Newborn Assessment by Hadi Hospital NICU.

NEWBORNNEWBORN
ASSESSMENTASSESSMENT
Full Term NewbornFull Term Newborn

General Appearance
APGAR is a quick test
performed on a baby at 1
and 5 minutes after birth.
•The 1-minute score
determines how well the
newborn tolerated the
birthing process.
•The 5-minute score tells the
doctor how well the newborn
is doing outside the mother's
womb.

General Appearance
Scoring
•0-3 points—the newborn is
serious danger and need
immediate resuscitation.
•4-6 points—the newborn’s
condition is guarded and
may need more extensive
clearing of the airway and
supplementary oxygen.
•7-10 points—are
considered good and in the
best possible health.

General Appearance
A. Head Circumference
Range: 32–37 cm (12.5–14.5 in)
Approximately 2 cm larger than chest
circumference
B. Chest Circumference
Average: 32 cm (12.5 in)
Range: 30–35 cm (12–14 in)
C. Body Length – Height
Average: 50 cm (20 in)
Range: 48–52 cm (18–22 in)
Growth: 2.5 cm (1 in) per month for first
6 months
D. Abdominal Circumference
Average: 32 cm (12.5 in)
Range: 31 to 33 cms
ANTHROPOMETRIC MEASUREMENTS

General Appearance
Weight
Average: 3405 g (7 lb, 8 oz)
Range: 2500–4000 g (5 lb, 8 oz–8 lb, 13 oz)
Physiologic weight loss: 5%–10% for term newborns, newborns
Growth: 198 g (7 oz) per week for first 6 months
Weight is influenced by racial origin and maternal

Gestational Age
Number of weeks that
have elapsed since the
first day of the last
menstrual period to the
time of birth.
This is usually retrieved
from mother’s Antenatal
History.

Gestational Age
• SGA- small for gestational
age-weight below 10th
percentile
• AGA-weight between 10 and
90th
percentiles (between 5lb
12oz (2.5kg ) and 8lb 12 oz
(4kg).
• LGA-weight above 90th
percentile
• IUGR-deviation in expected
fetal growth pattern, caused
by multiple adverse
conditions, not all IUGR
infants are SGA, may or may
not be “head sparing”
Classification of Size

Gestational Age
Physical Maturity
The physical maturity part of
the examination should be
done in the first two hours of
birth.

Gestational Age
Neuromuscular
Maturity – Ballards
The neuromuscular
maturity examination
should be completed
with 24 hours after
delivery.

Physical Examination - Skin
Milia
Petechiae

Facial Bruising
It is more common when there is a tight nuchal
chord, when the delivery is precipitous or difficult or
when the infant in bundled. This facial appearance
could be mistaken for cyanosis, but with a quick
comparison to the color of the rest of the body, the
diagnosis is obvious.
This type of bruising resolves over the course of
several days.
Perioral Cyanosis

Peeling
Meconium Stained

Forcep marksForcep marks
Vacuum Bruising

Jaundice

Physical Examination - Head
A baby's head is easily molded. Many newborns have
slightly lopsided heads. Sometimes a baby's head is
molded unevenly while passing through the birth canal.

Molding
This picture shows what
is usually noted
primarily on palpation:
the ridges that develop
when one bone slightly
overlaps the adjacent
one during delivery.
These overriding
sutures are part of
molding.
Complete resolution is
expected with time.

Breech Molding
With Breech positioning
in utero, the head is in a
position against the
uterine fundus. This
gives the newborn head
molding that is flat on
the top and elongated in
AP diameter.
As with any molding,
this appearance will be
improved significantly
over the next few days.

Bruising
Bruising of the vertex of the
head is a fairly common
finding in newborns.
The affected area may be
rather large (6-8cm is not
unusual) and may be
various shades of red and
blue.
In some cases, traumatic
blisters or bullae may be
present. If a scalp electrode
was used during delivery, a
small scab is often visible
is this area as well.
No treatment is required.

Caput Succedaneum
There is some molding
present here, but much
of what is frequently
mistaken for molding is
caput (scalp edema).
In the following photos,
the extent of the edema is
easily seen.

Caput Succedaneum
Firm, constant pressure
in one spot is the
easiest way to elicit the
characteristic of pitting
edema of caput.
In the following photo, the
extent of the edema is
easily seen.

After the pressure is
released, the pitting
indentation is clearly
seen. Although caput
can cross over suture
lines (since it affects the
scalp), it is often
predominantly or
entirely unilateral.
Evaluating for pitting
edema is a much more
useful diagnostic tool
than location.
The following day, caput is much less prominent. This is
consistent with the natural course of caput -- maximal at
birth, with rapid resolution over the next 24 - 48 hours

Cephalohematoma
When digital pressure is applied,
the fullness shifts from under the
finger to the surrounding areas.
In this photo, a bulge can be
appreciated anterior and
superior to the pressure point.
When pressure is released,
blood immediately refills this
area and the appearance (unlike
caput) is identical to the way it
was before.
In this baby, blood was
ballotable across most of the left
parietal bone.

Physical Examination - Eyes
Eyelid Edema
Most infants exhibit some
degree of eyelid edema after
birth. The puffiness may
make it seem that the infant
has difficulty opening one or
both eyes, but with a gentle
examination, the eye can be
easily evaluated.
Edema resolves over the
first few days of life.

Dysconjugate Eye Movements
Dysconjugate eye
movements is observed
when the eyes appear to
move independently.
Eyes may transiently
appear crossed or
divergent.

Subconjunctival hemorrhage
is a frequent finding in normal
newborns.
It results from the breakage of
small vessels during the
pressure of delivery.
The red area may be large or
small but is always confined
to the limits of the sclera.
Subconjunctival Hemorrhage

Congenital Glaucoma
This infant presented with hazy
bilateral corneal opacities on the
initial newborn exam.
The diagnosis of was relatively
easy as there was a strong family
historyof congenital glaucoma.
Congenital Cataracts
The opacities here occur
behind the pupil, as the pupil is
easily and clearly seen along its
entire circumference.

Physical Examination - Tongue
Ankyloglossia/Tongue-tie
Tongue-tie occurs in
approximately 4% of
newborns. Many babies
with this condition can
breastfeed without
difficulty, but in some
cases, a tight frenulum
makes latching on
difficult.

Physical Examination - Tongue
Epstein Pearl
The small papule seen in
the midline of the palate. It
represents epithelial
tissues that becomes
trapped during the palatal
fusion.
It is very common and
benign finding.

Physical Examination - Ears
Ears
Many variations in size and
shape exist within the label of
normal ear, but in general, the
normal ear is one in which all
structures (Helix, Antiehelix,
Tragus, Antitragus, Scaphoid/
Triangular fossa and external
auditory canal) are present and
well formed.

Ear Tag
A single, small ear tag is an
occasional finding on
physical examination. It is
often inherited as familial
trait.

Ear Pit
PREAURICULAR PITS are often a
subtle finding on Physical Exam.
They are located at a superior
attachment of the pinna to the face
and may be unilateral or bilateral.
Up to 10% of Asian infants will
have pits. They are less common
among Caucasians and African
Americans.
There is rare association between
ear pits and brachio-oto-renal
syndrome, so audiologic testing of
these infant is recommended. But
otherwise, this is considered
benign finding.

Stahl's Ear
Also known as Satyr ear, Spock
ear, or Vulcan ear, this deformity
of the pinna is characterized by a
flat helix at the superior pole, a
third crus extending into the helix,
and a flattened scaphoid fossa.

Lop Ear
This pinna deformity where
superior edge of the helix
is folded down. It may be
improved with Splinting.

Microtia
This pinna is not well formed
and is smaller than a normal ear.
Hearing evaluation is mandatory
in these infants and referral to
Paediatric ENT Specialist.

Physical Examination - Nose
NOSE
This picture shows a
normal nasal appearance.

Positional Nasal Deformity
An occasional finding on
Physicial exam is an
asymmetric appearance of a
nose due to a positional
deformity
Most likely, this results from
an unfortunate position in
utero.
The nares in this case are
assymetric and slightly
flattened towards the infant’s
right, eventhough the septum
is still centrally located.

Choanal Atresia
Appearance may LOOK NORMAL
outside but symptoms include:
1. Chest retracts unless the child is
breathing through mouth or crying
2. Difficulty breathing following birth,
which may result in cyanosis (bluish
discoloration), unless infant is crying
3. Inability to nurse and breathe at same
time
4. Inability to pass a catheter through
each side of the nose into the throat
5. Persistent one-sided nasal blockage
or discharge
Physical examination may show nasal obstruction.
Tests that may be done include:
1. CT scan
2. Endoscopy of the nose
3. Sinus x-ray

Physical Examination - Mouth
Micrognathia
Some babies are born with an
abnormally small jaw bone
(mandible is another name for the
lower jaw.)
This condition is called
micrognathia [my-kroh-NATH-ee-
ah] and can be associated with a
number of problems.
Infants with a small jaw can have
trouble eating and breathing. This
is because the small jaw pushes
the baby's tongue into the back of
the throat causing blockage of
breathing and swallowing.

Bohn’s Nodules
Bohn’s nodules are remnants of
dental lamina (cells which are
involved in tooth development)
They are normally found on the
labial (front) or buccal aspect of
the upper alveolar ridge.
Similar to Epstein pearls, there is
no form of treatment needed and
they will disappear over time.
Both Epstein pearls and Bohn’s
nodules are often mistaken as
neonatal teeth.

Neonatal Teeth
Natal teeth are present in the oral cavity
at the time of birth where as neonatal
teeth erupt during 30 days of life.
They might resemble normal primary
teeth in terms of size and shape.
However, they can be smaller, yellowish
and root formation of the teeth may not
be completed during the time of eruption.
The lack of root development at this stage
can usually cause the mobility of the
neonatal tooth.
Babies who have neonatal teeth are
often associated with syndromes such as
cleft lip and palate.
Neonatal teeth can be removed easily
with a cloth if they are interfering with
your breast feeding.

Physical Examination - Respiratory
Nasal Flaring
Nasal flaring is when the
newborn’s nostrils widen when
breathing.
It is often a sign that baby is
having difficulty of breathing.

Comparison: Common in newborn with Tachypnea.
A. Normal respiration. Chest and abdomen rise with inspiration.
B. Seesaw respiration. Chest wall retracts and abdomen rises with inspiration.
Physical Examination - Respiratory
In this photo, taken during inspiration, the
shadows between the ribs can be clearly seen.
Retractions may or may not occur in combination
with other signs of distress: nasal flaring, grunting,
and tachypnea.

Physical Examination - CVS
Murmur
A heart murmur is not a disease; it is
an extra or unusual sound heard by the
Paediatrician in the newborn’s
heartbeat during auscultation with a
stethoscope.
Murmurs range from very faint to very
loud and sometimes sound like a
whooshing or swishing noise. Normal
heartbeat sounds – "lub-DUPP" or "lub-
DUB" – are the valves closing as blood
moves through the heart.
It may be normal, or it could be a sign
that something may be wrong. Most
heart murmurs are harmless.
Some are signs of heart problems,
especially if other signs or symptoms of
a heart problem are present.

Physical Examination - CVS
Murmur
A newborn with an abnormal
murmur usually has other signs or
symptoms of a heart problem, or due
to congenital heart defects – heart
defects present at birth.
Congenital heart defects occur when
the heart, heart valves, or blood
vessels attached to the heart do not
develop normally before a baby is
born.
A newborn with an innocent murmur has a
normal heart and usually has no other
signs or symptoms of a heart problem.
Blood is flowing faster than usual through
the heart and blood vessels attached to
the heart.

Physical Examination - Abdomen
Inspection by assessing
the symmetry and shape of
the abdomen.

Scaphoid Abdomen
Scaphoid abdomen is when
the abdomen is sucked
inwards suggests the
presence of a gross
diaphragmatic hernia.

Distended with Hepatomegaly
Infant had significant
abdominal distention
secondary to a palpable
smooth mass extending from
the right upper quadrant to the
right pelvis; liver edge difficult
to determine.
Mild cutaneous venous
congestion over the abdominal
wall; no other lesions or
rashes.
Abdomen firm; no guarding or
dullness to percussion. Bowel
sounds normal. No
splenomegaly or other
palpable abdominal masses.

Variable Abdominal Veins

Physical Examination – Umbilical Cord
Umbilical Cord
LOOKING AT THE CUT
EDGE MORE CLEARLY
SHOWS THE NORMAL
VESSELS OF THE
UMBILICAL CORD. THE
TWO ARTERIES ARE TO
THE LEFT AND THE VEIN,
WITH A SPOT OF BLOOD
IN ITS LARGE LUMEN, IS
ON THE RIGHT.

Physical Examination – Umbilical Cord
Meconium Stained
This cord was stained by
the presence of meconium
in utero, which gives it a
dark green color.
When an infant shows
signs of meconium
staining, it is evidence that
meconium has been
present in the amniotic fluid
for some time.

Physical Examination – Genitorectal
(A) Hypospadias is a birth defect that
affects the foreskin and urethral tube.
Instead of the urethra being on the tip of
the penis, it is located on the underside of
the penis.
This abnormality occurs during fetal
development when the urethra is growing.
(B) A meatus located on the upper
surface is called Epispadias.
Both congenital conditions are usually
repaired surgically at a young age if they
are severe.

Cryptorchidism is the condition that absence of one or both testes from the
scrotum. This usually represents failure of the testis descend, during fetal
development from an abdominal position, through the inguinal canal, into
the ipsilateral scrotum.

Anorectal atresia, also known as imperforate anus, is a birth defect of the anus that
may require surgery to allow feces to pass out of the body.
There is no known cause for the condition, but immediate care may be required to
open the rectum within the first 24 hours after birth.

(A) Anterior and (B) side view of
ambiguous genitalia.
Note, enlarged clitoris, giving
genitalia a phallic appearance.

Hymenal Tag
Hydrocele

Physical Examination – Musculoskeletal
Check the curvature of the spine for scoliosis, kyphosis, lordosis, spinal
defects, and meningomyelocoeles.
SPINE

Scoliosis is an abnormal curvature of the spine. Instead of going
from top to bottom in a relatively straight line, a spine with scoliosis
may appear to have a side-to-side “S-shaped” or “C-shaped” curve.

Kyphosis is an abnormal rounding of
the spine that occurs in the upper and
middle part of the back. Only the most
serious cases will result in a
hunchback or cause discomfort or
breathing problems.

A normal spine, when viewed from
behind appears straight. However, a
spine affected by Lordosis shows
evidence of a curvature of the back
bones (vertebrae) in the lower back
area, giving the child a "swayback"
appearance.

Myelomeningocele is a neural tube defect in which the bones of the spine do not
completely form, and the spinal canal is incomplete. This allows the spinal cord and
meninges (the membranes covering the spinal cord) to protrude out of the newborn's
back.

In this condition there is a disruption in the normal relationship between
the head of the femur and the acetabulum (hip socket). DDH can affect
one or both hips. It can be mild to severe. In mild cases called unstable
hip dysplasia the hip is in the joint but easily dislocated. More involved
cases are partially dislocated or completely dislocated. A partial
dislocation is called subluxation
Developmental dysplasia of the hip (DDH),
previously known as congenital hip dysplasia is a
common disorder affecting newborn. The change in
name reflects the fact that DDH is a developmental
process that occurs over time. It develops either in
utero (in the uterus) or during the first year of life. It
may or may not be present at birth.
Hip

Extremity
Fingers and/or toes
are webbed or
joined, and that the
condition was
present at birth.

Left: polydactyly of the little finger (ulnar,
post-axial); right: polydactyly of the
thumb—also called thumb duplication
(radial, pre-axial)
Presence of additional toes or
fingers also called
Polydactylia or Polydactylism.
(Greek, poly = many, dactyly =
digit)

Metatarsus Adductus is a foot
deformity characterized by a sharp,
inward angle of the front half of the
foot. It is thought to occur as a result
of the infant's position inside the
uterus where the feet are bent inward
at the instep.

Physical Examination – Neurological - Tone
Passive Tone is generally
assessed by observing the
resting neonatal posture,
and may be measured by
the resistance to passive
movement of the limbs.
The normal resting posture
and passive tone of the
neonate varies with
conceptional age (CA)

The hypotonic term infant lies
supine in a frog-like position with
the hips abducted and the limbs
abnormally extended. Spontaneous
activity is decreased.
Decreased muscle tone can also be
recognized when the following are
observed:
•Vertical suspension
Decreased tone of the shoulder
girdle allows the infant to slip
through the examiner's hands and
the legs are extended.

observed:
• Ventral suspension
The infant appears limp with the
extended limbs and the head
drooping

observed:
• Head control
The head lags behind as the infant
is pulled from the supine to sitting
position and continues to lag when
the sitting position is reached

Hypertonia is associated with
dysfunction of the pyramidal or
extrapyramidal systems.
Spasticity is a form of hypertonia
that accompanies pyramidal tract
dysfunction.
It is characterized by an abnormal
lengthening-shortening reaction of
the muscle that is most apparent in
the distal portion of extremities.
• Opisthotonus
persistent arching of the neck
and trunk

Physical Examination – Neurological - Reflexes
The Moro Reflex is present
starting at 32 weeks gestation
and disappears by three to six
months of age. It is elicited by
the sudden dropping of the
infant's head in relation to the
trunk and results in abduction
and extension of the infant's
arms and opening of the hands,
followed by flexion.
Moro Reflex

The Plantar Reflex is well
established by 32 weeks
conceptional age and
disappears by three months of
age. During the normal plantar
grasp, the toes plantar flex
around the examiner's finger
when it is brought across the
ball of the foot.

Asymmetrical tonic neck
reflex is characterized by
extension of the upper and
lower extremities on the side to
which the head and neck is
turned with flexion of the
contralateral upper extremity
(fencing posture).

Stroking the palm of a baby's hand
causes the baby to close his/her
fingers in a grasp. The grasp reflex
lasts only a couple of months and
is stronger in premature babies.
Grasp Reflex
Step Reflex
This reflex is also called the
walking or dance reflex
because a baby appears to
take steps or dance when
held upright with his/her
feet touching a solid
surface.

This reflex begins when the corner of
the baby's mouth is stroked or touched.
The baby will turn his/her head and open
his/her mouth to follow and "root" in the
direction of the stroking. This helps the
baby find the breast or bottle to begin
feeding.
Root Reflex
Sucking Reflex
Rooting helps the baby become ready to suck.
When the roof of the baby's mouth is touched,
the baby will begin to suck. This reflex does
not begin until about the 32nd week of
pregnancy and is not fully developed until
about 36 weeks.

Physical Examination – Neurological - Cry
Cry assessment is easy to administer
and provides an early window into the
neurological status of the infant.
Atypical cries can be viewed as a
positive screen that should be referred
for a full neurological work up.
Therapy with parents to understand
their infants who show atypical
cry characteristics can facilitate a
positive developmental context during
infancy and young childhood.

A complete physical
assessment is a vital step
to be completed on a
newborn straight after
birth to determine
wellbeing of the baby.
Throughout herhospital
stay, Physicians, Nurses
and otherHealthcare
Providers should
continually assess the
newborn forchanges in

Newborn Assessment by Hadi Hospital NICU.

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Newborn Assessment by Hadi Hospital NICU.