Should I Be Around a Newborn Baby if I Have Pneumonia

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This guide aims to provide a structured approach to performing a newborn baby cess (NIPE) in an OSCE setting.

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Background

The Newborn Infant Physical Examination (NIPE)must be performed within 72 hours of birth by a qualified practitioner.¹

The purpose of the examination of the newborn is: ²

• To screen for congenital abnormalities that will benefit from early on intervention
• To make referrals for further tests or handling as appropriate
• To provide reassurance to the parents

A second examination is performed at 6-eight weeks of age, commonly by GP, to identify abnormalities that develop or become credible later.

Where to perform the NIPE

The NIPE test should be undertaken in a individual area which provides confidentiality for parents when personal data is being discussed.

The room should be warm and well lit (preferably natural calorie-free, particularly if jaundice is to be assessed).² Visual inspection, however, cannot reliably assess the level of jaundice and so if this is suspected a bilirubin level needs to be checked. ³

You'll ideally require a irresolute mat to carry out the test on.

Always make certain that the parents are present for the newborn check as this is an ideal time to answer queries and provide reassurance.

You might too exist interested in our OSCE Flashcard Collection which contains over 2000 flashcards that cover clinical examination, procedures, advice skills and data interpretation.

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Introduction

Wash your easily and don PPE if appropriate (alcohol gel must dry completely before treatment the newborn).

Introduce yourself to the parents including your name and role.

Ostend the baby'south name and appointment of birth.

Briefly explicate what the examination will involve using patient-friendly language: "Today I need to bear out a routine head to toe test of your child."

Gain consent to proceed with the examination:

• Parents should have received the National Screening Committee leaflet 'Screening tests for you and your baby' in the antenatal period.
• If the parents take not read the information booklet they must be given a re-create to read earlier to the examination.
• The aims and limitations of the examination should be fully explained.

Fairly expose the child for the cess: inquire the parents to undress the child downwards to their nappy.

Encourage the parents to ask questions during the check and to participate where appropriate.

The optimal fashion to perform the newborn check is past examining from head to toe sequentially. In reality, information technology's an opportunistic examination – if the baby is settled mind to their heart starting time, if they open their eyes bank check the fundal reflexes and if they're crying await at the palate!

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Questions to ask the parents

Beneath are some key points you would ideally cover in a full assessment of a newborn baby. It should be noted that in the context of an OSCE you lot are unlikely to be expected to cover all these history points due to time constraints.

Maternal history:

• Pregnancy details: date/fourth dimension and blazon of delivery/complications/high-risk antenatal screening results
• Breech presentation: if breech at 36 weeks gestation or delivery (if before), the baby will need to have an ultrasound scan of their hips as in that location is an increased run a risk of developmental dysplasia of the hip.
• Risk factors for neonatal infection
• Abnormalities noted on antenatal scans
• Family history: first-degree relatives with…hearing issues/hip dislocation/childhood heart bug/built cataracts/renal problems

Newborn history:

• Feeding pattern
• Urination
• Passing of meconium
• Parental concerns

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Weight

Ensure that the infant's weight is recorded and check on a weight chart whether the baby is:

• Small-scale for gestational historic period (<10th centile)
• Appropriate weight for gestational age (tenth-90th centile)
• Large for gestational historic period (>90th centile)

If a babe is pocket-size, yous should also plot caput circumference and length to make up one's mind whether this is symmetrical (small in all measurements) or asymmetrical (weight disproportionately low, caput circumference preserved).

Asymmetrical growth restriction is ordinarily due to placental insufficiency, whilst symmetrical growth restriction is more unremarkably due to fetal factors such as genetic abnormalities or intrauterine infection.

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Full general inspection

Inspect the color of the infant:

• Pallor: a pale colour of the pare that tin suggest underlying anaemia (e.grand. haemorrhage) or poor perfusion (e.g. congestive cardiac failure).
• Cyanosis: a bluish discolouration of the skin due to poor circulation (due east.g. peripheral vasoconstriction secondary to hypovolaemia) or inadequate oxygenation of the claret (eastward.g. correct-to-left cardiac shunting).
• Jaundice:a yellowish or greenish pigmentation of the skin and whites of the optics due to high bilirubin levels (e.g. newborn jaundice).

Audit the posture of the infant: note any gross abnormalities of posture (e.g. hemiparesis/Erb's palsy).

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Tone

Assess tone by gently moving the newborn's limbs passively and observing the newborn when they're picked upwardly (your cess of tone should go on throughout the examination).

Hypotonic infants are ofttimes described as feeling like a 'rag doll' due to their floppiness. Hypotonic infants oftentimes have difficulty feeding, as their oral fissure muscles cannot maintain a proper suck-swallow pattern or a good breastfeeding latch (hypotonia is common in children with Down'southward syndrome).

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Head

Size

Measure the infant'due south head circumference and record it in the notes.

Head size abnormalities

Microcephaly describes a head that is smaller than expected for historic period and sex. Microcephaly may be associated with reduced brain size or cloudburst.

Macrocephaly describes a caput that is larger than expected for age and sexual practice. Macrocephaly may be normal but may also be associated with hydrocephalus, cranial vault abnormalities or genetic abnormalities.

Shape

Inspect the shape of the caput and note whatsoever abnormalities.

Inspect the cranial sutures and annotation if they are closely applied, widely separated or normal.

Head shape abnormalities

Cranial moulding is common after birth and resolves within a few days.

Caput succedaneum is a diffuse subcutaneous fluid drove with poorly defined margins (often crossing suture lines) acquired by pressure on the presenting part of the head during commitment. It does not normally crusade complications and resolves over the beginning few days.^iv

Cephalhaematoma is a subperiosteal haemorrhage which occurs in i-2% of infants and may increase in size later on nascency. The haemorrhage is bound by the periosteum, therefore, the swelling does non cross suture lines (in contrast to a caput succedaneum). Cephalhaematoma is more mutual with instrumental commitment and may cause jaundice, therefore, bilirubin should be monitored.

Subgaleal haemorrhages occur between the aponeurosis of the scalp and periosteum and form a large, wiggling collection which crosses sutures lines. They are rare only may cause life-threatening claret loss.

Craniosynostosis is a condition in which 1 or more of the gristly sutures in an baby skull prematurely fuses, irresolute the growth pattern of the skull which can result in raised intracranial pressure and damage to intracranial structures.  Surgical intervention is required with the main goal being to permit normal cranial vault development to occur. This can be achieved by excision of the prematurely fused suture and correction of the associated skull deformities.⁷

Fontanelle

Palpate the anterior fontanelle: note if it feels flat (normal), sunken or jutting (abnormal).

Fontanelle abnormalities

A tense bulging fontanelle may suggest raised intracranial pressure level (e.g. hydrocephalus).

A sunken fontanelle may suggest dehydration.

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Peel

It is very of import to document any birthmarks or bruising/lacerations from birth trauma found on initial examination in case there are whatsoever child protection concerns in the futurity. At that place are body maps in the red book to help with this.

Colour: inspect the color of the skin and notation any pallor, cyanosis, erythema or jaundice.

Bruising/lacerations: notation the location and size of any bruises or lacerations which may have been sustained during childbirth.

Vernix: a waxy or cheese-like white substance plant coating the skin of newborn babies (this is a normal finding).

Examples of facial birthmarks

Examples of facial birthmarks include:

• Salmon patch (also known every bit a stork mark or nevus simplex): red or pink patches, often on an infant'southward eyelids, head or cervix caused by congenital capillary malformation. Salmon patches are very mutual and commonly fade by the age of two.
• Haemangiomas (also known as strawberry marks): blood vessels which grade a raised crimson lump on the pare which appears soon later nascence. Haemangiomas typically go bigger over the commencement half dozen-12 months and then shrink and disappear by the age of 7. They may require handling if they touch on vision, animate or feeding.
• Port-wine stain (also known equally naevus flammeus): red/regal marks on the face and neck which are typically present from birth and do not regress. Port-vino stains tin sometimes be associated with Sturge-Weber syndrome and Klippel-Trenaunay syndrome.

Other potential findings

Slate-greyness nevus is a beneficial, flat, congenital birthmark with wavy borders and irregular shape, normally located over the sacrum. It is nearly unremarkably blue in colour and tin can exist mistaken for a trample. They normally disappear within 3-5 years after birth.⁵

Milia are tiny white cysts containing keratin and sebaceous cloth. They are very mutual on the face and most resolve within the outset few weeks of life.

Erythema toxicum is a very common and benign condition seen in newborn infants. Information technology presents with various combinations of erythematous macules, papules, and pustules. Lesions usually announced from 48 hours of historic period and resolve spontaneously.

Neonatal jaundice can be physiological, appearing at two-three days and resolving past day ten. It can also be acquired by a broad range of unlike pathologies including haemolytic affliction, infection and Gilbert's syndrome.

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Face

Appearance: notation whatever dysmorphic features of the face (eastward.g. epicanthic folds in Downwards's syndrome).

Disproportion:annotation any asymmetry of the face (e.grand. facial nervus palsy secondary to instrumental delivery).

Trauma: annotation whatsoever evidence of facial trauma (eastward.g. bruising, lacerations) likely to have occurred during labour (due east.g. instrumental delivery).

Nose: inspect to assess the patency of the nasal passages (infants are obligate nasal breathers and therefore will present with respiratory distress and cyanosis at rest if they have bilateral choanal atresia).

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Optics

Audit the optics for bear witness of erythema or discharge (east.g. conjunctivitis).

Inspect the sclera by gently retracting the lower eyelid noting any discolouration (e.g. jaundice, subconjunctival haemorrhages). Subconjunctival haemorrhages often await dramatic but are adequately common after delivery and beneficial, you lot should, all the same, document their presence.

Inspect the position and shape of the eyes: look for evidence of ptosis or the presence of epicanthic folds (e.g. Down syndrome).

Fundal reflex

Correct terminology

The term fundal reflex is preferred over red reflex as the color of the healthy reflex varies depending on a patient's skin colour.

In patient'southward with lighter peel, the reflex typically appearsorange-cherry-red in color, whereas in those with darker pare, the reflex can beyellow-white or evenblue in color.

Assess for the fundal reflex in each eye:

one. Look through the ophthalmoscope, shining the light towards the patient's eye at a distance of approximately ane arm'south length.

two. Observe for a reddish/orange reflection in each pupil, acquired by light reflecting back from the vascularised retina.

Causes of an absent fundal reflex

Absence of the fundal reflex in children can be due to congenital cataracts, retinal detachment, vitreous haemorrhage and retinoblastoma.

An absent fundal reflex or the presence of a white reflex requires immediate ophthalmology referral.

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Ears

Inspect the pinna: notation whatever disproportion, pare tags, pits or the presence of accessory auricles.

All infants should undergo a hearing screening test prior to existence discharged from infirmary.

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Oral cavity and palate

Look for clefts of the difficult or soft palate: the full palate should be examined by visual inspection. Y'all will demand to use a tongue depressor and a torch, and ask a parent to help keep the baby's head still. You must visualise the whole palate, and see the key uvula to ensure it is intact. You cannot rely on palpation to exclude a cleft.

Inspect the tongue and gums: look for evidence of tongue-tie (ankyloglossia).

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Neck and clavicles

Audit the length of the neck and notation any abnormalities such equally webbing: a shortened webbed neck is typically associated with Turner'southward syndrome.

Inspect for neck lumps: a lump in the left posterior triangle of the neck may represent a cystic hygroma.

Expect for bear witness of a clavicular fracture: signs may include bruising, aperture of the clavicle and an abnormal position of the arm (fractures nearly unremarkably occur in the context of shoulder dystocia).

Cystic hygroma

Acystichygroma is a built lymphatic lesion which is typically identified prenatally or at nascency. A cystic hygroma can arise anywhere merely typically develops in the left posterior triangle of the neck. Cystic hygromas are benign but can be disfiguring and typically require surgical handling including drainage and use of sclerosing agents to foreclose reaccumulation of lymphatic fluid.

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Upper limbs

Assess the symmetry of the upper limbs: they should appear equal in size and length.

Inspect the fingers: count the fingers and note any abnormal morphology (eastward.m. polydactyly).

Audit the palms: cheque if the child has two palmar creases (normal).

Palpate the brachial pulse on each upper limb:annotation any asymmetry suggestive of an underlying vascular abnormality (due east.g. coarctation of the aorta).

Abnormalities of the manus

Polydactyly is a congenital abnormality where there are supernumerary fingers or toes.

A unmarried palmar crease is associated with Down's syndrome.

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Chest

Inspection

Observe the breast, paying particular attention to therespiratoryrate andworkofbreathing.

Respiratory rate

Count therespiratoryrate whilst observing the child. The normal respiratory rate of a newborn is 40-lx breaths per minute.

Work of breathing

Assess for signs of increased piece of work of breathing:

• Difficulty feeding
• Expiratory grunting
• Tracheal tug
• Supraclavicular recession
• Intercostal recession
• Subcostal recession
• Nasal flaring
• Abdominal breathing
• Head bobbing (secondary to sternocleidomastoid contractions)

Other clinical signs

Audit the breast for other relevant clinical signs:

• Pectus excavatum: a caved-in or sunken appearance of the breast.
• Pectus carinatum: protrusion of the sternum and ribs.
• Asymmetrical chest wall expansion: asymmetry may be noted unilateral lung pathology (east.1000. pneumonia).

Auscultation

Lungs

Apprehend each side of the chest in a symmetrical pattern, comparing side to side:

• Pay attention to theinspiratoryandexpiratory sounds at each placement.
• Note thequality andbook of the breathsounds.
• Note anyadditional sounds(e.k. wheeze, coarse crackles).
• Repeatauscultation on theposterior aspect of thechest.

Middle

Auscultate 'up' through the valve areas using the diaphragm of a paediatric stethoscope:

• Mitral valve: 5th intercostal infinite – midclavicular line (apex beat)
• Tricuspid valve: fourth or fifth intercostal space – lower left sternal edge
• Pulmonary valve: second intercostal space – left sternal edge
• Aortic valve: second intercostal space – right sternal border

Mind over each area with both thebong (for low pitched sounds – gallops and divide S2) and thediaphragm (high pitched sounds – pericardial rubs, S1/S2 and most murmurs).

The normal heart rate of a newborn is approximately 120-150 bpm.

If a murmur is noted, try to determine where it is heard loudest and if information technology radiates anywhere.

Pulse oximetry

Some centres recommend checking preductal and postductal oxygen saturations to amend detection of disquisitional congenital heart illness in newborn infants. Both readings should both be ≥95% and within 3% of each other.

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Belly

Inspection

Inspect for evidence of intestinal distension:causes include bowel obstruction, organomegaly and ascites.

Inspect the belly button: note any swelling (east.g. umbilical hernia) or erythema and discharge  (e.g. umbilical cord stump infection).

Inspect for show of an inguinal hernia in the groin: if present, arrange a paediatric surgical review.

Palpation

Palpate the belly to assess for organomegaly:

• Liver: should exist palpable no more than 2cm below the costal margin (if palpable lower in the belly consider hepatomegaly).
• Spleen: may exist palpable at the left costal margin in healthy infants (if easily palpable, consider splenomegaly).
• Kidneys: normally but palpable using deep bimanual palpation (if easily palpable consider polycystic kidney disease).
• Float: should non be palpable in healthy infants (if hands palpable, considering urinary tract obstruction).

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Genitalia

Annotation any ambivalence of genitalia: typically associated with congenital adrenal hyperplasia (CAH) in girls (boys with CAH accept normal ballocks).

Males

Cess of male person ballocks:

• Note the position of the urethral meatus: an abnormal position may be noted in hypospadias or epispadias.
• Notation the size of the penis: it should be at least 2cm.
• Assess for evidence of testicular swelling indicative of hydrocele: a collection of fluid around the testicle (the swelling will transilluminate when a light source is placed nearby).
• Palpate the scrotum to ensure both testes are present: a unilateral undescended testis is common and should be followed upwardly over time; bilateral absenteeism is considered a disorder of sexual evolution and should be investigated.

Females

Assessment of female genitalia:

• Audit the labia: to check they are not fused.
• Inspect the clitoris: to ensure it is a normal size.
• Annotation any vaginal discharge: white discharge is a normal finding, caused by exposure to maternal oestrogens.

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Lower limbs

Audit the lower limbs for abnormalities:

• Disproportion: the lower limbs should appear equal in size and length.
• Oedema: may indicate hypoalbuminaemia or congestive cardiac failure.
• Ankle deformities: talipes (club foot) is a common ankle deformity causing the pes to be turned in.
• Missing digits: ensure the correct number of digits are present on each foot.

Assess tone in both lower limbs:tone is typically decreased in infants with Downward's syndrome and may exist asymmetrically increased secondary to upper motor neuron lesions (due east.g. ischaemic stroke, intracranial bleeding).

Assess movement in both lower limbs:note any weakness which may bespeak an upper or lower motor neuron lesion or joint pathology.

Assess the range of knee joint movement: typically excessive in hypermobility.

Palpate and compare femoral pulses: this tin be difficult, peculiarly in an active baby, and requires exercise. Weak, absent-minded or delayed femoral pulses are a sign of coarctation of the aorta.

Hips

Both Barlow's and Ortolani's tests are carried out as part of the routine newborn examination to detect hip joint instability and dislocation. Each hip should be examined individually with all habiliment, including the nappy, removed.

Barlow's test

Barlow's test is performed by adducting the hip (bringing the thigh towards the midline) whilst applying calorie-free pressure on the knee with your pollex, directing the strength posteriorly. ⁶

If the hip is unstable, the femoral caput will slip over the posterior rim of the acetabulum, producing a palpable sensation of subluxation or dislocation.

If the hip is dislocatable the test is considered positive. The Ortolani manoeuvre is then used to ostend the positive finding (i.e. that the hip actually confused).

Ortolani'due south examination

Ortolani's test is used to confirm posterior dislocation of the hip joint. ⁷

one. Flex the hips and knees of a supine infant to 90°.

2. With your alphabetize fingers placing anterior force per unit area on the greater trochanters, gently and smoothly housebreak the infant's legs using your thumbs.

A positive sign is a distinctive 'clunk' which can be heard and felt as the femoral caput relocates anteriorly into the acetabulum.

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Back and spine

Inspect the spine for:

• Scoliosis
• Hair tufts
• Naevi
• Birthmarks
• Sacral pits

Hair tufts and sacral pits can be associated with underlying neural tube defects (e.grand. spina bifida).

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Anus

Audit the anus for patency:abnormal embryological development of the rectum can result in an imperforate anus.

Meconium should be passed within 24 hours: a delay is suggestive of obstruction or Hirschsprung'due south disease.

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Reflexes

Assess the newborn's reflexes

Assess a selection of the following reflexes which should all exist present in a healthy newborn. The absence of several reflexes may indicate an underlying neurological aberration.

Palmar grasp reflex

When an object is placed in the infant'southward hand and strokes their palm, the fingers will close and they will grasp it with a palmar grasp.^eight

Sucking reflex

Causes the kid to instinctively suck annihilation that touches the roof of their mouth, absence of this reflex is nearly credible during feeding.

Rooting reflex

Present at birth and disappears effectually four months of age, as it gradually comes under voluntary control.  A newborn infant volition turn its head toward annihilation that strokes its cheek or mouth to aid breastfeeding. ⁹

Stepping reflex

When the soles of the infant'south feet touch on a flat surface they will appear to walk by placing one foot in forepart of the other.¹⁰

Moro reflex

Support the babe's upper back with i hand, then drop back in one case or twice into your other hand. A normal Moro reflex involves the extension of the legs and caput whilst the artillery jerk upwards with the fingers extended. The arms are then brought together and the easily clamp into fists, and the infant cries. Asymmetry may be due to hemiparesis, brachial plexus injury or a fractured clavicle.

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To complete the examination…

Explain to the parents that the exam is now finished and offer to dress the baby.

Share the results of the assessment with the parents, explaining the reason for whatsoever referrals you feel are required.

Check if the parents take any further questions.

Thank the parents for their fourth dimension.

Dispose of PPE appropriately and wash your hands.

Summarise your findings

Document your findings and the need for farther investigations/referrals: in the Uk the NIPE is documented using a national online system (which you would print and place in the babe's notes).

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Reviewer

Dr Rebecca Naples

Paediatric Registrar

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Illustrator

Aisha Ali

Medical pupil and illustrator

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References

Text references

1. Newborn and Baby Physical Exam Screening Programme Handbook 2016/17. Public Health England. Published April 2016. Retrieved 15 March 2017.
2. Newborn Infant Concrete Exam. Nottingham Neonatal Service – Clinical Guidelines. Published Nov 2015. Retrieved 15 March 2017.
3. Jaundice in newborn babies under 28 days. NICE guidance. Published May 2010. Retrieved 15 October 2017. Available from: [LINK].
4. Slater BJ, Lenton KA, Kwan Medico, Gupta DM, Wan DC, Longaker MT (April 2008). "Cranial sutures: a brief review". Plast. Reconstr. Surg. 121 (4): 170e–8e. doi:10.1097/01.prs.0000304441.99483.97. PMID 18349596.
5. Circumscribed dermal melanosis (Mongolian spot) (1981) Kikuchi I, Inoue S. in "Biology and Diseases of Dermal Pigmentation", University of Tokyo Press, p83
6. French LM, Dietz FR (July 1999). "Screening for developmental dysplasia of the hip". American Family Doctor. 60 (ane): 177–84, 187–eight. PMID 10414637.
7. Storer SK, Skaggs DL (October 2006). "Developmental dysplasia of the hip". American Family unit Physician. 74 (8): 1310–half-dozen. PMID 17087424.
8. Jakobovits, AA (2009). "Grasping activity in utero: a significant indicator of fetal behaviour (the role of the grasping reflex in fetal ethology).". Periodical of perinatal medicine. 37 (5): 571–two. doi:10.1515/JPM.2009.094. PMID 19492927.
9. Odent M. The early on expression of the rooting reflex. Proceedings of the 5th International Congress of Psychosomatic Obstetrics and Gynaecology, Rome 1977. London: Academic Press, 1977: 1117-19.
10. Siegler, R.; Deloache, J.; Eisenberg, North. (2006). How Children Develop. New York: Worth Publishers. p. 188. ISBN 978-0-7167-9527-8.

Image references

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2. Brar_j- Flickr. Adapted by Geeky Medics. Microcephaly. Licence: CC Past.
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