Health Assessment of the Newborn The newborn requires thorough skilled observation to ensure a satisfactory adjustment to extra uterine life. Health assessment of newborn after delivery can be divided into: 1. Initial Assessment 2. Transitional Assessment 3. Assessment of gestational age 4. Behavioural asessment 5. Systemic physical examination Initial Assessment: Initial assessment is done by using the APGAR scoring system. APGAR score: It is method use to assess the newborn’s immediate adjustment to extra uterine life. • The score based on five signs 1. Appearance (colour) 2. Pulse (Heart rate) 3. Grimace (Reflex irritability ) 4. Activity (Muscle tone) 5. Respiratory rate • Each item is given a score 0, 1, or 2 • 0-3 severe distress • 4-6 moderate difficulty • 7-10 no difficulty adjusting to life • Evaluations of all five categories are made on 1-5 min after birth. APGAR score: Sign 0 1 2 Appearance (colour) Blue or pale Body pink, Extrimities Blue Completely Pink Pulse (Heart rate) Absent Slow (<100 /> 100/m Grimace (Reflex irritability ) No response Grimace Cough Or Sneeze Activity(Muscle tone Limp Some flexion Active movement Respiratory rate Absent Slow, Irregular Good, Crying Other initial assessment are- • Stabilization • Measuring weight. Transitional Assessment during the period of reactivity First period of reactivity (6- 8 hours after birth): During the first 30 minutes the newborn is very alert, cries vigorously, may suck a first greedily, and appears very interested in the environment. Physiologically the respiratory rate can be as high as 80 breaths/ min, crackles may be heard, heart rate may reach 180 beats/min, bowel sound are active, mucus secretions are increased and temperature may decrease slightly. Second period of reactivity: Began when the newborn awake from the deep sleep, it lasts about 2-5 hours. The newborn is alert and responsive, heart and respiratory rate are increased, gastric and respiratory secretions are increased, and passage of meconium commonly occurs. Following this stage is a period of stabilization of physiologic systems & vacillating patern of sleep & activity.

1. New Born Health Assessment
Hafiza AfrinHafiza Afrin
Nursing Instructor, JBFNINursing Instructor, JBFNI
BSN(DU),MPH(NSUBSN(DU),MPH(NSU)

2. Health Assessment of
the Newborn
The newborn requires thorough skilled observation
to ensure a satisfactory adjustment to extra uterine life.

3. Health assessment of newborn
after delivery can be divided into:
1. Initial Assessment
2. Transitional Assessment
3. Assessment of gestational age
4. Behavioural assessment
5. Systemic physical examination

4. Initial Assessment
Initial assessment is done by using the APGAR scoring system.
APGAR Score
APGAR score: It is method use to assess the newborn’s immediate
adjustment to extra uterine life
The score based on five signs
• 1. Appearance (colour)
• 2. Pulse ( Heart rate)
• 3. Grimace (Reflex irritability )
• 4. Activity(Muscle tone)
• 5. Respiratory rate

5. • Each item is given a score 0, 1, or 2
• 0-3 severe distress
• 4-6 moderate difficulty
• 7-10 no difficulty adjusting to life
• Evaluation of all five categories are made on 1-
5 min after birth.

6. Apgar Score
Sign 0 1 2
Appearance
(colour)
Blue or pale Body pink,
Extrimities Blue
Completely Pink
Pulse (Heart rate) Absent Slow (<100/min) > 100/m
Grimace (Reflex
irritability )
No response Grimace Cough Or Sneeze
Activity(Muscle
tone
Limp Some flexion Active movement
Respiratory rate Absent Slow, Irregular Good, Crying

7. Other initial assessment are-
• Stabilization
• Measuring weight.

8. Transitional Assessment
Transitional Assessment during the period of
reactivity: First period of reactivity (6- 8 hours
after birth):
• During the first 30 minutes the newborn is very
alert, cries vigorously, may suck a fist greedily, and appears very
interested in the environment. Physiologically the respiratory rate
can be as high as 80 breaths/ min, crackles may be heard, heart
rate may reach 180 beats/min, bowel sound are active, mucus
secretions are increased and temperature may decrease slightly.

9. Second period of reactivity:
Began when the newborn awake from the
deep sleep, it lasts about 2-5 hours. The
newborn is alert and responsive, heart and
respiratory rate are increased, gastric and
respiratory secretions are increased, and
passage of meconium commonly occurs.
Following this stage is a period of
stabilization of physiologic systems &
vacillating patern of sleep & activity.

10. Gestational Age Assessment:
• An accurate assessment of age is important
for 2 reasons
• Age and growth patterns appropriate to that
age aid in identifying neonatal risks
• Help in developing management plans
Gestational age can measure by weight for
gestational age chart.

11. Gestational Age Number of weeks that have elapsed since
the first day of the last menstrual period to the time of birth. This
is usually retrieved from mother’s Antenatal History.
Gestational Age:
• SGA- small for gestational age-weight below 10th percentile •
• AGA-weight between 10 and 90th percentiles
• LGA-weight above 90th percentile

13. Behavioural Assessment
• While babies may not speak their first
word for a year, they are born ready to
communicate with a rich vocabulary of body
movements, cries and visual responses: all part
of the complex language of infant behavior.

14. • The Neonatal Behavioral Assessment Scale
(NBAS) was developed in 1973 by Dr. T. Berry
Brazelton and his colleagues. The scale
represents a guide that helps parents, health
care providers and researchers understand the
newborn's language. " The scale is designed to
reveal an infant’s strengths and preferences,
so that parents may have a better
understanding of their newborn’s
capabilities.”

15. • The scale contains 28 behavioral and 18 reflex
items for parents and doctors to assess. It also
reviews a baby’s capabilities in several
different developmental areas: autonomic,
motor, state regulation, and social-interactive
systems. The result is not a score, but instead
an understanding of how infants integrate
these areas as they adapt to their new
environment.

16. Definition
•Head to toe physical examination of a newborn to look for any
abnormalities or pathology.
•Includes biochemical screening & certain special screening
(hearing assessment, Echocardiography)

17. • Assesment at birth
• Physical examination
• Biochemical screening
• Special screening
• Retinopathy Of Prematurity
• Hearing assesment
• Echocardiography

18. Physical examination
• Complete physical examination within 24
hours of birth.
• It is best to examine when the infant is quiet.
• Ensure infant is naked : he/she can be in
diapers, but you have to open it.
• Do not forget to wash your hands prior to
examination.

19. Measurements…
• Head circumference :
- Occipitofrontal circumference
- place measuring tape around front of head,
below the
brow and occipital area.
- Normal range 32cm-37cm
• Length & Percentile (refer growth chart)
• Weight & Percentile (refer groth chart)

20. Vital signs
a) Temperature : Rectal
b) Respirations : Normal rate is 40-60
c) Blood pressure : Correlates with gestational
age, post natal age, birth weight.
d) Pulse rate : Awake 120-160bpm, Asleep 70-
80bpm

21.  Colour
 Plethora (deep rosy
red)
 Jaundice
 Pallor
 Cyanosis(central,
peripheral,
acrocyanosis)
 “Blue on pink: or
“Pink on blue”
 Harlequin colouration
 Mottling
 Rashes
 Milia
 Erythema toxicum
 Candida albicans rash
 Transient neonatal pustular me
 Acne neonatorum
SKIN

22. SKIN
 Nevi/ Pigmented Lesions
 Macular hemangioma (“stork bites”)
 Port –wine stain (nevus flammeus)
 Mongolian spot
 Cavernous hemangioma
 Strawberry hemangioma

23. HEAD : General, Cuts, Bruises
o Anterior and posterior fontanelles
- Large anterior fontanelle
- Small anterior fontanelle
- Bulging fontanelle
o Molding
o Caput succedaneum
o Cephalohematoma
o Increased intracranial pressure
o Craniosynostosis
o Craniotabes

24. Neck & Facial Features
• Face : Look for obvious abnormalities.Note the general shape of the
nose, mouth and chin. Presence of syndromic features is often
diagnosed clinically throughout experience.
• Neck : Note shape, range of motion, and any webbing; palpate for masses
– Brachial palsy
– Erb’s palsy
– Fractured clavicle
• Ears : Unusual shape, low set ears, periauricular skin tags
(papillomas), hairy ears.

25. • Eyes : Observe shape, size and position of eyes. Note integrity and color
of iris and sclera. Ophthalmoscopic examination to assess pupillary size
and red retinal reflex
• Nose : Size and Shape;
Note placement of the septum
Formation of the nasal bridge;
Verify patency (Flat nasal bridge , Deviated septum , Choanal atresia ,
Nasal pit )
• Mouth : Hard & soft palate for evidence of cleft palate
Neck & Facial Features

26. Chest
• Observation : respiratory rate, chest symmetrical,
sternal/intercostal /subcostal recession, nasal flaring,
grunting, stridor
• Breath sounds : Equality bilaterally, presence of any
additional sound.
• Pectus excavatum : sternum that is altered in shape.
• Breast in newborn : May be abnormally enlarged (3-4cm)
due to effects of maternal estrogens.

27. Heart :
• Observation : heart rate, rhythm, quality of heart
sounds, active precordium
• Position of heart : may be determined by auscultation
• Presence of murmur
• Palpate the pulses (femoral) & define whether its
normal, weak or absent.
• Check for perfusion
• Signs of congestive heart failure : gallop, tachycardia &
abnormal pulses

28. Abdomen
• Observation : scaphoid abdomen, omphalocele,
gastroschisis
• Palpation : Check for distension, tenderness or
masses. Palpate liver, spleen, kidneys and groin
and note any masses
• Auscultation : Listen for bowel sound
• Inspect anus for position and verify patency

29. Umbilicus
• Should have 2 arteries 1 vein.
• Inspect for discharge, redness or edema around base
of the cord
• Appearance : should be translucent. A greenish
yellowish colour suggest meconium staining

30. Genitalia : Any infant with ambiguos genitalia
should not undergo gender assignment until a formal
endocrinology evaluation• Male
• Length : > 2cm
• Determine site of meatus
• Palpate bilateral testicles
• Examine for inguinal hernia
• Look for hypospadias, epispadias, chordae.
• Observe colour of scrotum
• Phimosos-foreskin cannot be retracted
• Cryptotorchidism-testes not descended
• Female
• Inspect for size and location of the labia,
clitoris, meatus, and vaginal opening
• Pseudomenses
• Vaginal tag a small appendage or flap on
the mucous membranes; common neonatal
variation that usually disappears in a few
weeks

31. Extremities : Examine the arms & legs
paying close attention to the digits
• Syndactyly
• Polydactyly
• Oligodactyly
• Congenital Talipes Equinovarus (CTEV)
• Metarsus Varus

32. Trunk & Spine
• Observe curvature and integrity
• Check for any gross defects of the spine. An abnormal
pigmentation/ hairy patches over the lower back should
increase the suspicion that an underlying vetebral
abnormality exists.
• A sacral or pilonidal dimple may indicate a small
meningocele or other anomaly.
• Spina bifida – defect in closure of the neural tube that is
associated with malformations of the vertebrae & spinal
cord

33. Hips
• Congenital hip dislocation ( Ortolani & Barlow
Maneuvers)
• Assymetry of the skin folds on the dorsal surface
• Shortening of the affected leg

34. Nervous System : Observe for any
abnormal movement/ excessive irritability
• Muscle tone
– Hypotonia : Floppiness
– Hypertonia : Extended arms&legs, hyperextension
of back & tightly clenched fists.
• Reflexes
– Rooting reflex
– Glabellar reflex
– Grasp reflex
– Neck righting reflex
– Moro’s reflex

35. Biochemical screening
• Simple laboratory investigation to diagnose congenital
metabolic disorder that may lead to mental
retardation and even death if left untreated.
• The goal of this screening is to give all newborns a
chance to live a normal life.
• It provides the opportunity for early treatment of
diseases that are diagnosed before symptoms appear
• Malaysia : G6PD deficiency & Congenital
Hypothyroidism

36. G6PD deficiency
• G6PD deficiency is one of the most common
genetic diseases affecting an estimated 400
000 000 people worldwide.
• All newborn screened for G6PD and in case of
deficiency should be explained to both
parents.
• Test : Beutler fluorescent spot test : rapid &
cheap test that identifies NADPH produced by
G6PD under UV light.

37. Congenital
Hypothyroidism
• Significant decrease in, or absence of thyroid
function present at birth.
• Approximately 1 in 4000 newborn infants has a
severe deficiency of thyroid function, while even
more have mild or partial degrees.
• If untreated for several months after birth, severe
congenital hypothyroidism can lead to growth
failure and permanent mental retardation.

38. Screening for ROP : is a disorder of
the developingretina of low birth weight preterm infants
that potentiallyleads to blindness.
• Infants with a birth weight of less than 1500 g
• Gestationalage of 32 weeks or less
• Infants who required oxygen supply

39. Hearing Assesment
• Early identification of hearingloss and appropriate
intervention within the first 6 monthsof life has
been demonstrated to prevent many of these
adverseconsequences and facilitate language
acquisition.

40. • Family History of Hearing Loss
• Perinatal Infection
• Craniofacial Anomalies
• Very Low Birth Weight
• Hyperbilirubinemia
(>340mmol/L)
• Bacterial Meningitis
• Ototoxic Medications
• Syndrome Associated with
Hearing Loss
• Prolonged Ventilation
• Severe Asphyxia at Birth
Hearing Assesment

41. ECHOCARDIOGRAPHY
• GDM ON S/C INSULIN
• GDM ON DIET CONTROL
• ANY CLINICALLY HEARD MURMUR
• LARGE FOR GESTATION AGE
• NEWBORN WITH MACROSMIC FEATURES
• SYNDROMIC NEWBORN (DOWN’S SYNDROME,

42. Physical Examination
Eyes Ears
< Normal Ear
Pinna Ear
Deformity >

43. Physical Examination
Nose Mouth

44. Physical Examination

45. Physical Examination
Normal Umbilical Cord Umbilical Hernia

46. Physical Examination
Gastroschisis

47. Physical Examination
Normal
Abnormal
Configuration
Female Genitalia

48. Physical Examination
Normal
Undescended Testes
Male Genitalia

49. Physical Examination
Ambiguous Genitalia Closed Rectum

50. Neuromuscular Maturity
• Neuromuscular system evaluation:
-Gestational maturity rating is measured after the baby is
born by the Ballard Scale, it consists of six evaluation
areas of Neuromuscular maturity and seven items of
physical maturity
-A score is assigned to each area. The more neurologically
mature the baby, the higher the score.

51. Neuromuscular Maturity
Neuromuscular system evaluation, includes:
• Posture - how does the baby hold his/her arms and legs
• Square window - how far the baby's hands can be flexed
toward the wrist
• Arm recoil - how far the baby's arms "spring back" to a
flexed position
• Popliteal angle - how far the baby's knees extend
• Scarf sign - how far the elbows can be moved across the
baby's chest
• Heel to ear - how close the baby's feet can be moved to the
ears.

52. Posture
•
•
•
•
•

53. Square Window

54. Arm Recoil
•
•
•
•

55. Popitleal Angle
•
•
•
•
•

56. Scarf Sign

57. Heel to ear
0 if he heel can easily be pulled to ear

58. Assessment of Reflexes
• Rooting & Sucking: touch infant’s lip, cheek or corner
of mouth with pacifier
-Infant turns head toward stimulus, opens mouth,
takes hold and sucks
Grasp:
Palmar- (between 3-4 months) Place finger in palm of
hand
-Infants finger curl around examiners fingers
Plantar- (lessens by 8 months) Place finger at base of
toes
-infants toes curl downward

59. Assessment of Reflexes
• Glabellar: tap forehead, bridge of nose, or maxilla
-Newborn blinks for first 4 or 5 taps (continuos
blinking means extrapyramidal disorder)
• Babinski Sign: stroke upward along lateral aspect of
sole, then move finger across ball of foot
• -All toes hyperextend, big toe will dorsiflex
(record as a positive sign)
-Absence requires neurological evaluation
-This should disappear after 1 yr. of age

60. Assessment of Reflexes
• Stepping or Walking: Hold infant vertically
allowing one foot to touch table surface
-Infant will simulate walking, term infant walk
on soles of feet & preterm walk on their toes
• Crawling: place newborn on abdomen
-newborn makes crawling movements with
arms and legs (disappears at 6 wk of age)

61. Nutrition
•An Infant may be put to breast feed shortly after birth or at least
within 4 hours of birth.
•Most infants are on demand feeding schedules and are allowed to
fed when they awaken
•Usually mothers are encouraged to feed their children every 3 to 4
hours during the day, and only when the when the infant awakens
during the night for the first few days after work
•Formula fed infants usually eat every 3 to 4 hours
•Water supplements are not recommended

62. Diagnostic Tests
•Blood glucose levels
•Urinalysis
•Bilirubin levels
•CBC
•Methods: heel-stick blood sample is obtained to detect a variety
of congenital conditions.
•Screening mandated by law, all states screen for phenylketonuria
(PKU) and hypothyroidism, but each state determines which test is
administered.

63. References
• Assessment of Growth of Infants Fed a New Formula - Full Text View -
ClinicalTrials.gov." Home - ClinicalTrials.gov. Web. 07 May 2010.
<http://clinicaltrials.gov/ct2/show/NCT00937014>.
• Excellent Care from the Moment of Birth. Web. 07 May 2010.
<http://newborns.stanford.edu/>.
• HMHB - Home. Web. 07 May 2010.
<http://www.hmhb.org/parent.html#new>.
• Olds, Sally B., Maternal-newborn Nursing & Women's Healthcare. Upper
Saddle River, N.J.: Pearson/Prentice Hall, 2004. Print

64. Skin:
• Note skin color:
• Usually pink
• If fingers and toes have a bluish tinge that sign of poor blood circulation
during the first few hours.
• Petechiae: Tiny reddish-purple spots on parts of the body that were
pressed hard during delivery. However, petechiae on all parts of the
body could be a sign of a disorder.
• Erythema toxicum :About half of all newborns develop a rash about 24
hours after birth. It is harmless and disappears in 7 to 14 days.

67. Head and neck:
• HEAD : Anterior and posterior fontanelles
• Large anterior fontanelle
• Small anterior fontanelle
• Bulging fontanelle
• Molding
• Caput succedaneum
• Cephalohematoma
• Increased intracranial pressure
• Craniosynostosis
• Craniotabes

68. Bulging fontanelle

70. Molding

73. Craniosynotosis

75. Neck & Facial Features:
• Face : Look for obvious abnormalities. Note
the general shape of the nose, mouth and
chin.
• Neck : The neck is examined for swelling,
growths, and twisting or spasms.
• Nose : Size and Shape. Note placement of the
septum & Formation of the nasal bridge;

76. • Ears : Examine the ears and note whether they are properly
formed and in the correct place. For example, low-set or
incorrectly formed ears may mean the newborn has a genetic
disorder and/or hearing loss.
• Eyes : Observe shape, size and position of eyes. Note integrity
and color of iris and sclera. Ophthalmoscopic examination to
assess pupillary size and red retinal reflex
• Mouth: examine the mouth for problems. Some newborns are
born with teeth, which may need to be removed, or a cleft lip or
cleft palate .

77. Heart & lungs:
• Need to listens the heart and lungs through a
stethoscope to detect any abnormality. Abnormal
sounds such as a heart murmur or lung congestion.
• Inspects the newborn's skin color. A blue color of the
face and torso may be a sign of congenital heart or
lung disease.
• Should watch the newborn breathe and count the
number of breaths in a minute. Grunting and/or flaring
nostrils with breathing and breathing too fast or too
slow can be signs of problems.
Heart & lungs:

78. Abdomen and genitals :
• Examines the general shape of the abdomen and also checks the
size, shape, and position of internal organs, such as the kidneys,
liver, and spleen. Enlarged kidneys may indicate a blockage to the
outflow of urine.
• Examines the genitals to ensure: Urethral opening and proper
location, testes should be present in the scrotum, the labia are
prominent because of exposure to the mother's hormones, and
they remain swollen for the first few weeks. Secretions from the
vagina that contain blood and mucus are normal. Also examines
the anus to make sure the opening is normally placed.