Physical ExaminationOf The Newborn W. S. HOWARD,MD

SUMMARYThe fragile newborn can be saved from subsequent trauma if a comprehensiveexamination is performed at birth. This article outlines what should be looked for andoffers guidelines on physical assessment for gestational age.

Dr. Howard is in family practice in Saint John, N.B.

THE CHANGE from the relatively hypoxic and parasiticintrauterine existance to extrauterine life is quite a

remarkable one. Fortunately, most newborns make thetransition easily and have a normal neonatal period. Sincephysical examination of the newborn often yields fewsignificantly abnormal findings, some physicians may beinclined to regard it as a dull chore. However, it is an

important task which should be performed carefully inorder to recognize already apparent problems, especiallythose which may need immediate attention, and to estab-lish a baseline of observation should problems develop later.

The actual physical examination of the newborn infantmay begin, in one sense, before the journey through thebirth canal. For example, hydramnios may be suspected or

confirmed clinically prior to delivery. In this case, thephysician should be on the lookout for problems. Death ofthe fetus in utero, tight wrapping of the cord about theneck, anencephaly and high obstructions of the gastro-intestinal tract are the major causes of hydramnios. It alsooccurs in almost one-third of the mothers of mongols,regardless of the presence of intestinal obstruction. Asanother example, hydrocephaly may be detected by X-raywhich may be done for one reason or another during thelatter part of pregnancy. Fetal malnutrition should besuspected if maternal weight and uterine size are notincreasing as the pregnancy advances.

Times of ExaminationThe physical examination may be categorized in time

periods.1. During delivery and immediately postpartum.2. 12-24 hours later.3. Prior to discharge from hospital at four to five days.Using this routine, the physician should be able to

answer two important questions as early as possible. Firstly,have pregnancy, labor and delivery (and the sometimesindiscriminate use of drugs) contributed to any form ofillness in the newborn infant? Secondly, can the physicianreport to the mother that she has delivered a normal,healthy baby without any apparent congenital malforma-tions? Choosing the opportune time to inform the parents

CANADIAN FAMILY PHYSICIAN/SEPTEMBER, 1974

of any abnormalities is an entirely different topic, and willnot be discussed here.

At this point, I would like to emphasize the importanceof communication between the obstetrician and pediatri-cian, particularly in high-risk pregnancies. In the case of thefamily physician who includes obstetrics in his practice, thepregnancy, delivery and care of the newbom are part andparcel of his job. Of course, he will obtain appropriateconsultations when indicated. I merely wish to state thatthe infant who will be or is at risk, should be anticipatedand/or recognized by all concemed as early as possible.There are a number of instances in which the abovestatement applies:

1. Low birthweight.

2. Low birthweight for gestational age.

3. Maternal diabetes.

4. Maternal toxemia.

5. Blood incompatibility, whether or not one is dealingwith the first pregnancy.

6. Congenital malformation, or family history of such.

7. Any form of complicated pregnancy, labor, or de-livery, including placental insufficiency.

8. The teenage, or elderly, primipara.

It is generally conceded that prenatal history can detecta high risk pregnancy approximately 60 percent of thetime.

The most common illnesses of the newborn which mostof us have to deal with are: infection, hyaline membranesyndrome, hypoglycemia and hypocalcemia, hyperbilirubi-nemia, anoxia and apnea, metabolic and respiratoryacidosis, and congenital malformations.

Beginning with the first physical examination and

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evaluation of the infant, it may seem very basic to reiteratethe famous and widely accepted Apgar method of scoring.However, how many of us could reproduce it on paper at amoment's notice? It is a most useful record which can beobtained in a matter of seconds. This evaluation should bedone at one minute and repeated at five minutes of life.

Head and NeckAny major congenital abnormality such as gross hydro-

c ephalus, meningomyelocele, cleft lip, omphalocele,anencephaly, major malformations of the extremities, etc.will be immediately evident at this point. The more detailedphysical examination should proceed as follows:

1. The skull - this will be much more rewarding in a fewdays if there is much molding or overlapping of sutures.

2. Eyes.3. Ears -observing size, placement, floppiness, cartilage,

presence or absence of skin tags, dimples, or sinuses.4. Nose - infants are obligatory nose-breathers and

choanal atresia should be suspected if there is evidence ofrespiratory distress. Bilateral choanal atresia is an acuteemergency which can be diagnosed immediately by passinga nasal catheter through each nostril. If this emergency ispresent, a nipple with the end cut off can be taped into themouth as a temporary lifesaving measure. It is interestingthat unilateral choanal atresia may be diagnosed much laterin life, or never.

5. Mouth, including tongue (size), palate and pharynx.6. Jaw (size) - micrognathia can cause extreme respira-

tory distress and later, feeding difficulty.7. Neck - hygroma, thyroglossal duct cyst, enlarged

thyroid, sternomastoid tumor, fractured clavicles, etc.,should be looked for.

The foregoing represents a reasonable initial examinationof the head and neck; it takes remarkably little time andcan provide a great deal of information. It goes withoutsaying that observations of the facies, respiration and crywill have been done by this time. A weak or a high-pitchedcry should put one on the alert.

The ChestExamination of the chest deserves and usually gets the

major attention of most physicians in an otherwise appar-ently healthy infant. The majority of acute problemsaffecting the newborn, both inborn and acquired, are

located here. Respiratory rate, movement with respiration

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and symmetry of size and motion on both sides should beobserved. Note should also be made of the use of accessorymuscles (if evident), and the presence or absence ofretraction. Auscultation of the lungs will have already beendone, looking for decreased air entry, ronchi, rales, etc.Percussion is probably not of exceptional value to most ofus at this point; however, hyper-resonance would suggestpneumothorax, pneumomediastinum or diaphragmatichernia.

Although most infants presenting with respiratory diffi-culty will have either the respiratory distress syndrome(especially prematures) or an infectious process, one mustkeep in mind the possibility of a congenital malformation ofthe lungs requiring surgical attention. These might becongenital lobar emphysema, congenital cyst in the lung, oresophageal atresia with tracheoesophageal fistula. Thepossibility of pneumothorax must always be remembered,since it occurs in one to two percent of all newborns. Manyare asymptomatic and go unrecognized. Of those diagnosed,most will resorb without therapy. Insertion of a needle inthe appropriate area can be life-preserving in the case oftension pneumothorax, congenital cyst or congenital em-physema.

Examination of the heart and circulatory system cannotbe over-emphasized; yet if the child appears to be normaland if color activity, heart rate and rhythm are seeminglynormal, this often concludes the initial examination of theheart. The presence or absence of murmurs is not nearly asimportant in the newborn as unusual cyanosis, respiratorydistress, or an enlarged liver. At this point one shouldalways check for femoral pulsations. If they are diminishedor absent, this is the clue to coarctation of the aorta. This isa common anomaly, accounting for a high percentage ofcongenital cardiac malformations, a high percentage ofcardiac failure in infancy, and a high percentage of cardiacmorbidity and mortality. It is also a potentially surgicallycorrectable disorder, the prognosis being much worse if thecoarctation is located preductally.

Passing note is made of the ductus arteriosus. This is partof the fetal vascular system which usually closes within12-24 hours of birth in the normal full-term infant. In thepremature infant, the ductus will remain open much longer.This is due to increased pulmonary resistance. The diagnosisof patent ductus arteriosus is not difficult to make in theneonatal period, and if this anomaly persists, the surgicalprognosis is good.

Genital AreaThe genitals and perineum must be examined carefully.

It would be very embarrassing to inform the mother of afemale child that she has a bouncing baby boy! Althoughsuch an event may never happen to most physicians,mistaken sex of the newborn is a distinct possibility.Female pseudo-hermaphroditism due to adrenal corticalhyperplasia is an example where diagnosis and appropriatetreatment is of the utmost importance, since death from anAddisonian crisis may ensue with little warning.

In the case of a male infant, the penis should beexamined carefully. The foreskin is normally adherent tothe glans, and one must ascertain that no degree ofhypospadias is present. It is much worse than embarrassingto circumcise a child with hypospadias.

The testes are not always palpable but this does notmean that cryptorchism is present. If the child is cold orcrying, the testes may be drawn up into the inguinal canal.

CANADIAN FAMILY PHYSICIAN/SEPTEMBER, 1974

A small hydrocele may be present and can be safelywatched for three to four months, at which time most willhave disappeared spontaneously.

In the female, the labia minora are prominent, but areusually covered over by labia majora in the full term infant.One should note the size of the clitoris, the presence of thevaginal orifice, and if possible, the presence and position ofthe urethral orifice. Vaginal bleeding may occur during thefirst few days of life. This is presumably due to withdrawalof maternal hormones and is usually of no significance.

Meconium may have been passed at the time ofexamination, but one should always examine the rectal areaas part of the routine.

The AbdomenIn examining the abdomen, one should look for unusual

flatness or concavity (diaphragmatic hernia?), as well as fordistension. Unusual fullness may originate from within thebowel or from elsewhere. One must consider air, blood,tumor, or enlarged organ(s) for any one of various reasons.The liver is normally palpable about two cm below thecostal margin. In the relaxed infant, the lower poles of thekidneys can be palpated. Visible contractions of thestomach or bowel are an ominous sign of gastrointestinalobstruction, although bowel loops may be visible throughthe thin abdominal wall of the small or wasted infant. Oneshould always check for imperforate anus.

The umbilicus should be examined for normal vascu-lature and one should note any abnormally dilated veinsover the abdominal wall. The latter may give a clue tovenous obstruction.

Skin and ExtremitiesThe normal full-term infant is covered with white vernix

caseosa. This is more abundant in the premature and less so,or absent, in the postmature. Presence or absence ofcyanosis has been mentioned. Mongolian spots are irregularareas of pigmentation seen most often on the buttocks.They occur in any race and usually disappear by age two.Hemangiomas are frequently seen in the newborn. Dermalsinuses should be looked for in the midline along the lengthof the spine, especially the lower part.

The extremities can be assessed quickly, noting palmarcreases, the number of fingers and toes, the presence orabsence of webbing, club foot, etc. This is a convenienttime to check the deep tendon reflexes, which will requireonly a few seconds. Congenital dislocation of the hips is notoften detected at the initial postpartum examination.However, it should be looked for; a careful re-check for thisimportant disorder must be a part of subsequent examina-tions.

Assessment of Gestational AgeIn a normal, healthy baby, this may not seem to be of

great importance; however, there are many cases when it isof vital significance. For example, a 2500 g newborn couldbe a normally grown premature 35-week infant or a fetallymalnourished (i.e. small-for-dates) term infant. It isimportant to be able to distinguish between the prematureand the fetally malnourished infant immediately after birth.There are definite physiological as well as physical, differ-ences between the two groups and their different problemscan be expected. Table 2 presents a simple but reliablemethod of estimating the gestation period. Further evalua-tion of the infant is very important. There may be manyproblems which are not evident at birth, but will becomemanifest during the hours or days thereafter. <

AcknowledgementI wish to express thanks to Dr. Jeanne R. Duncan,

neonatologist at the Saint John General Hospital, SaintJohn, N.B., for her much appreciated and valuable advice.

References1. VAN LEEUWAN, G. (Ed.) A Manual ofNewborn Medicine; YearBook Medical Publishers, Inc. (19 73).2. KLANS, M. H. and FANAROFF, A. A.: Care of the High-RiskNeonate. W. B. Saunders Company (1973).3. SCHAFFER, A. J., and A VER Y, M. E.: Diseases of the Newborn,3rd Edition. W. B. Saunders Company (1971).4. PIEROG, S. H. and FENORA, A.: Approach to the Medical Careof the Sick Newborn: The C. V. Mosby Company (1971).5. SLOBODY, L. B. and WASSERMAN, E.: Survey of ClinicalPediatrics, 5th edition. McGraw-Hill Book Company (1968).

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