What are the key components of a thorough physical examination for neonates?

Key Components of a Thorough Physical Examination for Neonates

A comprehensive neonatal physical examination should include systematic assessment of all body systems, with careful attention to growth parameters, vital signs, and neurological status to identify any abnormalities requiring intervention.

General Assessment and Vital Signs

• Measure and document vital signs including axillary temperature (36.5°C to 37.4°C), respiratory rate (<60 breaths per minute with no signs of distress), and heart rate (100-190 beats per minute when awake, as low as 70 beats per minute when sleeping) 1
• Plot accurate anthropometric measurements including weight, length, and head circumference on appropriate growth charts 1, 2
• For premature infants (<36 weeks gestation), correct measurements for gestational age for at least the first 24 months of life 1
• Observe general appearance, level of arousal, posture, tone, and spontaneous movements 1, 3

Head and Neck Examination

• Assess head shape and size, checking for macrocephaly, microcephaly, or craniosynostosis 3
• Palpate fontanelles for size, tension, and abnormalities 1
• Examine eyes for red reflex, pupillary reactivity, conjunctivitis, and response to visual stimuli 1, 3
• Assess ears for position, patency, and response to auditory stimuli 1
• Examine nose and mouth for patency, abnormalities, and evidence of respiratory distress 1
• Evaluate neck for masses, abnormal movement, and mobility 1, 3

Chest and Cardiovascular Assessment

• Observe chest for symmetric movement, shape abnormalities (pectus excavatum, pectus carinatum), and breast tissue 4
• Auscultate lungs for breath sounds, noting any abnormalities or signs of respiratory distress 1, 3
• Perform cardiac examination including heart rate, rhythm, and presence of murmurs 1, 3
• Note that murmurs in the immediate newborn period are often innocent and represent transition from fetal to neonatal circulation 3

Abdominal Examination

• Observe abdomen for distention, visible peristalsis, or abnormalities 1, 4
• Palpate for masses, organomegaly, or tenderness 1
• Examine umbilical cord for healing, number of vessels (two arteries and one vein), and signs of infection 2
• Assess for fluid balance and document any bilious or repetitive vomiting that may indicate pyloric stenosis or other gastrointestinal issues 1

Genitourinary Examination

• Examine genitalia for abnormalities, ambiguous features, or malformations 1, 4
• In males, check for descended testes, penile abnormalities, and urethral opening position 4
• In females, examine labia and clitoris for normal appearance 4
• Observe first void if possible, or document if already occurred 1

Extremities and Spine

• Assess extremities for symmetry, range of motion, and deformities 1, 4
• Perform Ortolani and Barlow maneuvers to evaluate for hip dysplasia 4
• Examine hands and feet for digit number, syndactyly, and positional abnormalities 4
• Inspect spine for straightness, sacral dimples, or cutaneous markers that might suggest spinal dysraphism 4
• Note that sacral dimples <0.5 cm in diameter located within 2.5 cm of the anal verge without cutaneous markers do not require further evaluation 4

Neurological Examination

• Assess muscle tone, posture, and symmetry of movement 1, 2
• Evaluate primitive reflexes including Moro, rooting, sucking, palmar and plantar grasp, stepping, and placing reflexes 1, 4
• Observe alertness, responsiveness to stimuli, and general neurological status 1
• Document any asymmetric movements that might suggest neurological injury 1, 3

Skin Assessment

• Examine entire skin surface for color, texture, birthmarks, rashes, or evidence of trauma 3, 4
• Assess for jaundice, which should be quantified with transcutaneous bilirubin or total serum bilirubin if present 2
• Document any bruising, petechiae, or abnormal pigmentation 3
• Evaluate skin for signs of infection or poor perfusion 1

Special Considerations

• For premature infants or those with risk factors, additional monitoring of oxygen saturation may be necessary 5, 6
• Neonates with one anatomic malformation should be evaluated for associated anomalies 3
• For infants with jaundice, measure total and direct bilirubin levels 2
• Newborn screening tests should be reviewed if available or plans made for completion 1, 2

Documentation and Follow-up Planning

• Document successful feeding (breastfeeding or bottle-feeding) with proper coordination of sucking, swallowing, and breathing 1
• Ensure newborn metabolic, hearing, and pulse oximetry screenings are completed per hospital protocol and state regulations 1
• Identify a source of continuing healthcare for follow-up after discharge 1
• Educate parents on signs of illness, feeding patterns, and when to seek medical attention 1

By systematically performing this comprehensive examination, clinicians can identify abnormalities requiring intervention and provide appropriate reassurance to parents about normal findings.