Newborn Assessment

Introduction

The Newborn Assessment is a fundamental competency for the MCCQE1 and a critical skill for any physician managing pediatric patients. In the context of the CanMEDS framework, this assessment integrates the roles of Medical Expert (clinical skills), Communicator (reassuring parents), and Health Advocate (screening and preventive care).

For the purpose of MCCQE1 preparation, you must distinguish between normal physiological transitions, benign findings, and pathological signs requiring immediate intervention. This guide focuses on the standard of care in Canada, adhering to Canadian Paediatric Society (CPS) guidelines.

Immediate Newborn Care: The Golden Minute

The first minute of life is critical. While most newborns transition seamlessly, approximately 10% require some assistance.

The APGAR Score

Assessed at 1 minute and 5 minutes. It is retrospective and used to assess response to resuscitation, not to decide when to start resuscitation.

The Routine Physical Examination

This examination usually takes place within the first 24 hours. Ensure the room is warm and lighting is adequate.

Growth Charting (WHO Growth Charts for Canada):

• Weight: Average ~3.5 kg. Newborns may lose up to 10% of birth weight in the first week but should regain it by day 10–14.
• Length: Average ~50 cm.
• Head Circumference (OFC): Average ~35 cm.

Weight Loss Calculation:
((Birth Weight - Current Weight) / Birth Weight) x 100 = % Loss

Comprehensive Head-to-Toe Assessment

Use the following tabs to navigate through the systematic review required for MCCQE1.

Canadian Guidelines & Routine Screening

To align with MCCQE1 objectives, you must be familiar with standard Canadian prophylaxis and screening protocols.

1. Prophylactic Medications

• Vitamin K: IM injection given within 6 hours of birth to prevent Vitamin K Deficiency Bleeding (VKDB). Oral administration is available but less effective and requires strict adherence.
• Erythromycin Eye Ointment: Historically for Neisseria gonorrhoeae prophylaxis.
  • Note: The Canadian Paediatric Society (CPS) recommends against routine use, advocating for screening pregnant women instead. However, it is still legally mandated in some provinces (e.g., Ontario, though parents can opt-out).
• Vitamin D: All breastfed infants in Canada should receive 400 IU/day starting at birth to prevent rickets.

2. Screening Tests

• Newborn Blood Spot Screening (Metabolic): Performed at 24–48 hours. Screens for Hypothyroidism, PKU, Sickle Cell, Cystic Fibrosis, etc. (Panel varies by province).
• Newborn Hearing Screening: Universal screening (OAE or AABR) usually prior to discharge.
• Critical Congenital Heart Disease (CCHD): Pulse oximetry screening on right hand (pre-ductal) and either foot (post-ductal).
  • Pass: $\ge$95% in either extremity and difference ≤3%.

3. Hyperbilirubinemia Screening

• All infants screened before discharge.
• Plot Total Serum Bilirubin (TSB) on the Bhutani Nomogram or Canadian equivalent guidelines to determine risk and need for phototherapy.

Key Points to Remember for MCCQE1

• Red Reflex: Absence is an ocular emergency (ophthalmology referral).
• Hip Exam: A “click” is often benign; a “clunk” (Ortolani) is pathological. Ultrasound is the imaging of choice for DDH, but usually performed after 6 weeks unless physical exam is positive.
• Murmurs: A continuous “machine-like” murmur is a PDA.
• Weight Loss: >10% requires evaluation of feeding (lactation support).
• Vomiting: Bilious vomiting (green) is malrotation with volvulus until proven otherwise (Emergency!).
• Hypoglycemia: Risk factors include IDM (Infant of Diabetic Mother), LGA, SGA, Preterm.

Sample Question

Explanation

The correct answer is:

• C. Observation and reassurance

Detailed Analysis: This clinical scenario describes a Cephalohematoma.

• Diagnosis: A cephalohematoma is a subperiosteal hemorrhage. Key distinguishing features provided in the stem are that it is “firm/fluctuant” and does not cross suture lines (because it is constrained by the periosteum).
• Management: The standard of care is observation. Most cephalohematomas resolve spontaneously over weeks to months.
• Complications: While generally benign, as the blood breaks down, it can lead to an increased load of bilirubin, so these infants should be monitored closely for jaundice.

Why other options are incorrect:

• A: Needle aspiration is contraindicated due to the risk of introducing infection (osteomyelitis/abscess).
• B: CT scan is unnecessary unless there are neurological signs suggesting intracranial hemorrhage or skull fracture (uncommon).
• D: Compression is not indicated and does not speed resolution.
• E: Antibiotics are not indicated as this is a traumatic/hemorrhagic process, not infectious.

Differential Diagnosis Note:

• Caput Succedaneum: Crosses suture lines, usually present at birth, edema (pitting), resolves in days.
• Subgaleal Hemorrhage: Crosses sutures, boggy, diffuse, can cause massive blood loss and shock.

References

1. Canadian Paediatric Society. (2023). Routine screening and prophylaxis for newborns. https://cps.ca 
2. Zaichkin, J., & Weiner, G. M. (2021). Textbook of Neonatal Resuscitation (NRP), 8th Edition. American Academy of Pediatrics / Canadian Paediatric Society.
3. Riederer, J. (2024). Toronto Notes 2024: Comprehensive Medical Reference and Review for the Medical Council of Canada Qualifying Exam Part I. Toronto Notes for Medical Students, Inc.
4. Public Health Agency of Canada. Family-Centred Maternity and Newborn Care: National Guidelines.
5. Medical Council of Canada. MCCQE Part I Clinical Decision-Making and Multiple-Choice Questions Objectives.