NEWBORN

Examination
Dr Ramadan Aboelhassan
Lecturer of Pediatrics
Head to Toe Assessment of Newborn

Head: General appearance

 NOTE: Size: ¼ of body size [33-35 cm circumference]
 Molding: Asymmetry of skull
 Cephalohematoma: collection of blood bet. skull bone &
periosteum
 Caput succedaneum: swelling over presenting part
Fontanels: “soft spot”
 Anterior fontanel – diamond shaped, measures 2-3 cm. wide & 3-
4 cm. long. Closes @ 12-18 months. @ juncture of frontal &
parietal bones. Overriding sutures in normal
 Posterior fontanel - triangular shaped; small [~0.5 cm.] hard to
feel; juncture of occipital & parietal bones. Closes 2 mos.
 *Depression indicates dehydration
 *Bulging > hydrocephalus
Eyes
 Eyes: usually blue or gray
 Permanent color develops 3 - 12 mos of age. Iris does not
develop color til 3-6 mos.
 Lacrimal [tear] glands- not fully mature
 Subconjunctival hemorrhage: from stress of vaginal delivery
 First 6 wks;
 transient strabismus; < 6 weeks, not able to focus.
 Constant strabismus, > 6 weeks, further assessment needed
and referral needed.
 Scant purulent discharge > erythromycin ointment
 Pupils round & equal; should constrict - normal response to light
 Subconjunctival hemorrhage
Subconjunctival hemorrhage
Nose

 Nose: Infants obligatory “nose

breathers”.
 Note size & shape, & presence of nasal
discharge or stuffiness.
 Clean nose with bulb syringe; saline
drops.
 Observe for nasal flaring
 Chonal atresia
Bilateral operated Chonal atresia
Mouth
 Mouth: Examine palate with index finger
 Cleft lip and/or cleft palate

 Epstein’s pearls [small, round, white cysts]

 Note size & shape of tongue and length of frenulum membrane

 Supranumery teeth aka natal teeth

 Sucking reflex- evaluate

 Rooting reflex
 Cleft lip and/or cleft palate
 Epstein’s pearls [small, round, white cysts in hard plate]
natal teeth
Ears/Neck
 Ears: Note position of ears in relation to eyes

Pinna should be fully formed and firm.

 Term infant: pinna recoils easily
 Preterm infant, < 36 wks - relatively shapeless and flat; little
cartilage. Slow recoil.
 Skin tag – harmless; may be associated w. kidney disease.
 Neck: Normal newborn neck short, chubby with creased skin
folds. Head support necessary. Inspect masses, limitation of
movement & webbing.

Clavicles: straight, palpate each clavicle for intactness

fracture common in larger infants delivered vaginally
Ear skin tag
Chest
 Chest: Inspect shape, symmetry, position,
development of nipples; breast tissue.
 Chest 12-13 in. [30 –33 cm.].
 Breast engorgement – maternal hormones.
 Normal respirations 40 – 60 breaths/minute.
Retractions abnormal; indicates respiratory distress.
 After 4 hr. transition period.
Grunting [hoarse sound - expiration]
 transient due to mucous in lungs. Suction.
 If retractions/grunting not clear by 4-6 hrs, may
indicate respiratory distress
 TTN; transient tachypnea of NB. RR = 70-80’s for
several hrs. [transition period] if more > 4 hrs., NICU.
Abdomen/Kidneys
 Abdomen: palpate for masses/organs
 Umbilical Cord: Inspect 3 vessels (“AVA”); falls off in
7 – 10 days. Let dry.
 If only 2 vessels present, artery and vein, observe
infant closely d/t association with heart or kidney
anomalies.
 Kidneys may be felt on right & left side of abdomen by
deep palpation.
 Symptoms and signs of infection
Genitalia - Male
 Genitalia: Male: Assess for gestational maturity &
sexual ambiguity.
 Scrotum in full term infant swollen; + rugae; both R & L
testes descended into scrotal sac.
 Testes may be in process of descending. If one or
both testes are undescended = “cryptorchidism”,
 Agenesis [no testes] or closed scrotal sac
 Normal length of newborn’s penis = ~ 2cm long.
Assess for urethral opening urinary meatus
Abnormal placement on dorsal surface *epispadias*;
ventral surface *hypospadias
Genitalia - Female

 Female: Vulva typically swollen. Labia minora

& clitoris large with labia majora covering both

 Female infants have “pseudomenstruation”

 “Hymenal tag” or small piece of pink tissue

protrudes between labia
Extremities
 Extremities: Assess for muscle tone
 Note length of arms/legs; should be
symmetrical
 Limp arm may have nerve damage [birth
injury] brachial plexus palsy.
 Observe palm: simean crease [single
 Assess: syndactyly: webbing of fingers/toes &
polydactyly: > than 10 fingers or toes.
 Assess sole creases; mature infant: 2/3rds or
full sole creases
Skin
 Reddish in color; smooth and puffy
 At 24 - 36 hours of age, skin flaky, dry and pink in color. Edema
around eyes, feet, genitals.
 Acrocyanosis: Bluish discoloration of hands and feet. Lasts for
24-48 hrs. Mucous obstruction may cause central cyanosis
 Milia: Pinpoint white papules; Disappear 2-4 wks
 Neck: Normal newborn neck short, chubby w. creased skin folds.
Support is necessary. Inspect for masses, limitation of movement
& webbing

Clavicles: straight, palpate for intactness; feel for fracture

Commonly found in larger infants delivered vaginally.
Milia: Pinpoint white papules
 Erythema toxicum neonatorum
can appear on the 2-5 day of life like
allergic reaction. It looks like red
blotchy rash, associated with whitish
papules (which may look like pustules
but without pus, contain eosinophiles)
on the trunk, extremities, and the face.
It disappears during 2-3 days usually.
No treatment is indicated.

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Erythema toxicum neonatorum

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Skin
 Lanugo: fine hair covering newborn’s upper arms, shoulders, &
back that decreases as gestational age increases
 Vernix caseosa: white, cream cheese like substance; skin
lubricant.
 Erythema toxicoum neonatorum NB rash; red rash with flea-
biten appearance.
 Stork Bites - . AKA telangiectasia - pink spots found on nape of
neck, nose, upper eyelids, upper lip. Disappear in 1-2 yrs.
 Mottling: Generalized red and white discoloration of skin of
exposed infants with fair complexion.
 Mongolian Spots: Collections of pigment cells [melanocytes]
that appear as patches across infant’s sacral area and buttocks.
Tend to occur in newborn’s of Asian, African, or Southern
European descent
Mongolian Spots
Skin
 Capillary Hemangiomas: 3 types, all are vascular

 Nevus flammeus: macular (flat), purple or dark red

lesions, present @ birth. Aka “port wine stain

 Strawberry hemangiomas: raised areas formed by

immature capillaries & endothelial cells. Occurs
typically in term infant.

 Cavernous hemangiomas: Raised; resembles

strawberry hemangioma Can be surgically removed
port wine stain
Back/Anus/Rectum
 Spine:
 Assess for intact spine without masses or
openings. Small indentation at base of spine
may be spina bifida occulta.
 Tuft of hair present at base of spine = Nevus
pilosus.
 Anus & Rectum: Assess rectal patency with
1st temp; lubricated thermometer. If rectum not
patent, called imperforate anus
Routine Exam of Newborn – Vital
Signs
 Vital Signs:
 Temperature (36.2-37.5) Initial rectal.
 Heart Rate: 110 –160 bpm.
 Femoral, radial, brachial pulses can be palpated;. Apical pulse
used for HR; auscultate 1 min
 Respiratory Rate: 40-60 min. Initial rate 80 /min.
 BP ~ 80/46 mmHg @ birth. By 10th day, 900/50.
Daily:
 Weight: 2,500-3,500 gm; compare with previous day. 5-10 %
weight loss acceptable
 Assess feedings daily. # voids/stools in 24 hrs.
Done once on admission to nursery:
 Length about 50 cm =
 Head: 35 cm
 Chest: 30 cm
REFLEXES

 Sucking – place finger in mouth; infant sucks right away.

 Moro – [“startle reflex”] elicit by loud noise; infant
extends arms & legs suddenly.
 Rooting – touch cheek; turns head in direction of touch.
 Babinski – stroke sole of foot from top to
bottom; toes fan out.
 Grasping – place finger in newborn’s hand;
grabs & hold.
Behaviors – Sleep/Awake
Predictable Behaviors:
1st 4 hours > delivery:
 1st period of reactivity: alert, active state; awake, crying,
sucking.
 Then Sleep phase 4-6 hrs.
 2nd period of reactivity 2-3 hrs. Sleep/awake during day.
Sleep States
 1. Deep Sleep
 2. Light Sleep
Awake States
 Drowsy; Quiet Alert – best time for breast feeding/bonding
 Active Alert; Crying
Assessment of maturity

 New Ballard Assessment scale: to assess gestational maturity;

 Assesses physical & neuromuscular maturity. Useful in
differentiating between SGA infant & miscalculated period
 SGA infant is mature gestationally.
Neuromuscular maturity
Physical maturity
Common life threatening
congenital anomalies of newborn
 Chonal atresia: unable to pass nosogastric tube through
nostal
 Peirre Robin syndome: micrognthia, respatory distress,
airway obstruction
 Diaphragmatic herina: scphoid abdomen, bowel sounds in
chest, respitory distress
 Tracheoesphegeal fistula: excessive salivation, unable to
pass nasogastric tube in stomach
 Intestinal obstruction: annual atresia, duadenal atresia
 Omphalocele, gastroschisis
 Neural tube defects: meningomylocele
 Duct- dependant congenital cyanotic heart diseases:
Meningomylocele
Gastroschisis
Peirre Robin syndome
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