newborn abnormal

7/23/2019 Newborn Abnormal

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Behavior This baby is 3 weeks old. When the exam begins, he has his eyes closed and

appears to be in a drowsy state. Within a few seconds he transitions to anawake state and maintains eye opening but his movements are not vigorous.

He responds to light and sound and has some habituation. One has to decide ifthis is just a sleepy baby or if this baby’s mental status is abnormal. His lack of

spontaneous facial and extremity movement is abnormal although he hasgrimace to light so he has reflexive movements.

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• Cranial Nerves The baby has full conjugate eyemovements. The face has a bland

appearance, but tickling the feet producesa full grimace and facial muscles arenormal. The baby’s cry is not high pitchedbut is softer and not as sustained as one

would expect. (The baby has a poor suck,which is demonstrated in the primitivereflex section the exam.)

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• Tone - Resting Posture

Although this baby’s resting posture shows

some flexion of the lower extremities, the upper

and lower extremities are in more extension thanflexion. The hips are fully abducted and there is

little spontaneous movement. There are some

gravity opposing movements but they are

infrequent. This baby has a “flat on the mat”appearance reflecting low tone and possible

weakness.

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• Tone - Upper Extremity Tone

On passive range of motion of the upper

extremities there is some tone, but the

tone is significantly less than expected.Shaking the hand back and forth

demonstrates the decreased tone in the

hand.

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• Tone - Arm Traction

With the arm traction maneuver there is

less resistance and the arm is more

extended than normal. There should bemore flexion at the elbow.

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• Tone - Arm Recoil

When arm recoil is tested there is very

little recoil. This indicates decreased tone

in the biceps muscles.

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• Tone - Scarf Sign

The scarf maneuver demonstrates low

shoulder girdle tone. The hand actually

can be pulled beyond the oppositeshoulder and the elbow goes past the

midline.

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• Tone - Hand Position

The baby’s hand is not in the typical

closed or fisted position. It is open with

more extension of the fingers and thumbthan is usually seen at this age. This is

consistent with hypotonia.

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• Tone - Lower Extremity Tone

There is increased range and less

resistance on passive range of motion at

the hips, knees, and ankles. The hips canbe abducted almost to the mat. The leg

can be extended too far at the hip and

knee. Ankle tone is diminished, which canbe demonstrated by flexing and extending

the ankle and shaking the foot.

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• Tone - Leg Traction

Although there is some tone on leg

traction it is less than normal. The leg

should not be straightened to the degreethat it is. There should be more flexion at

the knee.

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• Tone - Leg Recoil

There is some leg recoil for this baby but it

is not as strong as it should be because of

the low tone.

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• Tone - Popliteal Angle

The popliteal angle is about 160 degrees

and should be about 90 degrees. This

indicates low tone in the hamstringmuscles.

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• Tone - Heel to Ear

This baby’s tone is low enough that the

heel can almost be drawn up to the level

of the ear. The heel in a normal babywould only come to mid chest.

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• Tone - Neck Tone

On passive rotation of the head from

shoulder to shoulder, the chin goes past

the shoulder on each side. This confirmslow tone in the neck muscles.

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• Tone - Head Lag

Pulling the baby from the supine to the

sitting position demonstrates significant

head lag. Also the arms are fully extendedso there is no pulling or resistance with

traction. The baby fails to bring the head to

the upright position once he is in the sittingposition.

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• Tone - Head Control

The baby has a significant problem with

head control. With the neck flexed, the

baby cannot raise his head, whichindicates weakness of the neck extensors.

With the neck extended, the baby cannot

raise his head, which indicates weaknessof the neck flexors.

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• Positions - Prone When placed in the prone position with hisface on the mat, he is able to turn the

head to one side, but he doesn’t turn hishead from side to side which he should beable to do. His hips are too abducted sohis pelvis is flat on the mat and he doesn’t

bring his arms forward. Overall he hasfewer spontaneous movements than heshould have.

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• Positions - Ventral Suspension

In ventral suspension the baby is draped

over the supporting hand. His head is on

his chest and is not kept in the same planeas the trunk. The trunk is too rounded and

the extremities are extended. The baby

makes some effort to straighten his backso there is some strength, but the effort is

less than it should be.

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• Positions - Vertical Suspension

In vertical suspension there is the feeling

that the baby is slipping through the

examiner’s hands because of the low tonein the shoulder girdle muscles.

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• Reflexes - Deep Tendon Reflexes Testing deep tendon reflexes on this baby demonstrates that theyare present. This is important in trying to sort out if the baby has lowtone from an upper motor neuron lesion or if he has a lower motorneuron or muscle disorder.

• In older children and adults, an upper motor lesion causes spasticity

but in babies an upper motor neuron lesion can cause hypotonia. Adisease of the lower motor neuron is unlikely with the deep tendonreflexes being present.

• The baby could still have a muscle disorder but inspection of themuscles does not show diminished mass and the baby’s behaviorand the rest of the neurological exam indicates an upper motor

neuron problem.

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• Reflexes - Plantar Reflex

On stroking the lateral aspect of the

plantar surface of the foot the toes are up

going which is a normal finding for thebaby.

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• Primitive Reflexes - Suck, Root

There is some sucking but it is not as

vigorous or sustained as it should be. The

pacifier can be easily pulled from themouth. There is no root reflex, which is a

definite abnormality, and this baby has

had problems with feeding.

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• Primitive Reflexes - Moro

The baby has a Moro reflex with the arms

fully abducted and extended but he

doesn’t bring the arms back to the midline.So the Moro is present, but not as

complete as it should be.

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• Primitive Reflexes - Galant

The baby has a normal Galant or trunk

incurvation reflex. The trunk and hips

move towards the side of the stimulus.

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• Primitive Reflexes - Stepping

With the baby held in vertical suspension

and his feet touching the mat, he does not

have the expected reciprocal flexion andextension of the legs. The stepping or

walking reflex is absent in this baby.

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• Primitive Reflexes - Grasp

The baby has grasp reflex of both the

hand and the foot but both are weaker and

not as pronounced as they should be.

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• Head Shape and Sutures

The baby’s head shape is noted and the

sutures palpated. The only abnormality

noted is that the bifrontal diameter is lessthan the biparietal diameter. In the normal

infant they are usually the same.

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• Head Circumference The head circumference for the baby is 34.6 cm, whichis the 25th percentile. Measuring the head circumferencein this baby is very important because of his findings of

central or cerebral hypotonia, which reflects that thehypotonia is from an upper motor neuron problem. If thebaby had microcephaly, then that would indicate aprocess that had affected brain growth in utero. Themain diagnostic considerations for this baby are a

congenital brain malformation, a chromosomalabnormality or an inborn error of metabolism.

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newborn abnormal

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