Neonatal Top Ten List

This is a list of ten items that you should absolutely know after completing your rotation in Neonatology. This is
NOT to suggest that this is all you need to know for your neonatology rotation. Rather, all examiners will expect
you to know these basic facts and could easily ask you about them (as well as other topics) during your end of
rotation practical exam. (All numbers are for otherwise healthy, full term newborns)

1. Growth parameters
a. Weight (normal 2.5 to 4 Kilograms)
b. Length (about 50 cms)
c. Head circumference (32 to 37 cms)
2. Weight changes
a. Weight loss
i. Normal newborns can lose up to 10% of their birth weight in the first week of life
ii. Should regain birth weight by 10 to 14 days
iii. Loss of more than 10 % suggests inadequate intake of calories for the infants needs
b. Weight gain
i. After regaining birth weight, infants gain about 20 to 40 grams per day
ii. A typical 3.5 kg baby doubles his birth weight by 4 – 5 months, trebles it by 1 year
3. Normal newborn vital signs
a. Respiratory rate 30 – 40 in resting neonate (varies widely with state of newborn)
b. Heart rate 100 – 160 beats per minute (varies with state of newborn)
4. Nutritional requirements
a. Fluid requirements: 150mls + /kg/day
i. Initially infants take about 60 mls/kg/day, increasing up to about 150mls/kg/day over
the first week of life
b. Calorie requirements: 100 – 110 Kilocals/kg/day (fulfilled by breast milk or formula in volume
above)
i. Standard infant formula: 67 kcal / 100ml (20 kcal / 30 ml) 30 ml = 1 oz
5. Feeding history
a. If a mother is formula feeding you should know the type, volume and frequency of feeds. If the
mother is breastfeeding, know how often her baby is breastfed It is useful to know how long it
takes an infant to feed.
b. Breast milk ‘comes in’ typically between days 2 to 5. Prior to this the breast produces
colostrum. Colostrum is very nutritious and rich in immunological factors, but small in volume.
6. Advantages of breast feeding
a. Health, nutritional, immunological, developmental, psychological, social, economic and
environmental
b. For infant: decreased NEC (premature) and reduction in gastrointestinal infections, possible
decrease in URI / OM, possible improvement in neurodevelopment, decrease risk some
chronic diseases (diabetes and inflammatory bowel disease), maternal infant bonding
c. For mother: less postpartum bleeding, lactational amenorrhea, improved bone re-
mineralisation, reduced risk ovarian cancer and premenopausal breast cancer, quicker return
to pre-pregnant weight
d. Nutritionally complete for first 6 months, less expensive, less waste (bottles and other
equipment), fewer hospitalisations / GP visits
7. Stooling & voiding information
a. Most infants pass their first stool (meconium) by 24 hours and nearly all by 48 hours. Delayed
passage of stool is associated with Hirschprung’s disease or cystic fibrosis.
b. Most infants pass urine in the first 12 – 24 hours. Failure to pass urine suggests inadequate
fluid intake or some kind of malformation / obstruction (or that the urine passed unnoticed).
c. Urine output is a good marker of hydration status. Infants typically have 1-2 wet nappies on
first day of life, increasing to about one wet nappy per feed over the next week.
8. Newborn screen (heel prick test) is performed between 72 – 120 hours of life. It tests for:
a. Phenylketonuria, Galactosaemia, Homocystinuria, Maple syrup urine disease, Congenital
hypothyroidism, Congenital toxoplasmosis (pilot study in Ireland)
9. Mortality rates
a. Neonatal mortality rate: number of deaths of live born infants with birth weights greater or equal
to 500 grams during the first 28 days of life, per 1000 live births (currently in Ireland about 4 /
1000)
b. Perinatal mortality rate: number of stillbirths and neonatal deaths in first week of life per 1000
live and stillbirths (currently in Ireland about 10 / 1000)
10. Most common causes of mortality in newborn period (developed countries)
a. Congenital malformation, prematurity, infection, asphyxia

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 At the beginning:
 Hello.
 Shake the examiners hands.
 Shake the mother’s hand and introduce yourself: my name is X.
 Thank you for letting me examine your child.
 What is your baby’s name? Did she/he pass meconium?
 I will proceed with examination.
 I would plot on an appropriate centile chart (weight, length, head circumference)

Major Examination: (One major)

1. Cardiovascular Examination:
◦ Undress the baby (They will watch you how to undress the baby!)
◦ Make comments while are you undressing the baby.
General inspection (Quick at the end of the bed)
• Posture semi-flexed normal
• No dysmorphic features (Down syndrome)
◦ Small stature / brushfield spots/ epicanthic folds/ Mongolian slant/ protruding tongue
◦ Small ear sets/ bradycephaly/ single palmar crease/ short fingers
◦ 5th finger clinodactyly/ wide gap between 1st and 2nd toes
◦ Risk of: AVSD.
Skin: Cutis marmorata (exposed to cold air).
•
• Colour:
1. Pink normal!
2. Blue: cyanosis/ acrocyanosis = resp distress
3. Pale/grayish skin (poor perfusion)
4. Jaundiced (Yellowish):
- < 24 h of birth: Haemolytic disease / congenital infection sepsis (TORCH)
- 24 h – 2 weeks: Physiological Jaundice (UC bilirubin) / prematurity/ hypothyroidism/
breastfeeding/ haemolysis/ congenital hyperbilirubinaemia
- > 2 weeks: breast milk / biliary atresia/ neonatal hepatitis.

• Respiratory distress signs: Tachypnoea RR> 60, grunting, recession, nasal flaring, cyanosis
• No visible pulsation.
• CRT on sternum. >3 seconds = abnormal [w/ enough pressure to turn finger white]. Press over the
sternum for 5 secs
• Central cyanosis: observe inside the mouth.
• RR/ Resp pattern- Tachypnea w/out increased Work Of Breathing is suggestive of CVS disease rather
than respiratory. Offer to measure RR for 15 sec.
• Breast can be enlarged secondary to maternal oestrogen.
◦ White discharge “witches milk” can be seen, resolves within 1/52. (either sex)
◦ Wide space between nipples= turner syndrome
Palpate

• Apex beat: (in neonate usually 4th ICS (or 5th ICS) + midclavicular line.
extra marks: Feel the right side of the chest to exclude Dextrocardia.
• Thrills: Z line (Aortic, pulmonary, tricuspid, mitral)
• left parasternal heave to feel right ventricular hypertrophy.
Auscultate
• Listen in all 4 areas.
• Normal HR = 120-160 bpm.
• Murmurs: Innocent Classified based on Soft, Systolic, Position, Asymptomatic
◦ Asymptomatic or symptomatic (consistent w/ CHD= poor feeding, tachypnea, and cyanosis)
◦ VSD : commonest – pansystolic if large CCF signs. Rare < 2/52
◦ PDA: harsh continuous “ machinery” type murmur. 2nd to 3rd day of life wide pulse pressure
and bounding pulses.
◦ Coarctation of aorta – ejection systolic murmur, radiates interscapularly, absent/ weak femoral
pulses.
Other
• Hepatomegaly: RIF and then palpate upwards
◦ Newborns liver edge can be normally felt 2cm below right costal margin
◦ Causes: polycystic kidney disease, hepatitis, heart failure, haematological

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 • Femoral pulse: halfway between iliac crest and pubic symphysis. NB coarctation of aorta (Narrowing)
◦ Then palpate brachial pulse simultaneously to assess femoral vs brachial relative volumes

2. Abdominal Examination:
◦ Undress the baby (They will watch you how to undress the baby!)
◦ Make comments while are you undressing the baby.
◦ General inspection (Quick at the end of the bed)
Inspection – Abdomen
• An abdomen that looks full especially after a feed is normal. Distended or tense
abdomen indicates intestinal obstruction.
• Scaphoid abdomen= Diaphragmatic hernia
• Divarication of the recti (a gap of roughly 2.7 cm or greater between the two sides of the rectus
abdominis muscle) = normal finding
• Colour (refer to cardio), posture.
• Inspect umbilical cord (dries out soon after birth and detaches @ 2wks of age)
◦ Umbilical hernia is a benign self-resolving condition
• Omphalitis: peritoneal covering, central umbilicus
• Gastroschisis: no peritoneal covering, umbilicus to side
• Extra: Potter sequence: RENAL DYSPLASIA (CF: Squashed face, limb abnormalities, low set ears, flat
nose)
• Extra: Bladder exstrophy (failure of growth of lower abdominal wall and a breakdown of urogenital
membrane. Associated with epispadis and undescended testes, bladder protruding through abd wall,
anteriorly displaced anus and prolapsed rectal.
• Extra: Autosomal Recessive Polycystic Kidney Disease (Abdominal mass)

Palpation- Abdomen
• Flex the baby's legs to ensure the abdominal wall is relaxed and not tensed

1. Liver: RIF then palpate upwards (normally felt 2cm below the right costal margin) (Hepatomegaly
Congestive heart failure, Hameolytic anemia (Thalassemia, Hereditary spherocytosis))

• Spleen: Enlarges towards LIF (thus start at LIF). (some normal infants have a palpable spleen tip)
• Splenomegaly: CHICAGO:
- Cancer, Haemotolgical disorder, Infection (TORCH), Congestion portal hypertension,
Autoimmune (SLE,RA), Glucose storage disorder, Other (amyloidosis).

• Ballot the kidneys: kidneys that are easily palpable may be abnormally enlarged (hydronephrosis is
caused by a blockage in the urethra below the bladder from a condition called posterior urethral valves).

Auscultate- Abdomen
• Listen to bowel sounds (should stool within 24- 48hrs)

Others – refer to minor for more details (+ Minor)

• Genitalia
• Anus (Imperforate anus , patent normal)

Hands and Feet

• Inspect for polydactyly and syndactyly
• Talipes Equinovarus
◦ Internal rotation of the ankle joint
◦ May be positional (can be easily moved back into a neutral positon with
expectation of eventual resolution) or fixed

3. Neurological Examination:
◦ Undress the baby (They will watch you how to undress the baby!)
◦ Make comments while are you undressing the baby.
◦ General inspection (Quick at the end of the bed)
Inspection
• Level of alertness: Babies sleep up to 18 hrs on first day of life. Should wake with
gentle stimulation and spontaneously when due to feed.
• Muscle wasting, involuntary movements.
• Posture observation allows assessment of the peripheral tone

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 ◦ Strong flexion of all 4 limbs. Hypotonic babies (down syndrome – mention
dysmorphic features in GI) lay with their hips abducted and thighs lying
against the bed
◦ Movements of limbs

• Term baby should exhibit Spontaneous symmetrical movements in all limbs

• Common paroxysmal movements include jitteriness,
myoclonus, and choreoathetoid movements

Tone (+ Minor)
- Floppy: Down syndrome, Pradar willi syndrome
1. Peripheral
• Muscle tone is defined as resistance to passive stretching
• Move arms and legs to assess for peripheral tone
• Scarf sign: Positive if baby's elbow can be brought past the midline w/ little or no resistance
2. Central
• Pull baby up into central position by pulling from arms
◦ Head lag is present if the baby's head stays behind rather than in line with torso
• Vertical suspension. Hypotonia -> slip through examiner's hand
• Horizontal suspension. Hypotonia -> inverted letter U
• Good opportunity to examine spine: Palpate spine along entire length (also exclude
scoliosis)
• Midline skin abnormalities e.g. tufts of hair or discolouration -> underlying vertebral/ spinal
cord anomalies. (e.g. spina bifida),
• You can perform Galant reflex.

Primitive Reflexes (+ Minor)

• Rooting reflex: baby turns towards anything that strokes its cheek(disappear 6-8 weeks)
• Sucking reflex (disappear 6-8 weeks) : Poor sucking reflex can be due to Pradar willi
syndrome.
• Asymmetric Tonic Neck reflex /Fencing (disappears at 6 mo of age)
-In a supine infant: turning the head laterally – extension of the arm/leg on the side to the
turn and flexion of both on the side away from the turn.

• Moro reflex (by sudden extension of the baby's neck -> abduction and extension of infant's
arm). Goes away at 4-5 mo
- Asymmetrical response = due to brachial plexus injury (e.g. Erb's palsy- upper ventral rami
c5,6)
- Note Erb's due to pulling of head through vaginal canal or falling on your shoulder w/ neck to
side “waiters tip”
- Klumpke's (C7,8) is lower trunk defect and due to pulling baby via its hand out vaginal canal
or holding on to a tree while falling “CLAW HAND”
- Trauma (clavicle/ humerus fracture)
- Contralateral UMNL (newborn stroke) – Extra marks

• Palmar (3-4 mo) and Plantar grasp reflexes (12-18 mo).

• Stepping reflex. Disappears at 2 mo of age
• Galant reflex (stroking skin just lateral to vertebrae from thoracic to lumbar region -> lateral
flexion of the spine)

4. Head and Face Examination:

◦ Undress the baby (They will watch you how to undress the baby!)
◦ Make comments while are you undressing the baby.
◦ General inspection (Quick at the end of the bed)
◦ Major head circumference 3 times! {32-37cm}

Inspection- Head
• By looking down at the top of the infant's scalp
• Asymmetry e.g. Plagiocephaly (flattening of one side of back of skull -> diamond
shape). Self-resolving b/c due to baby's position in utero and torticollis.
• Large Macrocephaly >98th centile: Familial, Neurofibromatosis, raised ICP
(hydrocephaly/ subdural haematoma), Sotos syndrome (Macrosomia)
• Small Microcephaly < 2nd centile: familial, meningitis, cerebral palsy, crainosynostosis

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 • Brachycephaly (back – down), Dolichocephaly, forceps delivery

Palpate- Head
• Anterior 2-3cm (9-18 mons) and Posterior <1cm (2-4 mons) fontanelles.
◦ Tense= elevated ICP
• Middle (third) fontanelle in middle = Normal variant but also associated w/ Congenital
Hypothyroidism and Trisomy 21
◦ Small: hyperthyroidism
◦ Large: hypothyroidism,
◦ (bulging): hydrocephalus
◦ Sunken: dehydration
• Feel along the principle sutures of the skull:
- Metopic, Coronal, Sagittal, and lambdoid.

• Moulding of the skull due to pressure during delivery -> overlapping sutures (step b/w cranial bones)
◦ NBB Persistently abnormal skull shape w/ ridging along suture line= Premature
Fusion of the Sutures aka Craniosynostosis
• Scalp swellings
◦ Caput succedaneum = Oedema due to pressure on the scalp during delivery
(harmless and resolves over few days)
◦ Cephalohematoma= Blood in the scalp b/w periosteum and the bone
[Does not cross sutures or result in significant haemorrhaging]
◦ Subgaleal bleeding= Above periosteum, crosses sutures, and can result in
significant blood loss into the scalp
◦ Vacuum/Forceps- assisted delivery= can see marks consistent with the use of these
instruments
Inspection- Eyes
• Note positon and shape of the eye
• Brushfield spots, colobomata, subconjunctival haemorrahge (trauma), blue sclera (osteogenesis
imperfecta)
• Dacryocystocele
◦ Blue swelling between nose and medial eye -> indicates obstruction of the nasolacrimal duct
• Disconjugate eye movements are normal in first few weeks of life
• Inspect sclera: Red marks in conjunctiva -> subconjunctival haemorrhage are insignificant finding

Palpate- Eye
• Red reflex
◦ Should appear the same in both eyes
◦ Pathology: Diminished reflex, Dark spots in the reflex, White reflex, or
Asymmetry of the reflex. Cataracts = seen by naked eye as hazy lens.

Inspect- Nose
• Nasal septum often deviated in first few days of life (b/c of baby's position in utero
• Choanal atresia= Congenital obstruction of the nasal passages -> cyanosis during feeding
• Patent nostrils, Rubinstein-Taybi

Inspect- Mouth
• Symmetry: Asymmetric cry can be due to 1) Facial palsy or 2) Congenital absence
of the muscle which depresses the corner of the mouth (aka Asymmetric Crying
Facies)
• Cleft lip, Palate (soft and thin) (thorough = checking as far back as the uvula)
• Micrognathia (pierre robin seq assoc)
• Natal teeth, Epstein pearls {white cyst, palate, keratin, reso;ve spon}
• Rannula: cystic swelling mouth floor
Inspect- Ears
• Low-set ears: Line drawn straight back from the outside corner of the eye. If ear don't

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 intersect that line then = low-set
• Pre-auricular skin tag (usually isolated finding), pits, and dysplastic features.
• Microtia = underdeveloped pinna
• Treacher Collins , goldenhaar.

Inspect- Neck
• Torticollis= mass w/ deviation of the neck to one side
• Masses ddx= Cystic hygromas, SCM tumours, Thyroglossal cyst, Branchial cleft cyst, and Lymph
nodes
Palpate- Clavicles
• Both clavicles should be palpated
◦ Fracture suspected if there is any swelling, tenderness, or crepitus

Minor Examination: (Two Minors)

1. Skin Examination

• General inspection all over the body (front, back, head, legs, arms, genitalia)
• Refer to pages 8-11
• Rashes : Milia/ erythema toxicum/ nappy rash ( thrush)
• Birth marks:
o Mongolian blue spots: pigmented races v common
o Stork bites: haemangioma, usually disappear by 1 yrs
o Port wine stains:nevus flammeus, no fading or regression, a/w Sturge Weber sy
o Kasabach–Merritt syndrome (KMS):  Hemangioma with thrombocytopenia 
o Strawberry haemangioma: bright red, face, disappear by 7 yrs
o Cavernous haemangioma: large, cyst-like, firm, mass, anywhere. Beard distribution,
airway lesions, stridor. Tx propranolol/ steroids

2.
Head Examination
• Head size ( HC), shape, haematomas, fontanelles and sutures.
3. Three Primitive Reflexes
• Refer to Neuro Examination. Elicit reflex, disappearing age.
4. Male Genitalia
Genitalia ( Anus, testicles, penis)
• Ambiguous genitalia= not clearly male or female (cause: CAH)
• Babies should pass urine at least once in the first 24 hrs of life
• Inspect to confirm baby's sex. He is a boy.
• Dysmorphic features ( Down21, Edward18, Patau 13)
• Scrotum:
◦ Comment: Mass: Inguinal Hernia (Reducible) / Hydrocele (Transillumination)
◦ Hyperpigmentation: genetics/ congenital Adrenal Hyperplasia
◦ Abnormal colours: torsion, Infection epididymitis
◦ Palpate: two fingers press gently over the opening of inguinal canal and feel the testicle.
(Both sides)
◦ Testicles abnormalities: congenital absent testis, cryptorchidism (uni/bi lateral undescended
testicles), retractile testis (moveable by hand).
◦ No varicocele in babies.
• Penis:
◦ Urethral open at the tip Normal.
◦ Epispadias (Dorsum)
◦ Hypospadias (ventral) associated w/ hooding of the foreskin, abnormal curvature of the penis
aka Chordee “ EXTRA MARKS”
◦
• Anus
◦ Patent
◦ Imperforate anus (birth defects in which the rectum)
◦ Rash: contact dermatitis/ candida dermatitis/ seborrheic dermatitis
◦ Meconium passes in first 24 hrs of life. ***RARELY the meconium passes b/c of a perianal
fistula thus history of meconium passage should not be taken as proof that the anus is
patent.

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 • Female ( unlikely to examine female genitalia)
◦ Non-purulent discharge is normal phenomenon (white/pinkish discharge
can be present due to transfer of maternal hormones)
◦ Labia inspection

5. Tone
• Refer to Neuro Examination

6. Respiratory Examination
Inspection - Chest
• Breast hypertrophy normal in a neonate (male or female)
• Deformities: Pectus excavatum/carinatum?
• Posture semi-flexed normal
• Symmetrical chest movements
• Colour:
5. Pink normal!
6. Blue: cyanosis/ acrocyanosis = resp distress
7. Pale/grayish skin (poor perfusion)
8. Jaundiced (Yellowish):
- < 24 h of birth: Haemolytic disease / congenital infection sepsis (TORCH)
- 24 h – 2 weeks: Physiological Jaundice (UC bilirubin) / prematurity/ hypothyroidism/
breastfeeding/ haemolysis/ congenital hyperbilirubinaemia
- > 2 weeks: breast milk / biliary atresia/ neonatal hepatitis.
• Respiratory distress signs: Tachypnoea RR> 60, grunting, recession, nasal flaring, cyanosis
• Central cyanosis: observe inside the mouth.
• RR/ Resp pattern- Tachypnea w/out increased WOB is suggestive of CVS disease rather than
respiratory. Offer to measure RR for 15 sec.
◦ Use of accessory muscles
◦ Signs of diaphragmatic hernia, pneumothorax
• AUSCULTATE lungs if you haven't already done so

Extra:
Barlow test: by adducting the hip (bringing the thigh towards the midline) while applying pressure on the knee,
directing the force posteriorly.
Ortolani test: by flexing the hips and knees of a supine infant to 90°, then with the examiner's index fingers
placing anterior pressure on the greater trochanters, gently and smoothly abducting the infant's legs using the
examiner's thumbs.
 

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