Newborn Exam, by Dr. Nina Gold.
This video will introduce
you to the key aspects
of the newborn physical
exam, with a focus
on normal physical
findings versus those
that might suggest a congenital
anomaly or genetic condition.
When you enter the room,
congratulate the family
and introduce yourself.
Explain that you would like
to examine their infant
and ask if you have come
at a convenient time.
If the family agrees
to an exam, carefully
place the infant on her
back and unswaddle her
from any blankets.
Make a general observation
of your patient.
Is she asleep or awake?
Is her skin warm or
cool to the touch?
Are her vital signs
within normal range?
Is she having any
difficulty breathing?
If you note any signs
of distress or illness,
end the physical exam here and
notify the supervising resident
or attending physician.
If the baby looks
well but is crying,
console her by laying
your hand on her head,
or offering a pacifier
if the parents allow.
Proceed with the individual
aspects of your exam.
The simplest way to examine a
newborn is from head to toe.
By using the same
method during each exam,
you will be unlikely to
leave out important steps.
Head.
Gently place a hand behind the
posterior portion or occiput
of the skull.
Measure the head
circumference in centimeters
by wrapping a measuring
tape in a circle
just above her eyebrows to
the most prominent aspect
of the occiput and back again.
Determine if her head
is of normal size
by plotting the circumference
on a newborn birth chart.
The head circumference should
be in the average range
for infants of the
same gestational age,
and also fall approximately
in the same percentile
as the infant's
length and weight.
Next, what is the shape
of your patient's head?
A newborn skull is made up of
several bony plates that meet
along flexible cranial sutures.
In the center, they
form a soft spot known
as the anterior fontanelle.
There is also a smaller
fontanelle in the back:
the posterior fontanelle.
The first letters of the cranial
suture and fontanelle spell
out the word CLAMS.
C is for coronal suture.
L is for lambdoid suture.
A is for anterior fontanelle.
M is for metopic suture.
S is for sagittal suture.
This design allows the
skull to be malleable enough
to fit through the
birth canal, which
often leads to a temporary
deformation called molding.
Check the infant's skull
for bruising and swelling.
A bruise that doesn't
cross the suture lines
is called a
cephalohematoma, which
is caused by bleeding
below the periosteum,
and is more common
in births assisted
by a vacuum or forceps.
These infants are
at increased risk
of jaundice due to the breakdown
of hemoglobin as the bruise
resolves.
If the swelling
crosses suture lines,
it is most commonly due
to a caput succedaneum,
a fluid accumulation that
forms above the periosteum
due to the force of delivery.
The swelling typically resolves
within a few days of birth.
Rarely, you may see
more extensive swelling
that crosses suture lines due to
the rupture of emissary veins.
This is called a
subgaleal hemorrhage,
and can lead to more
serious complications
due to significant blood loss
in a large potential space.
Finally, run your fingers over
the skin of the infant's scalp.
If you feel any areas
where the skin is missing
or has an unusual
texture, it may
be a sign of cutis aplasia,
a congenital anomaly
in which the scalp has
not formed properly.
This finding is not
inherently dangerous,
but should prompt a
thorough examination
for other atypical
physical features.
Face.
After gathering a
general impression,
begin your examination of each
individual facial feature.
First, assess the ears.
To check the ear placement,
imagine a straight line
drawn from the outer
corner of the eye.
The upper portion of the
ear should meet this line.
If not, the ears may
be considered low set.
Now, imagine a second
line, drawn perpendicular
to the first.
Is the infant's ear
straight along this axis?
If it is tilted back, the ear
may be in a posterior rotation.
An atypical ear position
is not dangerous,
but may prompt consideration
for an underlying genetic
condition.
Next, assess ear formation.
Do the ears have a complete
rim of skin surrounding them,
called the helix?
Does the skin inside the helix,
called the crus, have folds,
or is it unusually smooth?
Finally, check the skin
beside the ear's tragus
for pits and skin tags.
While variation in ear
formation can be normal,
the presence of one of
these minor variants
may be associated with some
genetic conditions, as well as
hearing loss or anomalies of
the kidneys, the development
of which are controlled by some
of the same genes as the ears.
Now check the
infant's eyes, again,
beginning with an inspection.
Do they appear widely spaced?
Does the opening of the eye,
called the palpebral fissure,
point upwards or downwards?
Subtle variations in
eye spacing and rotation
are normal and may be
inherited from healthy parents.
To check the
infant's pupils, you
may have to coax her to open her
eyes by turning off the lights
or cupping your hand
over her eyelids.
When she opens them, quickly
assess the infant's red reflex
by shining the ophthalmoscope
light on the eye.
You should see a flash
of red in each eye,
indicating the normal presence
of retinal vessels in the eye.
If you see an
asymmetric red reflex,
particularly if the
color seen is white,
you may have detected
a retinal anomaly,
such as a congenital
cataract or a retinoblastoma.
Another atypical finding
is called a coloboma,
which are missing
pieces of tissue
in the structure
that form the eye.
A patient with either
of these findings
should be referred
to both ophthalmology
and medical genetics
for further evaluation.
Next, we examine the nose.
In the newborn, the most
important feature to assess
is patency of the
nares, as neonates are
preferential nasal breathers.
If there is any history of
respiratory distress or noisy
breathing when
feeding or crying,
patency can be proven by
passing a small French catheter
through each nares.
It is common for newborns to
have transient obstruction
from edema related to
suctioning after birth,
but the differential also
includes choanal atresia
or choanal stenosis, an
improper formation or narrowing
of the nasal airways.
Choanal atresia is a
characteristic finding
of the genetic condition
CHARGE syndrome, which
is an acronym for
coloboma of the eye,
heart abnormalities,
atresia of the choanae,
retardation of growth
or development,
genitourinary abnormalities,
and ear abnormalities.
Any infant found to
have choanal atresia
should be referred to an ear,
nose, and throat specialist,
as well as a medical geneticist.
The final features of
the face you will examine
are the mouth and jaw.
Gently insert your
gloved index finger
into the newborn's mouth.
A healthy baby will
reflexively suck on the glove.
In the anterior
portion of the mouth,
you will feel the hard palate.
As your finger
travels backwards,
you will feel the soft palate.
A division or cleft in
the hard palate or lip
may be easy to
detect by inspection.
Clefts in the soft
palate, however,
are more difficult
to observe by eye.
A patient with a cleft
palate or cleft lip
should be referred to an ear,
nose, and throat specialist,
and may need special
help with feeding.
Cleft palate is commonly an
isolated congenital anomaly,
but can also be associated
with other medical conditions.
Next, assess her tongue.
Is she able to
elevate her tongue
and push it past the lower gums?
If not, she may have
ankyloglossia, more commonly
known as tongue tie.
This finding is a minor
variant and is not
a sign of a genetic condition,
but could impair the infant's
ability to breastfeed.
A frenotomy, or release
of the frenulum,
may be indicated
if breastfeeding
is painful or inefficient.
Finally, do a brief
overall examination
of the infant's mouth looking
for other unusual findings,
such as a natal tooth.
Neck.
Note if there is obvious webbing
of the neck or redundant skin,
which can be found in Turner
syndrome or Noonan syndrome.
Now, run your fingers over
the infant's collarbones.
The clavicles should feel smooth
without any crepitus, breaks,
or step-offs.
Fractures of the clavicle
may occur during delivery,
particularly in infants
who had shoulder dystocia.
Chest.
Inspect the shape of the chest.
Does the sternum
lie flat, or is it
concave, called a pectus
excavatum, or convex,
called a pectus carinatum?
While these findings
are more common
in some connective tissue
and cardiac disorders,
such as Marfan Syndrome, an
isolated pectus abnormality
is considered a minor
variant, and is not
cause for a genetics referral.
Listen to the baby's heart.
You'll use the same
landmarks for auscultation
as you would when examining
an older child or adult.
A normal newborn heart
rate is between 120
to 160 beats per minute, making
the cardiac exam a challenge.
You may need to listen
for up to a minute
before you can clearly make
out the sounds of systole
and diastole.
Many newborns have a
continuous machinelike murmur
caused by the closing of the
patent ductus arteriosus.
This murmur is benign,
and in a full-term infant,
should resolve within the
first few days of life.
Other heart murmurs,
particularly those
that do not improve within days,
should be further evaluated.
The first steps
to undertake when
investigating a
newborn heart murmur
include obtaining pre-
and post-ductal oxygen
saturations, four extremity
blood pressures, and an EKG.
Assess the infant's respiration.
It is normal for infants to take
short pauses in their breathing
or breathe at a
slightly irregular rate.
This is called
periodic breathing,
and sometimes takes new
parents by surprise.
Auscultate along the apex of
the lungs and around their sides
and back.
The lungs should
sound equally loud
with clear passage of air
and no wheezes or crackles.
A newborn respiratory rate is
30 to 60 breaths per minute.
Abdomen.
First, inspect the abdomen.
Is it distended?
The skin around the umbilical
cord should look clean and dry.
Many infants have an outpouching
of skin around the umbilicus,
called an umbilical hernia.
Evaluate whether
an umbilical hernia
is reducible by gently pushing
it back toward the abdomen.
A hernia that feels firm
or is stuck in place
may be incarcerated
and should be evaluated
by a surgical specialist.
Next, palpate the
infant's abdomen
by placing one hand
on top of the other.
Push gently.
On the right side
of the abdomen,
assess the size of the liver.
The liver edge should either not
be palpable or lie very close
to the newborn's ribs.
Palpate around the abdomen,
carefully assessing for masses.
While rare, some infants may
have intra-abdominal neoplasms,
such as a neuroblastoma
or Wilms' tumor.
Groin.
Unfasten the infant's diaper.
Assess the femoral pulses
by placing your fingers
along the crease between the
thigh and the diaper area.
Don't push too hard.
It may take several
minutes before you can feel
a steady pulse on both sides.
If you are unable
to find the pulse
or it feels very
weak on one side,
you may have identified
an aortic coarctation.
This can be further
investigated by measuring
pre- and post-ductal
oxygen saturations and four
extremity blood pressures.
At this time, you may also
check for the presence
of an inguinal hernia.
Now, evaluate the genitalia.
In an infant with
female genitalia,
the labia and
clitoris may appear
engorged as a result
of maternal hormones.
Some newborns even
experience a small amount
of vaginal discharge
or bleeding.
Another common finding
is vaginal skin tags
on the posterior fourchette.
In an infant with
male genitalia,
assess if the testicles are
descended by palpating them
through the scrotum.
A swollen, enlarged
scrotum is usually
indicative of a hydrocele,
or a fluid collection
around the testes which
will spontaneously resolve.
Examine the penis for
any abnormal curvatures,
and that the foreskin
fully covers the glans.
Hooded foreskin is often
indicative of hypospadias,
or the ventral displacement
of the urethral meatus.
In all infants, assess
the patency of the anus
by using one hand to hold
the legs and the other
to gently spread apart
the gluteal cleft.
Replace the infant's diaper.
You will now assess the infant's
hips to test for hip dysplasia.
Hip dysplasia is a congenital
deformation or misalignment
of the hip joint, and is
more common in infants
who have a family history of
hip dysplasia, are female,
or who had a breech
presentation in utero.
Assess the hips one at a
time using two maneuvers.
In the Barlow maneuver,
first, adduct hip
by bringing the thigh
toward the midline.
Then, apply a gentle posterior
pressure to the knee.
In the Ortolani maneuver,
flex the infant's knees
to a 90-degree position.
Then, abduct the legs by
folding the thigh outwards.
If you feel a clunk
or dislocation,
close follow-up should be
arranged with the primary care
physician or an
orthopedic surgeon,
depending on the
severity of the finding.
All neonates with risk factors
should have a hip ultrasound
at four to six weeks of life,
regardless of a normal hip
exam.
Extremities.
Are there 10
fingers and 10 toes?
Many infants have a small nubbin
of skin attached the exterior
of the fifth finger.
This is a normal finding,
and may have been inherited.
What about the
length of the digits?
Do the fingers appear
short, called brachydactyly,
or long, called arachnodactyly?
Next, assess the palms.
A lone, horizontal
crease in the palm
is called a single
transverse palmar crease.
While this minor variant
is more common in infants
with neurologic conditions,
such as Down syndrome,
it is also found in about 1%
of the general population.
A minor variant
in hand morphology
should not prompt
referral to genetics,
unless it is one finding among
a constellation of others.
Major anomalies of the
hands or feet, however,
such as missing or
extra digits, should
prompt further investigation.
Back.
Now, gently turn the infant
over to inspect her back.
It is common for infants to have
blue-gray macules on their back
that fade over time.
You may see other normal
newborn rashes, such as erythema
toxicum, which
look like pustules
on an erythematous
base and appear
between 24 to 48 hours of life.
Look at the sacral area.
If you see a dimple there, check
if you can clearly visualize
the base of the indentation.
If you cannot, the infant may
have a spinal cord abnormality,
known as a tethered cord
or spina bifida occulta.
Other findings concerning
for a spinal cord
abnormality are a
conspicuous patch
of hair on the lower back or
an asymmetric gluteal cleft.
Neurologic.
The baby's mental
status can be described
as awake or asleep,
irritable or calm,
consolable or inconsolable.
To test her muscle tone,
pull her toward you.
Does her body feel
stiff and hypertonic,
or overly floppy and hypotonic?
Does her head come up with her
body to a sitting position,
or does it lag behind?
You can assess her motor
function by observation.
Does she move all
her extremities well?
Is her face symmetric?
Sensation can be
determined by noticing
how she responds to your touch.
A unique aspect of the newborn
exam is the primitive reflexes.
When assessing them, note
if they are symmetric,
as asymmetry may indicate
a neurologic or orthopedic
condition.
To test the Moro reflex,
hold the infant's hands
and pull forward until her
head is a few centimeters
above the bassinet.
Drop her head gently
into your other hand.
Her hand should open,
and her upper extremities
should extend and then retract.
The palmar grasp
reflex is easily
listed by pushing your
fingertip into the baby's palm,
causing her to wrap her
fingers around yours.
The rooting reflex is evaluated
by stroking the infant's cheek,
leading her to start suckling
her mouth in anticipation
of a feed.
After you have
completed your exam,
change the diaper if dirty,
and reswaddle the baby.
Place her on top of a blanket,
wrap one corner of the blanket
around her body, fold the
bottom of the blanket up
toward her chest,
and finally, tuck
the remaining side of
the blanket around her
and beneath her back.
Thank the family for allowing
you to examine their new baby,
and ask if they
have any questions.
Thank you for watching this
video on the newborn exam.
