A newborn's fontanelle is bulging, the eyes have white pupils, and there's a single palmar crease — three findings, three different urgencies. Knowing which is which saves lives.
The systematic head-to-toe newborn assessment identifies normal variants versus findings requiring immediate intervention. Start with vital sign baselines: HR 110–160 bpm overall at rest (apical, full 60 seconds; 120–160 when awake and active), RR 30–60 breaths/min, axillary temp 36.5–37.5°C, and weight (2,500–4,000 g for term). Head: measure head circumference (33–35 cm), assess fontanelles (anterior is diamond-shaped and soft/flat, closes by 12–18 months; posterior is triangular, closes by 2–3 months). A bulging fontanelle suggests increased ICP; a sunken one signals dehydration. Eyes: check the red reflex bilaterally — an absent or white reflex (leukocoria) requires urgent referral to rule out retinoblastoma or congenital cataracts. Ears: tops should align with the outer canthus of the eye; low-set ears are associated with chromosomal abnormalities. Skin: assess for acrocyanosis (normal in first 24–48 hours, limited to hands and feet) versus central cyanosis (abnormal, indicates hypoxemia). Document birthmarks: mongolian spots (blue-gray, sacral, benign), stork bites (flat pink, nape of neck, fade), and port-wine stains (flat, deep red-purple, do not blanch, may indicate Sturge-Weber syndrome). Abdomen: umbilical cord should have two arteries and one vein (three vessels total); a two-vessel cord warrants renal and cardiac evaluation. Hips: perform Ortolani and Barlow maneuvers to screen for developmental dysplasia.
Key Distinctions
Don't confuse acrocyanosis (hands and feet only, normal) with central cyanosis (trunk and mucous membranes, always abnormal). A single palmar crease (simian crease) suggests trisomy 21 but is not diagnostic alone — it needs genetic workup. Caput succedaneum crosses suture lines and resolves quickly; cephalohematoma does NOT cross suture lines and takes weeks to resolve.
Clinical Pearl
Two arteries, one vein — 'AVA' like a name. If you only count two vessels in the cord, think renal and cardiac anomalies and report immediately.