Examination of the newborn

Routine newborn examination is a systematic head to toe physical examination offered to all parents following the birth of their baby. Midwifery and Neonatal Nursing Staff trained under a programmed co-ordinated by the Scottish Multiprofessional Maternity Development Programme (SMMDP) will carry out this screening examination.

Examination of newborn infants will be carried out according to the standards of Routine Examination of the Newborn - Best Practice Statement (SMMDP).

• The routine examination will be carried out in a safe, warm, well lit environment. 
• Privacy should be provided particularly when discussing family health issues of a sensitive nature. 
• The examiner should allow sufficient time for an unhurried examination which includes discussing findings with the parents, referral if necessary and completing the relevant documentation.

• Examinations will be done once the baby is >6 hours old and before 72 hrs with parental consent.
• Baby less than 35 weeks or with significant congenital anomalies should be examined by the neonatal team. If any concerns prior to examination midwives should discuss with neonatal team.
• Babies admitted to SCBU should receive their detailed examination within 72 hours and definitely prior to discharge to postnatal ward.
• Babies born <34 weeks should be examined once they are 34 weeks unless clinical reason not to.
• Preterm babies repatriated from other hospitals who have had examination completed should have heart, hips and testes re checked as part of their discharge.

• The examination includes observation of general appearance, position and movement followed by a structured all over physical examination, as well as specific screening elements which involve examination of the baby’s eyes, heart, hips and testes.
• Prior to commencing the examination relevant antenatal, delivery and postnatal information is reviewed.
• Parents should be invited to be present for the check and fully updated once completed. 
• During this routine examination abnormalities and problems can be identified and initially referred to the neonatal /paediatric team. Where appropriate they will then be further referred for specific investigation, specialist assessment and treatment.
• The examination should be documented on maternity badger as detailed examination.

Please remain aware of babies with increased risk of jaundice and check with bilimeter where appropriate. Increased risk includes:

• IUGR
• infant diabetic mother
• bruising from delivery
• breast feeding
• previous sibling treated for jaundice
• <37+6 GA
• jaundice less than 24 hour should never be ignored

Pathways for onward referral to other departments are identified under each relevant section of this guideline.

Screening risk and examination of the hips allows early detection of a dislocated or dislocatable hip, and allows any required treatment to be to be in place appropriately, minimising risk of long term complications.

Newborns who meet the screening criteria for DDH will have a routine hip ultrasound at 2 weeks if dislocatable or 6 weeks if for uncertain examination or risk factors.

A positive hip result is an abnormal clinical hip examination (with or without risk factors), or presence of hip risk factors.

A suspected abnormality on clinical examination (look, feel, and move) is defined by:

• difference in leg length
• knees at different levels when hips and knees are bilaterally flexed
• reduced hip abduction
• lax hips
• palpable ‘clunk’ when undertaking the Ortolani or Barlow manoeuvre.

Any uncertainty on examination can trigger a request for USS

Risk Factors:

• family history of DDH in first degree relative
• breech after 36 weeks or at time of delivery
• oligohydramnious in pregnancy
• any features of moulding , asymmetrical lie / creasing.
• fixed foot deformities
• consideration should be given to the size of baby/babies in relation to the size of mum and
  subsequent space in uterus.

In twins if one baby meets the criteria, both should be referred for a scan.
Positional talipes equinovarus that are fully correctable with no other features are of no clinical significance.

Hips which are found to be clinically unstable should be referred on TRAK, for an early ultrasound (2/52) request as urgent.
All other referrals should be requested for 6/52.
Please give parent information leaflet at time of NBE

Preterm baby should not have hips checked till >34+0.

Babies with unilateral undescended testis should be reviewed at GP 6-8 week examination check.

Bilateral undescended testes require an inpatient review by paediatrician / ANNP +/- USS and surgical clinic referral.

Read: Heart murmurs in the neonate

Check pre and post ductal saturations.

• General examination and elicit red reflex.
• Primary purpose to screen for congenital cataracts.
• White babies have a bright, pinky red reflex. The reflex can be less bright and of a yellow/brown hue in non-white babies.
• If there are difficulties viewing the red reflex then prescribed eye drops (tropicamide & phenylephrine; kept in SCBU) can be used to dilate the pupils to allow a better assessment.
• Eye screen positive – discuss with paediatric team re ophthalmology referral.

Intranet guideline link no longer available.

Babies found to have an isolated single umbilical artery require no further investigations unless other relevant clinical concerns.

• Babies delivered following shoulder dystocia do not automatically require an x-ray to check for clavicle fractures.
• If there are concerns based on clinical examination of the clavicles or nerve palsies affecting the arms an X-ray of the clavicles should be requested.
• No specific management of the baby with fractured clavicle, consider paracetamol if pain is a concern. Allow the baby to move their arm as they are able but carers should maintain awareness and specifically don’t let the arm hang down, or pull baby forward using it. It can be secured inside the babygrow. No repeat scan required unless specifically requested.

Discuss with paediatric team.

Please refer for ultrasound if:

• high, further than 2.5cm from anal margin
• large > 5mm
• associated hairy patch / birthmark /other lesions
• neurological abnormality of the lower limbs.

Isolated simple sacral dimples require no scan

Babies who meet the criteria for BCG should have the referral form filled in and sent to Dr Duncan who will arrange appointment at BCG clinic run in ambulatory care unit.

Discuss with paediatrician.

Identification of talipes at birth or antenatally by USS.
Fixed:

• Immediate referral to Sarah Paterson, Extended Scope Physiotherapist at RHSC Edinburgh for advice and treatment

Positional:

• Equinovarus (down and in) Reassurance and advice to parents to encourage normal active movements by tickling and touching babies feet.

If foot position not correcting with active movement within 6-8 weeks GP should consider contacting the paediatric physiotherapy team for further advice. paediatricphysiotheray@borders.scot.nhs.uk.

• Calcaneovalgus (up and out) Refer for hip UUS due to associated potential for DDH.

Discuss with paediatric team, priority is to know whether the baby can pass urine and in boys to know the nature of the stream.

Referral to Glasgow team.
This should already be done and arrangements in place if detected antenatally.