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newborn exam by dr. Nina Gould
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 unsaddle 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 and the physical exam here and
notify the supervising resident or
attending physician if the baby looks
well but is crying consoled 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 and
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 girth chart
the head circumference should be in the
average range for infants of the same
gestational age and also fall
approximately the same percentile as the
infant's length and wait next what is
the shape of your patients 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 fontanel in the
back the posterior fontanelle the first
letters of the cranial sutures and
fontanel spell out the word clams
c is for coronal suture L is for
lambdoid suture a is for anterior
fontanelle M is firm a topic 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 cephalo
hematoma 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
haemoglobin as the bruise resolves if
the swelling crosses suture lines it is
most commonly due to a caplet suck Sedan
IAM 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 sub Gallio 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 faced 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 ears straight along this
axis if it is tilted back the ear may be
in a posterior rotation in a typical 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 crews
have folds or is it unusually smooth
finally check the skin beside the ears
tragus for pits and skin tags while
variation and 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 today
appeared 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 scene is white you may have
detected a retinal anomaly such as a
congenital cataract or retinoblastoma
another atypical finding is called a
Colo boma which are missing pages 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 our 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 nurse it is common
for newborns to have transient
obstruction from edema related to
suctioning after birth but the
differential also includes Conal atresia
or Conal stenosis in improper formation
or narrowing of the nasal airways cohen
el atresia is a characteristic finding
of the genetic condition charge syndrome
which is an acronym for Kolob oma of the
eye heart abnormalities atresia of the
kkona retardation of growth or
development genitourinary abnormalities
and ear abnormalities any infant found
to have Conal atresia should be referred
to an ear nose and throat specialists 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 newborns
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
left 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 type 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 for anatomy 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 needle 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 and isolated pectus
abnormality is considered a minor
variant and is not cause for genetics
referral listen to the baby's heart you
will 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 machine like 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 for 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 out 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 a stuck in place may be
incarcerated and should be evaluated by
a surgical specialist next palpate the
Invents abdomen by placing one hand on
top of the other pushed gently on the
right side of the abdomen assess the
size of the liver the liver edge should
either not be palpable or live very
close to the newborns ribs palpate
around the abdomen carefully assessing
for masses while where 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 forchette in an
infant with male genitalia assess if the
testicles are descended by palpating
them through the scrotum a swollen and
large 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
Forde skin 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 the hip by
bringing the thigh toward the midline
then apply a gentle posterior pressure
to the knee in the order lonny 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 an or
Hiep exam extremities are there ten
fingers and ten toes
many infants have a small number 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 arachnoid actally next
assess the palms alone horizontal crease
in the poem 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 the 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 toxic 'm which look like
pustules on an erythema to space 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
a wake or asleep irritable or calm
consolable
or inconsolable to test your muscle tone
pull her toward you
does her body feel stiff and hypertonic
or overly floppy and hypotonic gesture
had 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 extremity
should extend and then retract
our grasp reflux is easily listed by
pushing your fingertip into the baby's
palm causing her to wrap her fingers
around yours
the routing reflux 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 changed the diaper
if dirty Andrey swaddle the baby place
her on top of the blanket wrap one
corner of the blanket around her body
hold 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
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