Physical Assessment of the Newborn: Part 2 ® Evaluate maternal history Gentle and systematic . Prenatal – complications, possible infections or Perform hand hygiene (hand sanitizer or wash) environmental exposures, medications, substances Wear personal protective equipment as indicated of abuse (gloves, mask, gown) . Prior pregnancies spontaneous abortions, Perform while infant in quiet state whenever possible stillborns or infant / child deaths Use clean equipment . Labor / delivery / perinatal complications Keep infant warm, shield eyes Past medical and family history from exam light especially if there are anomalies Comfort during / after exam . Familial traits, physical or Change soiled diapers / redress developmental disorders following exam Infant how illness presented Perform hand hygiene after exam © K. Karlsen 2013 © K. Karlsen 2013 Observe before touching Observe before touching Auscultate before palpation – in quiet environment © K. Karlsen 2013 © K. Karlsen 2013 The S.T.A.B.L.E® Program © 2013. Handout may be reproduced for educational purposes. 1 Physical Assessment of the Newborn: Part 2 Observe before touching Measurements Auscultate before palpation – in quiet environment Weight Gentle palpation Length . Avoid if acute abdomen Head circumference . Extra care with Plot on growth chart by preterm infants . Sex . Gestational age Growth charts reproduced with permission from Pediatrics, Olsen et al. Volume 125, p. e214-e244, ©2010 American Academy of Pediatrics. © K. Karlsen 2013 © K. Karlsen 2013 Fetal development influenced by maternal environment, Fetal development influenced by maternal environment, uteroplacental function, and genetic growth potential uteroplacental function, and genetic growth potential Under optimal circumstances, fetal growth and Under optimal circumstances, fetal growth and development is appropriate development is appropriate . Appropriate for Gestational Age (AGA) . Appropriate for Gestational Age (AGA) Well-nourished appearance Well-nourished appearance © K. Karlsen 2013 © K. Karlsen 2013 Fetal development influenced by maternal environment, Small for Gestational Age (SGA) uteroplacental function, and genetic growth potential Symmetric – proportionate decrease in all growth Under suboptimal circumstances, parameters for gestational age usually defined fetal growth and development as < 10th percentile is impacted . Evaluate for infective, placental, chromosomal or . Small for Gestational Age (SGA) genetic causes . Intrauterine Growth Restriction (IUGR) © David A. ClarkMD Trisomy 18 Discordant twins © K. Karlsen 2013 © K. Karlsen 2013 The S.T.A.B.L.E® Program © 2013. Handout may be reproduced for educational purposes. 2 Physical Assessment of the Newborn: Part 2 Intrauterine Growth Restriction (IUGR) Intrauterine Growth Restriction (IUGR) Altered fetal growth in late gestation when lipid accumulation is greatest and growth is rapid Weight low for gestational age may or may not be < 10th percentile (SGA) Variable impact on length Relatively less impact on brain growth “head sparing” May appear long, wasted and “thin” © K. Karlsen 2013 © K. Karlsen 2013 Large for Gestational Age (LGA) . Weight > 90th percentile for Low birth weight gestational age (LBW): < 2500 grams Very low birth weight (VLBW): < 1500 grams Extremely low birth weight (ELBW): < 1000 grams © K. Karlsen 2013 © K. Karlsen 2013 Normal Developmental Reflexes Well Disappears Onset Active, alert Root Established At 34 – 36 3 – 4 Good tone . Stroke cheek close to 30 weeks weeks months Moderate flexion neonate’s mouth Strong cry, symmetric facies . Head should turn towards stimulus and mouth should open Symmetric strength and movement © K. Karlsen 2013 © K. Karlsen 2013 The S.T.A.B.L.E® Program © 2013. Handout may be reproduced for educational purposes. 3 Physical Assessment of the Newborn: Part 2 Developmental Reflexes Developmental Reflexes Well Disappears Well Disappears Onset Onset Suck Established At Palmar grasp Established At 34 – 36 28 – 32 30 weeks 12 months . Grasp when finger 32 weeks 6 months weeks placed into infant’s weeks palm on ulnar side . Attempts to tighten grasp when finger withdrawn © K. Karlsen 2013 © K. Karlsen 2013 Developmental Reflexes Developmental Reflexes Well Disappears Well Disappears Onset Onset Plantar grasp press Established At Moro Established At against sole of foot just . Arms extend, abduct, 28 – 32 25 weeks 38 weeks 12 months 37 weeks 6 months behind toes hands open weeks . Normal flexion and adduction of all toes . Followed by flexion of arms and closing of hands © Paul Larsen MD Click on video © Paul Larsen MD © K. Karlsen 2013 http://library.med.utah.edu/pedineurologicexam to replay © K. Karlsen 2013 http://library.med.utah.edu/pedineurologicexam Click to replay Developmental Reflexes Developmental Reflexes Well Disappears Well Disappears Onset Onset Truncal incurvation Established At Stepping Established At (Galant reflex) 3 – 4 34 – 36 3 – 4 28 weeks 40 weeks . Alternating stepping 38 weeks . Pelvis moves toward months movements when soles weeks months side of stimulus of feet touch a flat surface © Paul Larsen MD http://library.med.utah.edu/pedineurologicexam © K. Karlsen 2013 Click to replay © K. Karlsen 2013 The S.T.A.B.L.E® Program © 2013. Handout may be reproduced for educational purposes. 4 Physical Assessment of the Newborn: Part 2 Developmental Reflexes Developmental Reflexes Well Disappears Well Disappears Onset Onset Babinski stroke Established At Tonic neck Established At plantar surface from near 34 – 36 (fencing position) 6 – 7 38 weeks 12 months 35 weeks 1 month heel toward ball of foot weeks . Place infant supine with months . Normal dorsal flexion of great toe and head turned to one side spreading of other . Arm extends on side head is turned toes . Flexion of opposite arm © K. Karlsen 2013 © K. Karlsen 2013 Abnormal Findings Neurologic Exam for Weak suck / poor feeding Therapeutic Weak / shrill cry (Neuroprotective) Hypothermia Distressed facies Available for download from: Lethargy / irritability www.stableprogram.org Hypotonia / hypertonia (instructor or student menu) Accentuated or abnormal deep tendon reflexes (DTRs) Decreased or absent reflexes Seizures Coma © Paul Larsen MD © K. Karlsen 2013 http://library.med.utah.edu/pedineurologicexam Click to replay © K. Karlsen 2013 Normal: 36.5 to 37.5C (97.7 to 99.5F) Normal 120 to 160 beats per minute (bpm), Hypothermia* normal sinus rhythm . Mild: 36.4 to 36C (97.6 to 96.8F) May range 80 to 200 bpm with rest . Moderate: 35.9 to 32C (96.6 to 89.6F) or activity . Severe: < 32C (89.6F) Bradycardia Hyperthermia: > 37.5C (99.5F) Heart rate < 100 bpm Hypoxemia, hypotension, acidosis depress conduction system *World Health Organization (1997). Thermal protection of the newborn: Rule out heart block A practical guide Complete heart block © K. Karlsen 2013 © K. Karlsen 2013 The S.T.A.B.L.E® Program © 2013. Handout may be reproduced for educational purposes. 5 Physical Assessment of the Newborn: Part 2 Tachycardia Cardiac Output Sustained heart rate > 180 bpm at rest Heart rate x stroke volume = cardiac output . May indicate shock, poor cardiac output and / or Neonatal myocardium poorly compliant limited congestive heart failure capacity to stroke volume . Rule out arrhythmias or other causes of . To cardiac output, heart rate will increase tachycardia tachycardia may be a sign of poor cardiac output If > 220 bpm, consider supraventricular tachycardia (SVT) © K. Karlsen 2013 © K. Karlsen 2013 Measure when calm / use correct cuff size Compare right arm BP with leg BP . Undersized overestimates BP Normal leg slightly higher than arm . Oversized underestimates BP Abnormal arm 15 mmHg higher than leg Evaluate systolic, diastolic and mean blood pressure . May indicate coarctation or interrupted aortic arch Systolic Diastolic Mean 80 80 80 Graphs adapted with permission from: Versmold, et al. (1981) Pediatrics, 67(5). © K. Karlsen 2013 © K. Karlsen 2013 Evaluate Pulse Pressure Narrow (Low) Pulse Pressure To calculate systolic minus diastolic Vasoconstriction, heart failure (low cardiac output) Normal Compression from pneumopericardium . Term: 25 to 30 mmHg Example: 51 – 27 = 24 Tension pneumothorax Pulse pressure = 24 mmHg . Preterm: 15 to 25 mmHg Pericardial effusion © K. Karlsen 2013 © K. Karlsen 2013 The S.T.A.B.L.E® Program © 2013. Handout may be reproduced for educational purposes. 6 Physical Assessment of the Newborn: Part 2 Wide (High) Pulse Pressure Normal Large aortic runoff lesion patent ductus arteriosus, 30 – 60 breaths per minute truncus arteriosus, arteriovenous malformation (AVM) Easy effort . Without nasal flaring, grunting, AVM or retractions Abnormal > 60 breaths per minute < 30 breaths per minute if associated with other signs of respiratory distress . With labored breathing sign of exhaustion Normal capillary bed Gasping respirations ominous sign of impending cardiorespiratory arrest © K. Karlsen 2013 © K. Karlsen 2013 Easy to feel Strength pulses weak or absent Brachial and femoral pulses equal in strength Compare brachial to femoral Pedal pulses palpable . Brachial stronger than femoral consider All pulses equal right to left side coarctation or interrupted aortic arch To left To right brachial To left brachial artery artery To right brachial brachial artery artery © K. Karlsen 2013 © K. Karlsen 2013 Bounding evaluate for aortic run-off lesion Perfusion reflects cardiac output . Patent