Newborn Exam

Neonatal physical
examination
Dr.Shireen Noman Abed
Board certified in Pediatrics
Palestinian board, Egyptian Fellowship
Al-Naser Pediatric Hospital
Objectives
 The newborn infant should undergo a
thorough physical examination.
1st wash your hands then

Observe and listen then
Systematic head-to-toes examination.
 Record your findings.

Introduction
Child Mortality in the World
 Every minute 20 children under 5 die in the
world.
 i.e about 30,000 children die each day
 > 10 million children die each year
 4 million of these are neonatal deaths
 2/3 of neonatal mortality happens in the first
week of life and
 2/3 of these cases are in the first 24 hours of life
WHO, 2005
 Many cases of infant and neonatal
mortality can be prevented by
known, available and low-cost
technologies if they are accessible
to all
WHO, 2005
Estimated Distribution of Direct
Causes of 4 Million Neonatal
Deaths for the Year 2000
Infections, Other, 7%
36% Congenital
anomalia, 7%
Asphyxia,
23%
Prematurity;
27%
Modified from Lancet, 2005

Neonatal situation:
?How to improve
 Place and Infrastructure
 Equipment
 Human Resources
 Training
Main Objectives of Complete
Newborn Examination
 Check for:
 Danger signs
 Congenital malformations
 Traumas
 Assess growth and development
 Manage:
- care and treatment
- family advice
When to Conduct a Complete
Newborn Examination
 After birth:
 Immediately if a danger sign
 Usually within 2 hours after birth
 If the mother is worried
 Before discharge
 After discharge from the hospital:

 During the first week of life at a routine
visit
 During each follow up visit
 At any sick newborn’s visit

WHO, 2006
How and Where Perform a Newborn
Examination
 The newborn examination should be

conducted :
 In a warm room >250C
 in the presence of mother/family
 naked newborn
 thorough and systematic.
 Encourage the mother to ask questions
 Explain the results of the examination to
mother
 recorded in the baby’s file
WHO, 2006
Always Check First for Danger Signs
 Not feeding well
 Fast breathing (60 breaths/min or more)
 Severe chest indrawing
 Grunting
 Convulsions
 Hypoactive
 Temperature > 38ºC or < 35,5ºC
 Jaundice in newborn younger than 24 hours
WHO, 2006
Main Characteristics of a Healthy
Newborn at Birth (1)
 Respiratory rate (RR) - 30 –60/minute
 Heart rate (HR) - Over 100 per
minute
 Colour - Pink Body
 Temperature - 36.5°C – 37.5°C
 Posture - flexed arms and legs
 Movements - Active
SNL, 2004
Main Characteristics of a
Healthy Newborn at Birth
(2)
 A healthy newborn:
 Cries and reacts to light and sounds
 Moves both legs and arm equally
 Is able to suck
 Passes urine within 24h from birth
 first stool within 24 hours from birth.
SNL, 2004
THE FIRST 24 HOURS
 Complete P/E within 24 h of birth.
 listen to the heart and lungs first
 Warming the stethoscope

Apgar Score
 Activity
 Pulse
 Grimace
 Appearance
 Respiration
Virginia Apgar, 1953

Apgar Scoring
Score
Sign
0 1 2
Heart rate Absent Slow (<100 100≥
beats/min) beats/min
Breathing Absent Slow, irregular Cood, crying
Muscle Limp Some flexion Active motion

tone
Reflex No response Grimace Cough,
sneeze
irritability
Colour Blue or pale Pink body with Completely
WHO, 1997
blue extremities pink
Suggested scheme for neonatal
examination
examination
1. Vital signs 7. Neck
2. Anthropometrics, 8. Face
Gestational age 9. Chest
3.General appearance 10 Cardiovascular
system
4. Obvious congenital 11.Abdomen
anomalies
12. Neuromuscular
5. Skin system
6. Head 13. Skeletal system
examination
7. Neck
1. Vital signs 8. Face
2. Anthropometrics, 9. Chest
Gestational age
10 Cardiovascular
3.General appearance system
anomalies 12. Neuromuscular
5. Skin system
Vital signs
A. Temperature.
- rectal (1° higher than oral),
- oral,
- axillary (1° lower than oral).
B. Respirations.
- normal is 30-60 breaths/min.
C. Blood pressure.
D. Pulse rate.
- The normal is 100-180 beats/min
- usually 120-160 beats/min when awake
- 70-80 beats/min when asleep.
examination
8. Face
2.Anthropometrics,
9. Chest
Gestational age 10 Cardiovascular
5. Skin system
Anthropometrics
A. Head circumference and percentile

- normally 32-37 cm at term.
B. Length and percentile. growth charts
C. Weight and percentile. growth charts
D. Assessment of gestational age.

The new BALLARD score
examination
10 Cardiovascular
5. Skin system
General appearance
Observe, record the
general appearance:
- activity
- skin color
- obvious congenital
abnormalities
examination
system
5. Skin system
Anencephaly
Bilateral cleft lip
Omphalocele
examination
4. Obvious congenital system
anomalies 11.Abdomen
12. Neuromuscular
5. Skin system
Skin
A. Color
B. Texture
C. Rashes
D. Nevi
Skin
A. Color
1. Plethora (deep, rosy red color).
- common in polycythemia
- over oxygenated
- overheated infant
- obtain hematocrit on any plethoric infant.
Erythema neonatorum:
- overall blush to reddish color
- transition
- normal phenomenon
- lasts only several hours.
:Jaundice .2
 yellowish - indirect
 greenish - direct
bilirubin usually >5 mg/dL.
 <24 h old: abnormal:
- Rh incompatibility
- Sepsis
- TORCH
 After 24 h:
- previous diseases
- ABO
- physiologic
Pallor .3
may be secondary to:

- anemia
- birth asphyxia
- shock
- PDA
Cyanosis .4
(desaturation of 5 g of Hb)
a. Central cyanosis (bluish skin, including the

tongue and lips).
- congenital heart -lung disease.
- methemoglobinemia
b. Peripheral cyanosis (bluish skin with pink

lips and tongue).
c. Acrocyanosis
Acrocyanosis
(bluish hands and feet)
- may be normal within

the first few hours
- cold stress.
If in an older infant:
Hypovolemia
Extensive bruising .5
:(ecchymoses)
- ? Difficult delivery
 Petechiae (pinpoint hemorrhages):

coagulopathy should be considered.
Blue on pink" or "pink on" .6
:“.blue
may be secondary to:

- poor perfusion,
- inadequate oxygenation,
- inadequate ventilation,
- polycythemia.
:Harlequin coloration .7
clear line of demarcation
between an area of
redness and an area of
normal coloration
- cause is usually unknown.
- transient (lasting <20 min)
- or can be indicative of shunting of
blood (persistent pulmonary
hypertension or coarctation of the
aorta).
 It may divide the body into right
and left halves,
 or it may develop in the
dependent half of the body when
the newborn is lying on one side.
:Mottling .8
 may be seen in:
- healthy infants
- cold stress
- hypovolemia
- sepsis
 Persistent mottling,
called cutis marmorata
found in:
Down syndrome,
trisomy 13,trisomy 18.
Premature
:Vernix caseosa .9
 greasy white
substance that covers
the skin until the 38th
week of gestation.
 moisture barrier
 It is completely
normal.
Collodion infant .10
 can cause restriction

in growth of nose
and ears.
 This may be normal
or
 disease
Dry skin .11
 In most term
infants
 peeling in postdate
or post mature
 Congenital syphilis
and candidiasis
B. Rashes
Milia
- sebaceous retention
cysts,
- whitish, pinhead sized
 usually on: chin – nose
– forehead - cheeks.
- No Erythema is seen
- disappear within a few
weeks
- in 33% of Infants.
 Pearls: are large single
milia that can occur on
the genitalia and areola.
Erythema toxicum
 red skin with a
yellow white papule
 48 h after birth
 may appear as late

as 7-10 days
 papule contain
eosinophils
 resolves
spontaneously
Candida albicans rash
 diaper rash appears as
erythematous plaques with
sharply demarcated edges
 Satellite bodies (pustules
on contiguous areas of
skin) also seen
 Usually, the skinfolds are
involved
 treated with nystatin
ointment or cream 4 times
daily for 7-10 days.
Transient neonatal pustular melanosis
Three stages over the
entire body:
· Pustules.
· Ruptured with scaling
· Hyperpigmented
macules.
self-limiting, no specific
therapy.
Acne neonatorum
 over the cheeks, chin,
and forehead
 consist of comedones
and papules
 benign and requires
no therapy
 severe cases may
require treatment
with mild keratolytic
agents.
Herpes simplex
 pustular vesicular
rash, vesicles, bullae
 Tzanck smear will
reveal multinucleated
giant cells.
C. Nevi
Hemangiomas near the
eyes, nose, or mouths
that interfere with vital
functions or sight may
need surgical
intervention.
Macular hemangioma
("stork bites")
 true vascular nevus
 normally seen on the
occipital area,
eyelids, and glabella.
 disappear
spontaneously within
the first year of life.
Salmon Patch
Port-wine stain (nevus flammeus)
 usually seen at birth
 not blanch with
pressure
 not disappear with
time
 If appears over the
forehead and upper
lip: Sturge-Weber
syndrome
Mongolian spot
 dark blue or purple
bruise-like macular spots
 usually located over the
sacrum
 Usually present in:
- 90% of blacks
- <5% of white children
 disappear by 4 years of
age.
 They are the most
common birthmark.
Cavernous hemangioma
 large, red, cyst-like, firm, ill-defined
mass
 found anywhere on the body
 majority regress with age
 some require corticosteroid therapy
 In more severe cases: surgical
resection
 If associated with
thrombocytopenia:
Kasabach-Merritt syndrome:
thrombocytopenia associated with a
rapidly expanding hemangioma
Transfusions of platelets and clotting
factors
Strawberry hemangioma
(macular hemangioma)
 flat, bright red,
sharply demarcated
 commonly found on
the face
 Spontaneous
regression usually
occurs (70%
disappearance by 7
years of age)
examination
4. Obvious congenital system
anomalies 11.Abdomen
5. Skin 12. Neuromuscular
system
Head
A. size
.B. Anterior and posterior fontanelles
C. shape
D. swelling, cuts or bruises
.E. Increased intracranial pressure
F. Transillumination can be done for severe
.hydrocephalus and hydranencephaly
Anterior and posterior fontanelles
 A.F: usually closes at 9-12 months
 posterior fontanelle at 2-4 months
 A large anterior fontanelle is seen with:
hypothyroidism - osteogenesis imperfecta,
hypophosphatasia - chromosomal abnormalities
and SGA
 A bulging fontanelle may be associated
with:
- increased I.C. pressure, meningitis, or
hydrocephalus.
 Depressed (sunken) fontanelles:
dehydration
 A small A.F may be associated with:
- hyperthyroidism, microcephaly, or
craniosynostosis.
Molding
 temporary asymmetry
of the skull resulting
from the birth process.
 Most often seen with
prolonged labor and
vaginal deliveries
 A normal head shape is
usually regained
within 1 week.
Types of extradural fluid
collections seen in newborns
Caput succedaneum
 diffuse edematous
swelling of the soft
tissues of the scalp
 extend across the
suture lines.
 resolves within
several days
Cephalhematoma
 subperiosteal hemorrhage
 never extends across the suture line
 It can be secondary to a traumatic
delivery or forceps delivery.
 X-ray films or CT scans if fracture is
suspected (<5% of all
Cephalhematoma).
 Hematocrit and bilirubin should be
monitored
 Most cephalhematomas resolve in 2-3
weeks.
 Aspiration of the hematoma is rarely
necessary
Subgaleal hematoma
 Hemorrhage bleeding occurs below the
epicranial aponeurosis.
 It can cross over the suture line and onto
the neck or ear.
 It may be necessary to replace blood
volume lost and correct coagulopathy if
present.
Increased intracranial pressure
The following signs are
evident in an infant with
increased intracranial
pressure:
· Bulging anterior fontanelle
· Separated sutures
· Paralysis of upward gaze
(setting-sun sign)
· Prominent veins of the scalp
· Increasing macrocephaly
Craniosynostosis
 premature closure of
one or more sutures of
the skull.
 It should be considered
in any infant with an
asymmetric skull.
 On palpation of the
skull, a bony ridge over
the suture line
 X-ray studies of the
head should be
performed,
 surgical consultation
may be necessary.
Craniotabes
 benign condition
 softening of the skull
 usually occurs around the suture lines
 disappears within days to a few weeks

after birth.
 If the area is over most of the skull, it may
be secondary to a calcium deficiency, and
osteogenesis imperfecta
Plagiocephaly
 oblique shape of a head,
which is asymmetric and
flattened.
 It can be seen in preemies

and infants whose heads
stay in the same position.
examination
3.General appearance 10 Cardiovascular system
system
5. Skin
13. Skeletal system
6. Head
Neck
A. Size
B. Shape
C. Swelling
D. Clavicles
Neck webbing
examination
system
5. Skin
13. Skeletal system
6. Head
Face
shape, appearance, red reflex, infection: A. Eyes
nares, root, flaring: B. Nose
C. Mouth: mucus membrane, lips, palate, tongue,
masses, natal teeth
D. Chin
E. Ears: shape, size, position, tags, EOM
F. Facial asymmetry
Eyes
 red reflex
 Congenital cataracts
 sclera is deep blue:

osteogenesis
imperfecta
A. Brushfield's spots
B. Subconjunctival
hemorrhage.
C. Conjunctivitis.
Nose
 choanal atresia
 nasogastric tube.
 Nasal flaring is indicative of respiratory
distress.
Depressed nasal bridge
Mouth
 cleft palate.
 tongue-tie
may require surgical

treatment
A. Ranula
 cystic swelling in
the floor of the
mouth.
 Most disappear
spontaneously.
B. Epstein's pearls
 cysts containing
keratin
 Normal
 on hard and soft
palates
 resolve
spontaneously.
C. Mucocele
 small lesion on the oral

mucosa occurs
secondary to trauma
 subsides spontaneously.
D. Natal teeth
 usually lower incisors.
 X-ray films are needed
to know the type
1. Predeciduous teeth.
Supernumerary
usually loose
Removal is necessary to
avoid aspiration.
2. True deciduous teeth.

true teeth that erupt early.
should not be extracted.
E. Macroglossia
Beckwith's
syndrome
Pompe's disease
(type II glycogen
storage disease).
F. Frothy or
copious saliva
G. Thrush.
Ears
 shape or abnormal
position.
Low-set ears:
 Treacher Collins
 Triploidy
 trisomy 9 and 18
syndromes
Facial nerve injury
 Usually disappear within the first
week of life
 sometimes takes several months.
 If the palsy persists, absence of the

nerve should be ruled out.
(Möbius syndrome )
examination
system
5. Skin
13. Skeletal system
6. Head
Chest
A. Observation
B. Breasts
C. Auscultation
Breasts usually 1 cm lasts <1 week,

"witch's milk,“
Breast abscess
examination
2. Anthropometrics, Gestational
9. Chest
age
3.General appearance 10.Cardiovascular
4. Obvious congenital anomalies system
5. Skin
11.Abdomen
6. Head
7. Neck 12. Neuromuscular
system
13. Skeletal system
Cardiovascular system
A. Peripheral perfusion
B. Pulses
C. Signs of heart failure
D. Heart sounds
E. Murmurs
examination
2. Anthropometrics, Gestational 9. Chest
age
4. Obvious congenital anomalies
system
5. Skin 11.Abdomen
6. Head
12. Neuromuscular
7. Neck
system
13. Skeletal system
Abdomen
A. Observation
B. Palpation
C. Auscultation
D. Umbilicus
E. Genetalia
F. Anus and rectum
G. Lymph nodes
Umbilicus
 one artery and one vein:
- renal problems
- trisomy18
 Omphalitis:
Umbilical granuloma
Genitalia
 ambiguous genitalia
 A. Male:
- hypospadias, epispadias
- Undescended testicles
- Hydroceles
B. Female.
- Discharge from the
vagina
DSD (Ambiguous genetalia(
Anus and rectum
 imperforate anus.
 Meconium should
pass within 48 h
Lymph nodes
 Palpable lymph nodes:

- usually in inguinal and cervical
- in ~33% of normal neonates
examination
2. Anthropometrics, Gestational 9. Chest
age
4. Obvious congenital anomalies 11.Abdomen
5. Skin
6. Head
12. Neuromuscular
7. Neck system
13. Skeletal system
Neuromuscular system
A. Behavioral state: degree of aletness, crying
B. Posture
C. Spontaneous motor activity
D. Motor tone
E. Reflexes
F. Cranial nerves
G. Abnormal movemements
Frog-like posture
Primitive reflexes
F. General signs of
neurologic disorders
1. Symptoms of increased intracranial pressure
2. Hypotonia or hypertonia.
3. Irritability or hyperexcitability.
4. Poor sucking and swallowing reflexes.
5. Shallow, irregular respirations.
6. Apnea.
7. Apathy.
8. Staring.
9. Seizure activity
10. Absent, depressed, or exaggerated reflexes.
11. Asymmetric reflexes.
examination
2. Anthropometrics, Gestational
age 9. Chest
4. Obvious congenital anomalies
11.Abdomen
5. Skin
12. Neuromuscular
6. Head
system
7. Neck
13. Skeletal system
Skeletal system
shape, fingers/toes, creases: A. Extremities
B. Back and spine
C. Hips
Extremities
A. Syndactyly,
B. Polydactyly
C. Simian crease.
D. Talipes
equinovarus
(clubfoot)
E. Metatarsus
varus
Trunk and spine
 defects of the spine.
 abnormal
pigmentation or hairy
patches
 A sacral or pilonidal
dimple may indicate a
small meningocele
Hips
 Congenital hip
dislocation occurs in
~1 in 800 live births.
 Ortolani and
Barlow
Conclusion
 The newborn infant should undergo a
thorough physical examination.
1st wash your hands then

Observe and listen then
Systematic head-to-toes examination.
 Record your findings.

Thank you

Newborn Exam

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Neonatal physical

1st wash your hands then

 Record your findings.

Modified from Lancet, 2005

 Assess growth and development

 Usually within 2 hours after birth

 If the mother is worried

 After discharge from the hospital:

 At any sick newborn’s visit

 The newborn examination should be

 listen to the heart and lungs first

 Warming the stethoscope

Virginia Apgar, 1953

Muscle Limp Some flexion Active motion

A. Head circumference and percentile

B. Length and percentile. growth charts

C. Weight and percentile. growth charts

D. Assessment of gestational age.

may be secondary to:

a. Central cyanosis (bluish skin, including the

b. Peripheral cyanosis (bluish skin with pink

- may be normal within

 Petechiae (pinpoint hemorrhages):

may be secondary to:

 can cause restriction

 may appear as late

 usually occurs around the suture lines

 disappears within days to a few weeks

 It can be seen in preemies

 sclera is deep blue:

may require surgical

 small lesion on the oral

2. True deciduous teeth.

 sometimes takes several months.

 If the palsy persists, absence of the

Breasts usually 1 cm lasts <1 week,

 Palpable lymph nodes:

1st wash your hands then

 Record your findings.

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