Newborn Infant Physical Examination (NIPE)

Question 1

What is the purpose of the NIPE?

Answer 1

Carried out within 72hrs of birth

To screen for congenital abnormalities that will benefit from early intervention

To make referrals for further tests

To provide reassurance to the parents

Question 2

Where should you perform the NIPE?

Answer 2

Private area, warm and well lit room, changing mat

Parents present if possible - to answer questions and reassure

Question 3

How do you consent patients/parents?

Answer 3

Parents should receive National Screening Committee leaflet on ‘Screening tests for you and your baby’ - if not read, should be given a copy

Ask parents to undress child to nappy whilst you wash your hands

Question 4

What questions are useful to ask the parents before starting?

Answer 4

Pregnancy - date/time/type of delivery, complications, high-risk antenatal screening?

Breech? (if breech at 36wks or delivery - baby to have a full hip USS as increased risk of developmental dysplasia of the hip

Risk factors for neonatal infection - e.g. FHx congenital lung/heart problems, smoking at home

Other FHx - hearing, MSK, heart, eyes, renal etc.

Feeding/urination/meconium passing/parental concerns

Question 5

What should you do when assessing babies weight?

Answer 5

Check weight chart - small (<10th centile), appropriate (10-90th) or large (>90th)

If small - should plot head circumference and length to check if in proportion (foetal factors e.g. genetic abnormality/intrauterine infection) or asymmetrical (placental insufficiency)

Question 6

What are you looking for on general inspection?

Answer 6

Surroundings - ward, ventilation, fluids/drugs, parents etc.

Colour - pallor/cyanosis/jaundice/rashes

Posture - gross abnormality e.g. hemiparaesis?

Question 7

How do you assess tone? What are some causes of a hypotonic baby?

Answer 7

Move the newborn’s limbs passively and when they are picked up (should continue throughout examination)

Hypotonic - ‘floppy’ or ‘rag doll’ appearance - difficulty feeding as mouth muscles cannot maintain a proper suck-swallow pattern or hold on

Causes: genetic syndromes - Down’s, achondroplasia, Ehlers-Danlos, Fragile X, Prader-Willi, Retts etc; congenital cerebellar ataxia and hypothyroidism; Infection - meningitis, sepsis etc; TBI, UMN/LMN lesions; CP

Question 8

What features of the head do you assess?

Answer 8

Size - circumference (record in notes) - microcephaly (?small brain size/atrophy) vs marocephaly (?hydrocephalus, genetic abnormality)

Shape - regular? are sutures tight, widely separated or normal?

Question 9

What is cranial moulding?

Answer 9

Slight change in head shape, common after birth, resolves within a few days

Question 10

What is caput succedaneum?

Answer 10

Diffuse subcutaneous fluid collection - crosses suture lines

Caused by pressure on presenting part of the head during delivery

Usually uncomplicated and self resolving

Question 11

What is cephalhaematoma?

Answer 11

Subperiosteal haemorrhage in 1-2% of infants

Doesnt cross the suture lines

More common with instrumental delivery

May cause jaundice (monitor bilirubin)

Question 12

What are subgaleal haemorrhages?

Answer 12

Occur between aopneurosis of the scalp and periosteum - fluctuant collection of blood crossing suture lines

Rare but life-threatening

Question 13

What is craniosynotosis?

Answer 13

Premature fusion of infant skull - changes growth pattern = possible raised ICP and brain damage

Surgical intervention necessary = excision of the sutures

Question 14

How do you assess the fontanelle?

Answer 14

Palpate anterior fontanelle - flat? (normal) sunken or bulging? (dehydration/hydrocephalus)

Question 15

What are you looking for in the skin?

Answer 15

Colour

Bruising/laceration (from traumatic births)

Facial birthmarks - salmon patch, port wine stain, dry abrasions

Vernix - waxy/cheese-like white substance coating skin of healthy babies

Question 16

What is a Mongolian spot?

Answer 16

Benign, flat, congenital birthmark, wavy irregular borders, blue in colour, often found on the buttocks/back, more common in ethnic minorities

Can look like brusising and so raise child protection issues so important to document presence at birth

Normally disappear within 3-5yrs

Question 17

What is a nevus simplex?

Answer 17

Aka stork bite or salmon patch

Most common congenital capillary malformation in newborns, appearing in first year of life, usually disappearing within 18 months though ones on the back of the neck may never go away

Eyelid, glabella, back of neck

Question 18

What is a naevus flammeus?

Answer 18

Aka, port-wine stain

Large vascular formation that will remain for life

Question 19

What are milia?

Answer 19

Small white cysts containing keratin and sebaceous material

Common on face, most resolve within the first few weeks of life

Question 20

What is erythema toxicum?

Answer 20

Very common and benign condition

Various combinations of erythematous macules, papules and pustules

Lesions appear from 48hrs and resolve spontaneously

Question 21

What is neonatal jaundice?

Answer 21

Can be physiological

Appears from 2-3 days and lasts until day 10

Also pathology - haemolytic disease, infection, Gilbert’s syndrome

Question 22

What features should you note in the face?

Answer 22

Appearance - dysmorphic?

Asymmetry - nerve palsys?

Trauma?

Nose - patency of nasal passages - important as infants are obligate nasal breathers and will go into respiratory distress if they have bilateral choanal atresia (blockage of nasal passage - bone/soft tissue)

Question 23

What are you looking for in the eyes?

Answer 23

Evidence of erythema or discharge - e.g. conjunctivitis

Inspect the sclera - look for colour

Position/shape - e.g. ptosis

Assess red reflex with opthalmoscope - absence requires immediate opthalmology f/u (?congenital cataracts or retinoblastoma)

Subconjuncitval haemorrhages - look dramatic but are common and benign

Question 24

How should you assess the ears?

Answer 24

Inspect the pinna - asymmetry, prominence

Note position, skin tags etc

Question 25

How should you assess the mouth and palate?

Answer 25

Need a tongue depressor and torch - ask parent to keep babies head still Clefts of the hard or soft palate - must visualise, cannot exclude using palpation alone Central position of uvula? Tongue and gums - inspect for evidence of tongue tie

Question 26

How do you inspect the neck and clavicles?

Answer 26

Length of neck - short in Turner's syndrome Webbing of neck - again in Turner's Neck swelling Clavicular fracture - following traumatic birth e.g. shoulder dystocia

Question 27

How do you inspect the upper limbs?

Answer 27

Symmetry - size/length Fingers - correct number and morphology; any polydactyly Palms - two palmar creases on each hand? single in Down's Palpate brachial pulses

Question 28

How do you inspect the chest?

Answer 28

Chest wall deformities - pectus excavatum? Chest wall expansion- asymmetry in unilateral lung pathology e.g. pneumonia

Question 29

How do you examine the lungs?

Answer 29

Note respiratory distress - increased WOB or RR (30-60 normal in newborns) Auscultate - air entry bilaterally? added sounds? Will probably hear lots of transmitted sounds from upper airways that can be heard all around the chest (because they're so small)

Question 30

How do you examine the heart?

Answer 30

Auscultate Normal HR 120-150bpm Added sounds? Where loudest? radiating to axilla or back?

Question 31

How do you examine the abdomen?

Answer 31

Inspect for distension Inspect for inguinal hernias Palpate: - liver should be no more than 2cm bellow costal margin - spleen may be palpable - kidney only palpable on deep bimanual palpation - bladder should not be palpable

Question 32

How do you examine the umbilicus?

Answer 32

Inspect for any discharge or hernias Any nasty smells or erythema?

Question 33

How do you inspect male genitalia?

Answer 33

Position of meatus - excluding hypospadias or epispadius Size - at least 2cm Hydroceles - collection of fluid in scrotum which will transilluminate Scrotum - palpate to feel for both testes, if undescended should be followed up with age; bilateral absence = disorder of sexual development and should be investigated

Question 34

How do you inspect female genitalia?

Answer 34

Note any ambiguity e.g. congenital adrenal hyperplasia Inspect labia - not fused? Inspect clitoris - normal size? Vaginal discharge - white = normal due to maternal oestrogens

Question 35

How do you inspect the lower limbs?

Answer 35

Symmetry - size and length Tone, movement Palpate femorals - weak, absent or delayed ?coarctation of aorta Assess oedema Assess knees - hyper-extensile/dislocatable? Assess ankles - talipes? (club foot) Correct number of digits on feet

Question 36

What is Barlow's test?

Answer 36

Adducing the hip whilst applying slight pressure on the knee with your thumb - direct the force posteriorly If hip unstable - femoral head will slip over the posterior rim of acetabulum - palpable sensation of dislocation

Question 37

What is Ortolani's test?

Answer 37

Used to confirm posterior dislocation of the hip Flex hips and knees to 90 degrees - place index fingers on greater trochanter and apply anterior pressure - abduct the infants legs using thumbs Positive sign = 'clunk' as femoral head relocates back into acetebulum

Question 38

How do you inspect the back and spine?

Answer 38

Scoliosis Sacral dimple - associated with spina bifida - if other cutaneous stigmata (hairy patches, naevi etc) + abnormal neuro exam OR pit >5mm/>2.5mm away from anus - USS lower spine Abnormal skin patches Birthmarks

Question 39

How do you inspect the anus?

Answer 39

Patent? Meconium should be passed within 24hrs - delay may suggest obstruction or Hirschsprung's disease

Question 40

How do you assess the palmar grasp reflex?

Answer 40

When an object is placed into their hand and strokes their palm, fingers will close

Question 41

How do you assess the sucking reflex?

Answer 41

Child will instinctively suck on anything that touches the roof of its mouth

Question 42

How do you assess the rooting reflex?

Answer 42

Newborn will turn its head towards anything that strokes its cheek or mouth to aid breastfeeding Disappears by 4m as it becomes under voluntary control

Question 43

How do you assess the stepping reflex?

Answer 43

When the soles of their feet touch a flat surface, will appear to walk - placing one foot in front of the other

Question 44

How do you assess the Moro reflex?

Answer 44

Support the infants upper back with one hand and head with the other then drop back once or twice Legs + head extend, arms jerk up with fingers extended - arms then brought together and fists are clenched Asymmetry may be due to hemiparesis, brachial plexus injury or fractured clavicle Disappears between 3-6 months

Question 45

How do you complete the examination?

Answer 45

Share assessment results with parents and answer any questions Thank parents, ask them to redress their child Wash hands Document - there is a national online system/form for doing so