The newborn examination
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0. The Newborn Examination. Karen Montgomery-Reagan, D.O. OUCOM Department of Pediatrics. Overview. Review birth Hx and VS Listen to heart while infant quiet: Cardiovascular- inspection, palpation, and auscultation

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The newborn examination

0

The Newborn Examination

Karen Montgomery-Reagan, D.O.

OUCOM

Department of Pediatrics


Overview

Overview

  • Review birth Hx and VS

  • Listen to heart while infant quiet: Cardiovascular- inspection, palpation, and auscultation

  • Start from top: Head and Neck – head, face, ears, eyes, nose, mouth, and neck

  • Chest and Lungs

  • Abdomen – inspection, palpation, and auscultation

  • Genitourinary – kidneys and genitalia

  • Orthopedic – spine, upper and lower extremities


Vital signs

Vital Signs

  • Heart Rate (rates/min)

    • Awake 85-205

    • Sleeping 80-160

  • Respiratory Rate (breaths/min)

    • 30-60

  • Systolic Blood Pressure (SBP)

    • Infant SBP: 80

    • Age 12 hours: 50-70 / 25-45

    • Age 96 hours: 60-90 / 20-60

    • Hypotension defined in neonate to 28 days <60


Apgar score

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APGAR Score


Dubowitz ballard score

External Characteristics

To be done within few hrs of birth

Edema

Skin texture, color, and opacity

Lanugo

Plantar creases

Nipples and breasts

Ear form and firmness

Genitals

Neuromuscular Score

To be done within 24 hrs

Posture

Square Window

Arm recoil

Popliteal angle

Scarf sign

Heel to ear

Dubowitz/Ballard Score


Small for gestational age

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Small for Gestational Age

  • Symmetric

    • HC, length, weight all <10 percentile

    • 33% of SGA infants

    • Cause: Infection, chromosomal abnormalities, inborn errors of metabolism, smoking, drugs

  • Asymmetric

    • Weight <10 percentile, HC and length normal

    • 55% of SGA infants

    • Cause: Uteroplacental insufficiency, Chronic hypertension or disease, Preeclampsia, Hemoglobinopathies, altitude, Placental infarcts or chronic abruption

  • Combined

    • Symmetric or asymmetric

    • 12% of SGA infants

    • Cause: Smoking, drugs, Placental infarcts or chronic abruption, velamentous insertion, circumvallate placenta, multiple gestation


Large for gestational age

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Large for Gestational Age

  • Etiologies

    • Infants of diabetic mothers

    • Beckwith-Wiedemann Syndrome

      • characterized by macroglossia, visceromegaly, macrosomia, umbilical hernia or omphalocele, and neonatal hypoglycemia

    • Hydrops fetalis

    • Large mother


The newborn examination

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Skin

  • Color

    • Pallor: associated with low hemoglobin

    • Cyanosis: associated with hypoxemia

    • Plethora: associated with polycythemia

    • Jaundice: elevated bilirubin

    • Slate grey color: associated with methemoglobinemia


The newborn examination

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Skin

  • Jaundice

    • Total and direct bilirubin levels should be measured in newborns with jaundice.

    • Causes can be related to increased unconjugated hyperbilirubinemia (physiologic, breastfeeding, increased production, decreased hepatic uptake/conjugation) or conjugated (hepatobiliary disorders, ductal disturbances)

    • The AAP has published guidelines on the management of hyperbilirubinemia in the newborn.


The newborn examination

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The newborn examination

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Skin

  • Lanugo

    • Fine hair on shoulders and back

    • More common in preemies

    • Usually disappears in 2-4 weeks

  • Vernix Caseosa

    • Cheesy white covering


Skin lesions

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Skin Lesions

  • Petechiae

    • On scalp and face after vertex delivery

  • Sucking blister

    • Develops from infant sucking on skin in utero.

    • Disappears as infant progress with feeding.

  • Hemangiomas

    • Usually enlarges in 1st year of life.

    • Large facial hemangiomas may be associated with posterior fossa malformations.

    • MC benign tumor of infancy

    • Most require no intervention


Skin lesions1

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Skin Lesions

  • Telangiectatic Nevi

    • Also called salmon patches or stork bite nevi

    • Flat, pink lesion found on upper eyelids, forehead, nape of neck

    • Fade by 1-2 years old except those on nape of neck which may persist

  • Cutis Marmorata

    • Transient mottling of the skin

    • Occurs when baby is exposed to the cold


Skin lesions2

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Skin Lesions

  • Milia

    • Pinpoint white papules of keratogenous material.

    • Usually on nose, cheeks and forehead.

    • Can last for several weeks.


Skin lesions3

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Skin Lesions

  • Miliaria

    • Obstructed eccrine sweat ducts.

    • Pinpoint vesicles on forehead, scalp, and skinfolds.

    • Usually clears within one week.


Skin lesions4

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Skin Lesions

  • Transient Neonatal Pustular Melanosis

    • Small vesicopustules, generally present at birth.

    • Contain WBCs and no organisms.

    • Intact vesicle ruptures to reveal a pigmented macule surrounded by a thin skin ring.


Skin lesions5

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Skin Lesions

  • Erythema Toxicum Neonatorum

    • Most common newborn rash.

    • Lesions are firm, yellow or white pustules on a red and swollen base.

    • Lesions may be found in face, trunk and limbs.

    • Lasts about 5-7 days.

    • Wright Stain shows eosinophil sheets.


Skin lesions6

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Skin Lesions

  • Café au lait spots

    • Suspect nuerofibromatosis if there are many large spots


Skin lesions7

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Skin Lesions

  • Mongolian spots

    • Well demarcated symmetric bluish gray to deep brown to black skin markings

    • Common among people of Asian, East Indian, African, and Latino heritage.

    • Often on the base of the spine, on the buttocks and back

    • Generally fade in a few years and disappear by puberty.


Neurological exam

Neurological Exam

  • Posture

    • Term infants normal posture is hips abducted and partially flexed, with knees flexed.

    • Arms are abducted and flexed at the elbow.

    • Fists are often clenched, with the fingers covering the thumb

  • Tone

    • To test, support the infant with one hand under the chest. Neck extensors should be able to hold head in line for 3 seconds

    • There should be no more than 10% head lag when moving from supine to sitting positions.


Neurological reflexes

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Neurological Reflexes

  • Ensure symmetrical

  • Biceps jerk C5-C6, knee jerk L2-L4, ankle jerk S1-S2, anal wink S4-S5, truncal incurvation reflex T2-S1.

  • Primitive reflexes are present: Babinski, Moro, Galant, palmer and plantar grasps, sucking, rooting, placing/stepping, and asymmetric tonic neck reflex (Fencer’s pose).


Neurological exam1

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Neurological Exam

  • Cranial Nerve Exam

    • CN II: Pupillary reflex

    • Oculocephalic Reflex (doll’s eyes)

      • CN III, IV, and VI

      • If Brainstem intact:

        • Eyes deviate contralaterally

        • Look away from direction of rotation

    • CNV and VII: Corneal, sucking, and rooting reflexes

    • CN VIII: Response to Noise

    • CN IX and X : Gag reflex


Macrocephaly

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Macrocephaly

  • Causes

    • Familial with autosomal dominant inheritance

    • Hydrocephalus

    • Other conditions

      • Achondroplasia (skeletal dysplasia)

      • Sotos' Syndrome (Cerebral Gigantism)

      • Alexander's Disease

      • Canavan's Disease

      • Gangliosidoses

      • Glutaric aciduria Type I

      • Neurofibromatosis Type I


Microcephaly

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Microcephaly

  • Causes

    • Familial

    • Trisomy 13, 18, 21

    • Cornelia de Lange, Rubinstein-Taybi, Smith-Lemli-Opitz, Prader-Willi

    • Teratogen Exposure

      • Fetal Alcohol Syndrome

      • Radiation exposure in utero (<15 weeks gestation)

      • Fetal Hydantoin

    • TORCH Virus congenital infection

      • Cytomegalovirus, Rubella, Toxoplasmosis

    • Other causes

      • Meningitis/Encephalitis

      • Gestational Diabetes

      • Maternal hyperphenylalaninemia

      • Hypoxic-ischemic encephalopathy


Head examination

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Head Examination

  • Head

    • Check overriding sutures, number and size of fontanelles

  • Molding

    • Over-riding of cranial bones

    • Normal finding at delivery

    • Resolves spontaneously over first 5 days of life


Head trauma

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Head Trauma

  • Cephalohematoma

    • Not as common, but can occur after prolonged labor and instrumentation use.

    • Rupture of blood vessels that traverse skull to the periosteum

    • Fluctuant swelling, does not cross suture lines

    • No overlying discoloration, but possible fracture

    • Uncomplicated resolves in 2 weeks to 3 months, if fracture, Xray in 4-6 weeks to ensure closure, depressed fractures require neurosurgical consult.


Head trauma1

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Head Trauma

  • Caput seccedaneum

    • Common after prolonged labor.

    • Accumulation of blood above periosteum.

    • Soft tissue swelling that crosses suture lines with overlying petechiae, purpura or bruising.

    • Usually resolves spontaneously over several days.


Fontanelles

Anterior

Junction of coronal suture and sagittal suture

Mean newborn size: 2.1 cm (larger in black infants)

Often enlarges in first few months of life

Closes between 4 to 26 months (median 13.8 months)

Closes by 3 months in 1% of infants

Closes by 24 months in 96% of infants

Posterior

Junction of lambdoidal suture and sagittal suture

Mean newborn size: 0.5 to 0.7 cm

Closes by 2 months

Fontanelles


Fontanelles1

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Fontanelles

  • Exam of anterior fontanelle

    • Palpate fontanelle with infant sitting upright quietly

    • Auscultate for bruit (suggests AV malformation)

    • Macewen's Sign (percussion of fontanelle)

      • Dull cracked-pot sound suggests increased ICP


Fontanelles2

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Fontanelles

  • Bulging fontanelle

    • Crying, coughing or vomiting

    • Increased intracranial pressure: Hydrocephalus, Meningitis/encephalitis, Hypoxic-ischemic injury, Intracranial hemorrhage, Dermoid tumors of the scalp

  • Sunken fontanelle

    • Decreasedintracranial pressure (dehydration)

  • Large fontanelle or delayed closure

    • Congenital hypothyroidism,Trisomy 21, Rickets, Achondroplasia, Increased Intracranial Pressure


  • Head examination1

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    Head Examination

    • Craniosynostosis

      • Premature closing of cranial sutures

      • Results in growth restriction perpendicular to affected suture and compensatory overgrowth in unrestricted regions.

      • If accompanied by restricted brain growth or hydrocephalus, neurosurgical intervention is needed.


    Facial examination

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    Facial Examination

    • Facial Nerve Paralysis

      • Usually caused by compression of the facial nerve against the sacral promontory or by trauma of a forceps delivery.

      • The nasolabial fold on the affected side is not present, the corner of the mouth droops and the affected eye is unable to close.

      • Infant will have difficulty with feeding, drooling from the paralyzed side.

      • Most palsies resolved spontaneously within days.


    Ear examination

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    Ear Examination

    Assess for asymmetry or irregular shape

    • Note presence of auricular or pre-auricular pits, fleshy appendages, lipomas, or skin tags.

    • Low set ears

      • Below lateral canthus of eye

      • Associated with genitourinary anomalies, because these areas develop at similar times.

    • Malformed ears

      • Can be associated with Downs or Turners Syndromes


    Eye examination

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    Eye Examination

    • Normal Eye findings following delivery

      • Red reflex

        • Hold opthalmoscope 6-8” from eye.

        • Should transmit a clear red color back.

      • Equal pupil size and reactivity to light

      • Retinal or Subconjunctival Hemorrhages

        • Common after vaginal delivery

        • Clears spontaneously in 1-2 weeks

      • Lid edema

        • Force applied to open the eye often results in lid eversion

        • Examination should be postponed until the edema resolves

      • Eye Color

        • Permanent eye color usually not attained until age 6 months.


    Eye examination1

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    Eye Examination

    • Conjunctivitis

      • Relatively common in newborns.

      • Chemical

        • Silver nitrate prophylaxis given at delivery

        • Requires no treatment,

        • resolves within 48 hours

      • Gonorrheal

        • 24-48 hours old

        • Profound edema, purulent exudate

        • Tx – Penicillin G, Rocephin, or Claforan

      • Chlamydial

        • Occurs within 7-10 days

        • Watery discharge changes to copious/purulent

        • Tx – Erythromycin

      • HSV

        • Occurs within 2 weeks

        • Keratitis, cataracts, chorioretinitis

        • Tx – Topical and systemic antivirals


    Eye examination2

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    Eye Examination

    • Abnormal Funduscopic Exam

      • Lens opacity

        • Indicates congenital cataract

        • Associated with TORCH Virus infection

        • If monocular or dense cataract, newborn is at risk for developing amblyopia.

      • Leukocoria (White reflex or Cat’s eye reflex)

        • Suggests lens, vitreous or fundus abnormality

        • Evaluate for Retinoblastoma

    • Requires Opthalmologic Referral


    Eye examination3

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    Eye Examination

    • Coloboma (ocular tissue defect)

      • Eyelid margin defect: Treacher Collins Syndrome

      • Aniridia (absent iris)

        • Usually occurs bilaterally

        • Associated with poor visual acuity and nystagmus

      • Iris and retina defect: CHARGE association

        • Coloboma

        • Heart disease

        • Choanal Atresia

        • Postnatal growth retardation

        • Genital hypoplasia

        • Ear Abnormality

    • Requires Opthalmologic Referral


    Nose examination

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    Nose Examination

    • Babies are obligate nose breathers until 4 months old.

    • Check patency with stethoscope (listen over nares).

    • Look for nasal flaring as a sign of increased respiratory effort.

    • Choanal Atresia

      • Small NG tube unable to pass through nares.

      • Normally should meet no resistance.

      • Bilateral atresia

        • Cyanosis that is relieved with crying.

        • Is an emergency in the newborn.

        • Requires an oral airway and surgical repair


    Mouth examination

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    Mouth Examination

    • Observe the size and shape of the mouth

      • Microstomia – seen in Trisomy 18 and 21

      • Macrostomia – seen in mucopolysaccharidoses

      • Fish mouth – seen in Fetal Alcohol Syndrome

      • Macroglossia – associated with hypothyroidism and mucopolysaccharidoses

      • Small Chin – associated with Pierre Robin


    Mouth examination1

    Epstein pearls

    small white cysts which contain keratin

    frequently found on either side of the median raphe of the palate.

    Resolves in 1-2 months

    Natal Teeth

    Occurs 1 in 2,000 births

    Location is most often the lower incisors.

    Risk of aspiration if loosely attached, most require removal.

    More often present in newborns with cleft palate.

    Mouth Examination


    Mouth

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    Mouth

    • Ranulas

      • small bluish-white swellings of variable size on the floor of the mouth representing benign mucous gland retention cysts


    Mouth1

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    Mouth

    • Cleft Lip

      • Incidence 1 in 750 (Caucasian)

      • Can be seen with or without cleft palate

      • Common in Trisomy 13

      • Repair is usually at 3 months of age

    • Cleft Palate

      • Incidence 1 in 2500 (Caucasian)

      • Midline defect starts at uvula

      • May involve soft and hard palate and incisive foramen

      • Repair is usually before age 1 for normal speech


    Neck examination

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    Neck Examination

    • Palpation

      • Palpate all neck muscles

      • Webbed neck

        • Associated with Turner’s and Noonan’s Syndromes

      • Lymph Nodes

        • Unusual at birth, presence usually indicates congenital infection

      • Torticollis

        • Sternocleidomastoid muscle injury from birth trauma.

        • Hematoma and fibrosis results in muscle shortening.

        • Muscle adaptation from abnormal intrauterine position.


    Neck examination1

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    Neck Examination

    • Most common neck masses:

      • vascular malformations, abnormal lymphatic tissue, teratomas, and dermoid cysts

    • Cystic hygromas

      • Most common neck mass

    • Thyroglossal duct cysts

      • Typically midline and inferior to hyoid bone

      • Surgical consultation is required


    Chest lung examination

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    Chest/Lung Examination

    • Inspection

      • Supernumerary breast or nipple is common (10%)

      • Breast enlargement secondary to maternal hormones

      • Unilateral absence or hypoplasia of pectoralis major

        • Poland's Syndrome (Poland's Sequence)

      • Widely spaced nipples

        • Turner's Syndrome

        • Noonan Syndrome


    Chest lung examination1

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    Chest/Lung Examination

    • Inspection

      • Chest Deformity

        • Pectus Carinatum

          • Much less common than Pectus Excavatum

          • More common in males by ratio of 4:1

          • Narrow thorax with increased anteroposterior diameter

        • Pectus Excavatum

          • Gender predominance: Boys (3:1 ratio)

          • Mild: Oval pit near infrasternal notch

          • Severe: Sinking of entire lower sternum


    Chest lungs

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    Chest/Lungs

    • Observe

      • Respiratory pattern

        • Brief periods apnea are normal in transition, called “periodic breathing”

      • Chest movement

        • Symmetry

        • Retractions and Tracheal tugging

    • Ascultation

      • Audible stridor, grunting

      • Wheeze, rales, rhonchi


    Cardiovascular

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    Cardiovascular

    • Inspection

      • Check for pallor, cyanosis, or plethora

    • Palpation

      • Check capillary refill

        • Should be less than 3 seconds

      • Precordium

        • Feel for increased activity and thrill

      • Pulses

        • Ipsilateral femoral (postductal) and brachial (preductal) pulses should be equal in timing and intensity

        • Decreased femoral = coarctation of aorta

        • Bounding pulses often indicated PDA


    Cardiovascular1

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    Cardiovascular

    • Auscultation

      • Rhythm

        • Gallup Rhythms

        • Split S2 is Normal

        • Split S2 absent

          • Aortic or pulmonic valvular atresia or stenosis

          • Results in high pulmonary vascular resistance

      • Rate

        • Regular, irregular

      • Murmur

        • Quality, radiation, location of intensity


    Abdominal inspection

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    Abdominal Inspection

    • Abdominal Shape

      • Flat: Seen with decreased tone, Diaphragmatic hernia - abdominal contents in chest, Abnormal abdominal musculature

      • Distended: Consider obstruction, Excess air inside or outside the bowel, Fluid in the peritoneal cavity (ascites), Enlarged viscus


    Abdominal examination

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    Abdominal Examination

    • Abdominal wall defects

      • Usually diagnosed prenatally.

        • Omphalocoele

          • Covered with membrane unless it has ruptured.

          • Cord attachment at apex of defect.

          • 67% have an associated abnormality.

        • Gastroschisis

          • Not covered with a membrane.

          • Defect is to right of umbilicus.

          • Cord attachment to abdominal wall.

      • Management – immediate surgical consultation

    • Abdominal Auscultation

      • Normoactive bowel sounds all four quadrants


    Abdominal palpation

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    Abdominal Palpation

    • Abdominal Localized Mass

      • Gastrointestinal Duplications, Meconium ileus, Mesenteric or omental cyst, Pyloric stenosis, Volvulus, Wilms tumor, Neuroblastoma, Renal vein thrombosis

    • Liver

      • Usually palpable 2 cm below costal margin

      • Hepatomegaly

        • Many causes depending on presence or absence of hyperbilirubinemia (direct or indirect) and associated splenomegaly

  • Spleen

    • Not usually palpable

    • Splenomegally

      • Etiology can be infectious or extramedullary hematopoeisis

  • Kidneys

    • Length vertically should be 4.5-5.0 cm in full term infant.


  • Umbilicus

    Umbilicus

    • Umbilical Cord

      • Count number of vessels

        • 3 vessel cord is normal (1 vein and 2 arteries)

          • A single umbilical artery is present in up to 1%, which may be associated with asymptomatic renal anomalies

    • Umbilicus

      • Check for signs of bleeding, infection, granuloma, or abnormal communication with the intra-abdominal organs

    • Examine for umbilical hernias


    Male genitourinary examination

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    Male Genitourinary Examination

    • Inspection

      • Check glans, urethral opening, prepuce and shaft

        • Term normal length is 3.5 +/- 0.7 cm

        • Term normal diameter is 1.1 +/- 0.2 cm

        • Abnormally small penis

          • Reduced androgen effect or reduced growth hormone in 2nd and 3rd semester

      • Normally it is difficult to completely retract the foreskin.

      • Circumcised infants should be checked for edema, bleeding or complications at the incision site.

      • Full term infants should have brownish pigmentation and fully rugated scrotums


    Male genitourinary examination1

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    Male Genitourinary Examination

    • Hypospadias

      • A proximally displaced urethral meatus.

      • Wide variation from mild glanular to severe perineal.

  • Chordee

    • Ventral curvature of the penis.

    • May accompany hypospadias.

    • Can be due to skin tethering or a short urethra.

  • Circumcision should be delayed in these infants.


  • Male genitourinary examination2

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    Male Genitourinary Examination

    • Communicating Hydrocele

      • Incomplete obliteration of processus vaginalis

      • Painless, tense, fluctuant scrotal mass that transilluminates.

      • Withold surgery until after first year of life

      • Most will resolve spontaneously

  • Inguinal Hernia

    • Soft, nontender, reducible bulge in inguinal canal, especially at time of increased intra-abdominal pressure.

    • Becomes tender and tense with discoloration of overlying skin if incarcerated.

    • Requires elective surgical repair as soon as possible.


  • Male genitourinary examination3

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    Male Genitourinary Examination

    • Palpation of Testes

      • If not palpable must determine if it is retractile, ectopic or cryptorchid.

      • Unilateral retracted testicle

        • Testicle may be brought down into scrotum.

        • Follow-up examinations in the clinic.

      • Unilateral palpable ectopic or undescended testicle

        • Observe for descent.

        • Surgical correction at 6 month to 1 year.

      • Unilateral nonpalpable testicle (15% of cases)

        • Laparoscopy at 6 months to 1 year for evaluation.

        • Testicle found on laparoscopy in 50% of cases.

        • Orchiopexy brings testis into scrotum (98% efficacy).


    Female genitourinary examination

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    Female Genitourinary Examination

    • Inspection

      • Check labia, clitoris, urethral opening and external vaginal vault

      • Common normal findings

        • Prominent labia minora and clitoris

          • Clitoris can have a relatively prominent appearance, especially if the labia are underdeveloped or the infant is premature.

          • Clitoromegaly may be a sigh of masculinization or a virilizing tumor.

          • Can also be caused by increased androgen production or drug use.

        • Vaginal/hymenal skin tag

        • Mucoid/whitish discharge

        • Small amount of vaginal bleeding

          • Secondary to withdrawal of maternal hormones.


    Ambiguous genitalia

    Ambiguous Genitalia

    • Newborns with ambigious genitalia: require rapid diagnosis and treatment!

    • Potential clinical manifestations: hypoglycemia, hyperpigmentation, apneic episodes, seizures, hyperkalemia, dehydration, hypotension, vascular collapse, shock

    • Also social emergency: Refer to the infant as “your baby” or “your child,” delay naming the child/birth certificate until sex is determined


    Rectum and anus

    Rectum and Anus

    • Anus patent and not ectopic

      • Assess with probe or small finger

    • No fistulas present

    • Pilonidal dimple/cyst

      • pit or sinus in the sacral area

      • pilonidal dimple may also be a deep tract, rather than a shallow depression, leading to a sinus that may contain hair.

      • During adolescence the pilonidal dimple or tract may become infected forming a cyst-like structure called a pilonidal cyst. These pilonidal cysts may require surgical drainage or total excision to prevent reinfection

    • Meconium passed within 48 hours of birth


    Spinal dysraphism

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    Spinal Dysraphism

    • Spina Bifida Occulta

      • No abnormality of meninges, spinal cord or nerve roots

    • Spinal Meningocele

      • Meninges herniate through posterior vertebral arches

      • Spinal cord and nerve roots are not involved.

      • Most often occurs in low back

      • Anterior herniation at sacrum may also occur

        • May result in constipation or bladder abnormality

      • Usually asymptomatic and covered by full layer skin


    Spinal dysraphism1

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    Spinal Dysraphism

    • Myelomeningocele

      • Meninges, spinal cord and nerve roots are involved

      • Lumbosacral region in 75% of cases

      • Associated with dysfunction of multiple organ systems

      • Signs

        • Flaccid paralysis of lower extremities

        • Deep Tendon Reflexes absent

      • Associated Conditions

        • Hydrocephalus and Chiari II Malformation (80% of cases)

        • Neurogenic bladder

        • Urinary Incontinence

        • Stool Incontinence


    The newborn examination

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    Spinal dysraphism2

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    Spinal Dysraphism

    • Spinal Dysraphism

      • Dermatologic signs seen in 50-90% of cases

      • Skin findings may be only signs of occult lesion

      • Findings

        • Hypertrichosis

          • Increased vellus Hair

            • Non-pigmented fine "peach fuzz" hair covering body

        • Lipoma

        • Midline Hemangioma

        • Large midline dimple above gluteal crease

          • Do not probe dimple

          • Small sacral dimple within gluteal crease is normal

          • Not worrisome if bottom of dimple can be visualized


    Ue orthopedic examination

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    UE Orthopedic Examination

    Clavicle

    • May Fracture from Birth Trauma

    • Most common newborn orthopedic injury, especially large infants

    • Pain with movement and Moro reflex

    • Pseudoparalysis of extremity on fracture side

    • Sternocleidomastoid muscle spasm on affected side

    • Deformity or discoloration may be possible

    • Crepitus at fracture site

    • Palpable bony irregularity at fracture site


    Ue orthopedic examination1

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    UE Orthopedic Examination

    • Digits (Fingers and Toes)

      • Supernumerary Digit

        • Occur more often in black infants.

        • Tends to be hereditary

        • Frequently lateral to the 5th digit of hand or foot.

        • Extra digit may have a nail, attached by small pedicle.

        • Ligature around the digit allows it to fall off in several days.

      • Polydactyly

        • Extra-digit is located more often on the foot.

        • Bone is palpable within the extra-digit.

        • The digit may have voluntary movement.

        • Amputation of digit when child is > 1 year old.


    Ue orthopedic examination2

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    UE Orthopedic Examination

    • Digits

      • Syndactyly

        • Simple – involves soft tissue attachment only

        • Complex – involves fusion of bone or nail

        • Partial - web extends from base partially

        • Complete - web from base to tip of finger

        • Radiographs needed to determine degree of fusion.

        • Should refer to orthopedics.


    Ue orthopedic examination3

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    UE Orthopedic Examination

    • Upper Extremities

      • Single Palmar Crease

        • Seen in Down's Syndrome

        • Seen in 4% of normal babies

      • Ulnar or radial bone absence


    Ue orthopedic examination4

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    UE Orthopedic Examination

    • Upper Extremity

      • Brachial Plexus Injuries

        • Results from excessive traction of C5-T3 spinal nerve roots.

        • Erb-Duchenne palsy

          • Most common injury, involves C5-C7

          • Arm adducted, internally rotated, elbow extended, arm pronated, wrist flexed, “waiter’s tip if C7 involved.

        • Klumpke’s palsy

          • Incidence is rare, involves C8-T1.

          • Hand is paralyzed, no voluntary motion.


    Le orthopedic examination

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    LE Orthopedic Examination

    • Lower Extremities

      • Bowing of legs is normal variation

      • Positional deformities of foot

        • Foot should be easily replaced to normal position

      • Talipes Equinovarus (Clubfoot)

        • Heel inversion (varus) with internal rotation

        • Forefoot inverted and adducted (soles face each other)

        • Plantar flexion with inability to dorsiflex

        • Leg internal rotation

        • Refer immediately for serial casts

        • Severe clubfoot requires surgery


    Le orthopedic examination1

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    LE Orthopedic Examination

    • Metatarsus Adductus (In-Toeing)

      • Forefoot rotated inwardly

      • Banana shaped or C-shaped foot

      • Lateral border of foot convex

      • Medial border of foot concave

      • Base of fifth metatarsal (styloid) prominent

      • Both feet are inverted (face each other)

      • Mild or flexible improves during first 3 months of life

      • Full resolution spontaneously in 85% of cases

      • Rigid deformity requires treatment


    Le orthopedic examination2

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    LE Orthopedic Examination

    • Calcaneovalgus Deformity

      • Foot has up and out appearance

      • Foot dorsiflexes easily (long heel cord, ligaments lax)

      • Limited plantar flexion (less than 90 degrees)

      • Lateral Sole deviation (banana shaped)

      • Feet are everted (facing away from each other)

      • Heel position is valgus (medial malleoli are closer)


    Le orthopedic examination3

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    LE Orthopedic Examination

    • Congenital hip dislocation

      • Ortolani test

        • Attempts to dislocate hip

        • Hip clunk felt on exam

        • Must distinguish from a hip click which is benignl

      • Galeazzi's Sign

        • Compare the 2 femur lengths

      • Barlow's Test

        • Attempts to sublux unstable hip

          • Perform with caution


    Resources

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    Resources

    • http://dermatlas.med.jhmi.edu

    • http://www.fpnotebook.com

    • http://health.allrefer.com

    • http://health-pictures.com/index.htm

    • www.neonatolgy.org

    • Nelson’s Textbook of Pediatrics

    • American Family Physician, “The Newborn Examination: Parts I and II” January 2002.


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