General Examination

General. Record head circumference (HC, see Fig. 1 for normal percentiles), length and weight. Measurements should be corrected for gestational age in premature infants. Record both birth and current weight, as newborns lose 10% of their birth weight during the first week of life. Head circumference during the first year of life can be approximated by:

Figure I, continued.

[(Length in cm )/2] + 9.5 = mean HC for that length (mean HC +/- 2.5 cm approximates 2 standard deviations) Head and neck. Assess the anterior fontanelle as a direct measure of intracranial pressure. Although craniosynostosis may not be apparent at birth, abnormalities of head shape should be noted. Dysmorphic features such as short or down-slanting palpebral fissures, mid-face hypoplasia (flattened nasal bridge, wide set eyes), smooth/ long/short philtrum, low-set/malformed ears, or high/cleft palate should be specifically assessed.

Table 3. Coma scales for adults (and older children) and infants

Glasgow Coma Scale (GCS)

Alternate Scale for Infants

Category Activity


Best Response

Eye opening



Spontaneous To speech To pain None

Oriented Confused

Inappropriate words Incomprehensible sounds None

Follows commands Localizes pain Withdraws to pain Abnormal flexion Abnormal extension None

Spontaneous 4

To sound 3

To pain 2

None 1

Coos, babbles 5

Irritable 4

Cries to pain 3

Moans to pain 2

None 1

Normal spontaneous movement 6

Withdraws to touch 5

Withdraws to pain 4

Abnormal flexion 3

Abnormal extension 2

None 1

Abdomen and back. Assess for organomegaly. Examine the entire midline from nasion to coccyx for dimples, tufts of hair, hemangiomas and/or lipomas. Small dimples in the midline may be very subtle but should prompt additional investigation. Coccygeal dimples are an exception to this rule.

Skin and extremities. Record manifestations of syndromic conditions, such as cafe-au-lait spots, axillary freckling, large cutaneous hemangiomas, dysmorphic hands/ feet, or arthrogryposis (congenital contractures of arms/legs, suggests fetal movements reduced in utero).

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