The Comprehensive Infant Examination

1. Preparation for the exam

1. Before the exam, obtain permission from the parent to examine their child.
2. Ensure that all the equipment is available and disinfected adequately before starting. A stethoscope and ophthalmoscope are usually needed. Consider using a neonatal or pediatric-sized stethoscope, if available.
3. The exam will eventually take place on a safe, flat surface such as a warmer or bassinet — ensure that such a location is available.
4. Make sure to have a clean baby blanket available to keep the baby covered and warm during parts of the exam that do not require exposure. 
5. Wash hands to prevent transmission of infection. Some examiners use gloves for the entire newborn exam. In contrast, others don gloves only when a baby is still covered in vernix (that is, has not yet had a bath) and for examining the mouth, umbilical stump, and diaper area as newborns may void and stool during the exam. Either approach is acceptable.

2. Visual inspection

1. Before touching the baby, take a moment to observe the baby's general appearance and activity.
2. Take note of the parent-child interaction: whether the baby is breastfeeding, cuddling with a parent, or sleeping in the bassinet. It is essential to understand how the parents bond with the child.
3. Learn how the baby is acting. Note the color of the skin, symmetry of their facial movements, degree of activity, rooting or sucking behavior as signs of hunger, and any signs of breathing distress — including flaring of the nostrils or retractions of the skin under the ribcage. 
4. Throughout the exam, observe the skin for any rashes, hemangiomas, skin tags, or discoloration such as pallor or jaundice. 
5. There are many benign newborn rashes, including erythema toxicum, which is the most common newborn rash occurring in >50% of newborns and is caused by exposure to maternal hormones in utero. This rash does not bother the baby or require any treatment. Erythema toxicum typically resolves within a few weeks of life. 

3. Newborn measurements

1. To determine if the baby has grown appropriately in utero, first weigh the baby. The average weight of a newborn is around 7 pounds.
2. Newborns may be greater than the 90^th percentile of expected weight for gestational age if the mother has diabetes. Infections, such as HIV or Rubella, or drug exposure during pregnancy can cause the baby to be small for their gestational age and weigh in at less than the 10^th percentile of expected weight.
3. Next, measure the length of the baby with a measuring tape from the top of the head to the bottom of one of the heels. The average length at birth for a full-term baby is about 20 inches.
4. Then, measure the head circumference of the baby by wrapping a flexible measuring tape around the head just above the eyebrows and ears, and around the back where their head slopes up prominently from their neck.
5. A small head circumference can be a consequence of different factors, including cytomegalovirus or Zika virus infection in the first trimester, and can also be associated with hearing loss in the newborn.
6. A Ballard score is used for estimating the gestational maturity of babies who have an unknown gestational age at the time of delivery.
   1. The pediatrician usually performs the baby's first physical exam within 24 hours of birth. If there is uncertainty about the baby's gestational age, the physician will assess six physical components and then six neuromuscular components to estimate the baby's gestational maturity. Each physical and neuromuscular component is given a score from -1 to 5, and then gestational age is estimated after calculating the total score.

4. Heart and lung exam

1. If the baby is quiet, heart and lung auscultation may be prioritized, potentially starting these parts of the exam wherever the baby happens to be (for example, in the parent's arms) and even examining over clothing to keep the baby as quiet as possible. 
2. Move the baby to a safe, flat surface such as a warmer or bassinet. Ensure that the child is not left unsupervised and does not have the potential to fall off the surface. 
3. Undress the baby except for the diaper, or ask the parent to help. 
4. To help the baby stay quiet and warm, keep them wrapped in a blanket, pulling it down just enough to place the stethoscope directly on the baby's chest. 
5. Start by listening over the heart in the aortic, pulmonary, mitral, and tricuspid areas with the diaphragm and the bell of the stethoscope. This will ensure an appreciation of both high and low-pitched murmurs, if present. Heart arrhythmias are uncommon in newborns, but approximately 80% of newborns have a heart murmur in the first week of life — the primary cause being a patent ductus arteriosus (PDA). The PDA is a small blood vessel present in utero that connects the pulmonary artery to the aorta, causing blood to bypass the lungs. The PDA is not needed in extrauterine life and typically closes within the first few weeks, requiring no intervention.
6. The cardiovascular exam also includes palpation of both femoral pulses and simultaneous palpation of either the femoral pulse or the right brachial pulse. This will serve as a screen for congenital coarctation (or narrowing) of the aorta. 
   1. To feel both femoral pulses, the examiner should lightly palpate the second and third fingers of their right hand about mid-way over the baby's left inguinal ligament and the second and third fingers of their left hand over the baby's right inguinal ligament. A light pulse should be felt that is symmetric. 
   2. Once the symmetry of the femoral pulses is established, the examiner should move the fingers of one of their hands off the baby's femoral pulse and towards the right brachial pulse by palpating lightly medially to the biceps tendon near the antecubital fossa. Note the pulsation of the right brachial artery while still palpating one of the femoral pulses. These pulses should feel equal and symmetric. A weak or delayed femoral pulse relative to the brachial pulse could indicate coarctation of the aorta. 
7. For the lung exam, observe the respiratory effort with the baby's chest wall exposed. Look for signs of labored breathing, such as grunting, nasal flaring, or retractions (suprasternal, intercostal). 
8. Next, auscultate over the lungs, listening to upper and lower lung fields bilaterally in the front and back. Due to retained fetal lung fluid, newborns can have soft, diffuse crackles that typically resolve within 12-24 hours as the fluid is naturally resorbed. 

5. Head and neck exam

1. After listening carefully to the heart and lungs while the baby is quiet, move on to the head and neck exam. 
2. When evaluating the baby's head, start by feeling the anterior and posterior fontanelles. These are natural openings in the skull, under the skin, which usually close within the first year of life. The anterior fontanelle is the easiest to appreciate and should be soft and flat. The posterior fontanelle can be more difficult to appreciate as it is smaller, often less than a fingertip in diameter.
3. Next, palpate the skull sutures. Skull sutures on the baby have not yet fused, and it is common to feel ridges where the sutures have overlapped to decrease the head size to promote passage through the birth canal. 
4. Inspect the head and scalp for other findings, such as molding from the birth canal, scalp electrode site, or bruising from forceps or vacuum-assisted deliveries.
5. Next, move on to the eyes, looking for a symmetric, spontaneous opening of the eyes.
6. Check for any discharge, conjunctival redness, or jaundice. Due to the pressure of the birth canal, newborns often have eyelid swelling or conjunctival hemorrhages that resolve over several days and cause no long-term issues. 
7. It is important to check a retinal reflex with an ophthalmoscope to rule out congenital cataracts or eye tumors, such as retinoblastoma. Turning off the room lights while gently cradling the baby and rocking them back and forth may entice them to open their eyes briefly. 
8. The nose should be evaluated to ensure that the nares are open and without discharge. Newborns are obligate nasal breathers, particularly when feeding. Because of this, any nasal blockage, including choanal atresia, would be brought to attention by breathing difficulty during feeds. One nostril can be plugged at a time with the finger to ensure the baby is still breathing comfortably. 
9. Next, examine the baby's mouth. With a gloved finger, the hard and soft palate should be palpated for any clefts. The gums should be palpated for any natal teeth or cysts. 
10. The tip of the examiner's finger in the baby's mouth should stimulate the baby's sucking reflex, which can be evaluated for appropriate strength and coordination. 
11. The tongue should be evaluated for tongue tie, also called ankyloglossia, by visual inspection of the lingual frenulum and observation of tongue extrusion. Ankyloglossia can present with a heart-shaped tongue that has limited movement past the lower gumline.
12. The baby's ears should be evaluated for normal size and shape, as well as pre-auricular skin tags or pits. These anomalies can sometimes be associated with hearing loss or kidney disease.
13. The baby's neck should be evaluated for any indentations or masses that could indicate a residual branchial cleft with the potential for later infection. 
14. The clavicles should be palpated for crepitus, a crackling sensation beneath the skin, suggesting fracture from delivery trauma. 

6. Abdominal exam

1. At this point, the baby should be fully unwrapped except for the diaper and undressed to ensure a thorough examination. 
2. The baby's abdomen should first be auscultated for bowel sounds, like soft tinkling or water gurgling softly. 
3. Then the abdomen should be palpated throughout for an enlarged liver, a spleen, kidneys, or other masses. While not always possible, ideally, this portion of the exam will be done before a feed because deep palpation can cause the baby to spit up. Have a soft cloth available, just in case. 
4. The umbilicus should appear intact without drainage, bleeding, or redness. It will feel moist in the first few hours after birth but will dry up and typically fall off within 1-2 weeks. The parents should be counseled to keep the umbilicus dry during bath time so that it falls off sooner and is less likely to get infected (that is, do not submerge the baby in water until the umbilical stump falls off).

7. Genitourinary exam

1. The baby's genitals should be examined with the diaper entirely removed. 
2. For girls, mild swelling of the vulvar tissue with whitish vaginal discharge is commonly seen due to exposure to maternal hormones. 
3. For boys, the penis should be evaluated for the abnormal location of the urethra, such as hypospadias. Both testes should be palpated to ensure they are present within the scrotum. 
4. It is recommended to keep the penis pointing down as much as possible during the exam and cover it back up with the diaper as soon as the exam is complete to avoid getting urinated on. 
5. The anus should be inspected for normal location and patency. 

8. Back and extremities exam

1. The baby's back can be evaluated by turning it on its side or turning it over in the examiner's hands. 
2. The back of the head, neck, spine, buttocks, and gluteal cleft should be evaluated for birthmarks, clefts, tufts of hair, dimples, skin tags, or asymmetry that might indicate a spinal defect such as spina bifida. 
3. The baby's arms and legs should be evaluated for normal muscle tone, typically in flexion, with equal movement on both sides. 
4. The hips should be evaluated for instability by grasping each thigh and very gently applying pressure from above the hip joint to see if the femoral head dislocates posteriorly — this is called the Barlow maneuver.
5. Next, apply pressure from behind the hip joint to see if the femoral head dislocates anteriorly — this is called the Ortolani maneuver. Suppose a "clunk" is felt with either of these maneuvers, in that case, the child may have developmental dysplasia of the hip – a condition more common in babies born breech or "feet first." It may require special splinting to promote normal hip development.
6. The baby's hands and feet should be evaluated for an appropriate number of digits. It is normal for babies to have slightly blue-tinged hands and feet within the first 48 hours of life. This is called acrocyanosis and is due to the normal transitioning of blood flow. 

9. Primitive reflexes

1. Newborns exhibit primitive reflexes that disappear within the first several months of life. These reflexes should be checked to ensure normal neurological status and include the Moro reflex, the tonic reflex, the sucking reflex, the rooting reflex, and the grasp reflex. 
2. The Moro reflex is also called the startle reflex. It can happen spontaneously when the baby hears a loud noise. However, the reflex can be purposefully elicited by grasping both of the baby's hands, pulling their arms up until their shoulders are slightly off the exam table, and letting go. The baby should be startled by this movement and react by extending their arms, crying, and pulling their arms back in. This reflex lasts until about two months old. 
3. The tonic reflex can be elicited by turning the baby's head to one side, which results in the baby's arm on that side extending out. In contrast, the opposite arm flexes at the elbow. It is also called the fencing reflex and lasts until the baby is 5-7 months old. 
4. The sucking reflex occurs when the roof of the mouth is touched and the baby starts to suck. This reflex does not start until about the 32^nd week of pregnancy. It is not fully developed until the 36^th week, so premature babies often have difficulty feeding. 
5. The rooting reflex occurs when the corner of the baby's mouth is stroked or touched. The baby will turn its head and mouth toward the side touched, helping them find the breast or bottle to start feeding. This reflex lasts about four months. 
6. Infants demonstrate the grasp reflex when an object (like a finger or rattle) is placed on the palmar surface of their hands or feet. The fingers or toes reflexively wrap around the object. This reflex extinguishes by four months of age and is replaced with voluntary flexion of digits around objects as part of developing fine motor skills. 

10. Conclude the exam

1. Conclude the newborn exam by wrapping the baby in a blanket and swaddling tightly around the shoulders so that the blanket does not cover the face. The blanket should be loose around the lower body, allowing the hips and legs to move freely. Properly redressing and swaddling a newborn provides an opportunity for the clinician to teach new parents how to do this. 
2. Ensure not to leave the baby unsupervised — place them in a crib, bassinet, or in the parent's arms after the exam.
3. Share any physical exam findings with the baby's parents or simply state that "everything looks and sounds normal." Every parent wishes to have a healthy baby, and this will be reassuring for them to hear.