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A neonate, or newborn, is defined as a child less than 28 days old. A thorough physical
examination should be performed within the first 24 hours of life to identify abnormalities
and improve outcomes by offering timely treatment. Physical examination of the newborn
is typically performed sequentially from head to toe, keeping in mind common neonatal
pathologies based on family and prenatal history, risk factors, and geographic region.
Last updated: 18 May, 2022
Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza
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CONTENTS
Introduction
Vital Signs
General Exam
Chest
Extremities
Neurologic Exam
Clinical Relevance
References
Introduction
Before examining the infant, a thorough chart review should be performed.
Maternal history
Prior pregnancies, deliveries, and associated complications
History of siblings with congenital defects or genetic disorders
Complications during pregnancy:
o Gestational diabetes
o Hypothyroidism
o Eclampsia
Social behaviors (tobacco use, illicit drug use, alcohol use)
Preventative care during pregnancy:
o Adherence to routine prenatal care
o Tdap (tetanus, diphtheria, and pertussis) vaccine during pregnancy
Vital Signs
The normal range for neonatal vital signs is unique.
Temperature: 36.5℃–37.6℃ (97.7℉–99.5℉)
Heart rate: 120–160/min
Respiratory rate: 36–60/min
Pulse oximetry: > 90%
Blood pressure:
o Must be measured with a properly fitting, neonatal-sized blood
pressure cuff
o Usually only measured if renal or cardiovascular conditions are
suspected
During the perinatal period, growth parameters should be plotted daily on a
growth chart.
Length
Weight
o Below the 10th percentile is small for gestational age (SGA).
o Above the 90th percentile is large for gestational age (LGA).
Head circumference
o Below the 2nd percentile is considered microcephaly.
o Above the 98th percentile is considered macrocephaly.
General Exam
Physical exam findings
Physical exam findings can help confirm the gestational date (Ballard score):
Ballard scoring: scoring system that uses physical exam findings to determine likely neonatal maturity
and gestational age
Image by Lecturio.
The infant’s reaction to the examination is useful in assessing:
Alertness
Reactivity
Tone
Vigor
Respiratory effort
Tachypnea may indicate:
Pulmonary dysfunction
o Transient tachypnea of the newborn
o Meconium aspiration
o Pulmonary hypertension
o Pulmonary hypoplasia
Congenital cardiac abnormalities (the 5 Ts)
o Truncus arteriosus
o Transposition of the great vessels (TGV)
o Tricuspid valve atresia
o Tetralogy of Fallot
Fontanelles
Palpate the anterior (3–6 cm in diameter) and posterior (1–1.5 cm) fontanelles:
Normal: soft and flat
Sunken: may indicate dehydration
Tense or bulging: may indicate increased intracranial
pressure from meningitis or hydrocephalus
Sutures
Palpate for symmetry:
Temporary asymmetry from passage through the birth canal is normal
(sutures overlap to allow passage through the birth canal).
Persistent asymmetry may indicate craniosynostosis (early closure of the
sutures leading to an abnormal head shape).
Eyes
Note the spacing, symmetry, and positioning of the eyes.
o Hypotelorism and hypertelorism (narrowly and widely spaced eyes) are
often associated with genetic disorders.
Note the width and slant of palpebral fissures.
Note the appearance of the sclera, conjunctive, iris, and reactivity/symmetry
of the pupils.
Check for red reflex.
o Present in all infants
o Absent in one or both eyes in:
Retinoblastoma
Congenital cataracts
Retinopathy of prematurity
Look for purulent discharge from the tear duct.
o Dacryostenosis:
Blocked tear duct
Relieved by gentle massage with a warm towel
o Ophthalmia neonatorum:
Infection of the eye
Associated with periocular swelling, conjunctival injection
May require antimicrobials
Ears
Appearance
o Note the spacing, symmetry, and positioning of the ears.
o Low-set ears:
Associated with multiple genetic syndromes (e.g., Down’s
syndrome, Edwards syndrome, Patau’s syndrome)
Helices below the imaginary plane that go through both of the
child’s inner canthi
o Note any other abnormalities: abnormal rotation, pits, or skin tags →
should prompt evaluation of the kidneys
o Tympanic membranes are generally not visualized during the newborn
period.
Function
o Hearing tests must be performed on all infants before one month of
age, preferentially prior to discharge.
o The auditory brainstem response or the otoacoustic emissions test are
utilized.
Mouth
Look for natal teeth.
o Should be removed as they are an aspiration risk
o Often seen with Pierre-Robin sequence
Note if the mandible and maxilla fit together correctly or if
an under-/overbite is present.
Examine the tongue and the extent of protrusion to look
for ankyloglossia (“tongue-tie”).
Visualize and palpate the palate for the presence or absence of a cleft palate.
o Palpation is important because submucosal cleft palates are not
visible.
o Look for bifid or lateralized uvula as these may be a sign of
cleft palate.
Nose
Note the shape and symmetry of the nose.
Check for choanal atresia by occluding each nostril in turn and noting any
difficulty in respiration.
Neck
Observe the neck’s range of motion.
o Congenital torticollis is a common finding due to birth trauma and is
treated with physical therapy.
Inspect and palpate the extended neck for symmetry, masses, and
abnormalities.
o Medial masses may indicate a thyroglossal duct cyst.
Chest
Clavicles
Palpate for the presence of both clavicles.
Palpate for the presence of clavicular fractures, which may occur from
trauma during childbirth.
Chest
Inspect for chest wall symmetry, spacing of the nipples, and any visible
deformations.
o Wide-set nipples may indicate Turner syndrome.
Heart
Feel the chest wall for a displaced point of maximal impulse (PMI).
Auscultate heart sounds.
o Healthy: single S1, split S2
o Murmurs may indicate congenital cardiopathies:
Physiologic murmurs due to persistent fetal circulation are
common.
Pathological: any harsh-sounding murmur, diastolic murmur,
grade 3 or higher murmur
Abdomen, Back, and Genitals
Abdomen
General appearance: Examine for the presence of any noticeable deformities
(omphalocele or gastroschisis) or abdominal distension.
The umbilical cord stump:
o Should contain 2 arteries and 1 vein
Both genders:
o Verify patency of the anus.
o Look for “sacral dimple.”
Any dimple that is < 2.5 cm from the anal verge and < 0.5 cm in
diameter is considered normal.
All other sacral dimples should be investigated by ultrasound for
concern for spinal malformations.
Extremities
Hips
Inspect for any visible abnormalities.
Use Ortolani and Barlow maneuvers to assess hip stability (may
indicate developmental dysplasia of the hip).
Palpate for the femoral pulses.
Hands and feet
Inspect for any visible abnormalities, including:
o Syndactyly or polydactyly
o Overlapping fingers (may indicate Edwards syndrome)
o A single palmar crease (may indicate Down’s syndrome)
Look for talipes equinovarus (clubfoot).
Extremities
Assess radial, posterior tibial, and dorsalis pedis pulses.
Observe for spontaneous movement of the extremities.
o Brachial plexus injury during birth can give rise to various palsies:
Erb’s palsy
Due to hyperextension of the C5 to C7 spinal nerve roots
Forearm is medially rotated, and the hand pronated
(“waiter’s tip”)
Klumpke’s palsy
Injury to the distal portions of C8 and T1
Paralysis of the entire arm with areflexia
Neurologic Exam
General
o Tone:
Passive tone depends on the neonate’s maturity at birth.
Normal for an infant born at 24 weeks’ gestation to be more
splayed out at rest
A full-term infant should flex all extremities at rest.
Primitive reflexes:
o Suck reflex: Touching the roof of the mouth stimulates
sucking/swallowing.
o Rooting reflex: Touching the side of the neonate’s face/cheek
stimulates the neonate to turn their head to the ipsilateral side.
o Palmar grasp: Stroking the palm should stimulate the neonate to
grasp the hand.
o Moro reflex:
Lift the infant gently 2–3 inches by pulling the arms.
Carefully release the infant’s hands.
The infant should startle, which results in arm extension followed
by arm flexion.
o Deep tendon reflexes can also be evaluated.
Cranial nerve assessment
Table: Primitive reflexes
Duration 2–3 months after Less prominent 1 month after 5–6 months after 6
birth birth birth b
Clinical Relevance
The following conditions can be identified or suspected through physical
examination of the newborn:
Craniosynostosis: the premature fusion of one or more cranial sutures,
usually classified as simple or complex. Premature suture fusion can cause
abnormalities in skull and brain growth.
Meningitis: inflammation of the leptomeninges due to an infectious agent. A
bulging anterior fontanelle can be a sign of neuroinfection in neonates.
Infection can be suspected if other clinical signs are present, such as
temperature, tachycardia, and poor feeding.
Cleft lip and palate: a congenital defect of the lip and usually alveolus that
may involve the palate. Cleft palate may also occur independently of cleft lip.
Both occur when the facial structures of a fetus fail to fuse properly.
CHARGE syndrome: a rare genetic disorder in children affecting almost all
body systems due to impaired gene expression. CHARGE is an abbreviation
of coloboma, heart defects, atresia choanae, growth retardation, genetic
abnormalities, and ear abnormalities. Coloboma is a distinguishing clinical
finding seen in children with CHARGE syndrome.
Thyroglossal duct cyst: most common congenital cyst found in the midline
when palpating a neonate’s neck. Thyroglossal duct cyst forms in the
remnant of the thyroglossal tract.
Branchial cleft remnants: cysts, sinuses, or skin tags along the anterior
border of the sternocleidomastoid muscle or near the angle of the mandible,
lined primarily with stratified squamous epithelium. Cysts may also
contain lymphoid follicles.
Neonatal gynecomastia: breast hypertrophy due to androgens and
estrogens secreted by the mother that enter the fetal circulation.
Neonatal pneumonia: inflammation of the pulmonary parenchyma due
to infectious agents during the neonatal period.
Meconium aspiration syndrome: respiratory distress in newborns born
with meconium-stained amniotic fluid.
Truncus arteriosus (TA): congenital cardiopathy characterized by the
emergence of the pulmonary artery and aorta from a common trunk that
overrides a ventricular septal defect (VSD).
Transposition of the great vessels Transposition of the Great
characterized by “switching” of the great arteries. There are 2 presentations: the dextro
(D)- and levo (L)-looped forms. The L-looped form is rare and congenitally corrected, as
References
1. Olsson, J. M. (2020). The newborn. In R. M. Kliegman MD et al. (Eds.), Nelson textbook of
pediatrics. https://www.clinicalkey.es/#!/content/3-s2.0-B9780323529501000213
3. James, W. D. et al. (2020). Epidermal nevi, neoplasms, and cysts. In W. D. James MD etl a. (Eds.),
Andrews’ diseases of the skin. https://www.clinicalkey.es/#!/content/3-s2.0-
B9780323547536000290
4. Hedstrom, A. B., Gove, N. E., Mayock, D. E., & Batra, M. (2018). Performance of the Silverman
Andersen respiratory severity score in predicting PCO2 and respiratory support in newborns: A
prospective cohort study. Journal of Perinatology. doi: 10.1038/s41372-018-0049-3
5. Katz, M. H., & Doherty, G. M. (2020). Urology. In G. M. Doherty (Ed.), Current diagnosis &
treatment: Surgery. New York, NY: McGraw Hill
LLC. accessmedicine.mhmedical.com/content.aspx?aid=1171284274