Examination of the NewbornExamination Part 1:

Eyes, heart, hips and testes

Chris Kingsnorth

Before We Begin

Overview

• 4 presentations:

1. Introduction and pre-examination2. Examination part 1: Eyes, heart, hips

and testes3. Examination part 2: Top-to-toe4. Post-examination

Overview

• Examination of the NIPE’s main 4 areas of focus: Eyes, heart, hips +/- testes

• Common pathologies• Practical tips

Will be integrated into top-to-toe examination in Examination Part 2

General Principles of Examination

• Don’t be scared of the baby!• Be flexible in order examining based on baby’s

behaviour/ state of undress• Keep baby warm• Involve parents; explain examination and

findings• If unsure about findings, ask a senior• Be prepared to change nappies

Eyes

Examining the Eyes

• Assessing structure, not function• 2 main pathologies:

1. Congenital cataract2. Retinoblastoma

• Other features may suggest abnormalities (e.g. size/ shape/ position of eyes and optical structures)

Examining the Eyes: Risk Factors

• Birth wt <1500g• Gestational age <32 weeks• FHx of any childhood eye disorder inc.

congenital cataract/ glaucoma/ retinoblastoma

• Maternal infections during pregnancy e.g. rubella, toxoplasmosis, HSV

• Size, shape and symmetry of orbits and globes• Opening both eyes?• Squint?• Discharge/ crusting?• Shape + symmetry of irises

Examining the Eyes: External Structures

• Reflection of light from retina• Ophthalmoscope set to largest white disc• Shine into eyes from 15cm• Look for red reflex• May need gentle encouragement to open

eyes

Examining the Eyes: Red Reflex

• Absence of reflex suggests congenital cataract

• White reflex suggests retinoblastoma

Examining the Eyes: Abnormal Red Reflex

Examining the Eyes: Summary and Referral

Facts About 200 children a year are born in the UK with congenital cataract in one or both

eyes. Cataract is the largest treatable cause of visual loss in childhood in the UK.

Screening process

The screen is undertaken in a darkened room, with the baby in a supine position or, if necessary, over the parent’s shoulder.

The screen covers: a general examination of the eye, checking for the red reflex, and checking eye movement.

Referral and follow up

Babies with a positive screen should be referred for expert consultation by two weeks of age (newborn examination); by 11 weeks of age (6-8 week examination).

Parents should be given information about the suspected condition.

Heart

Examining the Heart

• Severe congenital heart defects often picked up antenatally or within minutes of birth

• Mainly assessing for murmurs which may warrant further investigation

• Includes assessment of CVS in general

Examining the Heart: Risk Factors

• FHx of congenital heart disease• Maternal conditions e.g diabetes, SLE• Rubella exposure during 1st trimester• Medications e.g. lithium therapy• Conditions inc. Down's, Noonan's and

Marfan's syndromes

Examining the Heart

• Cyanosis?• Heart rate • Pulse rate, rhythm and volume • Heart sounds + murmurs• Femoral pulse presence, volume + symmetry

Examining the Heart: Summary and Referral

Facts

Congenital cardiac defects are a leading cause of infant death. Critical or serious congenital cardiac malformations are found in approx. 6-8 in 1,000

newborn babies. One in 200 babies has a heart problem that requires treatment. Risk factors include a family history of congenital heart disease; maternal diabetes or

systemic lupus erythematosus; exposure to rubella during the first trimester; certain medication taken during pregnancy such as lithium therapy; also syndromes such as Down’s, Noonan’s and Marfan’s.

Screening process

The screen consists of general observation ofthe baby’s colour and respiration, palpation and auscultation of the heart and chest area

Rountine use of pulse oximetry as an adjunct to the full newborn physical examination is currently being piloted (2015)

Referral and follow up

Babies with a positive screening examination should have pulse oximetry to aid diagnosis and be referred to a senior paediatrician or other relevant expert urgently depending on the condition (newborn) or for 6-8 week old babies, referred at the time of the examination to a senior paediatrician or other expert

Parents should be given information about the suspected condition

Hips

Examining the Hips

• Examining for Developmental Dysplasia of the Hip (DDH)

• 2 presentations:

1. Hip already dislocated (congenital dislocation)

2. Hip can be dislocated easily (hip instability)

Examining the Hips: Risk Factors for DDH

• 1st degree FHx of hip problems in early life• Breech presentation @ 36/40, irrespective of

presentation at delivery and mode of delivery• Breech delivery if < 36/40

In multiple births, if any of the above risk factors are present, all babies should be referred for USS to identify which may be

affected

Examining the Hips: Barlow and Ortolani Manoeuvres

• Can be distressing for parents to watch• Examine one hip at a time

Examining the Hips: Barlow’s Manoeuvre

• Test for hip instability (i.e. can hip be dislocated?)

• Adduction of hip with posterior pressure on thigh

• +ve Barlow test = clunk as femoral head comes out of acetabulum

Examining the Hips: Ortalani’s Manoeuvre

• Test for congenital dislocation (i.e. hip already out of socket); also relocates hip if dislocated during +ve Barlow manouvre

• Abduction of hip with anterior pressure on thigh

• +ve Ortalani test = clunk as previously displaced head of femur falls into acetabulum

Examining the Hips: Summary and Referral

Facts

One or two in 1,000 babies have hip problems requiring treatment Major risk factors include a first degree family history of hips problems in early life, breech

presentation at 36 weeks of pregnancy or breech delivery at any gestation Undetected DDH or delayed treatment can result tin long term complications

Screening process

The screen is undertaken on a flat firm surface and the baby should be undressed

Referral and follow up

Babies with a positive screen (abnormal clinical examination) should be referred for urgent ultrasound and expert consultation. Newborns should be seen by 3 weeks of age, 6-8 week old babies should be seen by 10 week of age

Parent should be given information about the suspected condition

Testes

Examining the Testes

• To identify boys with unilateral or bilateral undescended testes (cryptorchidism)

• If missed can have detrimental effect of future fertility

• Bilateral undescended testes may be a sign of endocrine disease, therefore considered more serious

Examining the Testes: Risk Factors for Cryptorchidism

• 1st degree FHx (father or sibling) of cryptorchidism

• Low birth wt/ small for gestational age• Pre-term delivery

Examining the Testes

Inspection:

•Size/ shape/ symmetry of testes•Scrotal rugae (‘wrinkles’ on scrotum; lack of these suggests maldescent of testes)•Urethral meatus and hypospadias

Palpation: Are both testes palpable inside the scrotum?

Examining the Testes: Summary and Referral

Facts 1-2 in 100 baby boys have problems with their testes that require treatment Risk factors include first degree family history of cryptorchidism; low birth weight; small

for gestational age or pre-term delivery

Screening process

The screening examination consists of observation of the scrotum and penis, and palpation of the scrotal sac

Referral and follow up

Babies with bilateral undescended testes should be referred to a senior paediatrician within 24 hours of examination (newborn)

Babies at 6-8 weeks with bilateral undescended testes should be seen by a senior paediatrician within two weeks of examination

Babies with unilateral undescended testis should be reviewed at 6-8 weeks examination (newborn)

Babies with unilateral undescended testis at the 6-8 week examination should be reviewed by the GP between 24-30 weeks of age.

What Now?

• Download slides + checklist• Online MCQ:

https://www.goconqr.com/en-GB/p/3898260-Examination-of-the-Newborn--2--Examination-Part-1---Eyes--heart--hips-and-testes-quizzes

• Request a Podcast/ ask a question• Next presentation: Examination part 2: Top-

to-toe

Further Information

• http://www.mayoclinic.org/diseases-conditions/congenital-heart-defects/multimedia/congenital-heart-defects/sls-20076059

• NIPE eLearning package: http://cpd.screening.nhs.uk/nipe-elearning

References

• Eye diagrams: http://www.ilearn.rcm.org.uk/mod/book/view.php?id=611&chapterid=1721 (Originally from St Bart’s Hospital)

• Hip manouvre videos: https://www.youtube.com/watch?v=imhI6PLtGLc (Dr Nabil Ebraheim)

References

• Hip manoeuvre diagrams: A Comprehensive Newborn Examination: Part II. Skin, Trunk, Extremities, Neurologic. MARY L. LEWIS, MD, Dwight D. Eisenhower Army Medical Center, Fort Gordon, Georgia Am Fam Physician. 2014 Sep 1;90(5):297-302.

• NIPE summary tables: http://cpd.screening.nhs.uk/induction-resource/nipe#fileid11785