Newborn history and examination

history and examination PEDIATRICS

1. Newborn history and examination: G.ERIC MD4

2. Newborn history and examination: Format for case presentation History General Mother's name and age, parity, last menstrual period, expected date of delivery Past obstetric history Past pregnancies: when, gestation, fetal or neonatal problems, current status of childre Antenatal Number of antenatal visits, tests (hemoglobin; urine albumin, sugar; ultrasound; blood group, VDRL, HIV), tetanus toxoid immunization, supplements (iron, folic acid, calcium, iodine)

3. Obstetric or medical complications Obstetric complications (toxemia, urinary tract infections, twins/triplets, placenta previa , accidental hemorrhage); fetal problems (IUGR, hydrops , Rh isoimmunization ); medical problems (diabetes, hypertension); investigations, medications, course Labor Presentation, lie, onset of labor (spontaneous/induced), rupture of membranes (spontaneous/ artificial), liquor (clear/ meconium stained); duration of first and second stage of labor; fetal heart rate (tachycardia, bradycardia , irregular) Delivery Place of delivery, vaginal (spontaneous/ forceps/vacuum), cesarean (indication, elective/ emergency); local/ general anesthesia; other drugs; duration of third stage; postpartum hemorrhage

4. Immediate care at birth Resuscitation; time of first breath and cry; Apgar score; cord care; passage of urine/stool Feeding history Breastfeeding (when initiated, frequency, adequacy); other feeds Postnatal problems Feeding problems, jaundice, eye discharge, fever; current problems Family history History of perinatal illness in other siblings Past medical problems History of past medical problems, if any Personal/social history Socioeconomic status, family support

5. General examination Immediately after birth Weight, gestation, congenital anomalies, sex assigning, Apgar scores, examination of umbilical vessel, and placenta Appearance Vital signs Overall appearance: well or sick looking; alert/unconscious Temperature, cold stress; respiratory rate, retractions, grunt/ stridor ; heart rate, palpable femoral arteries; blood pressure, capillary refill time; cry; apneic spells Anthropometry Weight, length, head circumference, chest circumference Gestation Classification by intrauterine growth Assessment by physical criteria; more detailed assessment by expanded New Ballard examination Appropriate/small/large for gestational age; symmetric or asymmetric small for gestational age; signs of IUGR

6. Congenital anomalies Head to toeexamination for malformations or abnormalities Birth trauma Signs of trauma cephalohematoma Common signs Special signs Cyanosis, jaundice, pallor, bleed, pustules, edema, depressed fontanel Caput; eye discharge; umbilical stump: discharge or redness; jitteriness; eye discharge; oral thrush; development peculiarities (toxic erythema , Epstein pearls, breast engorgement, vaginal bleeding, capillary hemangioma , mongolian spot) Feeding Observe feeding on breast (check positioning and attachment) Reflexes Moro, grasp, rooting

7. Systemic examination Chest Shape; respiratory rate; retractions; air entry; adventitious sounds Cardiovascular system Apical impulse, heart sounds, murmur Abdomen Distension, wall edema, tenderness, palpable liver/spleen/kidneys, any other lump, ascites , hernial sites, gonads, genitalia Musculoskeletal system Deformities ; tests for developmental dysplasia of hip; club foot Central nervous system State of consciousness; vision, pupils, eye movements; facial sensation; hearing; sucking and swallowing; muscle tone and posture; power; tendon reflexes

8. Term Babies VS Preterm Babies (E) deep transverse creases on the soles; (F) faint marks on the sole, no deep creases

9. Term Babies VS Preterm Babies (C) well pigmented and pendulous scrotal sacs, with fully descended testes; (D) light pigmentation and not yet descended testes;

10. Term Babies VS Preterm Babies (A) Well-curved pinna , cartilage reaching up to periphery; (B) flat and soft pinna , cartilage not reaching up to periphery

11. Term Babies VS Preterm Babies CG) Well formed breast bud C>S mm); CH) Poorly developed breast bud; Cl

12. Term Babies VS Preterm Babies Cl ) silky hair, where individual strands can be made out; (J) fuzzy hair

13. Cephalohematoma . Note the overlying bruising

14. (A) Umbilical hernia; and (B) Inguinal hernia

15. Neurological examination Cranial nerves Neonates respond to cotton soaked in peppermint by 32 weeks of gestation. By 26 weeks the infant consistently blinks in response to light and by term gestation, fixation and following (tested using fluffy red yarn ball) is well established By 28 weeks the infant startles or blinks to loud noise. Sucking and swallowing are important aspects that should be examined as they give insight into the proper functioning of the V, VII, IX, X and XII cranial nerves . The act of sucking requires the coordinated action of breathing, sucking and swallowing. Suck-swallow coordination so as to accept paladai feeding is present by 32 weeks. Suck-swallow and breathing coordination occurs by 34 weeks when baby can breastfeed. However, perfect coordination of suck-swallow and breathing develops only by 38 weeks of gestation. This consists of the assessment of the level of alertness and examination of cranial nerves, motor and sensory system and neonatal reflexes.

16. Neurological examination Motor examination. By 28 weeks there is minimal resistance to passive manipulation of all the limbs and a distinct flexor tone is appreciated in lower extremities by 32 weeks. By 36 weeks, flexor tone is palpable in both the lower and upper extremities. This consists of the assessment of the level of alertness and examination of cranial nerves, motor and sensory system and neonatal reflexes

17. Neurological examination Primary neonatal reflexes. Moro reflex is best elicited by the sudden dropping of the baby's head in relation to trunk; the response consists of opening of the hands and extension and abduction of the upper extremities, followed by anterior flexion (embracing) of upper extremities with an audible cry. The hand opening is present by 28 weeks, extension and abduction by 32 weeks and anterior flexion by 37 weeks. Moro reflex disappears by 3-6 months in normal infants. The most common cause of depressed or absent Moro reflex is a generalized disturbance of the central nervous system. An asymmetrical Moro reflex is indicative of root plexus injury. This consists of the assessment of the level of alertness and examination of cranial nerves, motor and sensory system and neonatal reflexes

18. Moro reflex (A) Abduction and extension of arms is followed by (B) Adduction and flexion component The palmar grasp is clearly present at 28 weeks of gestation and is strong by 32 weeks. This allows the lifting of the baby at 37 weeks of gestation. This becomes less consistent on development of voluntary grasping by 2 months. The tonic neck response is another important response elicited by rotation of the head, that causes extension of the upper extremity on the side to which the face is rotated and flexion of the upper extremity on the side of the occiput (This disappears by 6 to 7months