Module 5
Module 5: Skin & Neurological
Differentiate newborn rashes and perform comprehensive neurological assessment
Welcome to Module 5!
Congratulations on reaching the final module of the Newborn Pediatric Physical Exam Course! In this advanced module, you’ll develop expertise in two critical areas: dermatological assessment and comprehensive neurological evaluation. These skills complete your ability to perform a thorough newborn physical examination.
Learning Objectives
By the end of this module, you will be able to:
- ✅ Differentiate benign newborn rashes from concerning skin conditions
- ✅ Identify classic newborn skin findings and understand their natural history
- ✅ Recognize red flags in skin findings that suggest serious pathology
- ✅ Perform systematic neurological examination in newborns
- ✅ Assess and interpret primitive reflexes and know their clinical significance
- ✅ Evaluate tone, symmetry, and movement patterns
- ✅ Recognize signs of birth injury or neurological compromise
- ✅ Know when urgent intervention or referral is needed
Lesson 1: Common Benign Newborn Skin Findings
Erythema Toxicum Neonatorum
Characteristics:
- Small, blanchable erythematous papules and pustules
- Often with white or yellow centers (resembles tiny pustules)
- Appear within first 24-48 hours of life
- Most commonly on trunk and upper extremities
- May come and go in different locations over several days
- Non-pruritic, non-tender
Pathophysiology:
- Self-limited inflammatory response
- Sterile pustules (culture negative)
- Unknown exact cause, possibly normal skin reaction
- More common in full-term infants
Clinical Course:
- Self-resolving within 7-14 days
- No treatment needed
- Lesions may wax and wane
- Can cause parental alarm due to appearance
Parent Counseling: “These little red bumps are a very common, temporary newborn rash. They’re sterile, nothing to treat, and will disappear on their own in about a week or two. This isn’t an infection and doesn’t indicate any health problem.”
Clinical Pearl: Can be confirmed by Wright staining of pustule contents showing eosinophils if diagnosis uncertain, but rarely needed.
Milia
Characteristics:
- Tiny (1-2 mm), white or yellow bumps
- Hard, non-blanching
- Not surrounded by erythema
- Commonly on nose, cheeks, forehead, and chin
- Present at birth or appear within first few days
- Non-pruritic
Pathophysiology:
- Blocked sebaceous glands
- Keratin-filled cysts
- Completely normal neonatal finding
Clinical Course:
- Spontaneously resolve within 2-4 weeks
- No treatment needed
- No scarring
Parent Counseling: “These are tiny blocked oil glands on baby’s skin. They’re completely normal and will clear up on their own in a few weeks. Don’t squeeze them - they’ll go away faster if left alone.”
Tip for Parents: Milia are not whiteheads and shouldn’t be treated like acne. Using moisturizers or any treatments is unnecessary and potentially harmful.
Mongolian Spots
Characteristics:
- Blue-gray or blue-black macules
- Irregular, poorly defined borders
- Most commonly over sacrum and buttocks
- Can appear on shoulders, back, or extremities
- Flat, non-blanching, non-pruritic
- Present at birth
Epidemiology:
- More common in infants with darker skin (50-90% of Asian, African, and Hispanic infants)
- Rare in Caucasian infants (5-10%)
- More common in males
Pathophysiology:
- Dermal melanocytosis
- Melanin-containing melanocytes in dermis rather than epidermis
- Completely benign finding
Clinical Course:
- Usually fade by age 2-4 years
- Occasionally persist into adulthood
- No treatment needed
- No functional consequences
Parent Counseling: “This is a flat, gray-blue mark on the skin that’s very common in babies. It’s completely harmless and will fade over time. This is not a bruise or indication of injury.”
Important Clinical Note: Because these can resemble bruises, document their location carefully in medical records. This helps prevent misunderstanding if questioned about potential abuse. The flat, non-blanching nature and typical locations (sacrum, buttocks) help differentiate from traumatic bruising.
Lanugo and Vernix Caseosa
Lanugo:
- Fine, downy hair covering (especially pronounced in preterm infants)
- Begins to shed around 32-36 weeks gestation
- Usually shed by term birth
- May persist longer in preterm infants
- Normal finding requiring no intervention
Vernix Caseosa:
- Waxy, white coating on skin at birth
- Protective layer during fetal development
- Provides initial moisture and temperature regulation
- Gradually absorbed; complete absorption in 24-48 hours
- No need to wash off aggressively - allow natural absorption
Parent Counseling: “Your baby has this waxy coating because it spent months in amniotic fluid. It’s protective and healthy - we don’t need to wash it off. It will come off on its own as your baby’s skin adjusts to air.”
Lesson 2: Birth-Related Skin Findings
Petechiae and Bruising
Petechiae:
- Non-blanching red-purple dots/pinpoint spots
- Common from delivery trauma
- Usually on face, neck, shoulders, presenting areas
- Typically benign when limited to presenting parts
Concerning Features:
- Extensive petechiae beyond head and neck
- Associated with systemic signs (fever, lethargy, poor feeding)
- Petechiae appearing after first 24 hours (suggests infection)
- Thrombocytopenia (if petechiae out of proportion to delivery trauma)
Bruising:
- Common on face, scalp, buttocks, genitalia from delivery
- Blanchable or non-blanching
- May have distinct pattern (forceps marks)
- Expected to fade within 1-2 weeks
Red Flags:
- Bruising inconsistent with delivery presentation
- Pattern suggesting non-accidental trauma
- Bruising appearing after hospital discharge
Herpes Simplex Infection
Presentation:
- Vesicles that appear at 5-7 days of age
- Grouped vesicles on erythematous base
- Often on presenting areas (scalp if vaginal delivery)
- May have associated conjunctivitis, respiratory symptoms, or systemic signs
Risk Factors:
- Maternal history of genital HSV (especially primary infection near delivery)
- Lack of adequate suppression therapy during pregnancy
Urgency: REQUIRES IMMEDIATE ACTION - TREAT EMPIRICALLY
Disseminated neonatal HSV carries high mortality and morbidity risk.
Management:
- Do not delay treatment pending culture confirmation
- Start IV acyclovir immediately if HSV suspected
- Obtain surface cultures (vesicles, mouth, rectum)
- Consider lumbar puncture and CSF culture
- Pediatric infectious disease consultation
Clinical Pearl: Even with maternal history of HSV, risk of transmission is low if mother on prophylaxis or has no prodromal symptoms at delivery. However, always maintain high suspicion for any vesicular rash in first 2-4 weeks of life.
Varicella (Chickenpox)
Timing:
- If rash appears before 5 days postpartum: intrauterine infection
- If appears days 5-10 after birth: perinatal exposure
- If appears >10 days: postnatal exposure
Congenital Varicella Syndrome:
- Maternal varicella in first 20 weeks gestation
- Features: skin scarring, eye abnormalities, limb hypoplasia, CNS involvement
- Severe manifestation with high morbidity
Neonatal Varicella:
- Perinatal exposure can cause disseminated disease
- High risk for severe pneumonitis, hepatitis, encephalitis
- Requires IV acyclovir and close monitoring
Prevention:
- Varicella-zoster immune globulin (VZIG) if maternal varicella develops 5 days before or 2 days after delivery
Lesson 3: Benign Vascular Lesions
Hemangiomas
Characteristics:
- Bright red or purple nodular lesions
- Soft, compressible, blanching
- Usually not present at birth (appear at days to weeks of life)
- Can vary in size from few mm to several cm
- Most common: head and neck area
Growth Pattern:
- Rapid growth phase (weeks to months)
- Plateau phase (months to years)
- Involution phase (gradual fade, may take years)
- Most resolve by age 5-7 years
Concerns:
- Rapid growth
- Location affecting vision, hearing, breathing, or feeding
- Appearance or location causing functional or cosmetic concern
- Multiple hemangiomas (possible syndrome)
Management:
- Observation for small, non-problematic lesions
- Dermatology referral for lesions in concerning locations
- Treatment options if indicated: topical steroids, oral propranolol, interferon
Parent Counseling: “This vascular birthmark will likely grow over the next several months, but most fade naturally over time. We’ll monitor it carefully. Treatment depends on size, location, and growth rate.”
Port Wine Stains (Nevus Flammeus)
Characteristics:
- Flat, non-blanching, macular lesion
- Pink, red, or purple coloring
- Usually unilateral
- Often on face (V1/V2 distribution - trigeminal nerve)
- Present at birth
- Darkens and thickens with age
Clinical Significance:
- Benign from skin perspective
- V1/V2 distribution associated with Sturge-Weber syndrome (25% of cases)
Sturge-Weber Syndrome Features:
- Port wine stain typically on V1 (ophthalmic) and/or V2 (maxillary) trigeminal distribution
- CNS involvement: leptomeningeal angiomatosis
- Risk for seizures, stroke-like episodes, glaucoma
- Progressive darkening and thickening of skin lesion
Screening for Sturge-Weber:
- Eye examination for glaucoma risk
- Neurological assessment
- Consider imaging (MRI) if V1 involvement
Management:
- Dermatology evaluation
- Ophthalmology evaluation if V1 involved
- Early laser therapy (pulsed dye laser) can improve appearance
- Genetic evaluation if concerned about syndrome
Salmon Patches (Nevus Simplex)
Characteristics:
- Flat, light pink macules
- Non-blanching (unlike simple erythema)
- Most commonly between eyebrows (“angel’s kiss”) or on nape of neck (“stork bite”)
- Present at birth
- Blanch partially with pressure
Clinical Course:
- Most commonly fade by 12-18 months
- Those on nape of neck may persist longer or indefinitely
- No treatment needed
- Purely cosmetic concern if persist
Parent Counseling: “These are light pink marks on the skin that are very common in newborns. Most fade on their own within the first year or two. If they persist, there are cosmetic options available, but they’re completely harmless.”
Lesson 4: Concerning Skin Findings Requiring Urgent Evaluation
Bullae (Fluid-Filled Blisters)
Non-Infectious Causes:
- Epidermolysis bullosa (genetic disorder affecting skin-basement membrane adhesion)
- Bullous pemphigoid
- Incontinentia pigmenti
Infectious Causes:
- Varicella or HSV (discussed above)
- Syphilis
- Candidiasis (usually on intertriginous areas)
- Staphylococcal scalded skin syndrome (SSSS)
Red Flags:
- Bullae appearing in first days of life (especially infectious or genetic concern)
- Bullae on palms/soles (possible epidermolysis bullosa)
- Associated systemic signs (fever, lethargy)
- Extensive involvement
Management:
- Culture any fluid (HSV, varicella, bacterial)
- Consider serologies if syphilis suspected
- Pediatric dermatology or genetics referral for genetic conditions
- Empiric treatment if infection suspected
Pustules with Systemic Signs
Characteristics Suggesting Infection:
- Pustules appearing after 24 hours
- Associated fever
- Maternal fever or infection
- Purulent discharge
- Systemic signs (lethargy, poor feeding, jaundice, seizures)
Common Organisms:
- Staphylococcus aureus
- Group B Streptococcus
- Listeria monocytogenes
- Enterococcus
Management:
- Blood cultures
- Possible lumbar puncture (if concerning features)
- Empiric IV antibiotics if systemic neonatal sepsis suspected
- Strict isolation precautions
Extensive Hemangiomas or Vascular Lesions
Red Flags:
- Multiple hemangiomas (>5)
- Large facial hemangiomas
- Rapid growth despite intervention
- Associated systemic findings (hepatomegaly, cardiac involvement)
Conditions to Consider:
- PHACES syndrome (Posterior fossa brain malformations, Hemangioma, Arterial anomalies, Cardiac defects, Eye abnormalities, Sternal cleft/supraumbilical raphe)
Management:
- Comprehensive imaging (brain MRI, echocardiography)
- Multidisciplinary evaluation
- Specialized dermatology assessment
Ichthyosis and Abnormal Skin Barriers
Presentation:
- Thick, scaly, leathery skin appearance
- Severe in collodion membrane presentation
- Associated with severe dryness and potential fluid/electrolyte loss
- Respiratory compromise possible if extensive
Types:
- Collodion membrane (temporary, usually resolves but may progress to ichthyosis vulgaris)
- Harlequin ichthyosis (severe genetic form, high mortality)
Management:
- Intensive skin care (emollients, avoid irritants)
- Consider dermatology evaluation
- Monitor for infection and fluid/electrolyte status
- Genetic evaluation for heritable forms
Lesson 5: Comprehensive Neurological Examination
Assessment Approach
The newborn neurological examination differs significantly from older children and adults. Key differences:
Sleep States Matter:
- Quiet alert state optimal for examination
- Avoid during deep sleep or feeding
- Avoid immediately after feeding (vomiting risk)
- Temperature control important (cold stress affects tone and behavior)
Behavioral State:
- Quiet alert
- Active alert
- Crying
- Sleep states
Systematic Approach:
- Observe before touching
- General behavior and state
- Cranial nerves
- Motor tone and posture
- Primitive reflexes
- Movement and strength
- Sensation (limited testing)
Lesson 6: Primitive Reflexes
Primitive reflexes are automatic responses that appear and disappear at predictable times. Their presence, absence, or persistence may indicate neurological dysfunction.
Moro Reflex (Startle Reflex)
Age of Appearance:
- Present at birth (may be absent in some preterm infants <32 weeks)
Age of Disappearance:
- 4-6 months
Elicitation:
- Method 1: Drop head suddenly 1-2 inches
- Method 2: Sudden loud noise
- Method 3: Sudden abdominal jerk
Normal Response (Complete Moro):
- Symmetric arm abduction and extension (“salute” position)
- Opening of hands
- Rapid adduction of arms back to midline
- Possible crying or startled appearance
- Legs may extend slightly
Abnormal Findings:
- Absent/Diminished: Prematurity, CNS depression, birth injury, brachial plexus injury
- Asymmetric: Unilateral weakness from brachial plexus injury, facial nerve injury, or hemiparesis
- Exaggerated: Hyperreflexia, spasticity, seizure activity
- Persistent: If present after 6 months, suggests neurological dysfunction
Rooting Reflex
Age of Appearance:
- Present at birth
Age of Disappearance:
- 3-4 months (may persist longer if breastfeeding)
Elicitation:
- Stroke cheek or perioral area
- Infant turns toward stimulus
- Opens mouth to root
Clinical Significance:
- Essential for feeding
- Indicates intact CNs V and VII
- Indicates intact brainstem
Abnormal Findings:
- Absent: CNS depression, prematurity, brachial plexus injury if unilateral
- Asymmetric: Facial nerve injury
Sucking Reflex
Age of Appearance:
- Present at birth (develops around 28 weeks gestation)
Age of Disappearance:
- 2-4 months
Elicitation:
- Place finger in mouth
- Infant sucks with rhythmic jaw movements
- Assess strength and coordination
Clinical Significance:
- Essential for feeding
- Indicates intact brainstem
- Assesses strength
Abnormal Findings:
- Weak: Prematurity, CNS depression, neuromuscular disease
- Absent: Severe CNS dysfunction
- Uncoordinated: Prematurity, neurological dysfunction
- Continued after 4 months: Neurological concern
Grasp Reflex
Age of Appearance:
- Present at birth
Age of Disappearance:
- 5-6 months
Elicitation:
- Place finger in infant’s palm
- Infant grasps finger with reflexive flexion
Normal Response:
- Strong grasp
- May lift infant slightly off surface if both hands grasping
- Symmetric
Abnormal Findings:
- Absent: Upper extremity weakness, nerve injury, CNS dysfunction
- Asymmetric: Brachial plexus injury, other unilateral weakness
- Weak: Prematurity, hypotonia
Clinical Pearl: Normal grasp reflex is surprising strong. Infant unable to maintain grip may indicate significant weakness.
Plantar Grasp Reflex
Age of Appearance:
- Present at birth
Age of Disappearance:
- 9-12 months
Elicitation:
- Press thumb or finger on sole of foot at metatarsal heads
- Infant flexes toes as if grasping
Clinical Significance:
- Less functionally important than palmar grasp
- Still indicates intact motor pathways
Stepping Reflex
Age of Appearance:
- Present at birth
Age of Disappearance:
- 4-6 weeks (disappears due to increased flexor tone in lower extremities)
- Reappears as voluntary walking develops around 12 months
Elicitation:
- Hold infant upright with feet touching flat surface
- Infant makes stepping motions as if walking
- Movements should be coordinated and alternating
Normal Response:
- Alternating leg movements
- Symmetric
- Forward progression
Abnormal Findings:
- Asymmetric: Weakness on one side
- Rigid extension: Increased tone
- Absent: Severe prematurity or dysfunction
Tonic Neck Reflex (Fencing Reflex)
Age of Appearance:
- Present at birth
Age of Disappearance:
- 3-4 months
Elicitation:
- Turn infant’s head to one side
- Extension of arm and leg on same side
- Flexion of opposite side arm and leg
- Resembles “fencing” position
Clinical Significance:
- Indicates intact brainstem reflexes
- Asymmetric reflex may suggest weakness
Abnormal Findings:
- Persistent asymmetric tonic neck reflex past 6 months: Abnormal (suggests spasticity)
- Absent: Less significant than other reflex abnormalities
Babinski Reflex (Plantar Response)
Age of Appearance:
- Present at birth
Age of Disappearance:
- 12-24 months
Elicitation:
- Stroke lateral sole of foot from heel to toe
- Normal neonatal response: Dorsiflexion of great toe with fanning of other toes
Important Note:
- Upgoing toes are NORMAL in newborns (until myelination complete)
- Downgoing toes in newborn may be abnormal
Abnormal Findings:
- Absent: Peripheral nerve injury, severe hypotonia
- Asymmetric: Unilateral weakness
Lesson 7: Tone Assessment
Tone assessment is critical for identifying neurological dysfunction. Both hypotonia and hypertonia are abnormal and warrant further evaluation.
Normal Newborn Tone
Characteristics of Normal Term Infant:
- Flexed posture at rest
- Resistance to passive extension
- Arm recoil (if extended, returns to flexed position)
- Popliteal angle (angle behind knee) approximately 80-90 degrees in flexed position
- Scarf sign (can bring elbow only across midline in flexed infant)
Expected Flexor Tone:
- Neck flexors: Good
- Arm flexors: Good
- Hip and knee flexors: Good
Position at Rest:
- Hands clenched
- Elbows flexed
- Hips and knees flexed
- Head midline or slightly turned
Hypotonia (Low Tone/”Floppy Baby”)
Presentation:
- Decreased resistance to passive movement
- Poor head control
- Arms and legs extended or in “frog-leg” position
- Difficulty holding up against gravity
- Weak cry or suck
- Poor feeding
Differential Diagnosis (Broad Categories):
Neurogenic (CNS Origin):
- Hypoxic-ischemic encephalopathy (HIE)
- Birth asphyxia
- Intracranial hemorrhage
- CNS malformations
- Metabolic encephalopathy
Neuromuscular:
- Spinal cord injury
- Brachial plexus injury (usually asymmetric)
- Congenital myasthenia gravis
- Congenital muscular dystrophy
- Spinal muscular atrophy
Systemic:
- Sepsis/infection
- Hypoglycemia
- Hypothermia
- Metabolic disorders
Genetic/Chromosomal:
- Down syndrome
- Prader-Willi syndrome
Red Flags Requiring Urgent Evaluation:
- Profound hypotonia with altered consciousness
- Poor feeding and weak suck
- Respiratory compromise
- Associated seizures
- Abnormal face or dysmorphic features
Management:
- Urgent pediatric evaluation
- Laboratory assessment (glucose, electrolytes, sepsis workup)
- Consider imaging (ultrasound, MRI)
- Metabolic screening if indicated
- Neurology consultation as appropriate
Hypertonia (Increased Tone/Stiffness)
Presentation:
- Increased resistance to passive movement
- Arms and legs may be extended or in abnormal positions
- Rigid posturing
- May be axial (trunk) or focal (limbs)
- Opisthotonus in severe cases (arching back)
Differential Diagnosis:
Neurogenic:
- Spasticity (upper motor neuron injury): Resistant extension; clasp-knife quality
- Birth injury to spinal cord
- HIE
- Tetanus
- Meningitis/encephalitis
Neuromuscular:
- Strychnine poisoning (rare)
- Tetanospasmin toxin
Metabolic:
- Hypocalcemia
- Hypomagnesemia
- Tetany
Red Flags:
- Stiffness with fever: Rule out meningitis
- Stiffness with seizures: CNS pathology
- Stiffness affecting respiration: Life threat
Management:
- Urgent evaluation for infection (meningitis)
- Assess for seizures (and treat if present)
- Check calcium, magnesium levels
- Neuroimaging if structural lesion suspected
- Temperature control
Lesson 8: Birth-Related Neurological Injuries
Brachial Plexus Injury
Mechanism:
- Traction injury during delivery
- Often with shoulder dystocia or difficult delivery
- Can occur even with vaginal delivery
Classification by Location (Erb vs Klumpke):
Erb Palsy (C5-C6) - Most Common (90%):
- Arm held in “waiter’s tip” position (adducted, internally rotated)
- Loss of shoulder abduction
- Loss of elbow flexion
- Intact wrist and finger movement
- Intact Moro on affected side may not be visible
Klumpke Palsy (C8-T1) - Less Common:
- Weakness of hand and wrist muscles
- Claw hand deformity
- May have associated Horner syndrome (ptosis, miosis, anhidrosis if T1 root involved)
- Shoulder and elbow relatively preserved
Assessment:
- Observe spontaneous movement
- Compare sides
- Assess Moro reflex (asymmetric if nerve involved)
- Palpate clavicle for fracture (may also limit movement)
Distinction from Fractured Clavicle:
- Brachial plexus: No visible deformity, crepitus, or swelling over clavicle
- Clavicle fracture: May feel crepitus or deformity; X-ray confirms
Expected Course:
- Most recover spontaneously within 3-6 months
- Some take up to 12-24 months
- Persistent injury (no improvement by 3 months) may warrant imaging and consideration of nerve grafting
Management:
- Gentle passive range of motion (arm kept loosely at side, not tightly swaddled)
- Avoid aggressive physical therapy
- Follow-up neurology or orthopedic surgery evaluation if no improvement by 3-4 weeks
- Imaging (ultrasound, MRI) for severe injuries or lack of improvement
Parent Counseling: “Your baby has an injury to the nerves that control arm movement. This happened during delivery. Most babies recover completely on their own over weeks to months. We’ll monitor the movement closely.”
Facial Nerve Injury
Presentation:
- Asymmetric face, especially with crying
- Drooping on affected side
- Inability to close eye on affected side
- Lack of nasolabial fold on affected side
Etiology:
- Birth trauma (forceps injury most common)
- Intrauterine compression (if positioned against maternal pelvis)
- Usually temporary (nerve compression rather than transection)
Assessment:
- Observe face at rest and with crying
- Check ability to close eyes
- Assess nasolabial folds
- Compare symmetry
Distinction from Central vs Peripheral:
- Peripheral facial nerve injury (lower motor neuron): Entire half of face affected, including forehead
- Central facial weakness: Forehead spared, lower face affected (unusual in newborn period)
Expected Course:
- Most resolve spontaneously within weeks
- Complete resolution common if nerve compression (not transection)
Management:
- Monitor for eye complications (corneal abrasion)
- If eye cannot close, consider protective eye care (lubricating drops, ointment, eye taping)
- Neurology consultation if persistent beyond 2-3 weeks
- Imaging if concerning features
Spinal Cord Injury
Risk Factors:
- Breech presentation
- Difficult delivery
- Excessive traction
- Associated bony injuries
Presentation:
- Flaccid paralysis below level of injury
- Loss of sensation below injury
- Bowel/bladder involvement
- Respiratory compromise if high injury
Assessment:
- Level of weakness/paralysis
- Associated spinal tenderness
- Back examination for dimples or masses
Immediate Management:
- Avoid further traction or movement
- Immobilize spine pending imaging
- Pediatric neurosurgery consultation
- MRI to assess damage
Lesson 9: Seizures and Seizure-Like Phenomena
Distinguishing True Seizures from Benign Movements
True Seizures:
- Sustained, purposeless movements
- Alteration of consciousness (though subtle in newborns)
- Autonomic signs (drooling, apnea, color change)
- Post-ictal period
- Abnormal EEG
Benign Sleep Myoclonus:
- Myoclonic jerks during sleep only
- Disappear with arousal or eye opening
- Normal consciousness otherwise
- Normal EEG
- Resolve by 2-4 weeks of age
Jitteriness:
- Tremulous movements (not true clonic jerking)
- Responsive to handling
- Normal sleep patterns
- Seen with hypoglycemia, hypocalcemia, withdrawal
Types of Neonatal Seizures
Subtle Seizures (Most Common):
- Eye deviation or nystagmus
- Mouth movements or drooling
- Limb jerking or pedaling
- Brief apnea
Clonic Seizures:
- Rhythmic jerking (may be focal or generalized)
- Slower than older children (1-3 Hz)
Tonic Seizures:
- Sustained posturing or stiffening
Myoclonic Seizures:
- Brief, shock-like jerks
Common Causes in Newborns
First Few Hours (Most Critical):
- Hypoxic-ischemic encephalopathy
- Intracranial hemorrhage
- Birth trauma
First 24 Hours:
- Hypoglycemia
- Hypocalcemia
- Hypomagnesemia
- Infection
- Withdrawal (maternal drugs)
After 24 Hours:
- Infection (meningitis, encephalitis)
- CNS malformations
- Metabolic disorders
- Genetic disorders
Management Approach
- Stabilize - Airway, breathing, circulation
- Stop seizure - Phenobarbital or phenytoin
- Evaluate - Labs (glucose, calcium, magnesium, blood/CSF cultures)
- Investigate - Imaging if indicated
- Treat cause - Address underlying condition
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Exercise 5.1: Newborn Skin Findings - Normal vs Pathological
Let’s practice differentiating benign newborn skin findings from concerning conditions that require intervention.
Exercise 5.1: Newborn Skin Findings Assessment
Your Challenge
Review descriptions of various skin findings in newborns. For each finding, identify it correctly, determine whether it's benign or concerning, explain the expected course, know when to worry or investigate further, and provide appropriate parent counseling.
View Skin Finding Descriptions
Exercise 5.2: Primitive Reflexes Assessment
Practice assessing and interpreting primitive reflexes in different clinical scenarios.
Exercise 5.2: Primitive Reflexes Assessment
Your Challenge
Review video descriptions of primitive reflex testing in different scenarios. For each reflex, identify what's being tested, determine if the response is normal or abnormal, know the expected developmental timeline, and understand the clinical significance of abnormalities.
View Reflex Testing Cases
Exercise 5.3: Tone and Comprehensive Neurological Examination
Master the complete neurological assessment, from tone evaluation to recognizing concerning neurological findings.
Exercise 5.3: Tone and Comprehensive Neurological Exam
Your Challenge
Review comprehensive neurological examination cases with detailed descriptions and images. Perform a complete assessment of tone, symmetry, alertness, and neurological function. Identify concerning findings, develop differential diagnoses, and recommend appropriate workup and referral.
View Comprehensive Neurological Cases
Course Completion Celebration!
Congratulations!
You've successfully completed the Newborn Pediatric Physical Exam Course!
What You’ve Accomplished
You have successfully completed all five modules of comprehensive newborn physical examination training:
Module 1: General Assessment & Vital Signs
- Mastered APGAR scoring and interpretation
- Learned normal vital sign ranges and how to identify abnormalities
- Developed systematic general appearance assessment skills
Module 2: Head, Eyes, Ears, Nose, Throat
- Distinguished benign birth findings from pathological conditions
- Learned critical red reflex examination technique
- Developed oral cavity assessment skills including tongue-tie evaluation
Module 3: Cardiovascular & Respiratory
- Practiced cardiac auscultation and murmur differentiation
- Learned to recognize respiratory distress patterns
- Developed cyanosis evaluation skills
Module 4: Abdomen, GU, & Musculoskeletal
- Mastered abdominal examination and hernia assessment
- Learned developmental dysplasia of hip screening
- Developed extremity and spine examination skills
Module 5: Skin & Neurological
- Differentiated benign newborn rashes from concerning skin conditions
- Mastered primitive reflex assessment and interpretation
- Learned comprehensive tone and neurological evaluation
- Recognized birth injuries and neurological red flags
Key Competencies You’ve Developed
Clinical Assessment Skills:
- Systematic, comprehensive physical examination
- Identification of normal findings and benign variants
- Recognition of pathological findings requiring intervention
- Risk stratification and appropriate urgency assessment
Knowledge Areas:
- Newborn physiology and expected variation
- Pathophysiology of common findings
- Natural history and expected resolution timelines
- Management principles and when to treat vs observe
Communication Skills:
- Parent counseling and reassurance for benign findings
- Explanation of concerning findings in understandable terms
- Clear documentation of findings
- Appropriate referral communication
Clinical Judgment:
- When to reassure parents
- When to investigate further
- When urgent referral is needed
- How to distinguish normal variation from pathology
- Integration of multiple findings into clinical picture
Critical Safety Principles to Remember
Always Prioritize:
- Red reflex examination - Never skip; potential vision-threatening or life-threatening conditions
- Feeding assessment - Safe nutrition is essential for newborn survival and growth
- Neurological assessment - Identifies birth injuries and metabolic emergencies
- Infection recognition - Newborn sepsis can progress rapidly
- Trust your gestalt - If baby “doesn’t look right,” investigate
Remember the Red Flags:
- Leukocoria (white pupil) = ophthalmology emergency
- Vesicular rash = possible HSV (treat empirically)
- Bulging fontanelle + fever = possible meningitis
- Profound hypotonia = urgent workup needed
- Persistent seizures = emergency management
Key Clinical Attitudes:
- Healthy skepticism: Don’t assume benign without assessment
- Parental partnership: Clear communication builds trust
- Documentation: Detailed notes protect patients and providers
- Continuous learning: Newborn medicine evolves; stay current
- Humility: When in doubt, consult colleagues or specialists
Resources for Ongoing Learning
For Clinical Reference:
- Keep these modules accessible for quick reference
- Revisit specific sections when examining similar findings
- Use the scenarios as mental models for future patients
For Skill Maintenance:
- Practice physical examination techniques regularly
- Video resources can reinforce technique
- Peer feedback improves clinical skills
- Case discussions enhance pattern recognition
For Advanced Learning:
- Pediatric neurology resources for detailed neurological assessment
- Pediatric dermatology resources for complex skin conditions
- Cardiac ultrasonography for murmur evaluation
- Orthopedic resources for skeletal variations
What Happens Next?
As you implement these skills in clinical practice:
- Be Systematic - Use the structure learned in this course for every exam
- Document Thoroughly - Clear, specific documentation is essential
- Develop Your Eye - Pattern recognition improves with experience
- Ask for Feedback - Mentors can help refine your technique
- Stay Current - Continue learning throughout your career
Final Wisdom
The newborn physical examination is a critical skill that:
- Builds parental confidence and trust
- Identifies important pathology early
- Prevents complications through early intervention
- Provides reassurance when findings are benign
- Guides appropriate referral and management
Every newborn examination is an opportunity to:
- Provide excellent clinical care
- Practice systematic thinking
- Support families during a vulnerable time
- Identify problems that could affect lifelong health
You now have the knowledge and skills to perform comprehensive, safe, and effective newborn physical examinations. Trust your training, be thorough, think critically, and never hesitate to ask for help when needed.
Course Complete!
You are now prepared to provide comprehensive, expert newborn physical examinations. Congratulations on your achievement!