Basic Pediatrics: Neonatal History 1 of 6

Lecturer: Dr. Matheus

October 7, 2015

NEONATAL HISTORY • anthropometric measures:

• weight
Informant: 
 • length
% Reliability • HC
• CC
General data: • AC
Baby boy/girl ____ born to a ____ year old, • CR
G____P____ blood type “__” at ____ weeks gestation after • RR
a pregnancy complicated by ___________. • temperature
• blood pressure
Labor lasted ____ (duration), with membranes _____ • may not be routine for a neonate
(intact/spontaneously ruptured/artifically ruptured) and • but if the baby is sick, usually blood pressure is
____ (clear/foul-smelling/meconium-stained) amniotic fluid. required
Delivered by ____ (spontaneous delivery/surgical, either • determination is quite difficult to obtain
CS or forceps) and with an APGAR score of __ & __ at 1 • therefore, automated machines would be better
and 5 minutes, respectively. The baby weighed __ grams
and was ____ and had ____ color on arrival in the nursery. For the assessment of the neonate, PE is head to foot. In
contrast, regional examination is done for the regular
MOTHER’S PROFILE pediatric assessment.
• occupation Depending on age of patient, you would have differences in
• education what would be normal,

• habits In the eyes, for example, palpebral fissures are closed in a
• nutritional status - affect intrauterine growth of baby strictly premature child. They are still fused.
• LMP, PMP, AOG, EDC

PRENATAL HISTORY - taken best per trimester • skin:

• First trimester • texture
• Second trimester • color
• Third trimester • rashes
• As well as mother’s: • hematomas
• gynecologic history • desquamation
• obstetric history • mottling
• family history • birthmarks
• milia
• mongolian spots
Particular questions in prenatal history include the following: • head
• shape
• Did the mother have prenatal check-up? • hair: amount, color and texture
• Had there been disease or illnesses during the prenatal • eyes
period? • sclerae
• For gynecologic history: • conjunctivae
• ask for important infections PRIOR TO PREGNANCY, • cornea
and during pregnancy that may be relevant • secretions
gynecologically, i.e. STDs • palpebral fissures
• had there been any abortions, miscarriages, how • extraocular movement
many times? • nystagmus
• strabismus
• pupils
• size
PHYSICAL EXAM • reaction to light
• age at the time of exam • lungs
• place the age as “30 minutes of life, 1 hour of • heart
life at the time of examination”
• in newborns, changes happen very quickly.
• it is possible to have a good apgar score
after birth; after an hour, RDS
• general appearance, maturity, muscle tone, cry,
color, nutritional, vital signs measurement

Bahaghari ‘15
Basic Pediatrics: Neonatal History 2 of 6
Lecturer: Dr. Matheus
October 7, 2015

• abdomen • common issues of newborn

• shape - usually globular, and soft • physiologic jaundice
• distended • umbilical care
• flat - pwede rin for normal newborn • not recommended anymore to place
• scaphoid anything on top of the cord;
• diaphragmatic hernia • not recommended to put ointments,
• globular veins cleansers, or alcohol, not unless the
• peristalsis cord is infected
• diastasis recti • EINC care recommends care that is
• umbilicus cutis “sparingly done.” Meaning, just leave it
• skin or normal type alone
• umbilical vessels • circumcision
• 2 arteries (small caliber but thick walled), • it is not indicated to do routine
• 1 vein (large caliber but thin walled) circumcision for males
• staining • there is cultural bias with regards to
• liver practice
• spleen • For Filipinos, circumcision is done
• genitalia before onset of adolescence
• female
• male: testes; check for rugae
• discharge [in-lec]
• urethral orifice comments regarding several conditions
• prepuce
• hydrocele formation
• note: upon presentation of a neonate with Rupture of membrane:
ambiguous genitalia, or when you are not sure if
• increased risk for infection for neonate as well as
the neonate is male or female, the advocacy is
mother
to validate sex by doing further studies (i.e.
• sepsis
chromosomal studies)
• Take into consideration the case of Delivery type:
Bahaghari, we really cannot tell if he really
• CS and TTN
is indeed a male or a female. His actions
and nuances are apparently very confusing.
CS babies are more prone to transient tachypnea of the
• extremities newborn, or also knwon as RDS II
• femoral pulsations
• fingers and toes - always count for the number Prenatal care
of digits; examine digits, even if babies usually
present with closed fists.
Maternal blood type
• hand crease
• ABO
• Rh
• history related to newborn care
• PROM, oligo/poly hydramnios, vaginal Infection risk
delivery, etc.
• maternal hepatitis carrier
• APGAR score
• give vaccine
• resuscitation
• immunoglobulin within 12 hours of birth
• HR, respiration, color
• maternal Group B Strep colonization
• examination of newborn with unique component and
• one of the major caues sepsis of newborn…
demonstration
• GBS, also E. coli
• fontanelle
• treatment will be (2) antibitoics: one given for
• reflexes gram positive bacteria, another for gram
• dysmorphism and gross abnormalities negative
• red reflex
• femoral pulses
• nutritional issues and breast feeding; counseling
of mothers regarding breastfeeding
• counseling starts at PRENATAL
CONSULTATIONS

Bahaghari ‘15
Basic Pediatrics: Neonatal History 3 of 6
Lecturer: Dr. Matheus
October 7, 2015

[in-lec] • Vital signs

comments regarding SGA and LGA babies • RR: 40-60 / min
• HR: 120-160 / min
• temperature (usually axillary or skin surface
SGA and LGA: temp) which may be affected by several factors:
• prone to hypoglycemic episodes • over-bundling
• other metabolic problems like electrolyte • heater
imbalances
• prone to infection SYSTEMIC PHYSICAL EXAMINATION
LGA: • growth measurements
• infants of diabetic mothers. • vital signs
• may present as large babies but may still be • general appearance
premature • posture
SGA: • flexion of head and extremities, toward chest
• hypothermia and abdomen

Head circumference is measured by using glabella

CLASSIFICATION OF NEWBORN BY WEIGHT AND anteriorly and posteriorly the prominent part of occiput as
GESTATIONAL AGE landmarks
• Help in predicting potential problems
• LBW: <2500 grams
A. Skin
• VLBW: <1500 grams
• general description
• ELBW: <1000 grams
• at birth
• term: completed 37 weeks to 42 weeks
• color is bright red
• preterm: less than 37 weeks gestation
• texure is soft with good elasticity
• postterm: more than 42 weeks gestation
• edema may be seen around eyes, face, scrotum
or labia due to trauma during normal
*abortus: less than 500 grams; however, there are also
spontaneous delivery
instances they will survive for a few days. Just do
supportive care, not intensive care. • may present with cyanosis of hands and feet
(acrocyanosis)
OTHER CLASSIFICATIONS
1. vernix caseosa
• SGA: <10th percentile
• soft yellowish cream
• LGA: >90th percentile
• thickly cover skin of newborn, may be found
• AGA: 10-90th percentile
only in the body creases and between the labia
• IUGR
• current practice dictates NOT TO REMOVE the
• describes less than optimal pattern of growth
vernix caseosa.
over a period of time intrauterinely.
• recent studies show that the vernix offers some
• It is possible to be IUGR but not SGA.
protection to the baby
CARDIOPULMONARY STABILITY
2. lanugo hair
• APGAR SCORE
• very fine
• heart rate
• distribution
• respiratory effort
• more premature, heavier lanugo
• color
• disappears during the first weeks of life
• tone
• reflex irritability
3. mongolian spots
• black coloration on lower back, buttocks,
anterior trunk, wrist, ankle
• not to be mistaken as bruise marks or a sign of
mental retardation
• they don’t totally disappear, but may fade
through the years without treatment

4. desquamation
• peeling of the skin over areas of bony
prominences
• occurs within 2-4 weeks of life
Bahaghari ‘15
Basic Pediatrics: Neonatal History
Lecturer: Dr. Matheus
October 7, 2015
• due to pressure and erosion of skin
• at the time of birth, smooth
• during desquamation, skin becomes rough
• after desquamation, very nice skin uli. :)
 • seen only with patients delivered through
5. physiologic jaundice
• to check despite jaundice not being apparent,
you may blanch the skin (e.g the cheek) and
check for yellow colour
• jaundice usually presents with cephalocaudal
progression
• if physiologic jaundice, appears AFTER 24
hours
• before 24 hours, pathologic jaundice
6. milia
• small, white or yellow pinpoint spots
• common on nose, forehead and chin of the
newborn
• due to accumulations of secretions from
sebaceous glands that have not yet drained
normally
• should not be expressed
• disappears at 1-2 weeks of life
 • more traumatic as compared to caput
B. Head
• anterior fontanelle
• diamond in shape
• located in the junction of 2 parietal and
frontal bones
• 2-3 cm width; 3-4 cm length
• closes between 9-18 months of age
• posterior fontanelle
• triangular in shape
• between parietal and occipital bones
• closes by the 2nd month of age
• fontanelles should be flat, soft and firm
• bulging of fontanelles may be due to:
• crying
• increase in ICP
• always correlate with present
coexisting conditions of the newborn
should there by any
4 of 6
7. Caput succedeum
• edematous swelling on the presenting portion of
the scalp during birth
vaginal route
• not usually seen with CS, except for
mothers with prolonged labor in which CS
becomes an indication
• due to pressure of the presenting part against
the dilated cervix
• effusion overlies periosteum with poorly defined
margins, no delineation, not confined to a single
area
• soft tissue swelling
• extends across the midlines and over the
suture lines
• does not usually cause complications; usually
resolves in a few days
• management consists of observation only

8. Cephalhemtoma
• subperiosteal collection of blood
succedeum
• secondary to rupture of blood vessels between
skull and periosteum
• where bleeding is limited by suture lines
• and therefore never crosses the suture
lines
• may have hemolysis -> subject to
hyperbilirubinemia -> may manifest with
exaggerated jaundice alongside with physiologic
jaundice
Doc puts emphasis that cephalhematoma happens
because of a rupture of a blood vessel due to prolonged
labor. It is therefore more severe than your caput.
Therefore, always evaluate for skull fractures that happen
during delivery.
Bahaghari ‘15
Basic Pediatrics: Neonatal History 5 of 6
Lecturer: Dr. Matheus
October 7, 2015

C. Eyes
• usually edematous eyelids
• grayish to bluish sclerae
• true color not determined until 3-6 months
• pupils should react to light
• absence of tears
• blinking reflex is present in response to touch
• can not follow objects
• rudimentary fixation of objects
1. eyelid edema
2. dysconjugate eye movements
• asymmetic
• one eye is more medial than the other
3. subconjunctival hemorrhage
• do nothing, resolves on its own
4. congenital cataracts
D. Ears
• pina should be flexible, cartilage present
• position: tip of pina above horizontal level of
palpebral fissues
• if not, positive for low-set ears
• associated with congenital problems or
chromosomal abnormalities
• appearance of ear structures may also be
dependent on age
• term baby
• well-formed ear
• cartilage is well-developed; therefore,
there is good recoil of the ear when
examiner attempts to fold it.
• preterm
• distinction of helix and anti-helix are not
very defined; flattened out structures
• less developed cartilage; upon folding of
the ear, they sremain folded.
• observe for ear tags
G. Neck
• usually short, thick
• usually surrounded by skin folds
• unless you extend the neck, you may not be able
to examine the neck
H. Gastrointestinal System
• mouth - should be examined for abnormalities
such as cleft lip and/or cleft palate
• Epstein pearls
• brittle, white, shiny spots near the center
of the hard palate
• mark the fusion of two hollows of the
palate
• should there be any, they dissapear in
time
• cheeks
• have a chubby appearance due to
development of fatty sucking pads that help to
create a negative pressure inside the mouth
which facilitates sucking
• tongue
• observe for normal tongue vs. ankyloglossia
(tongue-tied), easily corrected by surgery
• ankylogossia typically presents as a
heart-shaped tongue
• gums
• may appear with irregular edges
• sometimes back of gums contain whitish
deciduous teeth that are semi-formed but not
erupted
• recommended to pull them out because
these increase risk for aspiration
• abdomen - should be globular in shape
• umbilical cord
• bluish white at birth with two arteries and one
vein
• differentiate normal umbilical cord with cord
that has meconium stain

E. Nose I. Circulatory System

• nasal patency (stethoscope) • heart
• check for nasal atresia • apex lies between 3rd and 4th ICS, lateral to
• unilateral or bilateral left sternal border
• newborn child are commonly nasal breathers • 5th ICS already if 7 years old
but they are able to breath by mouth
• closing the mouth and closing one nares may J. Respiratory System:
hep you check for blockage • slight substernal retraction evident during
• eventually, baby becomes cyanotic inspiration
• nasal discharge - thin white mucus • respirations are chiefly abdominal
• dislocated nasal septum • in adults and older children, respiration relies
on diaphargm
F. Mouth and Throat • no contraction of muscles in expiration, not
• intact, high arched palate unless in times of respiratory distress
• sucking reflex - strong and coordinated • cough reflex is absent at birth
• rooting reflex • only becomes present at 1-2 days postnatal
• gag reflex
• minimal salivation

Bahaghari ‘15
Basic Pediatrics: Neonatal History 6 of 6
Lecturer: Dr. Matheus
October 7, 2015

• possible signs of RDS

• cyanois other than hands and feet
• flaring of nostrils
• expiratory grunting heard with or without the
use of stethoscope

K. Urinary System:
• normally, newborn has urine in the bladder and
voids at birth or some hours later
• female genitalia
• the more term, the labia majora covers labia Moro or startle reflex
minora Upon release of infant, observe for (1st) an abduction of
• the more preterm, the more prominent labia arms, then (2nd) an adduction of arms, as if an embrace
minora is
• labia and clitoris are usually edematous N. Extremities
• urethral meatus is located behind the clitoris • nail beds should be pink
• vernix caseosa is present between labia • fingernails may also have some meconium
staining
• male genitalia • creases on anterior two-thirds of sole
• urethral opening is at tip of the glans penis • indicator of maturity
(we do not see because it is covered by
• term baby should have creases on anterior
prepuce) two-thirds of the sole
• if patient has hypospadias, then you have • common feet abnormalities
chordee
• club feet
• opening may either be dorsal or ventral
• testes should be palpable in each scrotum
• if not palpable in the scrotum, palpate - END -
inguinal area to see if testes are still
descending
• scrotum is usually pigmented, pendulous, and
covered in rugae
• the more term, the more rugae


L. Endocrine System - dependent on maternal hormones

and not the baby’s
• swollen breasts
• appears on the 3rd day in both sexes and
lasts for 2-3 weeks; gradually disappears
without treatment
• NB: breastmilk should not be expressed as
this may result in infection or tissue damage
• maternal hormonal withdrawal
• female genitalia, normal with vaginal
discharge
• infantile vaginal bleeding or menstruation
• assure concerned mothers that it is
due to hormonal withdrawal Let’s slay the last few weeks of 2nd year’s first sem.
Happy studying!
M. Central Nervous System
• reflexes (e.g. Moro reflex) P.S.
• successful use of reflex mechanism is a As usual, kindly check for corrections should you find
strong evidence of normally functioning CNS any. :) Thanks!
• other reflexes include sucking, rooting, plantar
reflexes, etc.

Bahaghari ‘15