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
Why is newborn check useful?
Detecting medical problems
Parents value early diagnosis
Outcome can be improved
Enables planning of services
Newborn Examination
What do we examine in the newborn and six week baby checks?
Head to toe examination
•Genitalia•Anus•Hips•Femorals•Spine•Arms + Hands•Legs + Feet•Skin
•Head•Eyes•Palate•Tone•Heart•Chest•Abdomen
General inspection
How is the baby doing generally? Family history congenital problems Antenatal concerns? Inspect for dysmorphic features? Feeding Passed urine? Passed meconium?
Specific things to think about!
Heart Murmurs Femoral Pulses Undescended
Testes Absent red reflex Dislocatable /
dislocated hips Sacral dimples Imperforate anus
Infant Examination
Head
EyesPalateToneHeartChestAbdomenFemoralsGenitaliaAnusHipsSpineArms + HandsLegs + FeetSkin
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.
Infant Examination
HeadEyes
PalateToneHeartChestAbdomenFemoralsGenitaliaAnusHipsSpineArms + HandsLegs + FeetSkin 16
Tongue-tie
Usually do not require surgery, except if interfering with breast feeding; the tongue grows forward in 1st year
Infant Examination
HeadEyesPalateTone
HeartChestAbdomenFemoralsGenitaliaAnusHipsSpineArms + HandsLegs + FeetSkin 23
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
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
Infant Examination
HeadEyesPalateToneHeartChestAbdomen
Femorals GenitaliaAnusHipsSpineArms + HandsLegs + FeetSkin 38
Femoral Pulses
Absent femoral pulses implies coarctation of the aorta
Baby is at risk of sudden, unexpected collapse and may die without appropriate treatment
Infant Examination
HeadEyesPalateToneHeartChestAbdomenFemorals
GenitaliaAnusHipsSpineArms + HandsLegs + FeetSkin 41
Undescended testes
If bilateral undescended testes, what does it mean?
These babies may be FEMALE, especially if also have hypospadias
Hypospadias
Posterior hypospadias (particularly in the absence of palpable gonads) should be treated as ambiguous genitalia
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
Bilateral Undescended Testes
The baby may have Congenital Adrenal Hyperplasia
Steroid pathway problem
Steroid precursor Cortisol
Testosterone
Enzyme
Bilateral Undescended Testes
Absence of Cortisol
Salt losing crisis Non-specifically unwell (short time
period) Fits Death
Female genitalia
Oestrogen withdrawal bleeding Can occur in female infants aged 2 - 4 days
Not significant
Infant Examination
HeadEyesPalateToneHeartChestAbdomenFemorals Genitalia
AnusHipsSpineArms + HandsLegs + FeetSkin 53
Infant Examination
HeadEyesPalateToneHeartChestAbdomenFemorals GenitaliaAnus
HipsSpineArms + HandsLegs + FeetSkin
59
Infant Examination
HeadEyesPalateToneHeartChestAbdomenFemorals GenitaliaAnusHips
SpineArms + HandsLegs + FeetSkin
63
Sacral Dimples
Can you see the bottom of the dimple?
If not urgent referral
More worried if…. Poor leg movement Bowels not open
Infant Examination
HeadEyesPalateToneHeartChestAbdomenFemorals GenitaliaAnusHipsSpineArms + HandsLegs + Feet
Skin
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
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
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
Vomiting
Possets normal
Gastro-oesophageal Reflux 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
Vomiting Over-feeding
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)
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?
Infantile Colic
What is Infantile Colic? 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
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
Infantile Colic
Does it get any better? 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
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?
BronchiolitisHow common is it?
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
Bronchiolitis
Examination Findings Respiratory Distress Wheeze and crackles on ausculation Fever may be present but high fever (>39°C) is
uncommon
Infants At Risk
Infants that can be severely affected:
Ex-prems CLD Congenital Cardiac Conditions Immune deficiency Cystic fibrosis Household smokers IUGR/Small infants
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
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
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
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
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