Lecture 1 – The Healthy Newborn 03/03/2022

Arianna Rossi, Elena Marchetti

Neonatology – 01
03/03/2022

The Healthy Newborn

Yesterday, Professor Pilu has talked about the normal delivery, and today we talk about the normal
newborn. In the next lecture, Professor Pilu will talk about preterm delivery, and then we will talk about
preterm newborns.
The lecture is a bit different since it is a lecture about physiology, and not diseases. This is an overview on
what happens after a normal newborn is delivered.
First, overview of neonatology. Secondly, we see some definitions. Thirdly, we talk about transition from
intrauterine to extrauterine life and lastly, overview of neonatal clinical examination.

Introduction
Neonatology is the field of medicine which deals with newborns.
Definition of newborn: individual from day 0 to day 28 or 30 (according to different definitions). So, the
neonatal period includes the first month of life.
- Newborn (0-28/30 days)
- Infant (1-12 months)
- Preschool age (1-4 years)
- School age (5-10 years)
- Adolescence (11-18 years)

Neonatal period: from birth to the 28th-30th day of life.

It is the most vulnerable period for a child’ survival, as children face the highest risk of mortality, which is as
high as 17 neonatal deaths for 1.000 newborns worldwide.
This is a mean value, but if you translate this in rough number this means that in 2019 globally 2,4 million
children died in the first month of life. So, approximately 6.700 neonatal deaths/day worldwide. 1/3 of
neonatal deaths occur in the first days of life, and 3/4 occur within the first week of life.

This graph represents the decrease in the rate of infant mortality over last 30-50 years.
From WHO data of 2019, we see that neonatal mortality is still a huge problem in many countries and
settings. In the map, darkest green areas correspond to > 35 deaths per 1.000 live births, which is a huge
rate of neonatal death.

The majority (80%) of these newborn deaths result from 3 preventable and treatable conditions:
 Complications due to prematurity
 Intrapartum-related deaths (especially related to birth asphyxia)
 Neonatal infections
 This means that we can do better in improving neonatal mortality.

The issue of neonatal mortality is so important that one of the goals of WHO for 2030 is ending preventable
newborn deaths and stillbirths.

In the following graph, we see the reduction over the last century of neonatal deaths according to the
improvements in neonatal medicine (for example, in obstetric practice).
In fact, this is one of the fields of medicine which is still improving every day.
Invention of incubators/thermal regulation
This was one of those important inventions, which has improved neonatal medicine.
At the end of 19th century, they understood that if you put a baby of < 2 kg into a warm environment,
his/her conditions will improve dramatically. Nowadays, incubators are still a milestone of newborn care.

Another important thing we must consider in neonatal health is the problem of long-term disability.
In fact, it is important also to look at what happens later in newborn life.
- 1.3 million of newborns survive each year with major disabilities and 1 million with moderate long-term
or mild disability, such as learning and behaviour difficulties.
- Most of this disability is preventable.

The critical period of neonatal health is 1.000 days between conception and the 2nd year of life. This is not
a strict definition of life or vitality, but it helps us to understand that every intervention we do in this period
can have a potential impact for the long-term health of this individual (not only immediate positive effect).

Rapid growth…
During the first 2 years of life (1.000 days), each child grows with a much higher growth rate (higher than
that of puberty). There is a quantitative growth (in length, weight, head circumference).

…huge development
Also, there is a qualitative
growth, which means an
improvement and huge
development of all
functions of an individual
(metabolic organs,
cognitive development,
digestive system, immune
function, body
composition).

In this image, we see the brain development according to the week of gestation.
There is a huge development of the brain during the whole pregnancy.
For this reason, if a pregnancy stops at 37 weeks of gestation (baby delivered before term), the growth of
his/her brain will be interrupted. Indeed, there will be a huge risk of impairment during the early neonatal
life, with long-term consequences which may impact the whole life of an individual (disease).

 Definition of a process named Developmental origins of health and disease (DOHaD), according to
which what happens early in life (in the womb) lasts a lifetime.
One of the mechanisms through which this happens is epigenetics. Probably the long-term consequences
may be related to epigenetic modifications. There is a relationship between epigenetic modifications
happening early in life and long-term diseases (metabolic disorders, type 2 diabetes, obesity, or even
cardiovascular diseases).
During gestation or early in the life of the offspring, environmental exposures can lead to the establishment
of epigenetic modifications (histone modifications, DNA methylation, and non-coding RNA mediated
regulation).
The persistence of these modifications later in life may condition the offspring to develop disorders.
VIDEO: Role of epigenetics in neonatal medicine.

On the right: Modified painting from Salvador Dalí (“Girl at a window”).

The meaning is that early in life we have a series of windows opportunities
during which if we modulate the health of an individual, we can modify both
short-term and long-term consequences.
Classification
When we talk about newborns, we can classify them in 3 ways:
- Gestational age: classification according to the length of the gestation
- Neonatal weight: classification according to the newborn size (weight)
- Combination of gestational age and birth weight (BW/GA)

Classification according to gestational age

Definition Gestational age

Term 37 – 41+6 weeks

Post term ≥ 42 weeks

Preterm < 37 weeks

• Late preterm • 34 – 36+6 weeks
• Moderately preterm • 32 – 33+6 weeks
• Very preterm • 28 – 31+6 weeks
• Extremely preterm • < 28 weeks
Note: superscript numbers are the days (example: 41+6 weeks means 41 weeks + 6 days).

Comment:
Pre-term indicates all newborns who were born before 37 weeks gestation
However, according to the slide on brain development seen before, a newborn who was born at 32 weeks
is completely different from a newborn born at 36 weeks. So, we need to classify pre-term newborns in
subgroups: late preterm, moderately preterm, very preterm, and extremely preterm.
Diseases are completely different in preterm and term newborns.

Classification according to birth weight

Birthweight description Weight
Low birthweight Born weighting less than 2,500 g (5 lbs)
Very low birthweight Born weighting less than 1,500 g (3 lbs)
Extremely low birthweight Born weighting less than 1,000 g (2 lbs)
A newborn is macrosomic when birth weight is > 4000 g.

Italian newborns
These data are taken from a large study which has provided the normal growth curves for Italian infants.
(In blue boys, in orange girls)
They made a division between first-born
and non-first-born infants.
- In general, girls are a bit smaller
- Difference between first-born and
non-first-born: the latter are a bit
heavier, longer, and with a larger
head. The reason for this difference is
not clear, maybe the womb is a bit
more healthy and nourishing.

Classification according to gestational age and

neonatal weight (BW/GA)
By combining gestational age and neonatal weight, we
can define the appropriateness of birth weight for
his/her gestational age.
 Large for gestational age (LGA):
birth weight > 90° centile
 Appropriate for gestational age (AGA):
birth weight 10°- 90° centile.
 Small for gestational age (SGA):
birth weight < 10° centile.

Link to Stanford university to find other information on this classification:

https://med.stanford.edu/newborns/ professional-education/photo-gallery/general.html

By combining gestational age and birthweight, we get a growth curve (image). By inserting the newborn
parameters, you get a dot, and see if she/he is appropriate to gestational age or not.
Example: 38 weeks, 3 kg  the dot is a bit above the 50° centile  appropriate for gestational age.
Example: 38 weeks, 3.8 kg  the dot is exactly on the 97° centile  large for gestational age.
Example: 38 weeks, 2.1 kg  very small for gestational age.

This curve is for term infants, but the same type of reference chart is available also for newborn with lower
gestational age.

 Infants who belong to SGA or LGA groups are at high-risk for specific diseases.

Etiology of SGA:
- Maternal reasons: smoke, illicit drugs, undernutrition, or diseases like pre-eclampsia, maternal
hypertension
- Placental reasons (alterations in the way it provides nourishment to the fetus)
- Fetal diseases: malformations or chromosomal anomalies, TORCH infections, twins
Etiology of LGA:
- Maternal diabetes (most commonly)
- Fetal syndromes

Common problems related to SGA:

- Perinatal asphyxia: they do not receive enough oxygen and nourishment during pregnancy (chronic
fetal hypoxia-acidosis)
- Hypoglycemia: they are small, so low glycogen store, plus reduced gluconeogenesis
- Polycythaemia: increased EPO production following fetal hypoxia
- Hypothermia: related both to hypoglycemia and to low fat store
- Issue related to specific dysmorphic features (syndromes)

Common problems related to LGA:

- Perinatal asphyxia: for different reason compared to SGA.
They are very large  so, asphyxia can be due to trauma during the passage through the birth canal or
due to compression of umbilical cord (which reduces the perfusion to infants, leading to perinatal
asphyxia).
- Birth trauma (cephalohematoma, clavicle fracture, bruises)
- Meconium aspiration syndrome (respiratory disease of term infants)
- Hypoglycemia (hyperinsulinism)
- Issue related to specific dysmorphic features (syndromes)

SGA vs IUGR (or FGR)

Fetal growth restriction (FGR) = Intrauterine growth restriction (IUGR).
A low BW/GA ratio can be due to IUGR.
According to the timing of occurrence:
 Symmetrical IUGR (20-30%): early occurrence, etiology: foetal syndromes, maternal infections
 Asymmetrical IUGR (70-80%): late occurrence, etiology: placental disease, hypertension

SGA and IUGR are not equivalent, but they have 2 different definitions, which can overlap.
 IUGR: dynamic process, restriction of growth during pregnancy
 SGA: baby born in that precise moment, with a specific gestational age, who is appropriate/large/small
for that gestational age.
SGA is like a photograph (a baby born in a specific moment, with a weight related to that moment), while
IUGR is like a video (a baby is followed during gestation, and you depict his/her rhythm of growth).
Example: During gestation, if a baby is growing along the 50° centile  at a certain point, his/her growth is
at 25° centile, so he/she has an IUGR (change in the rhythm of growth). Once he/she is born at 25° centile,
he/she will not be SGA, since he/she will be above the 10° centile.

Physiology of neonatal transition

This is what happen immediately after delivery from a newborn and neonatologist perspective.
The birth of an infant is a phase of transition, which is not a simple process, as it requires the integrity of
several functions. Plus, these functions need to interact with one another. They are respiratory function,
cardiovascular function, and ability of thermal regulation.

Most of the time (90% of cases), you do not need to do anything to achieve a successful transition (minimal
or no need of support in the delivery room). However, in 10% of cases, the transition needs a certain
degree of support, with 1% requiring cardiopulmonary resuscitation.

Respiratory transition
At birth, 2 things happen:
- Cord clamping: separation between mother circulation and infant. When you clamp the cord, decrease
in oxygen concentration, increase in CO2, and decrease in pH  this change in blood gases represents a
stimulus to chemoreceptors in aorta and carotid body to start respiration.
- Thorax mechanical compression (ONLY in VAGINAL deliveries) during the passage through the birth
canal. This compression helps to clear the lungs from fluid (approximately 1/3 of lung fluid is cleared).
During first few breaths, the alveoli are cleared from liquid into lymphatic circulation.
During fetal life, lungs are full of liquids  when the baby is born, the lungs need to be cleared to start
respiration.
So, at birth:
a. Positive intrathoracic pressure
b. Alveoli distended
c. Lung fluid cleared into lymphatic circulation

Some manoeuvres can facilitate the first breaths:

- Tactile stimuli: midwives touch feet or gentle rub the
baby back in the delivery room. They can help starting
and maintaining breathing.
- Thermal stimuli: sudden change in temperature (as intrauterine temperature is 36-37°C, while
extrauterine temperature is 20-25°).

To be effective, respiratory transition also relies on:

- Surfactant production
- Adequate pulmonary blood flow (connection between breathing and cardiovascular system)
- Normal thoracic muscle tone: if a disease impairs muscular tone, also breathing will be impaired.

Surfactant production
It is a mixture of phospholipids and proteins
- Synthetized and secreted by pneumocytes type 2 since 24 weeks
gestation*
- Reduces the surface tension of alveoli, which prevents atelectasis at
the end of expiration

*A baby born before 24th week of gestation will not have enough
surfactant to breath  we have to supplement surfactant.

Adequate pulmonary blood flow

If there is a mismatch between ventilation and perfusion, you will not be able to have an efficient
respiratory transition and independent breathing.

From now on, we are referring to the picture below.

- FETAL CIRCULATION
During fetal life, the fetus is connected to the mother through the umbilical cord (where there are the
vessels going to the placenta)
Inside umbilical cord, there are 1 vein and 2 arteries.
 The vein (red), contrary to the other body veins, provides the oxygenated blood to the
fetus. It brings the oxygenated blood from placenta to the fetus.
 The arteries (blues) take deoxygenated blood from fetus and bring it to the placenta to
reoxygenate it. So, placenta works as lungs because it provides oxygenated blood and
clears deoxygenated blood.
1. Lower box: Blood arrives via umbilical vein  passes through the 1st fetal shunt, which is the
ductus venous  oxygenated blood skips the liver and enters the inferior vena cava.
2. Upper box: oxygenated blood from inferior vena cava enters the right atrium  through the 2nd
fetal shunt, which is foramen ovale, oxygenated blood passes into the left atrium  left ventricle
 aorta to the rest of the body (systemic circulation).
 !!! Only a small amount of oxygenated blood goes from right atrium to the right ventricle, since
most of the blood in the right ventricle comes from the superior vena cava (which is deoxygenated
blood)  deoxygenated blood reaches the pulmonary artery  3rd fetal shunt, which is ductus
arteriosus or ductus of Botallo (= communication between the aorta and the main pulmonary
artery).

- WHEN BABY IS BORN

When the cord is clamped, you stop fetal circulation and so remove placenta circulation.
First few breaths after birth  decrease in pulmonary venous return (PVR)  increase in pulmonary
blood flow (PBF) (Remember that to have a normal respiratory function, you also need a normal blood
flow in pulmonary circulation)  increased left atrium filling and pressure  closure of the shunts.

1. 1st shunt is closed because you no longer have umbilical vein, so you no longer need the
ductus venosus.
2. 2nd shunt closes because the foramen ovale closes in most of the individuals. For sure,
some of us have a patent foramen ovale without being aware of that.
3. The change in the pressure of oxygen stimulates the closure of the 3rd shunt (ductus
arteriosus)

So, during the first hours after

birth, changes in blood gases occur and help the transition to neonatal circulation.

Picture of fetal (left) and neonatal (right) circulation, with the 3 shunts closed.
In neonatal circulation,
 The ductus venosus becomes the ligamentum venosus.
 The foramen ovale closes.
 The ductus arteriosus becomes the ligamentum arteriosum.
This process does not happen immediately after birth, in fact the ductus arteriosum can remain patent for
the first hours or days (you can feel a murmur, related to the closure of the patent ductus arteriosus).
In the slides, you find a video showing these changes (slide 51).

Thermal regulation
When a baby is born, he/she risks losing heat for a variety of
mechanisms (convection, radiation, evaporation,
conduction). It is important to avoid hypothermia in the first
hours of life, since hypothermia is related to a variety of
diseases, like hypoxemia, metabolic acidosis, and
hypoglycemia.
There is a simple way to maintain thermal regulation, which
is skin-to-skin contact. In fact, after delivery, babies born
through vaginal delivery are placed on their mums’ thorax
to maintain their temperature.

When skin-to-skin is not possible (for example, when the

newborn requires attention from the neonatologist):
- Position the baby under/over a radiant warmer
- Dry the newborn
- Remove wet clothes.

 Preterm newborns face the highest risk to be

hypothermic because they are small, they have thin and
permeable skin, reduced subcutaneous fat, and wide
skin surface. To maintain temperature:
 They are put inside a plastic (polyethylene)
bag (which is like cookies bag used in
freezer).
 Head is covered with a hat (made by plastic
or normal hat).
 Heated mattress pad is used.

Apgar score
When a baby is born, we assign him/her an Apgar score, which described the newborn health. It was
invented in 1953 by Virginia Apgar (obstetrician and anaesthesiologist), who started to focus not only on
the mother but also on the newly born infant.
5 items (each one scoring from 0-2 points) are rated, then the cumulative score ranges from 0 to 10.
It describes roughly the newborn health.
- Respiration, crying
- Reflexes, irritability
- Pulse, heart rate
- Skin colour of body and extremities
- Muscle tone

Practical epigram of “APGAR” score:

- A  Appearance (skin colour)
- P  Pulse (heart rate)
- G  Grimace (reflexes)
- A  Activity (muscular tone)
- R  Respiratory effort

Here is the Apgar score (professor reads all the lines).

Acrocyanosis = cyanosis of extremities.

APGAR score is given at 1 minute and at 5 minutes.

If the score at 5 minutes is okay (8,9,10), you do not need to give another score at 10 minutes.
While, if the score at 1 minute is not good (2,3,4), you do not wait for the 5 minutes score, but you put in
place some measures like oxygen or positive pressure ventilation or adrenaline and you record them. Then,
you combine these actions with the Apgar score (as we see in the table in the section “Resuscitation” – the
numbers are the corresponding minutes after birth).

Normal vital signs

They are completely different
from the vital signs of adults or
older children  higher
respiratory rate and heart rate.

Heart rate may decrease during

sleeping.

Neonatal prophylaxis
In the delivery room, we do 2 prophylaxes:
1. Eye prophylaxis: antibiotic to prevent ophthalmia neonatorum, which is an eye infection commonly
caused by Neisseria Gonorrhoea and Chlamydia Trachomatis during the passage through the birth
canal
 Tobramycin, one drop for each eye
2. Vitamin K prophylaxis: vitamin K administration at birth (1 mg/kg) to prevent Hemorrhagic Disease
of the Newborn (HDN).
 Why? Because in newborns, there is a low vitamin K in human milk and inefficient gut microbiota 
transient deficit of vitamin-K dependent coagulation factors.

The healthy term newborn

Overall evaluation:
You put the baby on the mattress or on his/her bed and have a look at:
- Concordance appearance with gestational age (GA)
- Vigilance, behaviour, cry
- Muscular tone, posture, symmetry
- Activity, movements

Remember that the proportions of an infant are different from the ones of adults.

 Head is 1/4 of the entire baby length, while it is 1/8 of adults’ body.

SKIN
- Colour: pink - red (polycythaemia)
- Cyanosis of the extremities
- Birthmarks: specific alterations of skin colour, which are typical of neonatal period and typically resolve
in the first weeks or months of life.
 Erythema toxicum (erythema neonatorum toxicum): numerous small areas of red skin with
a yellow-white papule in the center. Lesions are most noticeable 48 hours after birth but
may appear as late as 7-10 days. This benign rash, which is the most common rash, resolves
spontaneously. Wright staining of the papule reveals eosinophils.
 Nevus simplex (fading macular stain; “stork bites”, “angel kiss”, “salmon patch”): common
capillary malformations on occipital area, eyelids, and glabella. They disappear
spontaneously within the first year of life.
Occasionally lesions on the nape of the neck may persist as a medial telangiectatic nevus.
 Transient neonatal pustular melanosis: 2-5 mm pustules, without erythema. Pustules
evolve and disappear within 48 hours, but they can leave an hyperpigmented macule
(which may persist for months).
 Milia: small white-yellow papule on the nose (frequently on chin, face, forehead, and
scalp). It resolves with no residual lesions. It is caused by sebaceous retention cysts.
 Mongolian spots: areas of black or bluish discoloration at the base of the spine and on
buttocks but can occur elsewhere. Usually, they do not disappear but fades over several
years. No need for treatment. More common in blacks and Asians.

There are a lot of pictures in the slides, just to give us an idea of the specific birthmarks. There will not be
specific questions about these pictures at the exam.
Erythema toxicum Nevus simplex Neonatal pustular melanosis
 Milia Mongolian spots

HEAD
Before birth, neonatal scan is used to exclude huge anomalies. Indeed, when you examine a newborn, you
are the person who is looking at that baby for the first time, so clinical examination needs to be very
detailed and comprehensive.
You should look at the baby from head to toes,
even though it is not always possible since
newborns always cry and move.
- Shape, size
- Fontanelles (tension and size), especially look
at the anterior one which is the largest
- Sutures (between bones) palpation

You can spot some consequences of birth trauma:

- Caput succedaneum (= “tumore da parto” in Italian): normal and common finding (mothers should be
reassured about it since it is not a problem for the baby).
 Diffuse edematous swelling of the scalp soft
tissues that may extend across the suture lines
 Mostly unilateral
 Does not increase after birth
 Secondary to the pressure of the uterus or
vaginal wall on areas of the fetal head
bordering the caput.
 Resolves within few days.
- Cephalohematoma: here we find bruises (not in the
previous), which are related to a traumatic delivery like with vacuum (or forceps, which are not used
anymore).
 Subperiosteal hemorrhage (not a swelling) not
extending across the suture line
 Increases in size after birth
 The only situation is which you do something
 is when you suspect a skull fracture in association with hematoma  X-rays or CT scan of
the head should be obtained
 Resolves within few weeks.

The most frequent obstetric trauma is the clavicle fracture (1% of all deliveries).
 Palpatory sensation of crepitus (like walking on fresh snow – “fresh snow” sign).
 When the fracture resolves, you can appreciate a firm lump in the place where clavicle was
broken.
 It often scares parents, but nothing should be done as it resolves spontaneously.

SENSE ORGANS
Sense What the newborn can do

Sight Immaturity of the visual system and low visual acuity

Focuses at about 20-25 cm (= distance from the mother milk)
Follows objects in motion
Distinguishes some colours (red, blue, green)
Sensible to changes in brightness
Hearing Distinguishes different sounds
Recognizes some verbal sounds (i.e. “pa”/”ba”) and the mother’s voice
Calms down for rhythmic sounds (i.e. heart beat)
Smell Reacts to sharp smells odours
Recognizes the mother’s perfume
Taste Distinguishes some tastes

Touch Reacts to tactile stimuli, especially on the hand and around the mouth

Comments:
 When you handle a baby, you should avoid sudden changes in room brightness.
 They are super reactive to tactile stimuli.

Regarding sight and hearing, we can complete clinical examination with eye and hearing screenings. Both
are performed during the first 2 days of life.

Red reflex screening (= eye screening)

Recommended in neonatal period, then performed during routine evaluation by primary care paediatrician.
Fundamental for early recognition of potential anomalies which can alter sight. You can see the same thing
when taking a picture and the eyes look like red.
- Low environmental light
- 60-80 cm between the child and examiner
You examine the 2 eyes at the same time and see if the reflex is present in both eyes and with the same
intensity.

The professor goes through the different scenarios (above).

Hearing screening
It can early detect any hearing impairment.
The image below was skipped.

VIDEO: https://www.nhs.uk/conditions/pregnancy-and-baby/newborn-hearing-test/

CARDIOVASCULAR SYSTEM
Normal neonatal heart rate: 120-160 bpm.
Sometimes during the day, they can have resting heart rate as low as 90 or 100 bpm. This is transient and
usually occurs when they are sleeping or very quiet.

When assessing CV system, we must always feel the pulses (not found in clinical examination of other ages
of life).
 Simultaneous assessment of upper (radial/brachial) and lower (femoral) pulses.
The detection of an abnormality, especially in femoral pulses, can be an important sign of a specific group
of congenital heart diseases including aortic coarctation (radial or brachial pulses present, but absent
femoral pulses).

During clinical examination, it is normal to assess MURMURS, which are very frequent during the first days
of life since they are related to transition from fetal to neonatal circulation. Many of them are due to patent
ductus arteriosum. The pathologic ones could be due to peripheral pulmonary stenosis or congenital heart
disease.

VIDEO (slide 89): Explanation on the most common neonatal murmurs and physiology (check out from
minute 5 to 10).

CCHD (congenital heart diseases) screening

To assess CV system, you can rely on heart rate, murmurs, and general well-being of infant. Moreover, to
improve the ability of detecting congenital heart diseases, we have a screening for those diseases which
might have been missed by prenatal congenital scan.
 Measuring arterial saturation on the right arm (pre-ductal site)  then, measure arterial saturation at
one foot (post-ductal site).

No need to remember the flow-chart (slide 91).

Remember that the screening is considered positive (i.e. presence of abnormality):
- if saturation is < 95% at any site, or
- if the 2 measurements are ≥ 95%, but there is a discrepancy of > 3%
 Refer the baby to a pediatric cardiologist to perform an echo.

Early identification of critical congenital heart disease:

• Hypoplastic Left heart Syndrome
• Pulmonary atresia
• Transposition of the great arteries
• Truncus
• Tricuspid atresia
• Tetralogy of Fallot
• Anomalous pulmonary venous return
But also, CCHD with later symptoms:
• Coarctation of the aorta
• Univentricular heart
• Epstein anomaly
• Double outlet right ventricle

RESPIRATORY SYSTEM
You simply need to assess the respiratory rate  normal range is between 40-60 bpm.
Then, you look at him/her in order to see if the baby is breathing well or not.
Periodic breathing (= change of respiratory rate over a short period of time) is quite normal.

ABDOMEN
Same things you do in individuals of other ages (look, touch, listen).
Remember to always listen to peristalsis: assess that bowel sounds can be heard on the whole abdomen.

NEUROLOGIC EXAMINATION
The most intriguing part of neonatal examination as it involves evaluation of neonatal reflexes, which are
specific of neonatal age.
Assess:
- Posture
- Tone
- Reactivity
- Spontaneous movement
- Primitive reflexes

Posture and tone

Image on the right: Normal newborn posture:
- Flexed and hypertonic limbs
- While body, neck and torso are relatively hypotonic (compared to limbs)

Posture is evaluated both at rest and during examination.

Image on the left: Abnormal posture and scarce tone  limbs are not in
the right posture (abandoned towards the bed), and the examinator needs
to keep the neck in the correct position (no control of head nor of axial
tone).

Image on the right: Abnormal tone.

Primitive reflexes (riflessi arcaici in Italian)

- Moro reflex:
Support the infant behind the upper back with one hand, and then drop the
infant back ≥1 cm to, but not on, the mattress. This should cause
symmetrical abduction of both arms and extension of the fingers (hands
open with extended fingers) followed by flexion and adduction of the arms.
We evaluate the reflex integrity and symmetry,
 Asymmetry may signify a fractured clavicle,
hemiparesis, or brachial plexus injury.
 If absent Moro reflex, suspect CNS disease.

- Placing – stepping reflexes: 2 reflexes in sequences.

 Placing: Hold the infant upright and place the dorsum of
the foot by the edge of the bed; the infant places the foot
on the surface.
 Stepping: Hold the infant upright under his arms while
supporting his head, have his feet touch a flat surface, the
infant will appear to take a step and walk.
You always elicit a “wow” from the parents.

- Galant reflex:
Suspend the infant in a prone position. Stroke the back on one side
(in a cephalocaudal direction). The infant should respond by
moving the hips toward the stimulated side.
- Rooting reflex: allow the baby to eat.
Stroke the lip and the corner of the cheek with a finger and the infant
will turn the head in that direction and open the mouth (and
hopefully suck and swallow).

- Tonic neck reflex (Fencing reflex):

With the infant in a supine position, turn the infant’s head to one
side, and the arm and leg on the side of the head that is turned will
extend outward, and there will be flexion of the limbs on the
opposite side.

- Grasp reflex (palmar and plantar)

Place a finger or object in the palm of the infant’s hand and the
infant will grasp the finger (flexion of the fingers will occur). This
reflex is also present in the feet of a newborn. Stroke up the middle
of the foot and the toes will curl under as if to grasp the examiner.
It is present until 2–3 months of age.

They are automatic reflexes, which disappear in the first few months of life. They are important since their
evaluation give us a rough idea on the CNS integrity.

VIDEO (slide 103): Complete neonatal examination.

Next time we will have a look at preterm infant diseases. Then, we will go back to term infants and their
diseases (jaundice, hyperbilirubinemia, asphyxia).

Q&A
Q: Can the Apgar score help in detecting congenital heart diseases?
A: You can classify congenital heart diseases according to the onset of symptoms. Some have a very early
onset (symptoms present in delivery room), while others have a later presentation (even after the first
week of life). Apgar score does not help in identifying congenital heart diseases, but it is a measure of the
general well-being of the infant, and it can help in guiding the resuscitation measures. Differently, for
congenital heart diseases, you need a deeper examination of the infant. To do that, you need
- Pregnancy history since most of them are detected during fetal life.
- Clinical examination
- Congenital heart diseases screening done in all infants during the first 24-48 hours of life.

Q: What is the recommended time for keeping the newborn in contact with the mother to prevent
hypothermia?
A: You can leave the baby with the mother as long as it is feasible (as much as possible). Then, you can give
a bath and dress the baby with his/her clothes to maintain the temperature.

Q: Is the neonatologist involved during the whole gestation?

A: In case of vaginal delivery with no complications, the neonatologist appears after 6-7 hours from
delivery. In case of caesarean section, the neonatologist is in the delivery room. If there are problems
during pregnancy (like malformations, or risk of preterm delivery), the neonatologist interacts with
obstetricians and provides a counselling to the family about potential management of baby at birth or
immediately after birth. For example, when there are congenital anomalies incompatible with life or when
risk of extremely preterm birth. In prenatal counselling, you discuss with the family what could be
reasonable to do for that baby. We said “potential” management of the baby since you, as neonatologist,
may go to the delivery room with a specific idea in mind and then, your approach can completely change. It
is one of the most interesting and challenging part of our job as you have to deal with uncertainty, while we
erroneously think that medicine is an exact science.

Q: When a reflex is pathologic?

A: When it is absent or persistent (considering that each reflex has a specific time of disappearance), but
the main problem is their absence. Remember it is only a small part of the neurologic examination and of
the overall assessment of the baby.