Newborn History and Physical

Examination
Alissa Barcelona Christel Mendoza
Definition
Perinatal period: 28
th
wk AOG upto 7
th
day after
birth
Neonatal period: 1
st
28 days after birth
Very early (birth to <24 hrs)
Early (birth to <7 days)
Late (7 days to <28 days)
Infancy: 1
st
year after birth
Epidemiology
2/3 of all deaths < 1yr old
Mortality is highest
during the 1st 24 hrs
after birth
FETAL
Placental insufficiency
Intrauterine infection
Severe congenital
malformations (anomalies)
Umbilical cord accident
Abruptio placentae
Hydrops fetalis
FULL TERM
Congenital anomalies
Birth asphyxia
Trauma
Infection
Meconium aspiration
pneumonia
Persistent pulmonary
hypertension (PPHN)
PRETERM
Severe immaturity
Respiratory distress
syndrome
Intraventricular
hemorrhage
Congenital anomalies
Infection
Necrotizing enterocolitis
Bronchopulmonary
dysplasia

http://www.doh.gov.ph
History
Past medical illnesses in the mother
and family
Previous maternal reproductive
problems
Events in present pregnancy
Description of the labor and delivery
Physical Examination
Requires patience, gentleness and
procedural flexibility
APGAR Scoring

APGAR Scoring 0 1 2
Heart rate Absent Below 100 Over 100
Respiratory effort Absent Slow, irregular Good, crying
Muscle tone Limp Some flexion of
extremities
Active motion
Response to catheter in
nostril (tested after
oropharynx is clear)
No response Grimace Cough or sneeze
Color Blue, pale Body pink,
extremities blue
Completely pink
Physical Examination
Vital Signs:
HR (N 120-160 bpm), vagal
slowing may be noted
(upto 80 bpm in postdated
infants
RR (N 30-60 breaths/min)
short pauses(5-10secs)
considered normal
Apnea: cessation of
breathing >20 secs or any
duration if accompanied by
cyanosis and bradycardia
Pulse oximetry- to screen
for PDA-dependent CHD


Blood pressure- not
routine, SBP gradient bet
upper and lower ext
>10mmHg suspect CoA
Temp N 36.4-37C (axillary)
Physical Examination
Anthropometrics
Head circ: N
32-26cm in
term infants
SGA: BW<10
th

percentile
AGA: 10
th
-90
th

percentile
LGA: >90
th

percentile
Length
Symmetric SGA Asymmetric SGA
Onset: early in
gestation
Brain size
corresponds with
body size
Causes:
smoking/drugs,
small maternal
size, chromosomal
anomaly, TORCH,
metabolic d/o
Onset: late in
gestation
No or minimal
effects on fetal
brain growth
Causes:
uteroplacental
insufficiency with
chronic fetal
hypoxia
Physical Examination
General appearance:
Physical activity (active and passive tone,
posturing)
Ankle or jaw myoclonus vs convulsive
twitching
Edema: generalized vs. localized

Skin
Plethora Jaundice
Pallor Cyanosis
S
k
i
n

Vernix caseosa
Skin
Mottling
Skin
Harlequin color change
Skin
Salmon patch
Skin
Port wine stain
Salmon Patch (Nevus
Simplex)
Port Wine Stain
small, pale pink, ill-defined,
vascular macules
usually symmetric
glabella, eyelids, upper lip,
and nuchal area
represent localized vascular
ectasia
persist for months, most
eventually fade
macular, sharply
circumscribed, pink to
purple, larger
unilateral
head and neck
represent mature
dilated dermal
capillaries
permanent
Mongolian spots
Milia
Sebaceous hyperplasia
Milia Sebaceous hyperplasia
Keratin-filled epithelial
cysts
Present at birth
No inflammatory
component
Caused by maternal
hormones
Does not generally
appear until after 2
weeks
More yellowish
Erythema toxicum
Milliaria crystallina
S
k
i
n

Transient pustular melanosis
Skull
Molding (esp. if normal firstborn cephalic delivery)
Suture lines and fontanels
Cranial synostosis: hard nonmovable ridge over the
suture
Anterior fontanel: diamond-shaped, 4-6cm at birth,
usually closes at 9-18mos
Posterior fontanel: closed at birth or admits tip of finger
till 2-4 mos
3
rd
fontanel: trisomy 21, preterm
Craniotabes
Large anterior fontanel
(N= 2010mm)
Achondroplasia
Apert syndrome
Athyrotic hypothyroidism
Cleidocranial dysostosis
Congenital rubella
syndrome
Hydrocephaly
Hypophosphatasia
Intrauterine growth
retardation
Kenny syndrome
Osteogenesis imperfecta
Prematurity

Pyknodysostosis
Russell-Silver syndrome
Trisomies 13-, 18-, and 21
Vitamin D deficiency
rickets

Small fontanel

Microcephaly
Craniosynostosis
Congenital
hyperthyroidism
Wormian bones

Skull
Caput succedaneum Cephalhematoma Subgaleal hemorrhage
Soft tissue swelling
ecchymosis
Diffuse
Crosses suture lines
1-2 days
Subperiosteal
bleeding
Does not cross
suture lines
2wks to 3 mos
Bleeding under the
aponeurosis of
occipitofrontalis muscle
2-3 wks
Eyes
Often spontaneously open when held up and
tipped gently
Retinal hemorrhages: common w/ vacuum-
assisted deliveries, resolve by 2-4 wks
Pupillary reflex: begins at 28-30 wks AOG
Congenital glaucoma
Leukokoria

Skull
Megalencephaly: hydrocephaly, storage
disease, achondroplasia, cerebral gigantism,
neurocutaneous syndromes, or inborn errors
of metabolism, or may be familial
Aplasia cutis congenita: atrophic or alopecic
scalp, sporadic or AD, assoc w/ Trisomy 13,
chromosome 4 deletion, or Johanson-Blizzard
syndrome
Face
Moebius syndrome: symmetric facial palsy sec
to absence or hypoplasia of CNVII nucleus
Ears: preauricular skin tags
Nose: choanal atresia
Mouth: natal or neonatal teeth, cleft palate,
Epstein pearls- accumulation of epith cells on
hard palate, retention cysts- gums, short
frenulum, sucking callus- labial tubercle which
disappears when suckling ceases

Neck
Goiter, cystic hygroma, branchial cleft rests,
teratoma, hemangioma, SCM
hematoma/fibrosis, clavicular fracture
Congenital torticollis
Redundant skin/webbing in a female
Thyroglossal and branchial arch sinus tracts
MC neck masses in the NB are vascular
malformations, abnormal lymphatic tissue,
teratomas, cystic hydromas and dermoid cysts

Lungs/Heart
Breathing is entirely diaphragmatic
Grunting- potentially serious CP distress/sepsis.
if benign resolves bet 30-60min after birth
Intercostal retractions: compensation for chest
wall stabilization
Lung sounds are more bronchial than vesicular
due to better transmission of large airway
sounds across a thin chest


Heart
PMI and auscultation
SVT: >220 beats/min
Systolic murmurs may be heard transiently in
normal NB as ductus arteriosus is closing (flow
murmurs) or w/ mild pulmonary branch stenosis
Diastolic murmurs should always be considered
abnormal
Suspect CHD in (1)persistent murmurs, (2)O2sat <
96% after 24 hrs, (3) failed hyperoxia test- arterial
PO2<100 after giving 100% inspired O2 w/o clear-
cut lung dse, or consider structural heart dse w/
complete intracardiac mixing if pO2 bet 100-250


Abdomen
Liver usually palpable 2cm below rib margin
Rectal gas should be present by 24 hrs of age
Umbilical hernias, omphalocele vs.
gastroschisis
Unusual masses: usually renal in origin
Cystic vs solid


Abdomen
Renal vein thrombosis: solid flank mass,
hematuria, HTN, thrombocytopenia, assoc w/
polycythemia, dehydration, maternal DM,
asphyxia, sepsis, nephrosis, hypercoagulable state
Omphalitis: acute periumbilical inflamm, may
extend and cause portal HTN
Single umbilical artery: occult renal anomaly
Voiding w/in 1
st
24 hrs, passage of meconium w/in
48 hrs




Genitalia
Severe hypospdias/epispadias: suspect
adrenogenital syndrome
Stretched penile length <2.5cm is abnormal and
requires evaluation
Hydrocele
If the testis has not descended by 4 mo, it will
remain undescended.
Voiding w/in 1
st
24 hrs, passage of meconium w/in
48 hrs (does not rule out imperforate anus)




Extremities
Fracture or nerve injury
Polydactyly, syndactyly, simian crease, hio
dislocation
Positional deformation, contractures
Fetal neuromuscular disease: breech,
polyhydramnios, failure to breathe, pulmonary
hypoplasia, dislocated hips, undescended testes,
thin ribs, and clubfoot
Extremities
Neurologic Examination
Level of alertness-evaluate in both sleep and
wakeful states
Cranial nerve exam is largely by observation
CN I:rarely tested, functional by 5-7mos
CN II:visual fixation on human face, (+)glare,
pupillary response, tracking, optic disc is light
pink/pale gray

CN III,IV,VI: Dolls eye maneuver to check for
conjugate eye movt, may be disconjugate at
birth; ptosis (CN III), pupillary reactivity seen in
neonates >32wks AOG
CN V: facial sensation w/ rooting reflex, corneal
reflex, grimace/ change in CR or RR w/ tactile
stimulation V1-3
CN VII: check facial symmetry at rest and upon
movt(e.g. crying)
CN VIII gross hearing, blink/startle w/ noise
CN IX,X,XII: intact if with good sucking (CN
V,VII,XII), swallowing (CN IX,X), gag reflex (CN
IX,X),tongue movt (XII)
CN XI: flexion and rotation of head
Motor Exam: posture- normal term NB have a
flexor attitude, preterms lie in extension; tone-
tested via traction response(pulling from supine
to prone position) if hypotonic, will show severe
head lag, strength-check symmetry of
spontaneous movt
Deep Tendon Reflexes: use index or middle
fingers; unsustained ankle clonus(upto 10 beats)
is normal
Primitive Reflexes:
Moro: carrying baby by his back and dropping
onto hand causes extension followed by flexion
of upper limbs, present from birth-5mos
Grasp: stroking ulnar side of the palm causes
hand grasp, applying pressure on ball of the foot
causes toe grasp, present from birth to
6mos(palmar) or 9-10mos(plantar)
Rooting/Sucking: stroking angle of mouth causes
sucking, birth to 3 mos
Tonic neck: turning head sidewise will cause
fencing posture towards direction of head,
birth (well-developed at 1 month) upto 5-6 mos
Sensory Exam: gross response to stroking,
withdrawal, crying, grimace