Newborn examination: head to toe and how to report it

• The newborn examination is a structured, head-to-toe check done by a qualified practitioner, usually within 72 hours of birth and again at 6 to 8 weeks of age ^[1][2].
• It screens for congenital problems that benefit from early detection, treatment or referral; it also reassures parents and gives space for questions ^[1].
• Four things are formal screening elements in the UK programme: eyes (including fundal reflex), heart, hips, and testes in boys ^[5].
• Work head to toe but opportunistically: listen to the heart if the baby settles, check the fundal reflex if the eyes open, look at the palate if the baby cries ^[1].
• Write down what you saw and what you did not see. The written record must be as careful as the hands-on part.

By the end of this page you should be able to:

1. Perform a newborn examination in a fixed, head-to-toe order without omissions.
2. List the normal findings and the abnormal findings that matter for each region.
3. Describe how a fundal reflex is elicited and what an absent reflex implies.
4. Perform and interpret the Barlow and Ortolani tests for hip instability.
5. Present a newborn examination aloud and in writing, leading with the important finding and stating the negatives that matter.

What it is: a screening examination of a newborn infant carried out in a warm, well-lit, private room, with the parents present and the baby undressed down to the nappy ^[1]. It is not designed to catch every subtle abnormality; it is designed to find the conditions where early action changes outcome, and to hand over anything uncertain to the child health team. The examination also opens the conversation with parents ^[1].

When it happens: a complete examination should be carried out within 72 hours of birth and again at 6 to 8 weeks of age ^[1][2]. The second check catches abnormalities that develop or become apparent later ^[1]. The Apgar score, resuscitation and immediate neonatal care are covered elsewhere and are not repeated here.

Weights, head circumference and feeding: record the weight, plot centiles and, where there are concerns, measure head circumference and length ^[2]. Weight and head circumference should be measured in the first week and again around 8 weeks, and at other times only if there are concerns ^[2]. Ask the parents about feeding, urination, passage of meconium within 24 hours, and any concerns of their own ^[1][2].

Parental communication begins before touching: explain what the examination involves in plain words, gain consent, check that parents have had the screening information booklet, and state the aims and the limits of the examination ^[1]. Use the examination as a teaching moment: skin care, cord care, safe sleep, feeding, immunisations, and how to seek help ^[2].

WHO guidance frames postnatal care as essential, routine care for women and newborns in any setting ^[3]; the practical steps below follow the UK NIPE programme and NICE recommendations ^[1][2].

• Absent fundal reflex, or a white pupil reflex ^[1].
• Absent or weak femoral pulses, or a very wide difference between pre- and post-ductal oxygen saturations ^[1].
• Positive Barlow or Ortolani test, breech presentation at or after 36 weeks, or any hip instability ^[1][4].
• An imperforate anus, fused labia, ambiguous genitalia, or bilateral absence of the testes ^[1].
• Abnormal tone, absent primitive reflexes, or a tense, bulging fontanelle ^[1].
• Respiratory distress, cyanosis, pallor or jaundice that is not physiological ^[1][2].

Set up the room before the baby arrives: warm, well lit (natural light helps when assessing jaundice), private, with a changing mat ^[1]. Make sure the parents are present, as this is the ideal time to answer questions and reassure them ^[1].

1. Wash your hands and use alcohol gel that has dried completely before touching the newborn ^[1].
2. Introduce yourself by name and role, confirm the infant's name and date of birth, and introduce the examination as a routine head-to-toe check ^[1].
3. Gain consent. Ask whether the parents received the screening information leaflet during pregnancy; give them a copy if they did not ^[1].
4. Explain the aims and the limitations of the examination, and state what you will and will not be able to reassure about ^[1].
5. Adequately expose the baby: ask the parents to undress the infant down to the nappy. Keep the baby warm throughout ^[1].
6. Take a structured history while observing the baby: pregnancy details, type of delivery and complications, antenatal screening results, breech presentation, risk factors for infection, abnormalities on antenatal scans, and family history of hearing problems, hip dislocation, childhood heart problems, congenital cataracts or renal problems ^[1].
7. Ask about current concerns: feeding pattern, urination, passage of meconium, and any concerns the parents have ^[1][2].

A chaperone is not needed when the parents are present, but the examination should be performed in a way that preserves dignity, and a second pair of hands helps with a wriggling baby. If a genital examination or anything sensitive is required, act according to local safeguarding and chaperone policy.

Examine from head to toe sequentially, but opportunistically: if the baby settles, listen to the heart first; if the eyes open, check the fundal reflex; if the baby cries, look at the palate ^[1]. Either way, the record must follow the same order every time so that nothing is missed.

Detailed instruction by region, written to be read aloud to yourself at the bedside:

1. General appearance. Stand back and inspect the whole baby. Note colour (pallor, cyanosis, jaundice), posture, behaviour, activity and the general symmetry of the head and facial features ^[1]. Cyanosis at rest raises the possibility of right-to-left cardiac shunting; palsy such as an Erb's palsy shows as abnormal posture of an arm ^[1].
2. Skin. Inspect colour and texture, and every birthmark and bruise. Vernix is a normal, waxy coating. Document the site and size of any bruise or laceration from birth trauma, and any birthmark, using a body map, because this matters later if there are safeguarding concerns ^[1]. Slate-grey naevus over the sacrum is common in darker-skinned infants and can be mistaken for a bruise; it usually fades over the first few years (3 to 5 in many, occasionally up to 6 to 10, with sources differing on the upper limit) ^[1]. Milia are tiny facial cysts that resolve in the first few weeks ^[1]. Erythema toxicum appears in the first few days of life (some sources from the first 24 hours, others in the second to fifth day) and resolves on its own ^[1].
3. Head. Measure head circumference and record it ^[1]; microcephaly and macrocephaly are both recorded where present ^[2]. Inspect cranial moulding, caput succedaneum, cephalhaematoma and subgaleal haemorrhage. Cranial moulding is common and resolves within days. Caput succedaneum is diffuse, with poorly defined margins, and often crosses suture lines. A cephalhaematoma is a subperiosteal bleed that does not cross suture lines and occurs in about 1 to 2% of infants ^[1]. Subgaleal haemorrhage is rare but can be life-threatening. Palpate the cranial sutures, and the anterior and posterior fontanelles: a bulging fontanelle suggests raised intracranial pressure; a sunken one suggests dehydration ^[1].
4. Eyes. Inspect for erythema, discharge, scleral colour and subconjunctival haemorrhage; note ptosis, epicanthic folds or asymmetry ^[1]. Retract the lower lid gently to look at the sclera for jaundice. Subconjunctival haemorrhages are common after delivery and benign but should be documented ^[1]. Elicit the fundal reflex in each eye separately: looking into the ophthalmoscope at about an arm's length, observe for a reflection from the retina. Healthy reflex colour varies by skin colour (orange-red in lighter skin, yellow-white or blue in darker skin), which is why the term fundal reflex is preferred to red reflex ^[1]. An absent fundal reflex or a white reflex needs urgent ophthalmology referral ^[1].
5. Ears. Inspect the pinna for asymmetry, skin tags, pits or accessory auricles ^[1]. Document differences, as these may be associated with renal or other anomalies; arrange the newborn hearing screen ^[1][2].
6. Mouth and palate. Inspect the tongue, gums and frenulum for tongue-tie. Then visualise the whole hard and soft palate with a tongue depressor and torch, with a parent helping to keep the head still, and confirm that the uvula is intact and midline. Palpation alone cannot exclude a cleft ^[1].
7. Neck and clavicles. Note a shortened webbed neck (Turner syndrome) and any lump in the left posterior triangle (cystic hygroma) ^[1]. Look for evidence of clavicular fracture after shoulder dystocia: bruising, a palpable discontinuity of the clavicle and an abnormal position of the arm ^[1].
8. Chest and heart. Count the respiratory rate (normal in the newborn is 40 to 60 breaths per minute) and look for increased work of breathing: nasal flaring, grunting, intercostal and subcostal recession ^[1]. Auscultate the lungs side to side and on the back. Then auscultate the heart upward through the valve areas with both bell and diaphragm; feel the apex beat; note murmurs and their radiation ^[1]. The normal heart rate is approximately 100 to 160 beats per minute ^[5]. Palpate and compare the brachial pulses. Palpate and compare the femoral pulses: weak, absent or delayed femoral pulses are a sign of coarctation of the aorta ^[1]. Where local policy uses it, check pre- and post-ductal oxygen saturations; both should be at least 95% with a difference of less than 3% ^[1]. Guidelines differ on the boundary itself: the NHS RoPeS guidance and the AAP 2025 algorithm treat 3% or more as borderline requiring a rescreen, the CAHS (Western Australia) document accepts 3% or less, and the BAPM framework accepts 2% or less.
9. Abdomen and umbilicus. Inspect for distension, an umbilical hernia, inflammation or discharge around the cord, and inguinal hernias ^[1]. Palpate for organomegaly: the liver should be palpable no more than 2 cm below the costal margin in a healthy infant, the spleen may be felt at the left costal margin, and the kidneys are usually only felt on deep palpation ^[1]. The bladder should not be palpable ^[1]. The abdomen should be soft.
10. Genitalia. Note any ambiguity of genitalia, which can indicate congenital adrenal hyperplasia in girls; boys with this condition usually have normal genitalia ^[1]. In boys: note the urethral meatus, the size of the penis (at least 2 cm), hydrocele and whether both testes are descended, following up a unilateral undescended testis and investigating bilateral absence ^[1]. In girls: inspect the labia and clitoris and note normal white vaginal discharge from maternal oestrogens ^[1].
11. Anus. Inspect for patency: abnormal development of the rectum can lead to an imperforate anus ^[1]. Meconium should be passed within 24 hours; delay suggests obstruction or Hirschsprung's disease ^[1][2].
12. Spine. Inspect for scoliosis, hair tufts, naevi, birthmarks and sacral pits; these can be associated with neural tube defects such as spina bifida ^[1]. Check the integrity of the skin over the whole back.
13. Limbs, hips and femoral pulses. Inspect each limb for symmetry of size and length, count digits, and note polydactyly or single palmar crease. A single palmar crease is associated with Down syndrome ^[1]. Inspect feet for oedema, ankle deformities such as talipes, and the correct number of digits ^[1]. Assess tone in both upper and lower limbs, movement and the range of knee movement. Again palpate and compare femoral pulses ^[1]. Perform the Barlow and Ortolani tests on each hip separately, with all clothing including the nappy removed ^[1].
    • Barlow test: stabilise the opposite side of the pelvis; adduct the hip while applying gentle posterior pressure at the knee. A palpable slip of the femoral head over the posterior acetabular rim is a positive test ^[1].
    • Ortolani test: stabilise the opposite side of the pelvis; flex the hip and knee to 90 degrees; apply anterior pressure to the femur while gently abducting the hip. A palpable clunk as the femoral head relocates into the acetabulum is a positive test ^[1].
    • Interpretation: these tests screen for hip instability and dislocation, which may indicate developmental dysplasia of the hip. Evaluation of spontaneous posture, a possible leg-length discrepancy in the thighs (Galeazzi sign), asymmetry of the lateral pelvic profile and reduced abduction should also be recorded ^[1][4].
14. Tone and primitive reflexes. Tone should be assessed throughout by gently moving the limbs passively and observing the baby when picked up; a hypotonic infant feels like a rag doll ^[1]. Primitive reflexes are usually present and include palmar grasp, sucking, rooting, stepping and Moro. Absence of several reflexes may indicate a neurological abnormality. Rooting gradually comes under voluntary control and fades around four months of age ^[1].

A positive or absent finding in any of the rows above should be graded as: urgent referral, routine referral, or explain and document. The following always warrant escalation at the same visit: an absent or white fundal reflex, clinical hip instability, absent femoral pulses, serious breathing difficulty, a major malformation of the genitalia or anus, and any sign of raised intracranial pressure ^[1][2].

Present a newborn examination in the same order every time, but lead with the most important positive finding.

1. Open with one sentence: who the baby is and the circumstances of the examination. "This is a 48-hour-old baby boy born at term by spontaneous vaginal delivery, of normal weight, examined as a routine newborn check."
2. State the setting and what you asked: growth centile, feeding, voiding and passage of meconium.
3. Give the positive findings first, in head-to-toe order, using short phrases: "Head is round and of normal size; fontanelles flat. Eyes show a normal fundal reflex in each eye. Heart sounds normal, heart rate 130, femoral pulses present and equal. Abdomen soft, liver edge just palpable, no masses..."
4. Then state the negatives that matter: "No murmur, no tachypnoea, no cyanosis, no jaundice, no dysmorphism, no sacral pits, no hip instability on Barlow and Ortolani, both testes descended."
5. Finish with two sentences: a summary, then the diagnosis and the differential or plan. "In summary, examination is entirely normal. No referral required; parents have been encouraged and told when to seek help. We discussed routine care, safe sleep, feeding and immunisations."
6. If a finding is abnormal, lead with it and end with the next step. "In summary, a unilateral absent fundal reflex; the differential includes congenital cataract, retinal detachment and retinoblastoma; I have arranged an urgent ophthalmology referral and spoken to the parents."

When writing in the notes, match the spoken order: patient details; date, time and examiner; history taken; examination by system, with each region labelled and negatives recorded as negatives; any measurement with units and centiles (head circumference, weight, femoral pulse comparison, saturation values); referrals made and to whom; and the advice given to the parents. Use the national screening documentation where it exists, and write legibly to UK standards.

Wording such as "suggestive of", "consistent with" and "cannot exclude" belongs in your summary, not in the physical findings: record what your fingers and ears detected, and put the interpretation in the summary.

Parental communication at the end should be calm and honest: share what was normal, explain any referral before it happens and never let a parent leave without knowing the next step and how to get help if the baby becomes unwell ^[2].

These are illustrative cases with invented patients and details. They show the spoken register only; the written record follows the same order and adds the measurements and timings.

Normal newborn, day 2 (spoken).

"Forty-eight-hour-old female infant, born at term by spontaneous vaginal delivery, weight on the 50th centile, breastfeeding well, has voided and passed meconium. General appearance normal, colour pink, no cyanosis or jaundice, posture symmetric. Skin normal, no birthmarks or bruising. Head circumference on the 50th centile, fontanelles flat, red reflex present in both eyes. Ears normal. Palate intact. Neck and clavicles normal. Respiration 44 with no increased work, heart rate 140 with normal sounds, femoral pulses present and equal, pre- and post-ductal saturations 98% and 97%. Abdomen soft, liver edge just palpable, umbilicus clean. Female genitalia normal with no discharge. Anus patent, meconium passed. Spine normal. Limbs symmetric, all digits present, hips stable with normal Barlow and Ortolani, tone normal and all primitive reflexes present. In summary, examination entirely normal, no referral needed. The parents were congratulated and routine care, safe sleeping, immunisations and how to seek help were explained."

Hip dysplasia on routine examination, day 2 (spoken).

"Twenty-four-hour-old male infant, born by breech vaginal delivery, otherwise well, feeding and voiding normally. General appearance normal and no dysmorphism. Head, eyes and ears normal. Palate intact. Neck, chest, heart and femoral pulses normal. Abdomen soft with no masses. Male genitalia normal, both testes descended, meatus terminal and foreskin normal. Spine normal. Left hip: Barlow positive with a palpable slip; Ortolani positive with a palpable clunk on abduction. Right hip normal. Tone and reflexes normal. In summary, clinically unstable left hip in an infant with breech presentation, most likely developmental dysplasia of the hip. A hip ultrasound and paediatric orthopaedic review were arranged, the diagnosis and treatment were explained, and the parents were told when and where to attend."

Left heart outflow concern, day 1 (spoken).

"Newborn female infant, term, delivered by emergency caesarean for fetal distress, pink when warmed but lower-limb pulses very difficult to palpate and blood pressure higher in the arm than the leg. General examination otherwise normal, head and eyes normal including fundal reflexes, lungs clear, heart rate 150 with a soft ejection systolic murmur loudest at the upper left sternal edge, no added sounds. Abdomen soft with no organomegaly. Palpable liver edge one centimetre below the costal margin, normal genitalia, no anomalies. In summary, clinical findings are suggestive of coarctation of the aorta. The paediatric cardiologist was informed, an urgent echocardiogram and pre- and post-ductal saturation checks were arranged, and the parents were spoken to about what to expect." ^[1]

• Skipping the hands, eyes, mouth, neck and back because the baby is hungry or crying.
• Treating the examination as either-or between opportunistic and systematic: it must be both, and the record must be systematic ^[1].
• Looking only through a magnifying glass at the red reflex and calling a white reflection "normal": absent or white fundal reflex needs urgent referral ^[1].
• Palpating the palate with a finger and not looking: you must visualise the whole palate and the intact uvula ^[1].
• Calling a murmur "innocent" before a full minute of auscultation and checking femoral pulses ^[1].
• Forgetting to remove the nappy before the hip tests and examining both hips at once ^[1].
• Confusing hypermobile hips (an audible click without a clunk) with a true positive Barlow or Ortolani.
• Not documenting birthmarks, bruises or birth trauma on a body map.
• Not recording negatives that matter, so the next clinician cannot tell what was excluded.
• Forgetting to tell the parents the plan in plain language before they leave.

• Examination is performed within 72 hours and again at 6 to 8 weeks ^[1][2].
• Examine head to toe and record in the same fixed order each time.
• Opportunistic checks help, but the record must be systematic ^[1].
• Four formal screening elements: eyes with fundal reflex, heart, hips, and testes in boys ^[5].
• Fundal reflex colour varies with skin colour; absent or white reflex needs urgent referral ^[1].
• Normal newborn respiratory rate 40 to 60 breaths per minute and heart rate about 100 to 160 beats per minute ^[5].
• Femoral pulses must be present and equal; weak or absent points to coarctation ^[1].
• Liver palpable no more than 2 cm below the costal margin ^[1].
• Visualise the whole palate; palpation alone is not enough ^[1].
• Barlow and Ortolani are performed on each hip separately with clothes off ^[1].
• Present with the important finding first, then the negatives that matter, then a summary and a plan.
• Document measurements and units, centiles, referrals, and the advice given to parents.