Newborn Cardiopulmonary Exam

Aka: Newborn Cardiopulmonary Exam, Newborn Chest Exam

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II. Physiology

  1. See Fetal Circulation

III. Exam: Breast and Xiphisternum

  1. Palpate for abnormality
  2. Inspection
    1. Unilateral absence or hypoplasia of pectoralis major
      1. Poland's Syndrome (Poland's Sequence)
    2. Chest Deformity
      1. Pectus Carinatum
      2. Pectus Excavatum
    3. Widely spaced nipples
      1. Turner's Syndrome
      2. Noonan Syndrome
  3. Breast Buds and Galactorrhea
    1. Resolves in first month of life
    2. Consult pediatric endocrinology if persistent

IV. Exam: Respiratory

  1. See Respiratory Distress in the Newborn
  2. Brief periods apnea are normal in transition
  3. Periodic breathing
    1. Common and normal in children
    2. Pauses in breathing up to 10-20 seconds are normal
      1. Unless associated Bradycardia, mental status change, or Skin Color change
    3. Apnea >20 seconds is abnormal and should prompt observation
      1. RSV Bronchiolitis in age 6-8 weeks is a risk for signficant apnea
  4. Evaluate for unequal breath sounds or unequal chest wall movement
    1. Pneumothorax
    2. Diaphragmatic Hernia
    3. Cystic malformation of the lung
  5. Observe for respiratory distress
    1. Tachypnea, grunting or Cyanosis
    2. Nasal flaring or intercostal retractions
    3. Consider causes (See Respiratory Distress in the Newborn)
      1. Respiratory Distress Syndrome in the Newborn
      2. Meconium Aspiration Syndrome
      3. Transient Tachypnea of the Newborn
  6. Stridor
    1. Laryngomalacia (most common)
      1. Larynx region collapses in the first few months of life in some infants (resolves by age 1-2 years)
      2. Better when supine and worse with feeding
      3. Considered benign if mild in an otherwise well appearing infant with normal growth
    2. Other Stridor causes to consider
      1. Serious airway Infections (croup, Bacterial Tracheitis, Epiglottitis)
      2. Subglottic Stenosis (infants that were previously intubated)
      3. Vocal Cord Paralysis (prior neck surgery)
      4. Hemangioma with local neck compression

V. Exam: Cardiovascular

  1. See Congenital Heart Disease
  2. Vitals (Normal Newborn)
    1. See Pediatric Vital Signs
    2. See Newborn Pulse Oximetry Screening for Congenital Heart Disease
    3. Pulse Oximetry screening for Congenital Heart Disease (prior to discharge at 24 hours)
  3. Appearance
    1. Cyanosis and Tachypnea frequently accompany Congenital Heart Disease
  4. Abnormal Pulses
    1. Diminished pulses in all extremities
      1. Diminished Cardiac Output (e.g. Aortic Stenosis)
      2. Peripheral Vasoconstriction
    2. Diminished femoral pulses
      1. Heart lesion dependent on ductus arteriosus (e.g. Aortic Coarctation)
    3. Bounding Pulses
      1. High Cardiac Output (e.g. Patent Ductus Arteriosus)
  5. Hypertension (See normal Blood Pressure above)
    1. See Hypertension in Infants
  6. Murmurs
    1. See Pediatric Murmur
    2. Pathologic murmur characteristics
      1. Holosystolic murmur, Diastolic Murmur or continuous murmur
      2. Harsh Heart Murmur or Grade 3 murmur or louder
    3. Newborn murmurs are often transient
      1. Tricuspid regurgitation
      2. Patent Ductus Arteriosus
  7. Altered position of precordial heart sounds
    1. Shifted right: Dextrocardia
  8. Gallup Rhythms
    1. Split S2
      1. Normal finding
    2. Split S2 is Absent
      1. Common with Cyanotic Congenital Heart Disease (Truncus Arteriosus, Hypoplastic Left Heart, pulmonic valve atresia)
      2. Results in high pulmonary vascular resistance

VI. References

  1. Drapkin (2019) Am J Emerg Med 37(6):1153-9 +PMID:30952605 [PubMed]
  2. Lewis (2014) Am Fam Physician 90(5): 289-96 [PubMed]

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