Ministry of Health
Examination of the Newborn
J D Matthews
(Minimal amendments RNH, JEH 1990,
The whole key to the management of
the newborn infant lies in a proper assessment of the baby at birth.
This necessitates obtaining certain
basic information in relation to two different individuals, the mother and the
baby, and obtained in two completely different ways, by the history and by the
Certain detailed and accurate
information is essential in order to evaluate the results of the physical
examination of the baby. This is required both for the mother and the
infant, and is recorded on a form such as the blue infant record card.
Know the relevance of each item on this card to the examination of the baby.
- The mother:
This includes social and family history, personal and reproductive medical
histories and especially knowledge of the current pregnancy, labour and
delivery. Important are the parent's blood groups, date of last menstrual
period, estimated date of delivery, duration of labour, state of fetal heart
during labour, length of second stage, duration of rupture of membranes,
presentation of fetus, whether or not there was an operative delivery, drugs
and anaesthetics given with their dosage and time of administration,
characteristics and quantity of amniotic fluid, and abnormalities of the
This information will have
determined whether the baby is at risk in terms of the mother having a 'high
risk' pregnancy or labour.
- The baby:
Condition at birth and Apgar scores at 1 and 5 minutes after birth and
details of any resuscitative measures used.
This information can be easily
recorded by filling in the appropriate part of page 2 of the Blue Infant
- Earliest possible
deviations both from usual and from normal. Especially important in relation
to serious correctable congenital malformations, where in some cases (e.g.
oesophageal atresia, imperforate anus, and diaphragmatic hernia) the early
diagnosis enables treatment which may make the difference between life and
death, and in some cases (e.g. congenital dislocation of the hips and club
feet) the earlier the diagnosis and initiation of treatment the less the
incidence of permanent and severe disability.
- Establishes a baseline
for subsequent examinations.
- Enables the doctor to give
parents a true account
of the baby's physical state, and where present to explain and reassure
about minor deviations from usual which if not explained are likely to cause
concern. Best pointed out by doctor rather than discovered by mother.
- Immediately after birth
- Before discharge from maternity
- Whenever there is any concern
about the infant's progress
These examinations should where
possible be carried out in the presence of the mother.
The Examination Itself
Requires a knowledge of limits of
both the usual and the normal.
- Remember that although the range
of normal is wide, the range of usual is much narrower. Therefore, regard
with suspicion any findings outside the range of usual.
- It is important that a few exact measurements
be made and recorded namely:- weight, crown-heel length, head circumference. These should be plotted on the appropriate centile
chart as all parameters of growth need to be related to gestational age for
sensible interpretation. Record the dimensions of any visible or palpable
structural abnormality. Record respiratory rate and heart rate
with infant quiet. While having a routine order of procedure in the
examination of the infant makes less likely the omission of any essential
part of the examination, your routine should be flexible. If the infant is
quiet and relaxed when first approached, auscultation of heart and palpation
of abdomen should precede more disturbing examinations such as those of the
mouth and hips.
- If the infant is struggling and
crying during auscultation of the heart, then temporary shunt reversal may
prevent hearing of a murmur present when the baby is at rest.
- In general does he look ill or
well? Is he normally active? Is the cry normal? Are there any obvious
malformations? (In particular, is the baby funny-looking, e.g. with Down
- What of his colour? Pallor?
Pallid cyanosis of shock? Cyanosis? Plethora? Jaundice? If pallor of skin,
what of mucus membranes and nail beds? Is the cyanosis generalised or
localised? Does the upper surface of the tongue look blue? What is the
response of the cyanosis to oxygen and on crying?
- Is the cord yellow? What of
respiration? Chest movements? Is there a grunt? Is there dyspnoea? The apex
beat is frequently visible on inspection.
- What of the shape of the head?
Do the bones move freely against each other along the suture lines?
- If the infant is small for dates
or unusually skinny, suspect fetal malnutrition. Check on weight for
length and look for other evidence of fetal malnutrition, such as dry scaly
skin on abdomen and extremities and/or abdominal skin creases and lack of
normal subcutaneous fat. (These babies need to be watched for hypoglycaemia
and fed early.)
More Detailed Examination
- Palpate the anterior
fontanelle, sagittal, coronal and lambdoid sutures and posterior
fontanelle. Exclude presence of a third fontanelle, craniotabes and
premature synostosis of skull bones.
- The eyes are most
easily examined if opened by the baby itself. This often occurs
spontaneously if the eyes shaded from light with hands.
- Shine a light from the
side to detect cataracts. Note presence of flattened bridge of nose or
epicanthic folds. Is there a coloboma (defect of iris)? Are there any
Brushfield's spots in the iris?
- Choanal atresia
is checked for by seeing if the infant can breathe with mouth closed and
then with left and right nostril occluded alternately. If in any doubt
check nasal airways with a catheter, and if this is too large, try a
feeding tube, and finally if necessary a probe. The nasal airway is the
vital one in the neonate.
- Sternomastoid muscles
should be palpated and the range of rotation of head to each side
- A short neck
is often significant and webbing should be looked for.
which are unusual in size or shape, are floppy and lacking in normal
cartilage, and especially if low placed, are of significance and may be
associated with urinary tract abnormalities.
- The mouth
should be fully inspected with a good light and spatula and the palate
inspected right back to the uvula to exclude minor degrees of cleft
- Asymmetry, thoracic cage
defects and spinal scoliosis should be noted.
- Apex beat position
should be confirmed or determined if not visible in order to help
determine heart size and possible presence of mediastinal shift.
of the chest may help give additional information, but apparent presence
of normal findings on percussion and auscultation does not exclude gross
intra-thoracic abnormality. Even the slightest suspicion about the state
of heart and lungs makes chest x-ray mandatory. If there is
definite displacement, or any doubt as to the position of the apex beat,
even in the absence of other signs of possible abnormality, such as
cyanosis, differences in the two sides of the chest with regard to
movement on respiration, air entry, breath sounds, and/or in percussion
note, then early x-ray of the chest is essential. The presence of a
'scaphoid' abdomen would favour the diagnosis of gross diaphragmatic
hernia with abdominal viscera largely in the thorax.
- Radiological findings even
suggestive of diaphragmatic hernia or any other space occupying lesion,
be it solid or cystic, or pneumothorax, are an urgent indication for
immediate transfer to a base hospital equipped and staffed to make the
definitive diagnosis and then to proceed without delay to carry out
- Before transfer,
where the infant's condition is so bad it is unlikely to survive
transport, certain immediate life saving measures may be indicated. For
example, in the infant with a large proven pneumothorax air should be
aspirated from the pleural cavity, and in the baby with so large an
intra-thoracic space occupying lesion that it causes severe cyanosis
relieved by oxygen, carry out intra-tracheal intubation and give
intermittent positive pressure oxygen.
Auscultation of the heart
- Presence of a significant
murmur in itself in the absence of associated evidence of cardiac
failure (i.e. increased respiratory rate, unexplained pallor, cyanosis,
sweating, enlarged liver and gallop rhythm), would only be an indication
for checking on femoral and peripheral pulses, x-ray of heart, doing an
electrocardiograph and watching carefully.
- If facilities for these
special investigations are not available,
then immediate transfer to a unit with such facilities is called for.
Evidence of significant systemic cyanosis or of early heart failure, or
any deterioration in baby's condition, e.g. not as energetic as
previously, or no longer taking feeds as well, is an indication for
transferring to a specialised cardiological unit.
- Scaphoid abdomen
suggests the presence of a gross diaphragmatic hernia. Distended abdomen
calls for more detailed examination and frequently additional
investigations to determine cause, which may vary from distension of
stomach and intestines as a result of resuscitation, to gross pathology
such as that associated with intrauterine peritonitis, or gross
- The liver and spleen
should be felt for, and where palpable, their size, shape and
consistency determined and recorded. Routine palpation of kidneys
should be carried out to determine whether they are present and if so
their position, size, shape and consistency.
- Careful inspection of
umbilicus should include checking on adequacy of cord, tie, or clamp.
A yellow cord at birth suggests intrauterine anoxia or haemolytic
disease. If on examination of the severed cord at the infant's end, only
two instead of the usual three umbilical vessels are found, then be
alerted to the greater chance of the baby having other more serious
congenital abnormalities not necessarily revealed on initial clinical
- If exomphalos
(omphalocele) is present,
this is an indication for applying a protective sterile plastic covering
and transferring urgently to a surgical unit experienced in neonatal
surgery. Prior to transfer give antibiotics capable of coping with both
gram positive cocci and gram negative bacilli.
- Routine palpation of
femoral pulses themselves and then simultaneously with the brachial or
radial pulses may be the first indication of the presence of coarctation
or of interruption of the thoracic aorta. This would warrant careful
examination of the cardiovascular system including x-ray, chest, ECG and
taking arm and leg blood pressures. Absence of a higher blood pressure
in the legs than that of the arms would strongly support the diagnosis
and indicate the need for urgent cardiological assessment. Presence of
normal femoral pulses does not exclude coarctation of the aorta at this
stage, and at each subsequent examination femoral pulses should continue
to be checked.
- Abnormality suggestive of
hermaphroditism should always be checked carefully and where present,
the infant referred early for specialist assessment and possible
biochemical, hormonal, cytological and chromosomal study.
- One of the causes of
pseudohermaphroditism is congenital adrenal cortical hyperplasia
(adreno-genital syndrome), which generally presents in the first few
days of weeks of life with a 'salt losing syndrome' of sudden onset.
Unless treated promptly and adequately for what it is, such an infant
will rapidly die - a death which could have been prevented, had the
diagnosis been thought of, confirmed and electrolyte and steroid therapy
been promptly initiated. Presenting symptoms include anorexia, vomiting,
diarrhoea, weight loss and extreme dehydration. Restriction of fluid and
salt intake results in sudden collapse and death.
- In boys
the presence of the 'hooded foreskin' strongly suggests the presence of
hypospadias which strongly contra-indicates carrying out circumcision.
- Inguinal hernias should be
looked for and other things being equal, be excised as soon as possible,
preferably before the infant goes home.
- In girls
an attempt should be made to separate the vulva. In this way, presence
of vaginal cysts and vulval fusion will not be missed.
- This can be excluded by
routine careful examination of the anus. Any unusual appearance in this
warrants careful investigation. It has to be remembered that passage of
normal meconium does not preclude the need for careful examination, e.g.
imperforate anus with associated recto-vaginal fistula. While routine
digital examination of anus is not regarded as necessary, insertion of
thermometer in taking temperature is advocated.
Congenital Dislocation of Hips
- Recognition in the early
neonatal period is essential for proper treatment to be started early
enough to result in the most satisfactory end results. The chances of
early diagnosis by demonstration of positive Ortolani's sign are
greatest when the examination is carried out immediately after birth.
The standard method is Barlow's test.
- This must be repeated at
all subsequent examinations until the infant is walking normally as the
first examination may fail to demonstrate an abnormal hip. It is
important that the baby should be properly relaxed during the
- All feet should be
examined at birth and where club feet (talipes, equino varus or talipes
varus) or calcaneo valgus deformities are present, referral to an
orthopaedic surgeon is indicated.
- Inability to dorsiflex and
externally rotate foot so that the little toe can be brought in contact
with the exterior aspect of the leg makes the diagnosis of 'club foot'.
- Inability to plantar flex
foot properly, i.e. to at least 45 degrees beyond the right angle, makes
the diagnosis of calcaneus deformity.
- The presence of normal
activity and limb movements and normal limb tone should be checked. In
addition attempts should be made to elicit normal grasp and Moro
'startle' reflex. Inability to do this strongly suggests significant
abnormality of central nervous system. Remember that when the infant is
crying it is sometimes not possible to elicit a normal Moro reflex. In
this case the infant should be quietened when failure to elicit normal
response would be significant.
Myelocoele & Meningomyelocoele
- This is to be regarded as
an indication for urgent referral to a neurosurgeon, especially where
the membrane is thin or defective, as early closing of the defect may be
called for where this is possible. Early surgery facilitates nursing
care and frequently makes it possible to return the infant to the mother
within a few days of birth. It also enables early treatment of any
associated congenital dislocation of the hips. In some cases the degree
of permanent neurological disability may be lessened by early operation.
- The ultimate prognosis of
many of these infants has been radically altered now that the associated
hydrocephalus frequently developing is amenable to shunt operation in
the early neonatal period.
- Here, even more than with
most atresias of the gastro-intestinal tract, early diagnosis,
preferably before the giving of the first feed with the associated
dangers of aspiration and pneumonia is essential, and proper management
in the time elapsing between diagnosis and surgical correction can be
- Thought of and looked for,
most cases can be diagnosed before the first feed is given. The
classical picture is of spluttering, choking, coughing, sometimes going
blue and returning to food.
- Every infant born to a
mother with hydramnios and/or mucousy after birth should have a large
soft plastic catheter (English size 6 or 8) passed through the mouth
into the stomach. Failure to pass the catheter into the stomach, or
where there is any doubt as to whether the catheter has entered the
stomach should lead to immediate radiological examination, initially
with a radio-opaque catheter in the oesophagus.
- The presence of the
catheter in the stomach can be suspected if it goes in far enough to
reach below the costal margin and confirmed by viewing the end of the
catheter or by palpating it through the abdominal wall.
- The large soft rubber or
plastic catheter is less traumatic than the smaller one which can be
passed through the nose and unlike it, is not able to bend back on
itself, giving a misleading impression that it has passed into the
- Routine physical examination
takes only a few minutes and should be carried out in all infants at the
earliest possible moment after birth, and again just before discharge from
the maternity hospital. Routine physical examination excludes obvious
abnormalities and helps make possible an earlier diagnosis of many not quite
so obvious conditions.
- Many of the serious correctable
congenital malformations can be detected at birth or within a few days,
provided they are thought of and looked for. Early diagnosis of certain of
these abnormalities, e.g. oesophageal atresia, greatly increases the chances
of successful surgery and frequently makes the difference between survival
and death. In other cases e.g. congenital dislocation of the hips, early
detection and commencement of treatment prevents or greatly reduces
permanent residual disability.