Neonatal Examination

The goal of initial care after delivery is to ensure optimal conditions for postnatal adaptation and perform initial neonatal examination:

  • bonding (mother – newborn) => important for lactation and neurodevelopment
  • breastfeeding (suck reflex)
  • prevent heat loss
  • care for the umbilical cord
  • temperature measurement
  • birth weight (and length)
  • Crede procedure (preventing gonococcal conjunctivitis)
  • medical documentation and newborn ID

NEONATAL EXAMINATION

Detailed clinical examination focuses on evaluating successfulness of postnatal adaptation, current status and diagnosing congenital anomalies; it involves analysis of obstetric and prenatal data. The conclusions of the examination (physiologic or pathologic newborn, any specific disorder that requires external specialist) determine the subsequent actions and transport of a newborn to either physiologic ward or neonatal intensive care unit.

Conditions requiring a Neonatologist to be present

NEUROLOGICAL EXAMINATION

Neurologic status of a newborn differs significantly from the adults due to its anatomical and functional immaturity (even more so in preterm infants). The optimal timing of neurological examinations derives from the various degrees/states of alertness (Prechtl – 5 states, Brazelton – 6 states):

  • deep sleep: non-REM; lies quietly; eyes firmly closed; deep breathing, no motor activity
    → growth hormones are active
  • active (light) sleep: REM; moves while sleeping; startles at noises; eyes firmly closed, but there may be slow rotating movements of the eyes = REM (rapid eye movement); bodily twitches and irregular or shallow breathing may be apparent
    → brain growth and differentiation may occur during active sleep
  • drowsy state: eyes may open and close, but look glazed in appearance; breathing is regular but faster and shallower than in sleep
  • awake, alert state: body and face are relatively quiet and inactive with bright shining eyes; sights and sounds will produce predictable responses
    → baby is most amenable to play
  • alert, but fussy state: transitional state to crying; available to external stimuli and may be soothed or brought to an alert state by attractive stimuli
  • crying: cries, screams (different types of cries communicate hunger, pain, boredom, discomfort and tiredness)
    → the most effective mode for attracting a caregiver

The most optimal state of alertness for neurological examination is the awake, alert state. For preterm infants, the optimal timing of the exam is as close to the term as possible, however, should the need arise, the infants can be examined at any time (suspected seizure activity, genetic syndrome, etc)

Posture

  • supine position with flexion of upper (elbow) and lower (hips, knees) extremities, closed fists due to flexor hypertonia (more apparent in term than in preterm infants)
  • asymmetrical posture (“fencing reflex”) due to asymmetrical tonic neck reflexes => when the face is turned to one side, the arm and leg on the side to which the face is turned extend and the arm and leg on the opposite side flex

Muscle tone

  • preterm infants with “physiologic” hypotonia => the muscle tone increases in the caudo-cranial direction with advancing gestational age (term infant presents with flexor hypertonia – see above)
  • Alterations to muscle tone due to:
    brain injury (perinatal asphyxia, hemorrhage, meningitis)
    nerve damage (birth injury)
    electrolyte dysbalance
    inherited metabolic disorders
    genetic syndromes (trisomy 21)
    myopathy

Primitive reflexes

  • inborn, unconditional, primitive, neonatal reflexes
  • rooting => suck => swallowing reflex, Moro and grasp reflex
  • automatic walking reflex, stepping reflex
  • primitive reflex usually die off around 2-3 months of agepathological persistence of reflexes after this time or pathologic absence of reflexes during the time when they should be present

Spontaneous movements

  • intensity and symmetry of movements
  • hypoactivity (sleep, sedatives, neurological injury)
  • hyperactivity, irritability (hypoglycemia, hyperthermia, pain, intracranial hypertension in meningitis or intraventricular hemorrhage, neonatal abstinence syndrome)
  • asymmetry (paresis, painfulness)

REFERENCES

① Parish E, Tailor R, Gandhi R. How to conduct a newborn examination. BMJ. 2018;360:j5726. Published 2018 Jan 15. doi:10.1136/sbmj.j5726