This article summarizes the initial assessment of normal newborns and describes a few of the common variations that may occur. These variations require a pediatric provider to reassure anxious new parents and provide follow-up communication with the subsequent primary care provider.
Key points
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It is important for primary providers to recognize normal variations and reassure anxious parents when these common variants are present.
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When a newborn practitioner is not providing the subsequent follow-up care, communication with the infant’s primary care provider regarding these findings as well as the pertinent perinatal history is critical.
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The after-visit or discharge summary provided to a parent may not be adequate to conveying findings. A phone call, especially when an infant remains at risk for hyperbilirubinemia or group B streptococcal disease, is the most efficient means of communication.
It is evident that the physical findings obtained at single examinations during the first six hours of life in health neonates may vary considerably.
Introduction
Birth is an exciting time for new parents. It is also a time of great anxiety and concern: “Is my baby healthy?” “How much does my baby weigh?” “Can my baby stay with me?” “Will our baby go home with us?” For many new parents, this is their first encounter with the health care system as a family. Many parents may not have thought about the need to choose a pediatrician. Some parents think their obstetrician will care for the baby. Some parents may have a pediatrician, but their pediatrician is not on staff at the hospital where they delivered. Instead, an unfamiliar pediatrician or neonatologist provides care for the infant when in the well-baby nursery. Physicians providing care for well newborns need to be aware and sensitive to these parental concerns.
As noted by Warren and Phillipi, “care of the family should be accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective.” The ability of pediatricians to meet these ideals might be limited, however, by demands and expectation for families and by the health care system. For instance, families may want to be discharged before the newborn has had a sufficient period of observation. Although most major problems present in the first 12 hours of life, problems, such as significant hyperbilirubinemia, certain ductal-dependent cardiac lesions, and gastrointestinal disorders, may take longer to present. “The hospital stay of the mother and her healthy term newborn infant should be long enough to allow identification of early problems and to ensure that the family is able and prepared to care for the infant at home.” Although regulations permit healthy term infants to remain hospitalized 48 hours after a vaginal birth and 96 hours after a cesarean delivery, it is uncommon for families with healthy newborns to want to stay the allotted time for observation. This might be a problem when an infant must be observed for 48 hours per group B streptococcal disease prevention guidelines.
The normal variations that newborns exhibit can also create anxiety for new parents. These variations result from a variety of factors, including mode of delivery, medications administered during labor and delivery, and changes related to transition from an intrauterine to extrauterine environment. It is the pediatrician’s role to identify abnormal clinical findings that may have implications in a newborn’s course as well as to reassure parents of normal newborn variations.
This article discusses some of these variations related to gestational age assessment, sizing, and physical examination not discussed elsewhere in this issue. Some of the common physical findings that may require additional evaluation and treatment are also discussed.
Introduction
Birth is an exciting time for new parents. It is also a time of great anxiety and concern: “Is my baby healthy?” “How much does my baby weigh?” “Can my baby stay with me?” “Will our baby go home with us?” For many new parents, this is their first encounter with the health care system as a family. Many parents may not have thought about the need to choose a pediatrician. Some parents think their obstetrician will care for the baby. Some parents may have a pediatrician, but their pediatrician is not on staff at the hospital where they delivered. Instead, an unfamiliar pediatrician or neonatologist provides care for the infant when in the well-baby nursery. Physicians providing care for well newborns need to be aware and sensitive to these parental concerns.
As noted by Warren and Phillipi, “care of the family should be accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective.” The ability of pediatricians to meet these ideals might be limited, however, by demands and expectation for families and by the health care system. For instance, families may want to be discharged before the newborn has had a sufficient period of observation. Although most major problems present in the first 12 hours of life, problems, such as significant hyperbilirubinemia, certain ductal-dependent cardiac lesions, and gastrointestinal disorders, may take longer to present. “The hospital stay of the mother and her healthy term newborn infant should be long enough to allow identification of early problems and to ensure that the family is able and prepared to care for the infant at home.” Although regulations permit healthy term infants to remain hospitalized 48 hours after a vaginal birth and 96 hours after a cesarean delivery, it is uncommon for families with healthy newborns to want to stay the allotted time for observation. This might be a problem when an infant must be observed for 48 hours per group B streptococcal disease prevention guidelines.
The normal variations that newborns exhibit can also create anxiety for new parents. These variations result from a variety of factors, including mode of delivery, medications administered during labor and delivery, and changes related to transition from an intrauterine to extrauterine environment. It is the pediatrician’s role to identify abnormal clinical findings that may have implications in a newborn’s course as well as to reassure parents of normal newborn variations.
This article discusses some of these variations related to gestational age assessment, sizing, and physical examination not discussed elsewhere in this issue. Some of the common physical findings that may require additional evaluation and treatment are also discussed.
Initial assessment of the newborn
The initial assessment of a normal, healthy newborn by a pediatrician should take place in the first 24 hours after birth. Attention should be paid to the maternal record, including antenatal history, labor and delivery course, postpartum record, and parental interview, to evaluate for risk factors or pregnancy complications that can affect an infant’s well-being and subsequent development. A thorough examination of each organ system should be performed and any variation of normal identified and discussed with the parents.
Assessing Gestational Age and Growth
Assessing newborn infants includes determining the gestational age of infants and obtaining measurements that include weight, length, and head circumference. Using a systematic method to assess the gestational age of infants is important when the dates are uncertain or if prenatal care was not obtained in the first trimester. The Ballard scoring system is a gestational age assessment tool that uses standardized physical examination findings to score infants in the areas of physical and neurologic maturity ( Fig. 1 ). Scores in each area are combined and a maturity rating score is assigned that approximates infant gestational age in weeks. In general, this gestational assessment is accurate to within approximately 2 weeks. These results can be compared with results determined from last menstrual period dating or by prenatal ultrasound if available.
The American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine have proposed new terminology to describe infants previously considered “term.” New designations have been established because research shows that infants between 39 0/7 and 40 6/7 weeks of gestation have lower morbidities than infants delivered before or after this gestational age :
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Early term (37 0/7 weeks of gestation through 38 6/7 weeks of gestation)
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Full term (39 0/7 weeks of gestation through 40 6/7 weeks of gestation)
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Late term (41 0/7 weeks of gestation through 41 6/7 weeks of gestation)
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Post term (42 0/7 weeks of gestation and beyond)
Once gestational age has been determined, an infant’s weight, length, and head circumference measurements are plotted on a growth chart to determine the percentile compared with other infants of the same gestational age. Recommendations from the Centers for Disease Control and Prevention (CDC) in 2010 are to use the World Health Organization (WHO) growth chart for infants 0 to 24 months of age. The WHO growth charts are recommended because they are based on infants who were predominantly breastfed for the first 4 months of life and were still receiving breast milk at 12 months. Thus, these growth charts represent infant growth under optimal conditions. Charts based on weight for age, length for age, weight for length, and head circumference for age are available for boys and girls from birth until 24 months of age ( Figs. 2 and 3 ).
Infants who fall outside the normal weight range (or 2 SDs above or below the mean) for gestational age are considered large for gestational age (LGA) (>90th percentile) or small for gestational age (SGA) (<10th percentile) ( Fig. 4 ). Intrauterine growth restriction occurs when the fetus is unable to reach its growth potential due to maternal, uteroplacental, or fetal factors that prevent adequate gas exchange or nutrient delivery. These infants are at greater risk of morbidity and mortality than constitutionally SGA infants. Causes of IUGR are shown in Box 1 .
Maternal factors
High blood pressure (chronic or pregnancy induced)
Chronic kidney disease
Advanced diabetes (class F or higher)
Cardiac or respiratory disease
Malnutrition
Infection (toxoplasmosis, other viruses, rubella, cytomegalovirus, herpes viruses)
Substance abuse (alcohol, illicit drugs, tobacco)
Clotting disorders
Autoimmune disease
Chronic exposure to high altitudes
Uterine or placental factors
Abnormal placentation
Chronic placental abruption
Abnormal cord insertion or cord anomalies
Fetal factors
Multiple gestations
Infection (cytomegalovirus, rubella)
Birth defects
Chromosomal anomalies
Identification of IUGR in pregnancy by an obstetrician should alert pediatricians that an infant is at higher risk of complications than other infants of the same gestational age. Infants who are constitutionally SGA may be admitted to the well-baby nursery. These small infants are at risk, however, for a variety of problems, including
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Abnormal temperature regulation due to decreased fat stores
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Poor feeding due to decreased muscle tone and stamina
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Hypoglycemia due to decreased glycogen stores
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Polycythemia from chronic in utero hypoxia
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Hypoxic-ischemic encephalopathy due to uteroplacental insufficiency and intolerance to labor
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Meconium aspiration syndrome due to perinatal stress
Complications of SGA extend past the immediate neonatal period with recent evidence suggesting that SGA infants may be at higher risk of lower IQ, obesity, diabetes, and cardiovascular disease in early adulthood and should be closely monitored for these conditions by a primary care physician.
LGA infants most commonly result from maternal diabetes or are caused by genetic predisposition to large size or large maternal weight gain during pregnancy ( Fig. 5 ). Infants who are LGA are at risk for birth trauma, increased rate of cesarean delivery, hypoglycemia, and respiratory distress.
Over the last quarter of the twentieth century there was an increase in the mean birth weight of infants born in the United States and other Western countries. A study of Canadian infants indicates that this finding is associated with an increase in maternal prepregnancy body mass index, gestational weight gain, and gestational diabetes and a decrease in maternal smoking and post-term deliveries. As a consequence, the proportion of LGA infants has increased whereas that of SGA infants has decreased. Infants whose birth weights exceed 4500 g have significant increased risk of morbidity and mortality. Birth trauma is more likely and their mothers are at increased risk for genitourinary injury and other intrapartum and postpartum complications. LGA infants may also be at risk for long-term health effects.
Physical Examination of the Newborn
The first physical examination performed by a pediatrician should be performed in the mother’s room to limit separation of mother and infant. The room should be warm and quiet with ample lighting. Initial impressions of the infant in a quiet state should be recorded followed by a systematic examination. Gestational age assessment information is important because premature infants have special considerations.
Birth trauma
Most newborn infants tolerate delivery with little to no physical trauma. Occasionally, temporary or permanent trauma to a newborn occurs. Recognition of trauma necessitates a careful physical and neurologic evaluation of the infant to establish whether additional injuries are present. Symmetry of structure and function should be assessed; the cranial nerves should be examined; and specifics, such as individual joint range of motion and scalp/skull integrity, should be evaluated.
Risk factors for birth trauma include the following:
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LGA infants, especially infants who weigh more than 4500 g
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Instrumental deliveries, especially forceps or vacuum
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Vaginal breech delivery
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Abnormal or excessive traction during delivery
Extracranial injuries
Caput Succedaneum
Scalp edema that results from the normal process of a vertex vaginal delivery is called caput succedaneum ( Fig. 6 ). This edema is seen most commonly over the presenting part of a newborn’s head, crosses suture lines, and resolves without intervention within several days. Bruising may accompany scalp edema especially in cases of vacuum extraction ( Fig. 7 ).
Cephalohematoma
Cephalohematomas are caused by rupture of vessels and collection of blood under the periosteum of the calvarial bones. In contrast to caput succedaneum, most cephalohematomas are unilateral, involve the parietal or occipital bones, and do not cross suture lines. The incidence of cephalohematomas is 1% to 2% of all deliveries but are more common in vacuum- or forceps-assisted deliveries. Cephalohematomas are fluctuant on palpation and the lesions resolve over months as the hematoma is broken down ( Fig. 8 ). Complications of cephalohematomas include elevated bilirubin levels and should be considered risk factors when evaluating infants for jaundice per American Academy of Pediatrics (AAP) Clinical Practice Guideline and Bhutani nomogram.
