Neonates should be examined immediately after delivery, and ideally before discharge from hospital (for hospital births) or next day for home births or rapid discharges. The initial examination is usually conducted by midwifery staff in cases of uncomplicated delivery, or by the on-call paediatrician following complicated births.
Some hospitals have a policy of conducting two paediatric neonatal examinations, one shortly after birth to detect any abnormalities that require urgent action, and one before discharge. A trial comparing one with two neonatal examinations (neonatal examination and screening trial - NEST) found no evidence of a net health gain from the policy of double examination. Babies examined twice were more likely to have suspected congenital abnormalities, especially hip abnormalities, but not more likely to require active management. There were no differences between the two groups with respect to use of community, outpatient, inpatient resources, or in health care received. It concluded that a single examination policy would save resources both during the postnatal hospital stay, and through fewer outpatient consultations.1
Initial post-delivery examination
A brief screening examination should be conducted checking the face, eyes, mouth, chest, abdomen, spine and limbs to exclude major abnormalities. A strong cry and a widespread pink blush over the face and body are good signs that all is well. Some children may be born with indiscriminate genitalia. In such cases it is important not to guess at the likely gender of the child, but advise that it is uncertain and that further tests will be needed. If you have sufficient clinical experience an orogastric tube should be passed when the neonate's mother has suffered polyhydramnios. This excludes oesophageal atresia.
The APGAR score
The Apgar score gives a reproducible, quantitative, semi-objective assessment of neonatal condition that is useful for assessing a baby's progress or deterioration immediately after delivery.2 It is important to document it for medicolegal reasons. It is most useful following complicated births or where there are unanticipated problems with the baby after delivery. It should be checked at delivery and 2 and 5 minutes subsequently; these results should be documented in the partogram, maternal and neonatal notes.
Routine neonatal examination
Known colloquially as 'the baby check', this examination should be carried out by a member of the paediatric team where the baby is still in hospital, or by the GP and primary care team following home births. NICE2 recommends that the aims of the examination are fully explained to the parent(s) before it is conducted. The findings should be shared with the parent(s) and recorded in the postnatal care plan and the personal child health record. NICE advises that the examination should be carried out within 72 hours of birth and incorporate:
A review of parental concerns and the baby's medical history
Family, maternal, antenatal and perinatal history
Fetal, neonatal and infant history including any previously plotted birth-weight and head circumference
Whether the baby has passed meconium and urine (and urinary stream in a boy)
Other screening tests as recommended by the UK National Screening Committee should also be carried out or arranged at this time.4
The examination is best conducted in a well-lit, warm, private room with the mother in attendance and able to see and help with what is being done.
Suggested schema for screening neonatal examination
First wash your hands thoroughly to reduce the risk of cross-infection. Then:
Listen and observe
Assess overall appearance. Note general tone, sleepiness and rousability. Observe general condition, proportions and maturity.
Look carefully for evidence of jaundice (preferably in bright, natural light). Are there any birthmarks, rashes or other skin abnormalities?
Listen to the baby's cry and note its sound.
Weigh the baby and plot this reading on its growth chart.
Perform a systematic 'head-to-toes' examination
This should be done carefully and in good light to detect abnormalities:
Head:
Shape, presence of fontanelle and whether normal, sunken or bulging
Measure and record head circumference on growth chart
Assess facial appearance and eye position
Look for any asymmetry or abnormality of facial form
Eyes:
Normal shape and appearance?
Check for presence of red reflex
Look for obvious cataracts or signs of ophthalmic infection
Ears:
Shape and size
Are they set at the normal level or 'low set'?
Check patency of external auditory meatus
Mouth:
Colour of mucous membrane, observe the palate
Check suckling reflex by inserting a clean little finger gently inside baby's mouth
Arms and hands:
Are they of normal shape and moving normally?
Look for evidence of traction birth injury (e.g. Erb's palsy) by checking neck, shoulders and clavicles
Count fingers and observe their shape – is there any evidence of clinodactyly (incurving of fingers)?
Check palmar creases – are they multiple or single? A single palmar crease may be normal, but can be a sign of Down's syndrome.
Peripheral pulses:
Check brachial, radial and femoral pulses for rate, rhythm and volume
A hyperdynamic pulse may suggest persistent ductus arteriosus
A weak pulse may occur with a congenital cardiac anomaly (impairing cardiac output and in conjunction with other signs from the examination)
Check for radio-femoral delay (aortic coarctation)
Heart:
Check cardiac position by palpation and feel for any thrill or heave
Listen to the heart sounds carefully and for any added sounds or murmurs
Suspected abnormalities require further examination ( and often more expert opinion and investigation)
Lungs:
Watch respiratory pattern, rate and depth for a few seconds
Look for any evidence of intercostal recession
Listen for stridor
Auscultate lung fields for for added sounds
Abdomen:
Look at abdominal girth and shape
Carefully check the umbilical stump for infection or surrounding hernia
Palpate gently for organs, masses or herniae
it is common to be able to feel the liver and/or spleen in healthy newborns
Check the external genitalia carefully (see Ambiguous Genitalia)
Palpate for testicles in boys
Inspect the anus (has meconium been passed?)
Back:
Look carefully at skin over back and at spinal curvature/symmetry
Is there any evidence of spina bifida occulta or pilonidal sinus hidden by flesh creases or dimples?
Palpate the spine gently
Hips:
Specifically test for congenital dislocation of the hip (a.k.a. congenital hip dysplasia) using combination of Barlow and Ortolani manoeuvres (follow link for more detail)
Legs:
Watch movements at each joint
Check for any evidence of talipes equinovarus
Count toes and check shape
CNS:
Observe tone, behaviour, movements and posture
Elicit newborn reflexes only if there is cause for concern
Further examination should be conducted as necessary according to any abnormalities that are detected, or suspicions of undetected illness in the baby.
Record findings
Always document the findings of the examination in the postnatal care plan and personal child health record. A proforma for the examination, kept within the notes, can save time and act as a prompt to ensure that no element of the examination is missed.
Other screening tests
NICE recommend that newborn screening tests, as currently advised by the UK National Screening Committee, should be offered to all UK-born children.
This includes the newborn heel-prick blood-spot test traditionally used to pick up phenylketonuria and hypothyroidism. The bloodspot or heel prick test is taken between 5 and 8 days ((ideally at day 5, count date of birth as day 0). It may include tests for other metabolic abnormalities in future.
Sickle Cell Disease: all newborn babies in England are to be offered screening for sickle cell disease, irrespective of family/ethnic origins the offer of screening is NOT based on an assessment of risk.5
Cystic Fibrosis. Biochemical screening is being phased in and should have become uniform after April 2007.
Medium-chain acyl CoA dehydrogenase. The Department of Health have funded a pilot study in six UK centres screening more than 700,000 babies. The remaining 7 centres will be funded from April 2009.
The routine neonatal screening examination should be repeated at 6–8 weeks and an assessment of visual fixation and social smiling conducted.
A hearing screen should be completed before discharge from hospital (or by week 4 in hospital programme/week 5 in the community programme).
Common abnormalities detected in the newborn screening examination
Capillary or macular haemangioma:
Also known as stork mark/bites, or salmon patch; found around eyes and nape of neck in 30–50% babies
Those around eyes normally disappear in first year, commonly persist if on nape of neck
Blue-black pigmented area:
Also known as Mongolian blue spots; seen at base of back and on buttocks. These are common in dark-skinned parents but can occur in Caucasian infants.
They normally disappear over first year
Urticaria of the newborn:
This is most evident on 2nd day as fluctuating, widespread erythematous rash with raised white/cream dot at centre of a red flare, mostly apparent on trunk; disappears spontaneously without treatment.
Heat rash:
Also known as miliaria may appear as either red, macular patches or superficial, clear vesicles that are most marked on forehead and around neck.
Associated with warm humid environment and will clear in cooler, drier conditions
Breast enlargement:
Seen in both girls and boys; may secrete small amount of milk ('witches milk')
Thought to be due to response to circulating maternal hormones
Not significant unless the condition persists/progresses
White pimples:
Also known as milia; seen on nose and cheeks, found in approximately 40% of newborns, due to blocked sebaceous glands
These clear spontaneously
Oral cysts:
These are found on palate near the midline and on the gums (also known as Epstein's pearls)
They may be larger and on floor of mouth
They usually resolve spontaneously
Teeth can be present at birth (no action required unless they are loose or abnormal, in which case they may have to be extracted)
Accessory skin tags:
Seen on face as accessory auricles anterior to the ears
Can be dealt with easily by surgical team
Vestigial extra digits:
Can usually be dealt with easily by surgical team
Sacral dimples:
These are common
Examine carefully to detect underlying sinus or evidence of spina bifida occulta
Deformity of the shape of the head in the immediate post-natal period and following days is common:
Such 'moulding' is non-pathological and usually resolves spontaneously
Assess whether there are any other craniofacial abnormalities
Seek expert input if unsure
Abnormalities that may indicate a significant underlying cause
Any wide separation of the fontanelles, with presence of islands of bone (Wormian bones) may indicate cranial abnormalities caused by a range of congenital syndromes.
A third fontanelle, found between the normal anterior and posterior fontanelles may indicate Down's syndrome.
Abnormally shaped or placed ears may indicate fetal alcohol syndrome, craniofacial abnormalities due to abnormal branchial arch development or conditions such as Edward's syndrome (trisomy 18) or congenital renal anomalies.
Single palmar crease can indicate Down's syndrome but may be found in children who do not suffer from this condition.
Abnormalities of the face, jaw and ears are often associated with hearing dysfunction; hearing tests should be performed and ENT assessment requested..
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