NEWBORN & 6 WEEK CHECK

1. NEWBORN &6 WEEK CHECK Kavitha Kanakanti Lydia Scott

2. BRIEF HISTORY • Any concerns? • Birth Hx – normal/C-section/instrumental, ?breech, birth wt & HC • FHx of DDH, cataracts • Feeding & wt gain • Wet nappy/meconium (newborn) • Development (6 weeks) – vision, hearing, smile

3. GENERAL EXAM • Dysmorphology • Skin colour • Rashes/birth marks • How they handle when you undress them • Weight

4. Dysmorphology

5. Downs Syndrome typical facial features of Down's syndrome: up slanting palpebral fissures, a suggestion of epicanthal folds, and a flat nasal bridge

6. Jaundice Investigation indicated if: • Jaundice at <24 hours • Conjugated hyperbilirubinaemia (direct bili >20mm/l or >10% total bili) • Prolonged jaundice >14 days • Need Ix according to hospital protocol Unconjugated hyperbilirubinaemia  may require treatment with phototherapy or exchange transfusion depending on gestation/age of baby

7. Rashes

8. Erythema toxicum very common, completely benign. Seen in about half of newborns. Lesions are erythematous macules, within which papules and pustules develop. Trunk most commonly involved. Resolves spontaneously within 10 days.

9. Milia Milia are tiny pearly white cysts that are on the surface of the skin mainly on the face..40% of newborn infants develop it.

10. Birth marks

11. Mongolian blue spot Caused by a collection of melanocytes scattered through deep dermis. Most frequently located over the sacral area. Found in Afro-Caribbean or Asian infants & less commonly in Caucasians. Usually present at birth, fade during early years.

12. Strawberry haemangioma Bright red, well demarcated, compressible Within few weeks of birth,10% Spontaneous regression 2- 10 years Large-feeding/visual problems/bleeding Reassure High dose steroids if indicated

13. Port Wine Stain Macular nevus present at birth Pale pink to purple Associated Sturge Weber 10%-Orbital with intracranial malformation, C/L hemiparesis, seizures,mental retardation Permanent defect of mature capillaries Cosmetic camouflage/Laser treatment

14. Capillary haemangioma(at birth) can occur in variety of sizes, locations, and combinations of capillaries & larger vessels. Simplest form is limited in size, superficial and largely capillary –a Capillary Haemangioma or Strawberry mark.

15. Capillary haemangioma(at 2yrs of age)

16. Cavernous haemangioma Cavernous haemangiomata are deeper, darker in colour and may be relatively large. Both tend to increase in size for a period & then gradually involute partially or totally. Parents should be re-assured that most lesions will resolve spontaneously by 5-6 years. They do not require routine follow-up.

17. HEAD/FACE • HEAD – shape, circumference, fontanelles • EARS – shape, position • EYES – position, red reflex • MOUTH – cyanosis, tongue, palate, sucking reflex

18. Head

19. Caput Succadaneum caput can cross over suture lines (since it affects the scalp), it is often predominantly or entirely unilateral. caput -- maximal at birth, with rapid resolution over the next 24 - 48 hours.

20. Cephalhaematoma Cephalohematoma is a collection of blood under the periosteum of a skull bone. Because of its location, it is impossible for cephalohematoma to cross suture lines.

21. Ears

22. Ear tag A single, small ear tag is an occasional finding on physical examination. It is often inherited as a familial trait.

24. Low set Ears If an imaginary line is drawn from the outer canthus of the eye straight back to the occiput (here the occiput is just where the edge of the blanket meets the head), a low set ear will fall completely below the line. An ear with normal set will cross or touch the same line. This infant had trisomy 18 as an underlying etiology.

25. Eyes

26. Cataracts Red reflux cant be seen. Refer paediatric ophthalmologists

27. Cataracts

28. Sub Conjunctival haemorrhage Subconjunctival haemorrhage is a frequent finding in normal newborns. It results from the breakage of small vessels during the pressure of delivery.

29. Gonococcal Conjunctivitis it typically presents in the first few days of life gonococcal conjunctivitis is an ophthalmologic emergency. bacteria can erode through an intact cornea, treatment is very aggressive and includes systemic intravenous antibiotics, frequent eye washes, and monitoring in a neonatal intensive care unit.

30. Mouth

31. CLEFT PALATE only the lateral margins of the palate are visible. Because the mouth is wide open to the nasal cavity, the NG tube can be seen passing through the nasopharynx as well as the mouth.

32. CLEFT LIP This infant has a normally formed, intact palate, but has a unilateral cleft on the left side of the lip. Feeding can be impaired in infants with cleft lip

33. NEONATAL TEETH This infant's tooth is erupted and is clearly visible. When the tooth is mobile, it can easily be removed with a gauze and a twisting motion.

34. CHEST/ARMS • LUNGS – resp rate, breath sounds • HEART – heart rate, murmurs • ARMS – inspect, brachial pulses • HANDS – palms, count fingers

35. Asymptomatic heart murmur • Ensure asymptomatic & feeding well • Check femoral pulses & pulse oximetry (pre-ductal and post ductal) • Middle Grade review prior to discharge • If baby well then arrange 6 week review with Consultant • If murmur loud/diastolic then needs middle grade review and scbu admission • Ask parents to return if symptoms suggestive of cardiac disease- e.g. breathlessness, sweatiness, not completing feeds, failure to gain weight, cyanosis etc.

36. Hands

37. NORMAL HAND Usually the babies have 2 creases which do not cross the whole of the palm.

38. Transverse Crease It is most characteristic feature in Downs syndrome. It is inherited as familial trait in 5%.

39. Polydactyly If the extra digit has a bony component referral should be to the hand surgeon, Professor S. Kaye in Leeds. If there is no bony component, referral may be needed to the plastic surgeon, Mr Fu in Bradford.

40. Oedema of the hand It IS common in Turner Syndrome. It is associated with other physical findings like short stature, short fourth metacarpal, webbed neck, high palate and nail dysplasia.

41. ABDOMEN/LEGS • ABDO – inspect, palpate, check for hernias, femoral pulses • GENITALS – insect, palpate testes • ANUS – patency • LEGS – inspect length/creases, hips • FEET – position, number of toes

42. Abdomen

43. Umbilical Hernia This is common and usually resolves spontaneously by 18 months. Ensure that the hernia is fully covered by skin. If bowel is visible, this might be a minor form of omphalocele.

44. Genitals • Hydrocoele: no treatment, normally resolves spontaneously within few months (if not gone within 1year then refer) • Hypospadias: urethral opening is in abnormal position; ensure flow of the urine ok; need to refer urology; advise baby shouldn’t be circumcised until seen

45. Genitals • Undescended testes: 2% babies; put on discharge letter/red book so GP aware; if not descended by 1 year needs referral • Ambiguous genitalia: explain genitalia not quite normal & baby will need further exam/Ix before sex rearing can be determined; inform neonatal consultant immediately

46. Legs

47. Club Foot

48. Talipes • Talipes, particularly equinovarus, is relatively common lower limb abnormality • Majority are positional with no need for specific treatment (but inform GP) • Sig. positional talipes need physio referral • Physio can refer to orthopaedics if needed • Fixed talipes (the foot cannot be moved back into position) need urgent orthopaedic referral and hip scan

49. Feet

50. Syndactyly If there is fusion of the bone referral is to the hand specialist as above . If not the referral is to the plastic surgeon as above.