Newborn Exam

Newborn Period

The first month of life (21-28 days)

Neonatal History Components

Family History (Maternal and Paternal genetic and medical histories), Maternal past OB history, OB history of current pregnancy (Prenatal, Peripartum/Delivery, Infant)

Term Infant

An infant born at ≥ 37 weeks Gestational Age (GA)

Preterm Infant

An infant born at < 37 weeks Gestational Age (GA)

Late Preterm Infant

An infant born between 34-36 weeks Gestational Age (GA)

Extremely Preterm Infant

An infant born at < 28 weeks Gestational Age (GA)

Postmaturity

A gestational age of > 42 weeks

Ballard Score

Scores assigned to physical and neuromuscular signs used for the estimation of gestational age

Delivery Room Exam Components

Observation, Inspection (for congenital anomalies, birth trauma), Auscultation (heart, lungs), and Placenta and umbilical cord inspection

APGAR Score Timing

Assessed at 1 minute, 5 minutes, and potentially 20 minutes (if score is low)

What does APGAR stand for?

Appearance, pulse, grimace, activity, respiratory effort

APGAR Score Example 1 (Score 4)

A 38-week male infant with central cyanosis, heart rate 80 BPM, grimace with suction catheter in nares, irregular spontaneous breaths, and some flexion of extremities

APGAR Score Example 2 (Score 1)

A 29-week female infant noted to be limp with central cyanosis, heart rate 60 BPM, no response to suctioning nares, and no spontaneous breaths

APGAR Score Example 3 (Score 9)

A 39-week female infant who cried immediately, moved all 4 extremities, coughed with suctioning, had a heart rate of 140 BPM, and blue hands/feet but no central cyanosis

Scoring Results

Normal: 7-10. Requires immediate resuscitation: 0-3

Newborn Physical Exam General Approach

Be gentle and support the newborn’s head, begin with observation and general survey.

Normal Newborn Heart Rate

120-160 beats/min

Normal Newborn Respiratory Rate

30-60 breaths/min

Normal Newborn Systolic Blood Pressure (Day 1)

50-70 mm Hg

Fever Temperature in Newborns

38 C

Important Measurements at Newborn Visits

Weight, length, and head circumference, used to monitor appropriate growth on a growth curve

Newborn Skin Inspection Findings

Bruising, petechiae, jaundice, meconium stain, cyanosis, edema, pallor, plethora, birth marks, vasomotor changes, and signs of trauma from birth

Jaundice in newborn

Jaundice in first 24 hrs of life is pathological

Newborn Skin Palpation Focus

Turgor and hydration

Newborn Head Inspection Findings

Edema, signs of birth injury/trauma, and symmetry

Newborn Head Palpation Focus

Fontanels and sutures

Newborn Face Inspection Findings

Symmetry, bruising, swelling, shape and location of facial features

Newborn Eyes Examination

Inspection of external eye and extraocular movements (for shape, size, set, swelling, redness, hemorrhage, discharge, intact features/landmarks), pupillary response, and retinal red reflex

Newborn Ears Examination

Inspection for position, formation, features, pits, and tags

Newborn Nose Examination

Inspection for size, shape, discharge, and midline nasal septum, along with testing nare patency

Nare patency (Newborns)

Newborns are obligate nose breathers

Newborn Mouth & Pharynx Examination

Inspection (using a flashlight, +/- tongue depressor) for size/shape of mouth, jaw and tongue, lesions, presence/formation of features, and frenulum tightness

Newborn Neck Examination

Inspection for masses, webbing, and positioning

Newborn Chest & Lungs Examination

Inspection for work of breathing, tachypnea, color, bruising, symmetry, mediastinum position, apnea, nasal flaring, and nipple location. Palpate clavicle for crepitus, auscultate for bilateral air entry, abnormal grunting, wheezing, stidor. Percussion is not recommended

Newborn Heart Examination

Inspection for color of skin. Palpate PMI, thrills, pulses in all 4 extremities. Auscultate for murmurs, rate/rhythm, CHF

Newborn Abdomen Examination

Inspection for distention, scaphoid abdomen, and umbilical cord (umbilicus cutis + umbilicus amnioticus). Auscultate bowel sounds. Percuss organ location. Palpate tenderness, masses, hernias, liver, spleen, kidneys

Newborn Genitalia & Anus Examination

Inspection for patent anus, development of external genitalia, and location of urethra

Male Newborn Genitalia Palpation

Checking for descended testicles, hydrocele, and hernia (foreskin is not retractable at birth, becomes retractable at 4 years old)

Female Newborn Genitalia Findings

White or bloody discharge is normal. Labial adhesions/hymen

Newborn Musculoskeletal Examination

Inspection for skeletal anomalies, size/shape/color of limbs and digits, symmetry at rest, symmetrical movement of extremities, palsies, and entire spine

Newborn Hip Exam Purpose

To check for hip dislocation

Ortolani Maneuver

A hip exam technique to check for posterior dislocation

Barlow Maneuver

A hip exam technique to check for subluxation or dislocation of an unstable hip

Newborn Neuro/Developmental Observation

Assessing cry quality, movements, and posture/posturing

Newborn Mental Status and Senses

Newborns are born with all 5 senses, can look at human faces, turn to a parent's voice, and recognize a parent's smell

Newborn Tone/Strength Assessment

Observing resting tone and active range of motion, ensuring symmetrical movement of all 4 extremities

Sucking Reflex (Newborn)

Appears at 14 weeks gestation

Palmar Grasp Reflex (Newborn)

Appears at 28 weeks, disappears at 4 months

Moro (Startle) Reflex (Newborn)

Appears at 28 weeks, disappears at 3 months

Caput Succedaneum

Scalp swelling located above the periosteum that crosses suture lines (like a "cap"), usually benign and self-resolves within a few days after birth

Cephalohematoma

Swelling over the parietal bone that is contained within suture lines

Brushfield Spots

Speckling of the iris due to aggregation of connective tissue, often seen in Trisomy 21 (Down syndrome)

Epstein Pearls

Keratin-filled cysts along gum margins and the roof of the mouth (also known as epithelial pearls). These are benign and common and self resolving

Choanal Atresia

An airway anomaly characterized by congenital narrowing of the nasal cavity, leading to nasal obstruction, breathing problems, and feeding problems. To diagnose, test for nare patency and nasal exam/scope confirms.

Arthrogryposis

A condition resulting from limited in utero movement, leading to multiple joint contractures. This is non-progressive but has no cure. Management involves PT, OT to improve ROM and functional outcomes

Erythromycin Eye Ointment (Newborn)

A routine preventative measure administered within 1 hour after birth to prevent ophthalmologic gonorrhea

Vitamin K Injection (Newborn)

A routine preventative measure administered within 4 hours after birth to prevent hemorrhagic disease of the newborn

Hepatitis B Vaccine (Newborn)

A routine preventative measure, administered with or without IVIG if maternal testing is positive for HBsAG.

Other Potentially Indicated Newborn Tests

Cord blood testing, bedside glucose testing, and hematocrit

Screenings Before Newborn Discharge

Newborn hearing test and Congenital Heart Disease (CHD) screening

State Sponsored Newborn Screen (NBS)

A genetic screening test performed at 24-48 hours of life to look for inborn errors of metabolism, galactosemia, sickle cell disease, hypothyroidism, congenital adrenal hyperplasia, and cystic fibrosis