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Genetic
o Small maternal size
o Chromosomal abnormalities (Trisomies 13, 18, 21, and Turner's syndrome)
o Congenital abnormalities
Intrauterine infections
o Viruses (rubella, CMV, ?varicella, ?HIV)
o Bacteria (tuberculosis)
o Spirochete (syphilis)
o Protozoan (toxoplasmosis, malaria)
Inborn errors of metabolism
o Hypophosphatasia
o Leprechaunism
o Some amino acidurias
Environmental
o Drugs (heroin, methadone, ethanol, diphenylhydantoin)
o X-rays (therapeutic)
o Smoking
Asymmetric (HC = Len > Wt, Wt <10 %ile) -- 55% of SGA infants
Environmental
o Drugs (including ethanol)
o Smoking
Placental unit insufficiency
o Placental infarcts or chronic abruption, velamentous insertion, circumvallate
placenta, multiple gestation.
Skin: Color
Pallor - associated with low hemoglobin
Cyanosis - associated with hypoxemia
Plethora - associated with polycythemia
Jaundice - Elevated bilirubin
Slate grey colour - associated with methemoglobinemia
Lesions
Milia - pinpoint white papules of keratogenous material usually on nose,
cheeks and forehead, last several weeks.
Miliaria - obstructed eccrine sweat ducts. Pinpoint vesicles on forehead
scalp and skinfolds. Clear within 1 week.
Transient neonatal pustular melanosis - small vesicopustules, generally
present at birth, containing WBCs and no organisms. The intact versicle
ruptures to reveal a pigmented macule surrounded by a thin skin ring.
Erythema toxicum - Most common newborn rash. Variable, irregular
macular patches. Lasts a few days. Wright's Stain shows sheets of
eosinophils.
Cafe au lait spots - suspect neurofibromatosis if there are many large
spots.
Junctional nevi - if large numbers, suspect tuberous sclerosis, xeroderma
pigmentosus, generalized neurofibromatosis.
Neurological Exam
State of alertness: Check for persistent lethargy or
irritability.
Posture: In term infant, normal position is one with hips abducted and
partially flexed and with knees flexed. Arms are adducted and
flexed at the elbow. The fists are often clenched, with fingers
covering the thumb.
Tone: Support the infant with one hand under his chest. The neck
extensors should be able to hold the head in line for 3 seconds.
Should not have more than 10% head lag when moving from
supine to sitting position.
Newborn
3 months
Grasp
Newborn
3 months
1 month
Extensor plantar
Newborn
8-12 months
Placing/stepping
Birth
1-2 months
ATNR
Newborn
3 months
Red Reflex - Hold the ophthalmoscope 6-8" from the eye. Use the +10
diopter lens. The normal newborn transmits a clear red colour back to
the observer. Black dots may represent cataracts. A whitish color may be
suggestive of retinoblastoma.
Ears
Check for asymmetry, irregular shapes. Look for auricular or preauricular pits, fleshy appendages, lipomas, or skin tags.
Nose
Look for flaring of the alae nasi as a sign of increased respiratory effort.
Look for hyper- or hypo-telorism. Check for choanal atresia (CA) as
manifested by respiratory distress (neonates are obligate nose
breathers). A soft NG tube should be passed through each nostril to
confirm patency if choanal atresia is suspected.
Mouth
Observe the size and shape of the mouth.
Microstomia - seen in Trisomy 18 and 21.
Macrostomia - seen in mucopolysaccharidoses.
Fish mouth - seen in fetal alcohol syndrome.
Epstein pearls - small white cysts which contain keratin, frequently found
on either side of the median raphe of the palate.
Ranulas - small bluish white swellings of variable size on the floor of the
mouth representing benign mucous gland retention cysts.
Tongue: Macroglossia - Hypothyroidism, mucopolysaccharidoses
Teeth: Natal teeth - occur in 1/2,000 births. Mostly lower incisors. Risk
of aspiration if loosely attached.
Cardiovascular System
Measure heart rate, blood pressure in upper and lower extremities,
respiratory rate.
Abdomen:
Examine umbilical cord and count the vessels. Note color of cord.
Palpate liver and spleen. It may be normal for the liver to be about 2 cm
below the right costal margin. The spleen is not usually palpable; if the
spleen is felt, be alert for congenital infection or extramedullary
hematopoeisis. After locating these organs (checking for situs inversus),
palpate for any abnormal masses.
Genitourinary Exam
Kidneys: Examined by palpation. The kidneys should be about
4.5-5.0 cm vertical length in the full term newborn. The
technique for palpation is either a) one hand with four
fingers under the baby's back, palpation by rolling the
thumb over the kidneys, or b) palpate the left kidney by
placing the right hand under the left lumbar region and
palpating the abdomen with the left hand (do the reverse
for the right kidney).
Male genitalia: Term normal penis is 3.60.7 cm stretched
length. Inspect glans, urethral opening, prepuce and shaft.
Normally difficult to completely retract foreskin. Observe
for hypospadias, epispadias. Inspect circumcised penis for
edema, incision, bleeding. Full term infant should have
brownish pigmentation and fully rugated scrotum. Palpate
the testes.
Female genitalia: Inspect the labia, clitoris, urethral opening
and external vaginal vault. Often a whitish discharge is
present; this is normal, as is a small amount of bleeding,
which usually occurs a few days after birth and is
secondary to maternal hormone withdrawal. Hymenal tags
may be present normally.