Examination of the Newborn

Neonatal and Infants

·        Neonatal is < 4 weeks

Examination of the Newborn

History

·        Maternal history: 

o  General health and well-being: past medical history and social history (partner, planned pregnancy, etc) 

o  Pregnancy: mediations, alcohol and other drugs, complications, infectious illness (toxoplasmosis, rubella, etc), EDD, scan findings, parental blood groups 

o  Family history: perinatal deaths, paediatric deaths, congenital problems (especially congenital dislocated hip)

o  Delivery history: length of labour, infection, resuscitation, APGAR, any concerns

o  Post-natal history: feeding, colour changes (blue, jaundice), behaviour, stools, urine

o  Have you any concerns about your baby?

Examination

·        Initial assessment immediately after birth to check adaptation to extra-uterine life (eg APGAR) and to look for major congenital anomalies, especially:

o  Dysmorphic features

o  Choanal atresia

o  Major limb defects 

o   Spina bifida

o   Anal atresia

o   Genital abnormalities

o   Birth trauma: bruising, cephalhaematoma

·        Examine on Resuscitare.  Check all equipment carefully first.

·        APGAR assessment – at one minute, then 5 minutes then every 5 minutes till a score of 10:

o   Heart rate: 2 for > 100, 1 for < 100, 0 for not present

o   Colour: 2 for pink, 1 for blue, 0 for pale 

o   Respiration: 2 for regular or strong cry, 1 gasping intermittently (may be bad sign – secondary hypoxia), 0 for none. May slow due to maternal drugs (eg pethidine)

o   Tone: 2 for active movement, 1 for limb flexion

o   Response to stimuli: On suction, 2 for coughs well, 1 depressed

·        Apnoea:

o   Primary Apnoea: pulse < 60 and cyanosis.  Give O2 and wait a minute

o   Secondary Apnoea: pulse < 60, pallor and floppiness: suction, ventilate, intubate

·        General inspection:

o   Dysmorphisms: eyes, ears, mouth, cry

o   Colour: central, peripheral

o   Respiratory effort: grunting, indrawing, flaring nostrils

o   Posture and movements: 

§  Normal: hips abducted, partially flexed, knees flexed, arms adducted, flexed at elbow, hands closed (not tightly), fingers over thumb

§  Abnormal: hypotonia, irritability

o   Skin: colour, rashes

·        Systemic examination:

o   Head:

§  Skull: fontanelles, sutures, birth trauma

§  Eyes: red reflex, opacities, conjunctivitis

§  Nose: patency

§  Mouth: palate and suck

§  Ears: hearing, tags

o   Neck: upper airway 

o   Chest: shape, deformities, respiratory distress, cardiac auscultation, peripheral pulses, respiratory auscultation 

o   Abdomen: cord, 3 vessels (2 arteries and a vein), shape, liver, spleen, kidneys, bladder, genitalia, urine stream, anus, passage of meconium, femoral pulses, 

o   Limbs and other bones: upper limbs, digits, palmar creases, clinodactyly, grasp, lower limbs, digits, hips, talipes (club foot), spine 

o   Neurological status: cry, jittery, spastic, grasping, activity, irritability, symmetry of movement, tone, neonatal reflexes

o   Neonatal reflexes: stepping, walking, Moro, grasp, rooting

·        Also:

o   Growth: weight, length, OFC ® plot

o   Offer vitamin K IM as prophylaxis against Haemorrhagic disease of the new born 

o   Cord blood for blood typing and Rhesus -ive, and also measure Cord pH (from artery) – measure of hypoxia 

o   If baby has patches of yellow Þ sitting in meconium for a while ® stain

o   If uncertainty about gestational age then formal assessment 

o   Re-examine at end of the first week of life, especially for signs of congenital heart disease. Takes ~ 48 hours for ductus to close

·        Other observations:

o   Micturition: usually soon after birth, infrequent for first 24 hours

o   Bowel: 99.9% passed meconium by 48 hours/  Otherwise ? Cystic Fibrosis, Hirshprungs

o   Jaundice: 40% develop it, but transient,  resolves by day 5

o   Vomiting: a little is common.  Green is bad (= bile)

o   Temperature: rectal best.  Same range as adults when dressed appropriately

o   Weight: 1^st 3 – 5 days may loose 5 – 10% of birth weight.  Should regain it in 7 – 10 days

·        In first week:

·        Immunisations: if mother HBsAg +ive then Hep b Vaccine and HBIG

·        Guthrie card