Early Newborn Assessment, Physical Examination, and Screenings

The newborn period is the most critical time for detecting and potentially preventing medical issues. Many health issues can be diagnosed at the time of birth, and early detection of these can prevent serious complications. Physical examinations and screening lab tests are essential tools for detecting conditions that may not be immediately apparent but can significantly impact a baby’s proper growth, development, and long-term health. According to Nelson Textbook of Pediatrics, “Early identification of congenital or acquired conditions through physical examination and screening allows for timely interventions that can prevent complications, reduce morbidity, and enhance overall outcomes.”

These assessments ensure that the newborn is receiving the best possible start in life and also provide parents with peace of mind and critical, necessary information about their newborn's health.

Physical Examination of the Newborn

The first assessment of a newborn occurs immediately after birth, usually done by attending obstetricians. This early examination evaluates the baby’s overall health, ensuring proper adaptation to life outside the mother’s womb. According to Nelson Textbook of Pediatrics, "The examination should begin with an assessment of the baby’s general appearance, including activity, tone, color, and breathing patterns." This initial evaluation identifies any urgent issues requiring immediate intervention.

After the baby is transferred from the delivery room to the ward, a more comprehensive physical examination is performed by a pediatrician. This comprehensive physical examination consists of:

1. The examination of the head and neck: Nelson Textbook mentions, "Inspection for cranial molding or birth injuries such as cephalohematoma" is essential. Birth injuries like cephalohematomas usually resolve naturally, but subgaleal hemorrhages require immediate intervention due to the risk of hypovolemic shock. “Palpation of fontanelles and sutures to assess for abnormalities like craniosynostosis” is also necessary. It helps to identify premature suture closure, which often impacts brain growth later in the baby’s life. The eyes should be inspected for red reflexes, which help rule out cataracts or retinoblastoma. Absence of the red reflex may indicate a serious issue requiring prompt ophthalmological evaluation. The corneas should be checked for cloudiness, which might suggest congenital glaucoma. A yellowish hue of the sclera may suggest hyperbilirubinemia.
2. The examination of the skin: The textbook suggests, "Examination for jaundice, rashes, or birthmarks, including Mongolian spots and hemangiomas." Jaundice may indicate hyperbilirubinemia, while petechiae could suggest infections or clotting disorders. "Identification of abnormal findings like cyanosis or petechiae." Cyanosis, particularly central cyanosis, may indicate serious cardiac or respiratory conditions that may need surgical and immediate interventions.
3. The examination of the heart and lungs: "Auscultation to detect heart murmurs, which may indicate congenital heart defects." Early detection of heart murmurs can lead to prompt management of conditions such as ventricular septal defects or patent ductus arteriosus. Nelson Textbook of Pediatrics mentions, "Monitoring for signs of respiratory distress such as grunting or nasal flaring" is also necessary. These signs might signal neonatal respiratory distress syndrome or transient tachypnea of the newborn. Screening for Critical Congenital Heart Disease (CCHD) is usually performed by pulse oximetry within the first 24 hours of birth. According to the textbook, "Early diagnosis through pulse oximetry can significantly reduce morbidity and mortality."
4. The examination of the abdomen: "Palpation for organomegaly or masses," and “Inspection of the umbilical cord for signs of infection," are recommended by the textbook.
5. The examination of hips and shoulders: "Conducting the Ortolani and Barlow maneuvers to screen for developmental dysplasia of the hip (DDH)." In the Ortolani maneuver, a palpable “clunk” suggests the reduction of a dislocated hip. The Barlow maneuver involves adducting the hips and applying gentle posterior pressure to detect instability. Early detection of DDH is crucial as untreated cases may lead to chronic pain, limb length discrepancies, and impaired mobility. Shoulders are also examined for clavicle fractures and brachial plexus injuries, as these are fairly common in difficult deliveries.
6. The examination of the neurologic system: "Assessment of reflexes, including the Moro, rooting, and grasp reflexes, as markers of neurological health." Absence or asymmetry of these reflexes may indicate underlying neurological or musculoskeletal issues that might need further investigation.

The physical examination is usually repeated within the first 24–48 hours and before discharge to detect conditions that may emerge after birth.

Parents also have an important role in supporting routine physical examinations. While medical professionals perform detailed assessments, parents can assist by observing and reporting any unusual signs or behaviors in their baby to the pediatrician. For example, parents can help by monitoring feeding and sleep patterns, checking the umbilical cord for signs of infection, observing skin color and sclera for early signs of neonatal jaundice, and noting the movement and reflexes of the baby.

Laboratory-Based Screenings

Newborn screening programs in Canada are designed to detect a variety of inherited and metabolic conditions. A small blood sample, collected via a heel prick within the first 24–48 hours of life, usually done in the hospital, is analyzed for a number of medical conditions. This test, often referred to as the heel prick test, is critical for identifying disorders that may not show immediate symptoms but can lead to severe complications if untreated. According to Nelson Textbook of Pediatrics, "Early identification through blood spot testing is vital for conditions such as phenylketonuria (PKU), congenital hypothyroidism, cystic fibrosis, and sickle cell disease."

Screening for Hearing and Visual Problems

Universal newborn hearing screening (UNHS) is a routine part of newborn care in Canada. This test uses otoacoustic emissions (OAEs) or auditory brainstem response (ABR) technology to detect hearing loss. Early identification ensures timely interventions such as hearing aids or cochlear implants, which are critical for language development.

Further screening for visual problems is not generally recommended for all babies. For preterm or high-risk newborns, a more specialized visual screening is usually performed to detect conditions like retinopathy of prematurity (ROP) or other developmental issues. These tests are typically recommended for babies born at less than 31 weeks’ gestation or with a birth weight under 1500 grams. The first screening is generally conducted 4–6 weeks after birth.

The Role of Parents

As a parent, you play a pivotal role in the early assessment of your baby. Make sure that your baby undergoes all recommended screenings within the first 48 hours. Ensure that you understand the results of the tests and follow up on any abnormalities. Ask your baby’s pediatrician about any alarm signs that you should check for as your baby goes through their first weeks. Finally, discuss your family’s medical history with your healthcare provider, as this may influence additional screenings. For example, G6PD Deficiency (aka favism) is not generally screened in Canada. However, G6PD deficiency is routinely screened in populations that are at higher risk, such as those with a family history of the condition or individuals in certain ethnic groups, like those of African, Mediterranean, or Asian descent.

Authored by:

Dr. Alireza Sarmadi
Family Physician

References

Nelson textbook of pediatrics 22^nd ed. Chapter 104

Nelson textbook of pediatrics 21^st ed. Chapter 113

Postpartum care: After a vaginal delivery - Mayo Clinic

Assessments for Newborn Babies - Stanford Medicine Children's Health

Physical Exam of the Newborn

Newborn Screening Tests (for Parents) | Nemours KidsHealth