Neonatal Examination

The programme for routine examination of neonates and infants varies between countries in the UK. In England,
all parents are offered a head to toe physical examination of their baby. This includes specific checks of the hips,
heart, eyes and, for boys, the testes. The examination takes place within 72 hours of birth and again at 6-8 weeks
of age.
[1]

Initial post-delivery examination
A brief screening examination should be conducted checking the face, eyes, mouth, chest, abdomen, spine and
limbs to exclude major abnormalities. A strong cry and a widespread pink blush over the face and body are good
signs that all is well. Some children may be born with indiscriminate genitalia. In such cases it is important not to
guess at the likely gender of the child, but advise that it is uncertain and that further tests will be needed. If you
have sufficient clinical experience, an orogastric tube should be passed when the neonate's mother has suffered
polyhydramnios. This excludes oesophageal atresia.
The APGAR score
The Apgar score gives a reproducible, quantitative, semi-objective assessment of neonatal condition that is
useful for assessing a baby's progress or deterioration immediately after delivery.
[2]
It is important to document it
for medicolegal reasons. It is most useful following complicated births or where there are unanticipated problems
with the baby after delivery. It should be checked at delivery and two and five minutes subsequently; these results
should be documented in the partogram, maternal and neonatal notes.
The Apgar Scoring System
Assigned score 0 1 2
Colour of baby Blue, pale Body pink, extremities
blue
Completely pink
Respiratory effort Absent Weak cry, hypoventilation Good, strong cry and adequate
breaths
Muscle tone Limp Some flexion of
extremities
Active motion with extremities well
flexed
Reflex irritability (response to plantar
stimulation)
No
response
Grimace Cry
Heart rate Absent Slow (<100 bpm) Fast (>100 bpm)
There is an excess of mortality and an increased risk of severe neurological morbidity in infants with total Apgar
score <7 at five minutes.
[3]
Routine neonatal examination
Known colloquially as 'the baby check', this examination should be carried out by a member of the paediatric
team where the baby is still in hospital, or by the GP and primary care team following home births. The National
Institute for Health and Care Excellence (NICE)
[2]
recommends that the aims of the examination should be fully
explained to the parent(s) before it is conducted. The findings should be shared with the parent(s) and recorded
in the postnatal care plan and the personal child health record. NICE advises that the examination should be
carried out within 72 hours of birth and incorporate:
A review of parental concerns and the baby's medical history
Family, maternal, antenatal and perinatal history
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Fetal, neonatal and infant history, including any previously plotted birth weight and head circumference
Whether the baby has passed meconium and urine (and urinary stream in a boy)
Other screening tests as recommended by the UK National Screening Committee should also be
carried out or arranged at this time
[1]

The examination is best conducted in a well-lit, warm, private room with the mother in attendance and
able to see and help with what is being done.
Suggested schema for screening neonatal examination
First wash your hands thoroughly to reduce the risk of cross-infection. Then:
Listen and observe
Assess overall appearance. Note general tone, sleepiness and rousability. Observe general condition,
proportions and maturity.
Look carefully for evidence of jaundice (preferably in bright, natural light). Note whether there are any
birthmarks, rashes or other skin abnormalities.
Listen to the baby's cry and note its sound.
Weigh the baby and plot this reading on its growth chart.
Perform a systematic 'head to toes' examination
This should be done carefully and in good light to detect abnormalities:
Head:
Shape, presence of fontanelle and whether normal, sunken or bulging.
Measure and record head circumference on the growth chart.
Assess facial appearance and eye position.
Look for any asymmetry or abnormality of facial form.
Eyes:
Establish that they are of normal shape and appearance.
Check for presence of red reflex.
Look for obvious cataracts or signs of ophthalmic infection.
Ears:
Note shape and size.
Establish whether they are set at the normal level or 'low-set'.
Check patency of external auditory meatus.
Mouth:
Check the colour of the mucous membrane; observe the palate.
Check suckling reflex by inserting a clean little finger gently inside the baby's mouth.
Arms and hands:
Establish whether they are of normal shape and moving normally.
Look for evidence of traction birth injury (eg, Erb's palsy) by checking the neck, shoulders
and clavicles.
Count the fingers and observe their shape; check for any evidence of clinodactyly (incurving
of fingers).
Check palmar creases - whether they are multiple or single. A single palmar crease may be
normal, but can be a sign of Down's syndrome (trisomy 21).
Peripheral pulses:
Check brachial, radial and femoral pulses for rate, rhythm and volume.
A hyperdynamic pulse may suggest patent ductus arteriosus.
A weak pulse may occur with a congenital cardiac anomaly (impairing cardiac output and in
conjunction with other signs from the examination).
Check for radio-femoral delay (aortic coarctation).
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Heart:
Check the cardiac position by palpation and feel for any thrill or heave.
Listen to the heart sounds carefully and for any added sounds or murmurs.
Suspected abnormalities require further examination (and often more expert opinion and
investigation).
Lungs:
Watch the respiratory pattern, rate and depth for a few seconds.
Look for any evidence of intercostal recession.
Listen for stridor.
Auscultate lung fields for added sounds.
Abdomen:
Look at abdominal girth and shape.
Carefully check the umbilical stump for infection or surrounding hernia.
Palpate gently for organs, masses or herniae.
It is common to be able to feel the liver and/or spleen in healthy newborns.
Check the external genitalia carefully (see the separate article on Ambiguous Genitalia).
Palpate for testes in boys.
Inspect the anus (establish whether meconium been passed).
Back:
Look carefully at the skin over the back and at the spinal curvature/symmetry.
Observe whether there is any evidence of spina bifida occulta or pilonidal sinus hidden by
flesh creases or dimples.
Palpate the spine gently.
Hips:
Specifically test for congenital dislocation of the hip (aka congenital hip dysplasia) using a
combination of Barlow and Ortolani manoeuvres (follow the link for more detail).
Legs:
Watch movements at each joint.
Check for any evidence of talipes equinovarus.
Count toes and check their shape.
CNS:
Observe tone, behaviour, movements and posture.
Elicit newborn reflexes only if there is cause for concern.
Further examination should be conducted as necessary according to any abnormalities that are
detected, or suspicions of undetected illness in the baby.
Record findings
Always document the findings of the examination in the postnatal care plan and personal child health
record. A proforma for the examination, kept within the notes, can save time and act as a prompt to
ensure that no element of the examination is missed.
Other screening tests
NICE recommends that newborn screening tests, as currently advised by the UK National Screening
Committee, should be offered to all UK-born children.
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This includes the newborn heel prick blood spot test traditionally used to pick up phenylketonuria and
hypothyroidism. The blood spot, or heel prick, test is taken between 5 and 8 days ((ideally at day 5,
count date of birth as day 0). It may include tests for other metabolic abnormalities in future:
Sickle cell disease: all newborn babies in England are offered screening for sickle cell
disease.
[1]

Cystic fibrosis: biochemical screening is offered to all newborn babies.
[1]

Medium-chain acyl CoA dehydrogenase (MCAD): the Department of Health introduced
routine MCAD deficiency screening in the neonatal blood spot test from February 2009.
[1]

The routine neonatal screening examination should be repeated at 6-8 weeks and an assessment of
visual fixation and social smiling conducted.
A hearing screen should be completed before discharge from hospital (or by week 4 in the hospital
programme/week 5 in the community programme).
Common abnormalities detected in the newborn screening
examination
Capillary or macular haemangioma:
Also known as stork mark/bites, or salmon patch; found around the eyes and nape of the
neck in 30-50% of babies.
Those around eyes normally disappear in first year, and commonly persist if on the nape of
the neck.
Blue-black pigmented area:
Also known as Mongolian blue spots; they are seen at the base of the back and on the
buttocks. These are common in dark-skinned parents but can occur in Caucasian infants.
They normally disappear over the first year.
Urticaria of the newborn:
This is most evident on day 2 as a fluctuating, widespread erythematous rash with a raised
white/cream dot at the centre of a red flare, mostly apparent on the trunk.
This disappears spontaneously without treatment.
Heat rash:
Also known as miliaria, this may appear as either red, macular patches or superficial, clear
vesicles that are most marked on the forehead and around the neck.
It is associated with warm humid environments and will clear in cooler, drier conditions.
Breast enlargement:
Seen in both girls and boys; the child may secrete a small amount of milk ('witches milk').
This is thought to be due to response to circulating maternal hormones.
It is not significant unless the condition persists/progresses.
White pimples:
Also known as milia; they are seen on the nose and cheeks and are found in approximately
40% of newborns, due to blocked sebaceous glands.
These clear spontaneously.
Oral cysts:
These are found on the palate near the midline and on the gums (also known as Epstein's
pearls).
They may be larger and on the floor of the mouth.
They usually resolve spontaneously.
Teeth can be present at birth (no action is required unless they are loose or abnormal, in
which case they may have to be extracted).
Accessory skin tags:
Seen on the face as accessory auricles anterior to the ears.
They can be dealt with easily by a surgical team.
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Vestigial extra digits:
These can usually be dealt with easily by a surgical team.
Sacral dimples:
These are common.
Examine carefully to detect underlying sinus or evidence of spina bifida occulta.
Deformity of the shape of the head in the immediate postnatal period and following days is common:
Such 'moulding' is non-pathological and usually resolves spontaneously.
Assess whether there are any other craniofacial abnormalities.
Seek expert input if unsure.
Abnormalities that may indicate a significant underlying cause
Any wide separation of the fontanelles, with presence of islands of bone (Wormian bones) may
indicate cranial abnormalities caused by a range of congenital syndromes.
A third fontanelle, found between the normal anterior and posterior fontanelles may indicate Down's
syndrome.
Abnormally shaped or placed ears may indicate fetal alcohol syndrome, craniofacial abnormalities due
to abnormal branchial arch development or conditions such as Edward's syndrome (trisomy 18) or
congenital renal anomalies.
Single palmar crease can indicate Down's syndrome but may be found in children who do not suffer
from this condition.
Abnormalities of the face, jaw and ears are often associated with hearing dysfunction; hearing tests
should be performed and ENT assessment requested.
Further reading & references
Fuloria M and Keiter S; The Newborn Examination: Part I. Emergencies and Common Abnormalities Involving the Skin,
Head, Neck, Chest, and Respiratory and Cardiovascular Systems.; Am Fam Phys 2002;65:61-8 [Full Text]. Very detailed.
Fuloria M and Kreiter S; The Newborn Examination: Part II. Emergencies and Common Abnormalities Involving the
Abdomen, Pelvis, Extremities, Genitalia, and Spine.; Am Fam Phys 2002 Jan 15;65:265-70 [Full Text]. Very detailed.
1. UK Screening Portal Programmes; UK National Screening Committee
2. Postnatal care: Routine postnatal care of women and their babies; NICE Clinical Guideline (2006)
3. Thorngren-Jerneck K, Herbst A; Low 5-minute Apgar score: a population-based register study of 1 million term births.;
Obstet Gynecol. 2001 Jul;98(1):65-70.
Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical
conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its
accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions.
For details see our conditions.
Original Author:
Dr Sean Kavanagh
Current Version:
Dr Colin Tidy
Peer Reviewer:
Dr Adrian Bonsall
Last Checked:
28/05/2013
Document ID:
1544 (v25)
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