NEWBORN heart and lung PHYSICAL EXAM// By a Neonatologist

Before I go on, I just want to say that so many people have said to me, I'm really bad at listening to heart murmurs. I'm always so nervous that I'm going to miss something. So before I talk any more about the heart, I just want to say two things. The first one is, is that if it's a really, really bad murmur that we need to do something about immediately, then you will hear it. That's the first thing. Everybody will hear it. The second thing is, is that listening for a murmur is just a very small part of the cardiac exam. And we look at many other things, the pulses, the perfusion, the pulse ox, to determine whether a baby has a cardiac disease or not. Sometimes in some really bad diseases, like a hyperplastic left heart syndrome or interrupted aortic arch, there is no murmur to be heard. These babies don't have murmurs anyway. Sometimes even the PDA is so open that you won't even hear that as a murmur. The blood is just rushing through it with no restriction at all. And you don't hear a murmur at all. But if there is a huge VSD or a bad pulmonary artery stenosis, you will hear that murmur. It won't be like a d-d-d-sh, d-sh, d-sh. It will be like a d-d-d-sh, d-d-d-sh, d-d-d-sh. And just remember that listening to the heart is one part of the cardiac exam. So make sure that you're looking at everything else as well. But start your exam by listening to the heart. So you really should be listening to the heart for up to 60 seconds, somewhere between 30 and 60 seconds. Make sure that the heart rate is somewhere between 100 to 200, really 180, depending on just how active the baby is. Listen for a regular heart rate. So d-d, d-d, d-d, d-d. Arrhythmias where the heart rate is irregular are actually pretty common in newborns. Most of them are pretty benign, like a premature atrial contraction. And a lot of the time, the babies completely outgrow this. But if you do hear an arrhythmia, then make sure that you tell somebody about it. And we should probably be getting an EKG just to make sure that it is a benign arrhythmia. Part of your cardiac exam should always include checking for pulses. So I always check for radial and femoral pulses. So radial pulses, follow back your index finger onto your wrist and check the radial pulse right there. Checking for femoral pulses is an absolutely crucial part of the newborn exam. So check just kind of like in the inguinal area and make sure that you feel the pulse as well. Not feeling femoral pulses could indicate a cardiac disease like a hyperplastic left heart or an interrupted aortic arch. So get used to feeling for femoral pulses on every single newborn baby. If the infant appears blue, then document your findings and make sure that you actually check it with a pulse ox. You may have to do something immediately about it if the baby looks blue, may need oxygen or more support. With any severe respiratory or cardiac concerns, then get both a pre-ductal as well as a post-ductal oxygen saturation. So pre-ductal is on the right wrist and post-ductal would be on the feet. To understand this better, go watch the videos on PPHN. But for now, if there is a big difference in the oxygen saturation between the pre-ductal and the post-ductal saturations, then you need to be worried about a severe cardiac or respiratory disease. So say this is 85 and your feet are 68, I would be very worried about that. Right, let's talk about the respiratory system. So remember, babies breathe faster than older kids and adults. They breathe between 30 to 60 times a minute. If they're breathing either much faster than this or much slower than this, then that could indicate concern. So again, get used to counting out the baby's breaths. There are a few other signs of respiratory distress in a newborn that you should be able to recognize and make sure that you document. So the first one is grunting and that's when the baby is making this noise. And that's literally when they're trying to stent open their lungs. They're trying to give their lungs CPAP to try to keep their lungs open. It's not really a symptom that you see in older children and adults. So really get used to hearing that and to recognizing what it is. Another sign of respiratory distress is nasal flaring and that's when you see the nostrils kind of go out and in very rapidly with all the breaths. That's the baby's desperate effort to decrease the resistance of the air passages so air can go in and out easier. So look for nasal flaring. Retractions are another sign of respiratory distress and that's where you see the skin get sucked in under the bones. So for example, if the skin is sucked in with each breath under the ribs that's called subcostal retractions. If it's sucked in right there above your sternal notch then that's called suprasternal retractions. If the whole sternum is kind of being sucked in then that's retrosternal retractions. So these are all signs that the baby is like using every single accessory muscle to try to breathe because they're in distress. Another sign of respiratory distress is obviously abnormal breath sounds. So get used to listening to the lungs with a stethoscope and make sure that you can hear good breath sounds on both sides of the lungs. Sometimes you won't hear breath sounds on one side at all and there could be complete collapse or god forbid some sort of abnormality in the way that the lung was made. Sometimes you'll just hear kind of gurgling or rattling in there. It could be liquid, it could be meconium, it could be an infection. So just get used to listening to the lung sound. Like we've already said, the nasal passages are really narrow and babies often swallow and inhale a bunch of gunk and fluid and everything at the time of delivery. So you'll very often hear like coarse upper breath sounds. If you feel like the baby's having difficulties breathing and they're so blocked up then you could suction it out. If it just sounds noisy and the baby is otherwise breathing fine then just leave everything alone. The baby will eventually cough and sneeze it all out. And every time you go to suction the nose it kind of irritates it more and gets it even more swollen. So like everything in neonatology, the less we do the better it is for the babies. And then the ultimate sign that we're definitely not getting enough oxygen in through the lungs is cyanosis, where the baby actually appears blue. I'm going to repeat this one more time. Cyanosis is when you have central cyanosis, so even the mouth and the lips appear blue. If just the hands and the feet appear blue, this is acrocyanosis and it can be completely normal in a newborn baby. Remember to check cyanosis with a pulse ox, most likely pre and post-doctal as well. Okay, remember to like this video and then go watch the next video on the hepatic system. Thank you so much for being here.