VIVA Aide Memoir Recognition and Management Flashcards
Congenital Cataract
Recognition and Management
Recognition
Available documentation and history
Parents’ perception of their baby’s appearance
Clinical Eye examination
The appearance of the baby’s eyes should be assessed with the naked eye, including eyelids fully open, both eyes being the same size, symmetry of size and clarity of the cornea, pupils are round and symmetrical and like the width of the practitioner’s little finger. Other anomalies should be detected: eyelashes curl inwards, subconjunctival haemorrhage, and Brushfield spots.
Ophthalmoscopic looking at the red reflex to check colour, and brightness, looking for shadows.
The lights should be dimmed and the baby calm, the eyepiece is held up to view the eye, at arm’s length away from the baby’s face and you want to do each eye separately and go across to look for red reflex and appropriate ethnicity and equal on both sides. White babies have an orange-red reflex. The reflex can be less bright and appear creamy yellow or magnolia in colour in black, Asian or minority ethnic babies. If the assessment is difficult, it can help to assess the baby’s parents’ red reflexes to determine the expected reflex colour.
When moving the light across the eye it’s reflecting the red blood cells at the back of the eyes and it’s the same as flash photography.
Absent, partial, or unclear red reflex needs referral.
Management:
If you are not sure, ask other practitioners to repeat the examination at the earliest but before 72h.
Babies with negative eye results from NIPE should have the NIPE repeated at 6-8w. Infants with screen-negative eye results for the NIPE infant screening examination should follow the Healthy Child Programme.
Babies with screen-negative eye results but with risk factors described above may be referred via locally agreed pathways.
Babies with screen-positive eye results following the NIPE newborn screening examination should be urgently referred via the NIPE pathway to an ophthalmologist within 2 weeks of the screening examination. However, if there are significant concerns at the time of the NIPE newborn screening examination, discussion with the ophthalmology service before the baby’s discharge home should be considered.
Surgery for severe cataracts is usually undertaken between 6 to 10 weeks of age for optimal visual outcome.
Babies with screen-positive eye results following infant screening examination should be referred promptly and seen by a consultant ophthalmologist or paediatric ophthalmology service by 11 weeks of age.
Jaundice
Recognition and Management
Recognition:
History to look for any risk factors.
Parents’ perception of their baby’s health.
Skin, sclera, and gums appear yellow. Baby lethargic, poor tone and activity alongside feeding pattern (poor feeding) and elimination (pale stool and dark urine)
You can check blunting the skin on examination and assessing skin under natural light. You can press lightly on the skin to assess the signs of jaundice in blanched skin.
TCBR, SBR. (SBR on ethnic babies as TCBR may not be as accurate)
Escalate to a senior pediatrician to come and review the baby immediately (or at least within 6 hours)
Undertake a serum bilirubin (SBR) level within 2 hours of the recognition of jaundice and repeat at 4-6 hours.
Plot the measurement on the correct gestational age plotting chart.
Management:
Care and treatment will depend on the results of the SBR: phototherapy Bili bed, or Bili blanket when they BF.
After 24h of age, TCBR can be used to support
Investigations to exclude pathological jaundice (blood group Coombs and DAT, FBC, septic screen, congenital tests, urine sample, lumbar puncture)
If not improving or SBR reaches the threshold for transfusion, you may consider exchange transfusion, parents will need additional support, debriefing and the baby transferred to NNU.
If improving but still high checks can be reduced to 12 hourly instead of 6 hourly. Phototherapy can be stopped when is below 50 micromls/L below the treatment line) (5 boxes BTL). Rebound SBR is checked 12-18h afterward.
Cryptorchidism
Recognition and Management
Recognition:
Available documentation and history
Observe the scrotum for symmetry, size and colour, line of the raphe, rugae, penis length and placement of urethral meatus and perineum. Check for other conditions and note that an inguinal hernia may occur in some males with undescended testes.
Carry out palpation of the scrotal sac to determine the location of the testes bilaterally. Undertake palpation of the inguinal canal and perineum if the testes are not located in the scrotal sac.
Where testes are felt bilaterally but high in the inguinal canal, this should be managed as screen positive.
The term ‘undescended’ applies to clinical findings of either ‘absence’ or ‘incorrect position’.
Management:
Babies with screen-negative results following the NIPE newborn screening examination should have the NIPE infant screening examination at 6 to 8 weeks of age. Infants with screen-negative results following the NIPE infant screening examination should then follow the Healthy Child Programme. Parents should be advised to contact their healthcare professional or emergency services if they have any concerns about their baby.
A screen-positive result is the absence or incorrect position of one or both testes. Babies with screen-positive findings of bilateral undescended testes following NIPE newborn examination should be seen for assessment by a senior paediatrician within 24 hours of the examination to rule out metabolic and disorders of sex development conditions and by a paediatrician urologist specialist within 2 weeks.
Babies with screen-positive findings of unilateral undescended testis following NIPE newborn examination should be reviewed by the GP during the NIPE infant examination at 6 to 8 weeks of age. Please note that confirmation of referral to GP will constitute an outcome in S4N.
Infants with screen-positive findings of bilateral undescended testes following NIPE infant screening 6 to 8-week examination should be referred and seen by a senior paediatrician within 2 weeks of the examination.
Infants with screen-positive findings of persistent unilateral undescended testis following NIPE infant screening 6 to 8-week examination should be reviewed by a GP between 4 and 5 months of age, then be referred to a surgeon if testis still absent or not descended (to be seen no later than 6 months of age).
Hypospadias/Epispadias
Recognition and Management
Recognition:
Available documentation, family history, and genetic history.
Clinical Examination
Urethral opening
The shaft of the penis is straight (no chordee)
Penis symmetrical
Rugae and scrotum equal on both sides, size, shape, and colour
Stream of urine if seen as an arch
Raphe line should be straight from the base of the scrotum to the tip of the penis.
Penis size, position, and meatus
Foreskin normal
Femoral pulses
Feeling inguinal canal
Feeling testes – always bilaterally
Management:
Referral to a senior pediatrician (reg or consultant). Surgery might be needed. USS renal in severe cases
Acrocyanosis
Recognition and Management
Recognition on observation
Management:
perform heart and respiratory examination, capillary refill time, heaves/thrills, and saturations. If any of the abovementioned tests are abnormal or if persistent acrocyanosis an ECHO (gold standard), ECG, referral, NEWTT, transfer to NICU, and BCG are needed.
Milia/Epstein’s Pearls
Recognition and Management
Recognition:
Small pearly white papules, commonly in clusters.
Management:
It will resolve on its own
No referral is required, keep skin clean, give the parents information and Keep skin clean and do not squeeze the ducts or blisters should resolve spontaneously
Hyperpigmented macule
Recognition and Management
Recognition:
Available documentation
Observe birth marks for skin colour, size, and location
Blue spots covering the back, buttocks, and sometimes shoulders
Management:
No referral is needed, except if >10cm macule, multiple macules, or unusual location.
As they can look like bruises, they should always be documented on the body map, and taken a picture of the spots.
Erythema Toxicum Neonatorum
Recognition and Management
Recognition:
Available documentation, parent’s perception, and physical observation
Observe the skin for rash and small yellow/white papules.
Management:
No need for referral unless an infection is suspected. If they don’t disappear within 48h or have white heads, consider infection risk and swab accordingly.
Hydrocele
Recognition and Management
Recognition:
The rugae disappear and the scrotum looks distended (large and fluctuant)
The scrotal sac will transilluminate when a light source is used. The light will pass through the fluid-filled scrotum. If hernia you notice a dark area.
On examination, the gentle pressure on the scrotum will reduce the size of the scrotum by draining the fluid back into the abdomen.
Management:
No treatment is usually needed because hydroceles generally decrease in size and resolve within 1-2 years of age.
If complicated with inguinal hernia, will need urgent review and surgery within a few weeks.
If the hydrocele is not resolved by 1-2 years of age, parents should see their GP to request a pediatric urological review and consider surgery (elective surgery repair).
Very little research on the timing of treatment differs in various countries. (orchidopexy)
CHD Congenital Heart Disease
Recognition and Management
Recognition:
Available Documentation on NIPE risk factors
Parents’ perception of their baby’s health: change of colour at rest or during feeds, breathlessness, baby too tired to feed and lethargy or poor muscle tone.
Cardiovascular examination:
Observation:
The general tone, central and peripheral colour, size and shape of the chest, respiratory rate, symmetry of chest movements, use of the diaphragm and abdominal muscles, and signs of respiratory distress such as recession or grunting.
Palpation:
- Femoral (post-ductal) pulses (to exclude CoAo) and compare with brachial (pre-ductal) pulses for rate, rhythm, and volume.
- Capillary refill time <2/3sec (assessment of perfusion)
- Position of the cardiac apex (exclude dextrocardia)
- Palpation of the liver to exclude hepatomegaly (may be present in congestive heart failure)
- Thrills: vibratory sensation felt on the skin, it is a turbulent blood flow you can feel (if you feel it means it is a significant murmur) and it feels like a cat purring under the skin.
- Heaves: visible pulsation over the pericardium, it is a distinct lifting movement of the chest and is associated with volume overload
Auscultation:
S1: closure of mitral/tricuspid valves (LUB) to prevent backflow of blood
S2: closure of aortic/pulmonary valves (DUB)
- 2nd IC space adjacent to the sternum left side (pulmonary area)
- 2nd IC space adjacent to the sternum right side (aortic area)
- 4th IC space lower left sternal border (tricuspid area)
- 5th IC space midclavicular line, “Apex” (mitral area)
- Mid-scapulae (coarctation area) on the back
Murmurs: LUBSHDUB is an audible turbulence of flow, and they can be significant or benign
- Significant: usually loud, usually heard over a wide area, usually harsh rather than soft, possibly associated with other abnormal findings.
- Benign: Typically soft, short, systolic, and localised to the left sternal border. They have no added sounds or clinical abnormalities associated
Discharge after 24 h for well-baby with light murmurs: no symptoms, feeding well, soft murmur, normal saturations, normal femoral pulses and with a follow-up in place.
Signs and symptoms that suggest major/critical CHD:
* Tachypnoea at rest, check RR (N.B transient tachypnoea of the newborn is a breathing disorder seen shortly after delivery in early term or late preterm babies. Transient means it is short-lived <48hrs. If associated with SOB, worsens when feeding etc. can indicate heart failure)
* Episodes of apnoea lasting longer than 20seconds or associated with colour change
* Intercostal, sub-costal, sternal, or supra-sternal recession, nasal flaring
* Central cyanosis and general colour
!!!! Urgent escalation with these fours as they are also associated with sepsis
- Heaves
- Thrills
- Absent or weak femoral pulses
- Murmur and extracardiac sounds
Management:
Discuss findings with a senior paediatrician or paediatrician with cardiology expertise and refer as appropriate.
Investigation: saturations monitoring, ECG, CXR (is it respiratory or cardiac), 4 limb BP.
Treatment: medicines, cardiac catheterization procedure, heart surgery, heart transplant.
Screen negative
Baby transfer to the healthy child programme
Make sure parents are aware that the baby’s heart is still developing, and that the next health assessment will be in 6-8 weeks.
Parents should be informed of S&S to observe, and what to do if seen, as per health promotion info. that concludes NIPE.
Screen positive
Babies with screen-positive heart results following the NIPE should be seen by a senior Paediatrician with expertise in cardiology as required. Urgency according to the clinical condition.
Confirmation of an assessment within 24hrs= an outcome in S4N.
If a suspected major serious or CCHD is found, the baby is to be seen as a matter of urgency, and certainly before discharge home.
Babies with screen-positive heart results following the NIPE infant screening exam should be referred according to the locally agreed referral process. Urgency according to condition.
NB: at our trust on OP referral to a paediatric cardiologist if risk factors (same as pre-disposing) present, even if screen-negative and/or clinically well.
DDH Developmental Dysplasia of the Hips
Recognition and Management
Recognition:
History and all available documentation
Hip Examination:
The symmetry of leg length
Allis sign (level of knees when hips and knees are bilaterally flexed)
Restricted abduction (away) of the hip in flexion (30 degrees)
*Please note that skin creases symmetry is no longer part of the NIPE screen.
Barlow manoeuvre to screen for dislocatable hip
Ortolani manoeuvres to screen for a dislocated hip
*Both manoeuvres should be undertaken on both sides to assess hip stability. If Barlow is positive, Ortolani should be performed to reposition the hip joint.
A suspected abnormality on clinical examination is defined by:
- Difference in leg length
- Positive Allis sign
- restricted unilateral limitation of hip abduction (30 degrees abduction) or gross bilateral restrictions of hip abduction
- palpable ‘clunk’ when undertaking the Ortolani or Barlow manoeuvre
Management:
Babies with screen-negative hip results on NIPE newborn clinical examination (and no national hip risk factors present, should have the NIPE infant screening examination at 6-8 weeks
Infants with screen-negative hip results on NIPE infant clinical examination at 6-8 weeks (and no national hip risk factors present - unless they have not been previously referred), should follow the Healthy Child Programme.
A screen-positive hip result is an abnormal clinical hip examination (with or without risk factors) and, or the presence of NIPE risk factors.
- For babies who are born at ≥ 34 weeks, hip USS should be undertaken between 4-6 weeks.
- For babies who are born at <34+0 weeks gestation, hip USS should be undertaken between 38+0 and 40+0 weeks corrected age.
Referral to orthopaedic services after hip USS will then depend on the scan result and the local management policy in place.
- For babies who are born ≥34+0 gestation, an outcome decision should be made by 6 weeks of age.
- For babies who are born <34+0 weeks gestation, an outcome decision should be made by 40+0 weeks corrected age.
Babies who attend for an ultrasound scan of the hips after a screen-positive newborn hip referral should have an outcome decision within the target timescale to ensure timely treatment.
An outcome decision is either:
* discharge from the hip screening pathway after review of normal hip USS results
* attendance for clinical assessment by an orthopaedic specialist (it is required that hip USS has been undertaken in advance of the decision)
Infants with screen-positive results following NIPE infant 6 to 8-week screening examination should be referred directly to a paediatric orthopaedic surgeon for urgent expert opinion and be seen by 10 weeks of age.
Talipes Equinovarus
Recognition and Management
Recognition:
Documentation of available history (family, maternal and neonatal)
Examination of the feet, mobility, and position.
Documentation in the postnatal record of foot position, probable type of talipes, and referral to a senior pediatrician
Management:
Positional
* Physiotherapy usually corrects this type of clubfoot although ensuring that movement is not restricted by clothing/bedding etc. can also allow self-correction
* Parents can massage the affected ankle/foot during bathing, massage or when moisturizing the skin. Parents can hold the leg and tickle the baby’s foot to watch the foot stretch and move outwards. Repeat a few times a day
Or move the foot out by the toes gently holding the knee still. Repeat a few times a day
* Re-assessment of the affected foot/feet for normal progress and alignment can occur at the 6 to 8-week infant examination
Fixed
* Ponseti Methods - Involves gently manipulating and stretching the baby’s foot into a better position. It’s then put into a cast from toe to groin. This is repeated and re-casted every week until they are normally aligned for about 5 to 8 weeks. After the last cast comes off, most babies need a minor operation to loosen the Achilles tendon at the back of their ankle. It is successfully treating more than 9 out of 10 cases of clubfoot. Long-term results are also very promising compared to previous surgical treatment methods.
* Surgery - Tenotomy under local anesthetic may be required to release the Achilles tendon
* Boots and Bars - Once alignment is corrected the baby is fitted with boots attached to a bar (brace) to maintain the position of the feet. Boots are worn 23 hours per day for the first 3 months. Alignment is re-assessed, and the boots can then be worn at night or when napping up to the age of 4-5 years. Regular footwear can be worn at all other times
