Inspect the abdomen. The abdomen of a newborn is protuberant as a result of the poor development of the abdominal musculature. If the abdomen is scaphoid, there should be a high index of suspicion that a diaphragmatic hernia is present and that the abdominal organs may be located in the chest.
Is an umbilical hernia present? The abdominal wall is relatively weak in newborns, especially in premature infants. Umbilical hernias are common in African-American infants. An umbilical hernia in a non-African-American child may be an indication of hypothyroidism.
Although uncommon, two major defects in the abdominal wall are well known. Omphaloceles are severe umbilical hernias in which some of the abdominal contents are located outside the body. Omphaloceles, which always involve the umbilicus and, as such, are always in the midline, may be isolated anomalies or may be associated with additional anomalies, such as in the Beckwith-Wiedemann syndrome. Gastroschisis, which results from an embryonic vascular deficiency, is similar to omphalocele in that abdominal contents are located outside the abdominal cavity. However, gastroschisis is never midline, is never covered by a membrane, and usually is located in the right upper quadrant. Gastroschisis may be associated with intestinal atresias, a condition known as apple peel bowel.
Inspect the umbilical cord stump. Is there evidence of yellow staining by meconium as a result of fetal distress? The normal umbilical cord contains two thick-walled arteries and one thin-walled vein. This examination needs to be performed in the delivery room, before the cord is treated with triple dye for antisepsis. Newborns with a single artery may have congenital abnormalities of the kidneys and spine. Drainage of a clear discharge from the umbilicus is suggestive of the presence of a patent urachus* or possibly an omphalomesenteric duct.
Auscultate the abdomen. The abdomen of a newborn infant is tympanitic, with metallic tinkling sounds being heard every 15 to 20 seconds.
Palpate the abdomen. To relax the abdomen, use your left hand to hold the infant's hips and knees in a flexed position while the child is sucking, and palpate with your right hand. In general, the liver edge may be felt as much as 0.75 inch (2 cm) below the right costal margin in the newborn. A liver edge more than 1.2 inches (3 cm) below the right costal margin is suggestive of hepatomegaly. The liver span can be measured by percussion, and this measurement is more accurate than abdominal measurements because respiratory conditions could hyperinflate the lungs and push a normal liver down into the abdominal cavity. Palpation of the spleen tip is less common.
Palpate the kidneys. Place your left hand under the right side of the child's back, and lift upward. At the same time, place your right hand in the child's right upper quadrant, and palpate for the right kidney. Reverse hands to palpate the left kidney.
Unless it is clinically indicated, the rectum is not examined. However, in infant girls especially, the patency of the anus should be determined by inspection while spreading the buttocks. In infants with imperforate anus, a blind dimple may be present;in infant girls, a rectovaginal fistula may allow passage of stool vaginally. In infant boys, an imperforate anus may be associated with a rectovesical fistula and no passage of meconium. Note that patency of the anus is established when the infant's temperature is taken rectally, as described previously. The presence of an imperforate anus may be the first evidence that the child has a condition known as VATER or VACTERL association—vertebral anomaly, cardiac defect, tracheo-esophageal fistula, renal defects, and limb defect (specifically, an anomaly of the thumb or radius)—a group of congenital anomalies that occur more commonly together than would be expected by chance.
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