Routine examination of the newborn infant

Question 1

Routine examination of the newborn infant

APGAR Score

Answer 1

• The Apgar score is used to describe a baby’s condition at 1 and 5 min after delivery
• It is also measured at 5-min intervals thereafter, if the infant’s condition remains poor.
• The most important components are the heart rate and respiration

Question 2

Neonatal resuscitation

Answer 2

If the infant does not start to breathe, or if the heart rate drops below 100 beats/min, airway positioning and lung inflation by breathing by mask ventilation are started

• tracheal intubation can be performed
• if the heart rate does not increase and adequate chest movement is not achieved, consider ‘DOPE’:
  
  • Displaced tube: often in the oesophagus or right main bronchus
  • Obstructed tube: especially meconium
  • Patient:
• tracheal obstruction
• lung disorders: lung immaturity or respiratory distress syndrome, pneumothorax, diaphragmatic hernia, lung hypoplasia, pleural effusion
• shock from blood loss
• birth asphyxia or trauma
• upper airways obstruction: choanal atresia.

Question 3

Routine examination of the newborn infant

Answer 3

Within 24 h of birth every baby should have a full and thorough examination, the ‘routine examination of the newborn infant’. Its purpose is to:

• detect congenital abnormalities not already identified at birth, e.g. congenital heart disease, developmental dysplasia of the hip (DDH)
• check for potential problems arising from maternal disease or familial disorders
• provide an opportunity for the parents to discuss any questions about their baby.

Question 4

Routine examination of the newborn infant

Answer 4

• Birthweight, gestational age and birthweight
• General observation of the baby’s appearance, posture and movements
• The head circumference is measured
• The fontanelle and sutures are palpated
• The face is observed
• If plethoric or pale, the haematocrit should be checked to identify polycythaemia or anaemia.
• Jaundice within 24 h of birth requires further evaluation
• The palate needs to be inspected, including posteriorly to exclude a posterior cleft palate, and palpated to detect an indentation of the posterior palate from a submucous cleft
• Breathing and chest wall movement
• On palpating the abdomen, the liver normally extends 1–2 cm below the costal margin
• The femoral pulses are palpated.
• The genitalia and anus are inspected
• Muscle tone is assessed by observing limb movements
• The whole of the back and spine is observed
• The hips are checked for developmental dysplasia of the hips

Question 5

Lesions in newborn infants that resolve spontaneously

Answer 5

• Peripheral cyanosis of the hands and feet – common in the first day
• Traumatic cyanosis from a cord round the baby’s neck or from a face or brow presentation
• Swollen eyelids and distortion of shape of the head from the delivery
• Subconjunctival haemorrhages – occur during delivery
• Small white pearls along the midline of the palate (Epstein pearls)
• Breast enlargement – may occur in newborn babies of either sex
• Capillary haemangioma or ‘stork bites’ – pink macules on the upper eyelids, mid-forehead and nape of the neck are common and arise from distension of the dermal capillaries
• Neonatal urticaria (erythema toxicum) – a common rash appearing at 2–3 days of age, consisting of white pinpoint papules at the centre of an erythematous base
• Milia – white pimples on the nose and cheeks, from retention of keratin and sebaceous material in the pilaceous follicles
• Positional talipes – the feet often remain in their in-utero position
• Caput succedaneum

Question 6

Some significant abnormalities detected on routine examination

Answer 6

• Port-wine stain (naevus flammeus). Present from birth and usually grows with the infant
• Strawberry naevus (cavernous haemangioma). Often not present at birth, but appear in the first month of life and may be multiple
  
  • It increases in size until 3–15 months old, then gradually regresses
• Extra digits
• Heart murmur – poses a difficult problem, as most murmurs audible in the first few days of life resolve shortly afterwards. However, some are caused by congenital heart disease. If there are any features of a significant murmur upper and lower limb blood pressures, and pre- and post-ductal pulse oximetry should be checked followed by an echocardiogram
• Midline abnormality over the spine or skull
• Palpable and large bladder
• Talipes equinovarus – which cannot be corrected as in positional talipes

Question 7

Testing for developmental dysplasia of the hip (DDH)

Answer 7

• The pelvis is stabilised with one hand. With the other hand, the examiner’s middle finger is placed over the greater trochanter and the thumb around the distal medial femur.
• The hip is held flexed and adducted. The femoral head is gently pushed downwards. If the hip is dislocatable, the femoral head will be pushed posteriorly out of the acetabulum
• The next part of the examination is to see if the hip can be returned from its dislocated position back into the acetabulum.

Question 8

Vitamin K therapy

Answer 8

• Vitamin K deficiency may result in haemorrhagic disease of the newborn
• can occur early, during the first week of life, or late, from 1 to 8 weeks of age
• In most affected infants, the haemorrhage is mild, such as bruising, haematemesis and melaena, or prolonged bleeding of the umbilical stump or after a circumcision
• some suffer from intracranial haemorrhage, half of whom are permanently disabled or die
• disease can be prevented if vitamin K is given by intramuscular injection

Question 9

Biochemical screening (Guthrie test)

Answer 9

Biochemical screening is performed on every baby. A blood sample, usually a heel prick, is taken when feeding has been established on day 5–9 of life. In the UK, all infants are screened for:

• phenylketonuria
• hypothyroidism
• haemoglobinopathies (sickle cell and thalassaemia)
• cystic fibrosis
• MCAD (medium-chain acyl-CoA dehydrogenase) deficiency – a rare inborn error of mitochondrial fatty acid metabolism causing acute illness and hypoglycaemia following fasting, which may also present as an ALTE (acute life-threatening episode

Question 10

Newborn hearing screening

Answer 10

• Evoked otoacoustic emission (EOAE) testing, when an earphone is placed over the ear and a sound is emitted which evokes an echo or emission from the ear if cochlear function is normal, is used as the initial screening test
• testing with automated auditory brainstem response (AABR) audiometry, using computer analysis of EEG waveforms evoked in response to a series of clicks, is performed, with referral to a paediatric audiologist if abnormal