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Clinical Examination > Newborn Infant Physical Examination (NIPE) > Flashcards

Newborn Infant Physical Examination (NIPE) Flashcards

1
Q

What is the purpose of the NIPE?

A

Carried out within 72hrs of birth

To screen for congenital abnormalities that will benefit from early intervention

To make referrals for further tests

To provide reassurance to the parents

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2
Q

Where should you perform the NIPE?

A

Private area, warm and well lit room, changing mat

Parents present if possible - to answer questions and reassure

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3
Q

How do you consent patients/parents?

A

Parents should receive National Screening Committee leaflet on ‘Screening tests for you and your baby’ - if not read, should be given a copy

Ask parents to undress child to nappy whilst you wash your hands

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4
Q

What questions are useful to ask the parents before starting?

A

Pregnancy - date/time/type of delivery, complications, high-risk antenatal screening?

Breech? (if breech at 36wks or delivery - baby to have a full hip USS as increased risk of developmental dysplasia of the hip

Risk factors for neonatal infection - e.g. FHx congenital lung/heart problems, smoking at home

Other FHx - hearing, MSK, heart, eyes, renal etc.

Feeding/urination/meconium passing/parental concerns

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5
Q

What should you do when assessing babies weight?

A

Check weight chart - small (<10th centile), appropriate (10-90th) or large (>90th)

If small - should plot head circumference and length to check if in proportion (foetal factors e.g. genetic abnormality/intrauterine infection) or asymmetrical (placental insufficiency)

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6
Q

What are you looking for on general inspection?

A

Surroundings - ward, ventilation, fluids/drugs, parents etc.

Colour - pallor/cyanosis/jaundice/rashes

Posture - gross abnormality e.g. hemiparaesis?

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7
Q

How do you assess tone? What are some causes of a hypotonic baby?

A

Move the newborn’s limbs passively and when they are picked up (should continue throughout examination)

Hypotonic - ‘floppy’ or ‘rag doll’ appearance - difficulty feeding as mouth muscles cannot maintain a proper suck-swallow pattern or hold on

Causes: genetic syndromes - Down’s, achondroplasia, Ehlers-Danlos, Fragile X, Prader-Willi, Retts etc; congenital cerebellar ataxia and hypothyroidism; Infection - meningitis, sepsis etc; TBI, UMN/LMN lesions; CP

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8
Q

What features of the head do you assess?

A

Size - circumference (record in notes) - microcephaly (?small brain size/atrophy) vs marocephaly (?hydrocephalus, genetic abnormality)

Shape - regular? are sutures tight, widely separated or normal?

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9
Q

What is cranial moulding?

A

Slight change in head shape, common after birth, resolves within a few days

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10
Q

What is caput succedaneum?

A

Diffuse subcutaneous fluid collection - crosses suture lines

Caused by pressure on presenting part of the head during delivery

Usually uncomplicated and self resolving

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11
Q

What is cephalhaematoma?

A

Subperiosteal haemorrhage in 1-2% of infants

Doesnt cross the suture lines

More common with instrumental delivery

May cause jaundice (monitor bilirubin)

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12
Q

What are subgaleal haemorrhages?

A

Occur between aopneurosis of the scalp and periosteum - fluctuant collection of blood crossing suture lines

Rare but life-threatening

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13
Q

What is craniosynotosis?

A

Premature fusion of infant skull - changes growth pattern = possible raised ICP and brain damage

Surgical intervention necessary = excision of the sutures

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14
Q

How do you assess the fontanelle?

A

Palpate anterior fontanelle - flat? (normal) sunken or bulging? (dehydration/hydrocephalus)

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15
Q

What are you looking for in the skin?

A

Colour

Bruising/laceration (from traumatic births)

Facial birthmarks - salmon patch, port wine stain, dry abrasions

Vernix - waxy/cheese-like white substance coating skin of healthy babies

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16
Q

What is a Mongolian spot?

A

Benign, flat, congenital birthmark, wavy irregular borders, blue in colour, often found on the buttocks/back, more common in ethnic minorities

Can look like brusising and so raise child protection issues so important to document presence at birth

Normally disappear within 3-5yrs

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17
Q

What is a nevus simplex?

A

Aka stork bite or salmon patch

Most common congenital capillary malformation in newborns, appearing in first year of life, usually disappearing within 18 months though ones on the back of the neck may never go away

Eyelid, glabella, back of neck

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18
Q

What is a naevus flammeus?

A

Aka, port-wine stain

Large vascular formation that will remain for life

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19
Q

What are milia?

A

Small white cysts containing keratin and sebaceous material

Common on face, most resolve within the first few weeks of life

20
Q

What is erythema toxicum?

A

Very common and benign condition

Various combinations of erythematous macules, papules and pustules

Lesions appear from 48hrs and resolve spontaneously

21
Q

What is neonatal jaundice?

A

Can be physiological

Appears from 2-3 days and lasts until day 10

Also pathology - haemolytic disease, infection, Gilbert’s syndrome

22
Q

What features should you note in the face?

A

Appearance - dysmorphic?

Asymmetry - nerve palsys?

Trauma?

Nose - patency of nasal passages - important as infants are obligate nasal breathers and will go into respiratory distress if they have bilateral choanal atresia (blockage of nasal passage - bone/soft tissue)

23
Q

What are you looking for in the eyes?

A

Evidence of erythema or discharge - e.g. conjunctivitis

Inspect the sclera - look for colour

Position/shape - e.g. ptosis

Assess red reflex with opthalmoscope - absence requires immediate opthalmology f/u (?congenital cataracts or retinoblastoma)

Subconjuncitval haemorrhages - look dramatic but are common and benign

24
Q

How should you assess the ears?

A

Inspect the pinna - asymmetry, prominence

Note position, skin tags etc

25
Q

How should you assess the mouth and palate?

A

Need a tongue depressor and torch - ask parent to keep babies head still

Clefts of the hard or soft palate - must visualise, cannot exclude using palpation alone

Central position of uvula?

Tongue and gums - inspect for evidence of tongue tie

26
Q

How do you inspect the neck and clavicles?

A

Length of neck - short in Turner’s syndrome

Webbing of neck - again in Turner’s

Neck swelling

Clavicular fracture - following traumatic birth e.g. shoulder dystocia

27
Q

How do you inspect the upper limbs?

A

Symmetry - size/length

Fingers - correct number and morphology; any polydactyly

Palms - two palmar creases on each hand? single in Down’s

Palpate brachial pulses

28
Q

How do you inspect the chest?

A

Chest wall deformities - pectus excavatum?

Chest wall expansion- asymmetry in unilateral lung pathology e.g. pneumonia

29
Q

How do you examine the lungs?

A

Note respiratory distress - increased WOB or RR (30-60 normal in newborns)

Auscultate - air entry bilaterally? added sounds? Will probably hear lots of transmitted sounds from upper airways that can be heard all around the chest (because they’re so small)

30
Q

How do you examine the heart?

A

Auscultate

Normal HR 120-150bpm

Added sounds? Where loudest? radiating to axilla or back?

31
Q

How do you examine the abdomen?

A

Inspect for distension

Inspect for inguinal hernias

Palpate:

  • liver should be no more than 2cm bellow costal margin
  • spleen may be palpable
  • kidney only palpable on deep bimanual palpation
  • bladder should not be palpable
32
Q

How do you examine the umbilicus?

A

Inspect for any discharge or hernias

Any nasty smells or erythema?

33
Q

How do you inspect male genitalia?

A

Position of meatus - excluding hypospadias or epispadius

Size - at least 2cm

Hydroceles - collection of fluid in scrotum which will transilluminate

Scrotum - palpate to feel for both testes, if undescended should be followed up with age; bilateral absence = disorder of sexual development and should be investigated

34
Q

How do you inspect female genitalia?

A

Note any ambiguity e.g. congenital adrenal hyperplasia

Inspect labia - not fused?

Inspect clitoris - normal size?

Vaginal discharge - white = normal due to maternal oestrogens

35
Q

How do you inspect the lower limbs?

A

Symmetry - size and length

Tone, movement

Palpate femorals - weak, absent or delayed ?coarctation of aorta

Assess oedema

Assess knees - hyper-extensile/dislocatable?

Assess ankles - talipes? (club foot)

Correct number of digits on feet

36
Q

What is Barlow’s test?

A

Adducing the hip whilst applying slight pressure on the knee with your thumb - direct the force posteriorly

If hip unstable - femoral head will slip over the posterior rim of acetabulum - palpable sensation of dislocation

37
Q

What is Ortolani’s test?

A

Used to confirm posterior dislocation of the hip

Flex hips and knees to 90 degrees - place index fingers on greater trochanter and apply anterior pressure - abduct the infants legs using thumbs

Positive sign = ‘clunk’ as femoral head relocates back into acetebulum

38
Q

How do you inspect the back and spine?

A

Scoliosis

Sacral dimple - associated with spina bifida - if other cutaneous stigmata (hairy patches, naevi etc) + abnormal neuro exam OR pit >5mm/>2.5mm away from anus - USS lower spine

Abnormal skin patches

Birthmarks

39
Q

How do you inspect the anus?

A

Patent?

Meconium should be passed within 24hrs - delay may suggest obstruction or Hirschsprung’s disease

40
Q

How do you assess the palmar grasp reflex?

A

When an object is placed into their hand and strokes their palm, fingers will close

41
Q

How do you assess the sucking reflex?

A

Child will instinctively suck on anything that touches the roof of its mouth

42
Q

How do you assess the rooting reflex?

A

Newborn will turn its head towards anything that strokes its cheek or mouth to aid breastfeeding

Disappears by 4m as it becomes under voluntary control

43
Q

How do you assess the stepping reflex?

A

When the soles of their feet touch a flat surface, will appear to walk - placing one foot in front of the other

44
Q

How do you assess the Moro reflex?

A

Support the infants upper back with one hand and head with the other then drop back once or twice

Legs + head extend, arms jerk up with fingers extended - arms then brought together and fists are clenched

Asymmetry may be due to hemiparesis, brachial plexus injury or fractured clavicle

Disappears between 3-6 months

45
Q

How do you complete the examination?

A

Share assessment results with parents and answer any questions

Thank parents, ask them to redress their child

Wash hands

Document - there is a national online system/form for doing so

Clinical Examination (34 decks)

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