GENERAL Measure and record height, weight, and head circumference. If the infant appears premature or is unusually large or small, perform a Dubowitz/Ballard exam to assess gestational age. Two parts: an external characteristics score, which is best done at birth, and a neuromuscular score, which should be done within 24 hours after birth. VERY LOW BIRTH WEIGHT Less than 1500 grams LOW BIRTH WEIGHT Less than 2500 grams FULL BIRTH WEIGHT 2500 - 4000 grams GESTATIONAL AGE Number of weeks that have elapsed since the first day of the last menstrual period to the time of birth PRETERM Birth occuring prior to completion of the 37th week TERM Birth occuring between the beginning of 38th week and before the completion of the 41st week. POSTTERM Birth at onset of 42nd week or thereafter NEW BALLARD SCORE PHYSICAL MATURITY Skin Lanugo Plantar surface Breast Eye/Ear Male genitals Female genitals NEW BALLARD SCORE NEUROMUSCULAR MATURITY Posture Square window Arm recoil Popliteal angle Scarf sign Heel to ear NEW BALLARD SCORE SCORE WEEKS -10 20 -5 22 0 24 5 26 10 28 15 30 20 32 28 34 30 36 38 38 40 40 48 42 50 44 PRETERM TERM POSTTERM PRETERM Infants delivered before 37 completed weeks Incidence: 6-15% Difficulty in adapting to extrauterine life with susceptibility to the ff: Infection Hyperbilirubinemia Hypoglycemia Hypocalcemia Cold stress PRETERM PHYSICAL FEATURES: Thin transparent skin and subcutaneous tissue Lanugo hair all over except in face Scarcely felt breast buds and barely visible nipples Flat shapeless pinna of ears Non-pigmented scrotum with undescended testes Widely separated labia majora with protruding labia minora Barely perceptible plantar creases PRETERM NEUROLOGIC FEATURES: Hypotonic Weak and slow sucking, rooting, grasp and Moro reflexes at 28 weeks POST TERM INFANTS Infants delivered after 42 weeks of gestation Predisposed to have the ff: Little vernix No lanugo hair Pale, dry and desquamating skin Long fingernails CLIFFORD STAGING (PLACENTAL DYSFUNCTION) FIRST STAGE Alert with loose hairless skin SECOND STAGE Meconiums stained navel and fingernails THIRD STAGE Old man facies SMALL FOR GESTATIONAL AGE (SGA) SYMMETRIC (hc=wt=len, all <10%): 33% of SGA Genetic Small maternal size Chromosomal abnormalities (Trisomies 13, 18, 21, and Turner's syndrome) Congenital abnormalities Intrauterine infections Viruses (rubella, CMV, ?varicella, ?HIV) Bacteria (tuberculosis) Spirochete (syphilis) Protozoan (toxoplasmosis, malaria) SMALL FOR GESTATIONAL AGE (SGA) SYMMETRIC (hc=wt=len, all <10%): 33% of SGA Inborn errors of metabolism Hypophosphatasia Leprechaunism Some amino acidurias Environmental Drugs (heroin, methadone, ethanol, diphenylhydantoin) X-rays (therapeutic) Smoking SMALL FOR GESTATIONAL AGE (SGA) ASYMMETRIC (hc=len>wt, wt<10%): 55% of SGA Uteroplacental insufficiency Chronic hypertension Preeclampsia Renal disease Cyanotic heart disease Hemoglobinopathies Placental infarcts or chronic abruption, velamentous insertion, circumvallate placenta, multiple gestation. Altitude SMALL FOR GESTATIONAL AGE (SGA) COMBINED: 12% of SGA infants Environmental Drugs (including ethanol) Smoking Placental unit insufficiency Placental infarcts or chronic abruption, velamentous insertion, circumvallate placenta, multiple gestation LARGE FOR GESTATIONAL AGE (LGA) Large mother (familial) Infants of diabetic mothers Beckwith-Wiedemann syndrome Hydrops fetalis SKIN COLOR Pallor: Ass. with anemia Cyanosis: Sign of hypoxemia Plethora: Ass. with polycythemia Jaundice: Yellowish discoloration of skin and mucous membrane Slate grey color : Methemoglobinemia NORMAL SKIN VARIANTS Milia - pinpoint white papules of keratogenous material usually on nose, cheeks and forehead, last several weeks. Miliaria - obstructed eccrine sweat ducts. Pinpoint vesicles on forehead scalp and skinfolds. Clear within 1 week. Transient neonatal pustular melanosis - small vesicopustules, generally present at birth, containing WBCs and no organisms. The intact versicle ruptures to reveal a pigmented macule surrounded by a thin skin ring. NORMAL SKIN VARIANTS Erythema toxicum - Most common newborn rash. Variable, irregular macular patches. Lasts a few days. Wright's stain shows sheets of eosinophils. Cafe au lait spots - suspect neurofibromatosis if there are many large spots. Junctional nevi - if large numbers, suspect tuberous sclerosis, xeroderma pigmentosus, generalized neurofibromatosis. NORMAL SKIN VARIANTS Harlequin phenomenon – Half erythema, half pallor commonly seen in preterms Cutis marmorata – Mottling. Lacy pattern seen in newborns less than 12 hours of age. Ass with cold stress. If persist, suspect congenital hypothyroidism Sucking blisters – Blisters seen in hands and wrists documenting ability of fetus to suck. NEUROLOGICAL EXAM State of alertness Posture: Normal position is fetal attitude with hips abducted and partially flexed, with knees flexed, and with arms adducted and flexed at the elbow. Fists are clenched with fingers covering the thumb Tone: Support with one hand under chest. Neck extensors should hold head in line for 3 seconds. Should have > 10% head lag. NEUROLOGICAL EXAM Reflexes Symmetrical Includes: Biceps jerk (C5-6) Knee jerk (L2-4) Ankle jerk (S1-2) Truncal incurvation reflex (T2-S1) Anal wink (S4-5) Other primitive reflexes: Moro, Palmar and plantar grasp Sucking, swallowing and rooting reflexes Asymmetric tonic neck reflex NEUROLOGICAL EXAM When reflexes appear and disappear: REFLEXES APPEARS DISAPPEARS Moro Newborn 3 months Grasp Newborn 3 months LE crossed extensors Extensor plantar Birth 1 month Newborn 8-12 months Placing/stepping Birth 1-2 months ATNR Newborn 3 months HEAD AND NECK Check the size and shape of the head Measure the head circumference Check for number and size of fontanelles Check for overriding sutures Note for encephalocoeles EYES Check for presence and size of the eyeball Check for colobomas, heterochromia Check for cloudiness of the cornea Inspect the conjunctiva as to presence of erythema, exudate, hemorrhage and jaundice. Check for pupillary size and reactivity to light Red reflex. Black dots may mean cataracts. Whitish color may suggest retinoblastoma EARS Check for asymmetry and irregular shapes Check for auricular or pre-auricular pits, fleshy appendages, lipomas or skin tags Check for the patency of the auditory canal NOSE Check for asymmetry and irregular shapes Look for flaring of the alae nasi as a sign of respiratory distress Check for hyper- or hypo-telorism Check for choanal atresia indicated by resistance to insertion of nasal catheter beyond 4cm mark MOUTH Check the size and shape of the mouth Microstomia: Trisomy 18 & 21 Macrostomia: Mucopolysaccharidoses Fish mouth: Fetal alcohol syndrome Normal lesions: Epstein pearls: Small white cysts containing keratin found on either side of the median raphe of palate Ranulas: Small bluish white swellings of variable size on the mouth floor representing benign mucous gland retention cysts PALATE Check for cleft lip and palate TONGUE Check for the size of the tongue Macroglossia: Found in congenital hypothyroidism and mucopolysaccharidoses TEETH Check for natal teeth which may occur in 1/2000 l.b. Mostly lower incisors. If loosely attached, risk of aspiration CHIN Check for size and shape of the mandible Micrognathia: Seen in Pierre-Robin syndrome, Treacher-Collins syndrome, and Hallerman Streiff syndrome NECK Palpate over all muscles Palpate clavicles for possible fracture Note for web neck as found in Turner’s, Noonan’s and Downs’ syndrome NECK Check for torticollis secondary sternocleidomastoid hematoma. to Note for neck masses, most common of which, cystic hygroma Lymph nodes, if present, indicate congenital infection CHEST AND LUNGS Observe respiratory rate and pattern Normal respiratory rate: 40-60 per minute Periodic breathing vs apnea Periodic breathing: Regular burst of breaths followed by respiratory pause of 5-10 seconds Apnea: Cessation of breathing for 20 seconds with/without bradycardia or cyanosis CHEST AND LUNGS Observe chest movements for symmetry and for retractions Listen for stridor, most common neonatal cause of which, laryngomalacia. Diminished breath sounds on either side suggests pneumonic consolidation, atelectasis, effusion, and other pulmonary problem. Some enlargement of the breasts may be secondary to maternal hormones (estrogen). CARDIOVASCULAR SYSTEM Measure heart rate and blood pressure in both upper and lower extremities Inspect the baby’s color for pallor, cyanosis or plethora Check for dynamic precordium indicative of heart failure CARDIOVASCULAR SYSTEM Check capillary refill (normal: 2 seconds) Check presence and character of pulses: in femoral pulses or radio-femoral delay indicates possible coarctation of aorta Bounding pulses suggest PDA Locate PMI with single finger on chest Abnormal location suggests situs inversus, pneumothorax, diaphragmatic hernia, or other thoracic problem CARDIOVASCULAR SYSTEM Note rhythm of heart rate Check presence of murmur. If present, determine intensity, timing, location and radiation Functional vs pathologic Functional murmur: brief, soft, systolic and lasts < 24 hours Pathologic murmur: loud, persistent, may have diastolic component ABDOMEN Note shape of abdomen – globularly shaped. Flat abdomen suggests decreased tone with abdominal contents in chest (CDH) or abnormal abdominal musculature. Distended abdomen signifies functional (ileus) or mechanical GI obstruction Observe for diastasis recti Observe for any obvious malformations (eg. omphalocoele, gastroschisis) ABDOMEN Examine umbilical cord and determine its color, number of vessels. Palpate liver which is normally about 2cm below the right costal margin Palpate spleen which is usually not palpable. If palpable, investigate for congenital infection or extramedullary hematopoiesis. Palpate for any abnormal masses ABDOMEN Auscultate for bowel sounds Examine for hernias – umbilical or inguinal Inspect anal area for patency and/or presence of fistulas GENITOURINARY EXAM KIDNEYS Palpate kidneys which should be about 4.55.0cm vertical length With one hand under the baby’s back, palpate by rolling the thumb over the kidneys Place right hand under the left lumbar region and palpate abdomen with left hand. Do reverse for right kidney GENITOURINARY EXAM MALE GENITALIA Inspect glans, urethral opening, prepuce and shaft. Observe for hypospadias or epispadias GENITOURINARY EXAM MALE GENITALIA Inspect penis. Term normal penis is 3.6+/0.7cm stretched length. After circumcision, inspect for edema, incision, bleeding Inspect the scrotum. Normal scrotum in term should have brownish pigmentation and rugae. Palpate the testes. GENITOURINARY EXAM FEMALE GENITALIA Inspect the labia, clitoris, urethral opening and external vaginal vault Whitish discharge, as is a small amount of bleeding, occurs a few days after birth secondary to maternal hormone withdrawal Hymenal tags may be present EXTREMITIES and SKELETAL SYSTEM SPINE Check the curvature of the spine for scoliosis, kyphosis, lordosis, spinal defects, and meningomyelocoeles EXTREMITIES and SKELETAL SYSTEM UPPER EXTREMITY Check for clavicular fracture, absence of radius or ulna Inspect creases and fingers EXTREMITIES and SKELETAL SYSTEM LOWER EXTREMITY Assess posture Do Ortolani maneuver to check for congenital hip dislocation Check toes APGAR SCORE APPEARANCE PULSE RATE GRIMACE ACTIVITY RESPIRATORY EFFORT Normal skin variants in newborns, EXCEPT: A. Milia B. Harlequin phenomenon C. Sclerema D. Epstein pearls E. Cutis marmorata Features of preterm infants: A. Scrotum with little rugae and undescended testes B. Breast with 5mm breast nodule and nipple C. Creases on anterior third of sole D. Labia majora well coaptated E. Thinning lanugo Apgar score of a newborn delivered limp, cyanotic all over, apneic with cardiac rate 50/min A. One B. Two C. Three D. Four E. Zero Routine newborn care, EXCEPT A. Tetracycline ophthalmic ointment B. Vitamin K C. Cord dressing D. Immunization – BCG and Hepatitis B E. None of the above