Newborn Exam

Aka: Newborn Exam, Neonatal Exam

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II. Exam: General (normal term newborn findings)

  1. Appearance
    1. With stimulation, a vigorously Crying Infant with pink skin, and moving all extremities equally (or resting them in flexion)
  2. Vital Signs
    1. See Pediatric Vital Signs
    2. See Newborn Pulse Oximetry Screening for Congenital Heart Disease (performed at 24 hours of life prior to discharge)
    3. Temperature: 36.5 to 38.0 C (97.7 to 100.4 F)
    4. Blood Pressure: 75-95/37-55 mmHg
    5. Heart Rate: 110 to 160 beats/minute
    6. Respiratory Rate: 40-60 breaths/minute
  3. Measurements
    1. Weight - Females
      1. Mean: 3.5 kg (7 lb 12 oz)
      2. Range: 2.8 to 4.0 kg (6 lb 3 oz to 8 lb 14 oz)
    2. Weight - Males
      1. Mean: 3.6 kg (8 lb 0 oz)
      2. Range: 2.9 to 4.2 kg (6 lb 7 oz to 9 lb 5 oz)
    3. Length
      1. Mean: 51 cm (20 in)
      2. Range: 48 to 53 cm (19 to 21 in)
    4. Head Circumference:
      1. Mean: 35 cm (14 in)
      2. Range: 33 to 37 cm (13 to 15 in)
  4. Gestational age assessment
    1. See Newborn Gestational Age Exam (New Ballard Score, Dubowitz Exam)
    2. Small for Gestational Age or IUGR (<10th percentile)
      1. Symmetric Intrauterine Growth Retardation
        1. All measurements (height, weight and Head Circumference) are Small for Gestational Age
        2. Associated with longterm in utero exposure or condition (e.g. maternal drug use, TORCH Virus)
      2. Asymmetric Intrauterine Growth Retardation
        1. Low birth weight for Gestational age, but Head Circumference is spared
        2. Associated with late pregnancy condition (e.g. late pregnancy conditions)
    3. Large for Gestational Age or Fetal Macrosomia (>90th percentile)
      1. Most commonly associated with maternal Diabetes Mellitus
      2. Other conditions including genetic disorders can also result in Fetal Macrosomia

III. Exam: Head

  1. See Newborn Head and Neck Exam
  2. Scalp swelling
    1. Normal
      1. Scalp Molding (Over-riding of cranial bones and resolving over first 5 days)
      2. Vacuum Caput (associated with vacuum extractor use)
      3. Caput Succedaneum (scalp swelling limited by Suture lines, and resolving within 48 hours)
      4. Cephalohematoma (scalp Hematoma limited by Suture lines, developing over days and resolving within months)
    2. Abnormal
      1. Subgaleal Hemorrhage (deep scalp Hematoma that crosses midline and Suture lines, risk of Hemorrhagic Shock)
      2. Encephalocele or Meningocele (midline swelling)
  3. Fontanelle
    1. Fontanelle should be soft, not sunken (e.g. Dehydration), and not bulging (e.g. Increased Intracranial Pressure)
    2. Anterior Fontanelle (up to 3 to 6 cm in diameter), and Posterior Fontanelle (up to 1 to 1.5 cm in diameter)
  4. Head Size
    1. See Microcephaly, Macrocephaly and Craniosynostosis
  5. Face
    1. See Facial Nerve Injury from Birth Trauma

IV. Exam: Ears, Nose and Throat

  1. See Newborn Head and Neck Exam
  2. Newborn Hearing Screening (performed before discharge after delivery)
    1. Obtain Automated Auditory Brainstem Response (ABR) or Transient Evoked Otoacoustic Emissions (OAE or TEOAE)
  3. Congenital Ear Anomaly
    1. Low Set Ears (pinna below the medial canthus level, e.g. Trisomy 21, Trisomy 18)
      1. Associated with Hearing Deficits (obtain Newborn Hearing Screening) and genitourinary anomalies (obtain renal Ultrasound)
    2. Microtia or Anotia (small, undeveloped or absent Ear Pinna, e.g. CHARGE Syndrome)
      1. May be associated with Hearing Deficit (obtain Newborn Hearing Screening)
    3. Pre-auricular Skin Tags, ear pits, fissures or sinuses
      1. Associated with Hearing Deficits (obtain Newborn Hearing Screening)
      2. Renal Ultrasound not indicated unless other dysmorphic features, Teratogen Exposure, deafness Family History or maternal diabetes
  4. Nose
    1. Infants are obligate nose breathers until 4 months old
      1. Reduce nasal congestion with Nasal Saline
    2. Check nasal patency with stethoscope (listen over nares)
      1. Evaluate for Choanal Atresia (fixed nasal obstruction) and if suspected, confirm with passage of small caliber catheter
      2. Bilateral Choanal Atresia in the newborn is an airway emergency
    3. Asymmetry of the nasal septum (most often due to in utero positioning)
      1. Correction of asymmetry by depressing the nasal tip predicts spontaneous resolution (refer non-correcting cases to otolaryngology)
  5. Mouth
    1. Cleft Lip and Cleft Palate
      1. Midline clefts require evaluation for midline defects involving the brain and other central structures
    2. Micrognathia (Mandibular Hypoplasia)
      1. Small Mandible undersized for the associated Maxilla associated with many congenital disorders (e.g. Pierre Robin Syndrome)
    3. Neonatal Teeth
      1. Lower gum teeth that (usually require extraction, especially if loose due to risk of aspiration)
    4. Ankyloglossia (short frenulum, Tongue-Tied)
      1. Short frenulum tethers the Tongue to the mouth floor and may inhibit feeding
    5. Benign Oral Lesions
      1. Epstein's Pearls (palatal Vesicles), Bohn Nodules (buccal white keratin Nodules) and Ranula (mouth floor mucus cysts)

V. Exam: Neck

  1. See Newborn Head and Neck Exam
  2. Birth Trauma
    1. Congenital Torticollis (Reduced neck range of motion typically due to Birth Trauma to sternocleidomastoid Muscle)
    2. Clavicle Fracture from Birth Trauma (associated with Shoulder Dystocia)
  3. Neck Masses
    1. Cystic Hygroma (Congenital lymphocytic malformation at the neck)
    2. Thyroglossal Duct Cyst (Congenital midline neck lesion moves with the Tongue)
    3. Branchial Cleft Cyst (Congenital lateral Neck Mass)
  4. Congenital Anomaly
    1. Webbed Neck (associated with Turner's Syndrome and Noonan Syndrome)

VI. Exam: Eye

  1. See Newborn Eye Exam
  2. Normal findings
    1. Subconjunctival Hemorrhages
    2. Disconjugate gaze (due to 20/400 Vision at birth)
    3. Dacryostenosis (blocked tear ducts)
  3. Abnormal findings
    1. Neonatal Conjunctivitis
      1. Distinguish Dacryostenosis from chemical Conjunctivitis, Gonococcal Conjunctivitis, Chlamydia Conjunctivitis and HSV Conjunctivitis
    2. Lens opacity (Congenital Cataract)
      1. Associated with TORCH Virus infection
    3. White reflex (Leukokoria) on Pupillary Light Reflex
      1. Evaluate for Retinoblastoma as well as the rest of the Leukokoria differential diagnosis
    4. Coloboma
      1. Ocular tissue defect (especially iris) associated with congenital syndromes (e.g. CHARGE Syndrome)
    5. Inner Epicanthal Fold
      1. Medial eye covered by small folds of skin which is associated with congenital syndromes (e.g. Down Syndrome)
    6. Orbital Orientation
      1. Downslanting Palpebral Fissure (as seen in Marfan Syndrome) or Upslanting Palpebral Fissure (as seen in Down Syndrome)
    7. Orbital Size
      1. Short Palpebral Fissure (Narrow Palpebral Fissure, e.g. Fetal Alcohol Syndrome)
    8. Orbital Separation
      1. Hypertelorism (widely spaced eyes, e.g. Trisomy 18) or Hypotelorism (narrowly spaced eyes, e.g. Fetal Alcohol Syndrome)

VII. Exam: Cardiopulmonary Exam and Chest

  1. See Newborn Cardiopulmonary Exam
  2. Breast and Xiphisternum
    1. Chest Deformities (Poland's Syndrome, Pectus Carinatum, Pectus Excavatum) or widely spaced nipples (e.g. Turner's Syndrome, Noonan Syndrome)
  3. Respiratory
    1. See Respiratory Distress in the Newborn
    2. Brief periods apnea are normal in transition
    3. Evaluate for unequal breath sounds or asymmetric chest movement (e.g. Pneumothorax, Diaphragmatic Hernia)
    4. Evaluate for Respiratory Distress in the Newborn
      1. Respiratory Distress Syndrome in the Newborn
      2. Meconium Aspiration Syndrome
      3. Transient Tachypnea of the Newborn
      4. Cyanosis and Tachypnea frequently accompany Congenital Heart Disease
  4. Cardiovascular
    1. See Congenital Heart Disease
    2. See Pediatric Vital Signs
    3. See Hypertension in Infants
    4. Obtain Newborn Pulse Oximetry Screening for Congenital Heart Disease at 24 hours (prior to discharge)
    5. Abnormal Pulses
      1. Diminished Pulses in all extremities (decreased Cardiac Output) or decreased femoral pulses (e.g. Aortic Coarctation)
      2. Bounding Pulses (high Cardiac Output such as in Patent Ductus Arteriosus)
    6. Pediatric Murmur
      1. Pathologic murmurs (Holosystolic, diastolic or continuous or harsh or grade III or louder)
      2. Transient murmurs (Tricuspid regurgitation, Patent Ductus Arteriosus)
    7. Absent Split S2
      1. Common with Cyanotic Congenital Heart Disease (Truncus Arteriosus, Hypoplastic Left Heart, pulmonic valve atresia)

VIII. Exam: Newborn Skin Exam

  1. See Newborn Skin Exam
  2. Normal transient rashes resolve in minutes to hours
    1. Examples: Heat Rash, Petechiae, Cutis Marmorata, Harlequin Color Change
  3. Normal short-term rashes resolve in days to months
    1. Examples: Erythema Toxicum Neonatorum, Neonatal Pustular Melanosis, Milia, Lanugo, Acne Neonatorum, Subcutaneous Fat Necrosis
  4. Normal - Birthmarks, long-term rashes that persists for month, years and possibly permanent
    1. Examples: Mongolian Spots, Nevus Simplex, Hemangioma
  5. Abnormal lesions that may be signs of systemic disease
    1. Pallor (e.g. Anemia), Mottling (e.g. Sepsis) or Cyanosis in Infants (e.g. Congenital Heart Disease)
    2. Neonatal Jaundice
    3. Gray Skin Coloration due to Inborn Errors of Metabolism
    4. Cutaneous Signs of Dysraphism (occult spinal cord lesion)
    5. Vesicles (Neonatal HSV versus Erythema Toxicum Neonatorum) or Bullae (e.g. Bullous Impetigo)
  6. Abnormal lesions associated with Congenital Anomaly or syndromes (in some cases)
    1. Aplasia Cutis Congenita (skull deformities)
    2. Nevus Flammeus or port wine stain (Sturge-Weber Syndrome, Klippel-Trenaunay-Weber Sydrome)
    3. Nevus Sebaceus (epidermal nevus syndrome, malignant potential)
    4. Congenital Melanocytic Nevi (malignant potential)
    5. Cafe-Au-Lait Macule (Neurofibromatosis, Tuberous Sclerosis, Albright Syndrome)

IX. Exam: Abdomen and Rectum

  1. See Newborn Abdominal Exam
  2. Perform abdominal exam while supporting infants hips and knees in flexed position
    1. Observe abdominal contour for ScaphoidAbdomen (congenital Diaphragmatic Hernia) or distention (Bowel Obstruction or Ascites)
    2. Palpate for Renal Mass (e.g. Wilms tumor, Hydronephrosis) and non-Renal Mass (e.g. Teratoma, Ovarian Torsion, Neuroblastoma)
  3. Abdominal wall defects
    1. Diastasis Recti abdominis (weak fascia at midline between the rectus Muscles, resolves spontaneously with time)
    2. Umbilical Hernia (spontaneously resolve by 3 years old in most cases)
    3. Evisceration (Gastroschisis, Omphalocele)
  4. Umbilicus
    1. See Umbilical Cord
    2. Observe for infection and bleeding
  5. Rectum and Anus
    1. Anus should be patent, not ectopic
      1. Imperforate anus associated with trisomy 18 and 21, as well as VACTERL anomalies
    2. Observe sacral region for Cutaneous Signs of Dysraphism (although a small, simple sacral dimple is normal)
    3. Expect meconium passed within 24-48 hours of birth (consider Hirschprung's Disease if not present)

X. Exam: Genitalia

  1. See Newborn Genitalia Exam
  2. Precautions
    1. Diagnosis of Ambiguous Genitalia requires urgent urology/endocrine/genetics Consultation prior to gender assignment
  3. Female
    1. Normal findings: Vaginal or hymenal Skin Tags, scant white or bloody discharge
    2. Abnormal: Ambiguous Genitalia signs (e.g. fused labia, clitoromegaly)
  4. Male
    1. Common findings: Undescended Testes, Communicating Hydrocele, Inguinal Hernia
    2. Contraindications to Circumcision: Hypospadias, Chordee, Buried penis
    3. Ambiguous Genitalia signs: Bilateral Undescended Testes, micropenis, bifid Scrotum

XI. Exam: Musculoskeletal

  1. See Newborn Orthopedic Exam
  2. Digit abnormalities (Supernumerary Digit, Polydactyly, Syndactyly, Clinodactyly)
  3. Single Palmar Crease (present in 3-10% of normal babies, and Trisomy 21)
  4. Brachial Plexus Injury related palsy (Erb Palsy, Klumpke Palsy)
  5. Positional deformities of foot (Talipes Equinovarus or Clubfoot, Metatarsus Adductus, Calcaneovalgus Deformity)
  6. Congenital Hip Dislocation (developmental hip dysplasia)
    1. Tests: Ortolani Test, Barlow Maneuver
    2. All girls born in Breech position should undergo Hip Ultrasound at 6 weeks or Hip XRay at 4 months of age

XII. Exam: Neurologic

  1. See Newborn Neurologic Exam
  2. Newborn Reflexes (Primitive Stepping Reflex, Rooting Reflex, Moro Reflex, Babinski Reflex)
  3. Position and Tone
    1. Normally in Fetal Position with extremities flexed and with hands closed
    2. Hold infant in vertical suspension (hypotonia is abnormal)
  4. Easily alerts, awakened by uncovering or stimulating foot or cheek

XIII. References

  1. Tschudy (2012) Harriet Lane Handbook, 19th Ed, Mosby Elsevier, Philadelphia
  2. Lewis (2014) Am Fam Physician 90(5): 289-96 [PubMed]
  3. Lewis (2014) Am Fam Physician 90(5): 297-302 [PubMed]

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