Routine Examination of the Newborn (Neonate Exam)

Dr Tom Leach

8 years ago

Introduction

Strictly speaking, a neonate is any baby <4 weeks old. Then up to 1 year old, the child is an ‘infant’.

Usually, within minutes after birth, a midwife or doctor will conduct a very brief overview examination, e.g. checking gender, checking gross abnormalities (e.g. breathing, cleft lip & palate). Then, within 48 hours of birth a doctor will perform a more thorough routine examination of the newborn.

Some doctors suggest the optimum time for neonatal exam is between 24-48 hours. This allows the foramen ovale time to close (and thus eliminates this physiological murmur) and allows time for neonatal jaundice to present.
However, usually in practice, the exam in performed <24h after birth.

This is not only important as it can identify any medical problems, but also it is an opportunity to meet with the parents, and discuss their concerns. Ideally you should perform the examination with both parents present. It may also provide an opportunity to counsel the parents in the case of any congenital defects.

The routine examination of the newborn has a poor sensitivity for picking up congenital abnormalities.
There is no proven benefit of having two doctors perform the examination to spot abnormalities

Serious Congenital abnormalities

(in order of prevalence)

Congenital heart disease
Developmental dysplasia of the hip
Talipes
Down’s Syndrome
Cleft lip and palate
Urogenital abnormalities
Spina bifida / anencephaly

Congenital abnormalities that spontaneously resolve

The majority of apparent abnormalities at birth will resolve with no treatment. Examples of these include:

Peripheral cyanosis – particularly hands and feet – will usually resolve within 24 hours
Traumatic cyanosis –can result from the umbilical cord around the baby’s neck, or a face/brow presentation. Typically causes a blue face, and there may also be petechiae on the head and neck. If there are any signs of cyanosis, you should perform pulse oximetry.
Distorted head shape / swollen eye lids –normal side effects of delivery
Subconjunctival haemorrhages
Cysts – in the gums and floor of the mouth
Breast enlargement / milk production –can occur in either sex and is completely normal
Vaginal discharge / blood –a small prolapse is also normal
Capillary Haemangioma (“stork bites”) – pink macules on upper eyelid, forehead and neck, due to capillary distension. Should fade within first year of life. Those on the neck will become covered with hair. May persist into adulthood on the neck, but are not visible due to hair.
Urtricaria (“hives”) – rash – dark red raised area, with white papules at the centre. Can be at any site, but most common on the trunk.
Epstein’s Pearls –harmless small white cysts along the midline of the palate. Resolve within weeks.
Milia –small white pimples on the face
Mongolian Blue Spots –look a bit like bruises. Dark/blue patches, usually around the base of the spine. Typically in Asian and African babies. Will fades over the first few years of life.
Umbilical Hernia –particularly common in African babies. Will resolve by age 2-3.
Positional talipes –the foot (or feet) remain internally rotated as if in the fetal position, but can be passively externally rotated and have a full range of movement.
True talipes equinovarus (club foot)– more serious. Again can involve one foot or both (50% of cases bilateral). Quite common (1 in 1000), and 2x as common in boys. Can usually be treated with physiotherapy, or in more serious cases, casts and splints. Surgery is rarely needed. It is generally caused by short/tight tendons, and thus in casts/splints, the tendons are gradually stretched, usually over a period of weeks or months.
Differentiating – in ture talipes equinovarus, it is now possible to dorsiflex the foot such that the dorsal surface of the foot touches the shin. In positional talipes, this is possible.

Other Abnormalities

Strawberry Naevus – not present at birth usually, but develops in the first few weeks of life. They are more common in premature babies. Looks a bit like a red strawberry. They tend to grow for 3-9 months, and then gradually recede. No treatment is needed, except for some rare instances, where it may obstruct vision or with the airway. Thrombocytopaenia can be present with large lesions.
Naevus flammeus – aka Port wine stain – this is usually present at birth, and grows as the child grows. Caused by abnormal capillaries in the skin (dermis layer). If it is particularly disfiguring laser treatment is available.

Pre-examination checklist

Before the examination, check:

Name
DOB
Gestational age
Birthweight – Including birthweight centile
Delivery type
Feeding / urinating / bowel movements (meconium passed?)
Any parental concerns?

As with all examinations, it is important to have a system! This exact system itself isn’t particularly important – it is just useful as a method not to forget what you are doing!

In this case we will go from head to foot.

Examination

General Inspection

Completely Undress the baby!
Have a general inspection, particularly looking at the baby’s appearance, posture and movements. Also note the general muscle tone, and the colour of the baby (pink, dusky, jaundiced)

If there is apparent cyanosis check the tongue as the most accurate indicator of central cyanosis. If present, central cyanosis requires immediate action!
If pale, check hematocrit for polycythaemia or anaemia
Hypotonia may be due to Down’s

Is the baby responsive?

Head

Measure head circumference – using a paper tape measure. this provides a rough estimate of brain size. You should plot your recordings on the growth chart.
Palpate the fontanel and sutures

Fontanel size is extremely variable.
Raised fontanel in crying is normal
If fontanel is raised when baby is not crying, raised ICP may be the cause. Cranial ultrasound is recommended in this instance.
A tense fontanel is also a late sign of meningitis, but often note seen
Sagittal suture is often separated
Coronal suture may be ‘over-riding’
It is normal for the skull bones to have been moved during birth
Should NOT be fused

Face

Check symmetry, e.g. of eyes, ears, nose
An unusual looking face could be the result of a congenital syndrome. There are hundreds! Seek expert help. Particularly common is:
Down’s Syndrome:

Oblique eye fissures with epicanthic skin folds
Flat nasal bridge
Light coloured spot in peripheral iris (Brushfield spots)
Protruding tongue (due to small oral cavity)
Short neck

Eyes

Check Red reflex with ophthalmoscope:
Retinoblastoma
Cataracts – 50% of cases are identified in this manner. Congenital cataracts can affect development of normal vision.
Corneal Opacity

Ears – tops of the eras should be level with the eyes. If the ears are lower down (‘low set’) then this is a possible sign of Down’s syndrome.
Palate –use your finger and a torch! A tongue depressor may damage to baby’s palate.

Make sure you check posteriorly to exclude posterior cleft lip and palate. Also at the back of the palate theri may be an indentation from a submucous cleft.
Natal teeth are sometimes present. If they are lose, they should be removed to avoid aspiration.

Chest

Breathing and chest wall movement – have a general inspection, looking for signs of respiratory distress

RR – 30-60 is normal

Auscultate the heart

HR – 110-160 is normal. May drop to 85 during sleep.

Congenital heart disease

50% of all murmurs in newborns will be ‘innocent’. An innocent murmur is usually; Mid systolic and Radiates to the back/axilla
Difficult to detect if it is innocent or not in many cases
If in doubt, get an echo
Communicate with parents. Tell them if the baby has an unusual feeding or other difficulties to bring them back straight away

Abdomen

Liver – usually 1-2 fingers below the costal margin
Spleen – usually palpable
Kidneys – may be palpable – particularly on the left
Bladder – palpable bladder could be a sign of urinary outflow obstruction. This is particularly true in boys, in whom it is possible to have a congenital urethral valve. This requires urgent ultrasound. If the valve is the cause, this can cause urinary retention and subsequent pylonephritis and serious kidney damage (reflux nephropathy).
Any other masses – are often renal, but still need investigation!
Umbilicus – check for hernia (usually benign) and infection
Usually abdomen is soft

Genitailia and Anus

Testes – confirm they are present!
Vagina – a small prolapse is normal
Doubt over the sex? – if there is ambiguous genitalia – DON’T GUESS THE SEX! – discuss this with the parents, and inform them you will need to conduct some tests.
Anus – present? Patent?

Limbs

Femoral pulses – check on both sides that they are present. Pulse pressure may be:
- Increased – patent ductus arteriosus
- Reduced –co-arctation of the aorta
Digits – check the baby has the correct number of digits on all limbs. Also check the palmar creases. A single palmar crease is a sign of Down’s Syndrome
Muscle Tone – if you haven’t look at it already. You can move the limbs gently, as you might in a neuro exam. As well as observing normal limb movements. You should sit the baby up and observe head control. In a normal neonate, they should be able to support their head very briefly when vertical.
Palmar crease – a single crease may be a sign of Down’s Syndrome
Grip –check that the baby is able to grip one of your fingers with their hand. Check both hands.

Spine

Have a good look at the whole of the spine, looking for any midline deformities. Also feel down the spine briefly.

DDH – Developmental dysplasia of the Hip

Leave this until last, as it often upsets the child. The baby needs to be relaxed – as crying often results in constriction of the muscles around the hips.

Barlow Test

With one hand, stabilise the pelvis
With the other hand, place your middle finger on the greater trochanter of the femur, and your thumb on the medial aspect of the femur. Then, with the hip flexed, try to adduct the hip, and press the hip down onto the mattress. In a normal hip, there will be no dislocation. In DDH you will feel posterior displacement of the greater trochanter.

Ortolani Manouvre

This is the test to try and replace the dislocated femur in the case of a positive Barlow test.
Abduct the effected hip, and you should feel (and sometimes here) the femur click back into place.
You can often get ‘clicks’ without displacement of the head of femur, and these are not significant.

DDH is:

6x more common in girls
Seen in children with a family history (20% of cases have FH)
More common in breech birth (30% are due to breech)
More common in neuromuscular disorders
Early recognition reduces morbidity. The affected limb can be splinted.
If unsure of the diagnosis, you can do USS.
Normally performed in the examination of the newborn, and again at 6 weeks of age. Some cases are monitored until the child is able to walk.
More accurately spotted with USS of the hip joint. This is being used increasingly in hospitals in the UK, mainly to confirm the diagnosis after a positive Barlow/Ortalani test. In some instances it is also used ot screen for the condition, but this is expensive and time consuming, Also remember that generally USS procedures are highly operator dependent.

Reflexes

Morrow Reflex – Support the child with your hand and forearm. Then gently but swiftly, tilt the child backwards. In normal circumstances, the child should outstretch their arms (and legs). This is a positive morrow reflex.
Rooting reflex – when you gently touch next to the baby’s mouth, the baby will turn their head and try to suckle.
Grasp reflex – place your finger in the baby’s palm. The baby should grasp with a firm grip
Stepping reflex – holding upright above the bed, and then gently brush the bed against the baby’s feet / shins. The baby should step. They may also be able to support some of their own weight.

Vitamin K therapy

Some babies suffer from Haemorrhagic disease of the newborn – not to be confused with haemolytic disease of the newborn! In this haemorrhagic condition, a vitamin K deficiency results in reduced production of clotting factors 2, 7, 9 and 10.

The deficiency is usually due to a variety of factors, including:

Vit K does not cross the placenta very well
Vit K stores are low at birth
Breast milk is low in Vit k
Formula milk is high in vit K, and thus the condition is rarely seen in formular fed babies
There is little gut flora in neonates – in a normal adult, bacterial flora produces much of the vit K we absorb.
Anticonvulsant therapy in the mother can impair vitamin K synthesis, and thus these babies are at increased risk of haemorrhagic disease.

Effects of vit K deficiency

Easy bruising
Hematemesis
Melena
Prolonged bleeding (e.g. of umbilical stump, or after circumscision)
Intracranial haemorrhage – rare, but serious. ½ of all babies that suffer from intracranial haemorrhage will have serve morbidity or mortality.

It can present at birth, or between age 1-8 weeks.

Management

All babies in the UK are given vitamin K therapy to prevent haemorrhagic disease. This is usually in the form of an IM injection shortly after birth.
This has been controversial, as one small study suggested a link between IM therapy and childhood cancer. This conclusion has not been confirmed by much larger studies. However, as a result, parents have the option of oral vitamin K therapy, which is given as 3 oral doses over the first 4 weeks of life, due to the variable oral absorption of vit K.
Mothers on anticonvulsant therapy – take prophylactic therapy from 36 weeks gestation, and the baby is given IM vitamin K after birth.

Anticoagulation in Pregnancy

Vitamin K agonists (such as Warfarin) are teratogenic! Thus is cases of planned pregnancy, where the mother is on long-term warfarin therapy, then heparin or LMWH (low-molecular-weight-heparin) are usually used.

Women planning a pregnancy are usually advised to swap their medication before trying for a baby
In other pregnancies, the therapy should be changed as soon as the pregnancy is confirmed
The greatest teratogenic effect is during the first trimester