The Newborn Examination

Clinical Rotations for Students

This introduction is not intended to be comprehensive, but is instead designed to cover the main components of the newborn examination. During your time in the nursery, we trust that you will become comfortable with the essential elements of the exam and be able to identify many of the common physical findings.

Before even touching the infant, notice the following: color, posture/tone, activity, size, maturity, and quality of cry.

This infant has a normal pink color, normal flexed posture and strength, good activity and resposiveness to the exam, relatively large size (over 9 pounds), physical findings consistent with term gestational age (skin, ears, etc), and a nice strong cry.

photo by Janelle Aby, MD

Inspect and palpate the head noting: bruising, edema, molding/shape, sutures, and fontanelles.

Bruising is visible on this infant's head. Scalp edema (caput succedaneum) is a very common finding. Cephalohematoma (sub-periosteal bleed) is occasionally noted. Gentle but firm palpation will help distinguish these two entities from each other and from molding. Suture frequently overlap each other ("over-riding") and fontanelle size varies. Within 24 hours, edema and molding will already show improvement.

photo by Janelle Aby, MD

Examine neck and clavicles for: range of motion, asymmetry, masses, or crepitus.

Infants have very short necks, but they should have full range of motion from side to side, and the neck should appear symmetric. To palpate clavicles, use a firm, steady pressure along the enitre length of the bone, from shoulder to sternum, to detect crepitus, edema, or step-offs that indicate clavicular fracture. The infant above has swelling over the left clavicle as a result of a fracture.

photo by Janelle Aby, MD

Assess the eyes for: symmetry, set/shape, discharge, erythema, and red light reflexes .

Eyes should be symmetric and in a normal position. Eyelid edema is common after birth and resolves a a few days. Slight yellow discharge in a normal eye may be benign, but injection in the conjunctiva (seen above in the baby's right eye) is abnormal. Red light reflexes can be seen by looking at the pupils through an ophthalmoscope; they may appear orange-yellow in darker skinned infants.

photo by Janelle Aby, MD

Make note of: ear set/shape, preauricular pits/tags, nasal shape/patency, palate, gums, lips and tongue.

Ears should not appear low or posteriorly rotated. Although nasal congestion can be present in newborns, there should not be nostril flaring or respiratory distress. Palate should be intact visibly and by palpation (submucosal clefts occur). Tongue should be freely mobile. In the photo above, the lingual frenulum under the tongue is restricting tongue elevation when the baby cries.

photo by Janelle Aby, MD

Observe: shape of thorax, position of nipples, and work of breathing.

Chest should have a normal contour with nipples near the mid-clavicular line. Small breast buds are present in term infants. Breathing should appear easy. The infant in the photo above has unusually prominent ribs as a result of intercostal retractions, a sign of respiratory distress.

photo by Janelle Aby, MD

Listen for and assess: breath sounds, heart murmurs, and femoral pulses.

Lung sounds should be clear and equal. Normal respiratory rate is 40 - 60 bpm. Normal heart rate is 120 - 160 bpm. Quality and location of murmurs should be noted. Femoral pulses are best obtained when the infant is quiet. They should feel strong and equal.

photo by Janelle Aby, MD

Assess: bowel sounds, liver, spleen, kidneys and umbilical cord .

Bowel sounds should be present and the abdomen soft. A liver edge in nornally palpable 1 - 2 cm below the right costal margin. A spleen should not be detected on physical exam. Kidneys may be palpated by an experienced examiner, but are likely enlarged if easily felt. The cord should be clean and dry. If fresh, the umbilical vessels may be assesssed also. There should be two arteries and one vein.

photo by Janelle Aby, MD

Evaluate: labia, hymen (or penis, testicles) and anus .

For girls, both labia majora and minora should be seen. Normal hymenal tissue is light pink with a central orifice between the labia minora. White or mucoid disharge (as in the photo) is normal. For boys, the penile shaft should appear straight with an intact foreskin. Testicles should be palpable bilaterally as small (1 cm) symmetric masses. The anus should have a visible orifice within the sphincter. Stool in the diaper is notevidence of patency.

photo by Janelle Aby, MD

Assess back and spine for: symmetry, skin lesions, and masses.

Back should appear symmetric and spine should be palpable all along its length. Unusual skin lesions, tags, or masses should be noted as these may indicate underlying spinal dysraphism.

photo by Janelle Aby, MD

Inspect extremities for: mobility, deformity, and stability.

Fingers and toes should be counted and evaluated for evidence of malformation. Arms and legs should appear symmetric bilaterally and have normal position and good tone. Ortolani and Barlow maneuvers are used to evaluate hips for subluxation or dislocation. This newborn has bilateral clubfeet.

photo by Janelle Aby, MD

Evaluate the following reflexes: suck, grasp (hands and feet), and Moro.

There are several other reflexes present at birth, but unless there is concern about the neurologic state of the infant, a general screening with the items listed above should be sufficient.

photo by Janelle Aby, MD