Assess the lips and philtrum. Is there a cleft of the lip? This may be to the left or the right of the midline and may be unilateral or bilateral. Is the philtrum well formed, with normal architecture? Flattening of the philtrum is seen in infants with fetal alcohol syndrome.
Test the sucking reflex. Put on a glove, and insert your index finger into the newborn's mouth. A strong sucking reflex should be present. The sucking reflex is usually strong by 34 weeks' gestation and disappears at 9 to 12 months of age. Feel for any clefts in the palate.
Inspect the gingivae. The gums should be raised, smooth, and pink.
Inspect the tongue. The normal frenulum may be short or may extend almost to the tip of the tongue. Because the production of saliva is limited in the first few months of life, the presence of excessive saliva in the mouth is suggestive of esophageal atresia.
Inspect the palate. Is there a cleft palate (see Fig. 12-32)? A bifid uvula may be associated with a submucosal cleft palate. Is the palate high-arched? Petechiae are commonly found on the hard and soft palates. Pinhead, whitish-yellow, rounded lesions on either side of the raphe on the hard palate are Epstein's pearls. These are mucous retention cysts and disappear within the first few weeks after birth. Similar cysts may be present on the gingivae. Inspect for neonatal teeth. These teeth have poor root systems and may have to be removed to prevent accidental aspiration.
Inspect the oropharynx. This can be performed while the infant is crying. Tonsillar tissue is not visible in the newborn. Small ulcers or clusters of small, whitish-yellow follicles on an erythematous base are sometimes seen on the anterior tonsillar pillars and are known as Bednar's aphthae. The cause is unknown, and they disappear within the first week after birth.
Listen to the child's cry. Evaluate the cry for its nature, pitch, intensity, and effort. A healthy child has a strong cry, indicative of normally functioning airways. The cry varies in intensity with breathing. The cry is high-pitched and shrill in diseases associated with increased intracranial pressure. Children born to drug-addicted mothers often have high-pitched cries.
A low-pitched, hoarse cry that is infrequent and low in intensity is often associated with hypothyroidism, hypocalcemic tetany, or Williams' syndrome. A sound that resembles a cat mewing suggests a condition known as cri du chat syndrome, caused by a deletion of the short arm of chromosome 5 (del 5p). Absence of crying is suggestive of severe illness or mental dysfunction.
Assess the mandible. Is it hypoplastic, small, and recessed? Occurring in isolation or in association with a U-shaped cleft of the palate in the Pierre Robin malformation sequence, micrognathia may be associated with life-threatening obstructive apnea, a medical emergency that necessitates immediate attention. To assess for obstructive apnea in such infants, the examiner listens with the stethoscope for air movement through the nose. Lack of audible air movement in the presence of appropriate movements of the chest is diagnostic of obstructive (as opposed to central) apnea. Such children should immediately be placed prone; with their face down, gravity pulls the tongue away from the posterior pharynx and enables air flow.
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The first trimester is very important for the mother and the baby. For most women it is common to find out about their pregnancy after they have missed their menstrual cycle. Since, not all women note their menstrual cycle and dates of intercourse, it may cause slight confusion about the exact date of conception. That is why most women find out that they are pregnant only after one month of pregnancy.