NEONATOLOGY
Newborn EXAMINATION (WITHIN 72 hrs after birth)
Important Q’s to ask prior to exam?
• Had baby passed meconium
• Is baby feeding ok?
• Any FHx of congenital heart, eye or hip problems?
Appearance CAJCOLD Red flags:
Posture/tone Floppy, poor activity • Peripheral cyanosis( acrocyanosis)
GENERAL INSPECTION Resp. effort Tachypnoea, nasal flaring, grunting, intercostal recessions • Jaundice
See common signs • Obvious mass (HSM, umbilical hernia)
Skin • E.g. erythema toxicorum, milia, naevus flammus, • Infected umbo stump, eyes
Mongolian spots, haemangiomas • ARDs
Auxiliary aids FiO2 (RA or oxygen) • Poor tone
• No red reflex (Rb)
Yellow- White creamy NATURAL anti-microbial + Vit E
biofilm covers fetus ® protect against bacteria in genital tract • Undescended testes
Vernix Caseosa
• DDH
• Mixture of desquamating cells and sebum
Fontanelle PP Cause
Bulging Crying, cough, vomit? OR raised ICP Hydrocephalus, meningitis, hypoxic ischamic injury,
dermoid tumour, hypothyroidism
HEAD AND NECK
Sunken Reduced ICP Dehydration, hypovol.
• Head shape & symmetry
Delayed closure Trisomy 21, rickets, achondroplasia, raised ICP?
• palpate suture lines &
fontanelles Craniosynostosis Premature closure of ≥ 1 suture Crouzon’s, Apert’s syndrome ® may RESTRICT brain
• Check for swelling, webbing, growth
skin folds and vein distension Exostosis Benign outgrowth of cartilaginous tissue on bone Idiopathic
• Move head & neck through
full ROM ® rotation bilaterally Microencephaly Macroencephaly Abnormal shape
to exclude torticollis
• Familial with AD inheritance • Familial • Caput succedaneum – like EDH
• Check head position in prone (haematoma above periosterum = usu.
• Hydrocephalus • Genetics: Trisomy 13, 18, 21
position due to prolonged labour)
Other conditions • Teratogen Exposure (EtOH,
• Achondroplasia (skeletal RT, Hydantoin) • Cephalohematoma – like SDH
dysplasia) • TORCH infection (haematoma in sub-periosteal space –
communicating veins)
• Sotos' Syndrome (Cerebral Other syndromes
Gigantism) • Plagiocephaly (Positional)
• Prader-Willi
• Alexander's Disease • Chignon (vacuum extraction)
• Cornelia de Lange,
• Canavan's Disease • Syndromic condition
• Rubinstein-Taybi,
• Neurofibromatosis Type I *General risk factors of haeamtoma –
• Smith-Lemli-Opitz, prolonged labour, instrumentation
**Most self-resolve but Comp. of haematoma-
jaundice, anaemia, linear skull fractures
FACE + ENT Face
•
•
Dysmorphic features (e.g. low set ears, nasolabial folds)
Facial nerve palsy (facial nerve compression against sacral promontory or via trauma of forceps delivery) ®
difficulty feeding, drooling on affected side
Sit upright ® let baby open eyes ® Swollen eyelids/eyes
• Red reflex • Conjunctivitis (swollen purulent discharge ® swab M/C/S)
• PEARL o Gonorrhoea - Rx: ceftriaxone
• Retinal / subconjunctival o Chlamydia ® Rx: azithromycin 20mg./kg for 7 days
haemorrhages ® common after o HSV ® Rx: antivirals 14 days
vaginal delivery (clears spont.) o DDx: Dacrocystocele – blocked tear duct (usu. unilateral)
Eye
• Lid oedema ® Rx: gentle massage
• Eye colour (not permanent until • Lens opacity (congenital cataract) assoc. with TORCH infection
6/12 old) • Leukocoria (Cat’s eye reflex) = lens, vitreous, fundus abnormality ®
• Visual behaviour: Eyes briefly • Coloboma (ocular tissue defect)
fixate and follow at 20c o Eyelid margin defect = treacher collins syndrome
o Aniridia (absent iris) =bilateral & poor acuity
• Listen over nares ® check for nasal flaring (increased RR effort)
Nose
• Choanal atresia = cannot pass through nares ®medical ED ® oral airway and surgical repair
• Microstomia –Trisomy 18 and 21 • Natal teeth
• Macrostomia – • Epstein pearls (white cysts containing keratin) on midline
Mouth mucopolysaccharidoses raphe of palate OR gum lines)
(Size • Thin lips–Fetal Alcohol Syndrome • Raculas = small bluish-white swelling (benign mucosal
and • Macroglossia –hypothyroidism and gland cysts)
shape) mucopolysaccharidoses • Cleft lip = trisomy 13 ® repair at 3/12
• Small Chin –Pierre Robin or OSA • Cleft palate = defect starting from uvula – must check w/
finger!! (need repair before age 1 for normal speech)
Asymmetry & irregular shape
• External ear ® hygiene, discharge, excoriation -® reflex to voice, bell
• Ear tags ® increased risk of hearing loss
Ear
• Low set ears (< 1/3rd above horizontal line below lateral canthus of eye) = GU anomaly (e.g. Potter’s, Down’s,
renal)
• Malformed ear = Down’s, Turner’s
, Palpate Neck masses
Neck muscles • Cystic hygromas (most common)
• Webbed neck = turner’s, Noonan’s • AVM
Neck •
•
LN = if present = unusual = congenital infection?
Torticollis = SCM injury from birth trauma ®
• Teratomas
• Dermoid cysts
hematoma and fibrosis causes muscle shortening
• Thyroglossal duct cysts ® surgical consult
[abnormal neck twist ® head tilt]
• abnormal lymphatic tissue
Stridor, grunting, wheezing, cough, grunting
Assess • MOUTH BREATHING (ABNORMAL) ® congenital issue è neonates mainly nasal breathers as breast feeding
• pallor, cyanosis, plethora
• Extra nipple = normal (10% supernumerary)
CHEST + Observe • Absent or hypoplasia of pectoralis major – Poland’s syndrome
breast • Breast enlargement (2o to maternal hormones)
LUNGS • Widely spaced nipples – Noonan, Turner’s
• RDS Thorax: configuration, symmetry, abnormalities
Observe
• Pectus carinatum = M > F - narrow thorax w/ increased AP diameter (rickets, uncontrolled asthma)
• WoB lung
• Pectus Excavatum = more common + M > F – pitting vs sinking of entire sternum (CT disorder)
• S1/S2
• Pre (R limb) vs post-ductal (legs) O2 sats ® > 2% difference = ?patent ductus arteriosus
Vitals
• 4 limb BP to see if 20% difference between upper and lower limb = aortic coarctation
• L 4th IC space MCL ® soft systolic murmur (grade 2 or less) = normal due to PFO (GOES AWAY W/ SITTING UP)
Auscultate
• Any audible GRADE 3 or murmur that persists even after manoeuvres ® pathological murmur
Inspect • Shape, asymmetry, distension, hernias
• Distended = obstruction vs ascites
Abdo / Umbo / Palpation for
o Hirschsprung, pyloric stenosis, duodenal atresia
• Liver (palpable) = <2cm below R costal margin
Anus organomegaly
• NB: spleen, kidney and bladder = NOT easily palpable
• Soft
• Femoral pulse (> 140bpm) ® if slow = aortic coarctation
• Masses
Check for Signs of bleeding, infection (omphalitis), granuloma
• Clean umbo Umbo
• Advise to clean + dry with cotton bud (normally falls off after 10-14 days)
• Patent anus (BO)
• colour of stools (meconium),
Anus
• patent anus, marks, fissures, polyps, prolapses
Upper Limbs Lower limbs
Limbs Pathology Pathology
• Symmetry • Birth trauma esp. large infants
Normal
Fractured Bowing Ø Rickets (Vit D def.)
• Thigh- symmetrical clavicle • Pain w/ movement + Moro Ø Trauma
creases
• SCM spasm on affected side Talipes Structural vs positional
• Thigh swelling equinovarus Ø Positional – can be corrected manually
(normal – IM injection, • Autosomal dominant (clubfoot) Ø Structural (bone involved) – ED surg
abnormal – cellulitis) Polydactyly • Extra-digit usu. on foot • C-shaped/banana foot (foot deviates
• Fingers/Toes for (Supernumerary
• Palpable bone present + finger can medially)
webbing, count digits digit) Metatarsus
move ® amputate digit when child adductus (in- • Splayed 1st web
• Feet for talipes > 1 y.o. toeing)
positional and fixed Some/all digits/toes wholly or partially • Feet pointing to each other ® self-
united resolves in 85% of c ases
Syndactyly
• Can cause fusion of bone with skin Calcaneovalgus • Limited PF (< 90o)
deformity
Single palmar
crease
Down’s • Everted dorsiflexed feet (up + out)
Birth asymmetry – Moro’s test
Risk factors for DDH
• Erb’s (C5-7) = arm adducted, IR,
• Breech birth OR breech at 36
Brachial plexus elbow extended, wrist flexed
weeks
(C5-T3) • Waiter tip = C7 palsy • Female (6:1)
• 1st born
• Klumpke’s (C8-T1)= paralysed
• FHx of DDH (1st deg)
hand
• Large baby (>4kg)
• Oligohydramnios (little
amniotic fluids)
• Spina bifida
ALL are indications for
HIP USS at 6 weeks
corrected
• e.g 30wks premmie with DDH
would have hip USS in 16 wks
Ortolani test anterior pressure on greater trochanter (push up ® ER) = hear
for the click for CDH IF DDH suspected
HIPS Ø relocate anteriorly to acetabulum • USS – check alpha >60 & beta angles <
55 for type (Graf classification –
(Nappy Barlow’s test push down ® adduct ® knee pressure
determine mature vs eccentric hip)
Galeazzi’s sign Compare 2 femur length ® LLD – see symmetrical skin folds
removed) • CLASS III GRAF ® Rx: Need to wear
strap harness (if coverage ratio < 40%
• LLD on USS)
• DDH – hip stability and • OR can abduct hips to reduce risk of
cong. Hip dislocation
DDH
, Male Female
Glans, urethral opening, prepuce, shaft Labia minora, clitoris, hymen:
• Small penis = low androgen (TT) • Clitoromegaly if:
REPRO SYSTEM • Hypospadia? Epispadias? = has baby passed urine? ® • labia underdeveloped
• ambiguous genitalia Surgery referral for cosmetics
• virilising tumour
• Chordee (ventral curvature of penis) = skin tethering, short
Inspect urethra? ® delay circumcision
• steroid usage in pregnancy
• Communicating hydrocele = incomplete obliteration of • CAH – newborn screening ® to prevent
processus vaginalis è painless, tense transilluminable mass Addisonian crisis
• Inguinal hernia = soft non-tender reducible bulge in inguinal • Vaginal / hymenal skin tag
canal esp. with increased intra-abdominal pressure (surgery • Mucous / whitish discharge
if incarcerated) ® surgery ASAP
• Vaginal bleed
• Unilateral Retractile = may self-resolve
Ambiguous genitalia ® need rapid Dx + Rx
• Palpable ectopic or undescended = may self-resolve
• Complications = hyperpigmentation, apnoea, seizure,
Palpate dehydration, HypoTN, hyperK, hypoGlycaemia
VACTERL • Cryptorchidism (non-palpable) = orchiopexy? ® referral to
• Social emergency = delay naming until sex determined
Ø Vertebra urologist
anomalies • Addisonian crisis (21-OH def.)
Ø Anal atresia
Ø Cardiac
abnormalities
Ø TOF
Ø Oesophageal
atresia
Ø Renal
anomalies
Ø Limb defects
Spina bifida Spinal meningocele Myelomeningocele
occulta
Normal
meninges, SC,
• Meninges herniates • Meninges, SC +nerve roots ALL
involved
SPINE and BACK spinal root
through posterior
vertebral arches ®
covered by skin • 75% in lumbosacral
• Check tone
• Scolioisis • Anterior herniation = • Assoc. with MOF ® flaccid
sphincter dysfn paralysis of lower extremities +
• Sacral dimples absent reflexes
• Tuft of hair • Normal SC + nerve
roots • Assoc. ® hydrocephalus,
neurogenic bladder, urinary &
stool incontinence
A. Palmar grasp reflex - fingers should close/grasp object if placed in palm
B. Sucking reflex - newborn instinctively suck anything that touches roof of mouth
C. Rooting reflex - a newborn turns head towards anything that strokes cheek or side of mouth
D. Stepping reflex - when lifted, if a newborn’s feet touch a flat surface they will motion walking by placing one foot in front of the other
Nervous System E. Moro reflex – support newborn’s upper back with one hand ® simulating backwards drop once or twice with your other hand ®
arms will then be brought together, and hands clenched as infant cries. [brachial plexus palsy]
1 Alert + active F. Babinski reflex – Toes point down (LMN lesion)
2 Head lag (1st few Moro
Primitive Galant (trunk
weeks – none by 3/12) Rooting Palmar grasp Tonic neck (fencer) Stepping
Reflex incurvation) (check for asymmetry)
3 Check tone
Onset 28 wk GA 28 28-32 35 wk GA 35 wk GA 35-36
4 High tone / rigid =
?withdrawal from Well-
32-34 40 37 32 4 wks PCA 37 GA
meds taken by mother established
5 Low tone = frog leg Disappears 3-4 mths 3-4 mths 6 mths 2 mths 7 mths 3-4 mths PCA
position + lifting a “rag
Stroke cheek • Infant in ventral • Hold infant with one hand Place finger on Rotate infants head Touch top of
doll” or corner of suspension with holding HEAD with elbow infant’s palm for to one side ® infant infants foot on
6 Muscle power mouth chest in palm of on bed and the other the gasping extends arm on edge of table
Infant’s head examiner’s hand buttock rotated side while ® infant wants
7 UMN vs LMN Elicit flexing opp. arm to step
turns • Firm pressure on • Sudden dropping of head
8 Reflexes – primitive towards side of spine ® in hand ® infant’s hand
stimulus infant flexes pelvis opens and extension and
to same side abduction of upper limb
Absent = hemiplegia, brachial
plexus palsy
Poor tone
Ø CNS (CP)
Ø Primary muscular disorder
Ø Genetics (Down’s, Prader-Willi)
