NEWBORN ASSESSMENT

Dr JD KABAMBA
LEARNING OBJECTIVES

At the end of this lecture, the student will be able to:

1. Set up a conducive environment for neonatal assessment
2. Take a thorough neonatal perinatal history
3. Carry out a comprehensive neonatal assessment
4. Assess competently the newborn gestation age using the physical
and neuromuscular maturity scoring system ( Ballard Score)
INTRODUCTION

A newborn should have a thorough evaluation performed within 24 hours of birth

to :
- Identify any abnormality that would alter the normal newborn course
- Identify a medical condition such as:
Congenital anomalies
Birth injuries
Jaundice
Cardiopulmonary disorders
This assessment includes review of the maternal, family, and prenatal history and a
complete examination.
INITIAL ASSESSMENT

1. Colour
2. Tone
3. Breathing
4. Heart rate

Can I Take Baby Home

APGAR SCORE
A stands for Appearance (skin color)
P stands for Pulse (heart rate)
G stands for Grimace response (reflexes)
A stands for Activity (muscle tone)
R stands for Respiration (breathing rate and
effort)

The score is reported at 1 minute and 5

minutes after birth for all infants, and at 5-
minute intervals thereafter until 20 minutes
for infants with a score less than 7
HISTORY
It includes the review of following:
 Past pregnancies (congenital anomalies, still births, genetic or syndromic conditions)
 Mother's and father's medical and genetic history (Age, DM, PE, Drugs….)
 Prenatal screening tests:
- ABO blood type
- Rhesus (Rh)
- Rubella status
- Syphilis screen
- Hepatitis B surface antigen
- Hematocrit or hemoglobin
- Urinalysis and urine culture
- HIV
- Diabetes
- Inherited conditions/ birth defects
- Maternal toxicology
  Delivery: The clinician performing the initial newborn examination should be
familiar with the events surrounding delivery, such as:
- Duration of labor
- Duration of rupture of membranes,
-Mode of delivery,
-Newborn's condition at delivery
-Resuscitation
It is important to determine the gestational age (GA) of the infant. Preterm infants
(GA below 37 weeks are at increased risk for morbidity and mortality compared
with term infants (GA 39 to 42 weeks).
PHYSICAL ASSESSMENT OF THE NEWBORN
PHYSICAL EXAMINATION

The examination area should be warm, quiet and should have good lighting.
It includes:
1. General appearance: body position , movement, color, and respiratory effort.
2. Body measurements : weight, length, and head circumference and vital signs.
3. Examination of individual body parts and organs.

The examination should be conducted in a systematic manner, as a consistent

approach ensures that all aspects are evaluated.
1. General appearance
- Determination of sex.
- Identification of any deformation or malformation
- Determination of the state of fetal nutrition ( amount of fat)
- Assessment of respiratory effort ( paradoxical, grunting)
- Assessment of position and movement
- Assessment of color (Acrocyanosis, pallor, jaundice, ruddy or plethoric…)
OBSERVATIONS FOR PHYSICAL ASSESSMENT
OBSERVATIONS FOR PHYSICAL ASSESSMENT (cont’d)
 Mottling of the skin refers to a red or blue infant’s lacy appearance of the
baby’s skin. It may be caused by cold or hot environment and resolves once
temperature is stabilized. If it persists, sepsis should be ruled out.

 Pallor (Twin 1) in neonates can be caused by sepsis, haemorrhage, twin-to-twin

transfusion.

 Central cyanosis may be due to hypoxia of any cause ( Pulmonary or cardiac)

 Acrocyanosis, often transient, may be due to cold environment or soon
after birth as circulation stabilizes.

 Jaundice : classified as physiological ( appears on day 2 or 3 after birth) and

pathological ( appears within 24 hours or 10 to 14 days after birth). The
former may be due to ABO & Rhesus incompatibility, G6PD deficiency and
congenital spherocytosis. The latter to infections, biliary atresia, neonatal
hepatic syndrome

 Ruddy (red): May be due to polycythaemia ( congenital heart disease, twin-

to-twin transfusion,…)
2. Measurements
 The length : measured from the top of
the head to the bottom of the feet, with
the legs fully extended.
 The fronto-occipital head circumference
(FOC) should be measured at its
maximum (from prominent point on the
occiput to just above the eyebrows).
 The weight: The newborn should
completely undressed.
Make sure the environment is quiet, warm
and hygienic !
3. Vital signs
 Respiratory Rate : 40-60
breaths/min (counted over a full
minute)
 Heart Rate : 120-160 beats/ min.
The heart rate may decrease to 85
to 90 beats per minute in some
term infants during sleep.
 Blood pressure can be measured
using a neonatal-size blood
pressure cuff in infants with
suspected cardiovascular or renal
abnormalities.
4. Skin
1. Milia are white papules due to retention of keratin and
sebaceous material in the pilaceous follicles.
2. Transient pustular melanosis: a generalized eruption of
superficial pustules overlying hyperpigmented macules.
3. Erythema toxicum consists of white papules on an
erythematous base. The lesions, which contain
eosinophils, usually develop on the second or third
postnatal day
Nevus simplex (also called macular stain, stork bite, or angel
kiss) is a pink-red capillary malformation.

Nevus flammeus, or port wine stain, is a low-flow capillary

malformation that can occur anywhere on the body.
5. Head
 Caput succedaneum is an area of edema over the
presenting part of the head. This common condition
typically is present at birth, crosses suture lines, and
resolves within a few days.

 Cephalohematoma is a sub-periosteal collection of blood

that does not cross suture lines, which may increase in
size after birth, and usually take weeks to months to
resolve.
6. Face
The face is examined for symmetry.
Facial palsies and asymmetric crying
facies are most obvious when the infant
is crying and may go unnoticed in the
quiet or sleeping infant.
Facial palsies are often seen in infants
who are delivered with the use of
forceps.
Missing naso-labial fold
Eyes:
-Spacing: Hypertelorism
-Palpebral fissures: Upslanting, downslanting
-Red light reflex: normal
if white ( Leucoria), suspect: cataract or retinoblastoma
- Eye movement: strabismus, nystagmus
- Sclerae
- Conjunctiva
- Cornea
- Pupils: Coloboma
Ears:
The ears are normally positioned when the helix
is intersected by a horizontal line drawn from
the outer canthus of the eye perpendicular to
the vertical axis of the head
- Position: Low ( Trisomies)
- External abnormalities: Ear tag
Mouth:
- Size: Trisomies, DiGeorge, Pierre Robin
- Shape:
- Interior: Ranula, Epstein pearls
Cleft palate, Ankyloglossia…….
Neck
- Masses: Cystic Hygroma, Haematoma
- Torticollis:trauma to the SCM muscle
caused by birth injury or intrauterine
malposition.
- Excess skin: Redundant ( genetic
syndromes)
- Clavicles: Absence , fracture
Cardio-vascular System Respiratory System
 Inspection: checking for tachypnea and  Note the rate and pattern of respiration.
cyanosis
 Normal RR:40-60/min
 Palpation: Apex beat on the 4th left ICS  Rapid rate indicates underlying respiratory
midclavicular line, brachial and femoral pulses condition.
 Auscultation: presence of murmurs  Observe chest symmetry, chest recessions
 Pulse oximetry and any abnormal sound ( grunting, stridor)
 Check for any chest deformity (pectus
excavatum)
Abdominal examination
 Check for distension and masses (liver and spleen). 1-2 cm liver can be normal.
 Check umbilical stamp for both number of vessels ( 1 vein, 2 arteries), umbilical and inguinal
herniae and infection.
 Ensure the anus patency ( to rule out imperforate anus)
Examination of the genitalia
 Check ambiguous genitalia  Male:
 Female: - Check the position of the urethral meatus
- Inspect labia minora and majora for hypospadias or epispadias
- Inspect clitoris, if enlarged, rule out CAH* - Check for scrotal swellings such as
- Reassure parents about the mucous tag hydrocele ( transillumination).
attached to the vaginal wall. - Check for the testes in the scrotum
- Blood-stained vaginal discharge is common (undescended and testicular torsion)
(caused by maternal oestrogens).
* Congenital Adrenal Hyperplasia
Examination of upper limbs Examination of lower limbs
 Examine arms for length, proportion and Legs:
symmetry.
 Examine legs for length, proportion and
 Inspect the presence movement to rule out symmetry.
palsies and tenderness  Examine for spontaneous movement to rule
 Check the number and structure of the digits out fractures and tenderness
Feet:
 Note the structure and number of digits
 Check for the feet deformities such as talipes
which may be positional or structural.

Brachial plexus injury Talipes equino-varus

Poly & syndactyly
Examination of Central Tone
Normal head lag Normal ventral suspension
Gently hold the neonate by the forearms and Turn the infant prone and lift them off the
pulling them upright. couch placing a hand under their chest.
There is an initial head lag and then the baby The normal newborn lifts both their head and
lifts their head and holds it upright for few pelvis almost in line with the trunk, with the
seconds with rounding of their back. upper and lower limbs semi-flexed.

Head lag should disappear by 3 months

Examination of normal neonatal reflexes

Rooting Reflex Sucking and Swallowing Reflexes

When the corner of the infant’s mouth is They are present in all term infants and
touched, the lower lip on that side and the preterm infants over 35 neurological features
tongue moves towards the point of stimulation. week’s gestation.
Moro Reflex Placing and walking reflexes
Lift the infant placing one hand behind their The placing reflex is elicited by bringing the
head and then the other hand behind their anterior aspect of the tibia against the edge of
back. the table.
Allow the head to drop a few degrees. The infant will lift the leg up to step on to the
table.
There is a rapid abduction and extension of the
arms with opening of the hands. The arms then These reflexes disappear by 6 weeks.
come together
Examination of normal neonatal reflexes

Palmar or Grasp Reflex Asymmetric Tonic Neck Reflex

When the infant’s palm is stimulated, the hand When the infant turns their head to one side,
closes. the arm extends to the same side and the
contralateral arm flexes.
It disappears by 2-3 months.
It disappears by 2-3 months of age.
GESTATIONAL AGE ASSESSMENT OF THE
NEWBORN
(Ballard Scoring System)
Ballard Score: Physical Assessment &
Neuromuscular Maturity
Ballard Score: Physical Assessment
1. Skin
2. Lanugo
3. Plantar Surface
4. Breast
5. Eye and Ear
6. Genitals: Male
6. Genitals: Female
Ballard Score: Neuromuscular Maturity
1. Posture
2. Square Window
3. Arm Recoil
4. Popliteal Angle
5. Scarf Sign
6. Heel-to-Ear