Doctor covers NEWBORN EXAM// Don't MISS these 11 findings!!

Hello and welcome to Tarla Talks NICU, where we take difficult medical concepts and make them easy for you to understand. Today we're going to do something a little bit different. Instead of going through the entire physical exam of an infant, we're going to go over 11, random number, frequently missed physical exam findings. It's important to pick up these findings for three different reasons. The first one is that something may need therapy, for example, a webbed toe or something like that. The second reason is that the parents may be disappointed in you as a clinician if you actually miss a finding, even if relatively it's very unimportant. And the third reason is that the more abnormal physical findings that an infant has, the higher the chance of that being part of a larger genetic syndrome. So even if the individual findings may be a variation of normal, for example, a slightly increased gap between the first and second toe, a simian crease on the hands, both of those could be considered normal variations in a healthy newborn, but put loads of variations like that together. And for example, in that case, there's a high incidence of the infant having down syndrome. Today, I'll be using this doll to demonstrate some of these physical findings. Thank you, Mary, for lending her to me. I'm sure that everybody can agree that she is excessively creepy, but unfortunately, this is where we are. So I'm sure that everybody has their own pathway for how they routinely examine a newborn infant, whether you go from head to toe, or whether you use the stethoscope first with the heart and the belly and everything. Either way, if you would like me to go over that, then leave a comment below. Today, I'm also not going to go over the more common things that we are all definitely looking for on a physical exam. So pretty much everybody is checking the red reflexes, everybody's listening for murmurs, everybody is checking for the hip clicks. So again, I'm not going to go over those today because they're not normally as missed, if you will. Okay, the first commonly missed finding are lesions of the scalp and hair. So commonly, after a baby is born, their hair, and they may have a lot of hair, can be thick and matted, especially before they've had their first bath. And so it's very easy, unless you're actually combing through the hair and going out of your way to look at the scalp, it's very easy to miss abnormalities on the scalp. Some lesions may be more obvious, like a caput or a cephalohematoma on either side, for example, they're very commonly in the parietal areas. Others may be more subtle, for example, you may just have an abnormal patch of hair, or abnormal walls of hair, which are both could be indicative of a genetic issue. Or there could be an entire area that's and maybe missing the patch of skin as well, like an acute asoplasia, also concerning for a genetic issue. There could be other lesions on the scalp too, for example, like a sebaceous nevus, which is kind of like that bubbly, like blistery type birthmark that you can see really quite commonly on the scalp. There could even be like a herpes lesion lurking in there. So with every baby, make sure that you're really combing through the hair and trying to separate the hair so that you have a really good look at the scalp. Okay, the second set of frequently missed physical exam abnormalities at birth are lesions of the ear. So on every baby, make sure that you examine the ear really well, make sure that it's a normal size, make sure that the ears appear symmetrical. Also look for the position of the ear as compared to the eyes. If you draw an through the eyes, then it should intersect right at the top of the pinna. So kind of like the upper third of the eye should intersect with that line, which amazingly is pretty perfect on this doll. If the eyes are low set or posterior rotated, then that could be a sign that there is something genetic going on. Then still on the ears, look for tiny ear pits, which are tiny pinpoint holes, right where the ear joins the skin. And you can see them unilaterally or bilaterally. Very often, if you find them, a parent will have had an ear pit just like that. Or they can be more common in different ethnicities. For example, about 10% of Asians can have ear pits. We used to get renal ultrasounds and all these babies with ear pits because of the rare association of brachio-otorenal syndrome. Now, however, we pretty much only will get renal ultrasounds if there are other concerns. For example, there's deafness as well. And obviously, any time that you see any ear abnormality, it's very important that you do have a good hearing screen as soon as possible in the child's life. The other thing that we can see very commonly in babies is ear tags. So kind of in the same position as the ear pits, that tiny little bits of skin right in front of the ears where the ears meet the face. So again, these are normally inherited from the parents. The third lesion that's commonly missed, believe it or not, is a cleft palate. So make sure that you get your gloved finger and you put it all the way into the baby's mouth and push up against the roof of the mouth. The first part of the mouth is the hard palate and the back end of the mouth has the soft palate. And you could have a cleft so the roof of the mouth isn't completely formed but there's like a slit-like hole in the middle of it. And that can be in the hard palate or in the soft palate. And you can literally feel it as like a ridge on the top of the mouth. So you really need to get in there and make sure that you can feel that palate really well because it could just be a partial cleft or a submucosal cleft. And all clefts will affect feeding and they all need to be repaired. So this really is something very important for you to pick up as soon as possible. Staying inside the mouth, the fourth lesion is ankyloglossia or a shortened frenulum. The frenulum is that tiny little bit of skin that attaches the base of the tongue to the floor of the mouth. And for whatever reason people are currently obsessed with it. It is definitely the diagnosis of the day. Mothers are constantly concerned about their infants having a shortened frenulum and I'm sure at some point you're going to be asked about it. I think that this has become such a common issue at the moment that it probably deserves its whole own new video. But for now just realize that most likely the majority of the frenulums do not need to be clipped. Generally if an infant can stick its tongue past the lower gums, so even if it can only stick it this far, then that shouldn't be concern and shouldn't affect feeding and in the future speech and everything. So you can use that to reassure the parents. Other things that may be reassuring for the parents are that if the baby is able to move its tongue from side to side or if the baby is able to reach the roof of its mouth with the tongue. Obviously there are definitely certain babies that eventually will benefit from getting their frenulums clipped. However we all kind of feel that this is quite over diagnosed at the moment. So be sure that on your physical exam you're at least looking to see what the tongue is capable of doing so that you can have that conversation with the parents. The fifth missed physical exam finding, and again you would be really surprised how often this happens, is a fracture of the clavicle. So this can happen obviously we expect it to happen more if it's a huge baby with a difficult vaginal delivery and a shoulder dystocia, but it can also happen in a pretty uncomplicated delivery. So make sure that you are feeling all along the length of the clavicle from the proximal end to the distal end. If you can't feel the whole clavicle from beginning to end or if you feel crepitus, which is kind of like a bubbly popping feeling somewhere along the clavicle, then the baby may have a fracture. The most common places for the fracture are right in the middle of the clavicle so that's kind of the most common place that we would feel the crepitus. If an infant does have a fracture then make sure that they don't have any other abnormalities, for example they don't have an Erb's palsy or even a Klumpsky's paralysis or something, and then also you should probably get an x-ray to actually confirm that the infant does have a fracture. Luckily baby bone is unbelievable at repairing itself, so really in most cases no splinting is required, no pain medications are required, just let the parents know that as that bone starts healing they might feel like a bony lump there for really a few months until that all kind of smooths itself out again. Okay the sixth physical exam finding is an umbilical hernia. So if the ring around the umbilicus is large or weak then it can herniate the abdominal contents through it and you will notice this especially if the infant is straining, so if it's trying to pass a bowel movement or if the baby is crying then the abdominal pressure goes up and you'll see that area around the umbilicus bulge out. Otherwise you can feel for the defect by pushing in your finger through that little defect in the abdomen just around the umbilicus, then you should record exactly how big that defect is, whether it's fingertip or smaller than that or even larger than that. It is very rare for intestines to actually herniate through the umbilicus and then get strangulated, so really there's very little danger with an umbilical hernia and most of them do close by themselves. If they haven't completely closed by the time the infant is about four years old then it does need to be repaired surgically, so again another thing you need to look for right after birth. The seventh frequently missed abnormality and I'm letting my female baby go for this one are abnormalities of the male genitalia. So the first thing that you should try to do is make sure that you feel both testes in the scrotum. In a term baby, both testes should be descended. If you can't feel both testes then palpate down the inguinal canal. There's a high chance that one of the testes is still in the process of descending. If you can feel it right there then really nothing else needs to be done and most likely it will just take a little bit of time until that testes descends into the scrotum. Also while you're looking at the scrotum, look for excess fluid within the scrotal sac. So this is called a hydroseal and if you put a flashlight right next to the skin you'll see that it transilluminates a bright red really well. That's because it's all fluid in there. This is extremely common in males at birth and it normally goes away over the first few days of life. So again you can reassure the parents. Then look at the penis itself and the urethral meatus. So that's the hole at the head of the penis where the urine and eventually the sperm comes out of. The meatus should be right at the tip of the penis. If it's too high which is an epispadius or too low then hypospadius then this is abnormal. So if that occurs if there's an epispadius or a hypospadius then these are contraindications to the infant getting circumcised. So this baby should not be circumcised within the first few days of life and eventually this will have to be repaired. So again you have to really go out of your way to see where that urethral meatus is coming out. The eighth frequently missed physical finding is an anal atresia and again you would be amazed how often this is missed on the initial exam. So sometimes it's because the baby's extremely sick or extremely premature and we're so busy stabilizing the baby that we're not doing the full physical exam. But sometimes the babies are in the nursery with their mothers for over a day until somebody recognizes that this infant doesn't have an anus. Sometimes it looks like there is an anus because you can see the puckering of the skin around where the anus should be. Normally that occurs when there's a low-lying fistula so in those cases the infant may be stooling out of another hole kind of pretty close to the anus which is why sometimes it does take a little bit of time to recognize that there is an abnormality. We used to check temperatures with rectal thermometers in babies and that used to make sure that we weren't missing any anal atresias. Now we've kind of moved away for that from other reasons, some sort of concerns with rectal perforations and stuff. Still you have to take a very good look at the entire anal area to make sure that that is patent. If there is an anal atresia even if there is a low-lying fistula then nearly all of them have to be repaired very very soon after birth whether it's just with a dilation or whether it's with an ostomy or something. So this is something that needs to be picked up very quickly. The ninth frequently missed physical exam finding is a sacral dimple. Again you need to turn the baby over and you really need to push apart the top of the buttocks to be able to identify the bottom of the sacrum. So a sacral dimple could look like just a deep hole at the bottom of the sacrum or it could be an area of discoloration or a very large hairy tuft. Most of these again are completely benign and they run in families but sometimes in abnormality in this area especially if it really does look extremely much larger than all the other ones that you're used to a lot of babies have little holes or tiny areas of hair there but if you do see something that looks a lot more dramatic than usual then it could represent an abnormality of the spinal cord and one of the most common things that that could indicate is a tethered cord where the spinal cord is abnormally attached to the bone or some part of the dura or something at the bottom of the back. Eventually as the infant grows everything gets stretched out and the infants can start having weakness or sensory issues and obviously this needs to be repaired. So if you do notice anything in the sacral area then the minimum that you should be doing is showing it to the parents and making sure that they are aware of your concerns. If it looks very bad then get an ultrasound to look for a tethered The 10th abnormality concerns the hands and feet and that is specifically the webbing or syndactyly when two fingers are basically fused together or webbed together. We generally miss syndactyly of the toes a lot more commonly than in the fingers so really get in there and separate each one of the toes to make sure that there isn't any webbing. It happens in about 1 in 3,000 infants so it's actually pretty common and again a lot of the times it's inherited from the parents. If it's really severe then it does need to be repaired normally between the ages of about 1 and 2 so make sure that you get in there and really check the fingers and the toes. And the 11th frequently missed physical finding is birthmarks. So honestly I don't think that we really all do miss birth marks a lot but I think that we're so used to seeing different birthmarks on infants that we don't go out of our way to really examine them properly and to check their size and to document them. It is still important to do that just to make sure that as the infants grow if they do develop more markings or more skin lesions then we can go back and compare to what they had at birth. So some of them as you know are very common for example the markings that infants have on their eyelids and the nape of their neck that we call the stork bites. These are also called the nevus simplex so just kind of like the reddening around the eyes and around the nape of the neck. And you've all seen those kind of bluish gray macules over the lower back. Sometimes they can be kind of all over the back and even down the legs. We used to call them mongolian spots and now more appropriately they're called congenital dermal melanocytosis so slightly longer word. Again it's important to record these even though most of them are going to go away. Other birthmarks may be more concerning for example if an infant has just a darker macule so a darker birthmark somewhere on the skin that is considered a cafe au lait patch or a much lighter area of the skin against completely flattened against the skin so a macule that's called an ash leaf spot. If an infant has loads of these then it's concerning for a neurocutaneous disease for example neurofibromatosis or tuberous sclerosis. Again most of these are not diagnosed in infancy but if you have multiple abnormal birthmarks with many ash leaf spots or many cafe au lait patches then it can be more concerning that this baby may end up being diagnosed with one of those. So again when you do see a birthmark after the baby is born make sure that you document it and point it out to the parents so that they're aware of what is actually on that baby. And again that was it thank you so much for watching all of that 11 completely arbitrary missed physical exam findings. I really do hope that you learned something. Like I said if you do want me to go through the entire physical exam then please leave a comment below otherwise remember to like and subscribe and again I want to thank you for being here. Thank you.