ART OF NEONATAL EXAMINATION & DANGER SIGNS.ppt

Neonate

1. ART OF NEONATAL
EXAMINATION
DEPARTMENT OF PAEDIATRICS
MVJ MC & RH

2. A normal neonate for the purpose of this guideline has
been defined as:
Birth weight greater than or equal to 2500 g
Gestation greater than or equal to 37 wk
Birth weight between 10th to 90th percentiles
on a standard intrauterine growth chart
No need for assisted ventilation or beyond for
resuscitation at birth
Apgar score greater than or equal to 7 at 1
minute
No postnatal illness such as respiratory
distress, sepsis, hypoglycemia or polycythemia
or requiring admission in neonatal unit

3. What are issues of concern in
the first few hours of birth in
normal newborn?

4. •Cleaning of the baby:All infants should be
cleaned at birth with a clean, sterile cloth to
remove blood clots and/or meconium present
on the body. One should not attempt to remove
vernix from the body by any means, as it can
result in trauma to skin and increase chance of
infections
•Baby Identification marking: Each infant
must have an identity band containing name of
the mother,hospital registration number, gender
and birth weight of the infant.
•Recording of weight: All the infants should be
weighed at within one hour of birth on a scale
with at least 5 gm sensitivity.

5. •Administration of Vitamin K: Vitamin K in
dose of 1 mg to term and 0.5 mg to preterm
infants must be routinely administered
intramuscularly to all neonates to prevent
vitamin K deficiency bleeding.
•Stomach wash: There is no role of routine
stomach wash after birth to prevent any kind
of gastritis. If the infant is born through
meconium stained liquor, the stomach may be
aspirated to remove the content to prevent
vomiting in early neonatal period.

6. •Examination at birth:The infant should be
examined thoroughly for cardio-respiratory
stability,malformation or trauma and
determination of gestation at birth using a
predesigned proforma.
•There is no need for routine passage of
catheter in the stomach for detection of
esophageal atresia, in the nostrils for detection
of choanal atresia or into the rectum for
detection of anorectal malformation.
•Body temperature to the infant must be
recorded by axillary route using electronic
thermometer. If mercury thermometer is used,
temperature should be recorded for 3minutes.

7. •Prevention of tetanus:If mother has not
received adequate tetanus immunization during
pregnancy, the infant should be given a
tetanus toxoid dose and concurrent tetanus
immunoglobulin 250 IU intramuscularly to
prevent tetanus neonatorum.
•Rooming in:There is no indication for
separating a normal infant from the mother for
routine observation in the nursery, irrespective
of the mode of delivery.
•During initial couple of hours after birth,
infants are awake and very active and this
opportunity should be utilized for bonding and
initiation of breastfeeding.

8. •Initiation of breastfeeding:The
breastfeeding must be initiated as early as
possible within one hour of birth.
•Communication with the family: The health
provider attending the birth of the infant must
communicate with the mother and other family
members regarding time, weight at birth,
gender and well being of the infant.
•The infant should be shown to the family with
particular attention given to the fact that family
members get to know the gender and about
the identity tag on the infant. This would avoid
any confusion with legal implications regarding
identity and gender of the infant.

9. WHAT ARE ISSUES OF
CONCERN DURING
INITIAL FEW DAYS OF
LIFE?

10. •Cord care:The umbilical cord must be kept
open and dry. The nappy should be folded well
below the umbilical stump
•Eye care:Eyes of the infant must be cleaned
with a sterile swab soaked in normal saline or
sterile water.Clean from inner to outer canthus
and use a separate swab for each eye.
•Exclusive breastfeeding
•Oil massage:Oil massage is a low cost
traditional practice well ingrained in Indian
culture . However, a paucity of data still exists
as to what oil should be used for this purpose .

11. •Evaluation for jaundice: All the infants must
be examined for the development and severity
of jaundice twice a day for first few days of life.
Visual assessment in daylight is the preferred
method.
•Vaccination:All the infants must be offered
the immunization at birth, before discharge, as
per their state policy.
•Bathing:Routine bathing in the hospital
should be avoided in view of risks of cross
infection and hypothermia.The infant can be
sponged, as required. Infant can be bathed at
home once discharged from the hospital.

12. •Sleep Position:All healthy neonates who are
born at term and have no medical
complications should preferably be placed
down for sleep on their back
•Traditional practices:A variety of traditional
practices are common place in India. These can
be beneficial such as oil massage,
inconsequential such as putting black mark on
forehead. However there are a variety of
harmful traditional practices such as applying
kajal/surma in eyes , putting oil in ear,putting
boric acids in nostrils or applying substances
such as cow dung on cord must be actively
discouraged.

13. When should normal
newborn be discharged
from hospital?

14. Ideally infant should be discharged after 72-96 h once all
the following criteria are fulfilled:
• Infant is free from any illness including significant
jaundice
• The infant has been immunized
• Adequacy of breastfeeding has been established.
• Mother is free from any significant illness and confident
to take care of her infant.
Early discharge (within first 24 to 48 h): This can be
considered for non-primigravida mothers with prior
breastfeeding experience and who fulfill the above
mentioned criteria before discharge. However
primigravida mothers should not be discharged before
72 hr in order to ensure adequate breastfeeding.

15. Adequacy of breastfeeding has been
established. This must be assessed in all
infants and the same would be indicated by
passage of urine at 6 to 8 times/24 hr,
onset of transitional stools,
baby sleeping well for 2-3 h after feeding.
If there is any concern about adequacy of
breastfeeding, the infant can be weighed on
the same weighing scale that was used to
weigh the infant at birth.Excessive weight loss
(normal 8-10% of birth weight by 3-4 days of
age) would indicate inadequate breastfeeding.

16. Art of newborn examination
Immediately after resuscitation
aimed at r/o congenital malformations
Examination of normal newborn
Gestational age assessment
Neurological examination of newborn
Problem oriented clinical approach
i.e. Resp distress, neonatal jaundice etc.,

17. History
THE FAMILY, MATERNAL, PATERNAL, PREGNANCY & PERINATAL
HISTORY SHOULD BE REVIEWED
FAMILYHISTORY:-
Inherited diseases (e.g.Metabolic disorders,
hemophilia, cystic fibrosis, H/o perinatal death)
Maternal history
Age/bld group
Maternal illness/PIH/RHD/diabetes
STD including HIV status
Recent infections/exposure

18. Mother’s & Infant’s Records
Items of particular relevance in the mother’s and infant’s
medical & nursing records are
Maternal age, occupation, and social background
Family history
History of maternal drug or alcohol abuse
Details of previous pregnancies & any medical problems
experienced by those children
History of maternal disease & drugs taken during
pregnancy

19. Mother’s & Infant’s Records (contd..)
Results of pregnancy screening tests (e.g., blood tests
including maternal syphilis & hepatitis B surface antigen,
prenatal ultrasound scans)
Results of special diagnostic procedures (e.g.,
amniocentesis, chorionic villous sampling)
Problems during labor & delivery
Infant’s condition at birth & if resuscitation was required
Any concerns about the infant from nursing staff or
parents
The infant’s birthweight
The gestational age & if there is any uncertainty about it
The Infant’s gender

20. Drug History
*Medications *Alcohol
*Drug Abuse *Tobacco
Current Pregnancy
Probable gest. age
Quickening (16-18 wks)
Results of fetal testing
Poly/oligohydramnios
Infection/surgery/PIH
Glucocorticoids/antibiotics/tocolytics
History(contd..)

21. LABOUR & DELIVERY
Presentation
ROM/fever/fetal Monitoring
Amniotic fluid (blood, meconium, volume)
Initial delivery room assessment (shock,
asphyxia,trauma, anomolies, infection, temperature)
Apgar score
Resuscitation/placental examination
History (contd..)

22. History in Neonatal skin examination

24. Prevalence of Serious Congenital Anomalies
(per 1000 live births)
ANOMALY PREVALENCE
Congenital heart disease 6-8 (0.8 identified in the
first day of life)
Developmental dysplasia of the hip 0.8 (about 7/1000 have
an abnormal initial
examination)
Talipes equinovarus 1.5
Down syndrome 1.5
Cleft lip & palate 0.8
Urogenital (hypospadias, undescended
testes)
1.2
Spina bifida/anencephalopathy 0.5

25. Objectives of Routine Examination of the Newborn
Detect congenital abnormalities not already
identified at birth (e.g., congenital heart disease &
developmental dysplasia of the hip)
Determine if any of the wide range of non acute
neonatal problems are present & initiate their
management or reassure the parents
Check for potential problems arising from maternal
disease, familial disorders, or problems detected
during pregnancy
Provide an opportunity for the parents to discuss
any questions about their infant
Initiate health promotion for the newborn

26. Developmental abnormalities in the newborn
Preauricular sinus Accessory tragus
Accessory nipple

27. First physical examination
Firstoverallvisual&auditoryappraisalofnaked
infantismostinformative
Somepartofclinicalassessmentisworthless
(Chestpercussion)
Comprehensiveexaminationvisuallytakes5-7mts

28. First physical examination(contd…)
Initial Examination aimed at
Whetheranycongenitalanomaliespresent.
Whetherinfanthasmadeplacentaltransitionfrom“water
breathing”to“airbreathing”.
Towhatextentgestation,labor,delivery,analgesicshave
affectedthenewborn.
Whetherheorshehasanysignofinfectionormetabolic
diseasewhichwasunsuspected.

29. General examination
Examine Neonate unclothed
Explore ideal time for examination
Just before scheduled feed
Appreciate Transient Skin Lesions
Erythema toxicum
Milia
Neonatal pustular melanosis
Epstein pearls
Mongolian spots
Visualize opening at either end
Watch out for jaundice

30. Main features of routine examination of
the newborn

31. Transient skin lesions in the newborn
Milia Miliaria crystiallina Miliaria rubra

32. Transient skin lesions in the newborn
Erythema toxicum

33. Transient skin lesions in the newborn
Transient neonatal pustular melanosis

34. Transient skin lesions in the newborn
Neonatal acne

35. Transient skin lesions in the newborn
Mongolian spots (Dermal melanosis)

36. Transient skin lesions in the newborn
Cutis marmorata

37. Transient skin lesions in the newborn
Nevus simplex

38. Head, Neck & Mouth
OFCatterm33-36cms.
CaputsuccedaneumV/sCephalhematoma
Minormouldingofskullbones-normal.
Craniotabescommoninpostmaturedbabies.
Normallytwo,occasionallysixfontanellesfelt.
Checkneckforrangeofmotion,goiter&cystic
swelling.
Checkinthemouth-cleftlip/palate,nataltooth,
clefts,Epstein’spearls.

39. Subgaleal hemorrhage and cephalhematoma

40. Eye examination
Physiological photophobia limits eye
evaluation in the newborn
Mild lid edema, matting of eyelids common
Sub-conjunctival hemorrhages, corneal
haziness in preterm are of no concern
Nystagmus, squint doesn’t warrant
immediate evaluation

41. Cardiorespiratory system
Color is probably single most important index of the cardiac
status
RR is 40-60/min, & most infants are periodic rather than regular
breathers
Be familiar with sequential changes during cardiopulmonary
adaptation
Normal H.R.-120-160/min & always feel femoral along with upper
limb pulses
Presence of a split S
2may be reassuring
Murmurs mean less in the newborn than at any other time

42. Features of a Heart Murmur in a Neonate
Features of an Innocent Murmur
Soft (grade 1/6 or 2/6) murmur at left sternal edge
No audible clicks
Normal pulses
Otherwise normal clinical examination
Features Suggesting a Murmur is Significant
Pansystolic
Loud (≥ grade 3/6)
Harsh quality
Best heard in the upper left sternal edge
Abnormal second heart sound
Femoral pulses difficult to feel
Other abnormality on clinical examination

43. Abdominal examination
See through phenomenon because of poorly
developed abdominal musculature
Liver usually palpable
Upper pole of kidneys often palpable for first two
weeks
Small umbilical hernia-normal phenomenon
Any palpable abdominal lump is renal in origin
unless proved otherwise.

44. Umbilical granuloma

45. Developmental anomalies of the umbilicus
Umbilical granuloma
Umbilical polyp
Urachal cyst

46. Genitalia and Rectum
MALE BABIES
Marked phimosis, hydrocele normal Phenomenon
Pendulous scrotum indicates euthermia
Length & width of penis should be noted
FEMALE BABIES
At term enlarged labia majora
occasionally mucosal tag
Pseudomenses & white discharge
ANUS & RECTUM should be checked for patency,
position & size

47. Extremities, Spine & Joints
Anomalies of the digits, club feet & hip
dislocation (CDH) are common
Mild tibial bowing-normal phenomenon
Check CDH by detecting clicks
Check spine for dimple, sinuses, tuft of
hair

48. Absolute Risk for a Positive Result on Routine
Examination of the Newborn Hip
NEWBORN
CHARACTERISTICS
ABSOLUTE RISK OF A
POSITIVE EXAMINATION
PER 1000 NEWBORNS
Over all
All newborns 11.5
Boys 4.1
Girls 19
Positive Family History
Boys 6.4
Girls 32
Breech Presentation
Boys 29
Girls 133

49. Developmental dysplasia of Hip-Algorithmic approach
Physical exam
Positive
Physical exam
inconclusive
Refer to orthopedist
Do not use triple diapers
Follow-up examination at 2
weeks
Physical exam
normal but risk
factors
Female or
Family history + male
Family history + female
or
Breech + male
Breech + female
Recheck at periodic intervals
Optional imaging:
*ultrasound<5 months old
*x-ray >4 months old
Imaging (see above)

50. Developmental dysplasia of Hip

51. Neurological examination
UndertakeitinstateIIIorIV-Pretchlscaleof
wakefulness
Assesscranialnervesduringcrying
Differentiatenormalv/spathologicalcry
Elicitminimum reflexes(DTR)&plantarsoften
extensor
Bareminimumneonatalreflexes
Moro’sreflex
Plantar/Palmargrasp
Placing&steppingreflex

52. Assessment of gestational age using the revised
Ballard method

53. Assessment of gestational age using the revised
Ballard method

54. Discharge examination
Atdischarge,Newbornshouldbereexaminedwith
followingpointsinmind
Heart -development of murmur, cyanosis or
failure
CNS -activity, sutures, fullness of fontanelle
Abdomen -any masses previously missed, stool &
urine output
Skin -jaundice, pyoderma

55. Cord -Infection
Infection -Any signs of sepsis
Feeding -spitting, vomiting, distension, Wt.gain
Maternal competence -to provide adequate care
PRACTISE IDEAL PERINATAL DISCHARGE POLICIES (D
5)
Discharge examination (contd…)

56. Danger signs
Summary
Not cried for 5 mts
Respiratory distress
Jaundice D
1, palm
& sole stains
Convulsion
Bleeding Neonate
Temp <36°C
Wt. <1500gms
Gest age <32 wks
DO NO HARM
STRIVE FOR INTACT SURVIVAL
BABY
Vomiting/Diarrhoea
Abdominal distension

57. THANK YOU