The Comprehensive Infant Exam

The newborn exam is important in establishing a baby's baseline health status as they enter the world. 

Newborn screening aims to detect potentially fatal or disabling congenital anomalies that require early intervention.

Within 1 to 5 minutes of birth, an Apgar score determines how well the baby has tolerated the birthing process. It is calculated by scoring the heart rate, respiratory effort, muscle tone, skin color, and reflex irritability. These objective signs can receive 0, 1, or 2 points.

If the baby is stable after birth, it is recommended to wait to examine them further until they have spent at least 1 hour of skin-to-skin time with their mother to promote bonding and establish breastfeeding. This also helps to regulate their heart rate and breathing.

If the gestational age of the baby is unknown, a Ballard score can be used for estimation based on the neuro-muscular and physical maturity.

A complete physical exam starts with observing the baby's physical activity, muscle tone, posture, and level of consciousness. Measurements of weight, length, and head circumference are taken. The baby's skin color, texture, and nails are noted, and the presence of any rashes is ruled out. 

Next, the eyes, nose, and ears are examined. The eyes are particularly checked for red reflex. The mouth palate, tongue, and throat are assessed for clefts and central cyanosis. 

Visual inspection of the infant's mouth can identify tongue-tie, also known as ankyloglossia, in which a short and thick band of tissue tethers the bottom of the tongue's tip to the floor of the mouth.

Polydactyly, the presence of one or more extra fingers may be an isolated abnormality, but warrants investigation for other congenital abnormalities.

The head and neck exam include an evaluation of the shape of the head, the fontanelles on the baby's skull, and the clavicles in the upper chest. 

During a chest exam, the practitioner listens to heart sounds, palpates femoral pulses, observes breathing patterns, and the sounds the baby makes while breathing. 

After that, the abdomen is checked for the presence of any masses or organomegaly.

The genitals and anus are examined to ensure that the baby has open passages for urine and stool. In girls, signs of ambiguous genitalia include clitoromegaly and fused labia, while in boys, it includes bilateral undescended testes, a micropenis, or a bifid scrotum.

Finally, the neurologic examination should assess the primitive reflexes, including the sucking, grasp, rooting, and Moro reflexes. 

The sucking reflex can be assessed by touching the baby's mouth roof, and the baby should start sucking in response. In grasp reflex, the baby's fingers or toes should reflexively wrap around the object placed on the palmar surface of the baby's hands or feet.

The rooting reflex can be elicited by touching or stroking the corner of the baby's mouth. The baby will turn their head, and mouth toward the side that is touched. The Moro reflex can happen spontaneously when the baby is startled.

The newborn exam is also a great opportunity to teach the family about important anticipatory guidance. Discuss hand hygiene, umbilical cord care, and aspects of safe sleep – placing the baby on their back, swaddled in a blanket, without additional blankets or stuffed animals in the sleeping space.

In this video, we demonstrate the clinical newborn exam and discuss how to progress through the steps. 

To begin, the medical provider should interact with the parents and seek permission to examine their child.

Before the exam, make sure that all the necessary equipment, including a stethoscope and ophthalmoscope, are available and are properly disinfected. Use a neonatal or pediatric-sized stethoscope, if available.

Next, ensure that a safe, flat surface is available for the exam and that the child is not left unsupervised or able to fall off the surface.

Keep a clean baby blanket ready to cover the newborn during parts of the exam that do not require exposure.

Before starting the exam, wash your hands thoroughly to prevent transmission of infection.

Wear gloves either for the entire newborn exam or only when the baby is still covered in vernix or yet to bathe. Always use gloves for examining the mouth, umbilical stump, and diaper area, as newborns may void and stool during the exam.

Before touching the baby, observe the baby's general appearance and overall activity.

Next, note the color of the skin, symmetry of their facial movements, degree of physical activity, and any rooting or sucking behavior as signs of hunger. Also, pay attention to any signs of breathing distress – including flaring of the nostrils or retractions of the skin under the ribcage.

Throughout the entire exam, examine the baby's skin for any rashes, hemangiomas, skin tags, or discoloration such as pallor or jaundice.

Study the parent-child interaction by observing activities such as breastfeeding or cuddling with a parent.

To determine if the baby has grown appropriately in-utero, first weigh the baby. The average weight of a newborn should be around 7 pounds.

 Newborns may be greater than the 90th percentile of expected weight for gestational age if the mother has diabetes. Infections such as HIV or Rubella, or drug exposure during pregnancy can cause the baby to be small for gestational age and weigh in at less than the 10^th percentile of expected weight.

Next, measure the length of the baby with a measuring tape from the top of the head to the bottom of one of the heels. The average length at birth for a full-term baby is about 20 inches.

Then, measure the head circumference of the baby by wrapping a flexible measuring tape around the head just above the eyebrows and ears, and around the back where his head slopes up prominently from his neck.

Small head circumference can be a consequence of different factors, including cytomegalovirus or Zika virus infection in the first trimester, and can also be associated with hearing loss in the newborn.

A Ballard score is used for estimating the gestational maturity of babies who have an unknown gestational age at the time of delivery.

The pediatrician usually performs the baby's first physical exam within 24 hours of birth. If there is uncertainty about the baby's gestational age, the physician will assess six physical components and then six neuromuscular components to estimate the baby's gestational maturity. Each physical and neuromuscular component is given a score from -1 to 5, and then gestational age is estimated after calculating the total score.

Prioritize the heart and lung auscultation if the baby is quiet, and perform this wherever the baby happens to be, for example, in the parent's arms.

Undress the baby except for the diaper, or ask a parent to help you do this.

Wrap the baby in a blanket to help them stay quiet and warm, pulling the blanket down just enough to place a stethoscope directly on the baby's chest.

Start by listening over the heart in the aortic, pulmonary, mitral, and tricuspid areas with both the diaphragm and the bell of the stethoscope. This will help to appreciate both high and low-pitched murmurs, if present.

Heart arrhythmias are uncommon in newborns, but approximately 80% of newborns have a heart murmur in the first week of life, typically caused by a patent ductus arteriosus or PDA. The PDA is a small blood vessel present in-utero which connects the pulmonary artery to the aorta, allowing blood to bypass the lungs. The PDA typically closes within the first few weeks after birth.

Next, screen for congenital coarctation of the aorta, which can compromise blood flow to the lower extremities. To assess this, place the fingertips of the 2nd and 3rd fingers of both hands lightly over the anterior hip crease and check for the equal, symmetric pulsation of the femoral arteries just under the skin.

Then, move one hand off the femoral pulse to the right brachial pulse by using your fingers to lightly palpate medial to the biceps tendon, noting the pulsation of the right brachial artery while simultaneously palpating the femoral pulse. These pulses should feel equal and symmetric. A weak or delayed femoral pulse relative to the brachial pulse could indicate coarctation of the aorta.

To perform the lung exam, observe respiratory effort with the baby's chest wall exposed. Look for signs of labored breathing such as grunting, nasal flaring, or suprasternal and intercostal retractions.

Next, auscultate over the lungs, being sure to listen to upper and lower lung fields bilaterally in the front and back. Newborns can have soft, diffuse crackles due to retained fetal lung fluid that will typically resolve within 12-24 hours as the fluid is naturally resorbed.

Start the head exam by feeling the anterior and posterior fontanelles of the baby's head.

Under the skin, these are natural openings in the skull, which usually close within the first year of life. The anterior fontanelle is the easiest to appreciate and should be soft and flat. The posterior fontanelle can be more difficult to appreciate as it is smaller, often less than a fingertip in diameter.

Next, palpate the skull sutures. Baby's skull sutures have not yet fused, and one can often palpate ridges where the sutures have overlapped to decrease the head size in order to promote passage through the birth canal.

Now carefully inspect the head and scalp for other findings, such as molding from the birth canal, a scalp electrode site, or bruising from forceps or vacuum-assisted deliveries.

For the eye exam, avoid manually forcing the baby's eyes to open. Turning off the room lights while gently rocking the baby back and forth or dipping their head back may entice them to briefly open their eyes.

First, look for the symmetric, spontaneous opening of the eyes, and then check for any discharge, conjunctival redness, or jaundice.

Newborns often have eyelid swelling or conjunctival hemorrhages due to the pressure of the birth canal. These symptoms typically resolve over several days and do not cause any long-term issues.

It is important to check the retinal reflex with an ophthalmoscope to ensure the baby does not have any congenital cataracts or eye tumors, such as retinoblastoma.

While examining the nose, ensure that the nares are open and without discharge.

Next, gently plug the baby's one nostril at a time with your finger, to ensure the baby is still breathing comfortably. Newborns are obligate nasal breathers, and therefore any nasal blockage, including choanal atresia, should be brought to attention by breathing difficulty during feeds.

For the mouth exam, first, palpate the hard and soft palate of the baby's mouth with a gloved finger and check for the presence of any clefts. Then, palpate the gums for any natal teeth or cysts.

The tip of your finger in the baby's mouth should stimulate the baby's sucking reflex. Keep the finger in the baby's mouth and make a note of the sucking reflex for appropriate strength and coordination.

Next, evaluate the baby's tongue for tongue tie, also called ankyloglossia, by visual inspection of the lingual frenulum and observation of tongue extrusion. Ankyloglossia can present with a heart-shaped tongue that has limited movement past the lower gumline.

Then examine the baby's ears for normal size and shape as well as pre-auricular skin tags or pits, which can sometimes be associated with hearing loss or kidney disease.

Now evaluate the baby's neck for any indentations or masses that could indicate a residual branchial cleft that has potential for later infection.

Finally, palpate the clavicles to check for crepitus, which is a crackling sensation beneath the skin, suggesting fracture from delivery trauma.

With the infant in only a diaper, auscultate the baby's abdomen for bowel sounds which can sound like soft tinkling or water gurgling softly.

Ideally, this portion of the exam should be carried out before a feed, because deep palpation can cause the baby to spit up. Palpate the baby's abdomen thoroughly to check for enlarged liver, spleen, kidneys, or other masses.

Now, examine the umbilicus and ensure that it is intact without drainage, bleeding, or redness. It will feel moist in the first few hours after birth but will dry up and typically falls off within 1-2 weeks. Counsel the parents to keep the umbilicus stump dry during bath time so that it falls off sooner and is less likely to get infected.

Examine the baby's genitals with the diaper fully removed and ensure that they are of normal size and shape.

For girls, mild swelling of the vulvar tissue with whitish vaginal discharge is commonly seen due to exposure to maternal hormones.

For boys, evaluate the penis for the abnormal location of the urethra, such as hypospadias. Palpate both testes to ensure that they are present within the scrotum.

Lastly, inspect the anus for normal location and patency.

For the back exam, turn the baby on its side or have it sit on the parent's lap with its back to you.

Evaluate the back of the head, neck, spine, buttocks, and gluteal cleft for birthmarks, clefts, tufts of hair, dimples, skin tags, or asymmetry that might indicate a spinal defect such as spina bifida.

Then, move on to examining the baby's arms and legs for normal muscle tone, typically in flexion, with equal movement on both sides.

Then evaluate the hips for instability by first performing the Barlow maneuver, grasping each thigh, and then very gently applying pressure from above the hip joint to see if the femoral head dislocates posteriorly.

The examiner should be gentle while performing the Barlow maneuver. Do not attempt to forcefully dislocate the femoral head by applying force posteriorly. Doing so can actually create hip instability.

Then perform the Ortolani maneuver by applying pressure from behind the hip joint to see if the femoral head dislocates anteriorly.

If you feel a "clunk" with either of these maneuvers, the child may have developmental dysplasia of the hip – which is a condition more common in babies that are born breech and may require splinting to promote normal hip development.

Next, evaluate the baby's hands and feet for the appropriate number of digits. It is normal for babies to have slightly blue-tinged hands and feet, or acrocyanosis, within the first 48 hours of life due to the normal transitioning of blood flow. 

Newborns exhibit primitive reflexes that disappear within the first several months of life. Test these reflexes to ensure the normal neurological status of the baby.

The Moro reflex can happen spontaneously when the baby is startled. Elicit this reflex by grasping both baby's hands, pulling their arms up until their shoulders are just slightly off the exam table, and letting go. The baby should react by extending their arms, crying, and then pulling their arms back in.

Next, check the tonic reflex by turning the baby's head to one side, which results in the baby's arm on that side extending out while the opposite arm flexes at the elbow.

After this, test the sucking reflex by touching the roof of the baby's mouth– and the baby should begin sucking in response. This reflex doesn't start until about the 32^nd week of pregnancy and isn't fully developed until 36 weeks – which is why premature babies often have difficulty with feeding.

Then elicit the rooting reflex by touching or stroking the corner of the baby's mouth. The baby will turn their head and their mouth toward the side that is touched – helping them to find the breast or bottle to start feeding.

Next, check the grasp reflex by placing an object such as a rattle or your finger on the palmar surface of the baby's hands or plantar surface of their feet. The baby's fingers or toes should reflexively wrap around the object.

Conclude your newborn exam by wrapping the baby in a blanket, swaddling them tightly around the shoulders so that the blanket does not cover their face and the blanket is loose around the lower body, allowing the hips and legs to move freely.

Ensure that you do not leave the baby unsupervised – place them in a crib, bassinet, or in the parent's arms at the conclusion of your exam.

Share any physical exam findings with the baby's parents or simply state that "everything looks and sounds normal.", as this will be reassuring for them to hear.