Evaluation of Newborn and Prematurity

Gezahegn D.(MD, Pediatrician)

• A quick initial physical examination of all newborns should be
performed in the delivery room and should focus on
congenital anomalies, maturation and growth, and
pathophysiologic problems that may interfere with normal
cardiopulmonary and metabolic adaptation to extrauterine
life.
• The entire body must be checked.
• This usually allows the clinician to reassure the parents that
their infant looks well and appears normal.
• After a stable delivery room course, a second and more
detailed examination should be performed within 24 hr of
birth.
• This assessment includes review of the
– Maternal and family history
– Prenatal and perinatal history
– Complete examination
– Screening tests
• Purpose of immediate evaluation
– Babies response to the transition from fetal life to extra
uterine life
– Reassurance sex of neonate
– Any congenital anomalies
– Check for birth trauma
– To see for any emergency conditions
 Objectives of Routine Examination of the
Newborn

• Detect congenital abnormalities not already identified at birth

(e.g., CHD and DDH).
• Determine whether any of the wide range of nonacute
neonatal problems are present and initiate their management
or reassure the parents.
• Check for potential problems arising from maternal disease,
familial disorders, or problems detected during pregnancy.
• Provide an opportunity for the parents to discuss any
questions about their infant.
• Initiate health promotion for the newborn
 Neonatal history taking

• Maternal profile
– age of the mother, occupation, parity, blood group and Rh, chronic
maternal illnesses (diabetes, hypertension, HIV, TB, renal diseases,
asthma, etc)
– history of sexually transmitted diseases (ask for symptoms like vaginal
discharge, genital ulcers, or investigations like VDRL, HIV test, Hepatitis
B virus status)
• Current pregnancy
– LNMP (last normal menstrual period), gestational age, ANC, bleeding,
diabetes, thyroid diseases, preeclampsia, eclampsia, acute (eg:UTI,
malaria) or
– chronic infection and maternal nutritional history during pregnancy
(detailed during first, second and third trimester)
• Previous pregnancy
– history of abortion, fetal death, early neonatal death, premature
and/low birth weight birth,
– history of early neonatal jaundice, history of birth defect.
• Drug history
– history of alcohol ingestion, cigarette smoking , any
– medications during pregnancy (anticonvulsants, anti TB, warfarin,
HAART, thyroid treatment drugs , antenatal steroid use,
contraceptives, cotrimoxazole, Aspirin, Albendazole)
• Social, personal and family history
– Family size, marital status, housing conditions, water source, waste
disposal, personal hygiene (hand washing habits, toilet use,bathing)
• Labor and delivery
– onset of labor, status of rapture of membrane in relation to onset of
labor (before or after onset of labor), duration of rapture of
membranes, duration of labor, mode of delivery,
– presence of meconium stained amniotic fluid, fetal presentation,
APGAR score, resuscitation at birth, birth weight.
• Presenting compliant
– Failure to suckle the breast, fever, breathing difficulty, abnormal body
movement, yellowish discoloration of the skin (jaundice),
– Altered mentation, vomiting, bleeding, birth defects
Physical examination
 APGAR score

Three levels of score

- Low APGAR score 0-3
- Moderate APGAR score 4-6
- Normal APGAR score 7-10
A newborn with an APGAR score of less than 7 needs special attention
• APGAR scoring
– The 1-minute APGAR score measures how well the newborn tolerated
the birthing process.
– The 5-minute APGAR score assesses how well the newborn is adapting
to the environment.
• General examination
– Dysmorphic features
– Movement of the extremities
– Tone (hypotonia/hypertonia)
– Color, Posture
– Respiratory distress
• Vital signs
– RR : 30 to 60 breathes per mi
– HR : between 120 and 160 bpm
– Axillary temperature: between 36.5 and 37.5
– Pulse oximetry: >90%
• Anthropometric measurement
• These measurements are plotted on standard growth curves
to determine the percentile according to gestational age and
assess intrauterine growth.
– Weight (term babies is 2500g -3999g).
– Measure the length (normal range is 48-53 cm),
– Measure head circumference (normal range is 33-38cm)
• Color:
– normal color is pink
– should not be blue, yellow, pale.
• HEENT
– examine the skull (caput succedaneum, subgaleal
hemorrhage, cephalohematoma), sutures
(craniosynostosis)
– Fontanel , face, nose, ears, mouth, neck, clavicles, eye
discharge, icterus, cataracts
• Mammary glands
– enlargement of breast tissue and discharge (physiologic)
• Respiratory system
– Check for signs of respiratory distress, breathing pattern,
respiratory rate, air entry to the lungs
– presence of abnormal sounds in the lungs, AP diameter
and symmetry of the chest, stridor
• Cardiovascular
– heart rate, heart murmurs, gallop rhythm, femoral pulses
• Abdomen
– shape (scaphoid, distension), look for any organ enlargement, mass, ascites,
kidneys,
– abdominal wall defect, examination of the umbilical stump (bleeding and
discharge), anal patency.
• External genitalia
– abnormalities of the genitalia both in male and female newborns (size of penis,
position of testicles, opening of urethral meatus (hypospadias / epispadias) ,
ambiguous genitalia), vaginal bleeding or discharge.
• Musculoskeletal
– Limb defects (clubfoot, syndactyly, polydactyly), symmetry and movement of
extremities to see fractures and birth injuries, spina bifida, joints (hip
developmental dysplasia of the hip, look gluteal fold symmetry), edema
• Skin examination
– Rash , jaundice, pallor, plethora, meconium staining, cyanosis,
etc.
– Acral (extremity) cyanosis is a normal finding in newborns
• Neurological examination
– level of alertness, spontaneous movements, muscle tone,
– Neonatal reflexes ...
• Moro reflex: completeness and symmetry
• Rooting reflex: absent or present
• Grasp reflex (arm and plantar ):strong, weak or absent
• Sucking reflex: absent, weak or vigorous
 Screening tests

• The American Academy of Pediatrics has developed newborn

screening fact sheets
– Critical CHD
– congenital adrenal hyperplasia
– congenital hearing loss
– congenital hypothyroidism
– cystic fibrosis
– PKU
– sickle cell disease and other hemoglobinopathies and
Critical CHD Screening
 Neonatal Classification

• Based on the gestational age

– Preterm : less than 37 Completed weeks
– Term : 37- 42 weeks
– Post term : more than 42 weeks
 Gestational age

• Estimated by
– First day of the last menstrual period
– first trimester U/S estimation: +/- 1wk
– Based on Ballard score: accurate within +/- 2 wk
• Physical maturity
• Neuromuscular maturity
Ballard Score
• The neuromuscular assessment includes an exam of the
following
– Posture -how the baby holds his or her arms and legs.
– Square window- how far the baby's hands can be flexed toward
the wrist.
– Arm recoil- how well the baby's arms spring back to a flexed
position.
– Popliteal angle- how well the baby's knees bend and straighten.
– Scarf sign- how far the elbows can be moved across the baby's
chest.
– Heel to ear- how close the baby's feet can be moved to the
ears.
Ballard Score cont…
 Neonatal Classification cot…

• Based on the birth weight

– Macrosomia : birth weight of 4000 gram and above
– Normal weight : 2500 – 3999 grams
– Low birth weight : 1500 – 2499 grams
– Very low birth weight : 1000 – 1499 grams
– Extremely low birth weight : less than 1000 grams
 Neonatal Classification cot…

• Birth weight and gestational age

– Appropriate for gestational age (AGA) if the birth weight is
between 10-90%
– Large for gestational age (LGA) if birth weight is greater
than 90%
– Small for gestational age (SGA) if birth weight is less than
10%
 Prematurity

• Key facts
• Every year, an estimated 15 million babies are born preterm
(before 37 completed weeks of gestation).
• Preterm birth complications are the leading cause of death
among children under 5 years of age, responsible for
approximately 1 million deaths in 2015 .
• Three-quarters of these deaths could be prevented with
current, cost-effective interventions.
• Across countries, the rate of preterm birth ranges from 5% to
18% of babies born
 Prematurity cont….

• Globally, prematurity is the leading cause of death in children

under the age of 5 years.
• Inequalities in survival rates around the world are stark.
• In low-income settings, half of the babies born at or below 32
weeks (2 months early) die due to alack of
– feasible, cost-effective care such as warmth
– breastfeeding support and
– basic care for infections and
– breathing difficulties
 Prematurity cont….

• Traditionally, a delivery date is determined 280 days after the

last menstrual period (LMP).
• However, only 4% of pregnant women actually deliver at 280
days, and only 70% deliver within 10 days of the estimated
delivery date.
• Infants born before 37 wk from the 1st day of the LMP are
termed premature by WHO.
 Prematurity cont….

• Preterm is defined as babies born alive before 37 weeks of

pregnancy are completed.
• There are sub-categories of preterm birth, based on
gestational age:
– extremely preterm (less than 28 weeks)
– very preterm (28 to 32 weeks)
– moderate to late preterm (32 to 37 weeks).
• In addition to classification by gestational age, classification is also
based on birthweight.
– Extremely low birthweight (ELBW) with a birthweight <1000 g
– Very low birthweight (VLBW) infants
<1500 g, and
– Low birthweight (LBW) infants <2500 g at birth
• Birthweight in general is a proxy for gestational age, but in the
cases of intrauterine growth restriction (IUGR) and small-for-
gestational-age (SGA) infants, birthweight can sometimes be
misleading for true gestational age
 Etiology
• Despite the frequency of preterm birth, it is often difficult to
determine a specific cause.
• The etiology of preterm birth is multifactorial and involves
complex interactions between
– Fetal
– Placental
– uterine, and
– maternal factors.
• In the setting of maternal or fetal conditions that prompt early
delivery, as well as placental and uterine pathology, causes of
preterm birth can sometimes be identified
Neonatal morbidity associated with prematurity
Neonatal morbidity associated with prematurity

* Major neonatal morbidities.

 MICRONUTRIENT SUPPLEMENTATION

• Iron supplementation
– recommended for human milk-fed preterm or low-birth-
weight infants who are not receiving iron from another
source
– 2–4 mg/kg per day of elemental iron may be initiated
when enteral feeds are well established
– starting at 2 weeks and continuing until 6 months of age
– all neonates with anemia of prematurity starting at 1 mo
of age and continuing until about 1 yr.
• Oral zinc
– daily dose of 1–3 mg/kg per day of elemental zinc
– Start at 2 wk to 6mo
– Zinc deficiency is associated with
• dysfunction in epidermal
• gastrointestinal,
• central nervous, immune, skeletal and
• reproductive systems
• Vitamin D supplementation
– Daily dose 400–800 IU may be initiated when
enteral feeds are well established
– 400–1000 IU per day until 6 months of age
• Vitamin A supplementation
– very preterm (< 32 weeks’ gestation) or very-low-
birth-weight (< 1.5 kg) infants
– daily dose of 1000–5000 IU
– Reduces bronchopulmonary dysplasia
• Calcium
– Supplemental bioavailable calcium and
phosphorus salts may be required by breast-fed
preterm infants until their weight reaches term
weight (3 to 3.5 kg)
 References

• Nelson text book of pediatrics 21st edition

• National neonatal guideline, 2021
• Fanaroff textbook of pediatrics, 11th edition
• WHO recommendations for care of the preterm or low-birth-
weight infant