Neonatal examination is one of the common short cases in pediatric clinical exams. All medical undergraduates should be able to perform a thorough baby check. If there is ever a shortage of children with impressive signs around the examination time, there is always a ready supply of neonates in postnatal wards ideally suited for doing a comprehensive baby check. Sometimes these newborns can be mild icteric or there can be one or more common newborn skin rashes.
The neonatal examination is standard irrespective of the gestation of the infant. Babies are quieter at beginning of exam so always it's a good idea to start with your inspection. You may auscultate the heart first before palpating anywhere else and disturbing the baby. Certain checks may be approached in somewhat opportunistic fashion. For example, if the baby's eyes are open when first approached, check the eyes and red reflexes.
If the baby yawns or cries with a wide open mouth, take your torch and check the oral cavity. Before you start your examination, it's important to prepare yourself. You will need a tape measure to check the head circumference, torch and tongue depressor to look inside the oral cavity, and the stethoscope to listen to the baby's heart sounds. Offer to perform fundoscopic examination.
Obtain consent from the mother and make sure to clean your hands thoroughly and wear gloves if available and keep the baby warm at all times and warm your hands as well before touching the baby. Let's look at this video where a healthy term newborn is examined to rule out congenital abnormalities and for the purpose of demonstration a running commentary is also given. You begin your examination with inspection of the baby. Look for any evidence of respiratory distress, presence of icterus or presence of any subtle or obvious dysmorphic facial features or body features.
It is recommended that you follow a head-to-toe approach so that there is a limited chance that you will miss any important physical signs or congenital abnormalities. First, Look at the scalp, the head and look for the anterior fontanelle and feel the anterior fontanelle for the size and feel for the posterior fontanelle and then feel along the suture lines and look for any evidence of wide suture separation or ridging and other important physical signs include presence of a kefal hematoma. which is identified by presence of a swelling which is demarcated by the skull bones. And you may also notice a caput if the child had a prolonged engagement during the second stage of labour.
Look at the face of the child, look for any abnormalities in the eye. Child may have cataract, child may have other pupillary abnormalities like aniridia and then look for evidence of low set ears. The ears are identified as low set or normally set based on an imaginary line drawn from the medial canthus to the lateral canthus and then extending that line. across the ears and in a normal baby, one third of the ear will go beyond that plane. But if the baby's ears are low set then the most part of the ear will go below that imaginary line.
After that proceed to examine the oral cavity. The important things The important things that you will appreciate include presence of a tongue tie or presence of neonatal or natal teeth and in hard palate you may also appreciate presence of Epstein pearls and it is important to use your finger and then feel along the heart palate to look for any evidence of a cleft palate. Next, proceed to examine the neck.
Palpation along the neck is important, especially children with sternomastoid tumors. You may be able to appreciate the mass along the line of the sternomastoid muscle. And then feel the two clavicles on either side to rule out any evidence of a clavicle fracture.
Feel along the clavicles to rule out any evidence of a fracture. Examine the hands of the baby. Look for any evidence of polydactyly or syndactyly and sometimes you will see other congenital abnormalities like incurving of the small finger.
indicating a clinodactyly and also look for any evidence of abnormal palma creases like a simian crease and look at the arm and the forearm to look for any abnormalities. The next is to examine the precutia. Look for any evidence of chest abnormalities like pectus excavatum or pectus carinatum and look for any abnormalities in the nipples and auscultate for the heart sounds. Then proceed to examine the abdomen.
Look for evidence of abdominal distension. Sometimes you may notice a scaphoid abdomen in the presence of a diaphragmatic hernia. And look at the umbilical cord and then go down and feel along the inguinal region for the hernial orifice that might indicate the presence of a inguinal hernia.
Feel the femoral pulses and when you feel the femoral pulses also feel the radial pulses together so that you will be able to appreciate a radiofemoral delay in the presence of a coarctation of aorta. Next proceed to examine the genitalia and sometimes you will appreciate ambiguous genitalia and in a boy make sure that the both testicles have descended into the scrotum and the penis is of the normal size and then look at the anus for any external abnormalities. Look at the lower limb and then come to feet. Look for any asymmetry in lower limbs.
and you might be able to appreciate cyanosis and look at the creases and other important abnormalities include presence or absence of any defects like talipes or calcaneovirus deformities. Next turn the baby over and feel along the spine. Feel along the spine.
So palpation along the spine is important so that you may you will not miss spina bifida and look for any abnormalities or signs of occult dystrophism including presence of any types of hair, like homa or presence of absence of other obvious abnormalities like meningocele and meningomyeles here. And it is also important to look at the hip joint and then rule out any evidence of dislocated hips. We do two tests, which are called Balu's test and Ottolani's test. In Balu's test, you try to see whether the child's hip joint is dislocatable.
And in Ottolani's test, you try to recognize a dislocated hip joint. To perform Barlow's test, it is recommended that you hold the two hips in this pair with thumbs on the medial side and the other fingers on the lateral side and you test one hip joint at a time. To perform the Barlow's test, you have to do the adduction and then slightly backward movement, the hip joint out of the capsule.
If the hip joint is dislocatable then with that movement, with your backward pressure and induction, you will be able to appreciate a hip plank and repeat the procedure in the other hip joint as well. In order to perform the Ottolani's test, you hold the hips in the same way like you held for demonstrating the Barlow's test with your thumbs on the medial side and the other fingers on the lateral side and then examine one joint at a time and then here you have to do the abduction and anterior movement of each joint. If the joint is dislocated you will be able to appreciate a clunk in the dislocated joint.
Next is to perform the fundoscopic examination. Again you use the fundoscope and then look each eye for the presence or absence of the red reflex. Absent red reflex will indicate presence of abnormalities such as congenital cataract and retinoblastoma. The next step is to look for presence of primitive reflexes.
This is called the Plant Grasp Reflex. It is also important to assess the maturity of the baby. The physical maturity of a newborn baby is assessed through several criteria. Look for the presence and the complexity of the plant increases and the level of development of the labia majora and then to the extent to which the minor is covered by the majora and in case of a boy look for the complexity of the presence of rugae in the scrotum are important and look at the breast bud which is again an important sign for as sing the maturity of the baby. And look at the skin and presence or absence of lanugo hair and look at the ear cartilage for the presence or absence of ear recoil.
I performed the newborn examination on this well-looking neonate. She looks adequately grown and I would like to plot her anthropometric parameters on her growth charts. She is pink, not etheric and has no respiratory distress. Her posture and quality of movement are that of a healthy term neonate.
Both anterior and posterior fontanelle are normal and there is no capillary hematoma or caput formation. Her facial appearance is normal including her eyes, ears and oral cavity. There are no abnormalities such as pre-auricula pits, tongue tie, natal teeth or cleft palate. Her neck examination is normal and there are no sternomastoid tumors or clavicular fractures.
Hands and feet are normal and there is no evidence of clinodactyly, syndactyly, simian creases or talopy sequinovirus. Both heart sounds are normal and there are no cardiac murmurs. There is no radiofemoral delay. There are no external chest abnormalities and the lungs are clear bilaterally.
Abdomen is not distended and there is no organomegaly. Hernial orifices are also normal. Genitalia are normal, anus is patent and normally positioned. Spine examination did not reveal any signs of occult spinal dystrophism. Both Ottolani and Barlow's tests are negative and are suggestive of normal hip examination.
Phendoscopic examination revealed normal red reflexes. Moro reflex is symmetrical. Based on my findings, I can conclude that this neonate is healthy and and I would like to reassure parents that routine newborn care is all.