Physical Examination of the

Newborn Infant

Delivery Room Evaluation

Primary responsibility: CARDIOPULMONARY

CHANGES

Closure of the ductus arteriosus

Cessation of umbilical circulation
Functional closure of the foramen ovale
Initiation of breathing

Transition from intrauterine to extrauterine life

 Reflection of cardiopulmonary and

neuromuscular changes in the first minutes of
life

APGAR SCORE

</= 4 :at risk

>/= 7 :normal
4-6 :borderline
</= 3 :abnormal

ROUTINE PROCEDURES
NGT to assess patency of the nares and
esophagus
Gastric fluid volume detect intestinal
obstruction

GESTATIONAL AGE EXAMINATION

first 24 hours of life
Premature: 37 weeks or less gestational age
Full term: 38 to 42 weeks gestational age
Post mature: more than 42 weeks

GESTATIONAL AGE EXAMINATION

SGA born prematurely: NM>P
LGA: P>NM

TERM INFANT
6-12 hours after birth
Temperature has stabilized
Initial attempt at nursing

GENERAL APPEARANCE
Level of alertness
Average sleep: 18-20 hours/day
Excessive lethargy: septicemia

Spontaneous movements
- Full term: flexor tone
- Eye movements

GENERAL APPEARANCE
Color
Cyanosis
Acrocyanosis- extremities
- cold stress

Central cyanosis - perioral region

- cardiopulmonary disease

Weight
Loss of up to 10% of birthweight acceptable
Fluid loss (withdrawal of maternal hormones, change in
renal function)

SKIN
Cyanosis
Pallor anemia, perinatal asphyxia, hypoglycemia,
thermal cold stress
Plethoric polycythemia, infant of diabetic mother,
early septicemia
Jaundice
Unconjugated bilirubin: yellow-orange
Conjugated bilirubin: yellow-green
Degree of Jaundice
-Face: 5-8mg%
-Face and upper trunk: 8-12mg%
Lower trunk and extremities: >12mg%

REMEMBER!
Jaundice during first 24
hours of life should never
be considered physiologic

SKIN
Erythema toxicum most common rash
White papulovesicular lesions on erythematous base
Except palms and soles

SKIN
Papular and pustular lesions
Milia retained sebaceous material
Miliaria obstruction of eccrine sweat glands

SKIN
True pustules: Staphylococcus infection
Vesicular lesions: herpes simplex
Minor Abnormalities
Capillary hemangiomas
Strawberry or cavernous lesions

Pigmented nevi
Mongolian spot- most common
Large, flat, greyish-blue spot
Lower trunk and buttocks

HEAD
Caput succedaneum edema in presenting
area of skull
Cephalohematoma collection of blood in
periosteum; associated with fractures
Normal Vaginal Delivery elongated, asymmetrical
Caesarean/Breech Vaginal Delivery well rounded

HEAD
Fontanels (6)
2 major
Anterior fontanel: 2-3 cm diameter
Posterior fontanel: 1 cm diameter

NORMAL: slightly sunken and soft

If persistently tense: increased intracranial pressure
If depressed: dehydration

HEAD
Head Circumference
Over the glabella and occipital prominence
Term: 32-37 cm

EYE
To open eyes
Gentle rocking of baby in side to side fashion
Hold baby in vertical upright fashion
Shape and position
Lateral upward slope: Trisomy 21
Lateral downward slope: renal dysplasia/hypoplasia
Narrow palpebral fissures and reduced intercanthal distance: Fetal
Alcohol syndrome

Conjuctiva
-check for abnormalities in development and discharge

EYE

Sclera usually white

Iris examin for congenital defects
Pupil should constrict when exposed to light
ROR should be observed
Cataracts and glaucoma: ROR absent
Retinoblastoma: White reflex

EAR
Difficult to see tympanic membrane
External auditory canal filled with vernix caseosa
and amniotic fluid debris
Angled more acutely

Hearing difficult to assess

Moro reflex

NOSE
Nasal flaring: respiratory insufficiency
Check for choanal atresia or stenosis
Use small catheter

MOUTH
Cleft lip and Cleft palate
Failure of fusion during development

Facial nerve palsy

Asymmetrical lip retraction when crying

Large tongue is typical

If excessive: hemangioma, lymphangioma, hypothyroidism

Esophageal atresia
Excessive salivation
Check with catheter

NECK
Short and not readily visible
Mildly hyperextend
Hematoma in sternocleidomastoid
Birth injury

Cystic hygromas
Most common mass in this age group
From lymphoid tissue
(+) transillumination

Thyroglossal duct cyst

most common midline mass

Webbing
Turner syndrome, Noonan syndrome

NECK
Resistance in flexing
Meningitis, subarachnoid hemorrhage with
meningeal irritation

Auscultation
Check bruits in thyroid area

THORAX AND LUNGS

Shape: round/barrel-shaped
Chest circumference: average 33 cm
Breathing: abdominal
Retractions: important signs of lung disease
Intercostal
Supraclavicular
suprasternal

Respiratory rate: 30-60 breaths/min

THORAX AND LUNGS

Apnea
cessation of breathing greater than 15 seconds or less
than 15 seconds but with bradycardia
May manifest neonatal sepsis

Periodic breathing
Period of respiration (<20 secs) separated by periods
of apnea (<10 secs) at least 3 times in succession

THORAX AND LUNGS

Breast

Full and engorged: maternal hormonal secretion

Witches milk: milky white secretions
Redness and induration: neonatal mastitis

Fractures
crepitus

Percussion
Difficult to localize

Auscultation
Awake and resting quietly
Crying if deep inspirations needed
Breath sounds ideally heard in midaxillary line in the midthorax
Bronchovesicular

CARDIOVASCULAR SYSTEM
Normal HR: 90-160 bpm
INSPECTION
Cardinal signs of heart disease
Cyanosis
Respiratory distress

Edema
Presacral, back, posterior scalp

CARDIOVASCULAR SYSTEM
PALPATION
PMI: 4th left interspace medial to midclavicular
line
Peripheral pulses
Relaxed and warm environment
Carotid, brachial, radial, femoral,
doralis pedis, posterior tibial
PDA: sharp, bounding
Shock: weak, thready
COA: UE>LE

CARDIOVASCULAR SYSTEM
PALPATION
Capillary filling time: assess degree of skin perfusion (1-2
seconds)

BLOOD PRESSURE
Cuff: 2/3 to of length of extremity
Hypertension is never benign

AUSCULTATION
Heart rate
Heart sounds
1st heart sound: apex
2nd heart sound: base (2nd left interspace

Heart murmurs
Innocent/Functional murmurs: soft vibratory quality; intermittent
Pathologic murmurs: more intense; persist beyond first days of life

ABDOMEN
Rounded, soft, moves synchronously with
respiration
MECONIUM: tarry black material
Intestinal cells, intesinal secretions, amniotic
material
Defecation prior to birth may lead to meconium
aspiration syndrome

ABDOMEN
Inspection
Slightly prominent veins
Umbilical cord
Jellylike consistency
2 arteries, 1 vein

Auscultation
Bruits: renal artery stenosis

Palpation
Most common intraabdominal mass: GUT related
Liver: 1-2 cm below right costal margin
Consistency
Hard or nodular: intrinsic liver pathology
Rubbery or firm: extrinsic pathology

Spleen: beyond 1cm below the left costal margin is

abnormal

GENITOURINARY SYSTEM
Inspection (Male)
Phallus- at least 1 cm length
Urethral opening
Hypospadias
1st degree: glans penis
2nd degree: shaft
3rd degree: from perineum to the base of penis

Scrotum: pigmented, rugae and median raphe should be

readily visible
Testes: easily palpable in the scrotum

Inspection (Female)
Labia majora
large and completely enclose labia minora
Red and edematous

GENITOURINARY SYSTEM
Inspection (Female)
Labia majora
large and completely enclose labia minora
Red and edematous

Urethral opening
Hypospadias
1st degree: glans penis
2nd degree: shaft
3rd degree: from perineum to the base of penis

Scrotum: pigmented, rugae and median raphe should

be readily visible
Testes: easily palpable in the scrotum

GENITOURINARY SYSTEM
Inguinal canals
Silk sign: indirect hernia

Ambiguous genitalia
Congenital adrenal hyperplasia
Endocrinologic workup and chromosomal analysis

Kidneys
Readily palpated
Right kidney more easily felt
Rubbery consistency, lobulated margin

Ovaries and Uterus

Rectal examination

MUSCULOSKELETAL SYSTEM
Limbs should be symmetrical, move
spontaneously and equally
Hip Joint Examination
Hip dislocation may lead to gait problems
Barlow and Ortolani maneuvers

NEUROLOGIC
Optimal time: immediately prior to feeding
Level of consciousness
Posture
Full term: flexor tone, symmetrical
Abnormalities:
Frog-leg position
opisthotonic

Movement of Extremities
Neonatal seizures
Lip smacking, bicycling movement, apnea

Sensory
Primary sensation: superficial pain (pinprick)
Crying or grimacing

NEUROLOGIC
Cranial Nerves
I (Olfactory) rarely tested
II(Vision)
- response to bright light
- ability to follow bright object over an arc of 60
- ophthalmoscopic examination
III, IV, VI
- extraocular movements
- infant should be in upright position

NEUROLOGIC
Cranial Nerves
V (Trigeminal)
- pinprick
- ability to securely close mouth during sucking
VII (Facial)
- effects readily seen during crying
- facial nerve injury
IX, X
-effective coordination of swallowing
XII
- effective sucking and milk expression
XI
- turning head to one side while restraining it at opposite side
-contraction of sternocleidomastoid

NEUROLOGIC
Basic reflexes
When infant is at quiet rest
Crying: reflexes are dampened
Slightly increased tone: brisk

Primitive Reflexes
Moro response
Hand opens and extends with abduction of upper extremities;
crying is often elicited
Appearance: 28 weeks
Disappears by: 4 months

Palmar grasp
Contraction of finger around the digit
Appearance: 28 weeks
Disappears by: 2-3 months

NEUROLOGIC
Primitive Reflexes
Asymmetric tonic neck response
Extension of the upper extremity on the side toward which
the face is turned; flexion of the contralateral extremity;
similar movements of lower extremity
Appearance: 35 weeks
Disappears by: 6 months

Placing and stepping response

Touching the dorsum of the foot to the examining table
Observe movement
Disappears by: 2 months

PREMATURE INFANTS
Weight and Gestational Age
Severe prematurity: <1000 gm birthweight; 24-28
weeks AOG
Moderate prematurity: 1000-2000 gm; 29-35
weeks AOG
Mild prematurity: 2000-2500 gm; 35-37 weeks
AOG

PREMATURE INFANTS
General Appearance

Little fat deposition

Muscular tone diminished
Severe respiratory distress may be present
Minimal activity
Cyanosis may be prominent

Skin
Shiny, translucent
Lanugo (scalp, forehead, shoulders, extremities)
Creases initially absent

PREMATURE INFANTS
Head, Eyes, Ears, Nose, Mouth
Fragile skull (reduced calcification)
Molding not substantial (small head)
Eyelids are fused until 24 weeks AOG
Hearing is present even in the most immature infant
Nose and mouth examined similar to term infants

Chest and Lungs

Pulmonary insufficiency
Intubation and mechanical ventilation often
necessary

PREMATURE INFANTS
Head, Eyes, Ears, Nose, Mouth

Fragile skull (reduced calcification)

Molding not substantial (small head)
Eyelids are fused until 24 weeks AOG
Hearing is present even in the most immature infant
Nose and mouth examined similar to term infants

Heart
Examination identical to mature infants
Patent ductus arteriosus
Appears during 3rd and 4th day of life
Loud systolic murmur

Abdomen
Diminished musculature (organs more palpable)
Necrotizing enterocolitis