Newborn Baby Examination Ellie Duckworth Stage 3 student, University of Cambridge School of Clinical Medicine 2nd May 2015

Newborn examination Newborn babies must be examined within 24 hours of birth Purpose of the examination: Detect congenital anomalies not already detected at birth Check for potential problems arising from maternal or familial disease Checked again at 6 weeks old (usually by GP)

Examination routine Usually described as examining ‘top to toe’ In reality, adapt the order of examination to when the baby is settled or crying: Auscultation first (before removing rest of clothing) Palate – more visible when the baby is crying, or feel with finger Sucking reflex – can also help to calm the baby down Leave most distressing parts until the end e.g. Moro reflex & hip examination

History Key points in taking a history from the mum: Pregnancy and mode of delivery Did they cry straight after birth? Any problems with breathing? Family history Congenital heart disease Hearing problems Hip dysplasia Has baby passed urine or meconium yet? Any problems with breast/bottle feeding?

General observations Undress down to the nappy Remember to look at the baby’s back as well Skin Colour Skin lesions Respiratory effort Spontaneous movements and posture – symmetrical? Dysmorphic features Good idea to learn a few key features associated with syndromes e.g. Downs

Erythema toxicum (neonatal urticaria) Illustrated textbook of paediatrics (Lissauer) Peripheral cyanosis www.nursingcrib.com Milia These are all skin lesions in newborns that resolve spontaneously. Peripheral cyanosis of the hands and feet is common in the first day of life. Milia – white pimples – retention of keratin and sebaceous material in the pilaceous follicles Erythema toxicum – common rash 2-3 days old, white pinpoint papules surrounded by erythema (fluid contains eosinophils) Blue spots – usually at base of spine & buttocks. More commonly seen in Afro-Caribbean & Asian babies. Fade slowly over first few years. Very important to document in newborn check – may be mistaken for bruises later (NAI) Erythema toxicum (neonatal urticaria) Mongolian Blue spot Illustrated textbook of paediatrics (Lissauer) Illustrated textbook of paediatrics (Lissauer)

Head Measure head circumference Fontanelle Tense Raised ICP Meningitis (late sign) Sunken Dehydration 3rd fontanelle Downs Check skull and facial bones for birth injuries Head circumference: Occipitofrontal circumference Tape facing DOWN THREE separate measurements Record the LARGEST of the 3 www.quickmedical.com

Birth injuries – location of extracranial haemorrhages www.abclawcenters.com

Eyes Check red reflex with ophthalmoscope Lack of red reflex Cataracts Retinoblastoma Ophthalmic infections www.kellogg.umich.edu Retinoblastoma

Ears Shape and size ‘Low set’ ears Patency of external auditory meatus www.gethelponline.org Shape and size ‘Low set’ ears Down’s Edwards Di George Turners Noonan Patency of external auditory meatus quizlet.com Edwards Syndrome Di George Syndrome

Mouth Colour of mucus membrane Palate Tongue tie Sucking reflex www.mothering,.com Mouth www.clapa.com High arched palate Colour of mucus membrane Palate High arched – Marfan’s Cleft lip/palate Tongue tie Sucking reflex Rooting reflex newborns.stanford.edu beyondspine.com In real life this is actually easiest to do if baby is yawning/crying Or feel palate/ tongue tie with finger Sucking reflex is very good for calming the baby down too! Rooting reflex – stroke baby’s cheek & they turn to suck the finger Cleft lip Rooting reflex Tongue tie

Arms & Hands Simianline.handresearch.com Check neck, shoulders & clavicles for traction birth injury Count fingers Shape of fingers – clinodactyly Palmar creases – multiple or single Grasp reflex cai.md.chula.ac.th Stroke back of fingers to get baby to open hand Clinodactyly – incurving of the fingers, can be associated with syndromes e.g. Down Single palmar crease (Simian line) can be normal or associated with Down syndrome Can move on to look at feet and legs at the same time Single palmar crease Clinodactyly

Erb’s Palsy Traction to brachial plexus nerve roots (by breech deliveries/shoulder dystocia) C5 & C6 injury  Erb’s palsy Most resolve completely by themselves Other birth injuries – facial nerve palsy shoulderdystociainfo.com Illustrated textbook of paediatrics (Lissauer)

Legs & Feet Watch movement of each joint Check for talipes equinovarus wikipedia Watch movement of each joint Check for talipes equinovarus Count toes Shape of toes Babinski reflex Grasp reflex hellomrdoctor.com Talipes equinovarus Talipes equinovarus – fixed, unable to manipulate feet back to normal position (cf. positional talipes) Babinski reflex – sign is positive (upward going plantar) in babies. This reflex should have disappeared by 2 years old. Babinski reflex

Peripheral pulses Heart Lungs Brachial, radial & femoral Radio-femoral delay Heart Apex beat Heaves or thrills Auscultation Lungs Watch respiratory pattern, rate and depth Grunting, head nodding, intercostal recession, stridor Do femoral pulses later when taking nappy off to look at genitalia

Abdomen Abdominal girth and shape Umbilical stump Omphalocoele/gastroschisis Umbilical stump Infection (Omphalitis) Hernia Palpate for organs, masses or hernia normal to be able to feel liver and/or spleen in newborns External genitalia Undescended testes Inspect anus for patency medscape.com At this point will need to undo nappy to examine abdomen Undescended testes (cryptorchidism) – 4% male term babies (more in prematurity). Unlikely to descend spontaneously after 6 mths so referred for surgical review then Omphalitis

Exomphalos/Omphalocoele Gastroschisis www.cdc.gov www.cdc.gov Omphalocoele – covered by transparent sac of amniotic membrane & peritoneum Gastroschisis – no covering sac – increased risk of dehydration & protein loss Exomphalos/Omphalocoele Gastroschisis

Back Check for skin lesions Palpate down the spine Looking for: Spina bifida occulta Pilonidal sinus Spina bifida occulta (1st pic) – failure of fusion of vertebral arch. May be assoc with overlying skin lesion (tuft of hair, lipoma, birth mark, small dermal sinus) Pilonidal sinus – infected tract under skin between buttocks biology-forums.com

Reflexes Moro’s reflex – birth3mths. Baby in supine position & head suddenly allowed to fall back  symmetrical opening of arms & then closing again Tonic neck reflex (fencing reflex) – birth to 6 mths wikipedia Moro reflex

Hips Checking for developmental dysplasia of the hip (DDH) Baby must be relaxed – crying/kicking causes tightening muscles around hip Middle finger on greater trochanter, thumb around distal medial femur. Hip held flexed & adducted Barlow – femoral head is pushed downwards & so if the hip is dislocatable then the femoral head is pushed posteriorly out of the acetabulum. Then try to abduct  clunk as femoral head returns to acetabulum (Ortolani) Illustrated textbook of paediatrics (Lissauer)

Guthrie test Blood sample (heel prick) taken on day 5-9 of life www.mun.ca Blood sample (heel prick) taken on day 5-9 of life In UK, all infants screened for: Phenylketonuria Hypothyroidism Haemoglobinopathies Cystic fibrosis MCAD (medium-chain acyl-CoA dehydrogenase Others e.g. Maple syrup urine disease namrata.co

Hearing screening Early detection and intervention of severe hearing impairment Prevents delay in speech and language development Evoked optoacoustic emission (EOEA) Earphone over the ear to emit sound The sound evokes an echo/emission from the ear if cochlear function is normal Automated auditory brainstem response (AABR) If normal test not achieved Uses computer analysis of EEG waveforms www.homerton.nhs.uk

Vitamin K Vitamin K deficiency can cause haemorrhagic disease of the newborn Usually mild symptoms – bruising, haematemesis, melaena, prolonged bleeding around umbilical stump Can be severe – intracranial haemorrhage IM injection of vitamin K given to most newborn infants in the UK immediately after birth Parents can request oral vitamin K but this requires 3 doses over first month of life to achieve adequate liver storage Severe vit K deficiency – 50% of those pts are permanently disabled or die

Questions?