Updated Newborn Reflexes Chapter 3 Pediatric
ASSESSMENT OF NEW BORN
Assessment
of new born requires proper observation, skill and knowledge. Assessment of
newborn is done under four headings:
1.
Initial
assessment by APGAR score.
2.
Transitional
assessment during the period of reactivity.
3.
Assessment
of gestational age.
4.
Physical
examination.
Initial Assessment by ARGLR Score
The
APGAR score was devised in 1952 by Dr. Virginia Apgar as a simple and
repeatable method to quickly and summarily assess. the health of newborn
children.
·
Appearance
·
Pulse
·
Grimace
·
Activity
·
Respiration
|
TABLE
3.1 |
|||
|
Sign/Score |
Zero |
1 |
2 |
|
Appearance/Colour |
Complete
blue/pale |
Extrmely
Blue, body pink |
Completely
pink |
|
Pulse/Heart rate |
Less
than 60 |
Between
60 to 100 |
More
than 100 |
|
Grimace/Reflexes |
Absent
|
Facial
movement only (grimace) with stimulation |
Pulls
away, sneezes, or coughs with stimulation |
|
Activity/Muscle tone |
Full
extended |
Some
flexion |
Well
flexion |
|
Respiration |
Absent
|
Irregular,
slow, weak cry |
Regular,
strong cry |
·
Score
0-3 severe distress
·
Score
4-6 mild to moderate distress
·
Score
7-10 absence of stress
The
factors influencing the APGAR score are infection of mother, immaturity,
congenital abnormality, maternal sedation, neuro-muscular disorders.
APGAR scoring should be done on 1st,
5th, 10th and 15th min.
Transitional Assessment daring the
Period of Reacitivity
Period of reactivity assess in
three periods.
First
Period of Reactivity
1St
stage- Start immediately after birth of child and continues to 6-8 hrs. During
this period child is very active, cry vigorously and greedily sucking.
Temperature is subnormal, increase pulse and respiration. Secretion from mouth
and nose are more. This is time for bondage i.e. starts feeding.
2nd stage - last for 2-4
hrs and during this time the child is drowsy and sleepy. Tempeture. pulse and
respiration decrease. Secretions also very less. Child will not pass meconium or
urine.
Second Period of Reactivity
Second period of reactivity last
for 2-5 hrs. Period starts when child wake up from sleep. Child will be active,
cries and suck vigorously. Meconium and urine is passes, Gag reflex will
present.
Third Period of Reactivity (Period of
Stabilization)
All the vitals come back normal.
No secretion from nose and mouth. Frequently child passes urine. Behavioural
assessment should be done at this period. Child cry, sleep, activities are
normal. New born sleep for 16-22 hrs. No differentiation between day and night
sleep.
Assessment of
Gestational age
Use of the Ballard Method
The Ballard scoring method uses
both neurological features and external features. Each feature is given a score
and these scores are added up to give a final score. This final score can be
converted to an estimated gestational age by consulting the table in figure.
Where possible, examine both the left and right sides of the body when doing
the Ballard score and give the average score observed on either side. Half
scores can be used.
Neurological
Features
All 6 neurological features are
assessed with the infant lying supine (the infant's back on the bed). The
infant should be awake but not crying.
1.
Posture: Handle the infant and observe the
position of the arms and legs. More mature infants (with a higher gestational
age) have better flexion (tone) of their limbs. Score 0 if both arms and legs
are fully extended.
Score 1 if there is slight
flexion of the legs only.
Score 2 if there is moderate
flexion of the legs.
Score 3 if the legs are flexed to
90° and the arms are partially flexed.
Score 4 if all limbs are fully
flexed against the body.
2.
Square Window: Gently press on the back of the
infant's hand to push the palm to-wards the forearm.
Observe the degree of flexion.
More mature infants have greater wrist flexion.
Score 0 if the wrist can only be flexed
to 90° only, giving the appearance of a "square window".
Score 1 if the wrist can be
flexed to 60°.
Score 2 if the wrist can be
flexed half way to the forearm.
core 3 if the wrist can be flexed
to 30°.
Score 4 if the palm of the hand
can be pressed against the arm.
3.
Arm Recoil: Fully bend the arm at the elbow
so that the infant's hand reaches the shoulder, and keep it flexed for 5
seconds. Then fully extend the arm by pulling on the fingers. Release the hand
as soon as the arm is fully extended and observe the degree of flexion at the
elbow (recoil). Arm recoil is better in more mature infants. Note that a score
of 1 is not given.
Score 0 if there is no arm recoil
at all.
Score 2 if there is some arm
recoil.
Score 3 if the arm recoil is good
and the arm is flexed half way back to the shoulder.
Score 4 if there is a brisk arm
recoil and the infant pulls the arm back almost to the shoulder.
4.
Popliteal Angle: With one hand hold the infant's
knee against the abdomen. With the index finger of the other hand gently push
behind the infant's ankle to bring the foot towards the face. Observe the angle
formed behind the knee by the upper and lower legs (the popliteal angle). More
mature infants have less extension of the knee.
Score 0 if the leg can be fully
extended to form an angle of 180°.
Score 1 if there is some
limitation to full extension of the leg.
Score 2 if the knee can only be
extended to 130°.
Score 3 if the knee can be
extended just beyond 90°.
Score 4 if the knee can be
extended to 90°.
Score 5 if the knee cannot be
extended to 90°.
5.
Scarf Sign: Take the infant's hand and gently
pull the arm across the front of the chest and around the neck like a scarf.
With other hand gently press on the infant's elbow to help the arm around the
neck. In more mature infants the arm cannot be easily pulled across the chest.
Score 0 if the arm can be wrapped
tightly around the neck (like a scarf).
Score 1 if the elbow can only be
pulled well across the chest but not fully wrapped around the neck.
Score 2 if the elbow reaches the
other side of the chest but cannot be pulled beyond the chest.
Score 3 if the elbow can only
reach the midline of the chest.
Score 4 if the elbow cannot be
pulled as far as the midline.
6.
Heel to Ear: Hold the infant's toes and gently
pull the foot towards the ear. Allow the knee to slide down at the side of the
abdomen. Unlike the illustration, the infants pelvis may be allowed to lift off
the bed.
Observe how close the heel can be
pulled towards the ear. More mature inf have less flexion of the hips and,
therefore, heel cannot bring towards the ear.
Score 0 if the heel can easily be
pulled to the ear.
Score 1 if the heel does not
quite reach the ear.
Score 2 if the heel can be pulled
most of the way to the ear.
Score 3 if the heel can be pulled
half way to the ear.
Score 4 if the heel
cannot not be pulled half way to the ear.
External Features
Six external features are
examined. The infant has to be turned over to examine the amount of lanugo. If
the infant is too sick to be turned over, then the amount of lanugo is not scored.
1.
Skin: Examine the skin over the front of the chest and
abdomen, and also look at limbs. More mature infants have thicker skins.
Score 0 if the skin appears very
thin, red, transparent and gelatinous (jelly-like).
Score 1 if the skin is thin and
smooth with many small blood vessels visible.
Score 2 if the skin is thicker
with only a few blood vessels seen. Fine peeling of the s is often noticed,
especially around the ankles.
Score 3 if the skin is pale and
slightly dry with only a few bigger blood vessels seen.
Score 4 if the skin is dry and
cracked with no blood vessels visible.
Score 5 if the skin is very thick
and looks like leather.
2.
Lanugo: This is the fine, fluffy hair
that is seen over the back of small infants. Except for very immature infants
that have no lanugo, the amount of lanugo decreases with maturity.
Score 0 if no lanugo is seen.
These are very small infants.
Score 1 if the lanugo is thick
and present over most of the back.
Score 2 if the lanugo is
thinning, especially over the lower back.
Score 3 if there are bald areas
with no lanugo.
Score 4 if very little lanugo is
seen. These are always bigger infants.
3.
Plantar Creases: Use thumbs to stretch the skin on
the bottom of the infant's foot Only note creases as very fine wrinkles, that
disappear with stretching, are not important.
More mature infants have more creases.
Score 0 if there are no creases
at all (there may be fine wrinkles).
Score 1 if shallow, red creases
are present, especially over the anterior sole.
Score 2 if deeper creases are
present on the anterior third of the sole only.
Score 3 if deep creases are
present over two thirds of the sole.
Score 4 if the whole sole is
covered with deep creases.
4.
Breast: Both the appearance of the breast
and the size of the breast bud are considered. Palpate for the breast bud by
gently feeling under the nipple with index finger and thumb. More mature
infants have a bigger areola and breast bud.
Score 0 if the areola (pink skin
around the nipple) is very small and difficult to see.
Score 1 if the areola is small
and flat, and no breast bud can be felt.
Score 2 if the breast bud can
just be felt and the areola is stippled (has fine bumps).
Score 3 if the areola is raised
above the surrounding skin and the breast bud is easily felt (3-4 mm).
Score 4 if the areola appears
distended and the breast bud is the size of a pea (5-10 mm).
5.
Ear: Both the shape and thickness of the external ear are
considered. With increasing maturity the edge of the ear curls in. In addition,
the cartilage in the ear thickens with maturity so that the ear springs back
into the normal position after it is folded against the infant's head.
Score 0 if the ear is soft and
flat and stays folded.
Score 1 if the ear slowly
unfolds, and the upper margin of the ear (pinna) has started to curl in.
Score 2 if the upper margin of
the ear is well curled and the ear unfolds quickly. Areas of cartilage still
feel soft, especially towards the edge of the ear.
Score 3 if the cartilage feels
firm throughout the ear, and the ear springs back rapidly if folded.
Score 4 if the ear feels stiff
and the whole ear margin is well curled in.
6.
Genitalia: Male and female genitalia are
scored differently. With maturity the testes descend in the male and the
scrotum becomes wrinkled. In females the labia majora increase in size with
maturity. Note that a score of 1 is not given.
Males:
Score 0 if the scrotum is very
small and smooth with no testes palpable.
Score 2 if there are a few
wrinkles (rugae) in the scrotum and one or both testes are felt in the groin.
Score 3 if the testes are in the
scrotum and the skin of the scrotum has a lot of wrinkles.
Score 4 if the scrotum
hangs low with fully descended testes.
Females:
Score 0 if the labia majora
(outer labia) are not formed, leaving the labia minora (inner labia) and
clitoris completely exposed.
Score 2 if the labia majora and
labia minora are of equal size.
Score 3 if the labia majora are
bigger than the labia minora.
Score 4 if the labia
majora cover the clitoris and labia.
The
Ballard Scoring Method
Each separate criteria is given a
score after examining that sign on the infant. These separate scores are then
added together to give a total score. From the total score the estimated
gestational age can be read off the table.
|
TABLE
3.2 |
|||||||
|
|
-1 |
0 |
1 |
2 |
3 |
4 |
5 |
|
Posture |
|
|
|
|
|
|
|
|
Square
window (wrist) |
|
|
|
|
|
|
|
|
Arm
recoil |
|
|
|
|
|
|
|
|
Popliteal
angle |
|
|
|
|
|
|
|
|
Scarf
sing |
|
|
|
|
|
|
|
|
Heel
to
ear |
|
|
|
|
|
|
|
|
TABLE
3.3 Physical Maturity |
|||||||||||||||||||||||||||||||||||
|
Skin |
Sticky,
friable,
transparent
|
Gelatinous,
red,
translucent |
Smooth,
pink; visible veins |
Superficial peeling
and/or rash;
few veins |
Cracking,
pale
areas; rare
veins |
Parchment,
deep
cracking; no
vessels |
Leathery,
cracked wrinkled |
||||||||||||||||||||||||||||
|
Lanugo |
None |
Sparse |
Abundant |
Thinning |
Bald
areas |
Mostly
bald |
Maturity Rating
|
||||||||||||||||||||||||||||
|
Plantar surface |
Heel-toe
0-50
mm; -1 <40
mm;-2 |
>50
mm, no
crease |
Faint
red
marks |
Anterior
transverse crease
only |
Creases
anterior 2/3 |
Creases
over entire sole |
|||||||||||||||||||||||||||||
|
Breast |
Imperceptible |
Barely
preceptible |
Flat
areola, no
bud |
Stippled
areola, 1-2 mm bud |
Raised
areola, 3-4
mm bud |
Full
areola, 5-10
mm bud |
|||||||||||||||||||||||||||||
|
Eye/ear |
Lids
fused loosely;-1 tightly;
-2 |
Lids
open; pinna flat; stays
folded |
Slightly
curved
pinna; soft;
slow recoil |
Well
curved pinna; soft but ready recoil |
Formed
and firm, instant recoil |
Thick
cartilage, ear
stiff |
|||||||||||||||||||||||||||||
|
Genitals
male |
Scrotum
flat
smooth |
Scrotum
empty, faint
rugae |
Testes
in upper canal, rare rugae |
Testes
descending, few
rugae |
Testes
down, good
rugae |
Testes
pendulous, deep rugae |
|||||||||||||||||||||||||||||
|
Genitals
female
|
Clitoris
Prominent ,
labia flat |
Clitoris
prominent, small labia
minora |
Clitoris
prominent,
enlarging minora |
Majora
and minora equally
prominent |
Majora
large, minora small |
Majora
cover clitoris and minora |
|||||||||||||||||||||||||||||
Physical Examination of New Born
Anthropometric Assessment
1.
Weight: It is measure on child weighing
machine, Normal newborn weight is 2.5 kg.
2.
Head circumference: The measurement tape is putting
over the eyebrows, above the ears and occipital prominence. Normal size is
33-35 cm.
3.
Chest circumference: The measurement tape is placed
over the nipples level. Normal size is 31-33 cm.
4.
Head to heal length:
It is measure by
infantometer. Normal length is 48-52 cm.
5.
Crown rump length: It is the length of sacrum to
head. It is equal to head circumference.
6.
Abdominal Circumference: It is the measurement of
abdominal girth.
Vital Sign
1.
Temperature
- 36.5 to 37.5°C
2.
Pulse/Heart
Rate - 140 - 160 beats/min
3.
Respiration
- 30 - 60 breathe/min
4.
Blood
Pressure - 60/40 mm of Hg, measure through oscillometer
General Examination
Posture
Well flexed, good muscle tone. In
premature, extremities or body may be extended.
Skin
In colour
bright red at first day and will be pinkish on second day. Skin will be smooth
shiny and easily peel off.
1.
Vernix caseosa: This is greenish-whitish layers
of sebum and cells it will remove at first bath or will be shaded off itself.
2.
Lanugo: These are tiny hairs present at
forehead, cheeks. It disappears within few weeks.
3.
Milia: It is white tiny papule present
at chin and forehead, cheeks. It disappears itself within few weeks.
4.
Acrocyanosis: It is the bluish extremities. It
appears when child cry excessively.
5.
Erythematous toxicum: Red patches appear within 24-48
hrs after birth at throat chest, abdomen and back. It disappears in few days.
6.
Mongolian spot: Deep bluish spot at the sacrum
region.
7.
Harlequin colour syndrome: When the child is kept in side
lying position, lower half of the body is pink and upper of body is white/pale.
Head
1.
Normally
head is round in shape.
2.
Moulding: This is changing of shape of
head at the time of passing through birth canal.
The head will come to its normal shape
within 24 hrs.
3.
Fontanella: These are junction of two or
more than two sutures. There are two fontanella:
·
Anteriorfontanella:
It is at the junction of frontal suture, coronal suture and saggital suture. It
is diamond in shape, it is 1-2 inches in length. Normal closing period is 1 to
1½ year.
·
Posteriorfontanellw
It is at the junction of saggital and lambdoid suture. It is triangular in
shape, 0.5-1 inch in length. Normal closing time is 1½ month.
Abnormalities:
·
Microcephaly: when the head circumference is 4
cm less than chest circumference.
·
Macrocephaly: when the head circumference is
more than 35 cm.
·
Fontanella: late closer of fontanella show
malnutrition of child.
·
Bulging
fontanella shows hydrocephalous.
·
Depress
fontanella shows dehydration.
Eyes
1.
No
tears, because of immaturity of lacrimal gland.
2.
Blinking
reflex.
3.
Glabellar
reflex.
4.
Pupillary
reflex.
5.
Doll's
eye reflex.
Ears
1.
Equal
to outer canthus of eyes.
2.
Loud
noise elicit startle reflex.
3.
Flexible
pinna.
Nose
1.
Nat
mal/patent nose.
2.
No
discharge.
3.
Sneezing
reflex.
4.
Glabellar
reflex.
Mouth
and Throat
1.
High
arched palate.
2.
Minimal
or absent saliva.
3.
Sucking
reflex.
4.
Rooting
reflex.
5.
Gag
reflex.
6.
Extrusion
reflex.
Neck
1.
Circular
in shape.
2.
Skin
fold is thick.
3.
Tonic
neck reflex.
Chest
1.
Round
in shape.
2.
Normal
Si and S2 sound.
3.
Symmetrical
nipples.
4.
Symmetrical
movements.
Common
variable:
Witch's milk-discharge
from nipples of child for one or two days under the influence of maternal
hormones.
Abdomen
1.
Round
in shape.
2.
Soft
on palpation.
3.
Abdominal
respiration.
4.
Umbilical
cords.
Genital
1.
Female
genital
·
Labia
majora will cover minora and clitoris.
Common
variable:
Pseudomenstruation:
It is a bleed from vagina of the baby under the influence of maternal hormones.
2. Male genital
·
Deep
pigmented scrotum with ruage
·
Palpable
testes
Back
1.
Spine
normal.
2.
Primary
curve present.
Extremities
1.
Ten
fingers in hands.
2.
Ten
fingers in feet.
3.
Grasping
reflex.
4.
Sole
flat.
5.
Creases
anterior two third.
New Born Reflexes
Foot
1.
Stroke
Inner Sole
·
Toes
curl around ("grasp") examiner's finger.
2.
Stroke
Outer Sole (Babinski)
·
Toes
spread, great toe dorsiflexion.
Doll's
Eyes
1.
Give
one forefinger to each hand - baby grasps both.
2.
Pull
baby to sitting with each forefinger.
3.
Eyes
open on coming to sitting (Like a Doll's).
4.
Head
initially lags.
5.
Baby
uses shoulders to right head position.
Walking
Reflex
1.
Hold
baby up with one hand across chest.
2.
As
feet touch ground, baby makes walking motion.
Protective
Reflex
1.
Soft
cloth is placed over the babies' eyes and nose.
2.
Baby
arches head and turns head side to side.
3.
Brings
both hands to face to swipe cloth away.
Rooting
Reflex
1.
Touch
newborn on either side of cheek.
2.
Baby
turns to find breast.
3.
Sucking
mechanism on finger is divided into 3 steps:
·
Front
of tongue laps on finger.
·
Back
of tongue massages middle of the finger.
·
Esophagus
pulls on tip of finger.
Tonic Neck (Fencing)
Reflex
1.
If
the Babies' head is rotated leftward:
·
The
left arm (face side) stretches into extension.
·
The
right arm flexes up above head.
2.
Opposite
reaction if head is rotated rightward.
Moro
Reflex (Startle Reflex)
1.
Hold
supine infant by arms a few inches above bed.
2.
Gently
drop infant back to elicit startle.
3.
Baby
throws arms out in extension and baby grimaces.
Hand-to-Mouth
(Babkin) Reflex
1.
Stroke
newborns cheek or put finger in baby's palm.
2.
Baby
will bring his fist to mouth and suck a finger.
Swimmer's
(Gallant) Response
1.
Hold
baby prone while supporting belly with hand.
2.
Stroke
along one side of babies' spine.
3.
Baby
flexes whole body toward the stroked side.
Crawling
Reflex
1.
Newborn
placed on abdomen.
2.
Baby
flexes legs under him/her and starts to crawl.
Class exercise
Reflexes in
newborn-
1. The reflex that
causes a baby's toes to spread when the sole of the foot is stroked is called
the:
A. Moro reflex
B. Babinski reflex
C. Root reflex
D. Tonic neck reflex
2. Why is it important to examine babies for certain
reflexes?
A.
To find proper growth of child
B.
To find abnormalities
C.
To find development delay
D.
All
3. The reflex for one arm to stretch out while the other
curls up when the baby's head is turned to the side is called the:
A. Moro reflex
B. Babinski reflex
C. Root reflex
D. Tonic neck reflex
4. The natural
response when an object is placed in a baby's hand is the-
A.
Startle reflex
B.
Grasping reflex
C.
Rooting reflex
D.
Sucking reflex
5. A baby's attempt to walk is called
the
A.
Rooting reflex
B.
Startle reflex
C.
Tonic Neck reflex
D.
Stepping reflex
6.
When a baby spreads her toe when the bottom of her feet are stroked is the
A. Babinski reflex
B. Babinski reflex
C. stepping reflex
D. Startle reflex
7.When
a baby feels like she is falling and curls her arms and legs closer to her body
it is the
A. Grasping reflex
B. Startle reflex
C. Tonic Neck reflex
D. Babinski reflex
8.
When pressure is applied to an infant's palms and the close their eyes, tilt
their head back and open their mouth it is the
A. Babinski reflex
B. Sucking reflex
C. Rooting reflex
D. Startle reflex
9.
When a baby turns her head and her arm and leg form a fencing position it is
the
Tonic Neck reflex
Babinski reflex
Rooting reflex
Stepping reflex
10.
A baby's attempt to walk is called the
Rooting reflex
Startle reflex
Tonic Neck relex
Stepping reflex
11.
When a baby automatically turns her face toward the stimulus and makes a
sucking noise/motion with mouth.
Sucking reflex
Rooting reflex
Babinski reflex
Startle reflex
12.
A natural reflex that happens when the roof of a baby's mouth is touched.
Rooting reflex
Tonic Neck reflex
Sucking reflex
Babkin reflex
