Nepnatal exam to help take good history in neonate

1. NEONATAL HISTORY
TAKING AND EXAMINATION
DR. HARUNA MAHAMA

2. OUTLINE
 Definitions
 Neonatal history/perinatal history
 Template
 EXAMINATION –Different parts

3. Objectives
 Important points to note about
maternal/obstetric history
 Details about perinatal and neonatal
period
 Key points to the examination of the
newborn

4. DEFINITIONS
 Neonate /newborn – a child in the first 28
days of life.
 Perinatal period –the one extending from
28 completed weeks of gestation of the
foetus to the end of the 7th completed days
of life
 Term –a baby who is 37 completed weeks
of gestation to less than 42 completed
weeks

5. Definitions
 Post term -42 completed weeks or more
 Young infant –baby who is within 2 months of
life.
 Gravidity is defined as the number of times that
a woman has been pregnant.
 Parity is defined as the number of times that she
has given birth to a fetus with a gestational age of
28 weeks or more, regardless of whether the child
was born alive or was stillborn.

6. Neonatal history
 Follows the same steps on how to take
paediatric history with more emphasis on
the perinatal, neonatal and
maternal/obstetric history

7. Before examining a newborn
 A general examination is not complete if a history
is not taken.
 The history should be taken from the mother,
together with the maternal and infant record book.
 Discussion with the staff who have cared for the
mother and infant is also important.
 The history will often identify clinical problems
and suggest what clinical signs to look for during
the examination.

8. The sections of a perinatal history
The maternal background:
 The mother’s age, gravidity and parity.
 The number of infants that are alive and the number that
are dead. The cause of death and age at death.
 The birth weight of the previous infants.
 Any problems with previous infants, e.g. neonatal
jaundice, preterm delivery, congenital abnormalities.
 The home and socioeconomic status.
 Family history of congenital abnormalities.

9. The sections of a perinatal history
 The present pregnancy:
 Gestational age based on menstrual dates, early
obstetric examination and ultrasound
examination.
 Problems during the pregnancy, e.g. vaginal
bleeding.
 Illnesses during the pregnancy, e.g. rubella.
 Smoking, alcohol or medicines taken.

10. Maternal investigations
VDRL (or RPR) and TPHA (or FTA)
results. Treatment if syphilis diagnosed.
HIV status.
Antiretroviral treatment, CD4 count and
viral load if HIV positive..
Blood groups.
Assessment of fetal growth and
condition.

11. The sections of a perinatal history
 Labour and delivery:
 Spontaneous or induced onset of labour.
 Duration of labour.
 Method of delivery.
 Signs of fetal distress.
 Problems during labour and delivery.
 Medicines given to the mother, e.g. pethidine,
antiretroviral treatment.

12. The sections of a perinatal history
 Infant at delivery:
Apgar score and any resuscitation
needed.
Any abnormalities detected.
Birth weight and head circumference.
Estimated gestational age.
Vitamin K given.

13. Infant since delivery
Time since delivery.
Feeds given.
Urine and meconium passed.
Any clinical problems, e.g.
hypothermia, respiratory distress,
hypoglycaemia.
Contact between infant and mother.

14. History template
 DEMOGRAPHICS
 MOTHERS NAME
________________________________________________
_______________________
 BABY’S DATE OF BIRTH ____________________
BABY’S TIME OF BIRTH _______________
 BABY’S BIRTH WEIGHT IN
GRAM___________________
 BABY’S CURRENT WEIGHTIN GRAM ______________
SEX ___________
 GESTATIONALAGE
 MOTHER’S(OR FATHER’S/OTHER’S?)INSURANCE
STATUS

15. History template
 PRESENTING COMPLAINT:
 FEVER - DURATION
 POOR/NOT FEEDING - DURATION
 JAUNDICE – DURATION
 DID NOT CRY AFTER BIRTH
 LETHARGY - DURATION
 INCONSOLABLE CRYING –
DURATION
 SEIZURES
 LOW BIRTH WEIGHT
 BIG BABY
 RESPIRATORY DISTRESS
– DURATION
 BIRTH INJURY (STATE
TYPE)
 OTHER – STATE AND
GIVE DURATION
 HISTORY OF PRESENTING
COMPLAINT:

16. History template
 DIRECT QUESTIONING:
OMIT WHAT HAS
ALREADY BEEN STATE -
---DURATION)
 GENERAL
 FEVER
 JAUNDICE
 POOR FEEDING
 RESPIRATORYSYSTEM:
 COUGH
 DIFFICULTY BREATHING
 NOISY BREATHING
 RUNNY NOSE
 INABILITY TO FEED
 OTHER (STATE)
 CARDIOVASCULAR
SYSTEM:
 DIFFICULTY BREATHING
 POOR FEEDING
 SWEATING ON FEEDING
 CYANOSIS
 OTHER (STATE)

17.  GASTROINTESTINAL SYSTEM
 VOMITING
 AGE AT FIRST PASSAGE OF MECONIUM
 DIARRHOEA
 ABDOMINAL DISTENSION
 POOR FEEDING
 OTHER

 FAMILY AND SOCIAL HISTORY

 OTHER RELEVANT HISTORY OR RELEVANT DETAILS

18. History template
 PAST MEDICAL HISTORY AND DRUG HISTORY
 IMMUNISATION HISTORY
 DEVELOPMENTAL HISTORY
 PREGNANCY HISTORY(INCLUDING SCREENING
TESTS)
 DELIVERY HISTORY
 FEEDING AND NUTRITIONAL HISTORY
 FAMILY AND SOCIAL HISTORY
 Summary

21. Head ticket of a newborn/neonate

22. Neonatal examination

23. Introduction
 Wash your hand and don PPE if appropriate.
 Introduce yourself to the parents and tell them
what you are about to do and why you need to do
it and get consent really.
 Confirm baby’s name and date of birth and
gender.
 The room should be warm and well lit (preferably
natural light, especially if jaundice is to be
assessed)

24. Newborn examination
 Head to toe examination
 Measure infants weight and head
circumference and plot it on the
appropriate centile charts.

25. Measurements
 Small for gestational age (<10th centile)
 Appropriate weight for gestational
age (10th-90th centile)
 Large for gestational age (>90th centile)
 If a baby is small, you should also
plot head circumference and length to
determine whether this is symmetrical
(small in all measurements) or
asymmetrical (weight disproportionately
low, head circumference preserved).

26. Centile chart

27. Continued
 Adequately expose the child for the assessment: ask the
parents to undress the child down to their nappy.
 Encourage the parents to ask questions during the check
and to participate where appropriate.
 The optimal way to perform the newborn check is by
examining from head to toe sequentially.
 In reality, it’s an opportunistic examination – if the baby is
settled listen to their chest , count the RR, HR first, if they
open their eyes check the red reflexes and if they’re crying
look at the palate!

28.  Inspect the colour of the infant:
 Pallor:
 Cyanosis:
 Jaundice:
 Inspect the posture of the infant: note any gross
abnormalities of posture (e.g. hemiparesis/Erb’s
palsy).

29. Tone
 Assess tone by gently moving the newborn’s limbs
passively and observing the newborn when they’re picked
up (your assessment of tone should continue throughout the
examination).
 Hypotonic infants are often described as feeling like a ‘rag
doll’ due to their floppiness. Hypotonic infants often
have difficulty feeding, as their mouth muscles cannot
maintain a proper suck-swallow pattern or a good
breastfeeding latch (hypotonia is common in children with
Down’s syndrome).

30. Head
 Size
 Measure the infant’s head circumference and record it in
the notes.
 Head size abnormalities
 Microcephaly describes a head that is smaller than expected
for age and sex. Microcephaly may be associated with
reduced brain size or atrophy.
 Macrocephaly describes a head that is larger than expected
for age and sex. Macrocephaly may be normal but may also
be associated with hydrocephalus, cranial vault
abnormalities or genetic abnormalities.

31.  Shape
 Inspect the shape of the head and note any abnormalities.
 Inspect 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 collection
with poorly defined margins (often crossing suture lines)
caused by pressure on the presenting part of the head during
delivery. It does not usually cause complications and resolves
over the first few days.
 Cephalhaematoma is a subperiosteal haemorrhage which
occurs in 1-2% of infants and may increase in size after birth.

32. Head
 Fontanelle
 Palpate the anterior fontanelle: note if it feels
flat (normal), sunken or bulging (abnormal).
 Fontanelle abnormalities
 A tense bulging fontanelle may suggest raised
intracranial pressure (e.g. hydrocephalus).
 A sunken fontanelle may suggest dehydration.

33. Skin
 is very important to document any
 birthmarks or bruising/lacerations
 from birth trauma found on initial
examination in case there are any child
protection concerns in the future.

34. Face
 Appearance: note any dysmorphic features of the
face
 Asymmetry: note any asymmetry of the face (e.g.
facial nerve palsy secondary to 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

35. Eyes
 Inspect the eyes for evidence of erythema or discharge (e.g.
conjunctivitis).
 Subconjunctival haemorrhages often look dramatic but are fairly common
after delivery and benign, you should, however, document their presence.
 Inspect the position and shape of the eyes: look for evidence of ptosis
 Red reflex
 Assess for the red reflex in each eye:
 Absence of the red reflex in children can be due to congenital cataracts,
retinal detachment, vitreous haemorrhage and retinoblastoma.
 The presence of a white reflex (leukocoria), regardless of whether the red
reflex is partly visible suggests the presence of one of the pathologies
mentioned previously.
 An absent red reflex or the presence of a white reflex requires immediate
ophthalmology referral.

36. Mouth and palate
 Look for clefts of the hard or soft palate: the full palate
should be examined by visual inspection. You will need 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 central 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).
 Cleft lip

37. Neck and clavicles
 Inspect the length of the neck and note any
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 neck may represent a
cystic hygroma.
 Look for evidence 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).

38. 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 (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).

39. Chest
Inspection
 Observe the respiratory rate and work of breathing.
 Respiratory rate
 Count the respiratory rate whilst observing the child.
The normal respiratory rate of a newborn is 40-60 breaths per
minute.
 Work of breathing
 Assess for signs of increased work of breathing
 Expiratory grunting
 Tracheal tug, Intercostal recession, Subcostal recession, Nasal
flaring, Head bobbing (secondary to sternocleidomastoid
contractions)
 Other clinical signs

40. Auscultation
Lungs
 Auscultate each side of the chest in
a symmetrical pattern, comparing side to side:
 Pay attention to the inspiratory and expiratory
sounds at each placement.
 Note the quality and volume of
the breath sounds.
 Note any additional sounds (e.g. wheeze, coarse
crackles).
 Repeat auscultation on the posterior aspect of
the chest.

41. Heart
 Auscultate ‘upwards’ through the valve areas using
the diaphragm of a paediatric stethoscope:
 Mitral valve: 5th intercostal space – midclavicular line (apex beat)
 Tricuspid valve: 4th or 5th intercostal space – lower left sternal
edge
 Pulmonary valve: 2nd intercostal space – left sternal edge
 Aortic valve: 2nd intercostal space – right sternal edge
 Listen over each area with both the bell (for low pitched sounds –
gallops and split S2) and the diaphragm (high pitched sounds –
pericardial rubs, S1/S2 and most murmurs).
 The normal heart rate of a newborn is approximately 120-160
bpm.

42. Abdomen
Inspection
 Inspect for evidence of abdominal distension: causes include
bowel obstruction, organomegaly and ascites.
 Inspect the umbilicus: note any swelling (e.g. umbilical hernia) or
erythema and discharge (e.g. umbilical cord stump infection).
 Inspect for evidence 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 2cm below the costal
margin (if palpable lower in the abdomen consider hepatomegaly).
 Spleen: may be palpable at the left costal margin in healthy infants
(if easily palpable, consider splenomegaly).

43. Genitalia
 Note any ambiguity of genitalia: typically associated with
congenital adrenal hyperplasia (CAH) in girls (boys with CAH
have 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 2.5cm.
 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 up
over time; bilateral absence is considered a disorder of sexual

44. Lower limbs
 Inspect the lower limbs for abnormalities:
 Asymmetry: the lower limbs should appear equal in size and length.
 Oedema: may indicate hypoalbuminaemia
 Ankle deformities: talipes (club foot) is a common ankle deformity
causing the foot to be 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
indicate an upper or lower motor neuron lesion or joint pathology.
 Assess the range of knee joint movement: typically excessive in
hypermobility.

45. 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 clothing, including the nappy, removed.
 Barlow’s test is performed by adducting the hip (bringing the
thigh towards the midline) whilst applying light pressure on the
knee with your thumb, 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
sensation of subluxation or dislocation.
 If the hip is dislocatable the test is considered positive. The
Ortolani manoeuvre is then used to confirm the positive finding
(i.e. that the hip actually dislocated).

46. Examinations continued
 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.g. spina bifida).
 Anus
 Inspect the anus for patency: abnormal embryological
development of the rectum can result in an imperforate anus.

47. Reflexes
 Assess the newborn’s reflexes
 Assess a selection of the following reflexes which should all be 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 infant’s hand and strokes their palm, the
fingers will close 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 birth and disappears around four months of age, as it gradually
comes under voluntary control. A newborn infant will turn its head toward
anything that strokes its cheek or mouth to aid breastfeeding. 9
 Stepping reflex

48. To complete the examination…
 Share the results of the assessment with the
parents, explaining the reason for
any referrals you feel are required.
 Check if the parents have any further questions.
 Thank the parents for their time.
 Dispose of PPE appropriately and wash your
hands.
 Summarise your findings

49. References
 U.k –NIPE
 Better care learning programmes
