Vital signs should be recorded by the nursing staff for all newborns admitted to the nursery. Body temperature is typically measured in the axilla. Fever, defined as a temperature ≥38.0° Celsius (or 100.4° Fahrenheit), is often caused by excessive environmental heat or overbundling when it occurs shortly after birth. Hypothermia may result if newborns are left in the delivery room unbundled and off the radiant warmer. A newborn with hypothermia or hyperthermia whose temperature fails to normalize in response to appropriate environmental measures should be evaluated for possible sepsis and central nervous system pathology.
A normal respiratory rate for a newborn is typically between 40 and 60 breaths per minute. A normal heart rate for a newborn is generally 100–160 beats/min, but varies considerably with sleep and activity level. If measured, pulse oximetry should be >95% in the term infant. However, it is important to realize that oxygen saturations may remain low for several minutes after birth. Data indicate that it takes approximately 8 minutes on average for pulse oxygen saturations to rise above 90%. Neonatal resuscitation guidelines published by the AAP in 2010 target a preductal saturation of >80% by 5 minutes of life and 85–95% by 10 minutes of life in both term and preterm infants. Blood pressure varies with gestation and birth weight. There is still debate regarding what constitutes an abnormal blood pressure in a neonate, but hypotension in the first 12–24 hours of life is typically defined as a mean blood pressure less than the gestational age. Hypertension in the full-term newborn is defined as a systolic blood pressure >90 mm Hg and diastolic blood pressure >60 mm Hg and a mean blood pressure >70 mm Hg. Blood pressures should be measured in all 4 extremities if there is any suspicion of cardiac disease. Coarctation of the aorta is characterized by elevated blood pressure in the upper extremities and decreased pressure in the lower extremities.
Weight, length, and head circumference should be measured and plotted on curves to assess intrauterine growth (Fig. 9–1). Newborns that are small for gestational age (SGA), historically defined as less than the 10th percentile on the growth curve, may warrant evaluation for congenital infections, chromosomal syndromes, or other causes if there is no identifiable cause for the growth retardation, such as multiple pregnancy or preeclampsia or other evidence of placental insufficiency. Infants that are SGA or LGA should be treated similarly to the infants of diabetic mothers and should be monitored for hypoglycemia in the first few hours of life.
Classification of newborns based on gestational age plotted against head circumference, length, and weight. AGA, appropriate for gestational age; LGA, large for gestational age; SGA, small for gestational age.
Although gestational age is usually estimated before delivery by prenatal ultrasound (preferably early on in the pregnancy) or the mother's last menstrual period, information is sometimes unavailable or inaccurate, and maturity should be reassessed postnatally. There are measures, such as Ballard's modified version of the Dubowitz exam (Table 9–2), that incorporate multiple elements of the physical exam and may be useful at 12–24 hours of life to help determine gestational age.
Table 9–2. Newborn Maturity Rating and Classification. ||Download (.pdf)
Table 9–2. Newborn Maturity Rating and Classification.
Square window (wrist)
Heel to ear
Gelatinous, red, transparent
Smooth, pink; visible veins
Superficial peeling and/or rash; few veins
Cracking, pale area; rare veins
Parchment, deep cracking; no vessels
Leathery, cracked, wrinkled
Faint red marks
Anterior trans-verse crease only
Creases anterior two-thirds
Creases cover entire sole
Flat areola; no bud
Stippled areola; bud, 1–2 mm
Raised areola; bud, 3–4 mm
Full areola; bud, 5–10 mm
Pinna flat; stays folded
Slightly curved pinna; soft; slow recoil
Well-curved pinna; soft; ready recoil
Formed and firm; instant recoil
Thick cartilage; ear stiff
Scrotum empty; no rugae
Testes descending; few rugae
Testes down; good rugae
Testes pendulous; deep rugae
Prominent clitoris and labia minora
Majora and mi-nora equally prominent
Majora large; minora small
Clitoris and minora completely covered
A physician should perform a complete physical exam of the newborn within the first 24 hours of life.
As on the initial brief examination, the color of the skin should be evaluated and the presence of cyanosis, pallor, or jaundice noted. The healthy newborn should be pink. Postterm infants often have dry, cracked skin. Clinical jaundice is rare in the first 24 hours of life and should trigger an evaluation. Plethora, often seen in infants of diabetic mothers, may indicate significant polycythemia. Practice varies, but most neonatologists consider a hematocrit >70% in an asymptomatic newborn and 65% in a symptomatic newborn grounds for a partial exchange transfusion. Symptoms of hyperviscosity include hypoxia, hypoglycemia, increased work of breathing, and seizures. Neurologic sequelae can be serious. Petechiae are often present over the face and upper torso, particularly when a nuchal cord is present. When present below the nipple line, petechiae should raise concern about the possibility of sepsis or platelet dysfunction. Bruising occurs frequently, especially with breech presentation, but should be noted because it may lead to excessive hemolysis and hyperbilirubinemia when extensive. Mongolian spots are dark purple-blue hyperpigmented areas usually over the back and buttocks that look like bruising, but are clusters of melanocytes deep within the dermis. They are present in a majority of black and Asian newborns and fade over time. Dermal sinuses, dimples, and cysts should be noted; they may indicate underlying defects or pose a risk for infection.
The most common newborn rash is erythema toxicum, which presents at 24–48 hours of life in almost half of all newborns as erythematous papular-pustular lesions that tend to spare the palms and soles. Other frequently seen benign rashes include milia, small white papules typically around the nares, and transient neonatal pustular melanosis, small vesicles or pustules present at birth that leave pigmented macules surrounded by scale when they disappear.
Hemangiomas and vascular malformations may be present at birth. Hemangiomas are benign tumors of vascular endothelium and are often not present at birth, but may be noted soon after. They eventually involute without therapy, but only after an initial period of growth, usually of 6–12 months. If present near the eyes or airways, they may require early intervention to prevent visual or airway compromise. In contrast, vascular malformations such as port-wine stains and salmon patches are always present at birth. Developmental anomalies composed of 1 or more types of vessels, they typically grow as the child grows and do not resolve spontaneously.
The head should be evaluated for any asymmetry. The suture lines may be open or slightly overriding, but premature fusion requires intervention, as it presents a constraint to brain growth. The anterior fontanelle should be soft, not tense or bulging, when the newborn is calm. It is typically 1–4 cm in size and may be enlarged with hypothyroidism or increased intracranial pressure. The posterior fontanelle is typically <1 cm and may not be palpable.
Scalp edema (caput succedaneum) can most easily be differentiated from a cephalohematoma (a localized collection of blood under the dura mater) by noting whether or not the swelling crosses suture lines; cephalohematoma is typically confined by suture lines. A cephalohematoma should raise awareness of the possible development of hyperbilirubinemia as the collection of blood is broken down and resorbed. Skull fractures can occur, and the skull should be palpated carefully.
The face should be evaluated for dysmorphic features, malformations, and asymmetries. Micrognathia may cause significant airway compromise in the neonate and is associated with various syndromes. The palate should be palpated to ensure that it is not high-arched or clefted. A naris is patent if there is air movement through it (demonstrated by holding cotton in front of it) when the mouth and other naris are closed. Subconjunctival hemorrhages are a common finding as a result of the birth process. An absent red reflex should prompt an immediate ophthalmologic evaluation to rule out a congenital cataract, retinoblastoma, or glaucoma. Pupils should be equal and reactive. Abnormalities of the positioning or formation of the eyes, nose, or ears may suggest specific syndromes or chromosomal defects. Although preauricular tags and pits have been associated with renal malformations, there is no current evidence to suggest that their presence, when an isolated finding, is sufficient to warrant a renal ultrasound. The neck should be examined for masses, cysts, and webbing. The clavicles should be palpated for crepitus, swelling, and tenderness, which would suggest an underlying fracture. Although not usually detected until several weeks of age, torticollis may occur as a result of ischemia within, or hemorrhage into, the sternocleidomastoid muscle at birth. It manifests as a head tilt with or without a fibrous mass palpable in the muscle. Surgery is rarely necessary; the overwhelming majority of cases are managed with a home stretching regimen or physical therapy.
The chest should be evaluated for deformities such as widely spaced or accessory nipples and pectus excavatum. Breast buds may be present in both sexes and are normal, a product of exposure to circulating maternal hormones in utero.
The respiratory effort and rate should be evaluated, looking for signs of respiratory distress. Early on, tachypnea may be the only sign of pathologic processes as varied as pneumonia, amniotic fluid and/ or meconium aspiration syndrome, sepsis, or congenital heart disease (CHD). Breath sounds are auscultated, paying attention to the quality of the breath sounds, the air entry, and any asymmetry that is present across the lung fields. Asymmetry of the breath sounds may indicate an area of consolidation from atelectasis or infection, a pneumothorax, effusion, or mass. Upper airway sounds, such as congestion or stridor, are often mistaken for abnormal breath sounds on exam. The listener can usually distinguish noises of upper airway origin from those of intrathoracic origin by listening for the presence of the sounds over the patient's neck. Respiratory distress or an abnormal lung exam should be evaluated with a chest radiograph. In an emergency situation in which a pneumothorax is suspected, a transilluminator may be used. Transillumination is increased over the side of a pneumothorax, but it is sometimes difficult to assess accurately and should be confirmed by chest radiograph when possible before needle aspiration or chest tube placement.
A hyperdynamic precordium may indicate underlying heart disease with volume overload to one or both ventricles. The heart is auscultated to evaluate the heart rate and rhythm and characterize the heart sounds. A split-second heart sound can assure the examiner that both the aortic and pulmonary valves are present. A murmur should be described by where it is heard, what it sounds like, if it occurs in systole or diastole, and how loud it is. Murmurs are often audible in the newborn and are frequently innocent. Innocent murmurs are often attributed to a closing ductus arteriosus or foramen ovale, but the most commonly heard innocent murmur in the neonate is produced by peripheral pulmonic stenosis (PPS). PPS murmurs occur during systole and are best heard over the back or axillae.
Murmurs may or may not be present in newborns with CHD. Ventricular septal defects, the most common form of CHD, have a characteristic harsh, systolic murmur associated with them. However, the pressures in the newborn pulmonary system are still high (roughly equal to systemic pressures), and thus there is usually no flow gradient across a large ventricular defect to produce a murmur in the first few days of life. Complex CHD typically presents as cyanosis, tachypnea, or shock and will rarely present as an asymptomatic murmur. Signs may develop quickly with closure of the ductus arteriosus if the lesion has ductal-dependent pulmonary or systemic flow. The initial steps in evaluating a stable patient for suspected CHD include 4-extremity blood pressure measurements, measurement of pre- and postductal saturations, electrocardiogram, chest radiography, and a hyperoxia test. The diagnosis of CHD is usually established by echocardiogram.
The examiner should listen for bowel sounds and palpate the abdomen for masses, organomegaly, or abnormal musculature. The liver is easily palpable in the newborn and the inferior edge is usually 1–2 cm below the right costal margin. It is often possible to palpate the kidneys and spleen. Absence of the abdominal musculature may be associated with significant urinary tract abnormalities. The umbilical stump should be assessed for redness or induration that may suggest the presence of an infection. Umbilical hernias are common and typically require no intervention in infancy. Omphalocele and gastroschisis are major abdominal wall defects and require emergent surgical evaluation. Omphalocele is a midline abdominal wall defect. Bowel, and often liver, herniate through the defect, and the umbilicus is typically on the anterior aspect of the omphalocele. Unless ruptured, an omphalocele is covered by a membrane. Omphalocele is associated with aneuploidies, certain genetic syndromes such as pentalogy of Cantrell, and other congenital structural malformations. The defect in gastroschisis is typically to the right of the umbilicus on the abdominal wall, and the etiology of the defect is thought to be due to vascular interruption. The entire bowel may be externalized, but the liver typically remains internal. Unlike omphaloceles, the externalized bowel is not covered by a membrane. Other bowel abnormalities such as bowel atresias and malrotation of the bowel may be present in infants with gastroschisis. Fetuses with gastroschisis are also at increased risk of developing intrauterine growth restriction.
The penile length and clitoral size should be inspected to rule out ambiguous genitalia. The labia majora should cover the labia minora and clitoris in a term female. White mucouslike discharge from the vagina is often present and is physiologic.
The scrotum should be evaluated for hernias or masses and descent of the testicles. Transillumination of the scrotum will help to distinguish a hydrocele from an inguinal hernia. The position of the urethral meatus is important to note, as the presence of hypospadias should preclude routine circumcision to allow for optimal surgical correction of the hypospadias.
The rectum should be evaluated for patency and position. An anteriorly displaced rectum may be associated with a rectogenital fistula.
The extremities, spine, and hips are examined for signs of fracture, malformation, or deformation. Range of motion of the joints is assessed. Arthrogryposis, contractures of the joints, may be seen with neuromuscular disease or oligohydramnios as a result of decreased or limited movement in utero. Abnormalities of the extremities, such as polydactyly or syndactyly, are seen in different chromosomal abnormalities and syndromes and may help in making the diagnosis. Particular attention should be paid to the examination of the hips (despite the fact that a dislocation may not be detectable in the first weeks of life) because developmental dysplasia of the hip (DDH) can cause permanent damage if left undetected throughout the first year of life. Either the Barlow or Ortolani test may be used to determine whether a dislocation is present. The Barlow test involves positioning the patient on the back, bringing the knees together at midline, and then pushing down and out on the upper inner thighs. The Ortolani test involves pushing downward on the femurs while abducting the hips. With both maneuvers the dislocation is detected as a clunk as the femoral head is dislocated from the acetabulum (posteriorly with the Barlow, laterally with the Ortolani). Asymmetry of the gluteal folds and skin creases of the legs is another clue to the presence of DDH.
Observing the activity level, alertness, and positioning of the newborn provides a tremendous amount of information about the overall state of health. A healthy, full-term newborn at rest should lie with the extremities flexed. Decreased tone may be a sign of neuromuscular or systemic illness such as sepsis. There should be spontaneous intermittent movement of all 4 limbs, and the baby should be alert during at least portions of the examination. Pupil size and symmetry should be noted. Primitive reflexes such as the Moro, grasp, suck, and tonic neck reflex should all be present at birth. To elicit the Moro reflex, the newborn is supported with a hand under the back and then rapidly dropped a few centimeters back toward the examination bed. The full Moro reflex consists of extension and then flexion and adduction of the arms (“embrace”), opening of the eyes, and a cry. Reflexes are elicited by tapping a finger over the appropriate tendon. Significant clonus may be a sign of central nervous system injury. A sacral dimple or tuft of hair over the sacral spine may indicate spina bifida occulta and should be evaluated with a spinal ultrasound; if the findings of the ultrasound are equivocal, a magnetic resonance imaging scan should be done at approximately 3 months of age.
The benefits of breastfeeding on everything from the strength of the immune system to developmental outcomes and IQ have been well documented. Human milk is the most easily digested form of infant nutrition, and its caloric value is superior to formula. Mothers should be counseled prenatally about the benefits of breastfeeding and encouraged by their obstetric caregivers to consider breastfeeding. Contraindications to breastfeeding include HIV infection, active tuberculosis infection, and the use of certain medications. Maternal hepatitis C virus (HCV) infection is not a contraindication to breastfeeding. Transmission of HCV via breastmilk is not documented in the absence of coexisting maternal infection with HIV. Nevertheless, infected mothers should be informed that transmission via breastmilk is theoretically possible.
Breastfeeding may be difficult and frustrating for new mothers. It is important that the newborn nursery staff work to provide mothers with the support and knowledge they need to make breastfeeding a positive experience. It is also important that mothers of newborns who require bottle supplementation (eg, a dehydrated, jaundiced infant) are reassured that their efforts at breastfeeding will not be derailed by exposure to the bottle during a limited, medically necessary period, and that breastfeeding can still ultimately succeed.
Regardless of the overwhelming literature to support the value of breast milk, many mothers in the United States choose to bottle-feed their children. Selection of the formula given to the newborn is often based on what formula is available in the nursery or by the mother's preference. Standard-term infant formula contains iron supplementation and provides 20 kcal/oz. No one formula is better than another for healthy term infants. Mothers with a family history of lactose intolerance sometimes request soy formula, and standard soy formula will provide adequate nutrition for growth and development. Formulas such as Alimentum and Nutramigen are available for infants with more significant protein allergy. Premature infant formulas contain 24 kcal/oz and provide higher amounts of protein, medium-chain triglycerides, and vitamins and minerals (eg, calcium and phosphorous) than standard formulas. The AAP currently recommends formula for the first year of life.
Voiding should be monitored closely in the nursery. Changes in the baby's weight and the frequency of urination can be used to assess the hydration status and adequacy of intake in a breastfeeding baby. The time of the first void of urine and stool should be documented. Failure to void in the first 24 hours of life should prompt an evaluation of renal function and hydration status. Failure to pass stool in the first 48 hours of life should prompt an evaluation for possible bowel obstruction; 94% of normal term newborns will pass meconium in the first 24 hours of life. Obstruction can result from conditions such as bowel atresia or stenosis, Hirschsprung's disease, and meconium ileus.
American Academy of Pediatrics and American Heart Association. Textbook of Neonatal Resuscitation. 5th ed. Dallas, TX: American Academy of Pediatrics; 2006.