The Newborn and Infant Physical Examination (NIPE) or Examination of the Newborn (EON) is performed on every newborn baby within the first 72 hours of life by doctors and midwives.

It is a screening tool used to identify congenital anomalies in babies as quickly as possible and make the appropriate referrals if needed. Whilst this is a top-to-toe examination, it focuses on the eyes, heart, hips and testicles.

Every baby has a NIPE performed, either in hospital before discharge or at home by a community midwife. Babies in the neonatal unit will typically wait until they are well enough for the examination e.g. NIPE is not performed for baby’s who are ventilated, on CPAP or have lots of different lines inserted. The NIPE can be performed on a pre-term baby but they will need to be 34+0 or older before their hips are checked.

The baby will have another check by their GP at 6-8 weeks of age as some conditions take longer to manifest with clinical signs.  

Consent

It is very important to fully consent the parents before performing this examination

This is usually done at the bedside with both parents, first confirming the name and date of birth of the baby before describing the examination as described above. Ask the parents if they are happy to proceed with the examination.

Screening Questions

There are some important screening questions that the parents need to be asked and they refer to first degree relatives of the baby e.g. the parents, siblings and half-siblings.

1. Are there any heart problems at birth in any first degree relatives, especially any that required surgery ? (Aortic Coarctation is the most commonly inherited cardiac anomaly so ensure to ask about a family history of this).
2. Are there any eye problems at birth in any first degree relatives e.g. congenital cataracts or retinoblastoma?
3. Are there any hip problems at birth in any first degree relatives, especially those that required treatment with harnesses or surgery?
4. Was the baby head down presentation from 36 weeks onwards?  

Other important questions to ask:

• Have they been feeding well?
• Have they passed urine?
• Have they opened their bowels?
• Any abnormalities that the parents have noticed or any issues they want to raise?

Have a look through the maternal medical notes. Look at the antenatal scans to ensure the baby’s position after 36 weeks and to see if any abnormalities have been reported e.g. with the baby’s internal organs or with the liquor volume.

Check if there are any maternal medical conditions or medications that could affect the baby’s health.

Examination

This article will describe the NIPE in a top-to-toe order but in reality, this is not always possible- you will need to be opportunistic e.g. listening to the heart when the baby is not crying and looking in the eyes when the baby opens them.

The examination needs to be performed in a well-lit, warm environment; either in a cot at the bed side or in a private room. *(There are normally clinical rooms on maternity wards for performing the NIPE in, usually with a resuscitaire)

Undress the baby down to their nappy and observe their tone- poor tone could be a sign of infection, brain damage or a syndrome, e.g. trisomy 21

Skin

• Assess the general colour of the baby- do they look visibly jaundiced or cyanosed?
  • Cyanosis would first manifest with bluish discolouration around the fingertips and mouth.
  • Some babies can be plethoric or bruised causing blueish/purplish discolouration to extremities or their face and this is not concerning if saturations are in normal range and stable and the baby is clinically well.

Example of jaundiced sclera in a newborn baby

Photo from NHS (Newborn jaundice – Symptoms – NHS)

• Ask the parents if they have noticed any birth marks on their baby.
• Have a careful look all over the baby and see if you notice any:
  • Erythema Neonatorum- this is known as the ‘newborn rash’ and presents as a blanching red blotchy rash across the skin of a newborn baby with small white fluid filled bumps in nearly 50% of newborns. It is benign and will fade naturally in the first few weeks of life. 
  • Milia- also known as milk spots are harmless small white cysts commonly over the nose and cheeks.
  • Vernix- the baby may still have vernix on their skin, commonly in the creases around the neck, axilla and groin.
  • Bruising- this can be common after a vaginal or instrumental birth or in babies who are large for gestational age, and should be documented carefully.
  • Birth Marks
    •  Stork marks: red or pink patches commonly on the eyelids, head, back of the neck
    • Strawberry marks: raised red lumps on the skin formed from blood vessels
    • Port wine stains: purple marks commonly seen on the face
    • Slate grey naevus: blue/grey marks commonly on the buttocks and lower legs of babies with darker skin tones. Can look like a bruise.
    • Congenital melanocytic naevi: brown or black moles.
    • If the birth marks are very large or close to the eyes, nose or mouth then refer to Dermatology.

Erythema Neonatorum

(Erythema Toxicum Neonatorum – an overview | ScienceDirect Topics)

Stork mark

Picture from NHS website (Birthmarks – NHS (www.nhs.uk)

Child’s face with a port wine stain over the left side

Photo from Children’s Health (Port wine stain)

Slate grey naevus (previously referred to as mongolian blue spots)

Photo from Healthline (Mongolian Blue Spots: Identification, Causes, and Risks)

If you find any of the above then show them to the parents so they know they are present, and document them. It is particularly important to document slate grey naevi and their location and size as babies can be referred for a safgeguarding assessment if midwives or GPs mistake these for bruises that have not been previously documented.  

Head

When looking at the baby’s head, does the size look too large or too small?

The head circumference can be recorded using a measuring tape; take three measurements and take an average to avoid any error and plot the value onto a growth chart.

Place the tape measure above the ears and the eyebrows.

Picture from Research Gate (The Measuring of the Head Circumference of Children [17]. | Download Scientific Diagram (researchgate.net))

Assess the shape of the head, specifically looking for:

• Cephalohematoma: build up of blood vessels ruptured during a vaginal or instrumental delivery which does not cross the suture lines and feels soft rather than boggy on palpation. This will naturally reduce in size of a few days. Measure the bilirubin levels in these babies as it can contribute to neonatal jaundice.
• Caput Succedaneum: soft tissue swelling that is not well-defined and crosses suture lines caused by the head being pressed in the birth canal. Again this will settle over a few days.
• Subgaleal Haemorrhage: accumulation of blood under the galeal aponeurosis of the scalp due to rupture of the emissary veins. This is rare but can occur in babies where there has been repeated attempts using a Kiwi/Ventouse mode of delivery. There will be a boggy swelling not limited by the suture lines which can progress to the eye region rather than resolving promptly like the above mentioned swellings. This is an emergency presentation and needs discussion with a senior colleague and neurosurgery.

Picture from Medical Illustration and Animation

(Cephalohematoma vs. Caput Succedaneum Illustration by Suzanne Hayes | Medical Illustration & Animation (medillsb.com))

Feel the sutures on the top of the baby’s head- they will be palpable as they remain flexible in a newborn to allow the brain to grow.

The fontanelles ‘soft spots’ will be felt anteriorly and posteriorly on the head and are regions where the sutures will eventually join. If the fontanelle is sunken then the baby may be dehydrated and if they are bulging then this can be a sign of birth injury or hydrocephalus. If the sutures fuse prematurely then this is a condition called craniosynostosis which requires an urgent Skull X-ray to diagnose and a referral to the Neurosurgery team.

Face

Assess the baby’s face carefully.

If there has been an instrumental delivery then there may be forcep marks across the cheeks or asymmetrical features if there is a facial palsy caused by nerve damage.  

Photo of Forceps marks from Neonatal Network South East (Wessex-postnatal-ward_Baby-check-findings-head-swellings.pdf)

Assess for any dysmorphic features e.g. wide-spaced eyes, prominent epicanthic folds, small mandible which could be a sign of an underlying genetic syndrome.

Look at the nose and see if it seems patent- babies breath through their noses so any obstruction can cause respiratory distress in a newborn.

Is there are a cleft lip?

Ears

Babies will have a newborn hearing screen which is separate to this examination.

Look at both ears- do they look anatomically normal? Is there an external auditory canal that you can see?

Are the ears low set? From the outer canthus of the eye (the corner where the upper and lower eyelids meet) draw an imaginary line straight back to the occiput. If the ears are below this line then they can be classed as low set which may be normal for the baby but should be considered as potentially part of a congenital syndrome if there are other dysmorphic features present.

Check at the front and the back of the ears for any additional skin tags or dimples. Dimples may cause recurrent infection later in life. There used to be a train of thought that pre-auricular skin tags or pits were associated with congenital renal anomalies and all infants with these would have a renal USS. This has been disproven but you may have experienced midwives who still think this is true. Just check your local guideline for more information.

Mouth

Use a tongue depressor and the light from the ophthalmoscope have a look around the mouth checking the palate and the uvula closely. Look closely for signs of a cleft palate and look for the uvula to ensure that it is not absent. In some cases there can be a bifid uvula in relation to a cleft palate. The uvula can be difficult to visualise at times so document carefully that the palate has not been fully examined so that the GP can have a close look at the 6-8 week check.

Any abnormal findings may be related to an underlying genetic abnormality and will need referral to the ENT team.

Photo from MayoClinic (Cleft lip and cleft palate – Symptoms and causes – Mayo Clinic)

Insert a gloved finger into the mouth and feel around the gums for any teeth. If present, refer to the Maxillofacial team so these teeth can be removed to avoid the baby choking or aspirating on the teeth as there is a risk that they can become loose.

Eyes

Examine the eyes:

• Are they symmetrical?
• Is there any discharge from the eye?
  • If the eye looks inflamed or the discharge is purulent then take a swab and test for chlamydia/gonorrhoea/herpes (inform parents that these tests are being performed.
  • If the discharge is particularly purulent or bloody, ask for a senior review and consider starting antibiotics without waiting for the results of the swab, these are usually given intramuscularly. If this infection is left too long without treatment then the baby may become systemically unwell and their vision could be affected.

Neonatal Conjunctivitis

Picture from ScienceDirect. (Neonatal Conjunctivitis – an overview | ScienceDirect Topics)  

• Look closely in the whites of the eyes- are there any subconjunctival haemorrhages? These are usually harmless and are commonly caused by increased pressure during birth. It is very important to document these however as they can be a sign of a shaken baby.
• Dim the lights of the room and use an ophthalmoscope to shine the light in each of the baby’s eyes. You are looking for the ‘red reflex’ in each of the eyes- a reflection of light back from the cornea. If you are having difficulty looking in the baby’s eyes then you may need to come back to this part of the examination later or you can try to reposition the baby to help open their eyes- lifting a baby’s head with a hand supporting the back of their head in a dark room can help to them to naturally open their eyes.The colour of the red reflex varies from baby to baby and in babies of different ethnicities it may look pale pink/orange which is also normal. If you unsure if the colour is normal, it may be useful to look in the parent’s eyes as a guide to compare to.
  • The main condition that we are hoping to identify in this test is a congenital cataract or retinoblastoma. Whilst rare, 20-40000 children are born each year globally with this condition. They can partially or fully obscure the red reflex and may present as duller than the other eye or fully white.

Right congenital cataract with microphthalmia – the loss of red reflex in right eye and smaller right pupil and eye size.

From New Zealand Doctor (Paediatric visual impairment | New Zealand Doctor)

If you suspect a congenital cataract then ask a senior colleague to come and assess the red reflex. If there is still no red reflex present then an urgent referral to Ophthalmology is required. Ideally they should review the baby before they are discharged home but if not, they need to be seen within 2 weeks of birth. If the Ophthalmologist confirms the presence of a congenital cataract then surgery usually occurs between 1-2 months of age.

Neck

Look at the neck to assess for any lumps which could be a cystic hygroma. Webbing of the neck can occur in Turners Syndrome.

Look at and palpate the clavicles for any bruises, bony deformity or abnormal arm positions as this could be a sign of clavicular injury. This is very important to assess if there has been a history of shoulder dystocia at birth. If you are concerned that the clavicle may be fractured then arrange an x-ray and discuss the findings with the orthopaedics team.

Two conditions to look for on examination:

• Erb’s Palsy: this is paralysis of the arm due to injury to the C5-C6 nerve roots of the brachial plexus. Main risk factors for this are a large baby, a history of shoulder dystocia, instrumental delivery. The baby will be unable to move the affected arm and present with a ‘waiter’s tip posture’; an adducted shoulder, internally rotated arm, extended elbow and pronated forearm. The Moro reflex will be absent on the affected side.
• Klumpke Paralysis: This is an injury to the nerve roots of C8-T1 of the brachial plexus and presents instead with a ‘claw hand’- the MCP joints are extended and the PIJ and DIJ are flexed.

Both of theses conditions are usually a clinical diagnosis.

Most cases can be managed conservatively and resolve gradually following a period of immobilisation of the affected limb before a period of physiotherapy. Surgical intervention, nerve decompression or nerve grafting, may be required in serious cases.  

Photo from Faiella and Gulden (Orlando Brachial Plexus Injury Lawyers | (407) 647-6111)

Hands

Count the fingers on each hand. If you identify Syndactyly (webbed fingers) or Polydactyly (extra fingers) then refer the child to the Plastic Surgery team.

Example if a child with syndactyly of their 4th and 5th digits

Photo from Medscape (Medscape Registration)

How many palmar creases does the baby have? The typical number is two on each hand. A single palmar crease can be a normal variant but it needs to considered with all of the other findings of the NIPE. For example, if the baby has dysmorphic features and poor tone in combination with the single palmar crease then consider if this could be sign of Trisomy 21.

Photo from SmartEngage (Single palmar crease)

Chest

Have a close look at the chest.

Are there any chest wall deformities e.g. pectus excavatum or pectus carinatum?

Are there any signs of respiratory distress e.g. intercostal recession (the chest sucking in between the ribs), subcostal recession (the abdomen sucking in as the baby breathes), tracheal tug (downward movement of the trachea on inspiration) or an increased respiration rate.

Auscultate the lungs, comparing on each side- can you hear normal breath sounds? Can you hear any wheeze or crackles? Is there equal air entry both sides?

Heart

In the NIPE, we are trying to identify if there are any structural or functional issues with the heart.

All four valves of the heart need to be listened to individually. The locations for these are:

• Upper right sternal edge (Aortic)
• Upper left sternal edge (Pulmonary)
• Lower left sternal edge (Tricuspid)
• The Apex (Mitral)

Listen for the two separate heart sounds carefully- this can be difficult due to the resting heart rate of a newborn being between 100-180 bpm so take your time:

• If you hear a murmur then it is important to explain to the parent’s carefully that this does not necessarily mean that their baby has a serious underlying cardiac condition. The ductus arteriosus takes around 12-48 hours to close in a healthy newborn baby, and sometimes can take up to 2 weeks, and so the murmur may just be a patent ductus arteriosus.
  • A benign murmur tends to be a soft systolic murmur heard over the left sternal edge. If a murmur is loud, harsh sounding and heard over more than one valve then this is more concerning.
  • Request an ECG for the baby if ANY murmur is identified. You are looking for a superior axis which would indicate AVSD or a large VSD, or can also be seen in Noonan’s. You are also looking for any other abnormal axis (an ECG should have a rightward axis in a newborn baby up until they are 7 days old when it changes to normal), any arrhythmias, any signs of ventricular strain. Ask a senior colleague to also listen to the baby’s heart.
• Check and pre and post-ductal saturations to rule out a duct-dependent heart lesion. Pre ductal saturations are checked on the right wrist or hand and post-ductal are checked in the left hand or either foot.
• If serious concern about congenital cardiac anomaly also check femoral pulses urgently (see below), take a blood gas for lactate and measure 4 limb BP
• If the baby is clinically stable e.g. normal oxygen saturations, no cyanosis, feeding well, then explain to the parent’s that their baby should ideally stay in hospital for 24 hours for their heart to be listened to again.
• By the review at the later date, the ductus arteriosus will have closed in most cases and the murmur will have resolved. If the murmur is still present then refer the cardiology team; an ECHO will be arranged to look for structural problems with the heart.

If the baby is clinically unwell on examination then escalate this urgently to a senior colleague; an inpatient ECHO will likely be arranged and the baby will need admission to the neonatal unit.

Pulse oximetry

Oxygen saturations are measured in two different locations:

• Pre-ductal/right hand: arterial blood before the ductus arteriosus
• Post-ductal/right foot: arterial blood after the ductus arteriosus

Normal readings are >/95% and the difference between the readings should be less than/equal to 3%. If there is a congenital heart defect then the post-ductal saturations tend to be lower as pulmonary blood mixes with the arterial blood passing through the duct.

It can be difficult to obtain a good trace on the saturation probe so take your time; ensure the baby is still and settled as a screaming/kicking baby can give you a poor trace. If you have abnormal readings, consider whether you need to try again with a different saturation probe, whether the hand/foot of the baby is warm enough to take an accurate reading and use a posey wrap to secure the probe to the baby’s hand/foot. It can be useful to try again when the baby is settled e.g. being held by the parents or whilst feeding. If you are still finding abnormal readings then re-assess the baby e.g. listen to the heart, feel the femoral pulses and escalate to a senior colleague.

Abdomen

Have a look at the baby’s abdomen.

• Does it look distended? This could be a sign of a congenital malformation e.g. congenital megacolon, anal atresia or malrotation, could also occur with hirschprungs / other congenital problem causing obstruction.
• Ask the parents whether their baby has been feeding well and vomiting. Any history of bilious vomiting is a red flag and requires admission to neonatal unit for work up for congenital anomaly, mainly malrotation.

Palpate the abdomen in all four quadrants- can you feel an enlarged liver or spleen?

Examine the umbilicus; the cord will still be attached and clamped.

• Depending on how old the baby is at the time of the examination, the cord can be small, shrivelled and black in colour. Reassure parents that this is normal and that they should aim to keep the cord clean and dry with the nappy folded down below it.
• The cord will naturally fall off in the first two weeks after birth and can smell slightly malodorous during this process. There may be a hernia at the site of the umbilicus or a granuloma.
• Assess the cord for any surrounding erythema and discharge as this may be a sign of infection. Swab any discharge and discuss with a senior about starting antibiotics as infection in a baby can quickly lead to sepsis. Consider whether the discharge from the umbilicus could be a sign of an underlying congenital issue such as a patent urachus.

Undo the nappy of the baby and palpate the Femoral pulses. Straighten the legs of the baby’s legs gently and lightly palpate the pulses where the thigh meets the trunk with the 2^nd and 3^rd fingers. They can be tricky to feel so take your time. If you are unable to feel the pulses then ensure you have carefully examined the baby’s heart, taken oxygen saturations, ask for a senior review and consider obtaining a four limb blood pressure and lactate as the weak femoral pulses could be the first clinical sign of coarctation of the aorta.

External Genitalia

Male babies:

• Have a close look at the penis looking for any abnormal size to the penis (usual length 1.1-1.6 inches), any abnormal curvature or hypospadias in which the urethral meatus is not at the tip of the penis e.g. on the underside.
  • If this is identified then the parents may also report an abnormal spray when their baby is passing urine. Refer the baby to Urology. Whilst awaiting this appointment, ask the parents not to arrange a circumcision for their baby as the urologists may use the foreskin as part of their surgical repair.
• Inspect the scrotum to assess that they are of normal size and symmetry.
  • The skin of the scrotum will be more pigmented than the rest of the body and will have rugae, small elevations, on the surface.
  • If the scrotum is swollen then assess for the presence of a hydrocele by holding a light behind the scrotum in a darkened room to assess for transillumination; if the light shines through then this is classed as transillumination positive and shows that there is fluid present in the scrotum. Most often a hydrocele will resolve naturally.
  • The testes then need palpating one at a time to identify their presence within the scrotum. If there are bilateral descended palpable testis- no action required
  • If you cannot feel the testicle within the scrotum then palpate higher in the inguinal (groin) region; because the testes descend from the abdomen, it could be that this process is not yet fully complete.
  • If there are palpable but unilateral undescended testis- document this finding and reassure parents that they should have descended by the GP 6-8 week check.
  • Impalpable testis- the testis could still be in the abdomen or may be retractile. If both testis are impalpable bilaterally then ask a senior colleague to review the baby and request and urgent abdominal ultrasound and karyotype test.  There could be an underlying sexual disorder present  so use gender neutral terms when referring to the baby and ask carefully about a family history of CAH (congenital adrenal hyperplasia).

Female babies:

• The genitalia of a newborn can be quite swollen at birth due to increased hormonal levels.
• Check that the labia are not fused together and that the clitoris are of normal size.
  • Clitoromegaly (an enlarged clitoris) could be a sign of an underlying disorder of sex differentiation of Congenital Adrenal Hyperplasia (CAH) and needs and urgent referral to endocrinology.
• There may be a small amount of vaginal bleeding and discharge; parents can find this quite distressing so reassure them that this is a normal response to maternal hormones.

Hips

The main condition that is screened for in the NIPE is Developmental Dysplasia of the Hip (DDH) in which the hip joint is abnormally formed increasing the risk of hip dislocation.

DDH Risk Factors to ask about:

• Breech presentation after 36 weeks gestation
• Breech presentation at birth between 28 weeks- term gestation
• First degree relative with DDH
• Multiple pregnancy in which one of the siblings fits the above criteria for breech presentation

To assess for DDH, stretch the neonates legs out straight:

• Are they the same length?
• Undo the nappy and look at the skin creases on the thighs- do they look equal? If there is one deep skin crease on one thigh compared to the other then this could be a concerning sign.
• Flex the baby’s knees and set the feet down flat. Crouch down and check if the knees are at the same height; if one knee is higher than the other then this could be a concerning sign of DDH.
• The main test for DDH are the Barlow and Ortolani tests:
  • These tests can look distressing to the parents and it is common the baby to cry during/after, so it is best to leave this test as one of the last steps in your NIPE.
  • Warn the parents before you perform them that whilst their baby may find the tests uncomfortable, they do not cause them pain.
  • Barlow Test: This checks for a hip that can be dislocated.
    • Stabilise the pelvis of the baby by putting one hand underneath their bottom.
    • For the hip that you are testing, adduct the hip and apply a forward pressure with the thumb over the knee. If the hip is unstable then the femoral head will slip out the acetabulum and produce a sensation of dislocation. A palpable and loud “clunk” or “click”  
  • Ortolani Test: This relocates a hip that has been dislocated.
    • Place your fingers down the medial side of the thigh being tested and press upwards gently, applying abduction to the lateral thigh. If the hip has been dislocated in the Barlow Test then the femoral head will slip back into the acetabulum and a ‘clunk’ will be clearly heard.

Commonly clicks in the hip can be heard but these are not concerning and do not require any further action. However if any of the national risk factors listed above (even with normal examination) then an ultrasound scan of the hips will need to be requested for 4-6 weeks time with a review by the orthopaedics team if this shows DDH. If there are abnormal findings on examination then an urgent orthopaedic review and inpatient hip ultrasound are required with a x-ray of the hips sometimes performed whilst awaiting the ultrasound scan.

Photo from GP Exams (Barlow-Ortolani – GP Exams)

(Video Link for Barlow and Ortolani: Examining for a Dislocated Hip in Infants – YouTube)

Feet

Count the toes on each foot. If you identify Syndactyly (webbed toes) or Polydactyly (extra toes) then refer the child to the Plastic Surgery team.

Stretching the legs out straight, look at the position of the feet:

• Talipes (otherwise known as club foot) is a common condition in which one or both feet are turned inwards. Often this condition is caused due to the position of the neonate in the womb and is more common if there is oligohydramnios (reduced amniotic fluid levels) or multiple pregnancy as there is less room for the baby’s to move .
• If you are easily able to straighten the neonates feet to normal position by stroking the outside of the foot or manipulating the foot then the talipes are ‘positional’. Reassure the parents that this condition will usually improve over a couple of months and provide an information leaflet on simple physiotherapy exercises that can be performed to help with straightening out the foot.  It is also advised to make sure that clothing is not too tight around the baby’s feet and that they are free to kick and stretch out their legs when they are being changed.
• If the feet cannot be manipulated back to their normal position then the talipes are ‘Structural’. There may be an issue with how the bones of the ankles/feet have developed. A referral to the Orthopaedics team is required and the baby will need to be seen in the first 2-4 weeks of age to ensure prompt treatment.

Talipes

Photo from NHS (Club foot – NHS)

Back

Now turn the baby over and have a look at the back of the head and neck- a mark from a suction cup or a cephalohematoma may be easier to see from this position.

Commonly babies can have a stork mark at the base of their neck.

Trace your finger down the spine of the baby- does it feel central or is there any scoliosis?

Look closely at the base of the spine:

• Sacral dimples can be very common in babies, they are located at the base of the spine above the crease of the buttocks. Look closely to see if you can see skin at the base of the dimple. If you can and there are no abnormal findings at the spine then the dimples need no further action.
• If the dimples are slightly off-centre, you cannot see the base of them, or they associated with any tufts of hair then this could a sign of sign of a tethered spinal cord or spina bifida. Ask the parents if there is any family history of any spinal cord problems.
• If you suspect any abnormalities then ask a senior colleague to have a look, arrange an non-urgent spinal ultrasound and speak to the neurosurgery team. If the ultrasound is abnormal then the baby may then require an MRI. 
• If there are any abnormal lower limb movements, any cysts around the spine or any fluid leaking from the dimples/pits then more urgent investigation is needed.

Check that the anus is patent- check it is open and in the right position. (ALWAYS CHECK THE BUM, I have seen two delayed diagnosis imperforate anuses in the past 5 years)

Ask the parents whether the baby has passed meconium yet. If the NIPE is performed before the neonate is 24 hours old then they may not have passed meconium yet however if it has been over 24 hours then delayed passage of meconium could be a sign of a congenital gastrointestinal anomaly. The main concern is Hirschsprung’s Disease. The parents will need informing that the baby will not be discharged from hospital until they have passed meconium.

Check the bottom and back of the legs of the neonate for any bruising or birth marks that need documenting.  

Reflexes

There are a few reflexes that are naturally present in healthy newborn babies:

• Suckle reflex: if you touch the roof of the baby’s mouth e.g. with a gloved finger they will naturally suck.
• Palmar grasp: the baby will close their fingers around an object placed in their hand.
• Moro Reflex: (also known as the Startle reflex). The baby’s back is supported with one hand and they are dropped into the other hand. The natural response is for the legs and hands to extend symmetrically before the arms are brought inwards. This can be useful in suspected clavicular injury as the injured arm will not move symmetrically with the uninjured arm or in hemiparesis. When performing this reflex, warn the parents that their baby will not be harmed as it does look as though their baby is being dropped!
• The Stepping reflex (hold the baby with their feet on a flat surface and they will place their feet in front of each other as if they are stepping) and Rooting reflex (stroke the baby’s cheek and they will turn their head towards it) can also be assessed.

(Video Link for Moro Reflex: physical exam -Newborn Normal: Primitive Reflexes – Moro – YouTube)

End of Examination

The examination is now complete and the neonate can be redressed.

If you have found anything abnormal during the examination then explain this to the parents along with the next steps e.g. if a senior colleague needs to come and examine their baby or if a referral to a different speciality is required.

Finally, the NIPE needs to be documented correctly. This usually takes place on the online national database system as well in the baby’s personal child health record. The record used will differ depending on the country that you are in, so make sure to have a look at the local guidelines of where you work; the examination may also differ from what is described above in some countries.

For NIPE documentation, there is a usually a body map where all birth marks and bruises need to be documented carefully. A copy of this body map stays in the book and then copies are distributed to the GP, Health Visitor and medical notes.

The NIPE is also an opportunity to identify if the baby is eligible for a BCG vaccination (Include link here for list of risk factors that make babies eligible), and they should be referred for their BCG at this time if they fit the criteria and the parents consent.

References

Newborn and infant physical examination (NIPE) screening: programme overview – GOV.UK (www.gov.uk)

Newborn and infant physical examination (NIPE) screening programme handbook – GOV.UK (www.gov.uk)

Birthmarks – NHS (www.nhs.uk)

Global prevalence of childhood cataract: a systematic review – PMC (nih.gov)

Erb’s palsy – Who is to blame and what will happen? – PMC (nih.gov)

[Clinical characteristics of abdominal distention in early newborns] – PubMed (nih.gov)    

Talipes (clubfoot) and the Ponseti technique | CUH

Written by Olivia Byrne, Junior Clinical Fellow at Leeds Teaching Hospital Trust

Edited by Dr Bex Evans, Paediatric Registrar