The Newborn Physical Exam

Best performed with the baby undressed under the warmer in the parent’s room.

Gestational Age
Ballard exam looks at skin texture, distribution of lanugo, plantar skin creases, breast size, ear firmness,
genitals and neuromuscular maturity. Accurate to within two weeks.  Ballard/Dubowitz exam

Measurements

• Plot weight, length, head circumference versus EGA on growth chart
• Appropriate for gestational age (AGA): Weight is within 10-90 percentile for the EGA
• Small for gestational age (SGA): Weight is < 10 percentile for EGA
• Symmetric growth retardation (Wt, length and HC are all <10%) represents slow growth early on
  in pregnancy and more likely to represent a syndrome or congenital infection.
• Asymmetric growth retardation (HC is spared) is usually the result of influences on growth later in
  the pregnancy such as placental insufficiency, in utero drug exposure, pregnancy induced
  hypertension or multiple pregnancies. Complications: Respiratory distress, hypoglycemia, hypothermia and polycythemia
• Large for gestational (LGA): Weight is > 90 percentile for EGA. Usually a result of infants of diabetic mothers, clinical syndromes, or genetic predisposition. Complications: Hypoglycemia, polycythemia, fractured clavicle, brachial plexus or facial palsy.

Temperature
Normal rectal temperature should be 36.5 to 37.5 degrees centigrade.
Infants at risk are premature infants and SGA babies, air conditioned rooms, inadequate or delayed
drying and warming after delivery
 

General Appearance
Alert from birth to 10 minutes
Sleep from 10 minutes to 2 hours
Variable from 2-10 hours after birth
 

Head
Anterior fontanel should measure 2.5 +/-1.5cm (one to two fingertips)
Posterior fontanel should be absent to < 0.5cm
Macrocephaly: HC is >95th % for gestational age. May be familial or due to cephalohemtoma, caput
succedaneum or underlying pathology such as hydrocephalus (transilluminate skull), cerebral gigantism
Microcephaly: HC is <3%. May be associated with a congenital infection, chromosomal abnormality, in
utero drug exposure or syndrome.
Molding: Occipital elongation from vaginal delivery. Improves in few days.
Cephalohematoma: Subperiostal collection of blood. Limited by suture lines. Resolves in few weeks.
Caput succedaneum: Collection of subQ edema. Can cross suture lines. Resolves in few days
Recognize the need for careful observation of the head size and shape, symmetry, facial features, ear size
and hair whorls as part of the examination for dysmorphic features

Eyes
Red reflex must be present and if absent is always a sign of pathology such as corneal opacity, cataract,
persistence of the vitreous humor, retinal detachment or retinoblastoma.
Evaluate contour of the pupil, colobomas, absent iris, conjuntival hemorrhages (resolves in few days)

Ear, nose and throat
Abnormalities of the external ear include abnormal position, preauricular pits (renal disease), skin tags
Evaluate patency of nares
Look for cleft lip or palate, bifid uvula may indicate submucosal cleft
Macroglossia may indicate hypothyroidism. Tongue tie (tight frenulum) no intervention necessary
Natal teeth, epidermal inclusion cysts, Ebstein’s pearls

Neck
Evaluate for masses, fistulas, cysts, torticollis, thyroid enlargement
Palpate along the clavicles for crepitus especially if LGA or difficult delivery

Chest
Retractions, grunting, respiratory rate (normal 30-40, irregular with <10 second pauses), respiratory effort,
chest excursions, lung sounds, symmetry
Evaluate for gynecomastia, milk, accessory nipples

Heart
Rate, rhythm (normal 110-160), murmurs, precordial activity, brachial and femoral pulses and perfusion
 

Abdomen
Liver span can be 1-2 cm down, spleen, kidneys, masses, hernias, umbilicus (two arteries and one vein),
diastasis recti

Genitourinary
Testes are 1-2 cm in size. Evaluate if descended or undescended vs retractile, hydrocoele
Look for chordee, hypospadius or small penis (3.5 cm is the average)
Vaginal discharge (clear fluid or blood)
Look for signs of virilization. Hypertrophy of the clitoris is common
Swollen labia and hymenal tags will resolve by one month

Anus
Check placement and patency. Generally do not need to perform rectal exam
 

Hip exam
Barlow exam produces dislocation of the hip. With the knees and hips flexed 90 degrees, place middle
finger on greater trochanter and thumb medially, adduct the hip and push down.
Ortolani exam relocates the hip that is dislocated. With the knees and hips flexed 90 degrees, place middle
finger on greater trochanter and thumb medially, abduct while pushing medially and forward on greater
trochanter
Positive exam is indicated by a clunk (not a click)
Assymetric posterior creases and leg length discrepency can also indicate DDH
Galeazzi exam compares the height of the knees when the baby is supine with hips and knees flexed and
feet are on surface of the examining table

Extremities
Look for polydactyly (supernumerary digits), clinodactyly, syndactyly
Foot deformities caused by in utero positioning straighten out easily. Resolve over weeks to months
Clubfoot deformities are not correctable with gentle pressure
Rocker bottom feet (vertical talus) 50% are associated with neuromuscular or chromosomal disorders.
Brachial Plexus Injury
Stretch on the brachial plexus usually with difficult deliveries
Erb's (C5-C6) loss of shoulder motion and elbow flexion
Klumpke's (C8- T1) loss of finger and wrist flexion and Horner's Syndrome

Spine
Evaluate spine for scoliosis or lumps or gaps between vertebrae which may indicate spina bifida
Look for pilonidal dimple. Normal if bottom is visualized. Not normal if hemangioma, lipoma or tuft of
hair. Evaluate for spinal abnormality

Skin
Color: jaundice, acrocyanosis, pallor, plethora, cyanosis, cutis marmorata (marble skin)
Lanugo, vernix caseosa (latin for cheesy varnish), postmature drying and cracking
Hemangiomas: nevus flammeus, strawberry hemangiomas, port wine stain (Sturge Weber)
Petechiae are common on face. Do not blanch with pressure
Milia: Hyperactive sebaceous glands
Erythema toxicum: most common skin lesion. White pustules on erythematous base. Eosinophils on GS
Mongolian spots
Cafe au lait spots: More than 5 suggest neurofibromatosis
Transient neonatal pustular melanosis
Sucking blisters

Neurologic
Assess tone. When pulled to sitting position head lags behind. Baby can hold head upright for seconds
Rooting reflex: stimulation of the upper lip mouth is opened, head turns toward stimulus
Sucking reflex: infant will grasp nipple or finger when placed in the mouth and start to suck
Moro (startle reflex): allow the head to drop a few centimeters while in the midline position and the neck
muscles are relaxed. Rapid arm extension with hands open followed by arms coming back together
Tonic Neck Response (fencer): turning head to one side will lead to extension of the arm on that side and
flexion of the other arm.
Galant: lateral curvature of the trunk w/ stimulation along paravertebral line 3 cm from midline.
Babinski: flexion and fanning of the toes with stroking of the dorsum of the foot
Palmar/plantar grasp: infant will grasp a finger when pressed in the infant's palm/sole of foot
Stepping and walking reflexes: When the dorsum of the feet touch a surface while the baby is held upright,
the baby will appear to take a step