Newborn examination Flashcards
Background
Background
The Newborn Infant Physical Examination (NIPE) must be performed within 72 hours of birth by a qualified practitioner.¹
The purpose of the examination of the newborn is: ²
To screen for congenital abnormalities that will benefit from early intervention
To make referrals for further tests or treatment as appropriate
To provide reassurance to the parents
A second examination is performed at 6-8 weeks of age, usually by GP, to identify abnormalities that develop or become apparent later.
Where to perform the NIPE
Where to perform the NIPE
The NIPE exam should be undertaken in a private area which provides confidentiality for parents when personal information is being discussed.
The room should be warm and well lit (preferably natural light, especially if jaundice is to be assessed).² Visual inspection, however, cannot reliably assess the level of jaundice so if this is suspected a bilirubin level needs to be checked. ³
You’ll ideally require a changing mat to carry out the examination on.
Always make sure that the parents are present for the newborn check as this is an ideal time to answer queries and provide reassurance.
Introduction
Introduction
Wash your hands and don PPE if appropriate (alcohol gel must dry completely before handling the newborn).
Introduce yourself to the parents including your name and role.
Confirm the infant’s name and date of birth.
Briefly explain what the examination will involve using patient-friendly language: “Today I need to carry out a routine head to toe examination of your child.”
Gain consent to proceed with the examination:
Parents should have received the National Screening Committee leaflet ‘Screening tests for you and your baby’ in the antenatal period.
If the parents have not read the information booklet they must be given a copy to read before to the examination.
The aims and limitations of the examination should be fully explained.
Adequately expose the child for the assessment: ask the parents to undress the child down to their nappy.
Encourage the parents to ask questions during the check and to participate where appropriate.
The optimal way to perform the newborn check is by examining from head to toe sequentially. In reality, it’s an opportunistic examination – if the baby is settled listen to their heart first, if they open their eyes check the fundal reflexes and if they’re crying look at the palate!
Questions to ask the parents
Questions to ask the parents
Below are some key points you would ideally cover in a full assessment of a newborn baby. It should be noted that in the context of an OSCE you are unlikely to be expected to cover all these history points due to time constraints.
Maternal history:
Pregnancy details: date/time and type of delivery/complications/high-risk antenatal screening results
Breech presentation: if breech at 36 weeks gestation or delivery (if earlier), the baby will need to have an ultrasound scan of their hips as there is an increased risk of developmental dysplasia of the hip.
Risk factors for neonatal infection
Abnormalities noted on antenatal scans
Family history: first-degree relatives with…hearing problems/hip dislocation/childhood heart problems/congenital cataracts/renal problems
Newborn history:
Feeding pattern
Urination
Passing of meconium
Parental concerns
Weight
Ensure that the infant’s weight is recorded and check on a weight chart whether the baby is:
Small for gestational age (<10th centile)
Appropriate weight for gestational age (10th-90th centile)
Large for gestational age (>90th centile)
If a baby is small, you should also plot head circumference and length to determine whether this is symmetrical (small in all measurements) or asymmetrical (weight disproportionately low, head circumference preserved).
Asymmetrical growth restriction is commonly due to placental insufficiency, whilst symmetrical growth restriction is more commonly due to fetal factors such as genetic abnormalities or intrauterine infection.
General inspection
General inspection
Inspect the colour of the infant:
Pallor: a pale colour of the skin that can suggest underlying anaemia (e.g. haemorrhage) or poor perfusion (e.g. congestive cardiac failure).
Cyanosis: a bluish discolouration of the skin due to poor circulation (e.g. peripheral vasoconstriction secondary to hypovolaemia) or inadequate oxygenation of the blood (e.g. right-to-left cardiac shunting).
Jaundice: a yellowish or greenish pigmentation of the skin and whites of the eyes due to high bilirubin levels (e.g. newborn jaundice).
Inspect the posture of the infant: note any gross abnormalities of posture (e.g. hemiparesis/Erb’s palsy).
Head
Head
Size
Measure the infant’s head circumference and record it in the notes.
Head size abnormalities
Microcephaly describes a head that is smaller than expected for age and sex. Microcephaly may be associated with reduced brain size or atrophy.
Macrocephaly describes a head that is larger than expected for age and sex. Macrocephaly may be normal but may also be associated with hydrocephalus, cranial vault abnormalities or genetic abnormalities.
Shape
Inspect the shape of the head and note any abnormalities.
Inspect the cranial sutures and note if they are closely applied, widely separated or normal.
Head shape abnormalities
Cranial moulding is common after birth and resolves within a few days.
Caput succedaneum is a diffuse subcutaneous fluid collection with poorly defined margins (often crossing suture lines) caused by pressure on the presenting part of the head during delivery. It does not usually cause complications and resolves over the first few days. 4
Cephalhaematoma is a subperiosteal haemorrhage which occurs in 1-2% of infants and may increase in size after birth. The haemorrhage is bound by the periosteum, therefore, the swelling does not cross suture lines (in contrast to a caput succedaneum). Cephalhaematoma is more common with instrumental delivery and may cause jaundice, therefore, bilirubin should be monitored.
Subgaleal haemorrhages occur between the aponeurosis of the scalp and periosteum and form a large, fluctuant collection which crosses sutures lines. They are rare but may cause life-threatening blood loss.
Craniosynostosis is a condition in which one or more of the fibrous sutures in an infant skull prematurely fuses, changing the growth pattern of the skull which can result in raised intracranial pressure and damage to intracranial structures. Surgical intervention is required with the primary goal being to allow normal cranial vault development to occur. This can be achieved by excision of the prematurely fused suture and correction of the associated skull deformities. 7
Fontanelle
Palpate the anterior fontanelle: note if it feels flat (normal), sunken or bulging (abnormal).
Fontanelle abnormalities
A tense bulging fontanelle may suggest raised intracranial pressure (e.g. hydrocephalus).
A sunken fontanelle may suggest dehydration.
Skin
Skin
It is very important to document any birthmarks or bruising/lacerations from birth trauma found on initial examination in case there are any child protection concerns in the future. There are body maps in the red book to help with this.
Colour: inspect the colour of the skin and note any pallor, cyanosis, erythema or jaundice.
Bruising/lacerations: note the location and size of any bruises or lacerations which may have been sustained during childbirth.
Vernix: a waxy or cheese-like white substance found coating the skin of newborn babies (this is a normal finding).
Examples of facial birthmarks
Examples of facial birthmarks include:
Salmon patch (also known as a stork mark or nevus simplex): red or pink patches, often on an infant’s eyelids, head or neck caused by congenital capillary malformation. Salmon patches are very common and usually fade by the age of two.
Haemangiomas (also known as strawberry marks): blood vessels which form a raised red lump on the skin which appears soon after birth. Haemangiomas typically get bigger over the first 6-12 months and then shrink and disappear by the age of 7. They may require treatment if they affect vision, breathing or feeding.
Port-wine stain (also known as naevus flammeus): red/purple marks on the face and neck which are typically present from birth and do not regress. Port-wine stains can sometimes be associated with Sturge-Weber syndrome and Klippel-Trenaunay syndrome.
Other potential findings
Slate-grey nevus is a benign, flat, congenital birthmark with wavy borders and irregular shape, usually located over the sacrum. It is most commonly blue in colour and can be mistaken for a bruise. They normally disappear within 3-5 years after birth. 5
Milia are tiny white cysts containing keratin and sebaceous material. They are very common on the face and most resolve within the first few weeks of life.
Erythema toxicum is a very common and benign condition seen in newborn infants. It presents with various combinations of erythematous macules, papules, and pustules. Lesions usually appear from 48 hours of age and resolve spontaneously.
Neonatal jaundice can be physiological, appearing at 2-3 days and resolving by day 10. It can also be caused by a wide range of different pathologies including haemolytic disease, infection and Gilbert’s syndrome.
Face
Face
Appearance: note any dysmorphic features of the face (e.g. epicanthic folds in Down’s syndrome).
Asymmetry: note any asymmetry of the face (e.g. facial nerve palsy secondary to instrumental delivery).
Trauma: note any evidence of facial trauma (e.g. bruising, lacerations) likely to have occurred during labour (e.g. instrumental delivery).
Nose: inspect to assess the patency of the nasal passages (infants are obligate nasal breathers and therefore will present with respiratory distress and cyanosis at rest if they have bilateral choanal atresia).
Eyes 👀
Eyes
Inspect the eyes for evidence of erythema or discharge (e.g. conjunctivitis).
Inspect the sclera by gently retracting the lower eyelid noting any discolouration (e.g. jaundice, subconjunctival haemorrhages). Subconjunctival haemorrhages often look dramatic but are fairly common after delivery and benign, you should, however, document their presence.
Inspect the position and shape of the eyes: look for evidence of ptosis or the presence of epicanthic folds (e.g. Down’s syndrome).
Fundal reflex
Correct terminology
The term fundal reflex is preferred over red reflex as the colour of the healthy reflex varies depending on a patient’s skin colour.
In patient’s with lighter skin, the reflex typically appears orange-red in colour, whereas in those with darker skin, the reflex can be yellow-white or even blue in colour.
Assess for the fundal reflex in each eye:
- Look through the ophthalmoscope, shining the light towards the patient’s eye at a distance of approximately one arm’s length.
- Observe for a reddish/orange reflection in each pupil, caused by light reflecting back from the vascularised retina.
Causes of an absent fundal reflex
Absence of the fundal reflex in children can be due to congenital cataracts, retinal detachment, vitreous haemorrhage and retinoblastoma.
An absent fundal reflex or the presence of a white reflex requires immediate ophthalmology referral.
Ears 👂
Ears
Inspect the pinna: note any asymmetry, skin tags, pits or the presence of accessory auricles.
All infants should undergo a hearing screening test prior to being discharged from hospital.
Mouth and palate
Mouth and palate
Look for clefts of the hard or soft palate: the full palate should be examined by visual inspection. You will need to use a tongue depressor and a torch, and ask a parent to help keep the baby’s head still. You must visualise the whole palate, and see the central uvula to ensure it is intact. You cannot rely on palpation to exclude a cleft.
Inspect the tongue and gums: look for evidence of tongue-tie (ankyloglossia).
Neck and clavicles
Neck and clavicles
Inspect the length of the neck and note any abnormalities such as webbing: a shortened webbed neck is typically associated with Turner’s syndrome.
Inspect for neck lumps: a lump in the left posterior triangle of the neck may represent a cystic hygroma.
Look for evidence of a clavicular fracture: signs may include bruising, discontinuity of the clavicle and an abnormal position of the arm (fractures most commonly occur in the context of shoulder dystocia).
Cystic hygroma
A cystic hygroma is a congenital lymphatic lesion which is typically identified prenatally or at birth. A cystic hygroma can arise anywhere but typically develops in the left posterior triangle of the neck. Cystic hygromas are benign but can be disfiguring and typically require surgical treatment including drainage and use of sclerosing agents to prevent reaccumulation of lymphatic fluid.
Upper limbs
Upper limbs
Assess the symmetry of the upper limbs: they should appear equal in size and length.
Inspect the fingers: count the fingers and note any abnormal morphology (e.g. polydactyly).
Inspect the palms: check if the child has two palmar creases (normal).
Palpate the brachial pulse on each upper limb: note any asymmetry suggestive of an underlying vascular abnormality (e.g. coarctation of the aorta).
Abnormalities of the hand
Polydactyly is a congenital abnormality where there are supernumerary fingers or toes.
A single palmar crease is associated with Down’s syndrome.
CHEST
Chest
Inspection
Observe the chest, paying particular attention to the respiratory rate and work of breathing.
Respiratory rate
Count the respiratory rate whilst observing the child. The normal respiratory rate of a newborn is 40-60 breaths per minute.
Work of breathing
Assess for signs of increased work of breathing:
Difficulty feeding
Expiratory grunting
Tracheal tug
Supraclavicular recession
Intercostal recession
Subcostal recession
Nasal flaring
Abdominal breathing
Head bobbing (secondary to sternocleidomastoid contractions)
Other clinical signs
Inspect the chest for other relevant clinical signs:
Pectus excavatum: a caved-in or sunken appearance of the chest.
Pectus carinatum: protrusion of the sternum and ribs.
Asymmetrical chest wall expansion: asymmetry may be noted unilateral lung pathology (e.g. pneumonia).
Auscultation
Lungs
Auscultate each side of the chest in a symmetrical pattern, comparing side to side:
Pay attention to the inspiratory and expiratory sounds at each placement.
Note the quality and volume of the breath sounds.
Note any additional sounds (e.g. wheeze, coarse crackles).
Repeat auscultation on the posterior aspect of the chest.
Heart
Auscultate ‘upwards’ through the valve areas using the diaphragm of a paediatric stethoscope:
Mitral valve: 5th intercostal space – midclavicular line (apex beat)
Tricuspid valve: 4th or 5th intercostal space – lower left sternal edge
Pulmonary valve: 2nd intercostal space – left sternal edge
Aortic valve: 2nd intercostal space – right sternal edge
Listen over each area with both the bell (for low pitched sounds – gallops and split S2) and the diaphragm (high pitched sounds – pericardial rubs, S1/S2 and most murmurs).
The normal heart rate of a newborn is approximately 120-150 bpm.
If a murmur is noted, try to determine where it is heard loudest and if it radiates anywhere.
Pulse oximetry
Some centres recommend checking preductal and postductal oxygen saturations to improve detection of critical congenital heart disease in newborn infants. Both readings should both be ≥95% and within 3% of each other.
Abdomen
Abdomen
Inspection
Inspect for evidence of abdominal distension: causes include bowel obstruction, organomegaly and ascites.
Inspect the umbilicus: note any swelling (e.g. umbilical hernia) or erythema and discharge (e.g. umbilical cord stump infection).
Inspect for evidence of an inguinal hernia in the groin: if present, arrange a paediatric surgical review.
Palpation
Palpate the abdomen to assess for organomegaly:
Liver: should be palpable no more than 2cm below the costal margin (if palpable lower in the abdomen consider hepatomegaly).
Spleen: may be palpable at the left costal margin in healthy infants (if easily palpable, consider splenomegaly).
Kidneys: normally only palpable using deep bimanual palpation (if easily palpable consider polycystic kidney disease).
Bladder: should not be palpable in healthy infants (if easily palpable, considering urinary tract obstruction).
