1. Assessment of the new born
DR AJIT GADEKAR
DEPARTMENT OF PEDIATRICS

2. Aims ……………………………
• To review anticipated problem
• To ascertain family worries
• To screen for specific target conditions
• To diagnose congenital malformation
• To collect baseline information
• To identify mother with substance abuse
• To initiate appropriate treatment

3. Assessment of fetal well being
• ANTEPARTUM TEST…………………………………………
• Fetal movement monitoring.. 30-40mts
..inacitvity > 1hr.
• non stress test – quick
non invasive
no discomfort
fatal activity accelerate FHR
required maturity > 32 wks

4. Fetal well being
• Non stress test result..reactive
..non reactive
..inadequate
• Reactive .. FHR 120-160
.. normal beat to beat variabilty
.. 2 acceleration 15 bpm not less than
15 seconds each in 20 mts period.

5. Fetal well being
• Contraction stress test ………………………
.. Uterine contraction compromise
unhealthy fetus.
.. Under hypoxic condition FHR show
characteristic pattern relative to
contraction

6. Fetal well being
• Contraction stress test is completed
 Spontaneous contraction within 3o mts
 lasted for 40-60 seconds
 frequency of 3 within 1o mts
• late deceleration type II
 FHR decelerate 15-30 seconds after contraction
 does not return to baseline until end of
contraction
 deceleration of uteroplacental insufficiency

7. Fetal well being
CST NEGATIVE.. 3 contraction/10mts for 40 sec
no late declaration
CST POSITIVE.. Consistent late deceleration
CST SUSPICIOUS.. Inconsistent late declaration
CST HYPERSTIMULATED.. No interpretation

8. Fetal well being
• Reactive NST
Chance of fetal demise.. 3/1000
• Negative CST
 chance of fetal demise 0.4/1000
• Positive CST following Non reactive NST
Risk of still birth , NMR 88/1000

9. Biophysical profile
• NST with real time ultrasonic parameters
 reactive NST
Adequate amniotic fluid volume
Fetal breathing movement
Fetal activity
Normal musculoskeletal tone

10. Biophysical profile
• Reassuring test ( 8-10 )
Repeat weekly , fetal demise 0.6/1000
• Less reassuring test ( 4-6 )
Repeat later the same day
• Very low score ( 0-2 )
Prompt delivery

11. Umbilical artery blood flow
• Non invasive technique
• To assess placental resistance
• Increased resistance is noticeable in fetal diastole
• Systolic frequency shift (S) , end diastolic
frequency shift (D) ,S : D , S-D/S (resistance
index),puslatility index ( PI )

12. Intrapartum assessment of fetal well
being
 fetal heart rate monitoring - tachycardia
Uterine activity
Beat to Beat variability … 5-10beats/mts
FHR acceleration - reassuring

13. Intrapartum assessment
• Decelerations
 early type I ( head compression deceleration )
Symmetric in shape , mirror of uterine
contraction , good beat to beat variability
Late type II ( uteroplacental insufficiency )
Variable type III ( cord pattern deceleration )

14. Ultrasound assessment
• Fetal abdominal circumference < 10 th centile
• Fetal head circumference
• Estimation of fetal weight accuracy +/-10 %
• Cerebral circulation – MCA

15. Assessment in the delivery room
• First interview
• Maternal history is history of new born

16. Normal values for umbilical cord blood
• UApH
• UApCO2 (mmHg)
• UApO2 (mmHg)
• UA-BE
• UVpH
• UVpCO2 (mmHg)
• UVpO2 (mmHg)
• UV-BE (meq/l)
• 7.26
• 53
• 17
• -4
• 7.34
• 41
• 29
• -3

17. Gestational age assessment
• Early obstetrics ultrasound + menstrual dates
• Direct ophthalmoscopy to visualize lens
 can be applied after 27th wk to vessels of lens
 cover entire anterior surface of lens 27-28wk
Reach to middle of the lens 31-32wk
Reach periphery at 33-35wk

18. Gestational age assessment
• Physical maturation
• Development of the nervous system

19. Physical maturation
• The physical assessment part of the
Dubowitz/Ballard Examination examines
physical characteristics that look different at
various stages of a baby's gestational maturity.
• Points are given for each area of assessment,
with a low of -1 or -2 for extreme immaturity
to as high as 4 or 5 for post maturity.

20. Physical assessment
• Farr et al 11 criteria 34 points
• Dubowitz et al 35 points for same criteria
• Parkin et al 4 criteria 13 points
• New Ballard score is valid for preterm

21. Physical assessment
• skin textures (i.e., sticky, smooth, peeling).
• lanugo (the soft downy hair on a baby's body) - is
absent in immature babies, then appears with
maturity, and then disappears again with
postmaturity.
• plantar creases - these creases on the soles of the
feet range from absent to covering the entire
foot, depending on the maturity.

22. Physical assessment
• breast - the thickness and size of breast tissue and areola
(the darkened ring around each nipple) are assessed.
• eyes and ears - eyes fused or open and amount of
cartilage and stiffness of the ear tissue.
• genitals, male - presence of testes and appearance of
scrotum, from smooth to wrinkled.
• genitals, female - appearance and size of the clitoris and
the labia.

23. How is neuromuscular maturity is
assessed
• posture - how does the baby hold his/her
arms and legs.
• square window - how far the baby's hands can
be flexed toward the wrist.
• arm recoil - how far the baby's arms "spring
back" to a flexed position.

24. How is neuromuscular maturity is
assessed
• popliteal angle - how far the baby's knees
extend.
• 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.

25. Examination of new born
• Answer any question mother may arise
• Introduce yourself to mother explain what you
are doing
• Fully examine the baby
• Give advise , information , arrange follow up , and
provide reassurance where appropriate

26. Examination of new born
• Observe mothers attitude to her baby
whether she is happy , tense , withdrawn
• Observe the colour , fascies , breathing
pattern , posture , movement

27. Order of examination
• Remove the baby's clothes except nappy
• Feel the AF for tension
• Look at the face for colour or any peculiarities
• Estimate RR , HR, listen to heart

28. Order of examination
• Palpate the abdomen
• Return to head examine scalp , skull , OFC
• Examine the eyes , ears , nose , mouth
• Examine the neck , clavicles

29. Order of examination
• Examine arms , hands , legs , feet.
• Remove the nappy
• Feel the femoral pulse
• exaamine the genitalia and anus

30. Order of examination
• Turn the baby to the prone position and
examine the back , spine , assess tone
• Return infant to supine position evaluate CNS
• Examine the hips
• Make sure u have not omitted anything.

31. Systematic review
• SKIN
 colour , texture , cyanosis , icteurs , pallor
skin rashes erythema toxicum , transient
neonatal pustular melanosis , Miliaria rubra

32. Systematic review – skin erythema
toxicum

33. Systematic review – skin normal
peeling

34. Icthyosis – avoid fluid loss involve
dermatologist , geneticist

35. Mongolian spot slate gray no
evaluation

36. Acrocynosis

37. Salmon patch (angel kisses), one over
forehead resolves late

38. Port wine stain
• congenital pink patches more intense and
purple-red in colour than salmon patches.
• The discoloration is not, of itself, a problem,
but it may be a clue to an underlying
condition.
• Port wine stains on the face may be associated
with sturge weber syndrome,
• extremities may be associated with klippel
trenaunay-weber syndrome, in which
overgrowth of an extremity may occur.

39. Port wine stain

40. Milia
 Milia are keratin filled epithethial cysts which
occur in up to 40% of newborns.
Spontaneous exfoliation and resolution is
expected within a few weeks.
 Parents will occasionally mistake these lesion for
neonatal acne, but Milia are present at birth and
have no inflammatory component. .

41. Milia

42. sebaceous hyperplasia
• The lesions are more yellow than Milia and
are the result of maternal androgen exposure
in utero.
• Sometimes referred to as "the miniature
puberty of the newborn"
• Sebaceous hyperplasia is a benign finding and
spontaneously resolves with time. No
evaluation is needed.

43. sebaceous hyperplasia

44. subcutaneous fat necrosis
• This red lesion is subcutaneous fat necrosis. On
palpation, there is a firm nodule in the
subcutaneous tissue under the area of redness
that is freely mobile with respect to the bony
structures underneath it.
• Subcutaneous fat necrosis is more common in
infants who have had difficult deliveries, cold
stress, or perinatal asphyxia.
• Lesions are typically asymptomatic and resolve
spontaneously within several weeks, usually
without scarring or atrophy.
• Hypercalcemia associated with subcutaneous fat
necrosis is rare, but is a potentially lethal
complication.

45. subcutaneous fat necrosis

46. Transient neonatal pustular melanosis
• The hallmark of this rash is the hyperpigmented
spots that remain (seen here on the chest) after
the fragile pustules (seen on the scrotum and
thigh) have resolved.
• Because the rash starts in utero, lesions may be
in any stage at birth.
• Despite the anxiety-provoking appearance of a
newborn covered in pustules in the delivery
room, no evaluation is needed.

47. Transient neonatal pustular melanosis

48. Petechiae
• Blanching the abdomen reveals more
petechiae than were appreciated on casual
examination.

49. Petechiae

50. Congenital melanocytic nevus
• Here is a typical appearance of a junctional
melanocytic nevus.
• The lesion is completely flat and is medium to
dark brown in colour.
• It may be present at birth. It may become slightly
raised as the infant grows and may become a
compound nevus if intradermal melanocytes
develop. It is considered a benign lesion.

51. Congenital melanocytic nevus

52. Cafe au lait spots
• Cafe au lait spots are lighter in colour than
melanocytic nevi, but they also may be congenital
macules.
• They are caused by an increased amount of melanin
in both melanocytes and epidermal cells, and may
increase in number with age
• Most children with cafe au lait spots do not have
neurofibromatosis, but the presence of six or more
of these spots that are larger than 0.5cm diameter is
considered to be a major clue to the diagnosis.

53. Cafe au lait spots

54. Cutis aplasia
• The red "excoriated" area and the hairless,
circular lesion anterior to the ear.
• Cutis aplasia is often thought of in association
with trisomy 13, but it can also be an isolated
finding in an otherwise well newborn

55. Cutis aplasia

56. Forceps mark
• The semi-circular red mark on this infant's
right cheek is a forceps mark.
• These marks have no consequence and will
spontaneously resolve. In rare cases when the
skin is abraded, antibiotic ointment may
facilitate healing.

57. Forceps mark

58. Head and skull overriding of sutures
• This picture shows what is usually noted
primarily on palpation: the ridges that develop
when one bone slightly overlaps the adjacent
one during delivery.
• These over-riding sutures are part of molding.
Complete resolution is expected with time.

59. Head and skull overriding of sutures

60. Breech moulding
• With breech positioning in utero, the head is in a
position against the uterine fundus.
• This gives the newborn head molding that is flat
on the top and elongated in AP diameter.
• As with any molding, this appearance will be
improved significantly over the next few days

61. Breech moulding

62. Cephalohematoma
• Cephalohematoma is a collection of blood under
the periosteum of a skull bone. Because of its
location, it is impossible for Cephalohematoma to
cross suture lines.
• If more than one bone is affected, there will be a
separation between the two areas at the suture
line as seen in this photo -- the sagittal suture
separates the bilateral parietal Cephalohematoma.
• On palpation, these areas feel fluctuent.

63. Cephalohematoma

64. Cephalohematoma

65. Firm, constant pressure in one spot is
the easiest way to elicit the
characteristic pitting edema of caput.

66. subgaleal bleed
• The subgaleal area (between the scalp and the skull)
is a large potential space, so when bleeding occurs
there, it easily moves to the dependent part of the
skull.
• As pressure is placed on that area, a fluid wave can
be seen that radiates from the occiptal area all the
way to the space over the anterior fontanelle .
• Because of the size of the space, exsanguination of
the baby's entire circulating blood volume into the
subglaeal space is a possiblity if active bleeding
continues.

67. Subgaleal bleed

68. Eye examination- dysconjugate eye
movements
During the first few months of life, newborns will
frequently have dysconjugate eye movements,
where the eyes appear to move independently.
Eyes may transiently appear crossed or divergent.
This phenomena is particularly noticeable when
the infant is falling asleep or being woken from
sleep. If the dysconjugate movement is fixed (one
eye is always out, or always in, relative to the
other), a paediatric ophthalmologist should be
consulted. But if the movements are transient, it
is a normal finding and will spontaneously
resolve.

69. dysconjugate eye movements
(roving eye)

70. Dacrocystoceles
bluish nodules inferior to the medial canthi of
both eyes, widely spaced eyes
(hypertelorism), and a flat nasal bridge.
They are caused by obstructions at both
superior and inferior ends of the nasolacrimal
duct. Though relatively small externally, these
lesions can obstruct the nasal passages.
internal nasal evaluation is recommended
when the dacrocystoceles are bilateral, even
when the patient is otherwise asymptomatic .

71. Dacrocystoceles

72. Subconjunctival haemorrhage
• Subconjunctival haemorrhage is a frequent
finding in normal newborns.
• It results from the breakage of small vessels
during the pressure of delivery.
• The red area may be large or small but is always
confined to the limits of the sclera.
• It is asymptomatic, does not affect vision, and
spontaneously resolves in several days.

73. Subconjunctival haemorrhage

74. gonococcal conjunctivitis
 When gonococcal conjunctivitis occurs, it typically
presents in the first few days of life with copius,
purulent discharge in the eyes.
 In this infant, the marked edema of the eyelids was the
first symptom noted, but with just slight pressure on
the lids, purulent material oozed out .
 Gonococcal conjunctivitis is an ophthalmologic
emergency. Because the bacteria can erode through an
intact cornea.
 Treatment is very aggressive and includes systemic
intravenous antibiotics, frequent eye washes, and
monitoring in a neonatal intensive care unit.

75. gonococcal conjunctivitis

76. Congenital glaucoma

77. Congenital cataract
• the opacities here
occur behind the
pupil, as the pupil is
easily and clearly
seen along its
entire
circumference.
• Red light reflexes
could not be
obtained from
either eye

78. Peters anomaly
• the opacity is central and
could be mistaken for
opacity of the lens, a view
from a more oblique angle
shows the cloudiness
extends over parts of the
iris as well.
• With the use of a flash, a
red reflex should have
been prominent in this
photo, but wasn't.

79. Normal ear
• the normal ear is
one is which all the
structures (helix,
antiehelix, tragus,
antitragus,
scaphoid/triangula
r fossa, and
external auditory
canal) are all
present and well
formed.

80. Ear tag
• A single, small ear tag is
an occasional finding
on physical
examination.
• It is often inherited as a
familial trait.

81. Ear pit
• They are located at the
superior attachment of the
pinna to the face and may
be unilateral or bilateral.
• There is a rare association
between ear pits and
Brachio-Oto-Renal
Syndrome .
• audiologic testing of these
infants is recommended,
but otherwise this is
considered a benign
finding.

82. Stahl's ear
• Also known as Satyr ear, Spock
ear, or Vulcan ear, this
deformity of the pinna is
characterized by a flat helix at
the superior pole, a third crus
extending into the helix, and a
flattened scaphoid fossa.
• When this deformity is severe
enough to be of cosmetic
concern, molding and splinting
can be initiated by a plastic
surgeon
• As an isolated finding, cosmesis
is the only concern, but the
appearance will not improve
with time. Exact etiology is
unknown.

83. lop ear
• This pinna deformity,
where the superior edge
of the helix is folded
down, is known as lop
ear.
• Again, it is typically an
isolated finding.
• This is another deformity
that may be improved
with splinting.

84. Prominent ear or cup ear
• Cup ear refers to an
auricle shape that stands
away from the head at the
superior, posterior, and
inferior aspects.
• In the past, this ear
morphology was thought
to be an indicator of
underlying neuromuscular
pathology, but more
recent experience does
not seem to support this
theory.
• This finding is only of
cosmetic concern.

85. Microtia
• In contrast to the
previous photos, this
pinna is not well-formed
and is smaller than a
normal ear.
• This is microtia. Hearing
evaluation is mandatory
in these infants and
referral to a pediatric
ENT specialist is
recommended.

86. Hypoplastic ear
• The ear is hypoplastic and
low set. Again, because
genetic syndromes are
frequently associated with
abnormal ear shapes, a
careful physical examination
should be performed.
• Even in the absence of other
findings, referral to a
pediatric ENT specialist may
be indicated, as an abnormal
pinna may be an indicator of
internal ear abnormalities

87. Low set ear
• Here, the low set
position of the ear (also
hypoplastic) can be
appreciated.
• If an imaginary line is
drawn from the outer
canthus of the eye
straight back to the
occiput a low set ear will
fall completely below the
line.

88. Dislocated nasal septum
• The septum is not
straight and the whole
bottom segment of the
nose appears to be
shifted to the baby's
left .
• Compressing the tip of
the nose gently can also
help distinguish this
condition from a
positional problem, as
the next photo
demonstrates.

89. Dislocated nasal septum
• When the tip of the nose
is compressed gently in
the presence of a
dislocated septum, the
deformity appears to
worsen. With positional
deformity, the septum
would stay straight, even
if the nares appear
uneven. recognition of
this condition and timely
referral is important to
prevent permanent
deformity.

90. Positional deformation of jaw
• the angle between the
upper and lower jaws
can be better
appreciated with the
gums closer together.

91. Epstein pearl
• The small white papule
seen in the midline of the
palate of this infant is an
Epstein pearl.
• It represents epithelial
tissue that becomes
trapped during the palatal
fusion. It is a very
common and benign
finding.

92. Bifid uvula
• The uvula is almost twice the
normal width, and although it
is not clearly bifid, there is a
suggestion of two halves. This
finding is known to be
associated with submucous
cleft ,
• Submucous cleft may be
noted on palpation, but it is
important to note that when
a newborn is comfortably
sucking on the examiner's
finger, one is palpating only
the hard palate. Direct
palpation of the soft palate is
necessary to evaluate for
submucous cleft.

93. Cleft lip
• unilateral cleft on the
left side of the lip. It is
important to distinguish
unilateral (or bilateral)
cleft lip from the more
unusual and concerning
midline clefts that can
occur.
• Midline clefts are often
associated with
underlying midline
defects in the brain or
other structures.

94. Bohn's nodules
• The white bumps present
on the upper gum in this
infant are Bohn's nodules.
• The exact etiology is
unknown, but they are
thought to arise from
remnants of the dental
lamina or from
heterotrophic salivary
glands.
• these nodules are a
benign finding and will
disappear with time.

95. Ankyloglossia
• Tongue-tie occurs in
approximately 4% of
newborns. Many babies
with this condition can
breastfeed without
difficulty, but in some
cases, a tight frenulum
makes latching on
difficult. In those cases,
frenotomy may be
indicated

96. Natal teeth
• Natal teeth usually occur in
this location in the
mandibular gum. In this
case, eruption cysts are still
completely covering the
teeth, but with palpation, 2
firm teeth can be
appreciated. They are also
partially visible as faint
white streaks within the
cysts. Natal teeth occur in
1:2000 - 1:3500 newborns.
They are usually part of the
primary dentition of the
child, so they should not be
removed unless they are
mobile, presenting an
aspiration risk,

97. Micrognathia
• Micrognathia, or "small
jaw", can often be best
appreciated when looking
at the profile of the infant.
While many infants may
appear to have a slightly
recessed chin, the
appearance above is
clearly abnormal.
Underlying genetic
conditions should be
considered in cases such
as this.

98. Neck - clavicle
• Clavicle fracture
• Notice asymmetry

99. Supernummerary nipple
• The brown macule
below the left nipple in
this infant is a
supernummerary nipple.
Found along the "milk
lines" they may be single
or multiple, unilateral or
bilateral. It is an
insignificant finding.

100. Prominent xiphoid
• This visible, firm lump in
the midline of the chest is
a frequently observed
finding in newborns. It is
simply a prominence of
the xiphoid process and
does not represent an
abnormality. With time,
this becomes less
noticeable.

101. Pectus excavatum
• With deep inspiration,
the sternum appears to
almost collapse into the
chest cavity. While
connective tissue
disorders, such as
Marfan's, may be
associated with this
finding, pectus excavatum
is more commonly a
benign, isolated entity.

102. Diastasis recti
• A vertical bulge down the
midline of the abdomen can
be seen in many newborns
when intra-abdominal
pressure increases. In this
photo, a shadow lateral to
the bulge can be seen going
up the left side of the
abdomen, starting near the
umbilical clamp. Diastasis
recti is caused by a relative
weakness of the fascia
between the two rectus
abdominus muscles. It is not
a herniation and is not
pathologic. With time, this
will disappear.

103. Normal umbilical cord
• Looking at the cut edge
more clearly shows the
normal vessels of the
umbilical cord. The two
arteries are to the left
and the vein, with a
spot of blood in its
large lumen, is on the
right.

104. Meconium stained umbilical cord

105. omphalitis
• this is the appearance of a
full-blown case of omphalitis.
The progression of erythema
over time can be clearly seen
from the circles marked on
the abdomen. The first circle
was drawn less than 12 hours
after redness was initially
seen, and the second circle
was drawn several hours
after that. Omphalitis of this
degree can be fatal, even
with aggressive antibiotic
therapy, so infection in this
area should always be taken
seriously.

106. Wharton's jelly cyst
• Also known as a "false
cyst" of the cord, a
Wharton's jelly cyst is an
area where liquefaction
of the jelly has occured.
Up to 20% of infants with
this condition have
associated anomalies.

107. Typical breech position
• When an infant has been in
breech position in utero,
the legs have a tendency to
remain in this position for
the first few days. As with
any positional deformity,
spontaneous resolution is
anticipated.
• This leg position does not,
of itself, indicate any
problems with the hips.

108. galeazzi sign
 A positive galeazzi sign
(unequal knee heights)
suggests a unilaterally
dislocated hip.
 It is important to remember
that bilateral dislocations will
likely appear symmetric, so
this assessment should only
be used in combination with
the Ortolani and Barlow
manuevers. The infant in this
photo has a negative galeazzi
-- the hips are normal.

109. Positive galeazzi sign

110. pavlik harness
pavlik harness

111. Abnormal hip abduction
• Limited abduction can be
a sign of DDH, so it is a
useful tool in assessment,
especially for older infants
when Ortolani and Barlow
manuevers are not
helpful.

112. Penile pearl
The tip of the foreskin is
another relatively
common location. The
pearl is a small, firm,
white nodule that
contains keratin. It will
spontaneously exfoliate
and resolve with time. It
is a normal finding and
is not a contraindication
to circumcision, if
desired

113. Hypospadias
• opening of the urethra on
the distal penile shaft. A
hooded foreskin, which
allows the glans to be
readily visible, is present.
Hypospadias affects
1:250 boys, but most
have a milder form than
that shown here.

114. Hypospadias

115. epispadias
• With epispadias, the
urethral meatus is dorsally
displaced. This condition is
much less common than
hypospadias, but also
presents a contraindication
to routine circumcision. In
it's severe forms,
epispadias is often
associated with exstrophy
of the bladder.

116. This is an example of severe epispadias
and bladder exstrophy

117. Chordee
• Chordee exists when there is
a ventral curvature of the
penis. It can occur in the
setting of hypospadias, but
can also be isolated, as in this
case. In this baby, the
curvature is most visible from
this view from the side.
Chordee is a contraindication
to circumcision in the
newborn period, but if
desired, circumcision can be
done at the time of surgical
correction

118. Hydroceles
• Hydroceles are a
frequent finding in
newborns. It is important
on palpation to identify
the normally small
testicles (approximately 1
cm) as separate entities
from the large, smooth-
walled fluid collections of
hydroceles.

119. Acute testicular torsion
• Because of the pathology
that is occuring in the
right testicle, the right
scrotum does not
transilluminate equally
with the left.

120. Ambiguous genitalia
• under-virilized male
with hypospadias,
micropenis, and bifid
scrotum (testes were
present bilaterally).

121. Ambiguous genitalia
• This infant is a male with
micropenis and a cleft
scrotum, but on initial
evaluation the gender
cannot readily be
determined. Genetic,
metabolic, and urologic
evaluation is necessary.

122. Hymenal tag
• In many girls, a small tag of
mucosal tissue can be seen
protruding from the
vaginal area at birth. This is
a hymenal tag, a benign
physical finding. With time,
this tissue will recede into
the vagina and decrease in
size. No further evaluation
is necessary.

123. Vaginal cyst

124. Paraurethral cyst
• This mass, present at
birth, was a paraurethral
cyst. The fact that the
hymen can still be seen
inferior to the mass helps
differentiate this from
imperforate hymen,
which could have a
similar appearance.

125. Extremeties
• Most newborns have
two major creases on
the palm, neither of
which completely
extend from one side
of the palm to the
other.

126. Transverse palmar crease
• A common variant, found in
approximately 5% of
newborns, a transverse
palmar crease is frequently
inherited as a familial trait.
Although single palmar
creases are also associated
with Down's syndrome and
other genetic disorders, the
absence of other
abnormalities on physical
exam should reassure the
examiner that no further
evaluation is necessary.

127. polydactyly
• Post-axial polydactyly is
the most common
variety. The extra digit
may seem almost fully
formed or may be
attached only by a thin
fleshy stalk. This is
typically an isolated
finding. A positive family
history is often obtained.

128. polydactyly
• In cases where the
attachment of the extra
digit is very thin, the
appendage can be
successfully tied off with a
silk suture. After allowing
some time for hemostasis
to occur under the
ligature, we usually snip
off the appendage with a
sterile scissors

129. Preaxial polydactyly

130. syndactyly
• This type of mild
syndactyly is found
occasionally on the
physical examination.
Again, this is a subtle
finding. If the exam is
not a careful one, this
can easily be missed
since both digits are
otherwise normally
formed. This is usually
an isolated finding, and
in this location, has no
impact on function

131. severe syndactyly.
• In this case, the syndactyly
is severe. All four of the
digits on the right were
completely fused together
(notice the four fused nail
beds). The thumb was
normally formed and can
be seen to the right of the
abnormal area. This was a
unilateral, isolated finding
in an otherwise well
newborn; amniotic bands
were thought to have
caused this problem.

132. polysyndactyly
• When the digits are fused
in addition to being too
numerous, the term
polysyndactyly is used.
Careful examination is
important to identify
conditions such as this. If
the socks (or mittens) are
not removed, this finding
can be easily missed. While
this is not expected to
cause a significant
functional problem,
cosmesis can be of concern
as the child gets older

133. clinodactyly
• A slight medial incurvation
of the fifth finger is a
frequent finding on the
newborn exam. It is often
inherited as a familial
trait. Although it can be
associated with several
genetic disorders,
including Down's
syndrome, the absence of
other physical findings will
confirm that it is a benign,
isolated finding. In this
case, no further
evaluation is necessary.

134. Finger hypoplasia
• On first inspection, this
infant's hands may
appear normal, but on
closer inspection, the
fifth fingers bilaterally
appear hypoplastic,
and there is a complete
absence of the nail on
the infant's left side

135. Toe hypoplasia

136. Overlapping toes
• it is a positional
deformity of no
significance

137. Edema of the feet
• Here is another baby
with edematous feet
as a result of
Turner's syndrome.
From this angle, the
excessive puffiness
behind the toes can
be easily seen.

138. Club foot
• With an attempt to bring
the foot to neutral
position, the rigidity of
the ankle is apparent.
Although the skin is
sliding and wrinkling, the
actual position of the
foot is not changed. The
dark discoloration
around the ankles are
slate grey patches
(mongolian spots), not
bruises.

139. Bilateral club foot The feet are plantar-
flexed and inverted. Because this is a bony
deformity, this position is rigid.

140. Sacral hair
• Many newborns,
especially those with
increased skin
pigmentation, will have
an increased amount of
hair over the lower
back and sacrum. This
appearance is entirely
within normal limits
and is not a marker for
underlying spinal
dysraphism

141. Neural tube defects

142. Sacral dimple
• Most of these dimples are
"simple dimples" and
require no further
evaluation.
• A simple dimple is one
that is located within 2.5
cm of the anus, has a base
that can be visualized and
is not associated with
other abnormality on
exam.

143. Sacral skin tag
• Skin tags in the sacral
area are also potential
indicators of spinal
dysraphism. In some
cases, the "tag" may in
actuality be a residual
tail.

144. Dysmorphology

145. Sandal gap deformity

146. Loose nuchal skin
• Abnormal skin folds over
the back of the neck can
be a marker for genetic
abnormality. Increased
nuchal thickness can be
seen on prenatal
ultrasound in some
infants with Down's
syndrome, and increased
nuchal lucency (thought
to be related to
lymphedema) has been
noted in fetuses with
Turner's syndrome.

147. Facial palsy in forceps delivery

148. Brachial plexus injury
• This photo shows how the
posture of the arms is
asymmetric: the left arm is
at the side and the hand is
medially rotated at a time
when the other arm is
flexed with crying. Most
brachial plexus injuries of
this type resolve
spontaneously.
Improvement in movement
can often be noted within
the first 24 hours. If
improvement does not
occur, referral to a
pediatric neurologist, and
possibly a physical
therapist, is warranted.