Babies
A baby is a neonate for its first 4 weeks and an infant for its first year. Neonates are classified by gestational age or birthweight ( Box 15.1 ).
The history
Ask the mother and look in the maternal notes for relevant history:
Maternal history
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Is there a family history of significant illness (e.g. diabetes, hereditary illnesses)?
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What were the outcomes of any previous pregnancies?
Pregnancy history
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How was maternal health?
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Did the mother take medications or other drugs?
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What did antenatal screening tests show?
Birth history
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What was the birthweight, gestation at birth and mode of delivery?
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Was there prolonged rupture of the fetal membranes or maternal pyrexia?
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Was there a non-reassuring fetal status during delivery or meconium staining of the amniotic fluid?
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Was resuscitation required after birth?
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What were the Apgar scores ( Box 15.2 ) and the results of umbilical cord blood gas tests?
15.2
Apgar score
Reproduced with permission of International Anesthesia Research Society from Current researches in Anesthesia & Analgesia Apgar V 1953; 32(4), permission conveyed through Copyright Clearance Center, Inc.
Clinical score
0
1
2
Heart rate
Absent
< 100 bpm
> 100 bpm
Respiratory effort
Absent
Slow and irregular
Good: strong
Muscle tone
Flaccid
Some flexion of arms and legs
Active movement
Reflex irritability
No responses
Grimace
Vigorous crying, sneeze or cough
Colour
Blue, pale
Pink body, blue extremities
Pink all over
Add scores for each line; maximum score is 10.
bpm, beats per minute.
Infant’s progress
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Has the infant passed meconium and urine since birth?
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In later infancy, what are the specific signs and systems and developmental progress, depending on the presenting problem?
Presenting problems and definitions
Infants cannot report symptoms, so you must recognise the presenting problems and signs of illness, which are non-specific in young infants. Always take the concerns of parents seriously.
Pallor
Always investigate pallor in a newborn, as it implies anaemia or poor perfusion. Newborn infants have higher haemoglobin levels than older children and are not normally pale. Haemoglobin levels of < 120 g/L (< 12 g/dL) in the perinatal period are low. Preterm infants look red because they lack subcutaneous fat.
Respiratory distress
Respiratory distress is tachypnoea (respiratory rate) > 60 breaths per minute with intercostal and subcostal indrawing, sternal recession, nasal flaring and the use of accessory muscles.
Cyanosis
Bluish discoloration of the lips and mucous membranes due to hypoxia is difficult to see in newborn infants unless oxygen saturation ( Sp O 2 ) is < 80% (normal is > 95%). Causes include congenital heart disease and respiratory disease, and cyanosis always needs investigation ( p. 28 ).
Acrocyanosis
Acrocyanosis is a bluish-purple discoloration of the hands and feet and is a normal finding, provided the newborn is centrally pink.
Jaundice
Many newborns develop jaundice in the days after birth. Look for yellow sclerae in newborns with coloured skin or you may miss it. Examine the baby in bright normal light. Normal physiological jaundice cannot be distinguished clinically from jaundice from a pathological cause. Do not use clinical estimates instead of measurements to evaluate jaundice.
Jitteriness
Jitteriness is high-frequency tremor of the limbs, and is common in term infants in the first few days. It is stilled by stimulating the infant and is not associated with other disturbance. If jitteriness is excessive, exclude hypoglycaemia, polycythaemia and neonatal abstinence syndrome (drug withdrawal). Infrequent jerks in light sleep are common and normal; regular clonic jerks are abnormal.
Dysmorphism
Identifying abnormal body structure (dysmorphism) is subjective because of human variability. Individual features may be minor and isolated, or may signify a major problem requiring investigation and management. A recognisable pattern of several dysmorphic features may indicate a ‘dysmorphic syndrome’ such as Down’s syndrome ( p. 36 ). Use caution and sensitivity when discussing possible dysmorphism with parents of a newborn child.
Hypotonia
Hypotonia (reduced tone) may be obvious when you handle an infant. Term infants’ muscle tone normally produces a flexed posture at the hips, knees and elbows. Hypotonic infants may lack this flexion. Hypotonia can occur with hypoxia, hypoglycaemia or sepsis, or may be due to a specific brain, nerve or muscle problem. Preterm infants have lower tone than term infants and are less flexed.
Apgar score
This first clinical assessment of a neonate is made immediately after birth. Tone, colour, breathing, heart rate and response to stimulation are each scored 0, 1 or 2 ( Box 15.2 ), giving a maximum total of 10. Healthy neonates commonly score 8–10 at 1 and 5 minutes. The score predicts the need for, and efficacy of, resuscitation. A low score should increase with time; a decreasing score is a cause for concern. Persistently low scores at 10 minutes predict death or later disability. Neonates with scores of less than 8 at 5 minutes require continued evaluation until it is clear they are healthy.
The physical examination of newborns
Timing and efficacy of the routine neonatal examination
Examine a newborn with the parents present. There is no ideal time. If it is performed on day 1, some forms of congenital heart disease may be missed because signs have not developed. If it is delayed, some babies will present before the examination with illness that may have been detectable earlier. Around 9% of neonates have an identifiable congenital abnormality but most are not serious. Always record your examination comprehensively to avoid problems if illness or physical abnormality is identified later. Fewer than half of all cases of congenital heart disease or congenital cataract are detected by newborn examination.
General examination
Examine babies and infants in a warm place on a firm bed or examination table. Have a system to avoid omitting anything, but avoid an overly rigid approach as you may be unable to perform key elements if you unsettle the baby. Do things that may disturb the baby later in the examination.
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Observe whether the baby looks well and is well grown.
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Look for:
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cyanosis
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respiratory distress
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pallor
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plethora (suggesting polycythaemia).
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Note posture and behaviour.
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Note any dysmorphic features.
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Auscultate the heart and palpate the abdomen if the baby is quiet.
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If the baby cries, does the cry sound normal?
Skin
Normal findings
The skin may look normal, dry, wrinkled or vernix-covered in healthy babies. There may be meconium staining of the skin and nails.
Prominent capillaries commonly cause pink areas called ‘stork’s beak marks’ at the nape of the neck, eyelids and glabella ( Fig. 15.1 ). Facial marks fade spontaneously over months; those on the neck often persist. Milia (fine white spots) and acne neonatorum (larger cream-coloured spots) are collected glandular secretions and disappear within 2–4 weeks. Erythema toxicum is a common fleeting, blanching, idiopathic maculopapular rash of no consequence, affecting the trunk, face and limbs in the first few days after birth.
Abnormal findings
Document any trauma such as scalp cuts or bruising.
Dense capillary haemangiomas (port wine stains) will not fade. Referral to a dermatologist is advisable, as laser treatment may help in some cases. Around the eye they may indicate Sturge–Weber syndrome (a facial port wine stain with an underlying brain lesion, associated with risk of later seizures, cerebral calcification and reduced cognitive function). Melanocytic naevi require follow-up and treatment by a plastic surgeon or dermatologist. A Mongolian blue spot ( Fig. 15.2 ) is an area of bluish discoloration over the buttocks, back and thighs. Easily mistaken for bruising, it usually fades in the first year.
Subcutaneous fat necrosis causes palpable firm plaques, often with some erythema under the skin. If extensive, there can be associated hypercalcaemia that may require treatment. Blisters or bullae are usually pathological.
Head
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Note the baby’s head shape ( Box 15.3 ) and any swellings.
15.3
Neonatal head shapes
Head shape
Description
Microcephalic (small-headed)
Small cranial vault
Megalencephalic (large-headed)
Large cranial vault
Hydrocephalic (water-headed)
Large cranial vault due to enlarged ventricles
Brachycephalic (short-headed)
Flat head around the occiput
Dolichocephalic (long-headed)
Head that looks long relative to its width
Plagiocephalic (oblique-headed)
Asymmetrical skull
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Feel the anterior fontanelle ( Fig. 15.3 ). Is it sunken, flat or bulging?
Fig. 15.3
The fetal skull from above.
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Palpate the cranial sutures.
Normal findings
Transient elongation of the head is common from moulding during birth. Caput succedaneum is soft-tissue swelling over the vertex due to pressure in labour. Overriding cranial sutures have a palpable step.
Abnormal findings
Cephalhaematoma is a firm, immobile, usually parietal swelling caused by a localised haemorrhage under the cranial periosteum. It may be bilateral, and periosteal reaction at the margins causes a raised edge. No treatment is required. Do not confuse this with the boggy, mobile, poorly localised swelling of subgaleal haemorrhage (beneath the flat sheet of fibrous tissue that caps the skull), which can conceal a large blood loss and is life-threatening if unrecognised.
Separated cranial sutures with an obvious gap indicate raised intracranial pressure. Rarely, the cranial sutures are prematurely fused (synostosis), producing ridging, and the head shape is usually abnormal. Abnormal head size requires detailed investigation, including neuroimaging.
Eyes
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Inspect the eyebrows, lashes, lids and eyeballs.
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Gently retract the lower eyelid and check the sclera for jaundice.
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Test ocular movements and vestibular function:
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Turn the newborn’s head to one side; watch as the eyes move in the opposite direction. These are called doll’s-eye movements and disappear in infancy (see Fig. 8.15 ).
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Hold the infant upright at arm’s length and move in a horizontal arc. The infant should look in the direction of movement and have optokinetic nystagmus. This response becomes damped by 3 months.
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Normal findings
Harmless yellow crusting without inflammation is common after birth in infants with narrow lacrimal ducts.
Term infants usually fix visually.
Abnormal findings
Eye infection gives a red eye and purulent secretions. An abnormal pupil shape is usually a coloboma (a defect in the iris inferiorly that gives the pupil a keyhole appearance, Fig. 15.4 ). This can also affect deeper structures, including the optic nerve, and lead to visual impairment. It can be associated with syndromes, as can microphthalmia (small eyeballs). Large eyeballs that feel hard when palpated through the lids suggest congenital glaucoma (buphthalmos).
Ophthalmoscopy
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Hold the baby in your arms. Turn your body from side to side so that the baby will open their eyes.
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Look at each pupil from about 20 cm through the ophthalmoscope. You should see the red reflex of reflected light from the retina.
Normal findings
Puffy eyes in the first days after birth impede the examination. If this happens, always examine again later because failure to detect and treat a cataract will cause permanent amblyopia.
Abnormal findings
An absent red reflex suggests cataract; refer to an ophthalmologist.
Nose
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Exclude obstructed nostrils (choanal atresia) by blocking each nostril in turn with your finger to check that the infant breathes easily through the other.
Mouth
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Gently press down on the lower jaw so that the baby will open their mouth. Do not use a wooden tongue depressor, as this may cause trauma or infection.
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Shine a torch into the mouth and look at the tongue and palate.
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Palpate the palate using your fingertip.
Normal findings
Epstein’s pearls are small, white mucosal cysts on the palate that disappear spontaneously.
White coating on the tongue that is easily scraped off with a swab is usually curdled milk.
Abnormal findings
Ankyloglossia (tongue tie) is when the lingual frenulum joining the underside of the tongue to the floor of the mouth is abnormally short, which may interfere with feeding. A white coating on the tongue, which is not easily removed and may bleed when scraped, is caused by Candida albicans (thrush). Macroglossia (a large protruding tongue) occurs in Beckwith–Wiedemann syndrome. A normal-sized tongue protrudes through a small mouth in Down’s syndrome (glossoptosis).
Cleft palate may involve the soft palate or both hard and soft palates. It can be midline, unilateral or bilateral and may also involve the gum (alveolus). Cleft lip can appear in isolation or in association with it. Refer affected infants early to a specialist multidisciplinary team. Micrognathia (a small jaw) is sometimes associated with cleft palate in the Pierre Robin syndrome, with posterior displacement of the tongue and upper airway obstruction.
A ranula is a mucous cyst on the floor of the mouth that is related to the sublingual or submandibular salivary ducts. Congenital ranulas may resolve spontaneously but sometimes require surgery.
Teeth usually begin to erupt at around 6 months but can be present at birth.
Ears
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Note the size, shape and position.
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The helix should attach above an imaginary line through the inner corners of the eyes.
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Check that the external auditory meatus looks normal.
Normal findings
The helix can be temporarily folded due to local pressure in utero.
Preauricular skin tags do not require investigation.
Abnormal findings
Abnormal ear shape and position is a feature of some syndromes.
Neck
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Inspect the neck for asymmetry, sinuses and swellings.
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Palpate any masses. Use ‘SPACESPIT’ (see Box 3.8 ) to interpret your findings.
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Transilluminate swellings. Cystic swellings glow, as the light is transmitted through clear liquid. Solid or blood-filled swellings do not.
Normal findings
One-third of normal neonates have palpable cervical, inguinal or axillary lymph nodes. Neck asymmetry is often due to fetal posture and usually resolves.
Abnormal findings
A lump in the sternocleidomastoid muscle (sternomastoid ‘tumour’) is caused by a fibrosed haematoma with resultant muscle shortening. This may produce torticollis, with the head turned in the contralateral direction.
Cardiovascular examination
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Observe the baby for pallor, cyanosis and sweating.
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Count the respiratory rate.
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Palpate for the apex beat with your palm in the mid-clavicular line in the fourth or fifth intercostal space.
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Note if the heart beat moves your hand up and down (parasternal heave) or if you feel a vibration (thrill).
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Count the heart rate for 15 seconds and multiply by 4.
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Feel the femoral pulses by placing your thumbs or fingertips over the mid-inguinal points while abducting the hips ( Fig. 15.5 ).
Fig. 15.5
Palpating the femoral pulses.
The pulse can be difficult to feel at first. Use a point halfway between the pubic tubercle and the anterior superior iliac spine as a guide.
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Auscultate the heart. Start at the apex using the stethoscope bell (best for low-pitched sounds). Then use the diaphragm in all positions for high-pitched sounds and murmurs ( Fig. 15.6 ).
Fig. 15.6
Auscultation positions in infants and children.
Recommended order of auscultation: 1, apex; 2, left lower sternal edge; 3, left upper sternal edge; 4, left infraclavicular; 5, right upper sternal edge; 6, right lower sternal edge; 7, right mid-axillary line; 8, right side of neck; 9, left side of neck; 10, posteriorly.
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Describe the heart sounds S 1 and S 2 , any additional heart sounds and the presence of murmurs. The fast heart rate of a newborn makes it difficult to time additional sounds. Take time to tune into the different rate of the harsh breath sounds of a newborn, as they are easily confused with a murmur.
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Do not measure the blood pressure of healthy babies. In ill babies, cuff measurements overestimate the values when compared with invasive measurements. The cuff width should be at least two-thirds of the distance from the elbow to the shoulder tip.
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Palpate the abdomen for hepatomegaly (see later).
Normal findings
In the early newborn period the femoral pulses may feel normal in an infant who later presents with coarctation because an open ductus arteriosus can maintain flow to the descending aorta. Routine measurement of postductal oxygen saturation is increasingly popular as an additional newborn screening test for congenital heart disease. Lower limb Sp O 2 should be 95% or higher.
Heart rates between 80 and 160 beats per minute (bpm) can be normal in the newborn, depending on the arousal state ( Box 15.4 ).
Abnormal findings
Infants with heart failure typically look pale and sweaty, and have respiratory distress (p. 298).
If the apex beat is displaced laterally, there may be cardiomegaly, or mediastinal shift due to contralateral pneumothorax or pleural effusion.
Weak or absent femoral pulses suggest coarctation of the aorta. Radiofemoral delay is not identifiable in the newborn.
Patent ductus arteriosus may cause a short systolic murmur in the early days of life because the pulmonary and systemic blood pressures are similar, which limits shunting through the duct. The murmur progressively lengthens over subsequent weeks or months to become the continuous ‘machinery’ murmur recognised later in childhood.
Transient murmurs are heard in up to 2% of neonates but only a minority have a structural heart problem. An echocardiogram is needed to make a structural diagnosis.
Respiratory examination
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Note chest shape and symmetry of chest movement.
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Count the respiratory rate (for 15 seconds and multiply by 4).
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Listen for additional noises with breathing.
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Look for signs of respiratory distress: tachypnoea; suprasternal, intercostal and subcostal recession; flaring of the nostrils.
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Remember that percussion of the newborn’s chest is not helpful.
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Use the diaphragm to auscultate anteriorly, laterally and posteriorly, comparing the sides. Breath sounds in the healthy newborn have a bronchial quality compared with older individuals ( p. 88 ).
Normal findings
Male and female newborn infants at term have small buds of palpable breast tissue. Small amounts of fluid are sometimes discharged from the nipple in the early days after birth.
Abnormal findings
Stridor indicates large airway obstruction and is predominantly inspiratory ( p. 79 ). Stridor and indrawing beginning on days 2–3 of life in an otherwise well baby may be due to laryngomalacia (softness of the larynx). Causes of respiratory distress include retained lung fluid, infection, immaturity, aspiration, congenital anomaly, pneumothorax, heart failure and metabolic acidosis.
Abdominal examination
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Remove the nappy.
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Inspect the abdomen, including the umbilicus and groins, noting any swellings.
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From the infant’s right side, gently palpate with the flat of your warm right hand. Palpate superficially before feeling for deeper structures.
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Palpate for splenomegaly. In the neonate the spleen enlarges down the left flank, not towards the right iliac fossa.
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Palpate for hepatomegaly:
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Place your right hand flat across the abdomen beneath the right costal margin.
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Feel the liver edge against the side of your index finger.
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If you feel more than the liver edge, measure the distance in the mid-clavicular line from the costal margin to the liver edge. Describe it in fingerbreadths or measure it with a tape in centimetres.
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Check that the anus is present, patent and normally positioned.
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Digital rectal examination is usually unnecessary and could cause an anal fissure. Indications include suspected rectal atresia or stenosis and delayed passage of meconium. Put on gloves and lubricate your little finger. Gently press your fingertip against the anus until you feel the muscle resistance relax and insert your finger up to your distal interphalangeal joint.
Normal findings
Abdominal distension from a feed or swallowed air is common.
You may see the contour of individual bowel loops through the thin anterior abdominal wall in the newborn, particularly with intestinal obstruction.
The umbilical cord stump usually separates after 4–5 days. A granuloma may appear later as a moist, pink lump in the base of the umbilicus. A small amount of bleeding from the umbilicus is common in the neonate.
The liver edge is often palpable in healthy infants.
In the neonate the kidneys are often palpable, especially if ballotted (see Fig. 12.12 ).
Abnormal findings
In excessive umbilical bleeding, check that the infant received vitamin K and consider factor XIII deficiency. Spreading erythema around the umbilicus suggests infective omphalitis and requires urgent treatment.
Umbilical hernias are common; they are easily reduced, have a very low risk of complications and close spontaneously in infancy. An omphalocoele, or exomphalos ( Fig. 15.7 ), is a herniation through the umbilicus containing intestines and other viscera, covered by a membrane that includes the umbilical cord. It may be associated with other malformations or chromosomal abnormality. Gastroschisis is a defect in the anterior abdominal wall with intestines herniated through it, without a covering membrane. The most common site is above and to the right of the umbilicus.
Inguinal hernias are common in the newborn, especially in boys and preterm infants ( Fig. 15.8 ).
Meconium in the nappy does not guarantee that the baby has a patent anus because meconium can be passed through a rectovaginal fistula.
Perineum
Female
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Abduct the legs and gently separate the labia.
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In preterm infants the labia minora appear prominent, giving a masculinised appearance that resolves spontaneously over a few weeks. Milky vaginal secretions are normal. Later in the first week, there is sometimes slight vaginal bleeding (pseudomenses) as the infant uterus ‘withdraws’ from maternal hormones. Vaginal skin tags are common and do not require treatment.
Male
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Do not attempt to retract the foreskin. It is normal for it to be adherent in babies.
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Check that the urethral meatus is at the tip of the penis.
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Note the shape of the penis.
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Palpate the testes.
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If you cannot feel the testes in the scrotum, assess for undescended, ectopic or retractile testes. Palpate the abdomen for smooth lumps, moving your fingers down over the inguinal canal to the scrotum and perineum.
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A retractile testis just below the inguinal canal may be gently milked into the scrotum. Re-examine at 6 weeks if there is any doubt about the position of the testes.
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Transilluminate any large scrotal swellings using a torch to see if the light is transmitted through the swelling. This suggests a hydrocoele but can be misleading, because a hernia of thin-walled bowel may transilluminate ( Fig. 15.9 ).
