The eyes should open spontaneously, especially in an uprightposition. Before 28 weeks’ gestational age, the eyelids may befused. Coloboma, megalocornea, and microphthalmia suggestother malformations or intrauterine infections. A cloudy corneagreater than 1 cm in diameter also may be seen in congenitalglaucoma, uveal tract dysgenesis, and storage diseases. Conjunctival and retinal hemorrhages are common and usually of no significance. The pupillary response to light is present at 28weeks of gestation. The red reflex of the retina is shown easily. A white reflex, or leukokoria, is abnormal and may be the result ofcataracts, ocular tumor, severe chorioretinitis, persistent hyper-plastic primary vitreous, or retinopathy of prematurity.
The mouth should be inspected for the presence of natal teeth, clefts of the soft and hard palate and uvula, and micrognathia. A bifid uvula suggests a submucosal cleft. White, shiny, multiple transient epidermal inclusion cysts (Epstein pearls) on the hard palate are normal. Hard, marble-sized masses in the buccal mucosa are usually transient idiopathic fat necrosis. The tympanic membranes are dull, gray, opaque, and immobile in the first 1 to 4 weeks. These findings should not be confused with otitis media.
The neck appears short and symmetrical. Abnormalities include midline clefts or masses caused by thyroglossal duct cysts or by goiter and lateral neck masses (or sinuses), which are the result of branchial clefts. Cystic hygromas and hemangiomas may be present. Shortening of the sternocleidomastoid muscle with a fibrous tumor over the muscle produces head tilt and asymmetrical facies (neonatal torticollis). Arnold-Chiari malformation and cervical spine lesions also produce torticollis. Edema and webbing of the neck suggest Turner syndrome. Both clavicles should be palpated for fractures.
Examination of the chest includes inspection of the chest wall to identify asymmetry resulting from absence of the pectoralis muscle and inspection of the breast tissue to determine gestational age and detect a breast abscess. Boys and girls may have breast engorgement and produce milk; milk expression should not be attempted. Supernumerary nipples may be bilateral and may be associated with renal anomalies.
Examination of the lungs includes observations of the rate, depth, and nature of intercostal or sternal retractions. Breath sounds should be equal on both sides of the chest, and rales should not be heard after the first 1 to 2 hours of life. Diminished or absent breath sounds on one side suggest pneumothorax, collapsed lung, pleural effusion, or diaphragmatic hernia. Shift of the cardiac impulse away from a tension pneumothorax and diaphragmatic hernia and toward the collapsed lung is a helpful physical finding for differentiating these disorders. Subcutaneous emphysema of the neck or chest also suggests a pneumothorax or pneumomediastinum, whereas bowel sounds auscultated in the chest in the presence of a scaphoid abdomen suggest a diaphragmatic hernia.