Routine Examination of the Newborn

Question 1

When is routine exam done and by whom?

Answer 1

Immediately after birth by midwife, paediatrician or obstetrician

Question 2

Why is the routine examination done?

Answer 2

To check for no major abnormalities such as baby should be pink/ breathing normally

Question 3

How do you manage if an immediate problem is found?

Answer 3

• Experienced paediatrician must discuss with parents
• Neonatal unit if v small, preterm or ill
• Uncertain sex- counsel parents that further investigations are needed

Question 4

When should a thorough exam be done?

Answer 4

within 72 hours of birth with parents/ mother

Baby must be naked

Question 5

What do you look for on inspection in thorough examination?

Answer 5

Tone (Head lag, flexion arm/leg, hold by stomach - floppiness indicates neuro/ chromo/ met/ sepsis issue)

Respiratory effort
Crying (good)
Colour
Obvious abnormalities
Assess movement

Question 6

What are you looking for on the skull of an infant?

Answer 6

Head circumference (normal)

Shape

Cranial sutures

Fontanelle (sunken = dehydrated, bluging = raised ICP)

Moulding/ caput/ cephalohaematoma

Question 7

What is moulding?

Answer 7

abnormal head shape that results from pressure on head during childbirth

(overlap/ close skull bones)

can decrease biparietal diameter by about 1 cm

Question 8

What is caput succedaneum?

Answer 8

Caput succedaneum involves serosanguinous, subcutaneous and
extraperiosteal fluid collection with poorly defined margins caused by the
pressure of the presenting part of the scalp against the dilating cervix during
delivery

Question 9

How does caput succedaneum look?

Answer 9

Swelling/oedema of scalp that appears as a lump or bump on their
head shortly after delivery

Typically forms over the vertex and crosses suture lines

Question 10

What is a cephalohaematoma?

Answer 10

A cephalohaematoma is a haemorrhage
of blood between the skull and the
periosteum (membrane that covers the
outer surface of all bones)

No pressure on the brain

Question 11

Why do cephalohaematomas occur?

Answer 11

Occurs in newborn due to small blood
vessels on the fetal head broken as a
result of minor trauma during birth
process

Question 12

When do cephalohaematomas arise?

Answer 12

The bleeding is gradual and hence,

becomes apparent hours-days after birth

Question 13

What does cephalohaematoma look like?

Answer 13

Increases risk of jaundice in the first days after birth

Bilateral parietal swelling

Takes months to resolve

Question 14

What are you looking for on the face?

Answer 14

Dysmorphia
Trisomy 21
Milia
Forcep mark on cheeks
Facial nerve damage
Micrognathia (Pierre Robin syndrome)

Question 15

What are the signs of trisomy 21?

Answer 15

flattened face 
small brachycephalic head
epicanthal folds
flat nasal bridge
small nose and mouth

Question 16

What is milia?

Answer 16

Benign, keratinous cysts appearing as tiny white bumps – should go away in
few days on their own

Question 17

What are signs of facial nerve damage?

Answer 17

Check for eye closure at rest as likely to need eye
lubricant drops to stop dry eye, this will usually resolve spontaneously but
occasionally damage can be permanent

Question 18

What is micrognathian (Pierre Robin syndrome)?

Answer 18

when jaw is undersized; symptom of various
craniofacial conditions; may need respiratory support until growth allows airways to
remain open, trachy in worst affected cases

Question 19

What should you check in ears in infants?

Answer 19

Patent External Auditory canals

Microtia with absent external auditory canals

Low set ears (Trisomy 18)

Question 20

What should you check for in an infants mouth?

Answer 20

Visualise palate

Check reflexes: root and suck

Cleft lip

Cleft palate

Natal tooth

Question 21

What should you check for in an infants eyes?

Answer 21

Red reflexes (cataracts- to stop ambylopia, early surgery)

Sub conjunctival haemorrhage (usually benign and will fade)

Petechiae

Congenital glaucoma/ colobama (Key hole shaped pupil)

Question 22

What should you check for in an infants nose?

Answer 22

Babies only breathe through their nose, not mouth (because their soft palate not as
developed, tongue too big and jaw not as developed, and being able to coordinate
breathing and swallowing is too much)

Question 23

What do you look at in the neck of a newborn?

Answer 23

Tone
Length
Webbing (Turner's)
Swelling
Feel for clavicles (ensure no traumatic fracture)

Question 24

What does hypotonia look like in a newborn?

Answer 24

arms and legs lying flat against bed, with very little head control when
lifting, will flop forwards when held prone (rag doll like)

Question 25

What are the parts of the limb examination in newborns?

Answer 25

``` All limb movement Arms Hands Legs Feet Hips ```

Question 26

How do you examine Arms?

Answer 26

Equal movement on both sides Erb's and Klumpke's palsy Palpate brachial pulse (radial too smol)

Question 27

What is Erb's and Klumpke's palsy?

Answer 27

Erb’s palsy: due to injury to brachial plexus usually due to shoulder dystocia during birth; will usually resolve spontaneously within first week or so, physio referral ``` ▪ Klumpke’s palsy: partial palsy of lower roots of brachial plexus, can occur due to traumatic vaginal delivery causing traction on an abducted arm (e.g. someone catching themselves by a branch as they fall from a tree) ```

Question 28

How do you examine the hands?

Answer 28

Check for 5 fingers (polydactyly and syndactyly) Reflex: Palmar grasp Check crease (Singly may be Trisomy 21)

Question 29

What are the different types of dactyly?

Answer 29

Polydactyly: >5 Syndactyly: partly/ wholly united Clindodactyly: curved finger into plane of palm

Question 30

How do you examine the legs?

Answer 30

Equal movement on both sides? Hemiplegia Equal length and skin folds Check femoral pulses – important for cardiac defects

Question 31

How do you examine feet?

Answer 31

Check for 5 toes (syndactyly, polysyndactyly, sandal gap) Reflex: Plantar grasp, Babinski Positional foot deformities Bilateral fixed talipes Pedal oedema (Chromosomal abnormality like Turner's)

Question 32

How do you deal with hand dactyly?

Answer 32

Polydactyly: • Post axial extra digit: needs specialist plastic surgery referral • Pre axial extra digit: plastics referral Syndactyly: If very severe can cause major functional problems

Question 33

How do you fix foot deformities?

Answer 33

o Positional foot deformity (positional talipes): easy to re-position back into a natural position, physio referral and should resolve with time o Bilateral fixed talipes (unable to easily position in neutral position): needs orthopaedic referral and will need surgical correction

Question 34

Hips don't lie

Answer 34

Look for DDH, dislocated hips, stepping reflex and breech legs

Question 35

How do you manage DDH?

Answer 35

Early detection of DDH is important as early splinting in abduction reduces long-term morbidity → specialist orthopaedic opinion should be sought in DDH

Question 36

What are Barlow and Ortolani's tests?

Answer 36

Barlow’s test (dislocation): pushes the femoral head backwards (toward the bed) and will dislocate the femoral head posteriorly if the hip joint is abnormal (shallow or poorly formed) – you may feel a clunk or an abnormal amount of posterior movement Ortolani’s test will relocate already dislocated femoral heads back into the acetabulum with a palpable clunk

Question 37

What are breech legs?

Answer 37

When a baby is lying bottom or feet first and must be delivered in this position, usually benign and will settle over the first week or so, need to check hips carefully and arrange hip ultrasound

Question 38

What do you look for in the chest?

Answer 38

Rate of breathing Equal chest wall movement Work of breathing (tracheal tug, intercostal and subcostal recession, head bobbing, nasal flaring, resp rate, grunting) Recession Chest shape (e.g. prominent xiphisternum)

Question 39

What do you listen for in the chest?

Answer 39

Equal air entry Normal breath sounds Heart rate Heart sounds Murmur

Question 40

What do you look for in the abdomen?

Answer 40

big but soft Abnormally: Extreme distension, shiny skin, visible veins Hernias Diastasis recti Urate crystals in Nappy Palpate/ listen: abdominal shape, soft and non tender, liver, spleen and kidney (organomegaly/ palpable mass), bowel sounds, check anus is patent and normally situated Bile stained vomit is always abnormal

Question 41

What is the commonest hernia?

Answer 41

Umbilical hernia: very common, almost always benign and will resolve spontaneously

Question 42

What do you look for in male genitalia?

Answer 42

Normal penis Both testes in scrotum Hernias

Question 43

What do you look for in female genitalia?

Answer 43

Normal anatomy Fused genitalia Size of clitoris (large may be CAH) Ambiguous genitalia

Question 44

What abnormalities may you discover on inspection of male genitalia - penis?

Answer 44

Normal size >2cm Hypospadias: urethral opening abnormally situated on underside of penile shaft (can be down at penile base), needs urological/surgical referral and is STRICT contraindication to circumcision Chordae: bend in penile shaft, can occur alone or with hypospadias, needs surgical referral and is contraindication to circumcision until surgical review

Question 45

What abnormalities may you discover on inspection of male genitalia - Scrotum/ Testes?

Answer 45

Normal are like peas, can be hard to feel Bilateral hydrocoeles: check you can get ‘above the mass’ and these will transilluminate brightly, surgical referral needed although most likely to spontaneously resolve Testes not fully descended: in inguinal canal (can often be gently milked into scrotum), GP should review to check descent

Question 46

What abnormalities may you discover on inspection of male genitalia - Inguinal canal?

Answer 46

Bilateral inguinal hernias: unable to feel the top of these masses and generally do not transilluminate. These can easily strangulate and need relatively urgent surgical review. Will need herniotomy

Question 47

How do you manage ambiguous genitalia?

Answer 47

Medical and social emergency, consultant involvement immediately, very careful management of family and urgent investigations. Ideally involve local or regional speciality team right from start.

Question 48

What do you look for when you examine the spine?

Answer 48

Straightness Look and feel all the way down Check for scoliosis/ marks/ moles etc. Lesions near base

Question 49

What lesion may be present near the base of the spine and how do you manage them?

Answer 49

o Sacral dimple: look for base, usually benign and needs no further action unless concern about fistula or associated with other abnormalities o Myelomeningocoele: needs urgent neurosurgical input o Assess sacrum for hair tufts, sacral pits (signs of underlying neural tube defect e.g. spina bifida) - very uncommon now due to folate given in pregnancy. Can get normal pits with no hair surrounding it, and can see where the pit ends — if none of these, must refer for SPINAL ULTRASOUND

Question 50

What do you look for on the skin?

Answer 50

Birth marks Jaundice Dry/ peeling skin Blood vessels

Question 51

What do parents need to be aware of when they leave?

Answer 51

Back to sleep and SIDS prevention information Routine screening (Guthrie test)- PKU, congenital hypothyroid, CF, MCADD, SCD + Hearing Routine health checks with midwife, HV and GP Routine childhood immunisation schedule Breastfeeding support groups