Physical Exam and Anticipatory Guidance of the Newborn:

Marcie Hamrick, MD

Mike Purdon, MD

Setting: At the bedside, with the baby undressed and under the warming lights. Invite the parent(s) to observe and participate in the exam and acknowledge how stressful it can be for a parent to have their baby scrutinized. Recognize that this may be the first time that the parents experience a medical assessment of their newborn. Find something that the parent or baby is doing well (supporting the head, baby's good, vigorous cry) and offer a compliment.

Exam:

Vital Signs-

Temperature: T >100.3 Note technique (rectal, axillary) and bundling.

Respiratory Rate: For all spontaneously breathing infants, term and premature, respiratory rates fall to within a range of 40-60 by one hour of age. Watch for: respiratory distress (grunting, flaring, cyanosis), tachypnea, bradypnea, apnea (>10s)

Heart Rate: 120-180 Watch for: bradycardia, tachycardia

Weight, Length, HC

Please read the protocols for hypoglycemia, febrile newborn and drug exposed babies and review the Harriet Lane chapter on Newborn Assessment: http://home.mdconsult.com/das/book/14910508/view/871?sid=72560538

Anticipatory Guidance:

Discuss temperature regulation in the newborn and the need for immediate attention in the event of fever. Teach the importance of rectal temperatures and 100.3.

General Observations: Nude, warm and settled if possible. Watch for: sick or well?, cyanosis, pallor, jaundice, symmetry, weak or high pitched cry, hoarseness, aphonia,

Skin: White vernix is most abundant in premature infants and is less prominent closer to term. Post term newborns have little or no vernix and the skin is dry, cracked and wrinkled. Scan for hemangiomas, urticaria, pustules, vesicular, nodular or gangrenous rashes. Check for dermal sinuses in the midline of the back, from occiput to coccyx and in the pilonidal region. Look carefully along the midline for dimples, sinuses, hirsute areas, or cystic swellings that suggest the presence of congenital cranial dermal sinuses or defects in the underlying vertebral column. Note ecchymoses, petechiae, milia, erythema toxicum, stork

bite (flame hemangiomas). Watch for: jaundice (always abnormal if noted on first day of life).

Anticipatory Guidance: Mongolian spots usually resolve by age 4, stork bites on the neck tend to persist whereas facial flame hemangiomas usually fade within months. Facial petechiae are normal, milia, and e. toxicum are transient.

Please Review Darmstadt's paper on neonatal skin care:

"The importance of neonatal skin care is exemplified by survey results suggesting that nearly 80% of newborns develop a skin problem (i.e., "rash") during the first month of life. But little information is available on which a rational approach to skin care in neonates may be based, and few instructions or recommendations for neonatal skin care are available in the literature." Please review this article: http://home.mdconsult.com/das/journal/view/14910508/N/11381572?sid=72560537&source=HS,MI  

Head: Most common abnormalities are caput succedaneum (crosses sutures) and cephalohematoma (subperiosteal and does not cross sutures). Absent suture separations or excessive spreading of the lines are significant. Run a fingertip from occiput to nasion along the sagittal and metopic sutures and

over the occiptoparietal junctures to define the lambdoidal sutures. Large fontanels and split sutures most often are a normal variant, but they can be associated with increased intracranial pressure or conditions that impair bone growth (eg. Hypothyroidism).

Anticipatory Guidance: Discuss molding, over-riding sutures that form ridges, fontanelles (anterior usually closes by 18-24 months and posterior usually closes at 2-6 months). Remind parents of Back to Bed, temporary nature of hair and need for changing head position with sleep.

Eyes: Hold the infant upright and note: size of the eyeball, haziness of clouding of the cornea, lens or media. Note dermoids or small hemangiomas. Watch both eyes for normal excursion or the lids and note proptosis, squint or asymmetric closure (facial nerve palsy). Red reflex (abnormal in retinoblastoma, congenital cataract).

Anticipatory Guidance: Discuss the antibiotic cream. Explain focal length, occasional dyscoordination of extraocular movements.

Ears: The ears can be grossly malformed, uncommonly large or small, angled abnormally or set lower on the head than normal. Very low placement plus unusual size, floppiness and perpendicularity to the skull suggest renal agenesis or chromosomal aberration. Malformations stemming from the first branchial arch often involve the ears, and one must look carefully for abnormal skin tags, dimples, and deep sinuses, especially in front and behind the tragus. The infant should respond to a loud noise or tone.

Anticipatory Guidance: Discuss hearing and the normalcy of ear wax.

Mouth: Note clefts of lip and palate (examine entire palate), symmetric movement of lip corners, excessive mucoid secretions (suggesting esophageal atresia). Look for retention cysts along the alveolar ridge, and the plaques of thrush. Note the size of the tongue and depress the lower jaw or take advantage of a cry to see the posterior pharynx. Examine the frenulum and note its length.

Anticipatory Guidance: Discuss Ebstein's pearls.

Nose: One can assess the patency of the posterior choanae by holding the mouth closed and listening with the stethoscope for the outrush of each naris. Inspection up the naris may reveal an encephalocoele.

Neck: Note length and mobility and inspect for congenital cysts, hygromas, thyroglossal duct cysts, and thyromegaly. Look for webbing and palpate the length of both clavicles to rule out fracture.

Chest: The chest deserves primary concern. Inspect for overinflation, symmetric movement, presence or absence of retractions and the use of accessory muscles. Auscultate for rales, rhonchi, and bowel sounds.

Heart: Size and position of the heart, as well as the rate, rhythm and strength of its sounds are as important as the presence or absence of murmurs. Note extrathoracic signs such as cyanosis, size of the liver, dilatation of superficial veins, and palpability of the femoral and distal arterial pulses.

Please review this nice article on pediatric murmurs (not limited to newborns)

http://home.mdconsult.com/das/journal/view/14910508/N/10670265?sid=72564584&source=HS,MI

Abdomen: Look for unusual flatness (diaphragmatic hernia) or excessive fullness (one must then determine if this is due to an excess of air within or outside the bowels, to excess fluid, to an enlarged viscous or viscera or to the presence of a cystic or solid tumor). Visible gastric or bowel patterns may be considered an almost certain sign of obstruction. The umbilicus should be inspected carefully for signs of infection, bleeding, polyp, granuloma or abnormal communication with intra-abdominal viscera.

Genitals: Male-size and formation of the penis, position of the meatus, size of the scrotum and the nature of its skin and descent of nondescent of the testes.

Female-size of the clitoris, the nature of the skin of the labia

majora, and if possible the position of the vaginal and urethral orifices. Note the fusion of the labia if present. One should palpate over the inguinal canals for presence of herniae or gonads and imperforate anus should be ruled out.

Back and Hips: Compare leg lengths and perform Barlow's maneuver.

Extremities: Do all four move well and approximately symmetrically? Note unusual resistance to flexion or extension or its converse: excessive malleability or flaccidity. Note polydactylism or syndactylism, clubbing, cyanosis, or unusual creasing of the palms or soles.

Reflexes:

Timing of Selected Primitive Reflexes:

Reflex: Onset Fully Developed Duration

Palmar grasp 28 wk 32 wk 2-3 months

Rooting 32 wk 36 wk Less prominent by 1 mo

Moro 28-32 wk 37 wk 5-6 months

Tonic neck 35 wk 1 mo 6-7 months

Parachute 7-8 mo 10-11 mo Permanent

General:

Please review this nice website with some anticipatory guidance pearls:

http://membersaol.com/fatdoc/pearls.htm

INSTRUCTIONS: YOUR NEWBORN

How often does my child need to eat?

Newborns should eat on demand, as often as they want. Usually this is about every few minutes to every few hours. If he is burping up large volumes after every feed, you may restrict each feed to a few minutes shorter than the usual and burp; then feed more if he still seems hungry. If your child is eating less than usual, do not be concerned unless the amount of urine he is producing, or the number of diapers that you are using, decreases. If this happens, you should call your doctor.

My newborn has noisy breathing, especially at night. What do I do?

It is very common for babies to have nasal congestion and noisy breathing. You can try to suction the nose with a plastic suction bulb. If unable to suction anything out, you may add some water or saline drops to the nose (your child will not like this), wait a few minutes, and then try suctioning again. Concerning signs associated with noisy breathing include grunting with each breath, movement of the nostrils open and closed, and movement of the skin of your child’s chest between each rib with breathing. If you notice these signs, you should call your doctor.

My baby sleeps during the day and then is awake all night! What do I do?

It is normal, especially for newborns, to have an opposite sleep-wake cycle from the rest of us. Bear with him/her, it will get better, usually within the first 4-8 weeks. Several factors can help train newborns to become synchronized with the new external environment: 1)cycled lighting, 2)feeding schedules—as the infant tolerates more food, lengthening the time between feedings helps allow for longer sleeping periods. Demand feeding, as opposed to fixed feeding, schedules help the baby develop a day-night cycle as well. 3)decreased stimulation at nighttime also helps babies develop more normal cycles. Studies have shown that frequent nighttime feeds, soothing and staying with the child until asleep, and cosleeping may prolong sleep disturbances.

Does my baby look yellow?!

Your baby’s skin may be yellow during the first week of life. This is called jaundice and it occurs in 60-70% of infants born in the U.S. It is caused by an accumulation of a substance called bilirubin, which is a natural antioxidant that may have some benefits for infants. It more often occurs in babies that are breastfeeding and in babies born before they are due. If the baby is feeding well, not acting overly-sleepy, and urinating normally, you should feel reassured. If the color continues to get worse after a few days, if it appears in the first 24 hours of life, or if there are any concerning signs, you should call your doctor. If the levels of bilirubin get too high, it may be dangerous and your baby may need treatment.

My new baby girl has some blood in her diaper! What can this be?

Newborns in the first few days of life may have pink or orange urine that looks like there is blood in it. Girls may have some vaginal bleeding due to the withdrawal of mom’s hormone levels. There also may be some blood in the baby’s mouth or in the first few stools that was swallowed during delivery.

When will the umbilical cord fall off?

The umbilical stump usually falls off after about 2 weeks. There is no special care required of the area, just soap and water when you bathe the baby. There may be some blood from the area. If there is any foul-smelling discharge or pus from the area, you should call your doctor.

How often should I bathe my new baby?

Babies should be bathed about once a week. If bathed too often, their skin is likely to get dry and flaky. It is best to use gentle, non-perfumed soaps and shampoos.

How do I cut my baby’s long nails? They grow so fast!

There are special nail clippers for babies that are safe to use or you may use manicure clippers. Do not be concerned if there is a little bleeding while clipping. You may also use your own mouth to bite the nails shorter, although some argue this may increase the likelihood of introducing an infection.

How often should my baby poop?

Anything between once every 5 days to 5 times each day is normal. Do not be alarmed if your baby is constipated—it is very common. Things you can do to stimulate a bowel movement: encourage more often feeds, give an ounce or two of fruit juice such as apple or prune,add karo syrup to feeds, or you can try using a rectal thermometer to stimulate the area.

How do I know how much my baby should wear to stay warm?

Babies don’t control their temperatures as well as we do. It is a good rule of thumb to dress them in one layer more than what you are comfortable wearing. Two piece outfits are easiest until the umbilical stump falls off.

When is it safe to go to public places with my baby? Or for people to come over and visit? Or travel on a plane?

There are no strict rules for this. In general it is best to stay at home with your baby for the first day or two of life. After that, it is important to have any visitors wash their hands before visiting the baby. Some people recommend waiting a week or two before going to crowded public places such as the mall, and four to six weeks before traveling on a plane.

It looks like my baby has a rash! What do I do?

It is very common for babies in the first six months or so to have rashes, especially on the face. These may be present at birth or develop later. Some common rashes look like pimples, red spots, and white bumps. If your child is acting normally, eating well, and does not have a fever, most likely the rash is not concerning and will go away with time. Also common is scaly skin on the scalp that may look like dandruff. It is not harmful, but you may use some oil on the scalp and a fine comb to brush away the flakes.

What do I do if my baby cries inconsolably for hours on end? It’s driving me crazy!

This may be due to a condition called colic, which is really common but no one knows what causes it. The most important thing to know is – it will get better. The guilt and sleepless nights parents experience is torturous and overwhelming and it is therefore really important that parents have good support. The condition usually disappears as quickly as it appears at about 3-4 months of age, regardless of what is done. The best things to do include taking rest breaks away from the baby and developing strategies for dealing with crying episodes. It may help to change the baby’s formula, if formula-fed, to a hypoallergenic or soy formula; herbal teas such as chamomile, vervain, licorice, and balm mint also have shown some benefit; reducing stimulation, especially in the evening, music, and parental attention are effective in some cases.

The baby’s father smokes, but he goes outside to do it. Is that OK for our baby?

It is best for the baby to not be exposed to cigarette smoke directly OR indirectly. The problems with smoke exposure can even occur if the baby is around the clothes or the breath of a smoker. Studies have definitely shown that exposure of any kind can increase the number of colds and ear infections the baby has, the risk of developing allergies and asthma, and the likelihood of food intolerances. Having a new baby in the house is an excellent reason to stop smoking. If there is a smoker in the house, it is best for that person to smoke outside and to change clothes, bathe, and brush their teeth before handling the baby.

Should we circumsize our new baby boy?

The best answer to this question is that it is the choice of the parents to make. There is no medical reason to circumcize a newborn. Reasons to do it include: there may be some protection from urinary tract infections of childhood, which are rare in both circumcized and noncircumcized babies, religious or cultural beliefs, enhanced hygiene, and a desire for the appearance of a circumcized penis for social reasons. Reasons NOT to do it include: it is not a necessary procedure, infants cannot consent to the procedure, the procedure is painful, it may cause decreased sexual sensitivity, and there are possible complications of the procedure. Doing the procedure at a later age is possible but more difficult and carries with it more risks. You should have a complete discussion with your doctor about this if you are not sure what to do.

The baby’s grandmother has a fever blister, or cold sore, on her mouth. Is it OK for her to cuddle with our new baby?

Herpes virus causes these sores of the mouth, and this virus can cause a very severe illness in a new baby. It is important that no one with a mouth sore come into contact with a new baby until the sores have healed. If your baby is exposed and becomes ill or gets a rash, notify your doctor immediately.

Is it OK to use a pacifier?

Yes, it is OK to use a pacifier. After 6 months of age, the pacifier should only be used while falling asleep to avoid teeth problems and mouth infections. At 10 months of age it is time to wean the pacifier and stop use all together.

How long do we need to use a car seat and where does it go?

The infant car seat should be facing to the back and in the middle of the backseat until about one year of age, or 20 pounds. Next a front-facing child seat should be used until the child is 40 pounds. After this you should transition to a booster seat and the car seat belt until the child is 80 pounds, or about 8 years old. All kids less than 12 years old should sit in the back seat.

RANDOM TIDBITS

You can store pumped breast milk in the freezer for up to 3 months or in the refrigerator for up to 48 hours. Unused pumped milk must be thrown away, so it is best to store it in small amounts. Warm in a warm cup of water as heat destroys the good antibodies that baby is getting from mom.

The color of poop means nothing unless it is red.

Cow’s milk should not be given until 1 year of age.

Honey may be dangerous to a child less than 2 years old.

Nighttime feeds are not needed after 4 months of age if the baby is gaining weight. You may substitute water feeding at night.

Try using a cup at 6-12 months. Throw the bottle away at 9-18 months. No need to wean the bottle.

Even after reading this whole darn thing I still have questions? What do I do?

Swedish Hospital has a nurse phone line devoted exclusively to answering questions about children and babies. The number is (206) 386-MOMS. Less urgent questions you should write down and remember to take them to your next appointment with your doctor. Also, there are physicians on call and may be reached by dialing the clinic number and going through the answering services, any time day or night for emergent concerns.

Key for Pictures

1. Congenital nevus: Congenital nevomelanocytic nevus. Larger nevi are associated with a higher incidence of malignancy and patients should be referred to a dermatologist. Small lesions may be associated with a higher than normal risk of developing melanoma, but the incidence is unknown. To date, there are no uniformly accepted guidelines for treatment.
2. Cutis marmorata: a transient, netlike, reddish-blue mottling of the skin caused by variable vascular constriction and dilatation. It is a normal response to chilling and upon re-warming, normal skin color returns. The discoloration occurs primarily over the trunk and extremities in infants. In neonates the condition is benign. However, if mottling persists beyond 6 months of life, it may be a sign of congenital hypothyroidism.
3. Harlequin skin change:
4. Facial Petechiae: Normal finding after vaginal delivery. Resolves in two to three days.
5. Molding
6. Cephalohematoma: Note that the hematoma does not cross suture lines. Most patients have an uncomplicated course of slow resolution over 1 or more months with possible calcification. Occasionally complications are seen, the most common being jaundice. Underlying hairline skull fractures occur with some regularity, but are rarely of clinical significance. The exception is the uncommon development of a leptomeningeal cyst. Needle aspiration of a cephalohematoma is contraindicated because of the risk of introducing infection.
7. Bell's (facial nerve) Palsy: The prognosis for facial nerve palsies is excellent, and recovery usually occurs in the first month. In the meantime, prevention of corneal drying is essential.
8. Preauricular skin tag: these represent remnants of the first branchial arch. Although they are often of little significance, they may be seen in serious malformations of branchial arch development involving multiple structures of the head and neck. Surgical removal may be indicated for cosmetic purposes.
9. Cleft lip
10. Cleft palate (posterior)
11. Facial HSV infection: Primary herpetic infections involving the skin typically present with fever, malaise, localized lesions and regional lymphadenopathy. The skin lesions generally result from direct inoculation. As vesicles become pustular, coalesce, ulcerate and then crust over. As a result, the lesions may simulate those of bacterial infection.
12. Cystic hygroma: occur mainly in the neck and axilla and are composed of fluid filled, thin walled cysts. They are soft and transilluminate brightly. Complications include: tracheal compression, hemorrhage and infection. These patients should be referred for consideration of excision.
13. Normal hyperpigmentation of an African American male newborn.
14. Hydrocoeles: are fluid accumulations with the tunica vaginalis or processus vaginalis. They are usually painless, and may resolve spontaneously over several months.
15. Hypospadias: occur in about 1 in 250 births. Infants with hypospadias should not be circumcised because the dorsal preputial skin may be necessary for penile reconstruction. Repair is usually undertaken at 1 year of age.
16. Sacral tuft:
17. Erb palsy: Brachial plexus trauma occurs in about 0.7 in 1000 births. The mechanism of injury in most cases is traction on the plexus during delivery. Although lesions have classically been divided into those affecting the upper (Erb palsy) or the lower spinal segment (Klumpke palsy) the distinction may not be clear in some cases. Treatment should be deferred for 7 to 10 days, then physical therapy and splinting should be undertaken.