A Comprehensive Newborn Examination: Part I. General, Head and Neck, Cardiopulmonary

Am Fam Physician. 2014 Sep ane;90(5):289-296.

  This is office I of a two-part article on the newborn examination. Role 2, "Peel, Trunk, Extremities, Neurologic," appears in this issue of AFP.

This clinical content conforms to AAFP criteria for continuing medical education (CME). See the CME Quiz Questions.

Author disclosure: No relevant financial affiliations.

Article Sections

  • Abstract
  • General Assessment
  • Head
  • Eyes
  • Ears
  • Nose
  • Rima oris
  • Neck
  • Heart
  • Lungs
  • References

A comprehensive newborn examination involves a systematic inspection. A Ballard score uses physical and neurologic characteristics to assess gestational historic period. Craniosynostosis is caused by premature fusion of the sutures, and 20% of children with this condition have a genetic mutation or syndrome. The crimson reflex assessment is normal if at that place is symmetry in both eyes, without opacities, white spots, or dark spots. If the cherry reflex findings are abnormal or the patient has a family history of pertinent eye disorders, consultation with an ophthalmologist is warranted. Newborns with depression-set ears should be evaluated for a genetic status. Renal ultrasonography should be performed merely in patients with isolated ear anomalies, such as preauricular pits or cup ears, if they are accompanied past other malformations or pregnant family unit history. If ankyloglossia is detected, a frenotomy may be considered if it impacts breastfeeding. The neck should exist examined for total range of motion considering uncorrected torticollis tin lead to plagiocephaly and ear misalignment. Proper auscultation is crucial for evaluation of the broncho-pulmonary circulation with shut observation for signs of respiratory distress, including tachypnea, nasal flaring, grunting, retractions, and cyanosis. Benign murmurs are oftentimes present in the first hours of life. Pulse oximetry should be performed in a systematic mode earlier discharge.

Part I of this 2-role article discusses the assessment of general wellness, caput and cervix, centre, and lungs. Part Two focuses on assessing extremities, and neurologic role.1

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Prove rating References

Screening for hypoglycemia should be performed in newborns who are large or small for gestational age, newborns of mothers with diabetes mellitus, and late preterm infants (34 to 36 6/7 weeks gestational historic period).

C

seven

Regardless of reddish reflex exam results, all newborns with a family history of retinoblastoma, cataracts, glaucoma, or retinal abnormalities should exist referred to an ophthalmologist who is experienced in the examination of children.

C

17

Hearing should be evaluated in all newborns before one month of age, only preferably before belch, using the auditory brainstem response or the otoacoustic emissions test.

C

20

Recent data indicate that ultrasonography should be performed in newborns with isolated ear anomalies, such as preauricular pits or cup ears, but when they are associated with one or more of the following characteristics: other malformations or dysmorphic features, teratogenic exposures, a family unit history of deafness, or a maternal history of gestational diabetes.

C

26, 27

Routine screening for congenital center disease via pulse oximetry is recommended before discharge at 24 hours of life or subsequently. Diagnostic echocardiography should be performed if screening results are positive.

C

40

General Cess

  • Abstract
  • General Assessment
  • Head
  • Eyes
  • Ears
  • Nose
  • Mouth
  • Cervix
  • Heart
  • Lungs
  • References

A detailed newborn examination should begin with full general observation for normal and dysmorphic features. A term newborn should have pink pare, rest symmetrically with the arms and legs in flexion, cry vigorously when stimulated, and move all extremities equally. Table 1 shows the normal ranges for newborn vital signs at 40 weeks' gestation.2–4 The new Ballard score (http://www.ballardscore.com) was designed to assess a newborn'south gestational age through a scoring system that combines concrete characteristics with neuromuscular development.5 A video depicting this examination is available at http://www.ballardscore.com/Pages/videos.aspx. In one case the kid'due south gestational age is established, weight, length, and head circumference should be plotted on a nomogram to determine percentiles. Using this information, the newborn can be classified equally average, large, or small for gestational age.

Table 1.

Normal Vital Signs in Newborns Born at 40 Weeks' Gestation

Vital sign Normal range

Heart rate

120 to 160 beats per minute*

Respiratory rate

40 to sixty breaths per minute

Systolic blood pressure level

lx to 90 mm Hg†

Temperature

97.7°F to 99.5°F (36.5°C to 37.5°C)‡

Weight

Females: three.5 kg (7 lb, 12 oz); range, two.8 to 4.0 kg (6 lb, 3 oz to 8 lb, 14 oz)

Males: 3.6 kg (eight lb); range, ii.ix to 4.two kg (six lb, 7 oz to ix lb, five oz)

Length

20 in (51 cm); range, 19 to 21 in (48 to 53 cm)

Caput circumference

fourteen in (35 cm); range, 13 to 15 in (33 to 37 cm)

A newborn is considered small for gestational age if nascency weight is beneath the 10th percentile. Intrauterine growth brake occurs when the baby'southward growth during pregnancy is poor compared with norms. Measurements that are symmetrically decreased suggest that the newborn has a chronic exposure (east.g., maternal smoking or drug utilise) that impacted growth, or a congenital infection such as a TORCH infection (toxoplasmosis, other agents, rubella, cytomegalovirus, canker simplex), a metabolic disorder, or a chromosomal abnormality (e.g., Turner syndrome, trisomies). Newborns with these atmospheric condition frequently display dysmorphic features or are only constitutionally small. If the causative factor occurred later in pregnancy (e.g., uteroplacental insufficiency), the caput circumference will exist preserved relative to other measurements.6 A newborn with a nativity weight above the 90th percentile is considered big for gestational age. The almost common cause is maternal diabetes mellitus, although other causes include a metabolic or genetic syndrome such as Beckwith-Wiedemann syndrome.

Because of an increased run a risk of hypoglycemia, the American University of Pediatrics recommends scheduled glucose screening for newborns who are big or minor for gestational age, newborns of mothers with diabetes, and late preterm newborns (34 to 36 half-dozen/seven weeks gestational age), and provides protocols for their management.7

Head

  • Abstruse
  • Full general Assessment
  • Head
  • Eyes
  • Ears
  • Nose
  • Mouth
  • Neck
  • Heart
  • Lungs
  • References

At 40 weeks' gestation, the average head circumference is 14 in (35 cm); range, 13 to 15 in (33 to 37 cm, tenth to 90th percentile).2 Microcephaly (isolated asymmetrically small caput, less than the second percentile or 2 standard deviations below the mean for age and sex) may indicate primal nervous organization malformation (eastward.g., holoprosencephaly, neural tube defect), an infection (e.chiliad., toxoplasmosis, cytomegalovirus infection), or a genetic syndrome (eastward.1000., trisomy xiii and 18 syndrome, fetal alcohol syndrome). Macrocephaly (isolated caput enlargement, greater than the 98th percentile or greater than two standard deviations above the hateful) may be hereditary or the result of a central nervous system disorder (e.g., hydrocephalus, encephalon tumor), and imaging may be needed.3,4

After evaluating the overall size and shape of the caput for asymmetry or gross structural abnormalities, the fontanelles and sutures should be palpated with the newborn in the upright position. Figure 1 illustrates a normal newborn skull and common deformities. The anterior fontanelle is generally 3 to 6 cm in diameter, whereas the posterior fontanelle is no larger than 1 to 1.five cm in bore. A large anterior fontanelle may signal increased intracranial pressure level, Down syndrome, hypophosphatemia, trisomy, or congenital hypothyroidism. Fontanelles are often small in newborns with microcephaly. A prematurely fused suture indicates craniosynostosis and occurs in one out of 1,000 newborns.8,9 Craniosynostosis limits growth of the skull in a direction perpendicular to the suture, while growth may continue in other directions. More than twenty% of cases are caused by specific unmarried-gene mutations or chromosomal abnormalities and may be associated with conditions such equally Crouzon, Apert, and Pfeiffer syndromes.x A misshapen caput may be acquired by prenatal compressions rather than true synostosis. If this is the case, the misshapen caput should resolve spontaneously within the get-go few months of life.11

Effigy 1.

Newborn head examination. (A) Normal skull. (B) Common deformities.

Copyright © Jordan Mastrodonato.

The scalp exam may reveal head succedaneum, cephalohematoma, and other lesions (Figure 2). A caput succedaneum is scalp edema that is not limited past suture lines, is often pitting, and decreases over time. Near caputs resolve within 48 hours. A cephalohematoma is caused by injury of a claret vessel in the subperiosteal layer of the calvaria. It is limited by suture lines and occurs more than commonly in deliveries in which forceps or a vacuum extractor was used. Cephalohematoma is a risk cistron for jaundice and sepsis and may worsen over 48 hours, potentially taking upward to iii to four months to fully reabsorb. Skull fractures are rarely present. If a fracture is depressed or accompanied by neurologic symptoms, computed tomography should be performed to rule out intracranial pathology.12

Figure 2.

The scalp test may reveal lesions in a newborn, such as (A) caput succedaneum (scalp edema) and (B) cephalohematoma (subperiosteal hemorrhage).

Copyright © Hashemite kingdom of jordan Mastrodonato.

Forceps use or a difficult delivery may too atomic number 82 to a facial nerve palsy resulting in the inability to close the eye, loss of the nasolabial fold, drooping at the corner of oral fissure, or the disability to contract the ipsilateral lower facial muscles. This usually resolves inside the showtime few weeks of life, but farther evaluation is warranted if symptoms persist.xiii

Eyes

  • Abstract
  • General Cess
  • Head
  • Eyes
  • Ears
  • Olfactory organ
  • Mouth
  • Neck
  • Heart
  • Lungs
  • References

The newborn evaluation should include noting eye color; pupil size; appearance of the conjunctiva, sclera, and eyelid; eye move; and spacing betwixt the eyes. Genetic syndromes often cause unusual eye shape, such as epicanthal folds (excess pare over the medial aspect of the centre) and upslanting of palpebral fissures associated with Down syndrome. Colobomas (a gap or defect in the construction of the eye, primarily the iris) may occur with many syndromes, including Accuse (coloboma of the eye, heart defects, choanal atresia, retraction of growth and/or development, genital and/or urinary abnormalities, and ear abnormalities and deafness). Infants with colobomas need a formal ophthalmology evaluation. Hypertelorism (increased infinite between the optics) and hypotelorism (decreased space between the eyes) are often associated with a genetic disorder.xiv The visual vigil of newborns is approximately 20/400, and a dysconjugate gaze is normal in the first 2 to three months of life. Subconjunctival hemorrhages from blood vessel rupture are also a common benign finding that may take weeks to resolve.

The scarlet reflex test is performed by using an ophthalmoscope, with the lens power set up at 0 and the examiner standing approximately 18 inches abroad. Light should project onto both optics simultaneously. A scarlet reflex result is normal if at that place is symmetry in both eyes without opacities, white spots, or nighttime spots (Effigy 3 15). The color of the reflex may be dissimilar among ethnic groups considering of varying amounts of pigmentation in the ocular fundus; however, the reflex should not exist white.14,16 Table 2 gives a differential diagnosis of leukokoria.14,16 An abnormal red reflex result warrants urgent referral to an ophthalmologist. Regardless of red reflex findings, all newborns with a family unit history of retinoblastoma, cataracts, glaucoma, or retinal abnormalities should be referred to an ophthalmologist experienced in the examination of children because of the high risk of serious eye abnormalities.17

Effigy 3.

Interpretation of ruddy reflex test results in a newborn. (A) Normal, symmetric red reflex. (B) Normal red reflex in the right eye, and aberrant, macerated scarlet reflex in the left center, which is almost usually acquired past refractive mistake between the eyes, but can as well be caused by a more serious pathology (e.g., retinoblastoma). (C) Normal red reflex in the right centre and no reflex in the left eye, which occurs when the reflection is blocked by an opacity such equally a cataract.

Reprinted with permission from Bell AL, Rodes ME, Collier Kellar L. Childhood eye examination [published correction appears in Am Fam Physician. 2014;89(2):76]. Am Fam Physician. 2013;88(4):246.

Table 2.

Mutual Causes of Leukokoria in the Newborn

Crusade Description

Cataract

Opacity or clouding of the lens, frequently due to a genetic or systemic disorder

Chorioretinitis

Inflammation of the retina and choroid, may be due to cytomegalovirus or toxoplasmosis

Coats disease

Built disorder caused past abnormal blood vessels behind the retina, leads to progressive deterioration of vision

Coloboma

Full-thickness defect of the eye

Persistent fetal vasculature

Failure of the hyaloid vascular organization and the embryonic vitreous to completely involute

Retinoblastoma

Most common intraocular tumor in children

Retinopathy of prematurity

Abnormal claret vessel development, occurs primarily in premature infants

Vitreous hemorrhage

Claret clot in the vitreous body, oft due to trauma or hemorrhagic disease

Dacryostenosis should be differentiated from ophthalmia neonatorum, which is conjunctivitis within the start four weeks of life (Table 3).18 With dacryostenosis, a blocked tear duct causes secretions to accumulate with a yellowish pasty appearance while the remainder of the eye appears normal.19 With conjunctivitis, however, in that location is often edema and conjunctival injection.18

Table three.

Etiologies of Ophthalmia Neonatorum

Etiology Timing and presentation

Chemical irritant

First 24 to 36 hours, conjunctival injection and erythema

Gonococcal infection

Days 2 to 7, bilateral purulent conjunctivitis

Chlamydia infection

Days 5 to 14, varies from mild hyperemia to diffuse swelling and chemosis

Herpes simplex virus infection

Days half dozen to xiv, keratoconjunctivitis is often present

Ears

  • Abstract
  • Full general Assessment
  • Head
  • Optics
  • Ears
  • Nose
  • Oral fissure
  • Neck
  • Heart
  • Lungs
  • References

Hearing should be evaluated in all newborns earlier i month of age, but preferably before discharge, using the auditory brainstem response or the otoacoustic emissions test.20 Assessing the size, shape, and position of the ears may reveal built abnormalities. Ears are considered low-fix when the helix of the ear meets the cranium at a level below that of a horizontal plane through both inner canthi (Figure 4). Depression-prepare ears are oft a sign of a genetic condition (due east.one thousand., Downward, Turner, or trisomy 18 syndrome). Microtia (modest and underdeveloped pinnae) is commonly associated with another defect, such as CHARGE syndrome.21 Because preauricular skin tags and ear pits are associated with permanent hearing impairment in newborns, screening and shut monitoring are warranted.22 There is a known association between ear and renal abnormalities, and a diverseness of syndromes demonstrate both ear and renal defects.23–25

Figure four.

Evaluation of ear position in a newborn. (A) Normal ear position. (B) Low-gear up, posteriorly rotated ear, which may be a sign of a genetic status, such as Down, Turner, or trisomy 18 syndrome.

Copyright © Jordan Mastrodonato.

In the past, there was uncertainty about which ear malformations warranted screening renal ultrasonography. Contempo data signal that ultrasonography should be performed in patients with isolated ear anomalies, such as preauricular pits or loving cup ears, only when they are associated with one or more of the following characteristics: other malformations or dysmorphic features, teratogenic exposures, a family history of deafness, or a maternal history of gestational diabetes.26–28 Ear canals should be observed for patency.

Nose

  • Abstract
  • Full general Assessment
  • Caput
  • Eyes
  • Ears
  • Olfactory organ
  • Mouth
  • Neck
  • Heart
  • Lungs
  • References

Choanal atresia occurs when 1 or both sides of the nasal airway are narrowed or blocked. To assess patency of the nostrils, a pocket-sized-caliber catheter can be passed through the nasal passages. If bilateral choanal atresia is present, the infant may accept cyanosis that is relieved by crying. Asymmetry of the nasal septum is often due to in utero positioning. If it tin can be corrected by depression of the tip of the nose, it will usually resolve on its own. All the same, disproportion that does not correct with depression of the nose tip indicates a dislocated septum, and the patient should exist evaluated past an otolaryngologist.29,thirty

Mouth

  • Abstruse
  • Full general Assessment
  • Head
  • Eyes
  • Ears
  • Nose
  • Mouth
  • Cervix
  • Heart
  • Lungs
  • References

The maxilla and mandible should fit together well and open at equal angles. Micrognathia (a small mandible) occurs with Pierre Robin syndrome. Table four details mutual oral cavity findings.31 Ankyloglossia occurs when a short frenulum attaches the tongue to the floor of the oral fissure, limiting its mobility. This may interfere with breastfeeding or impair joint, although frenotomy is controversial.32–34 Palpating the palate tin reveal submucosal and mucosal clefts. A bifid uvula is oftentimes associated with a submucosal scissure. Cleft lip and palate are the most mutual anomalies of the head and neck. Midline clefts warrant investigation for a midline defect in the brain or other abnormalities.35

Table 4.

Newborn Oral fissure Findings

Finding Description

Bohn nodules

Remnants of salivary gland tissue on the lateral attribute of the mucilage, resolve spontaneously

Epstein pearls

White cystic vesicles (1 to 3 mm) on the median palatal raphe of the mouth, oral counterpart to milia, resolve spontaneously

Natal teeth*

Often occur on the lower gum, should exist removed if loose considering of aspiration risk

Ranula

Mucus retention cysts on the flooring of mouth, often require surgical removal

Neck

  • Abstract
  • General Assessment
  • Caput
  • Eyes
  • Ears
  • Nose
  • Oral cavity
  • Neck
  • Centre
  • Lungs
  • References

The cervix should be inspected for full range of motion because built torticollis is a mutual musculoskeletal anomaly of newborns. Torticollis is primarily due to birth trauma to the sternocleidomastoid muscle that causes swelling or sometimes hematoma germination within the musculus. Information technology can usually be corrected with physical therapy.36 If not corrected, torticollis tin can lead to plagiocephaly and ear misalignment.

Other possible findings on the neck examination include webbing, which tin can occur with Turner syndrome, and branchial clefts, pits, and masses. A cystic hygroma is a built lymphatic malformation in the neck region. A midline cervix lesion may represent a thyroglossal duct cyst and typically shifts with movement of the tongue. The clavicles should be palpated for fracture, which may manifest only as asymmetric Moro reflex if nondisplaced. A suspected fracture should be confirmed with a radiograph. Fractures tin can be a result of birth trauma and are typically treated with analgesics for pain.37

Heart

  • Abstract
  • General Assessment
  • Caput
  • Eyes
  • Ears
  • Nose
  • Mouth
  • Neck
  • Heart
  • Lungs
  • References

When a newborn takes the first breath, subsequent decreases in resistance in the pulmonary vasculature and increases in oxygen concentration consequence in eventual closure of the shunts, which allow the newborn to transition to developed apportionment. Congenital middle disease occurs in approximately six out of 1,000 alive births.38 Newborns with heart disease often exhibit tachypnea without retractions. Cyanosis is ofttimes present with astringent disease.38 This appearance should be differentiated from acrocyanosis (isolated cyanosis of the hands and feet), which is normal in newborns.

Upon auscultation of the center in the standard four locations (correct upper sternal border, left upper sternal border, left lower sternal border, and between the fifth and sixth intercostal infinite in the midclavicular line), the first eye sound should be single and the second middle sound split. Table 5 summarizes important cardiac exam findings.38,39 Considering of changes in vasculature immediately later on nascence, benign murmurs are mutual in the commencement hours of life.38,39  Routine screening for congenital center affliction via pulse oximetry is recommended before discharge at 24 hours of life or later, or soon before discharge if before than 24 hours. Diagnostic echocardiography should be performed if screening results are positive (Table 6).40,41

Table v.

Newborn Cardiovascular Findings

Finding Clinical significance

Weak pulses

Poor cardiac output (e.1000., aortic stenosis)

Bounding pulses

High cardiac output (e.g., patent ductus arteriosus)

Single second heart sound

Often cyanotic eye illness (e.thou., truncus arteriosus, hypoplastic left center)

Holosystolic, continuous, harsh murmur

Pathologic

Form three or higher murmur

Pathologic

Diastolic murmur

Pathologic

Hepatomegaly

Left centre failure

Table 6.

Pulse Oximetry to Screen Newborns for Congenital Centre Disease

Timing Pulse oximetry reading Interpretation Next steps

24 hours of life or later (or shortly before discharge, if before)

≥ 95% in correct manus or foot, with 3% or less absolute departure in oxygen saturation betwixt the correct hand and human foot

Negative screening result

Plan for discharge

24 hours of life or later (or shortly before discharge, if earlier)

90% to 94% in right hand or human foot, or 3% or less accented difference in oxygen saturation betwixt the right manus and foot

Repeat screening needed in 1 hour

If echo results are in this range, repeat screening again in one hour; three readings in this range warrant echocardiography

24 hours of life or later (or soon before belch, if earlier) or on repeat screening

< xc% in right hand or foot

Positive screening result

Echocardiography

Lungs

  • Abstract
  • Full general Assessment
  • Head
  • Eyes
  • Ears
  • Nose
  • Mouth
  • Neck
  • Centre
  • Lungs
  • References

The respiratory test is important because the babe is transitioning from fetal to neonatal life. The alveoli are filling with air, the systemic vascular resistance is increasing, and the pulmonary vascular resistance is decreasing. The examiner should observe for signs of respiratory distress, including tachypnea, nasal flaring, grunting, retractions, and cyanosis. Breath sounds should exist equal on auscultation. Unequal breath sounds may bespeak a pneumothorax and should prompt imaging.

Transient tachypnea of the newborn occurs predominantly in those built-in via cesarean delivery or precipitous delivery. It is acquired by retained fluid in the lungs, which can event in alveolar hypoventilation.42 Treatment includes supportive respiratory care considering the condition resolves within 48 hours. Respiratory distress syndrome arises from lack of surfactant, which leads to alveolar collapse. Although it is most common in preterm infants, it may occur in term infants, particularly if the mother has diabetes. A previous article in American Family Physician includes a detailed review of respiratory distress in the newborn.43

Information Sources: A PubMed search was completed using the terms baby, newborn, developmental filibuster, developmental disturbance, and concrete examination. The search included meta-analyses, randomized controlled trials, clinical trials, and reviews. We also searched POEMs (patient-oriented evidence that matters), Clinical Testify, the Cochrane database, and Essential Evidence Plus. Search dates: January i, 2012, and May ii, 2014.

The opinions and assertions contained herein are the private views of the author and are not to be construed every bit official or as reflecting the views of the U.Southward. Army Medical Department or the U.Southward. Regular army Service at large.

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The Authors

MARY Fifty. LEWIS, Medico, is a staff pediatrician and didactics faculty physician in the Department of Family Medicine at Dwight D. Eisenhower Army Medical Center in Fort Gordon, Ga.

Writer disclosure: No relevant fiscal affiliations.

Accost correspondence to Mary L. Lewis, MD, Dwight D. Eisenhower Regular army Medical Center, 300 E. Hospital Rd., Fort Gordon, GA 30905 (e-mail: marigoldll@yahoo.com). Reprints are not bachelor from the writer.

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