Infant Examination & Common Infant Problems Dr Ian Woodcock ST3 Paediatrics

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

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

RED FLAGS

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

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

Absent Red Reflexes What does it mean? Take Action

Red reflexes Normal Red reflex absent Red reflex abnormal

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

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

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

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

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

Femoral Pulses If they are absent what does it mean?

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

Ambiguous Genitalia

Ambiguous Genitalia

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

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

Imperforate anus Can be subtle Needs early diagnosis and surgery

Investigation: Cross Table Lateral AXR in Prone Position

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

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

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

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

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

Sacral dimple

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

Milia

Erythema toxicum

Mongolian blue spot

Capillary haemangioma

Naevus What size naevus would you be worried about?

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

Vesicles Can be serious Herpes can kill very rapidly

Chicken pox Refer urgently Contact infection control ASAP

Things to Refer…

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

Common Infant Presentations to GP Vomiting Infantile Colic Bronchiolitis Jaundice

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

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)

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? 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

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? 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

Bronchilitis

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?

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 http://emedicine.medscape.com/article/961963-overview

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

Any Questions?