PERFORMING A NEWBORN ASSESSMENT

A detailed and systematic whole body examination of a stabilized newborn during the early
hours of life.
Every newborn requires a brief physical examination within the (1) first few minutes after birth
and then a full and detailed assessment within the (2) next 48 hours and (3) prior to discharge
from hospital. A follow-up assessment should be performed later in the (4) first week (by a
midwife or General Practitioner (GP)outside the hospital setting) and then at (5) 6-8 weeks after
birth. The physical examination component of the newborn assessment is the most important
screen for major occult congenital anomalies.
There is no optimal time to detect all abnormalities. Moss et.al., found 8.8% of newborns had
an abnormality on the first detailed examination with an additional 4.4% having abnormalities
only diagnosed at follow up examination

Purposes:
 To determine the normalcy of different body systems for healthy adaptation to
extrauterine life.
 To detect significant medical problems for immediate management.
 To detect any congenital problems present for early management and parent education.

Equipment:
 Measuring Tape  Stethoscope
 Soft rubber catheter or  Flash Light
 Rectal thermometer  Clean Gloves

General Instructions
The newborn must be stabilized before starting the assessment procedure, i.e. normal body
temperature and color.
The examination can be conducted without awakening the baby, although he will need to be
exposed at intervals for a complete and accurate examination.
Nurse’s hands must be washed thoroughly before touching the baby.
The newborn should be protected from harmful process such as chilling or nosocomial
infection.
Examination should be done systematically.
A head-to-toe and systems approach to be followed for complete examination.
The examination may be carried-out with the baby in a warmed crib or on an examination
table.

PROCEDURE
STEPS RATIONALE
Implementation
Wash hands thoroughly and dry them and Avoids any chance of introducing infection to
don gloves the baby.
General appearance: Uncover the baby and For a normal baby the findings include:
note general appearance. - Body symmetrical and cylindrical in
contour.
- Head large in proportion to the body.
- Narrow chest
- Protruding abdomen
- Small hips.

Take the head and body measurements Normal measurements are:

- Head circumference: 33 – 35 cm
- Chest circumference: 30 – 33 cm
- Crown rump length 34 – 35 cm
- Crown heel length 48 – 52 cm
Assess skin: note the color of skin especially
around mouth and finger nail beds.
Note any vascular nevi, milia, Mongolian
spots or trauma marks on the head, neck or
body.
Assess head: examine the head for
symmetry, caput, cephalhematoma and the
status of fontanelle
Normal skin is smooth, soft, elastic, warm
and moist. The skin is pink, nail beds are
blue. Color of palms and soles will improve
with activity.
Trauma marks may be present on babies
born by instrument delivery or those who
had tight nuchal cord.
Asymmetry indicates moulding.
- Swelling on the scalp from pressure of
the cervix indicates caput
succedaneum.
- Subperiosteal bleeding, which does
not cross suture line indicates
cephalohematoma.
 - bulging fontanelle indicates increased
intracranial pressure.

Skull shapes associated with premature closure of single sutures. Arrows denote directions of
continued growth across sutures that remain open. Heavy lines indicate areas of maximal
skull flattening. When combinations of sutures remain closed, more complex skull shapes
occur.
The scalp examination may reveal lesions in a newborn, such as (A) caput succedaneum
(scalp edema) and (B) cephalohematoma (subperiosteal hemorrhage).
Assess face: observe symmetry of infant’s Asymmetry is usually related to damage to
face. Note any characteristics feature like the facial nerve
flattened nose, folds below eyes, upturned
nose, etc.

Asymmetry caused by facial nerve paralysis, with inability to close eye, nasolabial fold
flattening, and inability to move lips on the affected side. Newborns with facial nerve
paralysis have difficulty effecting a seal around the nipple and consequently exhibit drooling
of milk or formula from the paralyzed side of the mouth.
Assess eyes: examine the baby’s eyes for
response to light, puffiness, discharge,
opacity or conjunctival hemorrhage/
Normally the eyes are gray, blue or brown in
color.
- Infants will close their eyes in
response to light
- Puffiness is common after forceps
delivery
- Subconjunctival hemorrhage occurs
due to pressure on the fetal head
during delivery.
- Opacity suggest cataract formation
- Ptosis of the eyelids suggest nerve
damage
- Minor drainage may occur after
prophylactic eye medication

Interpretation of red reflex test results in a newborn. (A) Normal, symmetric red reflex. (B)
Normal red reflex in the right eye, and abnormal, diminished red reflex in the left eye, which
is most commonly caused by refractive error between the eyes, but can also be caused by a
more serious pathology (e.g., retinoblastoma). (C) Normal red reflex in the right eye and no
reflex in the left eye, which occurs when the reflection is blocked by an opacity such as a
cataract.
Assess nose: observe the nose for Newborn breath through the nose flaring of
appearance, breathing and any flaring of nostrils indicates respiratory distress.
nostrils.
Assess ears: examine the ears for the
following:
- Firm and cartilaginous
- Presence of ear canal and hearing
- Location on the head.
- Ear lobes are firm and cartilaginous in
mature or term babies.
- Startle reflex/ moro to sudden noise
indicates that the newborn can hear.
- Deformed ear lobes with the upper
margin of the pinna rolled down and
thickened are seen in Down
syndrome.
- Low set ears are seen in trisomy 15
and 18.

Evaluation of ear position in a newborn. (A) Normal ear position. (B) Low-set, posteriorly
rotated ear, which may be a sign of a genetic condition, such as Down, Turner, or trisomy 18
syndrome.
Assess mouth:
- Examine the mouth and note the
presence of any of the following:
- Cleft lip or palate
- Epstein pearls
- Asymmetry when crying
- Natal teeth
- Macroglossia
- Pooling of saliva
Asses neck: examine the neck for the
following:
- Head freely movable
- Neck webbed on shoulders
- Extended arms on one side (shoulder
dystocia)
- Tightness of muscles on one side
- Asymmetry of the mouth when open
indicates facial nerve paralysis
- Pooling of saliva is a sign of
tracheooesophageal fistula / atresia.
- Macroglossia is seen in down
syndrome
- Short neck with flexible movement of
head to each side is normal.
- Neck webbed on shoulder is seen in
down syndrome and turner’s
syndrome
- Extension of one arm indicates
clavicle fracture or damage to
brachial nerve
- Tightness of neck muscle is a sign of
torticollis.
Identification of neck masses based on their location.
KEY:
1 = Preauricular area (parotid gland): congenital lesions-cystic hygroma, hemangioma,
venous malformation; inflammatory condition-lymphadenitis secondary to infection in upper
face and/or anterior scalp
2 = Postauricular area: congenital lesions-branchial cleft I (cystic, inflamed, or both);
inflammatory condition-lymphadenitis secondary to inflammation of posterior scalp
3 = Submental area: congenital lesions-thyroglossal duct cyst, cystic hygroma, dermoid cyst,
venous malformation; inflammatory condition-lymphadenitis secondary to inflammation in
perioral area, anteriour oral area, or nasal cavity
4 = Submandibular area: congenital lesions-cystic hygroma, hamangioma, ranula;
inflammatory condition-lymphadenitis of submandibular gland secondary to inflammation in
cheek and/or mid-oral cavity; in cystic fibrosis, enlartement of submandibular gland without
inflammation
5 = Jugulodiagastric area (tonsil node; normal structures include transverse process of C2
and styloid process): congenital lesions-bronchial cleft I or II, hemangioma, cystic hygrom;
inflammatory condition- lymphadenitis secondary to oropharyngeal inflammation
6 = Area of neck midline (normal structures include hyoid, thyrouid isthmus, and thyroid
cartilage): congenital lesions-thyroglossal duct cyst, dermoid cyst; inflammatory condition-
lymphadenitis
7 = Area at anterior border of sternocleidomastoid muscle (normal structures include
hyoid, thyroid cartilage, and carotid bulb): congenital lesions-branchial cleft I, II, or III (IV is
rare), laryngocele, hemangioma, lymphangioma, hematoma (fibroma of sternocleidomastoid
muscle)
8 = Spinal accessorry: inflammatory condition-lymphadenitis secondary to nasopharyngeal
inflammation
9 = Paratracheal area: thyroid mass, parathyroid mass, esophageal diverticulum, metastatic
lesion
10 = Supraclavicular area (normal structures include fat pad, pneumatocele from apical
lobe related to defect in Gibson fascia[prominent mass with Valsalva's maneuver]):
congenital lesion-cystic hygroma; neoplastic lesion-lipoma.
11 = Suprasternal area: thyroid mass, lipoma, dermoid cyst, thymis mass, mediastinal mass
Assess Chest: Examine the chest for the
following:
- Shape and movement with breathing
- Respiration pattern
- Grunting sound on expiration
- Retractions on inspiration
- Heart rate
- Clavicles palpable on both sides
- Presence of breast engorgement and
secretion of milk
Diaphragmatic breathing with symmetric
movement of chest and abdomen is normal.
- Quiet and free respiration at the rate
of 40 – 60 / minute is normal after
initial activity.
- Grunting indicates respiratory
distress.
- Clavicles clearly palpable if fracture is
present.
- Milk secretion is present in response
to maternal hormones.
Listening areas for clicks: upper right sternal
border (URSB) for aortic valve clicks; upper
left sternal border (ULSB) for pulmonary
valve clicks; lower left sternal border (LLSB),
or the tricuspid area, for ventricular septal
defects; and the apex for aortic or mitral
valve clicks.
The chest of a new-born baby is very short in comparison to its abdomen wall. As the baby
develops, this discrepancy should decrease as the maturing brain causes a change in muscle
activity.
Assess CVS: The normal heart rate is 120 – 160 bpm.
After making the baby quiet, auscultate the If cardiac murmurs are heard these should be
heart sounds and feel for pulses in the upper documented and informed to the
and lower extremities. pediatrician.
--- Murmurs are common in newborns during
the transition from intrauterine to
extrauterine life. Congenital heart defects
must be excluded.
Assess abdomen: observe the abdomen and - Normal abdomen should be round
note: and protruding
- Shape - Small scaphoid abdomen may
- Umbilical cord stump for presence of indicate diaphragmatic hernia.
three vessels - If three vessels are not found
- Any mass congenital malformations should be
- Bowel sounds investigated.
- Passage of meconium - Mass may indicate umbilical or
inguinal hernia or abdominal mass
- Bowel sounds are normally active.
- Passage of meconium indicates a
patent anus.
Assess genitalia:
Male: examine if:
- Foreskin covers the glans penis Normally foreskin covers glans penis
- Urethral meatus opens at the top of Deviation indicate hypospadias or epispadias.
the penis.
- Testicles are palpable in the scrotum If not palpable, undescended testicles should
bilaterally be investigated.
Female:
- Labia minora is prominent and is not
covered by labia majora
- Edematous genitalia Edema is normal in breech born babies
- Vaginal discharge and Vaginal discharge is a normal response to
pseudomenstruation. maternal hormones.

Assess Back: hold the newborn prone and Normally no abnormal curvatures and lesions
examine the back to evaluate the spine. Note are seen.
the presence of any:
- Dimple in the coccygeal or May denote pilonidal cyst.
sacrococcygeal region. May indicate fistula.
- Sinus opening or spina-bifida
- Tufts of hair.
Assess Anus: Presence of meconium on the catheter on
Verify the presence of a perforate anus by withdrawal indicates patency of anus.
inserting a soft rubber catheter gently into
the rectum. (if the newborn passes
meconium earlier, patency need not be
checked).

Assess upper extremities:

Note the proportions to the rest of the body, - Arms should be equal length when
symmetry and spontaneous movements of extended.
arms and hands.
 - Check if the baby holds hands in fists.
- If fingers show webbing,
polydactylism or syndactylism
- If fingernails are developed and
extend beyond fingertips.
- If any skin tags are present.
- Infant should normally resist having
arm extend.
- Long nails are present in post-term
babies.

Assess lower extremities:

Check the legs for the following:
- Symmetry and length - Should be equal
- Range-of-motion
- Proportion to the rest of the body.
- Symmetry of creases of legs and - If abduction is asymmetrical or hip
buttocks with knees flexed, abduct click is present, dislocated hip to be
legs to the table in frog-like position. suspected.
Assess if the legs are persistently limp
Assess feet:
Examine the soles for presence of wrinkles,
acrocyanosis and conditions such as
talipesequinovarus, talipescalcaneovalgus,
bow leg, webbing, polydactylism or
syndactylism.
Perform neurologic examination:
Elicit the following reflexes to assess the
nervous system:
a. Moro or embracing reflex:
- Hold infant at an angle of 45 – degree
and then permit the head to drop one
or two centimeters or
Persistent limpness, indicates spinal cord
lesion
Wrinkles are normally present in full-term
babies.
Wrinkles are absent in pre-term babies.
The first and second toes are widely
separated in down syndrome.
Acrocyanosis is common immediately after
birth.
The infant should respond by abducting and
extending his arms and fanning of fingers.
Sometimes there may be an accompanying
tremor. The arms then flex and embrace the
chest. (Bilateral arm extension and leg flexion
movements).
- Strike the examining table near the
head of the baby.

b. Rooting reflex Baby’s head turns towards the stimulated

- Stroke side of cheek, lips or mouth side, the mouth opens and begins to suck on
with the finger. the stimulating object.

c. Sucking and swallowing reflex. Rhythmical sucking movements will be felt.

- Place finger in baby’s mouth

d. Palmar grasp reflex Infants will grasp and hold the finger.
- With the baby in supine position and
the head in midline, place your fingers
in both the infant’s hands.

e. Plantar grasp reflex: place a finger or Baby will curl toes for a short period.
a thin object like pen or pencil at the
base of toes or place the examiner’s
thumb against ball of the infant’s feet.

f. Tonic neck reflex or fencing: place The arm and leg on the same side will extend
infant in supine position and turn and the arm and leg on the opposite side will
head to one side. flex assuming a fencing position.

g. Stepping or walking reflex. Hold infant Stepping movement with alternating flexion
upright with feet on a flat surface and extension will be seen.
h. Babinski reflex: stroke the lateral
aspect of the sole of the foot going
from heel to the toe with fingernail.
Normal response is the incurving of toes as in
the planter grasp with incurving and fanning
out (stretching out_ of all the toes.
Toes spread
Plantar flexion of the small toe
Dorsiflexion of the big toe

i. Head lag: grasp the infant’s hands and If head lag persist beyond 3 months of age it
arms and gently pull the infant to a signifies neurological complication.
sitting position. Note the degree of
the head lag and alignment of the
head with the body when in sitting
position.
a. Ventral suspension: hold the baby
prone and suspended over examiners
arm, the baby temporarily holds the
head level with the body and flexes
the limbs.

b. Blink reflex: shine a sudden bright This response shows normal light perception.
light at the baby’s eyes. A quick
closure of the eyes and a slight dorsal
flexion of the head are elicited.
In a corneal light reflex test, the child's attention
is attracted to a target (a light or a brightly
colored object), while a light is directed at the
child's eyes. (A) In normally aligned eyes, the light
reflex will be in the center of each
pupil. (B) Corneal light reflex in
esotropia. (C) Corneal light reflex in
exotropia. (D) Corneal light reflex in hypertropia.
c. Corneal reflex: when the eyes are
open, touch the cornea lightly with a
piece of cotton. Normally the eyes
close (avoid touching the eyelids and
lashes).
(A) Normal corneal light reflex in normally aligned
eyes. (B) Pseudostrabismus. The child appears to
be converging his left eye toward his nose
because of the enlarged epicanthal folds;
however, note that the light reflex is symmetric
in each eye. (C) True strabismus. Note the light
reflex is central in the fixating (the child's right)
eye, but is displaced in the nonfixating (the child's
left) eye.
Absence of this response denotes lesions of
the 5th cranial nerve.
d. Doll’s eye response: move the head
slowly to left or right. Eyes lag behind
and do not immediately adjust to new
position of head.
e. Extrusion: touch or depress the
tongue with finger, infant responds by
forcing it outward.
f. Gallant reflex: hold the baby in prone
position and slowly stroke along one
side of the spine toward the buttocks.
The infants reacts by moving the
buttocks toward the side that is
stroked in a curving movement.
This disappears as fixation develops.
This reflex usually lasts for about 4 months.
The infant’s legs are gently extended from a
flexed position before the reflex motion is
attempted leg extension is necessary to see
the proper incurvation of the trunk and
buttocks. The reflex lasts for about one
month.
 g. Perez reflex (incurvation of the trunk The examiner detect presence or absence of
reflex): support the baby in prone movement of the pelvis towards the
position over the examiners hand and stimulated side. This reflex is seen up to six
stroke with one finger along the months. Persistence beyond six months
infant’s back parallel to the spine indicates brain damage.
from sacrum to neck. Normally there
will be lordosis of the spine with
elevation of the pelvis and flexion of
the upper extremities and upward
movement of the head.

Inform the mother about the baby’s

condition and well-being.
Record the findings in the newborn
assessment record.

Summary
1. Some of the jerking and shaking movements seen in neonates are normal, but they
should be rechecked frequently during the first few weeks of life.
2. Variants in the findings caused by the infant’s sleepiness or hunger should be taken into
account and reevaluations should be carried out under different conditions.
3. Severe neurologic damage may be completely asymptomatic and impossible to detect
during the first few weeks of life.

Procedure for the toddler and early school-age child

1. The neurologic examination for the toddler and the early school-age child is similar to
that for the adult.
2. The Draw-A-Person Test and the Denver Developmental Assessment (see page 1360)
are both excellent methods for testing areas in the development of the child.
3. Beyond the neonatal period, specific gross and fine motor coordination testing,
accompanied by appropriate evaluation of the Denver test, will assist in assessing the
child’s level of development.
4. These tests also assess social and language development and are important screening
devices.
5. Interview techniques can also be useful in assessing development in the preschool child.