You are on page 1of 18

Examination of the newborn

Tiffany M McKee-Garrett, MD
Section Editor
Leonard E Weisman, MD
Teresa K Duryea, MD
Deputy Editor
Melanie S Kim, MD
Last literature review version 16.1: January 2008 his topic last updated: !u"ust 2#,
200$ !"ore#
$%&'D()$'% % T&e ne'(orn infant s&ould &a)e a t&orou"& *&ysical e+amination
*erformed 'it&in 2, &ours of (irt& to identify anomalies, (irt& in-uries, -aundice, or
cardio*ulmonary disorders .#/ 0 1deally, t&is e+amination s&ould (e *erformed as soon as
*ossi(le after deli)ery to identify *otential im*ediments to a normal ne'(orn course0
De*endin" u*on t&e len"t& of stay, anot&er e+amination s&ould (e *erformed 'it&in 2, &ours
(efore disc&ar"e from t&e &os*ital0
"AE&%AL *$S'&+ % T&e mot&er2s medical and *re"nancy &istory s&ould (e re)ie'ed0
Maternal illnesses *rior to *re"nancy, suc& as systemic lu*us eryt&ematosus or idio*at&ic
t&rom(ocyto*enia *ur*ura, or *re"nancy com*lications, suc& as "estational dia(etes or
&y*ertensi)e disorders, may affect fetal "ro't& or lead to ot&er com*lications0 Maternal
medications may &a)e intrauterine effects or (e e+creted in (reast mil30
Screenin, tests % T&e results of screenin" tests s&ould (e re)ie'ed0 T&ese tests ty*ically
are o(tained at t&e first *renatal )isit, or, if not a)aila(le, (efore deli)ery0 4See 51nitial routine
mana"ement of t&e ne'(orn560
La(oratory tests t&at are routinely a)aila(le are7
• Maternal (lood ty*e, anti(ody screen
• 8&esus 48&6 ty*e
• 8u(ella status 4immune or nonimmune6
• Sy*&ilis screen
• 9e*atitis : surface anti"en
8esults of ot&er maternal testin" may (e a)aila(le for7
• 9uman immunodeficiency )irus
• ;&lamydia, "onorr&ea 4See 5Screenin" for ;&lamydia trac&omatis5 and see
5E*idemiolo"y and *at&o"enesis of <eisseria "onorr&oeae infection56
• Tu(erculosis 4See 5Tu(erculosis in *re"nancy5 and see 5Tu(erculin s3in testin" and
ot&er tests for latent tu(erculosis infection56
Screenin" tests o(tained later in *re"nancy also im*act neonatal assessment0 T&ey include
testin" for dia(etes= maternal serum al*&a-feto*rotein measurement-tri*le screen= and
ultrasound e+amination, includin" fetal sur)ey, estimated fetal 'ei"&t, and amniotic fluid
)olume0 8esults of to+icolo"y screenin" s&ould (e a)aila(le in *atients '&o &a)e *ro(lems
'it& su(stance a(use0 4See 5>renatal screenin" and dia"nosis of neural tu(e defects5, see
51ndications for dia"nostic o(stetrical ultrasound e+amination5 and see 51nfant of a dia(etic
&is- factors for sepsis % !n assessment s&ould (e made of neonatal ris3 factors for se*sis,
es*ecially for Grou* : stre*tococcal 4G:S6 infection0 4See 5Grou* : stre*tococcal infection in
neonates and youn" infants560 8is3 factors for neonatal infection include7
• 1ntra*artum tem*erature ?#000,@A 4?B80C@;6
• Mem(rane ru*ture ?#8 &ours
• Deli)ery at DB$ 'ee3s "estation
• ;&orioamnionitis
• Sustained fetal tac&ycardia
T&e use and duration of maternal intra*artum anti(iotic *ro*&yla+is 41!>6 s&ould (e
documented0 1nfants '&o &a)e ris3 factors for se*sis and '&ose mot&ers did not recei)e
adeEuate 1!> reEuire e)aluation, includin" com*lete (lood count 4;:;6 and (lood culture,
e)en if t&ey are initially asym*tomatic0 T&ey s&ould (e o(ser)ed in &os*ital for at least ,8
&ours and may need em*iric anti(iotic t&era*y until culture results (ecome a)aila(le0
.erinatal course % T&e clinician *erformin" t&e initial ne'(orn e+amination s&ould (e
familiar 'it& t&e e)ents surroundin" deli)ery0 T&e duration of la(or, mode of deli)ery, t&e
ne'(orn2s condition at deli)ery, and resuscitation, if any, s&ould (e re)ie'ed0
/E%E&AL A..&'A)* % T&e e+amination can (e *erformed in t&e nursery or t&e mot&er2s
room0 T&e area s&ould (e 'arm and Euiet, and s&ould &a)e "ood li"&tin"0
T&e e+amination s&ould (e conducted in a systematic manner0 !lt&ou"& t&e e+act order is not
im*ortant, a consistent a**roac& ensures t&at all as*ects are e)aluated0
T&e e+amination (e"ins 'it& o(ser)ation of t&e infant2s "eneral a**earance, includin" *osition
and mo)ement, color, and res*iratory effort0 1t may (e con)enient to e+amine t&e &eart '&ile
t&e (a(y is lyin" Euietly0 1n "eneral, e+amination *roceeds from &ead to foot0 E+amination of
t&e &i*s, '&ic& is a*t to distur( t&e infant, usually is *erformed last '&ile t&e infant is su*ine0
T&e (a(y t&en is turned *rone to e+amine t&e (ac30
T&e date and time of t&e e+amination s&ould (y recorded0 Aindin"s considered normal close to
deli)ery, e", a transitional &eart murmur, may (e a(normal on t&e second or t&ird day after
(irt&0 T&e e+amination s&ould include assessment of "estational a"e0 Kno'led"e of t&e le)el of
maturity may (e im*ortant in t&e inter*retation of *&ysical findin"s0 4See 5>ostnatal
assessment of "estational a"e560
Appearance and posture % >rior to touc&in" t&e infant, muc& can (e learned (y o(ser)in"
t&e undressed infant in t&e restin", non-stimulated state0 Gender s&ould (e noted0 !n
ins*ection s&ould (e made for deformations and o()ious malformations, suc& as cleft li*0 !n
a(normal facial a**earance or ot&er a(normalities may indicate t&e *resence of a syndrome0
T&e state of nutrition can (e assessed (y notin" t&e amount of su(cutaneous fat on t&e
anterior t&i"&s and "luteal re"ion, or (y t&e amount of W&arton2s -elly in t&e um(ilical cord0
&espiratory effort % T&e infant2s res*iratory effort s&ould (e assessed0 >arado+ical
(reat&in" mo)ements, in '&ic& t&e a(domen mo)es out'ard and t&e c&est 'all mo)es in'ard
in ins*iration, are normal0 Si"ns of res*iratory distress, includin" ra*id (reat&in"= use of
accessory muscles 4e", nasal flarin"6= si"nificant su(costal, intercostal, su*racla)icular, or
su*rasternal retractions= or "runtin" are a(normal and su""est *ulmonary disease0
.osition % T&e ne'(orn2s *osture at rest usually reflects t&e intrauterine *osition0 Term
ne'(orns deli)ered from a )erte+ *resentation ty*ically lie 'it& t&e &i*s, 3nees and an3les
fle+ed0 1nfants '&o 'ere in a (reec& *osition often &a)e e+tended le"s0 ! fran3 (reec&
*resentation may result in mar3edly a(ducted and e+ternally rotated le"s0 ! normal infant
mo)es all e+tremities symmetrically0
)olor % ! normal infant a**ears *in30 !crocyanosis, a (luis& a**earance of t&e &ands, feet,
and *erioral area, is common on t&e first day after (irt&0 9o'e)er, central cyanosis, '&ic& is
seen (est on t&e ton"ue and mucous mem(ranes of t&e mout&, su""ests &y*o+emia0 :ruisin"
also may result in a (luis& discoloration0
>allor may indicate anemia, caused (y acute (lood loss at or s&ortly (efore deli)ery or a
c&ronic intrauterine *rocess0 ! ruddy or *let&oric infant may &a)e *olycyt&emia0 1nfants 'it&
*olycyt&emia may a**ear cyanotic e)en '&en t&ey &a)e adeEuate o+y"enation (ecause t&ey
&a)e a relati)ely &i"& amount of unsaturated &emo"lo(in0
9y*er(iliru(inemia results in -aundice, a yello' color (est assessed in natural li"&t0 Jaundice is
unusual in t&e first 2, &ours after (irt& and al'ays is *at&olo"ic0 1t is usually caused (y
&emolysis and reEuires e)aluation0 1ntrauterine stainin" of t&e s3in 'it& meconium may result
in a "reenis& discoloration0 4See 5;linical manifestations of uncon-u"ated &y*er(iliru(inemia in
term and near-term infants560
"EAS(&E"E%S % T&e infant2s 'ei"&t, len"t&, and &ead circumference s&ould (e measured
and recorded0 T&ese measurements are *lotted on standard "ro't& cur)es to determine t&e
*ercentile accordin" to "estational a"e and assess intrauterine "ro't&0 T&e 'ei"&t is classified
as a**ro*riate, lar"e, or small for "estational a"e0 4See 5Small for "estational a"e infant5 and
see 5Lar"e for "estational a"e ne'(orn560
!)era"e (irt& 'ei"&ts differ for male and female infants0 !t ,0 'ee3s "estation, t&e a)era"e
'ei"&t is B0F 3" 4#0t& to G0t& *ercentile, 20G to ,02 3"6 for males and B0C 3" 4#0t& to G0t&
*ercentile, 208 to ,00 3"6 for females .2/ 0
T&e fronto-occi*ital &ead circumference 4AH;6 s&ould (e measured at its ma+imum0 !t ,0
'ee3s "estation, t&e a)era"e AH; is BC cm 4#0t& to G0t& *ercentile, BB to B$ cm6 .2/ 0 T&is
measurement may c&an"e in t&e first fe' days after (irt& as moldin" and scal* edema
resol)e0 Some clinicians also measure c&est circumference, es*ecially if t&ere is concern a(out
lun" "ro't&0 ;&est circumference normally is 'it&in t'o cm of t&e &ead circumference0
T&e len"t& is measured from t&e to* of t&e &ead to t&e (ottom of t&e feet, 'it& t&e le"s fully
e+tended0 T&is measurement is difficult to do accurately0 !t ,0 'ee3s "estation, t&e a)era"e
len"t& is C# cm 4#0t& to G0t& *ercentile, ,8 to CB cm6 .2/ 0
0$AL S$/%S % Iital si"ns s&ould (e recorded at t&e time of t&e e+amination0 <ormal
tem*erature measured 'it& t&e t&ermometer in t&e a+illa is BF0# to B$ de"rees ; 4G$00 to
G80F de"rees A6 in an o*en cri( .#/ 0 8es*iratory rate is ,0 to F0 (reat&s *er minute in most
normal ne'(orns, and &eart rate is #20 to #F0 (eats *er minute0 9o'e)er, t&e &eart rate may
decrease to 8C to G0 in some infants durin" slee*0 !n increase 'it& stimulation is reassurin"0
:lood *ressure can (e measured usin" a neonatal siJe (lood *ressure cuff in infants 'it&
sus*ected cardio)ascular or renal a(normalities0
S1$% % T&e s3in s&ould (e ins*ected for a(normalities t&at may indicate an underlyin"
disorder0 !reas of a(normal *i"mentation, con"enital ne)i, macular stains, &eman"iomas, or
ot&er unusual lesions s&ould (e noted0 T&e follo'in" (eni"n and transient findin"s are
common in normal ne'(orns0
• Milia are '&ite *a*ules, freEuently found on t&e nose and c&ee3s0 T&ey result from
retention of 3eratin and se(aceous material in t&e *ilaceous follicles .2/ 0
• Transient *ustular melanosis is a "eneraliJed eru*tion of su*erficial *ustules o)erlyin"
&y*er*i"mented macules t&at occurs mostly in !frican-!merican ne'(orns0 T&e
*ustules usually are remo)ed 'it& t&e first (at& so t&at only t&e macules remain0 4See
5:eni"n s3in lesions in t&e ne'(orn560
• Eryt&ema to+icum consists of '&ite *a*ules, a**ro+imately # to 2 mm in siJe, on an
eryt&ematous (ase0 T&e *ustules contain eosino*&ils0 T&e ras& usually (e"ins on t&e
second or t&ird *ostnatal day0 Lesions occur less freEuently on t&e face t&an on t&e
(ody, and ne)er occur on *alms or soles .B/ 0 4See 5:eni"n s3in lesions in t&e
• Mon"olian s*ots are areas of (lue discoloration t&at occur on t&e (uttoc3s or o)er t&e
(ase of t&e s*ine 4s&o' fi"ure #60 T&ey *redominantly affect !frican-!merican and
!sian infants0 4See 5:eni"n s3in lesions in t&e ne'(orn560
• Macular stains 4often called salmon *atc&, stor3 (ite, or an"el 3iss6 are *in3-red
ca*illary malformations t&at occur on t&e u**er eyelids, middle of t&e fore&ead, or t&e
na*e of t&e nec3 4'&ere t&ey are 3no'n as stor3 (ites60 4See 5Iascular lesions and
con"enital ne)i in t&e ne'(orn560
*EAD % T&e siJe and s&a*e of t&e &ead s&ould (e ins*ected0 T&e *resence of a(normal &air,
scal* defects, unusual lesions or *rotu(erances, lacerations, and a(rasions or contusions
s&ould (e noted0
2ontanelles % T&e fontanelles s&ould (e *al*ated, *refera(ly 'it& t&e infant in t&e sittin"
*osition0 :ot& fontanelles normally are soft and flat0
• T&e anterior fontanelle is located at t&e -uncture of t&e meto*ic, sa"ittal, and coronal
sutures0 1ts siJe is )aria(le0
• T&e *osterior fontanelle is located at t&e -uncture of t&e sa"ittal and lam(doid sutures0
1t usually is o*en (ut smaller t&an # cm in diameter0
Sutures % T&e *rinci*al sutures of t&e s3ull 4sa"ittal, coronal, lam(doid, and meto*ic6 s&ould
(e *al*ated0 >assa"e t&rou"& t&e (irt& canal may result in moldin", a tem*orary asymmetry
of t&e s3ull caused (y o)erla**in" or o)erridin" of t&e sutures, *articularly t&e coronal0
9o'e)er, an asymmetric s3ull t&at *ersists for lon"er t&an t'o to t&ree days after (irt& or a
*al*a(le rid"e alon" t&e suture line is a(normal and su""ests craniosynostosis0 !lt&ou"& t&e
sutures normally can (e se*arated soon after deli)ery, 'idely s*lit sutures 'it& a full
fontanelle may indicate increased intracranial *ressure caused (y &ydroce*&alus0 4See
5H)er)ie' of craniosynostosis560
;raniota(es is a soft area of s3ull (one, usually in t&e *arietal re"ion, t&at "i)es a sensation of
a *in"-*on" (all '&en de*ressed0 1t commonly is found in *remature infants, and can occur in
a term infant '&ose &ead rested on t&e *el)ic (rim durin" t&e last fe' 'ee3s of "estation
.B/ 0 ;raniota(es can (e a *at&olo"ic findin" in sy*&ilis and ric3ets, alt&ou"& it usually occurs
in normal infants0
Ht&er causes of asymmetrical &ead s&a*e are caused (y t&e (irt& *rocess0
• ;a*ut succedaneum is an area of edema o)er t&e *resentin" *art of t&e &ead0 T&is
common condition ty*ically is *resent at (irt&, crosses suture lines, and resol)es
'it&in a fe' days .B/ 0
• ;e*&alo&ematomas are su(*eriosteal collections of (lood t&at are *resent in # to 2
*ercent of ne'(orns .B/ 0 Hn *al*ation, t&ey form a fluctuant mass t&at does not
cross suture lines0 T&ey often are (ilateral0 ;e*&alo&ematomas may increase in siJe
after (irt&, and usually ta3e 'ee3s to mont&s to resol)e0
• Su("aleal &emorr&a"es are collections of (lood (et'een t&e a*oneurosis co)erin" t&e
scal* and t&e *eriosteum0 T&ey occur in a**ro+imately , *er #0,000 deli)eries .,/ ,
alt&ou"& t&e incidence is increased (y )acuum deli)eries .C/ 0 :lood can e+tend
(eneat& t&e scal* and into t&e nec30 Su("aleal &emorr&a"es e+tend across suture
lines (ut feel firm and fluctuant0 4See 5H*erati)e )a"inal deli)ery560
2A)E % T&e face is e+amined for symmetry0 Aacial *alsies and asymmetric cryin" facies are
most o()ious '&en t&e (a(y is cryin" and may "o unnoticed in t&e Euiet or slee*in" (a(y0
2acial palsies % Aacial *alsies are usually seen in infants '&o are deli)ered 'it& t&e use of
force*s, and can also (e seen in t&ose 'it& a *rolon"ed deli)ery in mot&ers 'it& a *rominent
sacral *romontory0 Ty*ically, only t&e mandi(ular (ranc& of t&e facial ner)e is affected and t&e
infant 'ill &a)e diminis&ed mo)ement on t&e affected side of t&e face0 T&ere is often loss of
t&e nasola(ial fold, *artial closin" of t&e eye, and t&e ina(ility to contract t&e lo'er facial
muscles on t&e affected side, leadin" to t&e a**earance of a 5droo*in"5 mout&0 W&en cryin",
t&e mout& is dra'n o)er to t&e unaffected side0
Aacial *alsies resol)e com*letely in a fe' days to a fe' 'ee3s0 <o treatment is reEuired, 'it&
t&e e+ce*tion of t&e use of artificial tears in t&e eye on t&e affected side of t&e face0 !
*ersistent *alsy may im*ly a central lesion0
Asymmetric cryin, facies % !symmetric cryin" facies 4!;A6 are t&e result of con"enital
a(sence or &y*o*lasia of t&e de*ressor an"uli oris muscle0
Similar to facial *alsies, t&e muscles controllin" mo)ement of one side of t&e mout& are
affected 4'ea3ened6, t&us t&ere is asymmetry of t&e face u*on cryin"0 Knli3e facial *alsies,
t&e muscles controllin" mo)ement of t&e u**er face are normal= t&us, t&e nasola(ial folds are
normal, and '&en t&e infant cries, t&e fore&ead 'rin3les and (ot& eyes close normally0 T&is is
ty*ically a (eni"n condition and (ecomes less noticea(le as t&e c&ild "ets older0 9o'e)er, !;A
&as (een associated 'it& ot&er anomalies, *articularly t&ose of t&e cardio)ascular system .F/ 0
Hne *ros*ecti)e study of CCB2 infants re)ealed an incidence of !;A of 00B# *ercent .$/ , 'it&
t'o of t&e se)en affected infants &a)in" ot&er si"nificant malformations0 1n anot&er re)ie' of
BC infants, #F &ad ot&er associated anomalies, alt&ou"& many of t&em 'ere minor .8/ 0 W&en
!;A is dia"nosed, it is *rudent to *erform a t&orou"& e+amination for ot&er con"enital
anomalies and in)esti"ate for a(normalities of t&e cardio)ascular system0
E+ES % T&e initial e+amination of t&e eyes may (e difficult to *erform (ecause t&e eyelids
often are edematous after deli)ery0 Most infants 'ill o*en t&eir eyes s*ontaneously '&en &eld
)ertically in an en)ironment 'it& lo' am(ient li"&t0
Appearance and spacin, % T&e e+aminer s&ould note t&e *osition and s*acin" of t&e eyes,
'idt& of *al*e(ral fissures, eye color, a**earance of t&e sclera and con-uncti)e, condition of
t&e eyelids, *u*illary siJe, and eye mo)ement0 1f it a**ears a(normal, t&e distance (et'een
t&e eyes can (e measured and com*ared to standard )alues0 T&is *art of t&e e+amination is
im*ortant if ot&er dysmor*&ic features are *resent t&at su""est a syndrome 4e", Trisomy 2#
or fetal alco&ol syndrome60 4See 5;linical features and dia"nosis of Do'n syndrome560
!symmetry of t&e eyes may (e t&e result of *rominent e*icant&al folds 4s3in folds o)er t&e
medial as*ect of t&e eyes6, a difference in t&e siJe of t&e "lo(es, or *tosis0 E*icant&al folds
rarely are normal and usually su""est a syndrome 4e", Trisomy 2#60 Widened or narro'
*al*e(ral fissures are normal for some *atients (ut can (e *art of a syndrome com*le+ in
Extraocular movement % T&e e+aminer s&ould assess e+traocular muscle mo)ement0
Symmetrical mo)ement of t&e eyes s&ould occur as t&e *atient is &eld )ertically and mo)ed
"ently from side to side0
Sclerae % T&e sclerae normally are '&ite and clear, alt&ou"& scleral &emorr&a"es are a
common conseEuence of com*ression of t&e face and &ead due to t&e (irt& *rocess0 1n
*remature infants, t&e sclerae may a**ear li"&t (lue0 T&is is caused (y transmission of t&e
dar3er color of t&e underlyin" u)eal tissue t&rou"& t&e t&in underde)elo*ed sclerae .G/ 0 1f t&e
sclerae a**ear dee* (lue, osteo"enesis im*erfecta s&ould (e considered0 1n t&is condition, t&e
discoloration is caused (y inadeEuate de)elo*ment of scleral colla"en0
)on3unctiva % T&e con-uncti)a s&ould (e e+amined for &emorr&a"e, inflammation, or
*urulent disc&ar"e0 Su(con-uncti)al &emorr&a"es can occur s*ontaneously durin" (irt&, (ut
are more common follo'in" a traumatic deli)ery0 !dministration of sil)er nitrate for *re)ention
of o*&t&almia neonatorum due to "onococcal infection often results in c&emical con-uncti)itis0
4See 5Gonococcal infection in t&e ne'(orn5 section on H*&t&almia <eonatorum60
)ornea % T&e corneal diameter in most ne'(orns is a**ro+imately #0 mm .G/ 0 ;orneal
enlar"ement 4L#2 mm6 su""ests "laucoma, es*ecially if accom*anied (y *&oto*&o(ia,
e+cessi)e tearin", or corneal &aJe0 4See 5H)er)ie' of "laucoma in infants and c&ildren560
.upils % >u*ils s&ould (e assessed for t&eir s&a*e and reaction to li"&t0 <ormal *u*ils are
round and constrict in res*onse to a (ri"&t li"&t0 >u*illary reaction occurs consistently after B2
'ee3s "estational a"e (ut may (e a**arent in some infants as early as 28 'ee3s "estation
.#0/ 0 Defects in t&e iris 4e", colo(oma6 s&ould (e noted0
&ed reflex % T&e *resence of a red refle+ s&ould (e assessed 'it& an o*&t&almosco*e0 T&is
res*onse 'ill (e seen if t&e lens and underlyin" structures are clear0 !(normalities of t&e lens
4e", cataract6, )itreous 4e", *ersistent fetal )asculature6, or retina 4e", retino(lastoma6
*roduce a '&ite *u*il 4leu3o3oria60 4See 5!**roac& to t&e c&ild 'it& leu3ocoria560
EA&S % T&e ears are ins*ected for t&eir *osition, siJe, and a**earance0 T&e ears are in a
normal *osition if t&e &eli+ is intersected (y a &oriJontal line dra'n from t&e outer cant&us of
t&e eye *er*endicular to t&e )ertical a+is of t&e &ead .##/ 0 1f t&e &eli+ falls (elo' t&is line,
t&e ears are considered lo'-set0 !n ear is *osteriorly rotated if its )ertical a+is de)iates more
t&an #0 de"rees from t&e )ertical a+is of t&e &ead0
T&e ears s&ould (e ins*ected for (ranc&ial cleft cysts, sinuses, *reauricular s3in ta"s or *its,
or dys*lastic features0 Malformations of t&e e+ternal ear often are associated 'it& syndromes
of multi*le con"enital anomalies t&at include renal malformations .#2/ 0 1n addition, t&ese
a(normalities may indicate additional anomalies of t&e middle and inner ear t&at are
associated 'it& &earin" loss .##/ 0 >atients 'it& isolated minor ear anomalies 4suc& as
*reauricular s3in ta"s6 do not a**ear to &a)e a si"nificant increase in renal anomalies and
routine renal ima"in" for t&ese *atients a**ears to (e unnecessary unless accom*anied (y
ot&er ma-or malformations or multi*le con"enital anomaly syndromes .#B/ 0 4See 5;on"enital
anomalies of t&e ear5 section *reauricular *its60
T&e ear canals s&ould (e o(ser)ed for *atency0 IisualiJation of t&e tym*anic mem(ranes is
limited (y t&e small siJe of t&e ear canal and t&e *resence of )erni+ and ot&er de(ris0 T&is
e+amination usually is not done in t&e ne'(orn *eriod0
%'SE % T&e nose s&ould (e e+amined for its s&a*e and *atency0 T&e s&a*e of t&e nose may
(e a(normal (ecause of intrauterine deformation or t&e (irt& *rocess0 1n t&is case, it 'ill
return to a normal s&a*e 'it&in a fe' days of (irt&0 !n e+tremely t&in or unusually (road nose
or a de*ressed nasal (rid"e may occur 'it& some malformation syndromes0
T&e nares may a**ear asymmetric if t&e nasal cartila"e is dislocated from t&e )omerian
"roo)e 4se*tal de)iation60 T&is condition can (e distin"uis&ed from a *ositional deformity (y
de*ression of t&e ti* of t&e nose0 ! dislocated se*tum a**ears an"led 'it&in t&e nares and
does not resume a normal *osition '&en released0
>atency of t&e nares s&ould (e esta(lis&ed (ecause infants are *redominantly nose (reat&ers0
T&is can (e accom*lis&ed (y notin" t&e mo)ement of a *iece of cotton or t&read *laced in
front of eac& nare0 H(struction may (e caused (y edema related to )i"orous suctionin" after
(irt&, or &a)e anatomical causes, suc& as c&oanal atresia0 T&e latter can (e tested (y *assa"e
of a feedin" tu(e or suction cat&eter t&rou"& t&e nose0
"'(* % T&e siJe and s&a*e of t&e mout& s&ould (e assessed0 T&e ma+illae and mandi(le
s&ould fit 'ell to"et&er and o*en at eEual an"les (ilaterally0 !symmetry of t&e mout&
4asynclitism6 usually is caused (y intrauterine *osition and resol)es 'it& time0 ! small -a'
4micro"nat&ia6 may (e seen in 8o(in seEuence0 T&e li* s&ould (e e+amined for e)idence of a
cleft0 4See 5Syndromes 'it& craniofacial a(normalities5, section on 8o(in seEuence60
1nternal e+amination of t&e mout& includes t&e "in"i)a, ton"ue, *alate, and u)ula, and s&ould
(e *erformed (y ins*ection and (y *al*ation0
• Small, '&ite, (eni"n inclusion cysts on t&e *alate, 3no'n as E*stein2s *earls, are seen
in most (a(ies0 T&ey often are clustered at t&e mid*oint of t&e -unction (et'een t&e
soft and &ard *alate0
• Mucus retention cysts may occur on t&e "ums 4e*ulis6 or on t&e floor of t&e mout&
• T&e frenulum lin"uae, a (and of tissue t&at connects t&e floor of t&e mout& to t&e
ton"ue, may e+tend to t&e ti* of t&e ton"ue 4ton"ue-tie6 .B/ 0
• <atal teet& usually occur in t&e lo'er central incisor re"ion, and freEuently are
(ilateral .B/ 0 T&e incidence is a**ro+imately # in BC00 li)e (irt&s .#0/ , alt&ou"& t&e
*re)alence is &i"&er in infants 'it& cleft li* and *alate .#,/ 0 <atal teet& often are )ery
mo(ile, and usually are remo)ed to *re)ent t&e ris3 of as*iration0
• ;lefts of t&e soft or &ard *alate may (e )isi(le (y ins*ection0 >al*ation may (e needed
to detect a su(mucosal cleft .#C/ 0 ! (ifid u)ula may (e associated 'it& a su(mucosal
%E)1 % T&e nec3 s&ould (e assessed for a(normalities, includin" masses or decreased
"asses % ;ystic &y"roma, a lym*&an"ioma t&at is t&e most common lym*&atic malformation
in c&ildren, ty*ically *resents as a *ainless soft mass su*erior to t&e cla)icle t&at
transilluminates0 :ranc&ial cleft cysts may (e *al*ated in t&e u**er *ortion of t&e nec3=
masses in t&e lo'er *ortion may (e caused (y &ematomas0 Masses in t&e midline may (e
caused (y a t&yro"lossal duct cyst or an enlar"ed t&yroid0 4See 5T&yro"lossal duct cysts and
ecto*ic t&yroid560
1solated *al*a(le cer)ical lym*& nodes, u* to #2 mm in diameter, are common in &ealt&y
ne'(orns .B/ 0 Lym*&adeno*at&y also may result from con"enital infection0
orticollis % Torticollis, or 'ry nec3, usually results from trauma to t&e sternocleidomastoid
4S;M6 muscle caused (y (irt& in-ury or intrauterine mal*osition0 T&e in-ury causes a
&ematoma or s'ellin" 'it&in t&e muscle0 Torticollis also may (e caused (y de)elo*mental
a(normalities of t&e cer)ical s*ine0 1n affected infants, t&e &ead is ti**ed to one side and t&e
c&in rotated to'ard t&e ot&er0 4See 5!cEuired torticollis in c&ildren560
Excess s-in % 8edundant s3in in t&e nec3 may (e a feature of "enetic syndromes0 E+am*les
include Turner syndrome, in '&ic& t&e nec3 a**ears 'e((ed (ecause of redundant s3in alon"
t&e *osterolateral line, and Do'n syndrome, 'it& e+cess s3in at t&e (ase of t&e nec3
*osteriorly0 4See 5;linical manifestations and dia"nosis of Turner syndrome5 and see 5;linical
features and dia"nosis of Do'n syndrome560
)lavicles % :ot& cla)icles s&ould (e *al*ated0 >artial or com*lete a(sence of t&e cla)icle may
occur in con"enital syndromes, suc& as cleidocranial dysostosis0 ;la)icular fractures ty*ically
*resent 'it& irrita(ility and decreased motion on t&e affected side (ecause of *ain0 Si"ns
include tenderness, cre*itus, s'ellin" on t&e (one, and an asymmetric Moro res*onse0
)*ES % T&e c&est s&ould (e ins*ected for siJe, symmetry, and structure0
• ! small or malformed t&ora+ may result from *ulmonary &y*o*lasia or neuromuscular
• ;&est asymmetry may (e caused (y an a(sent *ectoralis muscle 4>oland seEuence6,
or result from a mass or a(scess0
• >ectus e+ca)atum 4funnel c&est6 or *ectus carinatum 4*i"eon (reast6 may occur as
isolated findin"s or as *art of con"enital syndromes0 4See 5>ectus carinatum560
:reast siJe and ni**le *osition s&ould (e noted0 T&e *resence and amount of (reast tissue
may (e &el*ful in assessment of "estational a"e0 :reast &y*ertro*&y caused (y e+*osure to
maternal &ormones occurs in (ot& males and females and can (e asymmetric0 Hccasionally,
(reasts 'ill secrete a t&in mil3y fluid 3no'n as 5'itc&2s mil35 for se)eral days to 'ee3s .B/ 0
T&e s*ace (et'een t&e ni**les s&ould (e noted0 Widely s*aced ni**les occur in some "enetic
syndromes 4e", Turner syndrome60 ;&arts are a)aila(le for determinin" normal interni**le
distance .#F/ 0 1n "eneral, an interni**le distance t&at is L2C *ercent of c&est circumference
is considered 'ide-s*aced0
Su*ernumerary ni**les, or accessory mammary tissue, is a common findin"0 T&ese occur 'it&
an incidence of a**ro+imately # in ,0 ne'(orns .#$/ and are more common in !frican-
!merican t&an '&ite infants .#,/ 0 T&ey are found inferior and medial to t&e true (reasts,
alon" t&e mil3 line, a )ertical line t&at e+tends from t&e a+illae to t&e *u(ic re"ion0
Su*ernumerary ni**les do not a**ear to (e associated ot&er anomalies, *articularly renal
malformations .#8,#G/ 0
)hest wall movement % T&e ri(s and sternum are incom*letely ossified in t&e ne'(orn,
resultin" in a &i"&ly com*liant c&est 'all0 :reat&in" in normal infants may (e *arado+ical, in
'&ic& t&e ri( ca"e mo)es in'ard and t&e a(domen mo)es out'ard durin" ins*iration0 1n
res*iratory disorders, t&e &i"& intrat&oracic *ressures "enerated to inflate *oorly com*liant
lun"s may cause retractions t&at are intercostal, su(costal, or su(+i*&oid 4su(sternal60
L(%/S % T&e infant2s (reat&in" rate and *attern s&ould (e o(ser)ed0 T&ese may fluctuate
de*endin" u*on t&e state of 'a3efulness, and '&et&er t&e infant is acti)e or cryin"0 T&e
res*iratory rate s&ould (e counted for a full minute to account for )ariations in rate and
r&yt&m0 ! normal rate is ,0 to F0 (reat&s *er minute0
1nfants 'it& res*iratory disorders often &a)e tac&y*nea and retractions0 Ht&er si"ns of
res*iratory distress include use of accessory res*iratory muscles 4e", flarin" of t&e nasal alae6
and "runtin"0 4See 5;&est 'all mo)ement5 a(o)e and see 5H)er)ie' of neonatal res*iratory
distress7 Disorders of transition560
Auscultation % !uscultation of t&e lun"s s&ould (e *erformed 'it& t&e infant as Euiet as
*ossi(le0 1n "eneral, t&is is (est accom*lis&ed (efore t&e infant is distur(ed (y *al*ation of t&e
<ormal (reat& sounds are (ronc&o)esicular and are &eard eEually on (ot& sides of t&e c&est0
T&e (reat& sounds s&ould (e clear, alt&ou"& some infants may &a)e scattered rales for a fe'
&ours after deli)ery0 !(normal (reat& sounds are unusual in t&e a(sence of tac&y*nea or si"ns
of res*iratory distress0 1n infants 'it& res*iratory disease, "runtin" sometimes is audi(le only
'it& a stet&osco*e0
)A&D$'0AS)(LA& S+SE" % >al*ation t&rou"& t&e c&est 'all determines t&e a*ical
im*ulse and locates t&e *osition of t&e &eart0 :ecause t&e ri"&t )entricle is dominant in t&e
ne'(orn, t&e *oint of ma+imal im*ulse is (est felt in t&e area of t&e left lo'er sternal (order0
>al*ation also can detect t&e *resence of a &ea)e, ta*, or t&rill0
Auscultation % !uscultation s&ould (e *erformed 'it& a 'armed stet&osco*e '&ile t&e (a(y
lies Euietly0 T&orou"& e)aluation necessitates auscultation of all areas of t&e *recordium, as
'ell as t&e (ac3 and a+illary areas0 T&e *rocess includes notin" t&e rate and r&yt&m and
listenin" carefully for t&e first and second &eart sounds0
*eart sounds % 9eart sounds usually are &eard (est alon" t&e left sternal (order0 >rominent
&eart sounds in t&e ri"&t c&est may si"nify de+trocardia0 1n "eneral, t&e first &eart sound is a
sin"ular sound caused (y nearly simultaneous closure of t&e tricus*id and mitral )al)es and is
(est &eard at t&e a*e+0 T&e second &eart sound, (est &eard at t&e left u**er sternal (order, is
caused (y closure of t&e *ulmonary and aortic )al)es and normally is s*lit0
"urmurs % 9eart murmurs are c&aracteriJed (y t&e intensity and Euality of t&e sound t&ey
create, '&en t&ey occur in t&e cardiac cycle, t&eir location, and '&et&er t&ey are transmitted0
T&e intensity of murmurs is "raded on a scale of 1 to I10 4See 5!uscultation of cardiac
• Grade 1 murmurs are nearly inaudi(le
• Grade 11 murmurs also are faint (ut can (e identified immediately
• Grade 111 murmurs are loud (ut &a)e no *al*a(le t&rill
• Grade 1I murmurs are loud and &a)e an associated t&rill
• Grade I murmurs can (e &eard '&en t&e stet&osco*e is (arely touc&in" t&e c&est 'all
• Grade I1 murmurs are audi(le '&en t&e stet&osco*e is not touc&in" t&e c&est 'all
1n t&e first fe' days after (irt&, most ne'(orns &a)e murmurs t&at are transient and (eni"n
in most cases0 T&ey usually are caused (y a *atent ductus arteriosus 4>D!6, or *ulmonary
(ranc& stenosis .#0,20/ 0 T&e latter is more li3ely if t&e murmur *ersists after 2, &ours '&en
most >D!s &a)e closed0 T&e >D! murmur is continuous, often descri(ed as 5mac&inery-li3e5 or
&ars& in Euality0 1t usually is loudest under t&e left cla)icle 4second intercostal s*ace6, (ut may
radiate do'n t&e left sternal (order0
T&e intensity and Euality of t&e murmur and associated findin"s usually can differentiate
innocent murmurs from &eart disease .2#-2B/ 0 Aeatures associated 'it& innocent murmurs
are .2/ 7
• Murmur intensity "rade 11 or less, &eard at left sternal (order
• <ormal second &eart sound
• <o audi(le clic3s
• <ormal *ulses
• <o ot&er a(normalities
Si"ns t&at su""est con"enital &eart disease are7
• Murmur intensity "rade 111 or &i"&er
• 9ars& Euality
• >ansystolic duration
• Loudest at u**er left sternal (order
• !(normal second &eart sound
• !(sent or diminis&ed femoral *ulses
• Ht&er a(normalities
.ulses % T&e femoral *ulses s&ould (e *al*ated '&en t&e infant is Euiet0 Diminis&ed femoral
*ulses may indicate coarctation of t&e aorta, '&ereas an increased *ulse *ressure may occur
'it& >D!0 1f femoral *ulses are a(normal, (rac&ial, radial, and *edal *ulses s&ould (e
.erfusion % >erfusion can (e assessed (y (lanc&in" t&e sole of t&e foot or t&e *alm of t&e
&and and notin" t&e ca*illary refill time, t&e time it ta3es for t&e return of *in3 color0 <ormal
ca*illary refill time is t'o seconds or less0
A4D'"E% % T&e a(domen s&ould (e e+amined '&en t&e infant is Euiet0 T&e siJe and o)erall
a**earance s&ould (e assessed0 T&e normal a(domen is sli"&tly *rotu(erant0 Distension is
a(normal and may indicate conditions suc& as intestinal o(struction, or"anome"aly, or ascites0
T&e a(domen may (e sca*&oid in t&e *resence of a dia*&ra"matic &ernia0 Many normal
infants &a)e diastasis recti, resultin" from t&e nonunion of t&e t'o rectus muscles0 T&e
*resence of an um(ilical &ernia s&ould (e noted0 Ht&er a(dominal 'all defects, suc& as
om*&alocele or "astrosc&isis, usually are identified at deli)ery0
.alpation % >al*ation of t&e a(domen s&ould (e"in su*erficially and *roceed more dee*ly
(ut remain "entle to a)oid causin" discomfort and stimulatin" t&e infant to cry0 9oldin" t&e
infant2s le"s in a fle+ed *osition and &a)in" t&e infant suc3 on a *acifier or t&e e+aminer2s
"lo)ed fin"er may facilitate rela+ation of t&e a(dominal 'all muscles0
T&e li)er ed"e normally is *al*ated one to t&ree centimeters (elo' t&e ri"&t costal mar"in0
T&e li)er s&ould (e soft 'it& a smoot& ed"e0 T&e s*leen usually is not *al*a(le, alt&ou"& some
normal infants may &a)e a *al*a(le s*leen ti*0
T&e 3idneys may (e *al*ated t&rou"& t&e anterior a(dominal 'all0 !not&er a**roac& to
*al*ation of t&e lo'er *oles of t&e 3idneys is to *lace t&e fin"erti*s a(o)e and (elo' t&e lo'er
Euadrants and a**ly moderate *ressure= t&is maneu)er tra*s t&e 3idneys (et'een t&e
fin"erti*s0 T&e left 3idney is more easily *al*a(le t&an t&e ri"&t0
!ny ot&er *al*a(le a(dominal mass is a(normal and reEuires furt&er in)esti"ation0 Most
a(dominal masses in ne'(orns are enlar"ed 3idneys caused (y &ydrone*&rosis or cystic renal
disease0 Masses may also result from tumors, suc& as neuro(lastomas or teratomas0
(mbilical cord % T&e um(ilical cord is ins*ected for "eneral a**earance, amount of
W&arton2s -elly, and t&e um(ilical )essels0 ! small cord may indicate *oor maternal nutritional
status or intrauterine com*romise0 Meconium stainin" s&ould (e noted, as s&ould any redness
or ooJin" from t&e stum*0 Eryt&ema surroundin" t&e stum*, andMor an odorous disc&ar"e may
indicate om*&alitis0
Sin,le umbilical artery % ! sin"le um(ilical artery 4SK!6 is *resent in 002 to 00F *ercent of
li)e (irt&s, occurrin" more freEuently in small for "estational a"e and *remature infants, and
t'ins .2,-2$/ 0
1n infants 'it& SK!, t&ere is an increased rate of c&romosomal and ot&er con"enital
anomalies0 Multi*le studies &a)e s&o'n t&at 20 to B0 *ercent of neonates 'it& SK! &ad ma-or
structural anomalies, often in)ol)in" multi*le or"ans .2,-2$/ 0 T&e most commonly affected
or"ans 'ere t&e &eart, "astrointestinal tract, and t&e central ner)ous system0
1n t&e remainin" $0 to 80 *ercent of infants 'it& SK!, SK! is an isolated findin"0 1n t&ese
neonates, t&ere is an increased incidence of occult renal anomalies0 T&is 'as (est s&o'n in a
meta-analysis of se)en studies t&at included 20, infants '&o 'ere screened for renal
malformations eit&er (y ultrasound or intra)enous *yelo"ra*&y .2F/ 0 H)erall, a renal anomaly
'as detected in #F *ercent of t&ese infants0 9o'e)er, in only one-&alf of t&ese *atients 'as
t&e a(normality *ersistent and considered si"nificant0 Iesico-ureteral reflu+ 4IK86 of "rade 2
or &i"&er 'as t&e ma-or renal findin" and 'as found in 20G *ercent of t&e total study
T&e clinical si"nificance of t&ese findin"s is unclear and o*inions differ on t&e )alue of
screenin" t&ese infants for renal a(normalities .2F,2$/ 0 T&e estimated *re)alence of IK8 in
t&e "eneral *o*ulation is #0B *ercent0 T&e relati)e ris3 of IK8 in infants 'it& a SK! com*ared
to t&ose 'it& t'o um(ilical arteries is not 3no'n0
!lt&ou"& no definiti)e ans'er is a)aila(le, screenin" 'it& renal ultrasono"ra*&y is
recommended in ne'(orns 'it& SK! .2,,2$/ 0
/E%$AL$A % T&e "enitalia usually are ins*ected immediately after (irt& to identify t&e
infant2s "ender or confirm t&e *renatal dia"nosis0 T&e ne'(orn 'it& "enitalia t&at a**ear
am(i"uous s&ould (e e)aluated as soon as *ossi(le0 4See 5E)aluation of t&e infant 'it&
am(i"uous "enitalia56
2emale % T&e siJe and location of t&e la(ia, clitoris, meatus, and )a"inal o*enin" s&ould (e
assessed0 T&e a**earance of t&e "enitalia )aries 'it& "estational a"e0 T&e la(ia minora and
clitoris are *rominent in *reterm infants, '&ile t&e la(ia ma-ora (ecome lar"er as t&e infant
a**roac&es term0 4See 5Gynecolo"ic e+amination of t&e ne'(orn and c&ild5 and see 5>ostnatal
assessment of "estational a"e560
T&e )a"inal o*enin" s&ould (e fully )isi(le0 Many infants &a)e )a"inal s3in ta"s, re*resentin"
t&e sli"&t *rotrusion of )a"inal e*it&elium at t&e *osterior fourc&ette0 Wit&dra'al from
maternal &ormones often results in a mil3y '&ite )a"inal disc&ar"e, '&ic& sometimes is (lood-
T&e la(ia minora s&ould (e se*arated to detect '&et&er t&e &ymen, '&ic& normally &as some
o*enin", is im*erforate0 T&is disorder can cause &ydrometrocol*os, '&ic& usually a**ears as a
(ul"in" &ymen, es*ecially 'it& cryin"0 Enlar"ement of t&e uterus resultin" from an
im*erforate &ymen may (e detected as a lo'er midline a(dominal mass0 4See 5Dia"nosis and
mana"ement of con"enital anomalies of t&e )a"ina560
"ale % T&e *osition of t&e meatus, siJe of t&e *enis, a**earance of t&e scrotum, and
*resence of testes s&ould (e e)aluated0 T&e fores3in normally is ti"&t or ad&erent in t&e
ne'(orn= easy retraction usually is not *ossi(le for se)eral mont&s to years0 Many infants
&a)e a small 4one mm6 '&ite se(aceous cyst at t&e ti* of t&e fores3in t&at is (eni"n0
T&e *enis is stretc&ed to assess len"t&0 <ormal *enile len"t& in t&e term male is 20C to B0C cm
4s&o' fi"ure 26 .28/ 0 T&e scrotum of t&e term male is ru"ated and *i"mented0 Enlar"ement
or s'ellin" of t&e scrotum may (e caused (y &ydroceles, &ernias or, rarely, testicular torsion0
9ydroceles are fluid collections around t&e testes, and usually resol)e s*ontaneously0 T&ey can
(e distin"uis&ed from &ernias (y transillumination of t&e scrotum0 !cute torsion *resents as a
*ainless s'ellin", usually 'it& discoloration of t&e scrotum0
*ypospadias % T&e uret&ral meatus usually can (e located 'it&out retraction of t&e fores3in0
Ientral location of t&e meatus 4&y*os*adias6 is relati)ely common, 'it& a *re)alence of 00B to
00$ *ercent in li)e male (irt&s .2G-B2/ 0 T&e meatus may (e located any'&ere from t&e
*ro+imal "lans to t&e *erineum, 'it& t&e more se)ere cases &a)in" a more *ro+imal meatus,
suc& as *erineal or scrotal &y*os*adias 4s&o' *icture #60
8is3 factors associated 'it& &y*os*adias include ad)anced maternal a"e, *re-e+istin"
maternal dia(etes mellitus 4*rior to *re"nancy6, "estational a"e DB$ 'ee3s, and maternal
*ro"estin or diet&ylstil(estrol inta3e .BB-BC/ 0 T&e *re)alence of &y*os*adias 'as increased in
(oys '&ose fat&ers &ad &y*os*adias .BC/ and )aried 'it& maternal et&nicity= male infants of
;aucasian mot&ers 'ere at t&e &i"&est ris3 and t&ose of 9is*anic mot&ers 'ere at t&e lo'est
ris3 for &y*os*adias .BB/ 0 4See 5Hutcome of diet&ylstil(estrol e+*osed indi)iduals5 section on
Genitourinary a(normalities60
!ssociated u**er "enitourinary tract anomalies in asym*tomatic (oys 'it& &y*os*adias are
uncommon .BF-BG/ , and often detected t&rou"& routine *renatal ultrasono"ra*&y .B0/ 0 T&e
3idneys and uret&ra de)elo* from distinct em(ryolo"ic structures and at different times
.2G,B0/ 0 T&e critical time for *&allic de)elo*ment is from 8 to #2 'ee3s "estation, '&ereas
t&e 3idney is 'ell de)elo*ed (y $ 'ee3s .2G/ 0 T&us, radio"ra*&ic e)aluation of (oys 'it&
&y*os*adias is rarely necessary, unless t&e infants are sym*tomatic or &a)e in)ol)ement of
ot&er or"an systems 4su""estin" a malformation seEuence6 .B0,,0/ 0
;on"enital anomalies of t&e "enital or"ans, suc& as undescended testes and interse+
conditions, occur in a**ro+imately si+ *ercent of *atients 'it& &y*os*adias .B2/ 0 T&us, male
infants 'it& &y*os*adias 4of any location6 s&ould (e carefully e+amined to detect non*al*a(le
testis 4unilateral or (ilateral, s&o' *icture 26 and (e e)aluated for interse+ conditions,
includin" con"enital adrenal &y*er*lasia .,#/ 0 4See 5Kndescended testes 4cry*torc&idism65,
see 5E)aluation of t&e infant 'it& am(i"uous "enitalia5 and see 5Dia"nosis of classic con"enital
adrenal &y*er*lasia due to ;N>2#!2 42#-&ydro+ylase6 deficiency560
1n addition, mono"enic defects &a)e (een associated 'it& &y*os*adias as illustrated in a study
t&at re*orted mutations of t&e 9HOD#B in affected male mem(ers of a sin"le lar"e 3indred
'it& &y*o*lastic syn*olydactyly and &y*os*adias .,2/ 0
1nfants 'it& &y*os*adias and (ilaterally *al*a(le testes s&ould (e referred to urolo"y, usually
'it&in B to F mont&s unless *arental concerns dictate an earlier referral .,0/ 0
;ircumcision is usually not recommended, eit&er (ecause t&e *re*utial s3in may (e necessary
for &y*os*adias re*air or (ecause t&e lac3 of )entral s3in ma3es circumcision difficult .2G/ 0 !
*ediatric urolo"ist s&ould (e consulted in t&e nursery if t&ere is a Euestion re"ardin"
*erformance of circumcision0
Epispadias % Dorsal location of t&e meatus 4e*is*adias6 is uncommon0 1t usually is
associated 'it& (ladder e+stro*&y0 4See 5E)aluation and initial mana"ement of infants 'it&
(ladder e+stro*&y560
estes % Testes s&ould (e *al*a(le in t&e scrotum or in"uinal canal and (e eEual in siJe0
:et'een 2 and C *ercent of full-term and B0 *ercent of *remature male infants are (orn 'it&
an undescended testicle0 Testes descend (efore si+ mont&s of a"e in most cases0 4See
5Kndescended testes 4cry*torc&idism6560
Ambi,uous ,enitalia % Si"ns of am(i"uous "enitalia include an enlar"ed clitoris, fused la(ial
folds, or *al*a(le "onads in a *&enoty*ic female, and (ifid scrotum, se)ere &y*os*adias,
micro*enis, or cry*torc&idism in a *&enoty*ic male0 !m(i"uous "enitalia may si"nal an
interse+ disorder0 T&ese conditions may (e caused (y a(normalities of se+ual differentiation or
con"enital adrenal &y*er*lasia0 1nfants s&ould (e e)aluated *rom*tly and t&e a**ro*riate
"ender assi"ned as soon as *ossi(le0 4See 5E)aluation of t&e infant 'it& am(i"uous "enitalia5
and see 5Dia"nosis of classic con"enital adrenal &y*er*lasia due to ;N>2#!2 42#-&ydro+ylase6
Anus % T&e anus is ins*ected for its location and *atency0 !n im*erforate anus is not al'ays
immediately a**arent0 T&us, *atency often is c&ec3ed (y careful insertion of a rectal
t&ermometer to measure t&e (a(y2s first tem*erature0
&(%1 A%D S.$%E % T&e s*ine is ins*ected for )erte(ral a(normalities or a neural tu(e
defect (y direct )isualiJation and *al*ation alon" t&e )erte(ral column0 T&e "luteal folds
s&ould (e se*arated to e+amine for t&e *resence of a sacral cleft or dim*le0 ! tuft of &air,
&eman"ioma, or discoloration in t&e sacrococcy"eal area may su""est an underlyin" )erte(ral
anomaly0 4See 5E*idemiolo"y= *at&o"enesis= clinical features= and com*lications of infantile
&eman"iomas5 and see 5E)aluation and dia"nosis of infantile &eman"iomas5, section on
Se"mental &eman"iomas60
Soft tissue masses alon" t&e s*ine t&at are co)ered 'it& normal s3in may (e li*omas or
myelomenin"ocoeles0 ! dim*le 'it&out a )isi(le (ase may indicate t&e *resence of a *ilonidal
sinus or tract to t&e s*inal cord0 ! tuft of &air from a sinus or dim*le sometimes is seen '&en
t&ere is e+tension of t&e tract to t&e intras*inal s*ace 4s*ina (ifida occulta60
E5&E"$$ES % T&e e+tremities are e+amined for deformities and mo)ement0 T&e &ands
and feet are ins*ected for syndactyly 4fusion of di"its6 and *olydactyly 4e+tra di"its60
Syndactyly and *olydactyly can (e normal )ariants in a ne'(orn 'it& an ot&er'ise normal
e+am or may (e associated 'it& )arious syndromes0 T&e *resence of a sin"le *almar crease,
also 3no'n as a simian crease, s&ould (e noted0 ! sin"le unilateral *almar crease occurs in C
to #0 *ercent of t&e normal *o*ulation .28/ and is common in ne'(orns 'it& Trisomy 2#0 4See
5;linical features and dia"nosis of Do'n syndrome560
T&e e+tremities s&ould mo)e s*ontaneously and eEually0 Decreased mo)ement of one lim(
may (e (ecause of *ain caused (y a fracture0
Lac3 of arm mo)ement may also (e (ecause of a (rac&ial *le+us in-ury0 T&is ty*ically occurs
'&en t&e cer)ical, or rarely t&e u**er t&oracic, ner)e roots are stretc&ed durin" deli)ery0 T&e
most common form is in-ury of t&e u**er roots 4;C, ;F, and sometimes ;$6, '&ic& results in
Er(2s *alsy .,B/ 0 1n t&is disorder, t&e arm is adducted and internally rotated, 'it& e+tension of
t&e el(o', *ronation of t&e forearm, and fle+ion of t&e 'rist, resultin" in t&e c&aracteristic
5'aiter2s ti*5 *osition of t&e &and0 T&e lac3 of s&oulder a(duction results in an asymmetric
Moro refle+, alt&ou"& &and mo)ement and a *almar "ras* are *resent0 Dia*&ra"matic
*aralysis may occur, leadin" to res*iratory distress0
1n-ury to t&e lo'er roots 4;8, T#6 nearly al'ays is associated 'it& in)ol)ement of t&e u**er
roots, resultin" in total (rac&ial *le+us *alsy0 1n addition to *aralysis of t&e s&oulder and arm,
affected infants &a)e 'ea3ness of t&e 'rist and fin"er fle+ors, so t&at t&e &and a**ears lim*0
T&e *almar "ras* refle+ is a(sent0 1n)ol)ement of t&e sym*at&etic outflo' from T# results in
9orner2s syndrome in a**ro+imately one-t&ird of se)erely affected infants .,B/ 0 1nfants 'it&
9orner2s syndrome &a)e *tosis and miosis0
*$.S % T&e &i*s s&ould (e e+amined to detect de)elo*mental dys*lasia of t&e &i* 4DD960
8is3 factors for DD9 include female "ender, deli)ery from t&e (reec& *osition, and *ositi)e
family &istory0 Girls deli)ered from a (reec& *resentation &a)e t&e &i"&est ris3 of #20 affected
*atients *er #000 li)e (irt&s 4#2 *ercent60 Aor t&ese *atients, screenin" for DD9 is
recommended at si+ 'ee3s of a"e 'it& &i* ultrasound or at four mont&s of a"e 'it& *lain films
.,,/ 0 4See 5E*idemiolo"y and *at&o"enesis of de)elo*mental dys*lasia of t&e &i*5 and see
5;linical features and dia"nosis of de)elo*mental dys*lasia of t&e &i*560
T'o dia"nostic maneu)ers to detect DD9 are *erformed 'it& t&e infant in t&e su*ine *osition0
T&e Hrtolani maneu)er reduces t&e already dislocated &i*0 T&e e+aminer2s inde+ and middle
fin"ers are *laced alon" t&e "reater troc&anter, and t&e t&um( is *laced alon" t&e inner t&i"&0
T&e &i* is a(ducted '&ile t&e femur is lifted anteriorly0 ! *ositi)e si"n occurs if a 5clun35 is felt
as t&e dislocated femoral &ead is re*laced into t&e aceta(ulum0
T&e :arlo' maneu)er dislocates an unsta(le &i* from t&e aceta(ulum0 T&e maneu)er is
*erformed 'it& t&e &i*s fle+ed at G0 de"rees and t&e e+aminer2s fin"ers *laced o)er t&e
lateral as*ect of t&e &i*0 T&e femur is adducted sli"&tly '&ile *osteriorly directed *ressure is
a**lied on t&e 3nee0 ! *ositi)e :arlo' si"n consists of a clun3in" sensation or feelin" of
mo)ement '&en t&e femoral &ead is dis*laced *osteriorly from t&e aceta(ulum0 !ny infant
'it& a *ositi)e Hrtolani andMor :arlo' si"n 'arrants referral to a s*ecialist for furt&er
e)aluation and *ossi(le treatment0
1n a normal infant 'it&out dys*lastic &i*s, neit&er of t&ese maneu)ers s&ould allo' t&e
femoral &ead to mo)e into or out of t&e aceta(ulum0 9o'e)er, many ne'(orns &a)e some
insta(ility of t&e &i*s in t&e first fe' 'ee3s after (irt& (ecause of la+ity of t&e ca*sule and
may &a)e (eni"n ad)entitial sounds 45clic3s56 t&at must (e distin"uis&ed from t&e 5clun3s5 of
true dislocations .,,/ 0
Knilateral DD9 may (e sus*ected (ecause of asymmetry of t&e t&i"& or "luteal folds0 1t is
detected (est 'it& t&e infant in a *rone *osition0 !not&er si"n is discre*ancy of le" len"t&s
4*ositi)e GaleaJJi si"n6, 'it& DD9 on t&e side of t&e s&orter le"0 KneEual le" len"t&s are
detected (est 'it& t&e infant su*ine, t&e 3nees fle+ed, and t&e feet restin" on a flat surface0
%E(&'L'/$) E5A"$%A$'% % T&e ne'(orn neurolo"ic e+amination includes an
assessment of t&e le)el of alertness, s*ontaneous motor acti)ity, tone, muscle stren"t&, and
*rimiti)e refle+es0
Alertness % T&e infant2s state of alertness is o(ser)ed0 T&e state 'ill de*end u*on t&e time
after deli)ery, and '&et&er t&e infant is slee*in" or &un"ry0 >ersistent irrita(ility or let&ar"y
are a(normal findin"s0
Spontaneous motor activity % !ll e+tremities s&ould &a)e symmetric, smoot&, and
s*ontaneous mo)ements0 Jitteriness or tremulousness can occur in normal a'a3e infants,
usually after a startle0
one and muscle stren,th % T&e normal term ne'(orn &as increased fle+or tone0 1n t&e
restin" *osture, t&e e+tremities are in moderate fle+ion0 Tone and muscle stren"t& are
assessed (y t&e *ull-to-sit maneu)er, in '&ic& t&e infant2s &ands are "ras*ed and t&e (a(y is
*ulled from a su*ine to sittin" *osition0 T&e normal infant 'ill offer some resistance, 'it&
fle+ion at t&e 3nees, el(o's, and an3les0 T&e &ead s&ould mo)e 'it& t&e (ody and &ead la"
s&ould (e minimal0 >ronounced &ead la" may indicate &y*otonia0
Muscle stren"t& also can (e tested (y &oldin" t&e infant in a )ertical *osition 'it& t&e feet on
a flat surface0 ! normal infant s&ould (e a(le to (ear 'ei"&t on t&e lo'er e+tremities '&ile
attem*tin" to stand0
&eflexes % <ormal infants &a)e many *rimiti)e refle+es0 T&ese refle+es s&ould (e tested
durin" t&e routine e+amination0
• T&e Moro refle+ is elicited (y t&e sudden do'n'ard mo)ement of t&e &ead and torso
from an u*ri"&t *osition0 1t consists of symmetric e+tension and a(duction of t&e arms
and o*enin" of t&e &ands, follo'ed (y fle+ion of t&e u**er e+tremities in an em(racin"
mo)ement0 !n audi(le cry often follo's0
• T&e rootin" refle+ is elicited (y a**lyin" li"&t tactile stimulation in t&e *erioral area0
T&e infant2s &ead s&ould turn to'ard t&e stimulation and t&e mout& s&ould o*en0
Suc3in" usually can (e elicited (y *lacin" a "lo)ed fin"er or a ni**le in t&e infant2s
mout&0 T&e normal term infant &as a stron", coordinated, and symmetric suc30
• Stro3in" or a**lyin" *ressure to t&e infant2s *alm 'it& t&e e+aminer2s fin"er elicits t&e
*almar "ras*0 T&e "ras* may ti"&ten 'it& attem*ts to remo)e t&e fin"er0
• T&e *lantar "ras*, manifested (y curlin" of t&e toes, is elicited (y a**lyin" *ressure to
t&e *lantar surface of t&e foot0
• T&e ste**in" refle+ is elicited (y &oldin" t&e infant in an u*ri"&t )ertical *osition and
"ently touc&in" t&e feet to a flat surface0 T&e infant2s feet 'ill mo)e in an alternatin"
ste**in" motion0
• ;ontact of t&e dorsum of t&e foot 'it& t&e ed"e of a ta(le 'ill elicit t&e *lacin" refle+,
in '&ic& t&e foot is lifted and *laced on t&e ta(le2s surface0