Physical Exam of the Newborn

Physical Examination of the Newborn

Should be examined at least two (2) and

preferably 3 times between birth and
discharge:
• in the delivery room immediately after
birth
• In the nursery or rooming-in area within 12
hours of birth
• Upon discharge, preferably in the presence
of the mother
 First 15 to 30 minutes
1. Immediate tachycardia to 160-180 bpm,
with gradual drop to 100-120 bpm
2. Irregular respirations, tachypnea to 60 to
80 respirations per minute, brief
moments of apnea
3. Moist-sounding lung fields, transient
grunting and retraction
4. Awake, moving, alert, easily startled,
crying, transient tremors
 Next 60 to 90 minutes
1. Sleepy or sleeping, somewhat
unresponsive
2. Heart rate 100 to 120 beats per minute,
transient tachycardia
3. Respiratory rate 50 to 60 respirations per
minute, transient tachypnea
4. Usually passage of meconium
 Next Several Hours
Again, awake, alert, easily startled, crying,
easily stimulated and reactive
 General Survey
Newborn should be naked when being
examined. Observe the infant’s posture,
skin colour, activity, muscle tone and gross
congenital abnormalities
 Vital Signs
Temperature
• If above 38°C and remains elevated,
check rectal temp as not as affected

Respirations
• All infants are periodic rather than regular
breathers
• Normal 40-60 breaths/min
 Vital Signs
Cardiac Rate
• 120-160bpm

Blood Pressure
• Not routinely done
• Flush Method
• Doppler Method
 Anthropometrics
Head Circumference
• Occipitofrontal circumference
• 32-36cm

Weight and Percentile

• Small for Gestational Age (SGA) – below 10th
percentile
– Symmetric
– Asymmetric
Appropriate for Gestational Age (AGA) –
between 10th to 90th percentile

Large for Gestational Age – above the 90th

percentile
 Length and Percentile
• Baby lies supine on recumbent length
table or measuring board.
• Crown of head touches stationery vertical
headboard
• Ensure that the legs remain flat on the
table and shifts the movable board against
the heel. Length is recorded to nearest
0.1cm
 Skin
• Assessed for general color
• Epidermis of newborn is thin, oxygenated
capillary blood makes it pink
 COLOR
PLETHORA
• Deep, rosy red, ruddy
color
• More common in
infants with
polycythemia
• Overoxygenated
• Overheated
 COLOR
JAUNDICE
• Yellowish color if
secondary to indirect
hyperbilirubinemia,
greenish color if
secondary to direct
 COLOR
PALLOR
• May be secondary to
anemia, birth
asphyxia, shock, or
PDA
 COLOR
CENTRAL CYANOSIS
• Bluish skin including
tongue and lips
• Caused by low oxygen
saturation in the
blood
 COLOR
ACROCYANOSIS
• Bluish hands and feet
only
• May be normal for a
newly born infant
because of vasomotor
instability and
peripheral circulatory
sluggishness
 Mottling
• Lacy red pattern may
be seen in healthy
infants and in those
with cold stress,
hypovolemia, or
sepsis
 Cutis Marmorata
• Persistent mottling
• Found in infants with
Down Syndrome
trisomy 13, or trisomy
18
 Vernix Caseosa
• Greasy white
substance
• Covers skin up to 38
weeks AOG
• Provide moisture
barrier
 Milia
• Tiny, sebaceous
retention cysts,
whitish, with pinhead-
sized concretions
• Usually on the chin,
nose, forehead, and
cheeks
 Erythema Toxicum
• Numerous small areas
of red skin with a
yellow-white papule
in center.
• Lesions are most
noticeable 48 hours
after birth may
appear as late as 7-10
days
 Miliaria Crystallina
• Non-inflammatory,
pinpoint clear vesicle
• Suddenly erupt in
profusion over large
areas of the body
surface, leaving
brawny desquamation
on healing
 Transient Pustular Melanosis
• Benign, self-limiting
condition which
requires no specific
therapy
• Three stages:
– Pustules
– Ruptured
vesicopustules with
scaling/typical halo
appearance
– Hyperpigmented
macules
 Macular Hemangioma
• “stork bites”
• True vascular nevus
normally seen in on
occipital area,
eyelids, and glabella
• Spontaneously
disappear within 1st
year of life
 Port-wine stain
• Nevus flammeus
• Usually seen at birth,
does not blanch with
pressure and does not
disappear in time
 Mongolian Spots
• Dark blue, or purple
bruise-like macular
spots usually located
over the sacrum
• Most common
birthmark
 Head
• Macrocephaly
• Microcephaly
– Associated with
infections and Trisomy
13, 18
 Head
• Anterior Fontanel
– Junction of coronal and sagittal sutures
– Closes at 9 – 18 months
• Posterior fontanel
– Junction of occipital and parietal bones
– Maybe close or admits the tip of finger till 2 –
4 months
 Caput Succedaneum
• After prolonged labor
• Poorly demarcated
soft tissue swelling
• Crosses the suture
lines
• Spontaneously resolve
within days
 Cephalhematoma
• Rupture of blood
vessels
• Well demarcated
swelling that corsses
the suture lines
• Resolves within
2-3wks
 Molding
• Temporary asymmetry
of the skull
• Prolonged labor and
vaginal deliveries
• Regains normal shape
within 1 week
 Face
Facial Nerve Palsy
• Compression by sacral
promontory or trauma
• Resolves within days
• Full recovery in weeks
to months
Moebius Syndrome
– Absence/ hypoplasia
CN VII
 Eyes
• Red Orange Reflex
• White pupil (cat’s eye reflex)
– Abnormal les, vitreous or fundus
– Sign of catarct
• Subconjunctival hemorrhage
– Benign
– Resolve in 2 weeks
 Nose
• Asymmetry of nares and deviation of
septum
• Choanal atresia
– Assessed by passage of nasogastric tube
 Ear
• Straight line from the canthi of the eye
across the face
• Low set – helix is below the line

• Pre – auricular skin tags are benign

• Hairy ears – usually of diabetic mother
 Mouth
• Check for palatal clefts and presence of
deciduous teeth
• Assessed by palpating
 Epstein Pearls
• Keratin containing
cysts
• Located at soft and
hard palate
• Resolves
spontaneously
 Ranula
• Cystic swelling in the
floor of the mouth
• Disappears
spontaneously
 Mucocele
• Lesion on oral mucosa
secondary to trauma
of salivary gland ducts
• Subsides
spontaneously
 Natal Teeth
• Lower incisors
• Predeciduous
– Should be extracted
– Risk for aspiration
• True deciduous
– Not extracted
 Macroglossia
• Enlargement of
tongue
• Seen in congenital
hypothyroidism
 Neck
• Elicit the rooting reflex for easier
examination
• Palpate the SCM, thyroid, presence fo
thyroglossal duct cysts
• Clavicular Fracture – decreased or absent
movement of the arm on affected side,
deformity, and discoloration.
 Chest
• Breast Hypertrophy
• Witch’s Milk
• Nipple Spacing
• Chest Shape

46
 Lungs
• Observed for a full
minute
• Resting state
• 30-60 cpm
• Abdominal Breathing
• Retractions

47
 Heart
• Location
• 110-140 bpm at rest
• 90-180 bpm
• Flow murmur
• Palpate all pulses
• PMI at 4th ICS

48
49
 Abdomen
• Liver 2cm below the
rib margin
• Spleen Tip
• Kidney Location
• Umbilicus - AVA
• Hernia
• Masses
• Distention

50
 Omphalocele vs Gastroschisis
• Central • Lateral
• Covered with a Sac
• No
• Made with Amnion,
Wharton’s Jelly and • Involves Intestinal
Peritoneum Loops Only
• Large Defects May Include:
Liver, Spleen, Gall Bladder,
Testes, Ovary
• 75% Associated Congenital
Anomalies:
• Beckwith-Wiedmann
Syndrome (Macrosomia
and Hypoglycaemia);
Trisomy 13 and 18; Non-
chromosomal 51
 Genitourinary
• Voiding within 12-24 hours
• Assess ambiguity
• Hernia vs Hydrocele
• Palpate the Testes
• Urethra

52
Ambiguous Genitalia

53
Hypospadias

54
Inguinal Hernia

55
Hydrocele

56
Transillumination

57
 Anus
• Meconium Passage
• 99% of term and
95% of preterm
within 48 hours
of life
• Patent Anus

58
 Extremities
• Fetal Posture
• Contracture and Flexure
• Up to 20-30 degree hip and knee flexion
• Transitory vs Permanent by 4-6 mos of
age
• Check the Hands and Feet

59
Hip Dislocation

60
Syndactyly

61
Polydactyly

62
Rockerbottom

63
Simean Crease

64
 Nervous System
• Mental Status: Altertness
• Head Circumference
• Head Shape
• Normocephalic
• Plagiocephalic
• Fontanelles
• Anterior: 2x2cm, diamond shaped, 9-18
mos
• Posterior: triangular, 6-8 weeks 65
 Nervous System
• Cranial Nerve I: Present Stimuli
• Cranial Nerve II and III:
• Fundoscopy
• 28 wk: Blinks to Light
• 32 wk: Closes to Light
• 37 wk: Follows Light or Face
• Reaction to Light: by 29-32 wk
• Cranial Nerve III, IV & VI: Doll’s Eye
• Cranial Nerve V:
• Corneal Reflex
• Nasal Tickle 66
 Nervous System
• Cranial Nerve VII: Observe Asymmetry
• Cranial Nerve VIII: Reaction to Stimuli
• Cranial Nerve IX: Gag Reflex, Quality of
Sucking
• Cranial Nerve X: Uvula, Quality of Crying,
Quality of Sucking
• Cranial Nerve XI: Turning of Head
• Cranial Nerve XII: Tongue Position and
Bulk
67
 Motor
• Spontaneity of Movement
• Symmetry of Movement
• Movement Against Resistance

68
 Sensory
• Gross Reaction to Stimuli

69
 Reflexes
• Deep Tendon Reflex
• Primitive Reflexes
• Moro Reflex
• Parachute Reflex
• Rooting Reflex
• Sucking Reflex
• Tonic Neck Reflex
• Placing Reflex
• Plantar Reflex
• Grasp Reflex
• Crawl Reflex
• Stepping Reflex 70