1.
Identify anatomical differences between children and adults.
2. Perform an
age-appropriate history and physical assessment of a child.
3. Use techniques that foster
child compliance and safety during physical assessment.
4. Incorporate the physical,
cognitive, and emotional development of children into comprehensive health
assessment.
5. Synthesize chapter
content by conducting a thorough assessment of child health and illness states.
6. Discuss the focus areas
in Healthy People 2010 as it relates to infant and child health.
7. Apply critical thinking
in selected simulations of pediatric physical assessment.
Overview of infants, children, and adolescents
Special considerations
Gathering the data
Physical assessment
Abnormal findings
Health promotion and
client education
Click on the
glossary term to listen to the audio.
acrocyanosis A normal finding in newborns and infants in which
during times of stress, especially exposure to cold environments, the hands and
feet appear cyanotic and are often accompanied by increased mottling of the
distal arms and legs.
adolescence The period between 11 and 21 years of age.
anterior
fontanelle One of the
infant’s skull openings, a 2- to 4-cm diamond-shaped opening, also known as a
“soft spot,” located at the top of the skull protects the brain during birth
and allows for skull and brain growth during infancy.
atopic
dermatitis (Eczema) A
chronic skin disorder characterized by intense itching, patches, erythema, and
papules that typically begins in the first year of life.
caput
succedaneum A condition that
is characterized by edema that results from a collection of fluid in the tissue
at the top of the skull.
cephalocaudal Head-to-toe.
cephalohematomas Blood collections inside of the skull’s
periosteum that do not cross suture lines.
choanal
atresia A congenital
defect that results in a thin membrane that obstructs the nasal passages.
coarctation
of the aorta A congenital
cardiac defect in the newborn that results in the narrowing of the aorta with
decreased femoral pulses and bounding upper extremity pulses, and causes
discrepancies in blood pressure and oxygen saturation between the upper and
lower extremities.
cranialsutures Palpable gaps between the bones of the skull.
craniosynostosis A condition that results in cranial deformity due
to premature fusion of the cranial bones.
cryptochidism The failure of one or both testicles to descend
through the inguinal canal during the final stages of fetal development.
developmental
dysplasis of the hip A congenital
disorder that results from inadequate development of the hip socket.
ductus
arteriosus Shunts
through which blood moves away from the heart and liver in the prenatal child.
ductus
venosus Shunts
through which blood moves away from the heart and liver in the prenatal child.
eczema (Atopic dermatitis) A chronic skin disorder
characterized by intense itching, patches, erythema, and papules that typically
begins in the first year of life.
epiphyseal
plates Plates
located in the ends of the bones.
foramen
ovale Shunts
through which blood moves away from the heart and liver in the prenatal child.
genu
valgum Knock knees,
a condition of the musculoskeletal system.
genu
varum Bowlegs, a
condition of the musculoskeletal system.
gynecomastia The benign development of breast tissue in males
resulting in a tender, mobile knot under the areola.
infant Children between 1 and 11 months of age.
innocent
murmur Heart sounds
that arise from increased blood flow across normal heart structures, they are
grade I–II/VI un intensity, are systolic (with the exception of the venous
hum), and are not associated with thrills or other cardiac symptoms.
labial
adhesion A condition
common in preadolescent females which occurs when the labia minora fuse
together.
lambdoidal
sutures Palpable gaps
between the bones of the skull that separate the temporal and occipital bones.
lanugo A covering of fine hair in newborns that is most prominent
on the upper chest, shoulders, and back.
laryngomalacia Congenital defect of the cartilage in the
larynx.
macrocephaly Any child whose head circumference is above the
95th percentile, the condition is associated with hydrocephalus, brain tumor,
and increased intracranial pressure.
metopic
sutures Palpable gaps
between the bones of the skull that separate the frontal and temporal bones.
microcephaly Any child whose head circumference is below the
5th percentile, may be caused by genetic disorders or intrauterine exposure to
cocaine or alcohol.
milia Tiny (less than 0.5 mm), smooth, white cysts of
the hair follicle.
mongolian
spots Benign areas
of dark bluish pigmentation caused by increased concentrations of melanocytes,
can be found anywhere on the body, but are most common at the base of the
spine.
morbilliform "Measleslike” rashes.
muscular
dystrophy An X-linked
genetic disorder that results in progressive loss of muscle function.
newborns Children between birth and 1 month of age.
otitis
media Middle ear
infections.
posterior
fontanelle One of the
openings in the infant’s skull, 1 to 2 cm in diameter located in the superior
occiput which protects the brain during birth and allow for skull and brain
growth during infancy.
preschooler Children between 3 and 5 years of age.
sagittal
suture Palpable gaps
between the bones of the skull that lies in the middle of the skull and crosses
the anterior and posterior fontanelles.
salmon
patches (Stork bites)
are small macules and patches caused by visible intradermal capillaries.
school
age Children are between 6 and 10 years
old.
scoliosis A lateral curvature of the lumbar or thoracic
spine that is more common in children with neuromuscular deficits.
sinus
arrhythmia (Heart period
variability) presents with heart rate increases during inspiration and
decreases during expiration.
teratogens Substances known to cause birth defects.
thelarche Breast budding, often the first pubertal sign in
females.
toddler Children who are at last 1 year old but who have not
yet reached 3 years of age.
tracheomalacia Congenital defect of the cartilage in the
trachea.
umbilical
hernia A protrusion
at the umbilicus, visible at birth.
vernix
caseosa A
cheesy-white substance that coats the skin surfaces at birth.
Circumspect assessment of a neonate is no
different from that of older patients: it must first consider an informative
history. What happened before the infant was actually seen? The historic
considerations concern familial predispositions to disease states, maternal
status, the course of pregnancy, and the nature of labor and delivery.
Assessment also requires understanding of the aftermath of intrauterine and
parturitional experience, and it further requires comprehension of the
phenomena of extrauterine adaptation (particularly cardiovascular and respiratory)
and the impact of the environment of the infant (particularly thermal factors).
One additional facet of global assessment is the relation of physical findings
to the time of their occurrence. Today's normal signs may be tomorrow's
abnormalities. Immediately after birth, the obstetrician needs to ascertain,
from a brief assessment of the infant, whether there is illness or
malformation. If neither is found, the next consideration is to evaluate for
the variant and minor abnormalities that are often discerned in otherwise
normal infants. Some unimportant variants may impress parents dramatically, and
these findings must be identified as insignificant, transient, or normal
variants. Specific examples are parental anxieties over cephalhematoma, small
anterior fontanel during the first day of life, erythema toxicum, physiologic
jaundice, caput succedaneum, genital edema, or hydrocele. The list of such
normal variations is long; the discussion in this chapter is largely concerned
with this type of physical finding. In this context, frequent comparison to
significant pathologic findings is unavoidable.
Approximately 8–12% of neonates require some
degree of resuscitation at delivery. This number increases as birth weight
decreases. Most causes involve asphyxia or respiratory depression. Below is an
algorithm for neonatal resuscitation.1
Fig. 1. Algorithm for neonatal resuscitation.
(Adapted from Neonatal Resuscitation Textbook, 5th edn. American
Academy of Pediatrics and American Heart Association, Appendix 2006)
In the delivery room, the Apgar score is an
effective indicator of the infant's progress in adapting to extrauterine life
(Table 1). Although traditionally performed at 1 and 5 minutes after birth, it is
effective for assessment in the delivery room at other times thereafter.2
Table 1. Apgar score
Criteria |
Mnemonic |
0 |
1 |
2 |
Color |
Appearance |
All blue, pale |
Pink body, blue extremities |
All pink |
Heart rate |
Pulse |
Absent |
<100 beats/min |
>100 beats/min |
Reflex response to nasal
catheter/tactile stimulation |
Grimace |
None |
Grimace |
Sneeze, cough |
Muscle tone |
Activity |
Limp |
Some flexion of extremities |
Active |
Respiration |
Respiration |
Absent |
Irregular, slow |
Good cry |
*A total score of 7–10 at 5 min is
considered normal; 4–6, intermediate; and 0–3, low.
The evaluation for major abnormalities can be
accomplished rapidly in the delivery room before the infant is given to the
parents or transferred to the nursery. Abnormalities that are discerned in the
nursery usually require special neonatal care that is less urgent. In the
nursery, the neonate continues to adapt to the extrauterine environment. The
neonate is observed for the onset of jaundice, tolerance of feedings, patterns
of voiding and defecation, and other signs that suggest normal or abnormal adaptation
to extrauterine life.
There should be sensitivity to indications of
suboptimal parent-infant rapport, the attitudes of parents and siblings to the
newborn, and the provision of information on parenting. The parents' overriding
emotional stake in a pregnancy is embodied in their infant. Even when all has
gone well, at the very least, parents require guidance. When all is not well,
firm and discrete support is essential. The obstetrician, who has been
intimately involved with the parents for several months during prenatal care,
is considered the parents' first reliable source of information when the infant
is born. An accurate evaluation of the infant is gratifying and reassuring to
all families.
Spontaneous activity of healthy infants waxes and
wanes for several hours following birth. The first 30–60 minutes are
characterized by hyperactivity, including a heart rate that may vary from 160
to 180 beats per minute and a respiratory rate of 60–80 breaths per minute.3 The neonate's eyes are often open, and spontaneous movements
are frequent. The infant's demeanor is one of irritation: muscle tone is
increased, tremors may occur, and spontaneous jerking movements of the
extremities may be frequent. After 30–60 minutes, the infant usually sleeps or
appears quite relaxed. Cardiac and respiratory rates decrease, spontaneous
movement is infrequent, and muscle tone is noticeably diminished. After 1–2
hours of diminished activity, a resurgence occurs for approximately 15–30
minutes; heart and respiratory rates are again elevated, and muscle tone is
again increased. This second interval of increased activity is more moderate
than the first. Generally, by 6 hours postpartum, infant behavior is more
predictable and less labile.
The sequence in which the various features of the
examination are assessed is a matter of personal preference. Regardless of the
system used, it is best to assess observations by the amount of disturbance
they produce. Infant evaluations that cause the least disturbance should be
done first. The examiner may then proceed to the more disturbing maneuvers that
are not so dependent on a quiet state for accurate interpretation.
Inspection without contact
A considerable amount of information is available
by simply looking at an infant. When first approaching the infant, the examiner
should not abruptly place a stethoscope on the infant's chest before doing
anything else.
The infant's overall size and contour are
immediately apparent, as is the relative size of the head, extremities, and
trunk. Microcephaly or cranial enlargement is frequently obvious. If hydrocephalus
is present, the forehead is often prominently protrusive (bossing). The cranial
vault appears large in relation to the face. The amount of subcutaneous fat is
assessable at a glance. A thin trunk often causes a normal head to appear
enlarged. The abdomen is either distended, flat, or scaphoid, or it may bulge
on one side because of a mass.
The baby's posture is also informative. Normal
flexion of the extremities indicates good muscle tone. Lack of flexion is
associated with hypotonicity, whereas excessive flexion usually suggests
hypertonicity. If only one arm is consistently straight and the infant does not
flex that extremity, brachial plexus injury must be considered. Breech
presentations are often identified by the characteristic positions of the lower
extremities (discussed later).
A number of features of the skin are immediately
obvious. If cyanosis is present, its distribution is of great importance;
generalized cyanosis is significant, but acrocyanosis is not. Jaundice, pallor,
rash, and evidence of trauma may be discernible. Abnormal facies should be
appreciated.
Spontaneous movements can be evaluated only if
the infant is undisturbed. At rest, sporadic, well-coordinated movements are
the rule, but they are not symmetrical. Bilaterally identical, repetitive
movements of the extremities are suggestive of seizure activity.4 Facial and eyelid twitches are also suggestive of
convulsions. The infant who moves little or not at all is usually flaccid as
well. Absent or diminished movement of one extremity when the others are used
normally is indicative of paresis or paralysis.
Information about respiration is first obtainable
by simple inspection. Retractions are obvious, and grunting and stridor are
audible to the naked ear. Increased anteroposterior diameter of the chest
(barrel chest) usually indicates an overexpanded lungs, which may be due to
meconium aspiration or respiratory distress syndrome type 2. If one side of the
chest appears larger than the other, pneumothorax, chylothorax, or
diaphragmatic hernia is suggested. If the left side of the chest is larger,
cardiomegaly associated with congenital heart disease is an additional
possibility.
Initial visual inspection can be of value in
obtaining information about the intrauterine environment. The small term or
preterm infant's hair is sparse, whereas the postmature infant's hair is very
dense. Furthermore, in postdate pregnancies the cord may be thin; this
condition may also be observed in mature infants who are small for dates.
Meconium staining may only be evident in the umbilical cord, or the cord may be
the only site where it is visible, particularly when meconium is passed shortly
before delivery. Fingernails are often long in postdate infants.
These diverse signs are described to emphasize
the value of a careful visual inspection. Once visual assessment is completed,
the examiner may proceed to the more manipulative aspects of the physical
examination.
Auscultation, palpation, and other manipulations
With the infant supine, the abdomen should be
palpated immediately after the initial inspection. If the infant is disturbed
by manipulations beforehand, adequate evaluation of the abdomen is difficult or
impossible. The examiner's fingertips must be gently placed and held on the
abdomen without exerting any downward pressure. Deep palpation should then
proceed gradually. The neonate is easily agitated by abrupt manipulations.
Auscultation of the anterior chest should follow abdominal palpation. In
conjunction with cardiac evaluation, the femoral and brachial pulses are gently
palpated. To palpate the extremities, the examiner envelopes them with his hand
and moves the joints gently. After completing the evaluation of the
extremities, the infant is pulled into the sitting position by his or her
wrists to evaluate head lag. The newborn may then be turned to the prone
position. Crying caused by the disturbance is of little concern, because the
resultant deep inspirations and the noise of crying are helpful in auscultation
of the lungs. The buttocks are separated, and the anus is observed for its
position and patency. The infant, who is probably crying at this point, is then
returned to the supine position. The hip joints are manipulated to rule out
congenital dislocation, and the head, neck, and face are examined. With one
hand holding a flashlight, the eyelids are gently separated with the examiner's
index finger and thumb. Light is shined tangentially into the eyes to rule out
corneal lesions and visible cataracts, and the examiner should ensure that a
red reflex is seen bilaterally. The next step is the neurologic evaluation
(discussed later). Examination of the mouth and throat is performed as the last
maneuver of the physical evaluation as it is the most agitating to the neonate.
Contour, proportions, and postures
The body of a normal newborn is essentially
cylindrical; head circumference slightly exceeds that of the chest. For a term
baby, the average circumference of the head is 33–35 cm (13–14 inches), and the
average circumference of the chest is 30–33 cm (12–13 inches).5 The infant's sitting height, measured from crown to rump, is
approximately equal to the head circumference. These values may vary somewhat, but
their relation to each other is normally constant. Values should be plotted on
an appropriate preterm or term growth chart to evaluate the neonate's head for
the presence of microcephaly or hydrocephaly.
During the first few days of life, the infant's posture
is largely the result of its position in utero. The normal infant who
was delivered from a vertex presentation tends to assume a relaxed fetal
position. During the first days of life, it is the “position of comfort” for
the infant. Crying episodes can often be ended by taking the infant from the
crib and gently curling him or her into the fetal position.
Other postures are associated with more unusual
infant positions. After a footling breech presentation, the thighs are abducted
in the “frog-leg” position. Infants born in the frank breech position tend to
keep their knees in the jackknife posture. After a brow or face delivery, the
head is extended and the neck appears elongated, but posture of the spinal
column is normal. Normal postures depend on normal muscle tone, which may be
visibly diminished in hypoxic infants, who do not maintain intrauterine
postures but remain in almost any position imposed on them.
Skin and subcutaneous tissue
At birth, the skin is extensively covered with vernix
caseosa. If it is not removed at birth, it dries and disappears within 24
hours. The skin is blush red and smooth at birth and progressively becomes dry,
flaky, and pink by the second or third day.
Physiologic jaundice is visible during the second or third day of life in
approximately half of all normal newborns disappearing between the fifth and
seventh days. Jaundice in the first 24 hours is abnormal and requires an
extensive diagnostic evaluation.6 Icteric skin may be difficult to detect when redness is
prominent, but blanching readily demonstrates the underlying yellow
discoloration. Early jaundice is more easily detected on the infant's face.
The subcutaneous tissue may be moderately
edematous for several days. Edema is most noticeable about the eyes, legs, and dorsal aspects
of the hands and feet. Peripheral cyanosis (acrocyanosis) involves the hands, feet,
and circumoral area. It is evident in most infants at birth and for a short
time thereafter. If limited to the extremities in an otherwise normal infant,
it is due to venous stasis and is innocuous. Localized cyanosis may occur in
presenting parts, particularly in association with abnormal presentations. In
breech presentations the buttocks or the feet and legs are edematous and blue
as a result of venous stasis; in a transverse lie, a prolapsed arm may be
similarly discolored and swollen because of obstructed venous return.
Occasionally, a circular area of edema and cyanosis in the scalp is present at
the top of the head as a result of pressure against a dilated cervix (caput
succedaneum). Occasionally, the forehead and scalp (or even the entire head above
the neck) are cyanotic.
Pallor usually accompanies other signs of distress except in anemic
infants in whom there has been a fetomaternal hemorrhage across the placenta
over a protracted period of time (chronic abruption). Such infants are in no
obvious distress even though their pallor may be extreme. Pallor is more
commonly a sign of acute blood loss, hypoxia, or poor peripheral perfusion due
to hypotension. Subcutaneous edema may mimic pallor.
Ecchymoses are most frequently due to trauma during difficult labor or
to brisk handling of the infant during or after delivery. They may also
indicate a bleeding diathesis with or without serious infection. High infant
serum bilirubin concentrations often follow the breakdown of a large amount of
extravasated blood.
Petechiae occur in a number of disease states involving
thrombocytopenia and should always prompt an investigation including a sepsis
workup and evaluation of the infant for TORCH infections. Occasionally in
normal infants, scattered petechiae are observed over the upper trunk or the
face as a result of increased intravascular pressure following delivery of the
fetal head. They usually fade within 24 to 48 hours, and new lesions do not
appear.
Mongolian spots are irregular areas of blue-gray pigmentation over the sacrum
and buttocks, but they may be so extensive as to cover the back and sometimes
the exterior surfaces of all the extremities as well. They are common in black
infants and in infants of Asian and southern European lineage. Mongolian spots
usually disappear by 4 years of age, or earlier.
Hemangiomas may appear as an isolated lesions in otherwise normal
infants, or they may be a component of several serious generalized disorders.
Microscopically, hemangiomas of the skin are capillary or cavernous. Capillary
hemangiomas are comprised of a mass of dilated capillaries in the superficial
skin. Port-wine nevi (nevus flammeus) are dense concentrations of such dilated
capillaries, which may be small and single or multiple and sparse; they may
also involve large areas, and occupy as much as half the body surface area.
Their color varies from pink to deep purple, and they are sharply demarcated.
The skin surface is not disrupted. These lesions are usually permanent, but
some pale lesions may virtually disappear. Port wine nevi over the face in a
trigeminal distribution suggest Sturge-Weber syndrome (cerebral calcification
and glaucoma on the same side as the lesions and hemiparesis on the opposite
side) and several other serious disorders are also sometimes associated with
nevus flammeus. Telangiectatic nevi (stork bites) are flat, red, localized areas of capillaries
that are considerably less dense than those seen in port-wine nevi. Easily
blanched, they are commonly situated on the back of the neck, the lower
occiput, the upper eyelids, and the nasal bridge. They disappear by 2 years of
age, but in many children they reappear evanescently during crying episodes.
Strawberry hemangiomas are not seen in normal term infants during the nursery
stay because they first appear during the second or third week of life. As a
result, they are seen in hospitalized premature infants or in term infants
after discharge. They are first evident as bright red, flat spots which are 1–3
mm in diameter and blanch easily. Subsequently, they grow in all directions,
protruding prominently from the skin surface. They may not reach their full
size for 1–3 months. The temptation to remove these lesions should be resisted
because they resolve spontaneously several weeks or months after reaching peak
growth. The cosmetic effect is best when they are allowed to resolve.
Resolution is heralded by one or more pale purple or gray spots on the surface
of the lesion, indicating spontaneous vascular sclerosis and obliteration. In
contrast, cavernous hemangiomas are in the subepidermal layer. They are more
diffuse and less sharply demarcated than capillary hemangiomas. The color of
the overlying skin may be normal or blue as a result of color transmission from
subjacent blood. Cavernous hemangiomas are spongy, but on occasion they are
tight cystic masses. Generally, these localized lesions have no other
significance. They grow at first (like strawberry hemangiomas) and then often
resolve spontaneously in a few months to 1–2 years. Growth of the lesion may
occasionally impair function of an adjacent organ (trachea, esophagus, or eye).
Large cavernous hemangiomas are often associated with serious thrombocytopenia
(Kasabach-Merritt syndrome). Mixed hemangiomas are common and are comprised of
a superficial strawberry lesion that is continuous with a deeper cavernous one.
Harlequin color change is a rare, peculiar discrepancy in color between the
longitudinal halves of the body, extending from the forehead to the symphysis
pubis. A curiosity of no known pathologic significance, the phenomenon is
elicited by placing the infant on his side for several minutes. The dependent
half of the body turns deep pink, while the upper half is pale. The colors are
reversed when the infant is turned onto the opposite side. The color change
often spontaneously occurs in the supine position.
Lanugo is fine hair, which is barely visible and characteristic of
the newborn period. It is more obvious in premature and postmature infants and
most easily seen over the shoulder, back, forehead, and cheeks.
Milia are minute, white papules on the chin, nose, cheeks, and
forehead. They are distended sebaceous glands that disappear spontaneously in
several days or weeks. Sudamina are tiny vesicles over the face and neck that are formed by
distention of sweat glands.
Erythema toxicum is a pink papular rash on which vesicles are often
superimposed. The vesicles may appear purulent and are thus confused with
staphylococcal pyoderma. They appear anywhere over the body within 24–48 hours
after birth and resolve spontaneously after several days. The vesicles contain
eosinophils that are demonstrable on a smear prepared with Wright's stain. The
rash is innocuous and its etiology is unknown.
Sclerema is hardening of the skin and subcutaneous tissue associated
with life-threatening disorders (septicemia, shock, severe cold stress). As a
rule, the cheeks and buttocks are first involved, then the calves and thighs,
and eventually even the entire body. Involved areas are not well demarcated.
Sclerema should not be confused with subcutaneous fat necrosis, which is
confined to small, sharply delineated areas in infants who are otherwise well.
Café-au-lait spots are irregular oval lesions of varying size and distribution
that are not elevated above the skin surface. If six or more of them are
present, neurofibromatosis must be suspected.
Puncture wounds or marks can result from attachment of fetal monitor
electrodes. Rarely, electrodes are inadvertently applied to eyelids and other
parts of the face. Puncture wounds may become infected, and merit observation
for signs/symptoms of infection by the health care provider.
Head
After vaginal deliveries from the vertex
position, molding of the head is apparent to some degree in virtually all
neonates. The change in shape is more pronounced in first-born infants and
infants whose heads have been engaged for prolonged periods. Pressure during
the usual vertex delivery causes flattening of the forehead with a gradual rise
to an apex posteriorly and an abrupt drop at the occiput. In brow
presentations, the forehead is unusually prominent, rather than flattened as in
vertex deliveries. When forces of the birth process are not exerted on the
cranium, its spherical contour is undisturbed. The infant's head is spherical in
breech deliveries and elective cesarean section. Molding has largely disappears
by the end of the second day of life.
At birth and for 1 or 2 days afterward, as a
result of molding, the edges of the cranial bones may overlap obliterating the
sutures. The lines of overlap seem to be ridges when palpated and the fontanels
are small. Later, as the shape of the cranium changes, the bones separate,
suture lines are palpable, and the anterior fontanel expands. Overlapping bones
are clearly visible in premature infants. In malnourished infants because of
impaired growth of the cranial bones, the sutures may be wide at birth, even
over 1 cm. The anterior fontanel is also large in malnourished infants for the
same reason, but it is also flat and soft. Inordinately large, flat anterior
fontanels and extensive suture separation suggest hypothyroidism, osteogenesis
imperfecta, and cleidocranial dysostosis. Small anterior fontanels are
characteristically noted in premature infants, in infants with microcephaly of
any etiology, and in craniosynostosis. The anterior fontanel may be firm and
bulging as a result of high intracranial pressure, suggesting hydrocephalus,
meningitis, subdural hematoma, cerebral edema, or intraventricular hemorrhage.
If there is doubt concerning the firmness and fullness of the anterior
fontanel, the infant should be taken from the crib and held erect in one arm
while the fontanel is palpated. A pathologically bulging fontanel does not
soften or flatten.
Eyes
Eyelids are frequently edematous during the first
2 days after delivery. Separation of lids must be accomplished gently because
forceful traction easily everts them, precluding an adequate view of the eyes.
Purulent conjunctival exudate is most often
caused by gonorrhea, chlamydia, and staphylococcal infection, and by a variety
of infections caused by Gram negative rods. The application of erythromycin or
silver nitrate to prevent neonatal conjunctivitis may also cause inflammation
of the lids.
Subconjunctival hemorrhages occur frequently. They
result from pressure on the fetal head during delivery, with resultant
impairment of venous return and rupture of capillaries in the sclera. They can
be seen in the sclera and are of no pathologic significance, even when the
entire sclera is reddened by extravasated blood. Retinal hemorrhages are
produced by the same mechanism and they may occur in as many as 10% of normal
neonates. They are flame shaped or round and are thought to be harmless.7 Extensive hemorrhage, however, over a large segment of the
retina may indicate the presence of a subdural hematoma.
Cataracts, if present, should be identified at the
time of the first nursery examination. Cataracts vary in size from pinpoint to
involvement of the entire lens. Occasionally they can develop several days or
weeks after birth. If the entire lens is affected, cataracts are easily seen by
shining a light tangentially into the eye by the light source being held to one
side. If the opacity is small, it can be identified only with an
ophthalmoscope. White pupils may also be seen in the presence of lesions deeper
in the eye, such as retinoblastoma. Cataracts are usually bilateral. They are a
major manifestation of intrauterine rubella infection and are occasionally seen
in cytomegalovirus infection. They may be transmitted as a dominant trait from
an affected parent. In congenital galactosemia, cataracts sometimes appear
several weeks after birth.
Corneal opacities are also discerned by directing
light to the eyes. They occur after trauma, in association with congenital
glaucoma, and as a result of infections such as herpes virus and congenital
rubella.
Iris coloboma is one of the most common
congenital malformations of the eye. The defect varies from a small notch at
the inner iris margin to a segmental absence, usually in the inferior portion.
It is generally limited to the iris and thus not associated with visual
difficulty. Infrequently, the defect involves deeper eye structures such as the
retina, macula, and optic nerve, thus impairing normal vision. Rarely,
colobomas are associated with serious generalized malformation syndromes.
Nose
Neonates are obligate nose breathers and cannot
ordinarily breath through their mouth. Any obstruction to the nasal passages
causes some degree of respiratory distress. Partial or complete occlusion may
be caused by mucus secretion that has not been removed or by choanal atresia or
stenosis, which can be life threatening. An oral airway and close observation
is indicated if nasal obstruction cannot be immediately alleviated.
Mouth and throat
Complete visualization of the mouth and pharynx is
difficult without tongue depression. Attempts to depress the tongue are usually
met with strong reflex protrusions of the depressed tongue. An excellent way to
view the mouth is by stimulating a cry before gently depressing the tongue.
Examination of the mouth is important for the identification of a cleft palate,
which often occurs in the absence of a cleft lip. A cleft palate may involve
either the hard or the soft palate, or both. Occasionally, only the uvula is
cleft.
Precocious or natal teeth occur infrequently and
are most often the lower central incisors. When covered with membranous tissue,
they are pink rather than white. If detachment is imminent, they should be
removed to prevent aspiration.
Epstein's pearls are small, white papular structures that occur on each side
of the midline of the hard palate. They are insignificant and usually disappear
within a few weeks after birth.
Neck
The neonate's neck is characteristically short
and abnormalities are infrequent. A webbed neck is seen in Turner's syndrome.
The webbing is characterized by a redundancy of skin that extends bilaterally
from the posterolateral aspect of the neck down to the medial portions of the
shoulders along the superior margins of the underlying trapezius muscles.
Branchial cleft cysts can be evident on the lateral aspects of the neck and
along the anterior margin of the sternomastoid muscle. They are generally firm
1 cm or less in diameter, and are covered by normal skin. More commonly dimples
are evident in these areas. These are branchial cleft sinuses, which are autosomal dominant traits. Branchial cleft cysts or
sinuses are rarely of clinical significance unless they become infected. Thyroglossal cysts are superficially evident as subcutaneous structures in the
midline of the anterior neck at the level of the larynx or above it. They
indicate the presence of a thyroglossal duct, which is an abnormal
remnant of thyroid gland formation. The duct extends deeply into the neck,
often opening at its deep end, onto the surface of the posterior tongue. The
duct can contain thyroid tissue. Surgical excision is generally indicated.
Goiters are usually visible and easily palpated in the midline of the anterior
neck. Goiters are generally the result of thyroid medication used in treatment of
maternal thyroid disorders. Goiters are commonly not functional; rarely,
however, they are associated with neonatal hyperthyroidism.
Thorax
The ribs are flexible and slight sternal
retractions can sometimes be evident during normal respiration. The xiphoid
cartilage, which is at the lower end of the sternum, can curve anteriorly to
produce a prominent pointed protrusion beneath the skin that disappears in
several weeks.
Supernumerary nipples are occasionally noted inferior and medial to the normal ones
along the “milk ridge”; less often, they can occur superior and lateral to the
normal nipples. These are harmless pink or pigmented spots that vary from a few
millimeters in diameter to the size of normal nipples, but they do not contain
glandular tissue.
Breast enlargement in the neonate appears on the
third day after birth, and toward the end of the first week a milk-like
substance (“witch's milk”) may be evident. Massaging the breasts with various
preparations is a common lay practice that often produces breast abscess
characterized by asymmetrical swelling around the areola and severe erythema of
the skin. Yellow or blood tinged, purulent material can exude from the nipple
or through inflamed skin. Breast abscesses are presumed to be due to Staphylococcus aureus until proved otherwise and are treated accordingly.
Lungs
Radiologic and blood gas studies should be
performed if the examiner is suspicious of a respiratory disorder. The
respiratory pattern should be observed before the infant is disturbed. Normal neonates
breathe at rates which vary between 40 and 60 respirations per minute. Rapid
rates are likely to be present for the first few hours after birth. Respiratory
rates fluctuate and for this reason several assessments may be necessary before
an abnormality becomes apparent. Periodic breathing, a frequent finding in
premature infants that requires no therapy, is characterized by sporadic
episodes in which respirations cease for up to 10 seconds. Periodic breathing
is not associated with cyanosis or bradycardia and is rare during the first 24
hours of life. It should not be confused with apneic episodes, which are of
longer duration, often cause cyanosis and bradycardia, and may appear at any
time.
In the normal neonate, respiratory movements are
predominantly diaphragmatic. The thoracic cage remains relatively immobile
while the abdomen rises and falls with inspiration and expiration.
Respiratory difficulties can be identified by
simply observing the infant. A number of abnormal signs are clearly indicative
of distress, generalized cyanosis being the most obvious and serious. A
sustained rate in excess of 60 respirations per minute after 3 or 4 hours of
age is abnormal. Irregular respirations associated with repeated apneic
episodes are often the result of depressed central nervous system function.
Retractions indicate an obstruction to airflow at any level of the respiratory
tract from the nose to the alveoli. They are visible with each inspiration and
are characterized by indrawing of the thoracic wall at the sternum, between the
ribs, above the clavicles, and below the inferior costal margins. The
respiratory grunt is an unequivocal sign of difficulty. It is a fascinating
compensatory mechanism by which an infant attempts to maintain a higher
end-expiratory pressure and thus increase arterial PO2 by prolonging alveolar distention. An audible sign during
each expiration is a variant of the respiratory grunt. Auscultatory sign in the
lungs is of less value in the neonate than in any other pediatric age group.
The chest is so small that localization of findings is often impossible. The
diminutive lung effectively transmits breath sounds from one region to another,
and the absence of breath sounds in one part of the lung may not be appreciated
because the sounds from the unaffected areas are transmitted from a distance.
With experience, diminution of air exchange can be confidently detected,
particularly when there is a discrepancy between the two lungs. Diminished
breath sounds occur in hyaline membrane disease, atelectasis, emphysema, and
pneumothorax, and as a function of shallow respirations from any cause. Rales
are heard in some infants with hyaline membrane disease, pneumonia, and
pulmonary edema, and occasionally in normal infants immediately after birth. They
are sometimes audible only after deep inspiration, which must be induced by
stimulating crying. Rhonchi are most frequently present after aspiration of
oral secretions or feedings.
Heart
Inspection occasionally reveals a small localized
area of pulsation on the chest wall at the fifth intercostal space in the
midclavicular line and toward the lateral half of the left hemithorax. The
pulsations are more evident in small infants with thin chest walls. If
pulsations are prominent in the epigastrium, the heart may be enlarged.
By palpation, the normal apical impulse can be
identified at the fifth intercostal space. Ascertainment of cardiac position is
particularly important in dyspneic infants. Detection of a shift to either side
is an important initial step in suspecting pneumothorax or diaphragmatic
hernia. In the rare occurrence of bilateral pneumothorax, cardiac impulse is
displaced downward toward the epigastrium and the heart is barely audible in
the thorax itself.
Auscultation is the most informative component of
the physical examination of the heart. The first and second heart sounds are
normally clear and well defined. The second sound is somewhat higher in pitch
and sharper than the first. Heart rates normally fluctuate between 120 and 160
beats per minute. In agitated states, a rate of 200 beats per minute may occur
transiently. The heart rate of premature infants is usually between 130 and 170
beats per minute, and during occasional episodes of bradycardia it may slow to
70 beats per minute or less. Murmurs are not necessarily indicative of
congenital cardiac malformations.8 Greater than 90% of murmurs detected during the neonatal
period are transient and not associated with anomalies. Conversely, murmurs are
sometimes absent in seriously malformed hearts. Systolic murmurs are the most
common and usually extend beyond the second sound into diastole. The appearance
of a murmur at any time requires evaluation of several additional physical
findings, such as peripheral pulses, blood pressure, size and consistency of
the liver, and size and contour of the heart on a chest film.
Routine physical exam
fails to detect more than 50% of ductal dependent heart disease. Early
detection, prior to ductal closure, is important as delayed diagnosis can lead
to cardiac failure, cardiovascular collapse, and death. Postductal pulse
oximetry screening in the first few days of life is an effective means for
detecting cyanotic congenital heart disease in otherwise healthy newborns.
Multiple studies have shown that infants with ductal dependent or cyanotic
heart disease have oxygen saturation levels below 95%. A increased
sensitivity can be achieved by adding the criteria of saturation of
less than 95% in both hand and foot or a difference of greater
than 3% between hand and foot. 9, 10
The state of the peripheral pulses is important.
Brachial, radial, and femoral pulses are the most easily evaluated. Normal
pulses are readily discernible, but the examiner's capacity to assess abnormal
weakness and fullness depends on experienced observations of normal neonates.
Weakness of all pulses is indicative of a diminished cardiac output. This
occurs in “hypoplastic left heart syndrome,” asphyxia with hypoxic myocardium,
cardiac failure from other causes, and in septic or hemorrhagic shock. Bounding
pulses generally appear several days after birth in premature infants who have
developed a large left-to-right shunt from the aorta to the pulmonary artery
through a patent ductus arteriosus. The presence of a murmur requires
assessment of liver size and consistency. In infants with right-sided
congestive heart failure, the liver is enlarged and firm with its inferior edge
5–6 cm below the right costal margin. A chest film is indispensable for initial
assessment of cardiac size and contour. Blood pressure is simply and accurately
measured with a Doppler apparatus and an ordinary blood pressure cuff. Blood
pressure readings are more easily obtained at the popliteal space with the cuff
around the thigh. A loose cuff may result in spuriously high readings and an
excessively tight cuff may yield falsely low readings.
Abdomen
INSPECTION
The abdomen is ordinarily cylindrical, sometimes
protruding slightly in normal term infants. Several gross abnormalities are
often apparent on inspection. Distention in its most severe form is
characterized by tightly drawn skin through which engorged subcutaneous vessels
can be seen. Localized bulging at one or both flanks suggests enlarged kidneys,
which is usually a result of hydronephrosis. A severe abnormality of contour
characterizes the rare malformation known as congenital absence of abdominal
musculature (“prune-belly” syndrome) in which renal and gastrointestinal
anomalies are present. The anterior aspect of the abdomen is sunken, or perhaps
slightly protuberant, whereas the intestines, which are covered only by skin
and a thin layer of subcutaneous tissue, bulge pendulously from the flanks.
PALPATION
With rare exceptions, the edge of the liver is
normally palpable below and often as far as 3 cm inferior to the right costal
margin. The tip of the spleen can sometimes be felt in normal infants.
Examination of the abdomen should include palpation of each kidney, and this is
most easily accomplished immediately after birth, when the intestines are not
yet distended with air. With the infant supine, a finger is place at the
costovertebral angle to maintain upward pressure while the other hand presses
downward toward the posteriorly placed finger. The kidney can be felt between
the fingers. The lower poles of each kidney are normally situated approximately
1 or 2 cm above the level of the umbilicus. If enlargement is present, they
extend below this level. By simple palpation, the astute examiner can identify
the majority of gross renal anomalies. If the bladder is distended, a firm
globular lower abdominal mass is palpable. If it persists to any degree after
voiding, the bladder is incompletely emptied, and an outlet obstruction may be
present. Masses perceptible elsewhere in the abdomen are usually intestinal.
Diastasis recti is an inconsequential longitudinal gap in the abdominal midline
between the two rectus muscles. It can be palpated from the epigastrium to the
umbilicus as a linear absence of abdominal wall musculature approximately 1 cm
in width. When the infant cries, a bulge is sometimes visible through the
linear gap in musculature. Diastasis recti disappears within a few weeks.
The normal umbilical cord sloughs from its
attachment at approximately 7–10 days of age. A single umbilical artery
requires search for congenital malformations. In some reports, a significant
number of these infants have major congenital anomalies, particularly renal and
gastrointestinal malformations. Other reports assert that the incidence of
anomalies is no higher in such infants.
Patency of the anus can be ascertained by inserting
the tip of a thermometer or a plastic feeding tube for a distance not in excess
of 1 cm, or observing the infant for passage of meconium prior to discharge.
Inguinal hernias occur most frequently in males,
particularly in low birth weight infants. They are usually unilateral, but can
occasionally be bilateral. The swelling can extend into the scrotum. Sometimes,
the hernia is not perceptible until the infant cries. The hernias contain
intestine, but in females the ovary and fallopian tubes may herniate as well.
Male genitalia
The prepuce covers the entire glans penis so that
the external meatus is not visible. The prepuce is not retractable in normal
neonates and sometimes cannot be completely displaced until 4–6 months of age
to as late as 3 years. It should not be forcibly retracted. This condition is
not phimosis and it is not an indication for circumcision. However, the trauma
of forceful retraction can cause phimosis. If the ventral surface of the glans
is not covered by preputial tissue, hypospadias is present. According to a
statement by the American Academy of Pediatrics, “there is no absolute medical
indication for routine circumcision of the newborn.”11 It is not an essential component of adequate health care.
Good penile hygiene accomplishes as much as a routine circumcision.
In term infants, the testes are in the scrotum.
In premature infants, the testes are in the inguinal canal or may not be
palpable. The scrotum varies in size according to the maturity of the neonate.
In premature infants, the scrotum is small and close to the perineum. In term
infants, the scrotum is large, hanging loosely at a greater distance from the
perineum. The term infant's scrotum is rugated over its entire surface back to
the perineal attachment. The scrotum of the premature infant is less
extensively rugated, becoming smoother toward the perineal attachment. Scrotal
rugation is one of several external signs used for the assessment of
gestational age.
Hydroceles are unilateral, with the affected side of the scrotum
appearing larger and cystic. Transillumination of a hydrocele reveals a striking
translucency and confirms the diagnosis. In inguinal hernias, the scrotal
contents are comprised of intestine or fluid (or both). It is opaque to
transillumination, or considerably less translucent than the hydrocele. A
hydrocele usually disappears spontaneously in a few days or weeks.
Female genitalia
The labia minora are usually more prominent than
the labia majora in preterm infants, whereas in term infants the reverse is
true. The clitoris varies in size.
The hymenal tag is a normal redundant segment of
the hymen that protrudes from the floor of the vagina and disappears in several
weeks. During the first week of life, a milk-white mucoid discharge, which is
sometimes blood tinged, may be evident in the vagina. This is a physiologic
manifestation of maternal hormonal influences and disappears within 2 weeks.
Extremities
Malformations most frequently involve the
fingers. Polydactyly, in its most common form, consists of a rudimentary digit
(digitus postminimus) attached to the lateral aspect of the little finger by a
thin pedicle. It can be eliminated by firmly tying a silk suture around the
pedicle close to the surface of the normal finger. Less commonly, an extra
fully formed digit is present that requires surgical removal. Syndactyly most
often involves the toes.
Fractures of the clavicle, humerus, and femur are
occasionally encountered in the newborn. Fractures should be suspected in any
infant who fails to move one extremity as extensively as the others.
Malposition and a visible local deformity at the fracture site are helpful
signs.
Clavicles must be palpated to ascertain their
presence as well as to detect fractures. Absence of the clavicles, either total
or segmental, is characteristic of cleidocranial dysotosis, an inherited
disorder of membranous bone formation in the skull, the clavicles, and
occasionally the pubic bone. Absence of the clavicles permits innocuous
anterior displacement of the shoulders so that they almost meet in the midline.
Neurologic evaluation
Abnormal neurologic signs are often transient,
but can be persistent. They may disappear by the time the infant is discharged
from the nursery, or they may be present throughout the nursery stay.
Predictions of later brain dysfunction cannot be made with consistent accuracy
on the basis of neurologic abnormalities during the newborn period.12
Observations should be made with as little disturbance
to the infant as possible. Reflexes that require the greatest degree of
disturbance should be elicited at the end of the examination. Spontaneous
movements should be studied first. Infants who are generally depressed will
move very little or not at all and can be hypotonic. Drugs administered to the
mother are frequent causes of depression. These drugs include analgesics
(Demerol), hypnotics (barbiturates, magnesium sulfate, alcohol), and local
anesthetics (lidocaine). Central nervous system infections, bacterial or
nonbacterial, and metabolic disturbances (hypoglycemia, hypermagnesemia,
hypothyroidism) also cause depression. Trauma to the central nervous system,
(cerebral contusion, subdural hematoma) also causes diminished or absent
spontaneous activity.
Hyperirritability and exaggerated responses to
ordinary tactile or acoustic stimuli are abnormal. These responses may range
from agitation or jitteriness to frank convulsions. They may thus be manifested
as localized twitches, gross rhythmic repetitive jerks of one or more muscle
groups (myoclonus), or generalized clonic convulsions. There is little to be
gained in attempting to localize central nervous system lesions based on focal
convulsive phenomena, in the neonate, because of the lack of correlation. There
is also little use in attempting to differentiate between a severely agitated
state characterized by ceaseless movement and a frank convulsion. Usually they
are of equal significance. These irritative phenomena are most commonly
observed during recovery from an asphyxia event after a period of depression.
They also occur in infants of narcotic-addicted mothers (heroin or morphine
withdrawal) and among infants of mothers who are habituated on barbiturates
(phenobarbital withdrawal). Hypocalcemia, hypomagnesemia, and hypoglycemia may
cause irritative phenomena. Maternal administration of high doses of local
anesthetics such as lidocaine may initially produce depression which is
followed by convulsions. Intracranial hemorrhage and occasionally central
nervous system infection may produce irritative responses early in their
courses.
Asymmetry in movement of the extremities
indicates weakness, paralysis, or bone fracture. In brachial plexus palsy, for
example, the affected upper extremity is hypoactive or immobile. Failure to
move the lower extremities suggests a spinal cord injury. Asymmetry of movement
or tone in any extremity is always abnormal.
Muscle tone is extremely important in neurologic
evaluation. The normal infant maintains some degree of flexion in all the
extremities, and extension by the examiner is followed by at least a partial
return to the previous position of flexion. Flexion posture is less pronounced
in premature infants. Poor head control (described later) is additional evidence
of abnormally diminished muscle tone.
The evaluation of certain reflex responses is
essential for assessment of the infant's neurologic status. The grasp reflex is
normally strong in term infants. It is elicited by placing a finger across the
palm at the base of the fingers. In response, the examiner's finger may be
grasped so firmly that using both hands, the infant can often be raised from
the surface of the crib. This response is considerably more feeble in premature
or depressed infants. It is absent or weak on the affected side in Klumpke-type
brachial plexus palsy.
The rooting reflex is activated by lightly
stroking the angle of the lips. The baby turns his head to the stroked side.
Recently fed infants and those who are lethargic or depressed merely purse the
lips or do not respond at all. Vigorous infants turn the head briskly and
instantly, pursuing the finger as long as contact with the lips is maintained.
The suck is evaluated by inserting a sterile
nipple into the mouth. In normal infants, particularly those who are hungry,
the response is immediate, coordinated, and forceful. Recently fed infants,
premature babies, and those who are depressed respond with varying degrees of
feebleness.
The knee jerk is normally brisk. It is weak in
depressed infants, exaggerated to the point of clonus in irritated ones, and
asymmetrical in infants who have spinal cord lesions, fractures of the femur,
or bone and joint infection of the examined extremity.
Ankle clonus is elicited by placing two fingers
against the anterior sole of the foot and abruptly dorsiflexing it with a short
brisk movement. The response will usually consist of several repetitive jerks
(beats) of the foot or none at all. If more than eight to ten beats occur, the
infant is probably in an irritated state.
Head control in the normal neonate is more
effective than is generally realized. With the infant supine, the examiner
takes the wrists and lifts him slowly to a sitting position. The normal term
infant reinforces the maneuver by contracting the shoulder and arm muscles
followed by flexion of the neck. As the upright sitting position is reached,
the infant controls his head by action of neck muscles and prevents its head
from falling forward onto the chest. In many infants, the head falls forward but
is soon righted to the erect position. Hypotonic infants, such as those with
Down's syndrome, have little or no head control, and they do not respond to
traction by activating the muscles of the arms and shoulders. The neck is
extremely lax, and the head bobs in any direction. There is no attempt to
assume an erect posture once the head has fallen to either side or onto the
chest.
The Moro reflex is demonstrable in all normal
neonates. It is often erroneously elicited by slapping the bassinet or jerking it.
Some examiners abruptly pull a blanket from under the baby. Others lift the
infant slightly off the crib surface by the wrists and allow him to fall back.
The most consistent responses are obtained by holding the baby in a supine
position with both hands, one palm beneath the sacrum and buttocks and the
other moving the hand down from the occiput and upper back. By suddenly moving
the hand down from the occiput onto the back, the head is allowed to fall
through an angle of approximately 30 degrees, thus activating the Moro reflex.
The normal response is characterized by straightening the arms and elbows away
from the body and by extending the wrists and fingers. This is followed by
return of the upper extremities onto the chest in a position of passive flexion.
A cry often accompanies the baby's startled response. A rapid single movement
of the hips and knees occurs quickly and is of short duration. If an extremity
does not respond fully, a localized neurologic defect or fracture should be
suspected. Suboptimal vigor of the overall response occurs in depressed
infants, whereas in premature infants the response is disorganized and
incomplete to varying degrees.
The final impression of the infant's neurologic
status is formed with caution. The neonate's relative neurologic immaturity
makes it difficult to localize a disorder or, in many instances, to be certain
there is any disorder at all. The incidence of spurious signs is high.
Furthermore, repeated observations are indispensable because abnormal signs are
often transient, disappearing in a matter of hours. Extremes are seldom a
puzzle; the gross abnormalities and the unequivocal normal state cause little
difficulty. The in-between phenomena are notoriously troublesome in the
physical examination generally and in the neurologic evaluation particularly.
On first inspection of many small-for-dates
infants, several obvious physical characteristics immediately suggest the presence
of impaired intrauterine growth.13 In asymmetric growth retardation, one is immediately
impressed by the seemingly large head, but head circumference is actually
normal or nearly so; it is the chest and especially the abdominal
circumferences that are reduced. The head merely appears large for the body.
The brain is spared or less affected by the intrauterine insult, which probably
had its inception relatively late in pregnancy. Because the ratio of brain mass
to liver mass is high, hypoglycemia is likely to be present in such infants.
Diminution of subcutaneous fat and loose, dry skin are prominent. Even though
their skin appears pale, many of these infants are polycythemic; their venous
hematocrit may be greater than 60. In the extreme, muscle mass over the
buttocks, thighs, and cheeks is also diminished. Since body length is not as
diminished as subcutaneous fat, these infants often appear thin and long.
Longitudinal skin creases in the thighs indicate severe subcutaneous fat
depletion, in contrast to the horizontal thigh creases of the larger infant,
whose nutritional state is far better. The baby is wide-eyed, presumably as a
result of chronic hypoxiain utero. The abdomen is flat or sunken
(scaphoid), rather than rounded as in the better-nourished infant. At birth,
the umbilical cord is commonly thin, in contrast to the normal cords, which are
rotund, gray, glistening, and moist. Because all cords wither progressively
after birth, their condition after 24 hours of age is of little diagnostic
significance. Scalp hair is typically sparse. Skull sutures are frequently wide
as a result of impaired bone growth. The anterior fontanel, although large, is
soft or sunken, thereby ruling out increased intracranial pressure as a cause
of the widened sutures. Most of these infants are more active than expected for
their low birth weight. The vigor of their cry may be particularly impressive.
Often, an alert, wide-eyed facial expression is combined with repetitive tongue
thrusts that stimulate a sucking motion. The overall impression of vigor and
well-being is misguided, for these are the result of stress caused by chronic
hypoxia in utero. Many of these infants convulse 6–18 hours
later, particularly those whose anterior fontanel is firm owing to cerebral
edema from intrauterine hypoxia. In contrast, when perinatal asphyxia is
severe, the infant is depressed, appearing flaccid and lethargic.
Another type of growth restriction, symmetric
growth restriction, is seen in small-for-dates infants whose appearance is
quite different from that described above. These infants, whose insult probably
occurred early, do not appear wasted. They are diminutive, but the head and
body are of proportionate size. The skin is not redundant, but it is thicker
(the subcutaneous vascular patter is obscure or absent) than expected for
infants of the same size who are appropriately grown for their gestational age.
They are generally quite vigorous and are much less likely to be hypoglycemic
or polycythemic. These are hypoplastic babies in whom major malformations can
be present or in whom an early intrauterine infection occurred (rubella or cytomegalic
inclusion disease).
Two general types of fetal undergrowth are
identifiable by body measurement and by reference to intrauterine growth
curves. In asymmetric growth restriction, which is more common than symmetric
growth restriction, the insult seems to begin during the last trimester. These
babies have a head circumference and body length within the normal percentiles,
generally between the 25th and 50th, but their body weight is below the 10th
percentile. Associated maternal factors most frequently include toxemia,
chronic hypertension, and chronic renal disease. The second type which is
symmetric growth restriction probably begins early in pregnancy. It is
characterized by equally distributed reduction in head circumference, body
length, and weight. All these measurements fall below the 10th percentile (Table
2). Associated factors include intrauterine viral infection,
chromosomal disorders, major congenital malformations, genetically small but
otherwise well infants, and possibly maternal malnutrition.
Table 2. Clinical
differences between two types of intrauterine growth restriction
Symmetric |
Asymmetric |
Universal, proportionate diminution in size and weight;
percentiles of head, length, and weight are similar |
Selective, disproportionate diminution in size and weight;
percentiles of head and length normal but weight below 10th percentile |
Subcutaneous fat appropriate for size; skin taut |
Subcutaneous fat diminished for size; skin redundant |
Congenital malformation frequent |
Congenital malformation infrequent |
Intrauterine nonbacterial infection frequent |
Intrauterine, nonbacterial infection rare |
Hematocrit usually normal |
Hematocrit often elevated |
Hypoglycemia and hypoproteinemia uncommon |
Hypoglycemia, hypoproteinemia common |
Diffuse scalp hemorrhage is an infrequent
occurrence that is characterized by bleeding into the entire scalp or a major
portion of it. Loss of blood may be significant and even life-threatening if a
coagulation defect is present. It can be associated with vacuum assisted
deliveries. The most severe bleeding is associated with failure to administer
vitamin K at birth or with other abnormalities of the clotting process that are
unrelated to vitamin K deficiency, such as hemophilia (factor VIII deficiency).
Hemoglobin levels may fall as low as 3 or 4 g/100 ml. Immediate transfusion is
lifesaving. Scalp hemorrhage is cumulative over the first 24–48 hours.
Tremendous swelling of the scalp extends over the forehead and behind the ears,
and a characteristic blue discoloration is seen through the overlying skin. The
scalp swelling is not limited by suture lines as in cephalhematoma. The life
threatening nature of this condition requires its early recognition. Swelling
of part of the scalp and blue discoloration of the skin are the earliest signs
that indicate a need for immediate attention.
Subcutaneous fat necrosis is a localized lesion
produced by pressure against the bony pelvis or by forceps. It may also occur if
the infant is slapped vigorously in attempts to stimulate the onset of
respiration. The area of pressure necrosis varies in size, is sharply limited
by distinct margins, and is always firm. The overlying skin remains intact and
is occasionally blue or red. Subcutaneous fat necrosis may not be apparent for
a number of days after birth. The lesion resolves in a few days to several
weeks and is of no pathologic significance. It occurs most often in the face
but also over the back and shoulders, arms, thighs, and buttocks.
Skull fractures may be linear or depressed.
Linear fractures are asymptomatic unless the force that inflicts them also
ruptures underlying blood vessels to produce a subdural hematoma. Depressed
fractures are often self-correcting, but they may require surgical evaluation
if the depressed bone compresses underlying brain tissue. These fractures may
result from the forceps application or from severe contraction of the pelvis
associated with prolonged labor.
Cephalhematoma is a collection of blood from ruptured blood vessels situated
between the surface of the parietal bone and its tough, overlying periosteal
membrane. It is usually unilateral, but occasionally bilateral. Within 24–48
hours, an obvious swelling develops beneath the scalp over one or both parietal
bones. Rarely, the occipital bone is involved, and even more rare, the frontal
bone is affected.14 A cephalhematoma is delineated by margins. It does not cross
suture lines, being limited to an area overlying a single bone. In contrast,
the margins of caput succedaneum are indistinct, and the swelling usually
crosses suture lines. Cephalhematoma disappears gradually in 2–3 weeks. In a
number of instances, X-ray examinations reveal a linear skull fracture beneath
it. There are no known abnormal sequelae, whether or not a linear fracture is
present. Occasionally, however, and particularly if the lesion is bilateral,
hyperbilirubinemia may result from breakdown of the extravasated blood. Vacuum
extraction is associated with an increase in neonatal cephalhematoma and
retinal hemmorrhages.15
Fractures of the clavicle and humerus are the
most common long bone fractures. The clavicle is affected far more frequently
than the humerus. Each of these injuries is produced during difficult delivery
of a shoulder or upper extremity in vertex or in breech deliveries. The
incidence of trauma increases with an increasing birth weight. They are more
frequent among infants who weigh more than 4000 g. Clavicular fracture is
usually detectable during movement of the shoulder when a snapping sensation is
palpable over the involved bone. Spontaneous movement of the upper extremity
may not be restricted, and the Moro response may be normal. Fracture of the
humerus is suspected by diminished motion of the extremity, pain on passive
movement, and often by swelling and a grossly visible deformity. Spontaneous
motion of the involved extremity is diminished, and forced movement is painful.
Reduced motion and pain are especially prominent in fractures of the humerus.
Fracture of the femur is an infrequent injury
generally associated with breech deliveries. Swelling of the thigh and severely
restricted spontaneous motion of the extremity are characteristic findings.
Occasionally, the involved thigh is blue because of associated hemorrhage into
muscle and subcutaneous tissue.
Intracranial hemorrhage due to trauma usually
occurs in the subdural space, in the subarachnoid space, or into brain
substance. Periventricular-intraventricular hemorrhage, frequent in premature
infants, is not usually the result of trauma.
Most subdural hematomas are produced by
stretching and tearing of large veins in the tentorium cerebelli. The resultant
collection of blood is usually inaccessible to aspiration by subdural taps.
This type of subdural hematoma is caused by compression of the head in the
anteroposterior diameter with expansion in the transverse diameter and
consequent stretching of the dura. The danger of compression of the skull is
greatest when it is abrupt. Abrupt compression and release can occur during
precipitous labor and delivery. Occasionally the same type of stress is imposed
when forceps are applied. Less frequently, a subdural hematoma occurs over the
surface of the cerebral hemispheres when veins in the subdural space are torn.
In this location, the collection of blood can be evacuated by subdural taps.
Signs of subdural hematoma include separation of the sutures and tense bulging
of the anterior fontanel, convulsions, coma, and repeated vomiting. Death is
not uncommon if treatment is not instituted.
Spinal cord injury is a rare event that is
virtually restricted to difficult breech deliveries. The spinal cord itself is
relatively inelastic and does not comply to stretching, whereas the vertebral
column is quite compliant. Since the spinal cord is fixed to the vertebral
column, stretching of the latter results in tears of the cord or rupture of
vessels within the spinal cord. The type of paralysis that results is a
function of the level at which the cord is injured. Trauma to the lumbar area
is most common, producing paralysis of the lower extremities, bladder, and anal
sphincter. Laceration in the cervical region may cause total paralysis below
the neck. When injury to the phrenic nerve is included, paralysis of the
diaphragm follows, and normal establishment and maintenance of extrauterine
respiration is impossible.
Rupture of the corneal membrane (Descemet's membrane)
may be due to forceps injury. The healing process involves formation of a
persistent white opacity (leukoma). Edema of the cornea occasionally occurs
from normal pressure during the birth process. The resultant corneal haziness
disappears in several days.
Brachial plexus palsy is a frequent occurrence
that can be related to traumatic delivery. Paralysis of an upper extremity is
usually partial, rarely complete. In vertex deliveries, it results from stretch
injury to the brachial plexus when the operator laterally flexes the head
excessively toward one of the shoulders, damaging the brachial plexus on the
stretched side. It also occurs during breech deliveries when the extruded body
is flexed laterally just prior to delivery of the head. Usually the involved
nerve trunks become edematous with the edema resolving within days or weeks,
and the paralysis is typically only temporary. Paralysis may be permanent if
nerves are torn.
Brachial plexus injury occurs in two forms. One
type (Erb's paralysis) involves the nerve trunks of the brachial plexus that
emanate from its upper spinal roots (C5, C6). It is by far the most common
variety, primarily producing variable degrees of weakness of the shoulder and
arm muscles. Spontaneous activity of that extremity is reduced. The arm is held
close to the body, and the elbow is straightened in contrast to that of the
opposite, unaffected arm. When the infant is lifted and held in the supine
position, the affected extremity is limp, whereas the normal one is held in a
flexed position. In eliciting of the Moro reflex, the paralyzed arm responds
little, if at all, but the fingers extend almost normally. Involvement is
primarily at the shoulder and arm and not in the hand muscles. The second type
of brachial plexus injury is infrequent. Klumpke's paralysis involves the nerve
trunks that originate from the lower spinal roots that supply the brachial
plexus (C7, T1). Principal clinical involvement is therefore in the hands and
forearms. The fingers are relaxed, not fisted as is normal. The infant's Moro
reflex is characterized by active motion of the shoulder and arm. The upper
extremities extend and abduct normally, but the wrists and fingers remain
flaccid.
Facial paralysis occurs as frequently in normal
deliveries as in traumatic ones. It probably results from pressure on the
facial nerve at a point just posterior to the lower part of the earlobe, where
it lies close to the surface. This pressure is exerted against the maternal
bony pelvis during labor or by forceps application. Facial paralysis is easily
detected when the infant cries. The paralyzed side of the face is immobile, and
the palpebral fissure remains open. The muscles on the functional side of the
face contract, the eyes closes, and the lips deviate toward the normal side.
Facial paralysis usually disappears spontaneously in a few days.
Paralysis of the diaphragm (phrenic nerve palsy)
usually occurs in association with brachial plexus injury, rarely, occurring by
itself. It is caused by the same forces that are implicated in brachial plexus
palsy, but with additional involvement of the phrenic nerve at its origin from
the roots of the cervical cord.16 The phrenic nerve receives fibers from the third, fourth, and
fifth cervical roots. Because the phrenic nerve is the only one that innervates
the diaphragm, respiratory distress may be severe. In one report, death
occurred in 20% of affected infants by the third month of life. The diagnosis
of diaphragmatic paralysis is strongly suggested in an infant who has
respiratory distress and a paralyzed upper extremity. It is confirmed on X-ray
film of the chest in which the paralyzed diaphragm is abnormally high.
The liver is more susceptible to injury than any
of the abdominal organs. Injury is most likely in the presence of liver
enlargement (as in Rh disease, congenital nonbacterial infections),
particularly in large infants. Most often, the liver parenchyma is focally
crushed during the trauma.
In the case of subcapsular hematoma, blood
collects beneath the capsule gradually, over a period of 24–72 hours. The
infant may be pale because of the resultant blood loss and the liver seems to
enlarge progressively, and in some infants a distinct mass (the hematoma) is
palpable. At some point during the accumulation of blood, the liver capsule may
rupture abruptly. Shock and cyanosis appear rapidly, if abdominal distention is
severe. Often, the blood in the peritoneal space imparts a bluish hue to the
abdominal skin and even occasionally also involves the scrotum. Since affected
infants often have a disorder of blood coagulation, they must be identified
rapidly. Blood transfusion is lifesaving. Surgical repair of the liver trauma
is definitive.
The spleen ruptures far less frequently than the
liver. In most instance, enlargement of the spleen is present as a consequence
of disorders such as syphilis, Rh disease, or one of the nonbacterial
intrauterine infections. An enlarged spleen is considerably more fragile than
an enlarged liver. Rupture from trauma causes direct blood loss; since there is
no accumulation beneath the capsule. Loss of blood into the peritoneal space
produces signs of hypovolemia. Blood transfusion and surgery are urgently
required for neonatal survival.
Small focal hemorrhage in the adrenals is asymptomatic.
It is sometimes first perceived months or years later when X-ray film of the
abdomen reveals calcifications. Adrenal hemorrhage is most likely to occur in
large infants during a dystocic labor. It is probably more frequent in breech
deliveries.
Massive adrenal hemorrhage usually produces a
flank mass and sometimes a bluish discoloration of overlying skin. Hemorrhage
rarely extends into the peritoneal space, but blood may seep downward to
surround the kidneys, which can therefore seem to be enlarged to palpation.
Signs of adrenal insufficiency are infrequently
observed. These include vomiting and diarrhea, hypoglycemia, and early
hypokalemia soon followed by hypernatremia. In the extreme, shock, seizures,
and coma ensue. Without signs of impaired adrenal function, the hemorrhage
itself may produce pallor and cyanosis and, occasionally, fever. Surgery may
not be necessary unless the blood loss is particularly copious. Restoration of
blood volume and treatment of adrenal insufficiency are essential.