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KristaRantakari
MaijaSeppä-Moilanen

Physical Examination of the Newborn

General remarks

  • Examination is easiest when the baby's basic needs have been satisfied and he/she is not hungry.
  • The examination table should be sufficiently warm to prevent heat loss. The baby must not be left unsupervised because he/she may suddenly kick and turn over, for instance.
  • Required equipment
    • Stethoscope suitable for examining a baby
    • Ophthalmoscope
    • Wooden spatula
    • 30% glucose or glycerol in a small syringe
      • Not absolutely necessary but often useful
      • A few drops instilled into the baby's mouth will calm him/her down, as necessary.
  • A nurse or midwife and the parents should be present during the examination.
    • The nurse can calm the baby down, as necessary.
      • For example, the nurse can use his/her (gloved) finger as a dummy; a few drops of 30% glucose or glycerol can be dripped onto the finger.
    • The mother/parents can be asked about matters related to pregnancy or heredity, for example.
    • The parents should be informed about normal and abnormal findings and about any further steps (such as normal follow-up at a child health clinic, checkups for jaundice or any other particular further measures).

History

  • Obtain information about the duration and course of the pregnancy, the course of the delivery, anything particular after delivery and any familial conditions (e.g. hereditary long QT interval).
  • Common significant factors
    • The mother's diseases and medication during pregnancy, such as diabetes or gestational diabetes or thyroid disorders
    • Risk factors for infection associated with delivery
      • Time to delivery since the waters broke (> 18 hours), maternal GBS, signs of maternal infection during delivery and any antimicrobial prophylaxis or treatment
    • Gestational weeks, absolute and relative birth measures (growth curves from either an electronic health record (EHR) system or some other locally relevant source)
      • Weight, height, head circumference; is there any growth disturbance?
    • Apgar score and cord blood pH, other acid-base balance and Hb (from an umbilical artery or vein)
    • Relative weight of the placenta
      • A large placenta (relative weight often > 40%) may be a sign of congenital nephrosis or foetal infection. If the relative weight of the placenta is > 25% and/or the placenta weighs > 1 000 g, samples should be taken from the baby to determine urinary protein and plasma albumin.
      • A small placenta may explain a small for gestational age infant (growth restriction), for instance.
    • How the baby is doing after birth, eating, weight (loss), jaundice Jaundice in the Newborn, any examinations (if done)
    • Routine screening
      • Umbilical cord blood TSH
      • Metabolic screening of the newborn (test package)
        • At the age of (36 h) 2-5 days; not reliable if done before the age of 36 h. Check also locally applied requirements.
      • Hearing screen (OAE)
    • Indications for special vaccinations: BCG BCG Vaccine, hepatitis vaccines Vaccinations

Clinical examination

  • Some examiners prefer to have the baby undressed before starting the examination. However, undressing may upset the baby, and it can also be done as the examination proceeds. In that case, auscultation of the heart and lungs, for example, can be done when the baby is calm, before taking off all his/her clothes. Also, the baby's muscle tone, movement and whole appearance can be assessed when undressing him/her.
  • The examination should be done carefully and systematically.
    • It is useful to go through the order of examinations in your mind in advance.
    • As an exception to systematic examination, it is a good idea to examine red reflexes of the eyes whenever the baby opens his/her eyes spontaneously.
  • During or towards the end of the examination, it is important to also inform the parents about normal findings. When informing them about any abnormal findings, it is important to consider their worries and emotions, which are often more intense when there is a newborn baby.
  • Example of an order of examination that has been found to be good (more detailed instructions are given for each section further down):
    1. General examination. Observe the baby for a while before touching him/her.
      • General status
      • Features, posture, appearance and movement, body proportions
      • Breathing (how it appears)
      • Colour
      • Skin
      • Nutritional status and fluid balance
    2. Heart and lungs
    3. Pulses at the femoral arteries
    4. Genitals
    5. Hips
    6. Skeleton and lower limbs
    7. Abdominal area
    8. Navel
    9. Face, ears, head, skull, suture lines, fontanelles
    10. Clavicles and upper limbs
    11. Holding the head up when pulled to a sitting position (head lag test)
    12. Primitive reflexes
      • Moro's (startle), sucking, grasping and stepping reflexes, asymmetric tonic neck reflex (ATNR)
    13. Posture, muscle tone and muscles
    14. Position when lying prone, turning the head to free the nose; examination of the spine and anus
    15. Eyes and eye reflexes
    16. Oral cavity, lingual frenulum and palate

Examinations in more detail

General examination

  • General status, posture, appearance and movement
    • Profound lethargy, incessant crying and sensitivity to handling, for example, are abnormal.
    • The normal posture is predominantly flexed. Newborn babies mostly keep their hands lightly fisted but keep opening them. Keeping them constantly fisted is abnormal.
    • Normal movement is symmetric, smooth and variable.
    • Newborn babies flex and extend their limbs and lift them against gravity.
    • Staying constantly in the same position, keeping the limbs on the underlying surface, a very flaccid or very stiff appearance are abnormal.
  • Features, proportions
    • Lesser structural abnormalities can be sought by examining features such as proportions, the shape, form and position of the eyes and ears, the form of the palate, any webbed neck (pterygium colli) or swelling of the feet (e.g. Turner's syndrome http://www.orpha.net/consor/cgi-bin/OC_Exp.php?lng=en&Expert=881); hands, feet, fingers and toes (e.g. single transverse palmar crease, webbed/fused fingers or toes (syndactyly), extra fingers or toes (polydactyly)).
  • Breathing
    • Does it appear effortless, laboured, rapid, slow?
    • The normal respiratory rate (RR) is 30-60/min.
    • Note the shape of the chest.
  • Colour
    • Blueish or pale skin around the mouth may give a false impression of cyanosis; it is normal if the baby appears otherwise normal.
    • Central cyanosis (lips, tongue) is abnormal.
    • Jaundice (skin or blood bilirubin test) Jaundice in the Newborn
  • Skin
    • Full-term newborns often have dry skin.
    • A variable number of harmless erythematous blotches and papules is often seen on the skin at the age of 1-2 days (erythema toxicum neonatorum ). Nothing can or needs to be done about them.
    • Birthmarks
      • Strawberry naevi, haemangiomas
        • Usually benign
        • There may at first be a rather light area on which a red naevus grows. It usually grows for about one year and then starts shrinking spontaneously.
        • Nothing needs to be done about strawberry naevi unless they are exceptionally large, their location is problematic (such as the eye area, an area subject to friction, the trachea) or there are many such naevi (more than 5), in which case the patient should be referred to a paediatric surgeon (vascular surgeon). If possible, pictures should be taken of strawberry naevi for the EHR system.
      • Flame naevi, or port-wine stains (Picture ), café au lait spots (Picture ) and pigmented naevi (Picture ) may warrant further examinations.
      • Mongolian spots http://dermnetnz.org/topics/lumbosacral-dermal-melanocytosis are common birthmarks in babies of Asian or African heritage. They are flat, blue-grey and, even though they look like bruises, painless and harmless pigmented lesions that usually disappear before school age and require no further examinations.
    • Skin infections
      • Purulent staphylococcal infections should be sought in the armpits, groin and nail folds, and the navel with its surroundings.
      • Ritter's disease (‘neonatal pemphigus'; Picture ) is due to a staphylococcal infection, bullous and often appears only at the age of about one week. The patient should be treated in a hospital.
  • Nutritional status and fluid balance
    • Lack of subcutaneous tissue may suggest a foetal growth disturbance (small-for-date infant).
    • Fluid balance can be assessed based on skin turgor, the tone of the fontanelle, and the mucosa, as well as weight changes.
    • Allowed relative weight loss from birth weight:
      • 12 h (age ½ a day): 3.5%
      • 24 h (1 day): 6%
      • 36 h (1.5 days): 8%
      • 48 h (2 days): 9%
      • 60 h (2.5 days): 10%

Heart and lungs

  • Auscultate the heart from all points, including the back.
  • In a healthy infant, the heart rate is 100-160/min.
    • A crying baby's heart rate may increase to up to 200/min.
    • During sleep, a healthy full-term baby's heart rate may fall to as low as 70/min.
    • Extrasystoles are quite common and often harmless.
  • Functional murmurs are common and, on the other hand, not all heart defects necessarily appear as murmurs. Murmurs in a newborn baby should be assessed by a paediatrician.
  • The normal respiratory rate in a newborn baby is 30-60/min.
  • Respiratory difficulty may be due to many causes (such as lung or heart diseases, infections or metabolic disorders).
  • An oxygen saturation gradient between the right upper limb (preductal) and another limb (postductal) may be an indication of a heart defect (TGA: postductal saturation higher), of increased pulmonary arterial pressure in insufficient adaptation (preductal saturation higher) or aortic stenosis (coarctation, preductal saturation higher).

Femoral pulses

  • Examination can best be done when the baby is relaxed.
  • Aortic stenosis (coarctation) should be suspected if the pulse at the femoral arteries cannot be felt or is clearly weak.
    • If so, measure blood pressures in all limbs (four limb blood pressures).
    • Coarctation of the aorta should be suspected if the pressures in the lower limbs are clearly lower than in the (right) upper limb (10 mmHg or higher gradient in systolic pressure).
    • Also note any oxygen saturation gradient.

Genitals

  • If external inspection leaves the child's gender unclear, urgent examinations need to be initiated and the baby needs to be referred to as the ‘child' (not ‘girl' or ‘boy').
  • Male infant
    • Both testes should be able to be felt at the bottom of the scrotum or be moved down to the bottom of the scrotum.
    • A penis appearing to be smaller than usual should be measured.
      • Its length from the surface of the symphysis to the tip of the penis should exceed 2.8 cm in a full-term baby.
    • There is often only a tiny opening in the foreskin covering the tip of the penis completely but this does not represent phimosis.
    • A cleft urethra or foreskin (such as hypospadia) or chordee (bowing or curvature of the penis) require non-urgent consultation of a surgeon.
    • A hydrocele does not require interventions.
  • Female infant
    • Check that the labia majora and minora and the clitoris appear normal.
    • Leucorrhoea and vernix caseosa in the pubic region are normal, as is a tiny spot of blood (the baby is undergoing hormonal changes).
  • Check (by asking) that the baby has urinated.
  • Small amounts of orange red urate precipitate are commonly found in urine passed by newborn babies and require no further examinations.

Hips

  • Look for congenital dislocation of the hip; see also Congenital Dislocation of the Hip.
  • Examination can best be done when the baby is relaxed.
  • Healthy hips are sturdy and can be completely abducted.
  • Snapping sounds from ligaments are common and innocent, as are slightly restricted abduction and what are called loose hips/neonatal hip laxity.
  • Asymmetric femoral folds as such do not signify hip dislocation.
  • Nearly 90% of cases of hip dysplasia can be found by screening tests (Ortolani's test) immediately after birth.

Skeleton and lower limbs

  • Assess the proportions, muscle tone, ankles, feet and toes and grasping with toes.
  • Clubfoot or rocker-bottom foot (convex sole of the foot due to malposition of the ankle bone) should be distinguished from more common malpositions of the feet. A surgeon should be consulted.
  • The proportions of the body and the limbs. Normally the centre of the longitudinal body axis is just above the navel.

Inspection and palpation of the abdomen

  • Determine the size of the liver by palpation: 1-2 fingerbreadths below the costal arch is normal.
  • The kidneys are often palpable.
  • Other masses need to be examined by ultrasound, for example.

Navel

  • Assess the umbilical stump observing any (incipient) infection.
  • The family should be instructed (by a nurse, for instance) in sufficiently thorough cleaning of the umbilical stump with water or, as necessary, with an antiseptic solution.
  • Any discharge from the navel that looks like faeces or urine is abnormal and requires further examinations (e.g. urachal cyst or fistula).
  • Umbilical hernias may enlarge at first but most of them resolve spontaneously before school age and often require no special follow-up or investigations.
    • Inguinal hernias always require non-urgent referral to a paediatric surgeon.

Face, ears, head, skull, suture lines and fontanelles

  • Facial features, any dysmorphic features, shape and location of the ears
  • Observe the baby's expressions, movements of the eyes and the mouth; these should be symmetric.
  • Skull: the suture lines and fontanelles are open.
  • The size of the fontanelles may vary greatly.
    • They must not be raised (bulging).
    • The head circumference must not be significantly abnormal.
  • A caput succedaneum is common, particularly in babies delivered using a vacuum extractor (in which case it may be called chignon, "false" caput succedaneum).
    • It usually heals spontaneously.
    • It may be sore at first and the baby may benefit from paracetamol, for example.
    • It predisposes the baby to jaundice.
    • True caput succedaneum
      • A collection of tissue fluid and blood in the subcutaneous tissue
    • Cephalhaematoma
      • Haemorrhage between the skull and the periosteum
      • The resulting cephalhaematoma does not cross the cranial suture lines.
    • Subgaleal haemorrhage (haematoma)
      • Venous haemorrhage extending to between the subcutaneous aponeurosis and the periosteum
      • Crosses cranial suture lines.
      • May be dangerous because the bleeding volume may be high, leading to hypovolaemia and anaemia. Haemoglobin levels should be monitored.

Clavicles and upper limbs

  • Inspect the upper limbs; the clavicles, proportions, hands, fingers, grips
  • A clavicular fracture may restrict movement of the ipsilateral upper limb but normal movement will be resumed spontaneously within a few days and the bone will unite within about a week. Any lump caused by the callus often disappears within a few weeks.
  • Damage to the brachial plexus may occur simultaneously with clavicular fracture or alone. If this is suspected, a physiotherapist should assess the case, and referral to a paediatric surgeon is usually indicated.
  • Duchenne-Erb paresis (C5-C6) considerably restricts the movement of the ipsilateral upper limb, making Moro's reflex asymmetric and preventing the arm from being raised above shoulder level. At rest, the upper limb will be close to the body in internal rotation-extension.
  • Typical features of Dejerine-Klumpke paresis (C8-T1) include weakness of limb extensors and sometimes Horner's syndrome Neurological Eye Symptoms.
  • Hand grip should be examined.

Pulling the baby to a sitting position, holding the head up

  • Pulling the baby up to a sitting position: the examiner brings the baby's hands to the midline and, holding from the wrists, uses one hand to pull him/her up towards the sitting position, while lightly supporting the baby's back and neck with the other hand.
    • Normally the head may lag slightly behind but the neck-shoulder region will be activated and the upper limbs slightly flexed.
    • The head hanging completely or strong tension over the midline is abnormal.
    • Observe whether the baby's head stays in the midline.

Primitive reflexes (Moro's, sucking, grasping, stepping and ATN reflexes)

  • During the examination, try to keep the baby's head in the midline to minimize the effect of the ATN reflex (ATNR) on the muscle tone.
    • When turning the head to one side, the ATNR causes extension of the ipsilateral limbs and flexion of the contralateral limbs.
  • To test for Moro's (startle) reflex, hold the baby behind the back and neck in a semi-sitting position. Bring his/her upper limbs to the midline and observe that the head is also in the midline. Suddenly drop your hand holding the baby slightly downward while continuing to support the baby. Normally, the baby will extend his/her upper limbs to the sides and pull them more slowly back to the midline. Normally, the baby is startled.
  • Grasping reflexes of the upper and lower limbs are normally symmetric.
  • The stepping reflex is symmetric. Alternatively, you can test for the placing reflex.

Posture, muscle tone and muscles

  • In a healthy newborn baby, the muscle tone in limb flexors is higher than in limb extensors.
  • The tone of trunk extensors is normally sufficient to keep the baby's head and trunk nearly level when the baby is raised in a horizontal position while lying prone on the hands of the examiner (holding the baby underneath the abdomen).
  • The strength of the neck flexors varies individually. Only some babies can hold their head up when raised carefully from the supine to the sitting position.
  • Significant muscle hypotonia or hypertonia, significant tremor and opisthotonos require further examinations.
  • In unclear cases, the examination should be repeated soon, within a few days to a week.

Position when lying prone, turning the head to free the nose; examination of the spine and anus

  • Observe the baby's position when he/she is lying prone; here, too, the position is predominantly flexed, with both upper and lower limbs often flexed.
  • A newborn baby should be able to free his/her airway by turning the head to the side.
  • Palpate the spine.
  • Confirm the location of the anus. An anterior anus will require assessment by a paediatric surgeon.
  • A sacral dimple, i.e. an indentation, depression or cavity in the upper part of the gluteal cleft requires no further measures unless it is inflamed/infected. However, first check with a probe, for instance, that the dimple has a bottom. If not, you should suspect a fistula and further examination is needed.
  • Check (by asking) that the baby has passed meconium. Delayed passing of the first faeces (meconium) may suggest Hirschprung's disease, for example.

Eyes and eye reflexes

  • Note any structural anomalies (such as epicanthus, coloboma).
  • If the baby is alert and keeps his/her eyes open, observe that the eye movements are free and complete.
  • Examine the pupillary reflexes.
  • Red reflexes
    • When the baby lies on his/her side and is calmly talked to, at least the upper eye often opens spontaneously allowing examination of the reflex.
    • Red reflexes should be symmetric. In ethnically dark babies, red reflexes often appear rather light (but they should still be symmetric).
    • Abnormal or asymmetric reflexes require further examinations.
  • Subconjunctival haemorrhage (sugillation) is common and harmless. It is usually associated with delivery and heals spontaneously.

Oral cavity, lingual frenulum and palate

  • Check the oral mucosa. If there are natal teeth, always write a non-urgent referral to a (paediatric) dentist.
  • Short lingual frenulum: If the lingual frenulum is clearly short, the tongue often appears heart-shaped. Only a significantly short lingual frenulum should be released. Labial frenulums should not be released.
  • Check the palate using a wooden spatula and light, and palpate it with a gloved finger to detect any cleft palate. When palpating with a gloved finger, you can simultaneously test for the baby's ability to suck.

Pictures