Department of Family Medicine, University of California, Riverside, Riverside, CA, USA
The initial newborn examination occurs immediately postpartum and will be repeated each day of the newborn’s hospital stay. This examination forms the basis for all subsequent management by providing an assessment of development and congenital abnormalities, if any. This examination is therefore comprehensive in nature.
The newborn history consists primarily of a review of the prenatal and delivery course, including complications, if any. Particular attention should be made of the family history of congenital abnormalities, maternal medical conditions, and prenatal exposures including infection, medications, tobacco, alcohol, and illicit drugs.
As noted, the newborn physical examination will serves as the baseline comparator for all subsequent examinations. It should, therefore, be comprehensive, detailed, and guided by an understanding of the most common areas of abnormality.
Vital signs include temperature, pulse, respiratory rate, length, weight, and head circumference. Temperature can be checked in a variety of locations and the specific location should be noted along with the reading. Pulse and respiratory rate are both measured most accurately with the infant resting quietly, preferably in a parent’s arms or lap. Length is often most easily measured by marking the disposable paper on the exam table. A mark can be made at the crown of the head. The infant’s legs can be fully extended and a mark is made at his or her heel. The infant is then removed and the distance between the two marks is recorded. The additional weight of clothing and diapers can be significant for infants, so weight should be measured with the infant fully disrobed. Head circumference is measured as the circumference from the brow (above the eyebrows) to the temple (above the ears) and around the occiput (roughly equivalent to the position of a hat band).
General observations should include whether the child appears healthy, comfortable, and normal.
Head and Neck
The face should be observed for rashes. The ear canals should be checked for patency and the ears for position. Also, the preauricular pits should be noted when present. One should check the mouth and soft palate for defects and make note of the mucosal lining for both moisture and oral thrush, if present. Both anterior and posterior fontanelles should be open. The neck should be palpated for adenopathy. When the child is gently raised from the table, the head lag should be noted.
All infants should be checked for red reflex and for normal eye movement in all directions. Reaction of pupils to light should be noted.
Although it is often difficult for students to distinguish heart sounds in a rapid infant cardiac cycle, note should be made of S1 and S2 in all infants and murmurs, if present. Congenital heart defects may not be apparent at birth and may be picked up for the first time in the physician’s office. Palpate peripheral pulses with particular note made of femoral pulses (both quality and symmetry).
Normal breath sounds and, if present, adventitial (rales, rhonchi, wheezes) sounds should be noted. Note should be made of the chest wall contour, especially at the sternum; the clavicle should be palpated for uneven contour, which may indicate a fracture. The provider should examine the breasts and palpate for breast tissue.
Particular note should be made of the umbilical stump if present. This generally detaches by 2–4 weeks of age. The umbilical region should also be examined for umbilical hernia, noted as either a palpable defect below the umbilicus or as a visible bulging of the area below the umbilical stump.
Males should be examined for the presence of both testicles. When applicable, the site of circumcision should be inspected. In uncircumcised males, the foreskin should be retracted to examine the glans. In females, patency of the vagina should be noted. The inguinal region should be examined for the presence of congenital hernias.
The anus should be checked for patency and note should be made of rashes that might represent either diaper contact dermatitis or candidiasis.
The entire course of the spine should be examined for evidence of spina bifida. Particular attention should be paid to the upper- and lowermost portions of the spine.
Note should be made of the tone of the skin, as well as the presence of any congenital birthmarks. Particular note should be made of the face, scalp, posterior neck, and sacral spine.
All extremities should be examined for symmetry and shape. Note should be made of muscle tone and symmetry of movement and normal posture. Hips should be examined for evidence of hip dysplasia via the Barlow and Ortolani tests. The Barlow test is performed with the hips flexed to 90° and adducted. Downward pressure is applied to the knees. In infants with unstable hips, an audible and/or palpable click is noted. The Ortolani test is performed with the hips flexed to 90°. The hips are then gently adducted and then abducted. Again, note is made of an audible and/or palpable click.
Laboratory and Diagnostic Studies
All states mandate routine neonatal screening for a variety of abnormalities, including phenylalanine and thyroid-related disease and hemoglobinopathies. When appropriate, newborns will also be screened for syphilis and hyperbilirubinemia. Additional laboratory studies may be indicated based on the prenatal and maternal history. Most newborns will also undergo a newborn hearing screen.
Most children will have received the first hepatitis B vaccine prior to discharge from the newborn nursery. Providers should confirm that this occurred.