Normal Newborn

Physical Examination

A complete physical examination is an important part of newborn care. Each body system is carefully examined for signs of health and normal function. The physician also looks for any signs of illness or birth defects. Physical examination of a newborn often includes assessment of the following:

vital signs: o temperature - able to maintain stable body temperature 98.6° F (37° C) in

normal room environmento pulse - normally 120 to160 beats per minuteo breathing rate - normally 30 to 60 breaths per minute

general appearance - physical activity, tone, posture, and level of consciousness skin - color, texture, nails, presence of rashes head and neck:

o appearance, shape, presence of moulding (shaping of the head from passage through the birth canal)

o fontanels (the open "soft spots" between the bones of the baby's skull)o clavicles (bones across the upper chest)

face - eyes, ears, nose, cheeks mouth - palate, tongue, throat lungs - breath sounds, breathing pattern heart sounds and femoral (in the groin) pulses abdomen - presence of masses or hernias genitals and anus - for open passage of urine and stool arms and legs - movement and development

PURPOSE OF NEWBORN ASSESSMENT ------

IDENTIFY NORMAL CHARACTERISTICS, ADNORMALITIES, AND PROVIDE BASELINE

FIRST THREE STEPS OF ASSESSMENT ------

RESPIRATIONS, HEART RATE, BOWEL SOUNDS

NORMAL HEART RATE ------

120-160

NORMAL RESPIRATIONS ------

30-60

NORMAL TEMPERATURE ------

97.8-99

NORMAL B/P ------

80/46

NORMAL HEAD CIRCUMFERENCE ------

13-14 IN (2 CM GREATER THAN CHEST CIRCUMFERENCE

HEAD 2-3 CM SMALLER THAN CHEST INDICATES ------

MOLDING

SMALL HEAD RELATED TO BODY SIZE ------

MICROCEPHALY

PREMATURE CLOSING OF SUTURES ------

CRANIOSTENOSIS

CHEST CIRCUMFERENCE ------

30-33 CM

12-13 IN

LENGTH ------

18-22 IN

WEIGHT ------

2500-4000 GM

5-9 LBS

VERNIX CASEOSA ------

WHITE CHEESY SUBSTANCE FOUND ON SKIN

LANUGO ------

DOWNY FINE HAIR SEEN ON PINNA, FOREHEAD, AND SHOULDERS

ACROCYNOSIS ------

PINK BODIES WITH BLUE EXTREMITIES

ERYTHEMA TOXICUM ------ NORMAL NEWBORN RASH BEEFY RED ON ABDOMEN, BACK, AND DIAPER AREA . DISAPPEARS 20-24 HOURS

MILLIA ------

SMALL PIN HEAD SIZE PEARLY BALLS ON NOSE AND FACE

TELANGIECTATIC NEVI ------

STORK BITE. BLANCHES WITH PRESSURE. FOUND ON UPPER EYELIDS, BACK OF NECK. FADES AT 1-2 YEARS

NEVUS FLAMMEUS ------ PORT WINE STAIN- RED/PURPLE, DOES NOT BLANCH. HUGE. FOUND ON FACE OR THIGH, FLAT BIRTH MARK

NEVUS VASCULOSUS ------

STRAWBERRY MARK, RAISED AREA CAUSED BY DILATED NEWLY FORMED CAPILLARIES, STAY SCHOOL AGE OR OLDER

CAPET SUCCEDANEUM ------

EDEMATOUS SWELLING BENEATH THE SCALP, COVERS SUTURE LINES,MOST COMMON OVER OCCIPUT,LAST 3-4 DAYS

CEPHALOHEMATOMA ------ NOT PRESENT @ BIRTH, DEVELOPS WITHIN 24 HOURS, SOFT BULGE DOES NOT COVER SUTURE LINE, LASTS 3-6 WEEKS

PLAGIOCEPHALY ------

FLATTENED OCCIPUT ON ONE SIDE AND PROMINENCE OF FRONTAL REGION. CAUSED BY LYING IN ONE POSITION

ANTERIOR FONTANELS ------

DIAMOND SHAPE, 1-6 CM, CLOSES @ 18 MONTHS, SAGITAL & CORONAL SUTURES

POSTERIOR FONTANELS ------

TRIANGLE SHAPE, 1-2 CM, CLOSES @2 MONTHS, SAGITAL & LONGITOIL SUTURE

EXTRA DIGITS ------ POLYDACTYLY

SYNDACTYLY ------ WEBBING OF DIGITS

PILONIDAL DIMPLE ------ CYSTS COVERED WITH A TUFT OF HAIR @ BASE OF SPINE, INDICATES NEURAL DEFECTS

REFLEXES THAT DISAPPEAR @ 3-4 MONTHS ------ ROOTING,PALMAR GRASP,EXTRUSION,DANCING

REFLEXS THAT DISAPPEAR @ 8 MONTHS ------ PLANTAR GRASP

REFLEXES THAT DISAPPEARS IN WEEKS ------ CRAWLING-6 WEEKS

GALANT-4 WEEKS

REFLEXES THAT DISAPPEAR @1 YEAR ------ BABINSKI

MORO (STARTLE REFLEX) DISAPPEARS IN.. ------

6 months

Newborn babies - they are so small, yet they are the focus of so much attention. Each year in the United States, more than 4 million babies are born - about seven babies every minute.

Today, babies have more opportunities than ever before to grow into healthy children, adolescents, and adults.

Advances in medical research, the advent of new vaccines and medications, and the development of new technologies have helped improve the healthcare of both well and sick newborn babies. Further, innovations in baby care equipment have made the tasks of caring for babies much easier.

A newborn baby brings many joys as well as many questions. Along with the happiness parents feel with the birth of their child, they often have concerns about his/her health and how to properly care for him/her. Fortunately, there are many knowledgeable healthcare professionals to guide you and teach

you, as parents and caregivers, about your new baby. With their help, you can become confident in your own abilities and knowledge as you love and care for your newborn.

NTHS

Newborn Appearance

What does a newborn look like?Parents often dream of what their new baby may look like, thinking about a pink, round, chubby-cheeked and gurgling wonder. It may be surprising for many parents to see their newborn the first time - wet and red, with a long head, and screaming - nothing at all like they had imagined.

Newborns have many variations in normal appearance - from color to the shape of the head. Some of these differences are just temporary, part of the physical adjustments a baby goes through. Others, such as birthmarks, may be permanent. Understanding the normal appearance of newborns can help you know that your baby is healthy. Some of the normal variations in newborns include the following, and are explained below:

color moulding vernix lanugo milia stork bites mongolian spots erythema toxicum acne neonatorum "baby acne" strawberry hemangioma port wine stains newborn breast swelling swollen genitals/discharge

Color A baby's skin coloring can vary greatly, depending on the baby's age, race or ethnic group, temperature, and whether or not the baby is crying. Skin color in babies often changes with both the environment and health.

When a baby is first born, the skin is a dark red to purple color. As the baby begins to breathe air, the color changes to red. This redness normally begins to fade in the first day. A baby's hands and feet may stay bluish in color for several days. This is a normal response to a baby's immature blood circulation. Blue coloring of other parts

of the body, however, is not normal.

Some newborns develop a yellow coloring called jaundice. This may be a normal response as the body rids excess red blood cells. However, it may indicate a more serious condition, especially if the yellow color appears in the first day and worsens. Jaundice can often be seen by gently pressing on the baby's forehead or chest and watching the color return. Laboratory tests may be needed to assess jaundice.

Moulding Moulding is the elongation of the shape of a baby's head. It occurs when the movable bones of the baby's head overlap to help the baby pass through the mother's birth canal. Normal shape usually returns by the end of the first week.

Vernix This is a white, greasy, cheese-like substance that covers the skin of many babies at birth. It is formed by secretions from the baby's oil glands and protects the baby's skin in the amniotic fluid during pregnancy. Vernix may not be present in babies who are born postterm (after 41 weeks of pregnancy). It does not need to be removed and usually absorbs into the skin.

Lanugo This is soft, downy hair on a baby's body, especially on the shoulders, back, forehead, and cheeks. It is more noticeable in premature babies, but is not usually seen in babies born very late in pregnancy.

Milia Milia are tiny, white, hard spots that look like pimples on a newborn's nose. They may also appear on the chin and forehead. Milia form from oil glands and disappear on their own. When these occur in a baby's mouth and gums, they are called Epstein pearls.

Stork bites or salmon patches

These are small pink or red patches often found on a baby's eyelids, between the eyes, upper lip, and back of the neck. The name comes from the marks on the back of the neck where, as the myth goes, a stork may have picked up the baby. They are caused by a concentration of immature blood vessels and may be the most visible when the baby is crying.

Most of these fade and disappear completely.

Mongolian spots Mongolian spots are blue or purple-colored splotches on the baby's lower back and buttocks. Over 80 percent of African-American, Asian, and Indian babies have Mongolian spots, but they occur in dark-skinned babies of all races. The spots are caused by a concentration of pigmented cells. They usually disappear in the first four years of life.

Erythema toxicum Erythema toxicum is a red rash on newborns that is often described as "flea bites." The rash is common on the chest and back, but may be found all over. About half of all babies develop this condition in the first few days of life. It is less common in premature babies. The cause is unknown but it is not dangerous. Erythema toxicum does not require any treatment and disappears by itself in a few days.

Acne neonatorum (baby acne)

About one-fifth of newborns develop pimples in the first month. These usually appear on the cheeks and forehead. It is thought that maternal hormones cause these, and they usually disappear within a few months. Do not try to break open or squeeze the pimples, as this can lead to infection.

Strawberry hemangioma This is a bright or dark red, raised or swollen, bumpy area that looks like a strawberry. Hemangiomas are formed by a concentration of tiny, immature blood vessels. Most of these occur on the head. They may not appear at birth, but often develop in the first two months. Strawberry hemangiomas are more common in premature babies and in girls. These birthmarks often grow in size for several months, and then gradually begin to fade. Nearly all strawberry hemangiomas completely disappear by nine years of age.

Port wine stain A port wine stain is a flat, pink, red, or purple colored birthmark. These are caused by a concentration of dilated tiny blood vessels called capillaries. They usually occur on the head or neck. They may be small, or they may cover large areas of the body. Port wine stains do not change color when gently pressed and do not disappear over time. They may become darker and may bleed when the child is older or as an adult.

Port wine stains on the face may be associated with more serious problems. Skin-colored cosmetics may be used to cover small port wine stains. The most effective way of treating port wine stains is with a special type of laser. This is done when the baby is older by a plastic surgery specialist.

Newborn breast swelling Breast enlargement may occur in newborn boys and girls around the third day of life. In the first week, a milky substance, sometimes called "witch's milk," may leak from the nipples. This is related to the mother's hormones and goes away within a few days to weeks. Do not massage or squeeze the breasts or nipples, as this may cause an infection in the breast.

Swollen genitals/discharge A newborn's genitals may appear different depending on the gestational age (the number of weeks of pregnancy). Premature baby girls may have a very prominent clitoris and inner labia. A baby born closer to full-term has larger outer labia. Girls may have a small amount of whitish discharge or blood-tinged mucus from the vagina in the first few weeks. This is a normal occurrence related to the mother's hormones.

Premature boys may have a smooth, flat scrotum with undescended testicles. Boys born later in pregnancy have ridges in the scrotum with descended testicles.

Gestational Assessment

Gestational Assessment

What is a gestational assessment?

Assessing a baby's physical maturity is an important part of care. Maturity assessment is helpful in meeting a baby's needs if the dates of a pregnancy are uncertain. For example, a very small baby may actually be more mature than it appears by size, and may need different care than a premature baby.

An examination called the Dubowitz/Ballard Examination for Gestational Age is often used. A baby's gestational age often can be closely estimated using this examination. The Dubowitz/Ballard Examination evaluates a baby's appearance, skin texture, motor

function, and reflexes. The physical maturity part of the examination is done in the first two hours of birth. The neuromuscular maturity examination is completed within 24 hours after delivery.

How is physical maturity assessed?

The physical assessment part of the Dubowitz/Ballard Examination examines physical characteristics that look different at various stages of a baby's gestational maturity. Babies who are physically mature usually have higher scores than premature babies.

Points are given for each area of assessment, with a low of -1 or -2 for extreme immaturity to as high as 4 or 5 for postmaturity. Areas of assessment include the following:

skin textures (i.e., sticky, smooth, peeling). lanugo (the soft downy hair on a baby's body) - is absent in immature babies, then

appears with maturity, and then disappears again with postmaturity. plantar creases - these creases on the soles of the feet range from absent to covering

the entire foot, depending on the maturity. breast - the thickness and size of breast tissue and areola (the darkened ring around

each nipple) are assessed. eyes and ears - eyes fused or open and amount of cartilage and stiffness of the ear

tissue. genitals, male - presence of testes and appearance of scrotum, from smooth to

wrinkled. genitals, female - appearance and size of the clitoris and the labia.

How is neuromuscular maturity assessed?

Six evaluations of the baby's neuromuscular system are performed. These include:

posture - how does the baby hold his/her arms and legs. square window - how far the baby's hands can be flexed toward the wrist. arm recoil - how far the baby's arms "spring back" to a flexed position. popliteal angle - how far the baby's knees extend. scarf sign - how far the elbows can be moved across the baby's chest. heel to ear - how close the baby's feet can be moved to the ears.

A score is assigned to each assessment area. Typically, the more neurologically mature the baby, the higher the score.

When the physical assessment score and the neuromuscular score are added together, the gestational age can be estimated. Scores range from very low for immature babies (less than 26 to 28 weeks) to very high scores for mature and postmature babies.

All of these examinations are important ways to learn about your baby's well-being at birth. By identifying any problems, your baby's physician can plan the best possible care.

Measurements

Measurements

Assessing a newborn's weight:

A baby's birthweight is an important indicator of health. The average weight for term babies (born between 37 and 41 weeks gestation) is about 7 lbs (3.2 kg). In general, small babies and very large babies are more likely to have problems. Babies are weighed daily in the nursery to assess growth and fluid and nutrition needs. Newborn babies may lose as much as 10 percent of their birthweight. This means that a baby weighing 7 pounds 3 ounces at birth might lose as much as 10 ounces in the first few days.

In most cases the metric system is used for weighing babies. This chart will help you convert grams to pounds.

Converting grams to pounds and ounces:

1 lb. = 453.59237 grams; 1 oz. = 28.349523 grams; 1000 grams = 1 kg.

Pounds

Ounces 2 3 4 5 6 7 8 9

0 907 1361 1814 2268 2722 3175 3629 4082

1 936 1389 1843 2296 2750 3203 3657 4111

2 964 1417 1871 2325 2778 3232 3685 4139

3 992 1446 1899 2353 2807 3260 3714 4167

4 1021 1474 1928 2381 2835 3289 3742 4196

5 1049 1503 1956 2410 2863 3317 3770 4224

6 1077 1531 1984 2438 2892 3345 3799 4252

7 1106 1559 2013 2466 2920 3374 3827 4281

8 1134 1588 2041 2495 2948 3402 3856 4309

9 1162 1616 2070 2523 2977 3430 3884 4337

10 1191 1644 2098 2551 3005 3459 3912 4366

11 1219 1673 2126 2580 3033 3487 3941 4394

12 1247 1701 2155 2608 3062 3515 3969 4423

13 1276 1729 2183 2637 3090 3544 3997 4451

14 1304 1758 2211 2665 3118 3572 4026 4479

15 1332 1786 2240 2693 3147 3600 4054 4508

What other measurements are taken of the newborn?

Warning Signs Other measurements are also taken of each baby. These include:

head circumference - the distance around the baby's head (head circumference is normally about 1/2 the baby's body length plus 10 cm).

abdominal circumference - the distance around the abdomen.

length - the measurement from crown of head to the hee

Warning Signs

What warning signs may indicate a problem with a newborn?

Your newborn baby is going through many changes in getting used to life in the outside world. Almost always this adjustment goes well, however there are certain warning signs you should watch for. Some general warning signs with newborns include, but are not limited to:

no urine in the first 24 hours at home. This can be difficult to assess, especially with disposable diapers.

no bowel movement in the first 48 hours. a rectal temperature over 100.4° F (38° C) or less than 97.5° F (36.5° C). a rapid breathing rate over 60 per minute, or a blue coloring that does not go away.

Newborns normally have irregular respirations, so you need to count for a full minute. There should be no pauses longer than about 5 seconds between breaths.

retractions, or pulling in of the ribs with respirations. wheezing, grunting, or whistling sounds while breathing. odor, drainage, or bleeding from the umbilical cord. yellow coloring of the eyes, chest, or extremities. crying, irritability, or twitching which does not improve with cuddling and comfort. a sleepy baby who cannot be awakened enough to nurse or nipple. any signs of sickness (i.e., cough, diarrhea, pale color). the baby's appetite or suck becomes poor or weak.

Every child is different, so trust your knowledge of your child and call your child's physician if you see signs that are worrisome to you.

Assessments for Newborn Babies

Assessments for newborn babies:Each newborn baby is carefully checked at birth for signs of problems or complications. A complete physical assessment will be performed that includes every body system. Throughout the hospital stay, physicians, nurses, and other healthcare providers continually assess a baby for changes in health and for signs of problems or illness. Assessment may include:

Apgar scoring:The Apgar score is one of the first checks of your new baby's health. The Apgar score is assigned in the first few minutes after birth to help identify babies that have difficulty breathing or have a problem that needs further care. The baby is checked at one minute and five minutes after birth for heart and respiratory rates, muscle tone, reflexes, and color. Each area can have a score of zero, one, or two, with ten points as the maximum. A total score of ten means a baby is in the best possible condition. Nearly all babies score between eight and ten, with one or two points taken off for blue hands and feet because of immature circulation. If a baby has a difficult time during delivery, this can lower the oxygen levels in the blood, which can lower the Apgar score. Apgar scores of three or less often mean a baby needs immediate attention and care. However, only 1.4 percent of babies have Apgar scores less than seven at five minutes after birth.

Birthweight and measurements:A baby's birthweight is an important indicator of health. The average weight for term

babies (born between 37 and 41 weeks gestation) is about 7 lbs. (3.2 kg). In general, small babies and very large babies are at greater risk for problems. Babies are weighed daily in the nursery to assess growth, fluid, and nutrition needs. Newborn babies may lose as much as 10 percent of their birthweight. This means that a baby weighing 7 pounds 3 ounces at birth might lose as much as 10 ounces in the first few days. Premature and sick babies may not begin to gain weight right away. Most hospitals use the metric system for weighing babies. This chart will help you convert grams to pounds.

Measurements:Other measurements are also taken of each baby. These include the following:

o head circumference (the distance around the baby's head) - is normally about one-half the baby's body length plus 10 cm

o abdominal circumference - the distance around the abdomen

o length - the measurement from crown of head to the heel

Physical examination:A complete physical examination is an important part of newborn care. Each body system is carefully examined for signs of health and normal function. The physician also looks for any signs of illness or birth defects. Physical examination of a newborn often includes the assessment of the following:

o vital signs:

temperature - able to maintain stable body temperature 98.6° F (37° C) in normal room environment

pulse - normally 120 to 160 beats per minute

breathing rate - normally 30 to 60 breaths per minute

o general appearance - physical activity, tone, posture, and level of consciousness

o skin - color, texture, nails, presence of rashes

o head and neck:

appearance, shape, presence of molding (shaping of the head from passage through the birth canal)

fontanels (the open "soft spots" between the bones of the baby's skull)

clavicles (bones across the upper chest)

o face - eyes, ears, nose, cheeks

o mouth - palate, tongue, throat

o lungs - breath sounds, breathing pattern

o heart sounds and femoral (in the groin) pulses

o abdomen - presence of masses or hernias

o genitals and anus - for open passage of urine and stool

o arms and legs - movement and development

Gestational assessment:Assessing a baby's physical maturity is an important part of care. Maturity assessment is helpful in meeting a baby's needs if the dates of a pregnancy are uncertain. For example, a very small baby may actually be more mature than it appears by size, and may need different care than a premature baby. An examination called The Dubowitz/Ballard Examination for Gestational Age is often used. A baby's gestational age often can be closely estimated using this examination. The Dubowitz/Ballard Examination evaluates a baby's appearance, skin texture, motor function, and reflexes. The physical maturity part of the examination is done in the first two hours of birth. The neuromuscular maturity examination is completed within 24 hours after delivery. Information often used to help estimate babies' physical and neuromuscular maturity are shown below.

Physical maturity:The physical assessment part of the Dubowitz/Ballard Examination looks at physical characteristics that look different at different stages of a baby's gestational maturity. Babies who are physically mature usually have higher scores than premature babies. Points are given for each area of assessment, with a low of -1 or -2 for extreme immaturity to as much as 4 or 5 for postmaturity. Areas of assessment include the following:

o skin textures (i.e., sticky, smooth, peeling).

o lanugo (the soft downy hair on a baby's body) - is absent in immature babies, then appears with maturity, and then disappears again with postmaturity.

o plantar creases - these creases on the soles of the feet range from absent to covering the entire foot, depending on the maturity.

o breast - the thickness and size of breast tissue and areola (the darkened ring around each nipple) are assessed.

o eyes and ears - eyes fused or open and amount of cartilage and stiffness of the ear tissue.

o genitals, male - presence of testes and appearance of scrotum, from smooth to wrinkled.

o genitals, female - appearance and size of the clitoris and the labia.

Neuromuscular maturity:Six evaluations of the baby's neuromuscular system are performed. These include:

o posture - how does the baby hold his/her arms and legs.

o square window - how far the baby's hands can be flexed toward the wrist.

o arm recoil - how far the baby's arms "spring back" to a flexed position.

o popliteal angle - how far the baby's knees extend.

o scarf sign - how far the elbows can be moved across the baby's chest.

o heel to ear - how close the baby's feet can be moved to the ears.

A score is assigned to each assessment area. Typically, the more neurologically mature the baby, the higher the score.

When the physical assessment score and the neuromuscular score are added together, the gestational age can be estimated. Scores range from very low for immature babies (less than 26 to 28 weeks) to very high scores for mature and postmature babies. All of these examinations are important ways to learn about your baby's well-being at birth. By identifying any problems, your baby's physician can plan the best possible care.