The cardiovascular examination should be performed first, ideally with the infant sleeping. Observation will show central cyanosis, the presence of which suggests congenital heart disease. Cyanosis of the hands and feet, or acrocyanosis, is normal in a newborn infant. Mild cyanosis around the mouth, or circumoral cyanosis, is normal if the tongue is pink. Next, the heart rate should be measured. A newborn heart rate can vary between 100 and 160 beats per minute while the infant is awake and quiet and may be as low as 75 to 80 beats per minute during sleep. Irregularities of rhythm are not uncommon; they usually result from premature atrial or ventricular contractions. The irregularity usually disappears when the infant becomes active and the heart rate increases. Heart murmurs in the first day of life are common and usually benign. On the other hand, congenital heart disease can be present without a murmur. Pulses should be palpated in both the upper and lower extremities. Diminished pulses in all extremities may be indicative of left ventricular dysfunction or critical aortic stenosis. Diminished femoral pulses when compared to brachial pulses suggest coarctation of the aorta or an interrupted aortic arch.

The respiratory examination is also best accomplished when the infant is quiet. Again, observation of the chest and its movements can reveal much about the infant’s status. One should

observe for respiratory rate (normal = 30 to 60) and for chest wall retractions, grunting respiration, and nasal flaring as signs of respiratory difficulty. Tachypnea in a newborn infant is a respiratory rate greater than 60 per minute. In an infant with normal lungs, the abdomen will rise and fall with inspiration and expiration due to diaphragm excursion, but with no associated subcostal retractions. Retractions indicate accessory muscle use and increased work of breathing. Asymmetry of the chest may indicate a problem as well.

Auscultation should first evaluate air entry to confirm that it is equal bilaterally. Asymmetry of air entry in conjunction with displacement of the heart tones can indicate a pneumothorax or a space-occupying mass (e.g., congenital diaphragmatic hernia). Heart tones may be distant when a pneumomediastinum is present. A decrease in air entry in combination with expiratory grunting and retractions may be indicative of respiratory distress syndrome. An irregular breathing pattern may be observed in normal newborn infants. Periods of rapid breathing interspersed with respiratory pauses for 10 to 15 seconds are referred to as periodic breathing.

A newborn infant’s abdomen is rounded and full. A scaphoid abdomen accompanied by respiratory distress is a sign of a diaphragmatic hernia. A mild narrow midline protrusion of the abdominal wall is likely diastasis recti, a benign condition resulting from the incomplete union of the rectus abdominus muscles. Umbilical hernias are also common. Either of the aforementioned may be revealed only with crying and may not be observed until the infant is several weeks old.

The umbilical cord should have three vessels. Superficial veins are often visible on the abdomen. Palpation of the abdomen is necessary for determination of distention; tenderness; liver, spleen, and kidney size; and masses. The liver examination is best approached by beginning palpation far below the right costal margin, palpating gently while moving upward to determine the location of the liver edge. In the normal newborn, the liver edge is generally located 1 to 2 cm below the right costal margin. The spleen is not normally palpable. Kidney palpation is more difficult. One hand should be placed under the flank and one anteriorly. Most abdominal masses in the newborn are associated with the kidney (e.g., multicystic or dysplastic, hydronephrosis). The bladder may be palpated just below the umbilicus. A palpable full bladder that does not resolve raises the concern of bladder outlet obstruction (e.g., posterior urethral valves).

The infant’s extremities should be observed for obvious deformities or anomalies such as extra digits, webbing, absent extremities, and clubfeet. Palpating the extremities serves to determine the presence of fractures. All joints should be observed for active range of motion and examined for passive range of motion. Arthrogryposis, or multiple joint contractures, may indicate a paucity of amniotic fluid in utero or a congenital neuromuscular disorder, either of which limits movement in utero.

Leg length inequality or asymmetric skin folds near the buttocks may indicate a dislocated hip, but the best way to assess this is by Ortolani and Barlow maneuvers. Since the femur is generally dislocated posteriorly, the hips should be flexed to a right angle while the examiner’s finger is placed over the greater trochanter and thumb over the lesser trochanter and the hips then abducted until the knee has reached the lateral position. This allows the posteriorly dislocated femur head to relocate to the correct position. This maneuver, referred to as Ortolani sign, will result in a “clunk” into place if the hip is dislocated. Another maneuver can be used to detect a hip at risk for dislocation. With the finger and thumb in the same position, the examiner should attempt to move the femur laterally and downward with the thumb and then medially and upward. With normal hips, no movement is felt. Barlow sign, or positive movement during this maneuver indicating excessive laxity in the hip joint, means that an infant should be followed closely for later dislocation.

The infant’s back should be examined by inspection for a myelomeningocele, as well as for skin pigmentation changes, tufts of hair, or dimples at the base of the spine indicating occult spinal dysraphism. The examiner should palpate the spine for occult spina bifida if a tuft of hair or dimple is present.