The Newborn Examination

Chapter 54 The Newborn Examination



Nilufer R. Goyal, MD, FAAP




Speaking Intelligently


The first examination of the newborn takes place at the time of delivery, with the assignment of Apgar scores, which provide a quick assessment of transition to extrauterine life. In uncomplicated vaginal deliveries, this initial assessment is performed by the delivery room nurse. The newborn is monitored closely in the first several hours. The complete newborn physical examination in the normal newborn is performed by the pediatrician within the first 24 hours of life. Most infants in the term nursery are healthy and have a normal course. The goal of reviewing the prenatal history and performing a complete physical examination is to identify abnormalities and congenital anomalies that may require prompt attention. Many abnormalities are identified with prenatal testing.



Medical Knowledge and Patient Care


Evaluation of the neonate begins in the delivery room. The 1- and 5-minute Apgar scores provide assessment of the newborn’s extrauterine transition. The vital signs, tone, color, perfusion, level of activity, and level of consciousness of the newborn are monitored closely during the first several hours after birth. In addition to performing daily physical examinations in the hospital, the pediatrician must be familiar with birth injuries and presentations of acute neonatal illnesses such as sepsis, pneumonia, and severe hyperbilirubinemia.



Basic Newborn Examination


General Observations: The first look will be a general assessment of wellness. Is the infant breathing comfortably? Is he/she alert, sleeping, or crying as if hungry or otherwise distressed? Are there any obvious anomalies? Look at the length, weight, and head circumference in relation to gestational age. These provide a general estimation of the in utero environment and nutrition. The order of the examination proceeds from the least- to most-intrusive maneuver. Many begin with cardiac auscultation of the calm infant.


Posture and Tone: Degree of flexion of extremities lends clues to the gestational age of the child as well as overall well-being. Sick infants may be limp and hold extremities more lax (hypotonia).


Head and Scalp Examination: The average head circumference for a term neonate is 35 cm. Molding resulting from overriding sutures may be prominent but resolves in the first few days. The anterior fontanelle is easy to palpate, whereas often the posterior fontanelle is not typically appreciated. Both should be soft and flat. Caput succedaneum is a boggy, indistinct swelling of the scalp, sometimes with bruising. As it recedes, there may be an underlying cephalohematoma. A cephalohematoma is a subperiosteal hematoma with clearly demarcated borders limited by suture lines. Observe for plagiocephaly, and check for an accompanying torticollis by assessing the sternocleidomastoid range of motion.


Face: Note the general features and position of the eyes and ears, and carefully observe the philtrum for clues to syndromic manifestations. To test for low-set ears, a line drawn from the inner canthus of the eye through the outer canthus should extend to intersect the ear. Abnormal formation of an ear pinna may be a clue to a urologic abnormality.


Eyes: Observe for a brief period of eye fixation, and check the red reflex by ophthalmoscope. A coloboma of the iris may be noted. Pressure during birth may cause a subconjunctival hemorrhage.


Oropharynx: Natal teeth are occasionally present. Epstein pearls are common benign fluid-filled nodules on the palate. A short lingual frenulum, or “tongue-tie,” can limit upward tongue movement and cause difficulty with breastfeeding. A cleft lip or palate is often an isolated finding. Submucous clefts are easily missed without palatal palpation. Clefts frequently cause significant feeding difficulties with poor suck and nasal regurgitation.


Neck and Clavicle Examination: The neck should be checked for cystic hygromas. There should be full range of motion. Clavicle fracture is detected by palpation for crepitus or discontinuity.


Anterior Chest and Breast Examination: Observe the shape of the chest. Some newborns have transient pronounced breast development.


Lung and Cardiovascular Auscultation: Assess rate and effort of breathing. Grunting, flaring, or retractions indicate respiratory distress. The cardiovascular examination should be performed in a quiet room using a pediatric stethoscope. Assess heart rate, rhythm, and point of maximal impulse. For murmurs, note the intensity, timing in the cardiac cycle, and characteristics. Auscultate both axillae and the back. Palpate femoral pulses, and assess for brachiofemoral delay.


Abdominal Examination, Including Umbilical Cord: The abdomen is optimally examined with a calm newborn. Assessment of hepatosplenomegaly and abdominal mass may be facilitated by flexion of the knees. Single umbilical artery may be associated with a renal anomaly.


Hip Examination: Developmental dysplasia of the hip (DDH) is assessed by observation for gluteal asymmetry and performing of the Ortolani and Barlow maneuvers (see Chapter 17, Teaching Visual: Examination of the Infant Hip).


Genital Examination: In normal-appearing male genitalia, identify the urethral meatal opening, signs of hypospadias or epispadias (which may be relative contraindications to circumcision), and also bilaterally descended testes and absence of hernia or hydrocele. Differentiate retractile testes from cryptorchidism by milking the testicle toward the scrotum.


Externally normal female genitalia have prominent labia minora with the labia majora incompletely covering the minora. Transient white vaginal discharge or drops of blood are due to maternal hormone effect. If there is concern for clitoral enlargement, promptly consult endocrinology regarding ambiguous genitalia.


Often urate crystals are seen in the diaper. These appear as orange, sandy stains on the diaper and may at times be mistaken for blood. This otherwise benign finding may be an indicator of relative dehydration and can cause significant parental anxiety.


Back and Spine Examination: Note the presence of sacral pits, hemangiomas, or tufts of hair in the midline of the spine. Mongolian spots are benign skin markings, usually found in children of darker skin and are not associated with any illness.


Extremity Examination: Note polydactyly, syndactyly, or clinodactyly. Check the feet for deformity. Evaluate for brachial plexus injury by assessing asymmetry of upper extremity movement and symmetry of the Moro reflex.


Neurologic Examination: This includes observation of activity, tone, and primitive reflexes. In the Moro reflex the legs and head extend while the arms jerk up and out with the palms up and thumbs flexed. Shortly afterward the arms are brought together and the hands clench into fists, and the infant often cries. In the rooting reflex, newborns will turn their head toward anything that strokes their cheek or mouth, searching for the object by moving their heads in steadily decreasing arcs until the object is found. The rooting and suck reflexes are related. With rooting, the newborn infant will turn his/her head toward anything that strokes his/her cheek or mouth, and the suck reflex allows the child to instinctively suck at anything that touches the roof of the mouth. The Babinski reflex appears when the side of the foot is stroked, causing the toes to fan out and the great toe to extend. The reflex is caused by a lack of myelination in the corticospinal tract in young children. The Babinski reflex is a sign of neurologic abnormality in adults and older children.


Skin Examination: There are many neonatal rashes. Some common benign exanthems include erythema toxicum and milia. Erythema toxicum neonatorum consists of small erythematous papules and occasionally pustules surrounded by a distinctive blotchy erythematous halo. Individual lesions are transient, often disappearing within hours and then appearing elsewhere on the body. Milia are tiny white papules found on the face that are due to trapped sebaceous material in glands of the skin (see Chapter 16, The Newborn Well Visit).

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Jul 18, 2016 | Posted by in PEDIATRICS | Comments Off on The Newborn Examination

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