Newborn Baby Birth Stats to Hang on Wall

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

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Groundwork

The Newborn Babe Concrete Examination (NIPE)must be performed within 72 hours of nativity 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 intervention
• To make referrals for farther tests or treatment as appropriate
• To provide reassurance to the parents

A second examination is performed at vi-eight weeks of historic period, usually by GP, to identify abnormalities that develop or become apparent subsequently.

Where to perform the NIPE

The NIPE examination should exist undertaken in a private surface area which provides confidentiality for parents when personal data is being discussed.

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

You'll ideally require a irresolute mat to bear out the examination on.

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

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

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Introduction

Wash your easily and don PPE if advisable (alcohol gel must dry out completely before handling the newborn).

Introduce yourself to the parents including your proper name and role.

Confirm the infant's name and date of birth.

Briefly explain what the examination will involve using patient-friendly language: "Today I need to acquit out a routine caput to toe examination of your child."

Gain consent to proceed with the exam:

• Parents should have received the National Screening Commission leaflet 'Screening tests for you lot and your babe' in the antenatal period.
• If the parents have not read the data booklet they must be given a copy to read earlier to the test.
• The aims and limitations of the examination should be fully explained.

Adequately expose the child for the assessment: ask the parents to undress the child downwardly to their nappy.

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

The optimal way to perform the newborn check is past examining from head to toe sequentially. In reality, information technology'due south an opportunistic exam – if the baby is settled heed to their heart first, if they open their eyes check the fundal reflexes and if they're crying wait at the palate!

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Questions to ask the parents

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

Maternal history:

• Pregnancy details: date/time and type of delivery/complications/high-risk antenatal screening results
• Breech presentation: if breech at 36 weeks gestation or delivery (if earlier), the baby volition need to have an ultrasound scan of their hips as there is an increased risk of developmental dysplasia of the hip.
• Gamble factors for neonatal infection
• Abnormalities noted on antenatal scans
• Family history: starting time-degree relatives with…hearing problems/hip dislocation/childhood heart problems/built cataracts/renal bug

Newborn history:

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

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Weight

Ensure that the infant'south weight is recorded and check on a weight chart whether the babe is:

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

If a baby is pocket-size, you should also plot head circumference and length to determine whether this is symmetrical (pocket-size in all measurements) or asymmetrical (weight disproportionately low, head circumference preserved).

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

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General inspection

Inspect the colour of the babe:

• Pallor: a pale color of the peel that can propose underlying anaemia (due east.g. bleeding) or poor perfusion (e.g. congestive cardiac failure).
• Cyanosis: a bluish discolouration of the skin due to poor circulation (eastward.1000. peripheral vasoconstriction secondary to hypovolaemia) or inadequate oxygenation of the blood (e.g. right-to-left cardiac shunting).
• Jaundice:a yellowish or green pigmentation of the pare and whites of the eyes due to high bilirubin levels (e.thousand. newborn jaundice).

Inspect the posture of the infant: note whatever gross abnormalities of posture (e.m. hemiparesis/Erb'south palsy).

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Tone

Assess tone by gently moving the newborn'due south limbs passively and observing the newborn when they're picked up (your assessment of tone should go along throughout the examination).

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

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Head

Size

Measure the infant'south caput circumference and tape it in the notes.

Caput size abnormalities

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

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

Shape

Inspect the shape of the head and note whatever abnormalities.

Audit the cranial sutures and note 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 delivery. It does not usually cause complications and resolves over the first few days.⁴

Cephalhaematoma is a subperiosteal haemorrhage which occurs in 1-2% of infants and may increase in size subsequently nascence. The haemorrhage is bound by the periosteum, therefore, the swelling does not cross suture lines (in contrast to a caput succedaneum). Cephalhaematoma is more common with instrumental delivery and may cause jaundice, therefore, bilirubin should exist monitored.

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

Craniosynostosis is a status in which one or more of the fibrous sutures in an baby skull prematurely fuses, changing the growth pattern of the skull which tin can consequence in raised intracranial force per unit area and harm to intracranial structures.  Surgical intervention is required with the primary goal being to allow normal cranial vault evolution to occur. This tin be achieved by excision of the prematurely fused suture and correction of the associated skull deformities.⁷

Fontanelle

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

Fontanelle abnormalities

A tense jutting fontanelle may suggest raised intracranial force per unit area (e.g. hydrocephalus).

A sunken fontanelle may advise dehydration.

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Peel

It is very important to certificate whatever birthmarks or bruising/lacerations from nativity trauma found on initial examination in instance there are any kid protection concerns in the future. There are trunk maps in the red book to help with this.

Colour: inspect the colour of the skin and note any pallor, cyanosis, erythema or jaundice.

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

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

Examples of facial birthmarks

Examples of facial birthmarks include:

• Salmon patch (also known as a stork mark or nevus simplex): red or pink patches, often on an babe's eyelids, caput or cervix caused by congenital capillary malformation. Salmon patches are very mutual and commonly fade past the age of two.
• Haemangiomas (also known equally strawberry marks): claret vessels which form a raised red lump on the skin which appears soon after nascence. Haemangiomas typically get bigger over the first half dozen-12 months and then shrink and disappear by the age of 7. They may require treatment if they impact vision, breathing or feeding.
• Port-vino stain (also known as naevus flammeus): blood-red/purple marks on the face and neck which are typically present from birth and do not regress. Port-wine stains can sometimes be associated with Sturge-Weber syndrome and Klippel-Trenaunay syndrome.

Other potential findings

Slate-greyness nevus is a beneficial, apartment, built birthmark with wavy borders and irregular shape, unremarkably located over the sacrum. Information technology is most commonly blueish in colour and can be mistaken for a bruise. They commonly disappear inside three-five years after birth.^v

Milia are tiny white cysts containing keratin and sebaceous textile. They are very common on the face up and most resolve inside the first few weeks of life.

Erythema toxicum is a very common and benign condition seen in newborn infants. It presents with various combinations of erythematous macules, papules, and pustules. Lesions usually appear from 48 hours of age and resolve spontaneously.

Neonatal jaundice tin can be physiological, appearing at 2-3 days and resolving by solar day x. It can also be caused past a broad range of different pathologies including haemolytic disease, infection and Gilbert's syndrome.

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Face

Advent: note any dysmorphic features of the face (e.thousand. epicanthic folds in Down's syndrome).

Asymmetry:note any asymmetry of the face (eastward.k. facial nerve palsy secondary to instrumental delivery).

Trauma: note any bear witness of facial trauma (e.grand. bruising, lacerations) likely to have occurred during labour (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 residue if they have bilateral choanal atresia).

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Eyes

Inspect the eyes for testify of erythema or discharge (e.g. conjunctivitis).

Inspect the sclera by gently retracting the lower eyelid noting whatever discolouration (due east.g. jaundice, subconjunctival haemorrhages). Subconjunctival haemorrhages oftentimes await dramatic but are adequately mutual after delivery and benign, yous should, however, 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's syndrome).

Fundal reflex

Correct terminology

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

In patient's with lighter skin, the reflex typically appearsorange-crimson in colour, whereas in those with darker skin, the reflex tin existyellow-white or evenblue in colour.

Assess for the fundal reflex in each eye:

1. Look through the ophthalmoscope, shining the low-cal towards the patient's middle at a distance of approximately one arm'southward length.

ii. Observe for a reddish/orange reflection in each pupil, caused by light reflecting dorsum from the vascularised retina.

Causes of an absent fundal reflex

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

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

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Ears

Inspect the pinna: note any asymmetry, skin tags, pits or the presence of accessory auricles.

All infants should undergo a hearing screening test prior to being discharged from hospital.

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Mouth and palate

Look for clefts of the hard or soft palate: the total palate should be examined past visual inspection. You will need to employ a tongue depressor and a torch, and inquire a parent to help proceed the babe's caput still. You must visualise the whole palate, and see the central uvula to ensure information technology is intact. You cannot rely on palpation to exclude a cleft.

Audit the natural language and gums: look for evidence of tongue-necktie (ankyloglossia).

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Neck and clavicles

Inspect the length of the neck and annotation whatsoever abnormalities such as webbing: a shortened webbed neck is typically associated with Turner's syndrome.

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

Wait for show of a clavicular fracture: signs may include bruising, discontinuity of the clavicle and an abnormal position of the arm (fractures most commonly 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 but typically develops in the left posterior triangle of the neck. Cystic hygromas are benign simply tin be disfiguring and typically require surgical treatment including drainage and use of sclerosing agents to prevent reaccumulation of lymphatic fluid.

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Upper limbs

Appraise the symmetry of the upper limbs: they should announced equal in size and length.

Inspect the fingers: count the fingers and note any abnormal morphology (e.g. polydactyly).

Inspect the palms: check if the child has two palmar creases (normal).

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

Abnormalities of the hand

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

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

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Chest

Inspection

Find the chest, paying particular attending to therespiratoryrate andpiece of workofbreathing.

Respiratory rate

Count therespiratoryrate whilst observing the child. The normal respiratory charge per unit of a newborn is 40-60 breaths per infinitesimal.

Work of breathing

Appraise for signs of increased work of breathing:

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

Other clinical signs

Inspect the breast for other relevant clinical signs:

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

Auscultation

Lungs

Auscultate each side of the chest in a symmetrical design, comparing side to side:

• Pay attention to theinspiratoryandexpiratory sounds at each placement.
• Note thequality andvolume of the jiffsounds.
• Annotation anyadditional sounds(e.m. wheeze, coarse crackles).
• Echoauscultation on theposterior aspect of thebreast.

Centre

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

• Mitral valve: 5th intercostal infinite – midclavicular line (apex beat)
• Tricuspid valve: 4th or fifth intercostal space – lower left sternal edge
• Pulmonary valve: 2nd intercostal space – left sternal edge
• Aortic valve: 2d intercostal space – right sternal edge

Listen over each expanse with both thebell (for depression pitched sounds – gallops and dissever S2) and thediaphragm (high pitched sounds – pericardial rubs, S1/S2 and most murmurs).

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

If a murmur is noted, effort 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 improve detection of disquisitional built centre disease in newborn infants. Both readings should both exist ≥95% and within 3% of each other.

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Belly

Inspection

Audit for show of abdominal amplification:causes include bowel obstruction, organomegaly and ascites.

Inspect the omphalus: note any swelling (eastward.thou. umbilical hernia) or erythema and belch  (due east.g. umbilical string stump infection).

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

Palpation

Palpate the abdomen to assess for organomegaly:

• Liver: should be palpable no more than than 2cm beneath the costal margin (if palpable lower in the abdomen consider hepatomegaly).
• Spleen: may exist palpable at the left costal margin in healthy infants (if hands palpable, consider splenomegaly).
• Kidneys: normally just palpable using deep bimanual palpation (if easily palpable consider polycystic kidney disease).
• Float: should not be palpable in salubrious infants (if easily palpable, because urinary tract obstruction).

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Genitalia

Note whatsoever ambiguity of genitalia: typically associated with congenital adrenal hyperplasia (CAH) in girls (boys with CAH accept normal genitalia).

Males

Assessment of male genitalia:

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

• Asymmetry: the lower limbs should appear equal in size and length.
• Oedema: may indicate hypoalbuminaemia or congestive cardiac failure.
• Ankle deformities: talipes (order foot) is a common ankle deformity causing the foot to exist turned inward.
• 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 Down's syndrome and may be asymmetrically increased secondary to upper motor neuron lesions (e.g. ischaemic stroke, intracranial haemorrhage).

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 genu joint motion: typically excessive in hypermobility.

Palpate and compare femoral pulses: this can exist hard, specially in an active baby, and requires practice. Weak, absent or delayed femoral pulses are a sign of coarctation of the aorta.

Hips

Both Barlow's and Ortolani's tests are carried out as role of the routine newborn test to notice hip articulation instability and dislocation. Each hip should be examined individually with all clothing, including the nappy, removed.

Barlow'due south examination

Barlow'south examination is performed by adducting the hip (bringing the thigh towards the midline) whilst applying lite pressure on the knee with your pollex, directing the force posteriorly. ⁶

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

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

Ortolani'south examination

Ortolani's examination is used to confirm posterior dislocation of the hip joint. ^vii

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

ii. With your index fingers placing inductive pressure on the greater trochanters, gently and smoothly abduct the infant'due south legs using your thumbs.

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

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Dorsum and spine

Inspect the spine for:

• Scoliosis
• Pilus tufts
• Naevi
• Birthmarks
• Sacral pits

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

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Anus

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

Meconium should be passed within 24 hours: a delay is suggestive of obstruction or Hirschsprung's affliction.

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Reflexes

Assess the newborn'due south reflexes

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

Palmar grasp reflex

When an object is placed in the baby's hand and strokes their palm, the fingers will shut and they will grasp it with a palmar grasp.⁸

Sucking reflex

Causes the child to instinctively suck anything that touches the roof of their mouth, absence of this reflex is most apparent during feeding.

Rooting reflex

Present at nascence and disappears around iv months of age, every bit it gradually comes under voluntary control.  A newborn infant will plough its caput toward anything that strokes its cheek or mouth to aid breastfeeding. ⁹

Stepping reflex

When the soles of the baby's feet touch a flat surface they will appear to walk by placing one foot in front end of the other.¹⁰

Moro reflex

Back up the infant's upper back with 1 hand, then driblet back once or twice into your other manus. A normal Moro reflex involves the extension of the legs and head whilst the arms wiggle upwardly with the fingers extended. The artillery are so brought together and the hands clench 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 test…

Explicate to the parents that the examination is now finished and offer to clothes the baby.

Share the results of the assessment with the parents, explaining the reason for any referrals y'all feel are required.

Bank check if the parents have whatever further questions.

Thank the parents for their time.

Dispose of PPE appropriately and wash your easily.

Summarise your findings

Document your findings and the need for further investigations/referrals: in the UK the NIPE is documented using a national online system (which you would print and place in the baby'due south notes).

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Reviewer

Dr Rebecca Naples

Paediatric Registrar

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Illustrator

Aisha Ali

Medical student and illustrator

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References

Text references

1. Newborn and Infant Physical Test Screening Programme Handbook 2016/17. Public Health England. Published April 2016. Retrieved 15 March 2017.
2. Newborn Infant Physical Exam. Nottingham Neonatal Service – Clinical Guidelines. Published November 2015. Retrieved 15 March 2017.
3. Jaundice in newborn babies nether 28 days. Dainty guidance. Published May 2010. Retrieved xv October 2017. Bachelor from: [LINK].
4. Slater BJ, Lenton KA, Kwan Doc, Gupta DM, Wan DC, Longaker MT (April 2008). "Cranial sutures: a brief review". Plast. Reconstr. Surg. 121 (4): 170e–8e. doi:ten.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 Printing, p83
6. French LM, Dietz FR (July 1999). "Screening for developmental dysplasia of the hip". American Family unit Physician. threescore (1): 177–84, 187–viii. PMID 10414637.
7. Storer SK, Skaggs DL (October 2006). "Developmental dysplasia of the hip". American Family unit Physician. 74 (8): 1310–6. 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).". Journal of perinatal medicine. 37 (5): 571–2. doi:10.1515/JPM.2009.094. PMID 19492927.
9. Odent M. The early 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, N. (2006). How Children Develop. New York: Worth Publishers. p. 188. ISBN 978-0-7167-9527-8.

Image references

1. Cornelia Csuk. Adapted by Geeky Medics. Cyanosis. Licence: CC BY-SA.
2. Brar_j- Flickr. Adapted by Geeky Medics. Microcephaly. Licence: CC BY.
3. Michael L. Kaufman. Adapted by Geeky Medics. Craniosynostosis. Licence: CC BY-SA.
4. Johann Dréo. Adjusted by Geeky Medics. Sunken fontanelle. Licence: CC BY-SA.
5. Tonicthebrown. Adapted past Geeky Medics. Salmon patch. Licence: CC Past-SA.
6. Dr. Wonko. Adapted by Geeky Medics. Port-wine stain. Licence: CC BY-SA.
7. Tom & Katrien. Adapted by Geeky Medics. Vernix. Licence: CC By-SA.
8. GeoWombats. Adapted past Geeky Medics. Slate-gray nevus. Licence: CC BY-SA.
9. FiP. Adapted by Geeky Medics. Subconjunctival haemorrhage. Licence: CC BY-SA.
10. Imrankabirhossain. Adapted by Geeky Medics. Cataract. Licence: CC By-SA.
11. Klaus D. Peter, Gummersbach, Germany. Adapted by Geeky Medics. Accessory auricle. Licence: CC BY three.0 DE.
12. BruceBlaus. Adapted by Geeky Medics. Cleft palate. Licence: CC By-SA.
13. Gzzz. Adapted by Geeky Medics. Ankyloglossia. Licence: CC BY-SA.
14. Vardhan Kothapalli. Adapted past Geeky Medics. Cystic hygroma. Licence: CC Past-SA.
15. Bobjgalindo. Adapted by Geeky Medics. Polydactyly. Licence: CC BY-SA.
16. Aurora Bakalli, Tefik Bekteshi, Merita Basha, Afrim Gashi, Afërdita Bakalli and Petrit Ademaj. Adapted by Geeky Medics. Pectus excavatum. Licence: CC By-SA.
17. Jprealini. Adapted by Geeky Medics. Pectus carinatum. Licence: CC Past-SA.
18. OpenStax College. Adapted by Geeky Medics. Talipes. Licence: CC BY.

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