Paediatrics: Physical Exam of Newborn

Question 1

Examination - Special Features of the Newborn

Answer 1

1. Small size
2. Uncooperative
3. Hypothermia on cold exposure (skin-mottling)
4. Neurological state varies with sleep, feeding, etc.
5. On going transitional changes in first few days of life e.g. changes in pulmonary pressure will affect the signs related to congenital heart disease (even if baby has VSD, since pulmonary pressure is still very high, there won’t be significant flow, thus you can’t hear the murmur in the first few weeks until there is pressure difference between L & R side)
6. Impact of intrauterine pressure effect (deformation) and birth process e.g. head molding, abnormal posture associated with breech presentation

Question 2

Aims of Newborn Examination

Answer 2

• Assess baby’s ability in adapting to extra-uterine life especially the cardiopulmonary status
• Look for major congenital anomalies, esp. those requiring urgent treatment
• Identify at risk babies that need postnatal monitoring and investigation based on perinatal history, stage of maturity, variation in size, presence of systemic or neurological abnormalities
• Mother’s competence in child care

Question 3

Examination- General observation

Answer 3

• Size, body proportion, maturity
• Colour e.g. plethora, pallor, cyanosis, jaundice, (skin mottling)
• Posture
• Cutaneous discoloration
• Generalized edema
• Gross malformation and dysmorphic features

Question 4

What is this?

Answer 4

Vernix caseosum: Cheesey whiteish thing covering the baby

[This is a protective layer, can help with better skin development] = some mothers may ask baby not to take bath for a few days, no need to wipe away

Sebum + protective factors
Mixture of detached skin, sebum

Question 5

What is this?

Answer 5

Erythema toxicum: Erythematous base with white papules, if you take away white papules and put under microscope, you will see eosinophils

Skin reaction to change from utero environment to external environment

Question 6

What is this?

Answer 6

Mongolian spot: usually over lumbosacral region, by 6-8 y/o will go away, it goes away

NOT melanocytic naevus

Question 7

What is this?

Answer 7

Petechiae: Should not be blanchable (DDx vascular lesions, which are blanchable)

Exclude congenital infections, clotting disorders (i.e. platelet)

Could be due to shoulder dystocia

Question 8

Examination of head and face

Answer 8

Head
* size (head circumference) and shape
* sutures and fontanelles, anterior fontanelle pressure (full and bulging in meningitis)
* caput succedenum, cephalhaematoma, subaponeurotic haemorrhage

Face
* dysmorphic features
* mouth lesion e.g. cleft palate
* eyes

Question 9

Answer 9

Salmon patch: Capilary malformation, blanchable

If it is very dark, if could be Sterg Weber

Question 10

Answer 10

Cephalhaematoma: Never cross suture line [not bleeding tendency, just due to combression to bony prominence]

Subaponeurotic haematoma: bleeding below aponeurosis, crosses midline! Subaponeurotic space can hold up to 200-300ml in newborn baby [life-threatening]

Baby looks like he’s wearing helmet, ears are pulled forward = subaponeurotic haematoma

Question 11

Examination of Neck & Skeletal System

Answer 11

Down’s syndrome, Noonan’s syndrome

Question 12

What is this?

Answer 12

Lymphedema of foot (if it is not pitting, it is lymphaedema, if it is pitting, could be heart failure, liver problem, kidney syndrome)

Question 13

Answer 13

Down syndrome

Question 14

What is this?

Answer 14

Patau syndrome

Question 15

What is this?

Answer 15

Corneal opacity

Question 16

How to perform cardio-respiratory assessment?

Answer 16

Look and Listen:
* peripheral vs central cyanosis
* stridor, grunting
* respiratory distress (tachypnoea, intercostal insucking)
* asymmetry

Feel:
* pulses
* cardiac impulses

Auscultate:
* Heart sounds, murmur
* Breath sounds, added sounds

Question 17

What are normal cardio-respiratory parameters?

Answer 17

• HR 120 (range -90 to160/min), slower when sleeping
• Pulses volume equal
• Normal apex beat at 5th ICS mid clavicular line
• Transient Innocent murmur common
• Respiratory rate 40-50 /min, higher in preterm infants with occasional periodic breathing

Question 18

abd examination of newborn

Answer 18

Look
* shape and size, umbilicus; visible veins, visible peristalsis (pyloric stenosis)
* External genitalia, perineum
* Hernia
* Anal patency

Feel
* Superficial palpation for or obvious mass / tenderness
* for liver ( normal 1-2 cm below costal margin soft), spleen, kidneys and other masses

Listen
* bowel sounds
* bruits

Question 19

Answer 19

This is Hirschsprung disease

NEC is very red

Question 20

Answer 20

Anal atresia with fistula: no proper anus, meconium coming out from fistula

Question 21

Answer 21

Hypospadias: DON’T CIRCUMCISE YET

The excess skin is needed to repair the hypospadias

Question 22

How to examine spine and hip?

Answer 22

Back
* Spina bifida, swellings
* Stigmata of underlying spinal defect –midline dimples, mass, tufts of hair, haemangioma
* Deformities e.g. scoliosis

Hips

Question 23

Neurological Examination

Answer 23

• State of alertness
• Posture e.g. flaccid, spasticity, focal abnormality e.g. Erbs palsy
• Muscle tone, tendon jerks
• Spontaneous movements
• Primitive reflexes –Moro, grasp, suckling, rooting
• Cranial nerves: eye movements, facial asymmetry, swallowing

Question 24

Norms and warning signs in neurological examination

Answer 24

Norms
* Predominantly flexor tone (reduced tone in premature infants)
* Sleeping for 18-20 hours/day, most alert mid-way between feeding, irritable when hungry
* Best visual at 18 inches but no consistent visual fixation
* Concomitant squint

Warning signs
* Frog like posture
* Jitteriness
* Altered conscious state
* Bulging fontanelles

Question 25

What posture is this?

Answer 25

Flexed posture

Question 26

Answer 26

Frog-like posture, abnormal

Question 27

Answer 27

L-side is flaccid = Erb’s palsy [C5-C6 injury] (internal rotation of arm + waiter’s tip)

Can have fractured clavicle

Question 28

How to screen for hip dislocation?

Answer 28

Ortolani: dislocate a dislocatable hip, then relocate to socket (flex hip and knee region, then push it back while holding knee = if it an unstable hip, you will dislocate the hip out of the socket) [ABduction, then push it back] (open the hip, then use finger to relocate dislocated hip back into the socket)

Barlow

If you hear any sound, book U/S and refer to orthopaedics [if you miss this, you will affect baby’s walking] = stabilise hip with pelvic harness (help hip develop)

Socket may be underdeveloped initially