What are the key components and interventions of a neonatal physical exam for a newborn?

Neonatal Physical Examination: Key Components and Systematic Approach

Immediate Post-Birth Assessment and Vital Signs

The vast majority (85%) of term newborns require only routine care—drying, warming, and skin-to-skin contact with the mother—while approximately 10% need stimulation and only 5% require active resuscitation interventions. 1

Initial Triage Criteria

• Newborns meeting all three criteria (term gestation, breathing or crying, and good tone) should remain skin-to-skin with mother for routine care rather than being moved to a radiant warmer. 2
• For infants requiring intervention, the two vital signs guiding management are heart rate and respirations, with approximately 60 seconds allotted to complete initial assessment and establish effective ventilation. 1

Vital Sign Parameters

• Axillary temperature should be maintained between 36.5°C to 37.4°C. 3
• Respiratory rate should be less than 60 breaths per minute without signs of distress. 3
• Heart rate ranges from 100-190 beats per minute when awake, as low as 70 beats per minute when sleeping. 3
• Weight, length, and head circumference must be plotted on appropriate growth charts. 3

Head and Neck Examination

Cranial Assessment

• Palpate fontanelles for size, tension, and abnormalities to detect increased intracranial pressure or dehydration. 3
• Assess for craniosynostosis by examining suture lines, as 20% of affected children have genetic mutations requiring further evaluation. 4
• Measure head circumference to identify macrocephaly or microcephaly. 5

Ophthalmologic Examination

• Perform red reflex testing bilaterally—normal findings show symmetry without opacities, white spots, or dark spots. 3, 4
• Abnormal red reflex findings or family history of eye disorders warrant immediate ophthalmology consultation. 4
• Assess pupillary reactivity, fixation, and following behavior. 3

Ear Examination

• Evaluate ear position, as low-set ears should prompt evaluation for genetic conditions. 3, 4
• Renal ultrasonography is indicated only if isolated ear anomalies (preauricular pits, cup ears) are accompanied by other malformations or significant family history. 4
• Assess patency and response to auditory stimuli. 3

Oral and Neck Assessment

• Examine nose and mouth for patency and respiratory distress signs. 3
• Assess for ankyloglossia (tongue-tie), which may warrant frenotomy if impacting breastfeeding. 4
• Evaluate neck for full range of motion, as uncorrected torticollis leads to plagiocephaly and ear misalignment. 4
• Identify neck masses by location: vascular malformations, abnormal lymphatic tissue, teratomas, and dermoid cysts. 5

Cardiopulmonary Assessment

Respiratory Evaluation

• Observe closely for signs of respiratory distress: tachypnea, nasal flaring, grunting, retractions, and cyanosis. 4
• Auscultate lungs bilaterally for breath sounds and abnormalities. 3
• Assess respiratory rate and pattern systematically. 3

Cardiac Examination

• Auscultate heart for rate, rhythm, and murmurs—benign murmurs are often present in the first hours of life representing transition from fetal to neonatal circulation. 3, 4
• Perform pulse oximetry systematically before discharge to detect critical congenital heart disease. 4
• Cyanotic newborns require expeditious evaluation with cardiology or neonatology involvement, as cyanosis is primarily secondary to respiratory or cardiac causes. 5

Abdominal and Genitourinary Examination

Abdominal Assessment

• Palpate for masses (often renal in origin), organomegaly, or tenderness. 3, 6
• Examine umbilical cord for two arteries and one vein—a single umbilical artery is associated with renal anomalies, intrauterine growth restriction, and prematurity. 6
• Assess cord site for healing and signs of infection. 3
• Document any bilious or repetitive vomiting, which may indicate pyloric stenosis or gastrointestinal obstruction. 3

Genitourinary Examination

• Examine external genitalia for abnormalities or ambiguous features. 3
• Signs of ambiguous genitalia include clitoromegaly and fused labia in girls; bilateral undescended testes, micropenis, or bifid scrotum in boys. 6
• Document first void if possible or confirm it has occurred. 3
• Assess urinary stream in males and genital appearance in females. 3

Musculoskeletal and Spine Assessment

Hip Examination

• Perform Ortolani and Barlow maneuvers—abnormal findings require further evaluation for developmental hip dysplasia. 3, 6
• Assess extremities for symmetry, range of motion, and deformities. 3

Spine Evaluation

• Sacral dimples less than 0.5 cm in diameter, located within 2.5 cm of the anal verge, without cutaneous markers do not warrant further evaluation. 6
• Dimples not meeting these criteria require ultrasonography to evaluate for spinal dysraphism. 6

Neurological Examination

Tone and Reflexes

• Assess muscle tone, posture, and symmetry of movement. 3
• Evaluate primitive reflexes: Moro, rooting, sucking, palmar and plantar grasp, stepping, and placing reflexes. 3
• Assess level of arousal, presence of spontaneous movements, and symmetry of movements. 5

Birth Trauma Assessment

• Examine for brachial plexus injuries, most common in large-for-gestational-age newborns—physical therapy may be required for normal function. 6
• Assess for facial nerve palsies, which usually resolve spontaneously. 5

Skin Assessment

Jaundice Evaluation

• Assess for jaundice and quantify with transcutaneous bilirubin or total serum bilirubin if present. 3
• Measure total and direct bilirubin levels in jaundiced newborns. 3, 5

General Skin Examination

• Evaluate for signs of infection or poor perfusion. 3
• Assess skin color, noting pallor (requiring complete blood count) or ruddy complexion. 5
• Visualize entire skin surface to distinguish benign findings and reassure parents. 6

Documentation and Screening Requirements

Mandatory Screenings

• Complete newborn metabolic screening per hospital protocol and state regulations. 3
• Perform hearing screening or review results if previously completed. 3
• Complete pulse oximetry screening before discharge. 3

Feeding Assessment

• Document successful feeding (breastfeeding or bottle-feeding) with proper coordination of sucking, swallowing, and breathing. 3

Follow-up Planning

• Identify a source of continuing healthcare for post-discharge follow-up. 3
• Educate parents on signs of illness, feeding patterns, and when to seek medical attention. 3

Special Considerations

Multiple Anomalies

• A newborn with one anatomic malformation should be systematically evaluated for associated anomalies. 5

Premature Infants

• Correct anthropometric measurements for gestational age for at least the first 24 months of life for infants born before 36 weeks gestation. 3