Last updated:
March 31, 2026
Table Of Contents
- Overview
- General Examination
- Examination of the Skin
- Examination of the Head
- Examination of the Eyes
- Examination of the Ears
- Examination of the Nose
- Examination of the Mouth and Throat
- Examination of the Neck
- Examination of the Chest
- Examination of the Abdomen
- Examination of the Genitals and Anus
- Examination of the Extremities
- Neurological Examination
Overview
The nursery exam is done in the nursery or NICU within 24 hours of birth to identify any abnormalities or anomalies that may impact the infant’s current or future well-being.
The presence of one or two isolated anomalies is not unusual. It is the sequences or constellations of anomalies that are associated with various congenital illnesses.
General Examination
Introduce yourself, explain, get consent, and sanitize. Start the exam with a general observation.
- Modified Pediatric GCS/ AVPU
- How is the baby lying in bed (attitude)
- Look for gross anomalies without touching
- Skin colour
- Breathing quality
- Anthropometric measurements
Modified Pediatric GCS
Eye opening
| Eye opening | Score |
|---|---|
| Spontaneous | 4 |
| To speech | 3 |
| To pain only | 2 |
| No response | 1 |
Best verbal response
| Best verbal response | Score |
|---|---|
| Coos and babbles | 5 |
| Irritable cries | 4 |
| Cries to pain | 3 |
| Moans to pain | 2 |
| No response | 1 |
Best motor response
| Best motor response | Score |
|---|---|
| Moves spontaneously and purposefully | 6 |
| Withdraws to touch | 5 |
| Withdraws in response in pain | 4 |
| Abnormal flexion to pain | 3 |
| Abnormal extension to pain | 2 |
| No response | 1 |
Vitals
| Vital sign | Reference range |
|---|---|
| Heart rate | 120-160 bpm |
| Respirations | 30-60 rpm |
| Blood pressure | 50-70 mmHg systolic |
| Temperature | 36.1 – 37.9 C |
Simplified comparison based on typical Ballard’s Score results for preterm and term neonates:
| Characteristic | Preterm Neonate (Premature) | Term Neonate |
|---|---|---|
| Skin Texture | Usually smoother and less mature skin | Skin is typically well-textured |
| Lanugo | Abundant lanugo (fine hair) is often present | Lanugo may be sparse or absent |
| Plantar Surface | Fewer creases on the sole | More defined creases on the sole |
| Breast Development | Less developed breasts (both genders) | More developed breasts (if female) |
| Eyes and Ear | Eyelids may be fused, soft ears | Lids open, firm ears |
| Genitalia Development | Male genitalia may be less developed, female genitalia less mature | Male and female genitalia are typically fully developed |
| Physical Maturity | Less subcutaneous fat, less muscle tone | Typically good subcutaneous fat and muscle tone |
Examination of the Skin
The skin of neonates is normally pink. Note that babies may have blue or purple extremities immediately after delivery.
| Skin finding | Description |
|---|---|
| Jaundice | Abnormal in the first 24 hours. Could be due to a hemolytic process, Rh isoimmunization, congenital hepatitis, etc. |
| Pallor | Suggests acute or chronic blood loss, or acidosis |
| Cyanosis | Suggests poor cardiac output or a cold baby |
| Plethora | Suggests polycythemia |
| Texture | Crackling or peeling of skin is typical of post-term infants |
| Edema | Describe whether it is generalized or localized |
| Bruising or petechiae | Suggests birth trauma or bleeding disorder |
| Cutis marmorata | Lacing or mottling of the skin because babies have poor temperature regulation. Capillaries can be seen through the skin. This is temporary |
| Vernix caseosa | Curdy, greasy (’cheesy’) white substance on term babies at delivery. This is normal |
| Erythema toxicum | Migratory pink, maculopapular rash seen after the first 24 hours. It is the immune system’s way of asserting itself. Normal and goes away after a few weeks |
| Staphylococcal scalded skin syndrome (SSSS) | Diffuse red rash, burn-like with denuded skin and Nikolsky sign. Requires broad-spectrum antibiotics and fluid STAT |
| Subcutaneous fat necrosis | Erythematous, indurated, circumscribed nodules. May be idiopathic or due to birth trauma. Does not require treatment, but calcium is checked periodically. |
| Capillary hemangioma | Red papules on the head or face. Does not usually present within the first 23 hours. It can grow in size, but involutes later |
| Port-wine stain | Flat red birthmark (patch). Unilateral facial port-wine stains are associated with Sturge-Weber syndrome |
| Mongolian spots | Blackish blue spots on the buttocks. These are clearly demarcated, unlike bruises. |
| Cafe-au-lait spots | Light brown spots. ≤ 3 is normal in a white infant. ≤ 5 is normal in a black infant. ≥ 6 is associated with various diseases, including neurofibromatosis type 1 and tuberous sclerosis |
Examination of the Head
Support the head by putting your hand behind the occiput. Look for scalp abnormalities. Gently palpate fontanelles. 6 fontanelles
| Fontanelle | Approximate width |
|---|---|
| Anterior fontanele | 1-4 cm |
| Posterior fontanelle | < 1cm |
Scalp layers
Some scalp findings
| Scalp finding | Description |
|---|---|
| Caput succedaneum | “Cone head” swelling of the head that crosses suture lines since it is superficial to the periosteum (between the scalp and subgaleal aponeurosis). It is common in babies delivered by SVD (due to pressure). It resolves within a few days |
| Cephalohematoma | Swelling of the head limited by suture lines since blood collects between the skull bone and periosteum. May follow with jaundice and may be associated with an underlying linear skull fracture |
| Subgaleal hemorrhage | A potentially massive bleed that is noted as a fluctuant, boggy mass with superficial skin bruising. It may obscure suture lines since it is superficial to the periosteum. It is associated with vacuum-assisted delivery (90% of babies). Monitor for hypotension or tachycardia since the scalp can hold a lot of blood, causing the baby to bleed out) |
| Meningocele | Usually located in the midline in the occipital region. Associated with underlying bony defects |
| Third fontanelle | Usually along the sagittal suture. Associated with various cogenital syndromes, especially Down syndrome |
| Bulging fontanelle | A sign of raised ICP suggestive of meningitis or encephalitis |
Examination of the Eyes
Babies are born with 20/400 vision.
Eye findings
| Eye findings | Description |
|---|---|
| Subconjunctival hemorrhage | These are common and are due to the stress of birth. Mother may also have them |
| Coloboma | “Latch-key” defect of the iris associated with CHARGE syndrome |
| Aniridia | Severe hypoplasia or absence of the iris. Has visual implication sand is associated with WAGR syndrome |
| Hyphaema or cloudy cornea | Corneal opacities require an ophthalmology consult |
| Leukocoria (white reflex) | This needs immediate attention (ophthalmology consult) since it suggests retinoblastoma, cataract or glaucoma |
| Secretions | Suggests conjunctivitis. Can order TORCH titres from the mother for congenital infections. |
Examination of the Ears
Malformed or malpositioned ears are associated with various congenital anomalies.
Ear findings
| Ear findings | Description |
|---|---|
| Microtia | This is a severely malformed ear. A CT scan should be ordered to see if the inner ear is developed |
| Preauricular pits and tags | These have a familial pattern and may be benign. They may also be associated with genitourinary defects or hearing abnormalities. Tags may be associated with a cleft palate |
Examination of the Nose
Examine the shape of the nose
Examine the patency of the nares – this is important because babies are obligate nose breathers.
Look for steam collection on a chilled reflex hammer placed under the baby’s nose. A light can also be shone, or an attempt to insert a nasogastric tube into the nares can be performed.
Nose findings
| Nose findings | Description |
|---|---|
| Abnormally flattened nose | Due to intrauterine compression |
| Flaring of the nasal alae | Seen in respiratory distress |
| Choanal atresia | This is the ‘A’ in CHARGE syndrome. The baby becomes cyanotic during feeding, but is relieved when crying (since they breathe through the mouth) |
| Nasal secretions | “Snuffles” are seen in congenital syphilis |
Examination of the Mouth and Throat
Examine the mouth using a gloved index finger.
Examine the sucking and rooting reflexes.
Examine the tongue
Examine the palate.
Examine the mandible; if the chin is small, the mandible is small.
Mouth and throat findings
| Mouth and throat findings | Description |
|---|---|
| Flat philtrum and thin lips | Seen in fetal alcohol syndrome |
| Natal teeth | If present, they may be removed due to the risk of aspiration |
| Epstein pearls (epithelial retention cysts) | Seen along the gum margins. Usually resolves in a month |
| Macroglossia | True macroglossia is seen in Beckwith-Wiedemann syndrome, congenital hypothyroidism and micropolysaccharidosis. Apparent macroglossia is seen in Down syndrome due to a small mouth |
| Ankyloglossia | An unusually short frenulum that reduces the mobility of the tongue |
| Cleft palate | |
| Micrognathia | A small mandible. Associated with multiple syndromes, including Pierre-Robin sequence |
| Subglottic hemangioma | This may block the airway |
Examination of the Neck
Look for webbing and masses.
Masses should be identified early since they can become infected.
Neck findings
| Neck findings | Description |
|---|---|
| Webbing | Excessive nuchal skin. Seen in Turner’s and Noonan’s syndrome |
| Midline neck mass | May be a thyroglossal duct cyst (oves with swallowing or tongue protrusion) |
| Neck mass anterior to SCM (lateral to midline) | May be a branchial cleft cyst |
| Neck mass posterior to SCM | May be a cystic hygroma |
| Congenital torticollis | Resistance is felt when turning the baby’s head to the opposite direction |
Examination of the Chest
Lungs
- Bones
- Air entry
- Should be bilateral
- Unilateral breath sounds suggest a pneumothorax
- Breath sounds
- Periodic breathing
- Grunting
- Added sounds: stridor or wheeze
- Absent on the left: pneumothorax or congenital diaphragmatic hernia. The point of maximal cardiac impulse is displaced in the case of a diaphragmatic hernia.
- Tachypnea (>60 RPM) or adventitious breath sounds suggest respiratory distress
- Decreased breath sounds suggest hyaline membrane disease
- Breast hypertrophy
- This is a normal response to circulating maternal hormones
- Some milk may even be produced
- Supernumerary nipples
- Looks like moles
- They can be surgically corrected later
- Pectus carinatum
- A bulging sternum
- Pectus excavatum
- An indented sternum
- Can compress the mediastinum if severe enough
Heart
The heart rate should be between 120 and 160 bpm.
Palpate the peripheral pulses on all 4 extremities
- Murmurs
- Murmurs are normal in the first few hours after birth
- Murmurs and cyanosis suggest a congenital heart defect
- Muffled heart sounds suggest pneumomediastinum
- The point of maximal impulse (PMI)
- Displaced PMI to the right suggests a congenital diaphragmatic hernia
- Displaced PMI to the left suggests cardiac enlargement
Examination of the Abdomen
Assess the shape of the abdomen.
Inspect and auscultate first before palpating or percussing the abdomen.
- Scaphoid abdomen
- Distended abdomen
- Excess gas
- Mass
- Peritoneal fluid
- The umbilical stump
- It should not be bleeding or harbour signs of infection
- Bowel sounds
- Herniaa
- Umbilical hernia
- Omphalocele appears as a midline defect with abdominal contents covered by the peritoneal membrane. It is seen in Beckwith-Wiedemann syndrome
- Gastroschisis appears as a defect lateral to the midline with abdominal contents lacking a peritoneal membrane covering. It is usually diagnosed in utero. There is an increased risk of malrotation and ischemia
- Polycystic kidneys
- This is the most common true abdominal mass in neonates
- Palpate the liver and abdominal mass
Examination of the Genitals and Anus
Check for patency of the anus, position of the urethral orifice, descension of the testicles
- Imperforate anus
- Associated with the VACTREL complex
- Hypospadias
- The urethral orifice is displaced ventrally
- Epispadias
- The urethral orifice is displaced dorsally
- Undescended testes
- Clitoral enlargement
- Temporary enlargement due to maternal hormones
- Enlarged bladder
- Suggests posterior urethral valves. This should be confirmed using an ultrasound
Examination of the Extremities
Are there ten fingers and 10 toes?
Check for developmental dysplasia of the hip (DDH), spinal alignment, webbing, fusion and polydactyly of the fingers and toes.
Ensure there are no absent bones, e.g., the radius in radial clubhand
- Positive Ortolani and Barlow manoeuvres
- “Click” or “thump” suggests developmental dysplasia of the hip
- Webbing
- Both bones are present, but their skin is fused
- Fusion (syndactyly)
- Both bones are fused
- Congenital absence of the radius
- Radius clubhand
- Congenital absence of the fibula
- Fibular hemimelia
- Club foot
Neurological Examination
Test the newborn reflexes
- Moro (”startle”) reflex
- The baby should abduct the arm at the shoulder and extend at the elbow with spread fingers
- Disappears at 3 months
- Abnormal in Erb’s palsy
- Palmar grasp reflex
- The baby grasps a finger in its palm
- Disappears at 4 months
- Abnormal in Klumpke’s palsy
- Sucking reflex
- The baby will suck a gloved finger or a nipple when placed in the mouth.
- Rooting reflex
- The baby turns the head towards the side where the cheek is touched
- Tonic neck reflex
- The baby assumes a “fencing position” on the opposite side when the neck is passively turned on one side
- Babinski reflex
- Upgoing (extensor) plantar
- Normal in babies
- Abnormal past 1/2 years of age.