Newborn Exam: Answers

Case 1

A new mother and her 5 day old infant present to your office for the infant’s first visit.  You congratulate the mother and start the visit by asking her about her pregnancy and if she had prenatal care.  She tells you that she was followed at the Allen pavilion so you ask her if it is OK that you review her record.  She agrees and even has her MR number available.  As you punch in the MR number, there is a knock at the door and it is your 3^rd year medical student for the first day of his ambulatory rotation.  You invite him in and ask him to observe for the time being.  When you are finished you have some time to review the case.  The medical student seems perplexed when he reads your note.  He wonders why there are so many questions about the mother, her pregnancy, and the immediate neonatal period, when the infant looks perfectly healthy at this time.  How do you explain?

The maternal history and prenatal course have significant implications for the newborn.  Maternal illnesses (eg lupus, thyroid disease, etc), maternal medication use, pregnancy complications (hypertension, diabetes, preeclampsia), infections, and postnatal complications can account for fetal growth and developmental problems and can increase the risk of infections in the newborn.

Generally we like to know:

• Moms age, gravid and para status (can alert to possible genetic risk factors)
• Mode of delivery i.e. vaginal or C-section; why if it were a C-section
• Maternal blood type/antibody screen/Rh type (can identify risk factors for hyperbilirubinemia)
• Rubella status (Congenital rubella has characteristic features and is a devastating illness; if nonimmune, mother should be immunized prior to future pregnancies)
• Syphilis screen (If mother is positive and improperly treated, or if there is passive acquisition by the infant of a positive blood test, infant may needs monitoring and  blood work as outlined in the Red Book)
• Hepatitis B status (If Mom is Hep B surface antigen positive, infant should have received HBIG and Hep B vaccine prior to discharge from hospital.  Infant should complete Hep B series by 6 months of age and infants titer’s should be checked 3 months after completion of Hep B series to ensure immunity)
• CG/Chlamydia (Gonococcal infection of the neonate generally affects the eye 2-5 days after birth.  Chlamydial infection of the neonate can present as a conjunctivitis 5-14 days after birth, or as pneumonia 2-19 weeks after birth).
• Tuberculosis risk/PPD result (If mom is PPD+, CXR negative she needs therapy, but infant does not need special evaluation or treatment.  If mother is suspected of having Tuberculosis disease, infant need special evaluation as outlined in the Red Book)
• Risk factors for sepsis, mainly Group B strep status of mother and if positive, was she treated with antibiotics.  (Treatment of the mother in the pre/peripartum period is protective against early onset disease, but not late onset disease).
• HIV status  (some mothers may decline testing)
• Maternal drug use/smoking/EtOH use
• Gestational age of infant/birth weight/apgars if known (Premature infants and low birth weight infants need special consideration/more frequent follow up)
• Neonatal course and how many days in hospital after delivery
• Presentation (Breech infants need to be screened for DDH)

Case 2

It is the first day of continuity clinic for your intern.  Her first patient is a one week old.  She tells you that she is very comfortable with eliciting a complete history, however, although she has examined older infants and children as a medical student, she has no experience with the newborn exam.  She asks you to highlight the important aspects of the newborn exam.  What do you tell her?

The newborn is approached from head to toe as are older infants , but special attention must be given to certain organ systems:

• General appearance:  Before even touching the infant one should try to get a general gestalt by looking at the activity level, color, and for any obvious malformations or dysmorphisms.  Note the position of the eyes and ears and note facial symmetry when the infant cries. Note the infants posture which generally reflects the infants position in utero.  Vertex infants generally lie with extremities flexed.  Note that the infant moves all extremities symmetrically.
  
• Skin: Normal skin color is pink.  Jaundice may be physiologic or secondary to ABO incompatibility.  Cyanosis of the hands and feet of a newborn (acrocyanosis) is not uncommon, however central cyanosis (tongue/lips) reflects hypoxemia and may be secondary to either heart or lung disease. Deep red color or plethora is common in polycythemic infants and pallor may be seen if anemia is present.
  
• Head: Note the shape of the head.  Molding is a temporary asymmetry of the head that is secondary to forces during the birth process. Swelling of the soft tissues of the scalp as a result of vaginal pressure can cause “caput succedaneum,” subcutaneous edema that extends across the suture lines.  This is in contrast to a cephalohematoma which is a subperiosteal hemorrhage that does not extend across the suture lines.  Subperiosteal blood can form into a palpable mass that can be fluctuant initially and over time feel firm as a result of calcification.  The mass can persist for weeks to months although most resolve within 1- 2 months. Fontanelles can be palpated anteriorly and posteriorly.  The posterior fontanelle closes first at 2-4 months of age; the anterior fontanelle at about 9-12 months of age.  A large anterior fontanelle may be associated with hypothyroidism, while a bulging fontanelle raises concerns for meningitis or hydrocephalus.  The head circumference is important to follow initially and at subsequent well child visits to rule out hydrocephalus and craniosynostosis.
  
• Eyes: Checking the red reflex is vital in screening for cataract. Glaucoma, and retinoblastoma. The reflex must be present and symmetric when comparing eyes and must be checked at each well child visit. Leukocoria is abnormal and warrants prompt referral to the ophthalmologist.  Subconjunctival hemorrhages are not uncommon after traumatic deliveries.
  
• Mouth: The hard and soft palates must be examined for the presence of a cleft. Looking for the uvula (bifid/absent).

• Chest: Palpate the clavicles to identify fractures. Physical findings of a fractured clavicle may include local swelling, crepitus, and asymmetric Moro. Auscultate the lungs and note the respiratory rate which is usually 40-60.
  
• Heart: The heart rate should be noted.  Newborn heart rates range from 100-180, and possibly lower in a sleeping newborn.  The heart should be auscultated for murmurs.  A VSD may not be heard in the immediate neonatal period as the infant is transitioning to adult circulation and high systemic pressures. Femoral pulses should be present and equal. See more details about heart murmurs in the Cardiac exam lecture.
  
• Abdomen: Palpate the abdomen for masses.  The most common masses in infancy are renal masses (hydronephrosis,cystic kidneys), neuroblastoma, and Wilms tumor.  This is best accomplished when the infant is asleep.  Check the umbilical stump for any evidence of granuloma formation or infection.
  
• Hips: Use the Ortolani and Barlow maneuver/Galeazzi sign to evaluate for dislocation of the hip.  Hips must be checked on each well child visit until the child is walking well.
  
• GU: Check for normal appearance of genitalia.  Girls commonly have a clear/white vaginal discharge which is normal. Boys should be evaluated for proper position of urethral meatus and bilateral descended testes.  Hydroceles are common and can be distinguished from hernias by transilluminating the scrotum.  Hydroceles generally resolve by several months to a year of age.
  
• Spine: Check for any dimples, deep clefts or hair tufts that may suggest underlying abnormalities of the spine.  Infants can be imaged if there is concern for spinal dysraphisms.
  
• Neuro: Evaluate the infant for the presence of primitive reflexes. Suck, palmar and plantar grasp, rooting, and Moro (startle) are the most easy to elicit.  Other primitive reflexes include: Galant, Stepping, Atonic neck, and Landau.

Case 3

A first time mother comes to your office with her 2 week old.  She is energetic and enthusiastic about being a new mother.  She tells you that things have been going well, however, she has generated a list of questions that she would like you to address:

1) I am worried that my baby has a problem with her nerves. 

            a) She is making all of these jerking movements particularly when she sleeps. Could these be seizures?

            b) Sometimes, especially when she’s been crying, her chin quivers.

• Nervous system is not mature and so these movements are completely normal for a newborn

2) My baby has little white bumps all over her nose and chin, and what look like pimples on her cheeks.  What can I use on her face to help them go away? 

• The lesions on the nose and chin are Milia: clogged immature oil sebaceous glands usually found on chin, nose, forehead, and cheeks. No intervention is necessary. Will resolve on their own. 
  
• Lesions on cheeks are neonatal acne.  Can be papules, comedones, or pustules that appear in the first few weeks of life secondary to stimulation of sebaceous glands by maternal androgens.  Non scarring and generally  resolve by 4-8 weeks of life.

3) My baby has a blister on the center of her lip.  Should I pop it?

• No, Sucking blister.

4) When my baby spit up some breast milk, I noticed some blood in it.  Could she be allergic to my milk?

• Check nipples for cracks

5)  When my baby was crying I noticed a white bump on her gums.  Could she be teething this early?

• These are “Bohns nodules” /mucoid gland cysts that will self resolve.

6) My baby’s stool initially was yellow and now it is more green.  Could she have a GI infection?

• Initially stool is meconium (tarry green black). After 24 hours transitional stools are evident which are greenish yellow/loose sometimes seedy up to about 3-4 days.  Subsequently, the stools depend on food taken in: breast fed -> yellow, loose, can be watery, seedy, mustardy. Formula fedà more formed, color varies yellow to brown to green to dark green if iron fortified formula or taking iron supplements.

7) My baby cries but has no tears.  Could she be dehydrated?

• No. Nonfunctioning lacrimal apparatus until 1-3 months of age

8) My baby has white discharge from her eyes since 1 week of age.  I was given antibiotic ointment by a PMD but the eyes are not better.   What can I do?

• Likely due to lacrimal duct stenosis/obstruction.  Massage and careful cleaning with warm water is recommended.    If symptoms persist past 1 year of age, should be referred to Ophthalmology for probing.

9) My baby has a red spot over her eyelid and just above the bridge of her nose.  It seems to get worse when he cries.  Will this go away?

• This is a capillary malformation that is commonly found over the eyelid, glabella, upper lip and nape of neck.. Also known as a salmon patch/nevus simplex and in lay terms as “angel kiss” and “stork bite.”  Lesions fade and disappear completely by 2 years of age although the lesions on the nape of the neck may persist.

10) When we left the nursery we were told to put the baby on her back to sleep. My mother-in-law said this was dangerous because if the baby vomits, she may choke.  She told me to put the baby on her side or her stomach to sleep.  What do you recommend?

• BACK TO SLEEP!  The back to sleep campaign has significantly reduced the rate of SIDS.  The AAP states that the safest sleeping position is supine.  Safe sleep also involves having the baby on a firm mattress/surface for sleep without any loose bedding, pillows, or blankets that could cause suffocation.  Infants should avoid overheating and cigarette smoke exposure. Co sleeping has its pro’s and cons. ( See sleep lecture.)

11) My baby hiccups often.  Is this dangerous?

• This is secondary to nervous system immaturity and is not dangerous nor is it as bothersome for infants, as it is for adults.  Most babies start to hiccup in the womb. 

12) My baby has swollen breasts.  Is this normal?

• This is secondary to infusion of maternal hormones from the placenta just before birth.  It can occur in both males and females and can be asymmetric.  Sometimes breasts can secrete a milky substance known as “witch's milk” for days to weeks.  This should not be forcefully expressed.

13) My baby girl has a bloody discharge in her diaper.  Should I be worried?

• No; Secondary to estrogen withdrawal .

14) My baby is always straining to go to the bathroom.  What can I give her for the constipation?

• If infants stools are soft infant is not constipated.  Most infants strain, turn red, and become fussy when stooling.  They don’t have the benefit of gravity to help.

15) I noticed that the baby’s diaper is stained an orange color.  What can this be?

• Urate crystals.  Sometimes may indicate a degree of dehydration.

16) My baby sneezes a lot.  I think she has a cold.  Can I give her Pediacare?

• Unlikely to be an acute illness.  This is the infant’s  way of getting rid of excess mucus or amniotic fluid.  Cold medicines are not recommended for infants less than 2 years of age.

17) My baby’s belly button sticks out a lot when she cries.  I’m worried that she’s in pain.  My mother-in-law told me to bind it with a baby girdle.  Will this help?

• Umbilical hernias are generally not at risk for incarceration.  Girdles and binding do no affect outcome and should not be used.   Most hernias decrease in size over the first year of life.  If the defect is very large or is of cosmetic concern to the family, the infant can be referred to the surgeon for repair but would wait until the child is 3-4 years of age.

18) I would like to pierce my baby’s ears.  When is the earliest I can do so?

• The answer to this question is very subjective.  Should at least wait until the infant has received  immunization against tetanus.

19) I want to take my baby to the DR to meet the rest of the family.  When is she old enough to travel on a plane?

• There is no age limit for air travel.  Rule our sepsis age infants should avoid crowds and closed spaces because they increase the risk of contact with infection.  Most recommend that the infant receives the first set of immunizations prior to travel to the DR.

20) My baby has beautiful blue eyes but my husband and I both have brown eyes.  What is the chance that her eyes will remain blue?

• By 3 – 6 months of age; although pigmentation of iris can continue to increase until 1 year of age

21) My baby doesn’t have an appointment for another few weeks.  Are there any reasons that I should call you prior to our next visit?

• Temperature of or above 100.4 rectally
• Unusual irritability or somnolence
• Refusal to feed
• Persistent or excessive/forceful vomiting
• Baby just doesn’t look right

Case 4

Your next patient is a 1 week old male born to a primiparous 20 year old mother.  Mom comes into your room alone and the infant is crying in the stroller.  She does not make any attempts to console the baby.  She looks tired and a bit overwhelmed.  You pick up the baby and sooth him easily.  Your initial impression is that the mother may be at risk for post partum depression.  How do you proceed? How common is post partum depression? How do you distinguish between postpartum blues and depression?

What are the risk factors for post partum depression?

Mothers should be routinely screened for post partum depression whether they “seem depressed” or not, and pediatricians, because of the frequency of visits, are in the unique position to do so.   In general, one must inquire about the mother’s ability to eat, sleep, and experience pleasure and if depression is suspected if the mother is a potential harm to herself or the infant.  Standardized screening tools exist to assess the risk of depression.  We have adopted the Edinburg Postnatal Depression Scale or EPDS. This is a 10 question form with a scoring system.  The maximum score is 30 and anything above 10 is considered possible depression.  Please see attached form.  As a complete screen is very time consuming, the QI project at Audubon identified 4 quick screening questions that our OB colleagues use to flag those mothers who may need further evaluation.  These questions are as follows:

• When the baby is asleep, do you have trouble sleeping?
• Do you cry even when there is no reason?
• Do you feel unable to do things?
• Are you anxious and bothered easily over small things?

If any of these answers if “yes” the mother is referred to the social worker for evaluation with the more complete Edinburg scale.  A mother who is found to be depressed is then referred to Psych.

The literature shows that 50 to 80% of mothers experience postpartum blues (heightened emotions and tearfulness) during the first 2 weeks post partum.  These symptoms generally resolve by 3 weeks post partum. More debilitating symptoms that last longer are characteristic of post partum depression.   Although small percentage of mothers may manifest with signs of depression in the first 2 weeks postpartum, many cases do not develop until 3-12 weeks post partum, and a few thereafter. 

Post partum depression affects 10-20% of mothers with a range of severity; the most severe being post partum psychosis (0.1% -0.2% of postpartum mothers), which is a psych emergency.  Clinical manifestations include insomnia, anxiety, sadness, tearfulness, feelings of hopelessness and of guilt, feelings of inadequacy, difficulty concentrating, and thoughts of death.  Obsessive tendencies and compulsions with respect to the infant’s health may overlap the other features.  Risk factors for post partum depression include: young maternal age, single marital status, marital discord/DV, lack of social support, lower education; psychosocial stressors; personal or family history of mood disorder particularly bipolar disorder; and depression during pregnancyàcommon in the population that we serve. 

Most cases can be treated with therapy and/or antidepressants.