In this lecture, I’m going to
discuss the newborn physical exam.
So before I even start, I want to say
two things about the newborn exam.
One is it can be tricky from
the standpoint of making sure
that the child is
So sometimes, you have
to be a little bit quick
because if you leave the child
unexposed for a period of time,
they can start getting cold.
You will notice that the skin starts to
mottle or look like marble a little bit
and that’s a sign that
infant is getting cold.
If you can, you can do a very
careful exam under a warmer.
The other thing about
the newborn exam is
it can be frustrating
especially with auscultation
and the reason is newborn infants might cry
and make it hard to hear what’s going on.
It’s okay if you leave an infant
and then come back to them later when they’re
sleeping to get the rest of your exam.
But let’s go through the newborn
exam really carefully here,
so we can understand not only
for an exam that might happen
but also for your general
practice on the pediatric wards.
So first, let’s review vital
signs and growth parameters.
It’s important that you have the height,
the weight and the head circumference
on every infant you exam.
And it’s important we
review the vital signs.
The heart rate should be usually between
90 and 160 in a healthy newborn child.
The respiratory rate is usually
high between 30 or 60, that’s fine.
From the standpoint of blood
pressure, we often don’t have one.
This is because it’s a
bit challenging to make.
We will use it in infants who are ill,
but if an infant is well, the blood
pressure is not a critical measurement.
And remember, pulse ox is
abnormal in the first day of life
and very abnormal in
the first 10 minutes.
So during the first 10 minutes, it’s normal
for him to go from 60% at birth to 90%.
Then it can take the rest of
the day to go up to 100%,
but expect abnormalities
in the pulse ox early.
In the second day of life, that pulse
ox should pretty much be normal.
In fact, many centers use that pulse ox
as a screen for congenital heart disease.
Now you’ve got the vitals, you
got the height, the weight
and the head circumference and you’ve
plotted them so you have percentiles.
Now, we’re going to do an exam
and we’re going to start at the
head and work our way down.
The first thing you’re going to do
on the head is feel the sutures.
Early in birth, sometimes they are
slightly overriding and elevated,
but that should stabilize
out relatively quickly.
Also you should feel a fontanelle
in the anterior portion of the
skull as is pictured here
and a very small sort of
finger-large posterior fontanelle.
You should feel both of those and
you should feel all those sutures
and if you feel any asymmetries or
abnormalities, those should be noted.
This could be a partial
craniosynostosis for example.
Next, we’re going to check the eyes and we
absolutely are going to do a red reflex.
The red reflex is useful
because when you’re looking in
and you’re seeing not
only the red reflex
but also the possibility
of slip lenses
which can happen with a
variety of infant diseases.
Also the red reflex may be absent
in a patient with retinoblastoma.
So it’s crucial to check those eyes.
Also look at the irises, if a coloboma is
present, this might be CHARGE syndrome.
Now, take a look at the ears.
As you draw a line backward from the eye,
it should intersect the
top third of that ear.
Also, you should note any
abnormalities of the ear.
Is it posterior placed, but is it rotated?
Are there pits?
Are there tags?
Abnormalities of the ear may
be associated with syndromes
or may be even just associated
with renal abnormalities.
For reason I don’t understand,
ears and kidneys can sometimes go
together in so many different ways.
Next, we’re going to check the mouth.
We’re going to look for
abnormalities of the lips.
We’re also going to put our finger into the
mouth and palpate the top of the mouth.
If there is abnormalities
and a cleft palate,
you may note them
obviously on exam.
But a palate on the
inside may be high arched
or may be abnormal as well with
a lack of patency on the inside
and that should all be noted.
While we’ve got our finger in
there, check the baby's suck.
It should be vigorous.
That’s technically part of the neuro
exam, but I would absolutely do it.
Also, we’re going
to check the nose.
In pretty much any infant at some
point, we may suck out both nares.
That usually is done in
the resuscitating room,
but we’re going to check
patency of the nose.
If a tube goes in but
can’t get through,
that patient may
have choanal atresia
which can cause respiratory
distress in an infant.