THE FIRST 24 HOURS The newborn infant should undergo a complete physical examination within 24 h of birth.

It is easier to listen to the heart and lungs first when the infant is quiet. Warming the stethoscope before using it decreases the likelihood of making the infant cry. I. Vital signs A. Temperature. Indicate whether the temperature is rectal (which is usually !higher than oral"# oral# or axillary (which is usually !lower than oral". B. Respirations. The normal respiratory rate in a newborn is 4$%&$ breaths'min. C. Blood pressure. (lood pressure correlates directly with gestational age# postnatal age of the infant# and birth weight. ()or normal blood pressure cur*es# . !ulse rate. The normal pulse rate is $% +$ beats'min in the newborn (usually 2$% &$ beats'min when awake# ,$%+$ beats'min when asleep". In the healthy infant# the heart rate increases with stimulation. II. Head "ir"um#eren"e$ lengt%$ &eig%t$ and gestational age A. Head "ir"um#eren"e and per"entile. -lace the measuring tape around the front of the head (abo*e the brow .the frontal area/" and the occipital area. The tape should be abo*e the ears. This is known as the occipitofrontal circumference# which is normally 02%0, cm at term. B. 'engt% and per"entile. C. (eig%t and per"entile. . Assessment o# gestational age. III. )eneral appearan"e. 1bser*e the infant and record the general appearance (eg# acti*ity# skin color# and ob*ious congenital abnormalities". IV. S*in A. Color +. !let%ora ,deep$ ros- red "olor.. -lethora is more common in infants with polycythemia but can be seen in an o*eroxygenated or o*erheated infant. It is best to obtain a central hematocrit on any plethoric infant. 2rythema neonatorum is a condition in which an infant has an o*erall blush to reddish color. It usually appears in the transition period and can occur when the infant has been stimulated. This is a normal phenomenon and lasts only se*eral hours. 2. /aundi"e ,-ello&is% "olor i# se"ondar- to indire"t %-per0iliru0inemia$ greenis% "olor i#

se"ondar- to dire"t %-per0iliru0inemia.. With 3aundice# bilirubin le*els are usually 4 mg'd5. This condition is abnormal in infants 24 h old and may signify 6h incompatibility# sepsis# and T1678 (toxoplasmosis# other# rubella# cytomegalo*irus# and herpes simplex *irus" infections. 9fter 24 h# it may result either from these diseases or from such common causes as 9(1 incompatibility or physiologic causes. 1. !allor ,&as%ed2out$ &%itis% appearan"e.. -allor may be secondary to anemia# birth asphyxia# shock# or patent ductus arteriosus. :uctal pallor is the term sometimes used to denote pallor associated with patent ductus arteriosus. 4. C-anosis ,desaturation o# 3 g o# %emoglo0in usuall- ne"essar- #or one to note a 0luis% "olor. a. Central "-anosis ,0luis% s*in$ in"luding t%e tongue and lips.. 7entral cyanosis is caused by low oxygen saturation in the blood. It may be associated with congenital heart or lung disease. 0. !erip%eral "-anosis ,0luis% s*in &it% pin* lips and tongue.. -eripheral cyanosis may be associated with met%emoglo0inemia$ which occurs when hemoglobin oxidi;es from the ferrous to the ferric form< the blood actually can ha*e a chocolate hue. =ethemoglobin is incapable of transporting oxygen or carbon dioxide. This disorder can be caused by exposure to certain drugs or chemicals (eg# nitrates or nitrites" or may be hereditary (eg# >9:8%methemoglobin reductase deficiency or hemoglobin = disease .>9:8 is the reduced form of nicotinamide adenine dinucleotide/". Treatment for infants is with methylene blue. ". A"ro"-anosis ,0luis% %ands and #eet onl-.. 9crocyanosis may be normal for an infant who has 3ust been born (or within the first few hours after birth" or for one who is experiencing cold stress. If the condition is seen in an older infant with a normal temperature# decreased peripheral perfusion secondary to hypo*olemia should be considered. 3. E4tensi5e 0ruising ,e""%-moses. may be associated with a prolonged and difficult deli*ery and may result in early 3aundice. -etechiae (pinpoint hemorrhages" can be limited to one area and are usually of no concern. If they are widespread and progressi*e# then they are of concern and a workup for coagulopathy should be considered. 6. 7Blue on pin*7 or 7pin* on 0lue.7 Whereas some infants are pink and well perfused and others are clearly cyanotic# some do not fit either of these categories. They may appear bluish with pink

undertones or pink with bluish undertones. This coloration may be secondary to poor perfusion# inadequate oxygenation# inadequate *entilation# or polycythemia. 8. Harle9uin "oloration ,"lear line o# demar"ation 0et&een an area o# redness and an area o# normal "oloration.. The cause is usually unknown. The coloration can be benign and transient (lasting usually 2$ min" or can be indicati*e of shunting of blood (persistent pulmonary hypertension or coarctation of the aorta". There can be *arying degrees of redness and perfusion. The demarcating line may run from the head to the belly# di*iding the body into right and left hal*es# or it may de*elop in the dependent half of the body when the newborn is lying on one side. :. ;ottling ,la"- red pattern. may be seen in healthy infants and in those with cold stress# hypo*olemia# or sepsis. -ersistent mottling# referred to as "utis marmorata$ is found in infants with :own syndrome# trisomy 0# or trisomy +. <. Verni4 "aseosa. This is a greasy white substance that co*ers the skin until the 0+th week of gestation. Its purpose is to pro*ide a moisture barrier. It is completely normal. +=. Collodion in#ant. In this condition# the skin resembles parchment# and there can be some restriction in growth of the nose and ears. This may be a normal condition or can be a manifestation of another disease. ++. r- s*in. =ost term infants do not ha*e dry skin. -ostdate or postmature infants can exhibit excessi*e peeling of skin. 7ongenital syphilis and candidiasis can present with peeling skin at birth. B. Ras%es +. ;ilia. =ilia is a rash in which tiny# sebaceous retention cysts are seen. The whitish# pinheadsi;ed concretions are usually on the chin# nose# forehead# and cheeks. >o erythema is seen. These benign cysts disappear within a few weeks after birth. These are seen in approximately 00? of infants. -earls are large single milia that can occur on the genitalia and areola. 2. Er-t%ema to4i"um. In erythema toxicum# numerous small areas of red skin with a yellowwhite papule in the center are e*ident. 5esions are most noticeable 4+ h after birth but may appear as late as ,% $ days. Wright@s staining of the papule re*eals eosinophils. This benign rash# which is the most common type# resol*es spontaneously. If suspected in an infant younger than 04 weeks@ gestation# it is

best to rule out other causes because this rash is more common in term infants. 1. Candida albicans ras%. C. albicans diaper rash appears as erythematous plaques with sharply demarcated edges. Aatellite bodies (pustules on contiguous areas of skin" are also seen. Bsually# the skinfolds are in*ol*ed. Cram@s stain of a smear or $? potassium hydroxide preparation of the lesion re*eals budding yeast spores# which are easily treated with nystatin ointment or cream applied to the rash 4 times daily for ,% $ days. 4. Transient neonatal pustular melanosis is characteri;ed by three stages of lesions# which may appear o*er the entire bodyD -ustules. ! 6uptured ! *esicopustules with scaling'typical halo appearance. 8yperpigmented ! macules. This benign# self%limiting condition requires no specific therapy. 3. A"ne neonatorum. The lesions are typically seen o*er the cheeks# chin# and forehead and consist of comedones and papules. The condition is usually benign and requires no therapy< howe*er# se*ere cases may require treatment with mild keratolytic agents. 6. Herpes simple4. 1ne can see a pustular *esicular rash# *esicles# bullae# or denuded skin. The rash is most commonly seen at the fetal scalp monitor site# occiput# or buttocks (presentation site at time of deli*ery". T;anck smear will re*eal multinucleated giant cells. C. >e5i. 8emangiomas near the eyes# nose# or mouth that interfere with *ital functions or sight may need surgical inter*ention. +. ;a"ular %emangioma ,7stor* 0ites7.. 9 macular hemangioma is a true *ascular ne*us normally seen on the occipital area# eyelids# and glabella. The lesions disappear spontaneously within the first year of life. 2. !ort2&ine stain ,ne5us #lammeus. is usually seen at birth# does not blanch with pressure# and does not disappear with time. If the lesion appears o*er the forehead and upper lip# then Sturge2 (e0er s-ndrome (port%wine stain o*er the forehead and upper lip# glaucoma# and contralateral 3acksonian sei;ures" must be ruled out. 1. ;ongolian spot. =ongolian spots are dark blue or purple bruise%like macular spots usually located o*er the sacrum. Bsually present in E$? of blacks and 9sians# they occur in 4? of white children and disappear by 4 years of age. They are the most common birthmark.

4. Ca5ernous %emangioma. 9 ca*ernous hemangioma usually appears as a large# red# cyst% like# firm# ill%defined mass and may be found anywhere on the body. The ma3ority of these lesions regress with age# but some require corticosteroid therapy. In more se*ere cases# surgical resection may be necessary. If associated with thrombocytopenia# ?asa0a"%2;erritt s-ndrome (thrombocytopenia associated with a rapidly expanding hemangioma" should be considered. Transfusions of platelets and clotting factors are usually required in patients with this syndrome. 3. Stra&0err%emangioma ,ma"ular %emangioma.. Atrawberry hemangiomas are flat# bright red# sharply demarcated lesions that are most commonly found on the face. Apontaneous regression usually occurs (,$? disappearance by , years of age". V. Head. >ote the general shape of the head. Inspect for any cuts or bruises secondary to forceps or fetal monitor leads. Transillumination can be done for se*ere hydrocephalus and hydranencephaly. 7heck for microcephaly or macrocephaly. A. Anterior and posterior #ontanelles. The anterior fontanelle usually closes at E% 2 months and the posterior fontanelle at 2%4 months. 9 large anterior fontanelle is seen with hypothyroidism and may also be found in infants with skeletal disorders such as osteogenesis imperfecta# hypophosphatasia# and chromosomal abnormalities and in those who are small for gestational age. 9 bulging fontanelle may be associated with increased intracranial pressure# meningitis# or hydrocephalus. :epressed (sunken" fontanelles are seen in newborns with dehydration. 9 small anterior fontanelle may be associated with hyperthyroidism# microcephaly# or craniosynostosis. B. ;olding. =olding is a temporary asymmetry of the skull resulting from the birth process. =ost often seen with prolonged labor and *aginal deli*eries# it can be seen in cesarean deli*eries if the mother had a prolonged course of labor before deli*ery. 9 normal head shape is usually regained within week. C. Caput su""edaneum. 7aput succedaneum is a diffuse edematous swelling of the soft tissues of the scalp that may extend across the suture lines. It is secondary to the pressure of the uterus or *aginal wall on areas of the fetal head bordering the caput. Bsually# it resol*es within se*eral days . Cep%al%ematoma is a subperiosteal hemorrhage that never extends across the suture line. It can be secondary to a traumatic deli*ery or forceps deli*ery.

F%ray films or computed tomography (7T" scans of the head should be obtained if an underlying skull fracture is suspected (4? of all should be monitored in these patients. =ost cephalhematomas resol*e in 2%0 weeks. 9spiration of the hematoma is rarely necessary E. Su0galeal %ematoma. 8emorrhage bleeding occurs below the epicranial aponeurosis. It can cross o*er the suture line and onto the neck or ear. It may be necessary to replace blood *olume lost and correct coagulopathy if present F. In"reased intra"ranial pressure. The following signs are e*ident in an infant with increased intracranial pressure. (ulging ! anterior fontanelle Aeparated ! sutures -aralysis ! of upward ga;e (setting%sun sign" -rominent ! *eins of the scalp Increasing ! macrocephaly The increased pressure may be secondary to hydrocephalus# hypoxic% ischemic brain in3ury# intracranial hemorrhage# or subdural hematoma. ). Cranios-nostosis. 7raniosynostosis is the premature closure of one or more sutures of the skull. It should be considered in any infant with an asymmetric skull. 1n palpation of the skull# a bony ridge o*er the suture line may be felt# and inability to freely mo*e the cranial bones may occur. F%ray studies of the head should be performed# and surgical consultation may be necessary. H. Craniota0es$ a benign condition# is a softening of the skull that usually occurs around the suture lines and disappears within days to a few weeks after birth. If the area is o*er most of the skull# it may be secondary to a calcium deficiency# and osteogenesis imperfecta and syphilis should be ruled out. I. !lagio"ep%al-. -lagiocephaly is an oblique shape of a head# which is asymmetric and flattened. It can be seen in preemies and infants whose heads stay in the same position. VI. >e"*. 2liciting the rooting reflex (see p 0+" causes the infant to turn the head and allows easier examination of the neck. -alpate the sternocleidomastoid for a hematoma and the thyroid for enlargement# and check for thyroglossal duct cysts. 9 short neck is seen in Turner@s# >oonan@s# and Glippel%)eil syndromes. VII. Fa"e. 5ook for ob*ious abnormalities. >ote the general shape of the nose# mouth# and chin. The presence of hypertelorism (eyes widely separated" or low%set ears should be noted.

A. Fa"ial ner5e in@ur-. Bnilateral branches of the facial (eighth" ner*e are most commonly in*ol*ed. There is facial asymmetry with crying. The corner of the mouth droops# and the nasolabial fold is absent in the paraly;ed side. The infant may be unable to close the eye# mo*e the lip# and drool trauma# most symptoms disappear within the first week of life# but sometimes resolution may take se*eral months. If the palsy persists# absence of the ner*e should be ruled out. VIII. Ears. 5ook for an unusual shape or an abnormal position. The normal position is determined by drawing an imaginary hori;ontal line from the inner and outer canthi of the eye across the face# perpendicular to the *ertical axis of the head. If the helix of the ear lies below this hori;ontal line# the ears are designated as low set. 5ow%set ears are seen with many congenital anomalies (most commonly Treacher 7ollins# triploidy# and trisomy E and + syndromes as well as fetal aminopterin effects". -reauricular skin tags (papillomas"# which are benign# are often seen. 8airy ears are seen in infants of diabetic mothers. Cross hearing can be assessed when an infant blinks in response to loud noises. IA. E-es. 7heck the red reflex with an ophthalmoscope. If a cataract is present# opacification of the lens and loss of the reflex are apparent. 7ongenital cataracts require early e*aluation by an ophthalmologist. The sclera# which is normally white# can ha*e a bluish tint if the infant is premature because the sclera is thinner in these infants than in term infants. If the sclera is deep blue# osteogenesis imper#e"ta should be ruled out. A. Brus%#ieldBs spots (salt%and%pepper speckling of the iris" are often seen with :own syndrome. B. Su0"on@un"ti5al %emorr%age. 6upture of small con3uncti*al capillaries can occur normally but is more common after a traumatic deli*ery. This condition is seen in 4? of newborn infants. C. Con@un"ti5itis. A. >ose. If unilateral or bilateral choanal atresia is suspected# *erify the patency of the nostrils with gentle passage of a nasogastric tube. Infants are obligate nose breathers< therefore# if they ha*e bilateral choanal atresia# they will ha*e se*ere respiratory distress. >asal flaring is indicati*e of respiratory distress. Aniffling and discharge are

typical of congenital syphilis. Anee;ing can be a response to bright light or drug withdrawal. AI. ;out%. 2xamine the hard and soft palates for e*idence of a cleft palate. 9 short lingual frenulum (tongue%tie" may require surgical treatment (especially if tongue mobility is limited". A. Ranula. 9 ranula is a cystic swelling in the floor of the mouth. =ost disappear spontaneously. B. EpsteinBs pearls. These keratin%containing cysts# which are normal# are located on the hard and soft palates and resol*e spontaneously. C. ;u"o"ele. This small lesion on the oral mucosa occurs secondary to trauma to the sali*ary gland ducts. It is usually benign and subsides spontaneously. . >atal teet% are usually lower incisors. F%ray films are needed to differentiate the two types because management of each is different. +. !rede"iduous teet%. Aupernumerary teeth are found in in 4$$$ births. They are usually loose# and the roots are absent or poorly formed. 6emo*al is necessary to a*oid aspiration. 2. True de"iduous teet%. These teeth are true teeth that erupt early. They occur in in 2$$$ births. They should not be extracted. E. ;a"roglossia. 2nlargement of the tongue can be congenital or acquired. 5ocali;ed macroglossia is usually secondary to congenital hemangiomas. =acroglossia can be seen in Be"*&it%Bs s-ndrome (macroglossia# gigantism# omphalocele# and se*ere hypoglycemia" and !ompeBs disease (type II glycogen storage disease". F. Frot%- or "opious sali5a is commonly seen in infants with an esophageal atresia with tracheoesophageal fistula. ). T%rus%. 1ral thrush# which is common in newborns# is a sign of infection resulting from C. albicans. Whitish patches appear on the tongue# gingi*a# or buccal mucosa. Thrush is easily treated with nystatin suspension ($. % .$ m5" applied to each side of the mouth# often with a cotton%tipped swab# 0%4 times per day for , days. AII. C%est A. O0ser5ation. )irst# note whether the chest is symmetric. 9n asymmetric chest may signify a tension pneumothorax. Tachypnea# sternal and intercostal retractions# and grunting on expiration indicate respiratory distress. B. Breat% sounds. 5isten for the presence and equality of breath sounds. 9 good place to listen is in

the right and left axillae. 9bsent or unequal sounds may indicate pneumothorax or atelectasis. 9bsent breath sounds with the presence of bowel sounds indicates a diaphragmatic hernia< an immediate x%ray film and emergency surgical consultation are recommended. C. !e"tus e4"a5atum. -ectus exca*atum is a sternum that is altered in shape. Bsually# this condition is of no clinical concern. . Breasts in a ne&0orn are usually cm in diameter in term male and female infants. They may be abnormally enlarged (0%4 cm" secondary to the effects of maternal estrogens. This effect# which lasts week# is of no clinical concern. 9 usually white discharge# commonly referred to as Hwitch@s milk#H may be present. Aupernumerary nipples are extra nipples and occur as a normal *ariant. AIII. Heart. 1bser*e for heart rate# rhythm# quality of heart sounds# acti*e precordium# and presence of a murmur. The position of the heart may be determined by auscultation. A. ;urmurs may be associated with the following conditions. +. Ventri"ular septal de#e"t ,VS .$ the most common heart defect# accounts for I24? of congenital heart disease. Typically# a loud# harsh# blowing pansystolic murmur is heard (best heard o*er the lower left sternal border". Aymptoms such as congesti*e heart failure usually do not begin until after 2 weeks of age and typically are present from & weeks to 4 months. The ma3ority of these defects close spontaneously by the end of the first year of life. 2. !atent du"tus arteriosus ,! A. is a harsh# continuous# machinery%type# or Hrolling thunder#H murmur that usually presents on the second or third day of life# locali;ed to the second left intercostal space. It may radiate to the left cla*icle or down the left sternal border. 9 hyperacti*e precordium is also seen. 7linical signs include wide pulse pressure and bounding pulses. 1. Coar"tation o# t%e aorta$ a systolic e3ection murmur# radiates down the sternum to the apex and to the interscapular area. It is often loudest in the back. 4. !erip%eral pulmoni" stenosis. 9 systolic murmur is heard bilaterally in the anterior chest# in both axillae# and across the back. It is secondary to the turbulence caused by disturbed blood flow because the main pulmonary artery is larger than the peripheral pulmonary arteries. This usually benign

murmur may persist up to 0 months of age. It may also be associated with rubella syndrome. 3. H-poplasti" le#t %eart s-ndrome. 9 short# midsystolic murmur usually presents anywhere from day to 2 . 9 gallop is usually heard. 6. Tetralog- o# Fallot typically is a loud# harsh systolic or pansystolic murmur best heard at the left sternal border. The second heart sound is single. 8. !ulmonar- atresia a. (it% VS . 9n absent or soft systolic murmur with the first heart sound is followed by an e3ection click. The second heart sound is loud and single. 0. (it% inta"t intra5entri"ular septum. =ost frequently# there is no murmur and a single second heart sound is heard. :. Tri"uspid atresia. 9 pansystolic murmur along the left sternal border with a single second heart sound is typically heard. <. Transposition o# t%e great 5essels is more common in males than females. a. Isolated ,simple.. 7ardiac examination is often normal# but cyanosis and tachypnea are present along with a normal chest x%ray film and electrocardiogram. 0. (it% VS . The murmur is loud and pansystolic and is best heard at the lower left sternal border. The infant typically has congesti*e heart failure at 0%& weeks of life. +=. E0steinBs disease. 9 long# systolic murmur is heard o*er the anterior portion of the left chest. 9 diastolic murmur and gallop may be present. ++. Trun"us arteriosus. 9 systolic e3ection murmur# often with a thrill# is heard at the left sternal border. The second heart sound is loud and single. +2. Single 5entri"le. 9 loud# systolic e3ection murmur with a loud# single second heart sound is heard. +1. Atrial septal de#e"ts ,AS s. a. Ostium se"undum de#e"t rarely presents with congesti*e heart failure in infancy. 9 soft systolic e3ection murmur is best heard at the upper left sternal border. 0. Ostium primum de#e"t rarely occurs in infancy. 9 pulmonary e3ection murmur and early systolic murmur are heard at the lower left sternal border. 9 split second heart sound is heard. ". Common atrio5entri"ular "anal presents with congesti*e heart failure in infancy. 9 harsh# systolic murmur is heard all o*er the chest. The second heart sound is split if pulmonary flow is increased.

+4. Anomalous pulmonar- 5enous return a. !artial. )indings are similar to those for ostium secundum defect 0. Total. With a se*ere obstruction# no murmur may be detected on examination. With a moderate degree of obstruction# a systolic murmur is heard along the left sternal border# and a gallop murmur is heard occasionally. 9 continuous murmur along the left upper sternal border o*er the pulmonary area may also be audible. +3. Congenital aorti" stenosis. 9 coarse# systolic murmur with a thrill is heard at the upper right sternal border and can radiate to the neck and down the left sternal border. If left *entricular failure is se*ere# the murmur is of low intensity. Aymptoms that occur in infants only when the stenosis is se*ere are pulmonary edema and congesti*e heart failure. +6. !ulmonar- stenosis ,&it% inta"t 5entri"ular septum.. If the stenosis is se*ere# a loud# systolic e3ection murmur is audible o*er the pulmonary area and radiates o*er the entire precordium. 6ight *entricular failure and cyanosis may be present. If the stenosis is mild# a short pulmonary systolic e3ection murmur is heard o*er the pulmonic area along with a split second heart sound. B. !alpate t%e pulses ,#emoral$ pedal$ radial$ and 0ra"%ial.. (ounding pulses can be seen with patent ductus arteriosus. 9bsent or delayed femoral pulses are associated with coarctation of the aorta. C. C%e"* #or signs o# "ongesti5e %eart #ailure. Aigns may include hepatomegaly# gallop# tachypnea# whee;es and rales# tachycardia# and abnormal pulses. AIV. A0domen A. O0ser5ation. 1b*ious defects may include an omp%alo"ele$ in which the intestines are co*ered by peritoneum and the umbilicus is centrally located# or a gastros"%isis$ in which the intestines are not co*ered by peritoneum (the defect is usually to the right of the umbilicus". 9 s"ap%oid a0domen may be associated with a diaphragmatic hernia. B. Aus"ultation. 5isten for bowel sounds. C. !alpation. 7heck the abdomen for distention# tenderness# or masses. The abdomen is most easily palpated when the infant is quiet or during feeding. In normal circumstances# the li*er can be palpated %2 cm below the costal margin and the spleen tip at the costal margin. 8epatomegaly can be seen with congesti*e heart failure# hepatitis# or sepsis. Aplenomegaly is found with cytomegalo*irus (7=J" or rubella infections or sepsis. The kidneys

(especially on the Gidney si;e may disease# renal *ein 9bdominal masses the urinary tract.

right" can often be palpated. be increased with polycystic thrombosis# or hydronephrosis. are more commonly related to

AV. Um0ili"us. >ormally# the umbilicus has two arteries and one *ein. The absence of one artery occurs in 4% $ of $$$ singleton births and in 04%,$ of $$$ twin births. The presence of only two *essels (one artery and one *ein" could indicate renal or genetic problems (most commonly trisomy +". If there is a single umbilical artery# there is an increased pre*alence of congenital anomalies and intrauterine growth retardation and a higher rate of perinatal mortality. If the umbilicus is abnormal# ultrasonography of the abdomen is recommended. In addition# inspect for any discharge# redness# or edema around the base of the cord that may signify a patent urachus or omphalitis. The cord should be translucent< a greenish%yellow color suggests meconium staining# usually secondary to fetal distress. AVI. )enitalia. 9ny infant with ambiguous genitalia should not undergo gender assignment until a formal endocrinology e*aluation has been performed 9 male with any question of a penile abnormality should not be circumcised until he is e*aluated by a urologist or a pediatric surgeon. A. ;ale. 7heck for dorsal hood# hypospadias# epispadias# and chordee. >ormal penile length at birth is 2 cm. >ewborn males always ha*e a marked phimosis. :etermine the site of the meatus. Jerify that the testicles are in the scrotum and examine for groin hernias. Bndescended testicles are more common in premature infants. 8ydroceles are common and usually disappear by year of age. 1bser*e the color of the scrotum. 9 bluish color may suggest testicular torsion and requires immediate urologic'surgical consultation. Infants will ha*e well% de*eloped scrotal rugae at term. 9 smooth scrotum suggests prematurity. B. Female. 2xamine the labia and clitoris. 9 mucosal tag is commonly attached to the wall of the *agina. :ischarge from the *agina is common and is often blood tinged secondary to maternal estrogen withdrawal. If the labia are fused and the clitoris is enlarged# adrenal hyperplasia should be suspected. 9 large clitoris can be associated with maternal drug ingestion. 5abia ma3ora at term are enlarged.

AVII. '-mp% nodes. -alpable lymph nodes# usually in the inguinal and cer*ical areas# are found in I00? of normal neonates. AVIII. Anus and re"tum. 7heck for patency of the anus to rule out imperforate anus. 7heck the position of the anus. =econium should pass within 4+ h of birth for term infants. -remature infants are usually delayed in passing meconium. AIA. E4tremities. 2xamine the arms and legs# paying close attention to the digits and palmar creases. A. S-nda"t-l-$ or abnormal fusion of the digits# most commonly in*ol*es the third and fourth fingers and the second and third toes. 9 strong family history exists. Aurgery is performed when the neonates are older. B. !ol-da"t-l- is supernumerary digits on the hands or the feet. This condition is associated with a strong family history. 9n x%ray film of the extremity is usually obtained to *erify whether any bony structures are present in the digit. If there are no bony structures# a suture can be tied around the digit until it falls off. If bony structures are present# surgical remo*al is necessary. 9xial extra digits are associated with heart anomalies. C. Simian "rease. 9 single trans*erse palmar crease is most commonly seen in :own syndrome but is occasionally a normal *ariant. . Talipes e9uino5arus ,"lu0#oot. is more common in males. The foot is turned downward and inward# and the sole is directed medially. If this problem can be corrected with gentle force# it will resol*e spontaneously. If not# orthopedic treatment and follow%up are necessary. E. ;etatarsus 5arus is adduction of the forefoot. This condition usually corrects spontaneously. AA. Trun* and spine. 7heck for any gross defects of the spine. 9ny abnormal pigmentation or hairy patches o*er the lower back should increase the suspicion that an underlying *ertebral abnormality exists. 9 sacral or pilonidal dimple may indicate a small meningocele or other anomaly. AAI. Hips. 7ongenital hip dislocation occurs in I in +$$ li*e births. =ore common in white females# this condition is more likely to be unilateral and to in*ol*e the left hip. Two clinical signs of dislocation are asymmetry of the skinfolds on the dorsal surface and shortening of the affected leg.

2*aluate for congenital hip dislocation by using the Ortolani and Barlo& maneu5ers. -lace the infant in the frog%leg position. 9bduct the hips by using the middle finger to apply gentle inward and upward pressure o*er the greater trochanter (1rtolani@s sign". 9dduct the hips by using the thumb to apply outward and backward pressure o*er the inner thigh ((arlow@s sign". (Aome clinicians suggest omitting the (arlow maneu*er because this action may contribute to hip instability by stretching the capsule unnecessarily." 9 click of reduction and a click of dislocation are elicited in infants with hip dislocation. If this disorder is suspected# radiographic studies and orthopedic consultation should be obtained. AAII. >er5ous s-stem. )irst# obser*e the infant for any abnormal mo*ement (eg# sei;ure acti*ity" or excessi*e irritability. Then e*aluate the following parameters. A. ;us"le tone +. H-potonia. )loppiness and head lag are seen. 2. H-pertonia. Increased resistance is apparent when the arms and legs are extended. 8yperextension of the back and tightly clenched fists are often seen. B. Re#le4es. The following reflexes are normal for a newborn infant. +. Rooting re#le4. Atroke the lip and the corner of the cheek with a finger and the infant will turn in that direction and open the mouth. 2. )la0ellar re#le4 ,0lin* re#le4.. Tap gently o*er the forehead and the eyes will blink. 1. )rasp re#le4. -lace a finger in the palm of the infant@s hand and the infant will grasp the finger. 4. >e"*2rig%ting re#le4. Turn the infant@s head to the right or left and mo*ement of the contralateral shoulder should be obtained in the same direction. 3. ;oro re#le4. Aupport the infant behind the upper back with one hand# and then drop the infant back cm or more tobut not onthe mattress. This should cause abduction of both arms and extension of the fingers. 9symmetry may signify a fractured cla*icle# hemiparesis# or brachial plexus in3ury. C. Cranial ner5es. >ote the presence of gross nystagmus# the reaction of the pupils# and the ability of the infant to follow mo*ing ob3ects with his or her eyes. . ;o5ement. 7heck for spontaneous mo*ement of the limbs# trunk# face# and neck. 9 fine tremor is usually normal. 7lonic mo*ements are not normal and may be seen with sei;ures.

E. !erip%eral ner5es +. Er02 u"%enne paral-sis in*ol*es in3ury to the fifth and sixth cer*ical ner*es. There is adduction and internal rotation of the arm. The forearm is in pronation< the power of extension is retained. The wrist is flexed. This condition can be associated with diaphragm paralysis. 2. ?lump*eBs paral-sis in*ol*es the se*enth and eighth cer*ical ner*es and the first thoracic ner*e. The hand is flaccid with little or no control. If the sympathetic fibers of the first thoracic root are in3ured# ipsilateral ptosis and miosis can occur. F. )eneral signs o# neurologi" disorders +. S-mptoms o# in"reased intra"ranial pressure (bulging anterior fontanelle# dilated scalp *eins# separated sutures# and setting%sun sign" (see p 02". 2. H-potonia or %-pertonia. 1. Irrita0ilit- or %-pere4"ita0ilit-. 4. !oor su"*ing and s&allo&ing re#le4es. 3. S%allo&$ irregular respirations. 6. Apnea. 8. Apat%-. :. Staring. <. SeiCure a"ti5it- (sucking or chewing of the tongue# blinking of the eyelids# eye rolling# and hiccups". +=. A0sent$ depressed$ or e4aggerated re#le4es. ++. As-mmetri" re#le4es.