Newborn Examination (NIPE)

Starting the exam

Congratulate the parents and introduce yourself stating your role. Check the baby’s details, explain to the parents what the examination will entail, and gain consent. This would also be an ideal time to ask the parents questions regarding any family history of issues with the heart, hips, eyes and testes during neonatal life as part of the NIPE screening. Other initial questions should include the baby’s feeding and bowel habits and whether they have passed any urine.

General inspection

Undress the baby, check the tone, posture and movements, then observe for any obvious abnormalities such as:

• Cyanosis
• Respiratory distress
• Pallor
• Jaundice
• Any dysmorphic features
• If baby is crying, what is the pitch? Is it feeble? Does it sound normal?

Head

Assess for:

• Head shape: Macro or microcephaly, hydrocephalus, plagiocephaly, is there cranial moulding?
• Any injuries: e.g., from forceps during an instrumental delivery
• Swellings: caput succedaneum, cephalhematoma
• Cranial sutures: lambdoid, sagittal, frontal; check if they are fused (craniosynostosis)
• Fontanelles: anterior and posterior; are they bulging? Sunken?
• Head circumference: measure from occiput to frontal bone (OFC)
• Ears: low set, periauricular tags, deformity such as microtia or atresia

Face

Inspect the face for any dysmorphic features suggesting underlying genetic conditions such as Down’s Syndrome.

Nose

Check for choanal atresia (obstructed nostrils) by blocking each nostril in turn using your finger and check if the baby breathes comfortably out of it. Ensure caution when assessing for choanal atresia.

Mouth

Press gently on the baby’s chin to open their mouth, or take the chance to have a look in the mouth when the baby is crying. Assess the oral cavity using a pen torch and a tongue depressor to ensure visualisation of the whole palate.

Assess for:

• Epstein’s pearls (common and benign bumps on the gums or palate)
• White coating of tongue (curdled milk or candida infection)
• Ankyloglossia (tongue-tie)
• Macroglossia
• Cysts such as ranula
• Teeth may rarely be present from birth

Palpate the palate, is it normal, high arched, cleft palate?

Eyes

For the baby’s eyes, assess for the following:

• Position of the eyes
• Symmetry and shape
• Red reflex using an ophthalmoscope
  • Absence or white reflex can suggest retinoblastoma or congenital cataracts
• Icteric sclera for neonatal jaundice
• Erythema or discharge due to conjunctivitis
• Subconjunctival haemorrhage to suggest trauma during the delivery
  • If present, ensure that this finding is documented in the baby’s red book

Skin

Commonly observed skin changes in neonates include:

• Congenital dermal melanocytosis (Mongolian blue spot)

• Milia
• Acne neonatorum
• Port Wine stain
• Strawberry naevus
• Stork’s beak mark
• Erythema toxicum neonatorum
• Melanocytic naevi

Back

Inspect for any midline skin changes, tufts of hair, sacral dimple, swelling and spine asymmetry or curvatures.

Palpate the spine as there could be spina bifida occulta present.

Chest

Normal observations in neonates are:

• Heart rate: 120-160 beats/minute
• Systolic BP: 50-70 mmHg
• Respiratory rate: 40-60 breaths/minute
• Temperature: 36.5-37.5°C

Cardiac

Inspect the baby, is the baby pink or cyanosed?

Palpate the precordium for the apex beat, and any heaves and thrills.

Palpate the femoral and brachial pulses and check the pre- and post-ductal O2 saturations by attaching the pulse oximeter to the baby’s right hand for pre-ductal saturations and to either foot for post-ductal saturations.

Weak or absent femoral pulses suggest coarctation of the aorta.

Auscultate the precordium using the bell initially and then the diaphragm. Describe the hearts sounds and note any additional heart sounds or murmurs.

Blood pressure is not routinely assessed in newborn examinations.

Respiratory

Assess the baby’s respiratory rate and effort. Are there any signs of respiratory distress such as tachypnoea, flaring of the nostrils, grunting or subcostal recession?

Inspect the baby’s chest shape and expansion. Is it equal?

Are there any airway noises such as stridor or stertor?

Auscultate with the diaphragm of the stethoscope. Percussion in babies not routinely used.

Abdomen

Inspect and palpate the abdomen in all 9 quadrants. Herniation of bowel contents through a defect in the abdominal wall may cause gastroschisis, or an omphalocele may herniate through the umbilicus.

Inspect the umbilical cord stump. A small amount of blood is commonly seen in neonates.

There may be abdominal distension due to feeds or swallowed air.

Ensure to palpate for the liver and spleen. Note that in neonatal splenomegaly, the enlarged spleen can be felt in the left flank as opposed to the right iliac fossa as seen in adults.

The liver edge is normally felt approximately 1 cm below the subcostal margins.

Note any other swellings such as inguinal hernias. Check that the anus is patent and ask the parents if the baby has passed meconium.

Genitalia

Inspect the external genitalia and anus in the baby.

Is it clear male or female genitalia or is their ambiguity?

In premature females, the labia minora are more prominent and this resolves with time.

In males examine the testes.

Ask the parents if the baby has passed urine or any faeces if not asked already.

Limbs

Upper Limbs

Count the fingers: normal amount, polydactyly or syndactyly.

Examine the palmar creases, a single palmar crease may be seen in Down’s syndrome and other genetic conditions.

Inspect the size of the limb, any asymmetry, deformity or abnormal posture and movement.

Look for presence for nerve palsies such as Erb’s or Klumpke’s palsy.

Lower Limbs

Palpate femoral pulses if not done so already.

Inspect the length of the lower limbs and note any abnormalities e.g., in the feet you may have talipes equinovarus (club foot).

Count the toes.

Hips

Inspect the creases in the groin.

Ensure hip abduction and adduction is symmetrical.

Perform Barlow and Ortolani tests to begin assessment for developmental dysplasia of the hip. Explain to the parents what the tests involve before performing them. Test each leg in turn:

• Barlow test: with the baby’s knee in a flexed position move the thigh in a lateral position then push downwards to try to dislocate the hip. A click/clunk sound means the hip is dislocated.
• Ortolani test: continue in the position created by Barlow test, stabilise the pelvis by firmly holding the symphysis pubis and coccyx with one hand, and abduct the hip slowly whilst applying pressure to the greater trochanter with your index and middle fingers of your other hand. A click/clunk sound indicates the hip has relocated.

Reflexes

All of the following reflexes should be present from birth in a healthy baby. The primitive reflexes are lower motor neurone responses and are useful aids in identifying neurological pathology due to congenital, pathological or traumatic causes.

Moro reflex

Ensure you warn the parents of what you are about to perform

Hold the baby up in front of you, over a soft surface such as the cot, supporting their upper body in one hand and their bottom in the other. Suddenly drop the baby’s upper body backwards. The baby abducting then adducting their arms is a normal response. The baby may also cry due to the fright.

Grasp reflex

Place a finger in the baby’s palm and they should grasp your finger

Suckling reflex

Place a finger in the baby’s mouth and touch the palate. The baby should suck your finger in response.

References:

Innes J.A, Dover A.R, Fairhurst K, editors. Macleod’s Clinical Examination E-Book. Elsevier Health Sciences; 2018

Qureshi Z, editors. The Unofficial Guide to Paediatrics e-book. Elsevier Health Sciences; 2017.

Baston H, Durward H. Examination of the newborn: a practical guide. Routledge; 2016 Dec 15.