Neonatology Examination

Question 1

What should be included in the history with the mother before examining the neonate?

Answer 1

Birth term, complications, first child, breast vs bottle, wet and dirty nappies, family hx

Question 2

When examining the baby, this finding is observed. What is it?

Answer 2

Cleft palate (black opening in the back of the mouth)

Question 3

What is this finding?

Answer 3

Cutis marmorata or mottled skin

Question 4

How would you assess nutritional status on a neonate?

Answer 4

Check thighs for subcutaneous fat and weigh the baby (3.5)

Question 5

What is paradoxical breathing

Answer 5

Abdomen out and chest in (40-60bpm)

Question 6

what is this finding?

Answer 6

Milia rash. white spots on face mainly around nose and cheeks

Question 7

what is this finding?

Answer 7

Erythema Toxicum. small papules on erythematous rash. around body

Question 8

How would you describe a normal pulse (normal for neonate)

Answer 8

the pulse has a rate of 120-160bpm and is strong (vs weak/full/bounding/absent) and regular rhythm (even beats vs irregular)

Question 9

How is central cyanosis assessed?

Answer 9

open mouth and look for blue

Question 10

What is included in the cardiology assessment of the newborn?

Answer 10

Central cyanosis
Capillary refill
Femoral Pulse for coarctation of the aorta
Palpate the liver (LIF -> 2cm below costal margin) for hepatomegaly in congenital infections and right sided heart failure
Heart palpation (left lower sternal edge) - should be of minor intensity. major = left-right shunt
Auscultation of 4 cardiac areas for murmurs (and check if louder on right or left)

Question 11

What are signs of congenital heart disease?

Answer 11

Poor feeding
tachypnea
cyanosis

Question 12

If you have auscultated the heart and found no murmers. what would you say to the examiner?

Answer 12

I can appreciate heart sounds 1 and 2 in all 4 cardiac areas at grade III (easily audible but without palpable thrill) with no added heart sounds

Question 13

When examining the neonate’s head you notice the head is asymmetrical with a bulge on the right side. What are your ddx and how would you distinguish them

Answer 13

Caput Succedaneum => Oedema between skin and periosteum, can cross sutures (can cross midline)
Subgaleal hemorrhage => Blood between subgalial anastomoses and periosteum, can cross sutures
Cephalohematoma => Blood between the periosteum and bone, cannot cross midline

Question 14

When Examining the Head and neck of the baby, list what needs to be done

Answer 14

Inspect the head for asymmetry (plagio/brachycephaly)
Palpate anterior, posterior (checking for 3rd in between) fontanelles as well as metopic, corona, sagittal, and lambdoid sutures for oedema, overlapping sutures (premature fusion)
Measure head circumference 3x (35cm)
Eyes: Dacryocystocele, subconjunctival hemorrhage (normal and self-limiting), and RED REFLEX (checking for (a)symmetrical reflex, white reflex, cataracts (hazy lens)
Ears: Draw imaginary line (low/high set), preauricular skin tag, and microtia
Nose: Check septum if displaced (due to birth), and Choanal atresia
Mouth: If given opportunity, check for microstomia and cleft palate when crying
Neck: Check for masses
Clavicle: Palpate for fractures from birth trauma

Question 15

When examining the neonate’s head, you note several markings. What is the likely cause?

Answer 15

Assisted delivery via forceps or vacuum

Question 16

When palpating the head, you notice that there is an interruption or “step” along a suture. What does this indicate?

Answer 16

Overlapping sutures, premature fusion of bone
Craniosynostosis

Question 17

what is this finding?

Answer 17

dacryocystocele. This is the blockage of the nasolacrimal duct

Question 18

What is the finding

Answer 18

Preauricular skin tag and microtia

Question 19

What is choanal atresia

Answer 19

When nasal passages are blocked by tissue or bony septum (90%)

Question 20

When examining the neonate, you note a mass just lateral to the midline. What is your ddx (5)

Answer 20

Cyst Hygroma (lymph sac)
Sternocleidomastoid tumor
Thyroglossal duct cyst
Branchial cleft cyst
Lymphadenopathy

Question 21

You are checking the red light reflex and notice there isnt any. What do you suspect?

Answer 21

Cataracts, retinoblastoma

Question 22

You are attempting the Moro reflex. What do you expect to see?

Answer 22

When the child is startled, the arms will spread in abduction and extension followed by flexion and adduction.

Question 23

You are inspecting a child and find erythema toxicum. Where is this usually found? How would you manage?

Answer 23

Usually found on the trunk. This will resolve spontaneously

Question 24

When inspecting a child, you notice that they have club foot.
What is the medical term?
Would this concern you?

Answer 24

Talipes equinovarus
If positional (can be dorsiflexed) then there is no concern but if it is fixed, then it requires orthopedic referral.

Question 25

What is this finding? Any indications?

Answer 25

Strawberry nevus, no indications unless affecting vision. Then give topical timolol

Question 26

What is this? What is it associated with?

Answer 26

Iris Coloboma. a/w CHARGE syndrome

Question 27

What is this?

Answer 27

Cataract

Question 28

What are some RF for the presence of DDH?

Answer 28

Breach position during birth (legs first)
Macrosomia
Family history of DDH
Female (6x)

Question 29

You suspect the neonate may be susceptible to a hearing problem. How is Newborn hearing screening performed?

Answer 29

AOAE - Automatic otoacoustic emission (earphone in ear to test cochlear function through echo)
AABR - automated auditory brainstem response (computer analysis of electroencephalogram)
Referral to pediatric audiologist

Question 30

What is this finding?
What is it associated with?

Answer 30

Cystic hygroma
associated with Trisomy 21, Noonan’s, and Turner’s

Question 31

What is this finding?
What is it associated with?

Answer 31

Epicanthic folds
Down’s Syndrome

Question 32

What is this child suffering from? His mother says his head is stuck in that position.

What can this cause?

Answer 32

Congenital Torticollis
This is due to the shortening of the sternocleidomastoid muscle which leads to an ipsilateral head tilt and contralateral rotation of the face and chin

This may lead to the child favoring one side and hence may develop plagiocephaly. Advise the parents to stimulate the opposite side. Surgical referral.

Question 33

What should be checked when looking at the eye

Answer 33

Symmetry
Distance (hyper/hypotelorism)
Palpebral fissure upslanted in down’s and downslanted in noonan’s
Opthalmoscope: Red light reflexes/white reflex/unequal refraction/cataract
Subconjunctival hemorrhage
Discharge –> conjunctivitis

Question 34

What is this finding?
What are some RFs? (2)
Give some associated problems (3)
How would you treat?

Answer 34

Cleft Palate
RFs: Maternal use of anticonvulsant therapy, family hx, male gender

Associated problems with feeding and bonding. Recurrent URTI (residue), otitis media (through Eustachian tube)

Question 35

How would you treat cleft lip/palate
When would you treat a cleft lip?
When would you treat a cleft palate?
How would you follow up this patient?

Answer 35

Refer to cleft lip/palate specialist unit for surgical repair
Cleft lip at 3 months
Cleft palate at 9-12 months to allow for maxillary growth for easier access
Long term follow up due to speech and dental problems

Question 36

Describe findings seen in the image. What is the most likely diagnosis?
What are other findings you expect to see with this diagnosis?
The baby becomes apneic and is taken to the ED. Why did this happen?

Answer 36

Pierre Robin Sequence:
Micrognathia, midline cleft palate, and posterior displacement of the tongue which may cause airway obstruction as it falls back => sleep apnea

Question 37

How is Choanal atresia diagnosed?
What is the treatment?

Answer 37

By inability to pass NG tube through either nostril
remember newborns are obligate nose breathers.

tx: Surgical repair