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Physical Examination of the Newborn

By

Deborah M. Consolini

, MD, Sidney Kimmel Medical College of Thomas Jefferson University

Last full review/revision Sep 2021| Content last modified Sep 2021
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A thorough physical examination should be done within 24 hours. Doing the examination with the mother and other family members present allows them to ask questions and the clinician to point out physical findings and provide anticipatory guidance. Routine screening tests to detect problems that cannot be seen during the physical examination are also done (see Screening Tests for Newborns ).

Basic measurements include length Length Physical growth includes attainment of full height and appropriate weight and an increase in size of all organs (except lymphatic tissue, which decreases in size). Growth from birth to adolescence... read more , weight Weight Physical growth includes attainment of full height and appropriate weight and an increase in size of all organs (except lymphatic tissue, which decreases in size). Growth from birth to adolescence... read more , and head circumference Head Circumference Physical growth includes attainment of full height and appropriate weight and an increase in size of all organs (except lymphatic tissue, which decreases in size). Growth from birth to adolescence... read more (see also Growth Parameters in Neonates Growth Parameters in Neonates Growth parameters and gestational age help identify the risk of neonatal pathology. Growth is influenced by genetic and nutritional factors as well as intrauterine conditions. Growth parameters... read more ). Length is measured from crown to heel; normal values are based on gestational age and should be plotted on a standard growth chart Physical Growth of Infants and Children Physical growth includes attainment of full height and appropriate weight and an increase in size of all organs (except lymphatic tissue, which decreases in size). Growth from birth to adolescence... read more . When gestational age is uncertain or when the infant seems large for gestational age Large-for-Gestational-Age (LGA) Infant Infants whose weight is > the 90th percentile for gestational age are classified as large for gestational age. Macrosomia is birthweight > 4000 g in a term infant. The predominant cause is maternal... read more or small for gestational age Small-for-Gestational-Age (SGA) Infant Infants whose weight is the 10th percentile for gestational age are classified as small for gestational age. Complications include perinatal asphyxia, meconium aspiration, polycythemia, and... read more , the gestational age can be more precisely determined using physical and neuromuscular findings (see Figure: Assessment of gestational age—new Ballard score Assessment of gestational age—new Ballard score A thorough physical examination should be done within 24 hours. Doing the examination with the mother and other family members present allows them to ask questions and the clinician to point... read more Assessment of gestational age—new Ballard score ). These methods are typically accurate to ± 2 weeks; however, in the sick neonate these methods are less reliable.

Assessment of gestational age—new Ballard score

Scores from neuromuscular and physical domains are added to obtain total score. (Adapted from Ballard JL, Khoury JC, Wedig K, et al: New Ballard score, expanded to include extremely premature infants. Pediatrics 119(3):417–423, 1991. doi: 10.1016/s0022-3476(05)82056-6; used with permission of the CV Mosby Company.)

Assessment of gestational age—new Ballard score

Many clinicians begin with examination of the heart and lungs, followed by a systematic head-to-toe examination, looking particularly for signs of birth trauma Birth Injuries The forces of labor and delivery occasionally cause physical injury to the infant. The incidence of neonatal injury resulting from difficult or traumatic deliveries is decreasing due to increasing... read more Birth Injuries and congenital abnormalities.

Cardiorespiratory system

The heart and lungs are evaluated when the infant is quiet.

The clinician should identify where the heart sounds are loudest to exclude dextrocardia. Heart rate (normal: 100 to 160 beats/minute) and rhythm are checked. Rhythm should be regular, although an irregular rhythm from premature atrial or ventricular contractions is not uncommon. A murmur heard in the first 24 hours is most commonly caused by a patent ductus arteriosus Patent Ductus Arteriosus (PDA) Patent ductus arteriosus (PDA) is a persistence of the fetal connection (ductus arteriosus) between the aorta and pulmonary artery after birth. In the absence of other structural heart abnormalities... read more Patent Ductus Arteriosus (PDA) . Daily heart examination confirms the disappearance of this murmur, usually within 3 days.

The respiratory system is evaluated by counting respirations over a full minute because breathing in neonates is irregular; normal rate is 40 to 60 breaths/minute. The chest wall should be examined for symmetry, and lung sounds should be equal throughout. Grunting, nasal flaring, and retractions are signs of respiratory distress Overview of Perinatal Respiratory Disorders Extensive physiologic changes accompany the birth process (see also Neonatal Pulmonary Function), sometimes unmasking conditions that posed no problem during intrauterine life. For that reason... read more .

Head and neck

A cephalohematoma Cephalhematoma The forces of labor and delivery occasionally cause physical injury to the infant. The incidence of neonatal injury resulting from difficult or traumatic deliveries is decreasing due to increasing... read more Cephalhematoma is a common finding; blood accumulates between the periosteum and the bone, producing a swelling that does not cross suture lines. It may occur over one or both parietal bones and occasionally over the occiput. Cephalohematomas usually are not evident until soft-tissue edema subsides; they gradually disappear over several months.

The clinician should inspect and palpate the palate to check for soft or hard palate defects. Orofacial clefts Cleft Lip and Cleft Palate Cleft lip, cleft lip and palate, and isolated cleft palate, are collectively termed oral clefts (OCs). OCs are the most common congenital anomalies of the head and the neck with a total prevalence... read more Cleft Lip and Cleft Palate are among the most common congenital defects. Some neonates are born with an epulis (a benign hamartoma of the gum), which, if large enough, can cause feeding difficulties and may obstruct the airway. These lesions can be removed; they do not recur. Some neonates are born with primary or natal teeth. Natal teeth do not have roots and may need to be removed to prevent them from falling out and being aspirated. Inclusion cysts called Epstein pearls may occur on the roof of the mouth.

Abdomen and pelvis

The abdomen should be round and symmetric. A scaphoid abdomen may indicate a diaphragmatic hernia Diaphragmatic Hernia Diaphragmatic hernia is protrusion of abdominal contents into the thorax through a defect in the diaphragm. Lung compression may cause persistent pulmonary hypertension. Diagnosis is by chest... read more Diaphragmatic Hernia , allowing the intestine to migrate through it to the chest cavity in utero; pulmonary hypoplasia and postnatal respiratory distress may result. An asymmetric abdomen suggests an abdominal mass.

The splenic edge is palpable in about 30% of newborns. Splenomegaly (splenic edge palpable > 2 cm below the left costal margin) suggests congenital infection or hemolytic anemia.

The kidneys may be palpable with deep palpation; the left is more easily palpated than the right. Large kidneys may indicate obstruction, tumor, or cystic disease.

The liver is normally palpable 1 to 2 cm below the costal margin. An umbilical hernia Classification of Abdominal Hernias A hernia of the abdominal wall is a protrusion of the abdominal contents through an acquired or congenital area of weakness or defect in the wall. Many hernias are asymptomatic, but some become... read more Classification of Abdominal Hernias , due to a weakness of the umbilical ring musculature, is common but rarely significant. The presence of a normally placed, patent anus should be confirmed.

In boys, the penis should be examined for hypospadias Hypospadias Congenital anomalies of the urethra in boys usually involve anatomic abnormalities of the penis and vice versa. In girls, urethral anomalies may exist without other external genital abnormalities... read more Hypospadias or epispadias Epispadias Congenital anomalies of the urethra in boys usually involve anatomic abnormalities of the penis and vice versa. In girls, urethral anomalies may exist without other external genital abnormalities... read more Epispadias . In term boys, the testes should be in the scrotum (see Cryptorchidism Cryptorchidism Cryptorchidism is failure of one or both testes to descend into the scrotum; in younger children, it is typically accompanied by inguinal hernia. Diagnosis is by testicular examination, sometimes... read more Cryptorchidism ). Scrotal swelling may signify hydrocele Congenital hydrocele The most common testicular and scrotal anomalies are Congenital hydrocele Undescended testes (cryptorchidism) Testicular torsion Rare anomalies include scrotal agenesis, hypoplasia, ectopia... read more Congenital hydrocele , inguinal hernia Inguinal hernia in neonates Inguinal hernias develop most often in male neonates, particularly if they are premature (in which case the incidence is about 10%). The right side is affected most commonly, and about 10% of... read more , or, more rarely, testicular torsion Testicular Torsion Testicular torsion is an emergency condition due to rotation of the testis and consequent strangulation of its blood supply. Symptoms are acute scrotal pain and swelling, nausea, and vomiting... read more . With hydrocele, the scrotum transilluminates. Torsion, a surgical emergency, causes ecchymosis and firmness.

In term girls, the labia are prominent. Mucoid vaginal and serosanguineous secretions (pseudomenses) are normal; they result from exposure to maternal hormones in utero and withdrawal at birth. A small tag of hymenal tissue at the posterior fourchette, believed to be due to maternal hormonal stimulation, is sometimes present but disappears over a few weeks.

Musculoskeletal system

Orthopedic examination includes palpation of long bones for birth trauma (particularly clavicle fracture) but focuses on detection of hip dysplasia Developmental Dysplasia of the Hip (DDH) Developmental dysplasia of the hip (formerly congenital dislocation of the hip) is abnormal development of the hip joint. (See also Introduction to Congenital Craniofacial and Musculoskeletal... read more . Risk factors for dysplasia include female sex, breech position in utero, twin gestation, and family history. The Barlow and Ortolani maneuvers are used to check for dysplasia. These maneuvers must be done when neonates are quiet. The starting position is the same for both: Neonates are placed on their back with their hips and knees flexed to 90° (the feet will be off the bed), feet facing the clinician, who places an index finger on the greater trochanter and a thumb on the lesser trochanter.

For the Barlow maneuver, the clinician adducts the hip (ie, the knee is drawn across the body) while pushing the thigh posteriorly. A felt but not heard clunk indicates that the head of the femur has moved out of the acetabulum; the Ortolani maneuver then relocates it and confirms the diagnosis.

For the Ortolani maneuver, the hip is returned to the starting position; then the hip being tested is abducted (ie, the knee is moved away from the midline toward the examining table into a frog-leg position) and gently pulled anteriorly. A palpable clunk of the femoral head with abduction signifies movement of an already dislocated femoral head into the acetabulum and constitutes a positive test for hip dysplasia.

The maneuvers may be falsely negative in infants > 3 months because of tighter hip muscles and ligaments. If the examination is equivocal or the infant is at high risk (eg, girls who were in the breech position), hip ultrasonography should be done at 4 to 6 weeks; some experts recommend screening ultrasonography at 4 to 6 weeks for all infants with risk factors.

Neurologic system

The neonate’s tone, level of alertness, movement of extremities, and reflexes are evaluated. Typically, neonatal reflexes, including the Moro, suck, and rooting reflexes, are elicited:

  • Moro reflex: The neonate’s response to startle is elicited by pulling the arms slightly off the bed and releasing suddenly. In response, the neonate extends the arms with fingers extended, flexes the hips, and cries.

  • Rooting reflex: Stroking the neonate’s cheek or lateral lip prompts the neonate to turn the head toward the touch and open the mouth.

  • Suck reflex: A pacifier or gloved finger is used to elicit this reflex.

These reflexes are present for several months after birth and are markers of a normal peripheral nervous system.

Skin

A neonate’s skin is usually ruddy; cyanosis of fingers and toes is common in the first few hours. Vernix caseosa covers most neonates > 24 weeks' gestation. Dryness and peeling often develop within days, especially at wrist and ankle creases.

Petechiae may occur in areas traumatized during delivery, such as the face when the face is the presenting part; however, neonates with diffuse petechiae should be evaluated for thrombocytopenia.

Many neonates have erythema toxicum, a benign rash with an erythematous base and a white or yellow papule. This rash, which usually appears 24 hours after birth, is scattered over the body and can last for up to 2 weeks.

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