Most newborn infants weigh between 2 500g and 4 000g at birth. Infants weighing less than 2 500g are called "low birth weight" (LBW). They may have a low birth weight because they are born preterm, because they have had slow intrauterine growth (fetal growth restraint), or because they have soft tissue wasting (recent fetal starvation).

The pattern of fetal growth is usually assessed at birth by correlating the infant's weight and size with the gestational age. Weight, crown-heel length and head circumference are measured and plotted on a size-for-gestational age standard. The combined Denver standard for males and females of all parities is most widely used (see page ...).

Weight for gestational age is usually used to divide newborn infants into different risk categories. Infants born with a birthweight below the 10th percentile for gestational age are referred to as underweight for gestational age (light for dates or small for gestational age). Similarly infants with a birth weight above the 90th percentile are called overweight for gestational age (heavy for dates or large for gestational age). Infants with birth weights falling between the 10th and 90th percentiles are regarded as being appropriate for gestational age. As weight and gestational age are being measured it is more accurate to refer to overweight, underweight and appropriate weight for gestational age. The newborn infant's length and head circumference can also be plotted on similar standards, and reflect the linear growth and brain growth of the fetus.

Some infants are symetrically underweight and short for their gestational age suggesting a prolonged period of slow intrauterine growth. As they have a length and head circumference below the 10th centile they can be correctly labelled as fetal growth restraint (intrauterine growth retardation). In contrast other infants are wasted with a normal length and head circumference suggesting that their weight has recently fallen due to soft tissue wasting. These wasted infants have suffered recent fetal starvation rather than prolonged slow intrauterine growth.

Assessing the gestational age and weight and the routine plotting of each infant on a weight for gestational age standard, is of great clinical importance as this information can be used to predict the perinatal risk of that particular fetus/infant. Head circumference is also important as it reflects brain size. Length is difficult to measure accurately and is not routinely recorded.

Common problems in Preterm and Underweight for Gestational Age Infants

	Preterm	UGA
Birth asphyxia	+	++
Meconium aspiration	-	++
Polycythaemia	-	++
Hypothermia	++	+
Hypoglycaemia	++	++
Hyaline membrane disease	++	-
Apnoea	++	-
Poor feeding	++	-
Patent ductus arteriosus	++	-
Birth trauma	+	-
Periventricular haemorrhage	++	-
Jaundice	++	+
Infection	++	-
Congenital abnormalities	+	++
Retarded postnatal growth	+	++
Retarded postnatal development	+	+

WEIGHT, LENGTH AND HEAD CIRCUMFERENCE FOR GESTATIONAL AGE STANDARDS.

THE HEALTHY NEONATE AND MINOR DISORDERS

A weight loss of up to 10% of birth weight may occur during the first 3 to 5 days of life. Birth weight is usually regained by the seventh day. Subsequent weight gain is usually about 200g a week (25-30 g/day) for the first three months.

Head circumference - 33 to 37 cm (average 35 cm)

Average increase approximately 7.5 mm/week (1 mm a day)

caput succedaneum: oedematous thickening of the scalp in the presenting area. It disappears within a day or two

anterior fontanelle: diamond-shaped and variable size, normally slightly concave and may be seen to pulsate

moulding: altered head shape in response to pressure, sometimes with overriding cranial bones

plagiocephaly: "parallelogram skull", with flattening of one side of the occiput and the opposite frontal region and face. Distinguish from unilateral craniosynostosis due to premature fusion of one coronal suture with lack of growth on that side (early surgical correction necessary)

craniotabes (softening of skull bones) is a normal finding in most newborns and many infants up to 3 months.

the newborn baby generally appears to have a short neck. Midline swellings such as dermoid and thyroglossal cysts are uncommon

sternomastoid "tumour" - a hard lump in the body of the sternomastoid muscle appearing some days after birth. Caused by trauma or avascular necrosis. It may cause torticollis which usually improves with physiotherapy. Uncommon.

examination difficult at first because of strong reflex closure. Baby often opens eyes if held erect.

pupil should appear black and not grey.

"red reflex" should be present.

colour of iris indefinite and not predictable.

sclerae often have a blue tinge.

tears rare in first few weeks.

infants are able to see from birth and should follow a red or bright moving object.

subconjunctival haemorrhage: a bright red patch, often adjacent to the cornea has no serious significance and disappears within a few weeks.

abnormally large eye/s may indicate congenital glaucoma (early treatment very important).

the newborn infant is an obligatory nose breather. Nasal obstruction, congenital (choanal atresia) or acquired (e.g. nasal secretions), may cause feeding problems or respiratory distress.

sucking blisters: thickened areas on the upper lip, usually in the midline.

epithelial pearls are small whitish areas a few mm across, usually visible in the midline on the hard palate. They are of no significance.

tongue-tie when the frenulum linguae is inserted into or near the tip of the tongue, rarely interferes with sucking or future speech and is usually best left well alone.

adventitious teeth may occasionally be present at birth. They are usually loose, do not interfere with sucking, and fall out spontaneously. Rarely, primary teeth may also be present at birth.

Protective greasy white substance secreted by fetal sebaceous glands. Not present in preterm infants, and decreases in quantity after term.

Traumatic cyanosis of the face

Due to many small petechial haemorrhages in the skin after congestion of the head with the cord around the neck.

Superficial skin peeling

Common during the first week. It is especially marked in post-term or wasted babies.

Colour at birth is poor guide to future shade. Lanugo is fine facial and body hair which is a feature of preterm babies.

White pin-head size spots mainly on and around nose. These are tiny sebaceous retention cysts and last a few weeks.

Red scald-like lesions around the mouth and cheeks due to regurgitated gastric juice (high hydrochloric acid content).

Flat blue-black areas over sacrum or buttocks, and occasionally on back, shoulders, hands and feet. Disappear by 4 years.

Salmon patches: superficial capillary haemangiomata may occur over the upper eyelids and on the nape of the neck (stork-bite). They usually fade by 1 year.

Strawberry naevus: a raised capillary haemangioma with a surface resembling a strawberry. At birth, the strawberry-to-be may show as a white (depigmented) patch of skin. Growth is rapid and it may easily reach 4 cm in diameter. It usually starts to subside by 1 year and most have disappeared by 7 years of age. Surgical removal is rarely necessary.

Port wine mark (naevus flammeus): may cover an extensive area. It persists for life. If situated over the ophthalmic division of the trigeminal nerve it may be associated with a meningeal haemangioma (Sturge-Weber syndrome). Large marks may require laser treatment later.

Very common. Red blotchy rash, associated with central pin-head papules (which may look like pustules but contain eosinophils) occurring between the second and eighth days. Seldom seen in preterm infants.

Localized areas of induration on back, thighs, or face (after forceps delivery). It has a dark red appearance and may fluctuate. Resolves spontaneously but needs to be differentiated from skin abscesses.

Very firm rubbery feel to the skin. Associated with severe infection, hypothermia or severe asphyxia.

Dry, loose skin hangs in folds due to loss of muscle and subcutaneous fat resulting from recent intrauterine starvation.

Breast enlargement is common in both male and female babies, usually lasting a week or two (but may persist for months). It is due to the effect of oestrogen and progesterone. No treatment is necessary. Handling must be avoided as this may cause true mastitis.

Gastrointestinal tract

Babies normally swallow a variable quantity of air when feeding and commonly bring up a small amount of milk when winded. Occasional large vomits without cause may occur. Persistent vomiting however, should be assessed carefully and investigated especially if bile is present.

alimentary tract obstruction due to atresia, meconium ileus, volvulus, strangulated hernia, inspissated milk, Hirschsprung's disease and necrotising enterocolitis

marked gastro-oesophageal reflux

infection (including urinary tract)

cerebral pathology (including intracranial bleed or meningitis)

Meconium is passed within 48 hours of birth in the majority of babies. (When passed in utero it usually indicates fetal distress). Obstruction may rarely be caused by a firm meconium plug, and may be relieved by gently inserting a small glycerine suppository into the anus.

Stools replace meconium on day 3 or 4.

Breast milk stools are usually bright yellow (vary from orange to green), may vary from watery to pasty, and may contain mucus or milk curds. Two to five stools are usually passed each day, but the variation ranges from one stool a week to 12 a day.

Cow's milk (formula) stools are pale yellow, firmer and less frequent (up to 5 a day)

"Starvation stools" which occur in under-fed infants are characteristically small and dark green

Blood in stools is commonly due to swallowed maternal blood (distinguished from fetal blood by Apt test)

newborn infants should pass urine within the first 24 hours

boys should pass urine with a good stream (dribbling suggests posterior urethral valves)

in the first few weeks the infant empties his bladder up to 20 times a day

urates may colour the urine heavily leaving a brick-red stain on the nappy (sometimes mistaken for blood)

the newborn kidney is less able to excrete a solute load and has a reduced concentrating capacity in comparison with the older child

Urine collection: most easily done using a collecting bag, but contamination is a risk. Uncontaminated urine may be obtained by suprapubic bladder puncture.

term male infants usually have testes in the scrotum at birth. The majority of incompletely descended testes come down within the first month

preterm babies tend to have incompletely descended testes and a less well-developed scrotum

fluid hernia (soft swelling of scrotum which transilluminates easily) is common. Most disappear spontaneously within the first year

foreskin is normally adherent to the glans penis and cannot be pulled back without trauma: 90% become fully retractable by the age of 3 years. Pulling back the foreskin in infancy is therefore not advisable and routine circumcision is medically unnecessary

a mucoid vaginal discharge is present in nearly all mature female infants at birth

vaginal bleeding occasionally occurs at the end of the first week (a hormone withdrawl effect of no pathological significance)

The physical examination of the newborn infant should be performed in a fixed order to ensure that nothing is forgotten. First basic measurements are made, then the infant is inspected generally. Thereafter the infant is examined by regions starting at the head and ending at the toes. Finally the neurological status is assessed. The step by step examination given below lists what should be done and gives the normal and abnormal findings.

MEASUREMENTS
BIRTHWEIGHT
Normal	2500g or above Between 10th and 90th centile for gestational age
Abnormal	Low birthweight(below 2500g) Underweight(below 10th centile) overweight.(above 90th centile) for gestational age
HEAD CIRCUMFERENCE
Normal	Between 10th and 90th centile for gestational age.
Abnormal	Small head (below 10th centile) or Large head (above 90th centile) for gestational age
CROWN-HEEL LENGTH
Normal	Between 10th and centile for gestational age. Measure accurately with tape or preferably measuring box.
Abnormal	Short (below 10th centile or tall (above 90th centile) for gestational age.
SKIN TEMPERATURE
Normal	Abdominal wall 36 - 36.5°C (or axilla 36.5 - 37°C)
Abnormal	Hypothermia (below 35°C).
GENERAL INSPECTION
GESTATIONAL AGE
Normal	Physical and neurological features of term infant.Term (37-41.9 wks).
Abnormal	Immature features in preterm infant (below 37 weeks). Postterm infants. (42 weeks and above) have long nails and are often wasted
WELLBEING
Normal	Active, alert.
Abnormal	Lethargic, appears ill.
APPEARANCE
Normal	No abnormalities.
Abnormal	Gross abnormalities. Abnormal faeces.
WASTING COLOUR
Normal	Well nourished. Pink tongue.
Abnormal	Soft tissue wasting. Cyanosis, pallor, jaundice, plethora.
SKIN
Normal	Smooth or mildly dry. Vernix and lanugo. Stork bite, mongolian spots, milia, erythema toxicum, salmon patches.
Abnormal	Dry, marked peeling.Meconium staining.Petechiae, bruising.Large or many pigmented naevi.Capillary or cavernous haemangioma. Skin infection. Oedema.
HEAD
SHAPE
Normal	Caput, moulding.
Abnormal	Cephalhaematoma,subaponeurotic bleed. Asymmetry, anencephaly, hydrocephaly, encephalocoele
FONTANELLA
Normal	Open, soft fontanelle with palpable sutures.
Abnormal	Full or sunken anterior fontanelle. Large or closed fontanelles. Wide or fused sutures.
HAIR
Normal	Wide familial variation.
Abnormal	Low posterior hair line.
EYES
POSITION
Abnormal	Hypertelorism or hypotelorism.
SIZE
Abnormal	Microphthalmia or macrocornea (glaucoma).
LIDS
Normal	Mild oedema common.
Abnormal	Marked oedema, ptosis bruising. Narrow palpebral fissures in FAS.
CONJUNCTIVAE
Normal	May have small subconjunctival haemorrhages
Abnormal	Pale or plethoric.Conjunctivitis. Excessive tearing when nasolacrimal duct obstructed.
CORNEA, IRIS AND LENS
Normal	Cornea clear, regular pupil, red reflex.
Abnormal	Opaque cornea,irregular pupil,cataracts, no red reflex, squint, abnormal eye movements.
NOSE
SHAPE
Normal	Small with upturned nostrils.
Abnormal	Flattened in oligohydramnios.
NOSTRILS
Normal	Both patent. Easy passage of feeding catheter
Abnormal	Choanal atresia. Blocked with dry secretions
DISCHARGED
Abnormal	Mucoid, purulent or bloody secretions
MOUTH
LIPS
Normal	Sucking blisters.
Abnormal	Cleft lip. Long smooth upper lip, no philtrum and thin vermillion border in FAS.
PALATE
Normal	Epstein's pearls
Abnormal	High arched or cleft palate.
TONGUE
Normal	Pink
Abnormal	Cyanosed, pale, macroglossia. Posteriorly placed (Pierre-Robin anomaly).
TEETH
Normal	None at birth
Abnormal	Adventitious or primary teeth.
GUMS
Normal	Small cysts.
Abnormal	Epulis.
MUCOUS MEMBRANES
Normal	Pink, shiny.
Abnormal	Thrush, ulcers.
SALVIA
Abnormal	Excessive if poor swallowing or oesophageal atresia.
JAW
Normal	Smaller than older child
Abnormal	Micrognathia in Pierre-Robin anomaly.
EARS
SITE
Normal	Pinna vertical at term.
Abnormal	Ears rotated backwards with poorly formed upper pinna (low set).
APPEARANCE
Normal	Familial variation.
Abnormal	Pre-auricular skin tag or sinus. Malformed ears. Hairy ears in I.D.M.
NECK
SHAPE
Normal	Usually short.
Abnormal	Webbing, torticollis.
MASSES
Normal	No palpable lymph nodes or thyroid
Abnormal	Cystic hygroma. Goitre. Sternomastoid tumour.
CLAVICLE
Abnormal	Swelling or crepitus if fractured.
BREASTS
Normal	Palpable breast nodules at term 0.5 to 1 cm. Enlarged, lactating breasts
Abnormal	Accessory or wide spaced nipples. Mastitis.
HEART
PULSES
Normal	Brachial and femoral pulses easily palpable. 120 - 160 beats per minute.
Abnormal	Pulses weak, collapsing, absent, fast or slow.
CAPILLARY FILLING TIME
Normal	Less than 4 seconds over chest and peripheries.
Abnormal	Prolonged filling time if infant cold or shocked.
BLOOD PRESSURE
Normal	Systolic 50 to 90mm at term.
Abnormal	Hypertensive or hypotensive.
PRECORDIUM
Normal	Mild pulsation felt over heart and epigastrium
Abnormal	Hyperactive precordium.
APEX BEAT
Normal	Heard maximally to left of sternum
Abnormal	Heard best in right chest in dextrocarida.
SOUNDS
Normal	Loud, single 2nd heart sound on day 1
Abnormal	Gallop, widely split second sound.
MURMURS
Normal	Soft, short systolic murmur common on day 1.
Abnormal	Systolic or diastolic murmurs.
HEART FAILURE
Abnormal	Oedema, hepatomegaly, tachypnoea or excessive weight gain.
LUNGS
RESPIRATION RATE
Normal	40-60 breaths per minute. Irregular in REM sleep. Periodic breathing with no change in heart rate or colour.
Abnormal	Tachypnoea - above 60 breaths per minute. Gasping. Apnoea with drop in heart rate, pallor or cyanosis
CHEST SHAPE
Normal	Symmetrical.
Abnormal	Hyperinflated or hypoplastic chest.
CHEST MOVEMENT
Normal	Symmetrical.
Abnormal	Asymmetrical in pneumothorax and diaphragmatic hernis.
RECESSION
Normal	Mild recession in prems
Abnormal	Subcostal recession in respiratory distress.
GRUNTING
Abnormal	Expiratory grunt in respiratory distress.
STRIDOR
Abnormal	Inspiratory stridor a sign of upper airway obstruction.
PERCUSSION
Normal	Resonant bilaterally.
Abnormal	Dull with effusion or haemothorax.
AIR ENTRY
Normal	Egual air entry over both lungs. Bronchovesicular.
Abnormal	Unegual or decreased.
ADVENTITIOUS SOUNDS
Normal	Transmitted sounds.
Abnormal	Crackles, wheeze or decreased.
ABDOMEN
UMBILICUS
Normal	2 arteries and 1 vein.
Abnormal	1 artery, 1 vein .Infection. Bleeding or discharge. Hernia. Exomphalos.
SKIN
Abnormal	Periumbilical erythema or oedema.
SHAPE
Abnormal	Distended or hollow.
LIVER
Normal	Palpable 1 cm below costal margin, soft.
Abnormal	Enlarged, firm, tender.
SPLEEN
Normal	Not easily palpated.
Abnormal	Enlarged, firm.
KIDNEYS
Normal	Often palpable but normal size.
Abnormal	Enlarged, firm.
MASSES
Normal	No other masses palpable. Full bladder can be percussed.
Abnormal	Palpable mass.
BOWEL SOUNDS
Normal	Heard immediately on auscultation.
Abnormal	Depressed or absent.
ANUS
Normal	Patent. Skin tags.
Abnormal	Absent or covered. Displaced anteriorly.
STOOLS
Normal	Meconium passed within 48 hours of birth. Yellow stools by day 5. Breastfed stool may be green and mucoid.
Abnormal	Blood in or on stool. White stools in obstructive jaundice. Offensive watery stools.
SPINE
Normal	Coccygeal dimple or sinus. Straight spine.
Abnormal	Sacral dimple or sinus. Scoliosis. Meningomyelocoele.
GENITALIA
PENIS
Normal	Urethral opeining at centre of glans.
Abnormal	Hypospadias. Micropenis.
TESTES
Normal	Descended by 37 weeks
Abnormal	Undescended.
SCROTUM
Normal	Well formed at term.
Abnormal	Inguinal hernia. Fluid hernia.
VULVA
Normal	Skin tags, mucoid or bloody discharge.
Abnormal	Fusion of labia.
CLITORIS
Normal	Uncovered in preterm or wasted infants.
Abnormal	Enlarged in adrenal hyperplasia.
URINE
Normal	Passed in first 12 hours.
Abnormal	Poor stream suggests posterior urethral valve.
ARMS
Normal	Flexed position in term infant.
Abnormal	Erb's palsy.
HANDS
Abnormal	Extra, fused or missing digits. Skin stags. Single palmar crease. Hypoplastic nails
HIPS
Normal	Click common. Fully abducted.
Abnormal	Dislocated or dislacatable. Limited abduction.
LEGS
Normal	Mild bowing of lower legs common
Abnormal	Dislocatable. Knees in breech.
FEET
Normal	Positional deformation.
Abnormal	Clubbed feet. Abnormal toes.
NEUROLOGICAL STATUS
BEHAVIOUR
Normal	Alert, responsive.
Abnormal	Drowsy, irritable, jittery.
POSTION
Normal	Flexion of all limbs at term.
Abnormal	Extended limbs or frog position in preterm and ill infants.
MOVEMENT
Normal	Active. Moves all limbs equally when awake. Stretches, yawns and twists trunk.
Abnormal	Absent, decreased or asymmetrical movement. Jittery or convulsions
TONE
Normal	Hypotonia in preterm infants.
Abnormal	Hypotonia or hypertonia. Asymmetrical tone.
HANDS
Normal	Intermittantly clenched.
Abnormal	Permanently clenched.
CRY
Normal	Good cry when awake
Abnormal	Weak, high pitch or hoarse cry.
VISION
Normal	Follow a face, bright light or red object.
Abnormal	Absent or poor following.
HEARING
Normal	Responds to loud noise.
Abnormal	No response.
SUCKING
Normal	Good suck and rooting reflexes after 36 weeks gestation.
Abnormal	Weak suck at term.
MORO REFLEX
Normal	Full extension then flexion of arms and hands. Symmetrical.
Abnormal	Absent, incomplete or asymmetrical response.

When the history has been taken and the physical examination completed, an overall assessment of the infant must be made and a list of the problems compiled. The management of each problem in turn must now be addressed.

Examination of the Hips:

The hips must be examined in all newborn infants to exclude congenital dislocation or an unstable hip.

The infant is examined lying on his back with the hips flexed to a right angle and knees flexed.

Ortolani test : Both thighs are held so that the examiner's fingers are over the greater trochanters and his thumbs rest on the inner aspects of each thigh. The thighs are then abducted: if a hip is dislocated, a 'clunk' can be felt and heard as the femoral head slips forward into its normal position in the acetabulum.

Barlows Test : demonstrates an unstable or dislocatable hip. One hand immobilizes the pelvis (thumb over pubic ramus, fingers over sacrum) while the other hand moves the opposite thigh into mid-abduction. If the hip is unstable, backward pressure on the lesser trochanter with the thumb on the inner side of the thigh causes the femoral head to slip out of the acetabulum. Conversely forward pressure on the greater trochanter with the fingers would tend to cause the head to spring back into the acetabulum. The same procedure is then carried out for the opposite side.