Newborn examination

General

1. Skin colour/warmth/perfusion
   • Any jaundice at less than 24 hours of age
   • Central cyanosis
   • Petechiae not fitting with mode of birth, or newly appearing or associated with purpura
   • Pallor
   • More than 3 café-au-lait spots in a Caucasian, more than 5 in a black African newborn baby
   • Multiple haemangioma
   • Haemangioma on nose or forehead (in distribution of ophthalmic division of trigeminal nerve)
   • Haemangioma or other midline skin defect over spine
2. Alert/responsive state
3. Activity
4. Range of spontaneous movement
5. Posture
6. Muscle tone

Assess Growth

1. Weight
2. Height
3. Head circumference
   1. Less than 10th percentile or greater than 90th percentile
   2. Excessive weight loss (more than 10 % of birth weight)

Head to Toe Exam

Scalp

lesions/swelling/bruising/ lacerations

1. Subgaleal haemorrhage 
2. Caput/cephalhaematoma
   1. Consider potential for developing jaundice
3. Fused sutures
4. Feel the anterior and posterior fontanelles
   1. Microcephaly (less than 2^nd percentile)
   2. Macrocephaly (greater than 98th percentile)
   3. Conditions associated with a large anterior fontanel (greater than 3 cm)
      1. Hydrocephaly
      2. Achondroplasia
      3. Hypothyroidism
      4. Osteogenesis imperfect
      5. Vitamin D deficiency rickets

5. Ears
   1. Assess the shape of the ears
   2. Palpate the tragus and posterior auricular area 
   3. Otoscopic exam including insufflation
   4. Position/Shape of the ears – Malformed external and middle ears may be associated with serious renal or other craniofacial malformations
      1. Unresponsive to noise
      2. Absent external auditory canal or microtia
      3. Drainage from ear

6.  Hearing:
   1. Any delay in language acquisition or loss of language milestones should prompt a referral for formal hearing testing
   2. Hearing impairment is estimated to occur in 1-2/1000 live births Some etiology of hearing loss in childhood
   3. Sensory neural:
      1. cochlear malformation
      2. damage to hair cells (due to noise, disease, ototoxic agents)
      3. 8th nerve damage
   4. Conductive: (most common)
      1. ear canal atresia
      2. cerumen impaction
      3. otitis media with effusion

7. Eyes/red reflex
   1. Presence of a red reflex bilaterally suggests absence of cataracts or intraocular pathology 
   2. Leukocoria (white papillary reflex) suggests
      1. cataracts, chorioretinitis
      2. retinopathy of prematurity
      3. persistent hyperplastic vitreous
      4. retinoblastoma
   3. Leukocoria mandates an immediate ophthalmologic evaluation.
   4. Asymmetric corneal light reflex
      1. Strabismus
      2. imbalance of ocular muscle tone

 If this is not corrected early it can lead to blindness. Proper coordination of eye movements should be achieved by 3-6 months; persistent eye deviation requires evaluation.

5. Visual acuity of a newborn is approximately 20/400
6. this rapidly normalizes and by 2-3 years of age is 20/30  –  20/20.

8. Skin
   1. Inspect all of the skin of the infant (including diaper area)
   2. Describe (size, shape, color, distribution) any rashes
   3. Note any areas lacking skin
      1. Benign lesions that parents may have questions about include:
         1. Small angiomatous present on the eye lids, nape of the neck, forehead
         2. Milia: small white spots on the skin, particularly on the nose and cheeks
         3. Erythema toxicum: yellowish/white pustules on an erythematous base that occur singly or in groups.
      2. Concerning changes include large angiomatous lesions, vesicles, pustules or areas lacking skin
   4. Midline abnormalities (dimple, hair tuff, moles) on the back may indicate an underlying abnormality in the bones/nervous system.
9. Mouth
   1. Check for cyanosis in lips/tongue
   2. Palate (hard and soft)  = Cleft lip and/or palate
   3. Tongue and frenulum
   4. Tonsil exam
10. Nose
    1. Nasal flaring
    2. Nasal obstruction especially if bilateral
    3. Dacryocyst
11. Chest
    1. Heart rate and then auscultate
       1. Newborne period: As the pulmonary vascular resistance decreases, flow through the Patent Ductus Ateriosus or Patent Foramen Ovale stops as these structures close. Some murmurs heard shortly after birth will disappear.
       2. Presence of central cyanosis is an important clue for congenital heart disease.
          1. “Ts”: Tetralogy of Fallot, Tricuspid Atresia, Transposition of the Great Arteries, Total Anomalous venous return & Truncus arteriosus (there are others but these are easy to remember)
       3. Beyond the Newborn period: 50% of children have innocent murmurs Non-pathologic murmurs include:
       4. Peripheral Pulmonary flow murmur:
          1. Soft (1-2/6) systolic ejection murmur heard in L upper sternal border with radiation to the axilla and back
       5. Venous hum
          1. Soft (1-2/6) continuous murmur heard in 1st or 2nd ICS) 
       6. Innocent murmur
          1. Soft (<3/6) early systolic murmur heard along the L sternal border between the 2nd/3rd or 4th/5th. Intensity varies with position & might be heard with the bell. “Vibratory/blowing/musical” in quality.
       7. Hemic murmur (flow murmur)
          1. Heard in states with increased physiologic need (fever,anemia). Heard at base of the heart, soft (<3/6) and often associated with tachycardia
    2. Chest; count the respiratory rate
12. Abdomen
    1. Splenomegaly
    2. Organomegaly
    3. Gastroschisis/exomphalos
    4. Bilious vomiting
13. Look at both hands; look at the palms
14. Feel both brachial pulses feel for the femoral pulses

15. Hips
    1. Barlow Maneuver and Ortalani Test – Developmental dysplasia of the hip (DDH)
       1. Place the baby on a firm surface in the supine position  
       2. Flex the thighs to a right angle to the abdomen and the knees at right angles to the thighs
       3. Grasp each thigh with your forefinger along the outside shaft of the femur, with your middle finger on the greater trochanter and thumb medially
       4. Adduct the femora fully and push down toward the bed. (Barlow maneuver)
       5. Gently abduct each leg from the position of full adduction so that the knees come to lie laterally on the table
       6. During adduction, push the greater trochanters medially and forward with your fingers (Ortalani test)

2. The infant may have a congenitally dislocated or subluxable hip if:
   1. You feel or hear a click during either adduction or abduction
   2. There is spasm or discomfort of the adductor muscles of the femur Developmental Dysplasia of the hip:

• 1/100 infants have clinically unstable hips
• 1/800-1000 experience true dislocation. 
• There is a positive family history in 20% of patients and associated generalized ligamentous laxity
• 9:1 female to male ratio.
• Developmental dysplasia typically presents after birth in most infants. 
• If it is present at birth, you should look for an underlying neuromuscular disorder. 
• This type of developmental dysplasia of the hip is called Teratologic DDH.

16. Genitalia. 
    1. Check that the testes are descended in boys
    2. Enquire whether the baby has passed urine.
       1. No urine passed within 24 hours
       2. Ambiguous genitalia
       3. Bilateral undescended testes
       4. Testicular torsion
       5. Hypospadias, penile chordee
       6. Penile torsion greater than 60%
       7. Micropenis (stretched length less than 2.5 cm)
       8. Unequal scrotal size or scrotal discolouration
       9. Testes palpable in inguinal canal
17. Look at the anus; assess patency. 
    1. Enquire whether meconium has been passed – often this is all too obvious
    2. No meconium passed within 24 hours
18. Check the legs for any abnormality
19. Ventrally suspend the baby
    1. Assessing the tone
    2. Inspect and run a hand down the length of the spine as far as the sacrum.
    3. Note any dimples.
    4. Suspend the baby facing you, with held by your thumbs under the arms. Babies with decreased tone tend to slip through the hands

20. Reflexes: Check for a Fencer’s position/moro reflex/Palmar grasp/Plantar Grasp
    1. Asymmetric Tonic Neck Reflex (Fencer’s position)
       1. Appears by 35 wks gestation
       2. is fully developed at 1 month & lasts 6-7 months 
    2. Moro Reflex (startle response)
       1. Appears by 28-30 wks gestation
       2. if fully developed at term & lasts 5-6 months 
    3. Palmar grasp
       1. Appears by 28 wks, is fully developed by 32 wks gestation
       2. lasts 2-3 months

Isolated abnormalities

The following anomalies are usually of no concern when isolated (3 or more such abnormalities are of concern)

• Folded-over ears
• Hyperextensibility of thumbs
• Syndactyly of second and third toes
• Single palmar crease on one hand
• Polydactyly, especially if familial
• Single umbilical artery
• Hydrocele
• Fifth finger clinodactyly
• Simple sacral dimple just above the natal cleft (less than 2.5 cm from anus and less than 5 mm wide)
• Single café-au-lait spot
• Slate grey naevi/congenital dermal melanocytosis (Mongolian spot)
• Single ash leaf macule
• Third fontanelle
• Accessory nipples

café-au-lait spot	Mongolian spot	Syndactyly of second and third toes	ash leaf macule