Immediately after birth, all infants should be briefly examined
for major congenital abnormalities, signs of serious illness, or
discrepancy between expected gestational age and weight for gestation.
The number of nursing evaluations in the next few hours depends
on anticipated problems and should focus on heart rate, respiratory
rate and effort, temperature, skin perfusion, skin color, and neuromuscular
activity. Observation of the first feeding, usually within 4 hours
of birth, indicates any underlying difficulty with sucking and swallowing.
If no abnormalities are noted at birth, further newborn observation should
occur at least every 8 hours. Any abnormalities detected at any
time warrant more frequent, thorough examinations and possible investigation
and initial therapy.
All infants should undergo a detailed medical examination within
24 hours of birth to ensure that investigation, treatment, or preventive
management, when indicated, is implemented as soon as possible and
to answer any concerns that a parent may have. Reassurance to a
mother (or guardian) shortly after delivery is immensely important
regardless of maternal experience with deliveries.1 Further
detailed examinations are necessary if any neonatal problems are
detected; infants discharged early, before 24 hours, should be reexamined
by 3 to 4 days of age.
The neonatal examination is best performed in an appropriately
equipped, warm, draft-free room, preferably with the mother present;
examining the infant under a servocontrolled radiant warmer is an
alternative. Thorough hand-washing before and after handling each infant
is essential to prevent the spread of pathogenic organisms. If possible,
the infant’s mother or guardian should be present during the
examination so the examiner may address any specific parental concerns
or questions and observe parental-infant interaction. Observation
of the infant’s appearance, posture, and state of consciousness
should precede the formal aspects of palpation and auscultation. Presence
of 1 anomaly suggests presence of another, since anomalies often
coexist. Constellations of physical findings may indicate the presence
of a syndrome. Evidence of trauma in one part of the baby should
lead to a search for trauma in other areas. Signs of birth trauma
are particularly common in large infants and in infants who underwent
difficult deliveries such as breech or forceps delivery.
The obstetric history of the pregnancy and delivery may provide
a clue or sign of possible neonatal problems. For example, polyhydramnios
may signal bowel obstruction; oligohydramnios may signal renal anomalies
and pulmonary insufficiency; small-for-gestational-age and postmature
infants are suspect for hypoglycemia and polycythemia; and prolonged
rupture of the membranes, maternal fever, and fetal tachycardia
may signal neonatal sepsis. The neonatal consequences of intrauterine
growth restriction, prematurity, multiple births, maternal diabetes,
and meconium-stained amniotic fluid are discussed in detail in other
The infant’s gestational age should be estimated and
body size compared with appropriate normal standards.
There are several ways to estimate gestational age, including
reliable maternal history (based on known first day of the last
menstrual period and regular pattern of menstruation before conception),
prenatal ultrasound scan taken before 20 weeks of gestation, and
physical characteristics of the skin, external genitalia, ears,
breasts, and neuromuscular behavior of the newborn infant (Fig. 44-1).2-4Preterm (or premature)
infants have less than 37 completed weeks of gestation, term infants
have completed 37 to 42 weeks, and postterm (or postmature)
infants are past 42 weeks of gestation.
Examination: First hours of life.
(Source: Adapted from Kempe C, Silver H, O’Brien
D, eds. Current Pediatric Diagnosis and Treatment. 3rd
ed. Los Altos, CA: Lange; 1974.)
Birth weight, occipitofrontal head circumference, and crown-to-heel
length should be measured and recorded. Length is measured from
vertex to heel with the infant’s legs fully extended. These
measurements are then compared for gestational age against standard growth
charts (Fig. 44-2).5 Ideally,
growth charts for the specific population should be used. Babies
born to mothers living at high altitude are smaller than babies
born at or near sea level. An infant is considered to be appropriate
for gestational age if it falls within 2 standard deviations of
the mean on these charts.6 Infants who are more
than 2 standard deviations below the mean are small for gestational
age, and those more than 2 standard deviations above the mean are
large for gestational age. Both groups need special observation7 (see Chapters 47 and 48). Twenty percent of infants with serious congenital malformations are
small for gestational age.8
Intrauterine growth charts showing the normal values
of body weight, length, and head circumference for infants born at
different gestational ages at sea level (Montreal).
(Source: From the data of Usher R, McLean F.
Intrauterine growth of live-born Caucasian infants at sea level:
standards obtained from measurements in 7 dimensions of infants
born between 25 and 44 weeks of gestation. J Pediatr. 1969;74:901-910.)
Most babies born at term cry at birth, quickly establish normal
regular breathing, and may remain awake and quite active for 30
minutes or more, during which the eyes are open; they make sucking,
chewing, and swallowing movements; and they may have bursts of flexion
and extension of the arms and legs with facial grimaces. This activity
may be continuous or interspersed with quiet periods. Following the
first few hours after birth, the normal term baby spends approximately
80% of the time in active or quiet sleep. The remaining
20% of the time is spent awake in varying states of activity
with or without crying.
When the infant cries, the cry should be vigorous. A weak or whimpering
cry is abnormal and warrants closer examination of the
baby. A high-pitched or shrieking cry suggests
an underlying neurologic problem. A hoarse cry may
result from vocal cord paralysis, hypothyroidism, or trauma to the
Initially, infants often adopt a position similar to that assumed
in utero (eFig. 44.1). Placing a crying infant
into this posture often calms the infant. About 2% of infants
have significant deformities caused by mechanical forces that acted
in utero to restrict motion or to create pressure on the limbs,
spine, thorax, or skull. Mechanical forces include oligohydramnios,
uterine malformations, or multiple pregnancies.
Position of comfort in a 20-hour-old infant. When placed
in this position, the infant, who had been crying, was quiet. The
ankles and metatarsals appear to be deformed, but all these apparent
deformities can be easily corrected with gentle pressure.
The normal infant is pink, well-perfused, and feels warm to the
touch, but exposure to even a moderately cold environment leads
to the hands and feet quickly becoming cool and slightly cyanotic.
The normal axillary temperature is between 36.5
°C and 37.4 °C. The most common reasons for a low or high temperature
are exposure to a cool environment and overheating (see Chapter 43). However, persistence of an abnormal temperature in a normal
thermal environment indicates underlying pathology. Hypothermia may
also occur with hypoglycemia, hypoxia, or hypothyroidism. Hyperthermia can
be seen during drug withdrawal and with intracranial or adrenal hemorrhage.
Fine, soft, lanugo hair covers the entire body in
very preterm infants and disappears from the face and lower back
between 32 and 37 weeks. The term infant has lanugo hair on the upper
back and dorsal aspects of the limbs. Vernix caseosa, a
thick white material with the consistency of soft cheese, covers
the skin of the entire body until 35 to 37 weeks. By term, the amount
of vernix has decreased so that it is present mainly in the flexor
creases. Also by term, the subcutaneous tissue is relatively thick,
and the fingernails and toenails are fully formed and extend slightly
beyond the ends of the digits. If fetal hypoxia occurs at term, meconium may
be passed into the amniotic fluid. If meconium has been in the amniotic fluid
for several hours, it will also stain the skin, fingernails, toenails,
and umbilical cord with a greenish hue. Fetuses at less than 34 weeks
of gestation rarely pass meconium in response to hypoxia. The postmature
infant (beyond 42 weeks) may have a somewhat wasted appearance with
dry, peeling skin, a decreased amount of subcutaneous tissue, long
fingernails, and an alert appearance.
A neonatal rash may also indicate a serious systemic infection.
Intrauterine infections may present with thrombocytopenic
purpura. A red maculopapular rash may occur with toxoplasmosis. Congenital
rubella often produces macular or slightly raised purple
lesions, called a “blueberry muffin” rash. Herpes simplex can cause
a few vesicles or a generalized vesicobullous eruption with an erythematous
base; these cutaneous lesions may precede disseminated disease or
may appear following the onset of disease in other organs. Congenital
syphilis may cause a pink, maculopapular rash that later turns
brown or becomes vesicobullous and hemorrhagic. Syphilitic rashes
commonly involve the palms or soles. Staphylococcal infection may
appear as pustules, generalized erythema, or extensive bullous eruptions
(termed scalded skin syndrome, toxic epidermal necrolysis,
or Ritter disease). Listeria monocytogenes can produce
purple, miliary granulomas of the skin. Cutaneous moniliasis often
produces macerated, erythematous skin, usually in the diaper area,
and often occurs in infants treated with antibiotics. Many of these
skin lesions contain viable organisms (eg, syphilis, herpes, Staphylococcus)
and are highly infectious. Some generalized viral infections are
characterized by small red papules that contain infiltrations of
The normal newborn often has some form of benign skin lesion.
These neonatal skin abnormalities include congenital absence of
skin (aplasia cutis), rashes, erythroderma, vesicles, pustules,
bullae, purpura, and petechiae are discussed in Chapter 357. Pigmented
skin lesions and nevi are discussed in Chapter 361, vascular lesions
in Chapter 364 and other genetic skin disorders in Chapter 360.
Pallor may result from anemia or poor perfusion.
With poor perfusion from vasoconstriction or low
cardiac output, capillary filling after blanching of the skin over
the tibia is delayed (> 3 sec). In pigmented babies, poor perfusion
is more readily detected by delayed capillary filling after blanching
of the toes or fingers. Pallor of mucous membranes in these infants
suggests anemia. A generalized gray hue may indicate
acidosis. Pale, mottled skin occurs with sepsis
or hypothermia. There may be cyanosis of the hands and feet (acrocyanosis),
which is normal immediately after birth or if the infant has been
exposed to a cold environment. Generalized cyanosis occurs
with significant arterial hypoxemia as well as with methemoglobinemia. Plethora may
indicate polycythemia. Harlequin skin describes
a transient change in the skin color: one side of the body turns
pale while the other side remains pink with a sharp line of demarcation
in the midline. Harlequin change can last for seconds or a few minutes
and may recur but is of no known pathologic significance.
Ecchymoses generally result from birth trauma
and are often present over the head after vertex delivery or on
the feet, lower limbs, and buttocks following breech delivery. With severe
birth trauma, there can be extensive hemorrhage into the muscles
underlying areas of bruised skin. Localized petechiae are
usually found in areas of vascular stasis or compression that occurred
during delivery, on the face after a vertex delivery, or on the
lower limbs after a breech delivery. More generalized petechiae
The skin overlying an area of subcutaneous fat necrosis often
appears red. The subcutaneous tissue is hard and sharply demarcated, with
lesions most common on the cheeks, buttocks, limbs, or back.
Neonatal jaundice, with a yellow skin color, is
caused by an elevation in indirect-reacting bilirubin. Elevation
of direct-reacting bilirubin gives a yellow-to-green discoloration.
It is easier to assess jaundice in a newborn by briefly pressing
on the infant’s skin with a finger and observing the color
in the blanched area. This is of particular value in pigmented infants.
The normal newborn commonly develops mild physiologic jaundice between
days 2 and 4 after birth. Jaundice in the first day warrants prompt
investigation; it is usually from sepsis or hemolytic anemia. The
differential diagnosis of neonatal jaundice is discussed in Chapter 53.
Scalp hair of the infant is fine and silky.
The head shape differs in infants who were in vertex
or breech positions. After vertex presentation and vaginal delivery,
there can be pronounced vertical elongation of the head. Breech
infants often have occipital-frontal head elongation, with a prominent
The cranial sutures should be palpably open and may be separated
by up to several millimeters. Temporary overlap of bones, due to molding,
should be distinguished from craniosynostosis (premature
closure of a suture). If a suture closes in utero, it prevents growth
of the skull perpendicular to the fused suture line, resulting in
a sustained, abnormal skull configuration. In contrast, after molding
occurs, the bones return to their normal positions in a few days,
sometimes with a small concomitant decrease in head circumference.
Normally, the anterior fontanelle is open, soft,
and flat; mean diameter is less than 3.5 cm. The posterior
fontanelle is often fingertip size or just palpably open.
A bulging or tense fontanelle, with
separation of the bony sutures, indicates increased intracranial
Caput succedaneum is edema of the scalp caused
by local pressure and trauma during labor. With severe trauma, there
may be extensive subgaleal hemorrhage under the
galea aponeurotica. The scalp is tensely distended, and the swelling
may extend to the suboccipital region and push the ears laterally.
Hemorrhage can be massive and produce shock. Cephalohematomas are
subperiosteal hemorrhages caused by the trauma of labor and usually
involve the parietal or occipital bones. Cephalohematomas are fairly
firm, fluctuant masses with a palpable rim that gives the impression
of a shallow crater in the bone under the mass. They are distinguished
from caput succedaneum because they do not extend beyond the suture
lines of the affected bone. Parietal bone cephalohematomas may be bilateral
but are palpably distinct from one another. Cephalohematomas should
not be aspirated; they gradually resorb but can calcify before disappearing.
Trauma to the head may also be accompanied by more serious intracranial
hemorrhage. Other common traumatic scalp lesions include puncture
wounds from fetal monitor electrodes and fetal scalp blood gas
sampling. A circular hematoma may be seen at the
site of application of a vacuum extractor.
The newborn’s face often gives the first clue to the
presence of a dysmorphic syndrome. There may be obvious malformations,
such as cleft lip or the characteristics of the Pierre Robin
sequence characterized by a small mandible (micrognathia),
a high-arched or cleft palate, and a tongue that falls back into
the hypopharynx (glossoptosis); this causes airway obstruction, which
must be recognized promptly and can be relieved with an oral airway
and by pulling the tongue or the mandible forward. Infants with fetal
alcoholexposure may be more difficult
to identify but may have growth deficiency, microcephaly, maxilla
hypoplasia, and short palpebral fissures.
Intrauterine position may cause asymmetry of the face. Pressure
over the stylomastoid foramen during labor and delivery may cause
a peripheral facial paralysis, which is most obvious
during crying. The paralysis usually resolves and should be distinguished
from congenital absence of the depressor anguli oris muscle, which
also results in an asymmetric crying facies.
Fracture of the zygomatic arch can occur during
labor and delivery; this is detectable by palpation. Forceps often
leave bruises on the face, usually in the shape of the forceps blade (see eFig. 44.2).
Newborns generally open their eyes to permit inspection when
they are awake, held upright, and shaded from bright light. An infant
who is quiet and alert during the examination will fix on the examiner’s
face and follow it, at least part way, as the examiner moves slowly
from side to side.
Congenital lid ptosis will manifest itself as a
drooping lid. Failure to close the eye fully can
occur with facial paralysis. Horner syndrome, caused
by lower brachial plexus injury, appears as ptosis, miosis, and enophthalmos. Congenital
microphthalmia is usually obvious on inspection and palpation. Mass
lesions, such as orbital tumors, hemangiomas, and encephaloceles,
may be immediately apparent. Proptosis may be due
to mass lesions or retrobulbar hemorrhage.
Birth trauma may also cause subconjunctival hemorrhages or hemorrhages in
the anterior chamber, vitreous, and retina. Forceps deliveries
can result in lacerations of the lid or globe.
A rupture of the Descemet membrane in the cornea may become apparent
because of corneal clouding.
Congenital glaucoma initially appears as an enlarged cornea that
becomes progressively cloudy. A corneal diameter of 11 mm or more is
suspect and warrants further investigation, as early detection is
important in preventing eye damage.
Ophthalmoscopic examination should begin by focusing on the anterior
portion of the eye and then progressing back to the retina. This
allows detection of anterior lesions, such as cataracts and colobomas (defects)
of the iris, which may occur alone but are often components of various
dysmorphic syndromes. The iris is blue or blue-gray in fair-skinned
babies but is dark gray to brown in darker pigmented infants. In
fair babies, a red reflex is transmitted back through
the lens, whereas in darker infants a paler orange-tan color
may be seen. Visualizing retinal vessels verifies focusing on the
retina. A cataract will appear as a black
opacity that interferes with light transmission through
the lens. A white pupillary reflex is abnormal
and may occur with a large retinoblastoma or developmental abnormalities
such as retinal coloboma, retinopathy of prematurity, and persistent
hypoplastic primary vitreous. A family history of retinoblastoma warrants
a thorough ophthalmologic examination to exclude small or peripheral
Conjunctivitis usually becomes apparent after
the second day of life; common pathogens include Staphylococcus
aureus, streptococci, and coliform bacteria. Gonococcal
conjunctivitis is acquired from the birth canal and can progress
rapidly to a panophthalmitis with eye destruction. Inclusion
blennorrhea is also acquired from the mother’s
birth canal; it is caused by Chlamydia trachomatis and
typically appears toward the end of the first week of life. The
various causes of conjunctivitis must be distinguished from one
another by Gram stain and appropriate cultures (see Chapter 588).
At term, the ears are well formed and contain sufficient cartilage
to retain a normal shape and resist deformation. Preauricular
pits are common and inherited in an autosomal dominant
pattern; preauricular skin appendages also may
be seen. When preauricular skin appendages are hereditary, they
may be associated with deafness. Malformed auricles or low-set
ears are found in many dysmorphic syndromes and are associated
with urogenital malformations.
Gently pulling the pinna back and down aids examination of the ear
canal and tympanic membrane.
The tympanic membrane sharply angles back more in an infant than
in an older child and is located more superiorly in relation to
the external canal. Otitis media is uncommon but should be considered
in an infant suspected of having an infection in the first days
after birth. A crude estimate of hearing can be
obtained if the infant is quiet and the examination is done in an
environment without distracting noise. The alert, normal newborn
will turn toward human speech and startle to a loud noise.
Most newborn infants are nose breathers; rarely, obstructive
lesions or foreign bodies in the nose can be lethal. Initially,
an infant will become cyanotic and have respiratory difficulty but,
if stimulated to cry, will breathe through the mouth. Occasional
sneezing is the normal mechanism infants use to clear the nose.
Nasal patency can be verified by checking each naris for a good
airstream with a thin strip of tissue or cotton. To avoid confusion,
the mouth may need to be occluded transiently. Unilateral or bilateral
anatomic obstruction from choanal atresia is rare.
When there is doubt, a thin catheter should be passed gently through
each nostril into the hypopharynx. Masses, such as an encephalocele
protruding into the nasopharynx, can also cause obstruction. Nasal stuffiness can
occur as a result of retained mucus or trauma. Nasal stuffiness
may be a sign of drug withdrawal.
Examination of the mouth of the newborn infant includes inspection
and palpation. A cleft palate may not be seen but
may be detectable by palpation; a cleft uvula should
raise suspicion of a palatal defect. Small, shiny white masses on
the gums (epithelial pearls) are common. White Epstein
pearls are found in the midline on the roof of the mouth,
at the junction of the hard and soft palate. A ranula is
a small benign mass (mucocele) that arises from the floor of the
mouth. A high-arched or narrow palate is
found in many dysmorphic syndromes.
The tongue may be attached to a short central frenulum; this
rarely interferes with feeding or future function. An enlarged or protruding
tongue can be seen with hemangiomas, isolated macroglossia,
hypothyroidism, or in Down and Beckwith syndromes. Infants with
Pierre Robin sequence have relative macroglossia because of a small
The normal, awake newborn will usually suck vigorously on a finger
placed in the mouth. With normal effective sucking, the
finger is actively drawn into the mouth by the movement of the tongue
against the palate in a forward-to-backward motion. This coordinated
function is easily distinguished from disorganized biting movements,
which are ineffective in feeding from the nipple.
Natal teeth, if present, usually erupt in the lower
incisor position. These can either be supernumerary teeth or true,
deciduous “milk” teeth. If very loose or the cause
of painful breast feeding, they may be removed. However, removal
of deciduous teeth will leave a defect for 7 years, until the permanent
teeth appear, and may alter positioning of the 6-year molars and
The neck of the newborn should have a full range of motion; limitation
may indicate an abnormality of the cervical spine. Cervical masses,
such as a goiter, cavernous hemangioma, or cystic
hygroma, may compress the trachea and cause inspiratory
obstruction, which may require tracheal intubation beyond the site
of obstruction to establish an airway. Brachial cleft anomalies include
cysts or sinuses along the anterior edge of the sternocleidomastoid
muscle. Thyroglossal duct cysts usually occur in
the ventral midline. Torticollis is seen with a
tightened sternocleidomastoid muscle on one side and an atretic
sternocleidomastoid muscle on the side toward which the head is
turned; facial asymmetry is a common accompaniment.
Lateral traction during delivery may damage the upper root of
the brachial plexus involving the fifth and sixth cervical roots, resulting
in paralysis of the shoulder and arm. The arm is held alongside
the body in internal rotation (Erb-Duchenne paralysis). The lower root
of the brachial plexus, involving the eighth cervical and first
thoracic roots, may be damaged, particularly during breech delivery. The
small muscles of the hand are paralyzed, resulting in a clawlike
posture (Klumpke paralysis). When there is neck trauma, the cervical
sympathetic nerves may be damaged, resulting in an associated Horner
syndrome, and the phrenic nerve may be injured, causing diaphragmatic
The chest of the normal newborn is barrel-shaped, with the xiphoid
often prominent. The most frequent birth injury to the thoracic
region is fracture of the clavicles, identified
by crepitation upon clavicle palpation. Supernumerary nipples are
a common minor anomaly; wide spacing of the nipple
is seen in Turner syndrome. Breast engorgement may
occur in boys or girls and increases over the first few days.
The normal respiratory rate is 35 to 60 breaths
per minute. Respiratory excursion is most easily
judged in the lateral view. Excursion of the abdomen is quite prominent,
as infants breathe principally with their diaphragms. With normal
breathing, the chest and abdomen move together. When the airway is
obstructed or the lungs are stiff, the abdomen appears to enlarge
and the chest cage appears to get smaller with inspiration (thoracoabdominal
asynchrony). The tissue between the ribs may be pulled
in during inspiration; these retractions are normal
during the first few minutes after birth. Thereafter, they are usually
a sign of increased inspiratory effort from noncompliant lungs or
airway obstruction. Inspiratory retractions of the ribs and sternum
occur in severe lung disease or occasionally with an abnormal chest
wall. Mild expiratory grunting, nasal flaring, and tachypnea occur
during the first few minutes after birth. There may also be scattered
crackles caused by residual intraalveolar lung fluid that clears
rapidly. These signs, attributable to retained lung fluid, are more
noticeable after cesarean section. Persistence or worsening of respiratory
symptoms may indicate more serious problems, such as respiratory
distress syndrome, bacterial pneumonia, meconium aspiration, or cardiac
Chest wall respiratory movement should be symmetric. One side
moving less or lagging behind the other suggests an elevated paralyzed
diaphragm from phrenic nerve palsy or an intrathoracic
mass such as herniation of bowel through a diaphragmatic
hernia. However, the absence of such findings does not rule
out these lesions. Breath sounds may be heard even when a pneumothorax is
present. Coughing in the newborn period is abnormal and
usually accompanies interstitial lung disease.
The point of maximal cardiac impulse is along the
left side of the sternum at the fourth to fifth interspace and medial
to the midclavicular line. The heart may be displaced if there is
a pneumothorax or space-occupying lesion.
The heart rate may be 160 to 180 beats per minute (bpm) during
the first few hours after birth. Thereafter, the normal awake
heart rate averages 120 to 130 bpm. Occasionally, a normal
newborn infant may have heart rates of 80 bpm, which may fall transiently
to 60 bpm for short periods. A persistent heart rate below 80 bpm
warrants investigation. Conditions associated with bradycardia include
birth asphyxia, increased intracranial pressure, hypothyroidism,
and heart block. Tachycardia occurs with hypovolemia,
fever, drug withdrawal, poor systemic perfusion, tachyarrhythmias,
anemia, and hyperthyroidism. Cardiac rhythm should be checked; premature atrial
contractions are not uncommon.
Despite the rapid heart rate, heart sounds can
be clearly distinguished. The pulmonic component of S2 may
be prominent on the first day. Splitting of the second sound is
audible along the left upper and midsternum. While postnatal circulatory
adjustments are occurring, transient benign murmurs can
be heard over the pulmonic area or cardiac apex. Murmurs accompanied
by other symptoms, such as cyanosis (see Chapters 49, 483, and 484), poor
perfusion, or tachypnea, and murmurs that persist past the first
day require further evaluation.
Over the first 12 hours, the mean blood pressure averages
50 to 55 mm Hg in term infants (see Chapter 56).
Pulses should be palpable in all 4 extremities, and there should
be no delay between brachial and femoral pulses (see Chapter 483).
An extremely hollow abdomen suggests absence of some of the normal
contents, such as diaphragmatic herniation of the
bowel into the chest. Distension occurs with dilatation
of the bowel from functional or anatomic obstruction, ascites, intraabdominal
blood, or a large mass. If abdominal distension is noted, an oral
catheter should be advanced into the stomach for decompression.
Signs of obstruction of the upper gastrointestinal tract include
polyhydramnios (excess amniotic fluid), regurgitation, and pooling
of secretions in the hypopharynx. When obstruction is suspected,
pass a soft catheter into the stomach and aspirate the gastric contents.
Bile-stained fluid suggests a high intestinal obstruction. In the
most common form of tracheoesophageal fistula, proximal
esophageal atresia prevents passage of the tube into the stomach.
Pass a radiopaque orogastric catheter and check its course by radiography.
Examine the structures of the abdominal wall. A gap between the
abdominal rectus muscles in the midline (diastasis recti),
most noticeable with crying, is quite common. There is also often
a small defect in the periumbilical musculature of the anterior
abdominal wall, which may allow an umbilical hernia; this
usually closes as the muscles develop toward the end of the first
year. There are several serious possible defects of the anterior
abdominal wall including omphalocele and gastroschisis as discussed
in Chapters 60 and 396.
Absence of the musculature of the anterior abdominal wall (the so-called prune belly
infant) is an anomaly associated with urinary tract abnormalities
(see Chapter 476).
The umbilical cord normally contains two arteries
and one vein, with the vein being larger than the arteries. Approximately
1% of newborns have a single umbilical artery, and
15% of these have 1 or more congenital anomalies, usually
involving the nervous, gastrointestinal, genitourinary, pulmonary,
or cardiovascular system. Otherwise normal infants with a single
umbilical artery rarely have a serious anomaly.12 Remnants
of the vitelline (omphalomesenteric) duct may persist
and communicate with the umbilicus. If the remnant is a mucosal
cyst, there may be umbilical mucus discharge. Persistence of the
entire duct will create a fistula with the ileum, and some meconium
may exit through the umbilicus. Persistent patency of the urachus results
in a sinus extending from the bladder to the umbilicus, with urinary
discharge from the umbilicus. A noncommunicating urachal cyst may also
develop along the line of the urachus.
Palpation of the abdomen to define the size and shape of the
internal organs should be gentle and not be done immediately after
a feeding in order to avoid infant aspiration of gastric contents.
The edge of the liver is normally felt 1 to 2 cm
below the right costal margin. The spleen tip may
be palpable but usually no more than 1 cm below the rib margin.
In some pathologic conditions, the liver and spleen may be so massively
enlarged that their edges are in the pelvis and not initially identified.
Renal examination is easiest on the first day, before the bowel
is filled with gas. The lower portion of each kidney is
normally palpable on each side; the lateral and lower edges can
be felt above the level of the umbilicus and lateral to the midclavicular
line. The right kidney is situated slightly lower than the left
kidney, and the palpable portion of the kidney normally feels about
2 cm wide. Enlarged kidneys may result from hydronephrosis, cystic
malformation, a neoplasm, or renal vein thrombosis. Over 50% of
all abdominal masses in the newborn arise from
the genitourinary system. Mass lesions may also be caused by gastrointestinal
malformation, neoplasms, or, rarely, neural lesions such as an anterior
Traumatic lesions to the abdomen at birth include
subcapsular hematoma of the liver, which appears as an enlarging
liver, an elevated right diaphragm, and shock when the hematoma
ruptures; adrenal hemorrhage, which appears as a discrete palpable
mass above the kidney and associated fever; and rupture of the spleen,
when splenomegaly has been present in utero, with free blood in
During the first few postnatal days, the umbilical cord stump
dries and then turns brown and brittle. The cord usually falls off
between 10 and 14 days, releasing a small amount of opaque, yellowish
discharge. Separation after 3 weeks, however, is not uncommon. Delayed separation
of the cord, past 3 weeks, often occurs in infants with defective
phagocyte function. A small, raw-appearing granuloma at the site
of cord separation is termed an umbilical polyp. During
the first week, a small amount of erythema at the rim of the umbilical
stump is common and of no consequence, but more extensive erythema,
a deeper red color, or associated edema may indicate the onset of omphalitis. Omphalitis
is a serious infection requiring intravenous antibiotic therapy
because of possible spread along the umbilical vein into the portal
venous sinus of the liver. Omphalitis may progress to peritonitis
or necrotizing fasciitis of the abdominal wall, which often proves
fatal despite antibiotic therapy.
In preterm female infants, separation of the labia majora may
give the illusion that the clitoris is enlarged.
In term female infants, the labia majora meet in the midline, covering
the rest of the genitalia. It is important to identify the urethra, which
is just below the clitoris, and the vagina as distinct orifices;
a single orifice or urogenital sinus is abnormal. Normally, the
vagina has white secretions secondary to fetal stimulation by maternal
hormones. These persist for a week or more and occasionally become
tinged with blood several days after birth. Hydrometrocolpos results from
an imperforate hymen or from vaginal atresia. It can present as
a lower abdominal mass or as a bulging mass protruding through the
labia and requires decompression.
The term male newborn has a penis approximately
3 to 4 cm long and a scrotum that is pigmented and has extensive
rugae. Penile length less than 2.5 cm is abnormal and requires endocrinologic
evaluation. The foreskin should not be forcibly retracted. Penile hypospadias is
a common anomaly that can vary from a small ventral cleft at the
distal end of the penile urethra to a major ventral defect along
the length of the penis. Chordee, a ventral bend
in the penis, commonly accompanies hypospadias. Epispadias, a
similar defect on the dorsum of the penis, is much less common and
is a variant of exstrophy of the bladder.
The testes are usually in the scrotum but, if not
fully descended, are often palpable in the upper scrotum or inguinal
canal. Unilateral undescended testes cause an asymmetry
in the scrotum, with an immature appearance on the affected side. Hydroceles or
fluid collections in the remnants of the processus vaginalis cause
a swelling of the scrotum. They are common, usually do not communicate
with the peritoneal cavity, and disappear gradually. Hydroceles
that fluctuate in size or that persist are in communication with
the peritoneal cavity and indicate a potential indirect inguinal hernia. Intestinal
herniation can occur in the newborn period. Testicular enlargement,
with discoloration of the overlying scrotum, suggests a testicular
torsion that is a surgical emergency.
Ambiguous genitalia is a problem that requires
investigation. Mild masculinization of the female newborn, with
some enlargement of the clitoris, usually can be distinguished from
mild feminization of the male neonate, with a small penis and hypospadias.
When the processes are more extensive, however, the distinction
between a girl with a very enlarged clitoris and a partially fused
and pigmented labium and a boy with a very small penis and extensive
hypospadias and bifid scrotum is much less clear (see Chapter 539).
Trauma to the external genitalia may occur during breech delivery.
In addition to ecchymoses, there may be hemorrhage into the testes,
scrotum, and pelvic muscles, which generally resolves in a few weeks.
Imperforate anus is not always obvious on inspection.
A fistula that opens onto the perineum, ventral to the normal anus,
may accompany the imperforate anus. However, this fistula will not have
the radiating skin creases of a normal anus. There can also be a
normal-appearing anal dimple with no opening. Presence of meconium
on the perineum and perianal area does not rule out imperforate
anus; meconium in the anal area may have been passed by way of the
skin fistula or, in a girl, a fistula from the rectum to the vagina.
The spine of the newborn is quite flexible in both the dorsoventral
and lateral axes; restricted movement suggests vertebral anomalies. The
entire length of the spine, including the sacrum, should be palpated
for bony defects and asymmetries. A midline abnormality of the
skin over the spine, such as a small dimple, tufts of hair, or a
pilonidal sinus, warrants close inspection, for any fluid extruding
may indicate a tract that can allow bacteria on the skin to reach
the cerebrospinal fluid. Midline cutaneous abnormalities may also
indicate an occult spina bifida or a diastematomyelia (division
of the spinal cord into 2 parts, which may become tethered as the
child grows). Neural crest defects of the spine include meningocele,
myelomeningocele, and rachischisis. Tumors
of the spine, presenting at birth, are usually teratomas (see Chapter 460).
Trauma and positional deformities secondary to intrauterine position
can occur in the newborn. The most common forms of trauma
of the limbs include fractures in the shaft of the femur,
humerus, or clavicles and injury to the brachial plexus, causing
paralysis of the hand and arm (discussed previously under examination
of the neck).
It is important to distinguish between joints in one extreme
of their normal position and joints that are deformed. As a rule,
if simple manual pressure will correct a deformed joint back to
its neutral position and a bit beyond, corrective positioning or
simple exercise and stretching will correct the deformity. If the
deformity cannot be corrected by gentle pressure, orthopedic evaluation
If the hips are flexed to 90 degrees, the legs normally can be
abducted until the knees touch the table the infant is lying on.
If this cannot be done, or if the maneuver can be done on one side
only, there may be developmental dysplasia of the hip. In
this condition, the head of the femur is displaced posteriorly, out
of the acetabular fossa. The affected leg may appear shorter. The
examiner will feel a click when abducting and adducting the hips in
about 10% of all infants. However, only 10% of
infants with hip clicks have developmental dysplasia of the hip.
Two diagnostic manipulations of the hip joint can test for a dislocatable
hip: the Ortolani and the subluxation maneuvers (see Chapter 215). Infants constrained in a breech position in utero tend to
keep their hips flexed after birth and resist full hip extension.
These infants, particularly girls, also have an increased incidence
of dislocatable hips.13
Malformations of the limbs include hemihypertrophy and hemiatrophy; in
both conditions, the limbs on each side of the body are noticeably
different in size but normally proportioned. With phocomelia, there
is underdevelopment and abnormal shape of the limbs to a variable
degree. The arms may be flipperlike with small digits projecting
from the ends, or there may be only a nubbin of tissue at the site of
origin of the limb. This malformation was particularly common among
infants whose mothers took the drug thalidomide during pregnancy,
but it also occurs spontaneously. The short limbs with achondroplastic and thanatophoricdysplasia are
evident at birth (see Chapter 179). Newborns
with arthrogryposis multiplex congenita have severe
contractions of multiple joints that cannot be corrected by simple
The most obvious anomalies of the hands and feet are fusions
of digits (syndactyly) and extra digits (polydactyly).
The latter may be well-formed digits or merely small tags of tissue. Some
minor malformations of hands and feet occur in many of the dysmorphic
syndromes. For example, widely spaced first and second toes, hands
with simian creases, downward displaced origin of the thumbs, and
incurved little fingers are found in trisomy 21 (Down syndrome).
A clenched hand with overriding index finger and
a convex or rocker-bottom foot are seen in trisomy
18. Bands originating from the amnion may wrap
tightly about a limb and cause a sharp, deep, circumferential depression.
These intrauterine constriction bands may amputate the digits or
cause localized edema by obstructing lymphatic drainage (see eFig. 44.3).
Circumferential amniotic constriction bands causing localized
edema with a “lobster claw” deformity of the hand. There
were also amputations of the distal phalanges of several fingers
on the other hand.