• Measure and document growth parameters and assess their appropriateness
• Detect congenital abnormalities early
• Neonatal complications'
• Assess parental competence
• Let mother talk about her baby and explain normal variations

• Warm and quiet
• 1-2 hours after feeding
• Mother's presence
• Fully undressed

1. Baby

• Uncooperative
• Short attention span
• Avoid cold exposure

1. Examiner

• Gentle, clean, warm hands and stethoscope
• General exam followed by systematic exam
• Starts with system that requires highest co-operation
• Uncomfortable exam left until later
• Order of exam changed to suit child's condition
• Before exam, establish good rapport with mother
• Mother encouraged to voice and query or abnormalities observed in the past 2 days
• Paed: sit in front of child when on mother's lap, kneel beside child when playing on floor
• Introduce yourself to Pt and parents
• Speak to child on same level and with soft voice
• Observation of child and family begins in waiting room and during interview
• Note relationship between parents and child
• Appearance of child: dress, hygiene, racial origin
• Child placed on mother's knees, or playing with toy
• Dr: patient, friendly, non-threatening, not conscious of own dignity
• Procedures requiring co-operation done first (eg. Developmental assessment)
• Explain what is to be done in soft persuasive voice, give age appropriate instructions
• Avoid asking leading questions

Note general well being

• Colour
• Hydration
• Nutrition
• Activity
• Posture
• Movt

 General inspection

• Assessment of size, maturity
• Colour changes: cyanosis, plethora, pallor, jaundice, and skin discoloration
• Position, posture, activity

Exam of face, H&N region

Rest of body

• Cutaneous pigmentation

May perform abdominal exam while Pt lying on mothers knees

Muscle power

• Hold Pt under armpits
• Forward parachute and wheelbarrow test - Pt support wt of body and some pressure on back on upper limbs (Dr lifts lower limbs up)
• Handgrip: using sweet

Ht and wt

• Usually measured by nurse
• After measuring head circumference, match against percentile charts

Linear growth

• Anthropometry important
• Standing height: no shoes, socks; using wall-mounted stadiometer
• Head: lower edge of orbit in line with external auditory meatus (Frankfurt plane)
• Sitting ht: Pt seated upright with straight back, upright, head in Frankfurt plane
• Ht's measured to 0.1cm

BW

• Electronic scale: fully undressed
• Nearest 0.1kg

Head circumference

• Firm, non-stretchable tape
• Frontal occipital diameter to nearest 0.1cm

< 2 years supine length measured while Pt lying down

Crown-heel length - light clothing, no shoes and socks, infant stadiometer

• Uncomfortable - therefore do last
• Pt on mothers knees
• Immobilise one of Pt's arms bet Pt's trunk and mother's
• Legs immobilised bet mother's knees
• Mother can hold Pt's head to facilitate Dr during exam

• NS assessed by observation of posture, tone and activity while the noted systems are being examined
• Interpret neurological findings: you must know time in uterus, chronological age
• Tight fisting - cerebral damage?
• Frog-like - hypotonia?
• Test tone
• Bring baby to sitting position
• Baby can help with elbow, minimal head lag
• Put baby in prone position
• Can baby raise head (normal for term baby)
• Ventral suspension
• Head in line momentarily
• Hold by armpit
• Hypotonic baby slips through
• Primitive reflex
• In mature baby
• Disappear by 4-6m
• Moro: hold head 45 degrees, should flex neck (if not, brachial plexus injury, # clavicle)
• Grasp: grasp finger, can pull herself up
• Rooting and sucking
• Congenital dislocation of hip uncommon in Asians, more common on left side
• Asymmetry?
• Additional skin creases?
• Shortening of limbs?
• Decreased hip movt? Test
• Externally rotate and abduct hips
• Can do until 990 degree
• Cluck may indicate dislocated hip
• Click not significant
• Put clothes and nappy on baby
• ID bracelet in place
• Make sure baby comfortable
• Exam completed in 5-7 minutes

Auscultation: when baby quiet

• Small warm stethoscope
• Start at apex, sternal border upward
• Count HR for 1 min (usually 120bpm)
• Listen to heart sound, murmur, extra sound, click
• Innocent murmur normal in newborn: soft-blowing murmur over left upper sternal border

Inspection

• Resp pattern and rate
• Normal RR 40-50/min
• Periodic respiration

Signs of respiratory distress

• Tachypnoea
• Grunting
• Flaring of ala nasi
• Use of accessory m's (IC, sternal)

Percussion not helpful in healthy infants

Auscultation

• over chest quadrants in front and back
• Chest sounds even?

Preparation

• Warm hands
• Relaxing environment: distract child but talking on topics they like, give them toys to hold
• Position child to allow for adequate exam: as mother to put child in lap, making a small examination couch
• Adequately expose child
• Go over presenting problems and formulate a list of possible features to active pursue for

INSPECTION

• Skin: skin and tense due to distension, lax and wrinkles in scaphoid shape abdomen, silver lines - striae
• Scars
• Colour
• Dilated veins - note direction of flow
• Ab wall movt on respiration
• Shape of abdomen: protrusion in midline - diastasis of rectus m; distension - generalised or localised; depressed or scaphoid: diaphragm, hernia etc
• Umbilicus: hernia, granuloma (retraction during voiding may indicate urachal anomaly, bluish discoloration may indicate intraabdominal haemorrhage)
• Visible peristalsis - intestinal obstruction, pyloric stenosis (place eyes at level of abdomen and shine torch tangentially across abdominal wall)
• Perineum: nappy rash, anal fissure, rectal prolapse, skin tag
• Laceration or bruises of anus, anal tone, asymmetry of buttock and thigh folds, hernia, genitalia

PALPATION

• Crying child - take advantage of inspiratory phase (abdomen more relaxed)
• Tenderness - gentle followed by deep palpation, observe for grimacing / other body language for pain
• Ticklish children: briefly place flat hand on abdomen before exam, putting child's hand over examiners during examination

Note anatomical regions for description

• L and R hypochondrium
• L and R lumbar
• L and R iliac
• Epigastrium - umbilical - hypogastrium

Masses?

Liver:

• Palpate from below upward
• Lower edge - palpable in young children below 2-3 yo
• Span 20kg: 8+/- 1.8cm
• 60kg 10.2 (2cm)
• Soft enlarged liver can be masked by forceful palpating hand directly over it

Spleen

• Tip could be palpable in young infant
• Kidney
• Should be rarely ballottable except for neonates
• Soft sausage-shaped mass of intussusception
• Indentable faecal masses (faecal impaction)

Additional tips

• Define char of any mass detectable on palpation
• Shape, outline, surface, edge, consistency, homogeneity
• Presence of thrill or bruit (when appropriate)
• Gas/fluid filled, transilluminate or not
• Familiarise yourself with list of common or rare but important cases of such mass lesions including the abdominal organs

Percussion for ascites

• Shifting dullness
• Fluid wave / thrill

AUSCULTATION

• Listen for peristalsis - place stethoscope firmly over abdomen
• Normal heard every 10-30 sec
• Gurgles, clicks, growls
• Absent in paralytic ileus
• Frequency and high-pitched (tinkling) in intestinal obstruction, gastro-enteritis and early peritonitis
• Venous hum for portal obstruction
• Renal arterial bruit for renal artery stenosis posteriorly over kidney area
• Murmur for coarctation of aorta

• Don't assume that mass on upper left is liver, and upper right is spleen
• Some paediatrics pt's have heart on other side
• You must outline the mass, and define the nature

• Rupture common bile duct in 4yo with non-accidental physical child abuse
• Enlarged gallbladders in children with critically ill state or Kawasaki disease (common in HK; early Tx prevents aneurysm)
• Haemangioma of liver resulting in heart failure, DIC with platelet consumption (Kasabach Maritt syndrome)
• Hepatogemaly in children with neurological problem (dystonia)
• Enlarged kidney in Pt with tuberous sclerosis (common in paed neuro)
• Ovarian cyst (pelvic mass) / granulosa cell tumour in girls presenting with precocious puberty or vaginal bleeding
• In any teenage female, mass could be a foetus
• Abdominal aortic aneurysm

Important surgical lesions in medical setting (slip through triage)

• Pyloric stenosis
• Intussusception (esp. infants)
• Necrotising enterocolitis
• Appendicitis
• Intestinal obstructions
• Inguinal hernia
• Torsion of testis

Note: Soft and large liver in paed pt often missed by inexperienced examiners

• Umbilicus
• Erythema
• Purulent / blood stained discharge
• Umbilical hernia at base?
• Palpate abdomen superficial in 9 quadrants
• Look at face of baby for tenderness, pain
• Then deep for organomegaly
• Liver edge up to 2 cm with regular margin and soft consistency can be felt in normal newborn
• Upper border of liver - defined by gentle percussion
• Palpation of spleen
• From umbilical region to diagonal
• Right-lateral position helps detection of small spleen
• Bi-manual palpation, ballotted
• Lower border of right kidney can sometimes be ballottable
• Bowel sounds heard during auscultation
• External genitalia
• Labia majora, covers minora and clitoris
• Anal patency via inspection

• Accessory auricle
• White pimples
• Capillary nevi
• 3rd fontanelles
• Wormian bone
• Urticaria
• Mongolian spots
• Breast enlargement
• Accessory digit
• 2 cord vessels
• Fused labia
• Sacral dimples

• Caput Succedaneum: ST swelling over skull; present in almost all babies via vaginal delivery
• Subaponeurotic haemorrhage
• Haemorrhage under scalp
• May be very severe
• Shock
• Anaemia
• Neonatal jaundice

DIAG

• Forceps
• Vacuum delivery
• Cephalhaematoma
• Bleeding under periosteum
• Swelling confined by suture lines (therefore swelling less extensive)
• Parietal bone most common
• Neonatal jaundice - prolonged

DIAG

• New-born skull
• 3rd fontanelle: not usually present, more frequent in chromosomal disorders
• Raised ICP: may feel anterior and posterior lateral fontanelles
• Acoustic windows, therefore can use US probe to see intracranial structure without using CT scan

Palpation of Anterior Fontanelle

• Pt should be upright and calm (affects tension of fontanelle)
• Feel tension, assess ICP
• Size - variation (1-3cm)
• Tension - more important

1. Closed anterior fontanelle / small anterior fontanelle

• Measure head circumference - decreased
• Craniostenosis (abnormal shape, bony ridges)
• Abnormal brain growth

1. Large anterior fontanelle

A) Normal head circumference

• Normotensive: IUGR, Hypothyroidism, Rickets, hypophosphatasia
• Increased tension: hydrocephalus, SOL

B) Large head circumference

• Hydrocephalus
• Intracranial lesions (eg. Haemorrhage, AVM)

1. 3rd fontanelle
2. Craniotabes

• Parasaggital area
• Irregular area of calcification

1. Wormian bone

• Soft area in occipital region
• Assoc. with osteogenesis imperfecta, cretinism

Subconjunctival haemorrhage

• Benign condition
• Subsided spontaneously within 10-14d (if not, assoc. intracranial haemorrhage possible)

Vision

• Baby can see well at birth
• Best at 2cm (10") away (babies are slightly long-sighted)
• Best distance to examine baby
• Occasional squint is normal

Ophthalmia Neonatorium

• Any discharge on inflammation in the first 3d (esp. 1st 24hr) investigate urgently as it may indicate gonococcal infection
• Can cause blindness due to corneal ulceration
• Gram smear for IC gram -ve diplococci and culture (need special culture medium)
• Intermediate onset - Staph, E Coli, Klebsiella, gonococcus
• Late onset - Chlamydia
• Eye prophylaxis Chlortetracycline eye ointment

• Palatal cysts (65-79%) - yellow white elevated cysts 1 mm diameter, nests of epithelial cells in midpalatal raphe at fusion of soft and hard palate
• May find teeth in new-borns
• Ankyloglossia (tongue-tie) (-2%) - male: female = 3:1; lingual frenum prevents protrusion of tongue, extends to papillated surface of tongue or causes fissure in tip
• Median alveolar notch (26%) - reduces when teeth erupt or persists as notch bet central incisors
• Commissural lip pits

• Miliaria - tiny blister
• Milia
• Haemangioma - nevus felmeus

Sternomastoid tumour (misnomer - explain to Pt's)

• Torticollis - tilt head to one side
• Facial asymmetry
• Early detection responded well to physio

• Not to express milk
• Watch for breast abscess
• Aka witch-milk

• Brachial plexus palsy (Erb's palsy)
• # clavicle
• Moro reflex: if one arm doesn't move, this is abnormal and suggests brachial plexus injury

1. Umbilical sepsis

• Discharge and periumbilical induration or erythema - treat as systemic infection (IV ABX) with urgency
• Delayed separation of cord (>10d)
• Umbilical sepsis
• Immunodeficiency problem
• Discharging urachus

1. Umbilical hernia

• Benign
• Unlikely to strangulate
• Subside spontaneously within 1st year (with growth of abdomen)
• Surgical Tx

1. Exomphalos

• Herniation of abdominal content into umbilicus

Congenital dislocation of Hip

• Penile length 3.5cm (<2.5cm abnormal)
• Penile width 0.9-1.2cm
• Testis volume 1-2cm

Micropenis

Very fat baby may hide penis under suprapubic fat

Boy

• Retractile testis
• Undescended testis
• Hydrocele - need to exclude hernia (require surgery, otherwise high change of strangulation)
• Hypospadias: urethral meatus is on the central surface bet the tip and the scrotum. The foreskin is cleft on the ventral surface. Watch micturition to see where the urine emerges
• Phimosis: foreskin

Girl

• Prominent clitoris: some female babies, preterm, androgenital syndrome (ambiguous genitalia?)
• Hymenal tag: hang out of vagina
• Discharge / Pseudomensus: hormonal effect of mother
• Labial fusion: lack of oestrogens