Do

• Palpate the anterior fontanel, assessing size and firmness
  • Place the infant in an upright position (and hopefully she/he will remain calm!)
  • Gently place your fingers over the anterior fontanel, located midline on the superior tempero-frontal portion of the skull.
  • Gently palpate for the edges of the fontanel.
• Palpate the posterior fontanel (may not be able to feel this)
  • Repeat the same procedure outlined above, feeling for the posterior fontanel, located in the midline occipital region.

Know

• Craniosynostosis: premature closure of cranial sutures. This can be primary due to closure of one or more sutures due to abnormal skull development. This occurs in ~ 1/2000 children and is most often present at birth. It can also be secondary due to abnormal brain development.
• Conditions associated with a large anterior fontanel (greater than 3 cm): hydrocephaly, achondroplasia, hypothyroidism, osteogenesis imperfecta, and Vitamin D deficiency rickets

Do

Assess whether the red reflex is present

The newborn infant spontaneously opens his/her eyes if the head is gently tipped forward/backward. This is more effective than trying to force open tightly shut eyelids!

Test corneal light reflex

Shine your ophthalmoscope or penlight in the newborn’s eyes; you are assessing whether the light is symmetrically placed on the cornea bilaterally. Many newborns appear to be “cross eyed” because of prominent epicanthal folds.

Know

• Presence of a red reflex bilaterally suggests absence of cataracts or intraocular pathology.
• Leukocoria (white papillary reflex) suggests cataracts, chorioretinitis, retinopathy of prematurity, persistent hyperplastic vitreous or retinoblastoma. Leukocoria mandates an immediate ophthalmologic evaluation.
• Asymmetric corneal light reflex is a sign of strabismus, an imbalance of ocular muscle tone. If this is not corrected early it can lead to blindness. Proper coordination of eye movements should be achieved by 3-6 months; persistent eye deviation requires evaluation.
• Visual acuity of a newborn is approximately 20/400; this rapidly normalizes and by 2-3 years of age is 20/30-20/20.

Do

• Assess the neonate for developmental dysplasia of the hip by performing:
  Barlow Maneuver and ortalani test
  • Place the baby on a firm surface in the supine position
  • Flex the thighs to a right angle to the abdomen and the knees at right angles to the thighs
  • Grasp each thigh with your forefinger along the outside shaft of the femur, with your middle finger on the greater trochanter and thumb medially
  • Adduct the femora fully and push down toward the bed. (Barlow maneuver)
  • Gently abduct each leg from the position of full adduction so that the knees come to lie laterally on the table
  • During adduction, push the greater trochanters medially and forward with your fingers (Ortalani test)

Know

The infant may have a congenitally dislocated or subluxable hip if:

• you feel or hear a click during either adduction or abduction
• there is spasm or discomfort of the adductor muscles of the femur

Developmental Dysplasia of the hip:

1/100 infants have clinically unstable hips; 1/800-1000 experience true dislocation. There is a positive family history in 20% of patients and associated generalized ligamentous laxity. 9:1 female to male ratio.

Developmental dysplasia typically presents after birth in most infants. If it is present at birth, you should look for an underlying neuromuscular disorder. This type of developmental dysplasia of the hip is called Teratologic DDH.

Do
As part of your newborn exam, elicit the following primitive reflexes.

Asymmetric Tonic Neck Reflex (Fencer’s position)

• Place the infant on his/her back
• Turn the newborn’s head to one side
• Observe the gradual extension of the arm on the side to which the head is turned
• Observe the flexion of the other arm

Moro Reflex (startle response)

• Hold the infant supine and support the infant’s head with one hand
• Gently move the infant’s head (while supporting it) below the level of the rest of the body
• Observe the infant extend both arms suddenly and rapidly with open hands
• Observe the infant bring both hands back to midline in an “embrace” movement

Palmar grasp

Place your index finders in each of the infant’s open hands

Observe the infant’s fingers close around your fingers in a firm grasp

Plantar grasp

• Place your thumb on the sole of the infant’s foot under the toes
• Observe the toes curl around your thumb

Know

Reflexes should be symmetric. Asymmetry suggests weakness in a particular muscle group.

Primitive reflexes disappear as the infant matures; persistence of these reflexes is a signal of underlying neurological dysfunction.

Asymmetric Tonic Neck Reflex (Fencer’s position)

Appears by 35 wks gestation, is fully developed at 1 month & lasts 6-7 months

Moro Reflex (startle response)

Appears by 28-30 wks gestation; if fully developed at term & lasts 5-6 months

Palmar grasp

Appears by 28 wks, is fully developed by 32 wks gestation & lasts 2-3 months

Do

• Inspect all of the skin of the infant (including diaper area)
• Describe (size, shape, color, distribution) any rashes
• Note any areas lacking skin

Know

• Benign lesions that parents may have questions about include:
  • Small angiomatous present on the eye lids, nape of the neck, forehead
  • Milia: small white spots on the skin, particularly on the nose and cheeks
  • Erythema toxicum: yellowish/white pustules on an erythematous base that occur singly or in groups.
• Concerning changes include large angiomatous lesions, vesicles, pustules or areas lacking skin
• Midline abnormalities (dimple, hair tuff, moles) on the back may indicate an underlying abnormality in the bones/nervous system.