29  Physical Examination
of the Newborn
TOM LISSAUER
Immediately after a baby is born, all parents want to
know, “Is my baby all right?” A quick initial physical
examination of all newborns should be performed in the
delivery room to ensure that there are no major anoma-
lies or birth injuries, that the newborn’s tongue and body
appear pink, and that breathing is normal. The entire
body must be checked. This usually allows the clinician
to reassure the parents that their infant looks well and
appears normal.
Many serious congenital anomalies will have been
identified prenatally, their presence anticipated, and a
management plan made before delivery. If the newborn
is sufficiently preterm or small for gestational age, has a
significant problem diagnosed prenatally, or is unwell
(e.g., respiratory distress), the newborn must be admitted
to an intermediate or intensive care nursery in accordance
with hospital guidelines. When the infant is born, the
parents will have been informed if a boy or girl. If there
is any doubt about the infant’s gender, it is important not
to guess but to inform the parents that further evaluation
is required before a definite decision is made.
During the first few hours after birth, healthy new-
borns are usually alert and reactive and will suck at the
breast. This behavior provides an initial opportunity for
the mother to form a close attachment with her infant
and to establish breastfeeding. Medical interference
during this time should be kept to a minimum.
Routine Examination
Every newborn infant should undergo a “routine examina-
tion of the newborn.”2,26,38 This is a detailed examination
performed by a trained health care provider within 24 to
72 hours of birth. The objectives of the examination are
listed in Box 29-1. The prevalence of the most common
significant congenital abnormalities is shown in Table
29-1. Some are detected prenatally, but many are first noted
in the delivery room or during the routine examination of
the newborn. They are described briefly in this chapter;
detailed descriptions are found elsewhere in the book.
PREPARATION
Before approaching the mother and infant, the mother’s
and infant’s medical and nursing records should be
checked. Relevant items are listed in Box 29-2.
INTRODUCTION TO THE MOTHER
The health care provider should introduce himself or
herself to the mother or, preferably, to both parents and
explain the purpose of the examination. It is usually best
at this stage to inquire whether there are any problems
with feeding or any other worries about the infant. Before
starting the examination the health care professional
must observe hand hygiene and ensure that the newborn
can be examined in a warm, private area with good
lighting.
ORDER OF THE EXAMINATION
The exact sequence in which the newborn is examined is
not important. What is important is that the entire body
is examined at some stage. If the newborn is quiet, one
may well take the opportunity to listen to the heart and
examine the eyes directly. It is often convenient to make
general observations of the newborn’s appearance,
posture, and movements while undressing him or her,
then to conduct the examination from head to foot, to
then remove the diaper to examine the genital region,
femoral pulses and hips, and finally to pick the newborn
up and turn him or her over to be prone and examine
the back and spine and assess tone in the prone position
(Figure 29-1). A checklist is helpful to record the findings
of the examination and to ensure that nothing has been
omitted. For example, in the United Kingdom, the
Newborn and Infant Physical Examination Program
requires a specific checklist to be completed and inserted
in the infant’s personal child health record. It also has
defined goals, target conditions (hips, eyes, heart, and
testes), and competency standards.
MEASUREMENTS
The infant’s birth weight, gender, and gestational age
should be noted. The 10th to 90th percentile for weight
at 40 weeks’ gestation for a male infant is 2.8 to 4.0 kg
(mean, 3.3 kg) and for a female infant is 2.7 to 3.9 kg
(mean, 3.2 kg; see Appendix B). The birth weight percen-
tile should be ascertained from the gestation-specific
growth chart. If the infant’s gestational age is uncertain,
it can be determined (±2 weeks’ gestational age) using a
standardized scoring scheme. Infants often lose weight
over the first 5 days of life up to a maximum of 10% of
birth weight.
The head circumference should be measured with a
disposable tape measure at its maximal occipital frontal
circumference and plotted on a gestation-specific growth
chart to identify microcephaly or macrocephaly and to
serve as a reference for future measurements. However,
the measurement can change markedly in the first few
days because of molding of the head during delivery. The
391
 392 PART 4  • THE DELIVERY ROOM

BOX 29-1 OBJECTIVES OF ROUTINE BOX 29-2  MOTHER’S AND INFANT’S

EXAMINATION OF THE RECORDS
NEWBORN Items of particular relevance in the mother’s and infant’s
Detect congenital abnormalities not already identified at medical and nursing records are:
birth (e.g., congenital heart disease, developmental dys- • Maternal age, occupation, and social background
plasia of the hip, cataract, undescended testes). • Family history of medical problems
Determine whether any of the wide range of nonacute • History of maternal drug or alcohol abuse, socially
neonatal problems is present, and initiate their manage- high-risk circumstances (e.g., severe learning difficul-
ment or reassure the parents. ties, maternal mental health problems, domestic vio-
Check for potential problems arising from maternal lence, child protection issues, unsatisfactory home
disease, familial disorders, or problems detected during conditions)
pregnancy.
Provide an opportunity for the parents to discuss any ques- • Details of previous pregnancies, complications and
tions about their infant. any medical problems experienced by those
Initiate health promotion for the newborn (e.g., breastfeed- children
ing, prevention of sudden infant death syndrome, safe • History of maternal disease and medication taken
transport in cars). during pregnancy
Ensure that a follow-up plan is in place for parents who • Results of pregnancy screening tests (e.g., blood tests
have been identified as being at risk of being unable to including maternal syphilis and hepatitis B surface
provide adequate care for the infant because of child antigen, prenatal ultrasound scans)
protection issues, mental health problems, substance • Results of special diagnostic procedures (e.g., amnio-
abuse, severe learning difficulties or severe social centesis, chorionic villus sampling)
deprivation. • Problems during labor and delivery (e.g., prolonged
rupture of membranes, fetal distress)
• Infant’s condition at birth and if resuscitation was
required
TABLE 29-1 Prevalence of Significant • Any concerns about the infant from nursing staff or
Congenital Anomalies (per 1000 parents (e.g., feeding concerns)
Live Births) • The infant’s birth weight
• The gestational age and if there is any uncertainty
Anomaly Prevalence about it
Congenital heart 6-8 (0.8 identified in the first • The infant’s gender
disease day of life)
Developmental dysplasia 0.7-1.1 (about 7/1000 have an
of the hip abnormal initial examination)
Talipes equinovarus 1.1
Down syndrome 1.3
If there is any doubt, the newborn’s oxygen saturation
Cleft lip and palate 0.8 should be checked with a pulse oximeter. Polycythemic
Urogenital—male infants (central hematocrit >65%) sometimes appear cya-
  hypospadias, 4 notic because they have more than 5 g of reduced hemo-
  undescended testes 45 globin per 100 mL of blood, even though they are
Spina bifida/anencephaly 0.5 adequately oxygenated. Peripheral cyanosis confined to
the hands and feet is common during the first day of life
and is of no clinical significance.

10th to 90th percentile is 33 to 36 cm (boys) and 32 to SYNDROMES

35 cm (girls) at 40 weeks.
The infant’s length (47 to 52 cm at 40 weeks) is mea-
sured routinely in the United States. Because the hips and
lower legs need to be held extended by an assistant, the
length is rarely measured accurately enough to identify
short stature or serve as a reliable reference value when
measured routinely.26 The length of the arms and legs
relative to that of the trunk is observed, although short
limbs from skeletal dysplasias can be difficult to appreci-
ate in the immediate newborn period.
GENERAL OBSERVATION OF APPEARANCE,
POSTURE, AND MOVEMENTS
Much valuable information can be gleaned by simply
observing the newborn. Central cyanosis is best observed
on the tongue. If present, it requires urgent investigation.
The facial appearance is observed. If the face is abnormal,
does the newborn have a syndrome? Down syndrome is
by far the most common syndrome. The characteristic
facies is often more difficult to recognize in the immedi-
ate neonatal period than in later life, but other abnor-
malities, such as the flat occiput, hypotonia, bilateral
single palmar creases, and a pronounced sandal gap (an
abnormal skin crease between the first two toes), are
helpful additional signs. In practice, the parents usually
need to be informed of the diagnosis before the results
of the chromosome analysis are available.
Many hundreds of syndromes have been described.
When the diagnosis is uncertain, a book or computer
database should be consulted and advice sought from a
pediatrician or clinical geneticist (see Chapter 31).
Assess the face for asymmetry, particularly when crying,
to identify facial palsy and asymmetric crying facies. In
 29  •  Physical Examination of the Newborn 393

General Observations Skin

Weight, length, Pallor
head circumference Jaundice
Gestation Plethora
Overall observation
Movements and tone Chest
Respiratory rate
Chest retractions
Heart sounds
Head and Face and murmur Pulses
Fontanelle Femoral
Facial appearance pulses
for dysmorphic
features

Eyes
Cataract
(red reflex) Genitalia and anus
Hypospadias
Mouth Undescended testes
Cleft lip and palate Ambiguous genitalia
Central cyanosis Anus–position and
Back appearance
Midline
Abdomen defects
Abdominal
distention Hips
Enlarged liver, Developmental
spleen, kidneys, dysplasia
Upper limbs of the hips
Digits or a mass
Palmar creases
Lower limbs
Talipes–positional/
equinovarus
Figure 29-1  Main features of routine examination of the newborn.

facial palsy, babies are unable to wrinkle their forehead
or close their eyes completely. Most resolve within a few
weeks. Asymmetric crying facies is usually due to congeni-
tal absence of the depressor anguli oris muscle. These
infants can wrinkle their forehead and close their eyes;
there is an association with congenital heart disease.
SKIN
Inspect the skin for color, texture, rashes, and birthmarks.
The skin of a Caucasian newborn looks reddish pink.
Skin may seem pale in the first few days in African or
Indian infants compared to parental skin color. Cracked,
peeling skin is common, especially in post-term infants.
The infant may be plethoric from polycythemia or unduly
pale from anemia or shock. If polycythemia or anemia is
suggested, the hemoglobin concentration or hematocrit
should be checked. Jaundice within the first 24 hours of
birth, unless mild, is most likely to be hemolytic and
requires urgent investigation and treatment. It may also
be a feature of congenital infection. Thereafter, manage-
ment is according to national guidelines. Traumatic cya-
nosis is blue discoloration of the skin, often with
petechiae. It can affect the presenting part in a face or
breech presentation or the head and neck if the umbilical
cord was wrapped around the infant’s neck. However, the
tongue remains pink.
Capillary hemangiomas (stork bites) are pink macules
appearing on the upper eyelids, the mid forehead, and
the nape of the neck from distention of dermal capillaries.
Those on the eyelids and forehead fade during the first
year, whereas those on the neck become covered with hair.
Port-wine stains (nevus flammeus) are caused by a
vascular malformation of capillaries in the dermis. They
are usually present at birth. When these lesions are
disfiguring, their appearance can be improved using
laser therapy. Port-wine stains affecting the ophthalmic
distribution of the trigeminal nerve may be associated
(in about 10%) with intracranial vascular anomalies
(Sturge-Weber syndrome). Severe lesions on the limbs are
associated with bone hypertrophy (Klippel-Trénaunay
syndrome). Port-wine stains must be differentiated from
strawberry nevi (cavernous hemangiomas), which are not
present at birth but appear during the first 1 or 2 months
of life.
Neonatal urticaria (erythema toxicum) is a common
rash that usually starts on the second or third day of life.
There are white pinpoint papules at the center of an ery-
thematous base. Eosinophils are present on microscopy.
The lesions migrate to different sites (see Chapter 102),
and the rash resolves around the fifth day. Neonatal pus-
tular melanosis is present from birth and contains neu-
trophils and is common in African-American infants. The
top of the pustule is readily removed on wiping, revealing
denuded skin, and may easily be mistaken for staphylo-
coccal infection. Affected lesions become hyperpigmented
and take several months to fade.
 394 PART 4  • THE DELIVERY ROOM
Milia describe benign white cysts that may be present
on the nose and cheeks from retention of keratin and
sebaceous material in the pilaceous follicles.
Small white pearls may be visible along the midline of
the palate (Epstein pearls).
Cysts of the gums (epulis) and on the floor of the
mouth (ranula) are mucus-retention cysts and do not
need any treatment.
In harlequin color change, there is longitudinal red-
dening down one half of the body and a sharply
demarcated blanching down the other side. This lasts for
a few minutes. It is thought to be due to vasomotor
instability.
Café au lait spots are common, but more than three
may indicate an underlying disorder.
Mongolian blue spots are blue-black macular discol-
orations at the base of the spine or on the buttocks. They
occasionally also occur on the legs and other parts of the
body. They occur most often in African-American or
Asian infants and fade slowly over the first few years of
life. They are of no clinical significance but are occasion-
ally misdiagnosed as bruises.
HEAD
The shape of the head should be noted. It may be asym-
metric from the infant’s intrauterine position or molded
from having to squeeze through the birth canal during
delivery. Newborns who have been in the breech position
in utero often have a prominent occipital shelf. After elec-
tive cesarean birth the infant’s head shape is round and
symmetric. The fontanelle and sutures are palpated. The
size of the anterior fontanelle is variable. If the fontanelle
is tense when the newborn is not crying, this may be from
elevated intracranial pressure, and cranial ultrasonogra-
phy should be performed. A tense fontanelle is also a late
sign of meningitis. After delivery, the sagittal suture is
often separated, and the coronal sutures are overriding.
The posterior fontanelle is often open, but small.
A caput succedaneum is bruising and edema of the
presenting part of the head. It extends beyond the margins
of the skull bones. A cephalhematoma is caused by bleed-
ing between the periosteum and the skull bone. It is
confined within the margins of the skull sutures and
usually affects the parietal bone. These conditions may
take several weeks to resolve. In subgaleal hemorrhage,
there is bleeding between the galea aponeurosis and peri-
osteum. Vacuum extraction and coagulopathy are risk
factors. The head may have a boggy appearance with
pitting edema of the scalp and anterior displacement of
the ears. Early recognition and treatment is paramount
because it may progress to hypovolemic shock. Bruising
and abrasions after forceps deliveries, from scalp elec-
trodes, or from fetal blood sampling are relatively
common (see Chapter 30).
In craniosynostosis, there is premature fusion of one
or more of the cranial sutures, usually resulting in a mark-
edly asymmetric skull with a palpable ridge along the
suture line. It may be isolated, but if more than one
suture is involved, it is often part of a syndrome (e.g.,
Crouzon or Apert syndrome). Because it may restrict
brain growth, surgery may be required to avoid neuro-
logic impairment and to improve cosmetic outcome.
EYES
The eyes should be checked both by inspection and with
an ophthalmoscope. The size, slant, and position of the
eyes should be noted. A coloboma is a defect in the iris,
resulting in a keyhole-shaped pupil. It may be associated
with a defect in the retina. It may be an isolated abnormal-
ity or part of the CHARGE syndrome (coloboma, heart
disease, atresia choanae, restriction of growth or develop-
ment, genitourinary tract abnormality, ear anomalies).
The red reflex should be elicited using an ophthalmoscope
held about 6 to 8 inches from the infant’s eyes and focused
on the pupil. During this part of the examination the room
needs to be darkened. The eyes will usually open if the
infant’s head is supported in the examiner’s hand and
raised to about 45 degrees or if the infant is held over the
mother’s shoulder. If the infant is asleep, the eyelids can be
gently opened, although this is often made more difficult
by the swelling of the eyelids, which is common during the
first few days of life. The red retinal reflex can be seen if the
lens is clear, but not if it is opaque from a congenital cata-
ract or enlarged and hazy from congenital glaucoma. If the
red reflex is abnormal, an ophthalmologist should be con-
sulted urgently. Congenital cataract is the most common
form of preventable childhood blindness. A white pupil-
lary reflex (leukocoria) is an important presentation of
retinoblastoma. In dark-skinned infants the reflex is often
more yellow than red. The American Academy of Pediat-
rics (AAP) recommends referral to an ophthalmologist for
all infants with a family history of significant eye disease
regardless of examination findings.
Swelling of the eyelids is common in newborns and
resolves during the first few days of life. Subconjunctival
hemorrhages are common. They occur during delivery
and resolve in 1 to 2 weeks. There may also be a mucoid
discharge affecting the eyes, often called a “sticky eye,” in
the first few days of life, which resolves spontaneously; if
more prolonged, it is often from a blocked or incom-
pletely canalized nasolacrimal duct. The eyelids can be
cleansed with sterile water. This condition must be con-
trasted with the erythematous, swollen eyelids with puru-
lent eye discharge seen in conjunctivitis. On the first day
of life, gonococcal infection is most likely, but is rare in
developed countries. In the United States, all infants are
given eye prophylaxis against gonococcal conjunctivitis.
Chlamydia trachomatis is rare on the first day, usually pre-
senting on days 5 to 14 of life.
EARS
The shape, size, and position of the ears are checked.
Low-set ears are positioned so that the top of the pinna
falls below a line drawn from the outer canthus of the
eye at right angles to the face. Low-set or abnormal ears
are characteristic of a number of syndromes. Malforma-
tions of the ear may be associated with hearing loss. Skin
tags anterior to the ear (preauricular tags) and accessory
auricles should be removed by a plastic surgeon. Preau-
ricular tags are usually isolated and benign, but infants
warrant their hearing checked with the newborn hearing
screen.43 They are sometimes associated with other dys-
morphic features, a family history of deafness, maternal
history of gestational diabetes, and increased risk for

renal anomalies. When a preauricular tag is associated
with other abnormalities or risk factors, a renal ultra-
sound is recommended.54 The need for a renal ultrasound
examination for an isolated preauricular tag has been
questioned; a meta-analysis showed similar risk of renal
tract anomalies to that of the general population.34 Con-
genital ear deformities, in which there is normal develop-
ment of the ear cartilage but abnormal architecture, may
resolve spontaneously, but in some of these patients
surgery is performed. Splinting of the ears in the early
neonatal period has been recommended to avoid the
need for surgery and improve cosmetic appearance.52
MOUTH AND PALATE
The mouth is observed for size, position, and asymmetry.
The palate must be inspected, including posteriorly, to
exclude a posterior cleft palate. It should also be palpated
to detect an indentation of the posterior palate from a
submucous cleft or a posterior cleft palate. If cleft lip and
palate are recognized prenatally, the parents will be fore-
warned and counseled about the likely appearance and
management. When diagnosed at birth, the parents will
need to be reassured about the good cosmetic results after
surgical repair. Before and after photographs of other
children are often helpful. Assistance in establishing
feeding may be required. The infant will need to be
referred to a multidisciplinary craniofacial service.
Micrognathia describes a small mandible and may be
associated with glossoptosis and a posterior cleft palate
(Pierre Robin sequence) and may cause upper airway
obstruction and feeding difficulties.
NECK
Redundant skin over the posterior neck together with a
flat occiput is a feature of Down syndrome. A webbed
neck is a feature of Turner syndrome, which may also be
associated with lymphedema of the feet. A short, webbed
neck may indicate abnormalities of the cervical spine
(Klippel-Feil syndrome). Cystic hygromas are soft, fluctu-
ant swellings usually in the posterior triangle that
transilluminate.
BREATHING AND CHEST
Breathing and chest wall movement are observed. The
respiratory rate should be less than 60 breaths per minute
without chest retraction, flaring of the alae nasi, or grunt-
ing (i.e., no signs of respiratory distress). If the breathing
is normal, it is extremely rare for significant abnormalities
to be detected on auscultation. If the infant has respira-
tory distress, further evaluation is required immediately.
Normal term infants may have periodic breathing with
pauses of up to 10 seconds between periods of regular
breathing.
Breast enlargement can occur in newborns of either
sex. A small amount of milk (“witch’s milk”) may be
discharged.
HEART
The normal heart rate is 110 to 150 beats per minute in
term infants but can drop to 85 beats per minute during
sleep. The heart sounds should be loudest on the left side
of the chest. Heart murmurs can be heard in about 0.6%
29  •  Physical Examination of the Newborn 395
BOX 29-3  FEATURES OF A HEART
MURMUR IN A NEONATE
FEATURES OF AN INNOCENT MURMUR
• Soft (grade 1/6 or 2/6) murmur at left sternal edge
• No audible clicks
• Normal pulses
• Otherwise normal clinical examination
FEATURES SUGGESTING A MURMUR IS
SIGNIFICANT35
• Pansystolic
• Loud (≥ grade 3/6)
• Harsh quality
• Best heard in the upper left sternal edge
• Abnormal second heart sound
• Femoral pulses difficult to feel
• Other abnormality on clinical examination
of infants at the routine examination of the newborn.1
Most are innocent and originate from the acute angle at
the pulmonary artery bifurcation or are from a patent
ductus arteriosus or tricuspid regurgitation.5 The problem
is to differentiate innocent murmurs from those caused
by significant heart lesions. Clinical features may serve as
a guide. Features of innocent and significant murmurs are
given in Box 29-3. These clinical criteria can help resi-
dents,20 general pediatricians,14,27 and pediatric cardiolo-
gists47 to identify significant heart lesions.
The usefulness of electrocardiograms and chest radio-
graphs in helping to distinguish innocent from significant
murmurs is controversial. The neonatal electrocardiogram
and chest radiograph are difficult to interpret, and these
tests have rarely been found to change decisions based
on the clinical examination.47,49 Many centers have
stopped performing them under these circumstances.
If a heart murmur is thought to be significant or cannot
confidently be diagnosed as innocent, the infant should
be referred directly for echocardiography. The manage-
ment of infants with an innocent murmur depends on
the availability of echocardiography. If echocardiography
is readily available, it can be performed directly and pro-
vides parents with a definitive diagnosis without delay. If
echocardiography is not readily available, a follow-up
medical examination should be arranged soon after dis-
charge and the parents warned to seek medical assistance
if their infant becomes symptomatic with poor feeding,
labored breathing, or cyanosis.
Most innocent murmurs disappear in the first year of
life, most in the first 3 months. However, any mention of
a heart murmur can create considerable parental anxiety,
which sometimes continues for years. Attention must be
paid to this to prevent parents from continuing to worry
about their child’s heart even after the murmur has
disappeared.57
ABDOMEN
Observe for abdominal distention, asymmetry, and signs
of umbilical inflammation. For abdominal palpation, the
 396 PART 4  • THE DELIVERY ROOM
infant must be relaxed. The abdomen is palpated to iden-
tify any masses. The liver is normally palpable 1 to 2 cm
below the costal margin. The spleen tip and left kidney
are sometimes palpable; assess for enlargement. If palpa-
tion of the abdomen detects abnormally large renal
masses or an enlarged bladder in a male infant, ultraso-
nography is required urgently to identify urinary outflow
obstruction. Most cases of urinary outflow obstruction
are now detected on prenatal ultrasound screening, as are
other major abnormalities of the kidneys and urinary
tract. Siblings of children with vesicoureteric reflux should
be screened for this condition because up to 40% are also
affected.45 The American Urological Association has pub-
lished clinical practice guidelines for screening siblings.46
Observe for a hernia in the inguinal canal. Umbilical
hernias are common, especially in African-American
infants. No treatment is indicated because they usually
resolve within the first few years of life. The incidence of
inguinal hernias is approximately 3% to 5% in term
infants and 13% in infants born at less than 33 weeks of
gestational age. Inguinal hernias in both term and preterm
infants are commonly repaired shortly after diagnosis to
avoid incarceration of the hernia. Given the lack of defini-
tive data, optimal timing for repair of inguinal hernias in
infants remains debatable. Early repair of inguinal hernias
in preterm infants must be further balanced against the
risk of postoperative apnea after general anesthesia.53
Single umbilical artery occurs in about 0.3% of new-
borns. It is associated with an increased risk for chromo-
somal abnormalities and congenital malformations,
particularly of the genitourinary system.21,33 A single
umbilical artery was associated with asymptomatic renal
anomalies in 7% in one series.9 The yield is low from
ultrasound screening of the kidneys and urinary tract
when this is an isolated finding,15,51 and most renal
abnormalities identified are transient or mild. The yield
is further reduced by routine prenatal ultrasound screen-
ing for congenital anomalies of the kidneys and urinary
tract. It is probably best reserved for those who also have
other anomalies on physical examination.
FEMORAL PULSES
Femoral pulses are palpated when the infant is quiet.
Pulse pressure is reduced if there is coarctation of the
aorta. If coarctation is suggested clinically, further evi-
dence can be obtained by comparing the blood pressure
in the arms and legs. A difference of more than 20 mm
Hg is significant, and immediate treatment is indicated.
Pulse pressure is increased with a patent ductus
arteriosus.
GENITALIA
In boys, the penis is checked for length and the position
of the urethral orifice. The presence of testes in the
scrotum is confirmed. The penis may appear to be short
but may be buried in suprapubic fat. A penis less than
1 cm long is a micropenis suggesting congenital hypopi-
tuitarism. In hypospadias, the urethral meatus is in an
abnormal position, usually on or adjacent to the glans
penis, but may be on the penile shaft or perineum. The
foreskin is hooded, and chordee, causing ventral curva-
ture of the shaft of the penis, may be present. Glandular
hypospadias without chordee may not require treatment,
but more severe forms require corrective surgery, and a
specialist opinion should be sought. Circumcision should
be withheld as the foreskin may be required at surgery.
The testis may feel enlarged on palpation; this is
usually from a hydrocele, which can be confirmed on
transillumination with a flashlight. Hydroceles are rela-
tively common in boys and usually resolve spontane-
ously. An undescended testis has failed to descend from
its embryologic position from the urogenital ridge on the
posterior abdominal wall through the inguinal canal to
the scrotum. Undescended testes may lie along the line
of descent but may not have reached the scrotum or may
be ectopic testes, which have deviated from the line of
descent. At birth, about 4% of full-term male infants have
an undescended testis; by 3 months, about 1% are still
undescended, with little reduction thereafter. An unde-
scended testis should be reviewed at about 6 weeks of age.
If still undescended, referral to a pediatric surgeon or
urologist is indicated. If both testes are undescended, the
infant should be reviewed by a senior clinician. It needs
to be considered if the infant is a virilized female with
congenital adrenal hyperplasia.
Neonatal testicular torsion usually occurs before birth.
The testis is usually hard, black, and nontender and is
rarely salvageable because it has usually already under-
gone infarction. A pediatric surgeon should be consulted
urgently to decide if the testis can be salvaged. Many
pediatric urologists will perform surgical fixation of the
contralateral testis.
In girls, the clitoris and labia minora are prominent if
the infant is preterm but are covered by the labia majora
at full term. There may be a white vaginal discharge or
small amount of bleeding from maternal hormone with-
drawal. There may also be prolapse of a ring of vaginal
mucosa. These lesions resolve spontaneously.
The anus is also inspected to check that its position,
appearance, and tone are normal.
Passage of urine and meconium should be monitored
and recorded and occur within 24 hours of birth in most
term newborns.
LIMBS AND HANDS AND FEET
The limbs and hands and feet are examined for general
appearance, symmetry and posture. Observe for sponta-
neous movement of all four limbs. Observe for limb
reduction defects; the midpoint of an infant’s length is
just above the umbilicus.
Examination of the hands and feet will identify extra
digits (polydactyly), fused digits (syndactyly), or short-
ened digits (clinodactyly). Extra digits are usually con-
nected by a thin skin tag, but can be completely attached
and contain bone. Extra digits should be removed by a
plastic surgeon; many pediatricians tie off thin skin tags
with a silk thread, but this may leave a stump of skin.
Polydactyly may be familial, but it can also be caused by
a dysmorphic syndrome.
About 45% of infants with trisomy 21 have single
palmar creases. Unilateral single palmar transverse creases
are also observed in about 4% of normal infants, but
bilateral single palmar transverse creases occur in less
than 1% of normal Caucasian infants.

Brachial plexus lesions cause lack of active movement
of the affected limb; passive movement is not painful or
restricted. The most common is Erb palsy from an upper
root palsy (C5, C6, and sometimes C7). The arm is held
internally rotated and pronated in the “waiter’s tip” posi-
tion. Although most brachial plexus injuries resolve, a
significant proportion have not recovered fully at 6
months of age. Those that do not recover steadily during
the first 2 months of life or are severe should be seen by
a specialist because surgical repair may be indicated.
Accompanying respiratory symptoms may be secondary
to damage of phrenic nerve roots (see Chapter 30).
Clavicle fractures most often occur during difficult
delivery of the shoulders. A lump on the clavicle may be
palpated or observed or identified because the infant
keeps the arm immobile. It results from callus around a
fracture and will heal without treatment.
In positional talipes, the feet are turned inward from
intrauterine compression, especially if there was oligohy-
dramnios. The foot is of normal size and can be fully
abducted and dorsiflexed to the neutral position, and the
dorsal surface of the foot can be brought into contact
with the anterior lower leg by passive manipulation. If
this maneuver can be performed, no treatment is required;
the parents can be shown passive exercises. With talipes
equinovarus, the affected foot is shorter than normal. The
entire foot is inverted and supinated, and the forefoot is
adducted. The heel is rotated inward and in plantar
flexion. The position of the foot is fixed and cannot be
corrected completely. It may be secondary to oligohy-
dramnios during pregnancy, a feature of a malformation
syndrome, or of a neuromuscular disorder such as spina
bifida. The infant must be referred directly to a pediatric
orthopedic surgeon. Feet in the calcaneus valgus position
are usually maintaining the position of the feet in utero.
It should be possible to dorsiflex the foot to bring its
dorsal surface into contact with the anterior lower leg and
to achieve normal plantar flexion. If this can be achieved,
spontaneous resolution can be expected.
HIPS
The hips are checked for developmental dysplasia of the
hip (DDH). In this condition the hip may be
• dislocated, with the femoral head out of the acetabu-
lum, and irreducible, as identified on limited hip
adduction.
• dislocatable, with the femoral head in the acetabulum
at rest, but can be pushed out of the acetabulum, as
identified in the Barlow maneuver.
• dislocated, but reducible when it can be returned to the
acetabulum, as identified in the Ortolani maneuver.
Checking for DDH is best left toward the end of the
examination because the procedure is uncomfortable. To
successfully perform this examination, the infant must lie
supine on a flat, firm surface and be relaxed because
crying or kicking results in tightening of the muscles
around the hip.
On straightening the legs, look for any asymmetry of
the thigh or gluteal folds and apparent leg length shorten-
ing. The knees are then fully flexed and the hips flexed to
29  •  Physical Examination of the Newborn 397
90 degrees. It should be possible to fully adduct the hips
so that the upper legs lie almost flat on the examination
surface. Limitation of abduction, to less than 45 degrees
from the midline, may be due to a dislocated hip. These
features are usually evident from 3 months of age; at
birth, hip instability is the main feature.
Then the Barlow maneuver is performed. The pelvis is
stabilized with one hand. With the other hand the exam-
iner’s index and middle fingers are placed over the greater
trochanter and the thumb placed along the middle thigh.
The Barlow maneuver is performed to posteriorly dislo-
cate an unstable hip that is lying in the joint (see Chapter
107). The hip is flexed to 90 degrees and adducted, and
the femoral head is gently pushed downward. If the hip
is dislocatable, the femoral head will be pushed posteri-
orly out of the acetabulum and will move with a clunk.
Next the Ortolani maneuver is performed, when the
hip is checked to see if a dislocated hip can be returned
from a dislocated position back into the acetabulum (see
Ortolani test, Chapter 107). From the adducted position
the hip is abducted, and upward leverage is applied by
lifting the trochanter anteriorly. A dislocated hip will
return with a clunk into the acetabulum. This is best felt
but can sometimes also be observed. Little force is
required for these procedures; excessive force can damage
the hip. During the test clicks might be elicited but are
not of long-term consequence. Any newborn with DDH
should be checked for a neuromuscular disorder, and the
spine should be examined to exclude spina bifida.
BACK AND SPINE
The entire back and spine are inspected and palpated for
midline and other defects and for curvature of the spine.
Spina bifida is often diagnosed prenatally. Affected infants
must be referred to a neurosurgical service. A nevus, swell-
ing, or tuft of hair along the spine or middle of the skull
requires further evaluation because it might indicate an
underlying abnormality of the vertebrae, spinal cord, or
brain. Ultrasound or magnetic resonance imaging delin-
eates the anatomy. Sacrococcygeal pits are common and
harmless, whereas a dermal sinus above the natal clefts
should be investigated because it might extend into the
intraspinal space and place the infant at increased risk for
meningitis.22
POSTURE AND MUSCLE TONE
Observe the newborn’s posture and tone. Is the infant
moving all four limbs fully, and are they held in a normal,
flexed position? Do the limbs feel normal on passive
movements? Infants who were in an extended breech
position in utero sometimes maintain this posture for
some days after birth. The newborn is picked up under
the arms while supporting the head. A hypotonic newborn
will feel as though he or she is slipping through one’s
hands. Most newborns support their weight with their
feet. When an infant is turned prone, the infant can lift
his/her head to the horizontal and straighten the back.
Hypotonic newborns flop down like a rag doll.
A detailed neurologic examination is required only if
an abnormality has been detected. Some pediatricians
routinely elicit a Moro reflex, during which sudden head
extension causes symmetric extension followed by flexion
 398 PART 4  • THE DELIVERY ROOM
of all limbs. However, if normal movement of all four
limbs has been observed, no further information will be
gained from this procedure. Because infants appear to
find it unpleasant and parents are often alarmed and
upset by it, many pediatricians omit the Moro reflex test
from the routine examination.
Most newborns are found to be normal on routine
examination. The parents should be strongly reassured
that the examination was normal, and any concerns they
have about their newborn should be addressed fully.
Parents should be informed of any abnormalities detected
on examination. This may be unexpected bad news and
should be handled with sensitivity by giving a full expla-
nation, allowing time for discussion, and giving a time­
scale for referral.
Limitations of the
Routine Examination
Examination of a newborn in the delivery room and at a
routine examination will identify a number of problems,
many of which are transient, although some are perma-
nent and significant. However, some significant abnor-
malities will not be identified. Sometimes this is because
of inexperience of the examiner or the difficulty of per-
forming a satisfactory examination in an uncooperative
newborn (e.g., getting a good view of the eyes and red
reflex, hearing a heart murmur, or testing for DDH).
However, some significant abnormalities will not be iden-
tified because of the limitations of the examination.
Parents might become upset or angry when it becomes
evident at a later stage that their child has a significant
problem. They need to be made aware that not all abnor-
malities can be detected at the initial examination. This
situation also stresses the importance of clear documen-
tation of the routine examination for future reference.
Some of the major limitations of the clinical examination
are considered below.
IDENTIFICATION OF SYNDROMES
Some syndromes can be difficult or impossible to identify
in the immediate neonatal period but become apparent
as the child grows older.
JAUNDICE
Jaundice usually develops after 24 hours of age, unless
caused by hemolysis. Significant jaundice can develop at
several days of age even though the infant was not signifi-
cantly jaundiced only 1 or 2 days earlier (see Chapter 100).
EYE ABNORMALITIES
The outcome for vision following surgery for congenital
cataracts is improved if surgery is performed before 8
weeks of age.11 However, a survey in the United Kingdom
revealed that only 35% of congenital cataracts were identi-
fied on the routine examination.41 This demonstrates the
difficulty in early recognition of eye abnormalities during
the routine examination of the newborn. Deficiency in
training of health care professionals42 and the rarity of
serious eye conditions, occurring in only 0.5 per 1000 live
births, contribute to the low rate of diagnosis.8
CONGENITAL HEART DISEASE
Six to eight infants per 1000 live births have congenital
heart disease. In a retrospective review of infants with
congenital heart disease born between 1987 and 1994,
33% presented before the routine examination with
symptoms or noncardiac abnormalities, 30% had an
abnormal routine examination, and 37% had a normal
routine examination.56 At discharge from the hospital, a
cardiac diagnosis or referral was made in 43% of infants
with congenital heart disease, but one third of the remain-
ing infants presented with symptoms or died from their
cardiac condition by 6 weeks of age. This review high-
lights the limitations of the routine examination in iden-
tifying significant structural heart disease.
The first is that the newborn examination may be
normal even when the infant has a significant or even
lethal structural heart lesion. At the time of the newborn
examination, the pressure in the right side of the heart is
still relatively high, and the ductus arteriosus may still be
patent. Infants with a ventricular septal defect (the most
common congenital heart lesion) or other heart lesions
might not have a heart murmur at the routine examina-
tion because the pressure difference between the left and
right sides of the heart will be insufficient to generate
turbulent flow at this stage.
A second reason is that infants with duct-dependent
lesions can present clinically with heart failure, shock,
cyanosis, or death just days or weeks after a normal
routine examination, when the ductus arteriosus closes.
Femoral pulses may be palpable at the initial examina-
tion because of blood flow through the ductus arteriosus.
An additional limitation is that a heart murmur may
be heard, but because most are innocent, those from
significant heart lesions are not always identified. Prena-
tal diagnosis of some severe heart lesions and the increas-
ing availability of echocardiography should reduce, but
will not eliminate, failure to identify structural heart
lesions before discharge from the hospital.
Pulse oximetry screening has been advocated to assist
the detection of ductal dependent lesions.25,36,50 The AAP30
recommends screening. It considers that infants will
require further assessment if any of the following criteria
have not been met:
1. Any oxygen saturation (Spo2) is less than 90%
2. Oxygen saturation is less than 95% in both extremities
on three measures, each separated by 1 hour.
3. There is a less than 3% absolute difference in oxygen
saturation between the right hand and foot on 3 mea-
sures, each separated by 1 hour.
DEVELOPMENTAL DYSPLASIA OF THE HIP
As a screening test, clinical examination for DDH is prob-
lematic.13 Ideally, all affected infants should be identified
in the neonatal period because early treatment prevents
or reduces the need for surgery. In practice, a significant
fraction of infants who subsequently require surgery are
not identified in the neonatal period. A survey from the
United Kingdom suggested that the operative rate, 0.7 per
1000 live births, has remained unchanged since screening
 29  •  Physical Examination of the Newborn 399

TABLE 29-2 Absolute Risk for a Positive Physical

Refer to orthopedist
Result on Routine Examination exam
Do not use triple diapers
positive
of the Newborn Hip
Newborn Absolute Risk for a Positive Physical
Characteristics Examination per 1000 Newborns Follow-up examination
exam in-
at 2 weeks
conclusive
Overall
All newborns 11.5
Boys 4.1 Female or Recheck at
Family history + male periodic intervals
Girls 19
Positive Family History
Physical Optional imaging:
Boys 6.4
exam Family history + female • Ultrasound <5
Girls 32 normal or months old
Breech Presentation but risk Breech + male • X-ray >4 months
Boys 29 factors old
Girls 133
Imaging
Breech + female
Data from American Academy of Pediatrics. Clinical practice guideline: early (see above)
detection of developmental dysplasia of the hip. Pediatrics. 2000;105:896.
Figure 29-2  Management of newborn infants with physical examina-
tion that is positive for developmental dysplasia of hip, inconclusive, or
normal with risk factors. (From American Academy of Pediatrics. Clinical
practice guideline: early detection of developmental dysplasia of the hip.
was introduced.24 Another study from South Australia Pediatrics. 2000;105:896. Copyright 2000 by the AAP.)
found a lower operative rate, at 0.45 per 1000 births, but
still only 56% of these infants were identified at the initial
clinical examination.12 However, DDH was diagnosed in
7.7 per 1000 live births, indicating that the hips of most
infants with an abnormal neonatal hip examination are
normal.
Health Promotion
An examiner might fail to identify DDH at the initial The routine examination is an opportunity to promote
examination because the examiner is inexperienced or preventive health care.
because the examination is suboptimal when the infant
is not relaxed. In some infants with a flat acetabular PREVENTION OF SUDDEN INFANT
shelf, the clinical examination may be normal in the DEATH SYNDROME
neonatal period, but the dysplasia progresses with age.44 All parents should be advised that infants should sleep
Also, the irreducible dislocated hip is easily missed on on their backs and that overheating and parental smoking
examination. are risk factors. Also, bed sharing and co-sleeping should
The risk for DDH is increased in female infants, in be avoided. Attention to preventive measures has mark-
those with a positive family history, and in infants with edly reduced the incidence of sudden infant death syn-
a breech presentation. The absolute risk for a positive drome in many countries.
result on routine examination of the newborn is shown
in Table 29-2. The risk is also increased in infants with a PROMOTION OF BREASTFEEDING
neuromuscular disorder. Mothers should be encouraged in and assisted with breast
Two strategies can improve the detection rate of DDH feeding.
in newborn infants. The hip examination can be per-
formed by pediatric orthopedists, or imaging of the hips HEARING, VISION, AND OTHER SCREENING
can be performed. Ultrasound will identify DDH, includ- Universal hearing screening should be performed per
ing a shallow acetabular shelf. However, ultrasound has hospital protocol. Children with increased risk for deaf-
a high false-positive rate, and it is only helpful in the first ness (e.g., family history, malformations of the ear includ-
5 months of life. Alternatively, a hip radiograph will iden- ing skin tags and pits)31 must receive early hearing testing.
tify DDH but only after 4 months of age. The imaging Similarly, infants at increased risk for vision loss should
can be performed on all infants or only on high-risk be referred to an ophthalmologist. Parents should be
infants or on those with a positive examination. given advice about early detection of hearing and vision
All these options have been considered in detail in the loss. Other screening tests including biochemical tests
AAP guidelines on early detection of DDH.3 They recom- should be performed according to local guidelines.
mend that the clinical procedure be performed by a prop-
erly trained health care provider. Management options DISCHARGE PLANNING
for infants with a positive or inconclusive test and for The routine examination is an opportunity to reinforce
those with a risk factor are summarized in Figure 29-2. the importance of immunization. (See Appendix C.)
Both the AAP and the European Society of Paediatric The newborn period is a good opportunity to provide
Radiology recommend risk factor–based selective ultra- advice on the need for car seats for infants. The AAP rec-
sound screening. ommends that preterm infants be tested for desaturation/
 400 PART 4  • THE DELIVERY ROOM
respiratory obstruction in a car seat prior to discharge. It
is important to remember that an infant can pass a car
seat challenge, though, and still have desaturations in the
car seat at another time. Therefore, neonates should be
observed while in the car seat and only remain in the car
seat for the duration of the trip.
With shortened stay of healthy newborns in the hos-
pital, performing a second full routine examination at
early (<48 hours) discharge is of limited value, in identi-
fying additional abnormalities.23,37 More important, the
initial routine examination must be performed by a prop-
erly trained health care professional. For example,
advanced neonatal nurse practitioners were found to be
more effective than trainee pediatricians in detecting
abnormalities.32
Criteria that must be met for the early (<48 hours)
discharge of term infants have been published.14 Before
any infant is discharged, the health care provider should
check that the infant has fed satisfactorily on at least two
successive occasions, is not jaundiced or the bilirubin has
been measured and a follow-up plan is in place, is breath-
ing normally, and has urinated and passed stool. The
clinician must also ensure that the mother is able to care
adequately for her infant and that the infant is going to
a suitable environment. Relevant follow-up care for the
infant should also be in place.
Assessment of Gestational Age
Formal assessment of gestational age is unnecessary for
the routine newborn examination. The best guide to an
infant’s gestational age is an early antenatal ultrasound
evaluation combined with information about the moth-
er’s last menstrual period. An evaluation of the clinical
methods of assessing gestational age showed that clinical
methods had 95% confidence intervals of 17 days,
whereas the antenatal ultrasound had 95% confidence
intervals of less than 7 days.55 Clinical assessment is most
important for infants whose gestational age is unknown
or discrepant with their growth.
Four methods can be employed to assess gestational
age: physical criteria,19,39 neurologic examination,4 com-
bined physical and neurologic examination,6,18 and
examination of the lens of the eye.28 Physical criteria are
used to establish gestational age because they progress in
an orderly fashion with increasing gestation. The assess-
ment of gestational age using neurologic criteria involves
the assessment of posture, passive and active tone, reflexes,
and righting reaction.4
Gestational age can be assessed most accurately by
combining the physical criteria and the neurologic assess-
ment. Dubowitz and Dubowitz described and developed
such a combined scoring system.17 Its disadvantage is that
it involves assessing 11 physical criteria and 10 neurologic
findings. Although the physical criteria allow clear dis-
tinction of infants with gestational ages older than 34
weeks, neurologic criteria are required to differentiate
infants between 26 and 34 weeks because the physical
changes are less evident. Ballard and colleagues abbrevi-
ated the Dubowitz scoring system to include 6 neurologic
and 6 physical criteria to shorten the time taken. The
revised Ballard examination (Figure 29-3) includes assess-
BOX 29-4 NEUROLOGIC EVALUATION
General appearance
Level of consciousness
Mechanical signs: head, spine, extremities
Cranial nerves
Motor: strength, tone, movements
Deep tendon reflexes
Primitive reflexes: Moro, grasp, suck, root
Autonomic: heart rate pattern, respiratory pattern, bladder
function, bowel function
ment for extremely premature infants.7 Regardless of
the method used, the assessment of gestational age
using physical and neurologic criteria is accurate only to
±2 weeks, with a tendency toward overestimation in
extremely premature infants.
Neurologic Assessments
A detailed neurologic assessment is not required for
routine examination of the newborn. It is reserved for
infants with a neurologic problem. The infant’s neuro-
logic evaluation combines elements of the standard neu-
rologic examination and a developmental assessment of
gestational age (Box 29-4). It also highlights the marked
effect of gestational age on neurologic development. With
experience, the examiner can accomplish a standard neu-
rologic evaluation with minimal or no discomfort to the
infant, an important goal, especially in fragile premature
infants.
LEVEL OF ALERTNESS
Newborn infants’ states of alertness at term are usually
categorized40 as follows:
State 1 (deep or quiet sleep): eyes closed, regular res-
piration, no movements
State 2 (light or rapid eye movement sleep): eyes
closed, irregular respiration, no gross movements
State 3 (awake, drowsy): eyes open, regular respiration,
no gross movements
State 4 (alert): eyes open, gross movements, no crying
State 5 (crying): eyes open or closed, crying
Healthy term newborns cycle between states of alert-
ness, and the different states of alertness can be identified.
In the preterm, there are cycles of activity and sleep, of
regular and irregular respiration, and of the absence or
presence of eye movements, but they tend to occur inde-
pendently rather than in distinct states of alertness. For
optimal neurologic examination, a term infant should be
alert and not crying (state 3). An infant who is persis-
tently in states 1 and 2 is likely to be abnormally
lethargic (e.g., from hypoxic-ischemic encephalopathy);
if persistently in state 5, to be abnormally hyperexcitable
(e.g., from drug withdrawal or hypoxic-ischemic
encephalopathy). The cry may also be abnormal (e.g.,
high-pitched from cerebral irritation, incessant from drug
withdrawal).
 29  •  Physical Examination of the Newborn 401

NEUROMUSCULAR MATURITY

1 0 1 2 3 4 5

Posture

Square
window
(wrist) 90° 90° 60° 45° 30° 0°

Arm recoil
180° 140°–180° 110°–140° 90°–110° 90°

Popliteal
angle
180° 160° 140° 120° 100° 90° 90°

Scarf sign

Heel to ear

PHYSICAL MATURITY Maturity Rating

Superficial Parchment, Score Weeks
Sticky, Gelatinous Cracking Leathery,
Smooth pink, peeling deep
Skin friable, red, pale areas, cracked,
visible veins and/or rash, cracking,
transparent translucent rare veins wrinkled –10 20
few veins no vessels

–5 22
Bald Mostly
Lanugo None Sparse Abundant Thinning
areas bald
0 24

Heel–toe 5 26
50 mm Anterior Creases
Plantar Faint Creases
no transverse over
surface 40–50 mm:1 red marks ant. 2/3
crease crease only entire sole 10 28
40 mm:2

Stippled Raised Full areola 15 30

Barely Flat areola,
Breast Imperceptible areola areola 5–10 mm
perceptible no bud
1–2 mm bud 3–4 mm bud bud 20 32

Lids fused Well-curved Formed 25 34

Lids open; Sl. curved Thick
pinna; and firm
Eye/ear pinna flat, pinna; soft; cartilage,
loosely: 1 soft but instant
stays folded slow recoil ear stiff 30 36
tightly: 2 ready recoil recoil
Testes 35 38
Scrotum Scrotum Testes in Testes Testes
Genitals, down;
flat, empty; upper canal; descending; pendulous;
male good
smooth faint rugae rare rugae few rugae deep rugae 40 40
rugae
Prominent Prominent Majora Majora Majora 45 42
Clitoris
Genitals, clitoris, clitoris, and minora large, cover
prominent,
female small enlarging equally minora clitoris
labia flat 50 44
labia minora minora prominent small and minora

Figure 29-3  Assessment of gestational age using the revised Ballard method. (From Ballard JL, et al. New Ballard Score, expanded to include
extremely premature infants. J Pediatr. 1991;119:417.)
 402 PART 4  • THE DELIVERY ROOM

efferent limb, specifically the autonomic component of

INSPECTION
The physical component of the neurologic examination
includes visual inspection and palpation of the head,
spine, and extremities. The entire body is observed for
visibly apparent congenital anomalies, birthmarks, or
bruises. The head and spine are palpated to ascertain the
presence of deformities, the position of the skull sutures,
and the size and shape of the fontanelles.
The size and shape of the head provide important
information regarding the occurrence of an insult to the
fetal brain. When fetal brain growth has been compro-
mised, head size is decreased relative to body length. A
large head at birth may be caused by macrocephaly, but
if the sutures are widely spaced it is likely to be from
raised intracranial pressure, for example from congenital
obstructive hydrocephalus. Postnatally, a rapidly expand-
ing head with widely separated sutures indicates raised
intracranial pressure from cerebral edema, epidural or
subdural hemorrhage, or acquired, progressive hydro-
cephalus, which may result from intraventricular hemor-
rhage in a premature infant.
CRANIAL NERVES
Despite the inability of the examiner to communicate
verbally with the infant, the functions of most of the 12
cranial nerves can be determined in the newborn infant
(Table 29-3). Indeed, cranial nerve evaluations can be
conducted even in premature infants near the lower limit
of viability.
Cranial nerve I (olfactory) is typically not examined,
given its rare involvement by a disease process and the
infant’s difficulty to provide an appropriate response.
Vision (cranial nerve II [optic]) is assessed both sub-
jectively and objectively. Healthy full-term and older pre-
mature infants fixate on and track the examiner’s face, a
ball of red wool, a card with concentric black and white
circles presented 20 to 30 cm from the infant’s face, or
other optokinetic stimuli. Horizontal eye movements are
more easily elicited than are vertical eye movements.
Visual orientation and tracking do not require a func-
tional occipital cortex.
The pupillary light reflex also assesses optic nerve
integrity. It is a subcortical function and requires an intact
cranial nerve III (oculomotor). Those nerves that subserve
extraocular movements include cranial nerves III, IV, and
VI (oculomotor, trochlear, and abducens, respectively).
Eye movements in all directions of gaze occur sponta-
neously or can be induced with oculocephalic maneuvers
(doll’s eye reflex). The doll’s eye reflex is typically elicited
with the infant in the supine position by simply turning
the head from one side to the other, whereupon the eyes
will deviate in the opposite direction. Vertical eye move-
ments can be ascertained by flexing or extending the
head. Alternatively, the infant can be held vertically and
rotated clockwise or counterclockwise. The eyes will
deviate in the direction opposite the spin. Rotation in the
axial plane induces vertical eye movements.
The eyes are observed for the presence or absence of
ptosis. Unilateral or bilateral ptosis occurs as a conse-
quence of dysfunction either of cranial nerve III, which
innervates the palpebral muscle (upper eyelid only), or
of ascending sympathetic nerves, which course through
the neck to innervate the tarsal plates (both eyelids).
Oculomotor nerve dysfunction producing ptosis is often
associated with ipsilateral pupil dilation, whereas sympa-
thetic nerve dysfunction producing ptosis is associated
with ipsilateral pupil constriction (Horner syndrome).
Cranial nerve V (trigeminal) has both sensory and
motor functions. Corneal and facial sensations can be
tested if indicated with a wisp of cotton applied to each
cornea to elicit a rapid blink or to the nares to elicit a
facial grimace. The motor component of cranial nerve V
subserves jaw (mandibular) opening and closure, which
are best tested by observing the infant’s sucking ability. A
persistently open mandible suggests trigeminal motor
paralysis.
Cranial nerve VII (facial) controls all superficial facial
movements, including eyelid closure, and taste, which is
rarely tested. Facial movements occur spontaneously and
are a component of the sucking and rooting reflexes.
Tickling the nares with a wisp of cotton should induce
facial grimacing, whereupon either unilateral or bilateral
facial paresis will become apparent.
Cranial nerve VIII subserves both hearing (auditory)
and vestibular functions (see Chapter 68). Hearing is
tested either subjectively or objectively, the latter by the

TABLE 29-3 Cranial Nerve Examination

Nerve Name Function Evaluation Method
I Olfactory (and tract) Smell Not tested
II Optic (and retina) Visual acuity and fields Face or red woolen ball or black and white concentric circles
III Oculomotor response, Extraocular movements; Observation of tracking; doll’s eye reflex
lid elevation pupillary reflex
IV Trochlear Extraocular movements Observation of tracking; doll’s eye reflex
V Trigeminal Mastication; facial sensation Corneal and suck reflexes; nasal stimulation
VI Abducens Extraocular movements Observation of tracking; doll’s eye reflex
VII Facial Facial expression; taste Nasal stimulation; corneal and sucking reflexes
VIII Auditory Hearing; spatial orientation Sounds and behavioral response; doll’s eye reflex
IX Glossopharyngeal Swallowing; vocalization Sucking and swallowing reflex; gag reflex; quality of cry
X Vagus Swallowing; vocalization Sucking and swallowing reflex; gag reflex; quality of cry
XI Spinal accessory Head and shoulder movement Observation
XII Hypoglossal Tongue movement Observation; atrophy; fasciculations

evoked otoacoustic emissions or automated auditory
brainstem response as used in newborn hearing screen-
ing. Subjective testing at crib side is typically accom-
plished with the use of a bell presented to either ear,
observing for increased alertness and possibly an orient-
ing response. Initially, the sound of the bell should be of
low intensity, increasing in loudness until a response is
obtained. The vestibular component of cranial nerve VIII
is not specifically tested other than through its interaction
with brainstem pathways that subserve reflex eye
movements.
The functions of cranial nerves IX and X (glossopha-
ryngeal and vagus, respectively) are combined to control
swallowing function and vocalization. Voluntary motor
functions are tested by observing the infant’s sucking and
swallowing abilities. In addition, the position and move-
ment of the soft palate are observed with a flashlight.
Decreased movement of the soft palate or absent gag
reflex suggests dysfunction of cranial nerves IX or X.
During the oral evaluation, cranial nerve XII (hypoglos-
sal) function is tested by examining the tongue, noting
its position, movement, and bulk. The presence of tongue
fasciculations is noted, which consist of random, worm-
like movements best appreciated along the lateral tongue
margins and which may be observed in spinal muscular
atrophy. Atrophy of the tongue is observed as scalloping
of its margins. Tongue fasciculations must be distin-
guished from tremors, the latter consisting of normal
rhythmic movements of the structure accentuated by its
protrusion during crying.
Cranial nerve XI (spinal accessory) is a pure motor
nerve. It innervates the sternocleidomastoid muscle of the
neck to produce either lateral or anterior flexion of the
head, depending on contraction of one or both muscles.
The nerve also innervates the trapezius muscle of the
shoulder to produce shoulder elevation. These functions
typically are tested by simple observation of head and
shoulder movements.
MOTOR FUNCTION
The motor system examination includes tests of skeletal
muscle posture, tone, and movement. During the initial
period of general observation, the position of the extrem-
ities is noted for flexion, extension, or neutral postures.
Healthy, full-term infants typically exhibit flexion of the
arms at the elbows and of the legs at the knees (Figure
29-4). Fisting of the hands, including adduction and
infolding of the thumbs, is usual. However, there is varied
movement of the fingers, including moving the thumb
away from the palm. This contrasts with the persistently
adducted thumb (cortical thumb) in a tightly fisted hand,
with few finger movements seen in infants with neuro-
logical damage.
Limb position and posturing are relatively symmetric,
although the infant manifests spontaneous movements
that are often asymmetric and jerky. Limb posture (flexion
or extension) also is influenced by the position of the
head. If the head is turned to one side, there is often
extension of the ipsilateral arm and leg and flexion of the
contralateral extremities (asymmetric tonic neck reflex).
While prone, the full-term infant maintains a flexed
29  •  Physical Examination of the Newborn 403
Figure 29-4  Full-term newborn at rest. Note that the posture of
the arms and legs is slightly asymmetric. The arms are partially flexed,
whereas the legs are flexed at the hips and knees.
posture of the arms and legs, with resultant elevation of
the pelvis as well as hip and knee flexion.48
Tone is characteristic of skeletal muscle because of an
intrinsic resistance to stretch that can be either active or
passive. Muscle at rest resides in a state of partial relax-
ation, and energy is required for its full contraction. Elon-
gation requires further muscle relaxation and concurrent
contraction of the opposing or antagonistic muscle. Thus
normal muscle tone depends on a sophisticated interac-
tion between agonistic and antagonistic muscles, which
are influenced by innervating peripheral nerves (sensory
and motor) as well as by the central nervous system.
Given the strategic role played by skeletal muscle in neu-
rologic function, it is not surprising that alterations in
muscle tone represent the clinical hallmark of a variety
of neurologic disease processes.
The assessment of muscle tone includes observation of
the infant’s posture and movement as well as the produc-
tion of an active or passive range of motion. If feasible,
the infant should be suspended in the horizontal plane
and the attitude and posture of the head, trunk, and
extremities observed. Thereafter, the infant is held in the
vertical plane to ascertain the extent and symmetry of
flexor tone of the extremities. While the infant lies supine,
the upper and lower extremities are extended and flexed
to ascertain the presence and extent of resistance. Head
control can be determined by lifting the supine infant
from the surface by the shoulders.
Increased resistance to passive movement indicates
hypertonicity (rigidity, spasticity), whereas reduced resis-
tance and unrestricted movement indicate hypotonicity.
In this regard, the neurologic component of the Dubow-
itz and Ballard scoring systems for determining gesta-
tional age largely reflects the maturation of muscle tone
in premature infants, from the weak, extended tone of
very premature infants to the active, flexed tone of the
term infant. Infants who are hypertonic often exhibit an
opisthotonic posture, in conjunction with obligate exten-
sion of the back and neck when suspended in either the
vertical or horizontal plane. Scissoring of the legs might
be evident. In contrast, the hypotonic infant, when held
in the vertical plane, tends to slide through the examiner’s
 404 PART 4  • THE DELIVERY ROOM
hands. In the horizontal plane, the infant drapes over the
examiner’s arms.48
Hypotonia should not be equated with weakness,
which is a reduction in muscle strength or power, whether
it is partial (paresis) or complete (paraplegia) paralysis.
Muscle weakness is ascertained through observation of
spontaneous or sensation-induced movements of the
extremities. Although muscle hypotonia and weakness
often occur together, hypotonia can be seen in the absence
of weakness (e.g., cerebellar dysfunction), and weakness
can occur when muscle tone is normal or even increased
(e.g., spastic paralysis). Indeed, hypotonia combined
with weakness typically denotes an intrinsic disease of the
peripheral nervous system (nerve or muscle), whereas
hypotonia with a preservation of muscle strength denotes
a disturbance of the brain or spinal cord.
DEEP TENDON REFLEXES
Deep tendon reflexes are elicited as they are for older
children and adults. The limb should be positioned in
partial flexion and the appropriate tendon tapped with
an infant reflex hammer. The head should be maintained
in the neutral position to prevent inducing an asymmetric
tonic neck response, which produces asymmetric reflex
activity. Typically, upper extremity deep tendon reflexes
are more difficult to elicit than lower extremity reflexes.
In newborn infants, the Achilles tendon is not tapped
directly; the reflex is elicited by tapping a thumb posi-
tioned on the plantar surface of the partially dorsiflexed
foot.
Interpretation of the results of testing deep tendon
reflexes is more problematic in neonates than older chil-
dren but may help to confirm an asymmetric lesion.
Ankle clonus is common and usually normal in the neo-
natal period. Eliciting plantar responses is not worth-
while because their interpretation presents problems.29,48
At this age, the plantar response is usually said to be
extensor, but it mainly depends on the strength of the
stimulus applied; a gentle stimulus will often induce a
flexor response.
DEVELOPMENTAL REFLEXES
The most frequently elicited primitive or developmental
reflexes include the rooting, sucking, grasp, and Moro
responses. These reflexes are fully developed and strong
in the healthy, full-term newborn and typically disappear
in the months to follow. Their persistence beyond the
TABLE 29-4 Neurologic Maturation of the Fetus and Newborn
Function 26 Weeks
Resting posture Flexion of arms
Flexion or extension of legs
Arousal Unable to maintain
Rooting Absent
Sucking Absent
Pupillary reflex Absent
Traction No response
Moro No response
Withdrawal Absent
From Fenichel GM. Neonatal neurology. 2nd ed. New York: Churchill Livingstone; 1985.
anticipated age of disappearance is an indicator of under-
lying central nervous system dysfunction. Other, less
commonly induced primitive reflexes include the crossed
extension, placing, and stepping reactions, all of which
make their appearance by 36 to 38 weeks’ gestational age.
BEHAVIORAL EVALUATION
Neonatal behavioral evaluation (e.g., the Neonatal Behav-
ioral Assessment Scale) has been developed to assess
higher cortical function.10 It includes 27 behavioral
responses and 20 reflex responses and requires special
training and is time consuming. It includes assessing con-
solability and habituation. For consolability, the crying
infant’s response to different techniques of calming is
assessed. It takes longer to console infants with brain
injury than normal infants. Full-term newborns exhibit
both visual and auditory habituation, which is elicited
with a bright light and loud bell, respectively. The eyes
are sequentially exposed to a bright light at a frequency
of about 1 per second; the normal response is an initial
strong blink followed by extinction after 3 to 5 exposures.
A similar blink response occurs with repetitive auditory
stimulations. Habituation is an indicator of cortical
inhibitory function. It demonstrates the ability to learn
diminished responses to repetitive stimuli. Failure to
respond initially to the sensory stimulation or a lack of
habituation suggests cortical dysfunction.
THE PREMATURE INFANT
The neurologic signs in premature infants differ markedly
with gestational age. In normal premature newborn
infants, pupil responses to light are present, although
sluggish, between 28 and 32 weeks’ gestation and seldom
present before 28 weeks (Table 29-4). Oculocephalic
(doll’s eye) reflexes are complete and even exaggerated in
infants as immature as 24 to 25 weeks. Paradoxically, the
oculovestibular (caloric) reflex is incomplete before 28 to
30 weeks, with reduced medial displacement of the eye
contralateral to the ear canal stimulated with cold water
(intranuclear ophthalmoplegia). Corneal and gag reflexes
are present in even the small premature infant, as is facial
grimacing to nasal stimulation.
The newborn’s responsiveness to the environment
depends not only on the state of health but also on the
gestational age. Infants of 25 to 30 weeks’ gestation
typically show intermittent arousal with external stimula-
tion, and their waking periods are relatively short when
30 Weeks 34 Weeks 38 Weeks
Flexion of arms Flexion of all limbs Flexion of all limbs
Flexion or extension of legs
Maintain briefly Remain awake Remain awake
Long latency Present Present
Long latency Weak Vigorous
Variable Present Present
No response Head lag Mild head lag
Extension; no adduction Adduction variable Complete
Withdrawal only Crossed extension Crossed extension

compared with full-term infants. By 31 to 32 weeks’ gesta-
tion the premature infant exhibits reasonable alertness
during wakeful stages. By term, the infant remains alert
for prolonged periods during wakefulness and readily
responds to visual, auditory, and tactile stimulation.
A notable difference in the neurologic status of the
premature and full-term neonate is that of muscle tone.
As indicated by the Dubowitz and Ballard scoring systems
for gestational age, the more premature the infant at
birth, the greater the muscle hypotonicity (see Figure
29-3). The hypotonicity is especially apparent when mea-
suring the popliteal and heel-to-ear angles and when
executing the scarf sign. The maturational changes in
muscle tone must be taken into account when evaluating
newborns of varying gestational ages.
At and before 28 weeks’ gestational age, a premature
newborn is extremely hypotonic. When held in vertical
suspension, the infant does not extend the head, trunk,
or extremities. The maturational change from hypotonia
of the small premature infant to the predominantly
flexion posture of the full-term infant is manifest first in
the legs and later in the arms and head. By 34 gestational
weeks, the infant lies in a froglike position while supine;
the legs are flexed at the hips and knees, but the arms
remain extended and relatively hypotonic.
Developmental reflexes appear at specific ages of gesta-
tion to become fully developed and strong in the healthy
full-term infant (see Table 29-4). The sucking and rooting
reflexes do not develop until 33 to 36 weeks’ gestational
age. The palmar and plantar grasp responses become
apparent at about 28 weeks and are strong by 36 weeks.
The Moro reflex makes its appearance at 24 to 26 weeks
and evolves through 38 weeks, at which age the entire
abduction-adduction response is present.
INTERPRETATION OF THE
NEUROLOGIC EXAMINATION
Interpreting the findings from a neurologic examination
of a newborn infant is difficult, because the interpretation
is markedly affected by the infant’s age and gestational
age and the infant’s level of alertness. The neurologic
examination has been widely studied as a predictor of
subsequent neurodevelopmental problems, but it is
limited because many abnormal neurologic signs may
be transient and because significant neurological abnor-
malities may take weeks or months to become manifest.
Serial examinations are more informative than a single
examination.
However, in spite of its limitations in specificity and in
predicting prognosis, the neurologic examination is useful
when considered in conjunction with a history suggestive
of a neurologic problem and neuroimaging. Neurologic
abnormalities that are persistent and marked or asymmet-
ric place the infant at increased risk of neurodevelopmen-
tal problems. The neurologic examination may be helpful
in delineating the extent of neurologic deficits (e.g., after
hypoxic-ischemic encephalopathy), which also informs
management planning. Multiple neurologic abnormali-
ties are more likely to be more significant than isolated
abnormalities. Preterm infants who have significant
abnormalities on neurologic examination at term are at
29  •  Physical Examination of the Newborn 405
higher risk of neurodevelopmental problems than those
with a normal examination.
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