Infant Examination &Common Infant Problems

Dr Ian WoodcockST3 Paediatrics

Aim

Newborn Examination Problems found during baby check Common Infant Problems presenting

in first few weeks of life: Vomiting Breathing Difficulties (very briefly) Colic Jaundice

Why is newborn check useful?

Detecting medical problems

Parents value early diagnosis

Outcome can be improved

Enables planning of services

Newborn Examination

What do we examine in the newborn and six week baby checks?

Head to toe examination

•Genitalia•Anus•Hips•Femorals•Spine•Arms + Hands•Legs + Feet•Skin

•Head•Eyes•Palate•Tone•Heart•Chest•Abdomen

General inspection

How is the baby doing generally? Family history congenital problems Antenatal concerns? Inspect for dysmorphic features? Feeding Passed urine? Passed meconium?

RED FLAGS

Specific things to think about!

Heart Murmurs Femoral Pulses Undescended

Testes Absent red reflex Dislocatable /

dislocated hips Sacral dimples Imperforate anus

Infant Examination

Head

EyesPalateToneHeartChestAbdomenFemoralsGenitaliaAnusHipsSpineArms + HandsLegs + FeetSkin

Absent Red Reflexes

What does it mean?

Take Action

Red reflexes

Red reflex absent Red reflex abnormal

Normal

Absent Red Reflexes

Congenital Cataracts

Optimal time for surgery is 4 – 6 weeks

Should be referred to an ophthalmologist early

Sub-conjunctival haemorrhages are of no significance.

Infant Examination

HeadEyes

PalateToneHeartChestAbdomenFemoralsGenitaliaAnusHipsSpineArms + HandsLegs + FeetSkin 16

Tongue-tie

Usually do not require surgery, except if interfering with breast feeding; the tongue grows forward in 1st year

Infant Examination

HeadEyesPalateTone

HeartChestAbdomenFemoralsGenitaliaAnusHipsSpineArms + HandsLegs + FeetSkin 23

Heart Murmurs

Duct dependent lesions

Baby only well if Ductus Arteriosus is open – this will close spontaneously at 6 – 60 hours of life, then the baby collapses

The vast majority of these babies have low sats (<94%) prior to the duct closing

Heart Murmurs

What are the signs of heart failure?

What would you tell parents?

Signs of heart failure

Breathless / breathing too fast Sweaty Not completing feeds Poor weight gain / Excessive weight gain Poor colour Sleepy “Not quite right”

ASK FOR HELP – A&E or GP

Infant Examination

HeadEyesPalateToneHeartChestAbdomen

Femorals GenitaliaAnusHipsSpineArms + HandsLegs + FeetSkin 38

Femoral Pulses

If they are absent what does it mean?

Femoral Pulses

Absent femoral pulses implies coarctation of the aorta

Baby is at risk of sudden, unexpected collapse and may die without appropriate treatment

Infant Examination

HeadEyesPalateToneHeartChestAbdomenFemorals

GenitaliaAnusHipsSpineArms + HandsLegs + FeetSkin 41

Undescended testes

If bilateral undescended testes, what does it mean?

These babies may be FEMALE, especially if also have hypospadias

Hypospadias

Posterior hypospadias (particularly in the absence of palpable gonads) should be treated as ambiguous genitalia

Male genitalia - hypospadius

1in 300 Combination of

1. Abnormal ventral opening of urethra 2. Ventral curvature (chordae) of penis

3. Hooded foreskin, deficient ventral skin Classified

Coronal,distal,midshaft,proximal,perineal

Ambiguous Genitalia

Ambiguous Genitalia

Bilateral Undescended Testes

The baby may have Congenital Adrenal Hyperplasia

Steroid pathway problem

Steroid precursor Cortisol

Testosterone

Enzyme

Bilateral Undescended Testes

Absence of Cortisol

Salt losing crisis Non-specifically unwell (short time

period) Fits Death

Female genitalia

Oestrogen withdrawal bleeding Can occur in female infants aged 2 - 4 days

Not significant

Infant Examination

HeadEyesPalateToneHeartChestAbdomenFemorals Genitalia

AnusHipsSpineArms + HandsLegs + FeetSkin 53

Imperforate anus

Can be subtle

Needs early diagnosis and surgery

Investigation:Cross Table Lateral AXR in Prone Position

Infant Examination

HeadEyesPalateToneHeartChestAbdomenFemorals GenitaliaAnus

HipsSpineArms + HandsLegs + FeetSkin

59

Dislocatable / dislocated hips

This does not include clicky hips!

Refer up to paediatrics urgently

Non-urgent hip referrals

Risk factors for DDH

Can you think of 4………..?

Hip Referrals (non-urgent)

1st degree relative Breech Significant talipes Abnormal examination

Infant Examination

HeadEyesPalateToneHeartChestAbdomenFemorals GenitaliaAnusHips

SpineArms + HandsLegs + FeetSkin

63

Sacral dimple

Sacral Dimples

Can you see the bottom of the dimple?

If not urgent referral

More worried if…. Poor leg movement Bowels not open

Infant Examination

HeadEyesPalateToneHeartChestAbdomenFemorals GenitaliaAnusHipsSpineArms + HandsLegs + Feet

Skin

Milia

Erythema toxicum

Mongolian blue spot

Capillary haemangioma

Naevus

What size naevus would you be worried about?

Naevus

Refer any naevus greater than 2 cms diameter (risk of malignant change)

Vesicles

Can be serious

Herpes can kill very rapidly

Chicken pox

Refer urgently

Contact infection control ASAP

Things to Refer…

Acute Referrals

Congenital heart disease including all heart murmurs

Absent femoral pulses Ambiguous genitalia, hypospadias or

bilateral undescended testes. Skin vesicles, moderate umbilical sepsis,

pustules, bullae Spinal or sacral pits where the base is not

easily visible

Urgent Referrals

Babies with possible genetic or syndromic abnormalities

Cleft lip and or palate abnormalities (contact cleft team asap – if no antenatal plan for urgent referral)

Absent red reflex Significant naevi Babies with antenatal diagnosis of

bilateral renal pelvis dilatation or dilatation >10mm

Babies with clinically dislocatable hips Possible brachial plexus injury

Paediatric Out Patients Referrals

Definite or possible fixed talipes Babies requiring post natal investigation for

possible inherited conditions Other significant abnormalities found on

antenatal screening or at the time of delivery

Any other baby about which you have concerns

Common Infant Presentations to GP

Vomiting Infantile Colic Bronchiolitis Jaundice

Vomiting

Possets normal

Gastro-oesophageal Reflux worse in neuro-developmental disabilities common - 50% spectrum - mild thicken feeds and positioning

advice Severe may require drug therapy Very severe may need fundoplication Complications - oesophagitis or Barrett’s, failure to

thrive

Vomiting Over-feeding

Infants fed on demand 150mls/kg/day until weaned Then 100mls/kg/day milk

Gastroenteritis Pyloric Stenosis

Occurs in 7 per 1000 live births 6:1 male:female preponderance Projectile vomiting non-bilious fluid after every feed Metabolic Alkalosis Surgical repair - Ramstedt’s Pyloromyotomy

Occult Infection (particularly UTI)

Infantile Colic

What is Infantile Colic? What causes it? What can be done? Does it get better? Differentials? Is it a risk factor for any other

serious condition?

Infantile Colic

What is Infantile Colic? Inconsolable crying, especially in the evenings

accompanied by infant bringing its legs up and exhibiting fisting and going puce in the face. Occurs in a paroxsymal fashion often worse in the evenings.

Affects bottle and breast fed babies equally

What causes it? No cause known. Sometimes is relieved by opening

bowels or passing flatus. ? caused by hunger, aerophagy, abdominal

distention or overfeeding

Infantile Colic

What can be done? Over the counter remedies (eg GripeWater or

Infracol) - varying success Continuing a routine Holding baby and gently jogging infant up and

down White noise such as static on radio Place in car seat on tumble dryer Leave the baby with someone else (trusted carer) Reassurance - this is the single most important

management role

Infantile Colic

Does it get any better? Yes. Most infants will have grown out of colic by 3-

4 months

Differentials? Intussusception Acute abdomen UTI Otitis Media

Is it a risk factor for any other serious condition?

Yes. It is a precipitating factor in NAI

Bronchilitis

What will you tell parents?

What is bronchiolitis? How common is it? How serious is it? How long will it last? What can I do? What should I look for?

BronchiolitisHow common is it?

Very common 70% of infants will contract it in the first year of life 22% symptomatic 3% of all infants < 1 year will be hospitalised with bronchiolitis

When is it most prevalent? Winter (Between November and March)

How do babies present? Repiratory distress (tachypnoea, recessions, decreased sats) Decreased feeding Neonates can present with apneas without respiratory

distress

Bronchiolitis

Examination Findings Respiratory Distress Wheeze and crackles on ausculation Fever may be present but high fever (>39°C) is

uncommon

Infants At Risk

Infants that can be severely affected:

Ex-prems CLD Congenital Cardiac Conditions Immune deficiency Cystic fibrosis Household smokers IUGR/Small infants

Which Children to Refer?

Poor feeding (<50% of usual fluid) Lethargy History of apnoea Respiratory rate >70/min Presence of nasal flaring and/or grunting Severe chest wall recession Cyanosis Oxygen saturation ≤94% Uncertainty regarding diagnosis.

Lower threshold for admission in infants with co-morbidities

Jaundice Can be split into early or prolonged Conjugated or Unconjugated Early:

Most common is physiological (60% babies) Immune haemolysis Infection

Prolonged Breast milk (9% of breast fed babies) Biliary atresia Congenital hypothyroidism CF Galactosaemia

Summary

Quick 5-10 minute top to toe examination

Wide ranges of problems being looked for - most are very rare

If in doubt - ask for help

Acute Referrals

Congenital heart disease including all heart murmurs

Absent femoral pulses Ambiguous genitalia, hypospadias or

bilateral undescended testes. Skin vesicles, moderate umbilical sepsis,

pustules, bullae Spinal or sacral pits where the base is not

easily visible

Any Questions?