Routine Examination Of Newborn Infant

Question 1

When must it be performed?

Answer 1

Within 72 hours of birth by a qualified practitioner

Question 2

What is the purpose of the examination?

Answer 2

• Screen for congenital abnormalities that will benefit from early intervention and have not already been detected at birth e.g eye abnormalities, CHD, undescended testes, DDH
• check for potential problems arising from maternal disease or familial disorders

To make referrals for further tests or treatment as appropriate
To provide reassurance to parents

Question 3

A second examination is performed when?

Answer 3

At 6-8 weeks of age, usually by GP to identify abnormalities that develop or become apparent later

Question 4

What is another name for it?

Answer 4

The Newborn Infant Physical Examination (NIPE)

Question 5

Where should it be done?

Answer 5

Private area which provides confidentiality to parents
Room should be warm and well lit
Changing mat to carry out examination
Always make sure parents are present

Question 6

What booklet should parents have received beforehand?

Answer 6

Screening tests for you and your baby

Question 7

Before approaching the mother and baby, what should be checked?

Answer 7

Obstetric and neonatal notes to identify relevant information

Question 8

What information should you gather initially?

Answer 8

Date, time and type of delivery
Were there any delivery complications
Antenatal screening results
If breech at 36w gestation or delivery the baby will need USS of hips (increased DDH risk)
RFs for neonatal infection
FH - first degree relatives with earring problems/hip dislocation/CHD/congenital cataracts/renal problems

Newborn history:
Feeding pattern
Urination
Passing of meconium
Parental concerns

Question 9

In terms of weight, what information is required?

Answer 9

Ensure it is recorded and check on weight chart - is baby small/appropriate/large for gestational age?
Measure head circumference with paper tape

Question 10

What should be noted on general inspection?

Answer 10

Inspect colour of infant
Pallor - anaemia or poor perfusion e.g congestive cardiac failure
Cyanosis - bluish discolouration due to poor circulation or inadequate oxygenation of blood
Jaundice

Inspect the posture - note any gross abnormalities e.g hemiparesis or Erb’s palsy

Question 11

How should you assess tone?

Answer 11

Gently move limbs passively and observe newborn as picked up
Hypotonic infants feel like a rag doll, often have feeding difficulties as their mouth muscles cannot maintain proper suck-swallow pattern o good breast feeding latch

Hypotonia common in children with Down’s syndrome

Question 12

How should the head be assessed?

Answer 12

Measure size = surrogate measure for brain size
Inspect shape
Inspect cranial sutures and note if closely applied, widely separated or normal
Cranial moulding is common after birth and resolves within a few days
Head shape abnormalities: cranial moulding, caput succedaneum, cephalhaematoma, subgaleal haemorrhages, craniosynostosis
Palpate anterior fontanelle

Question 13

A tense, bulging fontanelle when baby not crying may suggest…

Answer 13

Raised ICP - cranial USS should be performed to check for hydrocephalus
A tense fontanelle is also a late sign of meningitis

Question 14

A sunken fontanelle may suggest what?

Answer 14

Dehydration

Question 15

How should the face be assessed?

Answer 15

Note any dysmorphic features (may represent a syndrome e.g Down syndrome, which is most common)
Note any asymmetry of face e.g facial nerve palsy secondary to instrumental delivery
Facial trauma e.g bruising or lacerations
Inspect nose patency

Question 16

How will infant present if they have bilateral choanal atresia?

Answer 16

Respiratory distress and cyanosis at rest

Question 17

Describe eye assessment

Answer 17

Inspect for erythema or discharge
Inspect sclera for jaundice or subconjunctival haemorrhage (SCH fairly common after delivery and are benign, but should document there presence)
Inspect position and eye shape
Check red reflex with ophthalmoscope

Question 18

If red reflex is absent, what may be cause?

Answer 18

Congenital cataracts
Retinal detachment
Retinoblastoma
Vitreous haemorrhage

Question 19

An absent red reflex or presence of white reflex requires…

Answer 19

Immediate ophthalmology referral

Question 20

How do you assess for the red reflex?

Answer 20

Look through ophthalmoscope, shining the light towards the patient’s eye at a distance of approximately one arms length
Observe for a reddish orange reflection in each pupil = light reflecting back from the vascularised retina

Question 21

What should be looked for with regards to the mouth and palate?

Answer 21

Look for cleft of hard or soft palate
Including posteriorly, to exclude posterior cleft palate
Will need to use tongue depressor and torch and ask parent to keep baby’s head still
Check uvula
Inspect tongue and gums - look for evidence of tongue tie

Question 22

How should you inspect the neck and clavicles?

Answer 22

Inspect neck length
Note any webbing of neck
Inspect for neck lumps - in the left posterior triangle may represent a cystic hygroma (blockage in lymphatic system)
Look for evidence of clavicle fracture - bruising, discontinuity, abnormal arm position

Question 23

Describe the upper limb assessment

Answer 23

Assess symmetry
Inspect fingers, count number and note abnormal morphology
Inspect palms - check the child has 2 palmar creases
Palpate brachial pulse on each upper limb, note asymmetry (May suggest vascular abnormality e.g coarctation of aorta)

Question 24

What is a single palmar crease associated with?

Answer 24

Down syndrome

Question 25

Describe chest assessment

Answer 25

Check RR
Normal RR for newborn = 40-60
Check for signs of increased work of breathing
Inspect for pectus excavatum and pectus carinatum
Asymmetrical chest wall expansion may suggest lung pathology e.g pneumonia, pneumothorax
Auscultate lung and heart
Normal HR for newborn = 120-150bpm
Pulse oximetry (some centres recommend checking preductal and post ductal oxygen saturations to improve CHD detection)

Question 26

Describe the abdominal assessment

Answer 26

Inspect for distension
Inspect umbilicus - note swelling (hernia), erythema of discharge (umbilical stump infection)
Inspect for inguinal hernia in groin
Palpate abdomen:
- liver should be palpable no more than 2cm below costal margin
- spleen may be palpable at left costal margin
- kidneys usually only palpable using deep bimanual palpitation (if easy, consider polycystic kidney disease)
- bladder should not be palpable

Question 27

The femoral pulses should be palpated. Their pulse pressure is reduced and increased in..

Answer 27

Reduced: coarctation of aorta
Increased: PDA

Question 28

How should genitalia be assessed?

Answer 28

Note any ambiguity of genitalia - CAH especially in girls
Males:
- position of urethral meatus
- size of penis (at least 2cm)
- evidence of testicular swelling indicative of hydrocele
- palpate scrotum to ensure both testes present

Females:

• inspect labia to check they are not fused
• ensure clitorus normal size
• note any vaginal discharge (white is normal and caused by exposure to maternal oestrogen)

Inspect anus for patency

Question 29

Is unilateral undescended testis common?

Answer 29

Yes and should followed up over time

Bilateral = disorder of sexual development and should be investigated

Question 30

How should lower limbs be assessed?

Answer 30

Symmetrical
Check for oedema - hypoalbuminaemia or CCF
Ankle deformities - talipes foot (turned inwards)
Check digit number
Assess tone of both lower limbs and movement
Assess range of knee joint movement
Hip - Barlow and Ortolani tests

Question 31

What is Barlow’s test?

Answer 31

Stabilise hip with one hand
With other hand:
Middle finger over greater trochanter and thumb around distal femur

Hip held flexed and adducted
Gently push downwards
If hip is unstable, the femoral head will slip out the acetabulum (dislocation)

If the hip is dislocatable = positive test
The Ortolani manoeuvre is used to confirm positive finding

Question 32

What is the Ortolani test?

Answer 32

Done to confirm posterior dislocation
In same position as Barlow’s:
Gently abduct the hip
Upward leverage applied

Positive = distinctive ‘clunk’ which can be heard and felt as femoral head relocates into acetabulum

Question 33

Are ligamentous clicks without any movement of head of femur, of significance?

Answer 33

No

Question 34

Is DDH more common in girls or boys?

Answer 34

Girls 6x

Question 35

How should the back and spine be assessed?

Answer 35

Inspect for scoliosis, hair tufts, naevi, birthmarks, sacral pits

Question 36

What reflexes should be present?

Answer 36

Palmar grasp 
Sucking reflex
Rooting reflex 
Stepping reflex 
Moro reflex

Question 37

Will most babies support their head briefly when the trunk is held vertically?

Answer 37

Yes

Question 38

Describe the palmar grasp reflex

Answer 38

When object placed in infants hand and strokes their palm , the fingers will close and they will grasp it with a palmar grasp

Question 39

Describe the sucking reflex

Answer 39

Child instinctively sucks anything that touches the roof of their mouth

Question 40

Describe the rooting reflex

Answer 40

Present at birth and disappears around 4 months as it comes under voluntary control
Newborn turns it’s head toward anything that strokes it cheek or mouth to aid breastfeeding

Question 41

Describe the stepping reflex

Answer 41

When the soles of the infants feet touch a flat surface they will appear to walk by placing one foot in front of the other

Question 42

Describe the moro reflex

Answer 42

Support upper back with one hand then drop back once or twice into other hand
A normal reflex involves extension of legs and head whilst the arms jerk upwards with fingers extended. The arms then brought together and hands clench into fists and infant cries