Neonatal Clinical Examination Guide

This is a simplified neonatal examination guide designed to be a practical resource for both students and medical professionals. It covers essential steps in neonatal assessment, making it easier to understand the clinical examination of newborns. Each section is structured to provide a clear, concise overview, ensuring that key points are quickly accessible for learners at any stage of their training.

The guide is tailored to meet the needs of healthcare providers in a fast-paced environment, offering a streamlined approach to neonatal examination. By focusing on core components such as physical assessment and clinical observations, this guide serves as a reliable reference for improving proficiency and confidence in newborn care.

1. General Appearance

Technique

• Observe the newborn's overall appearance before any handling
• Note posture, spontaneous movements, color, and respiratory effort
• Assess the newborn's response to the environment

Normal Findings

• Alert and responsive
• Flexed posture with smooth movements
• Pink color with possible acrocyanosis (bluish hands and feet)
• Regular respirations (40-60 breaths per minute)
• Symmetrical movements

Abnormal Findings

• Lethargy or irritability
• Floppiness or rigidity
• Central cyanosis or pallor
• Respiratory distress (grunting, nasal flaring, retractions)
• Asymmetrical movements or tremors

2. Vital Signs

Technique

• Measure temperature (axillary or rectal)
• Count respiratory rate for full minute
• Measure heart rate (apical or radial pulse)
• Measure blood pressure (if indicated)

Normal Findings

• Temperature: 36.5-37.5°C (97.7-99.5°F)
• Respiratory rate: 40-60 breaths per minute
• Heart rate: 120-160 beats per minute
• Blood pressure: Systolic 60-90 mmHg, Diastolic 20-60 mmHg

Abnormal Findings

• Hypothermia: <36.5°C (97.7°F)
• Hyperthermia: >37.5°C (99.5°F)
• Tachypnea: >60 breaths per minute
• Bradypnea: <40 breaths per minute
• Tachycardia: >160 beats per minute
• Bradycardia: <120 beats per minute
• Hypertension or hypotension (based on gestational age and birth weight)

3. Head and Neck

Technique

• Inspect head shape and size
• Palpate fontanelles and sutures
• Examine eyes, ears, nose, and mouth
• Assess neck mobility and presence of masses

Normal Findings

• Head circumference proportionate to body size (32-37 cm)
• Anterior fontanelle soft and flat (1-4 cm wide)
• Posterior fontanelle small (<1 cm) or closed
• Eyes symmetrical, clear, and reactive to light
• Ears aligned with outer canthi of eyes
• Nose patent and midline
• Palate intact, symmetrical gum lines
• Neck with full range of motion, no masses

Abnormal Findings

• Microcephaly or macrocephaly
• Bulging or sunken fontanelles
• Craniosynostosis (premature closure of sutures)
• Cephalohematoma or caput succedaneum
• Eye discharge, subconjunctival hemorrhage, or cataract
• Preauricular tags or pits
• Choanal atresia
• Cleft lip or palate
• Torticollis or neck masses

4. Chest and Lungs

Technique

• Observe chest shape and symmetry
• Count respiratory rate for full minute
• Assess work of breathing
• Auscultate breath sounds in all lung fields
• Palpate for tactile fremitus

Normal Findings

• Chest symmetrical with equal expansion
• Respiratory rate 40-60 breaths per minute
• No signs of respiratory distress
• Clear breath sounds bilaterally
• No tactile fremitus

Abnormal Findings

• Asymmetrical chest movements
• Tachypnea (>60 breaths per minute) or bradypnea (<40 breaths per minute)
• Grunting, nasal flaring, or intercostal retractions
• Decreased breath sounds or adventitious sounds (crackles, wheezes)
• Pectus excavatum or carinatum

5. Cardiovascular System

Technique

• Inspect for central cyanosis
• Palpate precordium for thrills
• Auscultate heart sounds at all valve areas
• Palpate peripheral pulses (brachial and femoral)
• Assess capillary refill time

Normal Findings

• Pink mucous membranes and tongue
• No visible pulsations or thrills
• Regular heart rate (120-160 beats per minute)
• Clear S1 and S2 heart sounds
• No murmurs or with innocent murmurs
• Strong, equal peripheral pulses
• Capillary refill <3 seconds

Abnormal Findings

• Central cyanosis
• Visible pulsations or palpable thrills
• Irregular heart rate or abnormal rate (tachycardia >160 bpm, bradycardia <120 bpm)
• Pathological murmurs (grade 3/6 or higher, diastolic, continuous)
• Absent or weak peripheral pulses
• Prolonged capillary refill (>3 seconds)

6. Abdomen

Technique

• Inspect abdomen shape and umbilicus
• Auscultate bowel sounds in all four quadrants
• Palpate for masses or organomegaly
• Assess for hernias

Normal Findings

• Abdomen soft and non-distended
• Umbilical cord clean and dry
• Active bowel sounds in all quadrants
• No palpable masses
• Liver edge palpable 1-2 cm below right costal margin
• Spleen tip may be palpable
• No hernias

Abnormal Findings

• Distended or scaphoid abdomen
• Umbilical erythema, discharge, or omphalitis
• Absent bowel sounds
• Palpable masses
• Hepatomegaly or splenomegaly
• Inguinal or umbilical hernias

7. Genitourinary System

Technique

• Inspect external genitalia
• Palpate for descended testes in males
• Assess urinary stream if possible
• Check for ambiguous genitalia

Normal Findings

• Males:
  • Penis: straight, urethral opening at tip
  • Scrotum: rugated, pigmented
  • Testes: descended bilaterally
• Females:
  • Labia majora cover labia minora in term infants
  • Clitoris visible
  • Hymenal tag may be present
• Clear urinary stream

Abnormal Findings

• Hypospadias or epispadias
• Micropenis (<2 cm stretched length)
• Undescended testes
• Inguinal hernia
• Ambiguous genitalia
• Imperforate hymen
• Signs of urinary tract obstruction (distended bladder)

8. Musculoskeletal System

Technique

• Inspect limb symmetry and proportions
• Assess passive range of motion of all joints
• Perform Ortolani and Barlow maneuvers for hip dysplasia
• Examine hands and feet for abnormalities
• Assess muscle tone and strength

Normal Findings

• Symmetrical limbs with normal proportions
• Full range of motion in all joints
• Negative Ortolani and Barlow tests
• Hands: 5 separate digits, palmar creases present
• Feet: Aligned with legs, no clubfoot deformity
• Normal muscle tone (slight flexion at rest)

Abnormal Findings

• Asymmetry in limb length or bulk
• Limited range of motion in joints
• Positive Ortolani or Barlow test (hip dysplasia)
• Polydactyly, syndactyly, or clinodactyly
• Clubfoot or other foot deformities
• Hypotonia or hypertonia
• Fractures or birth injuries

9. Neurological Examination

Technique

• Assess level of consciousness and behavior
• Evaluate primitive reflexes (Moro, rooting, sucking, palmar grasp)
• Test muscle tone and strength
• Observe spontaneous movements
• Assess cranial nerves (as appropriate for age)

Normal Findings

• Alert and responsive when awake
• Present and symmetric primitive reflexes
• Normal muscle tone with slight flexion at rest
• Symmetrical spontaneous movements
• Intact cranial nerve functions:
  • Pupils equal and reactive to light
  • Eyes move conjugately
  • Strong suck and gag reflexes

Abnormal Findings

• Lethargy, irritability, or seizures
• Absent or asymmetric primitive reflexes
• Hypotonia or hypertonia
• Asymmetric movements or tremors
• Cranial nerve abnormalities:
  • Ptosis
  • Facial asymmetry
  • Weak suck or absent gag reflex

10. Skin

Technique

• Inspect entire skin surface, including scalp
• Note color, texture, and presence of lesions or birthmarks
• Assess skin turgor
• Examine nails

Normal Findings

• Pink color with possible acrocyanosis
• Smooth texture with normal turgor
• Transient benign lesions may be present:
  • Erythema toxicum
  • Milia
  • Mongolian spots
• Nails extend to fingertips

Abnormal Findings

• Jaundice
• Pallor or plethora
• Poor skin turgor (dehydration)
• Congenital nevi or vascular malformations
• Vesicles, pustules, or petechiae
• Skin dimples or sinuses (especially along spine)
• Abnormal nail formation

11. Additional Assessments

Technique

• Measure birth weight, length, and head circumference
• Plot measurements on appropriate growth charts
• Calculate Ballard or Dubowitz score for gestational age assessment
• Perform screening tests as per local guidelines (e.g., hearing, metabolic)

Normal Findings

• Birth weight: 2500-4000g for term infants
• Length: 48-53 cm for term infants
• Head circumference: 32-37 cm for term infants
• Measurements consistent with gestational age
• Ballard or Dubowitz score consistent with estimated gestational age
• Passed newborn screening tests

Abnormal Findings

• Low birth weight (<2500g) or macrosomia (>4000g)
• Length or head circumference outside normal range
• Disproportionate measurements (e.g., large head relative to body)
• Ballard or Dubowitz score inconsistent with estimated gestational age
• Failed screening tests requiring further evaluation

Conclusion

This comprehensive neonatal examination guide provides a structured approach to assessing newborns. It is essential to document all findings accurately and communicate any abnormalities to the healthcare team and parents. Remember that this examination is part of an ongoing assessment process, and serial examinations may be necessary to monitor the newborn's progress and address any emerging concerns.