NEWBORN PHYSICAL
I. History should include:
A. Date, time and location of birth, referring MD and hospital
B. Birth weight, length and head circumference
C. Sex and race
D. Post menstrual age by dates (OB estimate) and OB prenatal ultrasound exam. Also include postnatal assessment by Ballard exam (performed by admitting nurse but if you - the NNP or Resident - don’t believe it, perform it yourself).
A CAVEAT: several studies have demonstrated that antenatal steroids frequently improve the neurological maturity of the extra-low birth weight infant (< 1000 grams BW) to the point that we overestimate the gestational age via Ballard scoring. A more accurate assessment typically results when the physical score alone is doubled (ie, ignore the neurological score in the more vigorous and non-distressed ELBW infants). Based on these data, all infants are to be “labeled” as their OB gestational age (e.g., Boy Smith is a 5 week old former 26 week preterm infant) unless their Ballard exam is > 2 weeks greater or less than the Obstetrical EGA. In these cases, the Attending Neonatologist will determine the infant’s most likely gestational age.
E. Mother’s age and history of previous pregnancies (Gravid = # of pregnancies, Para = # of births (including stillborns and the current admission), Ab = # of abortions (spontaneous or therapeutic), Living = # of children, including this admission). Summarized as G3, P2, Ab1, L2.
F. Blood types of mother and baby, results of Coombs test.
G. Maternal serology: RPR, Hepatitis B, HIV and rubella. Must know results of RPR, HIV and HepB screen within the first 24 hours of life in order to begin appropriate therapy!
H. Complications of pregnancy, labor and delivery:
1. Maternal illness/infections. Describe the quality/quantity of prenatal care.
2. Use of drugs, prescribed or otherwise
3. Alcohol or smoking
4. Duration of labor/premature labor - tocolytic drugs
5. Duration of rupture of membranes - evidence of maternal infection, colonization, culture results, antibiotic therapy
6. Type of delivery- spontaneous vaginal, forceps, suction, C-section
7. Characteristics of amniotic fluid - oligohydramnios, polyhydramnios, meconium stained, foul-smelling, etc.
8. Abnormal presentation
9. Fetal monitoring results
10. Anesthesia used
I. APGAR scores at one and five minutes and every 5 minutes thereafter until the score exceeds six. Don’t guess an APGAR score, calculate it.
J. Neonatal course to date.
K. Social History: Where the mother lives, role of the father in the family, other members of the household, financial support and emotional support.
L. Plans for feeding: breast or bottle.
M. Plans for well child care (e.g. who is to child’s be primary MD).
PHYSICAL EXAM
VITAL SIGNS, MEASUREMENTS T, P, RR, BP, Wt, length, head circumference
including percentiles based on gestational age estimate (Ballard score).
GENERAL APPEARANCE
level of activity: active vs. lethargic
general perfusion and color: pink / blue / mottled / pale / jaundiced
nutritional status/hydration: edematous/ vs. dehydrated
gross abnormalities: well developed
SKIN
vernix
capillary hemangiomas (benign), “stork bites”
most commonly on eyelids, forehead, back of neck -
occasionally on trunk or extremities
Slate grey macules (benign), most common in Blacks or Asians
cafe-au-lait spots
> 5 suggestive of neurofibromatosis (if all > 1.5 cm)
milia (superficial epidermal inclusion cysts - generally on face)
erythema toxicum
“sheet burn”
“parchment skin” (seen in post-term babies)
dryness, turgor (assess hydration)
petechiae
common, benign - usually on face and upper body, occurs
2o intrathoracic pressure as the chest passes through the birth
canal
uncommon - pathologic as a result of thrombocytopenia.
important to note distribution and watch for progression.
“sucking blisters” - hands
peeling of skin in postmature baby
jaundice
HEAD
shape: molding or asymmetry (may be due to fetal posture or structural defect)
appearance: bruising
scalp: cradle cap, internal monitor sites, scalp blood sampling sites
forceps marks or evidence of vacuum assisted extraction
hair distribution
Palpation
caput succedaneum: diffuse, generally simply note as “caput”
symmetric scalp edema due to vertex
presentation, edema crosses sutures
cephalohematoma: sub-periosteal hemorrhage
feels like boggy edema but is located over one
particular bony area - may take months to resolve
- never crosses suture line
- can indicate linear skull fx or more occult
intracranial bleeding
sutures craniotabes is a soft area in in parietal
bone near sagittal suture (think cong. syphilis) fused, open, overriding
palpable fractures
FONTANELLES
anterior and posterior
may suggest increased intracranial pressure if soft, flat, depressed,
bulging or dehydration if depressed bulging, pulsatile
EYES
may be hard to assess in the first 24 hrs due to
chemical conjunctivitis, edema of lids, or fused eyes
reactiveness of pupils (PERRL)
red reflex - exam for retinoblastoma, corneal opacities
lens - look for congenital cataracts (occurs in 1:100,000 liveborn infants)
bulging eyes - may indicate congenital glaucoma
discharge - other than chemical conjunctivitis
conjunctival hemorrhage - common due to increased intrathoracic pressure
intercanthal distance - if increased may be due to congenital syndrome
EARS
external appearance and shape: low set or < 4 cm top
to bottom in a term baby may suggest congenital syndrome
papillomas: common in preauricular area.
external canals: check for patency or atresia
tympanic membranes: very difficult to visualize
preauricular sinus and skin tags
NOSE
external appearance: congenital abnormalities
flaring of nostrils: suggestive of resp. distress
patency of nares: congenital abnormalities or choanal atresia
congestion or discharge
MOUTH
external appearance: cleft lip, shape, etc.
precocious dentition (supernumary teeth)
long philtrum and thin upper lip suggestive of Fetal Alcohol Syndrome
PALATE
structural abnormalities
cleft - may cause feeding difficulty, aspiration
high arched - may suggest congenital syndrome
lesions - Ebstein pearls are whitish nodules on palate
a benign accumulation of epithelial cells
NECK
tone: increased tone may suggest neurological disease
palpation: masses include thyroid, cystic hygroma,
branchial cleft/cysts.
mobility: congenital torticollis (may palpate a mass as well)
CHEST
appearance: congenital deformities may cause asymmetry.
retractions suggest resp. distress.
resp. rate: > 60 for a sustained period of time is abnormal
BREAST
also hormonally stimulated - can palpate breast buds
LUNGS
auscultation: hear rales, wheezes, rhonchi, grunting. Compare
air movement on each side and between lung zones.
HEART
cyanosis? precordial activity
rhythm and rate commonly quite variable. Rate may
range from 100-180 in various states of rest/activity.
extrasystoles and sinus pauses are common
S1 and S2: may be grossly abnormal in valvular
heart disease (with split sounds).
murmurs: PDA murmur is common in first 24 hrs of
life. Describe quality and location.
gallops: very difficult to hear with rapid HR of newborn
PULSES
palpate in each extremity and compare UE and LE.
Delay in pulse transmission or decreased pulse
in LE may indicate coarctation of the aorta. Pulses
graded 0-4+. 0 = absent, 2+ = normal, 4+ = bounding.
ABDOMEN
bowel sounds - may not be present in early life
palpation for masses, distension, etc.
Any large mass = renal origin (~50% of time)
umbilicus - determine number of vessels
LIVER
commonly palpable to 1 cm below RCM
SPLEEN
may be palpable just below LCM
KIDNEYS
usually palpable, at least in part in a very relaxed
or premature infant.
GENITALIA
inspection: examine all structures to ascertain if they are
clearly male or female. Check urethral orifice, if displaced
may suggest a virilized female. Foreskin is often tight &
appears closed. Organs appear enlarged in proportion to
other body structures due to maternal hormones.
palpation: feel for testes in scrotum or inguinal canal. Scrotal
enlargement may be due to hydrocele which is relatively
common.
discharge: females may have “pseudomenses”
circumcision: not done until > 24 hrs of age. Watch for urination difficulty.
RECTUM
check for patency (evidence of stooling) and presence of fissures
HERNIAS
check inguinal regions
diastasis recti (midline weakness of the abdominal
musculature) is common and may simulate a ventral hernia
SPINE
inspect and palpate for deformity, deviation
inspect for dermal sinus tracts: may be anywhere along
the midline from the nose, over the skull, and down
the spine to the sacrum.
sacral dimples should be examined for presence of a floor
any discoloration or hairy lesion should be evaluated
CLAVICLE
inspect for asymmetry and palpate for fractures
EXTREMITIES
inspect for deformities. Fetal position may cause apparent
deformities that are self-correcting
check joints and observe for range of motion
NOTE: peripheral perfusion by color and capillary refill.
acrocyanosis is a common condition resulting in cyanosis of the
feet and hands and is due to sluggish peripheral circulation
when the limb is cold
HIPS
Test for congenital dislocation (or dislocatability) by:
observing for differences in leg movement
checking for differences in leg length
checking for asymmetry of leg skin and gluteal folds
manipulate the hips (abduction) with fingers held over
greater trochanter and feeling or hearing clicks.
DIGITS
count them. Extra digit buds or skin tags are common
and often familial.
Cleinodactaly (short 5th finger) often associated with
chromosomal abnormality (trisomies)
inspect the deformities
NEURO
degree of alertness
spontaneous movement
posture, limbs flexed or extended?
tone in response to stimulation
grasp, suck, Moro, root (shouldn’t do Moro in very premature infant)
DTRs (should be 0 - 1+)
response to light and sound
facial, brachial plexus palsies
VOIDING
95% of all infants void in the 1st 24 hrs
98% void in the first 48 hrs - most common reason for “delay”
in voiding is missing urination at birth (ie, in the DR).
STOOLS
90% of term infants pass stool in the 1st 24 hrs
98% stool in the first 48 hours - prolonged time without
stooling suggests meconium ileus (cystic fibrosis), meconium plug, or other congenital defect.
I. History should include:
A. Date, time and location of birth, referring MD and hospital
B. Birth weight, length and head circumference
C. Sex and race
D. Post menstrual age by dates (OB estimate) and OB prenatal ultrasound exam. Also include postnatal assessment by Ballard exam (performed by admitting nurse but if you - the NNP or Resident - don’t believe it, perform it yourself).
A CAVEAT: several studies have demonstrated that antenatal steroids frequently improve the neurological maturity of the extra-low birth weight infant (< 1000 grams BW) to the point that we overestimate the gestational age via Ballard scoring. A more accurate assessment typically results when the physical score alone is doubled (ie, ignore the neurological score in the more vigorous and non-distressed ELBW infants). Based on these data, all infants are to be “labeled” as their OB gestational age (e.g., Boy Smith is a 5 week old former 26 week preterm infant) unless their Ballard exam is > 2 weeks greater or less than the Obstetrical EGA. In these cases, the Attending Neonatologist will determine the infant’s most likely gestational age.
E. Mother’s age and history of previous pregnancies (Gravid = # of pregnancies, Para = # of births (including stillborns and the current admission), Ab = # of abortions (spontaneous or therapeutic), Living = # of children, including this admission). Summarized as G3, P2, Ab1, L2.
F. Blood types of mother and baby, results of Coombs test.
G. Maternal serology: RPR, Hepatitis B, HIV and rubella. Must know results of RPR, HIV and HepB screen within the first 24 hours of life in order to begin appropriate therapy!
H. Complications of pregnancy, labor and delivery:
1. Maternal illness/infections. Describe the quality/quantity of prenatal care.
2. Use of drugs, prescribed or otherwise
3. Alcohol or smoking
4. Duration of labor/premature labor - tocolytic drugs
5. Duration of rupture of membranes - evidence of maternal infection, colonization, culture results, antibiotic therapy
6. Type of delivery- spontaneous vaginal, forceps, suction, C-section
7. Characteristics of amniotic fluid - oligohydramnios, polyhydramnios, meconium stained, foul-smelling, etc.
8. Abnormal presentation
9. Fetal monitoring results
10. Anesthesia used
I. APGAR scores at one and five minutes and every 5 minutes thereafter until the score exceeds six. Don’t guess an APGAR score, calculate it.
J. Neonatal course to date.
K. Social History: Where the mother lives, role of the father in the family, other members of the household, financial support and emotional support.
L. Plans for feeding: breast or bottle.
M. Plans for well child care (e.g. who is to child’s be primary MD).
PHYSICAL EXAM
VITAL SIGNS, MEASUREMENTS T, P, RR, BP, Wt, length, head circumference
including percentiles based on gestational age estimate (Ballard score).
GENERAL APPEARANCE
level of activity: active vs. lethargic
general perfusion and color: pink / blue / mottled / pale / jaundiced
nutritional status/hydration: edematous/ vs. dehydrated
gross abnormalities: well developed
SKIN
vernix
capillary hemangiomas (benign), “stork bites”
most commonly on eyelids, forehead, back of neck -
occasionally on trunk or extremities
Slate grey macules (benign), most common in Blacks or Asians
cafe-au-lait spots
> 5 suggestive of neurofibromatosis (if all > 1.5 cm)
milia (superficial epidermal inclusion cysts - generally on face)
erythema toxicum
“sheet burn”
“parchment skin” (seen in post-term babies)
dryness, turgor (assess hydration)
petechiae
common, benign - usually on face and upper body, occurs
2o intrathoracic pressure as the chest passes through the birth
canal
uncommon - pathologic as a result of thrombocytopenia.
important to note distribution and watch for progression.
“sucking blisters” - hands
peeling of skin in postmature baby
jaundice
HEAD
shape: molding or asymmetry (may be due to fetal posture or structural defect)
appearance: bruising
scalp: cradle cap, internal monitor sites, scalp blood sampling sites
forceps marks or evidence of vacuum assisted extraction
hair distribution
Palpation
caput succedaneum: diffuse, generally simply note as “caput”
symmetric scalp edema due to vertex
presentation, edema crosses sutures
cephalohematoma: sub-periosteal hemorrhage
feels like boggy edema but is located over one
particular bony area - may take months to resolve
- never crosses suture line
- can indicate linear skull fx or more occult
intracranial bleeding
sutures craniotabes is a soft area in in parietal
bone near sagittal suture (think cong. syphilis) fused, open, overriding
palpable fractures
FONTANELLES
anterior and posterior
may suggest increased intracranial pressure if soft, flat, depressed,
bulging or dehydration if depressed bulging, pulsatile
EYES
may be hard to assess in the first 24 hrs due to
chemical conjunctivitis, edema of lids, or fused eyes
reactiveness of pupils (PERRL)
red reflex - exam for retinoblastoma, corneal opacities
lens - look for congenital cataracts (occurs in 1:100,000 liveborn infants)
bulging eyes - may indicate congenital glaucoma
discharge - other than chemical conjunctivitis
conjunctival hemorrhage - common due to increased intrathoracic pressure
intercanthal distance - if increased may be due to congenital syndrome
EARS
external appearance and shape: low set or < 4 cm top
to bottom in a term baby may suggest congenital syndrome
papillomas: common in preauricular area.
external canals: check for patency or atresia
tympanic membranes: very difficult to visualize
preauricular sinus and skin tags
NOSE
external appearance: congenital abnormalities
flaring of nostrils: suggestive of resp. distress
patency of nares: congenital abnormalities or choanal atresia
congestion or discharge
MOUTH
external appearance: cleft lip, shape, etc.
precocious dentition (supernumary teeth)
long philtrum and thin upper lip suggestive of Fetal Alcohol Syndrome
PALATE
structural abnormalities
cleft - may cause feeding difficulty, aspiration
high arched - may suggest congenital syndrome
lesions - Ebstein pearls are whitish nodules on palate
a benign accumulation of epithelial cells
NECK
tone: increased tone may suggest neurological disease
palpation: masses include thyroid, cystic hygroma,
branchial cleft/cysts.
mobility: congenital torticollis (may palpate a mass as well)
CHEST
appearance: congenital deformities may cause asymmetry.
retractions suggest resp. distress.
resp. rate: > 60 for a sustained period of time is abnormal
BREAST
also hormonally stimulated - can palpate breast buds
LUNGS
auscultation: hear rales, wheezes, rhonchi, grunting. Compare
air movement on each side and between lung zones.
HEART
cyanosis? precordial activity
rhythm and rate commonly quite variable. Rate may
range from 100-180 in various states of rest/activity.
extrasystoles and sinus pauses are common
S1 and S2: may be grossly abnormal in valvular
heart disease (with split sounds).
murmurs: PDA murmur is common in first 24 hrs of
life. Describe quality and location.
gallops: very difficult to hear with rapid HR of newborn
PULSES
palpate in each extremity and compare UE and LE.
Delay in pulse transmission or decreased pulse
in LE may indicate coarctation of the aorta. Pulses
graded 0-4+. 0 = absent, 2+ = normal, 4+ = bounding.
ABDOMEN
bowel sounds - may not be present in early life
palpation for masses, distension, etc.
Any large mass = renal origin (~50% of time)
umbilicus - determine number of vessels
LIVER
commonly palpable to 1 cm below RCM
SPLEEN
may be palpable just below LCM
KIDNEYS
usually palpable, at least in part in a very relaxed
or premature infant.
GENITALIA
inspection: examine all structures to ascertain if they are
clearly male or female. Check urethral orifice, if displaced
may suggest a virilized female. Foreskin is often tight &
appears closed. Organs appear enlarged in proportion to
other body structures due to maternal hormones.
palpation: feel for testes in scrotum or inguinal canal. Scrotal
enlargement may be due to hydrocele which is relatively
common.
discharge: females may have “pseudomenses”
circumcision: not done until > 24 hrs of age. Watch for urination difficulty.
RECTUM
check for patency (evidence of stooling) and presence of fissures
HERNIAS
check inguinal regions
diastasis recti (midline weakness of the abdominal
musculature) is common and may simulate a ventral hernia
SPINE
inspect and palpate for deformity, deviation
inspect for dermal sinus tracts: may be anywhere along
the midline from the nose, over the skull, and down
the spine to the sacrum.
sacral dimples should be examined for presence of a floor
any discoloration or hairy lesion should be evaluated
CLAVICLE
inspect for asymmetry and palpate for fractures
EXTREMITIES
inspect for deformities. Fetal position may cause apparent
deformities that are self-correcting
check joints and observe for range of motion
NOTE: peripheral perfusion by color and capillary refill.
acrocyanosis is a common condition resulting in cyanosis of the
feet and hands and is due to sluggish peripheral circulation
when the limb is cold
HIPS
Test for congenital dislocation (or dislocatability) by:
observing for differences in leg movement
checking for differences in leg length
checking for asymmetry of leg skin and gluteal folds
manipulate the hips (abduction) with fingers held over
greater trochanter and feeling or hearing clicks.
DIGITS
count them. Extra digit buds or skin tags are common
and often familial.
Cleinodactaly (short 5th finger) often associated with
chromosomal abnormality (trisomies)
inspect the deformities
NEURO
degree of alertness
spontaneous movement
posture, limbs flexed or extended?
tone in response to stimulation
grasp, suck, Moro, root (shouldn’t do Moro in very premature infant)
DTRs (should be 0 - 1+)
response to light and sound
facial, brachial plexus palsies
VOIDING
95% of all infants void in the 1st 24 hrs
98% void in the first 48 hrs - most common reason for “delay”
in voiding is missing urination at birth (ie, in the DR).
STOOLS
90% of term infants pass stool in the 1st 24 hrs
98% stool in the first 48 hours - prolonged time without
stooling suggests meconium ileus (cystic fibrosis), meconium plug, or other congenital defect.