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Assessment of the newborn infant

Assessment of the newborn infant
Author:
Tiffany M McKee-Garrett, MD
Section Editors:
Richard Martin, MD
Teresa K Duryea, MD
Deputy Editor:
Laurie Wilkie, MD, MS
Literature review current through: Apr 2022. | This topic last updated: May 02, 2022.

INTRODUCTION — The assessment of the newborn infant will be reviewed here. The routine care of the newborn infant is discussed separately. (See "Overview of the routine management of the healthy newborn infant".)

OVERVIEW — A newborn should have a thorough evaluation performed within 24 hours of birth to identify any abnormality that would alter the normal newborn course or identify a medical condition that should be addressed (eg, anomalies, birth injuries, jaundice, or cardiopulmonary disorders) [1]. This assessment includes review of the maternal, family, and prenatal history and a complete examination. Depending upon the length of stay, another examination should be performed within 24 hours before discharge from the hospital

HISTORY — The newborn history includes the following:

Review of this pregnancy, labor, and delivery, including prenatal screening tests and risk factors for sepsis.

Review of past pregnancies, including a history of congenital anomalies, still births, and/or genetic or syndromic conditions.

Review of the mother's and father's medical and genetic history. In particular, maternal illnesses prior to and during pregnancy, such as systemic lupus erythematosus (SLE), or pregnancy complications, such as gestational diabetes or preeclampsia, may affect fetal growth or lead to other complications. A review of maternal medications should be performed, as some maternal medications may have intrauterine effects or be excreted in breast milk. (See "Neonatal lupus: Epidemiology, pathogenesis, clinical manifestations, and diagnosis" and "Gestational diabetes mellitus: Screening, diagnosis, and prevention" and "Preeclampsia: Clinical features and diagnosis".)

Prenatal screening tests — In developed countries and some developing countries, prenatal screening tests are routinely performed. The results of these screening tests should be reviewed, as an abnormal finding may be indicative of a medical condition that warrants further evaluation. The following section is a summary of available prenatal testing. A more complete discussion of prenatal screening and care is presented separately. (See "Prenatal care: Initial assessment", section on 'Laboratory tests'.)

At the first prenatal visit, a standard panel of laboratory tests is obtained and usually includes the following:

ABO blood type.

Rhesus (Rh) type and antibody screen to detect antibodies potentially causing hemolytic disease of the newborn.

Rubella status (immune or nonimmune).

Syphilis screen.

Hepatitis B surface antigen.

Hematocrit or hemoglobin to detect anemia.

Urinalysis and urine culture to detect asymptomatic bacteriuria.

Chlamydia trachomatis screen.

Neisseria gonorrhoeae screen.

Human immunodeficiency virus (HIV) screen.

Selective screening is performed for thyroid disease, type 2 diabetes, and additional infections, including tuberculosis, toxoplasmosis, hepatitis C antibodies, trichomonas, herpes simplex virus, and cytomegalovirus.

Screening tests obtained later in pregnancy also impact neonatal assessment. They include the following:

Maternal diabetes testing. (See "Infants of women with diabetes".)

Maternal group B streptococcal (GBS) colonization testing. (See "Prevention of early-onset group B streptococcal disease in neonates", section on 'Identification of pregnancies at increased risk for early-onset neonatal GBS'.)

Screening for inherited diseases or birth defects such as Down syndrome or neural tube defects (NTD) (ie, multiple marker screen). (See "Neural tube defects: Overview of prenatal screening, evaluation, and pregnancy management" and "Down syndrome: Overview of prenatal screening".)

Fetal ultrasound examination, including fetal survey, estimated fetal weight, and amniotic fluid volume.

In mothers with history or suspicion of substance use disorder, maternal toxicology screening. (See "Substance use during pregnancy: Screening and prenatal care", section on 'Screening for substance use'.)

Screening for tuberculosis in at-risk women. (See "Tuberculosis in pregnancy".)

Repeat HIV screening in the third trimester and syphilis screening in the third trimester and at delivery (some states).

Repeat hepatitis B surface antigen at delivery.

Delivery — The clinician performing the initial newborn examination should be familiar with the events surrounding delivery. The duration of labor, duration of rupture of membranes, mode of delivery, the newborn's condition at delivery, and resuscitation, if any, should be reviewed. Infants who require resuscitation are at risk of developing postresuscitative complications, such as hypothermia, hypoglycemia, and central nervous system complications. (See "Neonatal resuscitation in the delivery room", section on 'Postresuscitation'.)

It is important to determine the gestational age (GA) of the infant. Preterm infants (GA below 37 weeks), including those born late preterm (GA 34 0/7 to 36 6/7 weeks), are at increased risk for morbidity and mortality compared with term infants (GA 39 to 42 weeks). (See "Postnatal assessment of gestational age" and "Preterm birth: Definitions of prematurity, epidemiology, and risk factors for infant mortality" and "Short-term complications of the preterm infant" and "Late preterm infants".)

Of note, infants who are born between 37 0/7 and 38 6/7 weeks of age (defined as early term) have a higher morbidity rate than term infants born between 39 and 42 weeks of gestation [2]. Early term infants have a higher risk for hypoglycemia, need for respiratory support, including intubation and mechanical ventilation, need for administration of intravenous (IV) fluids, hyperbilirubinemia, and/or need for treatment with IV antibiotics compared with more mature infants.

Risk factors for sepsis — An assessment should be made for the presence of the following neonatal risk factors for sepsis.

Maternal intrapartum temperature ≥38ºC (100.4ºF)

Membrane rupture ≥18 hours

Delivery at <37 weeks gestation

Chorioamnionitis

Maternal group B streptococcal colonization

The evaluation and management of infants with risk factors for sepsis are discussed in greater detail separately. (See "Clinical features, evaluation, and diagnosis of sepsis in term and late preterm infants", section on 'Maternal risk factors' and "Management and outcome of sepsis in term and late preterm infants", section on 'Antibiotic therapy' and "Management of neonates at risk for early-onset group B streptococcal infection", section on 'Management of the neonate'.)

PHYSICAL EXAMINATION

Overview — The examination can be performed in the nursery or the mother's room. The area should be warm and quiet, and should have good lighting.

The examination includes:

Observation of the infant's general appearance, including his/her body position at rest, body movement, color, and respiratory effort.

Body measurements (ie, weight, length, and head circumference) and vital signs.

Examination of individual body parts and organs.

The examination should be conducted in a systematic manner, as a consistent approach ensures that all aspects are evaluated. Although the exact order is not important, the examination is optimized by initially observing the infant's general appearance followed by auscultation of the lungs and heart while the infant is lying quietly. The examination usually proceeds from head to foot as outlined in the following sections. Examination of the hips and spine, which is apt to disturb the infant, usually is performed last. The hips are examined while the infant is supine, then the infant is turned prone to examine the back.

The date and time of the examination should be recorded. Findings considered normal close to delivery (eg, a transitional heart murmur) may be abnormal on the second or third day after birth. The examination should include assessment of gestational age (GA). Knowledge of the level of maturity may be important in the interpretation of physical findings. (See "Postnatal assessment of gestational age".)

General appearance — Prior to touching the infant, much can be learned by observing the appearance of the undressed infant in the resting, nonstimulated state. General inspection should include the following [3]:

Sex determination

Detection of birth defect ‒ Identification of any deformation (eg, metatarsus adductus) or malformations (eg, cleft lip), which may indicate the presence of a syndrome. (See "Birth defects: Epidemiology, types, and patterns", section on 'Deformations' and "Birth defects: Epidemiology, types, and patterns", section on 'Malformations'.)

Fetal nutrition ‒ Determination of the state of fetal nutrition, by noting the amount of subcutaneous fat on the anterior thighs and gluteal region, or by the amount of Wharton's jelly in the umbilical cord.

Respiratory effort assessment ‒ Paradoxical breathing movements, in which the abdomen moves outward and the chest wall moves inward in inspiration, are normal. Signs of respiratory distress are abnormal and suggest pulmonary disease. They include rapid breathing, nasal flaring, use of accessory muscles (eg, significant subcostal, intercostal, supraclavicular, or suprasternal retractions), and grunting. The respiratory count should be conducted over a full minute to account for the variable breathing rate in the neonate.

Position and movement ‒ The newborn's posture at rest usually reflects the intrauterine position. Term newborns who have been positioned in a vertex presentation typically lie with the hips, knees, and ankles flexed. Infants who were in a breech position often have extended legs. A frank breech presentation may result in markedly abducted and externally rotated legs, which may lead to lower extremity deformations. A normal infant moves all extremities symmetrically. Deviation of posture or abnormal movement may be an indication of birth injury or deformation due to intrauterine positioning. (See "Neonatal birth injuries" and "Lower extremity positional deformations".)

Color assessment ‒ A normal infant appears pink. Acrocyanosis, a bluish appearance of the hands, feet, and perioral area, is common in the first few days after delivery. However, central cyanosis, which is seen best on the tongue and mucous membranes of the mouth, suggests hypoxemia. Bruising also may result in a bluish discoloration.

Pallor may indicate anemia, caused by acute blood loss at or shortly before delivery or a chronic intrauterine process. A ruddy or plethoric infant may have polycythemia. Infants with polycythemia may appear cyanotic even when they have adequate oxygenation because they have a relatively high amount of unsaturated hemoglobin. (See "Neonatal polycythemia".)

Hyperbilirubinemia results in jaundice, a yellow color best assessed in natural light. Jaundice in the first 24 hours after birth is considered pathologic, and is usually caused by hemolysis and requires evaluation. Intrauterine staining of the skin with meconium may result in a greenish discoloration. (See "Unconjugated hyperbilirubinemia in term and late preterm infants: Epidemiology and clinical manifestations".)

Measurements — The following parameters are measured and recorded:

Weight

Length ‒ The length is measured from the top of the head to the bottom of the feet, with the legs fully extended. In order to accurately measure a newborn, a length board should be used by two examiners (one to hold the infant and one to measure the infant).

Head circumference ‒ The fronto-occipital head circumference (FOC) should be measured at its maximum (picture 1). This measurement may change in the first few days after birth as molding and scalp edema resolve.

Chest circumference ‒ Some clinicians also measure chest circumference, especially if there is concern about lung growth. Chest circumference normally is within 2 cm of the head circumference

Measurements are plotted on standard growth curves based on specific local or regional data to determine the percentile according to GA and assess intrauterine growth [4]. (See "Normal growth patterns in infants and prepubertal children", section on 'Growth charts' and "Infants with fetal (intrauterine) growth restriction" and "Large for gestational age newborn".)

In our nursery, we use the Olsen growth curves, which are sex-specific curves based on United States data from over 390,000 infants born between 22 to 42 weeks gestation (figure 1 and figure 2) [5]. Using the Olsen curve, at 40 weeks gestation, the average length is 51 cm (10th to 90th percentile, 48 to 53 cm) and the average FOC is 35 cm (10th to 90th percentile, 33 to 37 cm) [6].

The Newborn Cross-Sectional Study of the INTERGROWTH-21st Project, based on data from eight different global locations, developed growth curves for weight (table 1), length (table 2), and head circumference (table 3) for infants between 33 and 42 weeks gestational age [7].

In 2018, updated weight curves from the United Kingdom were published using data from all singleton births from February 2013 to December 2014 in England and Wales [8].

Vital signs — Vital signs should be recorded every 30 to 60 minutes during the transitional period (first four to six hours of life) and then every 8 to 12 hours subsequently. Normal routine vital signs for the newborn infant include:

Temperature measured with the thermometer in the axilla of 36.5 to 37.5°C (97.7 to 99.5°F) in an open crib [1].

Respiratory rate of 35 to 60 breaths per minute, which should be counted over a full minute [9].

Heart rate ‒ The 50th percentile for term infants is about 120 beats per minute with a range between the 2nd to 98th percentile of 102 to 162 beats per minute [10]. The heart rate may decrease to 85 to 90 beats per minute in some term infants during sleep. In these infants, an increase of heart rate with stimulation is reassuring.

Blood pressure can be measured using a neonatal-size blood pressure cuff in infants with suspected cardiovascular or renal abnormalities. (See "Etiology, clinical features, and diagnosis of neonatal hypertension", section on 'Noninvasive measurement'.)

Skin — The skin should be inspected for abnormalities that may indicate an underlying disorder, such as areas of abnormal pigmentation, congenital nevi, macular stains, or hemangiomas. The following is a summary of the benign and transient findings common in normal newborns, which are discussed in greater detail separately. (See "Skin lesions in the newborn and infant".)

Milia are white papules due to retention of keratin and sebaceous material in the pilaceous follicles. They are frequently found on the nose and cheeks, and resolve in the first few weeks of life. (See "Skin lesions in the newborn and infant", section on 'Milia'.)

Transient pustular melanosis is a generalized eruption of superficial pustules overlying hyperpigmented macules that occurs mostly in African-American newborns (picture 2). The pustules, which contain neutrophils, are usually unroofed and removed with the first bath so that only the macules remain.

Erythema toxicum consists of white papules approximately 1 to 2 mm in size on an erythematous base. The lesions, which contain eosinophils, usually develop on the second or third postnatal day and occur less frequently on the face than on the body, and never on the palms or soles (picture 3).

Congenital dermal melanocytosis (formerly referred to as Mongolian spots) appear as blue-grey, greenish-blue, or brown pigmented macules with indefinite borders due to delayed disappearance of dermal melanocytes. The diameter of the lesion may be 10 cm or more. Although they are typically located on the buttocks and over the base of the spine, these skin lesions can appear anywhere on the body (picture 4). They predominantly affect newborns of African and Asian ethnicity. (See "Skin lesions in the newborn and infant", section on 'Dermal melanocytosis'.)

Nevus simplex (also called macular stain, stork bite, or angel kiss) is a pink-red capillary malformation that may occur on the upper eyelids, upper lip, middle of the forehead, or the nape of the neck. (See "Vascular lesions in the newborn", section on 'Nevus simplex (macular stain)'.)

Nevus flammeus, or port wine stain, is a low-flow capillary malformation that can occur anywhere on the body (picture 5). It may or may not be a benign finding in the newborn. (See "Vascular lesions in the newborn", section on 'Port wine stains'.)

Skin conditions in the newborn caused by infection and infiltrative disease, congenital skin abnormalities, vascular lesions, and congenital nevi are discussed separately. (See "Vesicular, pustular, and bullous lesions in the newborn and infant" and "Skin nodules in newborns and infants" and "Vascular lesions in the newborn".)

Head

General inspection — General inspection includes noting the size and shape of the head and the presence of abnormal hair, skull and scalp defects, unusual lesions or protuberances, lacerations, abrasions or contusions, and facial asymmetry.

Fontanelles – The fontanelles should be palpated, preferably with the infant in the sitting position (figure 3). Both fontanelles normally are soft and flat.

The anterior fontanelle is located at the juncture of the metopic, sagittal, and coronal sutures. Its size is variable.

The posterior fontanelle is located at the juncture of the sagittal and lambdoid sutures. It usually is open, but smaller than 1 cm in diameter.

Tense and bulging fontanelle in a sitting infant who is not crying may be an indication of raised intracranial pressure (ICP), which may be present in patients with a subdural hematoma or bacterial meningitis. (See "Neonatal birth injuries", section on 'Subdural hemorrhage' and "Bacterial meningitis in the neonate: Neurologic complications".)

Sutures – The principal sutures of the skull (sagittal, coronal, lambdoid, and metopic) should be palpated (figure 3). Passage through the birth canal may result in molding, a temporary asymmetry of the skull caused by overlapping or overriding of the sutures, particularly the coronal. An asymmetric skull that persists for longer than two to three days after birth or a persistent palpable ridge along the suture line may suggest craniosynostosis. (See "Overview of craniosynostosis".)

Although the sutures normally can be separated soon after delivery, widely split sutures with a full fontanelle may indicate increased ICP caused by hydrocephalus. (See "Hydrocephalus in children: Physiology, pathogenesis, and etiology", section on 'Congenital' and "Macrocephaly in infants and children: Etiology and evaluation", section on 'Hydrocephalus'.)

Skull and scalp

Craniotabes – Craniotabes is a soft area of skull bone, usually in the parietal region, that gives a sensation of a ping-pong ball when depressed. It commonly is found in preterm infants, and can occur in a normal term infant whose head rested on the maternal pelvic brim during the last few weeks of gestation or due to maternal/fetal vitamin D deficiency [11,12]. Craniotabes can be a pathologic finding in syphilis and rickets.

Extracranial findings – Delivery can result in the following extracranial birth findings, which are discussed in greater detail separately (figure 4). (See "Neonatal birth injuries", section on 'Extracranial injuries'.)

-Caput succedaneum is an area of edema over the presenting part of the head. This common condition typically is present at birth, crosses suture lines, and resolves within a few days.

-Cephalohematomas are subperiosteal collections of blood that are present in 1 to 2 percent of newborns. On palpation, they form a fluctuant mass that does not cross suture lines, which may increase in size after birth, and usually takes weeks to months to resolve.

-Subgaleal hemorrhages are collections of blood between the aponeurosis covering the scalp and the periosteum. Subgaleal hemorrhages extend across suture lines and feel fluctuant. Blood loss from these hemorrhages can be extensive and life threatening

Face ‒ The face is examined for asymmetry. Facial palsies and asymmetric crying facies are most obvious when the infant is crying and may go unnoticed in the quiet or sleeping infant.

Facial palsies – Risk factors for facial palsy include delivery with the assistance of forceps and prolonged delivery in mothers with a prominent sacral promontory. Typically, only the mandibular branch of the facial nerve is affected and the infant will have diminished movement on the affected side of the face. The facial palsy is characterized by the loss of the nasolabial fold, partial closing of the eye, and the inability to contract the lower facial muscles on the affected side, leading to the appearance of a "drooping" mouth. When crying, the mouth is drawn over to the unaffected side.

Facial palsies resolve completely in a few days to a few weeks. No treatment is required, with the exception of the use of artificial tears in the affected eye. In addition, it is imperative to ensure that the infant can adequately feed prior to discharge. A persistent palsy may imply a central lesion.

Asymmetric crying facies (ACF) – ACF are the result of congenital absence or hypoplasia of the depressor anguli oris muscle.

Similar to facial palsies, the muscles controlling movement of one side of the mouth are affected, thus there is asymmetry of the face upon crying. Unlike facial palsies, the muscles controlling movement of the upper face are normal; thus, the nasolabial folds are normal, and when the infant cries, the forehead wrinkles and both eyes close normally. This is typically a benign condition and becomes less noticeable as the child gets older.

ACF can be an associated finding in some syndromes, such as 22q11.2 deletion syndrome and Cayler cardiofacial syndrome [13,14]. One prospective study of 5532 infants revealed an incidence of ACF of 0.31 percent [15], with 2 of the 17 affected infants having other significant malformations. In another review of 35 infants with ACF, 16 had other associated anomalies, although many of them were minor [16]. When ACF is diagnosed, it is prudent to perform a thorough examination for other congenital anomalies, in particular, identifying any cardiovascular abnormalities.

Eyes — The initial examination of the eyes may be difficult to perform because the eyelids often are edematous after delivery. Most infants will open their eyes spontaneously when held vertically in an environment with low ambient light.

The examiner should note the position and spacing of the eyes, symmetry of the eyes, width of palpebral fissures, eye color, appearance of the sclera and conjunctiva, condition of the eyelids, pupillary size, and eye movement.

Spacing ‒ Hypertelorism, an abnormally wide interpupillary distance, is associated with a large number of syndromes, including Apert syndrome (acrocephalosyndactyly type I) and trisomy 13. If eye spacing appears abnormal, the distance between the eyes should be measured and compared with standard values for the newborn infant (figure 5) [17].

Interpupillary distance approximately ranges from 3.25 to 4.5 cm (1.3 to 1.8 inches)

Inner canthal distance approximately ranges from 1.5 to 2.55 cm (0.6 to 1 inch)

Outer canthal distance approximately ranges from 5.2 to 7.3 cm (2 to 2.9 inches)

Symmetry ‒ Asymmetry of the eyes may be the result of prominent epicanthal folds (skin folds over the medial aspect of the eyes), a difference in the size of the globes, or ptosis. Epicanthal folds are rarely normal and usually suggest a syndrome (eg, trisomy 21) (picture 6) [17].

Palpebral fissures ‒ Widened or narrow palpebral fissures are normal for some patients, but can be part of a syndrome complex in others. Upward slanting from the inner canthus is typically seen in infants with Down syndrome (picture 6), whereas down slanting palpebral fissures are characteristic of Treacher Collins and Apert syndromes, and narrow short palpebral fissures in DiGeorge syndrome.

Eye movement ‒ The examiner should assess extraocular muscle movement. Symmetrical movement of the eyes should occur as the patient is held vertically and moved gently from side to side. Although asymmetric eye movement is common in the first month of life, asymmetric movement may be an indication of an abnormality within the brain or to cranial nerves III, IV, or VI.

Sclerae ‒ The sclerae normally are white and clear. In preterm infants, the sclerae may appear light blue because the darker color of the underlying uveal tissue is transmitted through the thin underdeveloped sclerae [18]. If the sclerae appear deep blue, osteogenesis imperfecta should be considered. In this condition, the discoloration is caused by inadequate development of scleral collagen.

Conjunctiva ‒ The conjunctiva should be examined for hemorrhage, inflammation, or purulent discharge. Subconjunctival hemorrhages can occur spontaneously during birth, but are more common following a traumatic delivery.

Cornea ‒ The corneal diameter in most newborns is approximately 10 mm [18]. Corneal enlargement (>12 mm) suggests glaucoma, especially if accompanied by photophobia, excessive tearing, or corneal haze (picture 7). (See "Primary infantile glaucoma".)

Pupils ‒ Pupils should be assessed for their shape and reaction to light. Normal pupils are round and constrict in response to a bright light. Pupillary reaction occurs consistently after 32 weeks GA, but may be apparent in some infants as early as 28 weeks gestation [19]. Defects in the iris (eg, coloboma) should be noted and may be suggestive of a syndrome, such as renal coloboma syndrome or CHARGE (coloboma, heart anomaly, choanal atresia, retardation of growth, genital and ear anomalies/hearing loss) syndrome. (See "Congenital anomalies and acquired abnormalities of the optic nerve", section on 'Optic disc coloboma'.)

Red reflex ‒ All neonates require an ophthalmoscopic examination to document the presence (or absence) of a red reflex [3,20]. A normal red reflex is seen if the lens and underlying structures are clear. The red reflex test is performed observing both eyes of the infant through an ophthalmoscope with the ophthalmoscope lens power set at "0" at a distance approximately 18 inches away from the infant. A normal red reflex emanates from both eyes and is symmetric in character without evidence of opacities or white spots (figure 6).

Dark spots in the red reflex, a markedly diminished reflex, presence of a white reflex, or asymmetry of the reflex are indications for referral to an ophthalmologist. Abnormalities of the lens (eg, cataract), vitreous (eg, persistent fetal vasculature), or retina (eg, retinoblastoma) produce a white pupil (leukocoria). (See "Approach to the child with leukocoria", section on 'Causes of leukocoria'.)

In a large observational study, the red reflex test was shown to be a useful screening test to detect anterior segment abnormalities (eg, coloboma, cataract, or vitreous and aqueous opacities) but was less sensitive in detecting posterior lesions (retinal abnormalities) [21].

Ears — The ears are inspected for their position, size, and appearance.

Position ‒ The ears are normally positioned when the helix is intersected by a horizontal line drawn from the outer canthus of the eye perpendicular to the vertical axis of the head [22]. If the helix falls below this line, the ears are considered low-set. An ear is posteriorly rotated if its vertical axis deviates more than 10 degrees from the vertical axis of the head.

External ear abnormalities ‒ The ears should be inspected for branchial cleft cysts (which may be located in the preauricular area and along the line anterior to the sternocleidomastoid in the neck), sinuses, preauricular skin tags or pits, or dysplastic features. External ear abnormalities increase the risk of additional anomalies of the middle and inner ear, which are associated with hearing loss [22,23]. They often are associated with syndromes of multiple congenital anomalies that include renal malformations [24].

However, patients with isolated minor external ear anomalies (eg, preauricular skin tags or pits) do not appear to have a significant increased risk of renal anomalies. As a result, routine renal imaging for patients with isolated minor ear abnormalities appears to be unnecessary unless accompanied by other major malformations or multiple congenital anomaly syndromes [25]. (See "Congenital anomalies of the ear", section on 'Preauricular pits'.)

Ear canal ‒ The ear canals should be observed for patency. Visualization of the tympanic membranes is limited by the small size of the ear canal and the presence of vernix and other debris. This examination usually is not done in the newborn period.

Nose

Nose shape ‒ The shape of the nose may be abnormal because of intrauterine deformation or the birth process. In this case, it will return to a normal shape within a few days of birth. An extremely thin or unusually broad nose, or a depressed nasal bridge may occur with some syndromes.

Nares ‒ Patency of the nares should be established because infants are predominantly nose breathers. This can be accomplished by noting the movement of a piece of cotton or thread placed in front of each naris. Obstruction may be caused by edema related to vigorous suctioning after birth, or be due to anatomical causes, such as choanal atresia. The latter can be tested by passage of a feeding tube or suction catheter through the nose. (See "Congenital anomalies of the nose", section on 'Choanal atresia'.)

The nares may appear asymmetric if the nasal cartilage is dislocated from the vomerine groove (septal deviation). This condition can be distinguished from a positional deformity by depression of the tip of the nose. A dislocated septum appears angled within the nares and does not resume a normal position when released. (See "Neonatal birth injuries".)

Mouth — Assessment includes evaluating the size and shape and the interior of the mouth. The maxillae and mandible should fit well together and open at equal angles bilaterally. Asymmetry of the mouth (asynclitism) usually is caused by intrauterine position and resolves with time. A small jaw (micrognathia) may be seen in Robin sequence (picture 8). The lip should be examined for evidence of a cleft. (See "Congenital anomalies of the jaw, mouth, oral cavity, and pharynx" and "Syndromes with craniofacial abnormalities", section on 'Pierre Robin sequence'.)

Assessment of the interior of the mouth includes examination of the gingiva, tongue, palate, and uvula. The following findings are commonly seen in the neonate:

Small, white, benign inclusion cysts on the palate, known as Epstein's pearls, are often seen. They are typically clustered at the midpoint of the junction between the soft and hard palate.

Mucus retention cysts may occur on the gums (mucocele) (picture 9) or on the floor of the mouth (ranula) (picture 10). (See "Congenital anomalies of the jaw, mouth, oral cavity, and pharynx", section on 'Mucoceles' and "Congenital anomalies of the jaw, mouth, oral cavity, and pharynx", section on 'Ranulas'.)

The frenulum linguae, a band of tissue that connects the floor of the mouth to the tongue, may be unusually short or extend to the tip of the tongue, resulting in ankyloglossia (tongue-tie) (picture 11). (See "Ankyloglossia (tongue-tie) in infants and children".)

Natal teeth (image 1) usually are primary mandibular incisors. Although they most commonly occur as an isolated finding, natal teeth may be associated with a variety of syndromes including chondroectodermal dysplasia (Ellis-van Creveld syndrome), pachyonychia congenita, Sotos syndrome, and Hallermann-Streiff syndrome. Treatment may involve observation, smoothing of the incisal edge (to prevent potential discomfort during breastfeeding and ulceration in the floor of the mouth), or extraction. Extraction should be considered if the teeth are not well secured and may be a potential aspiration risk, or if they pose problems with feeding. (See "Developmental defects of the teeth", section on 'Natal and neonatal teeth'.)

Clefts of the soft or hard palate may be visible by inspection. Palpation may be needed to detect a submucosal cleft [26]. A bifid uvula may be associated with a submucosal cleft.

Neck — The neck should be assessed for the following abnormalities, including examination of the clavicles:

Masses – Neck masses in the newborn infant may be differentiated by their location and include the following:

Cystic hygroma, a macrocystic lymphatic malformation, is the most common lymphatic malformation in children, typically presents as a painless, transilluminated, soft mass that is located superior to the clavicle (picture 12). (See "Vascular lesions in the newborn", section on 'Macrocystic lymphatic malformation (cystic hygroma)'.)

Branchial cleft cysts may be palpated along the anterior margin of the sternocleidomastoid (SCM) (picture 13). (See "Differential diagnosis of a neck mass", section on 'Branchial cleft cyst'.)

Hematomas may be the cause of masses in the lower portion of the neck.

Thyroglossal duct cyst or enlarged thyroid may be the cause of a midline mass. (See "Thyroglossal duct cysts and ectopic thyroid".)

Isolated palpable cervical lymph nodes, up to 12 mm in diameter, are common in healthy newborns [11]. However, lymphadenopathy also may result from congenital infection.

Torticollis – Torticollis, or wry neck, usually results from trauma to the SCM muscle caused by birth injury or intrauterine malposition. The injury causes a hematoma or swelling within the muscle. Torticollis also may be caused by developmental abnormalities of the cervical spine. In affected infants, the head is tipped to one side and the chin rotated toward the other. (See "Congenital muscular torticollis: Clinical features and diagnosis".)

Excess skin – Redundant skin in the neck may be a feature of genetic syndromes. Examples include Turner syndrome, in which the neck appears webbed because of redundant skin along the posterolateral line, and Down syndrome with excess skin at the base of the neck posteriorly. (See "Clinical manifestations and diagnosis of Turner syndrome" and "Down syndrome: Clinical features and diagnosis".)

Clavicles — Partial or complete absence of the clavicle may occur in congenital syndromes, such as cleidocranial dysostosis. Clavicular fractures typically present with irritability and decreased motion on the affected side because of pain. Signs include tenderness, crepitus, swelling on the bone, and an asymmetric Moro response. (See "Neonatal birth injuries", section on 'Clavicle'.)

Congenital pseudoarthrosis of the clavicle (CPC) is a rare anomaly and may mimic clavicle fracture in newborns. Caused by failure of the medial and lateral ossification centers of the clavicle to fuse, CPC is usually unilateral, more often seen on the right side and more commonly affecting females [27].

Chest

General inspection — The chest should be inspected for size, symmetry, and movement.

Abnormal size or shape

A small or malformed thorax may result from pulmonary hypoplasia or neuromuscular disorders.

Pectus excavatum (funnel chest) or pectus carinatum (pigeon breast) may occur as an isolated finding, or as part of congenital syndromes. (See "Pectus excavatum: Etiology and evaluation" and "Pectus carinatum" and "Chest wall diseases and restrictive physiology", section on 'Congenital and childhood abnormalities'.)

Asymmetry ‒ Asymmetry may be caused by an absent pectoralis muscle (Poland sequence) or result from a mass or abscess.

Chest wall movement — The ribs and sternum are incompletely ossified in the newborn, resulting in a highly compliant chest wall. Breathing in normal infants may be paradoxical, in which the rib cage moves inward and the abdomen moves outward during inspiration. In respiratory disorders, the high intrathoracic pressures generated to inflate poorly compliant lungs may cause retractions that are intercostal, subcostal, or subxiphoid (substernal).

Breast — Breast size and nipple position should be noted. The presence and amount of breast tissue may be helpful in assessment of GA. Breast hypertrophy caused by exposure to maternal hormones occurs in both males and females and can be asymmetric (picture 14). Occasionally, breasts will secrete a thin milky fluid known as "witch's milk" (galactorrhea) for several days to weeks [11].

Widely spaced nipples occur in some genetic syndromes (eg, Turner syndrome). If the nipples appear to be widely spaced, measurement of the distance between the nipples should be compared with available normative data [28]. In general, an internipple distance that is >25 percent of chest circumference is considered widely spaced.

Supernumerary nipple, or accessory mammary tissue, is a common finding, occurring with an incidence of approximately 1 in 40 newborns [29]. It is more common in African-American infants [30]. Supernumerary nipples are usually found inferior and medial to the true breasts, along the milk line, a vertical line that extends from the axilla to the pubic region. Supernumerary nipples are discussed in greater detail separately. (See "Breast disorders in children and adolescents", section on 'Accessory breast tissue'.)

Lungs

Observation ‒ The infant's breathing rate and pattern should be observed. These may fluctuate depending upon the state of wakefulness, and whether the infant is active or crying. The respiratory rate should be counted for a full minute to account for variations in rate and rhythm. A normal rate is 40 to 60 breaths per minute.

Infants with respiratory disorders often have tachypnea and retractions. Other signs of respiratory distress include use of accessory respiratory muscles (eg, flaring of the nasal alae) and grunting. (See "Overview of neonatal respiratory distress and disorders of transition".)

Auscultation — Auscultation of the lungs should be performed with the infant as quiet as possible. In general, this is best accomplished early in the assessment prior to palpation of the abdomen, head, and neck.

Normal breath sounds are bronchovesicular and are heard equally on both sides of the chest. The breath sounds should be clear, although some infants may have scattered rales for a few hours after delivery. Abnormal breath sounds are unusual in the absence of tachypnea or signs of respiratory distress. In infants with respiratory disease, grunting sometimes is audible only with a stethoscope.

Cardiovascular system

Palpation

Chest wall ‒ Palpation of the chest wall determines the apical impulse and locates the position of the heart. Because the right ventricle is dominant in the newborn, the point of maximal impulse is best felt in the area of the left lower sternal border. Palpation also can detect the presence of a heave, tap, or thrill.

Femoral arteries ‒ The femoral pulses should be palpated when the infant is quiet. Diminished femoral pulses may indicate coarctation of the aorta, whereas an increased pulse pressure may occur with PDA. If femoral pulses are abnormal, brachial, radial, and pedal pulses should be assessed.

Auscultation — Auscultation should be performed with a warmed stethoscope while the infant lies quietly. Thorough evaluation necessitates auscultation of all areas of the precordium, as well as the back and axillary areas. The process includes noting the rate and rhythm, listening carefully for the first and second heart sounds, and the presence of a murmur. The heart rate is normally 120 to 160 beats per minute, but may decrease to 85 to 90 beats per minute in some term infants during sleep.

Heart sounds ‒ The first heart sound is a singular sound caused by nearly simultaneous closure of the tricuspid and mitral valves and is best heard at the apex. The second heart sound, best heard at the left upper sternal border, is caused by closure of the pulmonary and aortic valves, and normally is split. Prominent heart sounds in the right chest may signify dextrocardia.

Heart murmurs ‒ Heart murmurs are characterized by the intensity and quality of the sound they create, when they occur in the cardiac cycle, their location, and whether they are transmitted. The intensity of murmurs is graded on a scale of I to VI. The intensity and quality of the murmur and associated findings usually can differentiate innocent murmurs from those associated with heart disease [31-33]. (See "Approach to the infant or child with a cardiac murmur", section on 'Distinguishing pathologic from innocent murmurs'.)

In the first few days after birth, most newborns have murmurs that are transient and benign. They usually are caused by a patent ductus arteriosus (PDA), or pulmonary branch stenosis [19,34]. The latter is more likely if the murmur persists after 24 hours when most PDAs have closed. The PDA murmur is continuous, often described as "machinery-like" or harsh in quality. It usually is loudest under the left clavicle (second intercostal space), but may radiate down the left sternal border. (See "Clinical manifestations and diagnosis of patent ductus arteriosus in term infants, children, and adults".)

Abdomen

Inspection — The abdomen should be examined when the infant is quiet. The size and overall appearance should be assessed. The normal abdomen is slightly protuberant. Distension is abnormal and may indicate conditions such as intestinal obstruction, organomegaly, or ascites. The abdomen may be scaphoid in the presence of a diaphragmatic hernia. Many normal infants have diastasis recti, resulting from the nonunion of the two rectus muscles, which may result in an umbilical hernia (picture 15). Other abdominal wall defects, such as omphalocele (picture 16) or gastroschisis (picture 17), usually are identified at delivery or prenatally by ultrasound. (See "Care of the umbilicus and management of umbilical disorders", section on 'Umbilical hernia' and "Omphalocele: Prenatal diagnosis and pregnancy management" and "Gastroschisis".)

Palpation — Palpation of the abdomen should begin superficially and proceed more deeply, but remain gentle to avoid causing discomfort, which results in the infant crying. Holding the infant's legs in a flexed position and having the infant suck on a pacifier or the examiner's gloved finger may facilitate relaxation of the abdominal wall muscles.

The liver edge normally is palpated 1 to 3 cm below the right costal margin. The liver should be soft with a smooth edge. The spleen usually is not palpable, although some normal infants may have a palpable spleen tip.

The kidneys may be palpated through the anterior abdominal wall. One approach to facilitate palpation of the lower poles of the kidneys is to place the fingertips above and below the lower quadrants and apply moderate pressure; this maneuver traps the kidneys between the fingertips. The left kidney is more easily palpable than the right.

Any other palpable abdominal mass is abnormal and requires further investigation. Most abdominal masses in newborns are enlarged kidneys caused by hydronephrosis or cystic renal disease. Masses may also result from tumors, such as neuroblastomas or teratomas.

Umbilical cord — The umbilical cord is inspected for general appearance, amount of Wharton's jelly, and the umbilical vessels.

A thin cord may indicate poor maternal nutritional status or intrauterine compromise.

Erythema surrounding the stump, and/or an odorous discharge may indicate omphalitis (ie, infection of the umbilicus). (See "Care of the umbilicus and management of umbilical disorders", section on 'Omphalitis'.)

A single umbilical artery (SUA) is present in approximately 0.2 to 0.6 percent of singleton live births, and at a higher incidence in twin gestations [35]. SUA is associated with an increased rate of chromosomal and other congenital anomalies, including renal abnormalities [36]. However, based on available there is a low risk of a significant renal abnormality in infants with an isolated SUA. As a result, we do not perform further imaging for healthy infants with a SUA if there is no other identified abnormality. (See "Care of the umbilicus and management of umbilical disorders", section on 'Single umbilical artery'.)

Genitalia — The genitalia usually are inspected immediately after birth to identify the infant's gender or confirm the prenatal diagnosis

Female — In the female infant, the size and location of the labia, clitoris, meatus, and vaginal opening are assessed. The appearance of the genitalia varies with GA. The labia minora and clitoris are prominent in preterm infants, while the labia majora becomes larger as the infant approaches term. The genitalia in growth-restricted females may appear immature due to decreased deposition of fat in the labia majora. (See "Postnatal assessment of gestational age" and "Gynecologic examination of the newborn and child", section on 'History and physical examination'.)

The vaginal opening should be fully visible. Many infants have vaginal skin tags, representing the slight protrusion of vaginal epithelium at the posterior fourchette. Withdrawal from maternal hormones often results in a milky white vaginal discharge, which sometimes is blood tinged.

The labia minora should be separated to detect whether the hymen, which normally has some opening, is imperforate (figure 7). Imperforate hymen can cause hydrometrocolpos, which usually appears as a bulging hymen, especially with crying. Enlargement of the uterus resulting from an imperforate hymen may be detected as a lower midline abdominal mass. (See "Congenital anomalies of the hymen and vagina".)

Male — The presence of testes, size of the penis, appearance of the scrotum, and the position of the urethral opening are evaluated.

Testes should be palpable in the scrotum or inguinal canal, and be equal in size. Between 2 and 5 percent of full term and 30 percent of preterm male infants are born with an undescended testicle. Testes descend before six months of age in most cases. (See "Undescended testes (cryptorchidism) in children: Clinical features and evaluation", section on 'Epidemiology and risk factors' and "Undescended testes (cryptorchidism) in children: Management", section on 'Natural history'.)

Testicular torsion that occurred prenatally presents with a firm, nontender testicle with discoloration of the scrotum. Size of the testicle will vary, depending on the extent of atrophy that has occurred prior to birth. In contrast, postnatal torsion presents with acute tenderness and swelling in a testicle that was previously noted to be normal on examination. (See "Neonatal testicular torsion", section on 'Clinical presentation'.)

The penis is stretched to assess length. Normal penile length in the term male is 2.5 to 3.5 cm (figure 8) [37]. The scrotum of the term male is rugated and pigmented. Enlargement or swelling of the scrotum may be caused by hydroceles, hernias, or, rarely, testicular torsion. Hydroceles are fluid collections around the testes, and usually resolve spontaneously. They can be distinguished from hernias by transillumination of the scrotum.

The urethral meatus usually can be located without retraction of the foreskin. The foreskin normally is tight or adherent in the newborn; easy retraction usually is not possible for several months to years. Some infants may have a small (1 mm) white sebaceous (epidermal) cyst at the tip of the foreskin that is benign.

The position of the urethral meatus should be determined. Abnormalities of the position of the urethral meatus include:

Hypospadias ‒ Hypospadias is a congenital anomaly of the male urethra that results in abnormal ventral placement of the urethral opening. The location of the displaced urethral meatus may range anywhere within the glans, the shaft of penis, the scrotum, or perineum (picture 18). Circumcision is usually not recommended, because either the preputial skin may be necessary for hypospadias repair or the lack of ventral skin makes circumcision difficult. A pediatric urologist should be consulted in the nursery if there is a question regarding performance of circumcision. The evaluation and management of hypospadias is discussed in greater detail separately. (See "Hypospadias: Pathogenesis, diagnosis, and evaluation".)

Epispadias ‒ Dorsal location of the meatus (epispadias) is uncommon. It usually is associated with bladder exstrophy. (See "Clinical manifestations and initial management of infants with bladder exstrophy".)

Atypical genitalia — Physical findings of ambiguous genitalia in a phenotypic female include an enlarged clitoris, fused labial folds, or palpable gonads; and in a phenotypic male, bifid scrotum, severe hypospadias, micropenis, or cryptorchidism. Ambiguous genitalia may signal an intersex disorder. These conditions also may be caused by abnormalities of sexual differentiation or congenital adrenal hyperplasia (CAH).

Infants with a suspected disorder of sexual differentiation (DSD) should be evaluated by a multidisciplinary team, including an endocrinologist, urologist, geneticist, and pediatrician/neonatologist. Because of the risk of adrenal crisis in infants with the salt-wasting form of CAH, evaluation should occur as soon as feasible after birth. (See "Evaluation of the infant with atypical genital appearance (difference of sex development)" and "Clinical manifestations and diagnosis of classic congenital adrenal hyperplasia due to 21-hydroxylase deficiency in infants and children".)

Anus — The anus is inspected for its location and patency. The anus cannot be assumed patent until the newborn has passed meconium, usually by 48 hours of age.

Imperforate anus is not always immediately apparent, and may be an isolated finding or part of a syndrome such as VACTERL (vertebral defects, anal atresia, cardiac defects, tracheoesophageal fistula, renal anomalies, and limb abnormalities) association. (See "Birth defects: Epidemiology, types, and patterns", section on 'Association'.)

Perineal groove is a rare condition typically seen in females and is defined as a well-demarcated moist sulcus of the perineum lined with mucous membrane that extends from the posterior fourchette of the vaginal opening to the anterior margins of the anus. Although it typically resolves without intervention, it can be associated with anal fissures that may require surgical intervention [38].

Trunk and spine — The spine is directly visualized and palpated along the vertebral column to detect abnormalities, such as a neural tube defect (NTD). Soft tissue masses along the spine that are covered with normal skin may be lipomas or myelomeningocele. The gluteal folds should be separated to inspect for the presence of a sacral cleft or dimple. A tuft of hair, hemangioma (picture 19), or discoloration in the sacrococcygeal area may suggest an underlying vertebral or spinal cord anomaly [39]. (See "Infantile hemangiomas: Epidemiology, pathogenesis, clinical features, and complications" and "Infantile hemangiomas: Evaluation and diagnosis", section on 'LUMBAR syndrome'.)

Sacral dimple — Simple single sacral midline dimples in the skin overlying the coccyx, which have a visible intact base and are less than 0.5 cm in diameter, are common (2 to 5 percent prevalence rate) and are typically benign with little or no clinical significance [39-48]. As a result, no further investigation is needed for these simple dimples.

In contrast, sacral dimples that are deep and large (greater than 0.5 cm), fall within the superior portion or above the gluteal cleft (>2.5 cm from the anal verge), or are associated with other cutaneous markers for NTDs (eg, hypertrichosis, and discoloration), are more likely to be associated with an underlying NTD (picture 20) [39-41,49]. If a sacral dimple has any of these characteristics, an ultrasound should be performed to screen for a NTD [40,45,48,50]. (See "Closed spinal dysraphism: Clinical manifestations, diagnosis, and management", section on 'Cutaneous'.)

Extremities

Hands and feet ‒ The hands and feet are inspected for syndactyly (fusion of digits) and polydactyly (extra digits). Syndactyly and polydactyly can be normal variants in a newborn with an otherwise normal exam or may be associated with various syndromes. The presence of a single palmar crease should be noted. A single unilateral palmar crease occurs in 5 to 10 percent of the normal population [37] and is more common in newborns with trisomy 21. (See "Down syndrome: Clinical features and diagnosis".)

Extremity movement ‒ The extremities should move spontaneously and equally. Decreased movement of one limb may be because of pain caused by a fracture, or paralysis due to a brachial plexus injury. (See "Neonatal birth injuries", section on 'Fractures'.)

Brachial plexus injury ‒ Brachial plexus injury typically occurs when the cervical, or rarely the upper thoracic, nerve roots are stretched during delivery. The pattern of injury is dependent upon which cervical roots are involved. (See "Brachial plexus syndromes", section on 'Neonatal brachial plexus palsy'.)

C5 and C6 injury (Erb palsy) accounts for approximately 50 percent of cases. Weakness involves the deltoid and infraspinatus muscles (mainly C5) and biceps (mainly C6). As a result, the upper arm is adducted and internally rotated, and the forearm is extended, while hand and wrist movement are preserved.

C5 to C7 injury (also referred to as Erb palsy) accounts for approximately 35 percent of cases and manifests as adduction and internal rotation of the arm, extension and pronation of the forearm, and flexion of the wrists and fingers (the "waiter's tip" posture).

C5 to T1 injury presents with arm paralysis and some sparing of finger flexion.

C7 to T1 injury is characterized by a flail arm and Horner syndrome.

C8 to T1 injury (Klumpke palsy) is the most infrequent pattern and manifests as isolated hand paralysis and Horner syndrome.

Hips — The hips should be examined to detect developmental dysplasia of the hip (DDH). The examination for hip instability must be performed gently and with the infant quiet and relaxed. Techniques to detect hip instability (eg, Ortolani and Barlow maneuvers) use adduction and posterior pressure to feel for dislocation, and abduction and elevation to feel for reduction. The sensation of dislocation or reduction is distinct and best described as a "jerk" or "clunk" and differs from that of benign joint popping or tendon snapping. Risk factors for DDH include female gender, in utero breech position, and a positive family history.

The epidemiology, diagnosis, and management of DDH are discussed in greater detail separately. (See "Developmental dysplasia of the hip: Epidemiology and pathogenesis" and "Developmental dysplasia of the hip: Clinical features and diagnosis", section on 'Examination' and "Developmental dysplasia of the hip: Treatment and outcome".)

Neurologic examination — The newborn neurologic examination includes an assessment of the infant's level of alertness, spontaneous motor activity, tone, muscle strength, and primitive reflex responses and is discussed in detail separately. (See "Neurologic examination of the newborn".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topics (see "Patient education: Newborn appearance (The Basics)")

SUMMARY AND RECOMMENDATIONS

Overview ‒ Assessment of a newborn infant is generally performed within 24 hours of life to identify any abnormality that would alter the normal newborn course or identify a medical condition that should be addressed. It includes review of the maternal, family, and prenatal history and a complete examination.

History ‒ The newborn history includes the review of the following:

Parent's medical and genetic history. In particular, any maternal illnesses prior to and during pregnancy and the use of maternal medications should be noted. (See 'History' above.)

Past pregnancies, including a history of congenital anomalies, still births, and/or genetic or syndromic conditions. (See 'History' above.)

Prenatal screening tests. (See 'Prenatal screening tests' above.)

Events surrounding delivery. (See 'Delivery' above.)

Risk factors for sepsis (maternal intrapartum temperature ≥38ºC [100.4ºF]. membrane rupture ≥18 hours, preterm delivery, and the presence of chorioamnionitis). (See 'Risk factors for sepsis' above and "Clinical features, evaluation, and diagnosis of sepsis in term and late preterm infants", section on 'Maternal risk factors'.)

Physical examination ‒ The physical examination can be performed in the nursery or the mother's room. The area should be warm and quiet and should have good lighting. It should be conducted in a systematic and consistent manner as a consistent approach ensures that all aspects are evaluated. The date and time of the examination should be recorded. Findings considered normal close to delivery (eg, a transitional heart murmur) may be abnormal on the second or third day after birth. The examination should include assessment of gestational age (GA). (See 'Overview' above.)

Although the exact order is not important, the examination is optimized by initially observing the infant's general appearance followed by auscultation of the lungs and heart while the infant is lying quietly. (See 'General appearance' above and 'Lungs' above and 'Cardiovascular system' above.)

The assessment then proceeds with measurements of body parts (ie, weight, length, and head circumference) and vital signs and examination of individual body parts and organs from head to toes. Examination of the hips and spine, which is apt to disturb the infant, usually is performed last. (See 'Measurements' above and 'Vital signs' above.)

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