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

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

Preterm delivery
Breech delivery
Cesarean section (C-section)
Instrumental delivery (Forceps; Vacuum extraction)
Multiple Birth
Intrauterine growth restriction
Perinatal asphyxia
Congenital malformation

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 age – pathological 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

Neonatal examination