4  Neonatal History & Examination

Published

September 29, 2025

4.1 Introduction

The newborn period, defined as the first 28 days of life, is a critical phase in human development. It represents a time of rapid physiological adaptation from intrauterine to extrauterine life, with major changes occurring in respiration, circulation, nutrition, and thermoregulation. During this period, morbidity and mortality are highest compared to any other stage of childhood, particularly in low- and middle-income countries such as Ghana.

For clinicians, the neonatal history and examination are essential tools in identifying normal adaptation, detecting abnormalities early, and guiding timely interventions. A detailed assessment requires not only the direct clinical examination of the neonate but also a careful review of maternal, antenatal, intrapartum, and immediate postnatal events.

4.2 Importance of Neonatal History and Examination

  • Early diagnosis of congenital anomalies – many conditions can be subtle at birth but become evident on detailed examination.
  • Assessment of perinatal risk factors – including maternal illnesses, infections, complications of labour, and prematurity.
  • Establishing baseline health status – for growth monitoring and subsequent follow-up.
  • Building rapport with the mother and family – ensuring continuity of care.
  • Guiding preventive strategies – such as immunisation, exclusive breastfeeding, and infection control.

4.3 Components of Neonatal History

The neonatal history is unique in that it depends heavily on information from the mother and available records, since the newborn cannot communicate symptoms. The history should be systematic and include the following areas:

4.3.1 Maternal History

Demographic and Social Factors

  1. Maternal age: Teenage and advanced maternal age pregnancies carry an increased risk.
  2. Parity and gravidity: Provide context about reproductive history.
  3. Socioeconomic status: influences access to care and nutrition.
  4. Occupational exposures: Such as chemicals or radiation.

Maternal Medical History

  1. Chronic illnesses: Diabetes, hypertension, renal disease, HIV, tuberculosis, and epilepsy.
  2. Medications during pregnancy: Some drugs (e.g., anticonvulsants, ACE inhibitors) are teratogenic.
  3. Substance use: Alcohol, tobacco, herbal medications, or recreational drugs.
  4. Family history: Genetic disorders, congenital anomalies, consanguinity.

4.3.2 Antenatal History

Antenatal Care

  1. Number and timing of visits.
  2. Use of supplements (iron, folic acid, tetanus immunisation).

Maternal Illnesses in Pregnancy

  1. Infections: TORCH (toxoplasmosis, rubella, cytomegalovirus, herpes, syphilis), malaria, urinary tract infections.
  2. Gestational diabetes and pre-eclampsia.
  3. Antepartum haemorrhage or polyhydramnios/oligohydramnios.

Fetal Wellbeing

  1. Results of ultrasound scans (growth, anomalies, multiple gestation, amniotic fluid volume).
  2. Reduced fetal movements.

4.3.3 Intrapartum History

Labour and Delivery

  1. Place of delivery (home, health centre, hospital).
  2. Duration and course of labour.
  3. Prolonged rupture of membranes (risk of infection).
  4. Use of intrapartum medications or anaesthesia.
  5. Mode of delivery: spontaneous vaginal delivery, assisted delivery, or caesarean section.

Condition of Baby at Birth

  1. Apgar scores at 1 and 5 minutes.
  2. Need for resuscitation.
  3. Cord events (e.g., prolapse, nuchal cord).
  4. Meconium-stained amniotic fluid (risk of aspiration).

4.3.4 Immediate Postnatal History

  • Cry at birth (immediate and vigorous or delayed).
  • Initiation of breastfeeding and feeding adequacy.
  • Passage of urine and meconium.
  • Neonatal resuscitation or admission to neonatal intensive care unit (NICU).
  • Administration of vitamin K, eye prophylaxis, and immunisations (BCG, OPV, Hepatitis B).

4.4 Components of Neonatal Examination

A thorough neonatal examination should ideally be conducted within the first 24 hours and repeated before discharge. It involves general observation, measurement of growth parameters, a head-to-toe physical examination, and a functional systems review.

4.4.1 General Considerations

  • Conduct in a warm, well-lit environment to avoid hypothermia.
  • Wash hands thoroughly and maintain asepsis.
  • Involve the mother to reduce stress and promote bonding.
  • Examine systematically from head to toe.

4.4.2 General Observation

  • Appearance: alert, active, lethargic, floppy.
  • Colour: pink, pale, jaundiced, cyanosed.
  • Cry: strong and lusty vs weak or absent.
  • Breathing pattern: regular or irregular, presence of grunting, nasal flaring, or retractions.
  • Movements: spontaneous, symmetrical, abnormal posturing.

4.4.3 Anthropometric Measurements

  • Weight: normal term 2.5–4.0 kg.
  • Length: 48–52 cm.
  • Head circumference: 33–35 cm.
  • Chest circumference: slightly less than head circumference. These values are plotted on neonatal growth charts.

4.4.4 Skin and Subcutaneous Tissue

  • Look for vernix caseosa, lanugo hair, birthmarks (Mongolian spots, café-au-lait spots), and congenital anomalies.
  • Assess for jaundice, petechiae, cyanosis, or dehydration.
  • Palpate for oedema (suggests renal or cardiac disease).

4.4.5 Head and Face

  • Shape and size: microcephaly, macrocephaly, cranial swellings (caput succedaneum, cephalohaematoma).
  • Fontanelles and sutures: size, tension (bulging may indicate raised intracranial pressure).
  • Eyes: red reflex (absent in congenital cataract or retinoblastoma), discharge, conjunctival haemorrhage.
  • Ears: position, size, and anomalies (low-set ears suggest chromosomal syndromes).
  • Nose: patency (choanal atresia if blocked).
  • Mouth: cleft lip/palate, Epstein pearls, ankyloglossia.

4.4.6 Neck

  • Masses such as cystic hygroma.
  • Neck mobility (torticollis).

4.4.7 Chest

  • Inspection: chest shape, symmetry, retractions.
  • Auscultation: breath sounds equal? murmurs present?
  • Palpation: heart apex position, thrills, or heaves.

4.4.8 Abdomen

  • Shape: scaphoid, distended.
  • Umbilical cord: number of vessels, infection, hernia.
  • Palpation: liver (normally 1–2 cm below costal margin), spleen, kidneys, masses.
  • Auscultation: bowel sounds.

4.4.9 Genitalia and Anus

  • Male: testicular descent, hypospadias, phimosis.
  • Female: labial size, vaginal discharge (may be normal pseudo-menstruation).
  • Anus: patency, imperforate anus.

4.4.10 Musculoskeletal System

  • Assess posture, limb movements, joint stability.
  • Look for polydactyly, syndactyly, clubfoot.
  • Check clavicles for fracture.
  • Hip stability (Ortolani and Barlow manoeuvres).

4.4.11 Neurological Examination

  • Tone: normal flexor tone vs hypotonia or hypertonia.
  • Primitive reflexes:
    • Moro reflex
    • Rooting reflex
    • Sucking reflex
    • Palmar grasp
    • Stepping reflex
  • Behaviour: alertness, consolability, irritability.

4.5 Special Considerations in Preterm Infants

Preterm babies (<37 weeks) require special attention. History should highlight maternal risk factors for preterm labour, and examination must assess:

  • Skin thin and translucent with little subcutaneous fat.
  • Lanugo hair more abundant. - Ear cartilage soft, pinna remains folded.
  • Breast buds small or absent.
  • Genitalia: undescended testes in males, prominent labia minora in females.
  • Poor muscle tone and weak reflexes.

4.6 Neonatal Screening and Preventive Measures

In many centres, neonatal assessment is complemented by screening tests:

  1. Metabolic screening: for congenital hypothyroidism, phenylketonuria (where available).
  2. Hearing screening: Otoacoustic emission tests.
  3. Pulse oximetry: to detect critical congenital heart disease.
  4. Blood sugar: in infants of diabetic mothers or small/large for gestational age.

4.7 Documentation and Communication

  • Findings must be documented systematically in the neonatal record.
  • Abnormal findings should be clearly communicated to senior clinicians and to the parents in a sensitive manner.
  • Recommendations for follow-up, investigations, or referrals must be made.

4.8 Challenges in Resource-Limited Settings

  • Inadequate access to prenatal care records.
  • Limited diagnostic facilities for neonatal screening.
  • High burden of home deliveries without skilled attendants.
  • Cultural practices influencing early care and feeding.

4.9 Conclusion

The neonatal history and examination form the foundation of paediatric practice. They provide critical information about the newborn’s adaptation, detect congenital anomalies, and guide early interventions. For medical students and clinicians in Ghana, mastering these skills is essential in reducing neonatal morbidity and mortality. A systematic approach, attention to detail, and sensitivity to family concerns are the cornerstones of effective neonatal assessment.