Newborn Examination

Examination of newborn infants will be carried out according to the standards of Routine Examination of the Newborn - Best Practice Statement (SMMDP).

The routine examination will be carried out in a safe, warm, well-lit environment.

Privacy should be provided particularly when discussing family health issues of a sensitive nature.

The examiner should allow sufficient time for an unhurried examination which includes discussing findings with the parents, referral if necessary and completing the relevant documentation

Examinations will be done once the baby is >6 hours old and before 72 hrs with parental consent.

Baby less than 35 weeks or with significant congenital anomalies should be examined by the neonatal team.  If there are any concerns prior to examination midwives should discuss with neonatal team.

Babies admitted to SCBU should receive their detailed examination within 72 hours and definitely prior to discharge to postnatal ward.

Babies born < 34 weeks should be examined once they are 34 weeks unless clinical reason not to.

Preterm babies repatriated from other hospitals who have had examination completed should have heart, hips and testes re checked as part of their discharge.

The examination includes observation of general appearance, position and movement followed by a structured all-over physical examination, as well as specific screening elements which involve examination of the baby’s eyes, heart, hips and testes.

Prior to commencing the examination relevant antenatal, delivery and postnatal information is reviewed.

Parents should be invited to be present for the check and fully updated once completed

During this routine examination abnormalities and problems can be identified and initially referred to the neonatal /paediatric team.   Where appropriate they will then be further referred for specific investigation, specialist assessment and treatment.

The examination should be documented on maternity badger as detailed examination.

Please remain aware of babies with increased risk of jaundice and check with bilimeter where appropriate.  Increased risk includes:

IUGR

Infant diabetic mother

Bruising from delivery

Breast feeding

Previous sibling treated for jaundice

< 37+6 GA

Jaundice less than 24 hours should never be ignored

Pathways for onward referral to other departments are identified under each relevant section of this guideline.

Developmental Dysplasia of the Hip (DDH) covers a spectrum of hip abnormalities ranging from hip dysplasia, reducible subluxation/dislocation and irreducible hip joint dislocation.

Screening risk and examination of the hips allows early detection and allows any required treatment to be to be in place appropriately, minimising risk of long-term complications.

Newborns who meet the screening criteria for DDH will have an urgent hip ultrasound at 2 weeks if hips are dislocatable or concerns re physical examination or 6 weeks if for uncertain examination or risk factors.

A positive hip result is an abnormal clinical hip examination (with or without risk factors), or presence of hip risk factors.

A suspected abnormality on clinical examination (look, feel, and move) is defined by:

• Asymmetry in leg length
• Knees unequal when hips and knees are bilaterally flexed
• Reduced hip abduction
• Any features of moulding, ears (significantly squashed or flat) head (excess moulding or abnormal shape not due to delivery mode) calcaneovalgus feet, asymmetrical lie / creasing.
• Lax hips
• Palpable ‘clunk’ when undertaking the Ortolani and Barlow manoeuvre. Ortolani is a test for hip joint reducibility and Barlow for dislocatability.

Any uncertainty on examination can trigger a request for USS

Risk Factors:

• Family history of DDH in first degree relative
• Breech presentation at or after 36 weeks irrespective of presentation at delivery. Includes ECV after 36 weeks
• Breech presentation at time of delivery if > 28 weeks
• Oligohydramnious in pregnancy
• Fixed foot deformities
• Consideration should also be given to the size of baby/babies in relation to the size of mum and subsequent space in uterus

In multiple pregnancy if one baby meets the criteria, both should be referred for a scan.

Positional talipes equinovarus that are fully correctable with no other features are of no clinical significance.

Hips which are found to be clinically unstable should be referred on TRAK, for an early ultrasound (2/52) request as urgent.

 All other referrals should be requested for 6/52

Please give parent information leaflet at time of NBE

Preterm baby should not have hips checked till >34+0

Babies with palpable but incompletely descended bilateral testes should have referral to paediatric surgeon at initial detailed check.

Babies with an isolated unilateral undescended testis should have it highlighted on badger documentation and have further assessment by GP at 6–8-week examination with referral to paediatric surgeon at this time if still indicated.

Absence of both testes should alert examiner to the fact the baby’s sex may be indeterminate and they require an inpatient review by paediatrician / ANNP.  They will require a USS and bloods and ongoing management as necessary.

Further guidance can be found on the disorders of sex development (DSD) website http://www.sdsd.scot.nhs.uk/

An isolated hooded foreskin may require no intervention but a mispositioned meatus or curvature of penis should be referred to paediatric surgeon for further assessment and management plan.  A stream of urine should be witnessed prior to discharge and parents should be advised not to have the baby circumcised. 

Information leaflets are available in the nursery.

Referrals to paediatric surgeons should be by letter to paediatric surgical secretaries at RHCYP

Heart Murmurs in the Neonate | Right Decisions

Pulse Oximetry screening is now routine and should be done 4-6 hours age, if not completed please do as part of check.  This is a screening for neonatal hypoxia that can pick up undiagnosed congenital cyanotic heart disease.

General examination and elicit red reflex

Primary purpose to screen for congenital cataracts

White babies have a bright, pinky red reflex.  The reflex can be less bright and of a yellow/brown hue in non-white babies.

If there are difficulties viewing the red reflex then prescribed eye drops (tropicamide& phenylephrine; kept in SCBU) can be used to dilate the pupils to allow a better assessment.

Eye screen positive – discuss with paediatric team re ophthalmology referral.

 For guidelines on management see –SPRUN guidelines or WoS_RenalAnomalies_Neonates

Babies found to have an isolated single umbilical artery require no further investigations unless other relevant clinical concerns.

Babies delivered following shoulder dystocia do not automatically require an x-ray to check for clavicle fractures.

If there are concerns based on clinical examination of the clavicles or nerve palsies affecting the arms an X-ray of the clavicles should be requested.

No specific management of the baby with fractured clavicle, consider paracetamol if pain is a concern.  Allow the baby to move their arm as they are able but carers should maintain awareness and specifically don’t let the arm hang down, or pull baby forward using it.  It can be secured inside the baby grow.  No repeat scan required unless specifically requested.

Discuss with paediatric team.

Please refer for ultrasound if:

High, further than 2.5cm from anal margin

Large > 5mm

Associated hairy patch / birthmark /other lesions

Neurological abnormality of the lower limbs.

Isolated simple sacral dimples require no scan

Babies who meet the criteria for BCG should have the referral form filled in and sent to Dr Smith who will arrange appointment at BCG clinic run in ambulatory care unit.

Discuss with paediatrician, new national guideline available on SPN

Identification of talipes at birth or antenatally by USS

Fixed:

Immediate referral to Sarah Paterson, Extended Scope Physiotherapist at RHSC Edinburgh for advice and treatment

Positional:

Equino Varus (down and in) Reassurance and advice to parents to encourage normal active movements by tickling and touching babies feet.

 If the foot position is not correcting with active movement within 6-8 weeks GP should consider contacting the paediatric physiotherapy team for further advice. paediatricphysiotheray@borders.scot.nhs.uk

CalcaneoValgus (up and out) Refer for hip UUS due to associated potential for DDH

Paediatric Plastic Surgery RHCYP Edinburgh

On-call registrar via NHS Lothian switchboard: 0131 536 1000

Email secretary: angela.mcerlane@nhslothian.scot.nhs.uk

Mr Patrick Addison (consultant): patrick.addison@nhslothian.scot.nhs.uk

Infant wound care advice:

1. Clean the wound(s) with sterile water
2. Apply wound closure strips (e.g. ‘SteriStrips’) if required – these can be left in place for 5-7 days.
3. Advise parents to keep wound(s) clean and dry
4. Monitor closely for signs of skin infection and treat promptly if required
5. Refer to plastic surgery if any concerns (unlikely they would do anything more acutely, unless there is concern of facial nerve injury etc, but could follow them up)

References:

1. Shannon Stone McCord, Moise L. Levy. Practical guide to pediatric wound care. SeminPlast Surg. 2006 Aug; 20(3): 192–199.   
   www.ncbi.nlm.nih.gov/pmc/articles/PMC2884765/

Referral to Glasgow team.
This should already be done and arrangements in place if detected antenatally.