NIPE

Question 1

What questions might you want to ask before/whilst performing NIPE exam?

Answer 1

Maternal history:

• Pregnancy details: date/time and type of delivery/complications/high-risk antenatal screening results
• Breech presentation: if breech at 36 weeks gestation or delivery (if earlier), the baby will need to have an USS of their hips as there is an increased risk of DDH
• Risk factors for neonatal infection
• Abnormalities notes on antenatal scans
• FHx: 1st degree relatives with hearing problems/hip dislocation/childhood heart problems/congenital cataracts/renal problems

Newborn history:

• feeding pattern
• urination
• passing of meconium
• parental concerns

Question 2

What are you looking for on general inspection?

Answer 2

• Pallor: underlying anaemia (haemorrhage) or poor perfusion (congestive cardiac failure)
• Cyanosis: poor circulation (peripheral vasoconstriction secondary to hypovolaemia) or inadequate oxygenation of the blood (right-to-left cardiac shunting)
• Jaundice
• Posture (Erb’s palsy, hemiparesis)

Question 3

How do you assess tone in a newborn?

Answer 3

• Gently move the newborn’s limbs passively and observe the newborn when they’re picked up

Question 4

What are common causes of hypotonia in newborns?

Answer 4

• Down’s syndrome
• Prader-Willi syndrome
• Hypothyroidism
• Cerebral palsy

Question 5

What do you need to assess in terms of the baby’s head?

Answer 5

• Head circumference
• Head shape (sutures, fontanelles, cranial moulding, caput succedaneum, cephalhaematoma, subgaleal haemorrhages, craniosynostosis)

Question 6

What are the causes of microcephaly?

Answer 6

• Normal variation, familial
• Congenital infections (TORCH)
• Perinatal brain injury (HIE)
• Foetal alcohol syndrome
• Patau syndrome
• Craniosynostosis

Question 7

What are the causes of macrocephaly?

Answer 7

• Hydrocephalus
• Cranial vault abnormalities
• Genetic abnormalities

Question 8

Describe caput succedaneum. How long does it take to resolve?

Answer 8

• Diffuse subcutaneous fluid collection with poorly defined margins caused by pressure on the presenting part of the head during delivery
• Crossing suture lines
• Resolves over the first few days

Question 9

Describe cephalhaematoma. How long does it take to resolve?

Answer 9

• Subperiosteal haemorrhage which occurs in 1-2% of infants and may increase in size after birth
• Haemorrhage is bound by the periosteum, therefore, the swelling does not cross suture lines
• More common with instrumental delivery and may cause jaundice, therefore, bilirubin should be monitored
• Can take a few months to resolve

Question 10

Describe subgaleal haemorrhages.

Answer 10

• Occur between the aponeurosis of the scalp and periosteum and form a large, fluctuant collection which crosses suture lines
• They are rare but may cause life-threatening blood loss

Question 11

Describe craniosynostosis.

Answer 11

• Condition in which one or more of the fibrous sutures in an infant skull prematurely fuses
• Changes the growth pattern of the skull which can result in raised ICP and damage to intracranial structures
• Surgical intervention is required with the primary goal being to allow normal cranial vault development to occur

Question 12

What does a tense bulging fontanelle indicate?

Answer 12

Raised ICP (hydrocephalus)

Question 13

What does a sunken fontanelle indicate?

Answer 13

Dehydration

Question 14

What are common facial birthmarks that might be seen during NIPE?

Answer 14

• Salmon patch
• Haemangiomas
• Port-wine stain

Question 15

Describe salmon patch birthmark.

Answer 15

• Naevus simplex
• Red or pink patches
• Often on infant’s eyelids, head, or neck
• Caused by capillary malformation
• Very common and usually fade by the age of 2

Question 16

Describe haemangiomas.

Answer 16

• Strawberry naevus
• Blood vessels which form a raised red lump on the skin which appears soon after birth
• Typically get bigger over the first 6-12 months and then shrink and disappear by the age of 7
• May require treatment if they affect vision, breathing, or feeding

Question 17

Describe port-wine stains.

Answer 17

• Naevus flammeus
• Red/purple marks on the face and neck
• Typically present from birth and do not regress
• May be associated with Sturge-Weber syndrome and Klippel-Trenaunay syndrome

Question 18

Describe slate-grey naevus.

Answer 18

• AKA Mongolian blue spot
• Benign, flat birthmark with wavy borders and irregular shape
• Usually located over the sacrum
• Most commonly blue in colour and can be mistaken for a bruise
• Normally disappear within 3-5 years

Question 19

Describe erythema toxicum.

Answer 19

• Very common and benign condition seen in newborns
• Presents with various combinations of erythematous macules, papules, and pustules
• Lesions usually appear from 48h of age and resolve spontaneously

Question 20

What do you look for when assessing a newborn’s face?

Answer 20

• Appearance: any dysmorphic features (e.g. epicanthic folds in Down’s syndrome)
• Asymmetry: asymmetry of the face many indicate facial nerve palsy secondary to instrumental delivery
• Trauma: bruising or lacerations likely to have occurred during labour
• Nose: assess patency of the nasal passages

Question 21

What do you look for when assessing a newborn’s eyes?

Answer 21

• Inspect for erythema or discharge (conjunctivitis)
• Assess sclera for jaundice, subconjunctival haemorrhages
• Position and shape, e.g. ptosis or epicanthic folds
• Fundal/red reflex

Question 22

What might an absent fundal reflex indicate? How should you manage newborns with absent fundal reflex?

Answer 22

1. Congenital cataracts, retinal detachment, vitreous haemorrhage, retinoblastoma
2. Immediate ophthalmology referral

Question 23

What should look for when assessing the ears?

Answer 23

Inspect the pinna - note any asymmetry, skin tags, pits, or the presence of accessory auricles

Question 24

What do you look for when assessing a newborn’s mouth?

Answer 24

• Clefts of the hard and soft palates

- Tongue-tie (ankyloglossia)

Question 25

What do you assess next in NIPE, after fully assessing the head and face?

Answer 25

Neck and clavicles

Question 26

How do you assess neck and clavicles in a newborn?

Answer 26

- Inspect length of the neck and note any abnormalities such as webbing - Inspect for neck lumps, i.e. cystic hygroma - Look and feel for evidence of clavicular fracture

Question 27

How do you assess the upper limbs during NIPE?

Answer 27

- Assess symmetry - Inspect the fingers (note any extra or abnormal digits, and trident hand) - Inspect the palms (note lack of 2 palmar creases) - Palpate the brachial pulse on each upper limb (asymmetry suggests coarctation of the aorta)

Question 28

How do you assess the chest during NIPE?

Answer 28

Inspect: - RR - Work of breathing - Pectus excavatum/carinatum Palpate: - Cap refill on sternum Auscultate: - Lungs - Heart

Question 29

How do you assess the abdomen during NIPE?

Answer 29

Inspect: - abdominal distension --> bowel obstruction, NEC, organomegaly, ascites - umbilicus - erythema, discharge, hernias - inguinal hernia (groin) Palpate: - liver - spleen - kidneys - bladder

Question 30

What are you looking for when inspecting genitalia in NIPE?

Answer 30

Females: - ambiguous genitalia (CAH) Males: - position of urethral meatus (hypospadias, epispadias) - size of penis (should be at least 2cm) - assess for testicular swelling indicative of hydrocele - check to see if both testes have descended

Question 31

How do you assess the lower limbs during NIPE?

Answer 31

Inspect: - symmetry - oedema - ankle deformities (talipes/clubfoot) - missing or extra digits Assess tone Assess movement in both limbs Assess the range of knee joint movement (?hypermobility) Palpate and compare femoral pulses

Question 32

Describe Barlow's test.

Answer 32

- Performed by adducting the hip - Apply light pressure on the knees with thumb, directing the force posteriorly - If the hip is dislocatable the test is considered positive

Question 33

Describe Ortolani's test.

Answer 33

- Used to confirm posterior dislocation of the hip - Flex the hips and knees of a supine infant to 90 degrees - With your index fingers placing anterior pressure on the greater trochanters, gently and smoothly abduct the infant's legs using your thumbs - Positive sign: distinctive 'clunk' which can be heard and felt and the femoral head relocated anteriorly into the acetabulum

Question 34

What are you looking for when assessing the back and spine during NIPE?

Answer 34

- Scoliosis - Hair tufts (spina bifida) - Naevi - Birthmarks - Sacral pits (spina bifida)

Question 35

What is important to determine when assessing the anus in NIPE?

Answer 35

Is it patent? | Ask if baby has passed meconium, and if meconium passage was delayed by >24h

Question 36

What can delayed passage of meconium indicate?

Answer 36

Obstruction or Hirschsprung's disease

Question 37

What reflexes must be assessed during NIPE?

Answer 37

- Palmar grasp reflex - Sucking reflex - Rooting reflex - Stepping reflex - Moro reflex