• Comprehensive physical examination performed within <72 hr of life 
• See: https://www.gov.uk/government/publications/newborn-and-infant-physical-examination-programme-handbook/newborn-and-infant-physical-examination-screening-programme-handbook
• See: https://www.gov.uk/topic/population-screening-programmes/newborn-infant-physical-examination
• Includes screening for:
  
  • developmental dysplasia of the hip 
  • congenital cataracts 
  • cryptorchidism 
• Assessment of the heart
• General physical examination
• Examination has limitations and cannot identify all abnormalities that may be present in the newborn period 
• Provides reassurance to parents and opportunity for discussion

• Maternal and baby notes 
• Stethoscope
• Ophthalmoscope
• Measuring tape

• Identify congenital malformations
• Identify common neonatal problems and initiate management
• Continue with screening, begun antenatally, to identify need for specific interventions (e.g. immunisation)

• Before undertaking clinical examination, familiarise yourself with maternal history and pregnancy records, including:
  
  • maternal medical, obstetric and social history
  • paternal medical history, if available
  • family health, history of congenital diseases
  • identify drugs mother may have taken during pregnancy and in labour
  • health of siblings
  • identify pregnancy complications, blood tests, ultrasound scans, admissions to hospital
  • identify maternal blood group, presence of antibodies, serology results for sexually transmitted diseases
  • duration of labour, type of delivery, duration of rupture of membranes, condition of liquor
  • Apgar scores and whether resuscitation required
  • birth weight, gestational age, head circumference

Consent and preparation

• Introduce yourself to mother and gain oral consent. Ask about particular concerns
• Keep baby warm and examine in quiet environment

Skin examination

• Hydration
• Rashes: including erythema toxicum, milia, miliaria, staphylococcal skin infection, Candida
• Pigmented lesions: naevi, Mongolian blue spots, birth marks, café au lait spots
• Bruises: traumatic lesions, petechiae
• Cutis aplasia
• Tufts of hair other than on head
• Vascular lesions: haemangioma, port wine stain, simple naevus
• Colour: pink/cyanosis/jaundice/pallor/plethora
• Acrocyanosis
• Cutis marmorata

Facial examination

• General facial appearance to identify common syndromes 

Eyes

• Shape
• Slant
• Size 
• Position
• Strabismus
• Nystagmus 
• Red reflex
• Presence of colobomata
• Discharges

Nose

• Nasal flaring
• Patency

Ears

• Shape 
• Position 
• Tags or pits

Mouth

• Size
• Cleft lip
• Symmetry of movement 
• Swellings, Epstein’s pearls, ranula, tongue-tie (for parental reassurance)
• Teeth
• Cleft palate, hard/soft palate, [by both inspection (using tongue depressor) and palpation]
• Sucking

Skull

• Palpate: 
  
  • skull for sutures and shape/cranio-synostosis
  • swellings on scalp, especially crossing suture lines, cephalhaematoma
  • signs of trauma associated with birth (e.g. chignon from vacuum extraction)
  • subgaleal haemorrhage [see Subgaleal haemorrhage (SGH) guideline]
  • sutures for ridging or undue separation

Neck

• Swellings
• Movement
• Webbing
• Traumatic lesions from forceps delivery

Clavicles

• For fracture

Arms and legs

• Position and symmetry of movement 
• Swelling and bruising

Hands and feet

• Extra digits (polydactyly)
• Syndactyly, clinodactyly, camptodactyly
• Palmar creases
• Skin tags
• Position and configuration of feet looking for fixed/positional talipes
• Overlapping toes

Hips

• Developmental dysplasia using Ortolani’s and Barlow’s manoeuvres [see Developmental dysplasia of the hip (DDH) guideline] 

Spine

• Curvatures 
• Dimples
• Sacrococcygeal pits
• Hairy tuft on skin overlying spine

Systems

• Examine (inspection, palpation, auscultation) each system

Respiratory

• Respiratory rate
  
  • grunting
  • nasal flaring
• Chest shape, asymmetry of rib cage, swellings
  
  • nipple position, swelling/discharge/extra nipples
• Chest movement
  
  • presence/absence of recession
• Auscultate for breath sounds

Cardiovascular

• Skin colour/cyanosis
• Palpate: 
  
  • precordium for thrills
  • peripheral and femoral pulses for rate and volume
  • central perfusion
• Auscultate for heart sounds, murmur(s), rate, rhythm 
  
  • Pulse oximetry check – see Pulse oximetry (universal) screening guideline

Gastrointestinal tract

• Abdominal shape
• Presence of distension
• Cord stump for discharge or inflammation/umbilical hernia
• Presence and position of anus and patency
• Stools passed
• Palpate abdomen for tenderness, masses and palpable liver 
• Auscultation is not routinely undertaken unless there are abdominal concerns

Genito-urinary system

• Inspect appearance of genitalia: ambiguous? 

Male genito-urinary system

• Penis size (should be >1 cm)
• Position of urethral meatus. Look for hypospadias
• Inguinal hernia
• Chordee
• Urinary stream
• Scrotum for colour
• Palpate scrotum for presence of 2 testes and absence of hydrocele

Female genito-urinary system

• Presence of vaginal discharge (reassure parents about pseudomenstruation)
• Skin tags 
• Inguinal hernia
• Proximity of genitalia to anal sphincter 
• Routine palpation of kidneys is not always necessary as antenatal scans will have assessed presence

Neurological system

• Before beginning examination, observe baby’s posture 
• Assess: 
  
  • muscle tone, grasp, responses to stimulation
  • behaviour
  • ability to suck
  • limb movements
  • cry
  • head size in relation to body weight
  • spine, presence of sacral pits, midline spinal skin lesions/tufts of hair
• If neurological concerns, initiate Moro and stepping reflexes
• Responses to passive movements: 
  
  • pull-to-sit
  • ventral suspension
• Palpate anterior fontanelle size (<3 cm x 3 cm) and tone

Documentation

• Complete neonatal examination record in medical notes and sign and date it. Also complete Child Health Record (Red Book) and/or in NIPE Smart if used
• Record any discussion or advice given to parents

Normal examination

• If no concerns raised, reassure parents of apparent normality and advise to seek advice if concerns arise at home
• GP will re-examine baby aged 6–8 weeks

Abnormal examination

• In first instance, seek advice from neonatal registrar/consultant 
• Refer to postnatal ward guidelines for ongoing management
• Refer abnormalities to relevant senior doctor