These are the few tips I learned today on neonatal examination…
1. Firstly we look at the child’s general appearance. See whether the child is in respiratory distress, discomfort, pain. Also we should observe the patient’s posture and movements. (For us to do this, the baby needs to be fully undressed)
2. Find out the patient’s gestational age. If we suspect the patient’s is a pre-term baby, use the Ballard score to assess his/her gestational age. (I will share on Ballard score later…). Also we should not forget to measure his/her birthweight, length and head circumference and plot the growth chart. Take note if the patient’s birthweight/ length or head circumference is below 5th percentile or above 95th percentile.
3. Palpate both anterior and posterior fontanelle. Feel whether is it tense or not. A tense fontanelle when the baby is not crying may be due to raised intracranial pressure and cranial ultrasound should be performed to check for hydrocephalus. Also we should palpate the sutures. The sagittal suture is often separated and the coronal suture may be overriding.
4. Observe the face. Look for any syndromic facies such as flat occiput, flat nasal bridge, hypertelorism, low set ears, unslanting of palpebral brigde, cleft lips, increase intercanthal distance, small jaw. etc etc. This features could indicate Down, Edward, Patau or Turner syndrome.
5. Also look at the face for any plethoric, cyanosis, jaundice or paleness. If yes, check the haematocrit to identify polycythaemia or anaemia. Central cyanosis is best seen on tongue. Jaundice within 24 hours of birth requires further evaluation.
6. Examina the eyes, checked for red reflex with an ophthalmoscope (cataracts, retinoblastoma and corneal opacity). Inspect the palate, including posteriorly to exclude posterior cleft palate.
7. Observe patient’s breathing and chest wall movement. Look for any sign of respiratory distress such as subcostal recession and chest wall indrawing. Confirm it by counting the respiratory rate. ascultate the heart for any murmur and count the pulse rate. The normal rate in babies is 110-160 beats/min, but may drop to 85 beats/min during sleep
8. Palpate the abdomen. Feel for any intraabdominal masses which most commonly is renal in origin. The liver normally extends 1-2 cm below the costal margin, the spleen tip may be palpable, as may the left kidney.
9. Inspect the genitalia and anus. In boys, look for presence of testis in scrotum. In girls, look for labia majora and labia minora. You should be able to differentiate between the two. Also look for any fistula or discharges.
10. Palpate for femoral pulses. Femoral pulses is reduced in case of coarcation of the aorta. This can be confirmed by measuring the blood pressure in the arms and legs. Femoral pulses is increased in case of patent ductus arteriosus.
11. Assess the muscle tone by observing limb movements and on sitting the baby while supporting the head. Most babies will support the head briefly when the trunk is held vertically.
12. Whole of back and spine is observed looking for any midline defects of the skin
13. The hips are checked for development dysplasia of the hips (DDH). This is left last as the procedure is uncomfortable.
