Simple approach to newborn examination

1. The Newborn Examination
Dr.Vinod Gandhi
MD (Ped), DNB (Ped)
Consultant Pediatrician & Neonatologist

2. Today’s Learning Objectives
 Classification of newborn
 Understand Apgar score
 Assess growth measurements
 Assess vital signs
 Estimate the gestational age
 Assess the different body systems
 Recognize normal findings in newborn examination
 Recognize common newborn problems
Remember to Wash your hand prior to examination

3. Classification of newborn
 Classification by
Gestational Age
Preterm <37 wks
Full term 37-40 wks
Post term >42 Wks
 Classification By
Birth Weight
LBW < 2500 g
VLBW < 1500 g
ELBW < 1000 g
 Classification By
Weight Percentiles of GA
AGA 10th-90th
SGA < 10th
LGA >90th

5. Examination of newborn
Should be done within 24 h. after birth
Complete physical exam.includes:
1. Vital signs
2. Physical exam
3. Neurological exam
4. Estimation of gestational age

6. Vital signs
Temperature
 Heart rate
 Respiratory rate
 Blood pressure
 Capillary refill time

7. Measurements
• Weight
• Length
• Head circumference

8. k

9. General examination
• Well or in Distress?
• Skin colour
– Pink is Normal
– Pallor associated with low hemoglobin or shock
– Plethora associated with polycythemia
– Blue Bruised part or cynosis
– Jaundice
– Common skin rashes
• Erythema toxicum, mongolian spot, Benign Pustular Melanosis

10. Cyanosis
– Cyanosis - Acro cyanosis is normal

11. Jaundice

12. Skin
• Purpura,echymosis
• Mottling
• Vernix caseosa

13. Skin
• Edema
• Mongolian spots
• Collodion infant

14. Skin rashes
• Milia
• Erythema toxicum
• Impetigo

15. Skin rashes
• Diaper rash
• Hemangiomas

16. HEAD : General, Cuts, Bruises
• Anterior and posterior fontanelles
Large anterior fontanelle
Small anterior fontanelle
Bulging fontanelle
• Molding
• Caput succedaneum
• Cephalohematoma
• Increased intracranial pressure
• Craniosynostosis
• Craniotabes

17. Head and Neck
• Macrocephaly / Hydrocephalus
• Microcephaly
• Subgaleal hemorrhage

18. Head and Neck
• Fontanelle
• Moulding
• Caput succedaneum

19. Head and Neck
• Craniosynostosis
• Cephalhematoma

20. Neck & Facial Features
• FACE : Any obvious abnormalities
Shape of the nose, mouth and chin
Presence of any syndromic features
• NECK : Shape
Range of motion
Webbing
Palpate for masses
– Brachial palsy
– Erb’s palsy
– Fractured clavicle
• EARS : Unusual shape,
Low set ears
Periauricular skin tags (papillomas)
Hairy ears.

21. Neck
•Webbing
•Masses: Sternomastoid tumor
Thyroid
•Cysts: Thyroglossal cyst
Cystic hygroma

22. Eyes
• Orbital Placement
• Hypertelorism is defined by an increased
interpupillary distance.
Hypotelorism Normal Hypertelorism

23. Eyes
• Pupils: equality, reactivity to light.
• Squint
• Cornea
• Conjunctiva
• Iris

24. Eyes
• Opthalmia neonatorum
• Congenital cataract
• Corneal opacity

25. Eyes
• Glaucoma
• Squint
• Subconjuctival bleed

26. Ear Examination
Assess for asymmetry or irregular shape
– Auricular or pre-auricular pits,
fleshy appendages, lipomas, or
skin tags.
– Low set ears
• Below lateral canthus of eye
• Associated with genitourinary
anomalies.
– Malformed ears
• Can be associated with Downs
or Turners Syndromes

27. • Ear Tag
Ear Examination

28. Nose
•Patency of each nostril;
exclude choanal atresia
•Flaring of nostrils
•Nasal septum

29. Mouth
•Cleft lip and palate
•Tongue tie

30. Mouth
•Epstein pearls
•Natal teeth
•Tongue size

31. Mouth
• Oral Thrush
• Ranula

32. Extremities
• Syndactyly
• Polydactyly
• Oligodactyly
• Congenital Talipes Equinovarus (CTEV)
• Metarsus Varus

33. Spine
• Inspect back for meningocele

34. Hips
• Congenital hip dislocation
– Assymetry of the skin folds on the dorsal surface
– Shortening of the affected leg

35. Chest/Lung Examination
• Inspection
– Supernumerary breast or nipple.
– Unilateral absence of pectoralis major
• Poland's Syndrome (Poland's Sequence)
– Widely spaced nipples
• Turner's Syndrome
• Noonan Syndrome

36. Chest/Lung Examination
• Inspection
– Chest Deformity
• Pectus Carinatum
• Pectus Excavatum
- Breast engorgements

37. Chest/Lungs
• Observe
– Respiratory pattern
• “periodic breathing”
– Chest movement
• Symmetry
• Retractions and Tracheal tugging
• Ascultation
– Audible stridor, grunting
– Wheeze, rales.

38. Heart and vascular system
• Tachypnea,tachycardia
• Increased pericordial activity
• Cyanosis: hyperoxia test
• Auscultation of heart sounds, murmurs
• Perfusion: Capillary refill time
•Palpate femoral pulsation: absent in coarctation of the aorta
•Bounding pulses often indicated PDA

39. Abdomen
• Organomegaly: liver may be palpable
• Masses
• Distension , scaphoid abdomen
• Umbilical stump: bleeding , meconium straining, granuloma,
discharge, inflammation
• Omphalocele and Gastroschisis

40. • Normal umbilical cord
• Meconium Stained Umbilical
Cord
• Omphalocele
Abdomen

41. • Scaphoid abdomen
• Abdominal distension
• Diastasis recti
Abdomen

42. Male Genitalia
•In full term,scrotum is well developped, both
testes are in the scrotum
•In preterm,scrotum is small with few rugae.
Testes are absent or high in the scrotum

43. Male genitalia
• Bilateral hydrocele
• Inguinal Hernias
• Hypospadias

44. Female genitalia
• In full term,labia majora completely cover labia
minora
• In preterm,labia majora is widely separated and labia
minora protruded

45. • Withdrawal bleeding
• Ambigious Genitalia
Female genitalia

46. Anus
• Meconium should pass in the first 48h after birth
• Delayed passage of meconium may indicate
imperforate anus or intestinal obstruction
• Urine should pass in the first 24h of life

47. • Imperforate Anus
• Sacro-coccygeal dimple
Anus

48. Nervous System
• Observe for any abnormal
movement/ excessive
irritability
• Muscle tone
– Hypotonia : Floppiness
– Hypertonia : Extended arms &
legs, hyperextension of back &
tightly clenched fists.

49. Neonatal reflexes
• Also known as primitive reflexes.
• Autonomic behaviors that do not require higher level
brain functioning
• Provide information about integrity of C.N.S.
• Their absence indicate C.N.S depression
• They are often protective and disappear as higher
level motor functions emerge.

50. Moro Reflex
• Most important reflex in
neonatal period
• Onset: 28-32 weeks GA
• Disappearance:4-6
months.
Neonatal reflexes

51. Significance of Moro
 Bilateral absence:
• CNS depression by narcotics or
anesthesia
• Brain anoxia and kernicterus
• Very Premature baby
 Asymmetric response:
• Erbs palsy , fracture clavicle or
humerus
 Persistence beyond 6th month:
• CNS damage
Neonatal reflexes

52. • Suckling Reflex
Appears at 32 wk &
disappears by 3 – 4 m
• Rooting Reflex
Appears at 32 wk &
disappears by 3 – 4 m
Neonatal reflexes

53. • Tonic neck reflex
Fencing posture
• Palmar grasp reflex
• Stepping reflex
• Placing reflex
Neonatal reflexes

54. Gestational Age Assessment
Obstetricians
- LMP
- Ultrasound
New Ballard score
Includes 6 External Characteristics
& 6 Neuromuscular Scores.

55. Ballard JL, et al. J Pediatrics; 1991: 119 (3)

56. THANK YOU!!