Newborn check examination

Introduction

• Wash hands
• Introduce self to parents
• Ask Baby’s name and DOB
• Explain examination to parents and obtain consent
• Congratulate parents
• Undress baby completely

General inspection

• Cry: feeble, pitch
• Colour: cyanosis, pallor, jaundice (haemolysis)
• Dysmorphic features, e.g. cleft lip, low set ears/epicanthic folds (Down’s syndrome)
• Posture, tone and movements: hypotonia (Down’s syndrome), hypertonicity, hemiparesis, opisthotonos, myoclonus

Top to toe

Cranium

• Look for
  • Cephalhaematoma
  • Caput succedaneum
  • Cranial moulding/deformities
  • Micro-/macrocephaly
• Feel fontanelles (bulging = raised intracranial pressure, e.g. hydrocephalus; sunken = dehydration), feel sutures (check fused)

Face

• Look for
  • Dysmorphic features
  • Cleft lip
  • Ears (low set/preauricular skin tags/deformity = Down’s syndrome)
• Feel with little finger inside roof of mouth (cleft palate; high-arched palate = Marfan syndrome) and determine presence of suck reflex

Eyes

• Look for
  • Erythema/discharge (conjunctivitis)
  • Icteric sclera
  • Subconjunctival haemorrhages (trauma during delivery)
• Check red reflex using ophthalmoscope (absent = congenital cataracts; white = retinoblastoma)

Upper limbs

• Shoulders: check aligned, feel clavicles
• Extend arms and check equal length
• Look at hands for
  • Single palmar creases (Down’s syndrome)
  • Extra digits (polydactyly)
  • Fused digits (syndactyly)

Chest

• Respiratory rate
• Capillary refill
• Look for signs of respiratory distress (indrawing of intercostal muscles)
• Feel for chest expansion
• Auscultate lung and heart sounds (check for murmurs; normal heart rate is 120-150bpm)

Abdomen

• Inspect for distension (bowel obstruction), scaphoid abdomen (diaphragmatic hernia)
• Comment on umbilical stump (any erythema, bleeding, discharge)
• Palpate for masses, hepatosplenomegaly and ballot kidneys (Wilms tumour)

Genitalia and femoral pulses

• Genitalia
  • Boys – feel testes (check both are descended and for a hydrocele); check foreskin and for hypo-/epispadias
  • Girls – check for labial fusion; both – check anus is patent
• Femoral pulses (absence suggests coarctation)

Hip tests

• For both tests grasp their flexed knees in your palms, placing your thumbs over the medial aspects of their knees and your fingers over the lateral aspects
• Hold both knees throughout but test one side at a time

Barlow’s test

• Detects dislocatable hip
• Flex adducted hip to 90˚, then push posteriorly in the line of the femoral shaft
• Dislocation is felt as a click

Ortolani’s test

• Detects hips which are already dislocated (‘out’)
• Flex hip to 90˚, then abduct hip (turn it out)
• On full abduction, apply anteriorly directed force to the upper leg (pull upper thigh towards you with your fingers, keeping the knee steady in your palm)
• Relocation is felt as a click.

Lower limbs

• Extend and check equal length
• Test range of movement at ankles
• Check feet for talipes (‘club foot’) and calcaneovalgus (abducted forefoot and dorsiflexed ankle)
• Look for extra digits (polydactyly), or fused digits (syndactyly)

Back

• Turn baby prone 
• Inspect for lipomas, tufts of hair (spina bifida), ‘port wine’ stains, and Mongolian blue spot
• Palpate for spinal abnormalities (spina bifida) and natal cleft

Finally

Reflexes

• Grasp reflex: place finger in baby’s palm. They should grasp it.
• Moro reflex: warn parents first. Hold the baby in a sitting position a few inches above a soft surface, supporting their head in one of your hands and their bottom in the other. Allow the baby to rock backwards quickly but very slightly towards the bed (with your hands still supporting their head and bottom). Their arms should abduct, adduct, then the baby will usually cry.

Questions to ask the mother before a newborn baby check

Labour

• How long since delivery
• Type of delivery
• Problems in labour (including breech, premature rupture of membranes)
• Medications in labour

Mother

• Any temperatures
• Overall health in pregnancy
• History of congenital hip dysplasia

Baby

• Pre-term / term / post-term
• Weight
• Breast / bottle-feeding (latching OK?)
• Urine (within 12 hours)
• Meconium (sticky black stool within 48 hours)
• Breathing

Questions to test your knowledge

What are the three main types of spina bifida?

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What is a cephalhaematoma and a caput succedaneum? What are their causes?

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What are the causes of microcephaly and macrocephaly?

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If you detect unstable hips during the examination, which condition would you be concerned about? How would you manage it?

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