|
|
|
|
Physical Exam and Anticipatory Guidance of the Newborn: Marcie Hamrick,
MD Setting: At the bedside, with the baby undressed and under the warming lights. Invite the parent(s) to observe and participate in the exam and acknowledge how stressful it can be for a parent to have their baby scrutinized. Recognize that this may be the first time that the parents experience a medical assessment of their newborn. Find something that the parent or baby is doing well (supporting the head, baby's good, vigorous cry) and offer a compliment. Exam: Vital Signs- Temperature: T >100.3 Note technique (rectal, axillary) and bundling. Respiratory Rate: For all spontaneously breathing infants, term and premature, respiratory rates fall to within a range of 40-60 by one hour of age. Watch for: respiratory distress (grunting, flaring, cyanosis), tachypnea, bradypnea, apnea (>10s) Heart Rate: 120-180 Watch for: bradycardia, tachycardia Weight, Length, HC Please read the protocols for hypoglycemia, febrile newborn and drug exposed babies and review the Harriet Lane chapter on Newborn Assessment: http://home.mdconsult.com/das/book/14910508/view/871?sid=72560538 Anticipatory Guidance: Discuss temperature regulation in the newborn and the need for immediate attention in the event of fever. Teach the importance of rectal temperatures and 100.3. General Observations: Nude, warm and settled if possible. Watch for: sick or well?, cyanosis, pallor, jaundice, symmetry, weak or high pitched cry, hoarseness, aphonia,
Skin: White vernix is most abundant in premature infants and is less prominent closer to term. Post term newborns have little or no vernix and the skin is dry, cracked and wrinkled. Scan for hemangiomas, urticaria, pustules, vesicular, nodular or gangrenous rashes. Check for dermal sinuses in the midline of the back, from occiput to coccyx and in the pilonidal region. Look carefully along the midline for dimples, sinuses, hirsute areas, or cystic swellings that suggest the presence of congenital cranial dermal sinuses or defects in the underlying vertebral column. Note ecchymoses, petechiae, milia, erythema toxicum, stork
bite (flame hemangiomas). Watch for: jaundice (always abnormal if noted on first day of life). Anticipatory Guidance: Mongolian spots usually resolve by age 4, stork bites on the neck tend to persist whereas facial flame hemangiomas usually fade within months. Facial petechiae are normal, milia, and e. toxicum are transient. Please Review Darmstadt's paper on neonatal skin care: "The importance of neonatal skin care is exemplified by survey results suggesting that nearly 80% of newborns develop a skin problem (i.e., "rash") during the first month of life. But little information is available on which a rational approach to skin care in neonates may be based, and few instructions or recommendations for neonatal skin care are available in the literature." Please review this article: http://home.mdconsult.com/das/journal/view/14910508/N/11381572?sid=72560537&source=HS,MI
Head: Most common abnormalities are caput succedaneum (crosses sutures) and cephalohematoma (subperiosteal and does not cross sutures). Absent suture separations or excessive spreading of the lines are significant. Run a fingertip from occiput to nasion along the sagittal and metopic sutures and
over the occiptoparietal junctures to define the lambdoidal sutures. Large fontanels and split sutures most often are a normal variant, but they can be associated with increased intracranial pressure or conditions that impair bone growth (eg. Hypothyroidism).
Anticipatory Guidance: Discuss molding, over-riding sutures that form ridges, fontanelles (anterior usually closes by 18-24 months and posterior usually closes at 2-6 months). Remind parents of Back to Bed, temporary nature of hair and need for changing head position with sleep. Eyes: Hold the infant upright and note: size of the eyeball, haziness of clouding of the cornea, lens or media. Note dermoids or small hemangiomas. Watch both eyes for normal excursion or the lids and note proptosis, squint or asymmetric closure (facial nerve palsy). Red reflex (abnormal in retinoblastoma, congenital cataract).
Anticipatory Guidance: Discuss the antibiotic cream. Explain focal length, occasional dyscoordination of extraocular movements. Ears: The ears can be grossly malformed, uncommonly large or small, angled abnormally or set lower on the head than normal. Very low placement plus unusual size, floppiness and perpendicularity to the skull suggest renal agenesis or chromosomal aberration. Malformations stemming from the first branchial arch often involve the ears, and one must look carefully for abnormal skin tags, dimples, and deep sinuses, especially in front and behind the tragus. The infant should respond to a loud noise or tone.
Anticipatory Guidance: Discuss hearing and the normalcy of ear wax. Mouth: Note clefts of lip and palate (examine entire palate), symmetric movement of lip corners, excessive mucoid secretions (suggesting esophageal atresia). Look for retention cysts along the alveolar ridge, and the plaques of thrush. Note the size of the tongue and depress the lower jaw or take advantage of a cry to see the posterior pharynx. Examine the frenulum and note its length.
Anticipatory Guidance: Discuss Ebstein's pearls. Nose: One can assess the patency of the posterior choanae by holding the mouth closed and listening with the stethoscope for the outrush of each naris. Inspection up the naris may reveal an encephalocoele. Neck: Note length and mobility and inspect for congenital cysts, hygromas, thyroglossal duct cysts, and thyromegaly. Look for webbing and palpate the length of both clavicles to rule out fracture.
Chest: The chest deserves primary concern. Inspect for overinflation, symmetric movement, presence or absence of retractions and the use of accessory muscles. Auscultate for rales, rhonchi, and bowel sounds. Heart: Size and position of the heart, as well as the rate, rhythm and strength of its sounds are as important as the presence or absence of murmurs. Note extrathoracic signs such as cyanosis, size of the liver, dilatation of superficial veins, and palpability of the femoral and distal arterial pulses. Please review this nice article on pediatric murmurs (not limited to newborns) http://home.mdconsult.com/das/journal/view/14910508/N/10670265?sid=72564584&source=HS,MI Abdomen: Look for unusual flatness (diaphragmatic hernia) or excessive fullness (one must then determine if this is due to an excess of air within or outside the bowels, to excess fluid, to an enlarged viscous or viscera or to the presence of a cystic or solid tumor). Visible gastric or bowel patterns may be considered an almost certain sign of obstruction. The umbilicus should be inspected carefully for signs of infection, bleeding, polyp, granuloma or abnormal communication with intra-abdominal viscera. Genitals: Male-size and formation of the penis, position of the meatus, size of the scrotum and the nature of its skin and descent of nondescent of the testes. Female-size of the clitoris, the nature of the skin of the labia majora, and if possible the position of the vaginal and urethral orifices. Note the fusion of the labia if present. One should palpate over the inguinal canals for presence of herniae or gonads and imperforate anus should be ruled out.
Back and Hips: Compare leg lengths and perform Barlow's maneuver. Extremities: Do all four move well and approximately symmetrically? Note unusual resistance to flexion or extension or its converse: excessive malleability or flaccidity. Note polydactylism or syndactylism, clubbing, cyanosis, or unusual creasing of the palms or soles. Reflexes: Timing of Selected Primitive Reflexes: Reflex: Onset Fully Developed Duration Palmar grasp 28 wk 32 wk 2-3 months Rooting 32 wk 36 wk Less prominent by 1 mo Moro 28-32 wk 37 wk 5-6 months Tonic neck 35 wk 1 mo 6-7 months Parachute 7-8 mo 10-11 mo Permanent
|
