A neonatal examination is a comprehensive head-to-toe assessment performed within the first 72 hours of life to evaluate a newborn’s adaptation to extrauterine life, detect congenital anomalies, and establish a baseline for ongoing care. It’s often repeated at 6–8 weeks to catch conditions that may emerge later.
Principles of Neonatal Examination
- Provision should be made to prevent neonatal heat loss during the physical assessment.
- A rapid overall assessment of the baby will be done at the time of birth, with a more detailed assessment completed on admissions.
- Where possible, the parents should be present during the assessment.
- Sequence of neonatal examination include:
- Inspection: Body proportion, posture, and skin, amount of subcutaneous fat, facial appearance, respiration, sleep status, movement, and responsiveness
- Auscultation: Heart, lung, and bowel sounds
- Palpation: Cranium, peripheral pulses, abdomen, liver, spleen, and kidneys
- Neurologic reflexes: Sucking/rooting, Moro, grasping, Babinski, etc.
- Others: Vital signs and measurement.
Structured Format for Neonatal Examination
| Section | Key Elements |
|---|---|
| General Appearance | Tone, color, posture, activity, cry, dysmorphic features |
| Vital Signs | Temperature, heart rate, respiratory rate, oxygen saturation |
| Head & Face | Fontanelles, sutures, head shape, facial symmetry, eyes (red reflex), ears |
| Mouth & Neck | Cleft lip/palate, tongue tie, neck masses, range of motion |
| Chest & Lungs | Symmetry, breath sounds, work of breathing, chest wall movement |
| Cardiovascular | Heart sounds, murmurs, femoral pulses, capillary refill |
| Abdomen | Shape, organomegaly, umbilical cord (vessels, hernia), bowel sounds |
| Genitalia & Anus | Patency, testicular descent, labial anatomy, anal opening |
| Hips | Barlow and Ortolani maneuvers for developmental dysplasia |
| Spine | Palpate for defects, sacral dimple, hair tuft |
| Extremities | Digits, movement, tone, reflexes, clubfoot, fractures |
| Neurologic | Moro, rooting, sucking, grasp reflexes; tone and alertness |
| Skin | Birthmarks, jaundice, rashes, vernix, lanugo |
The assessment of newborn can be divided into four phases.
- Initial assessment
- Transitional assessment
- Assessment of gestational age
- Comprehensive physical examination of the newborn, including newborn reflexes
Initial Assessment
The aim of neonatal examination of the baby at birth is to ensure and assess that lungs have expanded and that air passages are not obstructed and to make an early diagnosis of life-threatening congenital malformations and birth injuries.
The most frequently used method to assess the newborn at birth is Apgar score. The evaluation of all five criteria should be made at 1 and 5 minutes after birth and is repeated 45 minutes until the infant’s condition stabilizes.
Total score of 0-3 represent severe distress, score of 4-6 signify moderate difficulty, and score of 7-10 moderate the absence of difficulty in adjusting extrauterine life.
Transitional Assessment
Periods of reactivity during the first 24 hours after birth, the changes in heart rate, respiration, motor activity, color, mucus production, and bowel activity occur in an orderly predictable sequence. For the first 6-8 hours after birth, the newborn is in the first period of reactivity.
During the first 30 minutes, the infant is alert, cries vigorously, may suck his or her fingers or fist, and appears interested in the environment.
At this time, the neonate’s eyes are usually open, thus is an excellent opportunity for mother, father, and child to see each other. The newborn usually grasps the nipple quickly, satisfying both mother and child. Physiologically the respiratory rate may reach 80 breaths/min, crackles may be heard, heart rate may reach 80 beats/min, bowel sounds are active, mucus secretions are increased, and temperature may decrease slightly.
After this, the infant enters the second stage of the first reactive period, which generally lasts 2-4 hours. Heart and respiratory rates decrease, temperature continues to fall, mucus production decreases, and urine or stool is usually not passed. The infant is in the state of sleep and relatively calm. Any attempt at stimulation usually elicits a minimal response.
The second period of reactivity begins when the infant wakes from this deep sleep, it lasts about 2-5 hours and provides another excellent opportunity for child and parent to interact. The infant is again alert and responsive, heart and respiratory rates increase, and the gag reflex is active. Gastric and respiratory secretions are increase, and passage of meconium commonly occurs. This period is usually over when the amount of respiratory mucus decreased. After this stage is a period of stabilization of physiologic systems and vacillating pattern of sleep and activity.
Clinical Assessment of Gestational Age
To assess the gestational age new Ballard scale” can be used. It assesses six external physical and six neuromuscular signs. Each sign has a number score, and the cumulative score correlates with a maturity rating of 26-44 weeks of gestation.
Neuromuscular maturity
The neurological assessment is based on five fundamental observations.
Muscle tone:
Progressively increases in utero as maturity proceeds. The tone in the newborn baby is assessed by three parameters: (1) posture or attitude, (2) passive tone is evaluated by assessing popliteal angle and scarf sign, and (3) active tone is assessed by traction response and recoil.
Joint mobility:
The degree of flexion at ankle and wrist (square window) is limited in preterm babies because of relatively greater stiffness of joints in early gestation. As term approaches the joints become more flexible and relaxed to allow for easy molding during delivery.
Certain automatic reflexes appear at specific ages of gestational maturity, for example, Moro reflex appears as early as 28-30 weeks but lacks complete adduction phase till 38 weeks of gestation. Response of pupils to light is present after 30 weeks and baby may turn his head toward diffuse light during 32-36 weeks of gestation. Grasp response makes its appearance around 30 weeks, but a strong grasp can be elicited after 36 weeks,Neck flexors are able to contract in response to traction around 33 weeks of maturity. Rooting and coordinated sucking efforts are present by 34 weeks of gestation.
Fundus examination:
- The disappearance of the anterior vascular capsule of the lens has been used to assess the gestational age.
After 34 weeks of maturity, anterior capsular vessels are almost completely atrophy with graded changes in babies between 28 and 34 weeks of gestation. - Elicitation of the signs.
Square window:
- Hand is flexed on the forearm between thumb and index finger of examiner is relatively stiff, which limits the flexion at the wrist.
Arm recoil:
- The arm is extended and brought close to the trunk. When released, it briskly recoils or flexes in a term infant.
Popliteal angle:
- Thigh is held in knee chest position and examiner tries to extend the knee with gentle pressure behind the ankle. The angle is 90° or less in a term infant, 120° among babies of 33-36 weeks of gestation, and almost 180° in a neonate <32 weeks.
Scarf sign:
- The baby lies supine, and head is maintained in the midline. Arm is held at the wrist and pulled across the chest toward the opposite shoulder. In a preterm baby, elbow readily goes beyond the midline of the chest.
Physical Examination
A thorough head-to-foot examination of newborns is done to assess the general condition of baby in detail. This should be done in a systematic manner.
Elicitation of reflexes during Neonatal Examination
Reflexes are involuntary movements of the body parts. Some reflexes occur spontaneously whereas other movements occur as a response to specific stimuli. During Neonatal Examination, reflex should be done as part of newborn assessment to determine the brain and nervous system function.
Special Considerations
- Perform in a warm, well-lit, private setting with parents present.
- Use gentle handling and observe the baby’s spontaneous behavior before touching.
- Document findings clearly and refer for further evaluation if abnormalities are noted.
REFERENCES
- Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
- Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
- Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwer’s, ISBN-13:978-9388313285
- Marcia London, Ruth Bindler, Principles of Paediatric Nursing: Caring for Children, 8th Edition, 2023, Pearson Publications, ISBN-13: 9780136859840
- Naveen Bajaj, Rajesh Kumar, Manual of Newborn Nursing, 2nd Edition, 2023, Jaypee Publishers, ISBN:978-9354659294
- Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2024. PART IV, NURSING PROCESS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK610818/
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