The newborn examination is used as a screening tool to pick up abnormalities in the newborn baby. Without this examination, babies could go home with an extra digit, a heart murmur or spina bifida. It is the point at which referrals are sent to specialities that may need to follow-up the baby, for example, urology follow-up for hypospadias.
The examination is performed within the first 72 hours after birth. It is repeated at 6 – 8 weeks by their GP.
The initial check can be performed by a trained midwife or paediatric doctor. For home births the GP may visit to perform the baby check.
Principles
Wash your hands before and afterwards, and minimise the risk of introducing infection to the baby. Explain, reassure and keep the parents involved. Keep the baby warm and comfortable during the examination.
Every part of the body needs to be examined, so they need to be adequately exposed to allow a full examination of the skin. Start at the top of the head and work down to the toes.
Have a systematic approach, but be opportunistic. For example, if the baby has their eyes open it is a good opportunity to check the red reflex, and if they are settled it may be a good time to listen to the heart and breath sounds.
Before starting it is worth asking the parents if they have noticed any issues and specifically asking:
- Has the baby passed meconium?
- Is the baby feeding ok?
- Is there a family history of congenital heart, eye or hips problems?
Oxygen Saturations
Babies should have their pre-ductal and post-ductal oxygen saturations checked. This measures the oxygen level before and after the ductus arteriosus. Normal saturations are 96% or above. There should not be more than a 2% difference between the pre-ductal and post-ductal saturations. Abnormal saturations require further investigation and potentially admission to the neonatal unit.
The ductus arteriosus is located along the arch of the aorta and connects the aorta with the pulmonary artery. It normally stops functioning within 1 – 3 days of birth. It allows blood from the deoxygenated right sided circulation before the lungs to mix with the oxygenated left sided circulation after the lungs.
Certain congenital heart conditions are duct-dependent, meaning they rely on the mixing of blood across the ductus arteriosus. When the ductus arteriosus closes there can be a rapid deterioration in symptoms. These duct-dependent conditions may be picked up by measuring the difference in pre-ductal and post-ductal saturations.
Pre-ductal saturations are measured in the baby’s right hand. The right hand receives blood from the right subclavian artery, a branch of the brachiocephalic artery, which branches from the aorta before the ductus arteriosus.
Post-ductal saturations are measured in either foot. The feet receive blood traveling from the descending aorta, which occurs after the ductus arteriosus.
Examination Steps
General appearance:
- Colour (pink is good)
- Tone
- Cry
Head
- General appearance: size, shape, dysmorphology, caput succedaneum, cephalohaematoma and any facial injury
- Head circumference: known as the occipital frontal circumference (OCP)
- Anterior and posterior fontanelles
- Sutures: overlapping sutures are common and usually resolve as the baby grows
- Ears: skin tags, low set ears and asymmetry
- Eyes: slight squints are normal, epicanthic folds can indicate Down’s, purulent discharge could indicate infection
- Red reflex using an ophthalmoscope: check for symmetry. It is often more pale in darker skinned babies. It is absent with congenital cataracts and retinoblastoma.
- Mouth: cleft lip or tongue tie
- Put your little finger in their mouth to check the suckling reflect and feel the palate all the way back, checking for a cleft palate.
Shoulders and Arms
- Shoulder symmetry: check for a clavicle fracture
- Arm movements: check for an Erbs palsy
- Brachial pulses
- Radial pulses
- Palmar creases: a single palmar crease is associated with Down’s, but can be normal
- Digits: check the number of digits and if the fingers are straight or curved (clinodactyly)
- Use a sats probe on the right wrist for a pre-ductal reading
Chest
- Oxygen saturations in the right wrist and a feet: 95% and above is normal
- Observe breathing: look for respiration distress, symmetry and listen for stridor
- Heart sounds: listen for murmurs, heart sounds, heart rate and identify which side the heart is on heart
- Breath sounds: listen for symmetry, good air entry and added sounds
Abdomen
- Observe the shape: a concave abdomen may indicate diaphragmatic hernia with abdominal contents in the chest
- Umbilical stump: look for discharge, infection and a periumbilical hernia
- Palpate for organomegaly, hernias or masses
Genitals
- Observe for the sex, ambiguity and any obvious abnormalities
- Palpate testes and scrotum: check both are present and descended, check for hernias or hydroceles
- Inspect the penis for hypospadias, epispadias and urination
- Inspect the anus to check if it is patent
- Ask about meconium and whether the baby has opened the bowel
Legs
- Observe the legs and hips for equal movements, skin creases, tone and talipes
- Barlows and Ortolani manoeuvres: check for clunking, clicking and dislocation of the hips
- Count the toes
Back
- Inspect and palpate the spine: look for curvature, spina bifida and a pilonidal sinus
Reflexes
- Moro reflex: when rapidly tipped backwards the arms and legs will extend
- Suckling reflex: placing a finger in the mouth will prompt them to suck
- Rooting reflex: tickling the cheek will cause them to turn towards the stimulus
- Grasp reflex: placing a finger in the palm will cause them to grasp
- Stepping reflex: when held upright and the feet touch a surface they will make a stepping motion
Note any skin findings:
- Haemangiomas
- Port wine stains
- Mongolian blue spot
- Cradle cap
- Desquamation
- Erythema toxicum
- Milia
- Acne
- Naevus simplex (“stork bite”)
- Moles
- Transient pustular melanosis
Common Issues
Talipes, also known as clubfoot, is where the ankles are in a supinated position, rolled inwards. It can be positional or structural. Positional talipes is where the muscles are slightly tight around the ankle but the bones are unaffected. The foot can still be moved into the normal position. This requires referral to a physiotherapist for some simple exercises and will resolve with time. Structural talipes involves the bones of the foot and ankle and requires referral to an orthopaedic surgeon.
Undescended testes require monitoring and referral to a urologist.
Skin findings generally do not require any action. Many will fade with time.
Haemangiomas near the eyes, mouth or affecting the airway may require referral for treatment with beta blockers (i.e. propranolol). Otherwise they can be monitored and usually resolve with time.
Port wine stains are pink patches of skin, often on the face, caused by abnormalities affecting the capillaries. They don’t fade with time and typically turn a darker red or purple colour. Rarely they can be related to a condition called Sturge-Weber syndrome, where there can be visual impairment, learning difficulties, headaches, epilepsy and glaucoma.
Clicky or clunky hips require referral for a hip ultrasound to rule out developmental dysplasia of the hips.
Cephalohaematomas require monitoring for jaundice and anaemia.
Boney injuries may require an xray to look for fractures (e.g. clavicular fracture).
Soft systolic murmurs of grade 2 or less in otherwise healthy well neonates may be monitored, as these often resolve after 24 – 48 hours. This may be caused by a patent foramen ovale that closes shortly after birth. Any suspicion of heart failure or congenital heart disease requires referral to cardiology for an ECG and echocardiogram. If they are unwell, they require admission to the neonatal unit and immediate management.
After The Examination
- Discuss any abnormalities with a senior
- Action any abnormalities (e.g. ultrasound request for clicks hips)
- Document the examination findings on the newborn and infant physical examination (NIPE) computer system and in the baby’s red book
- Explain, reassure and answer any questions with the parents
- Arrange referrals and followup if required
Last updated January 2020