Physical Examination of The Newborn

• General examination
• Gestational age assessment/anthropometry
• Specific systemic examination

Objecives

• Determine adequacy of cardio- pulmonary transition
• Detect presence of congenital malformations
• State of well being

• Guiding principles
• Above all, do no harm
• Patience, gentleness, flexibility

State: deep sleep, light sleep, awake with light movements, large movements, crying

Colour: perfusion, cyanosis, jaundice, pallor, plethora, hyper-pigmentation

Posture: reflects intrauterine position and body tone, influenced by GA

Spontaneous activity: stretching, eye opening, yawning, opening of hands & limb movements

Respiratory effort: an indicator of how distressed or comfortable a newborn is even when the cause is not pulmonary

Skin Lesions

• Milia; pinpoint white papules of keratin on nose, cheeks & forehead lasts few wks.
• Miliaria; obstructed sweat glands, pinpoint vesicles on forehead lasts 1 wk
• Transient neonatal pustular melanosis; small vesicupustules contains WBCs, present at birth
• Erythema toxicum; most common rash, irregular patches contains eosinophils
• Café au lait spots

Vital Signs

• Temp
• Resp rate (40 – 60)
• Heart rate (110 – 160)
• BP (60 – 90)/(40 – 60)

Methods:

1. Blanching or flush
2. Doppler monitoring

Other Aspects of General Examination

• Distal airway; intercostal & sternal retractions, flaring, tachypnoea, grunting
• Upper airway; supra- sternal & sub-costal retractions
• Cardiac; tachypnoea without effort
• Neurodepression; apnoea, irregular resp
• Metabolic/septic; tachypnoea, apnea, minimal retractions

Gestational Age Assessment

The Ballard Score

The Ballard Score is a clinical tool used to assess the gestational age of newborns, particularly in cases where the date of conception is unclear or unknown. It evaluates both neuromuscular and physical maturity through a series of criteria, providing an estimate of the baby's developmental stage. This system is particularly useful for identifying premature infants and helping guide appropriate medical care.

The Ballard Score includes assessments of posture, muscle tone, skin texture, and other physical characteristics, with a higher score indicating greater maturity.

The Ballard Score is calculated by assessing six neuromuscular and six physical maturity criteria, each graded on a scale from 0 to 5. The scores from each criterion are then added together to give a total score, which corresponds to the newborn’s estimated gestational age.

Neuromuscular Maturity Criteria:

• Posture
• Square Window (Wrist Flexion)
• Arm Recoil
• Popliteal Angle
• Scarf Sign
• Heel to Ear

Physical Maturity Criteria:

• Skin
• Lanugo (fine body hair)
• Plantar Crease (foot creases)
• Breast Development
• Ear Cartilage & Recoil
• Genital Development (male or female)

Each of these criteria is scored based on the baby's development, with lower scores indicating immaturity or prematurity and higher scores indicating greater maturity. After summing the neuromuscular and physical scores, the total score is mapped to a gestational age in weeks, typically ranging from 20 to 44 weeks. This helps clinicians estimate how far along in gestation the newborn is.

Anthropometry

Head & Neck

• Head: shape, check for over-riding sutures, number of fontanelles and size, encephalocoeles, measure OFC
• Eyes: size, hyper/hypo-telorism, sub-conjunctival hemorrhage, cataracts, discharge
• Ears: asymmetry, low-set, irregular shape auricular & pre-auricular pits, lipomas, skin tags
• Nose: check for flaring, patency of internal nares (choanal atresia)
• Palate: check for cleft
• Mouth: shape, size
• Tongue: macroglossia
• Teeth: natal teeth
• Chin: micrognathia
• Neck: palpate clavicles for possible fractures, web neck, torticollis, cystic hygromas, lymph nodes

Chest & Lungs

• Respiratory Rate (RR)
• Respiratory Pattern
• Chest Movements for symmetry
• Listen for stridor, grunting
• Auscultate for breath sounds

Cardiovascular System (CVS)

• Check the baby's Heart Rate (HR), Blood Pressure (BP) in both upper & lower extremities, and Respiratory Rate (RR).
• Observe the baby's color for signs of pallor, cyanosis (blue discoloration), or any abnormalities.
• Palpate (feel) for capillary refill time, which is the time it takes for skin color to return to normal after gentle pressure.
• Feel for pulses in different areas like the radial and femoral (groin) pulses, and check for any delay in pulse between these sites.
• Listen to the baby's heart sounds and any murmurs (abnormal heart sounds) using a stethoscope.

Abdomen

• Examine the shape and contour of the baby's abdomen for any visible abnormalities or malformations.
• Look for common malformations like omphalocoele (protrusion of abdominal organs through the navel), gastroschisis (intestines outside the abdomen), or absence of abdominal muscles.
• Check the umbilical cord for any abnormalities in the number of blood vessels (normal is 2 arteries & 1 vein).
• Gently palpate the liver and spleen to assess their size and position. A normal liver may be felt up to 2cm below the costal margin.
• Listen for bowel sounds by using a stethoscope to ensure normal gastrointestinal activity.
• Look for any signs of hernias or abnormalities in the abdominal wall.
• Check for anal patency, ensuring that the baby can pass stool.

Urinary and Genital System (UGS)

• Assess the size and shape of the baby's kidneys through palpation.
• For male babies, measure the stretched length of the penis (at least 3cm) and inspect the urethral opening and testes.
• For female babies, inspect the labia, clitoris, and urethral opening.

Neurologic

• Observe the baby's state, whether they are in deep sleep, light sleep, awake with light movements, larger movements, or crying.
• Assess the baby's posture, which can reflect their intrauterine position and body tone, influenced by their gestational age.
• Check for muscle tone and head lag, which is the delay in head control when gently pulling the baby from a lying to a sitting position.

Primitive Reflexes

• Moro Reflex: Test this reflex by gently supporting the baby's head and neck with one hand and then suddenly lowering them. A normal response involves initial extension and abduction of arms followed by upper limb flexion and adduction with hand closure.
• Grasp Reflex: Observe the baby's grasp reflex when you place a finger in their palm.
• Rooting/Sucking Reflex: Stimulate the baby's cheek to see if they turn their head and mouth towards the stimulus, indicating the rooting reflex.
• Extensor Plantar Reflex: Observe the baby's foot response when the sole of the foot is stroked, which causes extension of the toes.