Newborn Infant Physical Examination (NIPE) Flashcards
What is the purpose of the NIPE?
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
Where should you perform the NIPE?
Private area, warm and well lit room, changing mat
Parents present if possible - to answer questions and reassure
How do you consent patients/parents?
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
What questions are useful to ask the parents before starting?
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
What should you do when assessing babies weight?
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)
What are you looking for on general inspection?
Surroundings - ward, ventilation, fluids/drugs, parents etc.
Colour - pallor/cyanosis/jaundice/rashes
Posture - gross abnormality e.g. hemiparaesis?
How do you assess tone? What are some causes of a hypotonic baby?
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
What features of the head do you assess?
Size - circumference (record in notes) - microcephaly (?small brain size/atrophy) vs marocephaly (?hydrocephalus, genetic abnormality)
Shape - regular? are sutures tight, widely separated or normal?
What is cranial moulding?
Slight change in head shape, common after birth, resolves within a few days
What is caput succedaneum?
Diffuse subcutaneous fluid collection - crosses suture lines
Caused by pressure on presenting part of the head during delivery
Usually uncomplicated and self resolving
What is cephalhaematoma?
Subperiosteal haemorrhage in 1-2% of infants
Doesnt cross the suture lines
More common with instrumental delivery
May cause jaundice (monitor bilirubin)
What are subgaleal haemorrhages?
Occur between aopneurosis of the scalp and periosteum - fluctuant collection of blood crossing suture lines
Rare but life-threatening
What is craniosynotosis?
Premature fusion of infant skull - changes growth pattern = possible raised ICP and brain damage
Surgical intervention necessary = excision of the sutures
How do you assess the fontanelle?
Palpate anterior fontanelle - flat? (normal) sunken or bulging? (dehydration/hydrocephalus)
What are you looking for in the skin?
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
What is a Mongolian spot?
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
What is a nevus simplex?
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
What is a naevus flammeus?
Aka, port-wine stain
Large vascular formation that will remain for life
What are milia?
Small white cysts containing keratin and sebaceous material
Common on face, most resolve within the first few weeks of life
What is erythema toxicum?
Very common and benign condition
Various combinations of erythematous macules, papules and pustules
Lesions appear from 48hrs and resolve spontaneously
What is neonatal jaundice?
Can be physiological
Appears from 2-3 days and lasts until day 10
Also pathology - haemolytic disease, infection, Gilbert’s syndrome
What features should you note in the face?
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)
What are you looking for in the eyes?
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
How should you assess the ears?
Inspect the pinna - asymmetry, prominence
Note position, skin tags etc
How should you assess the mouth and palate?
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
How do you inspect the neck and clavicles?
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
How do you inspect the upper limbs?
Symmetry - size/length
Fingers - correct number and morphology; any polydactyly
Palms - two palmar creases on each hand? single in Down’s
Palpate brachial pulses
How do you inspect the chest?
Chest wall deformities - pectus excavatum?
Chest wall expansion- asymmetry in unilateral lung pathology e.g. pneumonia
How do you examine the lungs?
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)
How do you examine the heart?
Auscultate
Normal HR 120-150bpm
Added sounds? Where loudest? radiating to axilla or back?
How do you examine the abdomen?
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
How do you examine the umbilicus?
Inspect for any discharge or hernias
Any nasty smells or erythema?
How do you inspect male genitalia?
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
How do you inspect female genitalia?
Note any ambiguity e.g. congenital adrenal hyperplasia
Inspect labia - not fused?
Inspect clitoris - normal size?
Vaginal discharge - white = normal due to maternal oestrogens
How do you inspect the lower limbs?
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
What is Barlow’s test?
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
What is Ortolani’s test?
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
How do you inspect the back and spine?
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
How do you inspect the anus?
Patent?
Meconium should be passed within 24hrs - delay may suggest obstruction or Hirschsprung’s disease
How do you assess the palmar grasp reflex?
When an object is placed into their hand and strokes their palm, fingers will close
How do you assess the sucking reflex?
Child will instinctively suck on anything that touches the roof of its mouth
How do you assess the rooting reflex?
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
How do you assess the stepping reflex?
When the soles of their feet touch a flat surface, will appear to walk - placing one foot in front of the other
How do you assess the Moro reflex?
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
How do you complete the examination?
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
