Assessment of the Newborn History and Physical Examination of the Newborn
Assessment of the Newborn History and Physical Examination of the Newborn
Lise Johnson
KEY POINTS
The initial examination of the newborn is an important opportunity to detect congenital anomalies and assess the infant’s transition from fetal to extrauterine life.
Routine pulse oximetry screening to detect critical congenital heart disease (CCHD) is recommended for all newborns, ideally between 24 and 48 hours of age.
All expectant parents dream of the healthy child and worry about the possibility of abnormality or illness in their infant. Most newborns have normal physical examinations and smooth transitions from fetal to extrauterine life; this is a source of delight and reassurance to families.
I. HISTORY. The family, maternal, pregnancy, perinatal, and social history should be reviewed (Table 8.1).
II. ROUTINE PHYSICAL EXAMINATION OF THE NEONATE. Although no statistics are available, the first routine examination likely reveals more abnormalities than any other physical examination. Whenever possible, the examination should be performed in the presence of the parents to encourage them to ask questions regarding their newborn and allow for the shared observation of physical findings both normal and abnormal.
A. General examination. At the initial examination, attention should be directed to determine (i) whether any congenital anomalies are present; (ii) whether the infant has made a successful transition from fetal life to air breathing; (iii) to what extent gestation, labor, delivery, analgesics, or anesthetics have affected the neonate; and (iv) whether the infant has any signs of infection or metabolic disease.
1. The infant should be undressed for the examination, ideally in a well-lit room under warming lights to avoid hypothermia which occurs easily in the neonatal period.
Table 8.1. Important Aspects of Maternal and Perinatal History
Developmental disorders including autism spectrum disorders
Disorders requiring follow-up screening in family members (e.g., developmental dysplasia of the hip, vesicoureteral reflux, congenital cardiac anomalies, familial arrhythmias)
Maternal History
Age
Gravidity and parity
Infertility treatments required for pregnancy, including source of egg and sperm (donor or parent)
Infectious disease screening in pregnancy (rubella immunity status; syphilis, gonorrhea, chlamydia, and HIV screening; hepatitis B surface antigen screening, group B Streptococcus [GBS] culture, varicella, cytomegalovirus, and toxoplasmosis testing, if performed; purified protein derivative [PPD] status and any past treatments; any recent infections or exposures)
Pregnancy complications (e.g., gestational diabetes mellitus, preeclampsia, infections, bleeding, anemia, trauma, surgery, acute illnesses, preterm labor with or without use of tocolytics or glucocorticoids)
Fetal Testing
First- and/or second-trimester screens for aneuploidy (serum markers and ultrasonographic examination)
Second-trimester (approximately 18 weeks) fetal survey by ultrasound Genetic testing, including preimplantation, chorionic villus sampling, amniocentesis genetic testing and cell free fetal DNA testing
Ultrasound monitoring of fetal well-being
Tests of fetal lung maturity
Intrapartum History
Gestational age at parturition and method of calculation (e.g., ultrasound, artificial insemination or in vitro fertilization, last menstrual period)
Presentation
Onset and duration of labor
Timing of rupture of membranes and appearance of amniotic fluid (volume, presence of meconium, blood)
Results of fetal monitoring
Fever
Medications, especially antibiotics, analgesics, anesthetics, and magnesium sulfate
Infant delivery room assessment including Apgar scores and any resuscitation measures required
Placental examination
Social History
Cultural background of family
Marital status of mother
Nature of involvement of father of baby
Household members
Custody of prior children
Maternal and paternal occupations
Identified social supports
Current social support service involvement
Past or current history of involvement of child protective agencies
Current or past history of domestic violence
2. Care providers should develop a consistent order to their physical examination, generally beginning with the cardiorespiratory system which is best assessed when the infant is quiet. If the infant being examined is fussy, a gloved finger to suck on may be offered. The opportunity to perform the eye examination should be seized whenever the infant is noted to be awake and alert.
B. Vital signs and measurements. Vital signs should be taken when the infant is quiet, if possible.
1. Temperature. Temperature in the neonate is usually measured in the axilla. Rectal temperature can be measured to confirm an abnormal axillary temperature, although they tend to correlate quite closely. Normal axillary temperature is between 36.5° and 37.4°C (97.7° and 99.3°F)
2. Heart rate. Normal heart rate in a newborn is between 95 and 160 bpm. Vagal slowing may be noted and appreciated as a reassuring sign. Some infants, particularly those born postdates, may have resting heart rates as low as 80 bpm. Good acceleration with stimulation should be verified in these infants. A normal blood pressure is reassuring that cardiac output is adequate in the setting of marked sinus bradycardia.
3. Respiratory rate. Normal respiratory rate in a newborn is between 30 and 60 breaths per minute. Periodic breathing is common in newborns; short pauses (usually 5 to 10 seconds) are considered normal. Apneic spells (defined as 20 seconds or longer) associated with cyanosis and/or bradycardia are not normal in term infants and deserve further evaluation (see Chapter 31).
4. Blood pressure. Blood pressure is not routinely measured in otherwise well newborns. When measurement of blood pressure is clinically indicated, care should be taken that the proper neonatal cuff size is chosen and the extremity used is documented in the blood pressure recording. A gradient between upper and lower extremity systolic pressure >10 mm Hg should be considered suspicious for coarctation or other anomalies of the aorta (see Chapter 41).
5. Pulse oximetry. Mild cyanosis can be easily overlooked in newborns, particularly those with darker skin pigmentation. Multiple studies over more than a decade have assessed the role of pulse oximetry to improve the detection of CCHD in neonates before hospital discharge. The results of these studies have led the U.S. Department of Health and Human Services and the American Academy of Pediatrics to recommend universal pulse oximetry screening in the newborn nursery. Recommended strategies include screening between 24 and 48 hours of age, ensuring staff are properly trained in pulse oximetry measurement, and using later generation pulse oximeters which are less sensitive to motion artifact. Criteria for a positive screening test that merits further clinical investigation for CCHD include (i) any oxygen saturation measure <90%; (ii) oxygen saturation <95% in the right hand and either foot on three measures, each separated by 1 hour; or (iii) there is a >3% absolute difference in oxygen saturation between the right hand and foot on three measures, each separated by 1 hour.
6. Measurements. All newborns should have their weight, length, and head circumference measured shortly after birth. These measurements should be plotted on standard growth curves such that the newborn may be determined to be appropriate for gestational age (AGA), small for gestational age (SGA), or large for gestational age (LGA). SGA or LGA newborns may require further evaluation of both the etiology and sequelae of these conditions (see Chapter 7). Newborns with extensive molding and/or caput may require a repeat head circumference measurement a few days after birth.
C. Cardiorespiratory system
1. Color. The healthy newborn should have a reddish pink hue, except for the possible normal cyanosis of the hands and feet (acrocyanosis). Excessive paleness or ruddiness should prompt hematocrit measurement to detect relative anemia (hematocrit <42%) or polycythemia (hematocrit >65%), respectively (see Chapters 45 and 46).
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