THE IMPORTANT MEASUREMENTS

HEAD CIRCUMFERENCE

Normal measurement: 33 to 35 cm (13 to 14 inches). In vaginal delivery, molding may reduce head circumference (HC) immediately after birth but it will return to normal size after two to three days. The HC is actually the occipitofrontal circumference (OFC).

Comparison to other measurements:It is approximately equal to crown-rump length (CRL) or sitting height which is about 31 to 35 cm in term infants. The relationship of HC to CRL is more reliable in identifying in high risk infants than that of the head and chest.The HC is usually greater than chest circumference (CC) by 2 cm.The head is one fourth of the total body length; this is because the head of the newborn is proportionately larger than the head of the adult

During the first four months, HC increases by half an inch a month and in the next 8 months, by one fourth inch a month.

Measure HC at the level of eyebrows to the most prominent portion of the infant’s head with the use of a tape measure. Measure it after birth, then after 48 hours because molding and caput succedaneum may misshape the head making the first measurement inaccurate.

Take note of the following changes in the head circumference:At birth HC may be equal or greater

than CC due to molding.After 2 to 3 days, HC is greater than CC

by 2 to 3 cm.After six months, HC is equal to CC.After 1 year, HC is less than CC.

. Abnormal findings:HC less than 32 cm is indicative of

microcephaly in term infants.HC that is 4 cm and greater than

CC or more than 37 cm is indicative of neurologic involvement such as hydrocephalus.

 

CHEST CIRCUMFERENCENormal CC range from 30.5 to 33 (12 to 13 inches), usually 2 cm less than HC.The CC is measured at the level of the nipple using a tape measure.A CC less than 30 cm indicates prematurity. An enlarged heart may make the left side of the chest larger.

ABDOMINAL CIRCUMFERENCE

Abdominal circumference (AC) is approximately the same as chest circumference.It is measured just above the level of the umbilicus. It is no longer recommended to measure AC below the level of the umbilicus because a full bladder may interfere with accurate measurement.

AC is not routinely measured unless there is a suspicion of abdominal distention due to obstruction in the gastrointestinal tract. The neonate’s abdomen usually enlarges after a feeding due to lax abdominal muscle.

WEIGHTBirth weight of full term newborn infants range from 6 to 8.5 lbs. or 2700 to 4000 g. Average is 3500 g. Birth weight should be recorded immediately after birth because weight loss occurs rapidly in newborns.The average female infant birth weight is around 7 lbs. while that of male infant is around 7.5 lbs. Boys is usually heavier than girls by 100 g or 3 ounces. The average birth weight of Filpino infants is 3000 grams.

Physiological Weight Loss – Newborns loss about 10% (6 to 10 oz) of their birth weight during the first 3 to 4 days of life due to: Excretion of fluids through the lungs,

urinary bladder and bowels Passage of meconium Withholding of calories and fluids

immediately after birth Minimal food intake because sucking is not

yet established and colostrum contains less calories than mature milk

Weight Gain Generally, breastfeed infants regain their

birth weight within 10 days and formula fed infants within 7 days.

Birth weight doubles at 5-6 months and triples at one year. By 2 years of age, expected weight gain is four times the birth weight.

Infants generally gain approximately 20 to 25 grams per day or 150 to 210 g weekly during the first five months of life. And about 15 grams (6 to 8 oz weekly) from 6 months to 1 year.

Keep in mind the following changes in weight of different ages:5-6 months --- 2X birth weight1 year --- 3X birth weight2 years --- 4X birth weight3 years --- 5X birth weight5 years --- 6X birth weight7 years --- 7X birth weight10 years --- 10X birth weight

Computation of Expected Weight Gain:

Term infants = (age in days – 10) X 20 + 3000 grams10 – Term infants takes 10 days to regain birth weight20 – A weight gain of 20 grams/day is expected during the first 5 months

Computation of Expected Weight Gain:

Pre-term infants = (age in days – 14) X 1514 – Pre-term infants takes 14 days to regain their birth weight15 – Amount of weight gain each day

Computation of Expected Weight Gain:

infants below 6 months old:Weight in grams = age in months X 600 + birth weight

6 months to 12 months:Expected weight in pounds = Age in months + 10Weight in grams = Age in months X 500 + birth weight

Computation of Expected Weight Gain:

1-6 years: weight in kg = age in years X 2 + 86-12 years: weight in kg = age in years X 7 – 5

2

When assessing birth weight, remember that:a.Birth weight is affected by race, nutrition,

intrauterine conditions and genetic factors.

b.Birth weight increases with each succeeding child in the family.

c.Plotting birth weight in a neonatal graph helps to identify newborns at risk because of their small or too large size.

d. Weight should be compared with height and head circumference to see any disproportion that indicates risk conditions. For example, a child’s head circumference may be too large for his birth weight and height causing the caregiver to suspect for possible hydrocephalus.e. The infant should be weighed not wearing a diaper. If a diaper is in place, subtract the weight of the diaper from the total weight.

f. The same weighing scale should be used every time the infant’s weight is measured to prevent inaccuracies.g. If the infant is being weighed on a bed that has a built-in scale:It is important to remove any extra sheets, toys or

diapersWhen weighing the critically ill neonate, lift the

intravenous infusion lines, as well as other pieces of equipment such as ventilator tubing, so they do not cause an inaccurately high weight

Abnormal Findings:Birth weight less than 1000 grams for term

infants is considered extremely low birth weight

Birth weight less than 1500 grams in term infants is considered very low birth weight

Birth weight less than 2500 grams for term infant is called Small for Gestational Age (SGA) infant in term infants.

Birth weight more than 4000 grams is known as Large for Gestational Age (LGA) infant. Infant may be born of a diabetic mother.

Weight loss of more than 10% of birth weight.

CONVERTING grams to pounds and ounces:

1 lb. = 453.59237 grams1 oz. = 28.349523 grams1000 g = 1 kg

LENGTH1.Newborn average head to heel length is 45 to 55 cm

(18 to 22 inches)2.Average is 50 cm.3.Female infants generally are 1/2 inch shorter than

male infants. The average length of boys is 20 inches or 50 cm and girls, 19.6 inches or 49 cm.

4.The height or length of the newborn increases by 2.5 cm or 1 inch a month from 1 to 5 months and 1.25 cm from 6 months to 1 year.

Remember that similar to weight, the rate of growth diminishes as the infant grows older. Total average increase in length during the first year of life is 25 cm distributed as follows:From birth to 3 months – 9 cmFrom 3 to 6 months – 8 cmFrom 6 to 9 months – 5 cmFrom 9 to 12 months – 3 cm

Formula for expected height: Height in cm = age in years X 5 + 80Height in inches = age in years X 2 + 32 ORHeight in inches = age in years X 2 ½ + 30

Remember that:

At 1 year – 30 inches of 1 ½ birth length2 years – ½ of mature height in boys3 years – 3 feet tall4 years – 40 inches or 2X birth length13 years – 3X birth length

Measure newborn length from top of the head to heel using a tape measure. Extending the neonate’s leg to its fullest extension and then recording the length from crown of head to heel is the most accurate way to measure length. One person should hold the infant’s in place while the other completes the measurements.

An adjunct to crown-heel measurement is the crown-rump measurement. This particular assessment is useful in determining anatomical abnormalities such as dwarfism.

A length of less than 47 cm is a sign of prematurity.

VITAL SIGNS

It is recommended that the newborn vital signs are measured:

On admission to the nurseryEvery 30 minutes until the condition of the

newborn is stable for at least two hoursEvery eight hours until discharged

TEMPERATURECharacteristics of Newborn Temperature1. Heat regulation is the second most important task a

newborn must achieve after birth. Heat regulation is achieve by maintaining a balance between heat loss and heat production.

2. The average newborn temperature at birth is around 37.2ºC. It is not unusual for the temperature to fluctuate during the first few hours after birth due to immature temperature regulating mechanism but it should stabilize within 10 hours. If chilling is prevented, newborn temperature stabilizes within 4 hours after birth.

3. The average newborn axillary temperature – average 37ºC. Rectal temperature is 0.2 to 0.8ºC higher.

4. Heat loss in newborns occur in four ways:Convection – the flow of heat from body surface to

the cooler surrounding air. Air conditioner and drafts cause heat loss by convection so keep newborn warm by wrapping her in warm blanket and by maintaining nursery ambient temperature at 24ºC or 75ºF.

Radiation – transfer of heat to cooler objects or surfaces not in contact with the body. Cold window surfaces or examining tables although not in contact with the newborn but located near the newborn creates heat loss by radiation. This type of heat loss can be prevented by moving the newborn away from cold objects.

Evaporation – loss of heat due to conversion of liquid to vapor. Wet newborns loss a great amount of heat when the amniotic fluid in their skin evaporates. Wipe newborn dry immediately to prevent heat loss by evaporation.

Conduction – loss of heat by way of cooler surfaces in contact with the body. This occurs when newborn is placed on a cold crib, weight scale or counter.

Newborns loss heat easily because:a.They have immature temperature regulating system.

In fact, they are not capable of shivering (employed by adults to increase metabolic rate to be able to produce more heat).

b.Of very little amount of subcutaneous fat to provide heat in their body.

c.They have a larger body surface area that results in more heat loss. Newborn loss heat four times than the adult for this reason.

a. They have little ability to conserve heat by changing posture and no ability to adjust own clothing in response to thermal stress.

b. They tend to take on the temperature of their environment; this means that newborns can become hypothermic or hyperthermic easily depending on the temperature of the environment. For example, exposure to cold environment can cause cold stress (hypothermia) which can lead to metabolic acidosis, this can be lethal even to normal newborn infants. The neonate increases metabolic rate to produce heat when exposed to cold. This requires oxygen and glucose. Too much cold exposure depletes oxygen and glucose in the body resulting in acidosis and hypoglycemia.

Newborns can conserve heat by:

a.Constricting blood vesselsb.Moving blood away from the skinc.Burning brown fat which is most abundant in

the intrascapsular region, thorax and perineal area

Newborn produced heat by:

a.Increasing muscular activity such as by kicking and crying which also increases metabolic rate and respiratory rate. Immature newborn with poor lung development may not be able to use this mechanism of heat production.

a.Burning brown fat – present only in newborns, begins to form at 17 weeks of gestation, the less mature the infant the less brown fat.

c. Increasing metabolic rate which consequently increases the need for oxygen. Inability to meet this increased oxygen requirement could lead to hypoxemia (decreased amount of oxygen in the blood) because oxygen is being utilized for heat production. The shivering mechanism in infant is underdeveloped

Baby’s temperature can be assessed with reasonable precision by touching with dorsum of hand over the abdomen, hands and feet.

In newborn, abdominal temperature is representative of the core temperature.

When feet are cold and abdomen is warm, it indicates that baby is in cold stress.

In hypothermia, both feet and abdomen are cold to touch(Taken from: Essential Newborn Nursing for Small Hospitals Learner’s Guide, WHO Collaborating Centre for Training and Research in Newborn Care, All India Institute of Medical Sciences, New Delhi, 2004)

Method of Temperature Assessment1.The method of choice when obtaining the

temperature of the children below 6 years old is the axillary because it is safer, more accessible and convenient. Place the thermometer in the axilla for 5 minutes and hold the hands over the abdomen to keep the thermometer in place.

2. In the past the initial temperature of the newborn is taken rectally to assess patency of the anus at the same time. Nowadays, waiting for the passage of meconium within the first 24 hours after birth is the preferable method of assessing anal patency.3. The glass mercury thermometer is still considered as the gold standard in taking the newborn temperature. It should be placed5 minutes when taking axillary temperature and for 3 minutes when taking rectal temperature.

4. When taking newborn temperature, it is important to remember that radiant warmer may falsely increase axillary temperature and crying may slightly increase body temperature.

Physiologic Fever 1.Transient fever on the 2nd to 4th day usually

occur secondary to fluid loss and poor intake of milk because of inability to suck well.

2.This is characterized by sunken fontanel, dry skin and decreased urinary output. The infant recovers from this fever once fluid intake is increased and feeding is established.

Hypothermia

1.Hypothermia occurs when the body temp. drops below 36.5 ºC. The newborn infant is most sensitive to hypothermia during the stabilization period in the first 6-12 hours after birth.

2.Effects of hypothermia: Acidosis – increased metabolic rate results in

increased production of carbon dioxide and metabolic waste products results in acidosis.

Hypoxemia – oxygen is utilized for increase metabolism in order to produce more heat instead of being used for oxygenation of cells and tissues.

Hypoglycemia – increased metabolic rate increase glucose utilization resulting in depletion of glucose stores and lowering blood glucose levels.

Water is used to lower body temperature but in an effort of the body to prevent heat loss, there occurs renal excretion of water and solute to prevent more heat loss thus depleting fluid stores in the body and altering the fluid and electrolyte balance.

3. Important immediate interventions for hypothermia include: Inform the doctor immediately Remove the wet cloth Place the baby under the heat source Encourage breastfeeding Start oxygen administration if the baby has

respiratory distress or cyanosis

Due to risk of burning the neonate, avoid using hot water bottle for (re)warming the baby.

Hypothermia and hyperthermia (above 37.5ºC) can be both sign of sepsis. If the newborn has been in a stable temperature environment with fairly constant temperature readings but begins to have fluctuating temperature readings (low, high or both), inform the doctor for evaluation.

Hyperthermia

1.The newborn is also at risk of hyperthermia which is a temperature above 37.5ºC. Although not as common as hypothermia, hyperthermia can be as equally dangerous.

2.Common causes of hyperthermia: Too hot external environment Too many covers or clothes on baby Infection

 Signs and Symptoms of hyperthermia: Irritability, fussy Abdomen and extremities are very warm to

touch Red flushed skin Hot and dry skin Lethargy Stupor, coma, convulsion for temp above 41ºC

Interventions for hyperthermia: Place the newborn in a cool environment (25

to 28ºC), and keep away from sources of heat such as direct sunlight

Undress the newborn partially or fully, if necessary.

Give frequent breastfeeds. Measure the newborn’s axillary temp every

hour until it is in normal range.

If the body temp is very high (>39ºC), sponge the baby with tap water. Do not use cold or ice water for sponge

If the newborn has been under the radiant warmer reduce the temp setting until temp becomes normal

Examine the infant for infection

RESPIRATORY RATECharacteristics of Newborn Respiration:

1.Range from 30 to 60 breaths per minute2.Respiratory Rate (RR) slows down during the

infancy period3.The respiratory environment is abdominal or

diaphragmatic in nature, the chest and abdomen should rise at the same time, and this is carried on during the infancy period.

1.Periodic respiration – With short periods of apnea, should not be longer than15 seconds and not accompanied by cyanosis

2.Loud and clear upon auscultation3.Respiration is irregular and shallow4.RR increases with sensory and tactile

stimulation

1.Newborns are obligate nose breathers. Unlike the adult, the newborn does not open his mouth to breath through it when the nose is obstructed. Keep nose clean and patent.

2.Infant is more at risk to develop infection than the adult because:

Inability to produce IgA in the mucosal lining

Short and straight eustachian tube can easily transmit infection from the pharynx to the middle ear

Closeness of the trachea to bronchi and its branching structures can easily transmit infection

Signs of Respiratory Distress:

1.Nasal flaring2.Chest retraction, indrawing of the chest when

breathing3.See-saw respiration – indrawing of the chest

and rising of the abdomen during inspiration.

1.Cyanosis other than the hands and feet. Cyanosis of the hands and feet should disappear when the infant cries. If the infant turns blue while crying, this is abnormal.

2.Respiratory grunting – noisy respiration3.More than 50 (tachypnea) and less than 30

(bradypnea) breaths per minute. Anaesthetics and analgesics given to the mother during labor tend to slow down respiration of the newborn because of their depressant effect.

1. Adventitious Chest Sounds in newborns: Rhonchi – a coarse snoring sound caused by air passing

through mucus in a major air passage, this is usually normal during the first 24 to 48 hours in a newborn infant

Rales – crackling sound caused by air passing through the fluid filled alveoli. It may be a manifestation of unabsorbed lung fluid and pneumonia

Stridor – a high crowing sound (rooster-like) heard on inspiration caused by narrowing of the air passages. It may be a sign of beginning obstruction.

Wheezing – a whistling sound heard on inspiration caused by air being pushed through narrowed bronchioles. May be a sign of obstruction.

Grunting – a grunt heard on inspiration caused by air pushed through a partially closed glottis. May be a sign of respiratory distress syndrome.

Absent/diminished breath sounds occur when air is not entering a lung or lobe of a lung on one side. May be a sign of atelectasis.

HEART RATE1.Full term infants have heart rate that ranges from

120 to 150 bpm approx. the same as FHR. It may go down as slow as 80 bpm when infant is asleep and may go up to as high as 160 bpm when he is vigorously crying. It slows down during infancy period

2. Rhythm is char. as sinus arrhythmia, rate increasing with inspiration and decreasing when expiration.

3. Newborn heartbeat is often irregular and heart murmurs may be heard until 6 months of age.4. Take apical pulse and respiratory rate first while he is asleep to obtain accurate results. Take temp last as the infant may struggle with the placement of thermometer in the axilla.

BLOOD PRESSURE1.BP at birth is approx. 80/40 mmHg rising to 100/50

mmHg by the 10th day of life. In the 1st week of life, BP may be slightly higher in lower extremities than the upper.

2.Pulse pressure is obtained by subtracting the diastolic pressure to the systolic pressure. For the term infant a wide PP is 25-30 mmHg and in pre-term, is 15-25 mmHg

3.BP is not routinely measured in newborns unless a cardiac anomaly is suspected or present.

4. Systolic pressure increases during the first 2 months and diastolic pressure during the first 3 months before gradually rising again.5.Abnormal finding: Calf systolic pressure 6-9 mmHg than systolic pressure in upper extremities may be indicative of coarctation of the aorta.

HEAD

The newborn’s head is disproportionately larger than the body because it is about one fourth of the total body length compared to being one eight only in adult.

FONTANELS1. Fontanels, also known as soft spots, are spaces located at

the areas where skull bones meet. The most prominent fontanels that are important to assess are the:

Anterior Fontanel (Bregma) – located at the junction of the two parietal bones and fused frontal bones. It is diamond shaped, about 3 cm long and 2 to 3 cm wide. The anterior fontanel closes at 12 to 18 months of age.

Posterior Fontanel (Lambda) – located at the junction of parietal and occipital bones. Begins to close at 2 months of age. Measures at about 0.5 to 1 cm in length. It may be so small in some newborns that it cannot be felt.

Fontanels are usually flat, soft and firm and may pulsate. They tend to bulge when the infant strains when passing stool, crying vigorously or coughs.

 Abnormal Findings:Very large fontanels may indicate

hypothyroidismBulging fontanel may indicate increased

intracranial pressureSunken fontanel is a sign of dehydrationAbnormally small fontanels or suture lines

that do not override or have spaces

SUTURE LINESSutures or suture lines are membrane covered spaces between skull bones. The four suture lines that can be palpated are:

1.Frontal Suture – can be palpated midline above the eyes running up the forehead and ending at the anterior fontanel.

2.Coronal Suture – can be palpated from the anterior fontanel running down the side of the head along the forehead line towards the ears.

3.Sagittal Suture – can be palpated running midline between the anterior and posterior fontanel.4.Lambdoid Suture – can be felt from the posterior fontanel running down the head above the occiput towards the area behind the ears.

MOLDING1. In vaginal delivery, the cranial bones in the part of the head

that enters the cervix molds to decrease the diameter (size) of the head and be able to fit in the birth canal. This is achieved by the sliding and overlapping of cranial bones to each other. This overlapping is called molding and it cause the newborn to become cone-head in appearance, the head flattened over the forehead and rises to a point of the posterior of the skull over the occiput. Molding is generally symmetrical in nature. This change in the contour of the head of the newborn is expected during the first two days of life. The head regains its normal shape within one week.

There is lack of molding in premature infants because their small skull can easily pass through the birth canal and those infants born by caesarian section and breech delivery.

Molding of Newborn Head

PRESENTATION

SITES OF MOLDING

Occipitoanterior Biparietal and suboccipitobregmatic are decreased

Occipitoposterior Occipitobregmatic increased, occipitofrontal decreased

Face presentation Submentobregmatic is decreased and occipitofrontal is lengthened

CAPUT SUCCEDANEUM1.Pressure of the presenting part against the cervix

delays venous return resulting in accumulation of fluid within the scalp, a condition called caput succedaneum.

2.This edema of the scalp is seen on the presenting part and has a generally symmetrical appearance and crosses the suture lines.

3.Caput succedaneum is present at birth, absorbs and disappears without treatment in 3 to 4 days.

CAPUT SUCCEDANEUM

CEPHALHEMATOMA1.Forceps delivery and too much pressure against the

pelvis may lead to rupture of several capillaries of the periosteum of the fetal skull resulting in bleeding and accumulation of blood between the skull bone and periosteum. This condition is known as cephalhematoma.

2.It is a swelling that never crosses suture lines, has a generally asymmetrical appearance and appears several hours after birth.

3.It resolves within 3 to 6 weeks after birth without treatment.4.Hemolysis of blood when the hematoma begins to resolve can lead to release of large amounts of bilirubin in the newborn’s bloodstream which may cause jaundice.

CEPHALHEMATOMA

PHYSIOLOGIC CRANIOTABES1.Craniotabes are soft areas in the cranial bones

that corrects without treatment within a few months after birth as the bones harden with the aid of calcium in milk. The bones can be indented by pressure applied by a finger at the margin of the parietal and occipital bones along the lambdoid suture. It returns to normal contour once pressure is removed.

2.It is caused by prolonged pressure of the fetal skull against the mother’s pelvis after the lightening that is why it is more common in firstborns. It is also found in infants born in breech presentation.3.May also indicate hydrocephalus, congenital syphilis or rickets.

PHYSIOLOGIC CRANIOTABES

HEAD CONTROL1. Although head lag is normal in newborn because of

the immaturity of the muscles and nervous system, the newborn exhibits some degree of head control in certain positions.

a. When the newborn is placed in sitting position, it will attempt to control the head in upright position.

b. If the newborn is placed in prone position, it will attempt to lift its head and move it fom side to side.

2.Excessive head lag is a sign of down syndrome, prematurity, brain damage and hypoxia.

EYES

1.The vision of term infants is characterized as:Visual acuity at birth is 20/150 to 20/190Myopic2.Eye reflexes:Blink reflex – shine a bright light of touch

newborn lightly, the infant should demonstrate an immediate blink.

Corneal reflex – apply light pressure on the cornea using a piece of cotton, the infant should demonstrate an immediate blink. This should occur symmetrically. This reflex is not generally examined unless brain or eye damage is suspected.

Pupillary reflex – shine light directly into the eye, the pupil should constrict instantly. They should have equal size constriction in the same amount of time.

3. Tears usually appear fter 3 to 4 months when lacrimal glands are mature.4. Subconjunctival hemorrhage – a flame-shaped hemorrhage on the white of the eye (sclera) is not uncommon. It’s harmless and due to birth trauma. The blood is reabsorbed in 2 to 3 weeks.5. When attempting to open the newborn’s eyes spontaneously for examination, the newborn is placed supine and the head is gently lifted.

Assess Normal Findings Abnormal Findings

Pupils Equal in size, round briskly to light and clear, should react

Coloboma – irregularly shaped pupilSluggish or asymmetrical action to light is a sign of intracranial pressure

Iris Almost all light skinned newborns have blue or grey eyes while dark skinned newborns will have brown eyes

Pink iris – sign of albinism

Opacities – congenital cataract especially if mother has history of rubella during pregnancy

Assess Normal Findings Abnormal Findings

True eye color does not show until the infant is 3 to 6 months old. Upper and lower margins of eyelids should visible when infant is quiet

Setting sun sign – iris beneath lower lid, sign of intracranial pressure, also seen in premature

Sclerae Completely white and clear Yellowish/Jaundice sclera is a sign of hyperbilirubinemia Blue sclera – sign of ostogenesis imperfecta

Assess Normal Findings Abnormal Findings

Discharge None newborns cry tearlessly because of immature lacrimal glands

Purulent discharge is a sign of infection

Conjunctiva Clear Conjunctivitis – redness, swelling, dischargeStimson’s line – small red line that runs across conjunctiva

Assess Normal Findings Abnormal Findings

Cornea Clear Corneal reflex is present at birth

Opacity, redness, inflammation

Eyeball Random movements Strabismus and nystagmus until four months

Doll’s eye until 10 days old (eyes do not follow in response to head movement)

Strabismus persisting past four months indicates muscle paralysis

Persisting Doll’s eye increased intracranial pressure

Assess Normal Findings Abnormal Findings

Can focus on objects 7 to 8 inches away,

Can follow up to midline

Eyelids Should follow cover eye when close and should fully raise when openBlink reflex presentEye edema is normal during the first two days of life

Absence of blink reflex indicate deafnessTyoptosis – early sign of neurologic problem

Assess Normal Findings Abnormal Findings

Placement in eye socket

Normally placed Exopthalmus – protrusion of eyeballEnopthalmus – deeply placed eyeballs

EARS

POSITION1.The top part of the pinna should be in line with

the outer canthus of the eye.2.Ears below this line are considered to be low

set and are found in children with Down’s syndrome.

STRUCTURE1.In term newborns, the ears should be firm with

cartilage and recoil rapidly after bending. Lack of cartilage in the ears indicates prematurity.

2.It is normal to find the ears folded over or flattened against the side of head at birth. This is due to pressure inside the uterus.

3.There should be no pinpoint openings in front of the ear.

4. Otoscopic examination is not advisable in newborns because the ear canal is usually filled with amniotic fluid that interferes with visualization of the tympanic membrane.5. Ears are considered small if less than 2.5 cm [5] in the term neonate.

FUNCTION1. The newborn can hear as soon as mucus is removed.2. They should turn to sound. Loud noise should elicit the startle reflex. If the newborn is not affected by a loud noise, it could be a sign of hearing impairment.3. Minor abnormalities may be signs of various syndromes, especially renal problems.

NOSE

1.The newborn’s nose should be assessed for Placement – located midline on the faceShape – symmetrical in placement and size Patency Close infant’s mouth and assess the quality of

respiratory effort. Obstruct one nare at a time to determine choanal

atresia which is a blockage in the posterior nasal passage.

Assess the movement of air in and out of the nares by placing a finger under the nares to feel air movement.

Presence of drainage – may have small amount of clear or white discharge.

2. Excessive or discolored nasal discharge may be a sign of congenital syphilis or other respiratory problems.

MOUTH AND THROAT

STRUCTURE1. Lip color is normally pinkish and should open evenly when

the infant cries.2. The mouth and jaw should move equally when the baby

cries.3. The soft and hard palate should be intact and the uvula

located at midline.4. The tongue should be symmetric in shape and movement,

free movable and should not protrude.5. Lingual frenulum attaches the underside of the tongue to the

lower palate. It should not be too tight to allow freedom of movement.

6. Small white cyst may be seen at the palate which are accumulation of epithelial cells and are called Epstein pearls. They disappear within two weeks.7. The patency of the esophagus should be checked by passing a stiff rubber catheter into the stomach in the following situations: Small-for-dates baby

Single umbilical artery Polyhydramnios Excessive drooling of salivao If there is no esophageal atresia and the catheter has

reached the stomach, gastric content should be aspirated. If gastric aspirate exceeds 20 ml in volume, it indicates high intestinal obstruction due to pyloric or duodenal atresia.

FACIAL PALSY

FUNCTION1. Rooting, sucking, gagging and extrusion reflex should be present

at birth. Assess sucking reflex by placing a gloved finger in the infant’s

mouth or by monitoring feeding. The newborn exhibits a strong suck when she is able to form a tight seal around the finger, nipple or bottle. A weak suck occurs if the infant is either unable to form a seal or unable to suck because of fatigue or deformity.

Assess for gag reflex by gently stimulating the posterior oral cavity. The infant should have a strong coughing response to the stimulation. Absence of gag reflex should be considered an emergency situation because the neonate cannot protect his airway without this reflex.

Assess for the rooting reflex by gently stroking the neonate’s cheek. The infant should respond by turning his head to the side that was stimulated. This is an important feeding reflex. Its absence indicates possible neurologic abnormality.

The extrusion reflex occurs when the infant responds to foreign objects in the mouth by pushing them outward with the tongue. ( Keehn Nicole F., Lieben Katrina, Newborn Assessment, Available at NetCE Website http://www.netce.com/courseoverview.php?courseid=257, Accessed 7/26/08)

2. It is normal for a newborn to have scanty saliva due to immature salivary glands.3. Some newborns have teeth at birth called precocious teeth or natal teeth. These teeth are usually located at the position of the lower incisors. If the teeth are loosely attached, they should be pulled to prevent aspiration. If not they can be left in place until they are shed off spontaneously.

ABNORMAL FINDINGS1.Cleft lip and palate.2.Asymmetry in lip movement indicate 7th cranial

nerve damage.3.Assymetric crying is a useful marker of associated

cardiovascular anomalies and congenital dislocation of lips.

4.Lip cyanosis indicates respiratory distress or hypothermia.

5.Macroglossia indicate prematurity.

6. Protruding tongue may indicate chromosomal disorder such as Down’s syndrome.7. Excessive saliva may indicate esophageal atresia or tracheoesophageal fistula.8. Presence of oral thrush that bleeds when touched in moniliasis transferred from the mother during delivery.9. A tight frenulum often referred to as tongue-tie, can prevent proper sucking. In this case frenuloplasty may be required to correct the defect.

NECK

STRUCTURE1. The neck of the newborn appears short and chubby with many skin

folds. It should be symmetric without webbing, flexible enough to allow free movement of the head equally to both sides.

2. The neck lengthens at 2 to 3 years of age. 3. Although it is not strong enough to support the head, the infant

should exhibit temporary head control when placed in sitting position.

4. When in prone, newborns can lift their head slightly and move from side to side

5. The thymus gland is usually enlarged due to rapid growth of glandular tissue and triples in size by 3 years. After 10 years, the thymus gland decrease in size.

ABNORMAL FINDINGS1. Enlarged thyroid gland may be sign of goiter or hyperactive

thyroid.2. Limited neck movement accompanied by pain is a sign of

meningeal irritation (opisthothorus).3. A distended vein is a sign of cardiopulmonary disorder.4. Rigidity of the neck or torticollis may be due to injury to

sternocleidomastoid muscle.5. Webbing of the neck, generally noticed from the back of the

neck, may be indicative of chromosomal abnormalities.

CHEST

STRUCTURE1. The chest usually looks small in relation to head. The

chest has a barrel shaped appearance almost circular should be symmetric with clavicles straight.

2. The shoulders are sloping with width greater than length.

3. Heart rate is heard to the left of midclavicular space at third or fourth interspace; may have functional murmurs.

4. The heart should be examined for its position and any murmurs.

ABNORMAL FINDINGS1.Chest retraction – respiratory distress2.Bulging of the chest – pneumothorax,

pneumomediastenum3.Displacement of the heart towards the right side

accompanied by respiratory difficulty and resuscitation problems is suggestive of either diaphragmatic hernia or pneumothorax on the left side.

4.Malformation – funnel shaped, pectus excavatum

BREAST

STRUCTURE1. The newborn’s breast nodule is approximately 6 mm (5 to

10mm)2. The nipples are prominent, well formed and symmetrically

placed.3. Engorgement of the breast in both male and female infants

is due to the influence of maternal hormones in the utero, it subside within 2 weeks.

4. Sometimes a thin watery fluid called witch’s milk is secreted by the newborn’s nipple. It disappears within the first week of life. It is caused by the influenced of maternal hormones.

ABNORMAL FINDINGS1.Malpositioned or widely spaced nipple2.Presence of supernumerary nipples3.Lack of breast tissue, less than 5cm, indicates

prematurity

THANK YOU !!!

Angeline s. zafeRlp-bsn 2a

REFERENCESInfant Care and Feeding 2nd edition. Maria Loreto Evangelista-Sia. RMSIA Publishing. pp. 38-57.