15.1). Facial marks fade spontaneously over months; those

on the neck often persist. Milia (fine white spots) and acne

neonatorum (larger cream-coloured spots) are collected glandular

secretions and disappear within 2–4 weeks. Erythema toxicum

is a common fleeting, blanching, idiopathic maculopapular rash

of no consequence, affecting the trunk, face and limbs in the

first few days after birth.

Abnormal findings

Document any trauma such as scalp cuts or bruising.

Dense capillary haemangiomas (port wine stains) will not

fade. Referral to a dermatologist is advisable, as laser treatment

may help in some cases. Around the eye they may indicate

Sturge–Weber syndrome (a facial port wine stain with an

underlying brain lesion, associated with risk of later seizures,

cerebral calcification and reduced cognitive function). Melanocytic

naevi require follow-up and treatment by a plastic surgeon or

dermatologist. A Mongolian blue spot (Fig. 15.2) is an area of

bluish discoloration over the buttocks, back and thighs. Easily

mistaken for bruising, it usually fades in the first year.

Jitteriness

Jitteriness is high-frequency tremor of the limbs, and is common

in term infants in the first few days. It is stilled by stimulating the

infant and is not associated with other disturbance. If jitteriness is

excessive, exclude hypoglycaemia, polycythaemia and neonatal

abstinence syndrome (drug withdrawal). Infrequent jerks in light

sleep are common and normal; regular clonic jerks are abnormal.

Dysmorphism

Identifying abnormal body structure (dysmorphism) is subjective

because of human variability. Individual features may be minor and

isolated, or may signify a major problem requiring investigation

and management. A recognisable pattern of several dysmorphic

features may indicate a ‘dysmorphic syndrome’ such as Down’s

syndrome (p. 36). Use caution and sensitivity when discussing

possible dysmorphism with parents of a newborn child.

Hypotonia

Hypotonia (reduced tone) may be obvious when you handle an

infant. Term infants’ muscle tone normally produces a flexed

posture at the hips, knees and elbows. Hypotonic infants may

lack this flexion. Hypotonia can occur with hypoxia, hypoglycaemia

or sepsis, or may be due to a specific brain, nerve or muscle

problem. Preterm infants have lower tone than term infants and

are less flexed.

Apgar score

This first clinical assessment of a neonate is made immediately

after birth. Tone, colour, breathing, heart rate and response

to stimulation are each scored 0, 1 or 2 (Box 15.2), giving a

maximum total of 10. Healthy neonates commonly score 8–10 at

1 and 5 minutes. The score predicts the need for, and efficacy of,

resuscitation. A low score should increase with time; a decreasing

score is a cause for concern. Persistently low scores at 10

minutes predict death or later disability. Neonates with scores

of less than 8 at 5 minutes require continued evaluation until it

is clear they are healthy.

The physical examination of newborns

Timing and efficacy of the routine

neonatal examination

Examine a newborn with the parents present. There is no ideal

time. If it is performed on day 1, some forms of congenital heart

disease may be missed because signs have not developed. If

it is delayed, some babies will present before the examination

with illness that may have been detectable earlier. Around 9%

of neonates have an identifiable congenital abnormality but most

are not serious. Always record your examination comprehensively

to avoid problems if illness or physical abnormality is identified

later. Fewer than half of all cases of congenital heart disease

or congenital cataract are detected by newborn examination.

General examination

Examine babies and infants in a warm place on a firm bed or

examination table. Have a system to avoid omitting anything, Fig. 15.1 Stork’s beak mark.

300 • Babies and children

Separated cranial sutures with an obvious gap indicate raised

intracranial pressure. Rarely, the cranial sutures are prematurely

fused (synostosis), producing ridging, and the head shape

is usually abnormal. Abnormal head size requires detailed

investigation, including neuroimaging.

Eyes

Examination sequence

• Inspect the eyebrows, lashes, lids and eyeballs.

• Gently retract the lower eyelid and check the sclera for

jaundice.

• Test ocular movements and vestibular function:

• Turn the newborn’s head to one side; watch as the

eyes move in the opposite direction. These are called

doll’s-eye movements and disappear in infancy (see

Fig. 8.15).

• Hold the infant upright at arm’s length and move in a

horizontal arc. The infant should look in the direction of

movement and have optokinetic nystagmus. This

response becomes damped by 3 months.

Normal findings

Harmless yellow crusting without inflammation is common after

birth in infants with narrow lacrimal ducts.

Term infants usually fix visually.

Abnormal findings

Eye infection gives a red eye and purulent secretions. An abnormal

pupil shape is usually a coloboma (a defect in the iris inferiorly

that gives the pupil a keyhole appearance, Fig. 15.4). This can

also affect deeper structures, including the optic nerve, and lead

to visual impairment. It can be associated with syndromes, as

can microphthalmia (small eyeballs). Large eyeballs that feel hard

when palpated through the lids suggest congenital glaucoma

(buphthalmos).

Ophthalmoscopy

Examination sequence

• Hold the baby in your arms. Turn your body from side to

side so that the baby will open their eyes.

Subcutaneous fat necrosis causes palpable firm plaques, often

with some erythema under the skin. If extensive, there can be

associated hypercalcaemia that may require treatment. Blisters

or bullae are usually pathological.

Head

Examination sequence

• Note the baby’s head shape (Box 15.3) and any swellings.

• Feel the anterior fontanelle (Fig. 15.3). Is it sunken, flat or

bulging?

• Palpate the cranial sutures.

Normal findings

Transient elongation of the head is common from moulding

during birth. Caput succedaneum is soft-tissue swelling over

the vertex due to pressure in labour. Overriding cranial sutures

have a palpable step.

Abnormal findings

Cephalhaematoma is a firm, immobile, usually parietal swelling

caused by a localised haemorrhage under the cranial periosteum.

It may be bilateral, and periosteal reaction at the margins causes

a raised edge. No treatment is required. Do not confuse this

with the boggy, mobile, poorly localised swelling of subgaleal

haemorrhage (beneath the flat sheet of fibrous tissue that caps the

skull), which can conceal a large blood loss and is life-threatening

if unrecognised.

Fig. 15.2 Mongolian blue spot.

15.3 Neonatal head shapes

Head shape Description

Microcephalic (small-headed) Small cranial vault

Megalencephalic (large-headed) Large cranial vault

Hydrocephalic (water-headed) Large cranial vault due to

enlarged ventricles

Brachycephalic (short-headed) Flat head around the occiput

Dolichocephalic (long-headed) Head that looks long relative to

its width

Plagiocephalic (oblique-headed) Asymmetrical skull

Anterior fontanelle

Posterior fontanelle

Sagittal suture

Frontal bone

Frontal suture

Sinciput

Occiput

Parietal bone

and eminence

Lambdoid suture

Fig. 15.3 The fetal skull from above.

The physical examination of newborns • 301

15

Cleft palate may involve the soft palate or both hard and soft

palates. It can be midline, unilateral or bilateral and may also

involve the gum (alveolus). Cleft lip can appear in isolation or

in association with it. Refer affected infants early to a specialist

multidisciplinary team. Micrognathia (a small jaw) is sometimes

associated with cleft palate in the Pierre Robin syndrome,

with posterior displacement of the tongue and upper airway

obstruction.

A ranula is a mucous cyst on the floor of the mouth that

is related to the sublingual or submandibular salivary ducts.

Congenital ranulas may resolve spontaneously but sometimes

require surgery.

Teeth usually begin to erupt at around 6 months but can be

present at birth.

Ears

Examination sequence

• Note the size, shape and position.

• The helix should attach above an imaginary line through

the inner corners of the eyes.

• Check that the external auditory meatus looks normal.

Normal findings

The helix can be temporarily folded due to local pressure in utero.

Preauricular skin tags do not require investigation.

Abnormal findings

Abnormal ear shape and position is a feature of some syndromes.

Neck

Examination sequence

• Inspect the neck for asymmetry, sinuses and swellings.

• Palpate any masses. Use ‘SPACESPIT’ (see Box 3.8) to

interpret your findings.

• Transilluminate swellings. Cystic swellings glow, as the

light is transmitted through clear liquid. Solid or blood-filled

swellings do not.

Normal findings

One-third of normal neonates have palpable cervical, inguinal

or axillary lymph nodes. Neck asymmetry is often due to fetal

posture and usually resolves.

Abnormal findings

A lump in the sternocleidomastoid muscle (sternomastoid

‘tumour’) is caused by a fibrosed haematoma with resultant

muscle shortening. This may produce torticollis, with the head

turned in the contralateral direction.

Cardiovascular examination

Examination sequence

• Observe the baby for pallor, cyanosis and sweating.

• Count the respiratory rate.

• Palpate for the apex beat with your palm in the

mid-clavicular line in the fourth or fifth intercostal space.

• Note if the heart beat moves your hand up and down

(parasternal heave) or if you feel a vibration (thrill).

• Count the heart rate for 15 seconds and multiply by 4.

• Look at each pupil from about 20 cm through the

ophthalmoscope. You should see the red reflex of

reflected light from the retina.

Normal findings

Puffy eyes in the first days after birth impede the examination.

If this happens, always examine again later because failure to

detect and treat a cataract will cause permanent amblyopia.

Abnormal findings

An absent red reflex suggests cataract; refer to an ophthalmologist.

Nose

Examination sequence

• Exclude obstructed nostrils (choanal atresia) by blocking

each nostril in turn with your finger to check that the infant

breathes easily through the other.

Mouth

Examination sequence

• Gently press down on the lower jaw so that the baby will

open their mouth. Do not use a wooden tongue

depressor, as this may cause trauma or infection.

• Shine a torch into the mouth and look at the tongue and

palate.

• Palpate the palate using your fingertip.

Normal findings

Epstein’s pearls are small, white mucosal cysts on the palate

that disappear spontaneously.

White coating on the tongue that is easily scraped off with a

swab is usually curdled milk.

Abnormal findings

Ankyloglossia (tongue tie) is when the lingual frenulum joining the

underside of the tongue to the floor of the mouth is abnormally

short, which may interfere with feeding. A white coating on the

tongue, which is not easily removed and may bleed when scraped,

is caused by Candida albicans (thrush). Macroglossia (a large

protruding tongue) occurs in Beckwith–Wiedemann syndrome. A

normal-sized tongue protrudes through a small mouth in Down’s

syndrome (glossoptosis).

Fig. 15.4 Coloboma.

302 • Babies and children

• Do not measure the blood pressure of healthy babies. In ill

babies, cuff measurements overestimate the values when

compared with invasive measurements. The cuff width

should be at least two-thirds of the distance from the

elbow to the shoulder tip.

• Palpate the abdomen for hepatomegaly (see later).

Normal findings

In the early newborn period the femoral pulses may feel normal

in an infant who later presents with coarctation because an

open ductus arteriosus can maintain flow to the descending

aorta. Routine measurement of postductal oxygen saturation

is increasingly popular as an additional newborn screening test

for congenital heart disease. Lower limb SpO2 should be 95%

or higher.

Heart rates between 80 and 160 beats per minute (bpm)

can be normal in the newborn, depending on the arousal state

(Box 15.4).

Abnormal findings

Infants with heart failure typically look pale and sweaty, and have

respiratory distress (p. 298).

If the apex beat is displaced laterally, there may be cardiomegaly,

or mediastinal shift due to contralateral pneumothorax or pleural

effusion.

Weak or absent femoral pulses suggest coarctation of the

aorta. Radiofemoral delay is not identifiable in the newborn.

Patent ductus arteriosus may cause a short systolic murmur in

the early days of life because the pulmonary and systemic blood

pressures are similar, which limits shunting through the duct.

The murmur progressively lengthens over subsequent weeks or

months to become the continuous ‘machinery’ murmur recognised

later in childhood.

Transient murmurs are heard in up to 2% of neonates but only

a minority have a structural heart problem. An echocardiogram

is needed to make a structural diagnosis.

Respiratory examination

Examination sequence

• Note chest shape and symmetry of chest movement.

• Count the respiratory rate (for 15 seconds and multiply

by 4).

• Listen for additional noises with breathing.

• Look for signs of respiratory distress: tachypnoea;

suprasternal, intercostal and subcostal recession; flaring of

the nostrils.

• Remember that percussion of the newborn’s chest is not

helpful.

• Use the diaphragm to auscultate anteriorly, laterally and

posteriorly, comparing the sides. Breath sounds in the

healthy newborn have a bronchial quality compared with

older individuals (p. 88).

Fig. 15.5 Palpating the femoral pulses. The pulse can be difficult to

feel at first. Use a point halfway between the pubic tubercle and the

anterior superior iliac spine as a guide.

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