Neonatal Assessment

pilonidal dimple

a small pit or sinus in the sacral area at top of crease between the buttocks; the sinus can become infected later in life

natal teeth

abnormal finding-may be benign or congenital abnormality

deviation from normal eyes

absent red light reflexes, unequal pupil reations, blue sclera

macrocephaly

head circumference is above the 90% for gestational age

microcephaly

head circumference is below the 10% range for gestational age

dextrocardia

heart on the right side of the chest

one umbilical artery and vein

often associated with heart or kidney malformation

failure to pass meconium

often associated with imperforated anus or meconium ileus

prominent clitoris and small labia minora

often present in preterm neonates

harlequin sign

one side of body is pink and the other side is white related to vasomotor instability

jaundice

pathological within the first 24 hours

hypertonia

tightly flexed arms and stiffly extended legs with quivering indicate possible drug withdrawal

deviations from normal respirations

periods of apnea >15 seconds. Tachypnea that may be related to sepsis, hypothermia, hypoglycemia, or respiratory distress syndrome. Respirations >30 may be related to maternal analgesia and/or anesthesia during labor

normal pulse

120-160 BPM. rate increases (to 180 BPM) when crying and decreases (to 100) when asleep. Murmurs may be heard; most are not pathological and disappear by 6 months

normal weight

2500-4000g (5lb 8oz- 8lb 13oz)

normal respirations

30-60 breaths per min, slightly irregular, diaphragmatic and abd breathing, rate increases when crying and decreases when sleeping

normal chest circumference

30.5-33cm (12-13in) or 2-3 cm less than head circumference

normal head circumference

33-35.5cm (13-14in)

normal neonate temp

36.4-37.2 C (97.5-99 F)

normal length

45-53cm (19-21in)

Normal neonatal weight loss in the first week

5-10% due to waterloss through urine, stools, and lungs and an increase in metabolic rate. Also related to fluid intake

thrush

a fungal infetion can be contracted during vaginal birth

deviations from normal weight

LGA, SGA

Port wine Stain

Nervus flammeus- purple to red-colored flar areas that can be located on various portions of the body. Do not disappear

caput succedaneum

a localized soft tissue edema of the scalp. Feels "spongy" and can cross suture lines. results from prolonged pressure of the head against maternal cervix during labor. resolves in first week of life

epispadias

the urethral opening is on the dorsal side of the penis

vernix caseosa

a protective substance secreted from the sebaceous glands that covered the fetus during pregnancy. looks like a whitish cheesy substance. may be noted in auxiliary areas and genital areas of full term neonates

normal cardiac

PMI at 3rd of 4th intercostal space, normal rhythm with variation related to respiratory changes, murmurs in 30% of neonates which disappear within 2 days of birth, peripheral pulses are present and equal, femoral pulse my be difficult to palpate

erythema toxicum

a rash with red macules and papules (white to yellowish-white papule in center surrounded by reddened skin) that appear in different areas of the body, usually the trunk area. Can appear within 24 hrs and up to 2 weeks benign, disappear without tx

circumoral cyanosis

a benign localized transient cyanosis around the mouth observed during transition stage if persists may be related to cardiac anomaly

normal rectum

anus is patent, passage of stool within 24 hours

normal musculoskeletal

arms and legs are symmetrical in length and equal in strength, full ROM, no clicks at joints, equal gluteal folds, c curve of spine with no dimpling

ballard maturational scale

assesses neuromuscular and physical maturity with 6 items observed for each area

unequal gluteal folds and/or positive barlows maneuver

associated with congenital hip displacement

mottling

benign transient pink and white blotches on the skin response to cold environment

possible cause for macrocephaly

can be related to hydrocephalus

large amounts of mucus drainage

can lead to resp distress

pigeon chest

can obstruct respirations

normal chest/lungs

chest is barrel shaped and symmetrical, breast engorgement may be present, clear or milky fluid from nipples, lung sounds are clear and equal, scattered crackles may be detected in first few hrs after birth due to retained amniotic fluid which will be absorbed through lymphatics

signs of respiratory distress

chest retractions, persistent crackles, wheezes, stridor peridoxical breathing, decreased breath sounds, prolonged periods of apnea (>15-20 seconds)

simian creases, short fingers, wide spaces between big toe and second toe

common with downs syndrome

funnel chest

congenital abnormality

cleft lip and/or palate

congenital abnormality in which the lip and/or palate does not completely fuse

hydrocele

enlarged scrotum due to excessive fluid

normal eyes

equal and symmetrical in size and placement, can follow objects within 12in of visual field, edema may be present due to pressure during labor and birth or reaction to eye prophylaxes, iris is blue-gray or brown, sclera is white or bluish-white, subconjunctival hemorrhages related to birth trauma, PERRLA, no tear production (begins at 2mths) strabismus and nystagmus related to immature muscular control

Deviations from normal posture

extension of extremeties-often related to prematurity, effects of medications given to mother during labor such as mgso4, analgesics, anesthesia, birth injuries, hypothermia, or hypoglycemia

polydactyly

extra digits, may indicate a genetic disorder

Normal Posture

extremities are flexed

lanugo

fine, downy hair that develops after 16 weeks gestation. Amount decreases as the fetus ages, often seen on back shoulders and forehead

mongolian spots

flat bluish discolored area on the lower back and/or buttock. Seen more often in AfAm, asians, latin, and native americans might be mistaken for bruising, need to document size and location. Resolves on own by school age

normal neurological

flexed position, rapid recoil of extremities to flexed position, positive newborn reflexes

hypotonia

floppy limb extremities indicate possible nerve injury related to birth, depression of CNS related to maternal medication received during labor or fetal hypoxia during labor, prematurity or spinal cord injury

deviations from normal head

fontanels are firm c bulging not related to crying, depressed fontanels, bruising or laceration at site of fetal scalp electrode or vacuum extractor, presence of caput succedaneum or cephalohematoma

cephalhematoma

hematoma formation between the periosteum and skull with unilateral swelling. Appears withing a few hours of birth and can increase in size over the next few days. It has a well defined outline and does not cross suture lines related to trauma to the head during prolonged labor, or use of vacuum. resolves within 3 months

deviation from normal temps

hypothermia or hyperthermia is related to infection, environmental extremities, and/or neological disorders

Deviations from normal length

if <45cm should be futher assessed for causes such as IUGR or prematurity

natal teeth

immature caps of enamel and dentin with poorly developed roots. usually 1 or 2 teeth are present usually benign but can be associated with congenital defects. often loose and need to be removed to decrease risk of aspiration

deviation from normal rectum

imperforated anus, anal fissures or fistulas

low set ears

indicate genetic disorders such as down syndrome

persistent murmurs

indicate persistent fetal circulation or congenital heart defects

pallor

indicates anemia, hypothermia, shock, or sepsis

absent red light reflexes

indicates cataracts

depressed fontanels

indicates dehydration

fontanels firm and bulging that is not related to crying

indicates increased intracranial pressure

unequal pupil reaction

indicates neurological trauma

blue sclera

indicates osteogenesis imperfecta

asymmetrical abdomen

indicates possible abdominal mass

decreased ROM and/or muscle tone

indicates possible birth injury, neurological disorder, or prematurity

paralysis

indicates possible birth trauma or spinal injury

swelling, crepitus, and or neck tenderness

indicates possible broken clavicle

absent startle reflex

indicates possible hearing loss

bradycardia

indicates possible sepsis, increased intracranial pressure, or hypoxemia

tachycardia

indicates possible sepsis, respiratory distress, congenital heart abnormality

abundant lanugo, thin and translucent skin, and increased amounts of vernix caseosa

indicates prematurity

persistent echymosis or petechiae

indicates thrombocytopenia, sepsis, or cengenital infection

Deviations from normal skin

jaundice, pallor, greenish yellowish vernix indicates passage of mecomium during pregnancy and/or labor, persistent echymosis or petechia, abundant lanugo, thin and translucent skin, large amounts of vernix caseosa, pilonidal dimple

normal mouth

lips, gums, tongue, palate, and mucus membranes are intact, pink and moist. reflexes are positive epstein pearls are present

possible causes for microcephaly

malformation, maternal drug or alcohol ingestion, or maternal infection during pregnancy

normal nose

may be flattened or bruised related to birth process, nares should be patent, small amount of mucus, neonates primarily breathe through their noses

no urination in 24 hours

may indicate possible urinary obstruction, polycystic disease, or renal failure

ambiguous genitalia

may require genetic testing to determine sex

deviation from normal head circumference

microcephaly, macrocephaly

What can interfere with accurate assessment of length

molding

normal head

molding present, fontanels are open, soft, intact, and slightly depressed- may bulge when crying, the anterior fontanel is diamond shaped, approx 2.5-4cm (closes by 18mths of age) the posterior fontanel is triangle shaped approx 0.5-1cm (closes between 2-4mths). May be difficult to palpate if excessive molding and sutures may be overriding if increased molding

hernias or diastasis recti

more common in african american neonates and usually resolves on their own within the first year

erythema toxicum

newborn rash

Normal blood pressure

not a routine part of the assessment but if needed should be taken in the arm and the leg. NORMAL VALUE: 50-75/30-45

displaced PMI

occurs in cardiomegaly

normal skin

pink with acrocyanosis, milia present on bridge of nose and chin, lanugo on back, shoulders, and forehead (decreases with increased gest age), peeling or cracked skin noted past 40 weeks, mongolian spots, hemangiomas, erythema toxicum

tremors

possible due to hypoglycemia, drug withdrawal, or cold stress

Things we assess in the neonate

posture, head circumference, chest circumference, length, weight, temp, respirations, pulse, blood pressure, skin, head, neck, eyes, ears, nose, mouth, chest/lungs, cardiac, abd, rectum, GU, musculoskeletal, neurological

babinski reflex

present at birth disappears at 1 year stroke lateral surface of sole in upward motion. should hyperextend and fan toes absent or weak response may indicate a possible neurological defect

moro reflex

present at birth disappears by 6 months. Jar the crib, symmetrical abduction of extremities. Asymmetrical response may be due to temporary or permanent birth injury, injury to clavicle, humerus, or brachial plexis

tonic neck

present between birth and 6 weeks disappears by 4-6 months with neonate in supine position turn head to side so chin over shoulder. should extend arms and legs in direction head was turned response after 6 months may indicate cerebral palsy

Strawberry Hemangiomas

raised bright red lesions that develop during the neonatal period. Spontaneously resolve during early childhood

decreased or absent breath sounds

related to meconium aspiration or pneumothorax

imperforated anus

requires immediate surgery

stork bites

salmon colored patch, often appear on the nape of the neck, on the eyelid, between the eyes or on the upper lip. Deepen in color when the neonate cries. Disappears in the first year of life

flat nasal bridge

seen with down syndrome

nasal flaring

seen with resp distress

normal neck

short with skin folds, positive kneck tonic reflex

normal abdomen

soft, round, protrubent, symmetrical, bowel sounds are present but may be hypoactive in first few days, passage of meconium in first 48 hours, cord is opaque with 2 arteries and 1 vein and covered with wartons jelly, cord becomes dry and darker in color within 24 hours post birth and detaches within 2 weeks

dubowitz neurological exam

standardized tool that assesses 33 responses in 4 areas to determine gestational age -habituation, movement and muscle tone, reflexes, neurobehavioral items

deviation from normal pulse

tachycardia (>160BPM) bradycardia (<100 BPM)

undescended testes

testes not palpated in the scrotum

habituation

the response to repetitive light and sound stimuli

hypospadias

the urethral opening is on the ventral surface of the penis

normal ears

top of pinna aligned with external cantus of the eye, pinna without deformities, well formed and flexible, neonate responds to noises with positive startle signs, hearing becomes more acute as eustachian tubes clear, neonates respond more readily to high pitched vocal sounds

syndactyly

webbed digits, may indicate a genetic disorder

deviation from normal neck

webbing-indicates genetic disorder absent tonic reflex-indicates nerve injury

milia

white papules on the face, more frequently seen on the bridge of the nose and chin exposed subaceous glands that resolve without tx. parents may mistake for white heads inform them to leave them alone

epstein's pearls

white pearl-like epithelial cysts on gum margins and palate benign and usually disappear within a few weeks

When should neonate regain the weight lost after birth

within 10 days