Examination of the Neonate - A Quick Review

The aim is to screen for abnormality, and to see if the mother has any questions or difficulties.
The following is a recommended routine before the baby leaves hospital—or during the 1st week of life for home deliveries.

Before the examination find out :

• If the birth weight was normal?
• Was the birth and pregnancy normal? 
• Is mother Rh–ve? 

For Examination 

• Find a quiet, warm, well-lit room. 
• Enlist the mother’s help. 
• Explain your aims. 
• Does she look angry or depressed? 
• Listen if she talks. 

Examine systematically, from head-to-toe. 

• Wash your hands meticulously.
• Note observations (eg T°; rectal is more reliable than tympanic). 

Head:

• Circumference (50th centile=35cm, ), 
• shape (odd shapes from a difficult labour soon resolve), 
• fontanelles (tense if crying or intracranial pressure increased; sunken if dehydrated). 

Eyes:

• Red reflex (absent in cataract & retinoblastoma);
• corneal opacities; 
• conjunctivitis. 

Ears:

• Shape; 
• position. Are they low set (ie below eyes)? 

Nose: 

• The tip of the nose, when pressed, shows jaundice in white babies.
• Breathing out of the nose (shut the mouth) tests for choanal atresia
• Ensure oto-acoustic screening is done 

Complexion: 

• Cyanosed, pale, jaundiced, or ruddy (polycythaemia)?

Mouth:

• Look inside; 
• insert a finger: is the palate intact? 
• Is suck good? 

Face:

• Does the baby’s face look normal? 
• Dysmorphism can be difficult to detect soon after birth as the baby may have some puffiness in the face.

Arms & hands:

• Single palmar creases (normal or Down’s). 
• Waiter’s (porter’s) tip sign of Erb’s palsy of C5 & 6 trunks . 
• Number of fingers. 
• Clinodactyly (5th finger is curved towards the ring finger, eg in Down’s).

Thorax:

• Watch respiration; 
• note grunting and intercostal recession (respiratory distress). 
• Palpate the precordium and apex beat.
• Listen to the heart and lungs. 
• Inspect the vertebral column for neural tube defects.

Abdomen:

• Expect to feel the liver. 
• Any other masses? 
• Inspect the umbilicus. Is it healthy? Flare suggests sepsis. 
• Next, lift the skin to assess skin turgor. 

Genitalia and Anus:

• Inspect genitalia and anus. Are the orifices patent? 
• Ensure in the 1st 24 hours the baby passes urine (consider posterior urethral valves in boys if not) and stool (consider Hirschprung’s, cystic fibrosis, hypothyroidism). 
• Is the urinary meatus misplaced (hypospadias), and are both testes descended? 
• The neonatal clitoris often looks rather large, but if very large, consider Congenital adrenal hyperplasia 
• Sometimes bleeding PV may be a normal variant following maternal oestrogen withdrawal.

Buttocks/sacrum:

• Is there an anus? 
• Are there ‘mongolian spots’? (blue—and harmless). 
• Tufts of hair ± dimples suggest bifi da occulta? Any pilonidal sinus?

Other important Points:

• Legs Test for congenital dislocation of the hip . Avoid repeated tests as it hurts, and may induce dislocation. 
• Can you feel femoral pulses (to ‘exclude’ coarctation)? 
• Note talipes . 
• Toes: too many, too few, or too blue?
• Is the baby post-mature, light-for-dates, or premature ?

CNS

• Assess posture and handle the baby. 
• Intuition can be most helpful in deciding if the baby is ill or well. 
• Is he jittery (hypoxia/ischaemia, encephalopathy, hypoglycaemia, infection, hypocalcaemia)? 
• There should be some control of the head. 
• Do limbs move normally. 
• Is the tone floppy or spastic? 
• Are responses absent on one side (hemiplegia)? 
• The Moro reflex rarely adds important information (and is uncomfortable for the baby). It is done by sitting the baby at 45°, supporting the head. On momentarily removing the support the arms will abduct, the hands open and then the arms adduct. 
• Stroke the palm to elicit a grasp reflex. 

Discuss any abnormality with the parents after liaising with a senior doctor.