7/29/2019 01 - Normal Newborn and Neurologic Exam

1/4 1

THE NORMAL NEWBORN

Fetal growth & development

Milestones of Prenatal development

Week Developmental events

1 Fertilization & implantation, beginning of embryonic period

2 Endoderm & ectoderm appear (bilaminar embryo)

3 First missed menstrual period; mesoderm appears

(trilaminar embryo); somites begin to form

4 Neural folds fuse; folding of embryo into human-like shape;

arm & leg buds appear; crown-rump length 4-5 mm

5 Lens placodes, primitive mouth, digital rays on hands

6 Primitive nose, philtrum, primary palate, crown-rump

length 21-23 mm

7 Eyelids begin

8 Ovaries & testes distinguishable

9 Fetal period begins; crown-rump length 5 cm; weight 9g

10 External genitals distinguishable

20 Usual lower limit of viability; weight 460 grams; length 19

cm

25 Third trimester begins; 900 grams; length 25 cm

28 Eyes open; fetus turns head down; weight 1,300 grams

38 Term

Somatic Development

Embryonic Period Implantation begins by 6 days post conceptual age By 2 weeks, implantation is complete &

uteroplacental circulation has begun

By 3 weeks, appearance of the primitive neuraltube & paired blood vessels; paired heart tubes

begin to pump

By 4-8 weeks, budding of arm & legs, appearanceof branchial arches which will form the maxilla,

mandible, palate, external ear

By the end of week 8, this period closes Fetal period

Begins at 9th week By 10th week, the face is recognizably human,

counter-clockwise rotation of intestinal contents

By 12th week, the gender of external genitalia isestablished

Lung development starts By 20-24 weeks, primitive alveoli, surfactant

production have begun

3rd week a neural plate appears on theectodermal surface

Neural tube central nervous systemNeural crest peripheral nervous system

5th week forebrain, midbrain, hindbrain Myelinization begins at midgestation & continues

until 2 years old

Fetal behavioral development

8 weeks: muscle contractions, lateral flexion movements 13-14 weeks: breathing & swallowing motion 17 weeks: grasp reflex appears, well-developed at 27th

week

26 weeks: eye opening 3rd trimester: respond to external stimuli with heart rate

elevation & body movements

Neonatal History

Gestational/ Maternal HistoryMothers general data: Mothers & fathers name, age,

gravidity & parity (G1P0), race, birthplace, present

address, religion, educational attainment, nutritional

status, state of health, illnesses before & during

pregnancy, familial diseases, infections, prenatal check-

up, intake of drugs/ alchohol, smoking, roentgen

exposure, familial diseases, outcome of previous

pregnancy, duration of gestation

Perinatal History Hours of labor Start of regular uterine contractions Rupture of bag of water Hours of delivery of the baby & placenta Obstetrical blood loss Fetal heart tone characteristic Manner of delivery Person who assisted the delivery

Neonatal History Presenting part upon delivery Spontaneous respiration or required resuscitation APGAR score Presence of cyanosis, pallor, jaundice, convulsions,

hemorrhage

Abnormal physical examination findings Type of feeding How long did the baby stayed in the nursery/ NICU Any use of antibiotics Hepatitis B vaccine given at birth Newborn/ Hearing screening done

Neonatal History should

1. Identify disabling diseases that are amenable to promptpreventive action or treatment (e.g. RDS)

2. Anticipate condition that maybe of late importance (e.g.gonococcal conjunctivitis)

3. Uncovers possible causative factors that may explainpathologic conditions regardless of their immediate future

significance (e.g. metabolic diseases)

Physical Examination of the Newborn Infant

Three periods of examination1. Immediately after delivery (focus on congenital

problems & adaptation to extra uterine life, birth

injuries)

2. At 24 hours of life (more detailed examination)3. Upon discharge (If possible together with the mother)

Anthropometric measurements Birth weight (normal: 3.4 kg; boys slightly > girls) Birth length (normal: 50 cm) Head circumference (normal:35 cm) Chest circumference (HC > (1-2 cm) than CC) Abdominal circumference

Physical Examination

Pulse/ cardiac rate: 120-160 bpm Respiratory rate: 30-60 breaths/ min Blood pressure: Not routinely taken unless the baby is ill

or with heart murmur

7/29/2019 01 - Normal Newborn and Neurologic Exam

2/4 2

General appearance

Posture (Flexion) Physical activity Edema Muscle tone Level of alertness (18-20 hours sleep) Color (cyanotic, acrocyanotic, pallor, plethoric, jaundice)

Skin

Vasomotor instability; mottling, acrocyanosis (bluediscoloration, coldness, sweating of extremities,

especially hands), harlequin color change

Cyanosis Pallor Plethora beefy red coloration of a newborn; boiled

lobster hue of the infants skin caused by an unusually

high proportion of erythrocytes per volume of blood

Jaundice or icterus Vernix caseosa: Grayish white cheeselike substance,

consisting of sebaceous gland secretions, lanugo &

desquamated epithelial cells that cover the fetus skin

Erythema toxicum (eosinophils): Pink popular rashfrequently superimposed with vesicles or pustule; rash

appears within 24-48 hours after birth & disappear

spontaneously after several days (benign)

Pustular melanosis (neutrophils) Milia: Nonpathologic dermatological condition

characterized by minute epidermal cysts containing

keratinous debris that occur on the face occasionally on

the trunk of the newborn

Milaria: Miunte vesicles & papules often with surroundingerythema, caused by occlusion of sweat ducts during

times of exposure to heat & high humidity

Mongolian spots: Benign bluish-black macule, between 2& 8 cm, occurring over the sacrum & on the buttocks of

some newborns. It usually disappears during earlychildhood

Capillary hemangioma: A blood-filled birthmark or benigntumor consisting of closely packed small blood vessels,

commonly found during infancy. It first grows, them may

spontaneously disappear in early childhood without

treatment (vascular tumor)

Meconium staining of skin, cord & nails (post-term) Lanugo (preterm) Vellus hair (term) Gelatinous skin Parchment-like skin (post-term) Tuft of hair Amniotic band (secondary to ruptured amnioticmembrane/ vascular compromise) Storks bite (benign vascular hematomas) Pigmented nevi Petechiae/ purpura

Head/ skull

Molding: The natural process by which a babys head isshaped during labor as it is squeezed into & through the

birth passage by the forces of labor; the head often

becomes elongated & the bones of the skull maybe

caused to overlap slightly at the suture lines. Usually

resolved during the 1st few days of life

Cephalhematoma (10-20% may have skull fractures) Caput succedaneum: A localized pitting edema in the

scalp of a fetus that may overlie sutures of the skull. It is

usually formed during labor as a result of the circular

pressure of the cervix on the fetal occiput (diffuse

swelling of the soft tissue of the skull)

Skull defects (anencephaly) Anterior & posterior fontanels (a: 7-18mos, p: 6-8 wks;

ecchymosis)

Craniosynostosis: Premature ossification of the sutures ofthe skull often associated with other skeletal defects; the

sutures close before or soon after birth without surgical

correction, the growth of the skull is inhibited, the head is

deformed& the eyes & brain are often damaged

Craniotabes: Benign congenital thinness of the top & backof the skull of a newborn. Because the rate of brain

growth exceeds the rate of ossification of the skull during

the last month of gestation

Microcephaly: Congenital anomaly characterized byabnormal smallness of head in relation to the rest of the

body & by underdevelopment of the brain resulting in

some degree of mental retardation

Macrocephaly: Congenital anomaly characterized byabnormally largeness of the head & brain in relation to

the rest of the body

Hydrocephaly: Pathologic condition characterized byabnormal accumulation of CSF, usually under increased

pressure, within the cranial vault & subsequent dilatation

of the ventricles

Cutis aplasia congenital Bruits

Face

Dysmorphic features: epicanthal folds, widely spacedeyes, microphthalmia, asymmetry, long philtrum, low set

ears

Asymmetrical face (7th CN palsy) Moebius syndrome: Hypoplasia of the 7th nerve nucleus)

Eyes

Dolls eye maneuver: A normal response in newborns tokeep the eye stationary as the head is moved to the right

or left. Reflex disappears as ocular fixation develops

Subconjunctival/ retinal hemorrhages Red orange reflex Leucokoria (white pupillary reflex)(Appearance of a

whitish reflex or mass in the papillary area behind the

lens): Cataracts, tumors, ROP

Chemical irritation White sclerae Blue sclerae (osteogenesis imperfecta) Chorioretinitis: Inflammatory condition of the choroids &

retina of the eye, usually d/t parasitic/bacterial infection

Ears

Anotia (Treacher-Collins syndrome): Congenital absenceof one or both ears

Microtia Preauricular tags & pits Dull gray tympanic membrane Low set ears Malformed ears

7/29/2019 01 - Normal Newborn and Neurologic Exam

3/4 3

Nose

Broad in appearance Choanal atresia: Congenital anomaly in which a bony or

membranous occlusion blocks the passageway between

the nose & pharynx

Flaring of the ala nasiMouth

Natal teeth (lower incisors)(remove if loose to avoid risk of aspiration)

Bifid uvula Cleft lip & palate Sucking pads Small tonsils High-arched palate Large tongue Ankyloglossia: A severe restriction of tongue movement

as a result of adhesion or fusion of the tongue to the floor

of the mouth

Retention cysts (ranula): Large mucocele in the floor ofthe mouth caused by destruction of the ducts of the

salivary glands

Epsteins pearls: Small white-pearl-like epithelial cyststhat occur on both sides of the midline of the hard palate

of the newborn

Micrognathia (Pierre-Robin syndrome):Underdevelopment of the jaw, especially the mandible

Excessive salivation Macrostomia

Neck

Short neck Hematoma on sternocleidomastoid muscle Cystic hygroma Branchial cleft cysts Thyroglossal duct cyst Webbing: Skinfolds connectinf adjacent structures such as

fingers or toes as the neck from the acromion to the

mastoid, associated with genetic abnormalities

Resistant neck to flexion (meningitis or SAH) Bruits of thyroid gland Congenital torticollis: An abnormal condition in which the

head is inclined

Clavicular fracture in LGA babies (large for gestationalage)

Thorax & Lungs

Chest Breast hypertrophy with or without milk (Witches

milk) Mastitis: Inflammation condition of the breast

common in lactation chaaracterized by pain,

swelling & redness

Supernumerary nipples Inverted nipples Widespread nipples Chest circumference: 2 cm < HC

Lungs Breathing is predominantly abdominal Retractions, grunting Asymmetric breathing

Stridor: Abnormal, high-pitched sounds caused byan obstruction in lungs or trachea usually heard

during inspiration, may ndicate glottic edema,

asthma, diptheria

Bronchovesicular breath sounds Apnea Periodic breathing Crackles or rales

Cardiovascular system

Normal resting heart rate: 90-160 bpm PMI at 4th ICS Characteristic of pulses: Coarctation of aorta Dextrocardia: Location of the heart in the right

hemithorax, either as a result of displacement or as a

congenital defect

Benign/ pathologic murmur Sinus bradycardia Blood pressure: Systolic 40-80 mmHg, Diastolic 20-55

mmHg, mean 25-60 mmHg

Abdomen

Liver palpable 2 cm BRCM Palpable splenic tip Gas in rectum by 24 hours Umbilical hernia Masses Scaphoid abdomen: diaphragmatic hernia Omphalocoele (Congenital herniation of intraabdominal

viscera thru a defect in the abdominal wall around

umbilicus), gastroschisis

Omphalitis: Inflammation of umbilical stump marked byredness, swelling & purulent exudates in severe cases

Umbilical cord: 2 arteries, 1 vein, Whartons jelly Tufts of hair

Genitourinary system Penis should at least be 2 cm in length Transitory hydrocoele: Accumulation of fluid in any

saclike cavity or duct specifically in the tunica vaginalis

testis or along the spermatic cord

Hypospadias: Developmental anomaly in male which theurethra opens on the underside of the penis or on

perineum

Tight prepuce Ambiguous genitalia (CAH) Pseudomenses Erection of the penis Voiding within 24 hours Undescended testes Large labia majora Hymenal tags: Normal redundant hymenal tissue

protruding from the floor of the vagina during the first

weeks of birth

Testicular torsionAnus

Passage of meconium within the 1st 12 hours after birth Imperforate anus Fistula in ano Meconium pearls

7/29/2019 01 - Normal Newborn and Neurologic Exam

4/4

4

Musculoskeletal system

Unequal limbs due to lymphangiomas (A benign yellowishtan tumor on the skin composed of a mass of dialted

lymph vessels)/ hemangiomas

Syndactyly (Fusion of the fingers/ toes)/ polydactyly(Presence of more than normal number of fingers or

toes)/ clinodactyly (Abnormal lateral or medial bending of

one or more fingers or toes)

Ortolani maneuver: Congenital hip dislocation Talipes equinovarus/ equinovalgus Amelia (Absence of one or more limbs)/ pocomelia Rocker-bottom feet Simian crease: Single crease across the palm produced

from the fusion of proximal & distal palmar creases

evident in children with Downs syndrome

Breech presentation: Intrauterine position of the fetus inwhich the buttocks or feet present

Brachial palsy** Barlow maneuver, Ortolani maneuver

NEUROLOGICAL EXAMINATION OF THE INFANT

General considerations

The following reflect the neurologic status of the baby Posture Sleep state Feeding Breathing Cardiac status

The optimal time to do NE is usually immediately prior tofeeding awake & responsive

Observation of the infant

At term the infant remains alert for reasonable periods oftime & responds to visual, auditory & tactile stimuli

Presence of congenital anomalies neural tube defects Look for neurocutaneous lesions caf au lait spots,

nevus

Observe respiratory movementsDevelopmental reflexes

Primitive reflexes which reflect the integrity of thebrainstem & spinal cord

Moro reflex Tonic neck reflex Grasp reflex Placing reflex Stepping reflex Parachute reflex

These reflexes are present at birth & disappear by 6months

Persistence: maturational lag or impaired CNS function Asymmetry: CNS or PNS dysfunction

Motor function

Evaluate the posture & tone Gentle manipulation of the infants limb allows for

assessment of muscle tone & strength

The baby should be supine with the head in midpositionwhile tone is evaluated so that the tonic neck reflex does

not augment tone unilaterally

Posture

There is hypertonia of the elbow, hip & knee flexorsduring the 1st three months

Flexion The newborn should be gently held in the horizontal

position & at vertical suspension to determine if flexor

tone is present & symmetric

Tone

Involves examination of passive & active tone Passive tone is evaluated by determining the degree of

resistance to passive movements of the joints

The active tone is evaluated by observing the babysresponse to gentle pulling from supine to the prone

position (traction response)

Cranial Nerve Examination

Cranial Nerve 1 Infrequently tested Pleasant, aromatic substances The newborn manifests arrest of activity & sucking

activity

Cranial Nerves 2, 3, 4, 6, 8 Assessment of the eyes Bilateral symmetric pupils (response to light by

blinking)

Ptosis: abnormality of CN 3 Grayish-white optic disc Eyes fix on bright object & face Presence of visual threat Observe conjugate eye movements on Dolls eye

maneuver

Cranial Nerve 5 Test for the corneal reflex by blowing air towards

the eyes

Observe for symmetrical closure of the eyelids Cranial Nerve 7

Facial movements are readily observed duringcrying

Observe for symmetry Cranial Nerve 11

Observed by turning the infants head to one sidewhile restraining it at the opposite shoulder

Observe contraction of the sternocleidomastoidmuscle

Cranial Nerves 9, 10, 12: Assess the quality of sucking &swallowing as well as the quality of the voice during

crying

Sensory testing Tests for pain & sensation are imprecise in this period, &

the gross response of infants to stroking & pinprick with

withdrawal, crying & changes in sucking rates maybe the

only information possible

- CHRABI