New born

examination
New born examination is a systematic and
orderly process to ensure a satisfactory
adjustment to extra uterine life.
 
Assessment of new born can be
divided into four phases
Initial assessment : Apgar score
 
       
SIGN ZERO ONE TWO
Heart rate Absent Below 100 Above 100
Respiratory Absent Slow and irregular Good, strong cry
rate
Muscle tone Flaccid, Some flexion of Well flexed
limp extremity
Reflex No response Grimace(sneezes) Cry (sneezes)
irritability
color Blue/pale Body pink, extremity completely
blue
SOME OF IMPORTANT
FEATURE OF APGAR
SCORE
1) At 1 min or 5 min after the neonate body
completely born.
2) Heart rate, respiratory rate, muscle tone, reflex
irritability and color.
3) New born baby is in the best possible condition if
score is 10. Score of 7-10 integrates no difficulty in
adjustment of life. Score of 4-6 signifies moderate
difficulty. If the score is 3 or below neonate is in
severe distress.
4) 1 min score is not useful for deciding upon the
intervention necessary for resuscitation because
action must be initiated even before that however
a 5min score is useful .
Transitional assessment during period of
reactivity
After birth during the first 24 hrs. when the neonates cries to adjust
with the environment. The vital function like heart rate, respiratory
rate, bowel activity, motor activity, colour, mucus production
occurs in orderly manner. This is the period of reactivity.
 
First Period Of Reactivity
1) First6-8 hrs. Especially first 30 min
neonates are alert, active, cry and a strong
sucking.
2) Respiratory rate may be more than 60.
3) heart rate more than 160/mt, bowel sound
heard.
4) mucous secretion increases and temperature
may decreased so exposure should be avoided.
Second Period Of Reactivity
1) This start 6-8 hrs.
2) After birth and last for 2 to 5 hrs. I.e.
when the neonate awake from the first
sleep.
3) During this period again neonate becomes
alert, active and responsive.
4) Heart rate, respiratory rate increased
slightly. Gastric secretion increased.
Clinical Assessment Of Gestational Age
1. For infant with gestational age of 26 weeks less
should be performed at a postnatal age of less than 12
hrs.
2. For infants with a gestational age of at least 26
weeks the examination can be performed within the
first 48 hr of life.
3.Neuromuscular adjustment after birth in extremely
immature neonates that require that follow up
examination be performed to further validate
neuromuscular criteria.
Physical Assessment
 GENERAL MEASUREMENT
USUAL MINOR FINDINGS MAJOR FINDINGS
FINDINGS
Head Molding after birth altering head Head circumference
circumference circumference head and chest <10 or>90th percentile
th

33-33.5 cm circumference equals for first 1-2

days after birth.
Chest    
circumference :-
30.5-33 cm
Head to heel
length:-48-53 cm
Birth weight:- Loss of 10% of birth weight in first Birth weight ,10th or >90th
2700-4000gm week; regained in 10-14 days, percentile
depending on feeding methods.
 VITAL SIGNS
USUAL FINDINGS MINOR FINDINGS MAJOR FINDINGS

Axillary temperature:- Crying slightly increasing Hypothermia

36.5-37.6 degree Celsius body temperature. Radiant Hyperthermia
warmer falsely increasing
axillary temperature.

Apical hearty rate:- Crying increases heart rate Bradycardia-resting rate <80-
120-140 beats/min and sleep decreases. 100 beats/min
Tachycardia- rate>160-180
beats /min
Respirations:- Crying increases respiratory Tachypnea-rate>60/min
30-60 breath/min rate and sleep decreases. Apnea- breathing stops for 20
sec
Blood pressure-65/41 mm of Crying and activity increases Systolic b.p in calf 6-9 mm of
hg in arm and calf( age 1- 2 B.Pd. hg less than in upper
days, mean 50 mm of hg) extremity( sign of co-arcation
of aiota)
General appearance
Posture- flexion of head and Frank breech- extended legs, Limp posture and extension
extremities, which rest on abducted and fully rotated of extremity.
chest and abdomen. thighs flattened occiput and
extended neck.
 SKIN
USUAL MINOR FINDINGS MAJOR FINDINGS
FINDINGS
At birth ,bright Neonatal Jaundiceafter progressive jaundice,
red,puffy,smooth 24 hrs, ecchymoses or petechiae especially in first 24 hrs
Second to third day, caused by birth trauma. generalized cyanosis
pink, flack dry Milia-distended sebaceous gland that pallor
Vernixcaseosa appear as tiny white papules on mottling
Lanugo cheeks, chin and nose grayness, plethora
Edema around Erythema Toxicum-pink pappular hemorrhage, ecchymosis or
eyes,face,legs,dorsa of rash with vesicle superimposed on petechia that persist
hands and feet and thorax, back, buttocks and abdomen;  
scrotum and labia may appear in 24-48 hrs and resolve Sclerema –Hard And Stiff Skin
Acrocyanosis- cyanosis after several days. Poor Skin Turgor
of hands and feet Harlequin Color Change- clearly Rashes,Pustules Or Blisters
Cutis marmorata- outlined color change as infant lies on  
transient mottling of side; lower half of body becomes pink Café-Au-Lait Spots- Light
skin after the exposure and upper half is pale. Brown Spots
of low temperature. Mongolian Spot-irregular areas of  
deep blue pigmentation, usually in Nevus Flammeus- Port Wine
sacral and gluteal regions. Stain
Telangiectatic Nevi- flat, deep pink
localized areas usually seen on back
of neck.
 
 HEAD
USUAL FINDINGS MINOR FINDINGS MAJOR FINDINGS
Anterior fontannel:- Molding after vaginal Fused suture
Diamond shaped, delivery Bulging or depressed
size varying from Third sagittal fontanel fontanel when quiet
barely palpable to 4- Bulging fontanel because of Widened sutures and
5 cm. crying and coughing fontanels
Posterior   Craniotabes-snapping
fontannel:- Caput succedaneum- edema sensation along lamboid
Triangular, 0.5 to 1 of soft tissue scalp suture that resembles
cm   indentation of ping
fontanel flat , soft Cephalohaematoma- pong ball.
and firm hematoma between
Widest part of periosteum and skull bone.
fontanel measured
from bone to bone
not suture to suture
 
 
 EYES
USUAL FINDINGS MINOR FINDINGS MAJOR FINDINGS
Lids usually Epicanthal folds in new born Pink color of iris, purulent
edematous Asian discharge
Color-slate gray, dark Nystagmus or strabismus Hypertelorism or
blue, brown   hypotelorism
Absence of tears Sub conjuctival hemorrhage- Congenital cataract
Corneal reflex to light ruptured capillaries usually Dilated or fixed pupil
Pupillary reflex to atlimbus. Absence of corneal or
touch   pupillary reflex
Blink reflex to touch  
and light
EARS
Position-top of pinna Inability to visualize tympanic Low placement of ears
on horizontal line with membrane because of filled aural Absence of startle reflex
outer canthus of eyes. canal  
Pinna flexible cartilage Pinna flat against head
soft. Irregular shape or size
Pits or skin tags
NOSE
Nasal patency Flattened and bruised Non patent canal
Nasal discharge Thick bloody nasal
Sneezing discharge
Flaring of nares
Copious nasal secretions or
stuffiness.
 MOUTH AND THROAT
USUAL MINOR FINDINGS MAJOR FINDINGS
FINDINGS
Intact, uvula in mid line Natal teeth-teeth present at birth, benign Cleft lip and cleft palate
Frenulum of tongue but may be associated with congenital Large protruding tongue or
Sucking reflex defects displaced tongue
Vigorous cry Epstein pearls-small, white epithelial Excessive salivation
Absent or minimal cysts along midline of heard palate Candidiasis
salivation In able to pass nasogastric tube
High pitched or absent,
abnormal cry.

NECK
Short, thick, usually Torticollis(wry neck)-head held to one Excessive skin fold, resistance
surrounded by skin folds side with chin pointing to opposite side to flexion and fractured clavicle

CHEST
Anteroposterior and lateral Funnel chest Depressed sternum
diameter equals Pigeon chest Asymmetric chest expansion
Slight sternal retractions Supernumerary nipples Redness and firmness around
evident during inspiration Secretion of milk substance from breast nipples
Xiphoid process evident Wide spaced nipples
Breast enlargement
 LUNGS
USUAL FINDINGS MINOR FINDINGS MAJOR FINDINGS
Respiration abdominal Irregular rate and depth of respiration Inspiratory stridor
Bilateral equal bronchial Periodic breathing Expiratory grunt
breath sound Crackles shortly after birth Retraction, persistent irregular
respiration
Repeated apneic spell
Sea saw respiration
Wheezing, diminished breath
sound
HEART
Apex-fourth to fifth Sinus arrhythmia-heart increase with Dextrocardia-heart on right side
intercostal space, lateral to inspiration and decrease with expiration. Displacement of apex
left sternal border Transient cyanosis on crying or straining Cardiomegaly
S2 is slightly sharper and Abdominal shunts
strong than s1 Murmur and thrill
Persistent central cyanosis
ABDOMEN
Cylindrical Umbilical hernia Abdominal distension, localized
Liver-2-3 cm palpable below Diastasis recti- midline gap between recti bulging, distended vein, absent
right costal margin muscle bowel sound, enlarged liver and
Spleen-tip palpable at first Wharton jelly-unusually thick umbilical spleen, ascites, visible peristaltic
week of age cord waves
Kidneys-palpable 1-2 cm Omphalocele or gastroschisis-
above umbilicus Protrusion of abdominal contents
Umbilical cord-two artery through abdominal wall or cord.
and one vein
Femoral pulses-equal
bilaterally
 FEMALE GENITALIA
USUAL FINDINS MINOR FINDINGS MAJOR FINDINGS
Labia and clitoris Pseudomensturation -blood tinged or Enlarged clitoris with urethral
usually edematous mucoid discharge meatus
Urethral meatus Hymenal tag Absence of vaginal opening
behind clitoris Meconium from vaginal
Urination within 24 opening
hrs. No urination within 24 hr,
ambiguous genitalia and
bladder extrophy.
MALE GENITALIA
Urethral opening at tip of Urethral opening is covered by Hypospadiasis
glans penis prepuce, inability to retract foreskin Epispadiasis
Testes palpable in scrotum ,testes palpable in inguinal canal Hydrocele
Smegma Scrotum small Inguinal hernia
Scrotum large and Epithelial pearls Mass in scrotum
edematous with rugae Meconium from scrotum
Urination within 24 hrs. Bladder extrophy
Ambiguous genitalia.
BACK AND RECTUM
Spine intact, patent anal Green liquid stool in infant under Anal fissure or fistula
opening phototherapy Imperforate anus
Passage of meconium Delayed passage of meconium in very Absence of anal reflex
within 48 hrs. low birth weight neonate. Tuft of hair along spine
Spina bifida.
 EXTREMITIES
USUAL FINDINGS MINOR FINDINGS MAJOR FINDINGS
Ten fingers and ten Partial syndactyly Polydactyly
toes Wide gap between first and second Syndactyly
Full range of motion toes Phocomelia
Creases on toe third Asymmetric length of toes Hemimelia
of sole ,symmetry of Dorsiflexion and shortness of Hyperflexiblity of
extremity hallux joints
Equal muscle tone Fracture
and equal brachial Absent range of motion
pulses. Limited hip abduction
Unsymmetrical gluteal
folds
Unequal muscle tone
NEUROMUSCULAR SYSTEM
Head lag while sitting Momentary tremors Hypotonia
Ability to turn head Hypertonia
from side to side when Asymmetric posturing
prone Opisthotonic posturing
Ability to hold head in Signs of paralysis
horizontal line with Tremors twitching and
back when hold prone. myoclonic jerks.
Reflexes of normal new born
 Reflex Stimulation to elicit Expected response Age of disappearance
reflex

Rooting Touching or stroking That turns in the Disappear when awake

the cheeks near the direction of stimulus 3-4 months and when
corner of mouth so that neonate can asleep 7-8 month
find mouth.

Sucking Touching the lips with Sucking movement Begins to diminishes at

the nipple of the breast that unable the new 6 month and disappear
or bottle born to take in food. if not stimulated soon
after birth.

Swallowing Accompanies the Food reaching the Does not disappear.

  sucking reflex. posterior of the mouth
  is swallowed.

Gagging When more is taken in Immediate return of Does not disappear.

the mouth than can be undigested food.
successively swallow.
 Reflex Stimulation to Expected Age of
elicit reflex response disappearance
Sneezing and Foreign substance Clearing upper Does not
coughing entering the upper passage of airway disappear.
and lower airway. by sneezing and
lower by
coughing.
Extrusion Substances placed Extrusion of the About 4 month.
on anterior substance to
position of tongue. prevent
swallowing.
Blinking Exposure of eyes Protection of eye Does not
to bright light from by rapid eyelid disappear.
a flash or sudden closure.
movement of
objects towards
light.
Doll’s eye Turned the new Normally eyes do When fixation
born head slowly not move. develop.
in right or left side.
 Reflex Stimulation to Expected Age of
elicit reflex response disappearance
Palmar reflex Object placed in Grasping of object 6 weeks-3 month
new born palm. by closely fingers purposeful graft is
a rounding. evident at 3
months of age.
Plantar grasp Touching the sole Toes grasp around 8-9 month in
of the foot at the very small objects. preparation for
base of toe. walking may
continue to be
preventing during
sleep.
Tonic neck pencil Turning the head 1) Arm and leg on 18-20 weeks tonic
position quickly to one side the side, the head neck reflex is
while the infant is is turn toward replaced by
supine. extend. symmetric
2) Arm and leg on positioning of both
the opposite side side of the body.
flexed.
3) Bothhands may
make fist.
 Reflex Stimulation to elicit Expected response Age of
reflex disappearance
Dancing Hold neonate in a Rapid alternating 3-4 weeks the
vertical position with flexion and extension neonate there after
a feet touching flat of legs as it sleepy. can bear some weight
from surface. on legs without
stepping.
Moro startling 1)Starting the infant 1) Generalize Strong up to 2
reflex with loud voice or muscular activity. months and disappear
apparent loss of due 2) Symmetric by up to 3-4 month.
to a change in abduction and
equilibrium. extension of arms and
2)Neonate is kept in legs with fanning of
supine position on fingers.
table or bed. 3) The thumb and
3)the nurse support index fingers.
right the upper back 4) The thumb and
and head with one index finger of each
hand and lower back hand form a c shaped.
and head with one  
hand and lower the
back others.
 Reflex Stimulation to Expected Age of
elicit reflex response disappearance
Babinski Stroking the Fans the toes Three month
reflex lateral aspect of (positive of age is
the sole of the Babinski variant.
foot with a reflex)
relatively sharp The adult
object (finger normally flexes
nail) from the toe, the new
head towards born reflex is
the little toe due to
and across the immature is
foot to big toe. due to
immature level
of development
of nervous
system.
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