11/13/24, 7\:07 PM Guide | Newborn baby assessment (NIPE)

Newborn baby assessment (NIPE)

Table of contents

Background

The Newborn Infant Physical Examination (NIPE) must be performed within 72 hours of birth by a quali
¹
The purpose of the examination of the newborn is\: ²
To screen for congenital abnormalities that will bene
To make referrals for further tests or treatment as appropriate
To provide reassurance to the parents
A second examination is performed at 6-8 weeks of age, usually by GP, to identify abnormalities that develop or become
apparent later.

Where to perform the NIPE

The NIPE exam should be undertaken in a private area which provides con
being discussed.
The room should be warm and well lit (preferably natural light, especially if jaundice is to be assessed).
² Visual inspection,
however, cannot reliably assess the level of jaundice so if this is suspected a bilirubin level needs to be checked.
³
You'll ideally require a changing mat to carry out the examination on.
Always make sure that the parents are present for the newborn check as this is an ideal time to answer queries and provide
reassurance.

Introduction

Wash your hands and don PPE if appropriate (alcohol gel must dry completely before handling the newborn).
Introduce yourself to the parents including your name and role.
Con
Brie
t o e e x a m i n a t i o n o f y o u r c h i l d .
"
Gain consent to proceed with the examination\:
Parents should have received the National Screening Committee lea
antenatal period.
If the parents have not read the information booklet they must be given a copy to read before to the examination.
The aims and limitations of the examination should be fully explained.
Adequately expose the child for the assessment\: ask the parents to undress the child down to their nappy.
Encourage the parents to ask questions during the check and to participate where appropriate.
The optimal way to perform the newborn check is by examining from head to toe sequentially. In reality, it’s an opportunistic
examination – if the baby is settled listen to their heart
crying look at the palate!
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Questions to ask the parents

Below are some key points you would ideally cover in a full assessment of a newborn baby. It should be noted that in the
context of an OSCE you are unlikely to be expected to cover all these history points due to time constraints.
Maternal history\:
Pregnancy details\: date/time and type of delivery/complications/high-risk antenatal screening results
Breech presentation\: if breech at 36 weeks gestation or delivery (if earlier), the baby will need to have an ultrasound scan of
their hips as there is an increased risk of developmental dysplasia of the hip.
Risk factors for neonatal infection
Abnormalities noted on antenatal scans
Family history\:
cataracts/renal problems
Newborn history\:
Feeding pattern
Urination
Passing of meconium
Parental concerns

Weight

Ensure that the infant's weight is recorded and check on a weight chart whether the baby is\:
Small for gestational age (\<10th centile)
Appropriate weight for gestational age (10th-90th centile)
Large for gestational age (>90th centile)
If a baby is small, you should also plot head circumference and length to determine whether this is symmetrical (small in all
measurements) or asymmetrical (weight disproportionately low, head circumference preserved).
Asymmetrical growth restriction is commonly due to placental insu
commonly due to fetal factors such as genetic abnormalities or intrauterine infection.

General inspection

Inspect the colour of the infant\:
Pallor\: a pale colour of the skin that can suggest underlying anaemia (e.g. haemorrhage) or poor perfusion (e.g. congestive
cardiac failure).
Cyanosis\: a bluish discolouration of the skin due to poor circulation (e.g. peripheral vasoconstriction secondary to
hypovolaemia) or inadequate oxygenation of the blood (e.g. right-to-left cardiac shunting).
Jaundice\: a yellowish or greenish pigmentation of the skin and whites of the eyes due to high bilirubin levels (e.g. newborn
jaundice).
Inspect the posture of the infant\: note any gross abnormalities of posture (e.g. hemiparesis/Erb's palsy).
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Cyanosis due to congenital heart disease [1]

Tone

Assess tone by gently moving the newborn's limbs passively and observing the newborn when they're picked up (your
assessment of tone should continue throughout the examination).
Hypotonic infants are often described as feeling like a ‘rag doll’ due to their
feeding, as their mouth muscles cannot maintain a proper suck-swallow pattern or a good breastfeeding latch (hypotonia is
common in children with Down's syndrome).

Head

Size

Measure the infant's head circumference and record it in the notes.
Head size abnormalities
Microcephaly describes a head that is smaller than expected for age and sex. Microcephaly may be associated with
reduced brain size or atrophy.
Macrocephaly describes a head that is larger than expected for age and sex. Macrocephaly may be normal but may also
be associated with hydrocephalus, cranial vault abnormalities or genetic abnormalities.

Shape

Inspect the shape of the head and note any abnormalities.
Inspect the cranial sutures and note if they are closely applied, widely separated or normal.
Head shape abnormalities
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Cranial moulding is common after birth and resolves within a few days.
Caput succedaneum is a di
caused by pressure on the presenting part of the head during delivery. It does not usually cause complications and
resolves over the
4
Cephalhaematoma is a subperiosteal haemorrhage which occurs in 1-2% of infants and may increase in size after birth.
The haemorrhage is bound by the periosteum, therefore, the swelling does not cross suture lines (in contrast to a caput
succedaneum). Cephalhaematoma is more common with instrumental delivery and may cause jaundice, therefore,
bilirubin should be monitored.
Subgaleal haemorrhages occur between the aponeurosis of the scalp and periosteum and form a large,
collection which crosses sutures lines. They are rare but may cause life-threatening blood loss.
Craniosynostosis is a condition in which one or more of the
the growth pattern of the skull which can result in raised intracranial pressure and damage to intracranial structures.
Surgical intervention is required with the primary goal being to allow normal cranial vault development to occur. This can
be achieved by excision of the prematurely fused suture and correction of the associated skull deformities.
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Fontanelle

Palpate the anterior fontanelle\: note if it feels
Fontanelle abnormalities
A tense bulging fontanelle may suggest raised intracranial pressure (e.g. hydrocephalus).
A sunken fontanelle may suggest dehydration.
Microcephaly [2]
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Skin

It is very important to document any birthmarks or bruising/lacerations from birth trauma found on initial examination in
case there are any child protection concerns in the future. There are body maps in the red book to help with this.
Colour\: inspect the colour of the skin and note any pallor, cyanosis, erythema or jaundice.
Bruising/lacerations\: note the location and size of any bruises or lacerations which may have been sustained during childbirth.
Vernix\: a waxy or cheese-like white substance found coating the skin of newborn babies (this is a normal
Examples of facial birthmarks
Examples of facial birthmarks include\:
Salmon patch (also known as a stork mark or nevus simplex)\: red or pink patches, often on an infant's eyelids, head or
neck caused by congenital capillary malformation. Salmon patches are very common and usually fade by the age of
two.
Haemangiomas (also known as strawberry marks)\: blood vessels which form a raised red lump on the skin which
appears soon after birth. Haemangiomas typically get bigger over the
by the age of 7. They may require treatment if they a
Port-wine stain (also known as naevus
from birth and do not regress. Port-wine stains can sometimes be associated with Sturge-Weber syndrome and
Klippel-Trenaunay syndrome.
Other potential
Slate-grey nevus is a benign,
sacrum. It is most commonly blue in colour and can be mistaken for a bruise. They normally disappear within 3-5 years
after birth.
5
Milia are tiny white cysts containing keratin and sebaceous material. They are very common on the face and most resolve
within the
Erythema toxicum is a very common and benign condition seen in newborn infants. It presents with various combinations
of erythematous macules, papules, and pustules. Lesions usually appear from 48 hours of age and resolve
spontaneously.
Neonatal jaundice can be physiological, appearing at 2-3 days and resolving by day 10. It can also be caused by a wide
range of di
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Salmon patch [5]

Face

Appearance\: note any dysmorphic features of the face (e.g. epicanthic folds in Down's syndrome).
Asymmetry\: note any asymmetry of the face (e.g. facial nerve palsy secondary to instrumental delivery).
Trauma\: note any evidence of facial trauma (e.g. bruising, lacerations) likely to have occurred during labour (e.g. instrumental
delivery).
Nose\: inspect to assess the patency of the nasal passages (infants are obligate nasal breathers and therefore will present with
respiratory distress and cyanosis at rest if they have bilateral choanal atresia).
Down's syndrome
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Eyes

Inspect the eyes for evidence of erythema or discharge (e.g. conjunctivitis).
Inspect the sclera by gently retracting the lower eyelid noting any discolouration (e.g. jaundice, subconjunctival
haemorrhages). Subconjunctival haemorrhages often look dramatic but are fairly common after delivery and benign, you
should, however, document their presence.
Inspect the position and shape of the eyes\: look for evidence of ptosis or the presence of epicanthic folds (e.g. Down's
syndrome).

Fundal re

Correct terminology
The term fundal re
colour.
In patient's with lighter skin, the re
re
Assess for the fundal re
1. Look through the ophthalmoscope, shining the light towards the patient’s eye at a distance of approximately one arm’s
length.
2. Observe for a reddish/orange re
Causes of an absent fundal re
Absence of the fundal re
and retinoblastoma.
An absent fundal re
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Subconjunctival haemorrhage [9]

Ears

Inspect the pinna\: note any asymmetry, skin tags, pits or the presence of accessory auricles.
All infants should undergo a hearing screening test prior to being discharged from hospital.
Accessory auricle [11]
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Mouth and palate

Look for clefts of the hard or soft palate\: the full palate should be examined by visual inspection. You will need to use a
tongue depressor and a torch, and ask a parent to help keep the baby’s head still. You must visualise the whole palate, and see
the central uvula to ensure it is intact. You cannot rely on palpation to exclude a cleft.
Inspect the tongue and gums\: look for evidence of tongue-tie (ankyloglossia).
Cleft lip and palate [12]

Neck and clavicles

Inspect the length of the neck and note any abnormalities such as webbing\: a shortened webbed neck is typically
associated with Turner's syndrome.
Inspect for neck lumps\: a lump in the left posterior triangle of the neck may represent a cystic hygroma.
Look for evidence of a clavicular fracture\: signs may include bruising, discontinuity of the clavicle and an abnormal position of
the arm (fractures most commonly occur in the context of shoulder dystocia).
Cystic hygroma
A cystic hygroma is a congenital lymphatic lesion which is typically identi
arise anywhere but typically develops in the left posterior triangle of the neck. Cystic hygromas are benign but can be
dis
reaccumulation of lymphatic
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Cystic hygroma [14]

Upper limbs

Assess the symmetry of the upper limbs\: they should appear equal in size and length.
Inspect the
Inspect the palms\: check if the child has two palmar creases (normal).
Palpate the brachial pulse on each upper limb\: note any asymmetry suggestive of an underlying vascular abnormality (e.g.
coarctation of the aorta).
Abnormalities of the hand
Polydactyly is a congenital abnormality where there are supernumerary
A single palmar crease is associated with Down's syndrome.
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Single palmar crease

Chest

Inspection

Observe the chest, paying particular attention to the respiratory rate and work of breathing.
Respiratory rate
Count the respiratory rate whilst observing the child. The normal respiratory rate of a newborn is 40-60 breaths per minute.
Work of breathing
Assess for signs of increased work of breathing\:
Di
Expiratory grunting
Tracheal tug
Supraclavicular recession
Intercostal recession
Subcostal recession
Nasal
Abdominal breathing
Head bobbing (secondary to sternocleidomastoid contractions)
Other clinical signs
Inspect the chest for other relevant clinical signs\:
Pectus excavatum\: a caved-in or sunken appearance of the chest.
Pectus carinatum\: protrusion of the sternum and ribs.
Asymmetrical chest wall expansion\: asymmetry may be noted unilateral lung pathology (e.g. pneumonia).

Auscultation

Lungs
Auscultate each side of the chest in a symmetrical pattern, comparing side to side\:
Pay attention to the inspiratory and expiratory sounds at each placement.
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Note the quality and volume of the breath sounds.
Note any additional sounds (e.g. wheeze, coarse crackles).
Repeat auscultation on the posterior aspect of the chest.
Heart
Auscultate ‘upwards’ through the valve areas using the diaphragm of a paediatric stethoscope\:
Mitral valve\: 5th intercostal space - midclavicular line (apex beat)
Tricuspid valve\: 4th or 5th intercostal space - lower left sternal edge
Pulmonary valve\: 2nd intercostal space - left sternal edge
Aortic valve\: 2nd intercostal space - right sternal edge
Listen over each area with both the bell (for low pitched sounds – gallops and split S2) and the diaphragm (high pitched
sounds – pericardial rubs, S1/S2 and most murmurs).
The normal heart rate of a newborn is approximately 120-150 bpm.
If a murmur is noted, try to determine where it is heard loudest and if it radiates anywhere.

Pulse oximetry

Some centres recommend checking preductal and postductal oxygen saturations to improve detection of critical
congenital heart disease in newborn infants. Both readings should both be ≥95% and within 3% of each other.
Pectus excavatum [16]

Abdomen

Inspection

Inspect for evidence of abdominal distension\: causes include bowel obstruction, organomegaly and ascites.
Inspect the umbilicus\: note any swelling (e.g. umbilical hernia) or erythema and discharge (e.g. umbilical cord stump infection).
Inspect for evidence of an inguinal hernia in the groin\: if present, arrange a paediatric surgical review.

Palpation

Palpate the abdomen to assess for organomegaly\:
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Liver\: should be palpable no more than 2cm below the costal margin (if palpable lower in the abdomen consider
hepatomegaly).
Spleen\: may be palpable at the left costal margin in healthy infants (if easily palpable, consider splenomegaly).
Kidneys\: normally only palpable using deep bimanual palpation (if easily palpable consider polycystic kidney disease).
Bladder\: should not be palpable in healthy infants (if easily palpable, considering urinary tract obstruction).
Umbilical hernia

Genitalia

Note any ambiguity of genitalia\: typically associated with congenital adrenal hyperplasia (CAH) in girls (boys with CAH have
normal genitalia).

Males

Assessment of male genitalia\:
Note the position of the urethral meatus\: an abnormal position may be noted in hypospadias or epispadias.
Note the size of the penis\: it should be at least 2cm.
Assess for evidence of testicular swelling indicative of hydrocele\: a collection of
transilluminate when a light source is placed nearby).
Palpate the scrotum to ensure both testes are present\: a unilateral undescended testis is common and should be followed
up over time; bilateral absence is considered a disorder of sexual development and should be investigated.

Females

Assessment of female genitalia\:
Inspect the labia\: to check they are not fused.
Inspect the clitoris\: to ensure it is a normal size.
Note any vaginal discharge\: white discharge is a normal
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Hypospadias

Lower limbs

Inspect the lower limbs for abnormalities\:
Asymmetry\: the lower limbs should appear equal in size and length.
Oedema\: may indicate hypoalbuminaemia or congestive cardiac failure.
Ankle deformities\: talipes (club foot) is a common ankle deformity causing the foot to be turned inward.
Missing digits\: ensure the correct number of digits are present on each foot.
Assess tone in both lower limbs\: tone is typically decreased in infants with Down's syndrome and may be asymmetrically
increased secondary to upper motor neuron lesions (e.g. ischaemic stroke, intracranial haemorrhage).
Assess movement in both lower limbs\: note any weakness which may indicate an upper or lower motor neuron lesion or joint
pathology.
Assess the range of knee joint movement\: typically excessive in hypermobility.
Palpate and compare femoral pulses\: this can be di
delayed femoral pulses are a sign of coarctation of the aorta.
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Talipes equinovarus [18]

Hips

Both Barlow's and Ortolani's tests are carried out as part of the routine newborn examination to detect hip joint instability and
dislocation. Each hip should be examined individually with all clothing, including the nappy, removed.
Barlow's test
Barlow's test is performed by adducting the hip (bringing the thigh towards the midline) whilst applying light pressure on the
knee with your thumb, directing the force posteriorly.
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If the hip is unstable, the femoral head will slip over the posterior rim of the acetabulum, producing a palpable sensation of
subluxation or dislocation.
If the hip is dislocatable the test is considered positive. The Ortolani manoeuvre is then used to con
that the hip actually dislocated).
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Adduct the hip
Ortolani's test
Ortolani's test is used to con
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1. Flex the hips and knees of a supine infant to 90°
.
2. With your index
using your thumbs.
A positive sign is a distinctive 'clunk' which can be heard and felt as the femoral head relocates anteriorly into the
acetabulum.
Abduct hip joint
Source\: geekymedics.com
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