Ashford and St. Peter’s Hospitals NHS Foundation Trust Neonatal Intensive Care Unit The Postnatal Ward Handbook: Duties and responsibilities of the junior doctors The Routine examination of the newborn Commonly encountered problems: 1. Cardiovascular system 2. Respiratory system 3. Neurological system 4. Gastrointestinal system 5. Musculoskeletal system / Orthopaedics 6. Renal system 7. Genitalia 8. Eyes 9. Infections / BCG and other vaccinations 10. Feeding / Palate 11. Physiotherapy F/U 12. Audiology 13. Syndromes 14. Others Page 1
Transcript
Ashford and St. Peter’s Hospitals NHS Foundation TrustNeonatal Intensive Care Unit
The Postnatal Ward Handbook:
Duties and responsibilities of the junior doctors
The Routine examination of the newborn
Commonly encountered problems:
1. Cardiovascular system 2. Respiratory system 3. Neurological system 4. Gastrointestinal system 5. Musculoskeletal system / Orthopaedics 6. Renal system 7. Genitalia 8. Eyes 9. Infections / BCG and other vaccinations 10.Feeding / Palate 11. Physiotherapy F/U 12.Audiology 13.Syndromes 14.Others
Please note:
The clinical guideline links in this handbook are correct as at the publication date. If a link is broken, this document will need to be updated accordingly.
The full list of neonatal guidelines can be found on the trust intranet.
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Duties and responsibilities of the junior doctors
There are 3 postnatal ward SHOs – one for Special Care Unit and two for Joan Booker Ward and you will all work together as a team.
The GP trainees and the FY2s from General Paediatrics are mainly allocated to do the baby checks (“Baby check SHO”).
The NICU SHOs are mainly responsible for seeing any babies that need a paediatric review (“Neonatal Reviews SHO”). The NICU SHO will help and support the “Baby Check SHO”, once all babies that require bloods or a management plan are seen.
This role allocation does not mean that there is no cross-over of responsibilities. The GP trainees and FY2s should not refuse to review any babies if asked by the midwifery team. Equally, the NICU SHOs should not leave all the baby checks to their General Paediatric colleagues.
The aim is for all babies to be seen in the morning and have a baby check.You should start with the babies that are likely to be discharged home the same day, but all babies on JBW should receive a baby check allowing the MWs to discharge the babies and mothers as soon as possible. Please don’t leave any checks for out of hours or the next day.
You will be asked to read about the routine examination of the newborn and be able to differentiate between normal variants and abnormalities that require intervention. You will have an induction on baby checks and a senior SHO or a Registrar will supervise you on your first working day (you will be observed for 10 baby checks or less if you feel confident or had previous experience). You are required at the end of the day to sign an educational agreement and you will be formally assessed with a CEX on the routine examination of the newborn.
Aim to perform 3-4 checks per hour and time yourself to know your pace and be able to identify early if you need extra help. This may be difficult in the beginning and the NICU SHOs and SpRs will help you, until you acquire the skills to perform the newborn examination, learn the different management protocols and be able to manage your workload.
Bleeps
5240 “Baby Check” SHO bleep – GP trainees and FY2s form the Paediatric department
5495 “Neonatal Reviews” SHO bleep – NICU SHOs5496 “SCU” SHO bleep – NICU SHOs5960 PN Ward SpR
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The “Baby Check” SHO bleep must be handed over in the morning by the night NICU SHO. The “Baby check SHO” should be informed of any babies that warrant an urgent review.At the end of the shift the “baby check SHO” should come up on the unit and hand over the bleep and any problems to the long day SHO. The rest of the bleeps will be kept in the doctor’s office on NICU out of hours.
The PN ward SpR is expected to attend the PN ward around midday. He/She will review the babies on SCU and any babies on JBW that the SHOs have identified with abnormalities or have any questions about their examination. If this does not happen the SHOs should take the initiative and contact the SpR on their bleep. SHOs should not feel intimidated and are always welcome to discuss their queries with the SpRs or the attending Consultants. The Neonatal Unit is almost always busy but time will be made to review babies on the postnatal ward.
The baby checks should be performed in the Nursery. All the equipment should be made available to you and a Nursery Nurse or a Health Care Assistant should be helping you, by gathering the babies and mothers next door with their notes.When both the “Baby check SHO” and the “Neonatal reviews SHO” are available for baby checks, the checks should still be performed in the nursery, but at no point should two families be in the same room discussing potentially sensitive data. Please try to co-ordinate between you, so that while one is taking a family history and examines a baby, the other person is filling in paperwork, prepares for blood tests or BCGs, in order to improve efficiency.
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Remember to check when you start in the morning whether any of the babies on your list have been antenatally identified as “High Risk” and are logged on the “High Risk Folder” (the yellow folder).
A management plan (e.g. for talipes, antenatal hydronephrosis, Hepatitis B) is noted next to the baby’s name and problem list to help you arrange investigations and follow up.
Please tick the baby’s name off and document the management you have carried out on the same page. This can be fed back to the Obstetric team at the mother and baby meeting on alternate Fridays during the NICU grand round.
If you have any concerns or queries, please discuss them with the SpR or attending Consultant.
A set of notes needs to be made up for all the babies that require anything more than a routine baby check (ie investigations, senior review, follow up). You are expected to write your examination and management plan in them so that this can be followed up if required.
***Do not write in the postnatal baby notes (blue set of notes) as the mothers take these notes home and are filled later on with the maternal notes.***
Follow up in Paediatric Outpatient Clinic
The follow up appointment is booked via the secretaries in the Paediatric Outpatient Department. Please ask the JBW clerk to call 2509 or 2545 to arrange the appointment and let the secretaries know the name of the attending Consultant on NICU in order to book the appointment. If there isn't a ward clerk available a nurse or MW will need to arrange this.
Family HistoryThe family history relevant to the routine examination of the newborn is poorly and inconsistently obtained.
Thus, you are now asked to fill in the Red Book the section regarding the family history, on page 6.
It consists of 9 questions that are answered with a yes and no format. These include:
Childhood deafness ; depending on the history (ie first degree relative with sensorineural deafness) you may need to discuss with a Registrar or a Consultant and arrange follow up in clinic. The HV will be performing a hearing screen on all babies in the community.
Fits in childhood ; The risk for unprovoked seizures is higher in children of parents who developed epilepsy before 20 years of age (nine per cent). Please advise to look out for seizures.
Eye problems ; o Congenital cataracts and o Retinoblastoma are the main concerns and require follow up (see guideline below).
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Hip problems ; increased likelihood of DDH on first degree relatives (see guideline below).
Remember to ask whether the baby was in breech position at any point in the 3 rd
trimester.
Reading and spelling difficulties ;
Asthma, eczema, hay fever, allergies ; increased likelihood for first degree relatives
Tuberculosis ; offer the BCG vaccine
Heart Conditions ; the incidence of congenital heart disease is around 1% and there is increased likelihood of congenital heart disease in first degree relatives. Check that the antenatal scans were normal and check whether an antenatal ECHO was performed. Look at the high risk folder in case an antenatal plan was formed. Perform a thorough cardiovascular examination and check oxygen saturations.
Any other particular illnesses or conditions in the mother’s or father’s family that you feel are important?
BCGs
The BCGs should all be performed in the morning and you can open the vial and use it for 4hrs (once reconstituted and kept in room temperature). The babies requiring a BCG should be identified antenatally and there is a section in the maternal notes indicating whether the baby needs a BCG. Please consent the parents before you perform the baby check and administer the vaccination while the baby is undressed at the end of your examination.
Try to open one vial per day if possible and vaccinate as many babies as possible. If there are any extra babies for BCG vaccination in the afternoon or out of hours, then it is preferable to open another vial rather than bringing the baby back in just for the vaccination.
You will be expected to observe how a BCG is given for a couple of times before you attempt to give one. A Senior SHO or a Registrar will supervise you for the first few injections until you feel confident with the procedure. This should be arranged on the same day that you are supervised for your baby check training. A DOPS form will be filled in to ensure you are competent.
For the BCG guideline please click here.
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Special Care Unit
The SCU is managed by a NICU SHO; and the SpR allocated to the PN ward should help and supervise you as required.
It is helpful to have the SCU nurse with you on the ward round, so you both know the plans for the babies.
There are strict criteria for SCU eligibility – if you wish to admit a baby to SCU please speak to the nurse in charge.
If a baby is to be discharged ensure they have: A completed formal baby check (documented in Red Book and Evolution Page) Information on the BCG vaccine and been offered it (duty of SCU SHO to consent
and administer SCU babies BCG vaccine) A completed SEND discharge summary Any necessary follow-up You are also responsible for completing the SEND daily updates for the babies in
SCU.
SCU Ward Attendees
Babies who have gone home and are coming back to the SCU for review or investigations (e.g. TFT’s, prolonged jaundice screens, FBC) are booked in the SCU diary.
The appointments are on Monday, Tuesday, Thursday and Friday at 14:00 & 14:30 (2 appointments available per day). These are to be used once or maximum twice for the same patient. If further follow up is required, this needs to be arranged through the Outpatient Department, with their Named Consultant (ie the Neonatal Consultant attending NICU on the day the baby was born).
Their results should be reviewed daily and the appropriate action taken. This includes calling the parents to inform them of normal results or making appointments for review or further tests.
Wash hands thoroughly (don’t use alcohol gel as when you check for the sucking reflex it is bitter for the baby). Wear gloves if you prefer (you‘ll need to handle the nappy area even if the baby has had their bowels open!).
Initial Details Thoroughly review the maternal notes, regarding:
antenatal scans (e.g. hydronephrosis – see guideline) blood tests (e.g. Hep B / HIV – see guideline) full history –past medical (e.g. maternal hyperthyroidism – f/u bloods required) and
obstetric history pregnancy complications details of labour and delivery (ROM, type of delivery, meconium, GBS carrier,
Apgars, weight) gestational age and sex of the baby
There may be plans in place for postnatal investigations and management – remember to check the (yellow) high risk folder.
Getting started Introduce yourself Ask mother if she has any concerns about the baby. Any problems in the pregnancy Any relevant family history (e.g. hips, heart, eyes, hearing and kidneys). Fill in page
6 on the RED BOOK. Enquire about the infant’s progress since birth, method of feeding, adequacy of
intake, alertness. Has the baby been on meconium or PROM (prolonged rupture of membrane)
observations - any abnormal temperature or other observations? Has the baby had blood sugar monitoring due to hypoglycaemia risk – see guideline Has the baby passed urine (most within 24hrs) and in boys is there a good stream? Has the baby passed meconium (90-95% by 48 hrs)? Was Vitamin K given i.m. or oral – With oral regime TTO for follow up doses
required – see guideline
Initial Observations - Is the infant well?Perform a general observation of the baby, including:
Colour : Cyanosis, pallor, jaundice – check a spun bilirubin level if concerned Blueness of hands and feet are common (acrocyanosis) Blueness of face ± facial petechiae common from cord around the neck / rapid
second stage (facial contusion) Tip: examine the tongue – it should be pink. If any doubt about possible cyanosis,
check oxygen saturations.
Respiratory pattern and rate – should be regular and <60 breaths per minute
Posture and movements – baby usually active, well flexed with good tone
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Any dysmorphic features?
Whilst baby is settled, auscultate heart: rate (normal 120-150bpm), heart sounds and murmurs
Systematic approachUndress infant completely except taking off the nappy. It is best to do this gradually in stages, and examine the exposed parts of the body as you go along. Many people adopt the “head to toe approach”.
Head Measure the head circumference if not already done by the midwife (2-3 OFC
measurements, take largest) Microcephaly <32.5cm at term Head shape (symmetry), skin (bruising, lacerations), palpate anterior and posterior
fontanelle, suture lines Caput- bruising and oedema of presenting part extends beyond margins of skull
bones, resolves in few days Cephalhaematoma- bleeding below periostium, confined to suture lines (resolves
over a few weeks) Subaponeurotic haemorrhage- collection of blood under the aponeurosis of the
scalp can be accompanied by significant blood loss. Presents with shock and pallor and with a flaccid, diffuse, boggy swelling that extends across suture lines and can causing bruising behind the ears, along the posterior hair line and around the eyes. Needs urgent senior review.
Ears- size, shape, position, presence of skin tags or pits
Eyes- pupil size and shape, clearness of cornea and check presence of red reflex, Swollen eyelids and subconjunctival haemorrhage are not uncommon from delivery, Sticky eyes may require treatment
Milia- white pimples on nose and cheeks (retention of keratin and sebaceous fluid in follicles)
Mouth- tongue, palpate hard and soft palate and perform visual inspection, jaw size, look for tongue tie
Neck- lumps/swellings (branchial and thyroglossal cysts, neonatal goitre- all rare) webbing/ low hairline, palpate clavicles for fractures
Arms- Fractures / Erb’s palsy,
Hands- number of digits, finger length (clinodactly 5th finger), palmar creases, grasp reflex
Chest- shape, respiratory and heart rate, heat sounds and murmurs, palpate praecordium and apex, palpate femoral pulses. Breast enlargement in either sex not uncommon (hormonal influence)
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Abdomen- shape, umbilical cord, palpate for liver (up to 1-2cm below costal margin is normal in neonates), spleen, kidneys and bladder
Single umbilical artery- associated with renal problems in 7% cases – check the findings on the anomaly scan around 22 weeks, and if the kidneys are normal and this is an isolated anomaly postnatal renal USS not indicated
Genitalia Boys- testes descended?, urethral meatus normally placed?, hypospadias? Girls- hymenal tags, mucoid discharge and vagina bleeding (small amount) are
common and resolve in first few weeks Tip: Urates in urine can cause salmon pinkish discharge in nappy that worries
parents
Anus- patency and position (anteriorly or posteriorly displaced anus may be an isolated finding or part of a syndrome). Presence of meconium does not mean anus is patent – the baby can have an anorectal malformation and fistula! ALWAYS LOOK FOR A PATENT ANUS.
Limbs- symmetry and movement, leg length, talipes
Tone- Pull to sit (observe head control and tone) Suspend prone- observe tone and head position
Spine- run finger along whole length of spine to palpate bony structures. Look for sacral dimples. Sacral dimple likely benign if small and at the gluteal crease. The base should be visible and there should be no associated redness or hairy patch. If in doubt get senior review – an ultrasound is occasionally requested to look for any deeper connections.
Skin Examine for rashes and birthmarks. Haemangiomas Erythema toxicum (reassure) Mongolian blue spots - base of spine and on buttocks, usually Afro-Caribbean /
Asian, fade over few years, no significance but please document – may be mistaken for bruising, dry skin – midwives suggest olive oil or simple moisturiser.
Examine primitive reflexes including Moro only if concerned about movements and posture.
Hips- DDH risks- female, breech at any time in the 3rd trimester, twins with one of them
lying breech, family history, oligohydramnios, talipes, lower limb abnormalities. Observe for symmetry of skin creases Perform Barlow and Ortalani examinations
Barlow –this examines if the hip is dislocatable. Stabilise the pelvis with one hand and with the other hand place your middle finger over the greater trochanter and the thumb around the distal medial femur. The hip is held flexed and adducted. The femoral head is gently pushed downwards /backwards. If hip dislocatable, the
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femoral head will be pushed posteriorly out of the acetabulum and a ‘clunk’ will be palpable or audible. A ‘click’ is more commonly felt and is not diagnostic of a dislocated hip.
Ortalani - this examines if the hip can be returned from its dislocated position back into the acetabulum. With same grip and hip flexed and abducted, lift femoral head forwards with middle fingers (gentle upwards leverage). A dislocated hip will return with a ‘clunk’ into the acetabulum.
If dislocated / dislocatable hips found on examination or any risk factors present for DDH please follow the relevant protocol and refer for hip USS.
Discuss examination with parents – give reassurance where appropriate, and arrange any necessary follow up. If you discover an abnormality, explain the findings to the parents. If you are not able to fully satisfy them with your explanation, tell them you will speak to a senior colleague, and ask a registrar to review the baby. If you find a serious abnormality, please discuss it with a Registrar or the attending Consultant.
Record examination on Evolution page and in Red book.
If there are any abnormalities the baby will need to have a set of notes made up by the Joan Booker ward clerk. Do not simply record this in the maternal notes as these will not be available once the baby returns to clinic.
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Postnatal Ward Check Referral Forms and Contact Details
Referral Problem Appendix/AddressErb’s Palsy Physiotherapy Referral Form (Appendix A)Developmental Dysplasia of the Hip Orthopaedic Referral Form (Appendix B)Congenital Talipes Equinovarus Physiotherapy Referral Form (Appendix A)Structural Talipes Physiotherapy Referral Form (Appendix A)Polydactyly and Skin Tags Refer to Paediatric Plastic Surgeon Miss.
Catherine Milroy at St. George’s HospitalSecretary - Sharon de Coteau020 8725 [email protected]
Hypospadia / Chordee Refer to Paediatric Urologist Mr. Murphy at St. George’s HospitalSecretary – Veronique [email protected]
Inguinal Hernia Refer to Paediatric Surgeon Mr. Okoye at St. George’s Hospital (will be seen in clinic here)Secretary – Veronique [email protected]
Absent Red Reflex & Retinoblastoma Refer to Mr. Kafil-Hussain at SPHFax referral letter (marked urgent) to 01784884350
Hepatitis B Immunisation Referral Letter to GP & Letter for parents - Appendix C
Mobile: INTERPRETER REQ’D?If Yes, which Language? Yes No Work Tel:
TIME SINCE ONSET:
Specify exact duration::
Less than 2 weeks 2-6 weeks > 6 weeks
Transport Required?Yes No
OTHER
OFF WORK DUE TO CURRENT PROBLEM? Yes No DISTURBED SLEEP DUE
TO THIS PROBLEM? Yes No
OCCUPATIONFLARE UP OF CHRONIC CONDITION? Yes No
DIAGNOSIS / OPERATION DATE AND DETAILS: SCAN / X-RAY FINDINGS:
REASON FOR REFERRAL: OTHER RELEVANT INFORMATION:
REFERRER’S SIGNATURE: REFERRER PRINT NAME: DATE:
GP/Consultant DETAILS: Please complete IN CAPITALSGP/Consultant Name: (PRINT) Surgery Address / Stamp: (PRINT)
FOR THERAPY OFFICE USE ONLY:
Date Received
Referral source (code)
Date prioritised
PriorityPrioritised
by(initials)
Tele contact
date
Letter sent date
1st
Appointment½ or 1hr
Physio
Comments/Further Action:
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Ethnic Group Prompt Card
To help us make sure that the services we provide are equally accessible and meet the needs of our diverse population we would like to have an accurate picture of the local people we serve.Please help us by giving the following information which will be treated confidentially.Indicate the ethnic group to which you feel you belong. If you are descended from more than one ethnic group please indicate the group to which you consider you most belong.
O Any Other Ethnic Group
OA Any Other Asian Background
OW Any Other White Background
P Pakistani
UK White British
Thank you
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Appendix B
Please fax and then place in internal post addressed to: Rowley Bristow Orthopaedic UnitFax number: 01932 722 689
REFERRAL TO ORTHOPAEDIC TEAM FOR DETECTION OF DEVELOPMENTAL DYSPLASIA OF THE HIP
Name of baby: ……………………………………………………………
D.O.B: ……………………………………………………………………………
Hospital number: ……………………………………………………………
Address: ……………………………………………………………
……………………………………………………………
Telephone number: ……………………………………………………………
Consultant: ……………………………………………………………
G.P. ……………………………………………………………
Reason for referral:
1. Dislocated / dislocatable hip on examination (Please note these will be seen as a priority) □
2. Clicky Hips on examination □3. Babies with a Family history of DDH □4. Breech deliveries □
(Breech presentation in third trimester regardless of presentation at delivery)
5. Both Twin Siblings □(Please refer both twins even if one twin was breech presentation or has abnormal hip examination with two separate forms)
6. Talipes (structural/fixed) □7. Muscle Weakness/ other deformity □
Please provide details of examination below
Referring doctor (Please print): …………………………………………………………….
Signature …………………………………………………………….
Date of referral …………………………………………………………….
Please provide parents with information leaflet and telephone number of the Rowley Bristow Orthopaedic Outpatient appointment line (01932 722 730)
This patient is on the Hepatitis B Immunisation Programme. Further doses of Hepatitis B vaccine are required to complete the course, and we would be grateful if this could be arranged through your practice
The next two at 1 and 2 months of age A booster at 1 year of age and pre-school booster at 5 years
Subsequent arrangementsA reminder will be sent out to you and the parents at 12 months indicating that a booster is due. They will also be sent a form to have blood tests at 13 months to identify babies who have acquired hepatitis B, and to assess if there has been an adequate antibody response. The baby will be reviewed in our Outpatient Department at 14 months to discuss the results. Further doses of vaccination may be necessary.
The Hepatitis B vaccine does not interfere with any of the other immunisations in the infant schedule, and they can be given as normal.
Please do not hesitate to contact us should there be any problems regarding the further Hepatitis B Immunisations.
Yours sincerely,
Dr.__________________
Copies to:Debbie Evans, Neonatal UnitHealth VisitorDr Margot Nicholls, Consultant in Communicable Disease Control, Health Protection Unit,County Hall North, Chart Way, Horsham, West Sussex, RH12 1XA
Your baby has received his/her first Hepatitis B vaccine. Further doses are required to complete the course, these are:
The next two at 1 and 2 months of age A booster at 1 year of age and pre-school booster at 5 years
These should be given by your GP practice, and a letter has been sent to them and your baby’s Health Visitor
Subsequent arrangementsYou will be sent a letter at 1 year to remind you that your baby’s hepatitis B vaccine booster is due. You will also be sent a form to have blood tests to check the baby’s Hepatitis B status and their antibody levels at 13 months. Your baby will be reviewed in our Outpatient Department at 14 months to discuss the results. It may be necessary to give further doses of the vaccine.
Your baby can receive all their other routine vaccines at the usual times.
Yours sincerely,
Dr. ____________________________
Designation _______________________
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Appendix D
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Commonly encountered problems:
Cardiovascular system Heart murmurs Cyanosis
Respiratory system Respiratory Distress (Tachypnoea, Grunting, Recessions, Stridor)
Neurological system Jitteriness vs Seizures Facial Nerve Palsy Erb’s Palsy
Gastrointestinal system Vomiting & Bile stained vomiting Anal atresia (Imperforate Anus) & Anteriorly displaced anus Umbilical hernia
Infections / BCG and other vaccinations Risk factors for infection / GBS BCG vaccination HepB vaccination Neonatal management of babies born to HepC positive mothers
Feeding / Palate Tongue tie Cleft lip and/or palate Weight loss
Physiotherapy F/U
Audiology
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Syndromes Down’s Syndrome
Others Jaundice Hypoglycaemia Vitamin K administration Peri-auricular skin tags
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Cardiovascular system
Heart murmurs
Heart murmurs affect 0.5 – 1% of all newborns.
46% - 62% are likely to have a “benign” murmur, commonly, a PDA or peripheral pulmonary artery stenosis.
Perform a full cardiovascular examination and lower-limb saturation
A) If the murmur is clinically soft, localised with normal pulses and saturations >95% and the baby is asymptomatic:
1. re-examine in 24 hours’ time, ideally by the same person.
2. If murmur still present, examination by a senior colleague to confirm that the murmur is clinically insignificant.
3. If so, arrange an appointment in 4 to 8 weeks’ time, provide a parent information sheet on heart murmurs & advise to return to hospital if there is:
Central cyanosis
Respiratory distress and/or excessive sweating
Poor feeding (>2 consecutive feeds of <50% usual volume) or poor weight gain
B) If there is any doubt about the clinical significance of the murmur:
1. Any potentially-significant murmurs must be reviewed by a senior colleague.
2. Perform:
CXR
ECG
4-limb blood pressures
Pre- and Post- ductal saturations
3. Discuss early echocardiography with the consultant
C) If limb saturations <95% and/or baby is symptomatic:
See “Cyanosis” +/- “Respiratory Distress”
The full guideline can be found here (Congenital Heart Disease and Neonatal Murmurs)
2. University Hospital of Southampton NHS Foundation Trust website:http://www.uhs.nhs.uk/OurServices/Childhealth/Neonatalsurgery/Conditionswetreat/AnorectalMalformations.aspx
Gastrointestinal system
Umbilical Hernia
Common especially in babies of African origin.
Results from failure of umbilical ring to obliterate.
Can be large, reducible and do not cause symptoms (warn parents hernia enlarges when
baby cries / strains due to increased intra- abdominal pressure and it is not the hernia
which is causing the crying / straining).
Majority resolve over first few years of life.
No referral required.
GP to refer to surgeons if not resolved by 4 years.
The incidence is about 0.3% and is three times more common in girls.
Management plan:
1. Refer for to the Rowley Bristow Orthopaedic Clinic all babies with:
An abnormal hip examination including clicky, dislocatable and dislocated hips
(pls ask for a senior review if uncertain)
A family history of Hip Dysplasia (first degree)
Breech deliveries (third trimester presentation regardless of presentation at
delivery)
Both twin siblings (refer both twins even if only one baby delivered by breech
presentation or has abnormal hip examination)
Talipes (structural/ fixed)
Muscle weakness or other deformity
2. The DDH Referral Form to the Rowley Bristow Orthopaedic Clinic can be found here
please fax the form to: 01932 872 015
and also post referral by internal mail within 24 hours of detection.
3. Give parents DDH Information Leaflet (click here) and advise them to phone Appointments (01932 722 730) in the Rowley Bristow Orthopaedic Unit in two weeks if they have not received an appointment.
4. The paediatric team DO NOT have to arrange ultrasound scans. All referrals for abnormal hip examination will be urgently reviewed and a hip ultrasound will be performed. For all other referrals, e.g. high risk cases, an ultrasound scan will be performed between three and six weeks.
The full guideline can be found here (DDH Guideline)
In structural talipes equinovarus, the affected foot is shorter and the calf muscles are
thinner than normal. The position of the foot is fixed and can't be easily corrected.
Management plan:
1. Refer to the physiotherapists as urgent - serial casting is required: Any baby with a structural talipes will commence Ponsetti management as early as appropriate (although preterm babies need to be 38 weeks gestation). Serial casting weekly (on average x6 casts) until correction is satisfactory. A
purcutaneous tenotomy is required in at least 80% of cases at the end of casting.
When the correction is complete, the babies feet are splinted in ‘boots and bar’ for
x3 months full time and during sleep up to the age of 4 years. In a small number of
cases further treatment of casting or other operations may be required. Post
tenotomy the baby will have a review appointment with the Consultant when
standing at about 1 year of age. There will be Annual reviews with the Consultant up to 5 years .
2. Referral for possible DDH: Any baby who has needed on-going treatment will be given an appointment in the Children’s Orthopaedic Clinic within 6 -8weeks to have a hip U/S Scan – to be arranged by the Physiotherapists.
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Musculoskeletal system / Orthopaedics
Polydactyly (& Skin Tags)
Define extra digits as pre-axial (radial side of hand, medial side of toes) - higher association with other
anomalies axial (midline) post-axial (ulnar side of hand, lateral side of toes) - often have strong family history
Do not tie off skin tags or extra digits with silk as this often leaves unsightly tags.
Refer to plastic surgery - Miss Catherine Milroy, Consultant Plastic Surgeon at St Georges Hospital
All patients with accessory digits or skin tags are to be referred to the plastic surgery service at the time of discharge from the postnatal ward.Please do not ask them to wait until they have been seen by the GP or in clinic to be referred.
Pedunculated accessory digits can be managed using a ligaclip device. It is said to be most effective when done early at less than 6 weeks of age.
Miss Milroy will however still use this technique in babies up to the age of 3 months. It is a quick, straightforward procedure that is done without local or general anaesthesia and the babies settle down quickly once they have had a feed post procedure. After 3 months of age, the management will include a general anaesthetic, so it is vital these babies are referred early.
Contact Number for Miss Catherine Milroy ‘s secretary: 02087251134 / Fax N:
02087252416
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Musculoskeletal system / Orthopaedics
Syndactyly
Syndactyly is a condition wherein two or more digits are fused together.
Can be simple or complex:
In simple syndactyly, adjacent fingers or toes are joined by soft tissue. In complex syndactyly, the bones of adjacent digits are fused.
Can be complete or incomplete:
In complete syndactyly, the skin is joined all the way to the tip of the finger In incomplete syndactyly, the skin is only joined part of the distance to the fingertip.
Syndactyly can be an isolated finding, or it can be found in association other abnormalities ( eg Poland syndrome, Apert syndrome or Holt-Oram syndrome).
Syndactyly of the border digits (thumb/ index finger or ring/ small fingers) is treated at early age to prevent the larger digit from curving towards the smaller digit with growth. Typically, syndactyly of these digits is treated at 6 months of age.
The treatment of syndactyly of the other digits is elective and is more commonly performed when the digits have grown, at 18– 24 months of age.
Management plan:
Perform a detailed examination and look out for associated abnormalities Inform your seniors Consider X-rays of the affected limbs Refer the baby to Plastic Surgeons for simple syndactyly (ie no bony involvement) and Or-
thopaedics for complex syndactyly (ie underlying bone deformity) - please discuss with the SpR or Consultant on call.
Arrange for follow up in clinic with the attending consultant in 6-8 weeks if syndactyly is not an isolated finding
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Musculoskeletal system / Orthopaedics
Sacral Dimple
If a sacral dimple is noted during the baby check, please ensure you can see the base and that there is no sinus to the skin.
If the dimple is at the tip of the coccyx, the baby has a normal lower-limb neurological examination and there are no skin marks or extra hair over the spine, then you can reassure parents and no ac-tion is required.
If the dimple is over the lumbar area, you can't see the base and there are extra hair or rashes, please inform your SpR and arrange for an USS of the lower spine.
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Renal system
Hydronephrosis
Measurement of the maximum anteroposterior diameter of the renal pelvis (RPD):
Anomaly scan at 22 weeksRPD of > 5mm is considered to be abnormal. Mild cases with will have a repeat scan at 34 weeks at St. Peter’s Hospital. More severe cases may be scanned more frequently, or referred to St.George’s Hospital for further management.
At 34 weeks AP diameter < 6mm is normal and no further intervention is required. AP diameter >10 mm is abnormal and should be further investigated.AP diameter 6 – 9 mm is a grey area, and management is highly controversial. Currently our ultrasonographers may report this group as “normal”, or report the actual diameter.
PostnatalOur radiologists consider RPD > 7mm to be abnormal (if USS performed after 48 hours and before 6 weeks). After 6 weeks postnatal age >10mm is considered to be abnormal.
Management plan:
Perform a physical examination to detect the presence of an abdominal mass (possible PUJ or MCDK) or palpable bladder (PUV).
RPD 6 - 9mm at 34 week scan or RPD 10 - 15 mm at 34 week scan
1. Start prophylactic antibiotics – Trimethoprim 2mg/kg once daily. Please fill out a hospital TTO form, or if an FP10 is used out of hours, please clearly document in the baby’s notes the dose of Trimethoprim prescribed.
2. Ultrasound scan (USS) of kidneys at 4 - 6 weeks 3. Arrange outpatient appointment for 6 – 8 weeks; ideally indicate on USS request
form when the date of the OPA is, as the radiology department will then ensure the USS is carried out prior to the clinic appointment.
RPD >15mm at 34 weeks
1. Start prophylactic antibiotics – Trimethoprim 2mg/kg once daily. Please fill out a hospital TTO form, or if an FP10 is used out of hours, please clearly document in the baby’s notes the dose of Trimethoprim prescribed.
2. Request early USS (ideally at 72 hours). 3. Suspect bladder outlet obstruction if bilateral in a male. This requires urgent
investigation with USS and MCUG to exclude posterior urethral valves - see management of bladder outlet obstruction.
If the mother has been seen at a tertiary centre, a clear plan should be outlined in her notes and should be followed accordingly.
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The full guideline can be found here (Renal Uropathies) – under review
Other renal uropathies
The full guideline can be found here (Renal Uropathies)
Genitalia
Ambiguous genitalia
If there is uncertainty over the sex of a baby review the baby as a matter of urgency.
Underlying causes include Congenital Adrenal Hyperplasia which may cause salt loosing crisis.
Initial Management:
Contact the Registrar and Consultant urgently.
Check U&Es and a Blood Sugar Level urgently
Do not designate a gender
Further Management:
Chromosomes need to be checked after obtaining parental written consent
Check urinary and blood steroid profile
Arrange for an USS of the pelvis (to establish whether the baby has a uterus)
* Remember not to designate a gender until the baby is fully investigated*
3% male term infants vs 33% male premature infants
Majority descend in the first few months after birth.
If remain undescended beyond first few years of life increased incidence of testicular cancer (x20), and infertility (sperm count reduced if testes in abdomen).
Management plan:
Unilateral Undescended Testes : Refer to GP to review at 6 weeks; they will refer to surgeons if testes remain undescended at that point.
Bilateral Undescented Testes: Discuss with the Registrar, as this raises the possibility of a virilised female infant –see ambiguous genitalia above. An abdominal USS may be required to visualise the testes and confirm absence of a uterus.
Referral to Paediatric Urologists may be required for hypospadius and chordee.
Discuss with the Registrar regarding need for referral.
Advise the family not to have the baby circumcised, at least until the baby is seen by the Urologists.
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Genitalia
Hydrocele vs Inguinal Hernias
Hydrocele:
Accumulation of fluid in tunica vaginalis due to persistence of a narrow patent processus vaginalis.
Typically scrotal, can be large, smooth and non tender. Transilluminates and is not reducible.
Majority resolve in first 6-12 months (obliteration of patent processus vaginalis continues after birth) and so no initial surgical follow up indicated.
If persist beyond a year GP should refer to surgeons.
Inguinal Hernia:
1-2% term newborns - 90% males Increased incidence in preterm babies (20-30% premature males).
Majority direct (1% indirect)Right > Left - 5%-10% are bilateral
Present as intermittent swelling in the groin or scrotum especially on crying or straining.
Refer to Paediatric surgeons for operative repair at diagnosis.
Risk of incarceration: baby presents as unwell (crying, irritable), vomiting, abdominal distension, mass becomes red, tender and irreducible.
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Eyes
Absent Red Reflex & Retinoblastoma
The red reflex test is used to screen for abnormalities of the back of the eye (posterior segment) and opacities in the visual axis, such as a cataract or corneal opacity.
An ophthalmoscope held close to the examiner’s eye and focused on the pupil is used to view the eyes from 12 to 18 inches away from the subject’s eyes.
To be considered normal, the red reflex of the 2 eyes should be symmetrical.
Dark spots in the red reflex, a blunted red reflex on 1 side, lack of a red reflex, or the presence of a white reflex (retinal reflection) are all indications for referral to an ophthalmologist.
Infants or children in high-risk categories, including relatives of patients with: retinoblastoma infantile or juvenile cataracts retinal dysplasia, glaucoma other vision-threatening ocular disorders that can present in infancy
should not only have red reflex testing performed in the nursery but also be referred to an ophthalmologist who is experienced in examining children for a complete eye examination regardless of the findings of the red reflex testing by the pediatrician.
Management plan:
All babies with an absent red reflex need to be reviewed by the Registrar and referred to the Ophthalmologists.
Mr Kafil-Hussain is our local Consultant Ophthalmologist who reviews all the neonates, please address the referral to him.
For the neonates in the high-risk category please arrange a follow up in clinic with Mr Hussain (please send a referral letter to Mr Hussain with the details of the patient and the reason for the request).
References:
Policy Statement, Red Reflex Examination in Neonates, Infants and Children, American Academy of Paediatrics, Volume 122, Number 6, December 2008
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Infections / BCG and other vaccinations
Risk factors for infection / GBS
Risk factors for infection:1. Prolonged rupture of membranes2. GBS colonisation3. Maternal pyrexia peri-natally4. Fetal tachycardia5. Need for resuscitation at birth6. Abnormal observations on the neonate postnatally
Recognition of sick infant – Signs and Symptoms (often subtle):
1. ↑ HR, ↑ RR +/- increased work of breathing2. Heart murmur3. Poor skin perfusion, skin mottling, cyanosis4. Quiet, not feeding well5. Temperature instability6. Lethargy, floppiness, full sunken fontanelle7. Abnormal movements (often focal and subtle)8. Irritable, high pitched cry9. Feed intolerance, abdominal distension10.Abdominal distension, enlarged liver11. Nursing staff or parents concerned
Special Situations
1. Positive High Vaginal Swab result after mother and baby discharged home:
Baby < 36 hours old: admit baby and follow the GBS protocolBaby > 36 hours old: baby to be assessed by doctor/ midwife by phone. If necessary a hospital assessment will be arranged.
2. Mothers who wish to go home before 24 hours of observation is complete
SHO should discuss with middle grade doctor or consultant. Document in the notes that mother wished to go home against medical advice and ensure that the baby is followed up by community midwife within 24 hours of discharge.
If antibiotics have been given, once they are stopped the baby does not need 24 hours observation and can go home straightaway.
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Management plan:
If a baby needs iv antibiotics please admit the baby to the SCU. Obtain iv access and send bloods off for FBC, CRP, B/C and blood gas. Start iv Co-amoxiclav (first line Abx for neonates) Admit the baby to Badger Inform seniors
The full guideline for neonatal sepsis and GBS can be found here.
Infections / BCG and other vaccinations
BCG vaccination
Intended Benefits:
Provides protection against tuberculosis. A live attenuated vaccine derived from Mycobacterium bovis which stimulates the
development of hypersensitibity to M. tuberculosis.
Disadvantages / Complications:
20% failure rate of the BCG vaccination. The expected reaction to successful BCG vaccination is initially induration at site of
injection. At 2 or more weeks a local lesion starts as a pustule and then may ulcerate and
subsides over several weeks or months leaving a small flat scar. If the lesion becomes large (>1mm), begins to discharge or an abscess forms,
medical advice should be sought. No live vaccine should be administered within 4 weeks of the BCG vaccine (none of
the scheduled vaccines given within the first 12 months are live; the first live vaccination is the MMR which is given at 13 months).
No vaccination should be given into the left arm for at least 3 months due to the risk of lymphaedenitis (scheduled vaccines in the first year of life are normally given into the anterolateral aspect of the thigh).
Recommended for: All infants (aged 0 to 12 months) living in areas where the incidence of TB is
40/100,000 or greater. Local areas Include Hounslow, Feltham, Bedfont. All infants (aged 0 to 12 months) with a parent or grandparent who was born in a
country where the incidence of TB is 40/100,000 or greater.https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/491527/WHO_estimates_of_tuberculosis_incidence_by_country__2014_v2.pdf
Intention to visit/live in a high-incident country for 3 months or more. Family history of TB in the past 5 years.
Prior to vaccination: Ensure that the maternal HIV status is negative.
Provide the “TB, BCG vaccine and your baby” leaflet to the parents and talk through the intended benefits and possible complications of the vaccine.
Obtain informed written consent (premade form).
Documentation of the vaccination:
In the RED BOOK On the postnatal case notes In the blue BCG folder
Ensure you document the date, site and method of administration, batch no. and expiry date and sign.
Preparing the vaccine:
Obtain 1 vial of BCG vaccine and a 1ml vial of BCG solvent. Prior to mixing ensure BCG vaccine has been stored in fridge and check expiry date.Draw up 1ml of the solvent into a 2 ml syringe using green (21G) needle and inject into BCG vaccine vial.Allow BCG vial to stand for 1 minute (do not mix or shake)Once made up the vaccine should be used within 4 hours.
Administration of vaccine:
Using a 1ml syringe draw up required volume (neonate 0.05ml) of BCG vaccine from BCG vial. Firmly attach a short bevel 25G (orange) or 26G (brown) needle onto the end of the syringe and ensure all air is expelled and the needle hub is filled with vaccine.
The BCG vaccine must be given intradermally into the left arm at the insertion of the deltoid muscle onto the humerus. Subcutaneous injections can lead to abscess formation, adenitis and other complications.
Undress baby so left upper arm is easily accessiblePosition the baby so that left arm accessible and in extended position (ideally in parents arms or lying on a flat surface)Stretch the skin between thumb and forefinger and insert needle (25 or 26G) bevel upwards) into the superficial layer of the dermis (almost parallel with the surface, bevel can usually be seen under the skin) for about 3mm.Inject vaccine slowly, considerable resistance is felt if vaccine administered correctly. If resistance is not felt the needle is too deep and should be removed and re-inserted before giving more vaccine.0.05ml of vaccine should give a 3mm blebA piece of sterile cotton wool or gauze can be placed on the site of injection for a few minutes but the site should not be covered for any period of time.
References:
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Immunisation against infectious disease - 'The Green Book' www.dh.gov.uk/en/Publichealth/Healthprotection/Immunisation/GreenbookBNF for Children BNF 2008 www.bnfc.orgGuidelines for the administration of intradermal BCG www.cumbria.nhs.uk/pct/about/publications/policies/clinical/guidelines_for_Intradermal.pdf
Infections / BCG and other vaccinations
Hep B vaccination
The full guideline can be found here (Hepatitis B immunisation & Hepatitis B 1 yr vaccine reminder)
Neonatal management of babies born to Hep C positive mothers
The full guideline can be found here (Hepatitis C positive mothers - neonatal management)
Feeding / Palate
Tongue tie
Discuss with Infant Feeding team
Cleft lip and/or palate
The condition is usually detected antenatally.
Cleft lip and/or palate can be an isolated finding or part of a syndrome. Check baby carefully for any other congenital abnormalities.
An isolated cleft palate is more easily missed, so remember to visualise the palate during the baby check. The baby may also present with milk regurgitation through the nose.
If the baby is term and there are no other abnormalities, the baby can be nursed on the postnatal ward or special care unit. Breastfeeding is often possible but may need a bottle with a special teat.
Cleft lip is usually repaired at around 3 months and palate between 6 and 9 months.
Management plan:
Perform a thorough examination of the baby and exclude any other abnormalities.
If the diagnosis was made antenatally, the family will be known by South Thames
Cleft Lip and Palate service (CLAPA team). Please inform the CLAPA team once
the baby is delivered on 07717571931.
If the condition was noted once the baby was born, please request a senior review
from the Registrar and/or Consultant. Contact the CLAPA team as soon as possible.
Feeding / Palate
Weight loss
Term babies may loose 4-7% of their weight after birth. Breast fed babies tend to loose more (5-10%) than bottle fed babies (2-6%). Term babies usually regain their birth weight in the 2nd week of life and pre-term babies in the 3rd week of life.
Weight loss of > 10% of the birth weight is a cause for concern.
Commonest Causes: Poor intake Breast feeding problems
Other Causes: Infection Inborn errors of metabolism Malabsorption Congenital cardiac disease
Take a detailed feeding history: 1.How much milk 2.How long is the baby feeding for3.How often is the baby feeding for4.Problems with latching on / sucking 5.Hx of vomiting6.Number of wet and dirty nappies 7.Nature of stool8.Hx of lethargy9.Presence of jaundice
Management plan:
1. Consider admission to the neonatal unit or SCU if the baby is on the postnatal
ward
2. Assess clinically for signs of dehydration, jaundice, cardiac disease
4. Start antibiotics if there are risk factors for infection perinatally or the baby
looks clinically unwell.
5. Treatment options: Top up feeds (bottle / cup / NGT) are preferred vs IV fluids
6. Offer feeding advice; involve the breast feeding advisor or a midwife.
Physiotherapy F/U
Audiology
All babies have a universal newborn hearing screen and high risk babies (eg babies with jaundice or FHx of deafness) will receive enhanced screening.
Syndromes
Down’s Syndrome
If you are suspecting the diagnosis of Down's syndrome on a newborn baby please inform the parents of the specific findings you have and record them in your notes. Do not give parents a diagnosis of Down's at this stage. Inform the Neonatal Registrar or Consultant urgently to review.
If the diagnosis is still considered bloods will be required for FISH and Chromosomes – please obtain written parental consent and fill in the relevant forms.
A useful source of information for parents and professionals is the Down's Association Syndrome website: http://www.downs-syndrome.org.uk/
NICE has published a guideline on the management of Neonatal Jaundice.
The Quick reference guide can be found here:http://guidance.nice.org.uk/CG98/QuickRefGuide/pdf/English
The Treatment Threshold Charts (Bilirubin Charts) can be found here:http://www.nice.org.uk/nicemedia/live/12986/48580/48580.pdf
The full guidelines for Prolongued Jaundice screen and Management of jaundice in the community can be found here
Jaundice - Community Management Jaundice - Prolonged, Screening Guideline
Others
Hypoglycaemia
The full guideline can be found here Hypoglycaemia: Guidelines for the Prevention and Management of Hypoglycaemia Hypoglycaemia: Prevention of Hypoglycaemia in the High Risk Infant - Care Plan
All babies should have vitamin K to prevent haemorrhagic disease of the newborn.
Vitamin K deficiency bleeding is rare and can occur early (1st week) or late (week 1-8).
Symptoms include: bruising, haematemesis & maleana, bleeding from umbilical stump or after circumcision, rarely intracranial haemorrhage.
IM Vitamin K:
Term babies should receive 1mg i.m. Vitamin K as soon as possible after birth. Preterm babies should receive Vitamin K im: 0.5mg if <1.5kg and 1mg if >1.5kg.
IM vitamin K is recommended in the following situations (as the oral absorption is variable):
If parents do not wish to have the IM preparation an oral alternative is available (phytomenadione).
Prescribe on the drug chart and as a TTO (via the inpatient list / 3 copies):
1st dose: 2mg - Day 0 (at birth)2nd dose 2mg - Day 4 to 73rd dose: 2mg - 1 month of age if the baby is exclusively breast fed (omitted if formula fed)
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For further information see: BNF for Children 2008 www.bnfc.org
Others
Peri-auricular skin tags
The ligaclip is used for preauricular skin tags that are non cartilaginous (see attached picture). It is important that these babies are seen early at the specialist centre so that Miss Milroy can select the ones that can also be managed as above.
Late referrals will increase the likelihood of missing out on this window and increases the chances of procedures under general anaesthesia. The anaesthetists at St Georges prefer to wait until the children are at least 10 months old for such elective plastic procedures.
