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Detailed Newborn Examination

General: Measure and record height, weight, and head circumference.

If the infant appears premature or is unusually large or small,


perform a Dubowitz/Ballard exam to assess gestational age (see
Dubowitz/Ballard scoring grid). The exam is divided into two parts:
an external characteristics score, which is best done at birth, and a
neuromuscular score, which should be done within 24 hours after
birth.

Small for gestational age (SGA)


Symmetric (HC = Wt = Len, all <10 %ile) -- 33% of SGA infants

Genetic
o Small maternal size
o Chromosomal abnormalities (Trisomies 13, 18, 21, and Turner's syndrome)
o Congenital abnormalities
Intrauterine infections
o Viruses (rubella, CMV, ?varicella, ?HIV)
o Bacteria (tuberculosis)
o Spirochete (syphilis)
o Protozoan (toxoplasmosis, malaria)
Inborn errors of metabolism
o Hypophosphatasia
o Leprechaunism
o Some amino acidurias
Environmental
o Drugs (heroin, methadone, ethanol, diphenylhydantoin)
o X-rays (therapeutic)
o Smoking

Asymmetric (HC = Len > Wt, Wt <10 %ile) -- 55% of SGA infants

Uteroplacental insufficiency -- onset usually after 24 weeks


o Chronic hypertension
o Preeclampsia
o Renal disease
o Cyanotic heart disease
o Hemoglobinopathies
o Placental infarcts or chronic abruption, velamentous insertion, circumvallate
placenta, multiple gestation.
o Altitude

Combined (symmetric or assymetric) -- 12% of SGA infants

Environmental
o Drugs (including ethanol)
o Smoking
Placental unit insufficiency
o Placental infarcts or chronic abruption, velamentous insertion, circumvallate
placenta, multiple gestation.

Large for gestational age (LGA)

Infants of diabetic mothers


Beckwith-Wiedemann syndrome
Hydrops fetalis
Large mother

Skin: Color
Pallor - associated with low hemoglobin
Cyanosis - associated with hypoxemia
Plethora - associated with polycythemia
Jaundice - Elevated bilirubin
Slate grey colour - associated with methemoglobinemia

Lesions
Milia - pinpoint white papules of keratogenous material usually on nose,
cheeks and forehead, last several weeks.
Miliaria - obstructed eccrine sweat ducts. Pinpoint vesicles on forehead
scalp and skinfolds. Clear within 1 week.
Transient neonatal pustular melanosis - small vesicopustules, generally
present at birth, containing WBCs and no organisms. The intact versicle
ruptures to reveal a pigmented macule surrounded by a thin skin ring.
Erythema toxicum - Most common newborn rash. Variable, irregular
macular patches. Lasts a few days. Wright's Stain shows sheets of
eosinophils.
Cafe au lait spots - suspect neurofibromatosis if there are many large
spots.
Junctional nevi - if large numbers, suspect tuberous sclerosis, xeroderma
pigmentosus, generalized neurofibromatosis.

Neurological Exam
State of alertness: Check for persistent lethargy or
irritability.

Posture: In term infant, normal position is one with hips abducted and
partially flexed and with knees flexed. Arms are adducted and
flexed at the elbow. The fists are often clenched, with fingers
covering the thumb.

Tone: Support the infant with one hand under his chest. The neck
extensors should be able to hold the head in line for 3 seconds.
Should not have more than 10% head lag when moving from
supine to sitting position.

Reflexes: Reflexes must be symmetrical. Biceps jerk test C5 and C6,


Knee jerk tests L2-L4, Ankle jerk tests S1, S2. Truncal incurvation
reflex tests T2 through S1. Anal wink test S4, S5. Other primitive
reflexes include the Moro, palmer and planter grasps, sucking and
rooting reflexes, and the asymmetric tonic neck reflex (ATNR).
Asymmetric tonic neck reflex (seen in ventral suspension with
arms rigidly extended and fists clenched) is abnormal.
When reflexes appear and disappear:
Reflex
Appears
Disappears
Moro

Newborn

3 months

Grasp

Newborn

3 months

LE crossed extensors Birth

1 month

Extensor plantar

Newborn

8-12 months

Placing/stepping

Birth

1-2 months

ATNR

Newborn

3 months

Head and Neck


Head: Check for overriding sutures, the number of fontanelles and their size.
Check for abnormal shape of head. Check for encephalocoeles. Measure
the head circumference.
Eyes
Check for colobomas, heterochromia.
Cornea - Check for cloudiness.
Conjunctiva - Inspect for erythema, exudate, edema, jaundice and
hemorrhage. Silver nitrate prophylaxis can cause a chemical
conjunctivitis. Check for pupillary size and reactivity to light.

Red Reflex - Hold the ophthalmoscope 6-8" from the eye. Use the +10
diopter lens. The normal newborn transmits a clear red colour back to
the observer. Black dots may represent cataracts. A whitish color may be
suggestive of retinoblastoma.

Ears
Check for asymmetry, irregular shapes. Look for auricular or preauricular pits, fleshy appendages, lipomas, or skin tags.

Nose
Look for flaring of the alae nasi as a sign of increased respiratory effort.
Look for hyper- or hypo-telorism. Check for choanal atresia (CA) as
manifested by respiratory distress (neonates are obligate nose
breathers). A soft NG tube should be passed through each nostril to
confirm patency if choanal atresia is suspected.

Palate: Check for cleft lip and palate.

Mouth
Observe the size and shape of the mouth.
Microstomia - seen in Trisomy 18 and 21.
Macrostomia - seen in mucopolysaccharidoses.
Fish mouth - seen in fetal alcohol syndrome.
Epstein pearls - small white cysts which contain keratin, frequently found
on either side of the median raphe of the palate.
Ranulas - small bluish white swellings of variable size on the floor of the
mouth representing benign mucous gland retention cysts.
Tongue: Macroglossia - Hypothyroidism, mucopolysaccharidoses
Teeth: Natal teeth - occur in 1/2,000 births. Mostly lower incisors. Risk
of aspiration if loosely attached.

Chin: Micrognathia - occurs with Pierre-Robin syndrome,


Treacher-Collins syndrome, Hallerman Streiff syndrome.
Neck: Palpate over all muscles, palpate clavicles for possible
fractures. Web neck found in Turner's and Noonan's
syndromes. Torticollis usually secondary to
sternocleidomastoid hematoma. Cystic hygromas most

common neck mass. Lymph nodes are unusual at birth and


their presence usually indicates congenital infection.
Note: Suspect tracheo-esophageal fistula (TEF) if polyhydramnios is
present.

Chest and Lungs


Observe respiratory rate, respiratory pattern (periodic breathing, periods
of true apnea). Observe chest movements for symmetry and for
retractions. Listen for stridor, grunting. Note that there may be some
enlargement of the breasts secondary to maternal hormones.

Cardiovascular System
Measure heart rate, blood pressure in upper and lower extremities,
respiratory rate.

Inspection: Check baby's color for pallor, cyanosis, plethora.


Palpation: Check capillary refill. Check pulses; note any decrease in

femoral pulses or radio-femoral delay as a sign of possible


coarctation of the aorta, note character of pulses (bounding or
thready). Locate PMI with single finger on chest; abnormal location
of PMI can be clue to pneumothorax, diaphragmatic hernia, situs
inversus, or other thoracic problem.

Auscultation: Note rhythm and presence of murmurs which may be


pathologic.

Abdomen:

Note shape of abdomen. Flat abdomens signify


decreased tone, abdominal contents in chest, or abnormalities in
abdominal musculature. Note abdominal distension. Observe for
diastasis recti. Observe for any obvious malformations e.g.
omphalocoele. An omphalocoele has a membrane covering (unless
it has been ruptured during the delivery) whereas a gastroschisis
does not.

Examine umbilical cord and count the vessels. Note color of cord.
Palpate liver and spleen. It may be normal for the liver to be about 2 cm
below the right costal margin. The spleen is not usually palpable; if the
spleen is felt, be alert for congenital infection or extramedullary
hematopoeisis. After locating these organs (checking for situs inversus),
palpate for any abnormal masses.

Auscultate for bowel sounds.


Examine for hernias - umbilical or inguinal.
Inspect anal area for patency and/or presence of fistulas.

Genitourinary Exam
Kidneys: Examined by palpation. The kidneys should be about
4.5-5.0 cm vertical length in the full term newborn. The
technique for palpation is either a) one hand with four
fingers under the baby's back, palpation by rolling the
thumb over the kidneys, or b) palpate the left kidney by
placing the right hand under the left lumbar region and
palpating the abdomen with the left hand (do the reverse
for the right kidney).
Male genitalia: Term normal penis is 3.60.7 cm stretched
length. Inspect glans, urethral opening, prepuce and shaft.
Normally difficult to completely retract foreskin. Observe
for hypospadias, epispadias. Inspect circumcised penis for
edema, incision, bleeding. Full term infant should have
brownish pigmentation and fully rugated scrotum. Palpate
the testes.
Female genitalia: Inspect the labia, clitoris, urethral opening
and external vaginal vault. Often a whitish discharge is
present; this is normal, as is a small amount of bleeding,
which usually occurs a few days after birth and is
secondary to maternal hormone withdrawal. Hymenal tags
may be present normally.

Extremities and Skeletal System


Spine: Scoliosis, kyphosis, lordosis, spinal defects,
meningomyelocoeles.
Upper extremity: Look for clavicular fracture, absence of
radius or ulna. Inspect creases and fingers.
Lower extremity: See posture above. Do Ortolani maneuver to
check for congenital hip dislocation. Check toes.

Bibliography for Newborn Exams


1. Klaus, MH and Fanoroff, AA: Care of the High Risk Neonate, 3rd
edition, Philadelphia, WB Saunders, 1986.
2. Fishman, MA: Pediatric Neurology, Orlando, Grune and Stratton, 1986.
3. Green, M and Haggerty, RJ: Ambulatory Pedistrics III, Philadelphia, WB
Saunders, 1984.
4. Barness, LA: Manual of Pediatric Physical Diagnosis, Fifth Edition,
Chicago, Year Book Medical Publishers, 1981.
5. Scanlon, JW, et al.: A System of Newborn Physical Examination,
Baltimore, University Park Press, 1981.
6. Avery, G: Neonatology, Second Edition, Philadelphia, JB Lippencott,
1981.
7. Ziai, M: Pediatrics, 3rd Edition, Boston, Little, Brown and Co., 1984.
8. Collier, JAB and Longmore, JM: Oxford Handbook of Clinical Specialties,
Oxford, Oxford University Press, 1987.
9. Behrman and Vaughan: Nelson's Textbook of Pediatrics, 12th Edition,
Philadelphia, WB Saunders, 1983.