2 - Examination and Practical Procedures

Question 1

When is a newborn examination carried out?

Answer 1

• In first 72 hours
• Secondly at 6-8 weeks old

Question 2

What is the purpose of the Newborn Infant Physical Examination (NIPE) ?

Answer 2

• Screen for congenital abnormalities that will benefit from early intervention
• To make referrals for further tests or treatment as appropriate
• To provide reassurance to the parents

Question 3

Where should you do a newborn examination?

Answer 3

• Private area which provides confidentiality for parents
• The room should be warm and well lit naturally
• Make sure that the parents are present for the newborn check as this is an ideal time to answer queries and provide reassurance

Question 4

What oxygen saturations do you need to measure in the newborn and why?

Answer 4

• Pre-ductal and post-ductal (based on position of ductus arteriosus)
• Normal saturations are 96% or above. There should not be more than a 2% difference between the pre-ductal and post-ductal saturations
• Certain congenital heart conditions are duct-dependent, meaning they rely on the mixing of blood across the ductus arteriosus. When the ductus arteriosus closes there can be a rapid deterioration in symptoms. These duct-dependent conditions may be picked up by measuring the difference in pre-ductal and post-ductal saturations

Question 5

How do you measure pre and post ductal oxygen saturations?

Answer 5

• Pre-ductal saturations: baby’s right hand. The right hand receives blood from the right subclavian artery, a branch of the brachiocephalic artery, which branches from the aorta before the ductus arteriosus
• Post-ductal saturations: in either foot. The feet receive blood traveling from the descending aorta, which occurs after the ductus arteriosus

Question 6

What are the general points you need to cover in a newborn baby exam?

Answer 6

• General appearance
• Head
• Shoulders and Arms
• Chest
• Abdomen
• Genitals
• Legs
• Back
• Reflexes
• Any skin markings

Question 7

What are we looking at in general appearance of baby in the newborn exam?

Answer 7

• Colour: jaundice, pallor, cyanosis
• Posture
• Tone
• Cry

Question 8

What are we looking at when looking at the head of a baby in the newborn exam?

Answer 8

• Size: Head cirumference
• Shape
• Fontanelle: posterior and anterior palpation for dehydration and raised ICP
• Ears: skin tags, low set ears and asymmetry. Suggest hearing screening
• Eyes: slight squints are normal, epicanthic folds can indicate Down’s, purulent discharge could indicate infection
• Red reflex: Absent with congenital cataracts and retinoblastoma.
• Mouth: cleft lip or tongue tie. Put little finger in mouth to check palate and suckle reflex

Question 9

What is the definition of the following head abnormalities you may find in a newborn?

• Caput succedaneum
• Cephalhaematoma
• Subgaleal haemorrhages
• Craniosynostosis

Answer 9

Question 10

How can you tell the difference between caput succedaneum and cephalohematoma?

Answer 10

Question 11

What are we looking at when looking at the shoulders and arms of a baby in the newborn exam?

Answer 11

• Neck lumps
• Shoulder symmetry: check for a clavicle fracture
• Arm movements: check for an Erbs palsy
• Brachial pulses
• Radial pulses
• Palmar creases: a single palmar crease is associated with Down’s, but can be normal
• Digits: number of digits and if fingers are straight or curved (clinodactyly)
• Sats probe on the right wrist for a pre-ductal reading

Question 12

What are we looking at when looking at the chest of a baby in the newborn exam?

Answer 12

• Respiratory rate: look for respiration distress, symmetry and listen for stridor
• Heart sounds: listen for murmurs, heart sounds, heart rate and identify which side the heart is on. Work upwards
• Breath sounds: listen for symmetry, good air entry and added sounds

Question 13

What is normal heart rate and respiratory rate in a newborn?

Answer 13

RR: 40-60

HR: 120-150

Question 14

What are some signs of respiratory distress in a newborn?

Answer 14

Question 15

What are we looking at when looking at the abdomen of a baby in the newborn exam?

Answer 15

• Inspect: umbilicus, groin for hernias, distension
• Palpate: liver, spleen, kidneys, bladder

Question 16

What are we looking at when looking at the genitals of a baby in the newborn exam?

Answer 16

• Check sex and record any ambiguity
• Palpate testes and scrotum: check both are present and descended, check for hernias or hydroceles
• Inspect the penis for hypospadias, epispadias and urination
• Inspect the anus to check if it is patent
• Ask about meconium

Question 17

What are we looking at when looking at the legs of a baby in the newborn exam?

Answer 17

• Observe the legs and hips for equal movements, skin creases, tone and talipes (club foot)
• Barlows and Ortolani manoeuvres
• Count the toes

Question 18

How do we do Barlow’s test?

Answer 18

Adduct hip (bringing the thigh towards the midline) whilst applying light pressure on the knee with your thumb, directing force posteriorly

If hip unstable, the femoral head will slip over the posterior rim of the acetabulum, producing a palpable sensation of subluxation or dislocation.

If the hip is dislocatable the test is considered positive. The Ortolani manoeuvre is then used to confirm the positive finding

Question 19

How do we do Ortolani’s test?

Answer 19

Used to confirm posterior dislocation of the hip joint

1. Flex the hips and knees of a supine infant to 90°.

2. With your index fingers placing anterior pressure on the greater trochanters, gently and smoothly abduct the infant’s legs using your thumbs.

A positive sign is a distinctive ‘clunk’ which can be heard and felt as the femoral head relocates anteriorly into the acetabulum

Question 20

What are we looking at when looking at the back of a baby in the newborn exam?

Answer 20

Inspect and palpate for:

• Scoliosis
• Hair tufts
• Naevi
• Birthmarks
• Sacral pits

Question 21

What reflexes do we check in the newborn baby exam?

Answer 21

• Moro reflex: when rapidly tipped backwards the arms and legs will extend
• Suckling reflex: placing a finger in the mouth will prompt them to suck
• Rooting reflex: tickling the cheek will cause them to turn towards the stimulus
• Grasp reflex: placing a finger in the palm will cause them to grasp
• Stepping reflex: when held upright and the feet touch a surface they will make a stepping motion

Question 22

What skin findings on a newborn exam do you need to note down?

Answer 22

• Haemangiomas
• Port wine stains
• Mongolian blue spot
• Cradle cap
• Desquamation
• Erythema toxicum
• Milia
• Acne
• Naevus simplex (“stork bite”)
• Moles
• Transient pustular melanosis

Question 23

What referral do you need to make for the following findings on a newborn exam:

• Positional talipes
• Structural talipes
• Undescended testes
• Haemangiomas
• Clicky hips
• Cephalohaematomas
• Boney injuries

Answer 23

Positional talipes: Foot can still be moved into the normal position, refer to physio

Structural talipes: Refer orthopaedic surgeon.

Undescended testes: monitoring and referral to a urologist.

Haemangiomas: near eyes, mouth or airway may require referral for treatment with beta blockers (i.e. propranolol)

Clicky hips: referral for hip ultrasound to rule out developmental dysplasia of the hips

Cephalohaematomas: monitoring for jaundice and anaemia.

Boney injuries: xray to look for fractures (e.g. clavicular fracture).

Question 24

If a baby has a soft systolic murmur on a newborn exam, what should you suspect?

Answer 24

• If grade 2 or less in otherwise healthy well neonates may be monitored, as these often resolve after 24 – 48 hours. Due to a patent foramen ovale that closes shortly after birth
• Any suspicion of heart failure or congenital heart disease requires referral to cardiology for an ECG and echocardiogram

Question 25

How do you finish up a newborn baby exam?

Answer 25

* Offer to dress baby * Discuss any abnormalities with a senior * Document findings on the **newborn and infant physical examination** (**NIPE**) computer system and in the baby’s **red book** * Explain, reassure and answer any questions with the parents * Arrange referrals and followup if required

Question 26

How do you perform a respiratory examination on a child?

Answer 26

1. **Intro, consent, PPE** 2. **Inspection** inc sounds and around the bed 3. **Hands:** tremor, eczema as atopy and asthma, CRT, clubbing 4. **Pulse:** femoral in babies 5. **Face** 6. **Tracheal position** 7. **Inspect chest** 8. **Palpate apex beat** 9. **Percuss** 10. **Chest expansion** (not in young/babies) 11. **Auscultate** 12. **Same on posterior** 13. **Lymph nodes** 14. **Pedal or Sacral Oedema**

Question 27

What is normal respiratory rate in children?

Answer 27

Question 28

What are some dysmorphisms you may look out for when doing paediatric cardiorespiratory exams?

Answer 28

Question 29

What signs help demonstrate the work of breathing in children?

Answer 29

Question 30

How do you complete a paediatric respiratory exam?

Answer 30

* Vital Signs * ENT * Growth charts

Question 31

How do you do a paediatric cardiovascular exam?

Answer 31

If baby always do 3 quiet things first (palpate femoral pulses, auscultate heart, auscultate lungs) Same as adult but check for **hepatomegaly** and **palpate femorals** https://geekymedics.com/wp-content/uploads/2020/09/OSCE-Checklist-Paediatric-Cardiovascular-Examination.pdf

Question 32

When has a child got hepatomegaly and what does this indicate?

Answer 32

* If liver edge felt 2cm below costal margins * Sign of heart failure

Question 33

Where do you feel the apex beat in a child?

Answer 33

Question 34

What may coarse bilateral crackles suggest in a CVS exam of a child?

Answer 34

Congestive Heart Failure

Question 35

How do you do an abdominal examination in a child?

Answer 35

Same as on adults * ‘What did you last have to eat, let’s find it, if not I will have to listen for it' * ‘Can you jump up and down’ - Not possible if guarding

Question 36

How may the following masses present on an abdo exam of a child * Neuroblastoma * Wilm's tumour * Intussupection * Faecal impaction

Answer 36

Question 37

need to do CNS, PNS, MSK, ENT, SKIN AND EYES

Question 38

What techniques can you use to undertake practical procedures in paediatrics?

Answer 38

* Get on same level as child * Distraction * Play specialists/therapists * Topical anaesthetics

Question 39

How do you report on a CXR?

Answer 39

Remember children usually AP

Question 40

How can you assess the age of a child on a CXR?

Answer 40

**Humeral heads physis present:** child, ossification starts around 14 yrs **No humeral heads:** preterm neonate as ossification occurs at term **Umbilical clips:** less than 2 weeks old

Question 41

How does an inhaled foreign body show on CXR of a child?

Answer 41

Hyperlucent thorax on the side foreign body is

Question 42

What is vater syndrome?

Answer 42

Question 43

What investigations should you do?

Answer 43

* Skeletal survey * If under 1 with neurology or encephalopathy need CT head Do a follow up skeletal surgery in 11-14 days

Question 44

What are the four types of fractures in paediatrics?

Answer 44

**Buckle:** Compression fracture from axial loading. Usually at metaphysis of long bones **Greenstick:** Fracture on one side of the cortex only, mid diaphyseal

Question 45

How are fractures through the growth plate classified?

Answer 45

Question 46

How do we measure peak expiratory flow in children?

Answer 46

* Stand upright * Meter is level * Fingers are not over the gauge * Breathe out maximally * Then take a deep breath * Place mouth around the mouthpiece * Ensure a tight seal * Breath out as hard and as fast as they can * Should make a huffing sound * Repeat 3 times * The highest recording from the 3 attempts * Plot this against their height

Question 47

What fractures in children are common in suspected physical abuse?

Answer 47

**Buckle:** Compression fracture from axial loading. Usually at metaphysis of long bones ## Footnote **Greenstick:** Fracture on one side of the cortex only, mid diaphyseal

Question 48

How does inhaler technique vary for different age groups of children?

Answer 48

Use **spacer** as child cannot coordinate clicking and breathing * **Up to 6 months:** lie flat or 45 degrees in parents arms and use facemask * **6 months-3 years:** sit up and hold the inhaler level and use facemark * **3 years+:** use a mouthpiece - listen for clicks.

Question 49

How do we measure the head circumference of a child?

Answer 49

Useful for under 2's * Placed above ears and midway between the eyebrows and the hairline to the occipital prominence at the back of the head * Record to the nearest millimetre and repeat 3 times * The maximum of these 3 is recorded and plotted on the growth chart

Question 50

How do you explain to a parent how to give an inhaler with a facemask?

Answer 50

* Put two halves of spacer together and attach face mask * Remove cap of inhaler and **shake it** * Hold mask **over mouth and nose in upright or 45 degree position** to keep valve open * Make sure child **lying on back** * Press inhaler and let child take **5-6 breaths or 20 seconds** * If second dose take inhaler out and **shake before second dose** **LISTEN FOR CLICKS** - if no clicks not adequate breaths

Question 51

How do you explain to a teenager how to use their inhaler?

Answer 51

* Take cap off, **shake** and press to release test spray * Check dose to check not empty * **Shake inhaler** * Sit or stand up straight and **tilt chin up** * **Breathe out completely** until lungs feel empty * Put lips around inhaler to make seal and start breathing in slowly * Press and **breathe in slowly** until lungs full * **Hold breath for 10 seconds** * Shake before any second doses * Rinse mouth if steroid inhaler

Question 52

How can you explain to a parent how to use their child's autoinjector?

Answer 52

* **Lie child flat and elevate legs** * Remove the safety cap * Place the tip of auto-injector against front or side of thigh, **holding the auto-injector at right angles** to the leg * Press hard and steadily into the thigh and **keep in place for 10 seconds after click** * Remove the auto-injector from the thigh, **massage the injection site** * Give a **second injection after 5-15 minutes** * Ensure an ambulance is on its way. Stay in position until medical assistance arrives * Auto-injectors need to be discarded in a safe manner, give to hospital or ambulance