| ID | 351 |
|---|---|
| Name | EXAMINATION OF THE NEONATE |
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| Investigations | |
| Management | All the newborn babies should have a thorough examination immediately after birth either of normal pregnancies or ‘babies at-risk’, preferably by a pediatrician. ‘Apgar Scoring’ usually done by attending obstetrician at 1 (one) & 5 (five) minutes after delivery. Neonatal examination check list A. Anthropometric measurements (at 50th centile): Weight- Male- 3.5 kg. Female- 3.4 kg. Length- Male- 50 c.m. Female- 49 c.m. O.F.C- Male- 35 c.m. Female- 35 c.m. Body proportion: Upper segment (1): Lower segment (1.7) B. Examinations of the body organs: Head: Size, shape; fontanelles, sutures; any swelling or sign of injury. Face: Donfiguration Eyes: Position, vision, epicanthic fold etc. Nose: Base, nostrils, any discharge Mouth: Cleft lip palate, gum, tongue, jaws. Ears: Position (e.g low set), development, canal, hearing etc. Neck: Long or short (as in klippel feil syndrome), webbing (as in Turner’s syndrome) any cyst or tumour, muscles. Chest: Shape, movement, position of nipples, any visible pulsation. Abdomen: Size & shape, abdominal wall any distention, any palpable organs, bowel sound. Umbilical cord: Any abnormality; single umbilical artery indicates possible association with other cong. malformations. Upper limbs: Erb’s palsy (traction of cervical 5 & 6 roots) is associated with breech & forceps deliveries. Arm is adducted & internally rotated at shoulder & lower arm is pronate------------- paralysis C8 & Tl roots are involved. These infants present with claw hand. Palm creases fingers. Hip: Cong. dislocation of hip should always be excluded by ortolani’s test. Genitalia: Male & female genital organs should be examined very carefully & gently. In female any bleeding pervagina. In male- undscended testes, ambiguous genitalia etc. Legs: Tone & activity should be looked for. Feet: club feet or talipes equinovarus; toes; nails. Spine & back: Any deformity, specially looking for spina bifida, meningo-myelocele etc. Skin: Meconium stain, cyanosis, pallor, icterus; erythema-toxicum; hairyness, scaliness etc. C. Examinations of the body systems: Respiratory system: Cry; cyanosis; airway clearance; resp. rate; grunting; Lungs- breath sound, any added sound; apnoeic spell. Cardiovascular system: Heart rate (> 100-I50/ min), heart sounds (any murmur?), visible pulsation, apex beat, neck vein engorgement, other pulsations. Nervous system: Different primitive neonatal reflexes should be assessed, such as Moro’s reflex, grasp reflex, sucking & rooting reflexes etc. Muscle tone & activities. Reflexes- Vide infra (see below). Alimentary system: Alimentary canal- to examine G I. tract it is preferable to ‘introduce a fine & soft nasogastric tube before giving any feed (first feed) to the baby (to exclude, any oesophageal atresia or tracheo-oesophageal fistula). Abdomen: Distention (if any), bowel sound & peristaltic movement, any mass, liver/Spleen whether palpable. Rectum- anal orifice intact or imperfbrate anus; any stool (meconeum). Renal system: In male- urethral meatus, hypospadias/epispadias. In female-urethro-vaginal fistula, hydro colpos. Bladder, kidney; look for urine- urine may pass even as late as 48-72 hours after delivery in normal cases, in that cases feeding should be ensured. Locomotor system: Limbs, joints, muscle tone & movements etc. Neurological reflexes of neonate & infancy13-17 Reflexes Age when reflexes Age when reflex is normally usually appears no longer obtainable Moro Birth 3 month Stepping Birth 6 week Placing Birth 6 week Sucking & rooting Birth 4 month awake 7 month asleep Palmar grasp Birth 6 month Plantar grasp Birth 10 month Adductor spread of knee jerk Birth 7 month Tonic neck 2 month 6 month Neck righting 4-6 month 24 month Landau 3 month 24 month Parachute reaction 9 month Persists Many special reflex patterns mediated by brain stem & spinal cord mechanisms are found in the newborn & first few months of life. Absence of reflex responses indicates general depression of central or peripheral motor functions; asymmetric responses suggest focal motor lesions, either peripheral or central. As the infant matures, the neonatal reflexes disappear in a predictable order as voluntary motor functions supersede them. Abnormal persistence of these reflexes is seen in infants with general developmental lag or with central motor lesions. Moro reflex- The Moro reflex is elicited by placing infant supine upon the examining table, the head supported by the examiner’s hand. The support is withdrawn suddenly, & the head is allowed to fall backward for 10-15 degrees. The reflex consists of extension of the trunk & extension & abduction followed by flexion & adduction of the arms, with less regular participation of the legs. Stepping reflex- The stepping reflex consists of movements of walking which are elicited when the infant is held upright and inclined forward with soles of feet touching a flat surface. Placing reflex- Cccurs when the infant is held erect and the dorsum of one foot is drawn along the under edge of a table top. The response consists of flexion followed by extension of the leg that is stimulated. Sucking & Rooting Reflex- The sucking reflex is initiated by stroking the lips. Stroking of the cheek produces the rooting reflex, which consist of turning the mouth toward the stimulus. Grasp reflex- Grasp reflexes are elicited by light pressure on the palms or on the soles of the feet. Tendon reflex- Tendon reflexes are generally present in the normal neonate; only the knee jerk may be easily obtainable. Brisk tendon jerks may be normal, and there may be adductor spread of the knee jerk and unsustained ankle clonus. Spontaneous clonus of arms, legs, and feet is seen in infants with cerebral disorders. Absence of tendon reflexes suggests a neuromuscular disorder, such as Werdnig-Hoffrnann disease. The Babinski sign- It is not helpful in infancy since either flexion or extension of toes may normally be obtained. Assessment of gestational age at birth by clinical criteria13-14-17 Since dates of last menstruation are frequently not forthcoming from the illiterate mothers, assess-ment of gestational age may be made on the basis of the follwing criteria: Physical characteristics: 1. Length: From crown to sole (cm) x 0.8 = gestational age (wks). Thus 50cm shall mean 40 wks. 40cm meaning 32 weeks. 2. Sole creases: Only anterior transverse- <36 wks. Occasional creases, mostly anteriorly- 36 to 38 weeks. Covered with multiple creases: 40 weeks. 3. Ear lobe: No cartilage- < 36 weeks. Some cartilage: 36 to 38 weeks; Stiff cartilage: 40 weeks. 4. Breast nodule: Not palpable at all or < 2mm- < 36 weeks. 2 to 4 mm- 36 to 38 weeks; 7 mm- 40 weeks. 5. Testes and scrotum: Testes in inguinal canal, or in scrotum but few ruge- < 36 weeks. Numbers of ruge more- 36 to 38 weeks. Extensive ruge, pendulous testes with full scrotum- 40 weeks. Reflexes & Tone: 1. Posture recoil- < Complete hypotoina < 32 weeks. Some flexion of lower limbs < 34 weeks. Good flexion of lower limbs < 36 weeks. Good flexion of lower limbs with some flexion of upper limbs: 36 to 38 wks. Good movements of both upper and lower limbs: 40 weeks. 2. Toe or heel to ear manoeuver- Easy < 34 weeks; Difficult < 36 weeks. Very difficult: 36 to 38 weeks; Not possible: 40 weeks. 3. Scarf sign- with the baby lying flat on back, his arm is moved across the body & the examiner makes a note of the extent to which the elbow reaches: Beyond the opposite side of the body < 32 wks. The same but with difficulty < 36 weeks. Only upto midline: 36 to 38 weeks. Stops short of midline: 40 weeks. 4 Window sign- based on flexion of the hand on forearm, or dorsiflexion of foot at ankle joint: Upto 90°- < 32 weeks; Upto 45°- < 36 weeks; Very little- 40 weeks. 5. Sucking & swallowing reflexes- weak & poorly synchronized < 32 weeks. Strong and synchronized < 34 weeks. 6. Rooting Reflex- When corner of mouth or lower lip of the baby is touched, mouth turns towards the stimulated side. Slow- < 32 weeks; Brisk and active- < 34 weeks. 7. Moro’s reflex- When the examiner bangs the table or the bed, there is extension of arms followed by flexion and adduction. The baby seems to be attempting to embrace. Weak- < 32 weeks; Strong- > 32 weeks. |
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