Introduction to the Newborn Physical Exam

The newborn physical exam is a vital part of pediatric healthcare, ensuring that the infant is healthy and free of any immediate medical concerns. This exam can be tricky because of two main challenges: the infant must remain warm, and crying may make it difficult to complete certain parts of the exam, like auscultation. However, by carefully following steps and guidelines, healthcare professionals can conduct thorough and efficient newborn assessments. In this article, I will walk you through the steps of a typical newborn physical exam, explaining each aspect and its significance.

Vital Signs and Growth Parameters

The first step in the newborn exam is assessing vital signs and growth parameters. This includes measuring the baby’s height, weight, and head circumference. These numbers provide essential insights into the baby’s growth and help plot percentiles, which are key for tracking development.
Next, you check the vital signs. In a healthy newborn, the heart rate typically falls between 90 and 160 beats per minute. The respiratory rate is higher than in older children and adults, often between 30 and 60 breaths per minute. Blood pressure is generally not taken unless the infant is unwell, as it can be difficult to measure in newborns. One of the most important measurements is the pulse oximetry, especially within the first 24 hours of life. It’s normal for the oxygen levels (pulse ox) to start as low as 60% at birth and gradually increase to about 90% by the end of the first day. By the second day of life, these levels should stabilize around 100%.

Head Exam and Skull Sutures

After taking the vitals, the next part of the exam focuses on the baby’s head. Feel the skull sutures — these are the soft spots between the bones of the skull. Shortly after birth, the sutures may feel slightly elevated or overlapping, which is normal and should resolve within a short time. The two fontanelles (soft spots) on the baby’s head, one at the front and one at the back, should also be palpated. Any unusual findings, like asymmetries or firmness, could suggest a condition such as craniosynostosis.

Eye and Ear Assessment

Moving on to the eyes, the red reflex test is essential. This test helps check for several possible conditions, including slipped lenses or retinal abnormalities like retinoblastoma. An absent red reflex could indicate a problem that requires further investigation. The irises should also be examined for signs of conditions like coloboma, which could indicate a syndrome such as CHARGE.
For the ears, draw an imaginary line from the eyes to the ears. The top of the ear should align with the outer corner of the eye. Any deviations, such as low-set or rotated ears, may indicate genetic syndromes. Ear tags or pits could also be associated with other conditions, including kidney issues.

Mouth and Neck Examination

The mouth exam involves checking for abnormalities such as a cleft palate. While you may spot a cleft palate visually, it’s also important to palpate the roof of the mouth to detect high arches or other hidden issues. During this exam, you should also assess the baby’s sucking reflex, which is crucial for feeding and part of the neuro exam.
The nose should be inspected for blockages, as newborns primarily breathe through their noses. If a tube cannot pass through the nasal passages, this could indicate a condition like choanal atresia, which requires immediate attention.

Chest, Abdomen, and Heart Auscultation

After examining the head and neck, the chest and lungs are next. Auscultation of the heart and lungs is a key part of the exam, though it can be tricky if the infant is crying. In fact, many newborns have murmurs within the first day of life, which are typically benign.
In the abdominal exam, it is normal to palpate the liver, spleen, and kidneys. A palpable liver is not concerning unless it extends more than three centimeters below the costal margin. Checking for an imperforate rectum is also essential, as it could indicate a serious condition requiring surgery.

Genitalia, Extremities, and Reflexes

Examining the genitalia is important for detecting any abnormalities. In some cases, ambiguous genitalia may suggest a condition like congenital adrenal hyperplasia, which would require further investigation.
For the extremities, count the baby’s fingers and toes, checking for syndactyly (fused digits) or polydactyly (extra digits). You should also check the hips for stability using the Ortolani and Barlow maneuvers, which help detect hip dysplasia. Examining the spine for sacral dimples or tufts of hair is also important, as these could suggest spinal abnormalities.

Neurological Exam

Finally, the neurologic exam assesses the baby’s reflexes. The suck reflex has already been checked, but you also need to assess the rooting reflex, where the baby turns its head towards a stimulus near its mouth, and the grasp reflex, where the baby grasps your finger. The Moro reflex, or startle reflex, involves gently lowering the baby’s head and watching for their arms to spread outward, then return inward.
The deep tendon reflexes are another part of the neuro exam. A little clonus in the newborn’s heels is normal, but any persistent abnormalities should be noted.

Conclusion

Conducting a newborn physical exam involves multiple steps, each important for ensuring the baby’s health and development. From checking vital signs and growth to assessing reflexes and organ function, every part of the process contributes to a comprehensive picture of the baby’s well-being. I’ve found this process insightful and have learned that others have had similar experiences. If you’re interested in learning more, you can check out this detailed video on YouTube: Newborn Physical Exam.