This guide aims to provide a structured approach to performing a newborn baby assessment (NIPE) in an OSCE setting.
The Newborn Infant Physical Examination (NIPE) must be performed within 72 hours of birth by a qualified practitioner.¹
The purpose of the examination of the newborn is:²
- To screen for congenital abnormalities that will benefit from early intervention
- 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 confidentiality for parents when personal information is 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 mother/parents are present for the newborn check, as an important part of the reason for the check is to answer queries and give reassurance.
- Hand hygiene is essential before and after the newborn check
- Always wash and use alcohol gel on your hands before examining the newborn
- Alcohol gel must dry completely before handling the newborn
Introduce yourself to the parents – state your name and role
Explain that you need to carry out a routine head to toe examination of their child.
- Parents should have received the National Screening Committee leaflet ‘Screening tests for you and your baby’ in the antenatal period
- If the parent has 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 fully explained
Ask the parent 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 first, if they open their eyes check the red reflexes and if they’re crying look at the palate!
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 however 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 – date/time and type of delivery/complications/high-risk antenatal screening results
- Breech – if breech at 36 weeks gestation or delivery (if earlier), the baby will need to have 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 – First-degree relatives with…hearing problems/hip dislocation/childhood heart problems/congenital cataracts/renal problems
- Newborn history – feeding pattern/urination/passing of meconium/parental concerns
Ensure that the baby’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 insufficiency, whilst symmetrical growth restriction is more commonly due to fetal factors such as genetic abnormalities or intrauterine infection.
Cry – note the volume (a weak cry may be an indicator the newborn is unwell) – in reality, this is not a particularly helpful sign
Posture – note any gross abnormalities of posture (e.g. hemiparesis/Erb’s palsy)
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 floppiness. Hypotonic infants often have difficulty feeding, as their mouth muscles cannot maintain a proper suck-swallow pattern or a good breastfeeding latch.
Measure head circumference and record it in the baby’s notes.
Microcephaly describes a head that is smaller than expected for age and sex. May be associated with reduced brain size or atrophy.
Macrocephaly describes a head that is larger than expected for age and sex. It may be normal, but may be associated with hydrocephalus, cranial vault abnormalities or genetic abnormalities.
Inspect the shape of the head and note any abnormality.
Inspect the cranial sutures and note if they are closely applied, widely separated or normal.
Cranial moulding is common after birth and resolves within a few days.
Caput succedaneum is a diffuse subcutaneous fluid collection with poorly defined margins (often crossing suture lines) caused by the pressure on the presenting part of the head during delivery. It does not usually cause complications and resolves over the first few days. 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, fluctuant 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 fibrous sutures in an infant skull prematurely fuses, changing 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. 7
Palpate the anterior fontanelle – note if it feels flat (normal), sunken or bulging (abnormal)
A tense bulging fontanelle may suggest raised intracranial pressure – e.g. hydrocephalus
A sunken fontanelle may suggest dehydration.
Colour – pallor / cyanosis / erythema / jaundice
Bruising / lacerations – may be secondary to trauma during childbirth
- Salmon patch
- Port wine stain
- Dry abrasions
Vernix – waxy or cheese-like white substance found coating the skin of newborn human babies (normal)
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.
Other potential findings
Mongolian spot is a benign, flat, congenital birthmark with wavy borders and irregular shape, usually located over the 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
Nevus simplex (stork bite, salmon patch) is a common congenital capillary malformation present in newborns, most commonly on the eyelid, glabella or back of the neck. It usually disappears during first year of life.
Naevus flammeus (port-wine stain) is a vascular malformation that does not regress.
Milia are tiny white cysts containing keratin and sebaceous material. They are very common on the face, and most resolve within the first few weeks of life.
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 different pathologies including haemolytic disease, infection and Gilbert’s syndrome.
Appearance – note any dysmorphic features
Asymmetry – e.g. facial nerve palsy
Trauma – likely to have occurred during labour (e.g. instrumental delivery)
Nose – patency of nasal passages – infants are obligate nasal breathers, therefore, will present with respiratory distress and cyanosis at rest if they have bilateral choanal atresia.
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)
Position and shape (e.g. any ptosis, epicanthic folds)
Assess for red reflex:
- Use your ophthalmoscope to assess for red reflex
- An absent red reflex requires immediate ophthalmology referral as it may suggest congenital cataracts or rarely retinoblastoma
Subconjunctival haemorrhages – these look dramatic but are fairly common after delivery and benign, you should, however, document their presence
Inspect the pinna – asymmetry / prominence / accessory auricles
Note position and any skin tags or pits
All infants should have a hearing screening test prior to discharge from hospital.
Mouth and palate
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.
Tongue and gums – inspect for evidence of tongue-tie (ankyloglossia)
Neck and clavicles
Length of neck – e.g. abnormally short in Turner’s syndrome
Webbing of the neck – e.g. Turner’s syndrome
Neck swellings – e.g. Cystic hygroma
Clavicular fracture – secondary to traumatic birth (e.g. shoulder dystocia)
Inspect for symmetry – ensure equal in size and length
Inspect fingers – ensure correct number and morphology
Inspect palms – should have two palmar creases on each hand
Palpate brachial pulses
Polydactyly is a congenital abnormality where there are supernumerary fingers or toes.
A single palmar crease is associated with Down’s syndrome.
Chest wall deformities (e.g. pectus excavatum)
Chest wall expansion – asymmetry may be noted unilateral lung pathology (e.g. pneumonia)
Note any respiratory distress (e.g. subcostal or intercostal recession, tracheal tug, grunting) – normal respiratory rate is 30-60 in newborns
Auscultate the lungs:
- Auscultate to ensure there is air entry bilaterally
- Listen for any added sounds – wheeze / crackles / grunting
Auscultate the heart:
- Use a paediatric stethoscope
- Normal heart rate is around 120-150bpm
- Listen for any added sounds (murmurs)
- If a murmur is noted, try to identify 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.
Inspect for evidence of abdominal distension
Inspect for evidence of any inguinal hernias – will need paediatric surgical review
Palpate the abdomen:
- Liver – should be no more than 2cm below costal margin
- Spleen – may be just about palpable
- Kidneys – only palpable on deep bimanual palpation
- Bladder – should not be palpable
Inspect for any discharge or hernias
Note any offensive smell and erythema – may suggest infection
Note any ambiguity of genitalia – e.g. congenital adrenal hyperplasia (in girls, boys with CAH will have normal genitalia)
- Position of meatus (exclude hypospadias or epispadias)
- Size of penis – should be at least 2cm
- Hydroceles – collection of fluid in the scrotum – transilluminates
- Hydroceles – collection of fluid in the scrotum – transilluminates
- Palpate scrotum to ensure both testes are present – 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
- Inspect labia – ensure they are not fused
- Inspect clitoris – ensure it is normal size
- Vaginal discharge – white discharge is normal due to maternal oestrogens
Inspect limb symmetry – should be equal in size and length
Assess tone in both lower limbs
Assess movement in both lower limbs
Palpate femoral pulses – This can be difficult, particular in an active baby, and requires practice! Weak, absent or delayed femoral pulses are a sign of coarctation of the aorta.
Assess for oedema
Assess knees – hyper-extensile/dislocatable
Ankle deformities – e.g. talipes
Ensure correct number of digits on each foot
Barlow’s and Ortolani’s test are carried out as part of the routine newborn examination to detect hip joint instability and dislocation. Hips should be examined individually with all clothing and nappy off.
1. 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. 6
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 maneuver is then used to confirm the positive finding (i.e. that the hip actually dislocated).
Ortolani’s test is used to confirm posterior dislocation of the hip joint.7
1. Flex the hips and knees of a supine infant to 90 degrees
2. Then with your index fingers placing anterior pressure on the greater trochanters, gently and smoothly abduct the infant’s legs 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.
This tests assesses specifically for posterior dislocation of the hip.
Back and spine
Inspect the spine for:
- Hair tufts
- Abnormal skin patches
- Sacral pits
Hair tufts and sacral pits can be associated with underlying neural tube defects (spina bifida).
Inspect the anus for patency
Meconium should be passed within 24 hours – delay is suggestive of obstruction or Hirschsprung’s disease
Assess the newborn’s reflexes
Palmar grasp reflex – When an object is placed in the infant’s hand and strokes their palm, the fingers will close and they will grasp it with a palmar grasp. 8
Sucking reflex – Causes the child to instinctively suck anything that touches the roof of their mouth.
Rooting reflex – Present at birth and disappears around four months of age, as it gradually comes under voluntary control. A newborn infant will turn its head toward anything that strokes its cheek or mouth to aid breastfeeding. 9
Stepping reflex – When the soles of their feet touch a flat surface they will appear to walk by placing one foot in front of the other. 10
Moro reflex – Support the infant’s upper back with one hand, then drop back once or twice into your other hand. The legs and head extend while the arms jerk up with the fingers extended. The arms are then brought together and the hands clench into fists, and the infant cries. Asymmetry may be due to hemiparesis, brachial plexus injury or fractured clavicle.
To complete the examination…
Share the results of the assessment with the parents, explaining the reason for any referrals you feel are required
Ask if the parents have any further questions
Thank the parents
Offer to dress the baby or allow parents to do so (depending on their preference)
Document your findings and suggest any relevant investigations or referrals
- In the UK the NIPE is documented using a national online system (which you would print and place in the babies notes)
Dr Rebecca Naples
Medical student and illustrator
2. Newborn Infant Physical Examination. Nottingham Neonatal Service – Clinical Guidelines. Published November 2015. Retrieved 15 March 2017.
3. Jaundice in newborn babies under 28 days. NICE guidance: https://www.nice.org.uk/guidance/cg98. Published May 2010. Retrieved 15 October 2017.
4. Slater BJ, Lenton KA, Kwan MD, Gupta DM, Wan DC, Longaker MT (April 2008). “Cranial sutures: a brief review”. Plast. Reconstr. Surg. 121 (4): 170e–8e. doi:10.1097/01.prs.0000304441.99483.97. PMID 18349596.
5. Circumscribed dermal melanosis (Mongolian spot)(1981) Kikuchi I, Inoue S. in “Biology and Diseases of Dermal Pigmentation”, University of Tokyo Press , p83
6. French LM, Dietz FR (July 1999). “Screening for developmental dysplasia of the hip”. American Family Physician. 60 (1): 177–84, 187–8. PMID 10414637.
8. Jakobovits, AA (2009). “Grasping activity in utero: a significant indicator of fetal behavior (the role of the grasping reflex in fetal ethology).”. Journal of perinatal medicine. 37 (5): 571–2. doi:10.1515/JPM.2009.094. PMID 19492927.
9. Odent M. The early expression of the rooting reflex. Proceedings of the 5th International Congress of Psychosomatic Obstetrics and Gynaecology, Rome 1977. London: Academic Press, 1977: 1117-19.