Before starting newborn screening, Vital signs should be checked first, especially heart rate and breathing rate.
- The normal heart rate for an adult is 60-100 beats per minute. The normal heart rate of newborns is much faster at 100-160 beats per minute.
- When a child is in deep sleep, his heart rate drops to 80-100 beats per minute
- Respiratory rate refers to the number of breaths a child inhales in one minute. In their first days, babies have a unique breathing pattern known as cyclic breathing, which results from the immaturity of the respiratory center in their brains.
- Cyclic breathing means that the child breathes rapidly several times, Then it slows down several times, Then it stops briefly before starting again, The pause duration can be up to 15 seconds.
- The normal respiratory rate for newborns is (30 – 60) breaths every minute in the resting position.
- When a baby cries, his breathing rate will increase.
- In the first period of birth, we worry about whether the temperature rises or falls. But after the first three days we become more concerned with high temperature or fever.
- The normal temperature for newborns in the first three days of birth ranges between (36.5 – 37.5) degrees Celsius or (97.7 – 99.5) degrees Fahrenheit.
- After the first three days a fever is defined as 38°C or 100.4°F and above.
- Blood pressure in newborns is usually not checked because it is technically difficult to measure. Instead, the time for capillary refilling is checked by using a finger to press the skin above the sternum (breastbone) until the skin turns white. Then the finger is lifted and the time required until The area turns pink again. This will usually take 2 seconds or less.
General assessment of the child:
This includes (weight, Measure the height, Head circumference) to ensure the baby’s size is within the normal range and in good proportion.
How is a child evaluated according to his appearance?
- If his weight and size are good, this indicates that he was born after a full pregnancy.
- Bending his arms and legs during a resting position indicates that he has good muscle tone, which indicates the maturity of his nervous system.
- At three days old, most newborns will have some jaundice. This does not mean that their condition is dangerous or that they need treatment unless the level of bilirubin in the blood is checked.
- Often, In the physical examination of the newborn on its first day, There may be blueness around the lips or fingers and toes, and this is nothing to worry about. In fact, when a child is born, his entire body is not one color (pink). Usually there is blueness or whiteness during the first few minutes, The baby’s color will then turn to its normal color, starting from his lips and the center of his chest. The limbs will take a little time to acquire their normal color because the heart, brain, and lungs have priority.
- By 24 hours of age we expect the toes and hands to have acquired their normal colour.
- The child’s continued presence of blueness in the lips indicates low oxygen.
To complete the general assessment, we look for signs of shortness of breath:
- Shortness of breath is the most common problem after childbirth. It could be a sign of natural transmission or an indicator of the disease, The most sensitive indicator of lung problems is tachypnea
- It is easy to see the breathing movements on the baby’s chest and the breathing rate can easily be calculated.
Heart examination in the child:
In order to examine the child’s heart, four different areas must be listened to: Each area reflects sounds coming from one of the heart valves.
- The right upper border of the sternum is the area of the aortic valve.
- The upper left border of the sternum is the area of the pulmonary valve.
- The lower left border of the sternum is the area of the tricuspid valve.
- The apex reflects the mitral valve.
- It is common to hear a benign heart murmur when examining the baby as he moves from the fetal stage to the newborn. The cardiac bypasses will close and the heart will begin pumping half the amount of blood to the lungs. By the second day, this process will be complete. The heart murmur will be weak or disappear completely. Any murmur that appears after the first day should be looked into. seriously.
- We begin by listening with a stethoscope for breath sounds on the right side of the chest and listening to the back.
- We hear from side to side to compare sounds
- If we notice after examining the lung that the breathing sounds on the right side are much louder than the sounds on the left side, this indicates a “pneumothorax,” which occurs when air leaves the lung and accumulates in the area between the lungs and the chest wall. This condition may be more evident in children, but in newborns we need to examine with a chest x-ray to confirm the condition due to the small chest of the newborn and the thinness of his chest wall.
- We may hear abnormal, harsh breathing sounds, indicating fluid or infection in the lungs.
Ensure that the spine is straight:
It is very common for infants to have a very small cavity at the base of the spine called the sacral commissure. In most cases, This cavity does not cause any problems. sometimes, A deep sacral cavity may indicate a problem in the lower part of your child’s spinal cord. This can affect nerve function in this area.
If the child has a deep sacral cavity, It will be verified that he does not suffer from other symptoms such as leg weakness, And cold and blue feet, And urinary incontinence.
Examination of the legs and thighs:
Since the baby cannot walk on his feet at birth, His feet are often in an unusual position.
- If we scratch the side of the foot from the heel to the little toe, The child will move his foot to the natural position. As long as the child can do this, the foot is healthy.
- By pressing firmly on the sole of the child’s foot with the thumb directly under the toes, He will automatically bend his toes downward and this is called the plantar reflex.
- If we scratch the sole of the foot from the heel to the toes, He will spread his fingers apart, This is called the Babinski reaction.
- In order to look at a newborn’s legs, we have to spread them. Make sure they are approximately the same length. The legs are often bent as a result of the fetus’s position inside the uterus. Once the child begins to stand on his feet, his feet will straighten.
- There is an area in the upper thigh called the femoral triangle consisting of:
- The inguinal crease: It is a fold in the skin between the leg and the trunk, and it forms the upper side of the triangle. The long side of the triangle is represented by a muscle known as the sartorius muscle, which crosses diagonally from the hip to the top of the knee.
- The last side of the triangle is another muscle called the adductor longus.
- There are many important organs that pass through this area, starting from the hip and moving towards the inner leg, which are: (femoral nerve, Then the artery, Then the vein, Then the lymphatic vessel.
- If the femoral artery pulse is strong, this indicates good blood flow to the child’s legs. This examination is not useful if the legs are bent. It must also be returned during the first years of its life.
- If the femoral artery pulse is not palpable or weak, There may be a possibility of aortic stenosis. Children who suffer from aortic stenosis need surgical intervention to correct the problem.
Examination of the hips:
- The newborn baby’s hips must be examined to ensure that he is safe from hip dysplasia through the Ortolani maneuver.
- The Ortolani test is a medical test intended to examine the stability of the hip joint in children, and it is considered one of the important steps in this examination. The test is performed by bending the knee and hip joints to a degree of (90) without changing the position of the leg. Then the examiner holds the knee joint with his hand so that the middle finger falls on the great trochanter of the femur and pushes it in the dorsal direction and in an adduction position, with the hips separated and moving in a lever motion over the trochanter in the ventral direction. If the hip joints are healthy The examiner does not feel any changes by palpation, while a slight instability leads to hearing a ticking sound.
- It is necessary to recognize this defect in the newborn period because the child is still flexible and can be treated using a comfortable and appropriate brace to return the femur to the correct position. Failure to properly diagnose it will lead to joint damage and thus permanent lameness and pain.
- While examining the hips, it is common to feel increased movement and some clicking, which is a reaction to pregnancy-related hormones (relaxin).
Examination of umbilical cord remnants:
- In newborns, an umbilical hernia can occur where part of the intestine exits through a hole in the abdominal wall created by the umbilical cord (umbilicus). This condition is usually not a problem and usually goes away by the age of 4 years.
- It is possible for infection of the umbilical stump to occur, which is called omphalitis, and it spreads quickly, so it is considered dangerous and causes damage to the skin in the area surrounding the abdominal wall, along with heat, redness, and swelling of the skin surrounding the umbilical stump.
- The organs in the baby’s abdomen are examined to detect masses and enlarged organs. We place the child lying on his back with the legs bent at the knees and hips toward the abdomen. This position softens the abdominal muscles.
- A baby can be born with small lumps in the breast tissue due to exposure to the mother’s hormones before birth. These tissues disappear with the disappearance of hormones.
Clavicle and neck bones:
- The clavicle is the bone most vulnerable to fracture during childbirth, and at that time a crack can be felt above the clavicle, as a result of the accumulation of air resulting from the fracture.
- The second most vulnerable bone to fracture is the humerus (the long bone in the upper arm). If there is a fracture in this bone, the infant will not move his arm and will cry when touched.
- Both injuries result from the shoulders tripping in the birth canal after the baby’s head emerges.
- An examination of the newborn’s neck can reveal the presence of masses resulting from the development of the fetus. They are often not serious but must be removed surgically.
- In adults, the skull consists of one bone, but in newborns the situation is different. Their skull consists of four separate bones.
- Sutures are the lines where bones meet and their intersection creates the fontanel or soft spot.
- The skull bones should not be fused during birth in order to facilitate their compression and passage into the birth canal.
- If the position of the ear is very low and tilts back towards the back of the head, this is not a normal position. We see it with some congenital syndromes.
- The presence of boils, which are skin growths in front of the ears or on the outer ear, may indicate hearing loss.
Examination of the nose and airways:
- There are many techniques to ensure that the internal and external passages of the child’s nose are open, One of them is to monitor the infant during breastfeeding. If the baby is able to breathe comfortably with his mouth full during feeding, his nose is unlikely to be blocked
- Several abnormalities may be encountered. Such as:
- hard cleft palate, It is very noticeable while looking at the newborn’s mouth
- Cleft lip
- Soft cleft palate: When we cannot see the uvula, this is an indication of the presence of a soft cleft palate that can interfere with eating.
Red light reflex check:
- Red light reflex is the test that is tried to screen for congenital cataracts. It is done using an ophthalmoscope, It is a magnifying instrument equipped with a bright light.
- In the case of children or adults, eye drops are given to dilate the pupil. Then conduct an examination and diagnosis.
- In newborns, the light is brought closer to the side so that the pupil is wide open.
Prepared by: Dalal Edriss
University of Colorado System