Neonatal Examination and Nursery Visit
Niloufar Tehrani, MD
You are performing an examination on a 16-hour-old newborn who was born at 39 weeks’ gestation to a 28-year-old, healthy, primigravida via normal spontaneous vaginal delivery. No complications occurred at delivery, and the Apgar score was 8 at 1 minute and 9 at 5 minutes. The newborn weighed 3,200 g (7 lb 1 oz) and was 50 cm (19.7 in) long at birth, with a head circumference of 34 cm (13.4 in). The mother received prenatal care beginning at 10 weeks of gestation; had no prenatal problems, including infections; and used no drugs, alcohol, or tobacco during the pregnancy. Her blood type is O Rh-positive. She is negative for hepatitis B surface antigen and group B streptococcus, and she is nonreactive for HIV, syphilis, chlamydia, and gonorrhea. The father is also healthy.
On physical examination, the newborn is appropriate size for gestational age, with length and head circumference in the 50th percentile. Aside from small bilateral subconjunctival hemorrhages, the rest of the physical examination is entirely normal.
1. What aspects of the maternal and birth history are important to review before performing the neonatal physical examination?
2. What other history is important for a complete new-born assessment?
3. What aspects of the physical examination of newborns are essential to explain to parents?
4. What physical findings mandate a more extensive workup prior to discharge?
5. What is the routine hospital course for a normal newborn?
6. What are important points to cover with parents at the time of discharge for a healthy, full term newborn?
7. What laboratory studies, if any, should be performed prior to discharge?
The initial newborn physical examination is an important first encounter with the pediatrician, the newborn, and the newborn’s parents all establishing relationships with each other. The key purpose of this examination is to assess the status of the newborn and detect any underlying medical problems. Relaying this information to the parent or parents is essential and answers the question foremost in a parent’s mind: “Is my baby ‘normal’?” By performing a physical examination in the parent’s or parents’ presence during the first 24 hours after the newborn’s birth, pediatricians can play a major role in allaying parental anxiety. The pediatrician’s role includes identifying medical problems or high-risk conditions in the prenatal screening (including ultrasonography), neonatal examination, and history. Evaluation and treatment, if necessary, can be initiated before discharge from the nursery.
Pediatric Prenatal Visit
The prenatal visit during the third trimester is recommended for all expectant families. This is the ideal time to establish the medical home and provides the pediatrician with the opportunity to speak with the parent or parents at a prenatal visit before meeting them in the hospital. The prenatal meeting provides a chance for parents to interview the physician, as well as the rest of the office staff, about general policies and procedures for well-child appointments, sick visits, and contacting the physician after hours. It also is a time to discuss what will take place at the hospital and explain the role of allied health professionals (eg, lactation specialists) in the overall care of the mother and newborn. For pediatricians and other health professionals, the prenatal visit is a time to gather vital medical information about the current pregnancy, identifying any high-risk conditions, and to inquire about any problems with previous deliveries. The pediatrician should also review any pertinent family history. In addition, the pediatrician needs to note specific needs of the parent or parents, which may include alternative medicines, cultural rituals, or ceremonies surrounding the birth of a newborn, such as circumcision. Whether the newborn will be born at home, in a birthing center, or in a typcial hospital setting, arrangements should be made to accommodate the wishes of the family.
The prenatal visit also allows physicians to assess any psychosocial issues that may negatively influence initial mother- newborn bonding, such as maternal drug use, no partner involvement, absence of a supportive social network, or lack of housing. Any of these issues may necessitate intervention by social services. The social environment that will surround the newborn at home will have a great effect on the child’s future. In addition, this visit provides an opportunity to emphasize the importance of breastfeeding and educate parents on its many benefits. Anticipatory guidance issues also can be discussed, including positioning the newborn on the back to sleep, safe bedding, and child passenger safety.
Neonatal Nursery Visit
At birth, the newborn undergoes a screening examination and risk assessment by the nursery personnel when the newborn is stable after any needed resuscitation. In the absence of abnormalities, the pediatrician is notified of the birth. The American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists recommend that the pediatrician should evaluate the newborn within 24 hours after birth to identify medical conditions that need to be addressed and determine the course of newborn care. In the delivery room, the newborn is dried, Apgar scores are assigned, and the newborn is placed skin to skin on the mother’s chest, with a blanket placed over the mother and newborn, to facilitate bonding and early breastfeeding.
If perinatal or delivery complications occur, such as maternal fever, maternal medication during labor and delivery, meconium aspiration, asphyxia, preterm birth, obvious newborn malformations, or distress, the newborn should be supported as necessary and kept on a radiant warmer for further assessment. The physician should be promptly notified to perform the neonatal physical examination, evaluating any problem and initiating treatment.
The perinatal history is the beginning of the newborn’s medical history and is significant in the newborn evaluation. To obtain all the pertinent history, it may be necessary to review the maternal medical record. Results of maternal laboratory tests, such as blood type; rapid plasma reagin status; purified protein derivative; HIV and hepatitis B status; chlamydial, gonococcal, and group B streptococcus cultures; and toxicology screen results should be noted (Box 23.1). The pediatrician also should obtain triple screen, prenatal ultrasonography, and amniocentesis results, if available. Maternal history, including medical conditions and medications used during pregnancy or delivery, prior deliveries, type of delivery, delivery room events, and Apgar scores should be reviewed before performing the neonatal physical examination. Given the Zika virus outbreak in the Americas in 2015 to 2016, it may be necessary to elicit travel history and perform appropriate screening in the mother and possibly the newborn. Obtaining this information helps focus the examination on findings suggested by previous medical history. Additionally, the occurrence of any unusual circumstances surrounding the delivery should be explained to the parent or parents at the time of the examination. For example, the need for a vacuum-assisted or emergent cesarean section may not have been understood. It is important to be prepared to discuss the medical implications of such events. Unexpected events related to the delivery, such as an emergency cesarean section, may be viewed as traumatic by the mother and predispose her to perinatal mood and anxiety disorders.
Box 23.1. What to Ask
•Did the mother receive prenatal care? If so, since what month of gestation?
•Were all prenatal studies normal?
•Does either parent have a history of sexually transmitted infections, such as syphilis, gonorrhea, or herpes?
•Does either parent have a history of alcohol, tobacco, or illicit drug use?
•Did the mother take any prescribed or over-the-counter medications routinely during pregnancy?
•Did the mother have any complications, such as bleeding or decreased fetal movement, during pregnancy?
•Were there any indications of a complicated delivery, including administration of maternal medications?
•Is there a family history of congenital anomalies or diseases?
•Is the mother planning to breastfeed?
•Does the neonate have any siblings? If so, what are their ages?
•Is anyone available to help with the new baby or siblings?
Every attempt should be made to perform the neonatal physical examination at the mother’s bedside. This gives the physician the opportunity to meet with the parent or parents and answer all their initial questions immediately. In certain circumstances, such as preterm birth or in cases in which the mother is being treated for a medical complication, it may be impossible to perform an initial bedside examination. Regardless of the timing of the examination, the physician or other health professional should discuss the results with the parent or parents after the examination has been completed.
The neonatal examination is performed with the newborn completely unclothed and the newborn’s body temperature maintained. The newborn is assessed for evidence of birth trauma and congenital malformations, and organ systems are assessed for normal physiology. The newborn’s birth weight, length, and head circumference are plotted. The physician should bear in mind that these measurements are often made in the delivery room and may be subject to error. The diagnosis of small for gestational age (SGA; weight <10th percentile) or large for gestational age (LGA; weight >90th percentile) can predispose a newborn to several medical problems. Temperature, respiratory rate, and heart rate are reviewed via the nursery record. In a newborn with suspected cardiac or renal anomalies, blood pressure is also measured. Feeding, voiding, and stooling patterns are also available in the nursery record and should be reviewed.
The newborn evaluation includes an expanded Ballard score, which includes parameters for neuromuscular and physical maturity to accurately estimate gestational age. A late preterm or near-term newborn (ie, 35–37 weeks of gestation) frequently does not have the physiologic maturity to feed vigorously and maintain body weight, glucose, or body temperature. These newborns are at high risk for readmission for treatment of jaundice, dehydration, and hypoglycemia. They should be closely followed.
The newborn’s overall appearance is noted, particularly for the presence of any dysmorphic features. The physician should determine whether the newborn looks normal or has any abnormal facial features, such as low-set ears and widely spaced eyes (see Chapter 84).
In the newborn, a thick layer of white vernix caseosa composed of sebaceous secretions and epidermal cells is frequently seen. The presence and location of any rashes or birthmarks should be carefully described and pointed out to the parent or parents. The particular location of the lesion as well as the pathology of the epidermal lesion may aid in specific diagnosis of it. Skin lesions resulting from birth trauma are documented and managed as necessary. Bruising should be differentiated from the benign dermal melanocytosis that often occurs in the sacral area. Skin color is noted. Cyanosis may be indicative of congenital heart disease, the presence of jaundice is suggestive of hyperbilirubinemia, and plethora may be a sign of polycythemia.
Head size and shape are evaluated, including the size of the fontanels and position of the sutures. The head may be significantly molded into a cone deformity secondary to pelvic pressure at the time of delivery. This deformity resolves within days after birth, which may result in a significant change in the head circumference. A cephalohematoma, which is a subperiosteal bleed that does not cross the suture line, appears as a unilateral or bilateral discrete lump on the side of the head. This finding may predispose the newborn to hyperbilirubinemia, and it may take up to 2 months for the condition to resolve. A cephalohematoma should be differentiated from a caput succedaneum, which is scalp edema that crosses the midline and may be ballotable. Edema usually resolves rapidly. Skull fractures may occur with birth trauma and may present as a step-off or crepitus on palpation of the skull. Such fractures are associated with cephalohematoma, but treatment is rarely required. Any unusual findings about the head may be a source of parental concern.
The eyes are evaluated for subconjunctival hemorrhages, colobomas, pupillary reaction, extraocular movements, and presence of red reflexes. If it is not possible to elicit a red reflex, an ophthalmologic evaluation is essential. Absence of this reflex is suggestive of conditions such as congenital cataracts or retinoblastomas. The color of the sclera and the spacing and symmetry of the eyes are also evaluated, because abnormalities may be suggestive of an underlying syndrome. For example, upslanting palpebral fissures can be seen in the setting of trisomy 21, and blue sclerae may be indicative of osteogenesis imperfecta.
The placement, size, and shape of the ear pinnae are noted as well, along with any preauricular or postauricular pits or appendages. The presence of a significant auricular abnormality may correlate with hearing loss or be suggestive of a genetic syndrome and necessitates further evaluation.
The nose is checked carefully for patency of the nares. This is easily accomplished by occluding airflow from 1 nostril and observing airflow from the other. Choanal atresia is an important condition to rule out, because newborns are obligate nose breathers until 3 months of age, and choanal atresia may result in respiratory distress. A nasal fracture also can occur during the delivery process. Such fracture presents as an asymmetric nose. If the physician presses on the nasal tip and the nares are symmetric, the diagnosis is a deformity that will resolve. If the nose falls to 1 side, however, the presence of a nasal septum fracture is probable, and prompt evaluation by an otolaryngologist is warranted.
The oropharynx is examined closely for any defects in the hard or soft palate. A bifid uvula may be indicative of a submucosal defect of the soft palate that may be difficult to appreciate without palpation (see Chapter 85). Common normal findings in the oropharynx, including Epstein pearls located at the midline on the hard palate and epithelial cysts along the gum line (ie, Bohn nodules), are also noted. Loose natal teeth should be removed to prevent the possibility of aspiration (see Chapter 31). The tongue is evaluated for mac-roglossia or a tight lingual frenulum (ie, ankyloglossia), which may interfere with effective breastfeeding.
The neck is palpated for sternocleidomastoid hematomas, masses, torticollis, and skin redundancy. The clavicles are evaluated for fractures, which are more common in newborns who are LGA or in the setting of a delivery complicated by shoulder dystocia.
The chest is inspected for respiratory effort and the lungs auscultated to ensure normal breath sounds throughout. The quality of the newborn’s cry is assessed as well. Laryngeal webs or a paralyzed vocal cord may present in the newborn. Chest wall deformities, such as pectus excavatum, are noted. If an absent rib is suspected, a chest radiograph should be obtained. The presence of breast buds is normal; however, supernumerary nipples are minor malformations, although no treatment is indicated. Widely spaced nipples are a common minor malformation in patients with Turner syndrome.
The heart is auscultated to ensure that it is in the proper position on the left side of the chest. Femoral and brachial pulses are palpated. The physician should listen for and document the presence of cardiac murmur. The presence of a murmur does not always indicate complex congenital heart disease. In the first 24 hours, a murmur may be a closing ductus; additionally, newborns can have functional murmurs. Peripheral pulmonic stenosis is a common benign heart murmur in the newborn that is characterized by transmission to the right side and back. The AAP, American Heart Association, and American College of Cardiology recommend universal screening for critical congenital heart disease by pulse oximetry reading for which the AAP algorithm is most commonly used (Figure 23.1). However, every murmur should be evaluated on an individual basis. If further assessment is indicated, 4 extremity blood pressures, an electrocardiogram, and a chest radiograph should be obtained. The presence of abnormal findings or a murmur associated with cyanosis, tachypnea, poor feeding, or congenital anomalies is highly suspicious for a pathologic cause. A consultation with specialists in pediatric cardiology should be sought and an echocardiogram obtained.
Figure 23.1. Critical congenital health disease screening protocol.
Abbreviation: pulse ox, pulse oximetry.
Reprinted with permission from Ewer AK, Martin GR. Newborn pulse oximetry screening: which algorithm is best? Pediatrics. 2016;138(5): e20161206.
It is easiest to palpate the abdomen before feeds. The abdomen is assessed for any masses or organomegaly (eg, polycystic kidneys, hepatosplenomegaly, adrenal hemorrhage) that warrant further investigation. Bimanual palpation may be helpful to identify masses. The umbilicus is examined to identify 3 vessels as well as the quality of the cord. A small, atretic cord can be the cause of low weight in the newborn. Erythema and swelling of the skin around the cord may be indicative of omphalitis, which is a serious infection.
In female neonates, the labia majora may be swollen, but the urethra and vaginal opening should be visualized to ensure patency. Hymenal tags are a common finding. Clitoral size is noted. Parents should be told that a physiologic vaginal discharge and the presence later of a pink or blood-tinged discharge are a normal neonatal response to maternal estrogen withdrawal. In male newborns, the penis is examined for size and length. The foreskin should be retracted sufficiently to reveal the location of the urethral meatus to assess for hypospadias. A testicular examination can rule out hydroceles, inguinal hernias, and cryptorchidism. Atypical genitalia may be indicative of an underlying disorder, such as congenital adrenal hyperplasia or disorders of sexual differentiation, and necessitates further evaluation (see Chapter 107).
The patency and location of the anus are assessed. Patency is confirmed after the newborn passes meconium, typically by 48 hours of age. An imperforate anus may be an isolated finding, or it may be indicative of a syndrome, such as vertebral, anal, cardiac, tracheal, esophageal, renal, and limb syndrome.
The newborn skeleton is assessed for evidence of skeletal dysplasia. All long bones are examined for a potential fracture secondary to birth trauma. The neonatal hip examination is important to detect developmental dysplasia of the hip, which is most likely to occur in cases of a breech position in utero. The Ortolani maneuver is performed to detect a dislocated hip. The “clunk” felt when performing the examination is the relocation of the femoral head of the affected hip in the joint capsule. In contrast, a “click” may be indicative of normal perinatal ligament laxity. The Barlow maneuver detects an unstable hip that may be at risk for dislocation. A positive result on either test is indicative of a hip that is or could be dislocated and warrants an orthopedic consultation. Treatment with a Pavlik harness is initiated until confirmatory testing on ultrasonography is reliable at 6 weeks of age (see Chapter 113). The spine is palpated completely to the sacrum. Sacral defects, deep sacral pits, or sacral tufts of hair warrant an investigation for conditions such as spina bifida occulta. The fingers and toes are counted and assessed for syndactyly or other abnormalities. The feet may be turned inward, outward, or up and are gently moved to a normal position to ensure flexibility. Deformities secondary to intrauterine pressure are common. Clubfoot or equinovarus deformations warrant evaluation by an orthopedic surgeon.
A newborn’s resting position is assessed to evaluate tone. All extremities should be flexed. The newborn then can be held prone for further evaluation of tone. Newborns are observed for motor activity, that is, moving arms and legs symmetrically. Response to sensory stimulation and deep tendon reflexes should be elicited. Facial movements are closely observed for symmetry. Primitive reflexes, such as suck, rooting, grasp, stepping, and especially Moro, are an important part of the newborn neurologic examination. The behavior of the newborn also can yield information about an intact neurologic system. The newborn should respond to sound, fixate on a face, and be capable of attempts at self-consolation.
Normal findings of the nursery physical examination are summarized in Box 23.2. Significant findings should be addressed immediately when noted at the initial nursery examination, including evidence of hydrocephalus, a ductal-dependent cardiac lesion, cyanotic congenital heart disease, a diaphragmatic hernia, an abdominal mass, or a possible chromosomal abnormality (eg, trisomy 13 or trisomy 18), all of which can be life-threatening. The physical conditions associated with trisomy 21 are rarely life-threatening, although suspicion of the diagnosis warrants consultation with a geneticist as well as evaluation for cardiac, abdominal, and other anomalies (see Chapter 42).
Box 23.2. Common Benign Physical Findings in Newborns
•Lanugo (ie, body hair)
•Swollen overall appearance
•Milia over bridge
Mouth and Throat
•Pectus excavatum or carinatum
•Females: swollen labia, hymenal tags, vaginal discharge
•Males: hydrocele, undescended testicle (palpated in inguinal canal)
•Click or clunk sound
•Feet turned up, in, or out, but malleable
•Primitive reflexes: Moro, grasp, rooting, stepping