & feeding, exaggerated startle

• Later: persistent grasp, moro and ATNR. Persistence of clenched hand. Absence of gag or cough reflex, pooling of secretion(bulbar palsy)

• Poor orientation to sound

• Convulsions

• Continuous fisting or thumb adduciton, index finger flexion, thumb opposition

• Continuous big toe extension or flexion of all toes

Delivery room

• APGAR

• Umbilical vessels

• Anal opening

• GI patency

• Skull and spine

• Genitals

• Palate

Sick neonate

• Thermal support-warmer temp set, servo/manual/measured, heater output

• Incubator-humidity, mode

• Spo2 probe-position, saturation, heart rate, PI, waveform

• ECG leads-rhythm, abnormality

• Plethysmography-RR

• ETCO2 monitor

• Blood pressure-cuff position, last BP

Sick Neonate

• Et tube-size, position, mist, secretion, fixed at• Alarms• Ventilator-type, mode, settings, Fio2, graphics, MV, TV, humidifier

temp, water level, vent circuits• Infusions-Inotrope, TPN, IVF, sedation, antibiotics, anticonvulsant• NCPAP/HHFNC• Diaper• IV site• Central line-position, bandage• Surgical wound• Phototherapy- Eye mask• DSC

Summary

• Newborn stabilization is most important priority

• Detailed examination requires time

• Should be done in settings

• Age/gestation specific nomograms

• May need to look back after clinical history