Newborn Examination
Short Case Neonatology
The Neonatal Examination (baby check)
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At birth
APGARs
HS, Lung Sounds,
Birth trauma
Count cord vessels
Blue book to document
Check antenatal record
- Maternal: Pregnancy : GP(TP)ATOPSL: G (gravida/preg), Parity (1 even if multip) (T=term, P=preterm), A/TOP (i.e. <20w) Stillbirths, Living
- Family: genetic, syndromic, congenital
- LMP (i.e. two weeks prior to start of prenatal)
- Prenatal history
- Labour
- Delivery
ROS: <37/40, Prolonged ROM >18hr, Mec, Maternal temps/chorio, GBS pos
Vit K, Hep B
Plot growth
BO, PU, FHx DDH
Opportunistic Ex
Red reflex (set on 10+) when open
Oropharynx when open
auscultate chest(RR40-60)/HS, then palpate abdo/Brach-femoral pulses, then saturations while quiet
INSPECT
Dysmorphology
Stridor (link stridor short case)
Inspiratory extrathoracic
Expiratory intrathoracic
Biphasic severe obstruction
Posture: flexion in lower limbs by 34/40, upper by 36/40, normal is fetal position with legs abducted but not frog-legged (link floppy child), fingers over thumbs
Movement: normal alternating limbs movements, sleep myoclonus, jaw tremble with cry
EXAMINATION
Abrasions, laceration, haematoma, fracture
Chignon🔈, caput succedaneum 🔈, caphalohaematoma, subgleal
Fontanelles (Posterior closes 1-3mo, Anterior closure 14m (3-24m)
Sutures (overriding, immobile > craniosynostosis, wide > hydroceph/ICP)
HC 32-37cm
Ear position symmetry
Nares
Neck: web (Turners or Noonan’s), mass (?cystic hygroma a lymphatic malfom), fistula (branchial)
HR 120-160
Loud S2 with loss of spliting ?pulm hypertension
Murmur
Abdo
Pull to sit (tone, head lag)
Moro (brachial plexus / facial palsy, absent in severe intracranial pathology)
Ventral suspension
Spine: midline birthmarks, hair tuffs, mass, pit, scoliosis, galant
Neural tube disorders (anenceph, spinabifida)
Stepping (dorsum under bench, steps over), walking (plantar on firm surface)
(reflexes if neuro concern)
SKIN
Gestational age (Ballard method)
6 week check
The Neonatal Examination (baby check)
--------------------------------
At birth
APGARs
HS, Lung Sounds,
Birth trauma
Count cord vessels
Blue book to document
Check antenatal record
- Maternal: Pregnancy : GP(TP)ATOPSL: G (gravida/preg), Parity (1 even if multip) (T=term, P=preterm), A/TOP (i.e. <20w) Stillbirths, Living
- Family: genetic, syndromic, congenital
- LMP (i.e. two weeks prior to start of prenatal)
- Prenatal history
- Labour
- Delivery
ROS: <37/40, Prolonged ROM >18hr, Mec, Maternal temps/chorio, GBS pos
Vit K, Hep B
Plot growth
BO, PU, FHx DDH
Opportunistic Ex
Red reflex (set on 10+) when open
Oropharynx when open
auscultate chest(RR40-60)/HS, then palpate abdo/Brach-femoral pulses, then saturations while quiet
INSPECT
Dysmorphology
Stridor (link stridor short case)
Inspiratory extrathoracic
Expiratory intrathoracic
Biphasic severe obstruction
- Intraluminal (mucous, milk, mec, or blood)
- Intramural (subglottic oedema from suction or tube)
- Extralumenal (vascular ring)
- Primary respiratory (TTN, HMD, Mec Asp, Cong pneumonia, pneumothorax)
- Space occupying lesions (diaphragmatic hernia, CCAM)
- Cardio (shunt, Left heart obstruction, myocardial disease, arrhythmias)
- Metabolic (hypoglycaemia)
- Sepsis
- Haematologic (anaemia, polycythemia)
Posture: flexion in lower limbs by 34/40, upper by 36/40, normal is fetal position with legs abducted but not frog-legged (link floppy child), fingers over thumbs
Movement: normal alternating limbs movements, sleep myoclonus, jaw tremble with cry
- paucity > link floppy child
- jittery (suppressible) > hypoglycaemia, NAS, sepsis, hypOcalcimia,
- seizures (not suppressible) > neonatal encephalopathy (HIE), ICH, meningitis, low BSL/Na/Ca/Mg, high Na/ammonia, kernicterus, in born errors, pyridoxine deficiency, NAS, malformation
- asymmetry > malformation, antenatal/perinatal stroke, brachial plexus (erbs C5/6 pickup sticks, klumpke C8/T1 7/8 lay them straight
- high pitched: cerebral irritation (meningitis, neonatal encephalopathy)
- coarse: upper airway obstruction
- crit-du-chat syndrome (chromosome 5p)
EXAMINATION
Abrasions, laceration, haematoma, fracture
Chignon🔈, caput succedaneum 🔈, caphalohaematoma, subgleal
Fontanelles (Posterior closes 1-3mo, Anterior closure 14m (3-24m)
Sutures (overriding, immobile > craniosynostosis, wide > hydroceph/ICP)
HC 32-37cm
Ear position symmetry
Nares
- shiny pink lesion ?frontal lobe encephalocele
- Metal condensation test (demonstrates bilateral patency)
Neck: web (Turners or Noonan’s), mass (?cystic hygroma a lymphatic malfom), fistula (branchial)
- Asymmetry: persistant fetal posturing, SCM fibrosis/tumour, cervical vertebra malformation (Klippel-Feil)
HR 120-160
Loud S2 with loss of spliting ?pulm hypertension
Murmur
- day 1 ?closing PDA ?valve ?vessel (eg coarct)
- new after day one ?A/VSD (minimal shunt initially)
Abdo
- Normal liver 2cm below rib (2.5cm span)
- increased in gestational diabetes...
- Kidneys
- Groin for indirect inguinal hernia
- Genitals
- Size, epi/hypospadia, testes: undescended/anorch, ectopic, hydrocele
- mucosal tag, discharge, pseudomenses
- ambiguous (link)
- virilised female (CAH, aromatase deficiency)
- undervirilised male (testicular defect, disorder of androgen production/action)
- chromosomal defect
- Anus: patency and position
- Asymmetrical buttock creases, weaker fem pulse on affected side
- Ortolani: cant abduct, or clunk with abduction = disclocated = ortho
- Barlow: clunk = dislocatable = ortho
- Subluxable (movement, some also include click) = US6w
- Any 1st deg rel or Breech >34/40 = US6w
- Any 2 of female, oligohy, foot deformities, torticollis, Bwt >4kg = US 6w
- Talipes calceneovalgus (postural if can get sole to vertical inversion)
- Talipes equinovarus (postural if little toe to tibia)
Pull to sit (tone, head lag)
Moro (brachial plexus / facial palsy, absent in severe intracranial pathology)
Ventral suspension
Spine: midline birthmarks, hair tuffs, mass, pit, scoliosis, galant
Neural tube disorders (anenceph, spinabifida)
Stepping (dorsum under bench, steps over), walking (plantar on firm surface)
(reflexes if neuro concern)
SKIN
- Erythema toxicum neonatorum (eosinophili pustules)
- Milia (pinhead size white (kerotene) papules on face)
- Miliaria: obstructed eccrine glands on head and skin folds
- Mongolian spot
- Café-au-lait, ashleaf
- Vascular malformations: present at birth, port wine of Sturge-weber
- Haemangiomata: not present at birth usually, grow for 6m then start to resolve
- Eyes block vision > amblyopia
- Ears block hearing > auditory amblyopia
- Beard region ?laryngeal involvement
- Stridor
Gestational age (Ballard method)
6 week check
- same
- wt gain 20-30g/day, HC ?hydrocep
- Lift head momentarily by 3w
- Fix and follow to midline by 5w
- Responsive smile by 6w (spontaneous smile by 5mo)
- Immunise