Neonatal examination

Dany Hamod
Neonatologist
SGH-UOB
 Step 1: Preparation
stethoscope

ophthalmoscope

spatula

tape measure

stadiometer (or equivalent)

centile chart.
Whoever performs the examination must be familiar
with the art of clinical examination

looking (inspection)

feeling (palpation)

listening (auscultation)

tapping (percussion)
 Step 2: observation

Looking to the neonate

 listen to the mother, who will already be the
best judge of her babys behaviour

Once all the information has been gathered

from these sources, the neonate can be
disturbed.
 Step 3: examination
One of the most difficult and important systems to
examine is the heart

Baby must be calm and content

Examine the heart first

The next steps are palpation and auscultation

Performed with the neonate undressed

 Before undressing the neonate

Concentrate on the exposed parts of the baby

before putting hands in a nappy full of
meconium
 Scalp
The scalp is most commonly the presenting part at
delivery

Easily traumatised and swelling with or without

bruising is relatively common

A cranial meningocele or encephalocele may also

produce a swelling

The scalp is also a common site for birthmarks or

other skin abnormalities
 Head
Shape
The shape of the head can provide useful
information, e.g. certain syndromes or
sequences of abnormal development result in
an abnormally shaped head, as does
premature closure of certain sutures
(craniosynostosis)
 Fontanelles and sutures
Fontanelles are areas where at least three bony
plates of the skull meet. They can be felt as soft
spots on the head

The posterior fontanelle normally measures less

than 0.5 cm at birth and closes shortly after it

The anterior fontanelle normally measures 15

cm in diameter at birth and does not close until
18 months of age
 Auscultate the fontanelle

Several diagnosis can be noticed from auscultation

 Sutures
Gaps between two bony plates of the skull

At birth the sutures may be easily palpable,

but the bone edges are not widely separated

Premature fusion of a suture may be palpable

as a prominent edge, but beware, because
overriding sutures can often be felt following
delivery, but they will resolve with time
 Size

The occipitofrontal head circumference is measured by

placing a tape measure around the head to encircle the
occiput, the parietal bones and the forehead (1 cm above the
nasal bridge)

This measurement should be repeated three times and the

greatest measurement of the three is taken as being correct

There are centile charts available that take into account the
babys sex and gestation, but if these are not available the
normal range for a term baby is between 32 and 37 cm
 Weight and Height
Birth to 6 month : 1.5 to 2.5 cm a month and 140
to 200 gram a week

Baby double his birth weight at age 5 month

From 6 to 12 month: 1 cm a month and 85 to

140 g a week

Baby triple his birth weight at 1 year

 Face
The overall appearance of the face can be
characteristic in certain syndromes, e.g. Downs
syndrome, Edwards syndrome

Individual features in isolation do not necessarily

indicate a syndrome, but in combination with
other features they make a syndrome more likely

See both the parents before commenting on

abnormal facies, as they may simply be familial
 It is also important to look at the symmetry of
the face

Asymmetry may result from abnormalities of

development of individual components,
postural deformities or syndromes, e.g.
hemihypertrophy, Goldenhars syndrome
 Nose
Babies are nasal breathers

The nose is often squashed in utero or during

the time of delivery, or it may not be
completely patent

Occluding each nostril in turn will check for

patency of the opposite nostril.
 Lips
External abnormalities of the lips are usually
obvious, but internal abnormalities are not
necessarily

Internal examination may require the use of a

spatula and a light source
 Mouth

Alveolar ridges (gums)

Tongue

Palate
 Alveolar ridges (gums)
Inspect for

cysts

Clefts

Neonatal teeth
 Tongue
Careful examination for

Cysts or dimples

Tongue size

Underside of the tongue should be inspected

along with the floor of the mouth
 Palate
Inspected carefully to exclude the presence of
a cleft palate

It is not sufficient just to palpate the palate as

clefts of the soft palate may be missed in this
way.
 Ears
Looke for

Size

Shape

Position

Abnormalities e.g. skin creases, and surrounding

anomalies, e.g. dimples and skin tags
 Eyes
Be familiar with the normal anatomy of the eye prior to its
examination

Check carefully to make sure that there are two of them

Look at their

Size
Position (including distance of separation)
Features around them (epicanthic folds, eyelids and
eyebrows)
Slant of the palpebral fissures
Color of sclera Defenition

White Normal

Blue Osteogenesis imperfecta

Yellow Jaundice

Red Hemorrhagic after delivery

Normal eye
Eyelid edema
Subconjunctival Hemorrhage
Congenital Glaucoma
 The iris

Normally blue

Circular with a round opening (the pupil) in the

center

Appears to have fibers radiating out from the center

Presence of white spots on the iris may be significant

 The cornea and lens
Should be clear

Opacification may be secondary to congenital

glaucoma, in which there is obstruction to the
drainage of the eye, or a cataract

You should be able to elicit a red reflex by

illuminating the eye with the ophthalmoscope
set at +10 dioptres and held 1520 cm from the
eye
normal
Retinoblastoma
 Neck
The neck may be shortened or webbed, or there
may be restriction of the range of movement
(congenital torticollis)

The neck should have no abnormal swellings or

dimples

The clavicles should be examined for fractures,

especially if there is any history of shoulder
dystocia
 Limbs

These should be of normal proportions,

symmetrical and normally formed
 Hands and feet

They should be

Positioned in line with the limbs

Symmetrical to each other

There are usually multiple palmar creases and

creases the length of the sole of the foot in
the term baby
 Digits
Count the number of digits on each hand and
foot

The digits should not be fused, shortened or

abnormally shaped

The nails should be perfectly formed

Skin of newborn
Acrocyanosis
Vernix caseosa
Lanugo hair
Desquamation
Physiologic jaundice
 Chest
The chest should be

Symmetrical

Shape

Two nipples, each situated just lateral to the

midclavicular line, one on each side
 Cardiovascular system
Consider

Heart rate
Heart rhythm

Heart position

Pulse volume
Heart noises
 Heart rate and rhythm

Normal resting heart rate of a term neonate is

approximately 120 140 beats per minute

Rhythm is normally regular

 Femoral pulses/pulse volume
Femoral pulses should be easily palpable in
the groin of the neonate

Pulses Diagnosis

Absent femoral pulses coarctation of the aorta

Bounding pulses PDA

 Heart sounds

Heart Sounds Mechanism

Lub Closure of mitral and tricuspid valve

Dub Split (closure of aortic valve and closure of

in neonate rapid heart rate split is difficult pulmonary valve )
to detect
Murmurs
 Liver size

The liver edge in a neonate is usually palpable

anything up to 1 cm below the costal margin.
Respiratory system

Color

Not to be used anymore

 Respiratory noises
A well baby breathes quietly

Grunting : when neonate attempts to exhale

against a partially closed glottis in an effort to
avoid collapse of the alveoli

Present when the neonate is disturbed or

accompanied by other symptoms of
respiratory disease
 Respiratory rate
4060 breaths per minute

Pattern is regular

Might have periods of up to 10 seconds when

they appear not to breathe
Signs of respiratory distress
 Abdomen
Shape: neither distended nor scaphoid. Helps for
diagnosis of underlying pathology e.g bowel
obtruction, diaphragmatic hernia

Enlarged organs: organs easily palpable than adult

Palpation of the abdomen is best performed by

approaching from the right-hand side of the baby
Two differences between a baby and an adult are:
 Palpable Organs
1. liver

2. Spleen

3. Kidneys

4. Bladder

5. Masses
 TENDERNESS

Not easy to perform

Tenderness usually indicates underlying

pathology (crying baby or a baby who draws
his knees up)
 Umbilicus
Number of vessels in cord

Two arteries and one vein

There is an association of renal anomalies

with cords with only one artery
Normal umbilical cord
Meconium stained umbilical cord
 Male genitalia
Scrotum

Smooth or have a rugged appearance

Large scrotum may be the result of a hydrocele

Confirm that there are testes present in each

half of it and that the rest of the genitalia are
normal
 Scrotum color Pathology

Transilluminate Hydrocele

Pigmentation of scrotum Maybe congenital adrenal hyperplasia

Discoloration Torsion of testicle

 Testes
Each testicle is approximately 11.5 cm diameter

In the absence of one testicle, the groin on the side

of the absent testicle should be carefully palpated
as the testicle may not have completed its descent
from the posterior abdominal wall

Absence of both testicles should alert the

practitioner to the fact that the babys sex may be
indeterminate
 Penis
The size of the penis at birth varies: centile charts for
stretched penile length

The skin on the underside of the penis can be tethered to the

scrotum (chordee)

The foreskin may be hooded in appearance and this may or

may not be associated with an abnormally placed meatus
(hypospadias)

A malpositioned meatus may be associated with

abnormalities of the urethra and kidneys and may result in a
poor urinary stream
 Female genitalia
Labia

Large labia : indeterminate sex and that there

may be testes within them

Pigmentation of the labia : early finding in

congenital adrenal hyperplasia
 Vagina

The hymen may cover the vaginal orifice, and

may be imperforate in some babies

Shortly after birth, some babies suffer

withdrawal bleeding and it is not uncommon
for this to continue for several days.
 Clitoris

The clitoris may seem quite large in preterm

babies

If it is felt that it is inordinately large then the

baby should be examined carefully to exclude
an indeterminate sex
Female genitalia
Maternal hormonal withdrawal
Infantile menstruation
 Anus
Patency

Even babies who have clearly been documented as

having passed meconium within hours of birth
have sometimes gone on to develop problems
associated with patency because of a slightly
malpositioned anus

It is important to take note of whether or not a

baby has passed meconium, allowing for the fact
that this may be delayed if the baby passed
meconium in utero.
Passage of meconium
 Position
The position of the anus: to diagnose anteriorly
placed anus may be associated with problems, e.g.
malformation of the rectum, constipation in later life,
etc.

Look carefully for evidence of leakage of meconium

from sites other than the anus

Never assume that the meconium at the tip of the

urinary meatus or covering the vaginal orifice is from
the anus; it may be coming from a fistula
 Groin
Determine if femoral pulses are palpable

Swellings in the groin

Mal-descended testes or hydroceles

Malpositioned ovaries in the female baby

Herniae or vascular anomalies

 Hips

Should appear symmetrical

Skin creases on the back of the legs

Good range of movement, being fully

abductable with no resistance to movement
 Ortolanis manoeuvre
Ortolanis manoeuvre will detect a congenitally dislocated hip

The baby should be placed on his back on a firm flat surface.

The legs are held with the hips and the knees flexed at right
angles

The hips are slowly abducted from the midline position,

through 90 while pushing forwards with the middle finger

Failure to abduct the hips fully is suggestive of congenital

dislocation, but not confirmatory

A click may be felt as a result of laxity of the ligaments of the

hip or it may originate from the knee
 Barlows manoeuvre
Barlows manoeuvre will identify an easily
dislocatable hip

Legs held as for Ortolanis manoeuvre, pressure is

applied to the front of the knee, forcing the femur
to slide backwards

If a dislocated or dislocatable hip is detected, the

two manoeuvres should not be repeated, as there
is a risk that the femoral head may suffer avascular
necrosis.
 Spine
The spine is best examined by placing the
baby face down, with its abdomen and chest
in the palm of one hand

The skin overlying the spine should be

inspected, as an overlying abnormality of skin,
e.g. a tuft of hair, a pit or a birthmark may be
an indication of an underlying abnormality.
 Central nervous system
Behaviour

Observe the babys reaction to external stimuli

Does he

Startle to loud noise

Quieten to the spoken word
Close the eyes in response to bright light
Cry when undressed
Cry when a feed is due
 Posture and tone
Baby will often adopt the position he was in in
utero

After birth he begins to adopt a flexed/curled

position

Preterm baby takes longer to achieve

Hypotonic babies may fail to flex

Posture
 Hypotonia can be detected by supporting the baby
by placing the practitioners hands, one under each
axilla

A baby with normal tone will remain supported, but

a baby with central hypotonia will slip through the
hands of the practitioner

Central hypotonia can be confirmed by lying the

baby face down, with its abdomen and chest in the
palm of one of the practitioners hands

A baby with normal tone will attempt to raise the

head and the legs, but a baby with hypotonia will lie
limply in the practitioners hand like a rag doll
 Reflexes

Reflex name How to perform

Moro Reflex

Stepping reflex holding the baby under the shoulders with both
hands , the baby will perform a stepping/ climbing
manoeuvre

Rooting reflex Gently stroking the skin of the babys cheek. He will
turn the head towards the side that is being
stimulated.

Suck reflex Placing the practitioners clean little finger in the

babys mouth. The baby will suck on the finger as it
would on a nipple or teat

Palmar grasp reflex Placing the practitioners little finger into the palm of
the baby. The babys hand will grasp the practitioners
finger

Plantar grasp reflex touching the sole of the babys foot with the
practitioners little finger. The babys toes will flex
towards the practitioners finger
Thank you