NWT Clinical Practice Guidelines for Primary Community Care Nursing -Guidelines for Pediatric Health Assessment

Physical Examination Of The Newborn

General

Observe the entire infant at the beginning of the • Consciousness, alertness, general behavior examination, before the assessment of specific • Symmetry of body proportions and body organ systems. It is important that the infant be movements (e.g. arms and legs, facial grimace) completely undressed and in a warm environment • State of nutrition and hydration with adequate illumination. • Colour • Any sign of clinical distress (e.g. respiratory) Assess the following:

Vital Signs Average values of vital signs for newborns: • Respiratory rate 30-60/minute, up to 80/minute • Temperature 36.5°C to 37.5°C if infant is crying or stimulated • Heart rate 120-160 beats/minute • Systolic blood pressure 50-70 mm Hg

Growth Measurements Measure and record length, weight and head • Average weight at birth 3500-4400 g circumference. If the infant appears premature or • Average head circumference at birth 33-35 cm is unusually large or small, assess gestational age (see Table 1-4, below, this chapter). For additional information about growth measurements, see "Well-Child Care," in chapter • Average length at birth 50-52 cm 3, "Prevention."

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Skin Colour • Transient neonatal pustular melanosis: Small • Pallor associated with low hemoglobin vesicopustules, generally present at birth, • Cyanosis associated with hypoxemia containing WBCs and no organisms; intact • Plethora associated with polycythemia vesicle ruptures to reveal a pigmented macule • Jaundice associated with elevated bilirubin surrounded by a thin skin ring • Erythema toxicum: Most common newborn Lesions rash, consisting of variable, irregular macular patches and lasting a few days • Milia: Pinpoint white papules of keratogenous Café au lait spots: Suspect neurofibromatosis if material, usually on nose, cheeks and forehead, • there are many (more than five or six) large which last several weeks spots • Miliaria: Obstructed eccrine (sweat) ducts appearing as pinpoint vesicles on forehead, scalp and skin folds; usually clear within 1 week

Head And Neck Head • Look for fleshy appendages, lipomas or skin Check for: tags • Overriding sutures • Perform otoscopic examination if sepsis is • Anterior and posterior fontanels (size, suspected; check canals for discharge and consistency) tympanic membranes for colour, brightness, • Abnormal shape of head (e.g. caput bony landmarks and light reflex succedaneum, molding, encephaloceles) • Measure head circumference. Nose: Inspection • Look for flaring of the alae nasi, which is a sign Eyes: Inspection of increased respiratory effort • Check cornea for cloudiness (sign of congenital • Look for hypertelorism or hypotelorism cataracts) • Check for choanal atresia, as manifested by • Check conjunctiva for erythema, exudate, orbital respiratory distress; neonates are obligate nose edema, subconjunctival hemorrhage, jaundice of breathers, so first check to determine if air is sclera coming from nostrils; if not and choanal atresia • Check for pupillary size, shape, equality and is suspected, a soft nasogastric tube can be reactivity to light (PERRL: pupils equal, round, passed through each nostril to check patency reactive to light), accommodation normal • Red reflex: hold ophthalmoscope 15-20 cm (6-8 Palate: Inspection And Palpation inches) from the eye and use the +10 diopter • Check for defects such as cleft lip and palate lens; if normal, the newborn's eye transmits a clear red colour back; black dots may represent Mouth: Inspection cataracts; a whitish colour may suggest • Observe size and shape of mouth retinoblastoma • Microstomia: seen in trisomy 18 and 21 • Macrostomia: seen in mucopolysaccharidosis Ears: Inspection • "Fish mouth": seen in fetal alcohol syndrome • Check for asymmetry, irregular shape, setting of • Epstein pearls: small white cysts containing ear in relation to corner of eye (low-set ears may keratin, frequently found on either side of the suggest underlying congenital problems, such as median line of the palate renal anomalies)

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Tongue: Inspection Neck • Macroglossia: indicates hypothyroidism or Inspection mucopolysaccharidosis • Symmetry of shape • Alignment: torticollis is usually secondary to Teeth: Inspection sternocleidomastoid hematoma • Natal teeth (usually lower incisors) may be • Neck mass (cystic hygroma is the most common present type) • Risk of aspiration if these are attached loosely Palpation Chin: Inspection • Palpate all muscles for lumps and the clavicles • Micrognathia may occur with Pierre Robin for possible fracture syndrome, Treacher Collins syndrome and • Lymph nodes cannot usually be palpated at Hallerman Streiff syndrome birth; their presence usually indicates congenital infection

Respiratory System Inspection • Breasts may be slightly enlarged secondary to • Cyanosis, central or peripheral (transient bluish presence of maternal hormones colour may be seen in extremities if infant is cooling off during the examination) Auscultation • Respiratory rate and pattern (e.g. periodic • Breath sounds breathing, periods of true apnea) • Inspiratory to expiratory ratio • Observe chest movement for symmetry and • Adventitious sounds (e.g. stridor, retractions crackles,wheezes, grunting) • Use of accessory muscles, tracheal tug, indrawing of intercostal or subcostal muscles Percussion is of little clinical benefit and should be avoided, especially in low-birth-weight or preterm Palpation infants, as it may cause injury (e.g. bruising, • Any abnormal masses (palpate gently) contusions).

Cardiovascular System • Respiratory rate • Abnormal location of PMI can be a clue to • Heart rate pneumothorax, diaphragmatic hernia, situs • Blood pressure in upper and lower extremities inversus viscerum or other thoracic problem • Capillary refill (<2 seconds is normal) See normal values in "Vital Signs," above, this • Peripheral pulses: note character of pulses chapter. (bounding or thready; equality); any decrease in femoral pulses or radial-femoral delay may be a Inspection sign of coarctation of the aorta • Colour: pallor, cyanosis, plethora Auscultation Palpation • Note rate and rhythm • Locate point of maximal impulse (PMI) by • Note presence of S1 and S2 heart sounds positioning one finger on the chest, in the fourth • Note presence of murmurs (consider murmurs intercostal space medial to the midclavicular line pathologic, as in congenital heart defects, until proven otherwise)

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Abdomen Inspection Palpation • Shape of abdomen: flat abdomen may signify • Check for any abnormal masses decreased tone, presence of abdominal contents • Liver and spleen: it may be normal for the liver in chest or abnormalities of the abdominal to be located about 2 cm below the right costal musculature margin; spleen is not usually palpable; if it can • Contour: note any abdominal distension be felt, be alert for congenital infection or • Masses extramedullary hematopoiesis • Visible peristalsis • Kidneys: should be about 4.5-5.0 cm vertical • Diastasis recti length in the full-term newborn • Obvious malformations (e.g. bowel contents • Techniques for kidney palpation: place one hand outside of abdominal cavity [omphalocele]; this with four fingers under the baby's back, then abnormality has a membranous covering [unless palpate by rolling the thumb over the kidneys; or it has been ruptured during delivery], whereas place the right hand under the left lumbar region gastroschisis does not) and palpate the abdomen with the left hand to • Umbilical cord: count the vessels (there should palpate the left kidney (do the reverse for the be one vein and two arteries); note colour, any right kidney) discharge • Hernias: umbilical or inguinal

Auscultation Percussion usually omitted unless problems such • Bowel sounds as abdominal distension are noted. Inspect the anal area for patency and for presence of fistulas or skin tags.

Genitalia The genitalia should be carefully assessed, with Palpation particular attention to any malformation, • Testes: ensure that both testicles are descended abnormalities or sexual ambiguity. into scrotum

Male Genitalia Female Genitalia Inspection Inspection • Glans: color, edema, discharge, bleeding • Check labia, clitoris, urethral opening and • Urethral opening: should be located centrally on external vaginal vault the glans (in hypospadias, the opening is found • Whitish discharge often present; this is normal, on the undersurface of the penis) as is a small amount of bleeding, which usually • Foreskin (prepuce): usually difficult to retract occurs a few days after birth and is secondary to completely maternal hormone withdrawal • Scrotum: in full-term infant, scrotum should • Hymenal tags, if they occur, are normal have brownish pigmentation and should be fully rugated

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Musculoskeletal System Inspection And Palpation • Count the toes Spine • Examine foot creases for assessment of • Check for scoliosis, kyphosis, lordosis, spinal gestational age (see Table 1-4, below, this defects, meningomyelocele chapter) • Examine the hips last, using Ortolani-Barlow Upper Extremities maneuver • Assess the shoulder girdle for injury and the clavicles for fracture (especially if the delivery Technique for Ortolani-Barlow hip examination: was traumatic and in large infants with a history • Place middle fingers over greater trochanters of shoulder dystocia) (outer upper legs) • Assess mobility of the shoulder and extension of • Position thumbs on medial sides of knees the elbow • Abduct the thigh to 90° by applying lateral • Inspect palmar creases for assessment of pressure with thumb gestational age (see Table 1-4, below, this • Move knee medially and then replace knee in chapter) starting position • Count the fingers • If there is a "clunk," the hip may be dislocatable • If there is a "click," the hip may be subluxable Lower Extremities • Assess the feet and ankles for deformity and mobility

Central Nervous System • Assess state of alertness • Begins when the corner of the baby's mouth is • Check for lethargy or irritability stroked or touched. The baby turns the head and • Posture: For term infant, normal position is one opens the mouth to follow and "root" in the with hips abducted and partially flexed and with direction of the stroking. This helps the baby to knees flexed; arms are adducted and flexed at find the breast or bottle to begin feeding. the elbow; the fists are often clenched, with fingers covering the thumb Sucking Reflex • Assess tone; for example, support the infant with • Begins about the 32nd week of pregnancy one hand under the chest; the neck extensors • Is not fully developed until about 36 weeks should be able to hold the head in line for 3 • Disappears by about 4 months after birth seconds; there should not be more than 10% • Premature babies may have weak or immature head lag when the infant is moved from a supine sucking ability to a sitting position Moro Reflex Reflexes • Present at birth Reflexes are involuntary movements or actions • Disappears by about 4-5 months after birth that help to identify normal brain and nerve • Often called a startle reflex because it usually activity. Some reflexes occur only in specific occurs when the baby is startled by a loud sound periods of development. The following are some or movement of the reflexes seen in newborns. • In response to the sound, the baby throws back the head, extends the arms and legs, cries, and Rooting Reflex then pulls the arms and legs back in • Present at birth • Disappears by about 4 months after birth

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Tonic Neck Reflex Stepping, Placing or Dancing Reflex • Appears about 2 months after birth • Present at birth • Disappears by about 6-7 months after birth • Disappears by 2 months after birth • When the baby's head is turned to one side, the • When dorsum of foot is placed under a table arm on that side stretches out and the opposite edge, the infant will step, lifting and placing the arm bends up at the elbow foot on to the table surface • Often called the fencing position Other Reflexes Palmar Grasp Reflex Reflexes must be symmetric. • Present at birth • Biceps jerk tests C5 and C6 • Disappears by about 2-3 months • Knee jerk tests L2-L4 • Stroking the palm of a baby's hand causes the • Ankle jerk tests S1 and S2 baby to close the fingers in a grasp • Landau or truncal incurvation reflex tests T2 • Reflex is stronger in premature babies through S1 • Anal wink tests S4 and S5

Apgar Score Apgar scoring (Table 1-3) is done at 1 and 5 At 5 Minutes minutes after birth. If necessary, it is repeated at >7: no asphyxia 10 minutes after birth. <7: high risk for subsequent dysfunction of central nervous system Interpretation 5-7: mild asphyxia At 1 Minute 3-4: moderate asphyxia <7: depression of nervous system 0-2: severe asphyxia <4: severe depression of nervous system

Table 1-3: Determination of Apgar score Feature evaluated 0 points 1 point 2 points Heart rate 0 < 100 beats/min > 100 beats/minute Respiratory effort Apnea Irregular, shallow or gasping breaths Vigorous, crying Color Pale or blue all over Pale or blue extremities Pink Muscle tone Absent Weak, passive tone Active movement Reflex irritability Absent Grimace Active avoidance * Sum the scores for each feature. Maximum score = 10, minimum score = 0

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Assessment Of Gestational Age

Gestational age can be assessed on the basis of the newborn's external characteristics.

Table 1-4: Assessment of gestational age External 28 weeks 32 weeks 36 weeks 40 weeks characteristic Ear cartilage Pinna soft, remains Pinna harder, but Pinna harder, springs Pinna firm, stands folded remains folded back into place when erect from head folded Breast tissue None None Nodule 1-2mm in Nodule 6-7mm in diameter diameter Male genitalia Testes undescended, Testes in inguinal Testes high in Testes descended, scrotal surface canal, a few scrotal scrotum, more scrotum pendulous, smooth rugae scrotal rugae covered in rugae Female genitalia Prominent clitoris Prominent clitoris; Clitoris less Clitoris covered by with small, widely larger, well- prominent, labia labia majora separated labia separated labia majora cover labia minora Plantar surface of Smooth, no creases 1 or 2 anterior 2 or 3 anterior Creases cover the foot creases creases sole

Screening Tests Phenylketonuria (PKU) Other Abnormalities Found On • For newborns tested for PKU in the first 24 Neonatal Screen hours of life, capillary blood screening test for • The neonatal screen uses a technique of thin PKU should be repeated at age 2-7 days layer chromatography to search for abnormal amino acid levels (of which phenylalanine is Congenital Hypothyroidism one) • Screening for congenital hypothyroidism (by TSH level in dried capillary blood sample) • The neonatal screen also checks for biotinidase should be performed in the first 7 days of life. If levels the TSH level is abnormal the laboratory will automatically check T4 level on the same sample. • If the child was born in hospital, verify whether this type of screening was done there

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