1. Examination of the Newborn Examination Part 1: Eyes, heart, hips and testes Chris Kingsnorth

2. Before We Begin

3. Overview 4 presentations: 1.Introduction and pre-examination 2.Examination part 1: Eyes, heart, hips and testes 3.Examination part 2: Top-to-toe 4.Post-examination

4. Overview Examination of the NIPE’s main 4 areas of focus: Eyes, heart, hips +/- testes Common pathologies Practical tips Will be integrated into top-to-toe examination in Examination Part 2

5. General Principles of Examination Don’t be scared of the baby! Be flexible in order examining based on baby’s behaviour/ state of undress Keep baby warm Involve parents; explain examination and findings If unsure about findings, ask a senior Be prepared to change nappies

6. Eyes

7. Examining the Eyes Assessing structure, not function 2 main pathologies: 1.Congenital cataract 2.Retinoblastoma Other features may suggest abnormalities (e.g. size/ shape/ position of eyes and optical structures)

8. Examining the Eyes: Risk Factors Birth wt <1500g Gestational age <32 weeks FHx of any childhood eye disorder inc. congenital cataract/ glaucoma/ retinoblastoma Maternal infections during pregnancy e.g. rubella, toxoplasmosis, HSV

9. Size, shape and symmetry of orbits and globes Opening both eyes? Squint? Discharge/ crusting? Shape + symmetry of irises Examining the Eyes: External Structures

10. Reflection of light from retina Ophthalmoscope set to largest white disc Shine into eyes from 15cm Look for red reflex May need gentle encouragement to open eyes Examining the Eyes: Red Reflex

11. Absence of reflex suggests congenital cataract White reflex suggests retinoblastoma Examining the Eyes: Abnormal Red Reflex

12. Examining the Eyes: Summary and Referral Facts  About 200 children a year are born in the UK with congenital cataract in one or both eyes.  Cataract is the largest treatable cause of visual loss in childhood in the UK. Screening process  The screen is undertaken in a darkened room, with the baby in a supine position or, if necessary, over the parent’s shoulder.  The screen covers: a general examination of the eye, checking for the red reflex, and checking eye movement. Referral and follow up  Babies with a positive screen should be referred for expert consultation by two weeks of age (newborn examination); by 11 weeks of age (6-8 week examination).  Parents should be given information about the suspected condition.

13. Heart

14. Examining the Heart Severe congenital heart defects often picked up antenatally or within minutes of birth Mainly assessing for murmurs which may warrant further investigation Includes assessment of CVS in general

15. Examining the Heart: Risk Factors FHx of congenital heart disease Maternal conditions e.g diabetes, SLE Rubella exposure during 1 st trimester Medications e.g. lithium therapy Conditions inc. Down's, Noonan's and Marfan's syndromes

16. Examining the Heart Cyanosis? Heart rate Pulse rate, rhythm and volume Heart sounds + murmurs Femoral pulse presence, volume + symmetry

17. Examining the Heart: Summary and Referral Facts  Congenital cardiac defects are a leading cause of infant death.  Critical or serious congenital cardiac malformations are found in approx. 6-8 in 1,000 newborn babies.  One in 200 babies has a heart problem that requires treatment.  Risk factors include a family history of congenital heart disease; maternal diabetes or systemic lupus erythematosus; exposure to rubella during the first trimester; certain medication taken during pregnancy such as lithium therapy; also syndromes such as Down’s, Noonan’s and Marfan’s. Screening process  The screen consists of general observation of the baby’s colour and respiration, palpation and auscultation of the heart and chest area  Rountine use of pulse oximetry as an adjunct to the full newborn physical examination is currently being piloted (2015) Referral and follow up  Babies with a positive screening examination should have pulse oximetry to aid diagnosis and be referred to a senior paediatrician or other relevant expert urgently depending on the condition (newborn) or for 6-8 week old babies, referred at the time of the examination to a senior paediatrician or other expert  Parents should be given information about the suspected condition

18. Hips

19. Examining the Hips Examining for Developmental Dysplasia of the Hip (DDH) 2 presentations: 1.Hip already dislocated (congenital dislocation) 2.Hip can be dislocated easily (hip instability)

20. Examining the Hips: Risk Factors for DDH 1 st degree FHx of hip problems in early life Breech presentation @ 36/40, irrespective of presentation at delivery and mode of delivery Breech delivery if < 36/40 In multiple births, if any of the above risk factors are present, all babies should be referred for USS to identify which may be affected

21. Examining the Hips: Barlow and Ortolani Manoeuvres Can be distressing for parents to watch Examine one hip at a time

22. Examining the Hips: Barlow’s Manoeuvre Test for hip instability (i.e. can hip be dislocated?) Adduction of hip with posterior pressure on thigh +ve Barlow test = clunk as femoral head comes out of acetabulum

23. Examining the Hips: Ortalani’s Manoeuvre Test for congenital dislocation (i.e. hip already out of socket); also relocates hip if dislocated during +ve Barlow manouvre Abduction of hip with anterior pressure on thigh +ve Ortalani test = clunk as previously displaced head of femur falls into acetabulum

24. Examining the Hips: Summary and Referral Facts  One or two in 1,000 babies have hip problems requiring treatment  Major risk factors include a first degree family history of hips problems in early life, breech presentation at 36 weeks of pregnancy or breech delivery at any gestation  Undetected DDH or delayed treatment can result tin long term complications Screening process  The screen is undertaken on a flat firm surface and the baby should be undressed Referral and follow up  Babies with a positive screen (abnormal clinical examination) should be referred for urgent ultrasound and expert consultation. Newborns should be seen by 3 weeks of age, 6-8 week old babies should be seen by 10 week of age  Parent should be given information about the suspected condition

25. Testes

26. Examining the Testes To identify boys with unilateral or bilateral undescended testes (cryptorchidism) If missed can have detrimental effect of future fertility Bilateral undescended testes may be a sign of endocrine disease, therefore considered more serious

27. Examining the Testes: Risk Factors for Cryptorchidism 1 st degree FHx (father or sibling) of cryptorchidism Low birth wt/ small for gestational age Pre-term delivery

28. Examining the Testes Inspection: Size/ shape/ symmetry of testes Scrotal rugae (‘wrinkles’ on scrotum; lack of these suggests maldescent of testes) Urethral meatus and hypospadias Palpation: Are both testes palpable inside the scrotum?

29. Examining the Testes: Summary and Referral Facts  1-2 in 100 baby boys have problems with their testes that require treatment  Risk factors include first degree family history of cryptorchidism; low birth weight; small for gestational age or pre-term delivery Screening process  The screening examination consists of observation of the scrotum and penis, and palpation of the scrotal sac Referral and follow up  Babies with bilateral undescended testes should be referred to a senior paediatrician within 24 hours of examination (newborn)  Babies at 6-8 weeks with bilateral undescended testes should be seen by a senior paediatrician within two weeks of examination  Babies with unilateral undescended testis should be reviewed at 6-8 weeks examination (newborn)  Babies with unilateral undescended testis at the 6-8 week examination should be reviewed by the GP between 24-30 weeks of age.

30. What Now? Download slides + checklist Online MCQ: https://www.goconqr.com/en- GB/p/3898260-Examination-of-the-Newborn-- 2--Examination-Part-1---Eyes--heart--hips-and- testes-quizzeshttps://www.goconqr.com/en- GB/p/3898260-Examination-of-the-Newborn-- 2--Examination-Part-1---Eyes--heart--hips-and- testes-quizzes Request a Podcast/ ask a question Next presentation: Examination part 2: Top- to-toe

31. Further Information http://www.mayoclinic.org/diseases- conditions/congenital-heart- defects/multimedia/congenital-heart- defects/sls-20076059 http://www.mayoclinic.org/diseases- conditions/congenital-heart- defects/multimedia/congenital-heart- defects/sls-20076059 NIPE eLearning package: http://cpd.screening.nhs.uk/nipe-elearning http://cpd.screening.nhs.uk/nipe-elearning

32. References Eye diagrams: http://www.ilearn.rcm.org.uk/mod/book/view.php?id=611&chapterid=1721 (Originally from St Bart’s Hospital) http://www.ilearn.rcm.org.uk/mod/book/view.php?id=611&chapterid=1721 Hip manouvre videos: https://www.youtube.com/watch?v=imhI6PLt GLc (Dr Nabil Ebraheim) https://www.youtube.com/watch?v=imhI6PLt GLc

33. References Hip manoeuvre diagrams: A Comprehensive Newborn Examination: Part II. Skin, Trunk, Extremities, Neurologic. MARY L. LEWIS, MD, Dwight D. Eisenhower Army Medical Center, Fort Gordon, Georgia Am Fam Physician. 2014 Sep 1;90(5):297-302. NIPE summary tables: http://cpd.screening.nhs.uk/induction- resource/nipe#fileid11785 http://cpd.screening.nhs.uk/induction- resource/nipe#fileid11785