6: Newborn Physical Examination

INTRODUCTION

Newborns are examined immediately after birth to check for major abnormalities and to help ensure that the transition to extrauterine life is without difficulty. The newborn infant should undergo a complete physical examination within 24 hours of birth. Perform the examinations that cause the least amount of disturbance first. It is easier to listen to the heart and lungs first when the infant is quiet. Warming the stethoscope before use decreases the likelihood of making the infant cry.

I. VITAL SIGNS

1. Temperature. Indicate whether the temperature is rectal (which is usually 1° higher than oral), oral, or axillary (which is usually 1° lower than oral). Axillary temperature is usually measured in the neonate, with rectal temperature done if the axillary is abnormal.

2. Respirations. The normal respiratory rate in a newborn is 40–60 breaths/min. Periodic breathing (≥3 apneic episodes lasting >3 seconds within a 20-second period of otherwise normal respirations) is normal and common in newborns.

3. Blood pressure. Blood pressure correlates directly with gestational age, postnatal age of the infant, and birthweight. (For normal blood pressure curves, see Appendix C.)

4. Heart rate. The normal heart rate is 100–180 beats/min in the newborn (usually 120–160 beats/min when awake, 70–80 beats/min when asleep). In the healthy infant, the heart rate increases with stimulation. See Table 48–1.

5. Pulse oximetry. Useful for screening for critical congenital cyanotic heart disease. The goal is to identify infants with structural heart defects associated with hypoxia that could have significant morbidity and mortality in the newborn period. These include hypoplastic left heart syndrome, pulmonary atresia, tetralogy of Fallot, tricuspid atresia, transposition of the great arteries, truncus arteriosus, and total anomalous pulmonary venous return. Routine screening for all newborns has been endorsed by the American College of Cardiology Foundation, American Heart Association, and American Academy of Pediatrics (AAP). These criteria may need to be modified in high-altitude areas. Recommendations include the following:

   1. Screen all healthy newborn infants. Best to screen when alert.

   2. Use a motion tolerant pulse oximeter.

   3. Screen at 24–48 hours of age or as late as possible for early discharge.

   4. Obtain oxygen saturation in the right hand and one foot

      1. Negative screen

         1. Results. Pulse oximetry reading of ≥95% in either extremity and a ≤3% difference between the right hand and foot.

         2. Plan. No further testing or treatment necessary.

      2. Positive screen is any of the following:

         1. Results. Any of the following:

            • (a) Pulse oximetry <90%. In either right hand or foot.

            • (b) Pulse oximetry 90 to <95%. In right hand and foot on 3 different measures, each separated by an hour.

            • (c) Pulse oximetry >3% difference. Between the right hand and foot on 3 different measures, each separated by an hour.ii.

         2. Plan. Perform a comprehensive evaluation for hypoxia. Rule out other reasons for hypoxia (respiratory, sepsis, and others). If no obvious cause is found, a diagnostic echocardiogram is done, and consider pediatric cardiology consultation.

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