of the Newborn
Linda L. McCollum, PhD, APRN, NNP-BC
Regional Outreach Coordinator
Emory Regional Perinatal Center
Emory University School of Medicine
80 Jesse Hill Jr Drive, SE
Atlanta, GA 30329
1. Outline a systematic approach to the physical examination of the newborn.
2. Discuss the significance of multiple minor malformations.
VITAL SIGNS & MEASUREMENTS
The following numbers are not absolutes, but merely general guidelines
Temperature: axillary = 97.7-99.5OF (36.5-37.5OC); skin = 97.3-99.1OF (36.3-37.3OC)
Respiratory rate: 40-60 breaths per minute (correlated with activity)
Breath sounds: bilateral and equal; auscultate both the anterior and posterior chest as well as both axillae
Heart rate: 120-160 beats per minute (correlated with activity)
Heart sounds: murmurs may be innocent or pathologic and consequently must be considered within the context of the total exam; when a murmur is detected, it should be described by:
location – usually in terms of the interspace and the sternal, midclavicular, or axillary lines
timing – systolic, diastolic, or continuous
intensity – grade I is barely audible or audible only after a period of careful auscultation
grade II is soft, but audible immediately
grade III is of moderate intensity, but not associated with a thrill
grade IV is louder, and may be associated with a thrill
grade V is very loud and can be heard with the stethoscope rim barely on the chest
grade VI can be heard with the stethoscope just slightly removed from the chest
radiation – transmission (for example, to the back)
pitch – high, medium, or low
quality – harsh, rumbling, or musical
Capillary refill: < 3 seconds
Peripheral pulses: 3+/4 and equal; remember to compare upper/lower and left/right pulses and pressures
0 not palpable
1+ difficult to palpate, thready, weak, easily obliterated with pressure
2+ difficult to palpate, may be obliterated with pressure
3+ easy to palpate, not easily obliterated with pressure (normal)
4+ strong, bounding, not obliterated with pressure
Blood pressure: findings should be compared to normals on the standard wall chart; because blood pressure varies with birthweight, the following “rules of thumb” may also be helpful in estimating MAPs (mean arterial pressures): 1 kg 35 mm Hg
2 kg 40 mm Hg Or, if you prefer an equation:
3 kg 45 mm Hg MAP (weight in kg x 10) + 20
4 kg 50 mm Hg
Measurements: weight, length, and head and chest circumference should all be plotted on a standard growth chart against gestational age; newborns initially lose weight, with a loss of < 10% considered acceptable (birthweight should be regained within the first 2 weeks); more “rules of thumb”:
Head circumference in cm + 1 (length in cm 2) + 10
Head circumference in cm - 2 chest circumference in cm
Voiding: worry if the baby has not voided by 24 hours of age or is putting out < 1-2 cc/kg/day; in the well term newborn, expect at least 3 wet diapers on the 3rd day, 4 or more on the 4th day, 5 or more by the 5th day, and thereafter > 6 wet diapers a day
Stooling: worry if the baby has not stooled within 48 hours of age; thereafter, the number of stools passed by healthy babies is extremely variable; formula-fed infants have one to several soft-formed light yellow to green-brown stools per day; breast-fed infants usually stool more frequently (often with each feeding) and have loose yellow stools
FINDINGS ON PHYSICAL EXAM
GENERAL – observe posture, tone and activity and their consistency with gestational age; evaluate the general state of nutrition and hydration; note any lack of symmetry, problems of relationship, or inappropriate size or structure
SKIN – observe central color (tongue and oral mucosa); note any pattern of coloration that is inconsistent with age; document size, color and placement of any markings, lesions or rashes
Acrocyanosis (peripheral cyanosis) – bluish discoloration of the hands and feet; due to vasomotor instability; benign in the otherwise well newly-born, but should not persist longer than 48 hours
Circumoral cyanosis – bluish discoloration of the lips and area surrounding the mouth; due to vasomotor instability; benign in the otherwise well newly-born, but should not persist longer than 24 hours
Plethora – ruddy red appearance; may indicate polycythemia
Pallor – pale appearance; many indicate anemia or come compromise of cardiac status
Cutis marmorata (mottling) – bluish marbling of the skin in response to chilling, stress, or overstimulation; another reflection of vasomotor instability; usually disappears when the infant is warmed or calmed
Harlequin color change – sharply demarcated deep red color in the dependent half of the body while the upper half is pale; due to autonomic instability of the cutaneous vessels; the response has no pathologic significance and generally disappears within the first few months of life
Jaundice – yellow appearance of the skin and sclera; may indicate hyperbilirubinemia
Common Newborn Lesions:
Erythema toxicum neonatorum (flea bite rash) – benign rash consisting of small yellowish-white papules (filled with eosinophils) on an erythematous base; occurs in up to 70% of term infants; generally appears on the 2nd or 3rd day of life, but may erupt as late as 1-2 weeks; usually spontaneously resolves within hours or days of appearance
Pustular melanosis – benign freckle-like lesions generally occurring in clusters on the face and extremities; begins in utero with superficial, vesiculopustular lesions (filled with neutrophils) which rupture around the time of delivery leaving small hyperpigmented macules which fade within a few months
Milia – multiple yellow or pearly white pin-head sized papules, usually scattered on the forehead, nose, cheeks, and chin; caused by the accumulation of sebaceous gland secretions which spontaneously resolve during the first few weeks of life
Miliaria – transient lesions resulting from obstruction of the sweat gland ducts; seen primarily over the forehead, scalp and skin folds; generally associated with excessive warmth and/or humidity, they resolve within a few hours to days if the infant is kept clean, dry and not over-heated; classified into four types by severity: initially, the escape of sweat into the epidermis causes the formation of clear, thin vesicles (miliaria crystallina); continued obstruction forces the sweat into the adjacent tissues and a small circle of erythema develops giving the appearance of grouped red papules (miliaria rubra or prickly heat), which may be followed by infiltration of leukocytes (miliaria pustulosa) and infection (miliaria profunda)
Cafe au lait patches – tan or light brown macules or patches with well-defined borders due to hyper- pigmentation of the epidermal cells; one patch is found in about 20% of normal children and is of no pathologic significance, however multiple (> 6) or unusually large (> 1.5 cm) spots are associated with neurofibromatosis
Mongolian spots – large gray or blue-green, irregularly shaped macules or patches caused by melanocyte infiltration of the dermis; generally found on the buttocks and flanks but they may extend over the back and shoulders; they have no pathologic significance and usually fade by school age, but may persist to adulthood
Pigmented nevus – dark brown or black macule or patch that occurs anywhere on the body, but most commonly on the lower back or buttocks; they are of variable size and depth of presentation and may be hairy; these lesions are generally benign, but malignant changes may occur in up to 10% thus warranting close observation for changes in size or shape
Nevus simplex (telangiectatis nevus) – flat, irregularly bordered pink macule composed of dilated and distended capillaries; they blanch with pressure and frequently become more prominent with crying; found most often on the nape of the neck (stork’s bite) or the bridge of the nose, upper eyelids and upper lip (angel’s kiss); usually fade by the second year of life, although those on the nape of the neck may persist
Port wine stain (nevus flammeus) – flat, nonblanching pink or reddish purple lesion with sharply delineated edges composed of dilated, congested capillaries directly below the epidermis; they can vary greatly in size and may appear on any part of the body, but most often occur on the face (those situated over the trigeminal nerve may be associated with Sturge-Weber syndrome); they neither grow in size nor resolve spontaneously and should be considered permanent unless laser surgery is attempted
Strawberry hemangioma – raised, lobulated, soft, and compressible bright red tumor with sharply demarcated margins; composed of dilated capillaries with associated endothelial proliferation in the dermal and subdermal layers; they generally increase in size the first 6 months and then gradually regress over the next several years; usually no treatment is required, but if the lesion interferes with vital functions or presents a risk of bleeding, systemic corticosteroids may be helpful
Cavernous hemangioma – large, raised, lobulated, soft, and compressible bluish-red tumor with poorly defined margins; composed of large venous channels and vascular elements lined with endothelial cells in the dermal and subcutaneous layers; they generally increase in size the first 6-12 months and then gradually involute; despite their appearance, these lesions are generally benign, but may indicate syndromology when associated with thrombocytopenia (Kasabach-Merritt syndrome) or limb hypertrophy (Klippel-Trenaunay-Weber syndrome); usually no treatment is required, but if the lesion interferes with vital functions or presents a risk of bleeding, systemic corticosteroid may be helpful
Petechiae – purplish red, pinpoint macules that do not blanch with pressure; caused by subepidermal hemorrhage; when found on the presenting part, they are the result of pressure during the descent and rotation of birth; usually fade within 24-48 hours, however if they continue to develop or are found on non-presenting parts, they may indicate trauma, infection or a bleeding disorder
Forceps mark – red, bruised or abraded area on the cheeks, scalp and face of infants born after application of forceps; when seen, examination for facial palsy or other birth trauma should be intensified
Chignon effect of vacuum extractor – circular abrasion with localized area of scalp edema after application of the suction cup for vacuum extraction; most resolve spontaneously
Subcutaneous fat necrosis – sharply defined subcutaneous nodule that may have a reddish or purplish discoloration; most often due to traumatic pressure (e.g., forceps, bony pelvis); generally appears during the first few weeks of life then gradually reabsorbs over a period of weeks to months
Sucking blister / callous – vesicle or bulla filled with clear, serous fluid that may easily rupture; caused by vigorous sucking, either in utero or after birth; consequently they are typically found on the lips, fingers, or hands; healing is spontaneous and no therapy is required
Other self-induced lesions – most frequently, these consist of little more than unintentional fingernail scratches; however infants that are irritable, restless, or in pain (e.g., neonatal abstinence syndrome) may fitfully rub against bed linens producing red, abraded or excoriated areas on prominent body parts
Abscess – localized collection of pus in a cavity; fetal monitoring sites are predisposing sites; incision and drainage is usually sufficient therapy, however the exudate should be cultured to direct antibiotic therapy
Thrush – adherent white patches on the tongue and mucous membranes; caused by Candida albicans which requires treatment with and oral form of nystatin (mycostatin)
Candida diaper dermatitis – moist, erythematous rash consisting of small white or yellow pustules; caused by Candida albicans which requires treatment with a topical form of nystatin (nystatin cream); differentiated from common diaper rash by its symmetrical distribution, the presence of satellite lesions, and the involvement of skin folds
Herpes simples virus – vesicles or pustules on an erythematous base which ulcerate and crust over rapidly; commonly seen in a cluster or linear arrangement; positive maternal history or CNS signs/symptoms raise the index of suspicion; treatment includes use of an antiviral agent (acyclovir)
Other congenital viral lesions – many of these infections (e.g., CMV, rubella) present with a combination of jaundice, petechiae, and/or purpura (slightly mounded, reddish-purple hemorrhagic spots resembling a “blueberry muffin”)
HEAD – measure occipital-frontal circumference (OFC); note any asymmetry or appearance out of relationship to the rest of the face and body; palpate fontanels and sutures; inspect hair for color, texture, distribution, and directional patterns
Size & Shape:
Microcephaly – abnormal smallness of the head (OFC < 10th percentile for GA); generally due to poor brain growth; it can be an isolated finding or it may be associated with genetic syndrome or congenital infection
Macrocephaly – excessive head size (OFC > 90th percentile for GA); may be associated with hydrocephalus, hydrancephaly, dwarfism, or osteogenesis imperfecta
Molding – temporary asymmetry of the skull resulting from the birth process; infants delivered from vertex presentation typically exhibit a cone-shaped distortion resembling the configuration of the birth canal; infants delivered from breech presentation typically exhibit an egg-shaped distortion conforming to the shape of the uterine fundus; both generally resolve within a few weeks
Caput succadaneum – diffuse edema of the soft tissues of the scalp caused by pressure on the head that was sufficient to restrict venous and lymph flow; the swelling has poorly defined edges, pits on pressure, and typically crosses suture lines; the swelling is maximal at birth but usually resolves within a few days
Cephalhematoma – collection of blood between the periosteum and skull (subperiosteal hemorrhage), generally resulting from birth trauma; the edges are clearly demarcated and never extend across suture lines; it is generally not apparent at birth, but is noted in the first day or two of life; initially it feels taunt but becomes fluctuant as the hematoma liquefies; resolution can take weeks to months; associated depressed skull fractures are very rare
Anterior fontanel (AF) – diamond-shaped space at the intersection of the metopic, coronal, and sagittal sutures; size varies from barely palpable to 4-5 cm across and generally closes by 18-24 months; an unusually large AF can be associated with hypothyroidism; a tense or bulging fontanel in a non-crying baby may be a sign of increased intracranial pressure while a sunken fontanel is a sign of severe dehydration
Posterior fontanel (PF) – triangular-shaped space at the intersection of the sagittal and lamboidal sutures; size varies from barely palpable to 1-2 cm across and generally closes by 2-3 months of age
Third fontanel – defect of the parietal bone along the sagittal suture; it may appear to be, but is not, a true fontanel; usually a normal variant but may be associated with Trisomy 21 or congenital hypothyroidism
Sutures – fibrous joints between the bones of the skull that are normally approximated and mobile; in the case of molding, they may be overriding or split up to 1 cm; excessively wide sutures may indicate increased intracranial pressure
Craniotabes – area of soft bone along a suture line; due to prolonged pressure on the cranium which interferes with bone mineralization; on palpation, pressing on the bone elicits a snapping sensation similar to pressing on a ping-pong ball; it is usually a normal variant that generally disappears within a few weeks, but may be associated with hydrocephalus, syphilis, or rickets
Craniosynostosis – premature closure of one or more sutures, resulting in an abnormal head shape; on palpation, the suture generally feels ridged and is immobile; it may be an isolated occurrence or may be associated with genetic syndromes or metabolic disorders (e.g., scaphocephaly due to craniosynostosis of the sagittal suture; brachycephaly due to craniosynostosis of the lamboidal sutures)
Hair & Scalp:
Hypertrichosis – abnormally excessive growth of hair; may be associated with some syndromes (e.g., Cornelia de Lange syndrome)
Low hair line – hair below the neck creases, particularly at the lateral margins; suggests genetic aberration (e.g., Turner syndrome)
Cutis aplasia (punched-out scalp defect) – absence of some of all of the layers of the skin resulting in an area that is bald and/or ulcerated; may be an isolated defect but is generally associated with Trisomy 13; treatment consists of keeping the area clean and dry (use of antibacterial dressings may be helpful) but large defects may require surgery
Whorl – spiral hair growth pattern associated with stretching of the scalp during brain growth; one or two hair whorls in the posterior parietal region is normal, however an abnormally placed whorl, absence of a whorl, or presence of > 3 whorls suggests abnormal brain growth and mental retardation
Nonconcordant or nonuniform color – reddish or blond hair in a baby of a dark-skinned race may indicate albinism; random patches of white hair may be familial, but a white forelock is associated with Waardenburg syndrome
EYES – observe shape, size and position of eyes; note integrity and color of iris and sclera; an ophthalmoscopic exam should be performed to assess pupillary size and reflex as well as the red retinal reflex
Strabismus – crossed-eyes appearance due to muscular incoordination; disappears within a few months of age
Nystagmus – rapid, searching movement of the eyeballs; usually disappears within a few months of age
Hypertelorism – eyes too widely spaced with greater than a palpebral fissure length between them; may be associated with mental retardation and a number of syndromes including chromosomal anomalies
Mongolian slant – upslanting palpebral fissures; outer canthus is higher than the inner canthus; common in Asian infants but may suggest Trisomy 21 in other ethnic groups
Epicanthal folds – a vertical fold of skin on either side of the nose that covers the inner corner of the eye; may give the appearance of pseudostrabismus; epicanthal folds with a mongolian slant are common in Asian infants but may suggest Trisomy 21 in other ethnic groups
Conjunctival / Subconjunctival hemorrhage – bright red area on the sclera near the iris; resulting from the rupture of a capillary in the delicate membrane that covers the eyelids and exposed surfaces of the sclera; can occur spontaneously, but is more common with traumatic delivery; usually resolves within a few weeks
Coloboma – keyhole defect typically occurring on the lower portion of the iris; associated with other anomalies
Brushfield spots – white specks scattered linearly around the circumference of the iris; may be a normal variant but are typically associated with Trisomy 21
Opacity of the lens or cornea – lack of the normal red reflex which may imply congenital cataract (most commonly associated with the TORCH viruses), retinoblastoma, or glaucoma
NOSE – observe size and shape; note placement of the septum and formation of the nasal bridge; verify patency
Flat nasal bridge – failure of formation gives the appearance of flat facies; may be associated with Trisomy 21
Deviated septum – may be due to true dislocation of the triangular cartilage or may be an optical illusion caused by asymmetry of the soft tissue secondary to position in utero; if the nares remain asymmetric when the tip of the nose is pushed to midline, the septum is dislocated and will require treatment
Choanal atresia – a congenital anomaly in which there is a membranous or bony obstruction of one or both of the posterior nasal passages; if bilateral, the infant will be cyanotic at rest and pink when crying; an oral airway (or intubation) may be required to establish adequate ventilation; must be differentiated from other causes of local obstruction (e.g., edema, glioma)
Nasal pit – an abnormal sinus or channel; as with any midline lesion on the head or back, one should check to be sure this does not represent the end of a tract that communicates with the CNS (danger signs include hairs implanted in the pit, fluid emerging from its depths or any underlying bony defect or cystic mass)
MOUTH - observe shape and symmetry of movement; note the definition of the philtrum and the size of the jaw; inside the mouth, examine the tongue, palate and gums
Smooth philtrum – an indistinct philtrum with thin upper lip and small palpebral fissures are classic features for fetal alcohol syndrome/effect
Micrognathia – small chin; associated with Robin sequence and other syndromes
Cleft lip + palate – unilateral or bilateral failure of closure of the frontal ridge; an absent or bifid uvula are lesser forms, indicating a submucous cleft palate; may be associated with other congenital anomalies
Macroglossia – large tongue which does not fit into the floor of the mouth; associated with Trisomy 21, Beckwith Wiedemann syndrome, hypothyroidism, and mucopolysaccharidosis
Ankyloglossia (tongue tie) – the frenulum on the underside of the tongue is short thus limiting movement of the tip of the tongue; if the tongue can protrude beyond the lips, no intervention is necessary as the tongue grows more rapidly than the frenulum and soon becomes freely mobile
Sublingual cysts – translucent or bluish swelling under the tongue; may be filled with mucus (mucocele) or salivary secretions (ranula); usually resolve spontaneously, but large ones that block the airway or interfere with eating need to be lanced or excised
Mucosal skin tag – a small appendage or tag on the oral mucosa; these are benign and recede spontaneously
Natal teeth – neonatal teeth or eruption cysts usually seen in the lower incisor region; they may cause ulceration of the infant’s tongue and pain with feeding, and there is presumed risk of aspiration; for these reasons, removal is generally recommended
Epstein’s pearls – small, whitish yellow clusters of epithelial cells seen at the junction of the hard and soft palates and on the gums; they are of no clinical significance and usually disappear by a few weeks of age
EARS – inspect for maturity, symmetry, size, and position; response to sound should also be noted; because the external auditory canal typically contains vernix, the otoscopic examination is usually deferred
Low set – superior helix falls below the canthal line of the eyes; due to failure of the primitive ear to migrate toward the crown of the head; common in many syndromes, most notably those involving the renal system
Posteriorly rotated – angle of placement is > 10-20O from vertical; due to failure of the primitive ear to migrate to the vertical axis; common in many syndromes, most notably those involving the renal system
Preauricular skin tag (cutaneous tag) – a small skin outgrowth usually in front of the ear; thought to be an embryological remnant of the first brachial cleft; may be familial or associated with other anomalies (renal)
Preauricular sinus (cutaneous pit) – an abnormal channel usually situated on the anterior portion of the ear; may be familial or associated with other anomalies (renal); may be blind, but if it communicates with the internal ear or the brain, chronic infection is likely
Darwinian tubercle – a normal variant appearing as a small nodule on the upper helix of the ear
NECK – note shape, range of motion, and any webbing; palpate for masses
Webbing – redundant skin at the posteriolateral portion of the neck; associated with Turner, Noonan, and Down syndromes
Cystic hygroma – lateral neck mass caused by development of sequestered lymph channels which dilate into large cysts; upon examination, the mass is soft, fluctuant, and appears translucent on transillumination; size and range from only a few cm to massive and may cause feeding difficulties or airway compromise; very small lesions may regress spontaneously, but surgical resection is usually required
Torticollis (wry neck) – fibrous contraction of the sternocleidomastoid muscle, most likely caused by trauma or intrauterine constriction with persistent head position; it is not usually noticed until about 2 weeks of age when a small (1-3 cm), hard, immobile mass is felt in the midportion of the muscle; if left to progress, the infant’s head will begin to tilt toward the affected side with the chin pointing upward and away in the opposite direction; untreated, it results in facial asymmetry, limited neck rotation, and a compensatory raising of the shoulder; most cases resolve if physical therapy is instituted immediately, but some cases may require surgical correction
Brachial palsy – a functional paralysis of part or all of the arm, resulting from traumatic delivery with stretching injury to the brachial plexus; when seen, examination for diaphragm paralysis or other birth trauma should be intensified; treatment generally consists of immobilization of the arm in abducted position to relieve brachial tension; if the nerve roots have not been permanently injured, neurologic function will begin to return within several days or weeks of birth as hemorrhage and edema resolve
Erb’s palsy – damage to the upper spinal roots C5-C6, resulting in paralysis of the upper arm; the arm is held in a “waiter’s tip”; the moro reflex is absent, but the grasp reflex is normal
Klumpke’s palsy – damage to the lower spinal roots C8-T1, resulting in paralysis of the forearm and hand; the arm and hand lie passively at the infant’s side; both the moro and grasp reflexes are absent
Fractured clavicle – suspected when there is a history of difficult delivery; crepitance may be felt and decreased movement of the shoulder may be noted soon after birth, or the fracture may not be evident for weeks, until a callus has formed which can be palpated as a mass over the clavicle; most are greenstick fractures and will heal without treatment beyond immobilization of the arm in a natural, functional position across the chest and avoiding pulling on the affected arm
CHEST – observe chest shape and number and position of the nipples; auscultate breath and heart sounds
Breast hypertrophy – breasts in both male and female newborns may be enlarged secondary to the effects of maternal estrogen; the enlargement subsides over several months
Witch’s milk – milky secretions due to the influence of maternal estrogen; an unusual, but normal finding in both males and females, the secretions generally disappear in 1-2 weeks
Widely spaced nipples – distance between the nipples > ¼ of the chest circumference; may be indicative of Turner syndrome
Supernumery nipples – pigmented and/or raised areas generally located anywhere on a vertical line drawn through the true nipple; in black infants, these lesions are common and are not associated with underlying defects; in white infants, the lesions are rare and thought to be related to renal anomalies; if an accessory nipple is lateral to the nipple line in any infant, renal anomalies must be ruled out
ABDOMEN – observe size, contour and muscular development; assess state of the umbilical cord; auscultate bowel sounds and look for visible bowel loops or peristaltic waves; palpate liver, spleen, kidneys and groin and note any masses; inspect anus for position and verify patency
Liver – the liver edge is normally felt 1-2 cm below the right costal margin (RCM); a liver that is palpated beyond the midpoint between the xiphoid process and the umbilicus is considered enlarged and may indicate right-sided heart failure
Spleen – the spleen is not normally felt on palpation; a spleen tip felt > 1 cm below the left costal margin (LCM) is an indication of disease such as intrauterine infection and erythroblastosis
Kidneys – normally the inferior poles of both kidneys can be felt, however the right kidney may be obscured by the liver; they should be approximately equal in size (4.5-5.0 cm in the full term infant) and smooth to the touch; failure to void in the first 24 hours of life requires evaluation; urine should be pale yellow to almost colorless
Umbilical Cord – the cord is normally bluish white and gelatinous at birth, but darkens and shrivels as it dies, falling off within 10-14 days
Two-vessel cord (single umbilical artery) – the cord normally contains three vessels (two arteries and one vein); absence of one of the arteries may be associated with congenital anomalies of the cardiovascular or renal system
Omphalitis – inflammation of the umbilicus; redness with discharge and a foul odor are signs of infection
Granuloma – overgrowth of granulomatous tissue at the umbilicus when the cord separates; most common in infants with large, thick umbilical cords; may require silver nitrate cauterization to stop the oozing and to eliminate a possible site of infection
Drainage from the umbilicus after the cord drops off – some drainage may be noted from the umbilical stump (due to exudation from excessive granulation tissue), but if fluid rapidly reaccumulates after wiping the umbilicus, two disorders should be considered:
Patent urachus – persistence of an embryologic communication between the urinary bladder and the umbilicus; suggested by a clear discharge (urine) from an otherwise normal appearing umbilical cord
Omphalomesenteric duct – persistence of an embryologic duct between the ileum and the umbilicus; suggested by seepage of ileal liquid from the umbilical stump
Umbilical hernia – skin and subcutaneous tissue covered protrusion of part of the intestine at the umbilicus; it is seen with some frequency in LBW and African-American males; small hernias usually reduce spontaneously within the first two years of life, but intervention is required with strangulation of abdominal contents or large size
Diastasis recti – a palpable midline gap between the rectus muscles of the abdominal wall; bulging may be seen when the infant cries; a benign finding in the absence of a hernia
Inguinal hernia – a muscle wall defect that allows loops of bowel to enter the soft tissues of the groin, which in the male may pass into the scrotum and must be differentiated from hydrocele (see below); bowel incarceration and ischemic injury to the testis are potential complications necessitating surgical intervention
Perianal Area – note anal position and patency; there are equations that can be used to determine if the anus is displaced, but as a general rule, the anus should be at least a finger-breadth from the scrotum or fourchette; patency is assessed by digital examination using the gloved little finger (insertion of a rectal thermometer presents the risk of perforating the rectum and should not be performed for assessment purposes); failure to stool in the first 48 hours of life requires evaluation; initial stools are sticky black (meconium), changing to soft brown-green (transitional), and thereafter differing by the type of feeding
Imperforate anus (anorectal agenesis) – may occur at several levels; presence of meconium in the vaginal or urethral orifice suggests a rectovaginal or rectourethral fistula; surgical intervention is always necessary
Anal stenosis (type I) –anus or lower rectum is narrowed but patent
Anal membrane (type II) – anal opening covered by a membranous diaphragm
Anal agenesis (type III) – anus is clearly imperforate with bowel ending as a blind pouch
Anal atresia (type IV) – rectum and anus are present as blind pouches but are separated by a variable distance
GENITALIA – never assign gender without palpating for testes; in a presumed female, palpate the labia for testes; in a presumed male, if no testes are palpated in the scrotum or inguinal canal and you are unable to “milk” them down, you must consider ambiguous genitalia and obtain chromosomes
Male – observe penile size and location of the meatus; if the foreskin is intact, it should not be forced back but the urine stream should be observed to make sure the opening in the foreskin is large enough; if circumcised, the tip of the penis will look quite red for the first few days and a yellow secretion may be noticed (if the redness persists beyond one week or there is swelling or crusted yellow sores that contain cloudy fluid, there may be an infection); inspect scrotum for size, rugae and presence of testes
Hypospadius – abnormal location of the urethral meatus on the ventral surface of the penis; severity is dependent on the placement of the meatus: circumcision is contraindicated for repair
Glanular hypospadius - the urethral opening is located at the base of the glans; no surgical correction is necessary (unless desired for cosmetic reasons) and a urologic work-up is not necessary unless other genital abnormalities or dysmorphic features are noted
Penile hypospadius – the urethral opening is situated between the glans and the scrotum; requires urologic work-up and corrective surgery
Penoscrotal hypospadius – the urethral opening lies at the penoscrotal junction; requires urologic work-up and corrective surgery
Epispadias – abnormal location of the urethral meatus on the dorsal aspect of the penis; commonly associated with exstrophy of the bladder
Chordee – curvature of the penile shaft caused by fibrous tissue growth in an area of failed urethral development or by skin traction as seen in hypospadias or epispadias
Cryptorchidism – failure of one or both testes to descent into the scrotum; most undescended testes will descend by 3 months of age
Hydrocele – collection of clear fluid in the scrotum; caused by the passage of peritoneal fluid through a patent processus vaginalis into the scrotum or by the presence of peritoneal fluid that has not been reabsorbed; upon examination, the entire circumference of the testis can be palpated and the hydrocele appears translucent on transillumination (differentiating it from inguinal hernia); most resolve within the 6-12 months of life
Female – inspect for size and location of the labia, clitoris, meatus, and vaginal opening
Pseudomenses – whitish serosanguineous or bloody vaginal discharge; due to the influence of maternal hormone; may persist for up to 10 days
Hydrocolpos – collection of fluid in the vagina; when the hymen is imperforate, it may bulge secondary to the accumulation of vaginal secretions, creating the appearance of a cystic mass between the labia; treatment is by incision at the apex of the bulge
Vaginal tag – a small appendage or flap on the mucous membranes; common neonatal variation that usually disappears in a few weeks
BACK – observe curvature and integrity
Pilonidal dimple - midline dimple in the lumbosacral region; may terminate in the subcutaneous tissue, a cyst, or a fibrous band or it may extend into the spinal cord and be associated with spina bifida
Spina bifida – defect in closure of the neural tube that is associated with malformations of the vertebrae + spinal cord; the type and degree of neurologic deficit is determined by the nature, location and size of the lesion
Spina bifida occulta – meninges and spinal cord are normal and the defect is covered by skin; most individuals have no problems and the defect may go unrecognized unless tufts of hair, lipomas, dimples, or other abnormalities are noted along the spine
Spina bifida cystica – vertebral defect characterized by a cystic sac containing meninges and/or spinal cord elements
Meningocele – the sac contains meninges and CSF , but the spinal cord and nerve roots are in their normal position
Myelomeningocele – sac contains spinal cord, or nerve roots, or both, in addition to meninges and CSF
EXTREMITIES – examine the hands, arms, and legs with close attention to the digits and palmar creases; length, contour, symmetry, size, and range of motion should be evaluated
Polydactyly (supernumerary digits) – extra digits on the hands or feet; frequently a familial tendency; treatment depends on the extent of the anomaly
Oligodactyly – presence of fewer than five digits on one or more extremities
Syndactyly – congenital webbing of the fingers or toes; frequently a familial tendency
Absent or aberrant nails – the fingernails of the full-term infant usually extend beyond the nail bed; spoon-shaped, dysplastic, hypoplastic, or absent nails are manifestations of a number of syndrome
Amniotic bands (Stretter dysplasia) – disruption of normal tissue caused by stips or bands of amnion; may range in severity from constriction defects of the soft tissue to congenital amputation or cleft
Clinodactyly – permanent lateral or medial curvature of one or more fingers (most commonly the 5th)
Camptodactyly – permanent flexion contracture of one or more fingers
Peculiar fisting – characteristically flexed fingers, with flexion contracture of the two middle digits, which are overlapped by the flexed thumb and index and little fingers; associated with Trisomy 18
Transverse palmar crease (simian crease) – single flexion crease due to hand closure without the thumb and fingers in apposition; it is suggestive of Trisomy 21, but may be a normal variant
Hammertoe – short metatarsal with dorsiflexion of hallux
Sandal gap (thong sign) – deep crease or wide gap between great and 2nd toe is a typical finding in Trisomy 21; the feet are broad and short and the plantar surfaces are creased with a deep long furrow
Rocker-bottom feet – as name implies; associated with Trisomy 18
Talipes equinovarus (clubfoot) - bony malformation with the foot turned downward and inward; must be differentiated from positional deformation; in the case of true clubfoot, orthopedic treatment is necessary
Congenital hip dislocation – suggested by asymmetric gluteal folds, positive Allis’s sign (discrepancy in knee height), &/or positive Ortolani’s or Barlow’s signs (palpable “clunk” of the femoral head as it slips into or out of the acetabulum); treatment consists of placement in a Pavlick harness or casting + traction
Sucking reflex - stroking the lips causes the infant to open mouth and begin sucking movements; disappears around 12 months
Rooting reflex – stroking the cheek and corner of the mouth causes the infant to turn the head toward the stimulus and the mouth should open; usually disappears at 3-4 months
Palmar reflex (grasp reflex) – stroking the palm of the hand with a finger should cause the baby to grasp the finger; the grasp will tighten with attempts to withdraw the finger; usually disappears at 2 months
Moro reflex (startle reflex) – in response to the sensation of loss of support, the infant will demonstrate first a spreading of the arms with open hands, followed by a hugging movement with closing of the fist; usually disappears at 4-6 months
Tonic neck reflex – with the infant in a supine, neutral position, turning of the head to one side should cause the baby to assume a “fencing position”; usually disappears at 7 months
Stepping reflex – when the infant is held upright and one foot is allowed to touch flat on a surface, the infant will step with one foot and then the other in a walking motion; after the reflex diminishes (3-4 months), the infant will not attempt stepping motions until it is ready to stand and walk
Truncal incurvation reflex - with the neonate in ventral suspension, stroking parallel to the spine will cause the pelvis to tilt toward the side of the stimulus; disappears at 3-4 months
Babinski toe reflex – the infant will hyperextend and fan its toes apart when the sole of the foot is stroked from the heel upward and across the ball of the foot; usually disappears at 12 months
Cranial Nerve Function
II, III, IV, VI Optical blink reflex - shine light
in open eyes, note rapid
Regards face or close object.
Eyes follow movement.
V Rooting reflex, sucking reflex.
VII Facial movements (e.g.,
Wrinkling forehead and
nasolabial folds) symmetric
when crying or smiling.
VIII Loud noise yields Moro reflex.
Acoustic blink reflex - infant
blinks in response to a loud
hand clap 30 cm (12 in) from
head. (Avoid making air
Eyes follow direction of sound.
IX, X Swallowing, gag reflex.
XI Head turns normally from side
to side, shoulder height is
XII Coordinated sucking and
swallowing. Pinch nose,
infant's mount will open and
tongue rise in midline.
90% of newborns with 3 or more minor malformations have one or more major defects as well
Scalp & Hair: punched out scalp defects
multiple hair whorls
hirsutism (not secondary to failure to thrive)
Ocular: epicanthal folds in varying degrees
lateral displacement of inner canthi
upslanting or downslanting palpebral fissures
true ocular hypertelorism (widely spaced)
Auricular: cutaneous tags or pits
incomplete helix development
lack of lobulus
low set ears
Hands: single transverse palmar crease
bridged (modified transverse) palmar crease
short and broad nails
narrow hyperconvex nails
hypoplasia of nails
asymmetry of fingers
clinodactyly (short incurved 5th finger)
camptodactyly (flexion contracture)
Feet: asymmetry of toes
clinodactyly (lateral or medial deviation of toes)
short metatarsal with dorsiflexion of hallux (hammertoe)
hypoplasia of nails
short, broad toe nail
deep crease or wide gap between great and 2nd toe (sandal gap)
Miscellaneous: aberrant frenulae of mouth
mild pectus excavatum (funnel chest)
scrotum extends distally on penis
labial hypoplasia with prominent clitoris
deep dimples or bony promentorils
deep sacral dimple
Do NOT count: capillary hemangioma (nevi simplex) of neck, forehead, or eyelids
incompletely outfolded helix of ear
darwinian tubercle of ear (small nodule on the upper helix)
mild to moderate inbowing of lower legs
shallow sacral dimple
mild syndactyly of 2nd and 3rd toes
hydrocele of testis
Adapted from: Smith DW (1976). Recognizable Patterns of Human Malformation. Philadelphia: WB Saunders.
Trisomy 21 (Down Syndrome):
Clinical Incidence: 1 in 600 overall, but risk increases with maternal age
Genetics: complete trisomy occurs in 95% (the remainder are unbalanced translocations and mosaicism)
features: short stature, muscular hypotonia, flattened occiput, flat face with depressed nasal bridge, mongoloid slant of eyes, epicanthal folds, Brushfield’s spots, high/arched palate, protrusion of the tongue, square-shaped hands with broad, short fingers (incurved 5th finger and low set thumb), transverse palmar crease (simian crease), deep crease or wide gap between great and 2nd toe (sandal gap), congenital heart (usually VSD) and other defects (umbilical hernia, duodenal atresia)
Course and prognosis: mildly to severely mentally retarded (IQ 25-75), although social performance is often beyond that expected for mental age
Trisomy 18 (Edward Syndrome):
Incidence: 1 in 3,500 live births; female to male ratio is 3:1
Genetics: complete trisomy occurs in 90% (the remainder are unbalanced translocations or mosaicism)
Clinical features: low set and/or abnormally shaped ears, micrognathia and microstomia, peculiar fisting, rocker bottom feet, congenital heart (usually VSD with PDA) and other defects (hernias, GU)
Course and prognosis: about 95% abort spontaneously; of those born live, 30% die within 1st month and 50% by 2 months (usually from heart failure); only 10% survive the 1st year with severe mental retardation
Trisomy 13 (Patau Syndrome):
Incidence: 1 in 5,000 live births
Genetics: complete trisomy occurs in 80% (the remainder are translocations)
Clinical features: microcephaly with sloping forehead and wide sagittal sutures and fontanels, punched out scalp defect, microphthalmia, hypertelorism, coloboma, cataracts, broad/flat nose, cleft lip + palate, malformed ears, clenched fingers with abnormal posturing of hands and wrists, polydactyly, simian creases, rocker bottom feet, cutaneous hemangiomas, congenital heart (usually VSD, PDA, or rotational anomalies) and other defects (hernia, omphalocele, GU), seizures
Course and prognosis: 44% die within the 1st month; 69% die by 6 months; and only 18% survive the first year with severe mental retardation
Turner Syndrome (XO):
Incidence: 1 in 5,000 (the most common abnormality in abortuses)
Genetics: complete monosomy occurs in 60% (the remainder have a structural variant of the X or mosaicism)
Clinical features: short stature, micrognathia, low set and sometimes malformed ears, webbed neck, low posterior hairline, lymphedema of hands and feet; widely spaced hypolastic nipples on a shield-shaped chest, congenital heart (usually coarctation of the aorta or aortic vavular stenosis) and other defects (gonadal dysplasia, GU)
Course and prognosis: while a severe defect prenatally, it is relatively benign after birth; intelligence is normal although there may be learning difficulties; cyclical estrogen replacement therapy will be indicated during adolescence and adult life to induce development of secondary sexual characteristics
Fetal Alcohol Syndrome (FAS):
Incidence: 1 in 600
Etiology: maternal alcohol consumption (outcome is associated with chronicity and amount of alcohol use)
Clinical features: microcephaly, short/small palpebral fissures, epicanthal folds, highly arched lateral eyebrows, flat midface with short/upturned nose, smooth/indistinct philtrum, thin upper lip, micrognathia, minor ear anomalies
Course and prognosis: variability in physical features presents a diagnostic dilemma; sometimes these children look perfectly fine at birth with the facial features becoming easier to recognize at 1-2 months of age; by 3-4 years, CNS symptoms, ranging from developmental delay to behavior problems, usually become apparent; screening must therefore continue throughout early childhood
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