Neonatal examination

What is a neonatal examination?

All babies born in the UK should have an examination within the first few days of life. This includes specific checks of the hips, heart, eyes and, for boys, the testes. The examination usually takes place within 72 hours of birth and again at 6-8 weeks of age.¹

Initial post-delivery examination

A brief screening examination should be conducted checking the face, eyes, mouth, chest, abdomen, spine and limbs to exclude major abnormalities. A strong cry and a widespread pink blush over the face and body are good signs that all is well.

Some children may be born with ambiguous genitalia. Ambiguous genitalia is a medical emergency and requires urgent assessment by a paediatrician.

If you have sufficient clinical experience, an orogastric tube should be passed when the neonate's mother has suffered polyhydramnios. This excludes oesophageal atresia.

The Apgar score

The Apgar score gives a reproducible, quantitative, semi-objective assessment of neonatal condition that is useful for assessing a baby's progress or deterioration immediately after delivery. It should be checked at one minute, at five minutes and, if needed, at ten minutes after birth.

Although UK practice still includes recording Apgar scores, it is not recommended that Apgar scoring be used to predict mortality or neurological outcome. Only a small proportion of babies with a very low Apgar score have significant neurodisability.²

All personnel attending deliveries in the UK are trained in neonatal life support (NLS) and follow the Resuscitation Council UK recommended assessment, which includes checking for colour, tone, breathing and heart rate after drying the baby with a warm towel. This is a better way of assessing the baby’s condition and resuscitation needs rather than the Apgar score.

Routine neonatal examination

Parent(s) have the right to decline all or part of the newborn and infant examination (NIPE). The reason for declining the examination should be recorded. The examination is increasingly done by NIPE-trained midwives in many hospitals, with much lower numbers being done by paediatricians. The examination may be performed by a GP and primary care team following home births. The recommended recording of the examination is now electronic. A paper copy of the electronic record is printed and attached in the red book for the parent’s benefit.

The National Institute for Health and Care Excellence (NICE) recommends that the aims of the examination should be fully explained to the parent(s) before it is conducted. NICE advises that the examination should be carried out within 72 hours of birth and incorporate:³

• A review of parental concerns and the baby's medical history.

• Family, maternal, antenatal and perinatal history.

• Fetal, neonatal and infant history, including any previously plotted birth weight and head circumference.

• Whether the baby has passed meconium and urine (and urinary stream in a boy).

• Other newborn screening tests as recommended by the UK National Screening Committee. These should also be carried out or arranged at this time.

The examination is best conducted in a well-lit, warm, private room with the mother in attendance and able to see and help with what is being done.

Suggested schema for screening neonatal examination

First wash your hands thoroughly to reduce the risk of cross-infection. Then:

Listen and observe

• Assess overall appearance. Note general tone, sleepiness and rousability. Observe general condition, proportions and maturity.

• Look carefully for evidence of jaundice (preferably in bright, natural light). Note whether there are any birthmarks, rashes or other skin abnormalities.

• Listen to the baby's cry and note its sound.

• Weigh the baby and plot this reading on its growth chart.

Perform a systematic 'head to toes' examination
This should be done carefully and in good light to detect abnormalities:

• Head:

  • Shape, presence of fontanelle and whether normal, sunken or bulging.

  • Measure and record head circumference on the growth chart.

  • Assess facial appearance and eye position.

  • Look for any asymmetry or abnormality of facial form.

• Eyes:⁴

  • Establish that they are of normal shape and appearance.

  • Check for presence of red reflex. If absent consider retinoblastoma.

  • Look for obvious cataracts or signs of ophthalmic infection.

• Ears:

  • Note shape and size.

  • Establish whether they are set at the normal level or 'low-set'.

  • Check patency of external auditory meatus.

• Mouth:

  • Check the colour of the mucous membrane; observe the palate.

  • Check suckling reflex by inserting a clean little finger gently inside the baby's mouth.

• Arms and hands:

  • Establish whether they are of normal shape and moving normally.

  • Look for evidence of traction birth injury (eg, Erb's palsy) by checking the neck, shoulders and clavicles.

  • Count the fingers and observe their shape; check for any evidence of clinodactyly (incurving of fingers).

  • Check palmar creases - whether they are multiple or single. A single palmar crease may be normal but can be a sign of Down's syndrome (trisomy 21).

• Peripheral pulses:

  • Check brachial, radial and femoral pulses for rate, rhythm and volume.

  • A hyperdynamic pulse may suggest patent ductus arteriosus.

  • A weak pulse may occur with a congenital cardiac anomaly (impairing cardiac output and in conjunction with other signs from the examination).

  • Check for radio-femoral delay (aortic coarctation).

• Heart:

  • Check the cardiac position by palpation and feel for any thrill or heave.

  • Listen to the heart sounds carefully and for any added sounds or murmurs.

  • Suspected abnormalities require further examination (and often more expert opinion and investigation).⁵

• Lungs:

  • Watch the respiratory pattern, rate and depth for a few seconds.

  • Look for any evidence of intercostal recession.

  • Listen for stridor.

  • Auscultate lung fields for added sounds.

• Abdomen:

  • Look at abdominal girth and shape.

  • Carefully check the umbilical stump for infection or surrounding hernia.

  • Palpate gently for organs, masses or herniae.

  • It is common to be able to feel the liver and/or spleen in healthy newborns.

  • Check the external genitalia carefully (see the separate Ambiguous Genitalia article).

  • Palpate for testes in boys.

  • Inspect the anus (establish whether meconium has been passed).

• Back:

  • Look carefully at the skin over the back and at the spinal curvature/symmetry.

  • Observe whether there is any evidence of spina bifida occulta or pilonidal sinus hidden by flesh creases or dimples.

  • Palpate the spine gently.

• Hips:

  • Specifically test for congenital dislocation of the hip (aka congenital hip dysplasia) using a combination of Barlow and Ortolani manoeuvres (follow the link for more detail) with timely onward referral.⁶

• Legs:

  • Watch movements at each joint.

  • Check for any evidence of talipes equinovarus.

  • Count toes and check their shape.

• CNS:

  • Observe tone, behaviour, movements and posture.

  • Elicit newborn reflexes only if there is cause for concern.

• Further examination should be conducted as necessary according to any abnormalities that are detected, or suspicions of undetected illness in the baby.

Record findings

• Always document the findings of the examination in the postnatal care plan and personal child health record. A proforma for the examination, kept within the notes, can save time and act as a prompt to ensure that no element of the examination is missed.

Other neonatal screening tests

See the separate Newborn Screening article.

Common abnormalities detected in the neonatal examination

• Capillary or macular haemangioma:
  

  • Also known as stork mark/bites, or salmon patch; found around the eyes and nape of the neck in 30-50% of babies.

  • Those around eyes normally disappear in the first year and commonly persist if on the nape of the neck.

• Blue-black pigmented area:
  

  • Also known as Mongolian blue spots; they are seen at the base of the back and on the buttocks. These are common in dark-skinned parents but can occur in white infants.

  • They normally disappear over the first year.

• Urticaria of the newborn:
  

  • This is most evident on day 2 as a fluctuating, widespread erythematous rash with a raised white/cream dot at the centre of a red flare, mostly apparent on the trunk.

  • This disappears spontaneously without treatment.

• Heat rash:
  

  • Also known as miliaria, this may appear as either red, macular patches or superficial, clear vesicles that are most marked on the forehead and around the neck.

  • It is associated with warm humid environments and will clear in cooler, drier conditions.

• Breast enlargement:
  

  • Seen in both girls and boys; the child may secrete a small amount of milk ('witches milk').

  • This is thought to be due to response to circulating maternal hormones.

  • It is not significant unless the condition persists/progresses.

• White pimples:
  

  • Also known as milia; they are seen on the nose and cheeks and are found in approximately 40% of newborns, due to blocked sebaceous glands.

  • These clear spontaneously.

• Oral cysts:
  

  • These are found on the palate near the midline and on the gums (also known as Epstein's pearls).

  • They may be larger and on the floor of the mouth.

  • They usually resolve spontaneously.

  • Teeth can be present at birth (no action is required unless they are loose or abnormal, in which case they may have to be extracted).

• Accessory skin tags:
  

  • Seen on the face as accessory auricles anterior to the ears.

  • They can be dealt with easily by a surgical team.

• Vestigial extra digits:
  

  • These can usually be dealt with easily by a surgical team.

• Sacral dimples:
  

  • These are common.

  • Examine carefully to detect underlying sinus or evidence of spina bifida occulta.

• Deformity of the shape of the head in the immediate postnatal period and following days is common:
  

  • Such 'moulding' is non-pathological and usually resolves spontaneously.

  • Assess whether there are any other craniofacial abnormalities.

  • Seek expert input if unsure.

Abnormalities that may indicate a significant underlying cause

• Any wide separation of the fontanelles, with presence of islands of bone (Wormian bones) may indicate cranial abnormalities caused by a range of congenital syndromes.

• A third fontanelle, found between the normal anterior and posterior fontanelles may indicate Down's syndrome.

• Abnormally shaped or placed ears may indicate fetal alcohol syndrome, craniofacial abnormalities due to abnormal branchial arch development or conditions such as Edwards' syndrome (trisomy 18) or congenital renal anomalies.

• A single palmar crease can indicate Down's syndrome but may be found in children who do not have this condition.

• Abnormalities of the face, jaw and ears are often associated with hearing dysfunction; hearing tests should be performed and ENT assessment requested.