NORMAL NEWBORN
• Perinatal period: 28th wk AOG upto 7th day
after birth
• Neonatal period: 1st 28 days after birth
– Very early: birth to <24 hrs
– Early: birth to <7 days
– Late: 7 days to <28 days
• Infancy: 1st year after birth
• Mortality is highest during the 1st 24 hr after
birth.
• Neonatal mortality accounts for 2/3 of all
infant deaths (deaths < 1yr of age).
Major Causes of Perinatal and Neonatal
Mortality
FETAL
• Placental insufficiency
• Intrauterine infection
• Severe congenital malformations (anomalies)
• Umbilical cord accident
• Abruptio placentae
• Hydrops fetalis
PRETERM
• Severe immaturity
• Respiratory distress syndrome
• Intraventricular hemorrhage
• Congenital anomalies
• Infection
• Necrotizing enterocolitis
• Bronchopulmonary dysplasia
FULL TERM
• Congenital anomalies
• Birth asphyxia
• Trauma
• Infection
• Meconium aspiration pneumonia
• Persistent pulmonary hypertension
Ten Leading Causes of Infant Mortality in the
Philippines (DOH, 2009)
1. Bacterial sepsis of newborn
2. Pneumonia
3. Respiratory distress of newborn
4. Disorders related to short gestation and low
birthweight, not elsewhere classified
5. Congenital malformations of the heart
6. Congenital pneumonia
7. Neonatal aspiration syndrome
8. Diarhea and gastroenteritis of presumed
infectious origin
9. Other congenital malformations
10. Intrauterine hypoxia and birth asphyxia
Physical Examination of the Newborn
• Requires patience, gentleness and
procedural flexibility
• Ideally done 2-3x prior to discharge:
 Immediately after birth
 Within 24 hours of birth
–
Prior to discharge, preferably in the
presence of the mother
• Vital signs
– Monitored every 30 mins after birth for
2 hrs or until stable
– HR (N 120-160 bpm), vagal slowing
may be noted (upto 80 bpm in
postdated infants, reassuring if w/
good acceleration on stimulation)
– RR (N 30-60 breaths/min), short
pauses(5-10secs) considered normal
– Apnea: cessation of breathing >20
secs or any duration if accompanied
by cyanosis and bradycardia
– Pulse oximetry- to screen for PDAdependent CHD
– Blood pressure- not routine, SBP
gradient bet upper and lower ext
>10mmHg  suspect CoA
– Temp N 36.4-37⁰C (axillary)
• Anthropometrics
– Head circumference(occipitofrontal
circumference):N 35cm in term infants
– Weight: SGA- BW<10th percentile
Symmetric SGA
Asymmetric SGA
 Onset: early in
 Onset: late in
gestation
gestation
 Brain size corresponds  No or minimal
with body size
effects on fetal brain
growth
 Causes:
smoking/drugs, small
 Causes:
maternal size,
uteroplacental
chromosomal
insufficiency with
anomaly, TORCH,
chronic fetal hypoxia
metabolic d/o
– AGA- BW between 10th-90th percentile
– LGA- BW >90th percentile,↑risk for
perinatal asphyxia, RDS, hypogly
– Length
• General appearance
– Physical activity (active and passive
tone, posturing)
– Ankle or jaw myoclonus/ jitteriness:
common in newborns, usually during
active mov’t
– Vs. convulsive twitching: abnormal,
during quiet state
– Edema: generalized (prematurity,
hypoproteinemia sec to severe
erythroblastosis fetalis, nonimmune
hydrops, congenital nephrosis, Hurler
syndrome) vs. localized (silver nitrate
irritation of the eyelid, lymphatic
malformation, Turner syndrome)
• Skin
– Signs of vasomotor instability: purple
lividity while crying, acrocyanosis
(harmless), mottling (may be assoc w/
serious illness/ transient fluctuation in
skin temp)
–
Harlequin color change:
Extraordinary division of the body
(pale- red) from forehead to pubis;
transient, harmless, speculated
pathogenesis: temporary imbalance in
tone of cutaneous BVs sec to
hypothalamic immaturity, must not be
confused with harlequin fetus-severe
and uncommon form of ichthyosis
manifesting with large plate-like scales
and fissures
Salmon Patch (Nevus
Simplex)
–
–
–
Port Wine Stain
 small, pale pink, ill macular, sharply
defined, vascular
circumscribed,
macules
pink to purple,
larger
 usually symmetric
 unilateral
 glabella, eyelids,
upper lip, and nuchal  head and neck
area
 represent mature
 represent localized
dilated dermal
vascular ectasia
capillaries
 persist for months,
 permanent
most eventually fade
– Cyanosis: high hgb content + thin
skin; becomes pale with
blanching(unlike ecchymosis) also
used in demonstrating icterus
– Pallor (Hct<42%): anemia, asphyxia,
shock, edema, postterm
– Plethora (Hct>65%): polycythemia
– Preterm: gelatinous and translucent
skin, lanugo
– Post-term: peeling, parchment-like
(ichtyosis congenita)
– Sebaceous hyperplasia: minute,
profuse, yellow-white papules
representing hyperplastic sebaceous
glands; forehead, nose, upper lip, and
cheeks;diminish gradually and
disappear within the first few weeks
– Cutis marmorata: evanescent, lacy,
reticulated red/blue vascular pattern
over most of the body surface at low
temp; represents an accentuated
physiologic vasomotor response that
disappears with increasing age
– Mongolian spots: slate-blue, welldemarcated pigmented areas among
blacks, native Americans&Asians,
tend to disappear within the 1st year
– Milia: tiny sebaceous retention cysts,
whitish, pinhead-sized, chin, nose,
forehead and cheeks, disappear w/in
a few wks
– Erythema toxicum: benign,1-3 days
after birth, lasts upto 1st wk,
eosinophils, face, trunk, extremities
– Miliaria crystallina: noninflammatory, pinpoint clear vesicles,
profuse eruption over large areas,
brawny desquamation upon healing
Pustular melanosis: benign,
neutrophils, present at birth, lasts 2-3
days, chin, neck, back, extremities,
palms or soles
Amniotic bands: may be due to
amniotic membrane rupture or
vascular compromise w/ fibrous band
formation
Vernix: spontaneously shed w/in 2-3
days
• Skull
 Molding (esp. if normal firstborn
cephalic delivery)- temporary skull
asymmetry; rpt HC after a few days
 Cranial synostosis: hard
nonmovable ridge over the suture
 Anterior fontanel:diamond-shaped, 46cm at birth,usually closes at 9-18mos
 Persistently large anterior fontanels
(N= 20±10mm): can be secondary to
achondroplasia, Apert syndrome,
cleidocranial dysostosis, congenital
rubella sydrome, HCP, IUGR,
osteogenesis imperfecta, prematurity,
Trisomy 13, 18, 21, Vit D deficiency
 Persistently small fontanels:
microcephaly, craniosynostosis,
congenital hypothyroidism, wormian
bones (intersutural bone formation)
 Posterior fontanel may be closed at
irth or admits tip of finger till 2-4 mos
 3rd fontanel: trisomy 21, preterm
 Craniotabes: soft areas in parietal
bones at the vertex near the sagittal
suture; common in preterms exposed
to uterine compression, resolve in wks
 Aplasia cutis congenita: atrophic or
alopecic scalp, sporadic or AD, assoc
w/ Trisomy 13, chromosome 4
deletion, or Johanson-Blizzard
syndrome

Caput succedaneum: diffuse,
±ecchymosis, soft tissue swelling from
the vertex delivery, occipital/parietal,


crosses suture lines, resolves in 1-2
days
Cephalohematoma: more tense, no
discoloration, subperiosteal bleeding
assoc w/ instrumented vaginal birth,
parietal,do not cross suture lines, may
not be visible at birth(slow process),
resolves in 2wks to 3mos, may
contribute to jaundice
Subgaleal hemorrhage: very loose,
soft swelling, bleeding under the
aponeurosis of occipitofrontalis
muscle, assoc w/ vacuum extractions,
linear skull fracture, suture diastasis
and/or rupture of the emissary vein,
nape to forehead, closely monitor for
poss extensive bleeding in large
potential space, resolves in 2-3 wks
• Face
 Moebius syndrome: symmetric facial
palsy sec to absence or hypoplasia of
CNVII nucleus
• Eyes
 Often spontaneously open when held
up and tipped gently
 Retinal hemorrhages: common w/
vacuum-assisted deliveries, resolve by
2-4 wks
 Pupillary reflex: begins 28-30 wks
AOG
 Congenital glaucoma: cornea>1cm
in term infant, photophobia, tearing
 Leukokoria: tumor, chorioretinitis,
retinopathy of prematurity, or a
persistent hyperplastic primary
vitreous
• Mouth
 Precocious dentition- normally shed
before eruption of deciduous teeth,
assoc w/ Ellis-van Creveld, HallermanStreiff and other syndromes
 Cleft palate- excessively high arch,
bifid uvula
 Epstein pearls- accumulation of epith
cells on hard palate, retention cystsaccumulation of epith cells on gums,
ankyloglossia- tongue-tied, short
frenulum, sucking callus- labial
tubercle which disappears when
suckling ceases
• Ears/Nose
 Preauricular sinus, pits, skin tags
 Alar flaring: dec in airway resistance
 Choanal atresia: assessed by free
passage of NGT through both nares
• Neck
 SCM lesions: hematoma (traumatic)
or fibrosis (fixed posistioning in utero)

Congenital torticollis: head turned
toward, face turned away from
affected side, may cause
plagiocephaly, facial asymmetry, and
hemihypoplasia if untreated
 Redundant skin/webbing in a female:
intrauterine lymphedema, Turner
Syndrome
 Thyroglossal and branchial arch sinus
tracts
 MC neck masses in the NB are
vascular malformations, abnormal
lymphatic tissue, teratomas, cystic
hydromas and dermoid cysts
• Lungs
 Breathing is entirely diaphragmatic
 Grunting: self-generated PEEP, sign
of potentially serious cardiopulmonary
distress/sepsis. if benign resolves bet
30-60min after birth
 Intercostal retractions: compensation
for chest wall stabilization
 Lung shounds are more bronchial than
vesicular due to better transmission of
large airway sounds across a thin
chest
• Heart
 Palpate PMI and auscultation to
determine heart location
 SVT: >220 beats/min
 Systolic murmurs may be heard
transiently in normal NB as ductus
arteriosus is closing (flow murmurs) or
w/ mild pulmonary branch stenosis
 Diastolic murmurs should always be
considered abnormal
 Suspect CHD in (1)persistent
murmurs, (2)O2sat < 96% after 24 hrs,
(3) failed hyperoxia test- arterial
PO2<100 after giving 100% inspired
O2 w/o clear-cut lung dse, or consider
structural heart dse w/ complete
intracardiac mixing if pO2 bet 100-250
• Abdomen/ Genitalia
 Liver usually palpable 2cm below rib
margin; Spleen palpable at tip of
costal margin
 Rectal gas should be present by 24
hrs of age
 Diastasis recti:separation of rectus
abdominis into R and L sides
 Omphalocele:midline, intestines
covered w/ peritoneum, assoc w/
Beckwith-Wiedemann, conjoined
twins, trisomy 18, meningomyelocele,
and imperforate anus vs.
gastroschisis: lateral, uncovered
 Unusual masses: usually renal in
origin

Cystic: hydronephrosis, multicysticdysplastic kidneys, adrenal
hemorrhage, hydrometrocolpos (sec
to imperforate hymen), intestinal
duplication, and choledochal, ovarian,
omental, or pancreatic cysts
 Solid: neuroblastoma, congenital
mesoblastic nephroma,
hepatoblastoma, and teratoma
 Renal vein thrombosis: solid flank
mass, hematuria, HTN,
thrombocytopenia, assoc w/
polycythemia, dehydration, maternal
DM, asphyxia, sepsis, nephrosis,
hypercoagulable state
 Omphalitis: acute periumbilical
inflamm, may cause portal HTN
 Single umbilical artery: occult renal
anomaly
 Severe hypospdias/epispadias:
suspect adrenogenital syndrome
 Stretched penile length <2.5cm is
abnormal and requires evaluation
 Hydrocele: transilluminating scrotal
mass, collection of peritoneal fluid due
to patency of processus vaginalis in
fetal life, monitored to ensure
resolution by the 1st yr of life
 If the testis has not descended by
4 mo, it will remain undescended.
 Voiding w/in 1st 24 hrs, passage of
meconium w/in 48 hrs (does not rule
out imperforate anus)
• Extremities
 Crepitus or “step-off” deformity:
consider clavicular fracture (most
common fracture in NB)or nerve injury
 Polydactyly; syndactyly; simian
crease; talipes equinovarus (clubfoot)foot turned inward and downward,
sole directed medially; metatarsus
varus- adduction of forefoot, usually
corrects spontaneously
 Barlow maneuver: assesses the
potential for dislocation of a
nondisplaced hip; performed with the
patient's knees and hips flexed, with
the thigh in adduction, the examiner
applies a posteriorly directed force.
Positive Barlow maneuver

Ortolani maneuver: causes reduction
of dislocation
Positive Ortolani maneuver



Hip clicks: high-pitched, usually
originate in the ligamentum teres or
occasionally in the fascia lata or psoas
tendon, do not indicate a significant
hip abnormality (vs “hip clunks” of hip
dislocation).
Midline sacral dimpling: common
finding, need no further eval unless
high-risk for spinal dysraphism (deep,
larger than 0.5cm, located > 2.5cm
from anal verge, assoc with other
cutaneous markers)
Fetal neuromuscular disease: assoc
w/ breech, polyhydramnios, failure to
breathe, pulmonary hypoplasia,
dislocated hips, undescended testes,
thin ribs, and clubfoot
Neurologic examination
• Level of alertness-evaluate in both sleep and
wakeful states
• Cranial nerve exam is largely by observation
 CN I:rarely tested, functional by 57mos
 CN II:visual fixation on human face,
(+)glare, pupillary response, tracking,
optic disc is light pink/pale gray
 CN III,IV,VI: Doll’s eye maneuver to
check for conjugate eye movt, may be
disconjugate at birth; ptosis (CN III),
pupillary reactivity seen in neonates
>32wks AOG
 CN V: facial sensation w/ rooting
reflex, corneal reflex, grimace/ change
in CR or RR w/ tactile stimulation V1-3
 CN VII: check facial symmetry at rest
and upon movt(e.g. crying)
 CN VIII gross hearing, blink/startle w/
noise
 CN IX,X,XII: intact if with good sucking
(CN V,VII,XII), swallowing (CN IX,X),
gag reflex (CN IX,X),tongue movt (XII)
 CN XI: flexion and rotation of head
• Motor Exam: posture- normal term NB have
a flexor attitude, preterms lie in extension;
tone- tested via traction response(pulling
from supine to prone position) if hypotonic,
will show severe head lag, strength-check
symmetry of spontaneous mov’t
• Deep Tendon Reflexes: use index or middle
fingers; unsustained ankle clonus(upto 10
beats) is normal
• Primitive Reflexes:
 Moro: carrying baby by his back and
“dropping” onto hand causes
extension followed by flexion of upper
limbs, present from birth-5mos
 Grasp: stroking ulnar side of the palm
causes hand grasp, applying pressure
on ball of the foot causes toe grasp,
present from birth to 6mos(palmar) or
9-10mos(plantar)
 Rooting/Sucking: stroking angle of
mouth causes sucking, birth to 3 mos
 Tonic neck: turning head sidewise
will cause “fencing posture” towards
direction of head, birth (welldeveloped at 1 month) upto 5-6 mos
• Sensory Exam: gross response to stroking,
withdrawal, crying, grimace
Neonatal Resuscitation Pearls
• Primary apnea: no spontaneous respiration
at birth but rapidly responds to tactile
stimulation
• Secondary apnea: no spontaneous
respiration despite 2 attempts at tactile
APGAR Scoring
Heart rate
0
Absent
1
Below 100
2
Over 100
Respiratory effort
Absent
Slow,
irregular
Good,
crying
Muscle tone
Limp
Active
motion
Response to catheter
in nostril (tested after
oropharynx is clear)
Color
No
response
Some
flexion of
extremities
Grimace
Body pink,
extremities
blue
Completely
pink
Blue,
pale
Cough or
sneeze
stimulation
• ET size: <1 kg= 2.5 uncuffed
1-2 kg= 3 uncuffed
2-4 kg= 3.5 uncuffed
• ET depth: Wt(kg)+6; for nasal intubation,
add 2cm
• Epinephrine: for asystole or severe
bradycardia
 1:10,000 0.1mg/ml
 Dose: 0.01-0.03mg/kg IV
0.03-0.1mg/kg IT
• Naloxone: for narcotic depression
 Dose: 0.1-0.2mg/kg
APGAR Scoring
• 0-3 requires immediate resuscitation
• not designed to predict neurologic outcome
• Low Apgar scores (0-3 at 5 mins) and
umbilical artery blood pH predict neonatal
death
• False Positive [(-) acidosis but ↓APGAR]:
 Prematurity
 Analgesics, narcotics, sedatives
 MgSO4
 Acute cerebral/SC trauma
 Precipitous delivery
 Congenital myopathy/neuropathy
 Lung anomaly/ airway obstruction
 Pneumonia/sepsis
 Hemorrhage-hypovolemia
• False Negative [(+) acidosis but normal
APGAR]:
 Maternal acidosis
 High fetal catecholamines
 Full term
Thermoregulation
• Body surface is 3x that of an adult
• Rate of heat loss is 4x that of an adult;
occurs via convection, conduction and
radiation, evaporation
• Mechanism of heat production
 inc metabolic rate and O2
consumption
 release of norepi oxidation of brown
fatnonshivering thermogenesis
 inc muscular activity
 hence hypoxemic, hypoglycemic and
sedated NB will not be able to
thermoregulate effectively
• Skin-to-skin contact is the optimal method of
thermoregulation
Other delivery room initial care
• Silver nitrate (1%), erythromycin (0.5%) or
tetracycline (1%) ophthalmic ointments to
protect against gonococcal ophthalmia
neonatorum
• 1mg of water-soluble phytonadione (Vit K1)
IM to prevent hemorrhagic dse of the NB
• Hep B vaccine for >2kg
• Newborn screening: CH, galactosemia,
CAH, G6PD deficiency, PKU, maple syrup
urine disease
• Hearing screen
Nursery Care
• Criteria for early discharge (<48 hrs):
uncomplicated antepartum, intrapartum,
postpartum courses, vaginal delivery,
singleton, completed 37wks, AGA, RR<60,
CR 100-160, axillary temp 36.5-37.4C,
normal PE, urination and stool x 1, at least 2
uneventful, successful feedings, (-)jaundice
w/in 24 hrs, good parental educability and
ability, normal labs/screening, no social risks
• If discharged <48 hrs after delivery, follow
up examination of the NB must be made
within 48 hrs of discharge
Breastfeeding
• Baby-Friendly Hospital Initiative
(WHO/UNICEF, `989) 10 steps to successful
breasfeeding:
1. Have a written breast-feeding policy
that is routinely communicated to all
health care staff.
2. Train all health care staff in the skills
necessary to implement this policy.
3. Inform all pregnant women about the
benefits and management of breastfeeding.
4. Help mothers initiate breast-feeding
within a half hour of birth.
5. Show mothers how to breast-feed and
how to maintain lactation even if they
should be separated from their infants.
6. Give newborn infants no food or drink
other than breast milk unless
medically indicated.
7. Practice rooming-in (allow mothers
and infants to remain together) 24 hr a
day.
8. Encourage breast-feeding on demand.
9. Give no artificial teats or pacifiers to
breast-feeding infants.
10. Foster the establishment of breastfeeding support groups and refer
mothers to them on discharge from
the hospital or clinic.
• Drugs and breastfeeding
 Less likely to affect neonate: weak
acids, composed of large molecules,
plasma bound, poorly absorbed
 Contraindicated: anti-neoplastics,
drugs of abuse, bromocriptine,
chloramphenicol, clozapine,
methimazole
 Avoid/give w/ caution: alcohol,
amiodarone, ASA, atropine, Bblockers, ciprofloxacin, phenobarbital
NEONATAL FEVER
• Definition of neonatal fever: rectal
temperature of 38ºC (100.4ºF)
• Causes:
 Environmental (e.g. overbundling)
unbundle and retake temp after 15-30 mins.
If rpt temp is normal in a healthy-appearing
infant w/o antipyretic, the infant may be
considered afebrile
 Dehydration
Rochester Criteria for Identifying Febrile Infants at
Low Risk for Serious Bacterial Infection
Infant appears generally well
Infant has been previously healthy:
Born at term (≥37 weeks of gestation)
No perinatal antimicrobial therapy
No treatment for unexplained hyperbilirubinemia
No previous antimicrobial therapy
No previous hospitalization
No chronic or underlying illness
Not hospitalized longer than mother
White blood cell count of 5-15,000 per mm3
Absolute band cell count of ≤1,500 per mm3
Ten or fewer white blood cells per high-power field on
microscopic examination of urine
Five or fewer white blood cells per high-power field on
microscopic examination of stool in infant with
diarrhea
 Vaccine reaction
• If these are ruled out, serious infection
(pneumonia, bacteremia, meningitis, viral
infection esp HSV or enteroviruses) can be
considered, although such infections often
occur w/o fever, and may even present w/
hypothermia (rectal temp <36ºC)
• Neonates who have a fever and do not
appear ill have a 7% risk of having a serious
bacterial infection
• Toxic appearing infants: defined as a clinical
picture consistent w/ the sepsis syndrome
(e.g. lethargy, signs of poor perfusion or
marked hypoventilation, hyperventilation or
cyanosis)
• Mainly at risk for late-onset neonatal
bacterial diseases (group B streptococci,
Escherichia coli, and Listeria
monocytogenes) and perinatally acquired
herpes simplex virus (HSV)
• Diagnostics: CBC, UA, BCS, UCS, CSF
CS/GS glucose and protein levels, HSV and
enterovirus polymerase chain reaction
should be considered, ±stool culture and
CXR
• Under most circumstances, all febrile infants
< 28 days of age, including those in the lowrisk group,should have a sepsis evaluation
and be hospitalized for parenteral
antimicrobial therapy (e.g. Ampicillin+
Gentamicin) pending culture results.
• Acyclovir if HSV infection is suspected(CSF
pleocytosis or known maternal history of
genital HSV)
• Alternative management (for low-risk infants
<28 days): complete sepsis evaluation,
hospitalization, careful observation w/o
parenteral antimicrobial therapy pending
culture results.
References:
• http://www.doh.gov.ph/kp/statistics/infant_deaths.html
• Nelson’s 19th ed
• Manual of Neonatal Care 7th ed by Cloherty et al
• Guide for History Taking, Physical Examination and
Diagnosis of Pediatric Patients 2nd ed UST Dept of
Pediatrics
• Baraff LJ, Bass JW, Fleisher GR, Klein JO, McCracken
GH, Powell KR, et al. Practice guideline for the
management of infants and children 0 to 36 months of
age with fever without source. Pediatrics. 1993;92:1–12.
• Luszczak, M. 2001. Evaluation and Management of
Infants and Young Children with Fever. Am Fam
Physician. 64(7):1219-1227.