Introduction
Before examining the infant, a thorough chart review should be performed.
Maternal history
- Prior pregnancies, deliveries, and associated complications
- History of siblings with congenital defects or genetic disorders
- Complications during pregnancy:
- Gestational diabetes
- Hypothyroidism
- Eclampsia
- Social behaviors (tobacco use, illicit drug use, alcohol use)
- Preventative care during pregnancy:
- Adherence to routine prenatal care
- Tdap (tetanus, diphtheria, and pertussis) vaccine during pregnancy
- Rhogam administration, if applicable
- Results of screening tests, including:
- Genetic screenings
- Glucose tolerance test (gestational diabetes screening)
- HIV and other sexually transmitted infection (STI) screening
- Urine drug screening
Infant’s birth history
- Gestational age
- Labor and delivery route and management:
- Duration of labor
- Duration of rupture of membranes
- Route of delivery
- Associated delivery complications:
- Prolonged rupture of membranes or preterm labor
- Group B streptococcal (GBS) status
- Shoulder dystocia or other malpresentations
- APGAR scores (see table below)
- Scoring system to evaluate newborns
- Performed at 1 and 5 minutes of life
- Low 5-minute APGAR scores correlate with increased cerebral palsy rates.
Sign | 0 points | 1 point | 2 points | |
---|---|---|---|---|
A | Appearance | Cyanotic or mottled | Cyanotic extremities, pink body | Pink extremities and body |
P | Pulse | Absent | < 100/min | > 100/min |
G | Grimace | No response to stimulation | Grimace with suction or aggressive stimulation | Cry on stimulation |
A | Activity | None | Some flexion of arms and legs | Active flexion against resistance |
R | Respirations | Absent | Weak, irregular, and slow | Strong cry |
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Vital Signs
The normal range for neonatal vital signs is unique.
- Temperature: 36.5℃–37.6℃ (97.7℉–99.5℉)
- Heart rate: 120–160/min
- Respiratory rate: 36–60/min
- Pulse oximetry: > 90%
- Blood pressure:
- Must be measured with a properly fitting, neonatal-sized blood pressure cuff
- Usually only measured if renal or cardiovascular conditions are suspected
During the perinatal period, growth parameters should be plotted daily on a growth chart.
- Length
- Weight
- Below the 10th percentile is small for gestational age (SGA).
- Above the 90th percentile is large for gestational age (LGA).
- Head circumference
- Below the 2nd percentile is considered microcephaly.
- Above the 98th percentile is considered macrocephaly.
Example of a height and weight growth chart for boys from 0–36 months of age
Image: “Growthchart for boys” by CDC. License: Public Domain
General Exam
Physical exam findings
Physical exam findings can help confirm the gestational date (Ballard score):
Ballard scoring: scoring system that uses physical exam findings to determine likely neonatal maturity and gestational age
Image by Lecturio.The infant’s reaction to the examination is useful in assessing:
- Alertness
- Reactivity
- Tone
- Vigor
Respiratory effort
Tachypnea may indicate:
- Pulmonary dysfunction
- Transient tachypnea of the newborn
- Meconium aspiration
- Pulmonary hypertension
- Pulmonary hypoplasia
- Congenital cardiac abnormalities (the 5 Ts)
- Truncus arteriosus
- Transposition of the great vessels (TGV)
- Tricuspid valve atresia
- Tetralogy of Fallot
- Total anomalous pulmonary venous return
Skin exam
- Coloration indicates general infant health:
- Pink with slight blue discoloration to hands and feet (acrocyanosis) is normal.
- Cyanosis of the face or lips may represent poor oxygenation.
- Pallor may indicate anemia.
- Red, plethoric face may represent polycythemia.
- Jaundice is indicative of elevated bilirubin.
- Careful examination to note birthmarks and other skin findings suggestive of genetic disorders
- Benign birthmarks:
- Nevus simplex (“stork bite” or “angel’s kiss”): common salmon-colored patch, often on the forehead, eyelids, and back of the infant’s head
- Congenital dermal melanocytosis (formerly known as “Mongolian spot”): dark-blue pigmentation, usually on the lower back
- Erythema toxicum: transient 1–2 mm erythematous papules
- Potentially concerning for genetic syndromes:
- Cafe-au-lait spots: flat, pigmented lesions; > 6 spots concerning for neurofibromatosis
- Ash-leaf spots: depigmented patches of skin common in tuberous sclerosis
- Nevus flammeus (“port-wine stain”): dark-red, large, flat patch of vascular origin; can be associated with Sturge-Weber syndrome
- Benign birthmarks:
Nevus simplex (“stork bite” or “angel’s kiss”): common salmon-colored patch, seen here on the nape of the patient’s neck
Image: “IMG_9564” by Abigail Batchelder. License: CC BY 2.0Congenital dermal melanocytos (formerly known as “Mongolian spot”): gray-blue patches spread over thigh (A); gray-blue patches spread over waist and breech (B)
Image: “Mongolian spot” by State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China. License: CC BY 4.0, edited by Lecturio.Clinical photograph of neurofibromatosis showing 3 cafe-au-lait spots on the left side of the lower back along with freckling
Image: “Cafe au lait spots” by Department of Pathology, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha, India. License: CC BY 2.0Hypomelanotic lesions (ash-leaf spots) on skin in a patient with tuberous sclerosis
Image: “Hypomelanotic lesions” by Department of Medical Genetics, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran. License: CC BY 3.0Sturge-Weber syndrome showing nevus flammeus (“port-wine stain”) on right nasal, periorbital, frontal, and maxillary areas, corresponding to trigeminal nerve distribution
Image: “Congestive skin lesion” by Istanbul Medeniyet University Goztepe Education and Research Hospital, Neurology Department, Istanbul, Turkey. License: CC BY 2.0
Head and Neck
Face and scalp
- Note the overall size and shape of head, paying attention to any abnormalities associated with common genetic conditions.
- Note overall symmetry of the face.
- Lacerations or ecchymosis (cephalohematoma or caput succedaneum) may be present if the infant was born via vacuum or forceps-assisted vaginal delivery.
Fontanelles
Palpate the anterior (3–6 cm in diameter) and posterior (1–1.5 cm) fontanelles:
- Normal: soft and flat
- Sunken: may indicate dehydration
- Tense or bulging: may indicate increased intracranial pressure from meningitis or hydrocephalus
Sutures
Palpate for symmetry:
- Temporary asymmetry from passage through the birth canal is normal (sutures overlap to allow passage through the birth canal).
- Persistent asymmetry may indicate craniosynostosis (early closure of the sutures leading to an abnormal head shape).
Diagram of a head with sagittal craniosynostosis. Note the fusion of the sagittal suture.
Image by Lecturio.Diagram of a head with lambdoidal craniosynostosis. Note the fusion of the lambdoid suture, the anterior and posterior protuberances, and the posterior displacement of the ear.
Image by Lecturio.Posterior plagiocephaly caused by lambdoid synostosis.
Image: “Posterior plagiocephaly caused by lambdoidal synostosis” by US National Library of Medicine. License: CC BY 2.0
(A, B) frontal and (C) posterior views of an infant with left lambdoid synostosis; the 3-dimensional computed tomography (CT) reconstruction (D, posterior view) shows premature fusion of the left lambdoidal suture (arrow). Note the facial asymmetry of the patient secondary to the lambdoid synostosis (B) that does not occur in positional plagiocephaly.
Eyes
- Note the spacing, symmetry, and positioning of the eyes.
- Hypotelorism and hypertelorism (narrowly and widely spaced eyes) are often associated with genetic disorders.
- Note the width and slant of palpebral fissures.
- Note the appearance of the sclera, conjunctive, iris, and reactivity/symmetry of the pupils.
- Check for red reflex.
- Present in all infants
- Absent in one or both eyes in:
- Retinoblastoma
- Congenital cataracts
- Retinopathy of prematurity
- Look for purulent discharge from the tear duct.
- Dacryostenosis:
- Blocked tear duct
- Relieved by gentle massage with a warm towel
- Ophthalmia neonatorum:
- Infection of the eye
- Associated with periocular swelling, conjunctival injection
- May require antimicrobials
- Dacryostenosis:
Ears
- Appearance
- Note the spacing, symmetry, and positioning of the ears.
- Low-set ears:
- Associated with multiple genetic syndromes (e.g., Down’s syndrome, Edwards syndrome, Patau’s syndrome)
- Helices below the imaginary plane that go through both of the child’s inner canthi
- Note any other abnormalities: abnormal rotation, pits, or skin tags → should prompt evaluation of the kidneys
- Tympanic membranes are generally not visualized during the newborn period.
- Function
- Hearing tests must be performed on all infants before one month of age, preferentially prior to discharge.
- The auditory brainstem response or the otoacoustic emissions test are utilized.
Detail of microtia (outer ear deformity). Right ear is normal.
Image: “Microtia” by Mulgamutt. License: Public Domain
Mouth
- Look for natal teeth.
- Should be removed as they are an aspiration risk
- Often seen with Pierre-Robin sequence
- Note if the mandible and maxilla fit together correctly or if an under-/overbite is present.
- Examine the tongue and the extent of protrusion to look for ankyloglossia (“tongue-tie”).
- Visualize and palpate the palate for the presence or absence of a cleft palate.
- Palpation is important because submucosal cleft palates are not visible.
- Look for bifid or lateralized uvula as these may be a sign of cleft palate.
Six-month-old girl before going into surgery to have her unilateral complete cleft lip repaired
Image: “Child born with cleft palate at 5 months of age” by King97tut. License: Public Domain
Nose
- Note the shape and symmetry of the nose.
- Check for choanal atresia by occluding each nostril in turn and noting any difficulty in respiration.
Neck
- Observe the neck’s range of motion.
- Congenital torticollis is a common finding due to birth trauma and is treated with physical therapy.
- Inspect and palpate the extended neck for symmetry, masses, and abnormalities.
- Medial masses may indicate a thyroglossal duct cyst.
- Lateral masses may indicate a branchial cleft cyst.
- Neck webbing and cystic hygromas are associated with Down’s and Turner syndromes.
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Chest
Clavicles
- Palpate for the presence of both clavicles.
- Palpate for the presence of clavicular fractures, which may occur from trauma during childbirth.
Chest
- Inspect for chest wall symmetry, spacing of the nipples, and any visible deformations.
- Wide-set nipples may indicate Turner syndrome.
- Accessory nipples may also be observed.
- Palpate for any developed breast tissue.
- Some infants may have neonatal gynecomastia.
- Inspect for chest wall movement with each breath.
- Look for paradoxical movement of chest segments indicating paralysis of the diaphragm or diaphragmatic hernia.
- Note the respiratory rate and heart rate (measured for a full minute).
- Note if the infant’s cry is weak or vigorous.
- Note if supplemental oxygen is being delivered and by what route.
- Note any signs of respiratory distress, including:
- Tachypnea (> 60/min) or apnea
- Accessory muscle use or retractions
- Grunting or nasal flaring
Lungs
Auscultate the lung fields bilaterally.
- Ventilation will be impaired in respiratory infections (e.g., neonatal pneumonia) and obstructive processes (e.g., meconium aspiration).
- Abdominal sounds auscultated in the chest may indicate congenital diaphragmatic hernia.
Heart
- Feel the chest wall for a displaced point of maximal impulse (PMI).
- Auscultate heart sounds.
- Healthy: single S1, split S2
- Murmurs may indicate congenital cardiopathies:
- Physiologic murmurs due to persistent fetal circulation are common.
- Pathological: any harsh-sounding murmur, diastolic murmur, grade 3 or higher murmur
Abdomen, Back, and Genitals
Abdomen
- General appearance: Examine for the presence of any noticeable deformities (omphalocele or gastroschisis) or abdominal distension.
- The umbilical cord stump:
- Should contain 2 arteries and 1 vein
- Should be examined for bleeding or signs of infection
- Should be examined for abdominal hernias, which must be noted and monitored for incarceration
- Palpate for the liver, which should be felt 2–3 cm below the right costal border.
- Spleen is difficult to palpate.
- Kidneys may or may not be palpated.
- Auscultate for bowel sounds.
Umbilical hernia in a 2-year-old child
Image: “A and B proboscoid hernia” by Surgeon Department, University Teaching Hospital Center, Yaoundé, Cameroon. License: CC BY 2.0Large omphalocele containing omphalomesenteric duct cyst
Image: “Omphalocele” by Yousuf Aziz Khan, MBBS, FCPS (Paediatric Surgeon), Department of Paediatric Surgery, National Institute of Child Health, Rafiquee Shaheed Road, Karachi – 75510, Sind, Pakistan. License: CC BY 3.0Gastroschisis in a newborn. Note the eviscerated bowel to the right of the umbilical insertion.
Image: “Gastroschis with concomitant jejuno-ileala tresia type III b” by Clinic of Pediatric Surgery, University Clinical Center Sarajevo, Sarajevo, Bosnia and Herzegovina. License: CC BY 3.0Gastroschisis silo
Image by Lecturio.
Back
Inspect and palpate for any congenital defects of the spine.
- Note the presence of any sacral dimples or “hair tufts,” which may indicate spina bifida occulta.
- Note any skin abnormalities or birthmarks.
Genitourinary
- Girls:
- Verify the presence of the labia, urethral meatus, and vaginal opening.
- Term female infants have prominent labia majora.
- Preterm female infants have prominent labia minora.
- A small amount of vaginal discharge and bleeding associated with withdrawal from maternal estrogens is normal.
- Note any signs of virilization (fused labia, cliteromegaly).
- Check for the presence of an imperforate hymen.
- Verify the presence of the labia, urethral meatus, and vaginal opening.
- Boys:
- Penis
- The foreskin is adhered to the glans.
- Should be allowed to come loose on its own within the span of the 1st few months
- Note the location of the urethral meatus:
- Epispadias: Urethra opens on the dorsal surface of the penis.
- Hypospadias: Urethra opens ventrally on the glans or the shaft of the penis.
- Scrotum
- Look for “bifid scrotum” or signs of ambiguous genitalia.
- Palpate for both testes.
- Can sometimes be palpated in the inguinal canal
- Should descend within the first 6 months of life
- Cremasteric reflex should be elicited.
- Look for hydrocele or inguinal hernias.
- Penis
- Both genders:
- Verify patency of the anus.
- Look for “sacral dimple.”
- Any dimple that is < 2.5 cm from the anal verge and < 0.5 cm in diameter is considered normal.
- All other sacral dimples should be investigated by ultrasound for concern for spinal malformations.
3-year-old child with undescended testes showing nonpalpable left testicle and prepubertal right testicle in scrotal position
Image: “47XYY” by Department of Endocrinology, Mohammed VI Hospital, Medical School, Mohammed the First University, 60 000 Oujda, Morocco. License: CC BY 3.0Baby boy with epispadias
Image: “Male baby with epispadias” by Department of Pediatric Urology, University Medical Center Regensburg, Germany. License: CC BY 2.0Ambiguous genitalia with bifid scrotum and micropenis
Image: “Bifid scrotum and micropenis” by Kocaeli University Faculty of Medicine, Department of Pediatric Endocrinology and Diabetes, Kocaeli, Turkey. License: CC BY 2.5(A) Clinical photograph of a child showing swelling on the right side of abdomen and empty right hemiscrotum
Image: “Congenital spigelian hernia” by Department of Surgery BPS Government College for Women Khanpur Kalan Sonepat. License: CC BY 3.0
(B) Operative photograph showing the hernia sac containing testis
Extremities
Hips
- Inspect for any visible abnormalities.
- Use Ortolani and Barlow maneuvers to assess hip stability (may indicate developmental dysplasia of the hip).
- Palpate for the femoral pulses.
Hands and feet
- Inspect for any visible abnormalities, including:
- Syndactyly or polydactyly
- Overlapping fingers (may indicate Edwards syndrome)
- A single palmar crease (may indicate Down’s syndrome)
- Look for talipes equinovarus (clubfoot).
A child with syndactyly
Image by Dumplestiltskin, PD.A: Preaxial poly-syndactyly of the right foot
Image: “F7” by Department of Pediatric Neurology, University Children’s Hospital of Zurich, Switzerland. License: CC BY 2.0
B: Mesoaxial polydactyly of the right hand
C: X-ray of the left hand showing a Y-shaped 3rd metacarpal bone
D: Postaxial polydactyly of the right hand
Extremities
- Assess radial, posterior tibial, and dorsalis pedis pulses.
- Observe for spontaneous movement of the extremities.
- Brachial plexus injury during birth can give rise to various palsies:
- Erb’s palsy
- Due to hyperextension of the C5 to C7 spinal nerve roots
- Forearm is medially rotated, and the hand pronated (“waiter’s tip”)
- Klumpke’s palsy
- Injury to the distal portions of C8 and T1
- Paralysis of the entire arm with areflexia
- Erb’s palsy
- Brachial plexus injury during birth can give rise to various palsies:
Neurologic Exam
- General
- Tone:
- Passive tone depends on the neonate’s maturity at birth.
- Normal for an infant born at 24 weeks’ gestation to be more splayed out at rest
- A full-term infant should flex all extremities at rest.
- Tone:
- Primitive reflexes:
- Suck reflex: Touching the roof of the mouth stimulates sucking/swallowing.
- Rooting reflex: Touching the side of the neonate’s face/cheek stimulates the neonate to turn their head to the ipsilateral side.
- Palmar grasp: Stroking the palm should stimulate the neonate to grasp the hand.
- Moro reflex:
- Lift the infant gently 2–3 inches by pulling the arms.
- Carefully release the infant’s hands.
- The infant should startle, which results in arm extension followed by arm flexion.
- Deep tendon reflexes can also be evaluated.
- Cranial nerve assessment
Palmar grasp | Rooting | Moro | Tonic neck | |
---|---|---|---|---|
Onset (gestation) | 28 weeks | 32 weeks | 28–32 weeks | 35 weeks |
Fully developed | 32 weeks of gestation | 36 weeks of gestation | 37 weeks of gestation | 1 month after birth |
Duration | 2–3 months after birth | Less prominent 1 month after birth | 5–6 months after birth | 6–7 months after birth |
The suck-swallow reflex causes the child to instinctively suck anything that touches the roof of the mouth and simulates the way a child naturally eats.
Image by Lecturio.A newborn infant will turn their head toward anything that strokes their cheek or mouth, as they are searching for the object by moving their head in steadily decreasing arcs until the object is found.
Image by Lecturio.To best observe the Palmar grasp reflex, place the infant on a bed where they could safely fall onto a pillow, and then offer the infant an index finger and gradually lift. The grasp of the finger may be able to support the child’s weight, but they may also release their grip suddenly and without warning.
Image by Lecturio.The Moro reflex is initiated by pulling the infant up from the floor and then releasing them:
Image by Lecturio.
1. They spread their arms.
2. They pull their arms in.
3. They cry.
Clinical Relevance
The following conditions can be identified or suspected through physical examination of the newborn:
- Craniosynostosis: the premature fusion of one or more cranial sutures, usually classified as simple or complex. Premature suture fusion can cause abnormalities in skull and brain growth.
- Meningitis: inflammation of the leptomeninges due to an infectious agent. A bulging anterior fontanelle can be a sign of neuroinfection in neonates. Infection can be suspected if other clinical signs are present, such as temperature, tachycardia, and poor feeding.
- Cleft lip and palate: a congenital defect of the lip and usually alveolus that may involve the palate. Cleft palate may also occur independently of cleft lip. Both occur when the facial structures of a fetus fail to fuse properly.
- CHARGE syndrome: a rare genetic disorder in children affecting almost all body systems due to impaired gene expression. CHARGE is an abbreviation of coloboma, heart defects, atresia choanae, growth retardation, genetic abnormalities, and ear abnormalities. Coloboma is a distinguishing clinical finding seen in children with CHARGE syndrome.
- Thyroglossal duct cyst: most common congenital cyst found in the midline when palpating a neonate’s neck. Thyroglossal duct cyst forms in the remnant of the thyroglossal tract.
- Branchial cleft remnants: cysts, sinuses, or skin tags along the anterior border of the sternocleidomastoid muscle or near the angle of the mandible, lined primarily with stratified squamous epithelium. Cysts may also contain lymphoid follicles.
- Neonatal gynecomastia: breast hypertrophy due to androgens and estrogens secreted by the mother that enter the fetal circulation.
- Neonatal pneumonia: inflammation of the pulmonary parenchyma due to infectious agents during the neonatal period.
- Meconium aspiration syndrome: respiratory distress in newborns born with meconium-stained amniotic fluid.
- Truncus arteriosus (TA): congenital cardiopathy characterized by the emergence of the pulmonary artery and aorta from a common trunk that overrides a ventricular septal defect (VSD).
- Transposition of the great vessels: congenital cyanotic cardiopathy characterized by the “switching” of the great arteries. There are 2 presentations: the dextro- and levo-looped forms. A pansystolic murmur can be heard in cases with a VSD. Transposition of the great vessels can present with a systolic murmur, sometimes accompanied by a trill.
- Tricuspid valve atresia (TVA): cyanotic congenital cardiopathy that consists of the lack of development of the tricuspid AV valve that presents with a holosystolic murmur.
- Tetralogy of Fallot: cyanotic congenital cardiopathy with 4 characteristic findings: overriding aorta, ventricular septal defect, pulmonary stenosis, and right ventricular hypertrophy. Tetralogy of Fallot presents with a harsh, loud systolic murmur.
- Total anomalous pulmonary venous return: rare cyanotic congenital cardiopathy that consists of the drainage of the pulmonary veins to other anatomical sites other than the left atrium. Total anomalous pulmonary venous return presents with a soft mid-systolic murmur.
- Omphalocele: an anterior abdominal wall defect in which the intestines are covered by peritoneum and amniotic membranes.
- Gastroschisis: a free (uncovered) protrusion of the intestine and/or other abdominal content through a defect located at the detachment of the umbilicus and normal skin.
- Down’s syndrome: a genetic syndrome caused by trisomy of chromosome 21; the most frequent cause of intellectual disabilities.
- Edwards syndrome: a genetic syndrome caused by trisomy of chromosome 18 with several characteristic findings, including a narrow skull, cleft palate and lip, cardiac murmurs, clenched overlapping fingers, and omphalocele.
- Patau’s syndrome: a genetic syndrome caused by the presence of the trisomy of chromosome 13. Some of the syndrome’s characteristic findings overlap with those found in Edwards syndrome.
- Developmental dysplasia of the hip: a group of clinical findings in which the head of the femur slips out of the acetabulum, causing abnormalities in the growth and development of the hip joint.
References
- Olsson, J. M. (2020). The newborn. In R. M. Kliegman MD et al. (Eds.), Nelson textbook of pediatrics. https://www.clinicalkey.es/#!/content/3-s2.0-B9780323529501000213
- Schor, N. F. (2020). Neurologic evaluation. In R. M. Kliegman MD et al. (Eds.), Nelson textbook of pediatrics. https://www.clinicalkey.es/#!/content/3-s2.0-B9780323529501006088
- James, W. D. et al. (2020). Epidermal nevi, neoplasms, and cysts. In W. D. James MD etl a. (Eds.), Andrews’ diseases of the skin. https://www.clinicalkey.es/#!/content/3-s2.0-B9780323547536000290
- Hedstrom, A. B., Gove, N. E., Mayock, D. E., & Batra, M. (2018). Performance of the Silverman Andersen respiratory severity score in predicting PCO2 and respiratory support in newborns: A prospective cohort study. Journal of Perinatology. doi: 10.1038/s41372-018-0049-3
- Katz, M. H., & Doherty, G. M. (2020). Urology. In G. M. Doherty (Ed.), Current diagnosis & treatment: Surgery. New York, NY: McGraw Hill LLC. accessmedicine.mhmedical.com/content.aspx?aid=1171284274