Examination of the newborn
Author
Tiffany M McKee-Garrett, MD
Section Editor
Leonard E Weisman, MD
Teresa K Duryea, MD
Deputy Editor
Melanie S Kim, MD
Last literature review version 16.1: January 2008 | This topic last updated: August 21,
2007
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INTRODUCTION — The newborn infant should have a thorough physical examination
performed within 24 hours of birth to identify anomalies, birth injuries, jaundice, or
cardiopulmonary disorders [1] . Ideally, this examination should be performed as soon as
possible after delivery to identify potential impediments to a normal newborn course.
Depending upon the length of stay, another examination should be performed within 24 hours
before discharge from the hospital.
MATERNAL HISTORY — The mother's medical and pregnancy history should be reviewed.
Maternal illnesses prior to pregnancy, such as systemic lupus erythematosus or idiopathic
thrombocytopenia purpura, or pregnancy complications, such as gestational diabetes or
hypertensive disorders, may affect fetal growth or lead to other complications. Maternal
medications may have intrauterine effects or be excreted in breast milk.
Screening tests — The results of screening tests should be reviewed. These tests typically
are obtained at the first prenatal visit, or, if not available, before delivery. (See "Initial routine
management of the newborn").
Laboratory tests that are routinely available are:

Maternal blood type, antibody screen

Rhesus (Rh) type

Rubella status (immune or nonimmune)

Syphilis screen

Hepatitis B surface antigen
Results of other maternal testing may be available for:

Human immunodeficiency virus

Chlamydia, gonorrhea (See "Screening for Chlamydia trachomatis" and see
"Epidemiology and pathogenesis of Neisseria gonorrhoeae infection")

Tuberculosis (See "Tuberculosis in pregnancy" and see "Tuberculin skin testing and
other tests for latent tuberculosis infection")
Screening tests obtained later in pregnancy also impact neonatal assessment. They include
testing for diabetes; maternal serum alpha-fetoprotein measurement-triple screen; and
ultrasound examination, including fetal survey, estimated fetal weight, and amniotic fluid
volume. Results of toxicology screening should be available in patients who have problems
with substance abuse. (See "Prenatal screening and diagnosis of neural tube defects", see
"Indications for diagnostic obstetrical ultrasound examination" and see "Infant of a diabetic
mother").
Risk factors for sepsis — An assessment should be made of neonatal risk factors for sepsis,
especially for Group B streptococcal (GBS) infection. (See "Group B streptococcal infection in
neonates and young infants"). Risk factors for neonatal infection include:

Intrapartum temperature ≥100.4ºF (≥38.5ºC)

Membrane rupture ≥18 hours

Delivery at <37 weeks gestation

Chorioamnionitis

Sustained fetal tachycardia
The use and duration of maternal intrapartum antibiotic prophylaxis (IAP) should be
documented. Infants who have risk factors for sepsis and whose mothers did not receive
adequate IAP require evaluation, including complete blood count (CBC) and blood culture,
even if they are initially asymptomatic. They should be observed in hospital for at least 48
hours and may need empiric antibiotic therapy until culture results become available.
Perinatal course — The clinician performing the initial newborn examination should be
familiar with the events surrounding delivery. The duration of labor, mode of delivery, the
newborn's condition at delivery, and resuscitation, if any, should be reviewed.
GENERAL APPROACH — The examination can be performed in the nursery or the mother's
room. The area should be warm and quiet, and should have good lighting.
The examination should be conducted in a systematic manner. Although the exact order is not
important, a consistent approach ensures that all aspects are evaluated.
The examination begins with observation of the infant's general appearance, including position
and movement, color, and respiratory effort. It may be convenient to examine the heart while
the baby is lying quietly. In general, examination proceeds from head to foot. Examination of
the hips, which is apt to disturb the infant, usually is performed last while the infant is supine.
The baby then is turned prone to examine the back.
The date and time of the examination should by recorded. Findings considered normal close to
delivery, eg, a transitional heart murmur, may be abnormal on the second or third day after
birth. The examination should include assessment of gestational age. Knowledge of the level
of maturity may be important in the interpretation of physical findings. (See "Postnatal
assessment of gestational age").
Appearance and posture — Prior to touching the infant, much can be learned by observing
the undressed infant in the resting, non-stimulated state. Gender should be noted. An
inspection should be made for deformations and obvious malformations, such as cleft lip. An
abnormal facial appearance or other abnormalities may indicate the presence of a syndrome.
The state of nutrition can be assessed by noting the amount of subcutaneous fat on the
anterior thighs and gluteal region, or by the amount of Wharton's jelly in the umbilical cord.
Respiratory effort — The infant's respiratory effort should be assessed. Paradoxical
breathing movements, in which the abdomen moves outward and the chest wall moves inward
in inspiration, are normal. Signs of respiratory distress, including rapid breathing; use of
accessory muscles (eg, nasal flaring); significant subcostal, intercostal, supraclavicular, or
suprasternal retractions; or grunting are abnormal and suggest pulmonary disease.
Position — The newborn's posture at rest usually reflects the intrauterine position. Term
newborns delivered from a vertex presentation typically lie with the hips, knees and ankles
flexed. Infants who were in a breech position often have extended legs. A frank breech
presentation may result in markedly abducted and externally rotated legs. A normal infant
moves all extremities symmetrically.
Color — A normal infant appears pink. Acrocyanosis, a bluish appearance of the hands, feet,
and perioral area, is common on the first day after birth. However, central cyanosis, which is
seen best on the tongue and mucous membranes of the mouth, suggests hypoxemia. Bruising
also may result in a bluish discoloration.
Pallor may indicate anemia, caused by acute blood loss at or shortly before delivery or a
chronic intrauterine process. A ruddy or plethoric infant may have polycythemia. Infants with
polycythemia may appear cyanotic even when they have adequate oxygenation because they
have a relatively high amount of unsaturated hemoglobin.
Hyperbilirubinemia results in jaundice, a yellow color best assessed in natural light. Jaundice is
unusual in the first 24 hours after birth and always is pathologic. It is usually caused by
hemolysis and requires evaluation. Intrauterine staining of the skin with meconium may result
in a greenish discoloration. (See "Clinical manifestations of unconjugated hyperbilirubinemia in
term and near-term infants").
MEASUREMENTS — The infant's weight, length, and head circumference should be measured
and recorded. These measurements are plotted on standard growth curves to determine the
percentile according to gestational age and assess intrauterine growth. The weight is classified
as appropriate, large, or small for gestational age. (See "Small for gestational age infant" and
see "Large for gestational age newborn").
Average birth weights differ for male and female infants. At 40 weeks gestation, the average
weight is 3.6 kg (10th to 90th percentile, 2.9 to 4.2 kg) for males and 3.5 kg (10th to 90th
percentile, 2.8 to 4.0 kg) for females [2] .
The fronto-occipital head circumference (FOC) should be measured at its maximum. At 40
weeks gestation, the average FOC is 35 cm (10th to 90th percentile, 33 to 37 cm) [2] . This
measurement may change in the first few days after birth as molding and scalp edema
resolve. Some clinicians also measure chest circumference, especially if there is concern about
lung growth. Chest circumference normally is within two cm of the head circumference.
The length is measured from the top of the head to the bottom of the feet, with the legs fully
extended. This measurement is difficult to do accurately. At 40 weeks gestation, the average
length is 51 cm (10th to 90th percentile, 48 to 53 cm) [2] .
VITAL SIGNS — Vital signs should be recorded at the time of the examination. Normal
temperature measured with the thermometer in the axilla is 36.1 to 37 degrees C (97.0 to
98.6 degrees F) in an open crib [1] . Respiratory rate is 40 to 60 breaths per minute in most
normal newborns, and heart rate is 120 to 160 beats per minute. However, the heart rate may
decrease to 85 to 90 in some infants during sleep. An increase with stimulation is reassuring.
Blood pressure can be measured using a neonatal size blood pressure cuff in infants with
suspected cardiovascular or renal abnormalities.
SKIN — The skin should be inspected for abnormalities that may indicate an underlying
disorder. Areas of abnormal pigmentation, congenital nevi, macular stains, hemangiomas, or
other unusual lesions should be noted. The following benign and transient findings are
common in normal newborns.

Milia are white papules, frequently found on the nose and cheeks. They result from
retention of keratin and sebaceous material in the pilaceous follicles [2] .

Transient pustular melanosis is a generalized eruption of superficial pustules overlying
hyperpigmented macules that occurs mostly in African-American newborns. The
pustules usually are removed with the first bath so that only the macules remain. (See
"Benign skin lesions in the newborn").

Erythema toxicum consists of white papules, approximately 1 to 2 mm in size, on an
erythematous base. The pustules contain eosinophils. The rash usually begins on the
second or third postnatal day. Lesions occur less frequently on the face than on the
body, and never occur on palms or soles [3] . (See "Benign skin lesions in the
newborn").

Mongolian spots are areas of blue discoloration that occur on the buttocks or over the
base of the spine (show figure 1). They predominantly affect African-American and
Asian infants. (See "Benign skin lesions in the newborn").

Macular stains (often called salmon patch, stork bite, or angel kiss) are pink-red
capillary malformations that occur on the upper eyelids, middle of the forehead, or the
nape of the neck (where they are known as stork bites). (See "Vascular lesions and
congenital nevi in the newborn").
HEAD — The size and shape of the head should be inspected. The presence of abnormal hair,
scalp defects, unusual lesions or protuberances, lacerations, and abrasions or contusions
should be noted.
Fontanelles — The fontanelles should be palpated, preferably with the infant in the sitting
position. Both fontanelles normally are soft and flat.

The anterior fontanelle is located at the juncture of the metopic, sagittal, and coronal
sutures. Its size is variable.

The posterior fontanelle is located at the juncture of the sagittal and lambdoid sutures.
It usually is open but smaller than 1 cm in diameter.
Sutures — The principal sutures of the skull (sagittal, coronal, lambdoid, and metopic) should
be palpated. Passage through the birth canal may result in molding, a temporary asymmetry
of the skull caused by overlapping or overriding of the sutures, particularly the coronal.
However, an asymmetric skull that persists for longer than two to three days after birth or a
palpable ridge along the suture line is abnormal and suggests craniosynostosis. Although the
sutures normally can be separated soon after delivery, widely split sutures with a full
fontanelle may indicate increased intracranial pressure caused by hydrocephalus. (See
"Overview of craniosynostosis").
Craniotabes is a soft area of skull bone, usually in the parietal region, that gives a sensation of
a ping-pong ball when depressed. It commonly is found in premature infants, and can occur in
a term infant whose head rested on the pelvic brim during the last few weeks of gestation [3]
. Craniotabes can be a pathologic finding in syphilis and rickets, although it usually occurs in
normal infants.
Other causes of asymmetrical head shape are caused by the birth process.

Caput succedaneum is an area of edema over the presenting part of the head. This
common condition typically is present at birth, crosses suture lines, and resolves
within a few days [3] .

Cephalohematomas are subperiosteal collections of blood that are present in 1 to 2
percent of newborns [3] . On palpation, they form a fluctuant mass that does not
cross suture lines. They often are bilateral. Cephalohematomas may increase in size
after birth, and usually take weeks to months to resolve.

Subgaleal hemorrhages are collections of blood between the aponeurosis covering the
scalp and the periosteum. They occur in approximately 4 per 10,000 deliveries [4] ,
although the incidence is increased by vacuum deliveries [5] . Blood can extend
beneath the scalp and into the neck. Subgaleal hemorrhages extend across suture
lines but feel firm and fluctuant. (See "Operative vaginal delivery").
FACE — The face is examined for symmetry. Facial palsies and asymmetric crying facies are
most obvious when the baby is crying and may go unnoticed in the quiet or sleeping baby.
Facial palsies — Facial palsies are usually seen in infants who are delivered with the use of
forceps, and can also be seen in those with a prolonged delivery in mothers with a prominent
sacral promontory. Typically, only the mandibular branch of the facial nerve is affected and
the infant will have diminished movement on the affected side of the face. There is often loss
of the nasolabial fold, partial closing of the eye, and the inability to contract the lower facial
muscles on the affected side, leading to the appearance of a "drooping" mouth. When crying,
the mouth is drawn over to the unaffected side.
Facial palsies resolve completely in a few days to a few weeks. No treatment is required, with
the exception of the use of artificial tears in the eye on the affected side of the face. A
persistent palsy may imply a central lesion.
Asymmetric crying facies — Asymmetric crying facies (ACF) are the result of congenital
absence or hypoplasia of the depressor anguli oris muscle.
Similar to facial palsies, the muscles controlling movement of one side of the mouth are
affected (weakened), thus there is asymmetry of the face upon crying. Unlike facial palsies,
the muscles controlling movement of the upper face are normal; thus, the nasolabial folds are
normal, and when the infant cries, the forehead wrinkles and both eyes close normally. This is
typically a benign condition and becomes less noticeable as the child gets older. However, ACF
has been associated with other anomalies, particularly those of the cardiovascular system [6] .
One prospective study of 5532 infants revealed an incidence of ACF of 0.31 percent [7] , with
two of the seven affected infants having other significant malformations. In another review of
35 infants, 16 had other associated anomalies, although many of them were minor [8] . When
ACF is diagnosed, it is prudent to perform a thorough examination for other congenital
anomalies and investigate for abnormalities of the cardiovascular system.
EYES — The initial examination of the eyes may be difficult to perform because the eyelids
often are edematous after delivery. Most infants will open their eyes spontaneously when held
vertically in an environment with low ambient light.
Appearance and spacing — The examiner should note the position and spacing of the eyes,
width of palpebral fissures, eye color, appearance of the sclera and conjunctive, condition of
the eyelids, pupillary size, and eye movement. If it appears abnormal, the distance between
the eyes can be measured and compared to standard values. This part of the examination is
important if other dysmorphic features are present that suggest a syndrome (eg, Trisomy 21
or fetal alcohol syndrome). (See "Clinical features and diagnosis of Down syndrome").
Asymmetry of the eyes may be the result of prominent epicanthal folds (skin folds over the
medial aspect of the eyes), a difference in the size of the globes, or ptosis. Epicanthal folds
rarely are normal and usually suggest a syndrome (eg, Trisomy 21). Widened or narrow
palpebral fissures are normal for some patients but can be part of a syndrome complex in
others.
Extraocular movement — The examiner should assess extraocular muscle movement.
Symmetrical movement of the eyes should occur as the patient is held vertically and moved
gently from side to side.
Sclerae — The sclerae normally are white and clear, although scleral hemorrhages are a
common consequence of compression of the face and head due to the birth process. In
premature infants, the sclerae may appear light blue. This is caused by transmission of the
darker color of the underlying uveal tissue through the thin underdeveloped sclerae [9] . If the
sclerae appear deep blue, osteogenesis imperfecta should be considered. In this condition, the
discoloration is caused by inadequate development of scleral collagen.
Conjunctiva — The conjunctiva should be examined for hemorrhage, inflammation, or
purulent discharge. Subconjunctival hemorrhages can occur spontaneously during birth, but
are more common following a traumatic delivery. Administration of silver nitrate for
prevention of ophthalmia neonatorum due to gonococcal infection often results in chemical
conjunctivitis. (See "Gonococcal infection in the newborn" section on Ophthalmia
Neonatorum).
Cornea — The corneal diameter in most newborns is approximately 10 mm [9] . Corneal
enlargement (>12 mm) suggests glaucoma, especially if accompanied by photophobia,
excessive tearing, or corneal haze. (See "Overview of glaucoma in infants and children").
Pupils — Pupils should be assessed for their shape and reaction to light. Normal pupils are
round and constrict in response to a bright light. Pupillary reaction occurs consistently after 32
weeks gestational age but may be apparent in some infants as early as 28 weeks gestation
[10] . Defects in the iris (eg, coloboma) should be noted.
Red reflex — The presence of a red reflex should be assessed with an ophthalmoscope. This
response will be seen if the lens and underlying structures are clear. Abnormalities of the lens
(eg, cataract), vitreous (eg, persistent fetal vasculature), or retina (eg, retinoblastoma)
produce a white pupil (leukokoria). (See "Approach to the child with leukocoria").
EARS — The ears are inspected for their position, size, and appearance. The ears are in a
normal position if the helix is intersected by a horizontal line drawn from the outer canthus of
the eye perpendicular to the vertical axis of the head [11] . If the helix falls below this line,
the ears are considered low-set. An ear is posteriorly rotated if its vertical axis deviates more
than 10 degrees from the vertical axis of the head.
The ears should be inspected for branchial cleft cysts, sinuses, preauricular skin tags or pits,
or dysplastic features. Malformations of the external ear often are associated with syndromes
of multiple congenital anomalies that include renal malformations [12] . In addition, these
abnormalities may indicate additional anomalies of the middle and inner ear that are
associated with hearing loss [11] . Patients with isolated minor ear anomalies (such as
preauricular skin tags) do not appear to have a significant increase in renal anomalies and
routine renal imaging for these patients appears to be unnecessary unless accompanied by
other major malformations or multiple congenital anomaly syndromes [13] . (See "Congenital
anomalies of the ear" section preauricular pits).
The ear canals should be observed for patency. Visualization of the tympanic membranes is
limited by the small size of the ear canal and the presence of vernix and other debris. This
examination usually is not done in the newborn period.
NOSE — The nose should be examined for its shape and patency. The shape of the nose may
be abnormal because of intrauterine deformation or the birth process. In this case, it will
return to a normal shape within a few days of birth. An extremely thin or unusually broad nose
or a depressed nasal bridge may occur with some malformation syndromes.
The nares may appear asymmetric if the nasal cartilage is dislocated from the vomerian
groove (septal deviation). This condition can be distinguished from a positional deformity by
depression of the tip of the nose. A dislocated septum appears angled within the nares and
does not resume a normal position when released.
Patency of the nares should be established because infants are predominantly nose breathers.
This can be accomplished by noting the movement of a piece of cotton or thread placed in
front of each nare. Obstruction may be caused by edema related to vigorous suctioning after
birth, or have anatomical causes, such as choanal atresia. The latter can be tested by passage
of a feeding tube or suction catheter through the nose.
MOUTH — The size and shape of the mouth should be assessed. The maxillae and mandible
should fit well together and open at equal angles bilaterally. Asymmetry of the mouth
(asynclitism) usually is caused by intrauterine position and resolves with time. A small jaw
(micrognathia) may be seen in Robin sequence. The lip should be examined for evidence of a
cleft. (See "Syndromes with craniofacial abnormalities", section on Robin sequence).
Internal examination of the mouth includes the gingiva, tongue, palate, and uvula, and should
be performed by inspection and by palpation.

Small, white, benign inclusion cysts on the palate, known as Epstein's pearls, are seen
in most babies. They often are clustered at the midpoint of the junction between the
soft and hard palate.

Mucus retention cysts may occur on the gums (epulis) or on the floor of the mouth
(ranula).

The frenulum linguae, a band of tissue that connects the floor of the mouth to the
tongue, may extend to the tip of the tongue (tongue-tie) [3] .

Natal teeth usually occur in the lower central incisor region, and frequently are
bilateral [3] . The incidence is approximately 1 in 3500 live births [10] , although the
prevalence is higher in infants with cleft lip and palate [14] . Natal teeth often are very
mobile, and usually are removed to prevent the risk of aspiration.

Clefts of the soft or hard palate may be visible by inspection. Palpation may be needed
to detect a submucosal cleft [15] . A bifid uvula may be associated with a submucosal
cleft.
NECK — The neck should be assessed for abnormalities, including masses or decreased
mobility.
Masses — Cystic hygroma, a lymphangioma that is the most common lymphatic malformation
in children, typically presents as a painless soft mass superior to the clavicle that
transilluminates. Branchial cleft cysts may be palpated in the upper portion of the neck;
masses in the lower portion may be caused by hematomas. Masses in the midline may be
caused by a thyroglossal duct cyst or an enlarged thyroid. (See "Thyroglossal duct cysts and
ectopic thyroid").
Isolated palpable cervical lymph nodes, up to 12 mm in diameter, are common in healthy
newborns [3] . Lymphadenopathy also may result from congenital infection.
Torticollis — Torticollis, or wry neck, usually results from trauma to the sternocleidomastoid
(SCM) muscle caused by birth injury or intrauterine malposition. The injury causes a
hematoma or swelling within the muscle. Torticollis also may be caused by developmental
abnormalities of the cervical spine. In affected infants, the head is tipped to one side and the
chin rotated toward the other. (See "Acquired torticollis in children").
Excess skin — Redundant skin in the neck may be a feature of genetic syndromes. Examples
include Turner syndrome, in which the neck appears webbed because of redundant skin along
the posterolateral line, and Down syndrome, with excess skin at the base of the neck
posteriorly. (See "Clinical manifestations and diagnosis of Turner syndrome" and see "Clinical
features and diagnosis of Down syndrome").
Clavicles — Both clavicles should be palpated. Partial or complete absence of the clavicle may
occur in congenital syndromes, such as cleidocranial dysostosis. Clavicular fractures typically
present with irritability and decreased motion on the affected side because of pain. Signs
include tenderness, crepitus, swelling on the bone, and an asymmetric Moro response.
CHEST — The chest should be inspected for size, symmetry, and structure.

A small or malformed thorax may result from pulmonary hypoplasia or neuromuscular
disorders.

Chest asymmetry may be caused by an absent pectoralis muscle (Poland sequence),
or result from a mass or abscess.

Pectus excavatum (funnel chest) or pectus carinatum (pigeon breast) may occur as
isolated findings or as part of congenital syndromes. (See "Pectus carinatum").
Breast size and nipple position should be noted. The presence and amount of breast tissue
may be helpful in assessment of gestational age. Breast hypertrophy caused by exposure to
maternal hormones occurs in both males and females and can be asymmetric. Occasionally,
breasts will secrete a thin milky fluid known as "witch's milk" for several days to weeks [3] .
The space between the nipples should be noted. Widely spaced nipples occur in some genetic
syndromes (eg, Turner syndrome). Charts are available for determining normal internipple
distance [16] . In general, an internipple distance that is >25 percent of chest circumference
is considered wide-spaced.
Supernumerary nipples, or accessory mammary tissue, is a common finding. These occur with
an incidence of approximately 1 in 40 newborns [17] and are more common in AfricanAmerican than white infants [14] . They are found inferior and medial to the true breasts,
along the milk line, a vertical line that extends from the axillae to the pubic region.
Supernumerary nipples do not appear to be associated other anomalies, particularly renal
malformations [18,19] .
Chest wall movement — The ribs and sternum are incompletely ossified in the newborn,
resulting in a highly compliant chest wall. Breathing in normal infants may be paradoxical, in
which the rib cage moves inward and the abdomen moves outward during inspiration. In
respiratory disorders, the high intrathoracic pressures generated to inflate poorly compliant
lungs may cause retractions that are intercostal, subcostal, or subxiphoid (substernal).
LUNGS — The infant's breathing rate and pattern should be observed. These may fluctuate
depending upon the state of wakefulness, and whether the infant is active or crying. The
respiratory rate should be counted for a full minute to account for variations in rate and
rhythm. A normal rate is 40 to 60 breaths per minute.
Infants with respiratory disorders often have tachypnea and retractions. Other signs of
respiratory distress include use of accessory respiratory muscles (eg, flaring of the nasal alae)
and grunting. (See "Chest wall movement" above and see "Overview of neonatal respiratory
distress: Disorders of transition").
Auscultation — Auscultation of the lungs should be performed with the infant as quiet as
possible. In general, this is best accomplished before the infant is disturbed by palpation of
the abdomen.
Normal breath sounds are bronchovesicular and are heard equally on both sides of the chest.
The breath sounds should be clear, although some infants may have scattered rales for a few
hours after delivery. Abnormal breath sounds are unusual in the absence of tachypnea or
signs of respiratory distress. In infants with respiratory disease, grunting sometimes is audible
only with a stethoscope.
CARDIOVASCULAR SYSTEM — Palpation through the chest wall determines the apical
impulse and locates the position of the heart. Because the right ventricle is dominant in the
newborn, the point of maximal impulse is best felt in the area of the left lower sternal border.
Palpation also can detect the presence of a heave, tap, or thrill.
Auscultation — Auscultation should be performed with a warmed stethoscope while the baby
lies quietly. Thorough evaluation necessitates auscultation of all areas of the precordium, as
well as the back and axillary areas. The process includes noting the rate and rhythm and
listening carefully for the first and second heart sounds.
Heart sounds — Heart sounds usually are heard best along the left sternal border. Prominent
heart sounds in the right chest may signify dextrocardia. In general, the first heart sound is a
singular sound caused by nearly simultaneous closure of the tricuspid and mitral valves and is
best heard at the apex. The second heart sound, best heard at the left upper sternal border, is
caused by closure of the pulmonary and aortic valves and normally is split.
Murmurs — Heart murmurs are characterized by the intensity and quality of the sound they
create, when they occur in the cardiac cycle, their location, and whether they are transmitted.
The intensity of murmurs is graded on a scale of I to VI. (See "Auscultation of cardiac
murmurs").

Grade I murmurs are nearly inaudible

Grade II murmurs also are faint but can be identified immediately

Grade III murmurs are loud but have no palpable thrill

Grade IV murmurs are loud and have an associated thrill

Grade V murmurs can be heard when the stethoscope is barely touching the chest wall

Grade VI murmurs are audible when the stethoscope is not touching the chest wall
In the first few days after birth, most newborns have murmurs that are transient and benign
in most cases. They usually are caused by a patent ductus arteriosus (PDA), or pulmonary
branch stenosis [10,20] . The latter is more likely if the murmur persists after 24 hours when
most PDAs have closed. The PDA murmur is continuous, often described as "machinery-like"
or harsh in quality. It usually is loudest under the left clavicle (second intercostal space), but
may radiate down the left sternal border.
The intensity and quality of the murmur and associated findings usually can differentiate
innocent murmurs from heart disease [21-23] . Features associated with innocent murmurs
are [2] :

Murmur intensity grade II or less, heard at left sternal border

Normal second heart sound

No audible clicks

Normal pulses

No other abnormalities
Signs that suggest congenital heart disease are:

Murmur intensity grade III or higher

Harsh quality

Pansystolic duration

Loudest at upper left sternal border

Abnormal second heart sound

Absent or diminished femoral pulses

Other abnormalities
Pulses — The femoral pulses should be palpated when the infant is quiet. Diminished femoral
pulses may indicate coarctation of the aorta, whereas an increased pulse pressure may occur
with PDA. If femoral pulses are abnormal, brachial, radial, and pedal pulses should be
palpated.
Perfusion — Perfusion can be assessed by blanching the sole of the foot or the palm of the
hand and noting the capillary refill time, the time it takes for the return of pink color. Normal
capillary refill time is two seconds or less.
ABDOMEN — The abdomen should be examined when the infant is quiet. The size and overall
appearance should be assessed. The normal abdomen is slightly protuberant. Distension is
abnormal and may indicate conditions such as intestinal obstruction, organomegaly, or ascites.
The abdomen may be scaphoid in the presence of a diaphragmatic hernia. Many normal
infants have diastasis recti, resulting from the nonunion of the two rectus muscles. The
presence of an umbilical hernia should be noted. Other abdominal wall defects, such as
omphalocele or gastroschisis, usually are identified at delivery.
Palpation — Palpation of the abdomen should begin superficially and proceed more deeply
but remain gentle to avoid causing discomfort and stimulating the infant to cry. Holding the
infant's legs in a flexed position and having the infant suck on a pacifier or the examiner's
gloved finger may facilitate relaxation of the abdominal wall muscles.
The liver edge normally is palpated one to three centimeters below the right costal margin.
The liver should be soft with a smooth edge. The spleen usually is not palpable, although some
normal infants may have a palpable spleen tip.
The kidneys may be palpated through the anterior abdominal wall. Another approach to
palpation of the lower poles of the kidneys is to place the fingertips above and below the lower
quadrants and apply moderate pressure; this maneuver traps the kidneys between the
fingertips. The left kidney is more easily palpable than the right.
Any other palpable abdominal mass is abnormal and requires further investigation. Most
abdominal masses in newborns are enlarged kidneys caused by hydronephrosis or cystic renal
disease. Masses may also result from tumors, such as neuroblastomas or teratomas.
Umbilical cord — The umbilical cord is inspected for general appearance, amount of
Wharton's jelly, and the umbilical vessels. A small cord may indicate poor maternal nutritional
status or intrauterine compromise. Meconium staining should be noted, as should any redness
or oozing from the stump. Erythema surrounding the stump, and/or an odorous discharge may
indicate omphalitis.
Single umbilical artery — A single umbilical artery (SUA) is present in 0.2 to 0.6 percent of
live births, occurring more frequently in small for gestational age and premature infants, and
twins [24-27] .
In infants with SUA, there is an increased rate of chromosomal and other congenital
anomalies. Multiple studies have shown that 20 to 30 percent of neonates with SUA had major
structural anomalies, often involving multiple organs [24-27] . The most commonly affected
organs were the heart, gastrointestinal tract, and the central nervous system.
In the remaining 70 to 80 percent of infants with SUA, SUA is an isolated finding. In these
neonates, there is an increased incidence of occult renal anomalies. This was best shown in a
meta-analysis of seven studies that included 204 infants who were screened for renal
malformations either by ultrasound or intravenous pyelography [26] . Overall, a renal anomaly
was detected in 16 percent of these infants. However, in only one-half of these patients was
the abnormality persistent and considered significant. Vesico-ureteral reflux (VUR) of grade 2
or higher was the major renal finding and was found in 2.9 percent of the total study
population.
The clinical significance of these findings is unclear and opinions differ on the value of
screening these infants for renal abnormalities [26,27] . The estimated prevalence of VUR in
the general population is 1.3 percent. The relative risk of VUR in infants with a SUA compared
to those with two umbilical arteries is not known.
Although no definitive answer is available, screening with renal ultrasonography is
recommended in newborns with SUA [24,27] .
GENITALIA — The genitalia usually are inspected immediately after birth to identify the
infant's gender or confirm the prenatal diagnosis. The newborn with genitalia that appear
ambiguous should be evaluated as soon as possible. (See "Evaluation of the infant with
ambiguous genitalia")
Female — The size and location of the labia, clitoris, meatus, and vaginal opening should be
assessed. The appearance of the genitalia varies with gestational age. The labia minora and
clitoris are prominent in preterm infants, while the labia majora become larger as the infant
approaches term. (See "Gynecologic examination of the newborn and child" and see "Postnatal
assessment of gestational age").
The vaginal opening should be fully visible. Many infants have vaginal skin tags, representing
the slight protrusion of vaginal epithelium at the posterior fourchette. Withdrawal from
maternal hormones often results in a milky white vaginal discharge, which sometimes is
blood-tinged.
The labia minora should be separated to detect whether the hymen, which normally has some
opening, is imperforate. This disorder can cause hydrometrocolpos, which usually appears as a
bulging hymen, especially with crying. Enlargement of the uterus resulting from an
imperforate hymen may be detected as a lower midline abdominal mass. (See "Diagnosis and
management of congenital anomalies of the vagina").
Male — The position of the meatus, size of the penis, appearance of the scrotum, and
presence of testes should be evaluated. The foreskin normally is tight or adherent in the
newborn; easy retraction usually is not possible for several months to years. Many infants
have a small (one mm) white sebaceous cyst at the tip of the foreskin that is benign.
The penis is stretched to assess length. Normal penile length in the term male is 2.5 to 3.5 cm
(show figure 2) [28] . The scrotum of the term male is rugated and pigmented. Enlargement
or swelling of the scrotum may be caused by hydroceles, hernias or, rarely, testicular torsion.
Hydroceles are fluid collections around the testes, and usually resolve spontaneously. They
can be distinguished from hernias by transillumination of the scrotum. Acute torsion presents
as a painless swelling, usually with discoloration of the scrotum.
Hypospadias — The urethral meatus usually can be located without retraction of the foreskin.
Ventral location of the meatus (hypospadias) is relatively common, with a prevalence of 0.3 to
0.7 percent in live male births [29-32] . The meatus may be located anywhere from the
proximal glans to the perineum, with the more severe cases having a more proximal meatus,
such as perineal or scrotal hypospadias (show picture 1).
Risk factors associated with hypospadias include advanced maternal age, pre-existing
maternal diabetes mellitus (prior to pregnancy), gestational age <37 weeks, and maternal
progestin or diethylstilbestrol intake [33-35] . The prevalence of hypospadias was increased in
boys whose fathers had hypospadias [35] and varied with maternal ethnicity; male infants of
Caucasian mothers were at the highest risk and those of Hispanic mothers were at the lowest
risk for hypospadias [33] . (See "Outcome of diethylstilbestrol exposed individuals" section on
Genitourinary abnormalities).
Associated upper genitourinary tract anomalies in asymptomatic boys with hypospadias are
uncommon [36-39] , and often detected through routine prenatal ultrasonography [30] . The
kidneys and urethra develop from distinct embryologic structures and at different times
[29,30] . The critical time for phallic development is from 8 to 12 weeks gestation, whereas
the kidney is well developed by 7 weeks [29] . Thus, radiographic evaluation of boys with
hypospadias is rarely necessary, unless the infants are symptomatic or have involvement of
other organ systems (suggesting a malformation sequence) [30,40] .
Congenital anomalies of the genital organs, such as undescended testes and intersex
conditions, occur in approximately six percent of patients with hypospadias [32] . Thus, male
infants with hypospadias (of any location) should be carefully examined to detect nonpalpable
testis (unilateral or bilateral, show picture 2) and be evaluated for intersex conditions,
including congenital adrenal hyperplasia [41] . (See "Undescended testes (cryptorchidism)",
see "Evaluation of the infant with ambiguous genitalia" and see "Diagnosis of classic congenital
adrenal hyperplasia due to CYP21A2 (21-hydroxylase) deficiency").
In addition, monogenic defects have been associated with hypospadias as illustrated in a study
that reported mutations of the HOXD13 in affected male members of a single large kindred
with hypoplastic synpolydactyly and hypospadias [42] .
Infants with hypospadias and bilaterally palpable testes should be referred to urology, usually
within 3 to 6 months unless parental concerns dictate an earlier referral [40] .
Circumcision is usually not recommended, either because the preputial skin may be necessary
for hypospadias repair or because the lack of ventral skin makes circumcision difficult [29] . A
pediatric urologist should be consulted in the nursery if there is a question regarding
performance of circumcision.
Epispadias — Dorsal location of the meatus (epispadias) is uncommon. It usually is
associated with bladder exstrophy. (See "Evaluation and initial management of infants with
bladder exstrophy").
Testes — Testes should be palpable in the scrotum or inguinal canal and be equal in size.
Between 2 and 5 percent of full-term and 30 percent of premature male infants are born with
an undescended testicle. Testes descend before six months of age in most cases. (See
"Undescended testes (cryptorchidism)").
Ambiguous genitalia — Signs of ambiguous genitalia include an enlarged clitoris, fused
labial folds, or palpable gonads in a phenotypic female, and bifid scrotum, severe hypospadias,
micropenis, or cryptorchidism in a phenotypic male. Ambiguous genitalia may signal an
intersex disorder. These conditions may be caused by abnormalities of sexual differentiation or
congenital adrenal hyperplasia. Infants should be evaluated promptly and the appropriate
gender assigned as soon as possible. (See "Evaluation of the infant with ambiguous genitalia"
and see "Diagnosis of classic congenital adrenal hyperplasia due to CYP21A2 (21-hydroxylase)
deficiency"),
Anus — The anus is inspected for its location and patency. An imperforate anus is not always
immediately apparent. Thus, patency often is checked by careful insertion of a rectal
thermometer to measure the baby's first temperature.
TRUNK AND SPINE — The spine is inspected for vertebral abnormalities or a neural tube
defect by direct visualization and palpation along the vertebral column. The gluteal folds
should be separated to examine for the presence of a sacral cleft or dimple. A tuft of hair,
hemangioma, or discoloration in the sacrococcygeal area may suggest an underlying vertebral
anomaly. (See "Epidemiology; pathogenesis; clinical features; and complications of infantile
hemangiomas" and see "Evaluation and diagnosis of infantile hemangiomas", section on
Segmental hemangiomas).
Soft tissue masses along the spine that are covered with normal skin may be lipomas or
myelomeningocoeles. A dimple without a visible base may indicate the presence of a pilonidal
sinus or tract to the spinal cord. A tuft of hair from a sinus or dimple sometimes is seen when
there is extension of the tract to the intraspinal space (spina bifida occulta).
EXTREMITIES — The extremities are examined for deformities and movement. The hands
and feet are inspected for syndactyly (fusion of digits) and polydactyly (extra digits).
Syndactyly and polydactyly can be normal variants in a newborn with an otherwise normal
exam or may be associated with various syndromes. The presence of a single palmar crease,
also known as a simian crease, should be noted. A single unilateral palmar crease occurs in 5
to 10 percent of the normal population [28] and is common in newborns with Trisomy 21.
(See "Clinical features and diagnosis of Down syndrome").
The extremities should move spontaneously and equally. Decreased movement of one limb
may be because of pain caused by a fracture.
Lack of arm movement may also be because of a brachial plexus injury. This typically occurs
when the cervical, or rarely the upper thoracic, nerve roots are stretched during delivery. The
most common form is injury of the upper roots (C5, C6, and sometimes C7), which results in
Erb's palsy [43] . In this disorder, the arm is adducted and internally rotated, with extension
of the elbow, pronation of the forearm, and flexion of the wrist, resulting in the characteristic
"waiter's tip" position of the hand. The lack of shoulder abduction results in an asymmetric
Moro reflex, although hand movement and a palmar grasp are present. Diaphragmatic
paralysis may occur, leading to respiratory distress.
Injury to the lower roots (C8, T1) nearly always is associated with involvement of the upper
roots, resulting in total brachial plexus palsy. In addition to paralysis of the shoulder and arm,
affected infants have weakness of the wrist and finger flexors, so that the hand appears limp.
The palmar grasp reflex is absent. Involvement of the sympathetic outflow from T1 results in
Horner's syndrome in approximately one-third of severely affected infants [43] . Infants with
Horner's syndrome have ptosis and miosis.
HIPS — The hips should be examined to detect developmental dysplasia of the hip (DDH).
Risk factors for DDH include female gender, delivery from the breech position, and positive
family history. Girls delivered from a breech presentation have the highest risk of 120 affected
patients per 1000 live births (12 percent). For these patients, screening for DDH is
recommended at six weeks of age with hip ultrasound or at four months of age with plain films
[44] . (See "Epidemiology and pathogenesis of developmental dysplasia of the hip" and see
"Clinical features and diagnosis of developmental dysplasia of the hip").
Two diagnostic maneuvers to detect DDH are performed with the infant in the supine position.
The Ortolani maneuver reduces the already dislocated hip. The examiner's index and middle
fingers are placed along the greater trochanter, and the thumb is placed along the inner thigh.
The hip is abducted while the femur is lifted anteriorly. A positive sign occurs if a "clunk" is felt
as the dislocated femoral head is replaced into the acetabulum.
The Barlow maneuver dislocates an unstable hip from the acetabulum. The maneuver is
performed with the hips flexed at 90 degrees and the examiner's fingers placed over the
lateral aspect of the hip. The femur is adducted slightly while posteriorly directed pressure is
applied on the knee. A positive Barlow sign consists of a clunking sensation or feeling of
movement when the femoral head is displaced posteriorly from the acetabulum. Any infant
with a positive Ortolani and/or Barlow sign warrants referral to a specialist for further
evaluation and possible treatment.
In a normal infant without dysplastic hips, neither of these maneuvers should allow the
femoral head to move into or out of the acetabulum. However, many newborns have some
instability of the hips in the first few weeks after birth because of laxity of the capsule and
may have benign adventitial sounds ("clicks") that must be distinguished from the "clunks" of
true dislocations [44] .
Unilateral DDH may be suspected because of asymmetry of the thigh or gluteal folds. It is
detected best with the infant in a prone position. Another sign is discrepancy of leg lengths
(positive Galeazzi sign), with DDH on the side of the shorter leg. Unequal leg lengths are
detected best with the infant supine, the knees flexed, and the feet resting on a flat surface.
NEUROLOGIC EXAMINATION — The newborn neurologic examination includes an
assessment of the level of alertness, spontaneous motor activity, tone, muscle strength, and
primitive reflexes.
Alertness — The infant's state of alertness is observed. The state will depend upon the time
after delivery, and whether the infant is sleeping or hungry. Persistent irritability or lethargy
are abnormal findings.
Spontaneous motor activity — All extremities should have symmetric, smooth, and
spontaneous movements. Jitteriness or tremulousness can occur in normal awake infants,
usually after a startle.
Tone and muscle strength — The normal term newborn has increased flexor tone. In the
resting posture, the extremities are in moderate flexion. Tone and muscle strength are
assessed by the pull-to-sit maneuver, in which the infant's hands are grasped and the baby is
pulled from a supine to sitting position. The normal infant will offer some resistance, with
flexion at the knees, elbows, and ankles. The head should move with the body and head lag
should be minimal. Pronounced head lag may indicate hypotonia.
Muscle strength also can be tested by holding the infant in a vertical position with the feet on
a flat surface. A normal infant should be able to bear weight on the lower extremities while
attempting to stand.
Reflexes — Normal infants have many primitive reflexes. These reflexes should be tested
during the routine examination.

The Moro reflex is elicited by the sudden downward movement of the head and torso
from an upright position. It consists of symmetric extension and abduction of the arms
and opening of the hands, followed by flexion of the upper extremities in an embracing
movement. An audible cry often follows.

The rooting reflex is elicited by applying light tactile stimulation in the perioral area.
The infant's head should turn toward the stimulation and the mouth should open.
Sucking usually can be elicited by placing a gloved finger or a nipple in the infant's
mouth. The normal term infant has a strong, coordinated, and symmetric suck.

Stroking or applying pressure to the infant's palm with the examiner's finger elicits the
palmar grasp. The grasp may tighten with attempts to remove the finger.

The plantar grasp, manifested by curling of the toes, is elicited by applying pressure to
the plantar surface of the foot.

The stepping reflex is elicited by holding the infant in an upright vertical position and
gently touching the feet to a flat surface. The infant's feet will move in an alternating
stepping motion.

Contact of the dorsum of the foot with the edge of a table will elicit the placing reflex,
in which the foot is lifted and placed on the table's surface.