examination of the newborn examination part 2: top-to-toe chris kingsnorth

Examination of the NewbornExamination Part 2: Top-to-Toe

Chris Kingsnorth

Before We Begin

Overview

• 4 presentations:

1. Introduction and pre-examination2. Examination part 1: Eyes, heart, hips

and testes3. Examination part 2: Top-to-toe4. Post-examination

Overview

• Integrate 4 focuses of NIPE screening (eyes, hips, heart and testes) into top-to-toe examination

• Practical tips

Overview: FrontHead (inc. face and mouth)

Eyes

Neck and clavicles

Limbs and digits

CVS (inc. heart, colour and pulses)

Respiratory systemAbdomen

Genitalia + anus

Skin

Hips

CNS (inc. tone, movements and

posture) +/- reflexes Cry

F

General appearance

Overview: Back

Spine

Heart soundsLung sounds

Skin

Tone

B

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

General Appearance

Start with baby lying on back on flat surface

•Colour•Breathing•Behaviour•Activity•Posture•Cry

Skin

• Colour• Texture• Birthmarks• Rashes Don’t forget to check the

back too (you can do this later, when examining

the spine)

Skin: Possible Findings

Cyanosis Erythema toxicum (Common (50%), not harmful;

clears within a few days)

Milia(Blocked pores. Common (50%), not harmful; clear within a few

weeks)

Mongolian blue spotMore common in Asian babies. Not harmful. Usually lumbosacral; may

occur anywhere. Can look like bruise

Always document birthmarks on a body map to avoid future

misinterpretation

Head

• Fontanelles• Face• Nose• Mouth + palate• Ears

Head: Possible Findings

Cleft palate +/- lip Micrognathia Microtia

Eyes

• NIPE screening focus point• Covered in detail in Examination Part 1: Eyes,

heart, hips and testes

Neck and Clavicles

• Size/ proportions• Shape • Symmetry of structures

Limbs, Hands, Feet and Digits

• Moving all 4 limbs?• Size/ proportions• Shape • Symmetry • Palmar creases• Sandal gap

Always count digits

Limbs, Hands, Feet and Digits: Possible Findings

Sandal gap Single palmar (simian) crease Syndactyly

Polydactyly

Heart and CVS

• NIPE screening focus point• Covered in detail in Examination Part 1: Eyes,

heart, hips and testes

Don’t forget to listen to the heart at the back too

(you can do this later, when examining the

spine)

Respiratory System

• Cyanosis?• Effort• Rate• Lung sounds• +/- Pulse oximetry

Don’t forget to listen at the back too (you can do

this later, when examining the spine)

Abdomen

• Shape and size• Palpate: Organomegaly/ masses?• Bowel sounds• Umbilical cord (esp. for discharge/ redness)

Abdomen: Possible Findings

Umbilical infection/ redness Umbilical hernia

Abdominal mass

Genitalia

Males: Testes = NIPE screening focus point (Covered in detail in Examination Part 1: Eyes, heart, hips and testes)

Females: Shape and size

Ambiguous: Seek senior advice

Anus

• Patent?• Passed meconium ≠ patent anus (possibility of

enterocutaneous fistula)

CNS

• Tone• Behaviour• Movements• Posture• Newborn reflexes only if concerned

CNS: Possible Findings

Other pathologies:

Hips

• NIPE screening focus point• Covered in detail in Examination Part 1: Eyes,

heart, hips and testes

Turning the Baby

Easiest and safest = roll baby onto side

Spine

• Inspect + palpate bony structures• ‘Divots’ suggesting non-continuity of

vertebrae/ absence of spinous process• Sinuses/ hairy tuft (possible spina bifida

occulta)• Meningocele/myelomenigocoele

Sacral dimples vs. sinuses; if unsure, ask for senior R/V

Spine: Possible Findings

Meningocele/myelomenigocoele Hair tuft

Completing the Examination

• Redress baby• Thank parents• Explain any findings/ need for Senior R/V• Invite questions

What Now?

• Download slides + checklist• Online MCQ:

https://www.goconqr.com/en-GB/p/3906445-Examination-of-the-Newborn--3--Examination-Part-2---Top-to-toe-quizzes

• Request a Podcast/ ask a question• Final presentation: Post-examination

Further Information

NIPE eLearning package: http://cpd.screening.nhs.uk/nipe-elearning

References

• How to roll a baby: https://www.youtube.com/watch?v=kVUeK77URJI

• Neurological abnormality videos: http://library.med.utah.edu/pedineurologicexam/html/newborn_ab.html#01

• Neonate skin conditions and images: http://www.dermnetnz.org/site-age-specific/neonate.html

References

• Cleft lip and palate diagram: http://www.transformingfaces.org/wp-content/uploads/2012/05/clp11.png