Examination at birth

Eyes see what the mind knows

Skilled , knowledgeable health professional !
Aim
o To describe and carry out an examination
of a baby soon after birth
Objectives
o To screen for malformations
o To observe smooth transition to extra
uterine life
o An asses overall of baby’s condition
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Examination at birth:
Assess
Ask
o Antenatal details
-Antenatal visits – TT, Iron-folate
-Supplementation, HIV/Syphilis screening
-Exposure to teratogens, infections
-Poly or oligohydramnios
o Postnatal details: Condition at birth;
resuscitation, Single umbilical
artery ,excessive drooling

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Assess:
Look for

o Weigh the baby

o Temperature

4
 APGAR SCORING
 Virginia Apgar was ananesthesiologist who
developed the score in order to ascertain the
effects of obstetric anesthesia on babies in
1952
 The Apgar scale is determined by evaluating
the newborn baby on five simple criteria on a
scale from zero to two, then summing up the
five values thus obtained. The resulting Apgar
score ranges from zero to 10. The five criteria
are summarized using words chosen to form
a backronym (Appearance, Pulse, Grimace, Acti
vity, Respiration)
 Componen
SCORE 01 02 t of
0
acronym
blue at
no cyanosis
extremities
blue or pale body and
Complexion body pink Appearance
all over extremities
(acrocyanos
pink
is)
< 100 beats > 100 beats
Pulse rate absent Pulse
per minute per minute
grimace on
Reflex no response
suction or cry on
irritability to Grimace
aggressive stimulation
grimace stimulation
stimulation
flexed arms
some flexio and legs
Activity none Activity
n that resist
extension
weak,
Respiratory strong,
absent irregular, Respiration
effort lusty cry
gasping
APGAR score at 0ne & Five
minutes
 8-10 Normal
 4-8 is moderately low
 Less then 4 is very low
Look for

Quick screening for malformations

Screen from top to bottom, midline, and back
examination
Orifice examination
Anal opening
Auditory canal
Nasal opening
Oral cavity

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EN-
Look for

Single umbilical artery

Simian crease
Dysmorphic features
Excessive drooling of saliva

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Look for

Look for abnormal swelling

Abnormality of limbs & spine
Eyes, ears, umbilicus
Observe
Breathing rate / pattern
Color
Heart rate
Activity- feeding , movements
10
Assess:
Auscultation

Grunting, Cry, Heart sounds

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 Assess:
Palpation
 Any abnormal swelling:
Caput, cephalhematoma
 Palpable femoral pulses
 Dislocation of hip
 Palpate the abdomen
 Feel for testes in male
baby

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Weighing the baby
 Prepare the scale: cover the pan with a clean
cloth/autoclaved paper; ensure the scale reads
zero
 Preparing and weighing the baby
 Remove all clothing
 Wait till the baby stops moving
 Weigh naked
 Read and record
 Return the baby to the mother
 Scale maintenance
 Calibrate daily
 Clean the scale pan between each weighing

13
EN-
 Temperature
 At birth-warmth, keep the baby in skin
to skin contact with the mother

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 Temperature recording
 Hands and feet should be checked
for warmth with the back of the hand
to see if the baby is in cold stress
 Temperature measurement
 Use clean thermometer
 Hold vertically in the axilla for 3 minute
 Read and record
 Normal 36.5ºC-37.5ºC

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 Examination within 24
hours
Objective
To describe and carry out an examination of a
baby within 24 hours of birth
Aim
To ensure that malformations are detected
To ensure establishment of breast feeding ;
maintenance of temperature ;classify baby
as normal or abnormal

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Examination within 24
hours

 Assess
 Ask, Check, Record
 Look, Listen, Feel

 Classify
 Treat or advise

Teaching Aids: ENC 17

EN-
Examination at 24 hrs:
Assess
Ask
o Breastfeeding
o Activity of the baby up
o Any other problems* ir ne
d u
an
r s
h
24 l
Check t o
m a
up or
o Weigh the baby um n
ni all y
o Temperature c o su
m e u
f is
e o ife
g f l
sa r s o
Record a s
• P 48 h
to 18
Assess:
Look for
 Color  Abnormal
 Skin swelling scalp
 Abnormality of
 Discharge from
limbs fingers ,
eyes, umbilicus back
 Count respiratory  Weight
rate  For breast
 Chest retractions feeding
 Position
 Attachment

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Assess:
Listen for
 Grunt
 Cry
 Auscultation of heart

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Assess:
Feel for
 Femoral pulse
 Temperature by touch
 Descent of testis
 Depth or extent of jaundice
 Feel for abdomen
 Confirm findings of inspection

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Record
Findings Normal Abnormal
Heart rate
Respiratory rate
Retractions
Color
Temperature
Feeding
Weight
 Assess:
Look for Listen for
 Discharge from Auscultation
eyes , umbilicus Heart Sound
 Breathing difficulty
Breathing sound
 Breast feeding-
Peristalsis sound
exclusivity and
adequacy
 Jaundice

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Assess:
Feel for
 Temperature by touch
 Depth or extent of jaundice
 Confirm findings of inspection, if
any

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 Danger signs

 Not feeding well  Floppy or stiff

 Less active than before  Temperature
 Fast breathing (>60/ >37.50C or <35.50C
min)  Umbilicus draining
 Moderate or severe pus or umbilical
chest in-drawing redness extending
to skin.
 Grunting
 >10 skin pustules
 Convulsions
 Bleeding from
umbilcal Stump
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Normal: feeding behavior
 Positioning
o Head in line with body
o Well, supported
o Abdomen touches
the mother abdomen
o Turned to the mother
 Attachment
o Mouth wide open
o Lower lip everted
o Little areola visible
o Chin touches mother breast
 Assessment of feeding adequacy26
It is NORMAL for a baby

 To pass urine six or more times a day after

day 2
 To pass six to eight watery stools (small
volume) in 24 hrs
 Female baby may have some vaginal
bleeding for a few days during the first week
after birth. It is not a sign of a problem.
 Loses weight and regains by 7-10 days

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 Normal breathing
 30 to 60 breaths per minute
 No chest in-drawing, no grunting on breathing out
 When assessing breathing:
 Count number of breaths for a full minute
 Babies may breathe irregularly for short periods
of time
 Small babies (<2.5 kg or born before 37
wks gestation) may:
 Have some mild chest in-drawing
 Periodically stop breathing for a few seconds
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R
E
T
R
A
C
T
I
O
N
S
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The umbilicus: Which one is
normal?

 Normal vs. Abnormal

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Umbilicus
The NORMAL umbilicus is:
Bluish-white in colour on day 1.
It then begins to dry and shrink and

If falls off after 7 to 10 days

No discharge

LOCAL UMBILICAL INFECTION

RED umbilicus or
RED skin around the umbilicus

POSSIBLE SERIOUS INFECTION

Umbilicus draining pus or

Umbilical redness, swelling extending to skin

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Skin pustules

Locate ? 32
Skin
A baby may have PUSTULES
MORE than 10 are aDANGER SIGN
 Refer this baby urgently

Less than 10 are a local skin

infection
 Treat them immediately

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Posture
 The normal resting posture of a term
newborn baby:
 loosely clenched fists
 flexed arms, hips, and knees
 Small babies (less than 2.5 kg at birth
or born before 37 weeks gestation)
 the limbs may be extended

 Babies born in the breech position may

have fully flexed hips and knees; the
feet the mouth; and legs may even
reach near the mouth.

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The normal resting posture
of a baby born breech

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ABNORMAL position of arm
and hand

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Color of the baby

 Normal vs. Abnormal

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Physical Exam other then
newborn
 Avoid touching painful areas until
confidence has been gained.
 Begin exam without instruments.
 Allow child to determine order of
exam if practical.
 Use the same format as adult
physical exam.
Infant Exam

 Examine on parent lap.

 Leave diaper on.
 Comfort measures such as pacifier or
bottle.
 Talk softly.
 Start with heart and lung sounds.
 Ear and throat exam last.
Toddler Exam

 Examine on parent lap if

uncooperative.
 Use play therapy.
 Distract with stories.
 Let toddler play with equipment / BP.
 Call by name.
 Praise frequently.
 Quickly do exam.
Physical
Assessment
 The approach is:
 Orderly
 Systematic
 Head-to-toe

 But FLEXIBILIY is essential

 And be kind and gentle
 but firm, direct and honest
Physical Assessment

General Appearance & Behavior

 Facial expression
 Posture / movement
 Hygiene
 Behavior
 Developmental
Status
Vital Signs

 Temperature: rectal only when

absolutely necessary
 Pulse: apical on all children under 1
year
 Respirations: infant use abdominal
muscles
 Blood pressure: admission base
line
Pediatric Vital Signs – Normal
Ranges
Infant Toddler School-Age Adolescent
 Heart Rate
80-150 70-110 60-110 60-100

 Respiratory Rate
24-38 22-30 14-22 12-22

 Systolic blood pressure

65-100 90-105 90-120 110-125

 Diastolic blood pressure

45 - 65 55-70 60-75 65-
85
Physical Assessment

 General  Heart
 Skin, hair, nails  Abdomen
 Head, neck,  Genitalia, Tanner
lymph nodes Scale,
 Eyes, ears, nose,  Rectal
throat  Musculoskeletal:
 Chest, Tanner Scale feet, legs, back,
gait
Palpation
 Use of your  Warm hands and
fingers and palms short nails
to determine:  Palpate areas of
 Temperature tenderness / pain last
 Talk with the child
 Hydration during palpation to
 Texture help him relax
 Shape  Be observant of
 Movement reactions to palpation
 Move firmly without
 Areas of hesitation
Tenderness
 HEENT

Head
Eyes
Ears
Nose
Neck
Throat
 HEENT: Head & Neck, Eyes,
Ears, Nose, Face, Mouth &
Throat
 Head: Symmetry of skull and face
 Neck: Structure, movement, trachea,
thyroid, vessels and lymph nodes
 Eyes: Vision, placement, external and
internal fundoscopic exam
 Ears: Hearing, external, ear canal and
otoscopic exam of tympanic membrane
 Nose: Structure, exudate, sinuses
 Mouth: Structures of mouth, teeth and
pharynx
Head

 Shape:
“NormoCephalic
– ATraumatic”
 Lesions
 ? Edema
 Head: Key Points

 Head Circumference (HC

 Fontannels/sutures: Anterior closes at 10-18
months, posterior by 2 months
 Symmetry & shape: Face & skull
 Bruits: Temporal bruits may be significant after
5 yrs
 Hair: Patterns, loss, hygiene, pediculosis in
school aged child
 Sinuses: Palpate for tenderness in older
children
 Facial expression: Sadness, signs of abuse,
allergy, fatigue
 Abnormal facies: “Diagnostic facies” of
common syndromes or illnesses
 Neuro Assessment
 Glasgow coma scale
 Pupil size
 Vital Signs
 Pain
 Seizure Activity
 Focal Deficits
 Bacterial Meningitis
Clinical Manifestations in an Older
Child
 High fever
 Headache
 Nuchal rigidity / stiff neck
 + Kernigs = inability to extend legs
 + Brudzinski sign = flexion of hips when
neck is flexed
 Purple rash (check for blanching)
 “Looks Sick”
 Eyes

 Red Reflex
 Corneal Light Reflex
 Strabismus:
 Alignment of eye important
due to correlation with brain
development
 May need to corrected
surgically
 Preschoolers should have
vision screening o
 Refer to ophthalmologist is
there are concerns
 Eyes: Key Points
 Vision: Red reflex & blink in neonate
 Examine external structure of the:
 1- Conjunctiva- glassy
 2- Sclera- clear
 3- Cornea- cover the iris and pupil
 4- pupils- compare for size, shape, test for reaction.
 5- Iris- color, size and clarity. 6-12 M.
 Snellen chart for older children
 Irritations & infections
 Amblyopia (lazy eye): Corneal light reflex,
binocular vision, cover-uncover test
Ear Exam

Pinna is pulled down and back to straighten ear

canal in
children under 3 years.
Common Ear Infections
Otitis Media
 Infection can lead
 Most common to rupture of ear
reason children drum.
come to the
pediatrician or  Chronic effusion can
emergency room lead to hearing loss.
 Fever or tugging at  Chronic ear effusion
ear in the early years
 Often increases at may lead to
night when they are decreased hearing
sleeping and speech
 History of cold or problems.
congestion
Nose & Throat / Mouth

 Exudate  Palate
 Pharynx  Gums
 Tonsils  Swallow
 Signs & Symptoms of  Oral Hygiene
Allerg  Condition of teeth
 Assess for symmetry,  Missing teeth
deformity, skin lesion.  Orthodontic
 Palpate for septal Appliances
deviation.
 Smooth and moist,
with pinkish color.
 Rhinitis
Nose: Key Points

 Exam nose & mouth after ears

 Observe shape & structural
deviations
 check patency, mucous membranes,
discharge, turbinates, bleeding
 Septum: (check for deviation)
 Nasal flaring is associated with
respiratory distress
Nose and Throat

Sinusitis:
 Fever
 Purulent rhinorrhea
 Facial Pain – cheeks, forehead
 Breath odor
 Chronic cough – could be day and
night
 (+) Post-nasal drip
Mouth & Pharynx: Key
Points
 Lips: color, symmetry, moisture, swelling,
sores, fissures
 Buccal mucosa, gingivae, tongue & palate
for moisture, color, intactness, bleeding,
lesions.
 Tongue & frenulum - movement, size &
texture
 Teeth - caries, malocclusion and loose teeth.
 Uvula: symmetrical movement or bifid uvula
 Voice quality, Speech
 Breath - halitosis
Ears, Nose and Throat

Sore Throats

Is it strept or is it viral
or could it be mono?

Lymph nodes
Neck: Key Points
 √ position, lymph nodes, masses,
fistulas
 Range of Motion (ROM)
 Check clavicle in newborn
 Head control in infant
 Trachea & thyroid in midline
 Carotid arteries
 Meningeal irritation
 Chest Assessment
•How does the child look?
•Color
•Work of Breathing: Effort
used to breathe
Auscultatio
n All 4 quadrants
 Front and back
 Take the time to listen
 clear to auscultation bilaterally
Chest

 Anatomy.
 Inspection: symmetry, movement of
chest wall.
 Breathing pattern- abdominal
breathing.
 Palpation:
 1- light palpation: in light circular
motion to detect lesion and masses
 2- deep palpation: palpate for
internal organ like liver and spleen.
Lungs & Respiratory: Key
Points
 Clubbing
 Snoring (expiratory): upper airway
obstruction, allergy,
 Dullness to percussion: fluid or mass
Increased or Decreased
Respirations
Stridor
Wheezing
 Chest Assessment

 Auscultation
 Wheezing
 Retractions
 Subcostal
 Intercostal
 Sub-sternal
 Supra-clavicular
Red Flags:
 grunting
 nasal flaring
 stridor
 All that Wheezes
isn’t always Asthma…
Think:
 Infection
 Foreign body aspiration
 Anaphylaxis
 Insect bites/stings,
medications, food
allergies
 And all Asthma
doesn’t always Wheeze!

 Cough
 Fatigue
 Reduced
exercise
tolerance