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 ┬ęCopyright
 Published: 29/11/2011

Examination of the Newborn

J D Matthews
(Minimal amendments RNH, JEH 1990, IMRW 1996)

Introduction History Examination
Importance
When
The Examination Itself Conclusion

Introduction

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 physical examination.

History

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.

  1. 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 placenta.

    This information will have determined whether the baby is at risk in terms of the mother having a 'high risk' pregnancy or labour.

  2. The baby: Condition at birth and Apgar scores at 1 and 5 minutes after birth and details of any resuscitative measures used.

Examination

This information can be easily recorded by filling in the appropriate part of page 2 of the Blue Infant Record Card.

Importance

  1. Earliest possible detection of 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.
  2. Establishes a baseline for subsequent examinations.
  3. 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.

When

  1. Immediately after birth
  2. Before discharge from maternity unit
  3. 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

General Overall Inspection Head Chest Auscultation of the Heart
Abdomen Femoral Pulses Genitalia Imperforate Anus Congenital Dislocation of the Hips
Feet Nervous System Myelocoele and Meningomyelocoele Oesophageal Atresia

General

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.

Overall Inspection

  • 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 Syndrome?)
  • 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

Head

  • 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 checked.
  • A short neck is often significant and webbing should be looked for.
  • Ears 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 palate.

Chest

  • 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.
  • Auscultation 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 corrective surgery.
  • 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 not 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.

Abdomen

  • 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 neoplastic disease.
  • 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 examination.
  • 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.

Femoral Pulses

  • 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.

Genitalia

  • 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.

Imperforate Anus

  • 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 examination.

Feet

  • 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.

Nervous System

  • 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.

Oesophageal Atresia

  • 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 vital.
  • 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 stomach.

Conclusion

  • 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.