17
Routine examination of the newborn infant

All babies are examined shortly after birth to check that transition to extrauterine life has proceeded smoothly and there are no major abnormalities. A comprehensive medical examination within 24 hours of birth, the ‘routine examination of the newborn infant’, should be performed.

The purpose is to:

• detect any abnormalities – a significant congenital anomaly is present at birth in 10–20 per 1000 live births
• confirm and plan the further management of any abnormalities detected antenatally
• consider potential problems related to maternal pregnancy history or familial disorders
• allow the parents to ask any questions and raise any concerns about their baby
• determine whether there is concern by caregivers about the care of the baby following discharge.
• provide health promotion, especially prevention of sudden infant death syndrome (SIDS) (see Chapter 16).

Preparation

Maternal charts (records):

• Check maternal antenatal, labor and delivery charts.

Equipment:

• Tape measure.
• Stethoscope.
• Ophthalmoscope.

Environment:

• Warm room free from drafts.
• Privacy, suitably lit.
• Examine on firm mattress in crib (cot).
• Both parents present if possible.
• Always wash hands and clean stethoscope before each examination.

The infant

• The baby must be completely undressed during the course of the examination so that all the body is observed.
• Need a content, settled infant for successful examination.
• Examination is performed opportunistically, i.e. eyes when open, heart when quiet, hips left until last. However, the examination must be complete.

Routine examination of newborn infants

(Table 17.1, Figs 17.2 and 17.3) (see video: Newborn examination)

Table 17.1 Significant congenital abnormalities which may be identified on routine examination.

Dysmorphic infant (see Chapter 9)

Cataracts (see Chapter 62)

Cleft lip and palate (see Chapter 40)

Congenital heart disease (see Chapter 49)

Urogenital – hypospadias, undescended testes (see Chapter 52)

DDH (developmental dysplasia of the hip)

Imperforate anus (see Chapter 48)

Spinal anomalies (see Chapter 59)

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Developmental dysplasia of the hip, DDH (congenital dislocation of the hip, CDH)

Clinical examination:

• Performed on all infants – part of routine neonatal examination.
• Infant must be relaxed – if crying or kicking there is tightening of the muscles around the hip.
• There may be asymmetry of skin folds around an affected hip and shortening of the affected leg.
• Fully abduct both hips; full abduction may not be possible if the hip is dislocated. Pelvis is stabilized with one hand; with the other, the examiner’s middle finger is placed round the greater trochanter and the thumb around the distal medial femur.
• Check if dislocatable posteriorly (Barlow maneuver) (Fig. 17.1a).
• Check if hip is dislocated and can be relocated into acetabulum (Ortolani maneuver) (Fig. 17.1b) Minimal force is required.

Risk increased:

• in female infants (9:1)
• if positive family history (20% of affected infants)
• if breech presentation (30% of affected infants)
• in infants with a neuromuscular disorder.

If abnormal or questionable clinical examination, arrange consultation with experienced orthopedic surgeon. If normal examination but breech presentation or, in some centers, positive family history, arrange hip ultrasound at 4–6 weeks of age. Ultrasound screening of all infants can identify some missed on clinical examination and some with shallow acetabular shelf not detectable on clinical examination, but has appreciable false-positive rate (7%). Not recommended for all infants in US or UK.

For management see Chapter 61.

Fig. 17.1 Barlow and Ortolani maneuvers.

Fig. 17.2 Checking for red reflex. If absent, i.e. the pupil is white (cataracts, glaucoma, retinoblastoma), refer directly to an ophthalmologist. Also check eye looks normal, e.g. for a coloboma, a key-shaped defect in the iris. (see Chapter 62)

Fig. 17.3 Routine examination of newborn infants. In the UK the Newborn Infant Physical Examination (NIPE) checklist is recorded in the child health record and communicated to the family practitioner.