Postnatal Case in Paediatrics: Complete Guide to History Taking, Examination, and Write-Up

PART 1: HOW TO APPROACH THE CASE

PART 2: HISTORY TAKING - FULL FRAMEWORK

A. Maternal and Antenatal History

• Mother's age, gravida/para status
• Blood group and Rh factor (was anti-D given if Rh negative?)
• Maternal comorbidities: diabetes (GDM or pre-existing), hypertension, thyroid disease, epilepsy, SLE, infections

• Was pregnancy booked? When was first antenatal visit?
• USG findings - any anomaly scan, nuchal translucency, anomalies detected
• Antenatal infections: TORCH (Toxoplasma, Rubella, CMV, HSV), GBS screening, HIV, Hepatitis B, VDRL
• Antenatal steroid use (for preterm) - betamethasone/dexamethasone given?
• Polyhydramnios or oligohydramnios
• Intrauterine growth restriction (IUGR)
• Pregnancy-induced hypertension / pre-eclampsia
• Gestational diabetes - controlled on diet, OHA, or insulin?
• Medications taken during pregnancy (teratogens: warfarin, phenytoin, valproate, isotretinoin, ACE inhibitors)
• Drug use, alcohol, smoking
• Any fever, rash, jaundice during pregnancy
• Genetic screening results: triple/quadruple test, amniocentesis, CVS

B. Labour and Delivery History (Intrapartum)

• Gestational age at delivery (term = 37-41+6 weeks; preterm < 37 weeks)
• Onset of labour: spontaneous or induced (reason for induction?)
• Duration of labour: prolonged labour?
• Mode of delivery: normal vaginal delivery (NVD), forceps/vacuum assisted, LSCS (reason - elective or emergency?)
• Rupture of membranes: SROM or AROM? Duration of ruptured membranes (>18 hrs = prolonged ROM, risk of GBS sepsis)
• Colour of liquor: clear / meconium stained (thin/thick/particulate - grading)
• Cord complications: nuchal cord, cord prolapse
• Placenta: normal delivery, retained placenta, abruption, previa
• Maternal fever during labour or chorioamnionitis?
• Any fetal distress: cardiotocograph (CTG) abnormalities, fetal bradycardia

C. Birth and Immediate Postnatal History

• Exact date and time of birth
• Birthweight - compare with gestational age (AGA, SGA, LGA)
• APGAR scores at 1 minute and 5 minutes (and 10 if depressed)

• Was resuscitation required? (bag-mask ventilation, chest compressions, epinephrine, intubation, surfactant)
• Time to first cry
• Delayed cord clamping done?
• Any birth injuries: caput succedaneum, cephalhaematoma, fractures, nerve palsies (Erb's/facial palsy)

D. Baby's Postnatal Course

• Where is baby being nursed? (postnatal ward with mother, NICU, SCBU)
• Feeding: breast/bottle/NG - established well? Sucking reflex good?
• Urine and meconium: first urine (should pass within 24 hrs), first meconium (within 48 hrs)
• Any episodes of: apnoea, cyanosis, seizures, jitteriness
• Temperature stability (cold stress?)
• Any jaundice - onset (physiological > 24 hrs; pathological < 24 hrs)
• Vitamin K given? (IM or oral - for prevention of haemorrhagic disease of newborn)
• BCG, Hepatitis B vaccine given?
• Newborn screening (heel prick/Guthrie test) done? (hypothyroidism, PKU, cystic fibrosis, haemoglobinopathies)
• Hearing screen done?
• Blood glucose monitoring if at risk (diabetic mother, preterm, SGA, LGA)

E. Family History

• Consanguinity
• Previous child with congenital anomalies or genetic conditions
• Family history of metabolic disorders, haemolytic anaemia (G6PD deficiency, haemoglobinopathies)
• History of neonatal deaths or stillbirths in family

F. Social History

• Living arrangements (housing adequacy, support systems)
• Maternal mental health - postnatal depression screening
• Substance use in household
• Safeguarding concerns

PART 3: PHYSICAL EXAMINATION - SYSTEMATIC HEAD-TO-TOE

1. GENERAL OBSERVATION (before touching)

• Colour: pink (normal), pale (anaemia, shock), plethoric (polycythaemia), jaundiced (bilirubin), central cyanosis, peripheral cyanosis
• Tone: normal, hypotonic (floppy - think hypothyroidism, Down syndrome, HIE, sepsis), hypertonic
• Activity: active, lethargic, irritable
• Cry: normal strong cry, weak cry, high-pitched cry (meningitis, HIE, hypocalcaemia), hoarse cry (hypothyroidism, laryngeal abnormality)
• Respiratory effort: normal, grunting, nasal flaring, subcostal/intercostal recessions, tachypnoea (RR > 60/min)
• Posture: normal flexed posture, opisthotonus (tetanus, meningitis), frog-leg position (hypotonia)
• Dysmorphic features: obvious syndromes (Down, Turner, Pierre Robin, etc.)

2. VITAL SIGNS AND ANTHROPOMETRY

3. SKIN

• Colour abnormalities (as above)
• Physiological conditions: vernix caseosa (white cheesy covering), lanugo (fine hair - especially preterm), milia (tiny white sebaceous cysts on nose), erythema toxicum neonatorum (benign pustular rash), Mongolian spots (blue-grey pigmentation - sacrum/buttocks)
• Pathological: petechiae (thrombocytopenia, infection), purpura, rash of congenital rubella/syphilis, vesicles (HSV, varicella)
• Birthmarks: port wine stain (Sturge-Weber), strawberry haemangioma, café-au-lait spots
• Skin turgor (dehydration assessment)
• Subcutaneous fat (nutritional assessment)
• Ichthyosis, epidermolysis bullosa

4. HEAD

• Shape: moulding (normal - resolves in days), dolichocephaly, plagiocephaly, microcephaly, macrocephaly
• Fontanelles:
  • Anterior fontanelle: diamond-shaped, normally flat and soft; bulging = raised ICP (meningitis, hydrocephalus); sunken = dehydration; normal up to 2 cm; closes 9-18 months
  • Posterior fontanelle: triangular, closes by 6-8 weeks
• Sutures: overriding (moulding), widely separated (raised ICP), craniosynostosis (premature fusion)
• Birth injuries: caput succedaneum (oedema crossing suture lines - present at birth, resolves quickly), cephalhaematoma (subperiosteal haemorrhage - does NOT cross sutures, appears 24-48 hrs, risk of jaundice), subgaleal haemorrhage (most dangerous - crosses suture lines)
• Scalp: electrode marks, forceps marks

5. FACE

• General: dysmorphic features (flat face, epicanthal folds, upslanting palpebral fissures of Down syndrome)
• Facial asymmetry (facial nerve palsy - look for when baby cries)
• Facial movements, jaw size (micrognathia - Pierre Robin sequence)

6. EYES

• Open eyes - usually does not open spontaneously initially; examine in dim light or hold baby upright
• Conjunctivae: subconjunctival haemorrhage (benign, due to delivery), pallor, icterus
• Red reflex: must be tested bilaterally - absent/white pupillary reflex (leukocoria) = retinoblastoma, congenital cataract, glaucoma - urgent referral
• Corneal clouding: congenital glaucoma
• Eye size: microphthalmia (congenital rubella, TORCH)
• Discharge: gonococcal/chlamydial ophthalmia neonatorum
• Nystagmus
• Pupillary reactions to light (if feasible)

7. EARS

• Position and shape: low-set ears (chromosomal abnormalities - Down, Turner, Trisomy 18/13)
• Pre-auricular pits or tags (associated with renal anomalies - check renal USS)
• Ear canal patency
• Hearing screening - automated auditory brainstem response (AABR) or otoacoustic emissions (OAE) - done before discharge

8. NOSE

• Nasal patency: choanal atresia - baby is obligate nasal breather; if cyanosed at rest but pink when crying = suspect bilateral choanal atresia. Test with catheter or cold spatula.
• Shape, nasal bridge (flat = Down syndrome)
• Nasal flaring (respiratory distress)

9. MOUTH AND OROPHARYNX

• Lips: cleft lip (midline or unilateral/bilateral)
• Palate: inspect with tongue depressor + light for cleft palate (including submucosal cleft - may be missed) - run finger along palate
• Gum pads: Epstein's pearls (white cysts along gum margins - normal), natal teeth (remove if mobile - risk of aspiration)
• Tongue: macroglossia (Beckwith-Wiedemann, hypothyroidism, Down syndrome), tongue-tie (ankyloglossia) - check with tongue-lift, affects feeding
• Jaw: retrognathia/micrognathia (Pierre Robin)
• Sucking reflex: stimulate by touching upper lip
• Rooting reflex: stroke cheek - baby turns to that side

10. NECK

• Webbing: Turner syndrome (XO), Noonan syndrome
• Goitre: congenital hypothyroidism, neonatal Graves' disease
• Cystic hygroma: soft, fluctuant, transluminates
• Sternocleidomastoid (SCM) tumour: palpable firm mass in SCM (birth injury - may lead to torticollis)
• Branchial cyst/fistula: along anterior border of SCM
• Range of neck movement: torticollis (head tilt)

11. CARDIOVASCULAR SYSTEM

• Inspection: cyanosis (central vs peripheral), respiratory distress, precordial bulge
• Palpation:
  • Apex beat: normally 4th ICS, MCL; displaced = cardiomegaly or pneumothorax
  • Heaves and thrills
  • Femoral pulses: bilaterally - absence/weakness = coarctation of aorta (EMERGENCY)
  • Compare right brachial + femoral pulse volume and timing (radioradial/radiofemoral delay)
• Auscultation (at all 4 areas + axillae + back):
  • Normal: S1 and S2 present; splitting of S2
  • Murmurs: innocent flow murmur common in first 24-48 hrs as ductus closes; pathological murmur (PDA, VSD, ASD, ToF)
  • Note: many serious congenital heart defects (cyanotic) present WITHOUT a murmur initially

12. RESPIRATORY SYSTEM

• Inspection: RR, symmetry of chest movement, chest shape (barrel chest, pectus excavatum/carinatum), signs of respiratory distress - grunting (most specific for RDS/transient tachypnoea), nasal flaring, subcostal recession, intercostal recession, sternal recession
• Palpation: tracheal position (deviation = pneumothorax, diaphragmatic hernia)
• Auscultation: equal air entry bilaterally; added sounds (crackles, wheeze); absent breath sounds on one side (pneumothorax, diaphragmatic hernia, pleural effusion)

13. ABDOMEN

• Inspection: shape (scaphoid = diaphragmatic hernia; distended = obstruction, organomegaly, ascites), visible peristalsis, abdominal wall defects
• Abdominal wall:
  • Umbilicus: number of vessels (normally 2 arteries + 1 vein; single artery = renal anomalies), patent urachus, umbilical hernia
  • Umbilical stump: dry and shrivelling (should fall off ~7-14 days); signs of omphalitis (redness, discharge, smell)
  • Gastroschisis: bowel herniates to RIGHT of umbilicus, no peritoneal sac - emergency surgical repair
  • Exomphalos/omphalocele: central defect, covered by sac, associated with Beckwith-Wiedemann syndrome
• Palpation: gently, with warm hands
  • Liver: normally palpable 1-2 cm below RCM; hepatomegaly = infection, haemolytic anaemia, heart failure, metabolic disease
  • Spleen: normally tip palpable; splenomegaly = infection, haemolytic anaemia
  • Kidneys: palpate bimanually in flanks; easily felt in neonates; enlarged = hydronephrosis, polycystic kidneys, Wilms' tumour (rarely at this age)
  • Any masses: neuroblastoma (adrenal mass - flank), sacrococcygeal teratoma
• Anus and rectum: inspect for patency (imperforate anus), position of anus (anterior displacement), any fistula
  • First meconium: should pass within 24-48 hrs; delay = imperforate anus, Hirschsprung's disease, CF, hypothyroidism

14. SPINE AND BACK

• Lay baby prone:
• Sacral dimples: simple dimple (< 2.5 cm from anus, < 0.5 cm deep, no other features) is benign; deep/complex/hairy/deviated dimple or skin tags = spinal dysraphism, tethered cord - needs USS spine
• Neural tube defects: meningocele (CSF filled sac, skin covered), myelomeningocele (open, neural tissue exposed - immediate sterile covering and neurosurgical referral), spina bifida occulta
• Scoliosis: congenital vertebral anomalies
• Hair tuft over spine: spinal dysraphism

15. GENITALIA AND GROINS

• Testes: palpate both sides of scrotum; are both testes descended into scrotum? (cryptorchidism - undescended testis if absent)
• Scrotum: hydrocele (transilluminates), inguinal hernia
• Penis and urethra: position of urethral meatus - at tip of glans (normal), ventral surface (hypospadias - DO NOT circumcise), dorsal surface (epispadias - associated with bladder exstrophy)
• Phimosis (normal in newborn - foreskin not retractable, do NOT force)
• Penile length: micropenis (< 2 cm stretched)

• Labia: ensure both labia majora and minora present; labial fusion
• Clitoris: clitoromegaly (congenital adrenal hyperplasia, maternal androgen exposure)
• Vaginal opening: mucoid white discharge (maternal oestrogen withdrawal, normal) or blood-stained discharge (normal - pseudo-menstruation), hydrocolpos
• Ambiguous genitalia: any neonate with ambiguous genitalia = medical EMERGENCY - do NOT assign sex until investigations; check 17-OH progesterone (CAH), karyotype, genital USS

• Inguinal region: inguinal hernias (more common in preterm and males)

16. HIPS

• Barlow's test: stabilise pelvis, adduct and apply posterior pressure - positive if hip can be DISLOCATED posteriorly out of acetabulum (clunk = dislocation)
• Ortolani's test: flex hip to 90°, abduct and apply anterior pressure - positive if previously dislocated hip can be REDUCED back into acetabulum (clunk = reduction)
• Look for: limited abduction (< 60° = suspect DDH), leg length asymmetry, asymmetric skin folds (extra folds on affected side), Galeazzi sign (unequal knee heights)
• Risk factors for DDH: female sex, breech presentation, positive family history, oligohydramnios, torticollis

17. UPPER AND LOWER LIMBS

• Number of digits: polydactyly (extra digits), syndactyly (fused digits), oligodactyly
• Palmar creases: single transverse palmar crease (simian crease) = Down syndrome, normal variant
• Camptodactyly: fixed flexion of fingers
• Talipes: equinovarus (CTEV - foot turned in and down), calcaneovalgus (foot turned out and up)
• Limb length: asymmetry (hemiplegia, hemihypertrophy)
• Brachial plexus injuries:
  • Erb's palsy: C5-C6; arm hangs adducted, internally rotated, extended at elbow ("waiter's tip" position)
  • Klumpke's palsy: C8-T1; weakness of intrinsic hand muscles
• Clavicles: palpate for fractures (crepitus, asymmetric movement) - common birth injury especially with shoulder dystocia

18. NEUROLOGICAL EXAMINATION

• Central tone: axial (head lag test - pull baby from supine to sitting, head should not fall back completely in term baby), ventral suspension (baby should maintain spine horizontal), vertical suspension
• Peripheral tone: limb tone - flexion at all joints

• CN II: red reflex, pupillary light reflex
• CN III/IV/VI: eye movements, pupils
• CN V: corneal reflex, sucking
• CN VII: facial symmetry during crying
• CN IX/X/XII: sucking, swallowing, cry quality

19. GESTATIONAL AGE ASSESSMENT

• Posture
• Square window (wrist)
• Arm recoil
• Popliteal angle
• Scarf sign
• Heel to ear

• Skin texture
• Lanugo
• Plantar surface creases
• Breast bud size
• Eye/ear cartilage development
• Genitalia

PART 4: HOW TO WRITE UP THE CASE

Suggested Write-Up Format:

• Temperature: [? °C]
• HR: [? bpm]
• RR: [? breaths/min]
• SpO₂: [? %] (right hand)
• BP: [if measured]

• Weight: [? grams] - [?th centile]
• Length: [? cm] - [?th centile]
• HC: [? cm] - [?th centile]

• Tone: Normal central and peripheral tone. No head lag.
• Moro reflex: symmetric, present.
• Sucking/rooting: present.
• Palmar grasp: present bilaterally.
• ATNR: present.

1. Continue breastfeeding support
2. Blood glucose monitoring (if at risk - LGA, IDM, SGA)
3. Transcutaneous bilirubin (TcB) / serum bilirubin if jaundice develops
4. Newborn metabolic screen (heel prick) - to be done at 24-72 hrs
5. Hearing screen before discharge
6. Pulse oximetry screening - confirm result
7. Review at 6 weeks for developmental check
8. Advise parents on:
   • Safe sleeping (back to sleep - reduce SIDS risk)
   • Feeding frequency and signs of adequate feeding
   • Normal physiological events: milia, erythema toxicum, Mongolian spots, umbilical stump care
   • When to seek help: fever, poor feeding, lethargy, jaundice, respiratory difficulty
9. Vitamin K: confirm given / complete oral course
10. Immunisation schedule explained

QUICK MEMORY AIDS

• Absent red reflex (cataract/retinoblastoma)
• Absent femoral pulses (coarctation of aorta)
• Respiratory distress + scaphoid abdomen (diaphragmatic hernia)
• Central cyanosis not responding to oxygen
• Ambiguous genitalia
• Bilious vomiting (intestinal obstruction)
• Imperforate anus
• Seizures
• Vesicles/petechiae (HSV/sepsis)

All Possible Questions to Ask in a Postnatal Case

SECTION 1: QUESTIONS YOU ASK THE MOTHER (History Taking)

About the Pregnancy

1. When did you first attend antenatal care? Was the pregnancy booked or unbooked?
2. How many times have you been pregnant before? Any previous deliveries, miscarriages, or abortions?
3. What is your blood group? Were you told your Rh factor?
4. Did you take folic acid before and during pregnancy?
5. Did you have any illness during pregnancy - fever, rash, jaundice?
6. Were you screened for infections - HIV, Hepatitis B, syphilis (VDRL), rubella?
7. Did you have diabetes during pregnancy? How was it controlled - diet, tablets, or insulin?
8. Did you have high blood pressure during pregnancy?
9. Did you have any swelling of hands and feet? Any headache, blurred vision? (pre-eclampsia)
10. Were any abnormalities found on ultrasound scan?
11. Was there too much or too little fluid around the baby? (polyhydramnios/oligohydramnios)
12. Did the baby move well throughout pregnancy? Any reduced fetal movements?
13. Did you take any medications or tablets during pregnancy?
14. Did you smoke, drink alcohol, or use any drugs during pregnancy?
15. Were you given any injections for the baby's lung maturity? (antenatal steroids - if preterm)
16. Was genetic screening done? Triple test, amniocentesis, or CVS?
17. Did you have thyroid disease during pregnancy?
18. Did you have any bleeding during pregnancy?

About Labour and Delivery

1. How many weeks pregnant were you when you delivered?
2. Did labour start on its own or was it induced? Why was it induced?
3. How long did labour last?
4. How was the baby delivered - normal delivery, forceps, vacuum, or caesarean? Why?
5. Did your water break on its own or was it broken artificially?
6. How long before delivery did your water break? (prolonged ROM > 18 hrs = GBS risk)
7. What colour was the fluid when the water broke - clear, or was it green/dark? (meconium)
8. Did you have a fever during labour?
9. Was there any problem with the umbilical cord?
10. Did the placenta deliver normally?
11. Were there any problems during delivery?

About the Baby After Birth

1. Did the baby cry immediately after birth?
2. Did the baby need any help to breathe at birth?
3. What was the baby's weight at birth?
4. Was the baby kept with you or taken to the special care unit?
5. Is the baby feeding well - breast or bottle?
6. How often is the baby feeding? How long at each feed?
7. Is the baby satisfied after feeds?
8. Has the baby passed urine yet? (should be within 24 hours)
9. Has the baby passed the first dark stool (meconium)? (should be within 48 hours)
10. Has the baby turned yellow? When did you notice it?
11. Was the baby given a Vitamin K injection?
12. Was the baby given the Hepatitis B vaccine?
13. Was BCG given?
14. Has the baby's hearing been tested?
15. Has the heel prick blood test been done?
16. Has the baby had any episodes of going blue, stopping breathing, or fitting?
17. Has the baby been well since birth - any concerns?
18. Is the baby sleeping well?

Family and Social History

1. Are you and your partner related to each other? (consanguinity)
2. Do you have any other children? Are they all healthy?
3. Is there any family history of heart problems, fits, or genetic conditions?
4. Is there any family history of hearing problems?
5. Is there any family history of hip problems?
6. Has anyone in the family had jaundice as a newborn or needed blood transfusion?
7. Is there a family history of G6PD deficiency or sickle cell disease?
8. Is there any family history of congenital anomalies or mental handicap?
9. Has anyone in the family had a baby who died in the first few weeks of life?
10. How are you feeling emotionally? Are you getting enough support at home? (postnatal depression screening - Edinburgh score)
11. Who is at home to help you with the baby?
12. Are there any worries about your home situation or your ability to care for the baby?

SECTION 2: EXAMINER QUESTIONS TO YOU (Viva / OSCE)

On History Taking

1. What is the significance of prolonged rupture of membranes (> 18 hours)? (Answer: Risk of Group B Streptococcal sepsis - screen baby, give antibiotics if symptomatic)
2. Why do you ask about maternal blood group? (Answer: Rh incompatibility and ABO incompatibility cause haemolytic disease of the newborn - early jaundice)
3. What is the significance of meconium-stained liquor? (Answer: Risk of meconium aspiration syndrome - can cause respiratory distress, chemical pneumonitis)
4. What is the significance of polyhydramnios? (Answer: Associated with oesophageal atresia, duodenal atresia, anencephaly, neuromuscular conditions affecting swallowing)
5. What is the significance of oligohydramnios? (Answer: Renal agenesis / obstructive uropathy - Potter sequence; IUGR; post-dates pregnancy)
6. Why ask about antenatal infections? (Answer: TORCH infections - congenital abnormalities, hepatosplenomegaly, IUGR, thrombocytopenia, hearing loss)
7. What maternal medications are teratogenic? (Answer: Valproate - NTD, phenytoin - fetal hydantoin syndrome, warfarin - nasal hypoplasia, isotretinoin - CNS/cardiac defects, ACE inhibitors - renal agenesis, thalidomide - limb defects)
8. When is jaundice physiological vs pathological? (Answer: Physiological = appears after 24 hrs, peaks day 3-5, resolves by day 10-14 in term. Pathological = appears within 24 hrs, persists > 2 weeks, bilirubin rising > 85 µmol/L/day, conjugated fraction raised)
9. What does APGAR stand for and what is the significance? (Answer: Appearance, Pulse, Grimace, Activity, Respiration. Score 7-10 = normal, 4-6 = moderate depression, 0-3 = severe depression)
10. What is the significance of a single umbilical artery? (Answer: Associated with renal anomalies in ~7% of cases; also cardiac and chromosomal anomalies - USS kidneys recommended)

On Physical Examination

1. Why do you examine the hips in every newborn? (Answer: To screen for developmental dysplasia of the hip (DDH) - early detection allows splinting and avoids later surgery)
2. What is Barlow's vs Ortolani's test? (Answer: Barlow = dislocating a reducible hip. Ortolani = reducing a dislocated hip. Positive clunk = refer for USS hip)
3. What is the red reflex and why is it important? (Answer: Tests for opacity in the visual axis. Absent = cataract, retinoblastoma, congenital glaucoma - urgent ophthalmology referral)
4. How do you test for choanal atresia? (Answer: Pass a 5 Fr catheter through each nostril, or hold cold spatula under nose and look for bilateral misting; baby cyanosed at rest, pink when crying)
5. What are the differences between caput succedaneum and cephalhaematoma?

1. What primitive reflexes are present in a newborn? (Answer: Moro, rooting, sucking, palmar grasp, plantar, ATNR, stepping, Galant)
2. What is the significance of an absent Moro reflex? (Answer: Bilateral absence = CNS depression (HIE, sedation), diffuse neuromuscular disease. Unilateral = brachial plexus injury, clavicle fracture, hemiplegia)
3. Why palpate the femoral pulses? (Answer: Absence or weakness = coarctation of the aorta - duct-dependent circulation, may collapse when ductus closes)
4. What is pulse oximetry screening for? (Answer: Critical congenital heart disease - measures pre-ductal (right hand) and post-ductal (foot) SpO₂; difference > 3% or absolute < 95% = refer for echo)
5. How do you assess gestational age in a newborn? (Answer: New Ballard Score - neuromuscular maturity (posture, square window, arm recoil, popliteal angle, scarf sign, heel to ear) + physical maturity (skin, lanugo, plantar creases, breast, eyes/ears, genitalia))
6. What is a sacral dimple and when is it concerning? (Answer: Concerning features = depth > 0.5 cm, > 2.5 cm from anus, not visualising the base, hairy tuft, skin tag, deviated gluteal cleft - needs spinal USS for tethered cord/spina bifida occulta)
7. What is the significance of ambiguous genitalia? (Answer: Medical emergency - most common cause is congenital adrenal hyperplasia (21-hydroxylase deficiency), salt-wasting CAH is life-threatening. Do NOT assign sex until full investigation: karyotype, 17-OHP, pelvic USS, electrolytes)
8. What is the significance of bilious (green) vomiting in a neonate? (Answer: Intestinal obstruction below the ampulla of Vater until proven otherwise - duodenal atresia, malrotation/volvulus, jejunal atresia, Hirschsprung's disease - surgical emergency)
9. What is erythema toxicum neonatorum? (Answer: Benign, common rash in 50% of term neonates; blotchy erythematous macules/papules/pustules; peaks day 2-3; contains eosinophils on smear; no treatment needed)
10. What is the anterior fontanelle - size and when does it close? (Answer: Diamond-shaped, 1-3 cm, flat and soft normally; bulging = raised ICP; sunken = dehydration; closes 9-18 months)
11. What constitutes physiological weight loss in a newborn? (Answer: Up to 10% of birthweight in first 3-5 days is normal. Should regain birthweight by 10-14 days. More than 10% or failure to regain = inadequate feeding, evaluate)

On Investigations

1. What investigations would you order for a jaundiced neonate < 24 hours?
   • Total and direct bilirubin (serum)
   • Blood group (baby and mother)
   • Direct Coombs test (DCT)
   • FBC (haemoglobin, reticulocyte count)
   • Peripheral blood smear
   • G6PD assay
   • LFTs, septic screen if needed
2. What is the newborn metabolic screen (heel prick) and what does it test for? (Answer: Done at 24-72 hours. Tests for: congenital hypothyroidism, PKU, cystic fibrosis, sickle cell disease, MCAD deficiency, and others depending on country's programme)
3. What investigations would you do for a baby with respiratory distress at birth?
   • Chest X-ray (first investigation)
   • Blood gas (ABG/capillary)
   • Blood glucose
   • Blood culture, FBC, CRP (sepsis screen)
   • Surfactant if RDS confirmed
4. What is the normal blood glucose range in a neonate? (Answer: > 2.6 mmol/L after 4 hours of age. < 2.6 mmol/L = hypoglycaemia - treat with feeds or IV dextrose depending on severity)
5. When would you do an echocardiogram in a newborn?
   • Persistent cyanosis not responding to oxygen
   • Absent femoral pulses
   • Failed pulse oximetry screen
   • Pathological murmur
   • Newborn of diabetic mother (hypertrophic cardiomyopathy)
   • Suspected structural heart disease on antenatal scan

On Management

1. What would you advise regarding safe sleeping to prevent SIDS?
   • Back to sleep (supine position)
   • Own cot/Moses basket in parents' room for first 6 months
   • Firm, flat, waterproof mattress
   • No pillows, duvets, soft toys
   • No co-sleeping (especially if parent smokes, drinks, obese)
   • Smoke-free environment
   • Not too hot, room temperature 16-20°C
   • Breastfeeding is protective
2. What is the purpose of Vitamin K at birth? (Answer: Prevention of haemorrhagic disease of the newborn (Vitamin K Deficiency Bleeding - VKDB). Newborns have low Vitamin K, low clotting factors, low gut flora. Given IM (single dose) or oral (3 doses). IM is more reliable, especially for breastfed babies)
3. When would you start phototherapy for neonatal jaundice? (Answer: Based on bilirubin level vs age in hours using threshold charts (NICE/AAP guidelines). Threshold varies with gestational age and risk factors. Exchange transfusion for severe/rising bilirubin not responding to phototherapy)
4. What are the risk factors for developmental dysplasia of the hip requiring USS?
   • Female sex
   • Breech presentation (any gestational age)
   • First-degree family history of DDH
   • Clinical instability on examination (Barlow/Ortolani positive or clicky hip)
   • Oligohydramnios
   • Neuromuscular conditions
5. When is hearing screening done and what methods are used? (Answer: Before discharge from hospital or within 4-5 weeks of birth. Methods: Otoacoustic Emissions (OAE) first; if fails, Automated Auditory Brainstem Response (AABR). Babies with risk factors (NICU > 5 days, family history, congenital infections) go straight to AABR)

Common Short Answer / MCQ Style Questions

1. What is the difference between SGA, AGA, and LGA? (Answer: Small for gestational age = birthweight < 10th centile; Appropriate = 10th-90th centile; Large = > 90th centile)
2. What is the definition of a preterm baby? (Answer: < 37 completed weeks of gestation. Extremely preterm < 28 weeks, Very preterm 28-32 weeks, Moderate to late preterm 32-37 weeks)
3. What is surfactant and when is it given? (Answer: Phospholipid mixture produced by Type II pneumocytes, reduces surface tension in alveoli. Exogenous surfactant given intratracheally for RDS in preterm babies, usually < 32 weeks or when FiO₂ > 0.3)
4. What is hypoxic ischaemic encephalopathy (HIE)? (Answer: Brain injury from perinatal asphyxia. Features: encephalopathy (reduced consciousness, seizures, abnormal tone), within 6 hours of birth. Therapeutic hypothermia (cooling to 33-34°C for 72 hours) is the treatment for moderate-severe HIE in ≥ 36 weeks babies - started within 6 hours of birth)
5. What is transient tachypnoea of the newborn (TTN)? (Answer: Most common cause of respiratory distress. Due to delayed clearance of lung fluid - common after elective LSCS. Presents: tachypnoea, grunting, mild hypoxia. CXR: streaky perihilar markings, fluid in horizontal fissure. Resolves within 24-72 hours. Treatment: supportive - oxygen, CPAP if needed)

QUICK CHEAT SHEET - "RED FLAG" QUESTIONS AT A GLANCE