1. Newborn Baby Examination
Ellie Duckworth
Stage 3 student, University of Cambridge School of Clinical Medicine
2nd May 2015

2. Newborn examination
Newborn babies must be examined within 24 hours of birth
Purpose of the examination:
Detect congenital anomalies not already detected at birth
Check for potential problems arising from maternal or familial disease
Checked again at 6 weeks old (usually by GP)

3. Examination routine Usually described as examining ‘top to toe’
In reality, adapt the order of examination to when the baby is settled or crying:
Auscultation first (before removing rest of clothing)
Palate – more visible when the baby is crying, or feel with finger
Sucking reflex – can also help to calm the baby down
Leave most distressing parts until the end e.g. Moro reflex & hip examination

4. History Key points in taking a history from the mum:
Pregnancy and mode of delivery
Did they cry straight after birth? Any problems with breathing?
Family history
Congenital heart disease
Hearing problems
Hip dysplasia
Has baby passed urine or meconium yet?
Any problems with breast/bottle feeding?

5. General observations Undress down to the nappy
Remember to look at the baby’s back as well
Skin
Colour
Skin lesions
Respiratory effort
Spontaneous movements and posture – symmetrical?
Dysmorphic features
Good idea to learn a few key features associated with syndromes e.g. Downs

6. Erythema toxicum (neonatal urticaria)
Illustrated textbook of paediatrics (Lissauer)
Peripheral cyanosis
Milia
These are all skin lesions in newborns that resolve spontaneously.
Peripheral cyanosis of the hands and feet is common in the first day of life.
Milia – white pimples – retention of keratin and sebaceous material in the pilaceous follicles
Erythema toxicum – common rash 2-3 days old, white pinpoint papules surrounded by erythema (fluid contains eosinophils)
Blue spots – usually at base of spine & buttocks. More commonly seen in Afro-Caribbean & Asian babies. Fade slowly over first few years. Very important to document in newborn check – may be mistaken for bruises later (NAI)
Erythema toxicum (neonatal urticaria)
Mongolian
Blue spot
Illustrated textbook of paediatrics (Lissauer)
Illustrated textbook of paediatrics (Lissauer)

7. Head Measure head circumference Fontanelle
Tense
Raised ICP
Meningitis (late sign)
Sunken
Dehydration
3rd fontanelle
Downs
Check skull and facial bones for birth injuries
Head circumference:
Occipitofrontal circumference
Tape facing DOWN
THREE separate measurements
Record the LARGEST of the 3

8. Birth injuries – location of extracranial haemorrhages

9. Eyes Check red reflex with ophthalmoscope Lack of red reflex
Cataracts
Retinoblastoma
Ophthalmic infections
Retinoblastoma

10. Ears Shape and size ‘Low set’ ears Patency of external auditory meatus
Shape and size
‘Low set’ ears
Down’s
Edwards
Di George
Turners
Noonan
Patency of external auditory meatus
quizlet.com
Edwards Syndrome
Di George Syndrome

11. Mouth Colour of mucus membrane Palate Tongue tie Sucking reflex
Mouth
High arched palate
Colour of mucus membrane
Palate
High arched – Marfan’s
Cleft lip/palate
Tongue tie
Sucking reflex
Rooting reflex
newborns.stanford.edu
beyondspine.com
In real life this is actually easiest to do if baby is yawning/crying
Or feel palate/ tongue tie with finger
Sucking reflex is very good for calming the baby down too!
Rooting reflex – stroke baby’s cheek & they turn to suck the finger
Cleft lip
Rooting reflex
Tongue tie

12. Arms & Hands
Simianline.handresearch.com
Check neck, shoulders & clavicles for traction birth injury
Count fingers
Shape of fingers – clinodactyly
Palmar creases – multiple or single
Grasp reflex
cai.md.chula.ac.th
Stroke back of fingers to get baby to open hand
Clinodactyly – incurving of the fingers, can be associated with syndromes e.g. Down
Single palmar crease (Simian line) can be normal or associated with Down syndrome
Can move on to look at feet and legs at the same time
Single palmar crease
Clinodactyly

13. Erb’s Palsy
Traction to brachial plexus nerve roots (by breech deliveries/shoulder dystocia)
C5 & C6 injury  Erb’s palsy
Most resolve completely by themselves
Other birth injuries – facial nerve palsy
shoulderdystociainfo.com
Illustrated textbook of paediatrics (Lissauer)

14. Legs & Feet Watch movement of each joint Check for talipes equinovarus
wikipedia
Watch movement of each joint
Check for talipes equinovarus
Count toes
Shape of toes
Babinski reflex
Grasp reflex
hellomrdoctor.com
Talipes equinovarus
Talipes equinovarus – fixed, unable to manipulate feet back to normal position (cf. positional talipes)
Babinski reflex – sign is positive (upward going plantar) in babies. This reflex should have disappeared by 2 years old.
Babinski reflex

15. Peripheral pulses Heart Lungs Brachial, radial & femoral
Radio-femoral delay
Heart
Apex beat
Heaves or thrills
Auscultation
Lungs
Watch respiratory pattern, rate and depth
Grunting, head nodding, intercostal recession, stridor
Do femoral pulses later when taking nappy off to look at genitalia

16. Abdomen Abdominal girth and shape Umbilical stump
Omphalocoele/gastroschisis
Umbilical stump
Infection (Omphalitis)
Hernia
Palpate for organs, masses or hernia
normal to be able to feel liver and/or spleen in newborns
External genitalia
Undescended testes
Inspect anus for patency
medscape.com
At this point will need to undo nappy to examine abdomen
Undescended testes (cryptorchidism) – 4% male term babies (more in prematurity). Unlikely to descend spontaneously after 6 mths so referred for surgical review then
Omphalitis

17. Exomphalos/Omphalocoele Gastroschisis
Omphalocoele – covered by transparent sac of amniotic membrane & peritoneum
Gastroschisis – no covering sac – increased risk of dehydration & protein loss
Exomphalos/Omphalocoele
Gastroschisis

18. Back Check for skin lesions Palpate down the spine Looking for:
Spina bifida occulta
Pilonidal sinus
Spina bifida occulta (1st pic) – failure of fusion of vertebral arch. May be assoc with overlying skin lesion (tuft of hair, lipoma, birth mark, small dermal sinus)
Pilonidal sinus – infected tract under skin between buttocks
biology-forums.com

19. Reflexes
Moro’s reflex – birth3mths. Baby in supine position & head suddenly allowed to fall back  symmetrical opening of arms & then closing again
Tonic neck reflex (fencing reflex) – birth to 6 mths
wikipedia
Moro reflex

20. Hips Checking for developmental dysplasia of the hip (DDH)
Baby must be relaxed – crying/kicking causes tightening muscles around hip
Middle finger on greater trochanter, thumb around distal medial femur.
Hip held flexed & adducted
Barlow – femoral head is pushed downwards & so if the hip is dislocatable then the femoral head is pushed posteriorly out of the acetabulum. Then try to abduct  clunk as femoral head returns to acetabulum (Ortolani)
Illustrated textbook of paediatrics (Lissauer)

21. Guthrie test Blood sample (heel prick) taken on day 5-9 of life
Blood sample (heel prick) taken on day 5-9 of life
In UK, all infants screened for:
Phenylketonuria
Hypothyroidism
Haemoglobinopathies
Cystic fibrosis
MCAD (medium-chain acyl-CoA dehydrogenase
Others e.g. Maple syrup urine disease
namrata.co

22. Hearing screening
Early detection and intervention of severe hearing impairment
Prevents delay in speech and language development
Evoked optoacoustic emission (EOEA)
Earphone over the ear to emit sound
The sound evokes an echo/emission from the ear if cochlear function is normal
Automated auditory brainstem response (AABR)
If normal test not achieved
Uses computer analysis of EEG waveforms

23. Vitamin K
Vitamin K deficiency can cause haemorrhagic disease of the newborn
Usually mild symptoms – bruising, haematemesis, melaena, prolonged bleeding around umbilical stump
Can be severe – intracranial haemorrhage
IM injection of vitamin K given to most newborn infants in the UK immediately after birth
Parents can request oral vitamin K but this requires 3 doses over first month of life to achieve adequate liver storage
Severe vit K deficiency – 50% of those pts are permanently disabled or die

24. Questions?