*3.4.2 Nose*

Remember that infants are obligate nose breathers and nasal congestion is common. Observe the nasal passage visually and describe whether they are patent and symmetrical.

## *3.4.3 Mouth*

Using a gloved finger, place it in the infant's mouth and observe their suck reflex and check if it's coordinated. Also remember to feel the palate [10].

You may be asked to comment on whether the infant has a lip tie or tongue tie especially if the infant has had difficulties with feeding. A tongue tie (ankyloglossia) refers to a short lingual frenulum [15]. You can observe this by seeing if the tongue fails to stick out or converts to a heart shape when protruding out. The tongue tie can impact on a tongues range of movement and ability to function [15]. A lip tie refers to a short labial frenulum and this results in a lip that looks like it's stuck to the gum [15]. This may affect the infant's ability to latch properly when feeding [15].

*The Newborn Baby Check DOI: http://dx.doi.org/10.5772/intechopen.99524*

#### *3.4.4 Ears*

Comment on the position and structure of the ear. Preauricular sinuses, skin tags or cysts should be followed up as they can be associated with congenital syndromes. It is hoped that these conditions have already been identified by this stage.

To complete the head exam, remember to comment on the neck. Torticollis is a condition that can affect an infant's range of neck movement [16]. Observing if the head looks tilted or if there's a preference to one side and restriction to full neck movement on examination can suggest torticollis [16]. Other opportunistic signs to look for are neck masses which can be associated with the thyroid or cervical chain lymph nodes [10].

#### **3.5 Upper limbs**

The upper limb exam is not too complicated. The aim is to check the general range of movement of the shoulder joints, elbows, hands and fingers. Assess the brachial pulses in both arms by placing a finger over the antecubital fossa. Count the number of fingers and look for webbing and check the palm for any deep creases.

#### **3.6 Anterior chest**

Comment on the shape and symmetry of the chest. Respiratory effort and rate should be looked at but in a well-baby this is usually normal. Using your thumb, check capillary refill time by placing it over the sternum and holding it there for 5 seconds. After letting go, the blood should return to the area within 4 seconds [17].

Auscultation of the heart will help identify any murmurs and additional heart sounds. In a child that is failing to thrive, looking for underlying heart disease is important [18].

Comment on the shape and position of the nipples. Evidence of breast buds and galactorrhoea may be present due to the maternal oestrogen effect and will resolve around the 2-month mark [19]. Seeking an endocrinologist opinion would be advisable if breast buds or galactorrhoea persists.

#### **3.7 Abdomen**

Comment on the shape and symmetry of the abdomen. Organomegaly can be detected by palpating the abdomen and feeling the liver, spleen and kidneys. It may be difficult to assess the abdomen if the infant is unsettled. Follow this by auscultating the abdomen for bowel sounds.

#### *3.7.1 Umbilicus*

Umbilical hernias are common and present in about 20% of newborns [20]. They can increase in size over the first few months of life [20]. Multiple references report that an umbilical hernia can be monitored if asymptomatic at this age [20]. Australian guidelines recommend that referral for such hernias wait until a child is 2 to 3 years of age and it is expected that up to 90% of hernias will close on its own by 5 years of age [20]. This is helpful to know when faced with a common presentation of a soft reducible umbilical hernia at this check.

#### *3.7.2 Inguinal hernias*

Inguinal hernias are common and present in up to 5% of newborns with a higher percentage seen in those born prematurely [20]. If present in an infant, a timely referral within 2–4 weeks is recommended [20]. This referral interval may vary for a neonate or an older child.

#### **3.8. Genitourinary**

#### *3.8.1 Male genitalia*

The penis should be observed and commented on for size, chordee and hypospadias [20, 21]. Chordee is when the penis is curved during an erection. Hypospadias is common and occurs in 1 in 125 males born [21]. It is a defect resulting in an opening of the urethra along the penile shaft, scrotum or perineum [21].

The scrotum should be felt for the presence of testes [21]. If they are empty, the examiner should locate the position of the testes. Maldescended testes may be "undescended" or "ectopic" [21]. The term undescended refers to a testis that presents within the normal line of descent and an ectopic testis is one outside this line. A retractile testis may be brought down by milking it down. A technique for examination would be to use one hand to lift up the suprapubic fat and then use two fingers of the other hand to palpate the areas of interest in the inguinal region with a circular motion [21].

Whilst examining the scrotum, look for the presence of a hydrocoele. This can be normal up until the age of 1 year for most infants [21]. If suspected, use an examination torch pressed against the side of the testis (transillumination) to confirm the presence of fluid surrounding the testis [22].

Signs of ambiguous genitalia may include a micropenis or bilateral undescended testes [23].

#### *3.8.2 Female genitalia*

The aim is to observe whether the genitalia is developing normally. Abnormal findings that may indicate ambiguous genitalia include clitoromegaly and fused labia [23].

#### **3.9 Anus**

After the genital examination, briefly look between the buttocks to observe the anus and particularly the skin around it. It's not uncommon to see a significant rash hidden within this area. There is no reason for performing a per rectal examination and this should not be done.

#### **3.10 Lower limbs**

#### *3.10.1 Hips*

The hip examination is a critical step during this examination as a delayed diagnosis of hip dysplasia can result in significant morbidity to the infant involved.

When taking the initial history, remember to go through potential risk factors for developmental hip dysplasia (DDH). Risk factors for DDH include being female, being a breech birth and having a family history of DDH [24]. Postnatally, some risk factors include tight swaddling of lower limbs in extension and adduction [24].

#### *The Newborn Baby Check DOI: http://dx.doi.org/10.5772/intechopen.99524*

In those babies up to the age of 8 weeks, the Ortolani and Barlow test are the preferred tests to detect DDH [24]. Leg length discrepancy, asymmetric gluteal creases and restricted hip abduction are also helpful signs to work up a DDH.

The Ortolani and Barlow test are performed as follows. The Ortolani test checks to see if a dislocated hip can be relocated or reduced back into the hip joint [24]. By holding the flexed and adducted hip, abduct the hip while putting gentle upward pressure with your fingers on the greater trochanter [24]. If the test is positive, a "clunk" should be heard as the hip is reduced back into the joint [24]. The Barlow test aims to dislocate a hip that is sitting within the joint [24]. The test is performed with the hip adducted while gently putting pressure down in the direction of the examination bed [24]. During this step, the examiner may feel the hip move out of the acetabulum. This is a Barlow-positive test.

In situations where a hip is dislocated and irreducible, it will be interpreted as an Ortolani negative and Barlow negative test. In this scenario, checking if the hip can abduct completely will pick up this uncommon presentation [24].

#### *3.10.2 Legs and feet*

With both hands on the infant's knees, straighten their legs to see if the knees, medial malleoli and feet line up. Leg length discrepancy can be a sign of unilateral hip dysplasia.

As we did for the upper limbs, check the range of movement of the lower limbs by moving the joints at the level of the hips, knees and ankles. Check the feet to see if there is evidence of talipes [25]. Again, count the number of digits on the infant's feet as you did for the hands earlier.

#### **3.11 Back**

Now that the front of the examination is complete, you can turn the baby over onto their tummy and continue with the remainder of the examination with the infant in a prone position.

Observe the back of the head to look for skull moulding or rashes. If you are able to, observe the degree of neck control and position of the head. This may not be possible with all infants due to immaturity.

Look at the back to see if there are any skin rashes. Skin lesions are discussed earlier in the chapter but one in particular that is seen on the back are Mongolian spots.

Look at the positions of the scapula and buttocks to see if they are roughly symmetrical and in line with each other and then run your hand along the infant's spine to see if it's straight [10]. At the base of the spine, you may find clues for spina bifida including sacral dimples or tufts of hair [10].

#### **3.12 Newborn reflexes**

To finish off the examination, a screen for reflexes can be performed. This includes the stepping reflex, palmar grasps, moro reflex and rooting reflexes. Most of these reflexes should still be present. The stepping reflex tends to disappear around 2 months of age so this might not be illicited if the infant is close to 8 weeks when the exam is done.

#### **3.13 Measurements and finishing the exam**

Finish off by checking the infant's weight, head circumference and length. Remember to document the findings of the examination and arrange appropriate follow up for any abnormalities that need attention. Thank the patient's family and allow the family to dress the infant.

#### **Newborn baby check**

Introduce yourself and ask parents identifying questions i.e. name, age, date of birth

#### Wash hands

Exposure – undress the child leaving them in a nappy which will be removed at the time of the genital and hip exam.

Position – place the child on an examination bed which is relatively firm and start with them in the supine position

#### General inspection


#### Head


#### Shoulders and arms


#### Anterior chest


#### Abdomen


#### Femoral region


• Females – check for fusion of labia and clitoromegaly to suggest ambiguous genitalia

#### **Newborn baby check**

Hips and legs


Change baby's position so they are now on their tummy (prone position)

• Assess head control

Posterior chest


Reflexes


#### **Table 1.**

*Summary of the newborn baby check.*
