Neonatal examination

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It’s 6pm on Saturday evening, and Jenny and Jake are keen to head home with their new baby, Jessica, now 30 hours of life. The midwife calls you to attend for the baby check.

 

Bottom Line:

  • Have a low suspicion for sepsis in any neonate
  • Identify and treat hypoglycaemia, dehydration & respiratory distress
  • Take a specific feeding history
  • Explain what you are doing and why
  • Pay close attention to the heart, femorals, eyes and hips!
  • Provide information relevant to the situation

Examining neonates can be both lovely and terrifying, sometimes simultaneously. This is quick guide to examining the neonate, and some questions to keep in the back (or front!) of your mind. In some cases, you will be the first doctor examining a newborn. The only way to get good at neonate exams is to do lots of them! On the upside, from this experience, you’ll have a better chance at spotting an unwell baby, both on the wards and in emergency.

You’ll need gloves, a fresh nappy & changing gear such as a warm wet wipe, an ophthalmoscope, a stethoscope, a tape measure and a neonate book to sign off, as appropriate. Read mum’s notes for the antenatal and intrapartum history, checking antenatal scans and details of the delivery  (+/- instrumentation/emergent delivery), gestational age, birth weight, any resuscitation required.

Identify any setup for sepsis:

  • Meconium liquor
  • <37/40
  • Maternal fever
  • Prolonged rupture of membranes >=18hrs (+/- maternal antibiotics)
  • Consider any neonate delivered vaginally, or with rupture of membranes with symptoms as potentially infected

or hypoglycemia:

  • Birthweight >4.5 kg or <2.5kg
  • Maternal diabetes
  • <37/40
  • Suspected sepsis

Ask if this is the parents’ first baby and the baby’s name. First, ask parents if they have any concerns and ensure specifically you address them before you finish. Ask about specifically about feeding. It’s easy to say “feeding’s good”, but this doesn’t mean much when evaluating for dehydration, weight gain or possible sepsis. Specifically ask feed type (breast milk/formula), mode (bottle/breast/NGT), frequency (either number/day or q?hrly, ask about sleeping through), feed completion (time at breast/not waking for feeds/fussing). This is a good time to ask about vomiting, and if baby has been reweighed (>10% weight loss in first few days is a concern). Ask about a family history of DDH; if positive arrange follow up as per your local guidelines.

Ask about sleeping. Some babies are sleepier than others, but in general, they should wake for feeds, every 2-4 hours.

During the exam, be systematic but opportunistic. Keep baby warm but examine every inch of skin. Listen to the heart and lungs before the baby gets too worked up. If the bub is looking around, check the eyes early, identify the red-reflexes and checking for the black dots of cataracts.

Boys will inevitably wee at you; it’s a great chance to reassure parents and exclude hypospadius!  Do the hips last, as Barlow/Ortolani may make the baby cry (if they’re not already). Check for tone by gently pulling the baby from supine to sitting, watching for head lag; it’s best to do this slowly and to warn the parents. You can compare when holding baby prone.

If the baby seems to handle a bit quietly or jittery, do a BSL. Do it yourself, now. (Hypoglycemia is a symptom of sepsis, right? If it’s <=2.6, escalate promptly. Your local service may have specific guidelines – the Queensland Neonatal Guidelines are here). The same goes for Jaundice and hyperbilirubinemia; if you think the baby is jaundiced, verify & treat as per your local guidelines.

Summarise your findings; if you see erythema toxicum or milia, name and explain it. Parents appreciate being reassured about normal things. Pay close attention to the heart/femoral pulses, hips and eye examinations; this is where a attention to detail is vital. Always consider murmurs (and the dreaded duct dependent lesion), developmental dysplasia of the hip, and congenital cataracts/eye abnormalities.  If you’re not sure, or you find anything significant, ask a senior to review with you.  This, in particular, goes for any possibly dysmorphic features, or aberrant cardiac, hip or eye findings you are uncertain about. There’s an excellent article on the Vic NETS website about dysmorphism.

Give advice! Have a spiel that covers the important and scary stuff, including signs and symptoms of sepsis & when to come back to hospital. Have a chat about what to expect in the first few days. Suggest that baby should feed every 2-4 hours and if not, that they should talk to their midwife. If the baby seems hot or is vomiting, or is  ‘not quite right’, they should bring baby to hospital for a review. Ensure the child will see a GP in the first week of life, for a repeat exam and to book in for vaccines as per the immunisation schedule, including parental pertussis vaccination.

If parents have declined Vitamin K or Hep B, it’s okay to challenge them on this. Ask their reasoning and discuss the risks of, for example neonatal Hep B or haemorrhagic disease of the newborn.

Ask about home – if it’s set up, other children, pets – with respect to baby safety.
Talk about SIDS/SUDI, it’s the number one cause of death under 1one year of age, and is only reduced by smoke-free environment and safe sleeping; mention other risks such as co-sleeping after a drink of alcohol. The SIDS & Kids is an excellent resource on safe sleeping, which I remember as the 7 Bs;

Baby,
By them self,
in a Bassinet,
at the Base,
on their Back,
wrapped in a Blanket
with Bugger all else (nothing else in the cot).
In your Bedroom for 6 months.


The Neonatal Exam:

The examination should be systematic but opportunisticObservation is more important than examination

Undress baby as you need to…Remember to keep them warm, but through the course of your exam, you must look at every inch of skin! Place them in a crib, or on a flat, secure surface.

Appearance

  • colour ?pink ?blue ?yellow
  • skin ?intact ?rashes ?birthmarks
  • ?dysmorphism; ear position; protruding tongue
  • breathing
  • behaviour ?jittery ?sleepy – BSL if concerned
  • cry
  • activity
  • posture
  • tone incl. cycle the legs
  • movements & posture
  • head lag
  • reflexes: Moro; grasp; rooting; fencing; walking; plantar
  • count fingers and toes

Then go for the head-to-toe approach…

Head & Fontanelles

  • ?facies
  • nose
  • mouth & palate (rooting reflex)
  • ear size, patency position & no pits
  • symmetry
  • plot head circumference and weight 

Eyes

  • opacities
  • red reflex 
  • Neck & Clavicles

    • sternomastoid lumps
    • clavicles present and no lumps suggestive of fracture? 

    Heart & Lungs

    • chest symmetrical
    • resp rate (count for a full minute) & work of breathing 
    • heart position
    • auscultate for murmurs
    • femoral pulse presence and volume
    • oxygen saturations 

    Abdomen

    • shape soft, distended or scaphoid?
    • bowel sounds
    • umbilicus appearance
    • organomegaly 

    Turn baby over, to examine…

    Spine

    • inspect & palpate
    • ?scoliosis
    • ?skin abnormal or hair
    • ?pits or sacral dimples 

    Buttocks

    • anus perforate, no pits
    • crease heights 
  • back in crib, nappy off
  • Genitals

    • intact & relatively unambiguous
    • distended testes, hydrocoeles?
    • ?hypospadius
    • ask parents – Wee’d & poo’d? 

    Hips

    • DDH (Barlow & Ortalani) with stabilised pelvis 

    Check Weight & Length

    Put baby back as you found them, dressed, wrapped and changed (or ask mum/dad to do whilst you fill in neonatal check in baby book).

    Document your examination findings in baby’s hospital notes and tell a midwife the plan! 

     

    References

    DFTB – Immunisation Quick reference

    Queensland Maternity and Neonatal Clinical Guidelines Program – Neonatal Examination

    Dysmorphology Assessment of the Newborn – Vic NETS

    SIDS & Kids Website

    Davies, Cartwright & Inglis, Pocket Notes on Neonatology, 2nd Ed. 2008. Elsevier: Australia

    Examination Adapted from; Examination of the Newborn: A Practical Guide. Helen Baston, Heather Durward Pg 3

    Trachtenberg, F et al. Risk Factor Changes for Sudden Infant Death Syndrome After Initiation of Back-to-Sleep Campaign. Pediatrics; Vol. 129 No. 4 April 1, 2012 
    pp. 630 -638 

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    About 

    A Paediatric Trainee based in Queensland, Australia, Henry is passionate about Adolescent Medicine & General Paediatrics, with a strong interest in Medical Education & Clinical Teaching. An admitted nerd & ironman with a penchant for Rubik's Cubes & 'Dad jokes'.

    @henrygoldstein | + Henry Goldstein | Henry's DFTB posts

    3 Responses to "Neonatal examination"

    1. Sarah Watson
      Sarah Watson 4 years ago .Reply

      Great overview! An invaluable resource when starting out with baby checks is the Stanford newborn gallery. Pictures of normal and not so normal. For the visual learners! http://newborns.stanford.edu/PhotoGallery/

    2. Stefan Johansson
      Stefan Johansson 4 years ago .Reply

      Great overview!
      I miss one major risk factor for hypoglycemia: being small-for-gest.age
      And I also believe à few words about jaundice fouls be added, not uncommon, treatable and potentially really bad for the baby.

      Keep up the good work!

      StefanJohansson, consultant neonatologist, Stockholm, Sweden

    3. Henry Goldstein
      Henry Goldstein 4 years ago .Reply

      Stefan – Great points! – Post now updated to include low birthweight as a risk for hypoglycaemia and having a low threshold to define hyperbilirubinemia. Neonatal Jaundice is an entire post in itself; I agree it’s essential to consider in the Neonate Exam. Thanks!

      Sarah – What a great resource! Thanks for the tip!

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