This is Dubbo Base Hospital Baby Check.
See also HNE Newborn check
Duties of daytime paediatric resident.
Overnight if night registrar has sufficient time, recommend 1-2 baby checks at night to assist day staff.
PREPARATION FOR NEWBORN CHECK:
1. Reviewing maternal history.
a. Review obstetric, social, family history.
b. Maternal age, social background, mental health history, note if mother is scoring highly with depressive symptoms, history of domestic violence.
2. Chronic maternal disease and/or medications.
3. Recreational drug and tobacco use - Example, antipsychotic medications, example olanzapine, may lead to baby sedation at breast-feed, SSRI medications and antidepressants may lead to withdrawal and jitteriness. Methadone may lead to sedation and/or withdrawal.
4. Previous pregnancies including complications, example, neonatal jaundice, ABO incompatibility, maternal Rhesus status, genetic conditions.
CURRENT PREGNANCY:
1. Result of pregnancy screening tests: e.g. blood group, serology and ultrasound scans.
2. Chorionicity if twins, example, monochorionic diamniotic or diamniotic.
3. Diagnostic procedures including amniocentesis.
4. If mother is unwell with any nonspecific illness, example, febrile illness for congenital CMV.
5. Gestational diabetes.
LABOUR AND BIRTH:
1. Progression of labour, onset duration, interventions, maternal temperature greater than 38 degrees, 3rd stage.
2. Evidence of non-reassuring foetal status in labour.
PRESENTATION AND MODE OF BIRTH:
1. Apgar scores and resuscitation at birth.
2. Any evidence of perinatal asphyxia with low cord gas, example, pH less than 7.1, base excess >10, lactate > 6.
3. Medications since birth: vitamin K, hepatitis-B; immunoglobulins; antibiotics.
4. Gestational age: late, preterm versus premature.
5. Observations since birth: Axillary temperature, weight, urine passed, passed meconium, Finnegan score if relevant.
6. Feeding since birt: sucking behaviour, alertness, mode of feeding ( breast versus bottle versus syringe).
EXPLANATION TO MOTHER: Paediatric resident and registrar will introduce themselves to parents and explain they are with the Paediatric Team and are performing a routine neonatal baby check.
Ask baby's name and confirm gender.
In particular, ask parents if there are any concerns regarding their baby or if they have specific questions.
Discuss feeding choice and progress.
Explain normal weight loss following birth: 1-2% of body weight per day up to the usual maximum of 10% weight loss at day 5.
Provide further information as requested.
Provide an appropriate environment for baby check - Ensure warmth. If room cool, consider overhead heating or wrapping in blanket when removing clothes for exam
Equipment:
1. Stethoscope - Resident to provide own.
2. Ophthalmoscope - Mobile stand.
3. Pencil torch or mobile phone.
4. Tongue depressor.
5. Tape measure.
6. Infant scales and growth charts.
PHYSICAL EXAMINATION: Use a systemic approach to the newborn examination where possible, a reasonable approach is head-to-toe and front-to-back. Undressing the baby to nappy to fully examine baby is appropriate, keeping it warm and covered if the room is cool.
A few items of the newborn exam are particularly difficulty if baby is crying (eyes, murmurs, femoral pulses and hips). Consider examining for red reflex and femoral pulses and cardiac examination for murmurs prior to systemic examination.
Hip examination is uncomfortable for baby, so leave this until last and warn mother that baby may cry.
General Appearance:
1. Whilst baby is quiet and alert, look at skin colour, warmth and perfusion, less than 3 seconds on sternum.
2. State of alertness and responsiveness - Confirm baby has opened its eyes, is looking at maternal face during feeding and is alert during feeds (it is not normal if baby is consistently not fixing on face at a distance of 2-3 feet).
3. Look at spontaneous activity of movements. Baby should be wriggly and moving arms normally, upper limbs and lower limbs.
4. Posture. Baby may be generally flexed (arms/ legs/ hips/ and feet) from in utero positioning, gradually less flexed over the coming weeks.
5. Muscle tone. Baby should have a flexed tone with normal strength - Rather than frogs legs or hypotonic position.
Growth and Feeding Status:
1. Weight, length and head circumference - Document whether excessive weight loss is present.
2. We recommend intervention with comp feeding if weight loss is greater than 10%. Discuss greater than 12% the registrar and consultant.
Skin:
1. Note colour. Baby should be pink; mild jaundice on faces is common.
2. Pronounced jaundice (image on jaundice guideline) of the whole body is less common - May merit serum bilirubin on a heel prick. Consider transcutaneous bilirubin if available.
3. Any jaundice less than 24 hours is abnormal and needs review.
4. Look at congenital subcutaneous skin lesions and oedema.
a. Examples of skin lesions are greater than 3 cafe-au-lait spots, multiple haemangiomas.
b. Haemangiomas on nose or forehead in distribution of ophthalmic division of trigeminal nerve.
c. Lesions over the midline of the spine - merit a paediatric review and consider an ultrasound +/- MRI.
d. Oedema over the feet, consider Turner syndrome.
e. Port wine stain ( on face consider Sturge-Webber syndrome)
f. Naevus flammeus ( stork bite) often at base of neck
g. Toxic erythema - a flat red spotty rash with whitish/yellowy pimples in the middle
h. Neonatal pustulosis (multiple small yellow pimples)
i. Milia (multiple , tiny white lesions on face and nose)
Head:
1. Note shape and symmetry.
2. Scalp.
a. Note anterior and posterior fontanelle.
b. Some fontanelles are smallish in size and as long as open, do not pose great concerning.
c. A gaping fontanelle should be followed.
d. Sutures, note positioning and overlapping.
e. Scalp lacerations.
f. Ridging of sutures needs review by paediatrician and consider xray of skill (especially if head small).
3. Note if head is excessively large, macrocephaly or excessively small, microcephaly.
Microcephaly - Definition, less than 5th percentile documented on electronic medical record charts.
Macrocephaly, documented head circumference greater than 97th percentile +/- bulging fontanelle.
4. Scalp swellings are important to document, example, subgaleal haemorrhage.
a. Caput and cephalohaematoma - Warn regarding jaundice.
b. Fused sutures and ridging.
Face:
1. Note asymmetry of face, features in movement - Notice asymmetry of crying. Facial nerve palsy will lead to a failure to close ipsilateral eye and a failure of the mouth to open on the ipsilateral facial nerve palsy.
Eyes:
1. Note size, similar colour, whether pupils are equal and concentric.
2. Red Reflex - Red reflex should be documented of both pupils. Note, in fairer individuals with pallor skin, red reflex appears orange-red and one should see blood vessels.
a. For red reflex in individuals with darker skin pigmentation - Red reflex may show red-light brown with blood vessels present.
3. Note if the cornea is dull or hazy.
4. Note if the cornea is bulging one side versus other.
5. Note if pupils are unequal, example, Horner's syndrome.
6. Note if there is a ptosis, droopiness of eyelid.
7. Note if there is purulent conjunctivitis one versus both eyes.
8. Note if there is yellow sclera.
Nose:
1. Note position and symmetry of nares and septum - Check to see if baby is breathing comfortably through nose. Note if there is snuffliness or nasal secretions.
2. Note if there is noisy stertorous breathing - Consider passing nasogastric tube through both nostrils.
3. Dacryocyst.
Mouth:
1. Note size, symmetry and movement.
2. Shape and structure of teeth and gums.
3. Lips.
4. Palate, hare and soft palate - Note if uvula is singular or bifid.
5. Note tongue and frenulum - Note features of potential tongue-tie.
Ears:
1. Note position, structure including patency of external auditory meatus.
2. Note if there is well formed cartilage.
3. Note if responsive to noise - Baby should startle with widening of the eyes and becoming still to noise.
4. Note if there is external auditory canal or microtia and note if there is drainage from ear.
Neck:
1. Note if there is structure and asymmetry. Note range of movements.
2. Note if there is torticollis.
3. Note if there is a thyroid or midline neck mass.
4. Note masses or swelling. Note if there is neck webbing.
Shoulder, Arms and Hands:
1. Note if the leg length is the same right and left - Place the heels next to each other.
2. Note proportions of upper limbs versus lower limbs and ratio of humerus to distal radius and ulna.
3. Note structure in digits and number of digits.
4. Note if there is swelling of clavicle or evidence of fractures.
5. Note if there is hypotonia.
6. Note if there is weakness of the arm, for example, Erb's palsy and Klumpke's paralysis - Try to differentiate between lower motor neurone Erb's palsy and perinatal stroke, example, right hemiparesis.
7. Palmar crease pattern.
Chest and Cardiorespiratory:
1. Note the chest size, shape and asymmetry. Note symmetrical chest rise and fall.
2. Breast tissue - Male and female infants may have breast tissue hyperplasia from maternal hormones with some minor milk production - Should resolve by 3 months.
3. Note if there is breast swelling for redness and infection, evidence of abscess.
4. Note number and position of nipples - Accessory nipples.
Respiratory:
1. Chest movement and effort of breathing - Baby should not have tracheal tug, subcostal recession or intercostal recession.
2. Note for regularity of breathing - Periodic breathing is irregular breathing with relatively rapid breathing, example, 5-10 seconds followed by brief pauses 5-10 seconds followed by relatively rapid breathing - No stop in breathing for greater than 20 seconds.
3. Note breath sounds and noisy breathing, stertor versus stridor.
4. Note if the voice quality is normal - Hoarse voice versus strong cry.
5. Note if cry is muffled.
Cardiac:
1. Feel pulses, brachial and femoral pulses (have baby relaxed with legs abducted and warm).
2. Note if pulse rate is between 100 and 160.
3. Note, pulse rate may fall to 70-90 whilst in deep sleep, but should respond greater than 100 when awake.
4. Note if heart rate is regularly irregular - Sinus arrhythmia versus irregularly irregular.
5. Note if has very rapid heart rate greater than 220 - ?SVT - Needs ECG.
6. Heart sounds, S1 and S2, added sounds, S4.
7. Note if there is murmur, pansystolic murmur, examine axilla, left sternal edge, right sternal edge, neck and left posterior thorax; ?if murmur radiates in these areas.
8. Pulse oximetry upper limbs and lower limbs greater than 3% difference between the two - refer to paediatricians for formal cardiac review.
9. If lower limbs 100%, still recommend checking upper limbs' saturations.
10. Tip for Auscultation: Place gloved finger in baby's mouth to suck - Lowers heart rate, or place baby's hand in its mouth to generate sucking which slows heart rate and makes murmurs more audible.
Abdomen:
1. Note shape and asymmetry, is abdomen distended or not.
2. Palpate for liver - if Greater than 3 cm below costal margin - Discuss with consultant, palpate for spleen - Any palpable spleen - Refer.
3. Kidneys and bladder - The latter 2 are hard to feel and infrequently felt.
4. Bowel sounds - Should be active.
5. Umbilicus. Note if there is malodorous smell and/or discharge. Note if cord is separated. Note if there is evidence of omphalitis with umbilical flare skin infection next to the umbilicus.
6. Note if tender abdomen - Watch for facial grimacing and discomfort rather than guarding in a neonate.
7. Note if there is a history of vomiting, in particular green vomiting or bilious vomiting.
8. Note if there is umbilical hernia - This generally needs no intervention. Review at 12 months-18 months.
9. Inguinal hernia - These generally are referred to surgeon in first week of life.
Genitourinary:
1. Has the newborn passed urine.
2. Rule of thumb "child should do a a number 1 by the end of day 1 and a number 2 by the end of day 2" i.e., urine should be passed within 24 hours and faeces should be passed within 48 hours - Refer to paediatric consultant if this fails to happen.
Male Genitalia:
1. Penis - Should be greater than 2.5 cm stretch length - Micropenis needs referral to paediatrician for hormonal abnormalities, example hypopituitary state. Note embedded penis may give the illusion of a microphallus.
2. Testes - Confirm they are present bilaterally and position of the testes including any discolouration.
3. Scrotal size and colour.
4. Look for masses such as hydrocoele - Transilluminate with ENT otoscope.
Female Genitalia:
1. Discuss pseudomenses - Small red discharge for the first few weeks - Should resolve.
2. Clitoris size, example greater than 10 mm - Refer for ambiguous genitalia.
3. Labia majora and labia minora.
4. Hymen.
Specific Abnormalities:
1. Hypospadias, penile chordee - Refer to paediatric surgeon - Child must not have circumcision attempted.
2. Penial torsion greater than 60%.
3. Unequal scrotal size or scrotal discolouration.
4. Undescended testes, testes palpable in inguinal canal or impalpable - Needs review with paediatrician or paediatric surgeon in coming months - Generally recommend orchidopexy and bringing testes down under 12 months - Refer to paediatric surgeon.
Anus:
1. Has newborn passed meconium - Concern should be raised if there is no meconium passed within 24-and at the latest by 48 hours - Consider rectal problems, Hirschsprung's disease, anal stenosis etc, watch for vomiting.
2. Note anal position - Note anterior ectopic anus.
3. Anal patency - If child has not passed stools by 48 hours - Consult with paediatrician and consider placing lubricated nasogastric tube gently up anus to assess whether the anus is patent or not.
Hips, Legs and Feet:
1. For developmental dysplasia of hip.
2. Most reliable features.
a. Leg-length discrepancy.
b. Reduced abduction - Hips should abduct to 85-90 degrees with child relaxed (if crying or resisting this is harder).
c. Feel for subluxation or hip clicks with palpation.
3. Less reliable features for hip dysplasia are Ortolani and Barlow's - Note enlocation and dislocation manoeuvres (be aware of false-negative Ortolani and Barlow's maneuvers: If there is a dislocated hip with persistent dislocation - Ortolani's and Barlow's tests will be negative).
4. Refer all leg-length discrepancy cases and hips that can be dislocated for urgent hip ultrasound in first 1-2 weeks - Refer all dislocated hips in first 1-2 weeks.
5. Remaining leg examination with leg length proportion, symmetry, structure of digits.
6. Risk factors for hip dysplasia: Breech presentation, fixed talipes equinovarus, fixed flexion deformity, severe oligohydramnios, twin pregnancy, first-degree relative with developmental hip dysplasia.
7. Note for contractures. Note for fixed talipes.
Back:
1. Note spinal column: Note any midline lesions, note for scapula, buttocks and symmetry, note extra gluteal fold and note the skin.
2. Note curvature of spine, note tufts of hair or dimpling or any pigmentation along midline.
Neurologic Review:
1. Throughout observation, note;.
a. Behaviour, posture, muscle tone movements and cry.
b. Examine reflexes.
c. Moro reflex, note asymmetrical Moro.
d. Note suck and grasp.
e. Note if the child has a weak, irritable or high-pitched cry or no cry. Note if the child does not respond to consoling. Note if there is inappropriate care response to crying. Note if there is an exaggerated or startled reflex.
2. Neonatal seizures. Note for abnormal movements and note whether the child is encephalopathic and obtunded - Consider metabolic conditions.
CONSULTATION AND FOLLOW-UP: If the paediatric resident and/or registrar have significant concerns, these should be documented in the bluebook and the electronic medical record.
The paediatrician on-call should be notified in a timely response to the aforementioned abnormalities detected.
If there are hip ultrasound, renal ultrasound, any blood tests, imaging, etc, these should be ordered and a referral plan for paediatrician documented in the medical record by the resident.
Alternatively, if there is a high degree of urgency, example, dislocated hip, the paediatrician should be notified and the child attendant on the ward round.
Yours sincerely,
Electronically Approved on 11/02/2022 11:46:50
Dr Dominic Fitzgerald, MBBS (Hons), FRACP