25 Apr 2019 ▪ Dr.

Delfin Santos

Physical Examination of the Newborn 01b

PEDIATRICS 02

Outline Activity Limp Some flexion Active motion

I. Prior to the PE 1 (Muscle tone) of extremities
II. Vitals and Anthropometrics 1 Respiration Absent Slow, irregular Good, crying
A. Vitals 1 (respiratory
B. Anthropometrics 1
III. Preparations 1
effort)
IV. General Inspection 1 *Tested after the oropharynx is clear
A. Posture 1 Score rating: 0-3 = critically low, 4-6 = fairly low, 7-10 = normal
B. Skin 2
V. Chest/Cardiorespiratory
A. Inspection
2
2
II. Vitals and Anthropometrics
B. Palpation and Auscultation 2
VI. Abdomen 2 A. Vitals
A. Inspection 2 • Heart rate (HR)
B. Auscultation 2 ○ From birth until 1 month, the normal range is 90-190 beats per
C. Palpation 2 minute and an average heart rate of 140 beats per minute
D. Percussion 2
(Bickley and Szilagyi, 2013)
VII. Genitourinary 2
A. Inspection 2 ○ One full minute is recommended
B. Palpation 3 • Respiratory rate (RR)
VIII. Neurologic 3 ○ 30-60 breaths per minute is the normal range in neonates
A. Mental State 3 (Bickley and Szilagyi, 2013)
B. Tone and Posture 3 ○ One full minute is recommended
C. Cranial Nerves 3
• Blood pressure (BP)
D. Deep Tendon Reflex 3
E. Primitive Reflexes 3 • Temperature
IX. Musculoskeletal 4 ○ Able to maintain stable body pressure in a normal room
A. Inspection 4 environment
B. Assessment of Tone and Range of Motion 4
X. HEENT 5 B. Anthropometrics
A. Head 5
• Weight
B. Eyes 5
C. Ears 5 • Length
D. Nose 5 ○ Measure from the heel to the occiput
E. Oral Cavity 6 ▪ Can use a recumbent board
F. Neck 6 ▪ An alternate way is to hold the baby upside down by its
XI. Ballard Scoring: Gestational Age Assessment 6 heels and then measure
A. Basic Principles 6
• Head circumference
B. Physical Maturity 6
C. Neuromuscular Maturity 7 ○ Measure from the occiput to the glabella
D. Gestational Age Evaluation 9 • Chest circumference
Quick Review 9 ○ Measure at the level of the nipples
Review Questions 10 • Abdominal circumference
References 10 ○ Measure just above or below the umbilicus
Changelog 10
▪ It is recommended to measure just above the umbilicus,
Appendix 11
because after the umbilicus, the abdomen slopes
downwards and measured circumference may decrease
Abbreviation Meaning
APGAR Appearance, Pulse, Grimace,
Activity, Respiration III. Preparations
PMI Point of Maximal Impulse • Prepare for the physical exam
ROR Red Orange Reflex ○ Review history/charts
▪ Prenatal, labor and/or delivery, presentation of illness,
growth data, and vital signs
I. Prior to the PE ○ Prepare equipment
• Prior to the physical examination, quickly assess the APGAR score, ▪ Otoscope and otoscopic specula
because it is a good way to evaluate an infant’s condition ▪ Ophthalmoscope
immediately after birth and to determine the effectiveness of ▪ Tongue blade/depressors
resuscitation if later required (Ehrenstein, 2009) ▪ Stethoscope with pediatric head
• APGAR stands for: ○ Prepare extra diapers and wash cloths
○ Appearance ○ Wash hands
○ Pulse • For the physical examination of the newborn, prioritize the baby’s
○ Grimace comfort over following a specific order of steps. However, still be as
○ Activity thorough as possible when conducting the exam
○ Respiration

Table 1. APGAR evaluation of newborn infants (Santos, 2019) IV. General Inspection
Sign Score
0 1 2 A. Posture
Appearance Blue, pale Body pink, Completely • Determine whether the posture is normal, hypertonic or hypotonic
(Skin Color) extremities pink ○ Normal
blue ▪ Symmetric arm and leg flexion
Pulse (Heart Absent < 100 ≥ 100 ▪ Hands are open
rate) ▫ May clench their fists periodically, but should have some
Grimace No response Grimace Cough or time with open hands
(Response to sneeze ○ Hypertonic
catheter in ▪ Flexed with clenched fists
nostril) * ○ Hypotonic
▪ Flaccid

Group 7: Espiritu, Florendo, Manabat, Mathay, Olabre, Saporsantos 1 / 11

 B. Skin • Lung findings may be difficult to localize, since breath sounds
• Note the appearance of the skin can be transmitted all over lung fields
○ Normal
▪ Pink Cardiovascular
▪ Presence of lanugo (fine hair)
• Check for pallor and signs of cyanosis Palpation
• Look from head to toe for: • Check for abnormal chest movements
○ Skin lesions ○ Hyperdynamic precordium
▪ Abnormal pigmentation ○ Heaves, lifts, or thrills
▪ Papules • Point of Maximal Impulse (PMI) is normally felt at 4th ICS,
▪ Vesicles midclavicular line
○ Skin retractions • Assess the pulses
• Check the back of the baby for: ○ Femoral pulse is the most important for this age group
○ Mongolian spots ○ Check for presence and character of the pulse
▪ Concentrated on lower sacral area ○ Note the character of the pulse
○ Nevus ▪ Normal, thready, bounding
○ Same lesions as above, also from head to toe ○ Coarctation of aorta is less likely if distal pulses are present

V. Chest/Cardiorespiratory Auscultation
• Auscultate at four areas: Aortic, Pulmonic, Tricuspid, Mitral
A. Inspection ○ Pulmonic heart sounds are important to elucidate
▪ Helps time sequence of heart events well
Respiratory Effort • Listen for murmurs, opening snaps, ejection clicks
• Look for signs of: ○ Pulmonic: S2 splitting, normal varying with respiration
○ Tachypnea ○ Tricuspid: S1 and murmurs
○ Accessory muscle use ○ Mitral at the apex: murmurs
○ Intercostal and substernal retractions • Listen with both diaphragm and bell
○ Chest indrawing ○ When using the bell, create an appropriate seal, but do not
○ Nasal flaring press too hard, as this may turn it into a diaphragm
○ Grunting ○ The bell is useful for listening for S3, S4, and diastolic
○ Wheezing, stridor murmurs, which are lower-pitched sounds
○ Abdominal breathing, which may be normal for newborns

Other Abnormal Movements

VI. Abdomen
• Observe the newborn for lip smacking, eye fluttering, bicycling, and
A. Inspection
tremors
• Note the shape of the abdomen
• Occasional tremor and twitching are not uncommon, but are a
○ Flat, scaphoid, or distended
concern if they are persistent
• Assess the umbilicus
○ Evaluate state of healing
Chest Appearance
○ In fresher umbilicus, check for 2 umbilical arteries and 1
• Assess whether the chest is broad, narrow, bell-shaped, or short
umbilical vein
• Note the symmetry of chest expansion ○ Check for umbilical and ventral hernia
• Note any chest well abnormalities: ▪ But they do not usually appear right away in the newborn
○ Pectus excavatum: caved in or sunken appearance period
○ Pectus carinatum: protruding outwards
• The xiphoid process is more prominently seen and felt in neonates B. Auscultation
• Listen to the bowel sounds: use the diaphragm
Breast ○ Auscultate one quadrant for 1 minute
• Note the placement, shape, and pigmentation of the breast ▪ Abdominal wall is thin, and sounds radiate easily to all parts
• Measure the nipple spacing ○ Check for bruits
• Check for breast budding and excessive breast tissue
○ Males may have excess breast tissue due to estrogen C. Palpation
stimulation from the womb • Perform light and deep palpation on all four quadrants
• Note any secretions and white milk discharge, which may be normal ○ Check for any masses and tenderness
○ For deep palpation: use the one hand to support the baby’s back
Precordium while pressing down with the other
• Determine whether the precordium is dynamic or hyperdynamic, and • Check the consistency, position, and possible enlargement of the
whether there are transmitted impulses liver, kidneys, and spleen
○ At this age, it is normal to easily palpate the spleen
B. Palpation and Auscultation ▪ For deep palpation of the spleen, try to touch the fingers of
• Try to find a time when the baby is not crying to auscultate. the hand at the back supporting the baby, and the hand
Otherwise, the heart or lung sounds may not be properly deep palpating
appreciated • A distended and full bladder may also be felt

Respiratory D. Percussion
• Measure the liver span
Auscultation ○ This is the only percussion step in the whole newborn PE
• Use the diaphragm
• Auscultate in all four lung fields VII. Genitourinary
• Listen from the front and the back
○ Front: Lower left → Lower right → Upper right → Upper left
A. Inspection
○ Back: Upper left → Upper right → Lower left → Lower Right
• Compare both sides for symmetry Labia Majora and Labia Minora
• Infant breath sounds are more vesicular than adults • In a term neonate, the labia majora are more prominent
○ Rarely hear bronchial breath sounds in infants, even with • In a pre-term neonate, the labia minora are more prominent
consolidation

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VERSION 02
• To inspect the vaginal introitus, deviate apart the labia majora
○ Whitish secretions may be normal due to estrogen stimulation
in utero

Anus and Rectum

• Assess the patency, position, fissures, and fistulas of the rectum
○ A feeding tube may be inserted in the rectum to test patency
• A rectal exam is not done routinely
• Tip up to see sacral dimple or pit that could communicate with the Babinski Reflex* Stimulating Birth to 1 year
spinal canal from the heel
○ Tufts of hair are suggestive of spina bifida occulta going forward
to the base of
B. Palpation the toes.
• In female neonates, check labia majora for masses Fanning out of
• In male neonates, check the inguinal area for hernia, and testicles the toes and
for ambiguous genitalia the extension of
○ Palpate for both testes, and check for an empty sac the big toe is a
▪ They may present with undescended testes positive sign for
this reflex
Rooting Reflex Stroke the Birth to 3–4
VIII. Neurologic perioral skin at months
the corners of
A. Mental State the mouth.
• Assess the neonate’s mental status from general observation The mouth will
○ This assessment should have been initiated from the beginning open and baby
of the neonate PE. will turn the
• Note if patient has appropriate response to exam procedures and head toward
physical manipulation the stimulated
○ E.g. Grimace when being poked or prodded and a good cry side and suck
Moro Reflex** Hold the baby Birth to 4
B. Tone and Posture supine, months
• Active extension and flexion of extremities and hips are indication of supporting the
tone and posture head, back, and
• Ensure that each side are symmetric legs. Abruptly
lower the entire
C. Cranial Nerves body about 2
• Normal cranial nerve tests cannot be performed, as the neonate will feet.
not be able to do maneuvers or follow commands The arms
• Inferentially, eye opening and blinking mean intact EOMs abduct and
• Observing facial symmetry with cry will indicate: extend, hands
○ Facial muscle strength open, and legs
○ Vocalization flex. Baby may
○ Ocular muscle strength (when the baby looks around) cry
Asymmetric Tonic Neck With baby Birth to 2
D. Deep Tendon Reflex Reflex supine, turn months
• Assess for normal tone and focal deficits head to one
• Usually only the patellar stretch reflex is elicited side, holding
○ No need for a reflex hammer jaw over
○ Use your finger and tap on the patellar tendon shoulder.
• Ankle clonus may be elicited by dorsiflexion of the foot The arms/legs
○ 7 to 8 beats are still normal on side to
which head is
E. Primitive Reflexes turned extend
while the
Table 2. Primitive reflexes in the neonate (Bickley & Szilagyi, opposite
2013). T/N: Only the first six reflexes (palmar grasp, plantar grasp, arm/leg flex.
Babinski, rooting, moro and asymmetric tonic neck) were discussed Repeat on
and elicited in the video series. The group added the rest for other side.
completion. Trunk Incurvation (Galant) Support the Birth to 2
Primitive Reflex Maneuver Ages Reflex infant prone months
Palmar Grasp Reflex Place your Birth to 3–4 with one hand
fingers into the months and stroke one
baby’s hands side of the back
and press 1 cm from
against the pal- midline, from
mar surfaces. shoulder to
The baby will buttocks.
flex all fingers The spine will
to grasp your curve toward
fingers the stimulated
Plantar Grasp Reflex Touch the sole Birth to 6–8 side
at the base of months Landau Reflex Suspend the Birth to 6
the toes. The infant prone months
toes will curl. with one hand.
The head will
lift up, and the

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VERSION 02
 spine will ○ Sinus tracts
straighten ○ Masses

Feet
• Assess the curvature and rotational deformities related to being
folded up in the uterus
○ Metatarsus varus
▪ Turned inward on its axis
○ Club foot
Parachute Reflex Suspend the 8 mo and does
infant prone not disappear
Hip
and slowly
lower the head • Inspect gluteal skin folds
toward a • Assess for significant asymmetry indicated in congenital dysplasia
surface of hip
The arms and
legs will extend B. Assessment of Tone and Range of Motion
in a protective
fashion Tone
Positive Support Reflex Hold the infant Birth or 2 • Passive flexion and extension of the upper and lower extremities to
around the months until 6 assess muscle tone
trunk and lower months
until the feet Range of Motion
touch a flat • Upper extremity range of motion
surface ○ Flex and extend shoulders and elbows
The hips, • Lower extremity range of motion
knees, and ○ Flex and extend hips and knees
ankles will • Hip range of motion
extend, the ○ Fully abduct hips
infant will stand ○ Done without difficulty or resistance to the table
up, partially ○ Done slowly because resistance is met if done fast
bear weight, ○ Note: Perform both Barlow and Ortolani maneuvers at the
sagging after end of exam
20-30 seconds ○ A dislocated hip has limited range of motion on one side

Ortolani Maneuver
Placing and Stepping Hold the infant Birth (best after • Fingers on greater trochanter
Reflexes upright as in 4 days; variable • Hands control both legs
positive support age to
• Fully abduct
reflex. Have disappear)
• Feel for the acetabulum and head of femur coming together or
one sole touch
clicking to join
the tabletop.
The hip and
knee of the foot
will flex and the
other foot will
step forward.
Alternate
stepping will
occur

*The Babinski reflex was discussed as part of the primitive reflexes in the video
series
**Do not attempt to elicit the moro reflex by startling the infant with a “bang” or
loud noise (Santos, 2019)

Assessment of Suck
• Use a pacifier or watch the baby feed

Figure 1. Ortolani Maneuver (Bickley & Szilagyi, 2013).

IX. Musculoskeletal
Ortolani Test
A. Inspection Place the baby supine with the legs pointing toward you. Flex the
• Assess symmetry, length, and deformities of extremities legs to form right angles at the hips and knees, placing your index
fingers over the greater trochanter of each femur and your thumbs
Digits over the lesser trochanters. Abduct both hips simultaneously until
• Note normal digit position, syndactyly, and polydactyly of both the the lateral aspect of each knee touches the examining table.
hands and feet
○ Make sure to fan the digits With a developmental dysplasia of the hip, you feel a “clunk” as the
▪ Checks if there are small webs femoral head, which lies posterior to the acetabulum, enters the
acetabulum. A palpable movement of the femoral head back into
Spine place constitutes a positive Ortolani sign.
• Inspect from skull down to coccyx - Bickley & Szilagyi, 2013
• Check for
○ Obvious scoliosis and other spinal abnormalities Barlow Maneuver
○ Tufts of hair • Hands in the same position as for Ortolani maneuver
○ Skin disruption, dimples • Middle finger on the greater trochanter

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• Stress hip posteriorly, superiorly, and laterally to try to bring it in
and out of acetabulum
• Repeat on the other side
• Stabilize non-tested side with other hand
Figure 2. Barlow Manuever (Bickley & Szilagyi, 2013).
Barlow Test
Pull the leg forward and adduct with posterior force; that is, press in
the opposite direction with your thumbs moving down toward the
table and outward. Feel for any movement of the head of the femur
laterally. Normally there is no movement and the hip feels “stable.”
A positive Barlow sign is not diagnostic of a dysplastic hip, but
indicates laxity and a dislocatable hip progressively, and the baby
needs to be re-examined in the future. If you feel the head of the
femur slipping out onto the posterior lip of the acetabulum, this
constitutes a positive Barlow sign. If you feel this dislocation
movement, abduct the hip by pressing with your index and middle
fingers back inward and feel for the movement of the femoral head
as it returns to the hip socket.
- Bickley & Szilagyi, 2013
X. HEENT
A. Head
• Note shape and symmetry of the head
○ Molding may be present due to birth process
• Check for lesions or scalp wounds
• Check for abnormal hair in scalp
• Feel sutures if widely split or overriding
• Assess fontanelles
○ Anterior fontanelle: open or closed, size
○ Posterior fontanelle: open or closed
▪ Some may have an open posterior fontanelle at birth
Figure 3. Anterior and Posterior Fontanelles (Bickley & Szilagyi, 2013).
Examination of the Fontanelles
• Upon inspection:
○ Carefully examine the fontanelle because its fullness
represents intracranial pressure
▪ A full anterior fontanelle with increased intracranial
pressure is seen when a baby cries or vomits
○ Pulsations of the fontanelle reflect the peripheral pulse and
are normal
• Learn to palpate the fontanelle
18.01b Physical Examination of the Newborn
VERSION 02
○ A bulging fontanelle is concerning for increased intracranial
pressure
○ A depressed fontanelle may suggest dehydration
- Bickley & Szilagyi, 2013
B. Eyes
• Provide shade or tip the head up to stimulate opening
○ Bright lights cause them to blink
○ Use techniques or colorful toys as fixation devices
• Look for:
○ Conjugate gaze, esotropia, exotropia
▪ Esotropia and exotropia may be normal
○ Discoloration
▪ Icterus
▪ Hemorrhage
▪ Redness from inflammation
• Check palpebra, conjunctiva, and pupils that should constrict briskly
• Elicit the red orange reflex (ROR) with ophthalmoscope
○ Check both eyes
○ Use zero diopters
○ Observe 10 inches or so above the face
○ Retinal abnormalities are not always bilateral
○ Check for cataracts with ophthalmoscope
Examination of the Eyes
• Persistent ocular discharge and tearing beginning at birth may
be from dacryocystitis or nasolacrimal duct obstruction.
• Failure to progress along these visual developmental milestones
may indicate delayed visual maturation.
• Congenital glaucoma may cause cloudiness of the cornea. A
dark light reflex can result from cataracts, retinopathy of
prematurity, or other disorders.
• A white retinal reflex (leukocoria) is abnormal, and cataract,
retinal detachment, chorioretinitis, or retinoblastoma should be
suspected.
• Occlusion of the lens may represent a cataract.
• Small retinal hemorrhages may occur in normal newborns.
Extensive hemorrhages may suggest severe anoxia, subdural
hematoma, subarachnoid hemorrhage, or trauma.
- Bickley & Szilagyi, 2013
C. Ears
• Note shape and any deformities of the ears
• Check for abnormal ear position
○ If the pinna is below the imaginary line drawn across the inner
and outer canthi of the eyes, ears are low-set
• Look for pits and tags, which may suggest internal ear structure
problems, kidney abnormalities, hearing difficulties
Examination of the Ear
• Small, deformed, or low-set auricles may indicate associated
congenital defects, especially renal disease.
• Perinatal problems raising the risk for hearing defects include
birth weight <1,500 g, anoxia, treatment with potentially ototoxic
medications, congenital infections, severe hyperbilirubinemia,
and meningitis.
- Bickley & Szilagyi, 2013
Otoscopic Exam
• Less extensive as compared to adult otoscopic exam
○ May be difficult to perform as the auditory canal might be filled
with vernix
• Ear canal is angled from inside and upward
○ Pull ear straight down
• Patency, masses, structures, tympanic membrane
• Light reflex is usually diffuse
○ May not visualize triangular cone of light
• Pneumatic otoscopy is of limited value because ear drums do not
move much
D. Nose
• Evaluate structure of the nose
○ Flattened nasal bridge
○ Deviated septum
• Occlude one nares at a time to demonstrate that infant can move
air through nares
○ Not seen in choanal atresia
5 / 11
 ▪ A feeding tube may be inserted in the canal to test for Lanugo
patency or blockage • Appears at 24-25 weeks
• Abundant on shoulders and upper back by 28 weeks
E. Oral Cavity • With increasing gestation, it starts to disappear
• Perform external observation of philtrum and vermillion border ○ Lower back area thins first
○ Absence suggests Fetal Alcohol Syndrome ○ Bald areas appear over lumbosacral area
• Use tongue blade to open mouth and assess the following: ○ Mostly bald by term
○ Tongue: position, size, and mobility (frenulum) ○ Amount and location may vary with nutritional status, ethnicity,
○ Gingiva hormonal, and metabolic factors
○ Natal teeth
○ Buccal mucosa
○ Gag reflex
○ Arching of palate
▪ Cleft palate
▪ Epstein pearls Figure 6. Ballard Scoring for Hair Changes. (Santos, 2019).
▫ Whitish inclusions at the junction between hard and soft
palate
▫ Normal and may disappear with time

F. Neck
• Note any masses, pits, clefts
○ Congenital cysts
○ Move skin around to see things appropriately
• Measure thyroid size and note position of trachea
• Palpate for neck nodes
○ Lymphadenopathy is not usual for this age
• Check clavicles to ensure that there is no fracture and crepitus
• Check range of motion by moving neck right and left
○ Look for possible torticollis

XI. Ballard Scoring: Gestational

Age Assessment
A. Basic Principles
• Based on two components:
○ Physical Maturity
○ Neuromuscular Maturity
• Scoring:
○ -1 to 5 = skin and popliteal angle
○ -2 to 4 = plantar surface and eyes/ears
○ 0 to 4 = posture and arm recoil
○ -1 to 4 = all other parameters
○ Low scores indicate immature babies while higher scores Figure 7. Lanugo Hair and Its Amount as an Indicator for Gestational Age
indicate mature/post-mature babies. (Karlsen, 2006).
• Timing
○ Most reliable if done by 12 hours of life Plantar Surface
• Keep infant warm • Assess creases on the plantar surface

B. Physical Maturity

Skin

Figure 8. Ballard Scoring for Plantar Surface Changes (Karlsen, 2006).

Figure 4. Ballard Scoring for Skin Changes (Santos, 2019).

Figure 9. Plantar Creases as an Indicator for Gestational Age (Karlsen,

2006).
Figure 5. Skin Changes as an Indicator for Gestational Age (Karlsen, 2006).

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 Breast Bud Female
• A grade of -1 and 0 are the same with no breast budding

Figure 16. Ballard Scoring for Female Genitalia Changes (Santos, 2019)
Figure 10. Ballard Scoring for Breast Bud Changes (Santos, 2019).

Figure 17. Morphological Changes of the Female genitalia and

Corresponding Ballard Score (Karlsen, 2006).

C. Neuromuscular Maturity

Principles of Neuromuscular Exam

• Positioning the newborn infant
○ Head midline with hips flat
• Reliability of exam altered by
○ Sedation
Figure 11. Breast Budding as an Indicator for Gestational Age. (Karlsen, ○ Anesthesia
2006) ○ Paralysis
○ Critically ill state
Eyes/Ears ○ Breech position
• May be stressful for premature and sick infants
○ Should be performed by skilled neonatal ICU personnel once
infant is stabilized and able to tolerate the exam

Posture
Figure 12. Ballard Scoring for Eyes and Ear Changes (Santos, 2019). • 0= flaccid, 4=fully flexed infant
○ As the baby matures, he becomes more flexed

Figure 18. Ballard Scoring for Postural Changes (Santos, 2019).

Figure 13. Eye and Ear Changes as Indicators for Gestational Age (Karlsen,
2006).

Genitals

Male Figure 19. Corresponding Ballard Scores for Postural Changes (Karlsen,
2006).

Figure 14. Ballard scoring for Male Genitalia Changes (Santos, 2019).
Square Window
• Assesses wrist flexibility and/or resistance to extensor stretching at
the wrist
• Press gently on knuckles to straighten fingers
• Apply gentle pressure on back of hand close to fingers to avoid wrist
rotation
• Stop pressing when resistance felt
• Angle decreases as gestational age increases
○ Take note: Wrist is the only joint that becomes more flexible
when baby matures

Figure 15. Morphological Changes of the Male Genitalia and Corresponding

Ballard Score (Karlsen, 2006).

Figure 20. Ballard Scoring for Extent of Wrist Flexion (Santos, 2019).

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 Figure 25. Corresponding Ballard Scores for the Popliteal Angle. (Karlsen,
2006)

Scarf Sign
• Tests passive tone of posterior shoulder girdle flexor muscles
• Supine position with head midline
• Hold infant’s hand across chest
• Use thumb of other hand to push elbow across chest or gently pull
arm across chest
• Stop when resistance is felt
• Score based on position of elbow at landmarks:
○ -1 = neck
○ 0 = contralateral axillary line
○ 1 = contralateral nipple line
Figure 21. Corresponding Ballard Scores for Wrist Flexion (Karlsen, 2006). ○ 2 = xiphoid process
○ 3 = ipsilateral nipple line
Arm Recoil ○ 4 = ipsilateral axillary line
• Tests for passive flexor tone of biceps muscle
• One arm at a time to avoid Moro reflex
• Hold infant’s head, place in supine position
• Briefly flex arms, then momentarily extend arm and release hand
• Score based on angle of recoil when arm returns to flexion Figure 26. Ballard scoring for Extent of Arm Adduction Across the Midline.
○ Angle decreases as the child matures (Santos, 2019).

Figure 22. Ballard Scoring for Extent of Arm Flexion (Santos, 2019).

Figure 23. Corresponding Ballard scores for Arm Recoil. (Karlsen, 2006)

Popliteal Angle
• Assesses maturation of passive flexor tone at the knee joint Figure 27. Corresponding Ballard Scores for the Scarf Sign. 1= contralateral
nipple line, 2= xiphoid process, 3=ipsilateral nipple line, 4= ipsilateral axillary line
• Refrain from touching hamstrings (muscle group being tested)
(Karlsen, 2006)
during maneuver
• Thighs in knee-chest position with knee fully flexed Heel to Ear
• Relax infant, then grasp foot at sides • Tests for passive flexion or resistance to extension of posterior hip
• Extend leg until resistance is felt flexor muscles
• Estimate angle behind the knee • Refrain from touching gluteus muscle (muscle group being tested)
○ Angle decreases as the child matures during maneuver
• Measurement unreliable if frank breech in utero • Rest leg alongside body
• Grasp foot along both sides
• Gently pull toward ear until resistance felt
• Measurement unreliable if frank breech in utero
• Score based on location of heel to landmarks
Figure 24. Ballard Scoring for Extent of Knee Extension. (Santos, 2019) ○ -1 = ear
○ 0 = nose
○ 1 = chin
○ 2 = nipple line
○ 3 = umbilical area
○ 4 = femoral crease

Figure 28. Ballard Scoring for Extent of Hip Flexion (Santos, 2019).

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 Anthropometrics
Length Heel to occiput
HC Occiput to glabella
CC Level of the nipples
AC Above or below the umbilicus
General Inspection
Normal: symmetric arm and leg
flexion, arms are open
Posture Hypertonic: flexed with clenched
fists
Hypotonic: flaccid
Normal: pink, presence of
lanugo
Check for: pallor, signs of
Skin cyanosis, skin lesions, skin
retractions
Mongolian spots: concentrated
on lower sacral area
Chest/Cardiorespiratory
Figure 29. Corresponding Ballard scores for Heel to Ear. 0= nose, 1= chin,
Respiratory effort: accessory
2= nipple, 3= umbilical area, 4= femoral crease. (Karlsen, 2006) muscle use, intercostal and
substernal retractions, chest
D. Gestational Age Evaluation indrawing
• Add scores of Physical and Neuromuscular Maturity Abdominal breathing: may be
• Total score correlates to week gestation normal
Other abnormal movements: lip
smacking, eye fluttering,
bicycling, tremors
Chest appearance: shape,
Inspection
symmetry, chest wall
abnormalities, xiphoid process
Breast: placement, shape,
pigmentation, nipple spacing,
breast budding, excessive
breast tissue, discharge,
secretions
Precordium: dynamic or
hyperdynamic, transmitted
impulses
Auscultation: using the
diaphragm, auscultate in all four
Respiratory lung fields
Infant breath sounds: more
vesicular
Palpation: abnormal chest
movements, PMI, femoral pulse
Cardiovascular (most important)
Auscultation: Aortic, Pulmonic,
Tricuspid, Mitral
Abdomen
Shape of the abdomen,
Inspection umbilicus (state of healing,
hernia)
Auscultation One quadrant for 1 minute
Light and deep palpation on all
four quadrants
Figure 30. Ballard Scoring System. Maturity rating can be calculated as
Palpation Liver, kidneys, spleen:
gestational age of the fetus in weeks. T/N: See appendix for a larger image consistency, position and
(Santos, 2019). enlargement
Percussion Liver span
Quick Review Genitourinary
Term: labia majora more
Summary of Key Terms prominent
Pre-term: labia minora more
PE Component Assess/Measure/Check for prominent
Prior to the PE Inspection
Vaginal introitus, secretions
Appearance (skin color)
Rectum: patency, position,
Pulse (heart rate)
fissures, fistulas
Grimace (response to catheter in
APGAR Sacral dimple, pit
nostril)
Female: labia majora (masses)
Activity (muscle tone)
Palpation Males: inguinal area (hernias),
Respiration (respiratory effort)
testes (ambiguous genitalia)
Vitals and Anthropometrics
Neurologic
Normal range: 90-190 bpm
HR (Birth-1 month) Appropriate responses to PE
Average: 140 bpm Mental State
and physical manipulation
Normal range: 30-60 breaths
RR (Neonates)
per minute

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VERSION 02
 Norma: active extension and
Tone and Posture
flexion of extremities and hips
Eye opening, eye blinking,
ocular muscle strength
Cranial Nerves
Facial symmetry: facial muscle
strength, vocalization
Normal tone, focal deficits
Patellar reflex: elicited with the
Deep Tendon Reflexes finger
Ankle clonus (normal: 7 – 8
beats)
Palmar grasp reflex
Plantar grasp reflex
Primitive Reflexes Babinski reflex
(Discussed in class and elicited in
the video series)
Rooting reflex
Moro reflex
Asymmetric tonic neck reflex
Musculoskeletal
Extremities: symmetry, length,
deformities
Digits: normal digit position,
syndactyly, polydactyly
Spine: abnormalities, tufts of
Inspection hair, disruptions, dimples,
masses
Feet: curvature, rotational
deformities
Hip: gluteal skin folds,
asymmetry
Upper extremities
Lower extremities
Tone and Range of Motion
Hip range of motion: Ortolani
maneuver, Barlow maneuver
Positive: palpable movement of
Ortolani Maneuver the femoral head back into
place
Stress hip posteriorly, superiorly
and laterally
Barlow Maneuver Positive: femur slipping out onto
the posterior lip of the
acetabulum
HEENT
Shape, symmetry, lesions,
wounds
Head
Anterior and posterior
fontanelles
Stimulate opening of the eyes
Look for: conjugate gaze,
esotropia, exotropia,
Eyes discoloration
Check palpebra, conjunctiva,
and pupils
Elicit the ROR
Deformities, abnormal ear
positions, pits and tags
Ears
Otoscopic exam: pull ear
straight down
Structure
Nose
Occlude one nares at a time
Philtrum, vermillion border,
Oral Cavity frenulum, gingiva, teeth,
mucosa, palatal arch, gag reflex
Masses, pits, clefts
Thyroid size, position of trachea
Neck
Neck nodes
Clavicles
Review Questions
1. Which part of the newborn PE exam requires percussion?
A. Lung assessment
B. Bowel sound assessment
C. Liver span
2. In the Ortolani maneuver, if a developmental dysplasia of the hip is
present, you will feel a “clunk/click”. This is due to the femoral
18.01b Physical Examination of the Newborn
VERSION 02
head, which lies posterior to the acetabulum, hitting the greater
trochanter.
A. Only the first statement is true.
B. Only the second statement is true.
C. Both statements are true.
D. Both statements are false.
3. A bulging anterior fontanelle is indicative of?
A. Dehydration
B. Increased intracranial pressure
C. Infection
4. A Ballard score of 1 for scarf sign indicates an elbow reaching
which landmark?
A. Contralateral axillary line
B. Contralateral nipple
C. Xiphoid
D. Ipsilateral nipple line
5. A Ballard score of 2 for heel to ear has the heel located on which
landmark?
A. Chin
B. Nipple line
C. Nose
D. Umbilical area
Answer Key: 1c, 2a, 3b, 4b, 5b
References
(1) ASMPH 2020. (2018). Physical Examination of the Newborn [Trans].
(2) Bickley, L. & Szilagyi, P. (2013). Bates’ Guide to Physical Examination and
History Taking (11th ed.)
(3) Ehrenstein, V. (2009). Association of Apgar scores with death and
neurologic disability. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2943160/
(4) Karlen, K. (2006). Gestational age assessment of the newborn. [Slides]
(5) Loyola University Health System. (2001). Normal newborn screening
physical exam. [Video]
Changelog
Changes in v02
(1) P1, Table 1. Rearranged table rows. Added scoring interpretation. (Santos,
2019)
(2) P2, Chest Appearance, A. Inspection. Changed to “The xiphoid process is
more prominently seen and felt in neonates.” (Santos, 2019)
(3) P2, Auscultation. Specified direction of auscultation. (Loyola University
Health System, 2001).
(4) P2, Auscultation. Added “as this may turn it into a diaphragm”. (Loyola
University Health System, 2001).
(5) P2, Abdomen. Added “they do not usually appear right away in the newborn
period”. (Loyola University Health System, 2001).
(6) P3. Anus and Rectum. Changed rest to test.
(7) P3, A. Mental State. Modified “grimace, cry” to “E.g. grimace when being
poked or prodded and a good cry”. (Santos, 2019).
(8) P3, B. Tone and Posture. Added “ensure that each side are symmetric”.
(Santos, 2019).
(9) P3, C. Cranial Nerves. Added “ocular muscle strength (when the baby looks
around)”. (Santos, 2019).
(10) P3, Plantar Grasp Reflex, Table 2. Added “will”. (Bickley and Szilagyi,
2013).
(11) P3, E. Primitive Reflexes. Added section on “assessment of suck”. (Santos,
2019).
(12) P4, Digits, A. Inspection. Removed “and nail beds”. (Santos, 2019).
(13) P3, Digits, A. Inspection. Added “Checks if there are small webs”. (Santos,
2019).
(14) P5, Eyes. Added “check both eyes for ROR” (Loyola University Health
System, 2001).
(15) P5, Otoscopic Exam, C. Ears. Changed to “abnormal” (Santos, 2019).
(16) P5, Otoscopic Exam, C. Ears. Added “A feeding tube may be inserted in the
canal to test for patency or blockage”. (Santos, 2019).
(17) P6, Oral Cavity. Added “tongue” for position, size, and mobility
(18) P6, Ballard Scoring. Added -2 to 4 for plantar surface and eyes/ears
(19) P6-9, Figures 5-29. Resized, cropped and changed the alignment.
(20) P6, Lanugo. Added a picture for Figure 7.
(21) P7, Neuromuscular Maturity. Moved principles of neuromuscular exam here.
(22) P8, Scarf Sign. Removed “contralateral” in contralateral neck.
(23) P9, Added Quick Review table.
(24) P10, #2, Review Questions. Changed to “Ortolani”. (Santos, 2019).
(25) P10, References. Added references.
10 / 11
 Appendix

Table 1. The New Ballard Scoring System for Determining Gestational Age in Weeks (Bickley and Szilagyi, 2013).

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