Physical Assessment of the Newborn: Part 1

® ®

®
 Review history
 Prenatal
 Labor/delivery
 Presentation of illness

 Approach
 Systematic
 Gentle

© K. Karlsen 2013

 Perform hand hygiene (hand sanitizer or wash)  Observe before touching

 Wear personal protective equipment as indicated
(gloves, mask, gown)
 Perform while infant in quiet state whenever possible
 Use clean equipment
 Keep infant warm
 Shield eyes from exam light
 Comfort during / after exam
 Change soiled diapers / redress
following exam
 Perform hand hygiene after exam

© K. Karlsen 2013 © K. Karlsen 2013

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 Physical Assessment of the Newborn: Part 1

 Observe before touching  Observe before touching

 Auscultate before palpating – in quiet environment  Auscultate before palpating – in quiet environment
 Gentle palpation
 Avoid if acute abdomen
 Extra care with
preterm infants

© K. Karlsen 2013 © K. Karlsen 2013

Ballard Score Principles of Ballard Exam

 Developed by Jeanne L. Ballard, MD  Timing

 Set of procedures and assessment parameters used  Most reliable if performed

to determine gestational age by 12 hours of life
 Evaluation of physical and neuromuscular maturity  Keep infant warm

A detailed monograph and explanation

about how to perform the Ballard exam
(written by Dr. Ballard), may be found
at www.BallardScore.com

. Ballard et al. (1991). J Pediatr.,119(3): 417-423.

Neuromuscular illustrations were adapted
with permission of Dr. Ballard
© K. Karlsen 2013 © K. Karlsen 2013

-1 0 1 2 3 4 5 -1 0 1 2 3 4 5
Sticky Gelatinous Superficial Cracking Parchment Leathery
Smooth pink peeling Superficial Parchment
Skin Friable Red Pale areas Deep Cracked Sticky Gelatinous Smooth Cracking Leathery
Visible veins and/or rash cracking peeling Deep
Transparent Translucent Few veins Rare veins Wrinkled Friable Red pink Pale areas Cracked
No vessels and/or rash cracking
Sparse Abundant Thinning Transparent Translucent Visible veins Few veins Rare veins Wrinkled
Lanugo No lanugo lanugo lanugo Lanugo Bald areas Mostly bald No vessels

Plantar
Heel- toe Heel- toe
Faint red Anterior Creases Creases over
 Skin – largest organ in the body
40-50 mm > 50 mm transverse
surface <40 = 2 No crease
marks crease only anterior 2/3 entire sole
 Stratum corneum  outer layer of epidermis
Im- Barely Flat areola
Stippled Raised Full areola
 Begins to develop after 21 weeks
Breast areola areola
 28 to 30 weeks is a few cell layers thick
perceptible perceptible no bud 5-10 mm bud
1-2 mm bud 3-4 mm bud
Slightly Well-curved
 By term is 10 to 20 cell layers thick
Lids fused: Lids open Formed Thick
Eyes / curved pinna pinna and firm cartilage
Loosely: -1 Pinna flat
ears Soft slow Soft but Instant recoil Ear stiff
Tightly: -2 Stays folded
recoil ready recoil
 Before epidermis and stratum corneum develop,
Scrotum Testes in Testes Testes
Male
Genitals
Scrotum
flat, smooth
empty upper canal descending Testes down
Good rugae
pendulous skin is transparent and thin
Faint rugae Rare rugae Few rugae Deep rugae
Clitoris Prominent Prominent Majora and
Female prominent clitoris clitoris minora Majora large Majora cover
equally clitoris and
Genitals Labia flat Small labia Enlarging Minora small minora
minora minora prominent
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 Physical Assessment of the Newborn: Part 1

-1 0 1 2 3 4 5 -1 0 1 2 3 4 5
Superficial Parchment Superficial Parchment
Sticky Gelatinous Smooth Cracking Leathery Sticky Gelatinous Cracking Leathery
peeling Deep Smooth pink peeling Deep
Friable Red pink Pale areas Cracked Friable Red Pale areas Cracked
and/or rash cracking Visible veins and/or rash cracking
Transparent Translucent Visible veins Rare veins Wrinkled Transparent Translucent Rare veins Wrinkled
Few veins No vessels Few veins No vessels

–1
0
1 2

© K. Karlsen 2013 © K. Karlsen 2013

-1 0 1 2 3 4 5 -1 0 1 2 3 4 5
Superficial Parchment Superficial Parchment
Sticky Gelatinous Cracking Leathery Sticky Gelatinous Cracking Leathery
Smooth pink peeling Deep Smooth pink peeling Deep
Friable Red and/or rash Pale areas Cracked Friable Red and/or rash Pale areas Cracked
Visible veins cracking Visible veins cracking
Transparent Translucent Few veins Rare veins Wrinkled Transparent Translucent Few veins Rare veins Wrinkled
No vessels No vessels

3
4

© K. Karlsen 2013 © K. Karlsen 2013

-1 0 1 2 3 4 5 -1 0 1 2 3 4
Superficial Parchment
Sticky Gelatinous Cracking Leathery No lanugo Sparse Abundant Thinning Bald areas Mostly bald
Smooth pink peeling Deep
Friable Red and/or rash Pale areas Cracked
Visible veins cracking
Transparent Translucent Few veins Rare veins Wrinkled
No vessels

 Fine, downy hair that begins to appear 24 to 25 weeks

 Abundant across shoulders and upper back by
28 weeks
5  With increasing gestation lower back area thins first 
bald areas appear over lumbo-sacral area
 By term, minimal to no lanugo present on back
 Amount and location may vary with nutritional status,
ethnicity, hormonal and metabolic factors

© K. Karlsen 2013 © K. Karlsen 2013

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 Physical Assessment of the Newborn: Part 1

-1 0 1 2 3 4 -1 0 1 2 3 4
No lanugo Sparse Abundant Thinning Bald areas Mostly bald No lanugo Sparse Abundant Thinning Bald areas Mostly bald

-1 0

© K. Karlsen 2013 © K. Karlsen 2013

-1 0 1 2 3 4 -1 0 1 2 3 4
No lanugo Sparse Abundant Thinning Bald areas Mostly bald No lanugo Sparse Abundant Thinning Bald areas Mostly bald

1 2 3

© K. Karlsen 2013 © K. Karlsen 2013

-1 0 1 2 3 4 -1 0 1 2 3 4
Heel–toe Anterior Creases Heel–toe Anterior Creases
> 50 mm Faint red Creases > 50 mm Faint red Creases
40 – 50 mm transverse over entire 40 – 50 mm transverse over entire
No crease marks anterior 2/3 No crease marks anterior 2/3
< 40 = – 2 crease only sole < 40 = – 2 crease only sole

 Prior to foot creases appearing, for very preterm

infants, measure foot length from tip of great toe to
back of heel
 Foot crease begins to appear on ball of foot between
28 and 30 weeks gestation
 As infant approaches term, creases should cover
entire plantar surface
-1 0 1

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 Physical Assessment of the Newborn: Part 1

-1 0 1 2 3 4 -1 0 1 2 3 4
Heel–toe Anterior Creases Stippled Raised Full areola
> 50 mm Faint red Creases Im- Barely Flat areola
40 – 50 mm transverse over entire areola areola 5–10 mm
No crease marks anterior 2/3 perceptible perceptible no bud
< 40 = – 2 crease only sole 1–2 mm bud 3–4 mm bud bud

 As gestation advances, breast tissue is stimulated to

grow by maternal estrogen
4  Evaluate size of areola and presence of any stippling
 Palpate breast tissue and estimate diameter in
millimeters
 36 weeks  1 to 2 mm nodule of breast tissue
3 palpable
2  By term  10 mm nodule of breast tissue usually
palpable
© K. Karlsen 2013 © K. Karlsen 2013

-1 0 1 2 3 4 -1 0 1 2 3 4
Stippled Raised Full areola Stippled Raised Full areola
Im- Barely Flat areola areola areola Im- Barely Flat areola areola areola
perceptible perceptible no bud 5–10 mm perceptible perceptible no bud 5–10 mm
1–2 mm bud 3–4 mm bud bud 1–2 mm bud 3–4 mm bud bud

-1 2
0
3
1
4

© K. Karlsen 2013 © K. Karlsen 2013

-1 0 1 2 3 4 -1 0 1 2 3 4
Lids fused: Lids open Slightly Well-curved Formed Lids fused: Lids open Slightly Well-curved Formed
Thick Thick
curved pinna pinna and firm curved pinna pinna and firm
Loosely: -1 Pinna flat cartilage Loosely: -1 Pinna flat cartilage
Soft slow Soft but Instant Soft slow Soft but Instant
Tightly: -2 Stays folded Ear stiff Tightly: -2 Stays folded Ear stiff
recoil ready recoil recoil recoil ready recoil recoil

 Cartilage content increases as infant matures -2

 Palpate for cartilage thickness, then fold pinna
toward face and release it  evaluate speed pinna
0
springs back
 If pinna remains folded, evaluate whether eyelids are
fused or whether one or both eyelids are open
 If eyelids loosely or partially fused, assign a number
of minus one (-1)

© K. Karlsen 2013 © K. Karlsen 2013

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 Physical Assessment of the Newborn: Part 1

-1 0 1 2 3 4 -1 0 1 2 3 4
Slightly Well-curved Formed Scrotum Testes in Testes Testes Testes
Lids fused: Lids open Thick Scrotum
curved pinna pinna and firm empty upper canal descending down pendulous
Loosely: -1 Pinna flat cartilage flat, smooth
Soft slow Soft but Instant Faint rugae Rare rugae Few rugae Good rugae Deep rugae
Tightly: -2 Stays folded Ear stiff
recoil ready recoil recoil
 Testes
 Begin to descend from peritoneal cavity between
2 28 to 30 weeks
3  Both palpated in lower inguinal canals by end of
4 33rd to 34th week / scrotal skin thickens
1
 Completely descended by 40 weeks
 Rugae (creases over scrotum)
 Extremely preterm  scrotum flat and smooth
 By 40 weeks, scrotum covered with numerous
thickened rugae and scrotum pendulous
© K. Karlsen 2013 © K. Karlsen 2013

-1 0 1 2 3 4 -1 0 1 2 3 4
Scrotum Testes in Testes Testes Testes Prominent Prominent Majora and Majora Majora
Scrotum Clitoris
empty upper canal descending down pendulous clitoris clitoris minora large cover
flat, smooth prominent
Faint rugae Rare rugae Few rugae Good rugae Deep rugae Small labia Enlarging equally Minora clitoris and
Labia flat prominent minora
minora minora small

0  Assess with hips abducted to 45

1  Extremely preterm  labia flat, clitoris very prominent
2
3  As fetus matures, clitoris less prominent, labia minora
becomes more prominent
4
 Closer to term  clitoris and labia minora enveloped
by enlarging labia majora
 Labia majora contains fat – size affected by intrauterine
nutrition  correlate findings with assessment of
growth (small, average or large for gestational age)
© K. Karlsen 2013 © K. Karlsen 2013

-1 0 1 2 3 4 -1 0 1 2 3 4 5
Prominent Prominent Majora and Majora Majora
Clitoris
clitoris clitoris minora large cover Posture
prominent
Small labia Enlarging equally Minora clitoris and
Labia flat prominent minora
minora minora small
Square
window
0 (wrist)
3
Arm
recoil
1
4
Popliteal
angle

Scarf
sign

Heel to
ear
© K. Karlsen 2013 © K. Karlsen 2013

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 Physical Assessment of the Newborn: Part 1

-1 0 1 2 3 4
 Positioning Neuromuscular exam may be too
 Head midline stressful for preterm and sick infants
 Hips flat  should only be performed if
indicated and by skilled neonatal ICU
personnel once infant stabilized and 1
 Reliability of able to tolerate the exam
exam altered by:
 Sedation 2
 Anesthesia
 Paralysis
 Critically ill state
 Breech position

© K. Karlsen 2013 © K. Karlsen 2013

-1 0 1 2 3 4 -1 0 1 2 3 4

> 90 90 60 45 30 0

3  Assesses wrist flexibility and/or resistance to extensor

stretching at the wrist
 Press gently on knuckles to straighten fingers
 Apply gentle pressure on back of hand close to fingers
4  avoid wrist rotation
 Stop pressing when resistance felt
 Angle decreases as gestational age increases

© K. Karlsen 2013 © K. Karlsen 2013

-1 0 1 2 3 4 -1 0 1 2 3 4

> 90 90 60 45 30 0 > 90 90 60 45 30 0

2
0 3
4

–1 1

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 Physical Assessment of the Newborn: Part 1

0 1 2 3 4 0 1 2 3 4

180 140-180 110-140 90-110 < 90 180 140-180 110-140 90-110 < 90

 Tests for passive flexor tone of biceps muscle

Flex Release
 Test one arm at a time in order to avoid Moro reflex
 Supine position Extend Score
 Hold infant’s hand
 Briefly flex arm  then momentarily extend arm
and release hand
 Scores based on angle of recoil when arms return
to flexion

© K. Karlsen 2013 © K. Karlsen 2013

0 1 2 3 4 0 1 2 3 4

180 140-180 110-140 90-110 < 90 180 140-180 110-140 90-110 < 90

1 2 3 4

© K. Karlsen 2013 © K. Karlsen 2013

-1 0 1 2 3 4 5 -1 0 1 2 3 4 5

180 160 140 120 100 90 < 90 180 160 140 120 100 90 < 90

 Assesses maturation of passive flexor tone about  Place thigh in knee-chest position with knee fully flexed
the knee joint  Allow infant to relax, then grasp foot at sides
 Refrain from touching hamstrings (muscle group being  Extend leg until resistance is felt
tested) during maneuver  Estimate angle behind the knee

 Measurement unreliable if frank

breech in utero

© K. Karlsen 2013 © K. Karlsen 2013

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 Physical Assessment of the Newborn: Part 1

-1 0 1 2 3 4 5 -1 0 1 2 3 4 5

180 160 140 120 100 90 < 90 180 160 140 120 100 90 < 90

0 2
3
1
4

© K. Karlsen 2013 © K. Karlsen 2013

-1 0 1 2 3 4 -1 0 1 2 3 4

neck axillary nipple xiphoid nipple axillary neck axillary nipple xiphoid nipple axillary
line line process line line line line process line line
 Tests passive tone of the posterior  Tests passive tone of the posterior
shoulder girdle flexor muscles shoulder girdle flexor muscles

 Supine position with head midline  Supine position with head midline

 Hold infant’s hand

across chest

© K. Karlsen 2013 © K. Karlsen 2013

-1 0 1 2 3 4 -1 0 1 2 3 4

neck axillary nipple xiphoid nipple axillary neck axillary nipple xiphoid nipple axillary
line line process line line line line process line line
 Use thumb of other hand to gently push 1
elbow across chest or gently pull arm
across chest

 Stop when resistance is felt

2
 Scores based on position of elbow at
landmarks

© K. Karlsen 2013 © K. Karlsen 2013

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 Physical Assessment of the Newborn: Part 1

-1 0 1 2 3 4 -1 0 1 2 3 4

neck axillary nipple xiphoid nipple axillary ear nose chin nipple umbilical femoral
line line process line line line area crease
 Tests for passive flexion or resistance to extension
3 4 of posterior hip flexor muscles

 Measurement unreliable if
frank breech in utero

© K. Karlsen 2013 © K. Karlsen 2013

-1 0 1 2 3 4 -1 0 1 2 3 4

ear nose chin nipple umbilical femoral ear nose chin nipple umbilical femoral
line area crease line area crease
 Refrain from touching gluteus  Refrain from touching gluteus
muscle (muscle group being muscle (muscle group being
tested) during maneuver tested) during maneuver

 Rest leg alongside body  Rest leg alongside body

 Grasp foot along both sides

© K. Karlsen 2013 © K. Karlsen 2013

-1 0 1 2 3 4 -1 0 1 2 3 4

ear nose chin nipple umbilical femoral ear nose chin nipple umbilical femoral
line area crease line area crease
0
 Gently pull toward ear until
resistance felt 2

 Scores based on location of heel

1
to landmarks

© K. Karlsen 2013 © K. Karlsen 2013

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 Physical Assessment of the Newborn: Part 1

Physical Maturity
-1 0 1 2 3 4 5

Sticky Gelatinous Superficial Cracking Parchment Leathery

Smooth pink peeling and/or
Skin Friable Red rash Pale areas Deep cracking Cracked
Visible veins
Transparent Translucent Few veins Rare veins No vessels Wrinkled

No lanugo Sparse lanugo Abundant Thinning Bald Areas Mostly bald

Lanugo
-1 0 1 2 3 4 lanugo Lanugo

Heel- toe > 50 mm Anterior

Plantar 40-50 mm Faint red marks transverse Creases Creases over
surface No crease crease only anterior 2/3 entire sole
< 40 = -2

Barely Flat areola no Stippled areola Raised areola Full areola

Breast Im-perceptible perceptible bud 1-2 mm bud 3-4 mm bud 5-10 mm bud

Lids fused: Lids open Slightly Well-curved Formed and

pinna firm Thick cartilage
Eyes / ears Loosely: -1 Pinna flat curved pinna
ear nose chin nipple umbilical femoral Tightly: -2 Stays folded Soft slow recoil
Soft but ready
recoil Instant recoil Ear stiff

line area crease Male

Genitals
Scrotum flat,
smooth
Scrotum empty
Faint rugae
Testes in upper
canal
Testes
descending Testes down
Good rugae
Testes
pendulous
Rare rugae Few rugae Deep rugae

Clitoris Prominent Prominent

Female clitoris clitoris Majora and Majora large Majora cover
prominent minora equally clitoris and
Genitals Labia flat Small labia Enlarging prominent Minora small minora
minora minora

Neuromuscular Maturity
3 4
Posture

Square
window
(wrist)

Arm recoil

Popliteal
angle

Scarf sign

© K. Karlsen 2013 © K. Karlsen 2013 Heel to ear

Score Weeks
-10 20
-5 22
0 24
5 26
10 28
15 30
20 32
 Sum scores 25 34
 Physical maturity 30 36
 Neuromuscular maturity 35 38
 Total score correlates to 40 40
weeks gestation 45 42
50 44
© K. Karlsen 2013

The S.T.A.B.L.E® Program © 2013. Handout may be reproduced for educational purposes. 11