Perinatal Medicine Flashcards
Events leading up to Newborn infant physical examination (NIPE)
- baby condition stable → midwife/paediatrician check if baby pink + breathing normally + no major abnormalities
- if sig problem found → explain to parents
- preterm/small/ill → admission to neonatal unit
- problem with baby’s sex → explain to parents further evaluation necessary
- give Vit K at birth to prevent VKDB unless parents do not give consent
- within 72 hours = full examination/NIPE
purpose of NIPE
- Detect congenital abnormalities: eye, CHD, undescended testes, DDH
- check for potential problems arising from maternal disease or familial disorders
- provide an opportunity for parents to discuss any questions about their baby
when should NIPE be repeated, and by who?
6-8 weeks of age, usually by the GP
Newborn infant physical examination
- Birthweight (centile) + gestational age
- General observation (appearance, posture, movements)
- Head circumference (centile, max 3 measurements, surrogate for brain size)
- fontanelles + sutures: palpate, anterior fontanelle size variable, sagittal often separated, coronal may be overriding, tense fontanelle when baby not crying may be raised ICP → cranial USS to check for hydrocephalus
- face: Down syndrome
- plethoric/pale: Hot measured (polycythaemia/anaemia), central cyanosis (best seen on tongue)
- jaundice: within 24hrs birth requires further evaluation
- eyes: ophthalmoscope red reflex (if absent → cataracts)/retinoblastoma/corneal opacity
- palate: posterior cleft palate, palpate to detect indentation of posterior palate from a sub mucous cleft
- breathing and chest wall movement: respiratory distress
- palpating abdomen: liver extends 1-2cm below costal margin, spleen tip may be palpable as may the kidney on left side, intra-abdominal masses need further ix
- femoral pulses: pulse pressure reduced in aortic coarctation, increased in patent ductus arteriosus
- genitalia and anus: anus potency, presence of testes in scrotum
- muscle tone: if abnormal/asymmetrical, primitive reflexes may be checked
- back and spine
- hips: for DDH (left last as procedure is uncomfortable)
Conditions in newborn infants that resolve spontaneously
- peripheral cyanosis of hands + feet: common in first day
- traumatic cyanosis: cord around baby neck → blue discolouration, petechiae over head and neck or affected part but not tongue
- swollen eyelids and distortion of shape of the head from delivery
- subconjunctival haemorrhages: during delivery, but documented to avoid confusion with NAI when older
- small white pearls along midline of palate (Epstein pearls)
- cysts of gums (epulis) or floor of mouth (radula)
- breast enlargement: small amount of milk may be discharged
- white vaginal discharge or small withdrawal bleed in girls
- capillary haemangioma or ‘stork bites’
- erythema toxicum: 2-3 days of age, common, white pinpoint papule at centre of an erythematous base, fluid contains eosinophils, concentrated on trunk, come and go at different sites
- milia: white papule on nose and cheeks, from keratin retention and sebaceous material in the pilosebaceous follicles
- congenital dermal melanocytosis (Mongolian blue spots): blue-grey macular discolouration at base of spine and buttocks, misdiagnosed as bruises
- umbilical hernia: common
- positional talipes: feet remains in utero position, unlike true talipes equinovarus, the foot can be fully dorsiflexed to touch he front of the lower leg
Some significant abnormalities detects on routine examination
- Port-wine stain (naevus flames): vascular malformation of capillaries in dermis
- Strawberry naves (infantile haemangioma): appear in first month of life and may be multiple, increase in size 3-15 months of age then gradually regress, more common in preterm infants, topical timolol (b-blocker to speed regression), oral propanolol with large lesions or interferes with vision or airway, ulceration/haemorrhage may occur
- natal teeth consisting of the front lower incisors: remove if loos as aspiration risk
- extra digits: sometimes connected by thin skin tag
- heart murmur: most murmurs in first few days of life resolve shortly afterwards, some caused by CHD. If doubt → UL/LL BPs + pre-ductal/post-ductal pulse oximetry followed by echocardiogram
- midline abnormality over the spine or skull: e.g. tuft of hair, swelling or naevus → further eval as may indicate underlying abnormality of vertebrae, spinal cord, or brain
- palpable and large bladder: UOO particularly in boys with posterior urethral valves, eval with USS
- talipes equinovarus
Checking for DDH (2 manoeuvres)
Infant needs to be relaxed
Pelvis stabilised with one hand, other hand middle finger placed over greater trochanter and thumb around the distal medial femur
Barlow manoeuvre = hip held flexed, femoral head gently adduct and pushed downwards → if hub dislocatable, femoral head will be pushed posteriorly out of the acetabulum
Ortolani manoeuvre = abduct hip, upward leverage applied, dislocated hip will return with clunk into acetabulum
Should be possible to abduct hips fully, restricted if hips dislocated
DDH RFs
female
positive FHx
breech presentation
neuromuscular disorders
DDH Ix and Tx
tx:
- early recognition and splinting
- seek orthopaedic opinion
ix:
- USS of hip joint (not currently recommended in UK as expensive, requires considerable expertise, and many false positives)
Vitamin K
VKDB:
- first week of life or 1-8 weeks of age
- mostly mild = bruising, haematemesis, melaena, prolonged bleeding of umbilical stump
- severe = intracranial haemorrhage → disabled/die
Vit K levels
- low in breast milk, high in formula
- low when taking anticonvulsants
- liver disease
Tx:
- IM after birth
- some parents prefer oral preparation (3 doses over first 4 weeks of life to achieve adequate liver storage)
- mothers on anticonvulsant therapy = oral prophylaxis from 36 weeks’ gestation and baby give IM vitamin K
Newborn hearing screening
To detect severe hearing impairment
Automated otoacoustic emission (AOAE) testing as initial screening test
- refer to paediatric audiologist if abnormal test result
Automated auditory brainstem response (AABR) audiometry: computer analysis of EEC waveform evoked IRT series of clicks
Oxygen saturation screening for critical CHD
Within first 24 hours of life to identify duct-dependent CHD as early diagnosis and tx can prevent collapse when duct closes 24-48 hours after birth
- low post-ductal O2 sat (left hand/feet) or abnormally large difference between pre-ductal (right hand) and post-ductal measurments → medical review and ECG
universal screening not approved in UK but performed in some hospitals
newborn blood spot screening
CF screening
on all babies
blood sample (heel prick) taken when feeding established on day 5 to detect:
- congenital hypothyroidism
- haemoglobinopathies (sickle cell and thalassaemia)
- CF
- 6 inherited metabolic diseases = PKU, MCAD, maple syrup urine disease, isovaleric academia, glutamic acuduria type 1, homocystinuria
CF screening = serum immunoreactive trypsin measurement (raised if pancreatic duct obstruction) → if raised, DNA analysis to reduce false-positive rate
