1. Infant Examination & Common Infant Problems
Dr Ian Woodcock
ST3 Paediatrics

2. Aim Newborn Examination Problems found during baby check
Common Infant Problems presenting in first few weeks of life:
Vomiting
Breathing Difficulties (very briefly)
Colic
Jaundice

3. Why is newborn check useful?
Detecting medical problems
Parents value early diagnosis
Outcome can be improved
Enables planning of services

4. Newborn Examination
What do we examine in the newborn and six week baby checks?
Head to toe examination
Head
Eyes
Palate
Tone
Heart
Chest
Abdomen
Genitalia
Anus
Hips
Femorals
Spine
Arms + Hands
Legs + Feet
Skin

5. General inspection How is the baby doing generally?
Family history congenital problems
Antenatal concerns?
Inspect for dysmorphic features?
Feeding
Passed urine?
Passed meconium?

6. RED FLAGS

7. Specific things to think about!
Heart Murmurs
Femoral Pulses
Undescended Testes
Absent red reflex
Dislocatable / dislocated hips
Sacral dimples
Imperforate anus

8. Infant Examination Eyes Head Palate Tone Heart Chest Abdomen Femorals
Genitalia
Anus
Hips
Spine
Arms + Hands
Legs + Feet
Skin

9. Absent Red Reflexes
What does it mean?
Take Action

12. Red reflexes
Normal
Red reflex absent
Red reflex abnormal

13. Absent Red Reflexes
Congenital Cataracts
Optimal time for surgery is 4 – 6 weeks
Should be referred to an ophthalmologist early
Sub-conjunctival haemorrhages are of no significance.

14. Infant Examination Palate Head Eyes Tone Heart Chest Abdomen Femorals
Genitalia
Anus
Hips
Spine
Arms + Hands
Legs + Feet
Skin 16

15. Tongue-tie
Usually do not require surgery, except if interfering with breast feeding; the tongue grows forward in 1st year

17. Infant Examination Heart Head Eyes Palate Tone Chest Abdomen Femorals
Genitalia
Anus
Hips
Spine
Arms + Hands
Legs + Feet
Skin 23

18. Heart Murmurs Duct dependent lesions
Baby only well if Ductus Arteriosus is open – this will close spontaneously at 6 – 60 hours of life, then the baby collapses
The vast majority of these babies have low sats (<94%) prior to the duct closing

19. Heart Murmurs What are the signs of heart failure?
What would you tell parents?

20. Signs of heart failure Breathless / breathing too fast Sweaty
Not completing feeds
Poor weight gain / Excessive weight gain
Poor colour
Sleepy
“Not quite right”
ASK FOR HELP – A&E or GP

21. Infant Examination Femorals Head Eyes Palate Tone Heart Chest Abdomen
Genitalia
Anus
Hips
Spine
Arms + Hands
Legs + Feet
Skin 38

22. Femoral Pulses
If they are absent what does it mean?

23. Femoral Pulses Absent femoral pulses implies coarctation of the aorta
Baby is at risk of sudden, unexpected collapse and may die without appropriate treatment

24. Infant Examination Genitalia Head Eyes Palate Tone Heart Chest Abdomen
Femorals
Genitalia
Anus
Hips
Spine
Arms + Hands
Legs + Feet
Skin 41

25. Undescended testes If bilateral undescended testes, what does it mean?
These babies may be FEMALE, especially if also have hypospadias

26. Hypospadias
Posterior hypospadias (particularly in the absence of palpable gonads) should be treated as ambiguous genitalia

27. Male genitalia - hypospadius
1in 300
Combination of
1. Abnormal ventral opening of urethra
2. Ventral curvature (chordae) of penis
3. Hooded foreskin, deficient ventral skin
Classified
Coronal,distal,midshaft,proximal,perineal

28. Ambiguous Genitalia

29. Ambiguous Genitalia

30. Bilateral Undescended Testes
The baby may have Congenital Adrenal Hyperplasia
Steroid pathway problem
Enzyme
Steroid precursor
Cortisol
Testosterone

31. Bilateral Undescended Testes
Absence of Cortisol
Salt losing crisis
Non-specifically unwell (short time period)
Fits
Death

33. Female genitalia
Oestrogen withdrawal bleeding Can occur in female infants aged days
Not significant

34. Infant Examination Anus Head Eyes Palate Tone Heart Chest Abdomen
Femorals
Genitalia
Anus
Hips
Spine
Arms + Hands
Legs + Feet
Skin 53

35. Imperforate anus
Can be subtle
Needs early diagnosis and surgery

36. Investigation: Cross Table Lateral AXR in Prone Position

37. Infant Examination Hips Head Eyes Palate Tone Heart Chest Abdomen
Femorals
Genitalia
Anus
Hips
Spine
Arms + Hands
Legs + Feet
Skin 59

38. Dislocatable / dislocated hips
This does not include clicky hips!
Refer up to paediatrics urgently

39. Non-urgent hip referrals
Risk factors for DDH
Can you think of 4………..?

40. Hip Referrals (non-urgent)
1st degree relative
Breech
Significant talipes
Abnormal examination

41. Infant Examination Spine Head Eyes Palate Tone Heart Chest Abdomen
Femorals
Genitalia
Anus
Hips
Spine
Arms + Hands
Legs + Feet
Skin 63

42. Sacral dimple

43. Sacral Dimples Can you see the bottom of the dimple?
If not urgent referral
More worried if….
Poor leg movement
Bowels not open

44. Infant Examination Skin Spine Head Eyes Palate Tone Heart Chest
Abdomen
Femorals
Genitalia
Anus
Hips
Spine
Arms + Hands
Legs + Feet
Skin

45. Milia

46. Erythema toxicum

47. Mongolian blue spot

48. Capillary haemangioma

49. Naevus
What size naevus would you be worried about?

50. Naevus
Refer any naevus greater than 2 cms diameter (risk of malignant change)

51. Vesicles
Can be serious
Herpes can kill very rapidly

52. Chicken pox
Refer urgently
Contact infection control ASAP

53. Things to Refer…

54. Acute Referrals Congenital heart disease including all heart murmurs
Absent femoral pulses
Ambiguous genitalia, hypospadias or bilateral undescended testes.
Skin vesicles, moderate umbilical sepsis, pustules, bullae
Spinal or sacral pits where the base is not easily visible

55. Urgent Referrals
Babies with possible genetic or syndromic abnormalities
Cleft lip and or palate abnormalities (contact cleft team asap – if no antenatal plan for urgent referral)
Absent red reflex
Significant naevi
Babies with antenatal diagnosis of bilateral renal pelvis dilatation or dilatation >10mm
Babies with clinically dislocatable hips
Possible brachial plexus injury

56. Paediatric Out Patients Referrals
Definite or possible fixed talipes
Babies requiring post natal investigation for possible inherited conditions
Other significant abnormalities found on antenatal screening or at the time of delivery
Any other baby about which you have concerns

57. Common Infant Presentations to GP
Vomiting
Infantile Colic
Bronchiolitis
Jaundice

58. Vomiting Possets Gastro-oesophageal Reflux normal
worse in neuro-developmental disabilities
common - 50%
spectrum - mild thicken feeds and positioning advice
Severe may require drug therapy
Very severe may need fundoplication
Complications - oesophagitis or Barrett’s, failure to thrive

59. Vomiting Over-feeding Gastroenteritis Pyloric Stenosis
Infants fed on demand
150mls/kg/day until weaned
Then 100mls/kg/day milk
Gastroenteritis
Pyloric Stenosis
Occurs in 7 per 1000 live births
6:1 male:female preponderance
Projectile vomiting non-bilious fluid after every feed
Metabolic Alkalosis
Surgical repair - Ramstedt’s Pyloromyotomy
Occult Infection (particularly UTI)

60. Infantile Colic What is Infantile Colic? What causes it?
What can be done?
Does it get better?
Differentials?
Is it a risk factor for any other serious condition?

61. Infantile Colic What is Infantile Colic? What causes it?
Inconsolable crying, especially in the evenings accompanied by infant bringing its legs up and exhibiting fisting and going puce in the face. Occurs in a paroxsymal fashion often worse in the evenings.
Affects bottle and breast fed babies equally
What causes it?
No cause known. Sometimes is relieved by opening bowels or passing flatus.
? caused by hunger, aerophagy, abdominal distention or overfeeding

62. Infantile Colic What can be done?
Over the counter remedies (eg GripeWater or Infracol) - varying success
Continuing a routine
Holding baby and gently jogging infant up and down
White noise such as static on radio
Place in car seat on tumble dryer
Leave the baby with someone else (trusted carer)
Reassurance - this is the single most important management role

63. Infantile Colic Does it get any better? Differentials?
Yes. Most infants will have grown out of colic by 3- 4 months
Differentials?
Intussusception
Acute abdomen
UTI
Otitis Media
Is it a risk factor for any other serious condition?
Yes. It is a precipitating factor in NAI

64. Bronchilitis

65. What will you tell parents?
What is bronchiolitis?
How common is it?
How serious is it?
How long will it last?
What can I do?
What should I look for?

66. Bronchiolitis How common is it? When is it most prevalent?
Very common
70% of infants will contract it in the first year of life
22% symptomatic
3% of all infants < 1 year will be hospitalised with bronchiolitis
When is it most prevalent?
Winter (Between November and March)
How do babies present?
Repiratory distress (tachypnoea, recessions, decreased sats)
Decreased feeding
Neonates can present with apneas without respiratory distress

67. Bronchiolitis Examination Findings Respiratory Distress
Wheeze and crackles on ausculation
Fever may be present but high fever (>39°C) is uncommon

68. Infants At Risk Infants that can be severely affected: Ex-prems CLD
Congenital Cardiac Conditions
Immune deficiency
Cystic fibrosis
Household smokers
IUGR/Small infants

69. Which Children to Refer?
Poor feeding (<50% of usual fluid)
Lethargy
History of apnoea
Respiratory rate >70/min
Presence of nasal flaring and/or grunting
Severe chest wall recession
Cyanosis
Oxygen saturation ≤94%
Uncertainty regarding diagnosis.
Lower threshold for admission in infants with co- morbidities

70. Jaundice Can be split into early or prolonged
Conjugated or Unconjugated
Early:
Most common is physiological (60% babies)
Immune haemolysis
Infection
Prolonged
Breast milk (9% of breast fed babies)
Biliary atresia
Congenital hypothyroidism CF
Galactosaemia

71. Summary Quick 5-10 minute top to toe examination
Wide ranges of problems being looked for - most are very rare
If in doubt - ask for help

72. Acute Referrals Congenital heart disease including all heart murmurs
Absent femoral pulses
Ambiguous genitalia, hypospadias or bilateral undescended testes.
Skin vesicles, moderate umbilical sepsis, pustules, bullae
Spinal or sacral pits where the base is not easily visible

73. Any Questions?