• 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.
The helix can be temporarily folded due to local pressure in utero.
Preauricular skin tags do not require investigation.
Abnormal ear shape and position is a feature of some syndromes.
• Inspect the neck for asymmetry, sinuses and swellings.
• Palpate any masses. Use ‘SPACESPIT’ (see Box 3.8) to
• Transilluminate swellings. Cystic swellings glow, as the
light is transmitted through clear liquid. Solid or blood-filled
One-third of normal neonates have palpable cervical, inguinal
or axillary lymph nodes. Neck asymmetry is often due to fetal
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.
• Observe the baby for pallor, cyanosis and sweating.
• 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.
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.
An absent red reflex suggests cataract; refer to an ophthalmologist.
• Exclude obstructed nostrils (choanal atresia) by blocking
each nostril in turn with your finger to check that the infant
breathes easily through the other.
• 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
• Palpate the palate using your fingertip.
Epstein’s pearls are small, white mucosal cysts on the palate
White coating on the tongue that is easily scraped off with a
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
• 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
• Palpate the abdomen for hepatomegaly (see later).
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%
Heart rates between 80 and 160 beats per minute (bpm)
can be normal in the newborn, depending on the arousal state
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
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
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.
• Note chest shape and symmetry of chest movement.
• Count the respiratory rate (for 15 seconds and multiply
• Listen for additional noises with breathing.
• Look for signs of respiratory distress: tachypnoea;
suprasternal, intercostal and subcostal recession; flaring of
• Remember that percussion of the newborn’s chest is not
• Use the diaphragm to auscultate anteriorly, laterally and
posteriorly, comparing the sides. Breath sounds in the
healthy newborn have a bronchial quality compared with
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.
Fig. 15.6 Auscultation positions in infants and children.
Recommended order of auscultation: 1, apex; 2, left lower sternal edge;
3, left upper sternal edge; 4, left infraclavicular; 5, right upper sternal
edge; 6, right lower sternal edge; 7, right mid-axillary line; 8, right side of
neck; 9, left side of neck; 10, posteriorly.
15.4 Normal ranges for heart and respiratory
Sign Preterm neonate Term neonate
Heart rate (beats per minute) 120–160 100–140
• Feel the femoral pulses by placing your thumbs or
fingertips over the mid-inguinal points while abducting the
• Auscultate the heart. Start at the apex using the
stethoscope bell (best for low-pitched sounds). Then use
the diaphragm in all positions for high-pitched sounds and
• Describe the heart sounds S1 and S2, any additional heart
sounds and the presence of murmurs. The fast heart rate
of a newborn makes it difficult to time additional sounds.
Take time to tune into the different rate of the harsh breath
sounds of a newborn, as they are easily confused with a
The physical examination of newborns • 303
Umbilical hernias are common; they are easily reduced, have a
very low risk of complications and close spontaneously in infancy.
An omphalocoele, or exomphalos (Fig. 15.7), is a herniation
through the umbilicus containing intestines and other viscera,
covered by a membrane that includes the umbilical cord. It
may be associated with other malformations or chromosomal
abnormality. Gastroschisis is a defect in the anterior abdominal
wall with intestines herniated through it, without a covering
membrane. The most common site is above and to the right
Inguinal hernias are common in the newborn, especially in
boys and preterm infants (Fig. 15.8).
Meconium in the nappy does not guarantee that the baby
has a patent anus because meconium can be passed through
• Abduct the legs and gently separate the labia.
• In preterm infants the labia minora appear prominent,
giving a masculinised appearance that resolves
spontaneously over a few weeks. Milky vaginal secretions
Male and female newborn infants at term have small buds of
palpable breast tissue. Small amounts of fluid are sometimes
discharged from the nipple in the early days after birth.
Stridor indicates large airway obstruction and is predominantly
inspiratory (p. 79). Stridor and indrawing beginning on days 2–3
of life in an otherwise well baby may be due to laryngomalacia
(softness of the larynx). Causes of respiratory distress include
retained lung fluid, infection, immaturity, aspiration, congenital
anomaly, pneumothorax, heart failure and metabolic acidosis.
• Inspect the abdomen, including the umbilicus and groins,
• From the infant’s right side, gently palpate with the flat of
your warm right hand. Palpate superficially before feeling
• Palpate for splenomegaly. In the neonate the spleen
enlarges down the left flank, not towards the right iliac
• Place your right hand flat across the abdomen beneath
• Feel the liver edge against the side of your index
• If you feel more than the liver edge, measure the
distance in the mid-clavicular line from the costal
margin to the liver edge. Describe it in fingerbreadths
or measure it with a tape in centimetres.
• Check that the anus is present, patent and normally
• Digital rectal examination is usually unnecessary and could
cause an anal fissure. Indications include suspected rectal
atresia or stenosis and delayed passage of meconium. Put
on gloves and lubricate your little finger. Gently press your
fingertip against the anus until you feel the muscle
resistance relax and insert your finger up to your distal
Abdominal distension from a feed or swallowed air is common.
You may see the contour of individual bowel loops through
the thin anterior abdominal wall in the newborn, particularly with
The umbilical cord stump usually separates after 4–5 days. A
granuloma may appear later as a moist, pink lump in the base
of the umbilicus. A small amount of bleeding from the umbilicus
The liver edge is often palpable in healthy infants.
In the neonate the kidneys are often palpable, especially if
In excessive umbilical bleeding, check that the infant received
vitamin K and consider factor XIII deficiency. Spreading erythema
around the umbilicus suggests infective omphalitis and requires
Fig. 15.7 Small exomphalos with loops of bowel in the umbilicus.
From Lissauer T, Clayden G. Illustrated Textbook of Paediatrics. 2nd edn.
Fig. 15.8 Bilateral inguinal hernias in a preterm infant. An inguinal
hernia is primarily a groin swelling; only when it is large does it extend into
the scrotum. From Lissauer T, Clayden G. Illustrated Textbook of
Paediatrics. 2nd edn. Edinburgh: Mosby; 2001.
• Inspect and palpate the entire vertebral column from neck
to sacrum for neural tube defects.
Sacral dimples are common and unimportant, provided the dimple
base has normal skin and they are single, <5 mm in diameter
Pigmented patches may indicate spina bifida occulta. Dimples
above the natal cleft, away from the midline, or hairy or pigmented
patches with a base that cannot be visualised require further
This includes tone, posture, movement and primitive reflexes.
General neurological assessment
• Look for asymmetry in posture and movement, and for
• To assess tone, pick the baby up and note if they are stiff
or floppy. Note any difference between each side.
are normal. Later in the first week, there is sometimes
slight vaginal bleeding (pseudomenses) as the infant uterus
‘withdraws’ from maternal hormones. Vaginal skin tags are
common and do not require treatment.
• Do not attempt to retract the foreskin. It is normal for it to
• Check that the urethral meatus is at the tip of the penis.
• Note the shape of the penis.
• If you cannot feel the testes in the scrotum, assess for
undescended, ectopic or retractile testes. Palpate the
abdomen for smooth lumps, moving your fingers down
over the inguinal canal to the scrotum and perineum.
• A retractile testis just below the inguinal canal may be
gently milked into the scrotum. Re-examine at 6 weeks if
there is any doubt about the position of the testes.
• Transilluminate any large scrotal swellings using a torch to
see if the light is transmitted through the swelling. This
suggests a hydrocoele but can be misleading, because a
hernia of thin-walled bowel may transilluminate (Fig. 15.9).
• An inguinal hernia usually produces a groin swelling but, if
large, this may extend into the scrotum. Try to reduce it
by gently pushing the contents upwards from the scrotum
through the inguinal canal into the abdomen.
The testes are smooth and soft, and measure 0.7×1 cm across.
The right testis usually descends later than the left and sits
A hydrocoele is a collection of fluid beneath the tunica vaginalis
of the testis and/or the spermatic cord (p. 234). Most resolve
In hypospadias the meatal opening is on the ventral aspect
of the glans, the ventral shaft of the penis, the scrotum or
more posteriorly on the perineum (Figs 15.10 and 15.11A). In
epispadias, which is rare, it is on the dorsum of the penis.
Chordee is curvature of the penis and is commonly associated
with hypospadias and tethering of the foreskin (Fig. 15.11B).
Fig. 15.9 How to transilluminate a scrotal swelling.
Fig. 15.10 Varieties of hypospadias.
Fig. 15.11 Hypospadias and chordee. A Penile shaft hypospadias.
B Lateral view showing the ventral curvature of the penis (chordee). From
Lissauer T, Clayden G. Illustrated Textbook of Paediatrics. 2nd edn.
The physical examination of newborns • 305
Facial nerve palsy causes reduced movement of the cheek
muscles, and the side of the mouth does not turn down when
the baby cries. Most cases are transient.
Primitive reflexes in newborn and
The primitive reflexes are lower motor neurone responses that are
present at birth but that become suppressed by higher centres
by 4–6 months. They may be absent in infants with neurological
depression or asymmetrical in infants with nerve injuries.
Persistence into later infancy may indicate neurodevelopmental
abnormality (p. 141). There are many examples and there is no
need to elicit them all because their individual value is limited.
• Gently stimulate the palm or sole with your finger to
produce a palmar or plantar grasp.
Ventral suspension/pelvic response
• Hold the baby prone and look for neck extension. Stroke
the skin over the vertebral column to produce an extensor
response with pelvic elevation.
• Hold the baby upright and touch the dorsum of their
foot against the edge of a table. The baby will flex
the knee and hip, placing their foot on the table
• Lower the upright baby towards the table surface.
When the feet touch the surface, a walking movement
• Support the supine baby’s trunk and head in a
semi-upright position. Let their head fall backwards
slightly. The baby will quickly throw out both arms and
spread their fingers (Fig. 15.13B).
• Gently stroke the baby’s cheek. The baby turns to that
side and their mouth opens, as though looking for a
nipple. This is ‘rooting’. If you place your finger in a healthy
infant’s mouth, they will suck it vigorously.
• Turn the supine infant’s head to the side. The arm and leg
on the same side will extend and the arm and leg on the
opposite side will flex. This reflex is present at term and
maximal at 1 month (Fig. 15.13C).
• Inspect the limbs and count the digits.
• If the foot is abnormally positioned, gently try to place it in
a normal position. If the abnormal position is at all fixed,
• Examine the hips to check for developmental dysplasia of
• Lay the baby supine on a firm surface.
• Inspect the skin creases of the thighs for symmetry.
• Power is difficult to assess and depends on the state of
arousal. Look for strong symmetrical limb and trunk
• Tendon reflexes are of value only in assessing infants with
neurological or muscular abnormalities.
• Check sensation by seeing whether the baby withdraws
from gentle stimuli. Do not inflict painful stimuli or use a
• Check eyesight by carrying the alert baby to a dark
corner. This normally causes the eyes to open wide. In a
bright area the baby will screw up their eyes.
Ideally, electronic audiological screening should also be
performed in the newborn period.
Movements should be equal on both sides.
Tone varies and may be floppy after a feed.
Reflexes are brisk in term infants, often with a few beats of
The plantar reflex is normally extensor in the newborn.
Hypotonic infants may have a ‘frog-like’ posture with abducted
hips and extended elbows. Causes include Down’s syndrome,
Increased tone may cause back and neck arching and limb
extension; the baby feels stiff when picked up. Causes include
meningitis, asphyxia and intracranial haemorrhage.
Brachial plexus injuries include Erb’s palsy, which affects
brachial plexus roots C5 and C6, producing reduced movement
of the arm at the shoulder and elbow, medial rotation of the
forearm and failure to extend the wrist (Fig. 15.12). Klumpke’s
palsy may be seen after breech delivery due to damage to roots
C8 and T1, with weakness of the forearm and hand. These
injuries can be associated with ipsilateral Horner’s syndrome
and/or diaphragmatic weakness in severe cases. Most perinatal
brachial plexus injuries recover over subsequent weeks.
Fig. 15.12 Erb’s palsy. The right arm is medially rotated and the wrist is
flexed. From Lissauer T, Clayden G. Illustrated Textbook of Paediatrics. 2nd
A small percentage of normal babies have single palmar creases
but this is also associated with Down’s syndrome (see Fig. 3.31B)
and other chromosomal abnormalities. Tibial bowing is common
It is common to hear or feel minor ligamentous clicks during
hip examination. These are of no consequence and feel quite
different to the dislocation and relocation of DDH. If in any doubt,
obtain an expert opinion. Never use the term ‘clicky hips’.
Oligodactyly (too few digits), polydactyly (too many) or syndactyly
(joined digits) may occur. In talipes equinovarus the foot is
plantar-flexed and rotated, with the sole facing medially. In
talipes calcaneovalgus the foot is dorsiflexed so that the heel is
prominent and the sole faces laterally.
Many cases of DDH have associated risk factors, including
a family history, breech delivery, positional talipes (especially
calcaneovalgus) or oligohydramnios.
Some centres offer hip ultrasound screening.
• Weigh the infant fully undressed using electronic scales
• Use a paper tape to measure the maximal occipitofrontal
circumference round the forehead and occiput (Fig.
15.15). Repeat the measurement three times, noting the
largest measurement to the nearest millimetre.
• Measure the crown–heel length using a neonatal
stadiometer (Fig. 15.16). Ask a parent or assistant to hold
the baby’s head still and stretch out the legs until the baby
• Examine each hip separately. Hold the thigh with the
knee and hip flexed and your thumb on the medial
• Move the proximal end of the thigh laterally and then
push down towards the examining table (Barlow
manœuvre, Fig. 15.14A); a clunk indicates that the hip
• Now abduct the thigh; if you feel a clunk, this is the
head of the femur returning into the acetabulum
(Ortolani manœuvre, Fig. 15.14B). If the femoral head
feels lax and you feel a clunk with an Ortolani
manœuvre without first performing the Barlow
manœuvre, then the hip was already dislocated.
Fig. 15.13 Primitive reflexes. A Placing
reflex. B The Moro reflex. C Tonic neck reflex.
Fig. 15.14 Examination for developmental dysplasia of the hip.
A The hip is dislocated posteriorly out of the acetabulum (Barlow
manœuvre). B The dislocated hip is relocated back into the acetabulum
is fully extended (the least reproducible of the three
• Record the results on a centile chart appropriate to the
Perform a final top-to-toe inspection to avoid missing anything
and to allow the parents a further opportunity to ask questions.
The physical examination of infants
Examination of young infants beyond the newborn period is
similar to the newborn examination. Transient neonatal findings
will no longer be present. Older infants are usually happier when
examined on their parent’s lap than on an examination table.
The examination of the ears should include otoscopy (p. 314).
You should check the hips whenever you examine an infant
until they are walking normally. After the first few months the
Ortolani and Barlow manœuvres cannot be performed and
the most important signs are limitation of abduction in the hip,
and thigh skin crease asymmetry. Neurological history and
examination should take account of the developmental stage
of the child. The primitive reflexes disappear by 4–6 months.
In later infancy, ask additional questions to obtain information
about neurodevelopmental progress (Box 15.5).
Fig. 15.15 Measurement of head circumference.
Fig. 15.16 Measuring length accurately in infants.
15.5 Developmental attainment of preschool children at different ages*
Skills 4 months 6 months 10 months 1–2 years 2–3 years 3–5 years
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