Transcript Newborn Problems - York General Practice VTS

Infant Examination &
Common Infant Problems
Dr Ian Woodcock
ST3 Paediatrics
Aim



Newborn Examination
Problems found during baby check
Common Infant Problems
presenting in first few weeks of life:
Vomiting
 Breathing Difficulties (very briefly)
 Colic
 Jaundice

Why is newborn check useful?

Detecting medical problems

Parents value early diagnosis

Outcome can be improved

Enables planning of services
Newborn Examination

What do we examine in the
newborn and six week baby checks?

•Head
•Eyes
•Palate
•Tone
•Heart
•Chest
•Abdomen
Head to toe examination
•Genitalia
•Anus
•Hips
•Femorals
•Spine
•Arms + Hands
•Legs + Feet
•Skin
General inspection







How is the baby doing generally?
Family history congenital problems
Antenatal concerns?
Inspect for dysmorphic features?
Feeding
Passed urine?
Passed meconium?
RED FLAGS
Specific things to think about!







Heart Murmurs
Femoral Pulses
Undescended
Testes
Absent red reflex
Dislocatable /
dislocated hips
Sacral dimples
Imperforate anus
Infant Examination
Head
Eyes
Palate
Tone
Heart
Chest
Abdomen
Femorals
Genitalia
Anus
Hips
Spine
Arms + Hands
Legs + Feet
Skin
Absent Red Reflexes

What does it
mean?
Take Action
Red reflexes
Normal
Red reflex absent
Red reflex abnormal
Absent Red Reflexes

Congenital Cataracts

Optimal time for surgery is 4 – 6 weeks


Should be referred to an ophthalmologist
early
Sub-conjunctival haemorrhages are
of no significance.
Infant Examination
Head
Eyes
Palate
Tone
Heart
Chest
Abdomen
Femorals
Genitalia
Anus
Hips
Spine
Arms + Hands
Legs + Feet
Skin
16
Tongue-tie

Usually do not require surgery,
except if interfering with breast
feeding; the tongue grows forward
in 1st year
Infant Examination
Head
Eyes
Palate
Tone
Heart
Chest
Abdomen
Femorals
Genitalia
Anus
Hips
Spine
Arms + Hands
Legs + Feet
Skin
23
Heart Murmurs



Duct dependent lesions
Baby only well if Ductus Arteriosus is open
– this will close spontaneously at 6 – 60
hours of life, then the baby collapses
The vast majority of these babies have low
sats (<94%) prior to the duct closing
Heart Murmurs

What are the signs of heart failure?

What would you tell parents?
Signs of heart failure

Breathless / breathing too fast
Sweaty
Not completing feeds
Poor weight gain / Excessive weight gain
Poor colour
Sleepy
“Not quite right”

ASK FOR HELP – A&E or GP






Infant Examination
Head
Eyes
Palate
Tone
Heart
Chest
Abdomen

Femorals
Genitalia
Anus
Hips
Spine
Arms + Hands
Legs + Feet
Skin
38
Femoral Pulses

If they are absent
what does it
mean?
Femoral Pulses


Absent femoral
pulses implies
coarctation of the
aorta
Baby is at risk of
sudden,
unexpected
collapse and may
die without
appropriate
treatment
Infant Examination
Head
Eyes
Palate
Tone
Heart
Chest
Abdomen
Femorals

Genitalia
Anus
Hips
Spine
Arms + Hands
Legs + Feet
Skin
41
Undescended testes


If bilateral
undescended
testes, what does
it mean?
These babies may
be FEMALE,
especially if also
have hypospadias
Hypospadias

Posterior
hypospadias
(particularly in the
absence of
palpable gonads)
should be treated
as ambiguous
genitalia
Male genitalia - hypospadius



1in 300
Combination of

1. Abnormal ventral opening of urethra

2. Ventral curvature (chordae) of penis

3. Hooded foreskin, deficient ventral skin
Classified

Coronal,distal,midshaft,proximal,perineal
Ambiguous Genitalia
Ambiguous Genitalia
Bilateral Undescended Testes


The baby may have Congenital
Adrenal Hyperplasia
Steroid pathway problem
Steroid precursor
Enzyme
Testosterone
Cortisol
Bilateral Undescended Testes





Absence of Cortisol
Salt losing crisis
Non-specifically unwell (short time
period)
Fits
Death
Female genitalia


Oestrogen withdrawal bleeding
Can occur in female infants aged 2
- 4 days
Not significant
Infant Examination
Head
Eyes
Palate
Tone
Heart
Chest
Abdomen
Femorals
Genitalia

Anus
Hips
Spine
Arms + Hands
Legs + Feet
Skin
53
Imperforate anus


Can be subtle
Needs early
diagnosis and
surgery
Investigation:
Cross Table Lateral AXR in Prone Position
Infant Examination
Head
Eyes
Palate
Tone
Heart
Chest
Abdomen
Femorals
Genitalia
Anus

Hips
Spine
Arms + Hands
Legs + Feet
Skin
59
Dislocatable / dislocated hips


This does not
include clicky
hips!
Refer up to
paediatrics
urgently
Non-urgent hip referrals

Risk factors for DDH

Can you think of 4………..?
Hip Referrals (non-urgent)




1st degree relative
Breech
Significant talipes
Abnormal examination
Infant Examination
Head
Eyes
Palate
Tone
Heart
Chest
Abdomen
Femorals
Genitalia
Anus
Hips

Spine
Arms + Hands
Legs + Feet
Skin
63
Sacral dimple
Sacral Dimples



Can you see the
bottom of the
dimple?
If not urgent
referral
More worried if….


Poor leg movement
Bowels not open
Infant Examination
Head
Eyes
Palate
Tone
Heart
Chest
Abdomen
Femorals
Genitalia
Anus
Hips

Spine
Arms + Hands
Legs + Feet
Skin
Milia
Erythema toxicum
Mongolian blue spot
Capillary haemangioma
Naevus

What size naevus
would you be
worried about?
Naevus

Refer any naevus
greater than 2 cms
diameter (risk of
malignant change)
Vesicles


Can be serious
Herpes can kill
very rapidly
Chicken pox


Refer urgently
Contact infection
control ASAP
Things to Refer…
Acute Referrals





Congenital heart disease including all heart
murmurs
Absent femoral pulses
Ambiguous genitalia, hypospadias or
bilateral undescended testes.
Skin vesicles, moderate umbilical sepsis,
pustules, bullae
Spinal or sacral pits where the base is not
easily visible
Urgent Referrals







Babies with possible genetic or syndromic
abnormalities
Cleft lip and or palate abnormalities
(contact cleft team asap – if no antenatal
plan for urgent referral)
Absent red reflex
Significant naevi
Babies with antenatal diagnosis of bilateral
renal pelvis dilatation or dilatation
>10mm
Babies with clinically dislocatable hips
Possible brachial plexus injury
Paediatric Out Patients Referrals




Definite or possible fixed talipes
Babies requiring post natal investigation for
possible inherited conditions
Other significant abnormalities found on
antenatal screening or at the time of
delivery
Any other baby about which you have
concerns
Common Infant Presentations to GP




Vomiting
Infantile Colic
Bronchiolitis
Jaundice
Vomiting

Possets


normal
Gastro-oesophageal Reflux






worse in neuro-developmental disabilities
common - 50%
spectrum - mild thicken feeds and positioning
advice
Severe may require drug therapy
Very severe may need fundoplication
Complications - oesophagitis or Barrett’s, failure to
thrive
Vomiting

Over-feeding





Gastroenteritis
Pyloric Stenosis






Infants fed on demand
150mls/kg/day until weaned
Then 100mls/kg/day milk
Occurs in 7 per 1000 live births
6:1 male:female preponderance
Projectile vomiting non-bilious fluid after every feed
Metabolic Alkalosis
Surgical repair - Ramstedt’s Pyloromyotomy
Occult Infection (particularly UTI)
Infantile Colic






What is Infantile Colic?
What causes it?
What can be done?
Does it get better?
Differentials?
Is it a risk factor for any other
serious condition?
Infantile Colic

What is Infantile Colic?



Inconsolable crying, especially in the evenings
accompanied by infant bringing its legs up and
exhibiting fisting and going puce in the face.
Occurs in a paroxsymal fashion often worse in the
evenings.
Affects bottle and breast fed babies equally
What causes it?


No cause known. Sometimes is relieved by opening
bowels or passing flatus.
? caused by hunger, aerophagy, abdominal
distention or overfeeding
Infantile Colic

What can be done?







Over the counter remedies (eg GripeWater or
Infracol) - varying success
Continuing a routine
Holding baby and gently jogging infant up and
down
White noise such as static on radio
Place in car seat on tumble dryer
Leave the baby with someone else (trusted carer)
Reassurance - this is the single most important
management role
Infantile Colic

Does it get any better?


Differentials?





Yes. Most infants will have grown out of colic by 34 months
Intussusception
Acute abdomen
UTI
Otitis Media
Is it a risk factor for any other serious
condition?

Yes. It is a precipitating factor in NAI
Bronchilitis
What will you tell parents?






What is bronchiolitis?
How common is it?
How serious is it?
How long will it last?
What can I do?
What should I look for?
Bronchiolitis
How common is it?




Very common
70% of infants will contract it in the first year of life
22% symptomatic
3% of all infants < 1 year will be hospitalised with bronchiolitis
When is it most prevalent?

Winter (Between November and March)
How do babies present?



Repiratory distress (tachypnoea, recessions, decreased sats)
Decreased feeding
Neonates can present with apneas without respiratory
distress
Bronchiolitis

Examination Findings



Respiratory Distress
Wheeze and crackles on ausculation
Fever may be present but high fever (>39°C) is
uncommon
Infants At Risk

Infants that can be severely
affected:
Ex-prems
 CLD
 Congenital Cardiac Conditions
 Immune deficiency
 Cystic fibrosis
 Household smokers
 IUGR/Small infants

Which Children to Refer?









Poor feeding (<50% of usual fluid)
Lethargy
History of apnoea
Respiratory rate >70/min
Presence of nasal flaring and/or grunting
Severe chest wall recession
Cyanosis
Oxygen saturation ≤94%
Uncertainty regarding diagnosis.
Lower threshold for admission in infants with comorbidities
Jaundice



Can be split into early or prolonged
Conjugated or Unconjugated
Early:
Most common is physiological (60% babies)
 Immune haemolysis
 Infection


Prolonged
Breast milk (9% of breast fed babies)
 Biliary atresia
 Congenital hypothyroidism
 CF
 Galactosaemia

Summary



Quick 5-10 minute top to toe
examination
Wide ranges of problems being
looked for - most are very rare
If in doubt - ask for help
Acute Referrals





Congenital heart disease including all heart
murmurs
Absent femoral pulses
Ambiguous genitalia, hypospadias or
bilateral undescended testes.
Skin vesicles, moderate umbilical sepsis,
pustules, bullae
Spinal or sacral pits where the base is not
easily visible
Any Questions?