Neonatal examination is easiest to remember if you approach it in a head-to-toe way:

- Vital statistics - Birthweight (3.5kg = average term infant), Head Circumference (35cm) and Length (50cm) - These should be plotted on a centile chart.

- General observations - The baby must be fully undressed for the examination. Pay particular attention to the baby's natural movement, limb positioning and check over their skin. Check the feet for evidence of malformation (talipes).

- Hands - Check for a single palmar crease which can indicate Down syndrome but might be normal. Look for evidence of traction birth injury (e.g. Erb's palsy) by checking neck, shoulders and clavicles. Check for normal numbers and shape of fingers.

- Fontanelles - Palpate the fontanelles and sutures. Fontanelle size can vary a lot. Mainly you are assessing the prescence of the fontanelle and its tenseness. If the fontanelle is tense when the baby is not crying it may indicate raised intracranial pressure and cranial ultrasound may be indicated.

- Face - Abnormal facial features suggest a syndrome.

- Colour - Plethoric appearance (red) may suggest polycythaemia. Pale appearance may be anaemia. Check the tougue for central cyanosis - if present this prompts immediate further assessment. Assess the limbs for peripheral cyanosis. Check for jaundice which starts on the head and moves down. If this is present in the first 24 hours it has a high probability of having a serious cause and needs further assessment

- Eyes - Assess with an ophthalmoscope. Particularly look for the prescence of the red reflex (absence my indicate retinoblastoma) and any cataracts.

- Palate - This must be examined and palpated all the way posteriorly to exclude a cleft palate.

- Chest - Assess breathing and chest movement.

- Heart - Assess the rate and rhythm. Normal rate is 110-160 beats/min though this can be as low as 85 beats/min while the baby is sleeping.

- Abdomen - It is normal for the liver to extend 1-2cm below the costal margin. The spleen tip and left kidney can sometimes be palpated. Examine the abdomen for masses or abnormalities.

- Genitalia and anus - Check for the normality of external genitalia, urethral opening and anal orifice. In boys check the testes are in the scrotum - 4% will have one or both undescended at birth (cryptorchidism), reducing to 1.5% at 3 months. They will be rechecked at the 8 week check up.

- Femoral pulses - Pulse pressure can be reduced in coarctation of the aorta or increased in a patent ductus arteriosus

- Muscle tone - Most babies will support their heads momentarily when the baby is held vertically.

- Back and spine - Examine the whole of the back and spine checking for any midline skin defects

- Hips - Do this last as it is distressing. Check for developmental dysplasia of the hips using Barlow and Ortolani maneuveres. For Barlow's test, make sure the infant is relaxed and place one hand on the opposing leg to stabilise the pelvis. On the other side put your middle finger on the greater trochanter and your thumb on the distal medial femur. Hold the hip flexed and adducted and gently push the femoral head downwards. If it is dislocatable the head will be pushed posteriorly out of the acetabulum. Next perform Ortolani's to see if the hip can be returned from disclocation. Apply upward levarage with the hip abducted. You will hear a 'clunk' if the head slips back into the acetabulum.

- Reflexes

- Moro reflex- the startle reflex is present at birth, peaks in the first month of life and begins to disappear around 2 months of age. Hold the baby horizontal and then drop its head suddenly by moving your palm down a few inches. The legs and head extend while the arms jerk up and out with the palms up and thumbs flexed.

- Palmar grasp reflex- appears at birth and persists until five or six months of age. Put your finger in the babys hand, the fingers will close and they will grasp it. Interestingly if you stroke the back of the hand you can reverse the movement.

- Rooting reflex-  present at birth, disappearing at around four months of age. Stroking the babys cheek will cause it to turn its head toward your hand.

- Sucking reflex- present at birth. Test by putting a gloved fingertip into the babies mouth.

- Stepping reflex- present at birth. Hold baby vertical and touch their soles to a flat surface and they will make a stepping or walking movement.

    Possible OSCE stations

    - You could be asked to assess a brand new baby, in the delivery room. In this case make sure you start the examination with assessment of the Apgarscore at both 1 and 5 minutes. This is out of 10 and assesses the babies vitals.

    - If asked to do an 8 week check, the above examination still stands. However the most important points in an 8 week check are the talk to the parents about how things are going. Talk to mum about recovering from the birth and sensitively assess her mental status to check for postnatal depression. Get a feel for the family set up and discuss immunisations. Finally don't forget to look at the babies health record (ask to see the red book) and add their vitals to the growth and head circumference charts. 

     

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